1. Lee Dresang, MD and Ann Evensen, MD University of Wisconsin School of Medicine and Public Health Department of Family Medicine

2. Schedule 5-10 minutes: Review AAFP ALSO ® Program options 15 minutes: Demonstrate how different program options approach the topic of shoulder dystocia 15 minutes: Review ALSO ® research studies and publications and discuss future study decision-making 15 minutes: Review process of bringing ALSO ® to a new country and engaging new partners in the international ALSO ® community

3. Objectives Describe the ALSO ®, BLSO SM, C-BLSO SM and Global ALSO ® program content and intended audiences Demonstrate the similarities and differences in how the management of shoulder dystocia is taught in the different curricula Identify the content areas where ALSO ® makes the most significant impact according to published studies Describe the process of adapting ALSO ® and BLSO SM curricula to meet the needs of international maternity care learners.

4. Introductions Lee Dresang, MD Professor of Family Medicine ALSO ® Editorial Board Member Chief Editor of Global ALSO AAFP BLSO SM and C-BLSO SM Co-Editor Introduced ALSO to Ecuador, Guatemala and Honduras Ann Evensen, MD Assistant Professor of Family Medicine ALSO ® Advisory Faculty Introduced ALSO ® to Ethiopia and India

5. Advanced Life Support in Obstetrics Began in 1991 in Madison, WI hospital cafeteria Mission: help physicians and other health care providers develop and maintain the knowledge and skills they need to effectively manage potential emergencies during the perinatal period Now in 62 countries, over 150,000 participants

6. ALSO ® was not for every audience.. ALSO ® /BLSO SM Instructor C-BLSO SM (Community-Based Life Support in Obstetrics) Provider Global ALSO BLSO SM (Basic Life Support in Obstetrics) Provider ALSO ® 1993 ALSO ® Instructor 1994 C-BLSO SM 2009 Global ALSO 2009 BLSO SM 2012

7. ALSO ® /BLSO SM Instructor Course

8. ALSO ® /BLSO SM Instructor topics Didactics/Demonstrations Adult Learning Styles How to Integrate Mannequins into Teaching Megadelivery Testing Improving Lecture Skills How to Give Feedback Workstations: Practice giving a lecture Practice leading a mannequin station Practice leading OB cases and fetal surveillance Practice leading maternal resuscitation/hemorrhage

9. Community-Based Life Support in Obstetrics (C-BLSO SM )

12. Similarities between courses Evidence-based Use of mannequins and small groups to engage learners Mixture of didactics and hands-on workstations Mnemonics used as learning aids

13. Differences between courses Complexity of material Topics covered Global ALSO ® Communicable and non-communicable diseases Traditional birth attendants Community recognition and action plans BLSO SM Ambulance transport How competency is demonstrated

14. Differences in learners ALSO ® learners often have maternity care in job description BLSO SM learners likely to not be providing regular maternity care, but have strengths in other clinical areas BLSO SM and C-BLSO SM learners may have lower literacy levels Global ALSO ® learners have patients with unique needs, limited resources Instructor Course prepares learner for BLSO SM and ALSO ® Provider courses

15. Considerations for choosing a program Job description Literacy level Topic areas covered Time available to attend or teach course

16. Questions or Comments? About ALSO ® program offerings? About how to make a choice for your learners?

17. ALSO ® vs BLSO SM

18. Shoulder dystocia

19. ALSO ®

20. HeLP - R Shoulder Dystocia H Help!! L Legs - Elevate the legs – McRoberts P Pressure - Suprapubic Pressure R Rotate to hands and Knees BLSO SM

21. C-BLSO SM BLSO SM No text No pre-course study or test Community planning

22. Global ALSO ®

24. Question

25. Methods

26. Funding

27. Colombia

28. Colombia – Maternal mortality and morbidity ALSO® study Prospective intervention cohort study 43,315 births; 30 maternal deaths between 2005 and 2009 Intervention: 2-day ALSO ® course in September 2007 Calculation of pre and post: Mortality Index Severe Maternal Outcome Ratio (SMOR)

