Sugical Quality and Task-Shifting in Sub Saharan Africa

Maternal and perinatal outcomes after Caesarean Section in Sierra LeoneLack of access to emergency obstetric care is one of the main causes of the high maternal mortality ratio in Sierra Leone. Task-sharing is a tool to increase access to caesarean section. Almost 1300 patients have been included in the study to evaluate quality of cesarean sections performed by Medical doctors and Associate Clinicians.Globally, five billion people cannot access safe and affordable surgical care when needed. Every year, one and a half million deaths can be avoided if safe essential and emergency surgical care would have been available. Shortage of health care staff is considered the main reason for the extensive unmet need for surgery. Sierra Leone has one of the highest maternal mortality ratios in the world, with 11 mothers dying of pregnancy related complications, for every 1000 live born babies. Many of these deaths could have been avoided if emergency obstetric and surgical services would have been available. One possibility to improve access to essential obstetric and surgical care is to train non-physicians clinicians (health workers with a level of basic medical training between a doctor and a nurse). Transferring surgical tasks from specialists to non-specialists is an innovative approach called surgical task-sharing. To date, there are few studies that have examined the safety of this increasingly applied solution for the expansion of surgical health care workers. Surgical task-sharing will only be beneficial if quality of care is maintained. The aim of this project is to assess quality of surgical care in Sierra Leone and examine differences in mortality and morbidity after caesarean sections performed by medical doctors and non-physician clinicians. Other related areas that the will be examined are: risk factors for postoperative mortality, long-term (1 and 5 year) outcomes, catastrophic health expenditure and women’s experience. Before the start of the study in October 2016, the anesthesia teams in the 9 participating hospitals were trained to do the inclusion and the in-hospital data-collection. In addition, three research nurses were trained to conduct home visits and supervise the data collection process in the hospitals. 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). Of the 1376 babies, 261 (19.0%) were perinatal deaths (53 antepartum stillbirths, 155 intrapartum stillbirths and 53 early neonatal deaths). So far we have shown that caesarean sections performed by ACs are not inferior to those undertaken by doctors. Therefor is task-sharing a safe strategy to improve access to emergency surgical care in areas where there is a shortage of doctors. Manuscripts in development are focussed on perinatal outcomes, unintended economic consequences and delay in reaching the health facility.