title: Cluster randomised trial of an active, multifaceted educational intervention based on the WHO Reproductive Health Library to improve obstetric practices.
abstract: OBJECTIVE
  We conducted a trial to evaluate the effect of an active, multifaceted educational strategy to promote the use of the WHO Reproductive Health Library (RHL) on obstetric practices.
  
  
  METHODS
  Cluster randomised trial. The trial was assigned the International Standardised Randomised Controlled Trial Number ISRCTN14055385.
  
  
  METHODS
  Twenty-two hospitals in Mexico City and 18 in the Northeast region of Thailand.
  
  
  METHODS
  The intervention consisted primarily of three interactive workshops using RHL over a period of 6 months. The focus of the workshops was to provide access to knowledge and enable its use. A computer and support for using both the computer and RHL were provided at each hospital. The control hospitals did not receive any intervention.
  
  
  METHODS
  The main outcome measures were changes in ten selected clinical practices as recommended in RHL starting approximately four to six months after the third workshop. Clinical practice data were collected at each hospital from 1000 consecutively delivered women or for a 6-month period whichever was reached sooner.
  
  
  RESULTS
  The active, multifaceted educational intervention we employed did not affect the ten targeted practices in a consistent and substantive way. Iron/folate supplementation, uterotonic use after birth and breastfeeding on demand were already frequently practiced, and we were unable to measure external cephalic version. Of the remaining six practices, selective, as opposed to routine episiotomy policy increased in the intervention group (difference in adjusted mean rate = 5.3%; 95% CI -0.1 to 10.7%) in Thailand, and there was a trend towards an increased use of antibiotics at caesarean section in Mexico (difference in adjusted mean rate = 19.0%; 95% CI: -8.0 to 46.0%). There were no differences in the use of labour companionship, magnesium sulphate use for eclampsia, corticosteroids for women delivering before 34 weeks and vacuum extraction. RHL awareness (24.8-65.5% in Mexico and 33.9-83.3% in Thailand) and use (4.8-34.9% in Mexico and 15.5-76.4% in Thailand) increased substantially after the intervention in both countries.
  
  
  CONCLUSIONS
  The multifaceted, active strategy to provide health workers with the knowledge and skills to use RHL to improve their practice led to increased access to and use of RHL, however, no consistent or substantive changes in clinical practices were detected within 4-6 months after the third workshop.
authors.affiliation: UNDP/UNFPA/WHO/World Bank Special Programme on Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland. gulmezoglum@who.int
authors.forename: A M
authors.initials: AM
authors.lastname: Gülmezoglu
authors.forename: A
authors.initials: A
authors.lastname: Langer
authors.forename: G
authors.initials: G
authors.lastname: Piaggio
authors.forename: P
authors.initials: P
authors.lastname: Lumbiganon
authors.forename: J
authors.initials: J
authors.lastname: Villar
authors.forename: J
authors.initials: J
authors.lastname: Grimshaw
mesh_terms: D002983:Clinical Competence / Q000592:standards*; D016000:Cluster Analysis; D005260:Female; D006282:Health Personnel / Q000193:education*; D006801:Humans; D008800:Mexico; D009774:Obstetrics / Q000193:education*; D011247:Pregnancy; D011256:Pregnancy Outcome; D011295:Prenatal Care / Q000592:standards*; D018456:Reproductive Medicine; D013785:Thailand