29. Colombia – Maternal mortality and morbidity ALSO® study

30. Post-ALSO® maternal mortality went down but near misses and morbidity increased Hypotheses: May reflect that increased severe morbidity is among women who would have died previously May reflect improved reporting due to awareness brought about by ALSO®

31. Guatemala

32. Guatemala – Maternal mortality and postpartum hemorrhage study Prospective intervention cohort study San Juan de Dios Regional Hospital in Quetzaltenango, Guatemala ALSO ® introduced in 2004 and incorporated into medical school and residency curriculum Monitor maternal mortality and maternal mortality due to postpartum hemorrhage on an annual basis post-ALSO ®

33. Guatemala – Maternal mortality and postpartum hemorrhage study

34. 34 Guatemala – Maternal mortality and postpartum hemorrhage study Hemorrhage is no longer the leading cause of maternal mortality Drop in maternal mortality has not been seen in similar regional hospitals in Guatemala

35. Honduras

36. Honduras – comfort level and obstetric outcomes study Designed as randomized controlled trial, but mid-study discovered that providers trained in ALSO® (experimental group – Hospital Escuela) were also working at control hospital (Hospital de Seguridad Social) Converted to cohort intervention study 48 participants: 11 OBs, 17 OB residents,15 medical students, 2 certified nurse midwives, 2 nurses, and 1 “other”. Survey assessing comfort managing obstetrical emergencies and outcomes were monitored pre-course and immediately, 6 months and 12 months post-course ALSO ® courses taught October 2005

37. ALSO ® Comfort Managing Obstetrical Emergencies Studies – United States Improved comfort level managing obstetrical emergencies through twelve months post-ALSO® Bower D, Wolkomir M, Schubot D. The effects of the ALSO® course as an educational intervention for residents. Family Medicine 1997;29:187- 193. Taylor H, Kiser W. Reported comfort with obstetrical emergencies before and after participation in the Advanced Life Support in Obstetrics (ALS0) course. Family Medicine 1998;30:103-107.

38. Results: Improved comfort managing obstetrical emergencies From pre-course to immediately post-course and 12 months post-course, respondents had significant increase in reported comfort for 9 of 13 OB emergencies. Other 4 emergencies had highest baseline comfort levels: pre-eclampsia/eclampsia, preterm labor, breech and post-partum hemorrhage.

39. Results: Vacuum and forceps Prior to ALSO ®, vacuum was never used and forceps was rarely used at Hospital Escuela At 6 months post-ALSO ®, 13 participants had used a vacuum and 18 forceps At 12 months post- ALSO ®, 18 reported vacuum use and 20 forceps use

40. Results: Episiotomy Decrease in episiotomy rate from 60% to 20% from pre-ALSO® to two months post-ALSO®

41. Results: Active management of third stage of labor After ALSO ®, active management of the third stage of labor was established as the norm at Hospital Escuela. Pitocin, traction on the cord, and Brandt’s maneuver (countertraction on the uterus) now used in vast majority of deliveries.

42. Tanzania

43. Tanzania – prolonged labor and neonatal care study Prospective intervention cohort study 558 women before 550 women after Intervention: 2-day ALSO ® course for all high- and mid- level providers at Kagera Regional Hospital Sorensen B, Rasch V, Massawe S, Nyakina J, Elsass P, Nielsen B. Impact of ALSO ® training on the management of prolonged labor and neonatal care at Kagera Regional Hospital, Tanzania. Int J Gynaecol Obstet. 2010;111:8-12.

