Discussion
PPH
SAID
In this randomized controlled trial, including 130 mid-and low-level health providers in a rural setting in Western Ethiopia, we have demonstrated that the SDA, an mHealth intervention, was associated with an increase in knowledge and particularly skills managing PPH. Notably we also found an increase in the learning curve up to 12 months from being introduced to the app. These findings are important as they address a main cause of maternal mortality and morbidity and indicate that an mHealth tool might be an important steppingstone for bridging the outreach gap in improving the quality of emergency care in especially the peripheral rural parts of the health system.The use of mHealth in low-and middle-income countries on maternal and neonatal care has been tested in a growing number of studies, however studies are often of poor methodological quality and few studies deal with mHealth as education and training of health professionals especially within emergency obstetric care [Improved competencies in health workers’ skills and knowledge on PPH management, have been examined in other SDA trials from Rwanda and Congo, and our findings are consistent with the documented effect of the SDA intervention in these studies [A RCT study from Ethiopia also investigated the effect of the SDA and found a non-significant reduction in perinatal mortality and an increase in skills and knowledge in skilled birth attendants for neonatal resuscitation at 6 and 12 months after the intervention [Conventional BEmONC training courses vary in length from a few days to several years [A cluster RCT from Nigeria examined the effect of simulation-based, low-dose, high frequency training plus mobile mentoring (LDHF/m-mentoring) compared to traditional group-based training (TRAD) on health workers’ knowledge and skills competencies on BEmONC with mixed results [Tools to measure training impact are often not validated or standardized, rather are they constructed for the occasion. Different training modalities were compared to each other in few studies we could identify [It is remarkable that the small-dose, high-frequency training by the SDA demonstrates full retention of skills and knowledge, and even an increasing instead of declining learning curve up to 12 months after its introduction.Most studies about the quality of BEmONC are observational and concern referral rather than outreach health facilities [Financial and qualified workforce restraints are pointed out as main barriers to provision of safe delivery care [Weaknesses inherent to the study design can be discussed. The randomization at health facility level was chosen to avoid that health providers in the control group had access to the SDA. We had no observations that this took place. Randomization was made by district with the aim to make intervention and control facilities as comparable as possible regarding infrastructure. Subsequent statistical control of within-cluster correlation and confounders was performed. Blinding of participants was impossible due to the nature of the intervention, knowledge tests were blinded as the scoring was done without knowledge of the health facility, though skills testing was unblinded. This may have caused information bias. Test enhanced learning could explain part of the results though the control group showed only slight and generally non-significant increase in skills- and knowledge score. Extrapolation of these findings to other settings should be cautious as organization of the health system and quality assurance might vary much between different countries, even between different health facilities. Furthermore, the increase in skills and knowledge in test situations might not cause improved management and clinical outcomes in real work situations as this may depend on other factors such as an “enabling environment” hereunder availability of drugs, equipment, staffing and supervision. All this said, it remains that this is one of few randomized controlled trials in a low-income setting to demonstrate a clear effect of an mHealth intervention within a health topic of major importance.