Severe and acute maternal morbidity: Lithuanian experience and review.

OBJECTIVE: To measure the incidence of severe acute maternal morbidity (SAMM) and to find the risk factors that could be useful in trying to predict the development of SAMM. METHODS: The data were collected prospectively in 7 maternity units from different Lithuanian regions over a 1-year period. Every woman with a clinical diagnosis of severe preeclampsia, eclampsia, Hemolysis, Elevated Liver enzymes, and Low Platelet count (HELLP) syndrome, severe hemorrhage, uterine rupture, or severe sepsis during pregnancy or delivery or until the 42nd day post partum was included after verification of diagnosis by using clinical criteria. RESULT: One hundred and six cases of SAMM and one maternal death were identified during the study among 13,399 deliveries (7.91/1000 deliveries 95% CI 6.48-9.56). There were 57 cases of severe preeclampsia, 3 cases of eclampsia, 38 cases of severe hemorrhage, 3 cases of uterine rupture, and 4 cases of severe sepsis. One maternal death occurred due to HELLP syndrome, so the case-fatality ratio for severe morbidity was 0.99%. CONCLUSIONS: The incidence of SAMM and case-fatality rate in Lithuania are similar to those in other European countries. The main risk factors for SAMM were previous peripartum hemorrhage, previous hypertension, previous renal diseases, lack of antenatal care, and dystocia.

A fourfold difference in the incidence of type 1 diabetes between Sweden and Lithuania but similar prevalence of autoimmunity.

We investigated whether other autoimmune disorders in addition to type 1 diabetes are more common in Sweden than Lithuania, and if there are any differences in inheritance patterns of both type 1 diabetes and other autoimmune disorders. Data from 517 children in southeast Sweden and 286 children in Lithuania aged 0-15 years were included in the study. Age- and sex-matched control children were randomly selected. Information was collected by questionnaire. Of the children with diabetes in Sweden, 13.2% had a family member with type 1 diabetes compared to 7% of children with diabetes in Lithuania (P < 0.01) (OR = 2.01). No such difference was seen for other autoimmune diseases in family members of children with diabetes (Sweden 12%, Lithuania 14%, n.s.). Control children in Lithuania had family members with autoimmunity more frequently (15.3%) than control children in Sweden (7.4%, P < 0.001) (OR = 2.26). This difference was most pronounced in mothers. The Lithuanian control children had an autoimmune disease more frequently than the controls in Sweden (4.7% versus 1.5%, respectively, P < 0.001) (OR = 3.21). There seem to be environmental factors that specifically contribute to the development of type 1 diabetes, factors which are less related to the development of autoimmunity in general.

Severity at onset of childhood type 1 diabetes in countries with high and low incidence of the condition.

Severity of Type 1 diabetes mellitus (DM) at presentation was compared between south-east Sweden and Lithuania where incidence of childhood Type 1 diabetes is three times lower than in Sweden. New cases of diabetes at age 0-15 years from August 1995 to March 1999 in south-east Sweden and from August 1996 to August 2000 in Lithuania were included. Symptoms and clinical characteristics at diagnosis were recorded. Data about the close environment were collected using questionnaires. Lithuanian children were diagnosed in a more severe condition, mean pH 7.30 and HbA(1c) 11.5% compared with mean pH 7.36 and HbA(1c) 9.7% in Swedish children (P<0.0001). More Lithuanian than Swedish children were diagnosed in ketoacidosis (pH < or = 7.2, hyperglycaemia and ketonuria), 21.3 versus 7.3% (P<0.0001). Only 4.6% of Swedish children and 1.0% of Lithuanian children had no symptoms (P=0.007). Children in families with at least one first degree relative with diabetes (12.2% in Sweden and 8.4% in Lithuania, NS) had laboratory values at diagnosis closer to normal than sporadic cases in either country. Factors predicting ketoacidosis in Sweden were an unemployed mother and absence of infections in the 6 months before diagnosis. In Lithuania it was younger age and mother with less education. Additional educational activities for doctors are needed in countries with low incidence to reduce prevalence of ketoacidosis at onset.

Changes in women's health in the Baltic republics of Lithuania, Latvia and Estonia during 1970-1997.

The rapid political, economic and social changes occurring in the Baltic republics of Estonia, Latvia and Lithuania fundamentally affect female health. Demographic trends, morbidity and mortality indicators point to a general decline in the status of women's health in the three Baltic republics since their independence from the Soviet Union. The transition period from socialist to market economy has clearly taken a toll in women's health. These have to be taken into consideration by health authorities in Lithuania, Latvia, Estonia as well as the European Union during the undergoing reforms being planned for healthcare systems in all EU countries in accession.

Physician workforce reform in Lithuania: an inevitable transition.