44. Tanzania – prolonged labor and neonatal care study (results) No change in cesarean delivery rate for prolonged labor (5.1% vs 4.4%; RR 0.87; 95% CI 0.51-1.48) Decrease in episiotomy rate from 17.2% to 8.9% (RR 0.52; 95% CI 0.37–0.72). Increase in newborns given to their mothers within 10 minutes, from 5.6% to 71.5% (RR 12.71; 95% CI 9.04–17.88) Decrease from 6 to 0 neonatal deaths before discharge among those born with an Apgar score after 1 minute of 4 or more (P=0.03) Sorensen B, Rasch V, Massawe S, Nyakina J, Elsass P, Nielsen B. Impact of ALSO ® training on the management of prolonged labor and neonatal care at Kagera Regional Hospital, Tanzania. Int J Gynaecol Obstet. 2010;111:8-12.

45. Tanzania -- Postpartum Hemorrhage study Prospective intervention cohort study 510 women before 505 women after Intervention: 2-day ALSO ® course for all high- and mid- level providers at Kagera Regional Hospital Deliveries observed and blood loss measured by 6 research assistants from 7 weeks before until 7 weeks after intervention Sorensen B, Rasch V, Massawe S, Nyakina J, Elsass P, Nielsen B. Advanced Life Support in Obstetrics (ALSO ® ) and post-partum hemorrhage: a prospective intervention study in Tanzania. Acta Obstet Gynecol Scand. 2011;90:609-614.

46. Tanzania -- Postpartum Hemorrhage study Sorensen B, Rasch V, Massawe S, Nyakina J, Elsass P, Nielsen B. Advanced Life Support in Obstetrics (ALSO ® ) and post-partum hemorrhage: a prospective intervention study in Tanzania. Acta Obstet Gynecol Scand. 2011;90:609-614. Pre-ALSO®Post-ALSO®Relative Risk Reduction Postpartum Hemorrhage (>500ml) 168 (32.9%)92 (18.2%)45% Severe postpartum hemorrhage (>1000ml) 47 (9.2%)22 (4.3%)52%

47. Tanzania -- Postpartum Hemorrhage study

50. Launching an International ALSO ® Program

52. ALSO ® Launch “To Do” List

53. Find funding and local partner Grants, universities, NGOs, commercial/private entity Choice will affect course success and sustainability License partner Complete pre-course survey to inventory local resources and practices Pilot course Help to sustain program

54. ALSO ® Launch “To Do” List Find local partner License partner Set expectations Protect contractual partners and their investment Complete pre-course survey to inventory local resources and practices Pilot course Help to sustain program

55. ALSO ® Launch “To Do” List Find local partner License partner Complete pre-course survey to inventory local resources and practices Done by local partner Pilot course Help to sustain program

56. ALSO ® Launch “To Do” List Find local partner License partner Complete pre-course survey to inventory local resources and practices Pilot course Opportunity for both partners to learn For local partner – will this help our community? Worth time and money? For you – what are local resources, language skills, maternal care needs? Help to sustain program

57. Pilot Course “To Do” List Arrange funding Identify course director and teaching team Recruit learners Purchase supplies Mannequins Forceps, vacuums Maternal resuscitation Neonatal resuscitation Perineal repair LOGISTICS

58. Pilot Course Logistics Need in-country help and knowledge Devil is in the details! Culturally sensitive daily teaching schedule Print materials (syllabus, written test book and score sheets, megadelivery score sheets, course evaluations, instructor candidate evaluations, other course materials such as OB cases if electricity is unreliable) Participant and instructor food, travel, housing, per diems Certificates Visas Customs

59. Sustainability – “it takes a village” Make syllabus/slide adaptations (with AAFP ALSO ® Board permission) Identify in-country champion Set up in-country Advisory Board Develop roll out plan Connect to AAFP ALSO ® social networking site “AAFP Connections” Invite representative to ALSO ® International Meeting Collect data

60. Discussion Questions How would you find out if a country license has already been granted? How would you go about finding a local partner? Who would be a good choice for an advisory board? Where would you start looking for funding?

61. Thank you for joining us today! Lee Dresang, MD lee.dresang@fammed.wisc.edu Ann Evensen, MD ann.evensen@uwmf.wisc.edu Diana Winslow, RN, BSN, ALSO ® Program Manager dwinslow@aafp.org www.aafp.org