eRapport

Sugical Quality and Task-Shifting in Sub Saharan Africa

Prosjekt
Prosjektnummer
90063600
Ansvarlig person
Aalke Johan van Duinen
Institusjon
NTNU, MH-fakultetet, Institutt for klinisk og molekylær medisin
Prosjektkategori
Doktorgradsstipend
Helsekategori
Reproductive Health and Childbirth, Generic Health Relevance
Forskningsaktivitet
6. Treatment Evaluation, 8. Health Services
Rapporter
2021 - sluttrapport
This thesis has documented: 1. Access to timely essential surgery • The standard model that is used to estimate the population living in a 2-hour travel distance, consistently underestimated travel times. • A more conservative model with slower travel speeds corresponds better with patient-reported travel times. • The 2-hour threshold as adopted by the LCoGS, is relevant concerning the risk for perinatal death, but it is not a clear cut-off. 2. Specialist surgical workforce density • Caesarean sections performed by associate clinicians are not inferior to those undertaken by medical doctors. • Task-sharing is a safe strategy to increase the surgical workforce. 3. Surgical volume • Task-sharing is a safe strategy to increase the surgical volume with regards to caesarean sections. 4. Perioperative mortality • The 30-day perioperative maternal mortality after caesarean sections in nine hospitals representing all four regions in Sierra Leone is 1.3%. • Caesarean sections in nine Sierra Leonean hospitals representing all four regions in Sierra Leone result in an extremely high perinatal mortality rate of 190 per 1,000 births. • Late presentation in the facilities and lack of adequate foetal monitoring likely contribute to the high perinatal mortality rate. 5. Protection against impoverishing and catastrophic expenditure • Many women in Sierra Leone are facing catastrophic expenditure and impoverishment related to caesarean sections. • Expenses are mainly related to food and transport and the poorest are most affected. • The Free Health Care Initiative is effective in reducing the risk for catastrophic expenditure related to caesarean section. The project has informed the Sierra Leonean Ministry of Health and Sanitation and other stakeholders within the health sector about: 1. Surgical task-sharing is a safe tool to increase the surgical workforce and volume regarding caesarean sections. Expanding implementation of task-sharing should be considered. 2. The 30-day perioperative mortality after caesarean section was with 1.3% higher than in other countries, with most deaths in the medical doctor group. Structured training programs with focus on clinical and surgical skills should not only be available for associate clinicians but also for medical doctors. 3. Poor foetal monitoring was associated with poor neonatal outcomes after caesarean section. Strengthening foetal monitoring and resuscitation including training of all maternal health workers should be a priority together with the provision of sufficient equipment. 4. The Free Health Care Initiative is successful in protecting women against catastrophic expenditure and impoverishment in relation to caesarean sections. Policy makers should consider expanding this success to patients in need for emergency procedures such as laparotomies and fracture management. 5. Travel and food expenses related to caesarean section pushes patients into poverty even if there are no hospital charges. Providing free food for pregnant and lactating women and investment in a functional ambulance system can decrease financial barriers and improve access to emergency obstetric care.
2020 - sluttrapport
This thesis has documented: 1. Access to timely essential surgery • The standard model, used to estimate geographical proximity, consistently underestimated the travel time. • A more conservative travel time model corresponded better to patient-reported travel times. • The 2-hour threshold as determined by the LCoGS, is clinically relevant with respect to reducing perinatal death, but it is not a clear cut-off. 2. Specialist surgical workforce density • Caesarean sections performed by ACs are not inferior to those undertaken by MDs. • Task-sharing is a safe strategy to increase the surgical workforce. 3. Surgical volume • Task-sharing is a safe strategy to increase the surgical volume. 4. Perioperative mortality • The 30-day perioperative maternal mortality rate related to caesarean sections in Sierra Leone is 1.3%. • Caesarean sections in Sierra Leone are associated with an exceptionally high perinatal mortality rate of 190 per 1,000 births. • Late presentation in the facilities and lack of adequate foetal monitoring likely contribute to the high perinatal mortality rate. 5. Protection against impoverishing and catastrophic expenditure • Many women in Sierra Leone are facing catastrophic expenditure and impoverishment related to caesarean sections. • Expenses are mainly related to food and transport and the poorest are most affected. • The Free Health Care Initiative is effective in reducing the risk for catastrophic expenditure related to caesarean section. The project has informed the Sierra Leonean Ministry of Health and Sanitation and other stakeholders within the health sector about: 1. Surgical task-sharing: Caesarean sections performed by ACs are non-inferior to those undertaken by MDs and therefor a safe strategy to increase the obstetric and surgical workforce and volume. 2. Perinatal mortality: Caesarean sections in Sierra Leone are associated with an exceptionally high perinatal mortality rate of 190 per 1,000 births. Poor foetal monitoring can be one of the main reasons for poor neonatal outcomes after caesarean section. Therefor training in foetal monitoring and resuscitation for all health maternal health workers should be a priority together with the provision of sufficient equipment. 3. The Free Healthcare Initiative is successful in protecting women against catastrophic expenditure and impoverishment in relation to caesarean sections. Policy makers should consider expanding this success to other emergency procedures such as laparotomies and fracture management. 4. Travel and food expenses related to caesarean section pushes patients into poverty even if the hospital charges are free. Providing free food for pregnant and lactating women and investment in a functional ambulance system can decrease financial barriers improve access to emergency obstetric care.
2019
Lack 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.
2018
Lack 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). 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. Currently data is analyzed with the focus on perinatal outcomes, economic effects and delay.
2017
Lack 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 and May 2017 almost 1300 patients were included in the study. About 90 percent of the patients were followed up with home visits. In addition, semi-structured in-depth interviews were performed with 16 women, to assess experiences in relation to caesarean section. Data is currently analyzed and prepared for publication.
2016
Lack 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. More than 400 patients have been included a study to evaluate the maternal and neonatal outcome after caesarean, performed by doctors and non-physician 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 and December 2016 more than 400 patients, of the planned 1200 patients, were included in the study. More than 200 home visits were conducted including semi-structured in-depth interviews to assess women’s experience in relation to caesarean section. The planned number of 1200 inclusion is expected to be reached in May or June 2017.
Vitenskapelige artikler
Geraedts TJM, Boateng D, Lindenbergh KC, van Delft D, Mathéron HM, Mönnink GLE, Martens JPJ, van Leerdam D, Vas Nunes J, Bu-Buakei Jabbi SM, Kpaka MS, Westendorp J, van Duinen AJ, Sankoh O, Grobusch MP, Bolkan HA, Klipstein-Grobusch K

