Caesarean section performed by medical doctors and associate clinicians in Sierra Leone

Abstract

Background Many countries lack sufficient medical doctors to provide safe and affordable surgical and emergency obstetric care. Task‐sharing with associate clinicians (ACs) has been suggested to fill this gap. The aim of this study was to assess maternal and neonatal outcomes of caesarean sections performed by ACs and doctors. Methods All nine hospitals in Sierra Leone where both ACs and doctors performed caesarean sections were included in this prospective observational multicentre non‐inferiority study. Patients undergoing caesarean section were followed for 30 days. The primary outcome was maternal mortality, and secondary outcomes were perinatal events and maternal morbidity. Results Between October 2016 and May 2017, 1282 patients were enrolled in the study. In total, 1161 patients (90·6 per cent) were followed up with a home visit at 30 days. Data for 1274 caesarean sections were analysed, 443 performed by ACs and 831 by doctors. Twin pregnancies were more frequently treated by ACs, whereas doctors performed a higher proportion of operations outside office hours. There was one maternal death in the AC group and 15 in the doctor group (crude odds ratio (OR) 0·12, 90 per cent confidence interval 0·01 to 0·67). There were fewer stillbirths in the AC group (OR 0·74, 0·56 to 0·98), but patients were readmitted twice as often (OR 2·17, 1·08 to 4·42). Conclusion Caesarean sections performed by ACs are not inferior to those undertaken by doctors. Task‐sharing can be a safe strategy to improve access to emergency surgical care in areas where there is a shortage of doctors.

The rate and perioperative mortality of caesarean section in Sierra Leone

“…The in-facility perioperative mortality of caesarean section was in line with previous studies in West Africa,31 but higher than the risk of maternal death in some other countries in sub-Saharan Africa, with recorded maternal mortality rates of between 5.43 per 1000 operations in a 2016 prospective cohort study in 22 countries,32 and 10.9 per 1000 in a recent meta-analysis 33. It was also similar to the rate of 1.3% (16 in 1274) recorded among women who underwent caesarean section in nine hospitals in Sierra Leone between October 2016 and May 2017 34. Compared with rates of 0.05% in some high-income countries,35 mortality following caesarean section is about 30 times higher in Sierra Leone.…”

“…Caesarean section has known risks41 of both immediate42–44 and long-term complications,45 and rapid increases in the volume of surgery must be coupled with adequate training of clinicians and robust quality controls, among other interventions 6 11. Indeed, we believe that most of the caesarean sections in this review were performed to save lives—a prospective study of 1274 patients undergoing caesarean section in nine hospitals in Sierra Leone in 2016–2017 showed that most procedures are done as an emergency procedure and on maternal indication34—but clinical audits are needed to ensure caesarean sections are not carried out unnecessarily, and attention should be given to the possibility that the procedure itself may contribute to mortality, in the short and long terms 41…”

Perinatal outcomes of cesarean deliveries in Sierra Leone: A prospective multicenter observational study

“…The present study was part of a prospective observational multicenter study of women who underwent cesarean delivery in nine hospitals in Sierra Leone between October 1, 2016, and May 5, 2017. Both associate clinicians and medical doctors performed cesarean deliveries (Table ) . Associate clinicians had completed 2‐year surgical training and the medical doctors were either specialists or non‐specialists.…”

“…Sierra Leone has one of the world's poorest perinatal health indicators, with a national cesarean delivery rate of 2.9% and an overall perinatal mortality rate of 39 per 1000 pregnancies . A prospective multicenter study assessing outcomes after cesarean deliveries performed by medical doctors and associate clinicians in Sierra Leone revealed a five times higher perinatal mortality rate (190 per 1000 births [n = 261/1376]) . This finding urged us to explore the causes of this alarmingly high perinatal mortality.…”

A realized vision of access to safe, affordable surgical and anaesthesia care

“…The Commission articulated a broad array of research themes, seven of which are found within the breadth of papers in this supplement including: policy, quality and safety, training and education, partnership, information management, care delivery innovation and burden. However, there are four important themes that are not covered, including cost and finance, determinants and barriers, impact of disease and prevention.…”