Colin McCord

Meeting the need for emergency obstetric care in Mozambique: work performance and histories of medical doctors and assistant medical officers trained for surgery

Objective  Nonphysicians in Mozambique have been performing major surgery for more than 20 years, with documented outcomes equivalent to those of specialists. The purpose of this study was to make an inventory of all government hospitals so as to document obstetric surgery performed by ‘técnicos de cirurgia’ (TCs) and to elucidate their retention at district level.

Bypassing primary care facilities for childbirth: a population-based study in rural Tanzania

In an effort to reduce maternal mortality, developing countries have been investing in village-level primary care facilities to bring skilled delivery services closer to women. We explored the extent to which women in rural western Tanzania bypass their nearest primary care facilities to deliver at more distant health facilities, using a population-representative survey of households (N = 1204). Using a standardized instrument, we asked women who had a delivery within 5 years about the place of their most recent delivery. Information on all functioning health facilities in the area were obtained from the district health office. Women who delivered in a health facility that was not the nearest available facility were considered bypassers. Forty-four per cent (186/423) of women who delivered in a health facility bypassed their nearest facility. In adjusted analysis, women who bypassed were more likely than women who did not bypass to be 35 or older (OR 2.5, P </= 0.01), to have one or no living children (OR 2.2, P = 0.03), to have stayed in a maternity waiting home prior to delivery (OR 4.3, P </= 0.01), to choose a facility on the basis of quality or experience (OR 2.1, P </= 0.01), to have a high level of trust in health workers at the delivery facility (OR 2.7, P </= 0.01), and to perceive the nearest facility to be of low quality (OR 3.1, P </= 0.01). Bypassing for facility delivery is frequent among women in rural Tanzania. In addition to obstetric risk factors, a major reason for this appears to be a concern about the quality of care at government dispensaries and health centres. Investing in improved quality of care in primary care facilities may reduce bypassing and improve the efficiency and effectiveness of the health system in providing coverage for facility delivery in rural Africa.

Increasing access to surgical services in sub-saharan Africa: priorities for national and international agencies recommended by the Bellagio Essential Surgery Group.

In this Policy Forum, the Bellagio Essential Surgery Group, which was formed to advocate for increased access to surgery in Africa, recommends four priority areas for national and international agencies to target in order to address the surgical burden of disease in sub-Saharan Africa.

Essential Surgery at the District Hospital: A Retrospective Descriptive Analysis in Three African Countries

In the first of two papers investigating surgical provision in eight district hospitals in Saharan African countries, Margaret Kruk and colleagues find low levels of surgical care provision suggesting unmet need for surgical services.

The Quality Of Emergency Obstetrical Surgery By Assistant Medical Officers In Tanzanian District Hospitals

Five countries in sub-Saharan Africa use nonphysicians to perform major emergency obstetrical surgery. In Tanzania, assistant medical officers provide most of this surgery outside of major cities. Questions about the quality of surgery by nonphysicians have kept most African countries from following this example. We reviewed the records of all patients admitted for complicated deliveries to fourteen district hospitals during four months. Among 1,134 complicated deliveries and 1,072 major obstetrical operations, there were no significant differences between assistant medical officers and medical officers in outcomes, risk indicators, or quality. There were significant differences between mission and government hospitals.

Assessment of capacity for surgery, obstetrics and anaesthesia in 17 Ghanaian hospitals using a WHO assessment tool

Objectives  To survey infrastructure characteristics, personnel, equipment and procedures of surgical, obstetric and anaesthesia care in 17 hospitals in Ghana.

Risk factors for excess mortality in harlem: Findings from the harlem household survey

INTRODUCTION In 1980, age-adjusted mortality rates in Central Harlem were the highest among New York Citys 30 health districts. This population-based study was designed to describe the self-reported frequency of selected health conditions, behavioral risk factors, preventive health practices, and drug use in the Harlem community. METHODS From 1992 to 1994, in-person interviews were conducted among 695 adults aged 18 to 65 years who were randomly selected from dwelling-unit enumeration lists for the Central Harlem health district. Descriptive statistics were computed for men and women separately, and compared to other population-based surveys. RESULTS Self-reported medical insurance coverage in Harlem was unexpectedly high (74% of men, 86% of women) as was lifetime use of preventive health practices, e.g., blood cholesterol screening (58% of men, 70% of women). However, lifetime rates of substance use, e.g. crack cocaine (14%) and self-reported history of traumatic events, e.g., witnessing someone seriously injured or violently killed (49% of men, 21% of women) were also high in Harlem, especially in comparison to other populations. CONCLUSIONS This study has identified important patterns of similarities and differences in risk behaviors between Harlem and other populations. Potential solutions to the health problems of Harlem may lie in the creation of strategies that operate at the community, municipal, and regional level, as well as at the level of individual behavior and risk-taking.

Assessment of Surgical and Obstetrical Care at 10 District Hospitals in Ghana Using On-Site Interviews

BACKGROUND For most of the population in Africa, district hospitals represent the first level of access for emergency and essential surgical services. The present study documents the number and availability of surgical and obstetrical care providers as well as the types of surgical and obstetrical procedures being performed at 10 first-referral district hospitals in Ghana. MATERIALS AND METHODS After institutional review board and governmental approval, a study team composed of Ghanaian and American surgeons performed on-site surveys at 10 district hospitals in 10 different regions of Ghana in August 2009. Face-to-face interviews were conducted documenting the numbers and availability of surgical and obstetrical personnel as well as gathering data relating to the number and types of procedures being performed at the facilities. RESULTS A total of 68 surgical and obstetrical providers were interviewed. Surgical and obstetrical care providers consisted of Medical Officers (8.5%), nurse anesthetists (6%), theatre nurses (33%), midwives (50.7%), and others (4.5%). Major surgical cases represented 37% of overall case volumes with cesarean section as the most common type of major surgical procedure performed. The most common minor surgical procedures performed were suturing of lacerations or episiotomies. CONCLUSIONS The present study demonstrates that there is a substantial shortage of adequately trained surgeons who can perform surgical and obstetrical procedures at first-referral facilities. Addressing human resource needs and further defining practice constraints at the district hospital level are important facets of future planning and policy implementation.

Emergency obstetric surgery by non‐physician clinicians in Tanzania

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.

Neighbourhood mortality inequalities in New York City, 1989–1991 and 1999–2001

Objectives: To examine whether inequalities in mortality across socioeconomically diverse neighbourhoods changed alongside the decline in mortality observed in New York City between 1990 and 2000. Design: Cross-sectional analysis of neighbourhood-level vital statistics. Setting: New York City, 1989–1991 and 1999–2001. Main results: In both poor and wealthy neighbourhoods, age-adjusted mortality for most causes declined between the time periods, although mortality from diabetes increased. Relative inequalities decreased slightly—largely in the under 65 years population—although all-cause rates in 1999–2001 were still 50% higher, and rates of years of potential life lost before age 65 years were 150% higher, in the poorest communities than in the wealthiest ones (relative index of inequality 1.7 and 3.3, respectively). The relative index of inequality for mortality from AIDS increased from 4.7 to 13.9. Over 50% of the excess mortality in the poorest neighbourhoods in 1999–2001 was due to cardiovascular disease, AIDS and cancer. Conclusions: In New York City, despite substantial declines in absolute mortality and rate differences between poor and wealthy neighbourhoods, great relative socioeconomic inequalities in mortality persist.