***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: INTRODUCTION Majority of studies on evaluation of emergency management courses have focused on outcomes such as knowledge and skills demonstrated in non- clinical or traditional testing manner . Such surrogate outcomes may not necessarily reflect vital changes in practice . The aim of this study was to determine if and to what extent , specific training in the management of life threatening emergencies result ed in an increased in compliance with established care guidelines of doctors working in the emergency departments of public sector hospitals in Pakistan . METHODS A cluster r and omised controlled trial was conducted in three districts hospitals in three cities ( Khairpur , Vehari and Peshawar ) of Pakistan . Thirty-six doctors , 18 in intervention ( trained in ESS-EMNCH training ) and 18 in control ( untrained ) , were enrolled and 248 life threatening emergency events , 124 in each group , were observed for the correct use of the Airway , Breathing , Circulation ( ABC ) structured approach . The outcome measure was structured approach defined a priori . Data was analysed by using STATA software . RESULTS At individual level , 79 ( 63.7 % ) life threatening episodes were managed according to the structured approach in the intervention group and 46 ( 37.1 % ) were managed according to the structured approach in controls ( OR 2.98 , 95%CI 1.78 - 4.99 , p-value=0.0001 ) . At cluster level , the mean percentage ( 95 % CI ) of the structured approach used by doctors in the intervention group [ 62.9 % ( 50.4 - 75.3 % ) ] , was significantly higher than those in the control group , [ 36.3 % ( 26.3 - 46.4 ) ] ( p-value=0.001 ) . CONCLUSIONS 5-day training of ESS-EMNCH significantly increased the compliance with established care guidelines of doctors during their management of life threatening emergency episodes in the public sector hospitals in Pakistan Background Maternal , perinatal and neonatal mortality remains high in low-income countries . We evaluated community and facility-based interventions to reduce deaths in three districts of Malawi . Methods We evaluated a rural participatory women ’s group community intervention ( CI ) and a quality improvement intervention at health centres ( FI ) via a two-by-two factorial cluster r and omized controlled trial . Consenting pregnant women were followed-up to 2 months after birth using key informants . Primary outcomes were maternal , perinatal and neonatal mortality . Clusters were health centre catchment areas assigned using stratified computer-generated r and omization . Following exclusions , including non-birthing facilities , 61 clusters were analysed : control ( 17 clusters , 4912 births ) , FI ( 15 , 5335 ) , CI ( 15 , 5080 ) and FI + CI ( 14 , 5249 ) . This trial was registered as International St and ard R and omised Controlled Trial [ IS RCT N18073903 ] . Outcomes for 14 576 and 20 576 births were recorded during baseline ( June 2007–September 2008 ) and intervention ( October 2008–December 2010 ) periods . Results For control , FI , CI and FI + CI clusters neonatal mortality rates were 34.0 , 28.3 , 29.9 and 27.0 neonatal deaths per 1000 live births and perinatal mortality rates were 56.2 , 55.1 , 48.0 and 48.4 per 1000 births , during the intervention period . Adjusting for clustering and stratification , the neonatal mortality rate was 22 % lower in FI + CI than control clusters ( OR = 0.78 , 95 % CI 0.60–1.01 ) , and the perinatal mortality rate was 16 % lower in CI clusters ( OR = 0.84 , 95 % CI 0.72–0.97 ) . We did not observe any intervention effects on maternal mortality . Conclusions Despite implementation problems , a combined community and facility approach using participatory women ’s groups and quality improvement at health centres reduced newborn mortality in rural Malawi Background Fetal and neonatal mortality rates in low-income countries are at least 10-fold greater than in high-income countries . These differences have been related to poor access to and poor quality of obstetric and neonatal care . Methods This trial tested the hypothesis that teams of health care providers , administrators and local residents can address the problem of limited access to quality obstetric and neonatal care and lead to a reduction in perinatal mortality in intervention compared to control locations . In seven geographic areas in five low-income and one middle-income country , most with high perinatal mortality rates and substantial numbers of home deliveries , we performed a cluster r and omized non-masked trial of a package of interventions