<div>Re: Training in the use of intrapartum electronic fetal monitoring with
cardiotocography: systematic review and meta‐analysis. Cardiotocography
training is a complex intervention and requires complex evaluations: a
letter to editor.</div><div>Lightly K, Weeks AD, Scott H</div><div>Correspondence to Dr Kate Lightly –
klightly@liverpool.ac.uk</div><div>07875642837</div><div>Clinical Research Fellow, Sanyu Research Unit, University of Liverpool
and Liverpool Women’s NHS Foundation Trust, members of Liverpool Health
Partners, Crown Street, Liverpool, L8 7SS.</div><div>Professor Andrew D Weeks</div><div>Professor of International Maternal Health, Sanyu Research Unit,
University of Liverpool and Liverpool Women’s NHS Foundation Trust,
members of Liverpool Health Partners, Crown Street, Liverpool, L8 7SS.</div><div>Professor Hazel Scott</div><div>Dean of School of Medicine, School of Medicine, University of Liverpool,
Cedar House, Liverpool, L69 3GE.</div><div>Running title - CTG training requires complex evaluations</div><div>We congratulate Kelly et al on
their review on the effects of training in cardiotocography
(CTG).<sup>i</sup> It is a critical step towards understanding
how to correctly implement CTG training. However, we query the relevance
of some of the included studies and whether using Kirkpatrick’s model
adequately captures all of the relevant complexities. We believe that
further work is needed to understand how such training will impact on
practice.</div><div>Some of the CTG research projects reviewed were poorly representative of
the needs of clinicians tasked with improving fetal monitoring in their
hospitals. For clinicians, their <b>population</b> of interest is
practising clinicians who work on labour wards (sometimes infrequently);
studies involving undergraduates alone may not be generalisable.
Training in intermittent auscultation is also relevant. Considerable
detail on the training <b>intervention</b> is required, including not
only the format of teaching, but the duration, curriculum and proportion
of relevant staff trained. Detail is also required of supporting
interventions and context, as training alone is unlikely to impact
change. Many would consider ‘no training’ unethical and therefore not a
relevant <b>comparator</b> . In the UK, CTG training and competency is
now required for all maternity staff.<sup>ii</sup> The ultimate
aim of CTG (and therefore CTG training) is to detect the hypoxic fetus,
so that timely intervention can be undertaken to avoid perinatal harm,
without unnecessary intervention. Therefore, the <b>outcomes</b> of
interest have to include intrapartum stillbirths, hypoxic ischaemic
encephalopathy and mode of delivery.</div><div>Kirkpatrick’s model was used in this review to evaluate training at four
levels (reaction, knowledge, behaviour change and organisational
performance). However, it does not attempt to understand why
interventions work, or the context, or the causal pathways between
training and change in practice.<sup>iii</sup> Whether
participants like training (‘reaction’) is of little relevance, and
knowledge acquisition (‘knowledge’) is a proxy which does not equate
with improved on the job performance and outcomes. Maternal and
perinatal outcomes (‘performance’) were only collected in a small number
of studies.</div><div>CTG training is a complex intervention which aims to create change, not
simply knowledge acquisition. We therefore believe that a formal Realist
Evaluation is needed. This emerging methodology has been used
successfully to understand healthcare change processes and supplement
traditional Cochrane style reviews. It aims to understand why complex
interventions work, how, for whom, in what context and to what
extent<sup>iv</sup>. Collaboration with the relevant authors to
gain detailed intervention descriptions, with a realist approach, may
add some much needed explanatory power to this critical
subject.</div><div>Training alone is unlikely to impact change. Even the best educational
package will fail without the necessary support - it needs an
educational and working culture which supports learning and change,
aligned and clear policies, and motivated, well supported drivers and
leaders.</div><div>How doctors learn and what supports them to put new knowledge into
practice are key research questions. High quality, methodologically
appropriate, properly funded studies are needed to address these
questions. Not answering them means many research findings are
redundant, as they simply will not be implemented.</div><div>References</div><div><sup>I</sup> Kelly S, Redmond P, King S, Oliver‐Williams C, Lamé
G, Liberati E et al. Training in the use of intrapartum electronic fetal
monitoring with cardiotocography: systematic review and meta‐analysis.
BJOG. 2021; 00: 1–12.
https://doi.org/10.1111/1471-0528.16619</div><div><sup>ii</sup> NHS England. Saving Babies’ Lives Version Two. A
care bundle for reducing perinatal mortality. London: NHS England 2019.
[cited 2021 Feb 3]. Available from:
www.england.nhs.uk</div><div><sup>iii</sup> Moreau KA. Has the new Kirkpatrick generation
built a better hammer for our evaluation toolbox? Med Teach. 2017 Sep;
39(9): 999-1001. https://doi.org/10.1080/0142159X.2017.1337874</div><div><sup>iv</sup> Wong G, Westhorp G, Greenhalgh J, Manzano A, Jagosh
J, Greenhalgh T. Quality and reporting standards, resources, training
materials and information for realist evaluation: the RAMESES II
project. Health Services and Delivery Research. 2017 <i>5</i> (28):
1–108. https://doi.org/10.3310/hsdr05280.</div><div>Acknowledgements – Nil</div><div>Disclosure of interests - Nil</div><div>Contribution to authorship</div><div>KL wrote the first draft of this letter and then it was revised by AW
and HS.</div><div>Details of ethics approval – N/A</div><div>Funding – Dr Lightly’s PhD entitled “Improving intrapartum fetal
monitoring in India: A mixed methods approach” is funded by
MRC/DfID/Wellcome Trust Joint Global Health Trials Fund. MR/R006/1801</div>