> For the complete documentation index, see [llms.txt](https://research.ambitiousimpact.com/llms.txt). Markdown versions of documentation pages are available by appending `.md` to page URLs; this page is available as [Markdown](https://research.ambitiousimpact.com/bemonc/simulation-based-training-for-emergency-obstetric-and-newborn-care/2-theory-of-change.md). # 2 Theory of change *The theory of change (ToC) focuses on strengthening the capabilities of the health workforce in facilities through low-dose, high-frequency (LDHF) simulation-based training and the systems needed to support it, including monitoring and supply chain support.* ## 2.1 Barriers preventing high-quality BEmONC in LMICs **Many of the barriers to high-quality care are well understood and potentially addressable.** Experts and practitioners we spoke with described severely unprepared facilities, including a lack of knowledge about resuscitation and other essential practices and shortages of basic commodities needed to provide care. **Academic reviews identify several barriers to high-quality care** ([Bolan et al., 2021](https://doi.org/10.9745/GHSP-D-20-00362); [Filby et al., 2016](https://doi.org/10.1371/journal.pone.0153391); [Reddy et al., 2022](https://doi.org/10.1371/journal.pgph.0001134); [Vaughn et al., 2019](https://doi.org/10.1136/bmjqs-2017-007573)), including: * Organizational factors such as poor ownership, high turnover, and lack of leadership. * Minimal or nonexistent quality-improvement and monitoring systems. * Workforce challenges, including insufficient staffing, gaps in workforce quality, lack of professional identity, and lack of competency standards. ## 2.2 Proposed intervention and activities **This capacity-building organization will establish training and quality-improvement systems for SBAs in low-performing healthcare facilities, with the aim of improving the quality of care mothers and babies receive through better delivery of BEmONC signal** [**functions**](#user-content-fn-1)[^1]**.** **We expect the organization to deliver LDHF simulation-based training and ongoing clinical mentorship and supervision, alongside a small supply chain "readiness" package where needed to ensure that facilities have the key commodities required to deliver BEmONC signal functions.** The training model will rely on master trainers who train and support selected facility staff (in-facility champions) to lead regular simulation-based practice for SBAs. Table 2 provides further details on these components. **Table 2: Key components of this charity’s activities** | Key component | Details | | ------------------------------------- | -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | **Low-dose, high-frequency training** | “LDHF is a capacity-building approach that promotes maximal retention of clinical knowledge, skills, and attitudes through short, targeted in-service simulation-based learning activities, which are spaced over time and reinforced with structured, ongoing practice sessions on the jobsite.” [(Jhpiego, n.d.-b)](https://hms.jhpiego.org/wp-content/uploads/2016/08/LDHF_briefer.pdf) In practice, master trainers will support in-facility champions to run regular simulation-based training sessions for SBAs using simulation materials (e.g., [here](https://shop.laerdalglobalhealth.com/product/neonatalie/)) and monitor progress toward full BEmONC delivery. | | **Monitoring and supervision** | The organization will support facilities to track progress using BEmONC signal function indicators, likely through clinical observations and other monitoring approaches. [Established indicators and assessment tools already exist](https://emonc.org/en/). If monitoring identifies deviations from the standard of care or slow progress, the organization is likely to help facilities prioritize and implement corrective action. | | **Supply chain strengthening** |

The organization will monitor the availability of key commodities needed to deliver BEmONC signal functions. In some settings, it may also need to help ensure a reliable supply of these commodities. The commodities required to fulfill all BEmONC signal functions include:
• Oxytocin
• Tranexamic acid
• Calibrated drape or other tool to objectively measure postpartum blood loss
• Magnesium sulfate
• Complete MVA kit
• Misoprostol
• Long-sleeve gloves
• Vacuum extractor
• Ringer’s lactate
• Intravenous (IV) set
• 250–280 mL self-inflating bag for newborns
• Appropriate masks (no. 0 and 1)
• Radiant warmer with skin temperature setting range of 32°C–37°C
• First line parenteral antibiotic (ampicillin/amoxicillin + gentamicin), or according to country context, taking antimicrobial resistance pattern into account
• Kangaroo mother care (KMC) chair/bed
• Binder or equivalent
• Oxygen source (cylinder or concentrator; interfaces: newborn prongs or nasal mask)
• Pulse oximeter with neonatal probes