that included community mobilization focusing on birth planning and hospital transport , community birth attendant training in problem recognition , and facility staff training in the management of obstetric and neonatal emergencies . The primary outcome was perinatal mortality at ≥28 weeks gestation or birth weight ≥1000 g. Results Despite extensive effort in all sites in each of the three intervention areas , no differences emerged in the primary or any secondary outcome between the intervention and control clusters . In both groups , the mean perinatal mortality was 40.1/1,000 births ( P = 0.9996 ) . Neither were there differences between the two groups in outcomes in the last six months of the project , in the year following intervention cessation , nor in the clusters that best implemented the intervention . Conclusions This cluster r and omized comprehensive , large-scale , multi-sector intervention did not result in detectable impact on the proposed outcomes . While this does not negate the importance of these interventions , we expect that achieving improvement in pregnancy outcomes in these setting s will require substantially more obstetric and neonatal care infrastructure than was available at the sites during this trial , and without them provider training and community mobilization will not be sufficient . Our results highlight the critical importance of evaluating outcomes in r and omized trials , as interventions that should be effective may not be . Trial registration Clinical Trials.gov Background Antenatal care provides an important opportunity to improve maternal underst and ing of care during and after pregnancy . Yet , studies suggest that communication is often insufficient . This research examined the effect of a job aids-focused intervention on quality of counseling and maternal underst and ing of care for mothers and newborns . Methods Counseling job aids were developed to support provider communication to pregnant women . Fourteen health facilities were r and omized to control or intervention , where providers were trained to use job aids and provided implementation support . Direct observation of antenatal counseling sessions and patient exit interviews were undertaken to assess quality of counseling and maternal knowledge . Providers were also interviewed regarding their perceptions of the tools . Data were collected before and after the job aids intervention and analyzed using a difference-in-differences analysis to quantify relative changes over time . Results Mean percent of recommended messages provided to  pregnant women significantly improved in the intervention arm as compared to the control arm in birth preparedness ( difference-in-differences [ ΔI-C ] = + 17.9 , 95%CI : 6.7,29.1 ) , danger sign recognition ( ΔI-C = + 26.0 , 95%CI : 14.6,37.4 ) , clean delivery ( ΔI-C = + 21.7 , 95%CI : 10.9,32.6 ) , and newborn care ( ΔI-C = + 26.2 , 95%CI : 13.5,38.9 ) . Significant gains were also observed in the mean percent of communication techniques applied ( ΔI-C = + 28.8 , 95%CI : 22.5,35.2 ) and duration ( minutes ) of antenatal consultations ( ΔI-C = + 5.9 , 95%CI : 3.0,8.8 ) . No relative increase was found for messages relating to general prenatal care ( ΔI-C = + 8.2 , 95%CI : -2.6,19.1 ) . The proportion of pregnant women with correct knowledge also significantly improved for birth preparedness ( ΔI-C = + 23.6 , 95%CI : 9.8,37.4 ) , danger sign recognition ( ΔI-C = + 28.7 , 95%CI : 14.2,43.2 ) , and clean delivery ( ΔI-C = + 31.1 , 95%CI : 19.4,42.9 ) . There were no significant changes in maternal knowledge of general prenatal ( ΔI-C = -6.4 , 95%CI : -21.3,8.5 ) or newborn care ( ΔI-C = + 12.7 , 95%CI : -6.1,31.5 ) . Job aids were positively perceived by providers and pregnant women , although time constraints remained for health workers with other clinical responsibilities . Conclusions This study demonstrates that a job aids-focused intervention can be integrated into routine antenatal care with positive outcomes on provider communication and maternal knowledge . Efforts are needed to address time constraints and other communication barriers , including introduction of on-going quality assessment for long-term sustainability BACKGROUND Maternal mortality is higher in west Africa than in most industrialised countries , so the development and validation of effective interventions is essential . We did a trial to assess the effect of a multifaceted intervention to promote maternity death review s and onsite training in emergency obstetric care in referral hospitals with high maternal mortality rates in Senegal and Mali . METHODS We did a pragmatic cluster-r and omised controlled trial , with hospitals as the units of r and omisation and patients as the unit of analysis . 