Surgical care by non-surgeons in low-income and middle-income countries: a systematic review.

BACKGROUND: Anecdotal evidence suggests that task-shifting or the redistribution of responsibilities from fully-trained surgeons to clinicians with fewer qualifications could become a major component of surgical care delivery in many low-income and middle-income countries (LMICs). Our goal was to summarise the scope of surgical task-shifting in LMICs through a systematic review of the medical literature. METHODS: We searched PubMed, EMBASE, CINAHL, LILACS, and African Index Medicus databases for papers and abstracts published between 1975, and November, 2014, that provided original data regarding non-surgeon providers, the type and volume of operations they perform, and the outcomes they achieve. The search was done in English, French, Spanish, and Portuguese, and included terms related to surgery, non-physician providers, and LMIC country names. Outcomes included the number of non-physicians and non-surgeons practicing surgery in LMICs, their qualifications, practice models and locations, and the types and volume of operations performed. FINDINGS: We identified 65 articles and 14 abstracts that described non-surgeon and non-physician providers performing 46 types of surgical procedures, across eight surgical disciplines, in 41 LMICs. These procedures extended beyond those recommended by WHO, such as male circumcision and emergency obstetric surgery. Non-surgeons and non-physicians provided a large amount of surgical care in some locations, including 90% of obstretric surgeries, 38·5% of general surgery procedures, and 43% of non-obstetric laparotomies at three separate hospitals. Of the 38 papers that specified urban or rural locations, 35 described task-shifting in rural areas or district hospitals. A variety of formal training models for surgical task-shifting were noted, including collaborations between national governments, WHO, and private non-governmental organisations. Surgical providers often had no formal surgical training, and did not operate under the supervision of a fully trained provider. INTERPRETATION: Our results suggest that non-surgeon physicians and non-physician clinicians provide surgical care many in low-resource settings. A limitation of our study is that our search was conducted in only four languages. Because many studies described the same country, countries or regions in overlapping time frames, it was not possible to determine the total number of task-shifting providers. In view of the shortage of fully-trained surgeons in many LMICs, it seems likely that task-shifting is far more widespread than is indicated by the medical literature. More research is needed to accurately determine the full extent and implications of surgical task-shifting in LMICs worldwide. FUNDING: None.

Maternal near miss and maternal deaths in Mozambique: a cross-sectional, region-wide study of 635 consecutive cases assisted in health facilities of Maputo province.

BACKGROUND: Life-threatening events during pregnancy are currently used as a measure to assess quality of obstetric care. The aim of this study is to assess prevalence of near miss cases and maternal deaths, to elucidate the causes and to analyze avoidable factors based upon the three-delays approach in southern Mozambique. METHODS: Near miss cases comprised five categories: eclampsia, severe hemorrhage, severe sepsis, uterine rupture and severe malaria. Pregnant women surviving the event were interviewed during a 5-month period within five health facilities offering comprehensive emergency obstetric care in Maputo City and Province. Family members gave additional information and were interviewed in case of the patient's death. RESULTS: Out of 27,916 live births, 564 near miss cases and 71 maternal deaths were identified, giving a total maternal near miss ratio of 20/1,000 live births and maternal mortality ratio of 254/100,000 live births, respectively. Near miss fatality rate was 11.2%. Among near miss cases hemorrhage accounted for the most common event (58.0%), followed by eclampsia (35.5%); HIV seroprevalence was 22.3%. Inappropriate attendance in antenatal care services (21.1%), late or wrong diagnosis (12.6%), inadequate management immediately after delivery (9.6%), no monitoring of blood pressure and other vital signs (9.2%) were the most prevalent factors contributing to the severe morbidity under study. Third delay was identified in 69.7% of the interviews. In more than one fourth of near miss cases treatment was not started immediately. Lack of blood derivates and unavailable operating room were reported in 42.0% and 35.0%, respectively. CONCLUSIONS: Near miss cases were frequent and related to delays in reaching and receiving adequate care. First and third type of delay contributed significantly to the number of maternal near miss cases and deaths. Maternal health policies need to be concerned not only with averting the loss of life, but also with ameliorating care of severe maternal complications at all levels including primary care. Sexual and reproductive health services for adolescents should be prioritized to prevent adverse outcomes.

Infibulated women have an increased risk of anal sphincter tears at delivery: a population-based Swedish register study of 250 000 births.