The health system in Lithuania before independence was the same centralized system, the Semashko model that was prevalent throughout the former Soviet Union. The Soviet system focused more on quantity than quality, which resulted in a greater number of physicians per 100,000 than found in Western Europe. As in other Central and Eastern European countries, the health system in Lithuania has undergone substantial change since 1990. A major part of the reform of physician workforce in the former communist countries has been development of primary health care as a centerpiece of the health systems. This move in Lithuania has been hindered to some degree by the shortage of general or family practitioners. The focus on specialists in the old Soviet system led to a severe shortage of physicians in general practice. Only about 10% of physicians were general practitioners (GPs) in 1993 compared to a European Union average of 35%. That percentage had increased to 16% by 1998. Programs have been established to both train new GPs and to retrain specialists to become GPs, although a shortage of teachers and finances are problems facing these programs. Although the physician workforce in Lithuania has undergone substantial reform since 1990, real change has been slow. The physician to population ratio in Lithuania has failed to decline, moving from 387 per 100,000 population in 1991 to 398 in 1997, before dropping to 395 in 1998. The ratio remains substantially higher than current EU averages, reflecting a difficulty in reducing the number of physicians. Here we review what has happened to the physician workforce in Lithuania since independence and evaluate policies implemented. Efforts to reduce the number of physicians are also assessed. The results in Lithuania are compared to those in other CEE countries and to EU averages.

Meeting patient's expectations in primary care consultations in Lithuania.

OBJECTIVE: Patient satisfaction with health care services is considered an important factor of health care. Although research on patient satisfaction has become standard in Western Europe, in countries such as Lithuania the concept of patient satisfaction is still a relatively new one. This study aimed to investigate how the meeting of patients' expectations is related to increased satisfaction with medical consultation. STUDY DESIGN: The methodology used by Williams et al. in the UK was applied to the Lithuanian health care setting. Forty physicians from 22 primary health care centres attending courses on general practice at Vilnius University were recruited for the study. Every third adult patient coming to a practice during a 5-day period was invited to participate in the study. In all, 609 patients coming to meet their physician regarding health problems were included in the study sample. The patients were asked to complete three standardized questionnaires: the Patient Intentions Questionnaire prior to the consultation, and the Expectations Met Questionnaire and Medical Interview Satisfaction Scale after the consultation. Cronbach's alpha statistic was used for the validation of the questionnaires and principal components analysis was used to determine the factors of patient expectations. RESULTS: The response rate was 78%. ANALYSIS: of 460 sets of questionnaires revealed that satisfaction with medical consultation is higher among patients who have a greater number of expectations met. Physicians' success in meeting different types of patient expectations also had different influences on patient satisfaction. The most important expectations to be met were "understanding and explanation", followed by expectations of "emotional support", while "getting information" was less important. CONCLUSIONS: The most frequently reported expectations on the Patient Intentions Questionnaire were for "getting information" and "understanding and explanation" of the patients' health problem items, and the least mentioned were for emotional support items. Patients with more expectations met were found to have significantly higher scores on the satisfaction index. Satisfaction with the consultation is best predicted by meeting the patient's expectations for understanding and explanation, and for emotional support. Providing desired information to the patient as well as meeting the patient's expectations for diagnostic procedures and treatment is less associated with patient satisfaction.

Epidemiology of insulin-dependent diabetes mellitus around the Baltic Sea. The DIABALT Study Group.

Great spatial variation in the incidence of IDDM is found among countries around the Baltic Sea, a relative small area on the global scale. We present recent data on IDDM incidence from countries around the Baltic Sea, monthly variation and time trends in incidence from the early 1980s to the early 1990s. The change in IDDM incidence was calculated from logarithms of incidence using linear regression. The incidence was high in the countries to the north and west from the Baltic Sea, being the highest in Finland (35 per 100,000/year) followed by Sweden (26), Denmark (22) and Norway (21). In the countries on the eastern and southern coast of the Baltic Sea the incidence was markedly lower, in Estonia the incidence (10) was the highest within these countries, though slightly less than one third of that in Finland, while it was in Lithuania 7, Latvia 7 and Poland 6. There was an increasing trend in incidence of IDDM in Finland, Norway and Poland. In Sweden the incidence increased from 1978 to 1984, but since then the trend has been flat. In Estonia, Latvia and Lithuania, no significant change in incidence was seen. The reasons for large differences observed in the incidence of IDDM between countries around the Baltic Sea area are unknown, but a complex interaction between genetic and environmental risk factors that can vary in different ethnic, socio-economic and cultural settings play an important role in this variation.

Incidence trends in childhood onset IDDM in four countries around the Baltic sea during 1983-1992.

We present secular trends of childhood onset insulin-dependent diabetes mellitus (IDDM) in Finland, Estonia, Latvia and Lithuania during the period of 1983-1992. Incidence data were obtained from the national IDDM registries. The average age-standardized incidence per 100,000/year was 35.0 in Finland, followed by 10.2 in Estonia, 7.1 in Lithuania and 6.5 in Latvia. A male excess in incidence was recorded in Finland (1.15) and Latvia (1.01). In all countries, the highest age-specific risk of IDDM was observed in the 11-13 year age range. The large difference in incidence between Finland and other Baltic countries was see even in 1-2 year-old children. During the 10-year study period overall changes in incidence of IDDM were relatively small in these four countries. The incidence increased in Finland and Lithuania on average by 1% and 1.4% per year, respectively. A statistically significant increase was recorded only in 0-4 year old children in Finland, at 5.6% per year. In Estonia, an 8.3% increase in this age group, however, was not statistically significant. The different trends in the age-group specific incidence rates were confirmed in Finland. In conclusion, from 1983 to 1992 the incidence of childhood onset IDDM was increasingly in Finland and Lithuania, while in Latvia and Estonia it was stable. There are still great differences in IDDM incidence between the countries around the Baltic Sea.

