Background: Clinical officers perform much of major emergency surgery in Malawi, in the absence of medical officers. The aim of this study was to validate the advantages and disadvantages of delegation of major obstetric surgery to non-doctors.

Objective  Nonphysicians in Mozambique have been performing major surgery for more than 20 years, with documented outcomes equivalent to those of specialists. The purpose of this study was to make an inventory of all government hospitals so as to document obstetric surgery performed by ‘técnicos de cirurgia’ (TCs) and to elucidate their retention at district level. Design  Cross‐sectional study of surgical procedures during 2002; longitudinal study of TCs and doctors graduating in 1987, 1988 and 1996. Setting  All 34 hospitals with an operating theatre in Mozambique. Population  Records of 12 178 major surgical obstetric operations were examined, and 59 medical officers and 34 TCs were interviewed. Methods  Analysis of all surgical registers during 2002 in all government rural, provincial, general and central hospitals in Mozambique. TCs and doctors who had graduated in the specified years were traced and interviewed; health ministry records were reviewed to confirm assignments. Main outcome measures  Proportion of major obstetric surgeries performed by TCs. Proportion of TCs and medical doctors still at rural/district level at 7 years after graduation. Results  Major obstetric surgery is conducted by nonphysicians in 57% of the 12 178 operations scrutinised. In district hospitals, they conducted 92% of 3246 operations. Retention of TCs and medical doctors at district hospital level differed markedly: after 7 years, 88% of the TCs remained in post compared with none of the medical doctors. Conclusion  Nonphysicians, trained in surgery, do most of the emergency obstetric surgery in Mozambique, and almost all of that performed in district hospitals. Nonphysicians, compared with physicians, stay longer in rural areas. After 7 years, around 90% of nonphysicians are still working in district hospitals, while almost no physicians remain there.

Objective To compare the training and deployment costs and surgical productivity of surgically trained assistant medical officers (te´cnicos de cirurgia) and specialist physicians (surgeons and obstetrician/gynaecologists) in Mozambique in order to inform health human resource planning in a developing country with low availability of obstetric care and severe physician shortages. Te´cnicos de cirurgia have been previously shown to have quality of care outcomes comparable to physicians.Design Economic evaluation of costs and productivity of surgically trained assistant medical officers and specialist physicians.Setting Hospitals and health science training institutions in Mozambique.Population Surgically trained assistants, medical officers, surgeons and obstetrician/gynaecologists in Mozambique.Methods The costs of training and deploying the two cadres of health workers were derived from a review of budgets, annual expenditure reports, enrolment registers, and accounting statements from training institutions and interviews with directors and administrators. Productivity estimates were based on a hospital survey of physicians and técnicos de cirurgia. Results The 30-year cost per major obstetric surgery was $38.9 for te´cnicos de cirurgia and $144.1 for surgeons and obstetrician/ gynaecologists. Doubling the salaries of técnicos de cirurgia resulted in a smaller but still substantial difference in cost per surgery between the groups ($60.3 versus $144.1 per procedure). One-way sensitivity analysis to test the impact of varying other inputs did not substantially change the magnitude of the cost advantage of te´cnicos de cirurgia. ConclusionTraining more mid-level health workers in surgery can be part of the response to the health worker shortage, which today threatens the achievement of the health Millennium Development Goals in developing countries.

Objective To evaluate the outcome of caesarean delivery performed by assistant medical officers and specialists in obstetrics and gynaecology with particular attention to post‐operative complications. Design We performed a nonrandomised analysis of 2071 consecutive caesarean deliveries at Maputo Central Hospital. Of these, 958 (46.3%) were performed by assistant medical officers (medical assistants trained for surgery) and the rest (53.7%) by specialists in obstetrics and gynaecology. The age and parity distributions of women in the two groups were almost identical. Setting University Hospital in Maputo, covering all emergency obstetrics with about 48,000 deliveries per year. Population Two thousand and seventy‐one consecutive caesarean deliveries. Main outcome measures Post‐operative complications and the duration of post‐operative hospital stay. Results There were no differences in the indications for caesarean delivery. The surgical interventions associated with caesarean delivery did not differ in the two groups. The only significant difference was in the group of superficial wound separation due to haematoma, which was slightly more common (0.35%vs 0.05%) in the group operated on by assistant medical officers (Odds Ratio 2.2; 95% Confidence Interval 1.3–3.9) Conclusion Training selected medical assistants to perform caesarean delivery, even on women in poor general condition, is justified in settings in which doctors are scarce.