OBJECTIVE: To investigate the risk for anal sphincter tears (AST) in infibulated women. DESIGN: Population-based cohort study. SETTING: Nationwide study in Sweden. POPULATION: The study population included 250 491 primiparous women with a vaginal singleton birth at 37-41 completed gestational weeks during 1999-2008. We only included women born in Sweden and in Africa. The African women were categorized into three groups; a Somalia group, n = 929, where over 95% are infibulated; the Eritrea-Ethiopia-Sudan group, n = 955, where the majority are infibulated, compared with other African countries, n = 1035, where few individuals are infibulated but had otherwise similar anthropometric characteristics. These women were compared with 247 572 Swedish-born women. METHODS: Register study with data from the National Medical Birth Registry. MAIN OUTCOME MEASURES: AST in non-instrumental and instrumental vaginal delivery. RESULTS: Compared with Swedish-born women, women from Somalia had the highest odds ratio for AST in all vaginal deliveries: 2.72 (95%CI 2.08-3.54), followed by women from Eritrea-Ethiopia-Sudan 1.80 (1.41-2.32) and other African countries 1.23 (0.89-1.53) after adjustment for major risk factors. Mediolateral episiotomy was associated with a reduced risk of AST in instrumental deliveries. CONCLUSION: Delivering African women from countries where infibulation is common carries an increased risk of AST compared with Swedish-born women, despite delivering in a highly technical quality healthcare setting. AST can cause anal incontinence and it is important to investigate risk factors for this and try to improve clinical routines during delivery to reduce the incidence of this complication.

Female genital mutilation in Sierra Leone: who are the decision makers?

The objectives of this study were to identify decision makers for FGM and determine whether medicalization takes place in Sierra Leone. Structured interviews were conducted with 310 randomly selected girls between 10 and 20 years in Bombali and Port Loko Districts in Northern Sierra Leone. The average age of the girls in this sample was 14 years, 61% had undergone FGM at an average age of 7.7 years (range 1-18). Generally, decisions to perform FGM were made by women, but father was mentioned as the one who decided by 28% of the respondents. The traditional excisors (Soweis) performed 80% of all operations, health professionals 13%, and traditional birth attendants 6%. Men may play a more important role in the decision making process in relation to FGM than previously known. Authorities and health professionals' associations need to consider how to prevent further medicalization of the practice.

Pregnancy loss: spontaneous and induced abortions among young women in Lusaka, Zambia.

An estimated 60% of all adolescent pregnancies in low-income countries are unintended. The present study was carried out at the university hospital in Lusaka, Zambia over a four-month period in 2005. The aim was to explore experiences of pregnancy loss and to ascertain the girl's contraceptive knowledge and use and their partner's involvement in the pregnancy/abortion. Eighty-seven girls aged 13-19 years admitted to hospital for incomplete abortions were interviewed. Of these girls, 53 (61%) had had a spontaneous abortion and 34 (39%) had undergone an unsafe induced abortion. Significantly more girls with an unsafe induced abortion were single, students, had completed more years in school and were in less stable relationships. Girls' overall contraceptive knowledge and use was low and most pregnancies were unplanned. Partners played a decisive role in terminating pregnancy through unsafe induced abortion. Traditional healers, girls themselves and health professionals were the main abortion providers. Young women's health risks due to unprotected sex and lack of contraceptive services should urgently be addressed. The existence of the abortion law and access to emergency contraception should be better publicized in Zambia.

Correction: Stillbirths in urban Guinea-Bissau: A hospital- and community-based study.

[This corrects the article DOI: 10.1371/journal.pone.0197680.].

Deaths among young, single women in 2000-2001 in the West Bank, Palestinian Occupied Territories.

A study in 2000-2001 of causes of death of women of reproductive age (15-49) in the West Bank, Palestinian Occupied Territories, found that 154 of the 411 deceased women aged 15-49 with known marital status were single. Death notification forms for reported deaths were analysed and verbal autopsies carried out, where possible, with relatives of the deceased women. We found important differences in the age at death and causes of death among the single and married women, which can be attributed to the disadvantaged social status of single women in Palestinian society, exacerbated by the current unstable political situation. 41% of the deceased single women were under 25 years of age at death compared to 8% of the married women. The proportion of violent deaths and suicides among the single women was almost twice as high as among the married women, mainly in those below age 25. The single women were also more likely to die from medical conditions which indicated that they faced barriers to accessing health care. The fieldwork was conducted at the height of the Intifada and the Israeli military response, with heavy restrictions on mobility, limiting the possibility of probing deeper into the circumstances surrounding sensitive deaths. More research into the socio-cultural context of single women in Palestine society is needed as a basis for intervention.

