Date of Award

January 2018

Document Type


Degree Name

Medical Doctor (MD)



First Advisor

Urania Magriples



Inadequately treated, severe preeclampsia and eclampsia (PE/E) may rapidly lead to severe complications in both mothers and neonates and are estimated to cause 60,000 maternal deaths globally each year. Simulation-based training where health providers review basic emergency obstetric and newborn care through highly realistic cases have demonstrated promising results in low- and middle-income countries (LMIC). Two international simulation training programs, Helping Mothers Survive and PRONTO International, have demonstrated improved overall use of evidence-based practices (EBPs) in active management of third stage of labor and hemorrhage management, though individual skills varied. However, the impact of simulation training on use of EBPs for PE/E diagnosis and management in such settings has not been reported.


PRONTO International’s simulation-based training was embedded within a statewide maternal and newborn health quality improvement project in Bihar, India. This mixed methods study evaluated change in the use of evidence-based clinical skills by nurse mentees during simulated cases at primary health clinics (PHC). We compared the proportion of skills completed during mentees’ first and last participation in simulated severe preeclampsia and eclampsia cases. Semi-structured interviews were conducted with nurse mentors to explore barriers and enablers to high quality preeclampsia care in Bihar. Qualitative data were analyzed using the thematic content approach.


A total of 39 matched pre- and post-training simulation video pairs, including 94 nurse mentees from 33 PHCs, were analyzed. Results demonstrated a significant increase in the number of ‘key history questions asked’ from 1 to 2 (p=0.03), which demonstrates improvement in nurse mentees’ ability to gather histories and make preeclampsia diagnoses. Additionally, ‘key management steps completed’ increased from 2 to 3 (p=0.03), reflecting mentees increased rates of antihypertensive administration and foley catheter and intravenous catheter insertion. Key barriers to preeclampsia care included knowledge gaps, resource shortages, hierarchy between nurses and physicians, poor relationships between nurses and patients, and fear of retaliation from patients’ families. Strategies that facilitated high quality care included case-based and participatory learning, promotion of teamwork and communication, and effective leadership.


Simulation-based training increased the use of clinical skills by nurse mentees in simulated severe preeclampsia and eclampsia cases. Barriers affect all aspects of clinical management, and must be addressed in order to improve care. Teamwork, communication, and leadership are key mechanisms to facilitate high quality preeclampsia care in LMICs.


This thesis is restricted to Yale network users only. It will be made publicly available on 05/29/2021