Evaluating the cascade of care for hypertension in Sierra Leone.

Trop Med Int Health 2021 11;26(11):1470-1480. Epub 2021 aug 18

PMID: 34350675

Sevalie S, Youkee D, van Duinen AJ, Bailey E, Bangura T, Mangipudi S, Mansaray E, Odland ML, Parmar D, Samura S, van Delft D, Wurie H, Davies JI, Bolkan HA, Leather AJM

The impact of the COVID-19 pandemic on hospital utilisation in Sierra Leone.

BMJ Glob Health 2021 10;6(10).

PMID: 34635552

Sung S, Hørthe H, Svendsen ØV, van Duinen AJ, Salvesen Ø, Vandi A, Bolkan HA

Early evaluation of the transition from an analog to an electronic surgical logbook system in Sierra Leone.

BMC Med Educ 2021 Nov 15;21(1):578. Epub 2021 nov 15

PMID: 34781930

van Duinen AJ, Westendorp J, Ashley T, Hagander L, Holmer H, Koroma AP, Leather AJM, Shrime MG, Wibe A, Bolkan HA

Catastrophic expenditure and impoverishment after caesarean section in Sierra Leone: An evaluation of the free health care initiative.

PLoS One 2021;16(10):e0258532. Epub 2021 okt 15

PMID: 34653191 - Inngår i doktorgradsavhandlingen

Ashley T, Ashley H, Wladis A, Bolkan HA, van Duinen AJ, Beard JH, Kalsi H, Palmu J, Nordin P, Holm K, Ohene-Yeboah M, Löfgren J

Outcomes After Elective Inguinal Hernia Repair Performed by Associate Clinicians vs Medical Doctors in Sierra Leone: A Randomized Clinical Trial.

JAMA Netw Open 2021 01 04;4(1):e2032681. Epub 2021 jan 4

PMID: 33427884

Bakker J, van Duinen AJ, Nolet WWE, Mboma P, Sam T, van den Broek A, Flinkenflögel M, Gjøra A, Lindheim-Minde B, Kamanda S, Koroma AP, Bolkan HA

Barriers to increase surgical productivity in Sierra Leone: a qualitative study.

BMJ Open 2021 Dec 21;11(12):e056784. Epub 2021 des 21

PMID: 34933865

Lindheim-Minde B, Gjøra A, Bakker JM, van Duinen AJ, van Leerdam D, Smalle IO, Bundu I, Bolkan HA

Changes in surgical volume, workforce, and productivity in Sierra Leone between 2012 and 2017.

Surgery 2021 07;170(1):126-133. Epub 2021 mar 27

PMID: 33785194

Lonnée HA, Taule K, Knoph Sandvand J, Koroma MM, Dumbuya A, Jusu KSK, Shour MA, van Duinen AJ

A survey of anaesthesia practices at all hospitals performing caesarean sections in Sierra Leone.

Acta Anaesthesiol Scand 2021 03;65(3):404-419. Epub 2020 des 5

PMID: 33169383

van Duinen AJ, Adde HA, Fredin O, Holmer H, Hagander L, Koroma AP, Koroma MM, Leather AJ, Wibe A, Bolkan HA

Travel time and perinatal mortality after emergency caesarean sections: an evaluation of the 2-hour proximity indicator in Sierra Leone.

BMJ Glob Health 2020 Dec;5(12).