Stillbirths in urban Guinea-Bissau: A hospital- and community-based study.

BACKGROUND: Stillbirth rates remain high in many low-income settings, with fresh (intrapartum) stillbirths accounting for a large part due to limited obstetrical care. We aimed to determine the stillbirth rate and identify potentially modifiable factors associated with stillbirth in urban Guinea-Bissau. METHODS: The study was carried out by the Bandim Health Project (BHP), a Health and Demographic Surveillance System site in the capital Bissau. We assessed stillbirth rates in a hospital cohort consisting of all deliveries at the maternity ward at the National Hospital Simão Mendes (HNSM), and in a community cohort, which only included women from the BHP area. Stillbirth was classified as fresh (FSB) if fetal movements were reported on the day of delivery. RESULTS: From October 1 2007 to April 15 2013, a total of 38164 deliveries were registered at HNSM, among them 3762 stillbirths (99/1000 births). Excluding deliveries referred to the hospital from outside the capital (9.6%), the HNSM stillbirth rate was 2786/34490 births (81/1000). During the same period, 15462 deliveries were recorded in the community cohort. Of these, 768 were stillbirths (50/1000). Of 11769 hospital deliveries among women from Bissau with data on fetal movement, 866 (74/1000) were stillbirths, and 609 (70.3%) of these were FSB, i.e. potentially preventable. The hospital FSB rate was highest in the evening from 4 pm to midnight (P = 0.04). In the community cohort, antenatal care (ANC) attendance correlated strongly with stillbirth reduction; the stillbirth rate was 71/1000 if the mother attended no ANC consultations vs. 36/1000 if she attended ≥7 consultations (P<0.001). CONCLUSION: In Bissau, the stillbirth rate is alarmingly high. The majority of stillbirths are preventable FSB. Improving obstetrical training, labour management (including sufficient intrapartum monitoring and timely intervention) and hospital infrastructure is urgently required. This should be combined with proper community strategies and additional focus on antenatal care.

Postoperative outcome of caesarean sections and other major emergency obstetric surgery by clinical officers and medical officers in Malawi.

BACKGROUND: Clinical officers perform much of major emergency surgery in Malawi, in the absence of medical officers. The aim of this study was to validate the advantages and disadvantages of delegation of major obstetric surgery to non-doctors. METHODS: During a three month period, data from 2131 consecutive obstetric surgeries in 38 district hospitals in Malawi were collected prospectively. The interventions included caesarean sections alone and those that were combined with other interventions such as subtotal and total hysterectomy repair of uterine rupture and tubal ligation. All these surgeries were conducted either by clinical officers or by medical officers. RESULTS: During the study period, clinical officers performed 90% of all straight caesarean sections, 70% of those combined with subtotal hysterectomy, 60% of those combined with total hysterectomy and 89% of those combined with repair of uterine rupture. A comparable profile of patients was operated on by clinical officers and medical officers, respectively. Postoperative outcomes were almost identical in the two groups in terms of maternal general condition - both immediately and 24 hours postoperatively - and regarding occurrence of pyrexia, wound infection, wound dehiscence, need for re-operation, neonatal outcome or maternal death. CONCLUSION: Clinical officers perform the bulk of emergency obstetric operations at district hospitals in Malawi. The postoperative outcomes of their procedures are comparable to those of medical officers. Clinical officers constitute a crucial component of the health care team in Malawi for saving maternal and neonatal lives given the scarcity of physicians.

Major surgery delegation to mid-level health practitioners in Mozambique: health professionals' perceptions.

BACKGROUND: This study examines the opinions of health professionals about the capacity and performance of the 'técnico de cirurgia', a surgically trained assistant medical officer in the Mozambican health system. Particular attention is paid to the views of medical doctors and maternal and child health nurses. METHODS: The results are derived from a qualitative study using both semi-structured interviews and group discussions. Health professionals (n=71) were interviewed at both facility and system level. Eight group discussion sessions of about two hours each were run in eight rural hospitals with a total of 48 participants. Medical doctors and district officers were excluded from group discussion sessions due to their hierarchical position which could have prevented other workers from expressing opinions freely. RESULTS: Health workers at all levels voiced satisfaction with the work of the "técnicos de cirurgia". They stressed the life-saving skills of these cadres, the advantages resulting from a reduction in the need for patient referrals and the considerable cost reduction for patients and their families. Important problems in the professional status and remuneration of "técnicos de cirurgia" were identified. CONCLUSION: This study, the first one to scrutinize the judgements and attitudes of health workers towards the "técnico de cirurgia", showed that, despite some shortcomings, this cadre is highly appreciated and that the health delivery system does not recognize and motivate them enough. The findings of this study can be used to direct efforts to improve motivation of health workers in general and of técnicos de cirurgia in particular.

