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

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.

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

BACKGROUND: Surgical task-sharing may be central to expanding the provision of surgical care in low-resource settings. The aims of this paper were to describe the set-up of a new surgical task-sharing training programme for associate clinicians and junior doctors in Sierra Leone, assess its productivity and safety, and estimate its future role in contributing to surgical volume. METHODS: This prospective observational study from a consortium of 16 hospitals evaluated crude in-hospital mortality over 5 years and productivity of operations performed during and after completion of a 3-year surgical training programme. RESULTS: Some 48 trainees and nine graduated surgical assistant community health officers (SACHOs) participated in 27 216 supervised operations between January 2011 and July 2016. During training, trainees attended a median of 822 operations. SACHOs performed a median of 173 operations annually. Caesarean section, hernia repair and laparotomy were the most common procedures during and after training. Crude in-hospital mortality rates after caesarean sections and laparotomies were 0·7 per cent (13 of 1915) and 4·3 per cent (7 of 164) respectively for operations performed by trainees, and 0·4 per cent (5 of 1169) and 8·0 per cent (11 of 137) for those carried out by SACHOs. Adjusted for patient sex, surgical procedure, urgency and hospital, mortality was lower for operations performed by trainees (OR 0·47, 95 per cent c.i. 0·32 to 0·71; P < 0·001) and SACHOs (OR 0·16, 0·07 to 0·41; P < 0·001) compared with those conducted by trainers and supervisors. CONCLUSION: SACHOs rapidly and safely achieved substantial increases in surgical volume in Sierra Leone.

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

BACKGROUND: In response to the high maternal mortality ratio, Sierra Leone has adopted an associate clinician postgraduate surgical task-sharing training programme. Little is known about learning curve characteristics for caesarean sections among associate clinicians. The aim of this study is to evaluate the number of caesarean sections needed to be performed by associate clinicians until there is no further significant reduction in operation time. METHODS: This prospective study evaluates the first 50 caesarean sections performed by trainees between January 2011 and June 2016. Primary outcome was total operating time in minutes (incision to suturing time). Secondary outcomes were length of hospital stay, surgical site infections, estimated operative bloodloss and in-hospital postoperative mortality. RESULTS: A total of 1174 caesarean sections performed by 24 trainees were analysed. Total operation time significantly reduced during the first 15 operations from mean (SD) operation time 72 (27)-51 (18) min after 15 procedures (p < 0.001). Estimated bloodloss did not significantly vary among the first 50 caesarean sections. Surgical site infections were reported in 3.7% of the operations, which was higher during the first 15 operations (6.8%) compared to the following 35 operations (2.3%). Length of stay reduced from median (range) 9 (2-39)-6 (2-127) days after 15 operations, but there was no reduction in maternal mortality. CONCLUSION: While gaining experience, the operation time of associate clinicians significantly reduced during the first 15 caesarean sections. Estimated bloodloss is not related to trainees experience.