Identifying practices and ideas to improve the implementation of maternal mortality reduction programmes: findings from five South Asian countries.

OBJECTIVE: The successful implementation of programmes to reduce maternal mortality is constrained by a 'know-do' gap: the disparity between what is known and the application of that knowledge in policy and practice. This study identified innovations, practices and ideas aimed to improve project and programme implementation. DESIGN: Cross-sectional. SETTING: Five South Asian countries: Afghanistan, Bangladesh, India, Nepal and Pakistan. SAMPLE: Sixteen projects and programmes, and 100 key informants. METHODS: In-depth review of documents, key informant interviews and focus-group discussions. MAIN OUTCOME MEASURES: Innovations and ideas to improve programme implementation, and their perceived effects. RESULTS: Delegation of duties to intermediate-level health workers, incentivisation of health workers, providing the means to overcome financial barriers for accessing care, quality improvements and knowledge transfer were examples of ideas put into practice to improve programme implementation. There was a perception that these improved service use and availability, but objective evidence was lacking. CONCLUSIONS: Some innovations, practices and ideas are supported by evidence of effect, and could be replicated, whereas others have not been formally evaluated. Testing of these innovations is required before more widespread adoption can be recommended, although experiences should be shared to narrow the 'know-do' gap, even though the evidence on beneficial effects remains unclear.

Radiological findings when very small lung volumes are irradiated in breast and chest wall treatment.

Acute pneumonitis following breast irradiation is a rare and transient phenomenon that can be easily managed by drugs. The aim of this study is to evaluate late sequelae on lung, after postoperative radiotherapy (RT) for breast cancer. We were concerned with investigating late radiological findings when very small lung volumes are involved in the irradiated volume. We studied 28 consecutive patients. They underwent clinical examination and all staging procedures before surgery, evaluation of pulmonary function with spirometry, postoperative chest x-ray and high resolution computed tomography (HRCT) of the lung before RT. Clinical examinations were usually performed every 3 months after RT. A second chest x-ray, HRCT and spirometry were carried out after nearly 7 months from the end of RT. We estimated the irradiated lung volume by measuring the area of the lung surface enclosed by the 50% isodose (LA50) in each profile. We found a significant correlation between LA50 and the score of radiological findings after RT. No correlations were found between other factors (i.e., adjuvant chemotherapy, age, weight, smoking) and lung fibrosis. No woman developed radiation pneumonitis syndrome or respiratory symptoms. Our results indicate that irradiation of the breast and/or chest wall is well tolerated if treatment planning is done accurately. The fibrosis likelihood is strongly correlated to the irradiated lung volume. The use of tangential fields limits radiological changes that can be detected only by HRCT examination and are not associated with clinical symptoms.