Primary infertility after genital mutilation in girlhood in Sudan: a case-control study.

BACKGROUND: In theory, infections that arise after female genital mutilation (FGM) in childhood might ascend to the internal genitalia, causing inflammation and scarring and subsequent tubal-factor infertility. Our aim was to investigate this possible association between FGM and primary infertility. METHODS: We did a hospital-based case-control study in Khartoum, Sudan, to which we enrolled women (n=99) with primary infertility not caused by hormonal or iatrogenic factors (previous abdominal surgery), or the result of male-factor infertility. These women underwent diagnostic laparoscopy. Our controls were primigravidae women (n=180) recruited from antenatal care. We used exact conditional logistic regression, stratifying for age and controlling for socioeconomic status, level of education, gonorrhoea, and chlamydia, to compare these groups with respect to FGM. FINDINGS: Of the 99 infertile women examined, 48 had adnexal pathology indicative of previous inflammation. After controlling for covariates, these women had a significantly higher risk than controls of having undergone the most extensive form of FGM, involving the labia majora (odds ratio 4.69, 95% CI 1.49-19.7). Among women with primary infertility, both those with tubal pathology and those with normal laparoscopy findings were at a higher risk than controls of extensive FGM, both with borderline significance (p=0.054 and p=0.055, respectively). The anatomical extent of FGM, rather than whether or not the vulva had been sutured or closed, was associated with primary infertility. INTERPRETATION: Our findings indicate a positive association between the anatomical extent of FGM and primary infertility. Laparoscopic postinflammatory adnexal changes are not the only explanation for this association, since cases without such pathology were also affected. The association between FGM and primary infertility is highly relevant for preventive work against this ancient practice.

Determination of polybrominated diphenyl ethers at trace levels in environmental waters using hollow-fiber microporous membrane liquid-liquid extraction and gas chromatography-mass spectrometry.

In this study, we present a simple and easy-to-use extraction method that is based on a hollow-fiber microporous membrane liquid-liquid extraction (HF-MMLLE), as an extraction technique, followed by gas chromatography-mass spectrometry (GC-MS) to determine a group of brominated flame retardants (BFRs), polybrominated diphenyl ethers (PBDEs), at trace levels in aqueous samples. The hollow-fiber membrane (HF) filled with organic solvent was immersed into the aqueous sample, spiked with the analytes at ng l(-1) level, and stirred for 60 min. The proposed method could attain enrichment factors (E(e)) up to 5200 times, after optimising parameters, such as organic solvent, stirring speed and extraction time, that affect the extraction. The HF-MMLLE-GC-MS method was successfully applied to the extraction of PBDEs from tap, river and leachate water samples with spike recoveries ranging from 85% to 110%. The method validation with reagent and leachate water samples provided good linearity, detection limits of 1.1 ng l(-1) or lower, both in reagent and leachate water, as well as satisfactory precision in terms of repeatability and reproducibility with values of % relative standard deviation (%RSD) lower than 8.6 and 16.9, respectively.

Extracting Syringe for determination of organochlorine pesticides in leachate water and soil-water slurry: a novel technology for environmental analysis.

The Extracting Syringe (ESy), a novel membrane-based sample preparation technique directly coupled as an autosampler to gas chromatography, has been employed for the analysis of organochlorine pesticides (OCPs) in raw leachate water. The ESy has also been applied for extraction of OCPs from contaminated soil samples and its performance has been compared to liquid-solid extraction (LSE) and accelerated solvent extraction (ASE). Extraction of 3-mL leachate sample at the optimised conditions resulted in enrichment factors from 32 (Endrin aldehyde) to 242 (Endrin) and detection limits from 1 to 20 ng/L. The inter-day and intra-day repeatability (% RSD) at 100 and 500 ng/L were <6% and <24%, respectively. The relative recovery at 100 and 500 ng/L ranged from 68% (Aldrin) to 116% (Endrin aldehyde); except Heptachlor that showed 51 and 60%, respectively. The ESy extraction of the slurry-made soil samples revealed occurrence of Endosulfan I (18.2 microg/g soil), 4,4'-DDE (2.6 ng/g soil), Endosulfan II (8.7 microg/g soil) and Endosulfan sulfate (1.1 microg/g soil); showing good agreement with LSE results. The total ESy consumption of organic solvents was 4.2 mL from which only 0.6 mL n-undecane was used during the extraction step (7 microL for the extraction per se), while in the LSE and ASE, it was 420 and 18.1 mL, respectively. The ESy extraction time (0.5 h) was comparable to the ASE time (0.6 h); and the time required for the LSE was 3.75 h. To sum up, the ESy has shown its competency to LSE and ASE technologies, demonstrating its applicability for environmental analysis of organic pollutants, towards green techniques for green environment.