| ### Why high-frequency, hands-on simulation is needed **We think some medical skills require frequent, hands-on simulation to maintain proficiency.** Birth complications can be relatively rare, high-stress situations that require clinicians to act quickly and confidently. Newborn resuscitation illustrates this challenge: around one in ten term newborns need simple measures such as drying and stimulation to begin breathing, around one in twenty need additional support including assisted breathing, and a much smaller proportion require more intensive interventions, such as a breathing tube, chest compressions, or emergency medicines [(Dempsey et al., 2026)](https://doi.org/10.1002/14651858.CD009106.pub3). **Clinicians therefore cannot rely on opportunities to practice these skills while providing care.** Rapid intervention is critical, while the situations requiring more complex procedures, such as assisted breathing, can be relatively infrequent. **Repeated hands-on practice and feedback can help clinicians retain these skills and prevent skill decay.** Systematic reviews of similar training programs suggest that skills can deteriorate rapidly and that refresher training can reduce this decline ([Dempsey et al., 2026](https://doi.org/10.1002/14651858.CD009106.pub3); [Morris et al., 2020](https://doi.org/10.1542/peds.2019-3938)). While other training approaches may also be valuable, we think that resuscitation and other core BEmONC signal functions are less suited to approaches such as online-only training because they require clinicians to develop and maintain practical skills. ## 2.3 Key assumptions and uncertainties **Figure 3 presents the ToC for this charity.** For better readability, we recommend using the interactive version available [here](https://theoryofchangebuilder.com/chart/SPfR3ck9).
Figure 3: Theory of change for simulation-based BEmONC training

Figure 3: Theory of change for simulation-based BEmONC training

The assumptions in Table 3 correspond to the numbered steps in the ToC diagram. We indicate our current level of uncertainty and where each assumption is discussed in more detail. **Table 3: ToC assumptions** | No. | Assumption | Evidence/Explanation | | ----- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ | | | **Assumptions we are relatively confident in** | | | 1–6 |

The adapted curriculum is of sufficient quality and fidelity to drive genuine competency gains.

The charity has access to subject-matter experts and existing open-source materials.

The curriculum includes orientation for in-facility champions to ensure that ongoing facility-based practice is structured and sustained between master trainer visits.

|

BEmONC training curricula are well-documented by the World Health Organization (WHO), Jhpiego, and Laerdal Global Health.

Gomez et al. (2018) adapted a comprehensive BEmONC curriculum for Ghana covering labor management, PPH, eclampsia, newborn resuscitation, infection prevention, and KMC.

This intervention follows a set playbook established by the WHO and experts, and will rely on training regimens that have been developed and made openly available by other actors.

Multiple organizations (Jhpiego, Laerdal, PRONTO) have adapted and tested BEmONC curricula across SSA and South Asia.

| | 2–6 |

Selected countries and facilities are underserved by existing major actors.

Facility-level data is accurate enough to prioritize effectively.

Note: facility-level selection within countries requires additional ground-truthing.

| See [Additionality and geographic assessment](/bemonc/simulation-based-training-for-emergency-obstetric-and-newborn-care/5-neglectedness-and-geographic-assessment.md). | | 3–6 |

Charity-employed master trainers maintain fidelity to the LDHF model at least as well as government-selected trainers in the Gomez et al. (2018) study. There is a sufficient pool of qualified candidates (nurses, midwives, clinical officers) in target countries.

Note: we expect that fidelity monitoring becomes more resource-intensive at scale.

|

Gomez et al. (2018) used government-selected master trainers. The proposed charity-employed model trades higher cost for consistency of delivery by hiring its own trainers.

We are not concerned about talent constraints and expect the nonprofit to be able to hire trainers easily.

| | 5–9 |

Ongoing peer practice sessions sustain competency between master trainer visits.

In-facility champions are sufficiently motivated and supported to maintain their coordination role over 12 months.

| We think in-facility champions can be recruited, trained and motivated. Monitoring their performance may be challenging, however. | | 6–10 | LDHF can work for high-acuity, low-frequency BEmONC procedures. Training attendance and engagement rates are sufficient in the target implementation context. | See [Section 3](/bemonc/simulation-based-training-for-emergency-obstetric-and-newborn-care/3-evidence-review.md). | | 9–13 |

Ongoing support via master trainers and in-facility champions maintains sufficient motivation for providers to apply BEmONC skills in real deliveries.

Motivation sustained by ongoing support is durable enough to persist between master trainer revisit cycles (every 6–12 months).

|

Rowe et al.’s (2018) meta-analysis of clinical practice interventions found that training alone decays without ongoing support and monitoring as practitioners revert to standard practice and high turnover erodes institutional knowledge.

