Abstract

Sir,

We express our profound appreciation to the authors for reporting on the evaluation of the ALSO course in Kagera region, Northwestern Tanzania. That study evaluated the impact of the training on the major cause of direct maternal deaths. Oxytocin has been the uterotonic of choice in Tanzania but this has challenges in terms of storage which may limit its effectiveness, so the registration of misoprostol for the prevention and treatment of post-partum hemorrhage in Tanzania in September 2007 and this training of health care workers is welcomed.

Emergency Obstetric Care (EOC) training is the most frequent component of interventions (52–65% of the 54 interventions reviewed) that improved maternal health in low income countries in a recent systematic review, the other components were placement of providers, refurbishment of existing infrastructure and improved supply of drugs, supplies and equipment.

Most low resource countries have a high burden of maternal deaths and use in-service EOC training programs to improve the quality of skilled attendance at birth. Most of these programs are not reported or evaluated in detail and those evaluated have weak study designs. The direct obstetric case fatality rate can be used as a crude index of quality of EOC services after implementing interventions to improve EOC and skilled birth attendance. Such process indicators reflect impact on health care outcomes and are relatively cheap to collect. They also provide a wider range of assessment for the EOC training being evaluated. Including a control group through a cluster randomized approach will also strengthen the design but is likely to increase the costs associated with the study.

EOC training programs are usually funded by donor organizations in low resource countries and are usually not linked to any system of routine in-service training/updates. One contributing factor may be the cost associated with organizing training. The cost of the ALSO course taught by Tanzanian trainers was reported as $125, which may restrict its access by midwives and middle cadre health care workers. The use of evidence-based training methods of short duration linked to certification to practice midwifery which are partly funded by government and the health care provider will likely result in sustainable in-service EOC training programs in low resource settings.