Being different and vulnerable: experiences of immigrant African women who have been circumcised and sought maternity care in Sweden.

The purpose of the study was to explore the encounters with the health care system in Sweden of women from Somalia, Eritrea, and Sudan who have been genitally cut. A qualitative study was performed through interviews with 22 women originally from Somalia, Sudan, and Eritrea who were living in Sweden. The women experienced being different and vulnerable, suffering from being abandoned and mutilated, and they felt exposed in the encounter with the Swedish health care personnel and tried to adapt to a new cultural context. The results of this study indicate a need for more individualized, culturally adjusted care and support and a need for systematic education about female genital cutting for Swedish health care workers.

The challenge of improving perinatal care in settings with limited resources. Observations of midwifery practices in Mozambique.

The aim of this study was to observe and analyse midwifery care routines related to asphyxia and hypothermia during the perinatal period and to investigate the effect of an in-service education program. A direct non-participant pre- and post-intervention observation study of midwifery a performance during childbirth was conducted at a labour ward in Maputo. The observed groups consisted of 702 and 616 midwifery-attended deliveries. Examination was also conducted of the partographs (702 vs. 616). The quality of midwifery care related to prevention and early detection of asphyxia and hypothermia was found to be inadequate and the intervention had no significant effect upon the midwives' performances. This could be attributed to the quality of the intervention itself or to failure of implementing managerial decisions such as transfer of partograph documentation from obstetricians to midwives. Change in professional performance does not automatically follow awareness of evidence-based midwifery practices, but requires behavioural change, which may be more difficult to achieve.

Global maternal health and newborn health: Looking backwards to learn from history.

The late appearance of the 'M' on the international health agenda - in its own right and not just as a carrier of the intrauterine passenger - is thought-provoking. The 'M' was absent for decades in textbooks of 'tropical medicine' until the rhetoric question was formulated: 'Where is the "M" in MCH?' The selective antenatal 'high-risk approach' gained momentum but had to give way to the fact that all pregnant women are at risk due to unforeseeable complications. In order to provide trained staff to master such complications in impoverished rural areas (with no doctors), some countries have embarked on training of non-physician clinicians/associate clinicians for major surgery with excellent results in 'task-shifting' practice. The alleged but non-existent 'human right' to survive birth demonstrates that there have been no concrete accountability and no 'legal teeth' to make a failing accountability legally actionable to guarantee such a right.

Postoperative outcome of caesarean sections and other major emergency obstetric surgery by clinical officers and medical officers in Malawi.

BACKGROUND: Clinical officers perform much of major emergency surgery in Malawi, in the absence of medical officers. The aim of this study was to validate the advantages and disadvantages of delegation of major obstetric surgery to non-doctors. METHODS: During a three month period, data from 2131 consecutive obstetric surgeries in 38 district hospitals in Malawi were collected prospectively. The interventions included caesarean sections alone and those that were combined with other interventions such as subtotal and total hysterectomy repair of uterine rupture and tubal ligation. All these surgeries were conducted either by clinical officers or by medical officers. RESULTS: During the study period, clinical officers performed 90% of all straight caesarean sections, 70% of those combined with subtotal hysterectomy, 60% of those combined with total hysterectomy and 89% of those combined with repair of uterine rupture. A comparable profile of patients was operated on by clinical officers and medical officers, respectively. Postoperative outcomes were almost identical in the two groups in terms of maternal general condition - both immediately and 24 hours postoperatively - and regarding occurrence of pyrexia, wound infection, wound dehiscence, need for re-operation, neonatal outcome or maternal death. CONCLUSIONS: Clinical officers perform the bulk of emergency obstetric operations at district hospitals in Malawi. The postoperative outcomes of their procedures are comparable to those of medical officers. Clinical officers constitute a crucial component of the health care team in Malawi for saving maternal and neonatal lives given the scarcity of physicians.