We think supportive supervision is tractable through phone calls and occasional visits, and is highly important for program success.

| | 10–14 | Competency gains from LDHF training in simulation are sufficient in magnitude and durability to change provider behavior in real clinical situations, not just in assessed simulation settings. | Key consideration for the ToC and its main mechanism. See [Evidence review](/bemonc/simulation-based-training-for-emergency-obstetric-and-newborn-care/3-evidence-review.md). | | 12–14 |

Feedback loops between monitoring and evaluation (M\&E) data and program/facility decisions are functional and timely.

Corrective action is triggered by process metrics (signal function rates).

|

Adaptive management based on M\&E is integral to the Kamala et al. (e.g., Kamala et al., 2025) Safer Births Bundle of Care (SBBC) model, which combined continuous quality improvement with simulation training and achieved substantial mortality reductions.

Signal function performance rates (e.g. BEmONC signal functions performed per complication) provide actionable process metrics that can drive corrective action faster than health outcome tracking.

| | 14–15 | Improved BEmONC practice at the facility level is sustained over time and reaches a sufficient number of births to generate population-level mortality reductions. | See [Evidence review](/bemonc/simulation-based-training-for-emergency-obstetric-and-newborn-care/3-evidence-review.md). | | | **Remaining uncertainties / Priority questions for prospective founders** | | | 4–7 |

Charity procurement can address the marginal gap in affected geographies.

Note: Commodity constraints vary substantially by geography. E.g., some contexts may have near-complete access to oxytocin and other essentials, while post-USAID-cut environments may face more acute shortages.

|

Expert views on the role of commodities are mixed, so we are uncertain about the need for this step in the ToC.

We think ensuring timely supply for a set of medicines and commodities could place a significant burden on the nonprofit’s resources and therefore presents a risk to the ToC.

| | 4–8 |

Commodity stock data collected during master trainer visits is accurate and triggers restocking or corrective action.

Master trainer capacity to monitor commodities during training visits does not crowd out time for clinical coaching.

|

We think it is feasible for master trainers to monitor commodity stocks during routine visits.

Signal function readiness assessment tools on the emonc.org platform include commodity availability as a tracked indicator alongside clinical practice.

Note: The LDHF programs we model this charity on did not provide or monitor medicines (2018). This is an additional intervention feature we are proposing.

| | 5–8 |

In-facility champions reliably collect signal function performance data alongside clinical duties.

M\&E challenges are operational—incentives, digitization, standardization—rather than methodological.

| We rate M\&E concerns as moderate for implementation (see [Key factors](/bemonc/simulation-based-training-for-emergency-obstetric-and-newborn-care/7-implementation.md)). Newborn death event rarity at facility level limits statistical power for outcome evaluation, so process indicators (signal function performance rates, commodity readiness scores) are the primary monitoring outputs. | | 7–11 | The organization can create or manage supply chains for key products successfully, if necessary. |

We expect this to be challenging and more expensive than in contexts where commodity support is not needed. However, we think it may end up being a necessary component of the intervention.

We have an overall view that the commodities involved are inexpensive and relatively straightforward to source and distribute. Based on our prior experience with other incubated organizations, we do not expect these challenges to be insurmountable.

| | 8–12 |

Feedback loops between M\&E data and program decisions are functional and timely.

Charity staff and facility management have the capacity and authority to act on findings.

| The Mwanza case in Kamala et al. [(e.g., Kamala et al., 2025)](https://doi.org/10.1056/NEJMoa2406295) illustrates that corrective action must be triggered quickly when monitoring detects poor implementation. We are somewhat concerned that feedback loops may not be sufficiently rapid—especially when relying on facility staff who are not directly employed by the charity. | | 11–14 | Facility readiness (commodities, equipment, adequate staffing ratios) is a meaningful constraint in target facilities that the program can address. |

Facility readiness surveys in LMICs document commodity stockouts and equipment gaps as barriers to BEmONC provision (Sayeed et al., 2026).

The relative magnitude of supply constraints versus skills gaps varies by context and requires assessment during geographic selection.

| | 13–14 |

Providers are intrinsically motivated by improved patient outcomes, or the program design (supportive supervision, recognition, structured mentorship) generates sufficient extrinsic motivation.

Motivation is sustained beyond the initial training period through ongoing master trainer engagement.

|

Motivation is the least-studied COM-B (capability, opportunity, motivation, behavior) component in the BEmONC literature and is identified by experts as a significant barrier.

Experts noted health workers are very overworked. They also identified teamwork and communication failures driven by hierarchy between doctors and midwives as an important barrier to good care.

These motivational and structural barriers are unlikely to be fully addressed by training and ongoing mentorship alone, especially at scale in diverse health system contexts.

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