Staffan Bergström

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.

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

BackgroundClinical 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.MethodsDuring 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.ResultsDuring 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.ConclusionClinical 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.

Obstetric care in low-resource settings: what who and how to overcome challenges to scale up?

Each year, approximately 2 million babies die because of complications of childbirth, primarily in settings where effective care at birth, particularly prompt cesarean delivery, is unavailable.

A comparative study of caesarean deliveries by assistant medical officers and obstetricians in Mozambique

Objective To evaluate the outcome of caesarean delivery performed by assistant medical officers and specialists in obstetrics and gynaecology with particular attention to post‐operative complications.

Economic evaluation of surgically trained assistant medical officers in performing major obstetric surgery in Mozambique

Objective  To compare the training and deployment costs and surgical productivity of surgically trained assistant medical officers (técnicos de cirurgia) and specialist physicians (surgeons and obstetrician/gynaecologists) in Mozambique in order to inform health human resource planning in a developing country with low availability of obstetric care and severe physician shortages. Técnicos de cirurgia have been previously shown to have quality of care outcomes comparable to physicians.

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.

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.

Malaria-related maternal mortality in urban Mozambique

All pregnancy-related maternal deaths that occurred at the central hospital of Maputo during the 5 years between 1989 and 1993 were reviewed. The 239 maternal deaths recorded represented a maternal mortality ratio of 320/100,000 live births. Overall, 15.5% of the deaths were directly attributable to malaria, and 19.7% of the women who died were found to be parasitaemic (with Plasmodium falciparum) prior to death. Autopsies on 161 of the women who died showed histological evidence of malarial infection in the spleens of 44 (27.3%). Many (37.8%) of the malaria-related deaths occurred in adolescent primigravidae, and most were associated with severe anaemia. Pregnancy outcome was generally poor. Unbooked deliveries, and poor antenatal care were identified as risk factors for maternal death from malaria. The current policy of prescribing antimalarials in pregnancy based on symptomatic malaria alone should be reviewed. Improved primary prevention is required in order to reduce the high risk of malaria-related mortality in all pregnant women in the urban study area, especially among adolescents.

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.

Setting Research Priorities to Reduce Almost One Million Deaths from Birth Asphyxia by 2015

Joy Lawn and colleagues used a systematic process developed by the Child Health Nutrition Research Initiative (CHNRI) to define and rank research options to reduce mortality from intrapartum-related neonatal deaths (birth asphyxia) by the year 2015.