Table 2.

Key elements of the simulation-based training on respectful emergency obstetric care for CHRD

Element	Sub-element	Training at CHRD
Participant orientation	Orientation to the simulator	One month before the simulation sessions (phase 3), the participants attended the phase 2 didactic training sessions on the six topics with the trainers. On day 1 of the simulation phase, trainers discussed the simulation methodology, including the structure for briefings before and after the scenarios, and the ground rules for the learning exercise. At the outset of each of the six simulation sessions, the trainers presented the scenario.
	Orientation to the environment	The hybrid training was jointly conducted by some trainers in the room with the trainees, and other trainers participating online. The training occurred at the trainees’ workplace in a dedicated training room.
Simulator type	Simulator make and model	2 MamaNatalies (Laerdal) 2 NeoNatalies (Laerdal) Trainers (in person) served as actors
	Simulator functionality	MamaNatalie supports: Deliveries and drills • Normal delivery • Assisted delivery: forceps and vacuum • Breech delivery • Postpartum Hemorrhage NeoNatalie supports: • Oxygen delivery procedures • Suctioning techniques • Positive pressure ventilation • Spontaneous chest rise and fall • Ventilation with bag-valve mask • Closed chest compressions • Auscultate heart sounds • Manual umbilical pulse
Simulation environment	Location	CHRD provided a dedicated training room. The room has enough space to be used for both didactic sessions and for acting out the simulations.
	Equipment	4 mannequins (2 MamaNatalies and 2 NeoNatalies by Laerdal) Internet access, six laptops, six tablets, a conference phone, smartphones, projector, and a screen for remote participants 2 bassinets Mock supplies with realistic packaging
	External stimuli	Normal hospital noise levels
Simulation event/scenario	Event description	Each of the six scenarios was partially scripted (see sample in Appendix).
	Learning objectives	• Understand how the obstetric team can work together more effectively • Understand and implement best practices in treatment of six conditions (post-partum haemorrhage, preeclampsia/eclampsia, maternal sepsis, physiological childbirth, obstetrical maneuvers, neonatal resuscitation))
	Group vs. individual practice	Two groups of 5–6 trainees each (including midwives, nurses, anesthetists and obstetricians)
	Use of adjuncts	n/a
	Facilitator/operator characteristics	10 Malagasy facilitators participated in the Training-of-Trainers sessions. They included five physicians, four midwives and one nurse who were employed by the MOH. The training-of-trainers sessions were conducted by the Swiss team members (all doctors, some with experience with simulation, others with experience with other types of role play and participatory training) In Ambanja, two administrators dealt with all the technological and logistical arrangements, including ensuring that the internet connections worked, logistical support for participants and trainers, etc.
	Pilot testing	No
	Actors/confederates/standardized/simulated patients	Simulated patients were played by facilitators (professional midwives who had participated in the training-of-trainers)
Instructional design (for educational interventions)	Duration	8 days of 2-h sessions: Day 1: Overview of the following days Days 2–7: One simulation session each day Day 8: Review of the training, knowledge test, closing Schedule for simulation sessions: Briefing on the simulation scenario (10 min) Simulation (15 min) Debriefing (40 min) Review of national protocols for treatment of each condition (15 min) Questions and discussion (10 min)
	Timing	Twelve hours of didactic training were conducted 1 month before the simulation sessions. The participants took the same knowledge test three times: once before the didactic learning sessions, on the final day of the simulation sessions, and 6 months after the training.
	Frequency/repetitions	Only once
	Clinical variation	Six topics were covered; each was only covered once (per group)
	Standards/assessment	Utilizing Madagascar national standards (MoH)
	Adaptability of intervention
	Range of difficulty	Emergency obstetric and newborn care scenarios
	Nonsimulation interventions and adjuncts	One month prior to the simulation sessions, the participants received 12 h of didactic training on the six topics and management of COVID-19. These were delivered by a previously trained MOH trainers in-person coming from the capital (trained during the TOT) and the Swiss teams remotely
	Integration	n/a—this was continuing education, not pre-professional training
Feedback and/or debriefing	Source	1–2 participants and onsite trainers not involved in enacting the scenario were designated as observers using checklists on timing, interaction, and technical skills Trainers participating remotely via Zoom
	Duration	Approximately 40 min of debriefing per scenario
	Facilitator presence	Yes, 5 facilitators were present in the room and 1–3 others remotely
	Facilitator characteristics	See above
	Content	Technical topics: post-partum hemorrhage, pre-eclampsia/eclampsia, management of labor, obstetric maneuvres for dystocic deliveries, maternal sepsis, and neonatal resuscitation Other skills: respectful patient care; inter-personal collaboration on the team
	Structure/method	The trainers guided the trainees through a group evaluation of their actions. Together, they identified any problems and discussed potential strategies for improvement, with a focus on strengthening communication and interaction among staff and attention to the quality of care patients received. The sessions ended with reviews of relevant national protocols and standards and a question-and-answer session.
	Timing	Debriefing was conducted immediately after each simulation
	Video	Yes, both Zoom and videos were recorded on smartphones by two trainers in the room. The Zoom videos showed the full scene while the smartphone recordings provided close-ups.
	Scripting	Yes – one sample script is provided (in French) in the Appendix and all scripts are available from the authors.