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Effect of the competency-based Helping Mothers Survive Bleeding after Birth (HMS BAB) training on maternal morbidity: a cluster-randomised trial in 20 districts in Tanzania
  1. Fadhlun Alwy Al-beity1,2,
  2. Andrea Pembe2,
  3. Atsumi Hirose1,
  4. Jessica Morris3,
  5. Sebalda Leshabari4,
  6. Gaetano Marrone1,
  7. Claudia Hanson1,5
  1. 1 Department of Public Health Sciences, Karolinska Institutet, Solna, Sweden
  2. 2 Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
  3. 3 International Federation of Gynecology and Obstetrics (FIGO), London, UK
  4. 4 School of Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
  5. 5 Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
  1. Correspondence to Dr Fadhlun Alwy Al-beity;{at}


Background Training health providers is an important strategy to improve health. We conducted a cluster-randomised two-arm trial in Tanzania to assess the effect of a 1-day competency-based training ‘Helping Mothers Survive Bleeding after Birth (HMS BAB)’ followed by eight weekly drills on postpartum haemorrhage (PPH)-related morbidity and mortality.

Methods Twenty districts in four purposefully selected regions in Tanzania included 61 facilities. The districts were randomly allocated using matched pairs to ensure similarity in terms of district health services in intervention and comparison districts. In the 10 intervention districts 331 health providers received the HMS BAB training. The other half continued with standard practices. We used the WHO’s near miss tool to collect information on severe morbidity (near misses) of all women admitted to study facilities. We performed interrupted time series analysis to estimate differences in the change of near miss per delivery rate and case fatality rates. We also assessed implementation of evidence-based preventive and basic management practices for PPH as secondary outcomes.

Results We included 120 533 facility deliveries, 6503 near misses and 202 maternal deaths in study districts during study period (November 2014 to January 2017). A significant reduction of PPH near misses was found among women who suffered PPH in the intervention district compared with comparison districts (difference-in-differences of slopes −5.3, 95% CI −7.8 to −2.7, p<0.001) from a baseline PPH-related near miss rate of 71% (95% CI 60% to 80%). There was a significant decrease in the long-term PPH near miss case fatality (difference-in-differences of slopes −4 to 0) (95% CI −6.5 to −1.5, p<0.01) in intervention compared with the comparison districts. The intervention had a positive effect on the proportion of PPH cases treated with intravenous oxytocin (difference-in-differences of slopes 5.2, 95% CI 1.4 to 8.9) (p <0.01).

Conclusion The positive effect of the training intervention on PPH morbidity and case fatality suggests that the training addresses important deficits in knowledge and skills.

Trial registration number PACTR201604001582128.

  • near miss
  • postpartum haemorrhage
  • PPH near miss
  • competency-based training
  • Tanzania
  • maternal morbidities and mortalities

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  • Handling editor Stephanie M Topp

  • Contributors CH and FAA conceptualised the study in Tanzania with support from AP, and JM. GM, FAA, AH and CH performed the statistical analysis. FAA, CH, AP and SL were involved into the operationalisation of the study and the data collection support. FAA and CH wrote the first draft of this protocol. All authors contributed to the manuscript development and commented on several drafts of the manuscript. All authors read and approved the final manuscript.

  • Funding This study was funded by Laerdal Foundation for Acute Medicine (40070).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Senate Research and Publication Committee of Muhimbili University of Health and Allied Health Science

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Additional data will be archived on the Dyrad Digital Repository.

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