Save mother’s life in Sierra Leone : Obstetric surgical care by Non-clinicans

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In Sierra Leone, one in eight women are dying during pregnancy or delivery. A skilled birth attendant carries less than half of deliveries and less than twenty percent are carried out in health facilities. These deaths are preventable by simple surgical procedure. However, when proper intervention is not provided in timely manner, the result is miserable.

Surgical interventions are often regarded as too expensive and complex but not cost-effective particularly in the resource-limited setting because it needs specialized staff and equipment.

However, in small district hospitals or rural hospitals in Africa and some other regions, giving a major role of providing surgery to non physician clinicians compensate the shortage of professional surgeons. This is especially true for emergency obstetrical surgery—a critical component to reduce maternal mortality.

Still, Sierra Leone and many other sub-Saharan African countries are reluctant to permit non-physicians to do cesarean sections and other major emergency obstetrical surgery[1]. In addition to lack of resources, the major concern is that such complex surgical skills and knowledge cannot be adequately transferred to non-physicians without enough training.

Actually, the studies compare the obstetrical operations done by non-physicians and professionals; there were no significant differences in outcomes, risk indicators, quality-of-care indicators, mortality or morbidity among the mothers or the infants[2].

Non-specialist physicians providing the majority of surgical obstetric services in district hospitals can fill the gap of surgeons and anesthesiologists working in rural area. Therefore, national policy focusing on development of a clear, evidence-based training, supervision should be established.


[1] F. Mullan and S. Frehywot, “Non-Physician Clinicians in Forty-seven Sub-Saharan African Countries,” Lancet 370, no. 9605 (2007): 2158–2163[2] Colin McCord, et al, the Quality Of Emergency Obstetrical Surgery By Assistant Medical Officers In Tanzanian District Hospitals,Health Affairs, 28, no. 5 (2009): w876-w885

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7 Responses to “Save mother’s life in Sierra Leone : Obstetric surgical care by Non-clinicans”

  1. gingershu Says:

    Whilst in developed countries, specialist training ensures quality of care, saving lives takes priority in developing countries – and who steps up to the job is not as important. I think it is a process that has to run its course until impoverished countries or communities are able to attain a level of social advancement that is able provide specialized health care. It doesn’t seem like such a long time ago when distant, rural villages in Taiwan relied on physicians’ assistants barely out of high-school to operate on patients in emergency settings when qualified surgeons simply were not available…something that would shock people now!

  2. rfleury Says:

    You are right, maternal mortality in Sierra Leone is the highest of the world. The “Sierra Leone Demographic and Health Survey 2008 Preliminary Report” (1) even suggest Sierra Leone’s maternal mortality ratio (MMR) is increasing.

    But like in Professor Oona Campbell’s view,(2) “a very effective thing you can do to prevent maternal death is to make sure that women who don’t want to be pregnant, who have an unmet need for contraception, are ‘contracepting’. That does not work for women who do want to get pregnant obviously.” Indeed, for the global population, it is more complex: three categories of delays are underlying key determinants and lead to Sierra Leone’s high maternal mortality ratio: 1) delay in decision to seek care; 2) delay in reaching care and 3) delay in receiving care. (3)

    Your advocacy seems to focus on the latest one – non-physicians to do cesarean sections and other major emergency obstetrical surgery – but “still less than half of births (42 percent) are delivered by a health professional.” (2)

    Considering resources scarcity, should we advocate: 1) family planning emphasizing on contraception and safe abortion; 2) prevent hemorrhage for rural home delivery 3) service District EmONC facilities on the basis of 4 BEOC and 1 CEOC per 500,000 people.

    (1)http://www.statistics.sl/Sierra%20Leone%20Demographic%20Health%20Survey%20Preliminary%20Report.pdf
    (2) http://www.youtube.com/watch?v=ovN_ZldXgJk
    (3) http://www.maternityworldwide.org/pages/the-3-delays-model.html

  3. curiousmo Says:

    It’s interesting that one of the major causes of increasing maternal mortality in the United States is the extraordinarily high rate of C-sections (more than 1 in 3 births). Indeed, C-sections can save lives, but there must be a balance between too many (as in the U.S?) and too few (as in Sierra Leone). Meredith

  4. linda1972 Says:

