Maternal near-miss and mortality in Sayaboury Province, Lao PDR.

BACKGROUND: Maternal near-miss (MNM) incidence is the indicator reflecting maternal healthcare services. This study aimed to determine the burden of maternal near-miss and maternal deaths in Sayaboury Province, Lao PDR. METHODS: A descriptive study was done in a cohort of 1215 pregnant women, who had their last normal menstrual period (LMP) between 1 August and 31 December, 2010. WHO criteria for MNM were used to identify near-miss cases and maternal deaths during February-November 2011. Data of maternal characteristics, MNM, and maternal deaths were prospectively collected by primary health care workers in the villages under supervision of health staff in local health centers and by the head nurses of the gynecology-obstetric wards in the studied hospitals. Frequencies with 95% confidence intervals (CIs) were used to describe maternal near-misses and maternal deaths. RESULTS: Overall, 92.5% of the 1215 pregnancies were delivered, 7.5% were aborted. Eleven women were identified as near-miss cases, giving a maternal near miss (MNM) ratio of 9.8 (95% CI: 4.9-17.5)/1,000 live births. With two maternal deaths, the maternal mortality ratio (MMR) was 178 (95% CI: 50-650)/100,000 live births. Together, these constituted 13 cases of severe maternal outcome (SMO) and given the SMO ratio of 11.6 (95% CI: 6.2-19.8)/1,000 live births. CONCLUSION: The study shows a surprisingly low MNM ratio and MMR in Sayaboury Province, Lao PDR. Generalization of the results is limited by problems in applying standard criteria for the identification of near-misses in the communities and local hospitals. However, the findings are considered to have important implications for the improvement of maternal health services in low resource settings, e.g. to obtain valid and reliable maternal near miss and maternal deaths for the whole country.

Effectiveness of a clinically integrated e-learning course in evidence-based medicine for reproductive health training: a randomized trial.

CONTEXT: For evidence-based practice to embed culturally in the workplace, teaching of evidence-based medicine (EBM) should be clinically integrated. In low-middle-income countries (LMICs) there is a scarcity of EBM-trained clinical tutors, lack of protected time for teaching EBM, and poor access to relevant databases in languages other than English. OBJECTIVE: To evaluate the effects of a clinically integrated e-learning EBM course incorporating the World Health Organization (WHO) Reproductive Health Library (RHL) on knowledge, skills, and educational environment compared with traditional EBM teaching. DESIGN, SETTING, AND PARTICIPANTS: International cluster randomized trial conducted between April 2009 and November 2010 among postgraduate trainees in obstetrics-gynecology in 7 LMICs (Argentina, Brazil, Democratic Republic of the Congo, India, Philippines, South Africa, Thailand). Each training unit was randomized to an experimental clinically integrated course consisting of e-modules using the RHL for learning activities and trainee assessments (31 clusters, 123 participants) or to a control self-directed EBM course incorporating the RHL (29 clusters, 81 participants). A facilitator with EBM teaching experience was available at all teaching units. Courses were administered for 8 weeks, with assessments at baseline and 4 weeks after course completion. The study was completed in 24 experimental clusters (98 participants) and 22 control clusters (68 participants). MAIN OUTCOME MEASURES: Primary outcomes were change in EBM knowledge (score range, 0-62) and skills (score range, 0-14). Secondary outcome was educational environment (5-point Likert scale anchored between 1 [strongly agree] and 5 [strongly disagree]). RESULTS: At baseline, the study groups were similar in age, year of training, and EBM-related attitudes and knowledge. After the trial, the experimental group had higher mean scores in knowledge (38.1 [95% CI, 36.7 to 39.4] in the control group vs 43.1 [95% CI, 42.0 to 44.1] in the experimental group; adjusted difference, 4.9 [95% CI, 2.9 to 6.8]; P < .001) and skills (8.3 [95% CI, 7.9 to 8.7] vs 9.1 [95% CI, 8.7 to 9.4]; adjusted difference, 0.7 [95% CI, 0.1 to 1.3]; P = .02). Although there was no difference in improvement for the overall score for educational environment (6.0 [95% CI, -0.1 to 12.0] vs 13.6 [95% CI, 8.0 to 19.2]; adjusted difference, 9.6 [95% CI, -6.8 to 26.1]; P = .25), there was an associated mean improvement in the domains of general relationships and support (-0.5 [95% CI, -1.5 to 0.4] vs 0.3 [95% CI, -0.6 to 1.1]; adjusted difference, 2.3 [95% CI, 0.2 to 4.3]; P = .03) and EBM application opportunities (0.5 [95% CI, -0.7 to 1.8] vs 2.9 [95%, CI, 1.8 to 4.1]; adjusted difference, 3.3 [95% CI, 0.1 to 6.5]; P = .04). CONCLUSION: In a group of LMICs, a clinically integrated e-learning EBM curriculum in reproductive health compared with a self-directed EBM course resulted in higher knowledge and skill scores and improved educational environment. TRIAL REGISTRATION: anzctr.org.au Identifier: ACTRN12609000198224.