46 public first-level and second-level referral hospitals with more than 800 deliveries a year were enrolled , stratified by country and hospital type , and r and omly assigned to either the intervention group ( n=23 ) or the control group with no external intervention ( n=23 ) . All women who delivered in each of the participating facilities during the baseline and post-intervention periods were included . The intervention , implemented over a period of 2 years at the hospital level , consisted of an initial interactive workshop and quarterly educational clinical ly-oriented and evidence -based outreach visits focused on maternal death review s and best practice s implementation . The primary outcome was reduction of risk of hospital-based mortality . Analysis was by intention-to-treat and relied on the generalised estimating equations extension of the logistic regression model to account for clustering of women within hospitals . This study is registered with Clinical Trials.gov , number IS RCT N46950658 . FINDINGS 191,167 patients who delivered in the participating hospitals were analysed ( 95,931 in the intervention groups and 95,236 in the control groups ) . Overall , mortality reduction in intervention hospitals was significantly higher than in control hospitals ( odds ratio [ OR ] 0·85 , 95 % CI 0·73 - 0·98 , p=0·0299 ) , but this effect was limited to capital and district hospitals , which mainly acted as first-level referral hospitals in this trial . There was no effect in second-level referral ( regional ) hospitals outside the capitals ( OR 1·02 , 95 % CI 0·79 - 1·31 , p=0·89 ) . No hospitals were lost to follow-up . Concrete actions were implemented comprehensively to improve quality of care in intervention hospitals . INTERPRETATION Regular visits by a trained external facilitator and onsite training can provide health-care professionals with the knowledge and confidence to make quality improvement suggestions during audit sessions . Maternal death review s , combined with best practice s implementation , are effective in reducing hospital-based mortality in first-level referral hospitals . Further studies are needed to determine whether the benefits of the intervention are generalisable to second-level referral hospitals . FUNDING Canadian Institutes of Health Research Objectives To determine the effect of  training residents in interpersonal and communication skills  on women ’s satisfaction with doctor – woman relationship in labour and delivery rooms . Design A stepped wedge cluster r and omised trial . Setting 4 tertiary care teaching maternity hospitals in Damascus , Syria . Participants 2000 women who gave birth to a living baby in the four study hospitals and consented to participate in the intervention took part in the study . Women with difficult labour and high-risk pregnancies were excluded . All were interviewed at home after discharge . Interventions A specially design ed training package in communication skills was delivered to all resident doctors at the four hospitals . Primary outcome measures The main outcome measure was women ’s satisfaction with interpersonal relationships in labour and delivery rooms measured via a series of questions on a Likert scale modified from the Medical Interview Satisfaction Scale . Results At the individual level , the mean for the average satisfaction score was 3.23 ( SD 0.72 ) of a possible score of 5 in the control group and 3.42 ( SD 0.73 ) in the intervention group . Using generalised linear mixed models , we were unable to detect a difference between the mean for the average satisfaction score of women in the intervention arm and that of women in the control arm ; the 95 % CI associated with the effect of the intervention ranged from –0.08 to 0.15 . Conclusions Despite slight changes in the observed residents ’ communication skills , the training package in communication skills does not seem to be associated with higher satisfaction scores of women . This raises the question of whether training individuals without further structural changes in the delivery of care and without further reinforcement of the training can have an impact on improving the quality of doctor – patient communication . Trial Registration Number IS RCT To report on the design and basic 
    Output:
    
Intervention effects were not consistent across studies .
Implementation strategies targeting health professionals could lead to improvement in obstetric care in LMICs .