Delivering effective simulations in low-resource settings comes with unique challenges—from limited equipment to constrained faculty support. Yet, innovation and adaptability can make a profound difference.
In this AI-generated episode, we highlight key insights from the literature on simulation in low- and middle-income countries, with a special focus on the Safer Births Bundle of Care project and its approach to maximizing impact despite limited resources.
Enjoy listening!
Episode transcript
Transcript
Anna: Hi everyone, and welcome back to SimScience Recap! I’m Anna, glad to have you with us for
Episode 3.
Adrian: Hey Anna! Hey, listeners!
Anna: Today we’re talking simulation-based education in low-resourced settings. What’s being done?
What’s working? And, um, most importantly, what’s actually saving lives?
Adrian: Yeah, that’s right, Anna. This is a big one. There’s been a growing body of research around
how simulation can be adapted and scaled in low- and middle-income countries.
Anna: Wow!
Adrian: And today, we’re digging into seven peer-reviewed studies, with a spotlight on a standout
one from Tanzania.
Anna: Tanzania? Okay! Let’s dive right in then. You mentioned Tanzania, what’s going on there?
Adrian: Right. So, the headline paper for this episode is by Kamala and Ersdal, published in the New
England Journal of Medicine in 2025.
Adrian: This was a massive stepped-wedge randomized trial, carried out over three years in 30
hospitals across five regions in Tanzania.
Adrian: They rolled out something called the Safer Births Bundle of Care, or SBBC. It’s uh, quite the
undertaking.
Anna: Okay, “bundle of care”… that sounds kinda broad, right? Um, what did it include?
Adrian: Great question. The bundle combined frequent in-situ simulation training, use of real-time
clinical data to guide training, innovative training tools like NeoNatalie Live and MamaNatalie,. And
also, it included some new clinical tools like a novel fetal heart rate monitor and newborn heart rate
monitor.
Adrian: For the simulation component of the bundle… you know… Facility champions were trained
to become simulation facilitators, through the SimBegin program. Then … they led the simulation-
training in the health facilities, while also receiving mentoring by trained regional and national
facilitators. So it was both education and systems-level improvement.
Anna: And what did they find? Was it effective?
Adrian: Yes-very much so. They followed over 281,000 mothers and nearly as many babies. Perinatal
deaths-that includes babies who died during labor or within 24 hours after birth-dropped from 15.3
to 12.5 per 1,000 births. That’s an 18% reduction, which is significant.
Adrian: And for the newborns, the early newborn mortality reduction was 40%.
Anna: That’s already impressive. But I think you mentioned something about maternal mortality too?
Adrian: Exactly. Maternal deaths due to postpartum hemorrhage were cut by 75%—that’s a
staggering number…. It shows how impactful especially the training were when it came to managing
bleeding after birth, which is a leading cause of maternal death globally.
Adrian: The healthcare workers at the hospitals gained confindence in decision making and the
needed skills to treat this life threatening condition. And it worked!
Anna: And just to be clear – these were simulation-based trainings?
Adrian: Yes, but not just “training” in the traditional workshop sense. This was facilitator-led scenario
training in the actual labor ward, with structured debriefs focused on reflection-based learning.
Adrian: These weren’t isolated sessions either – they were frequent, short, and tightly connected to
clinical data. Teams would look at their local stats and then practice the exact scenarios where gaps
were showing up.
Anna: So, it was responsive-learning from their own data?
Adrian: Exactly. And it built a learning system inside the hospitals. Local champions led most of the
sessions, and tools like NeoBeat and Moyo helped staff make clinical decisions in real time. It’s a
beautiful example of simulation being integrated into the day-to-day delivery of care.
Anna: That sounds like a really well-integrated model. But, um, what about the broader landscape?
Were other studies using simulation in similar ways?
Adrian: Yes – and I’ll walk you through six others that give us a good global picture.
Adrian: First up is Robinson et al., a systematic review of 97 studies using simulation in LMICs.
Anna: Ninety-seven. Wow!
Adrian: Yep. They found that most programs used low-tech mannequins, scenario-based training,
and synthetic part-task trainers. The majority focused on neonatal resuscitation and obstetric care.
Anna: So simulation is clearly a priority in those areas.
Adrian: Definitely. But Robinson also pointed out that reporting standards were lacking. It was hard
to compare studies or replicate them. They’re calling for global reporting frameworks specific to
simulation in LMICs.
Adrian: Next is Puri et al. A policy-level paper from the BMJ.
Anna: Uh huh.
Adrian: They looked at how simulation can improve patient safety and diagnostic accuracy in LMICs.
They emphasized simulation as a system-strengthening tool, not just an educational add-on.
Anna: Any real-world examples?
Adrian: Yes, they highlighted Helping Babies Breathe, PRONTO, and even telesimulation in
Botswana—training clinicians in real time over video. It’s a strong case for embedding simulation into
national health strategies.
Anna: Alright, so let’s talk about Walker et al..
Adrian: Ok.
Adrian: They ran a cluster-randomized trial in Kenya and Uganda, using a four-part intervention that
included simulation.
Anna: Oh.
Adrian: The main training element was PRONTO, which used, uh, low-tech birth simulators to train
teams in emergency response.
Anna: And outcomes?
Adrian: Well, they saw a 34% reduction in stillbirths and early neonatal deaths for preterm and low-
birthweight babies. Like SBBC, it paired simulation with mentoring and team communication skills.
Adrian: Then we have Vadla et al. From Haydom Lutheran Hospital who implemented the Golden
Minute Campaign in Tanzania, combining individual skill-training, scenario team trainings and data-
guided feedback.