Increasing incidence of childhood-onset type I diabetes in 3 Baltic countries and Finland 1983-1998.

AIMS/HYPOTHESIS: We aimed to study the incidence of Type I diabetes in 4 countries, Estonia, Latvia, Lithuania and Finland, during 1983-1998, focusing on the two separate periods of 1983-1990 and 1991-1998. METHODS: Population-based incidence data from nationwide diabetes registries were used. Crude and age-standardized incidence rates using the proportions of 39%, 32% and 29% for 5-year age groups (0-4, 5-9 and 10-14 years) were calculated. Yearly incidence was evaluated and the means between the two periods compared. RESULTS: Between 1983-1990 and 1991-1998 there was a statistically significant incidence increase in all 4 countries of Estonia, Lativia, Lithuania and Finland (relative risk 1.15, 95%-Confidence interval 1.10-1.19) and as well as in the 3 Baltic states of Estonia, Latvia, Lithuania (relative risk 1.13, 95%. Confidence interval 1.04-1.22). The crude incidence increased in Estonia from 10.1 (95%-Confidence interval 8.9-11.4) to 12.3 (11.0-13.8), in Latvia from 6.6 (5.8-7.3) to 7.4 (6.6-8.2) and in Lithuania from 6.8 (6.2-7.5) to 7.8 (7.1-8.5). In Finland the incidence rose from 34.6 (33.3-36.0) in 1983-1990 to 40.8 (39.4-42.2) in 1991-1998. In children under 5 years of a age a statistically important increase was seen in Estonia and Finland. The highest incidence for a single year was recorded for all participating countries in the late 1990 s. The highest annual incidence rate of childhood onset Type I diabetes in the world ever known was recorded in Finland in 1998 with 48.5 cases per 100 000 person-years. CONCLUSION/HYPOTHESIS: The incidence of Type I diabetes has increased since 1983 in the three Baltic states as well as in Finland. Long-term monitoring is needed for a better detection in changes in incidence.

Seasonal variation in the incidence of Type 1 diabetes mellitus during 1983 to 1992 in the countries around the Baltic Sea.

AIM: To examine seasonal patterns of incidence of Type 1 diabetes mellitus incidence in children aged 0-14 years in Finland, Sweden, Estonia, Latvia and Lithuania during 1983-1992 (1987-1992 for Finland). METHODS: The study used a method that models incidence data using combinations of sine waves to model seasonal variation around a possible linear trend. RESULTS: In Finland, a significant pattern was found for combined sexes and age groups 0-9 and 10-14 years. A significant pattern was also confirmed for 10-14 year-old boys. In Sweden, the best model with significant pattern was found separately for boys and girls and age groups 0-9 and 10-14 years, however, a significant pattern was confirmed for older girls only. A seasonal pattern in older boys in Finland and girls in Sweden was characterized by two cycles with decreased incidence in June and November-December. The pattern among younger children (0-9 or 5-9 years) had one cycle with a decreased incidence in May-June. In Estonia, a significant pattern was found for the age group 0-14 years and combined sexes. No significant seasonal patterns were found in Latvia and Lithuania. CONCLUSIONS: The seasonal pattern with two cycles among older children and one cycle only among younger children may indicate different triggers of Type 1 diabetes mellitus for different age groups.

Assessing future health workforce needs

The choice of a strategy to assess the future health workforce (HW) is value-based and depends on what health outcomes and service objectives policy-makers have set.Various models, approaches and toolkits have been proposed and tried over the years by international agencies, as well as by individual countries.Workforce situation analysis for determining future staff requirements typically builds upon variables such as expected population growth, technological and social change, skills mix, individual performance and health policy.There is little benefit in educating adequate numbers of doctors or nurses, and then seeing them migrate to other countries because the labour market cannot integrate them, or because working conditions are not attractive enough.Assessing future HW needs is not only about projecting the numbers. Policy-makers need also to address the issues of recruiting, educating, distributing, retaining, motivating and managing the HW, which implies improving the knowledge about the expectations and behaviours of health workers.Addressing needs implies more than producing more workers; scaling up can be achieved by improving competences, changing skills mix, and by augmenting productivity.It is important to see HW planning as a process that engages the main stakeholders in assessing needs for change and in devising strategies to achieve those changes.The better the information base and the technical capacity to use it, the better the diagnosis and the selection of interventions will be.Monitoring is essential to adjust interventions to a changing environment.Sufficient and predictable funding must be available to invest in workforce development. The benefits will soon be apparent in terms of better access to services, more efficient utilization of resources and higher satisfaction of citizens