Gestational diabetes mellitus prevalence in Maela refugee camp on the Thai–Myanmar Border: a clinical report

Background: Individuals in conflict-affected areas rarely get appropriate care for chronic or non-infectious diseases. The prevalence of gestational diabetes mellitus (GDM) is increasing worldwide, and new evidence shows conclusively that the negative effects of hyperglycemia occur even at mild glucose elevations and that these negative effects can be attenuated by treatment. Scientific literature on gestational diabetes in refugee camp settings is critically limited. Methods: A 75 g 2-hour glucose tolerance test was administered to 228 women attending the antenatal care (ANC) clinic in Maela refugee camp on the Thai–Myanmar border. Prevalence of GDM was determined using the HAPO trial cut-offs [≥92 mg/dL (fasting),≥180 (1 hour), and≥153 (2 hour)] and the WHO criteria [≥126 mg/dL (fasting), and 140 mg/dL (2 hour)]. Results: From July 2011 to March 2012, the prevalence of GDM was 10.1% [95% confidence interval (CI): 6.2–14.0] when the cut-off determined by the HAPO trial was applied. Applying the older WHO criteria yielded a prevalence of 6.6% (95% CI 3.3–9.8). Age, parity, and BMI emerged as characteristics that may be significantly associated with GDM in this population. Other risk factors that are commonly used in screening guidelines were not applicable in this diabetes-naïve population. Discussion: The prevalence of GDM is lower in this population compared with other populations, but still complicates 10% of pregnancies. New evidence regarding gestational diabetes raises new dilemmas for healthcare providers in resource-poor settings. Efforts to identify and treat patients at risk for adverse outcomes need to be balanced with awareness of the risks and burdens associated with over diagnosis and unnecessary interventions. Screening approaches based on risk factors or using higher cut-off values may help minimize this burden and identify those most likely to benefit from intervention

Conflict, Inclusivity, and Transformation of the Rice Value Chain in Myanmar

In numerous low- and middle-income countries, agricultural value chains (AVC) are undergoing rapid transformation, yet scant evidence exists regarding such changes in fragile and conflict- affected settings, and little is known about inclusivity in this transformation. This study focuses on changes in Myanmar's rice value chain - using unique large-scale primary data - from 2013 to 2022, during an economic boom and subsequent political upheaval and conflict. We document remarkable shifts, including a fourfold increase in rice exports, propelling Myanmar to the world's fifth-largest rice exporter. Concurrently, domestic market conditions improved, and there was modernization in the ‘hidden middle’ of the value chain including increased investments in modern milling equipment and drying methods. At the farm level we note greater adoption of modern inputs (e.g., improved seed) and harvest/post-harvest technologies and increased reliance on modern specialized service providers. The transformation was not everywhere inclusive, and modernization in some areas decelerated due to conflict. Mills and farms in insecure and conflict-affected areas, as well as remote millers and smallholders, participated to a lesser extent, and the gaps widened during the crisis years. The rapid modernization in Myanmar’s rice value chain from 2013 to 2019 highlights the positive impacts of stable governance, infrastructure investment, and liberalization on AVC transformation while the observed variations in modernization inclusivity across different segments of the value chain underscore the complex interplay between governance, conflict, and AVC transformation

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

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

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