Anna: Hmmm.
Adrian: They aimed to get bag-mask ventilation started within 60 seconds of birth-that’s the “Golden
Minute” for newborns who don’t breathe right away.
Anna: Did it work?
Adrian: It did-ventilation within 60 seconds went from 16% to 68%. But here’s the catch: those gains
faded when training stopped. The study makes a strong case for continuous, embedded simulation
instead of one-off sessions.
Adrian: There’s also a complementary paper-also by Kamala-looking at the Safer Births Bundle of
Care rollout process, you know the first paper we discussed. In one year, they recorded over 35,000
individual trainings and more than 260 team simulations across the 30 hospitals.
Anna: That’s a lot of training.
Adrian: It is-and the key was sustainability. Staff kept training even during high workloads, and
sessions were tailored to actual performance data. The study also highlights the power of a no-blame
learning culture in driving engagement.
Adrian: Mdoe et al. from 2023… uh, they explored how healthcare workers felt about SBBC. Across
149 interviews, participants said the bundle was relevant, empowering, and improved their ability to
respond in emergencies.
Anna: Was simulation part of that feedback?
Adrian: Absolutely. Staff appreciated regular, short scenario training, and especially the reflective
debriefs. They felt safer admitting mistakes, learning together, and improving practice based on real
cases. Actually, there is a very powerful quoate, uh.. from one of the midwives, you know. Maybe
you can read it Anna?
Anna: Sure Adrian. The midwife said, and I quote: “it was very scary, once you get say fresh stillbirth,
you rush to hide the case note where matron cannot see it, you think what I will say about it, I have
done wrong, what will happen to me and so on, so, it was very difficult times. But nowadays if you
get fresh stillbirth, you colleagues call you with love, please come let us sit down and discuss the
strength and the areas for improvement. We discuss . . . . identified gaps and make them our
objectives for training further that we aim at not repeating the same mistakes tomorrow”.
Adrian: Yeah right. So a shift from a blame and shame culture, to a safer learning culture, that is
amazing!
Anna: I agree. So, Adrian… across all these studies, simulation is more than just a teaching tool–it’s
part of the infrastructure for delivering better care.
Adrian: Exactly. When simulation is frequent, context-specific, and tied to clinical data, it becomes a
driver of systemic change. The Kamala and Ersdal paper is a shining example of that.
Anna: And a reminder that in simulation, sustainability and integration are just as important as
technology.
Adrian: Couldn’t have said it better.
Anna: That’s all for this episode of SimScience Recap. Thanks for joining us–and if you found this
useful, pass it on to a fellow simulation educator or researcher.
Adrian: Until next time–keep learning, keep simming, and keep pushing the boundaries of what’s
possible in global health education.
Anna: And for our listeners, before we go, a quick reminder: this podcast is the result of a
collaboration between human expertise and AI capabilities. While our team carefully selects topics,
reviews the literature, and ensures the quality of the content, AI helps synthesize insights, analyze
data, and structure the discussion into an engaging narrative. Together, we bring you the latest in
simulation research in an accessible and dynamic way.
Anna: Be sure to check out our website, SimZine… There you will find introduction, transcripts, and
links to all the articles we discussed. And don’t forget to subscribe to the SimScience Recap podcast
for more of these deep dives into the world of simulation!
References
1. Robinson SJA, Ritchie AMA, Pacilli M, Nestel D, McLeod E, Nataraja RM. Simulation-Based Education of Health Workers in Low- and Middle-Income Countries: A Systematic Review. Glob Health Sci Pract. 2024 Dec 20;12(6):e2400187.
2. Walker D, Otieno P, Butrick E, Namazzi G, Achola K, Merai R, et al. Effect of a quality improvement package for intrapartum and immediate newborn care on fresh stillbirth and neonatal mortality among preterm and low-birthweight babies in Kenya and Uganda: a cluster-randomised facility-based trial. The Lancet Global Health. 2020 Aug 1;8(8):e1061–70.
3. Kamala BA, Ersdal HL, Moshiro RD, Guga G, Dalen I, Kvaløy JT, et al. Outcomes of a Program to Reduce Birth-Related Mortality in Tanzania. New England Journal of Medicine [Internet]. [cited 2025 Mar 12];0(0). Available from: https://www.nejm.org/doi/full/10.1056/NEJMoa2406295
4. Vadla MS, Mduma ER, Kvaløy JT, Mdoe P, Hhoki BH, Sarangu S, et al. Increase in Newborns Ventilated Within the First Minute of Life and Reduced Mortality After Clinical Data-Guided Simulation Training. Simul Healthc. 2024 Oct;19(5):271–80.
5. Kamala BA, Moshiro R, Kalabamu FS, Kjetil T, Guga G, Githiri B, et al. Practice, Experiences, and Facilitators of Simulation-Based Training During One Year of Implementation in 30 Hospitals in Tanzania. SAGE Open Nurs. 2025 Jan 3;11:23779608241309447.
6. Mdoe P, Mduma E, Rivenes Lafontan S, Ersdal H, Massay C, Daudi V, et al. Healthcare Workers’ Perceptions on the “SaferBirths Bundle of Care”: A Qualitative Study. Healthcare (Basel). 2023 May 29;11(11):1589.
7. Puri L, Das J, Pai M, Agrawal P, Fitzgerald JE, Kelley E, et al. Enhancing quality of medical care in low income and middle income countries through simulation-based initiatives: Recommendations of the Simnovate Global Health Domain Group. BMJ Simulation and Technology Enhanced Learning. 2017 Mar 1;3:S15–22.
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