Summary Background Maternal and neonatal mortality rates remain high in many low-income and middle-income countries. Different approaches for the improvement of birth outcomes have been used in ...community-based interventions, with heterogeneous effects on survival. We assessed the effects of women's groups practising participatory learning and action, compared with usual care, on birth outcomes in low-resource settings. Methods We did a systematic review and meta-analysis of randomised controlled trials undertaken in Bangladesh, India, Malawi, and Nepal in which the effects of women's groups practising participatory learning and action were assessed to identify population-level predictors of effect on maternal mortality, neonatal mortality, and stillbirths. We also reviewed the cost-effectiveness of the women's group intervention and estimated its potential effect at scale in Countdown countries. Findings Seven trials (119 428 births) met the inclusion criteria. Meta-analyses of all trials showed that exposure to women's groups was associated with a 23% non-significant reduction in maternal mortality (odds ratio 0·77, 95% CI 0·48–1·23), a 20% reduction in neonatal mortality (0·80, 0·67–0·96), and a 7% non-significant reduction in stillbirths (0·93, 0·82–1·05), with high heterogeneity for maternal ( I2 =64·0%, p=0·011) and neonatal results ( I2 =73·2%, p=0·001). In the meta-regression analyses, the proportion of pregnant women in groups was linearly associated with reduction in both maternal and neonatal mortality (p=0·019 and p=0·009, respectively). A subgroup analysis of the four studies in which at least 30% of pregnant women participated in groups showed a 49% reduction in maternal mortality (0·51, 0·29–0·89) and a 33% reduction in neonatal mortality (0·67, 0·60–0·75). The intervention was cost effective by WHO standards and could save an estimated 283 000 newborn infants and 36 600 mothers per year if implemented in rural areas of 74 Countdown countries. Interpretation With the participation of at least a third of pregnant women and adequate population coverage, women's groups practising participatory learning and action are a cost-effective strategy to improve maternal and neonatal survival in low-resource settings. Funding Wellcome Trust, Ammalife, and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Birmingham and the Black Country programme.
Summary Background Around 105 million people in India will be living in informal settlements by 2017. We investigated the effects of local resource centres delivering integrated activities to improve ...women's and children's health in urban informal settlements. Methods In a cluster-randomised controlled trial in 40 clusters, each containing around 600 households, 20 were randomly allocated to have a resource centre (intervention group) and 20 no centre (control group). Community organisers in the intervention centres addressed maternal and neonatal health, child health and nutrition, reproductive health, and prevention of violence against women and children through home visits, group meetings, day care, community events, service provision, and liaison. The primary endpoints were met need for family planning in women aged 15–49 years, proportion of children aged 12–23 months fully immunised, and proportion of children younger than 5 years with anthropometric wasting. Census interviews with women aged 15–49 years were done before and 2 years after the intervention was implemented. The primary intention-to-treat analysis compared cluster allocation groups after the intervention. We also analysed the per-protocol population (all women with data from both censuses) and assessed cluster-level changes. This study is registered with ISRCTN, number ISRCTN56183183, and Clinical Trials Registry of India, number CTRI/2012/09/003004. Findings 12 614 households were allocated to the intervention and 12 239 to control. Postintervention data were available for 8271 women and 5371 children younger than 5 years in the intervention group, and 7965 women and 5180 children in the control group. Met need for family planning was greater in the intervention clusters than in the control clusters (odds ratio OR 1·31, 95% CI 1·11–1·53). The proportions of fully immunised children were similar in the intervention and control groups in the intention-to-treat analysis (OR 1·30, 95% CI 0·84–2·01), but were greater in the intervention group when assessed per protocol (1·73, 1·05–2·86). Childhood wasting did not differ between groups (OR 0·92, 95% CI 0·75–1·12), although improvement was seen at the cluster level in the intervention group (p=0·020). Interpretation This community resource model seems feasible and replicable and may be protocolised for expansion. Funding Wellcome Trust, CRY, Cipla.
Context Children with severe combined immunodeficiency who receive a T cell-depleted hematopoietic stem cell transplantation (HSCT) have delayed immune reconstitution. Objective To examine the use of ...recombinant human insulin-like growth factor-I (rhIGF-I) therapy to stimulate thymopoiesis after HSCT. Clinical case A child with Omenn syndrome failed T cell reconstitution 6 months after HSCT. She started rhIGF-I therapy just before age 18 months. The initial dose (40 μg/kg twice daily) was increased every 2 weeks to a maximum dose of 120 μg/kg twice daily. Results The patient's absolute T cells increased from 7 to 132/mm³ and 662/mm³ after 3 and 5 months of rhIGF-I therapy, respectively, and her blastogenic response to phytohemagglutinin normalized. Three months after discontinuation of rhIGF-I therapy, the T cells continued to increase (to 2,427/mm³) although the blastogenic response to phytohemagglutinin decreased. Conclusion This is the first known use of rhIGF-I therapy to help restore thymopoiesis in a child.
Science of Health Care Delivery Starr, Stephanie R.; Agrwal, Neera; Bryan, Michael J. ...
Mayo Clinic proceedings. Innovations, quality & outcomes,
September 2017, 2017-09-00, 2017-09-01, Letnik:
1, Številka:
2
Journal Article
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The purpose of this special article is to describe a new, 4-year Science of Health Care Delivery curriculum at Mayo Clinic School of Medicine, including curricular content and structure, methods for ...instruction, partnership with Arizona State University, and implementation challenges. This curriculum is intended to ensure that graduating medical students enter residency prepared to train and eventually practice within person-centered, community- and population-oriented, science-driven, collaborative care teams delivering high-value care. A Science of Health Care Delivery curriculum in undergraduate medical education is necessary to successfully prepare physicians so as to ensure the best clinical outcomes and patient experience of care, at the lowest cost.
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