PMID: 33355267 - Inngår i doktorgradsavhandlingen

Adde HA, van Duinen AJ, Oghogho MD, Dunbar NK, Tehmeh LG, Hampaye TC, Salvesen Ø, Weiser TG, Bolkan HA

Impact of surgical infrastructure and personnel on volume and availability of essential surgical procedures in Liberia.

BJS Open 2020 Sep 18. Epub 2020 sep 18

PMID: 32949120

van Duinen AJ, Westendorp J, Kamara MM, Forna F, Hagander L, Rijken MJ, Leather AJM, Wibe A, Bolkan HA

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

Int J Gynaecol Obstet 2020 Aug;150(2):213-221. Epub 2020 mai 29

PMID: 32306384 - Inngår i doktorgradsavhandlingen

Holmer H, Kamara MM, Bolkan HA, van Duinen A, Conteh S, Forna F, Hailu B, Hansson SR, Koroma AP, Koroma MM, Liljestrand J, Lonnee H, Sesay S, Hagander L

The rate and perioperative mortality of caesarean section in Sierra Leone.

BMJ Glob Health 2019;4(5):e001605. Epub 2019 sep 4

PMID: 31565407

Drevin G, Mölsted Alvesson H, van Duinen A, Bolkan HA, Koroma AP, von Schreeb J

"For this one, let me take the risk": why surgical staff continued to perform caesarean sections during the 2014-2016 Ebola epidemic in Sierra Leone.

BMJ Glob Health 2019;4(4):e001361. Epub 2019 jul 19

PMID: 31406584

Husby AE, van Duinen AJ, Aune I

Caesarean birth experiences. A qualitative study from Sierra Leone.

Sex Reprod Healthc 2019 Oct;21():87-94. Epub 2019 jun 12

PMID: 31395239

Svendsen ØV, Helgerud C, van Duinen AJ, Salvesen Ø, George PM, Bolkan HA

Evaluation of a surgical task sharing training programme's logbook system in Sierra Leone.

BMC Med Educ 2019 Jun 11;19(1):198. Epub 2019 jun 11

PMID: 31186016

van Duinen AJ, Kamara MM, Hagander L, Ashley T, Koroma AP, Leather A, Elhassein M, Darj E, Salvesen Ø, Wibe A, Bolkan HA

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

Br J Surg 2019 01;106(2):e129-e137.

PMID: 30620069 - Inngår i doktorgradsavhandlingen

Bolkan HA, van Duinen A, Samai M, Bash-Taqi DA, Gassama I, Waalewijn B, Wibe A, von Schreeb J

Admissions and surgery as indicators of hospital functions in Sierra Leone during the west-African Ebola outbreak.

BMC Health Serv Res 2018 Nov 09;18(1):846. Epub 2018 nov 9

PMID: 30413159

Bolkan HA, van Duinen A, Waalewijn B, Elhassein M, Kamara TB, Deen GF, Bundu I, Ystgaard B, von Schreeb J, Wibe A

Safety, productivity and predicted contribution of a surgical task-sharing programme in Sierra Leone.

Br J Surg 2017 Sep;104(10):1315-1326. Epub 2017 mai 18

PMID: 28783227

Waalewijn BP, van Duinen A, Koroma AP, Rijken MJ, Elhassein M, Bolkan HA

Learning Curve Characteristics for Caesarean Section Among Associate Clinicians: A Prospective Study from Sierra Leone.

World J Surg 2017 Dec;41(12):2998-3005.

PMID: 28887676

Doktorgrader
Aalke Johan van Duinen

Caesarean Sections in Sierra Leone: An Evaluation in the Light of the Lancet Global Surgery Indicators

Disputert:
november 2021
Hovedveileder:
Håkon Angell Bolkan
Deltagere
  • Håvard Adde Postdoktorstipendiat
  • Mark Shrime Prosjektdeltaker
  • Hampus Holmer Prosjektdeltaker
  • Ola Fredin Prosjektdeltaker
  • Fatu Forna Prosjektdeltaker
  • Marcus Rijken Prosjektdeltaker
  • Josien Westendorp Doktorgradsstipendiat
  • Michael M Kamara Prosjektdeltaker
  • Mohammed Elhassein Prosjektdeltaker
  • Barbro Elisabeth Darj Prosjektdeltaker
  • Thomas Ashley Prosjektdeltaker
  • TB Kamara Prosjektdeltaker
  • AP Koroma Prosjektdeltaker
  • Andy Leather Medveileder, biveileder
  • Lars Hagandar Medveileder, biveileder
  • Arne Wibe Medveileder, biveileder
  • Håkon Angell Bolkan Hovedveileder
  • Aalke Johan van Duinen Doktorgradsstipendiat
  • Lars Hagander Medveileder, biveileder

eRapport er utarbeidet av Sølvi Lerfald og Reidar Thorstensen, Regionalt kompetansesenter for klinisk forskning, Helse Vest RHF, og videreutvikles av de fire RHF-ene i fellesskap, med støtte fra Helse Vest IKT

Alle henvendelser rettes til Helse Midt-Norge RHF - Samarbeidsorganet og FFU

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