Reasons for SBA graduate attrition from the workforce (2009–2016).

<p>Reasons for SBA graduate attrition from the workforce (2009–2016).</p

Median (minimum^* and maximum) number of clinical skills achieved per group in graduating students.

<p>Median (minimum^{<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0164363#t005fn002" target="_blank">*</a>} and maximum) number of clinical skills achieved per group in graduating students.</p

Accelerated Training of Skilled Birth Attendants in a Marginalized Population on the Thai-Myanmar Border: A Multiple Methods Program Evaluation

<div><p>Background</p><p>To evaluate a skilled birth attendant (SBA) training program in a neglected population on the Thai-Myanmar border, we used multiple methods to show that refugee and migrant health workers can be given effective training in their own environment to become SBAs and teachers of SBAs. The loss of SBAs through resettlement to third countries necessitated urgent training of available workers to meet local needs.</p><p>Methods and Findings</p><p>All results were obtained from student records of theory grades and clinical log books. Qualitative evaluation of both the SBA and teacher programs was obtained using semi-structured interviews with supervisors and teachers. We also reviewed perinatal indicators over an eight-year period, starting prior to the first training program until after the graduation of the fourth cohort of SBAs.</p><p>Results</p><p>Four SBA training programs scheduled between 2009 and 2015 resulted in 79/88 (90%) of students successfully completing a training program of 250 theory hours and 625 supervised clinical hours. All 79 students were able to: achieve pass grades on theory examination (median 80%, range [70–89]); obtain the required clinical experience within twelve months; achieve clinical competence to provide safe care during childbirth. In 2010–2011, five experienced SBAs completed a train-the-trainer (TOT) program and went on to facilitate further training programs. Perinatal indicators within Shoklo Malaria Research Unit (SMRU), such as place of birth, maternal and newborn outcomes, showed no significant differences before and after introduction of training or following graduate deployment in the local maternity units. Confidence, competence and teamwork emerged from qualitative evaluation by senior SBAs working with and supervising students in the clinics.</p><p>Conclusions</p><p>We demonstrate that in resource-limited settings or in marginalized populations, it is possible to accelerate training of skilled birth attendants to provide safe maternity care. Education needs to be tailored to local needs to ensure evidence-based care of women and their families.</p></div

Demographic characteristics of SBA students who completed training at SMRU 2009–15.

<p>Demographic characteristics of SBA students who completed training at SMRU 2009–15.</p

Perinatal indicators before (2008) and after introduction of SBA training programs (2009–2015).

<p>Perinatal indicators before (2008) and after introduction of SBA training programs (2009–2015).</p

The proportion of graduates attaining more senior SBA positions in total and at SMRU.

<p>The proportion of graduates attaining more senior SBA positions in total and at SMRU.</p

Single Low Dose Primaquine (0.25mg/kg) Does Not Cause Clinically Significant Haemolysis in G6PD Deficient Subjects

<div><p>Background</p><p>Primaquine is the only drug consistently effective against mature gametocytes of <i>Plasmodium falciparum</i>. The transmission blocking dose of primaquine previously recommended was 0.75mg/kg (adult dose 45mg) but its deployment was limited because of concerns over haemolytic effects in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. G6PD deficiency is an inherited X-linked enzymatic defect that affects an estimated 400 million people around the world with high frequencies (15–20%) in populations living in malarious areas. To reduce transmission in low transmission settings and facilitate elimination of <i>P</i>. <i>falciparum</i>, the World Health Organization now recommends adding a single dose of 0.25mg/kg (adult dose 15mg) to Artemisinin-based Combination Therapies (ACTs) without G6PD testing. Direct evidence of the safety of this low dose is lacking. Adverse events and haemoglobin variations after this treatment were assessed in both G6PD normal and deficient subjects in the context of targeted malaria elimination in a malaria endemic area on the North-Western Myanmar-Thailand border where prevalence of G6PD deficiency (Mahidol variant) approximates 15%.</p><p>Methods and Findings</p><p>The tolerability and safety of primaquine (single dose 0.25 mg base/kg) combined with dihydroartemisinin-piperaquine (DHA-PPQ) given three times at monthly intervals was assessed in 819 subjects. Haemoglobin concentrations were estimated over the six months preceding the ACT + primaquine rounds of mass drug administration. G6PD deficiency was assessed with a phenotypic test and genotyping was performed in male subjects with deficient phenotypes and in all females. Fractional haemoglobin changes in relation to G6PD phenotype and genotype and primaquine round were assessed using linear mixed-effects models. No adverse events related to primaquine were reported during the trial. Mean fractional haemoglobin changes after each primaquine treatment in G6PD deficient subjects (-5.0%, -4.2% and -4.7%) were greater than in G6PD normal subjects (0.3%, -0.8 and -1.7%) but were clinically insignificant. Fractional drops in haemoglobin concentration larger than 25% following single dose primaquine were observed in 1.8% of the population but were asymptomatic.</p><p>Conclusions</p><p>The single low dose (0.25mg/kg) of primaquine is clinically well tolerated and can be used safely without prior G6PD testing in populations with high prevalence of G6PD deficiency. The present evidence supports a broader use of low dose primaquine without G6PD testing for the treatment and elimination of falciparum malaria.</p><p>Trial Registration</p><p>ClinicalTrials.gov <a href="https://www.clinicaltrials.gov/ct2/show/NCT01872702?term=NCT01872702&rank=1" target="_blank">NCT01872702</a></p></div

Demographic and haematologic parameters of subjects who experienced large haemoglobin drops (>25%) or fall below 7g/dL after primaquine dose.

<p>Demographic and haematologic parameters of subjects who experienced large haemoglobin drops (>25%) or fall below 7g/dL after primaquine dose.</p

Spectrophotometric enzymatic activity (IU/gHb) in G6PD hemizygous, homozygous and heterozygous subjects.

<p>Spectrophotometric enzymatic activity (IU/gHb) in G6PD hemizygous, homozygous and heterozygous subjects.</p

Analyses by linear mixed-effects modelling of mean fractional changes in haemoglobin by G6PD phenotype.

<p>Analyses by linear mixed-effects modelling of mean fractional changes in haemoglobin by G6PD phenotype.</p