    Perinatal mortality and maternal death remain substantial problem in developing countries worldwide. It is importance to provide all high risk populations with optimal level of health services. Surgical interventions are necessary but not in majority of cases. In resource limited setting, we could not afford having all kinds of medical specialist in remote area. A few years ago, I have been a pediatrician who performed daily cesarean section, appendectomy, and other surgical emergency procedures in community hospital. There was not a major problem, all procedure we have learned in medical school and we practiced a lot so that we were experienced enough to save our patients’ life. What more important is to have front liners who are able to do the screening so that timely referral could be made and proper intervention could be delivered in time. Furthermore, telemedicine and consultant by phone (may be Skype if internet is available) are very useful, non-physicians i.e. public health officers and nurse staff in health centers who are on duty need to have access to 24-hour telephone contact with their professional consultants in the catchment area. Health personnel could be (and need to be) trained to perform all necessary tasks which they have to perform in their health services. For the sustainability of rural health system, we might have to make choice between hiring well-trained, very specialized personnel (most of them finally move to practice in larger cities) and having lower-qualified personnel who love and belong to the communities. Inequitable distribution of health personnel is there and finally human resource development is the most critical part of health care system after all.

  5. ddowell1 Says:

    Training traditional birth attendants (TBAs) has been a prominent strategy of the international Safe Motherhood Initiative for several decades. The effectiveness of this strategy has been questioned during the last decade, and there have been calls to focus on increasing the numbers of more highly trained skilled birth attendants (SBAs) instead. However, because of a shortage of SBAs, especially those willing to practice in rural areas, TBAs may be the only option for many women, including many women in Sierra Leone. Recent studies have demonstrated that TBAs can effectively retain training in the management of labor and can be effective in reducing maternal mortality. Misoprostol is another promising potential intervention that has recently been shown to be safe, effective, and feasible for use by TBAs. I agree with Woori and with Linda that maternal mortality must be addressed, especially in countries with extremely high maternal mortality rates, such as Sierra Leone, and that training TBAs is probably more feasible and sustainable than training and/or recruiting SBAs.

  6. pveligati Says:

    As an Ob/Gyn physician who worked in India and seen botched up cases sent in to the university hospital by “registered medical practitioners”, I feel that the answer to reducing MMR in countries like Sierra Leone may not be training non-clinicians to perform c-sections. “Primum no nocere” or first do no harm is a fundamental principle taught to all medical students. Even after performing hundreds of c-sections, there is always the challenge of a difficult cesarean because of mother’s anatomy, baby’s position, stage of labor or presence of infection. I cannot imagine someone be able to adequately train a TBA/SBA who has no knowledge of anatomy and physiology, especially to perform a c-section in resources poor settings with lack of blood and antibiotics.

    The most important causes of maternal mortality that need to be dealt with in countries like Sierra Leone are non–health sector activities like improving womens education, water and sanitation, roads and communication. Conflict areas and refugee populations in countries like Sierra-Leone and Angola have very high MMR. Change to a stable political structure will have a huge impact on reduction of MMR. In addition, a wide range of cultural and behavior issues of families and communities need to be addressed.

    http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=dmssa&part=A1437&rendertype=figure&id=A1454

    If we want to address the direct causes of maternal deaths, as the graph from the above site shows, most deaths occur due to unsafe abortions, hemorrhage and sepsis. A significant number also occur due to indirect causes from illnesses aggravated by pregnancy, like malaria, Tb and AIDS. Only 13% are due to obstructed labor. I agree skilled attendance at delivery is important to the early recognition of these complications and transfer to a comprehensive health care center, but not necessarily to perform c-sections locally. By training an SBA or TBA to perform c-sections locally, we may get these unfortunate women from the pan into the fire. The indications chosen by these inadequately trained personnel may be inappropriate (payment/money may be incentives to perform unnecessary surgeries), surgery performed incorrectly leading to bladder/bowel complications, or lack of ancillary services like blood and antibiotics may lead to death anyway.

  7. woorimoon Says:

    Thank you for all replies here. Although I believe raining of TBA/SBA is one of the effective strategy, another aspects contributing high maternal mortality should be addressed at the same time. As rfelury commented, decreasing the incidence of high-risk pregnancy it self is critical problem. Thank you for Linda to share your unique experience. Yes, we need to strengthen the 1st line. 🙂

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