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Observational Study
. 2019 Jan;106(2):e129-e137.
doi: 10.1002/bjs.11076.

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

A J van Duinen  1   2   3 , M M Kamara  4   5   6 , L Hagander  7 , T Ashley  3   4   8 , A P Koroma  4   9 , A Leather  10 , M Elhassein  11 , E Darj  12 , Ø Salvesen  1 , A Wibe  1   2 , H A Bolkan  1   2   3
Affiliations
Observational Study

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

A J van Duinen et al. Br J Surg. 2019 Jan.

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.

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Figures

Figure 1
Figure 1
Nine hospitals in Sierra Leone where both medical doctors and associate clinicians performed caesarean section and surgery for uterine rupture. 1, Kabala Governmental Hospital; 2, Kambia Governmental Hospital; 3, Magburaka Governmental Hospital; 4, Port Loko Governmental Hospital; 5, Kenema Governmental Hospital; 6, Princess Christian Maternity Hospital, Freetown; 7, Lion Heart Medical Centre; 8, Magbenteh Community Hospital; 9, Serabu Catholic Hospital
Figure 2
Figure 2
Study flow chart. *Including laparotomy for uterine rupture. †Procedures performed by trainees and health workers without formal surgical training. ‡Patient identification data required to trace patient file and carry out follow‐up visit. §Analysed data from patients with and without home visit. AC, associate clinician
Figure 3
Figure 3
Perinatal outcomes and maternal morbidity for caesarean sections performed by associate clinicians compared with medical doctors. *Analyses based on a total of 1376 babies. †Based on visual estimation by the surgical provider. Odds ratios are presented with 90 per cent confidence intervals. AC, associate clinician
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