Background: The Helping Babies Breathe (HBB) program teaches basic newborn resuscitation techniques to birth attendants in low-resource settings. Previous studies have demonstrated a decrease in mortality following training, mostly in large hospitals. However, low-volume clinics in rural regions with no physician immediately available likely experience a greater relative burden of newborn mortality. This study aimed to determine the impact of HBB trainings provided to rural Ghanaian midwives on their skills retention and on first 24 hour mortality of the newborns they serve. Methods: American Acadamy of Paediatrics (AAP)-trained Master Trainers conducted two 2-day HBB trainings and 2-day refresher courses one year later for 48 midwives from Ghanaian rural health clinics. Trainee skills were evaluated by Objective Structured Clinical Examination (OSCE) at three time points: immediately after training, four months after training, and four months after the refresher. Midwives recorded the single highest level of resuscitation performed on each newborn delivered for one year. Results: 48 midwives attended the two trainings, 32 recorded data from 2,383 deliveries, and 13 completed OSCE simulations at all three time points. The midwives’ OSCE scores decreased from immediately after training (94.9%) to four months later (81.2%, p < 0.00001). However, four months following the refresher course, scores improved to the same high level attained initially (92.7%, p = 0.0013). 5.0% of neonates required bag-mask ventilation and 0.71% did not survive, compared with a nationwide first 24 hour mortality estimate of 1.7%. Conclusions: The midwives’ performance on the simulation exercise indicates that an in-depth refresher course provided one year after the initial training likely slows the decay in skills that occurs after initial training. Our finding that 5.0% of newborns required bag-mask ventilation is consistent with global estimates. Our observed first 24 hour mortality rate of 0.71% is lower than nationwide estimates, indicating the training likely prevented deaths due to birth asphyxia.
Introduction: Despite significant demand and evidence indicating cost-effectiveness, surgical care is neglected in low- and middle-income countries (LMIC). Research indicates complex charitable surgical interventions are more effective in specialty hospitals than in short-term mission trips. This study aims to determine the effectiveness, cost-effectiveness, and economic impact of a multi-specialty charitable ambulatory surgical center in a LMIC. Materials and methods: Surgeries performed at an ambulatory surgery center (ASC) in rural Honduras in six specialties were evaluated for a one-year period for complications, infections, and patient satisfaction. Each patient's decrease in disability was determined by the World Health Organization Disability Assessment Schedule (WHODAS 2.0), and these data were used to estimate the cost per Disability Adjusted Life Year (DALY) averted. Economic benefit was calculated by the human capital approach and the value of a statistical life (VSL) approach. Results: Of the 963 surgeries performed, four patients (0.4%) experienced surgical site infections and 16 (1.6%) experienced complications, comparable to rates at ASCs in high-income countries. Cost per DALY averted was $638.08. The economic benefit was $17.9 million using the human capital approach and $328.4 million using the VSL approach. Conclusions: Our findings suggest a multi-specialty charitable surgical center in a low-middle income country can achieve similar outcomes to surgery centers in high-income countries. The operations were slightly less cost-effective than many short-term surgical missions, likely due to the investment in equipment and local labor which leads to the more favorable outcomes. This model of charitable surgical care provides a substantial benefit to the population. Highlights:
Williams syndrome, a disorder caused by a genetic deletion and characterized by moderate intellectual disability with relatively strong language skills and a hypersocial personality, was first described in the medical literature in 1961. However, 120 years earlier, Charles Dickens wrote the novel Barnaby Rudge, which follows an "idiot" through London's Gordon Riots of 1780. We propose that Dickens based this character on a person he knew with Williams syndrome. Common features include an "elfin" face, decreased cognitive ability and dependence on a caretaker, strong language skills with emphatic and perseverative speech, anxiety, and an empathetic, overly trusting personality. In the novel, these traits lead the character Barnaby to be duped into actively participating in the riots, which nearly results in his hanging. This example of fiction providing a description of a disorder more detailed than that of medical journals more than a century later should encourage physicians to look to sources beyond traditional scientific articles for valuable clinical information.
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