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

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

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. 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.

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.

Can training non-physician clinicians/associate clinicians (NPCs/ACs) in emergency obstetric, neonatal care and clinical leadership make a difference to practice and help towards reductions in maternal and neonatal mortality in rural Tanzania? The ETATMBA project.

OBJECTIVES: During late 2010, 36 trainees including 19 assistant medical officers (AMOs) 1 senior clinical officer (CO) and 16 nurse midwives/nurses were recruited from districts across rural Tanzania and invited to join the Enhancing Human Resources and Use of Appropriate Technologies for Maternal and Perinatal Survival in the sub-Saharan Africa (ETATMBA) training programme. The ETATMBA project was training associate clinicians (ACs) as advanced clinical leaders in emergency obstetric care. The trainees returned to health facilities across the country with the hope of being able to apply their new skills and knowledge. The main aim of this study was to explore the impact of the ETATMBA training on health outcomes including maternal and neonatal morbidity and mortality in their facilities. Secondly, to explore the challenges faced in working in these health facilities. DESIGN: The study is a pre-examination/postexamination of maternal and neonatal health indicators and a survey of health facilities in rural Tanzania. The facilities surveyed were those in which ETATMBA trainees were placed post-training. The maternal and neonatal indicators were collected for 2011 and 2013 and the survey of the facilities was in early 2014. RESULTS: 16 of 17 facilities were surveyed. Maternal deaths show a non-significant downward trend over the 2 years (282-232 cases/100,000 live births). There were no significant differences in maternal, neonatal and birth complication variables across the time-points. The survey of facilities revealed shortages in key areas and some are a serious concern. CONCLUSIONS: This study represents a snapshot of rural health facilities providing maternal and neonatal care in Tanzania. Enhancing knowledge, practical skills, and clinical leadership of ACs may have a positive impact on health outcomes. However, any impact may be confounded by the significant challenges in delivering a service in terms of resources. Thus, training may be beneficial, but it requires an infrastructure that supports it.

A qualitative process evaluation of training for non-physician clinicians/associate clinicians (NPCs/ACs) in emergency maternal, neonatal care and clinical leadership, impact on clinical services improvements in rural Tanzania: the ETATMBA project.

OBJECTIVES: The Enhancing Human Resources and Use of Appropriate Training for Maternal and Perinatal Survival in sub-Saharan Africa (ETATMBA) project is training non-physician clinicians as advanced clinical leaders in emergency maternal and newborn care in Tanzania and Malawi. The main aims of this process evaluation were to explore the implementation of the programme of training in Tanzania, how it was received, how or if the training has been implemented into practice and the challenges faced along the way. DESIGN: Qualitative interviews with trainees, trainers, district officers and others exploring the application of the training into practice. PARTICIPANTS: During late 2010 and 2011, 36 trainees including 19 assistant medical officers one senior clinical officer and 16 nurse midwives/nurses (anaesthesia) were recruited from districts across rural Tanzania and invited to join the ETATMBA training programme. RESULTS: Trainees (n=36) completed the training returning to 17 facilities, two left and one died shortly after training. Of the remaining trainees, 27 were interviewed at their health facility. Training was well received and knowledge and skills were increased. There were a number of challenges faced by trainees, not least that their new skills could not be practised because the facilities they returned to were not upgraded. Nonetheless, there is evidence that the training is having an effect locally on health outcomes, like maternal and neonatal mortality, and the trainees are sharing their new knowledge and skills with others. CONCLUSIONS: The outcome of this evaluation is encouraging but highlights that there are many ongoing challenges relating to infrastructure (including appropriate facilities, electricity and water) and the availability of basic supplies and drugs. This cadre of workers is a dedicated and valuable resource that can make a difference, which with better support could make a greater contribution to healthcare in the country.

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.

Training non-physician mid-level providers of care (associate clinicians) to perform caesarean sections in low-income countries.

Comprehensive emergency obstetric care including major surgery such as caesarean section is a major health system problem in rural areas of poor countries, where there are no doctors. Innovative trainings of mid-level workforce have now demonstrated viable, scientifically valid solutions. Delegation of major surgery to duly trained 'non-physician clinicians' - 'task shifting' - should be seriously considered to address the human resources crisis in poor countries to cope with current challenges to enhance maternal and neonatal survival. Nationwide, non-physician clinicians in Mozambique perform approximately 90% of caesarean sections at the district hospital level. A comparison between the outcomes of caesarean sections provided by this category and medical doctors, respectively, demonstrates no clinically significant differences. These mid-level providers have a remarkably high retention rate in rural areas (close to 90%). They are cost-effective, as their training and deployment is three times more cost-effective than that of medical doctors.

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.

Health complications of female genital mutilation in Sierra Leone.

UNLABELLED: Sierra Leone has one of the highest rates of female genital mutilation (FGM) in the world, and yet little is known about the health consequences of the practice. PURPOSE: To explore whether and what kind of FGM-related health complications girls and women in Sierra Leone experience, and to elucidate their health care-seeking behaviors. PATIENTS AND METHODS: A feasibility study was conducted to test and refine questionnaires and methods used for this study. Thereafter, a cross-section of girls and women (n = 258) attending antenatal care and Well Women Clinics in Bo Town, Bo District, in the southern region and in Makeni Town, Bombali District, in the northern region of Sierra Leone were randomly selected. Participants answered interview-administrated pretested structured questionnaires with open- ended-questions, administrated by trained female personnel. RESULTS: All respondents had undergone FGM, most between 10 and 14 years of age. Complications were reported by 218 respondents (84.5%), the most common ones being excessive bleeding, delay in or incomplete healing, and tenderness. Fever was significantly more often reported by girls who had undergone FGM before 10 years of age compared with those who had undergone the procedure later. Out of those who reported complications, 187 (85.8%) sought treatment, with 89 of them visiting a traditional healer, 75 a Sowei (traditional circumciser), and 16 a health professional. CONCLUSION: The high prevalence rate of FGM and the proportion of medical complications show that FGM is a matter for public health concern in Sierra Leone. Girls who undergo FGM before 10 years of age seem to be more vulnerable to serious complications than those who are older at the time of FGM. It is important that health care personnel are aware of, and look for possible complications from FGM, and encourage girls and women to seek medical care for their problems.

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.

Emergency obstetric surgery by non-physician clinicians in Tanzania.

OBJECTIVE: To calculate the met need for comprehensive emergency obstetric care (CEmOC) in 2 Tanzanian regions (Mwanza and Kigoma) and to document the contribution of non-physician clinicians (assistant medical officers [AMOs]) and medical officers (MOs) with regard to meeting the need for CEmOC. METHODS: All hospitals in the 2 regions were visited to determine the proportion of major obstetric interventions performed by AMOs and MOs. All deliveries (n = 38 758) in these hospitals in 2003 were reviewed. The estimated met need for emergency obstetric care (EmOC) was calculated using UN process indicators, as was the contribution to that attainment by AMOs. Hospital case fatality rates were also determined. RESULTS: Estimated met need was 35% in Mwanza and 23% in Kigoma. AMOs operating independently performed most major obstetric surgery. Outside of the single university hospital, AMOs performed 85% of cesareans and high proportions of other obstetric surgeries. The case fatality rate was 2.0% in Mwanza and 1.2% in Kigoma. CONCLUSION: AMOs carried most of the burden of life-saving EmOC-particularly cesarean deliveries-in the regions investigated. Case fatality was close to the 1% target set by the UN process indicators, but met need was far below the goal of 100%.