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Enhancing access to emergency obstetric care through surgical task shifting in Sierra Leone: confrontation with Ebola during recovery from civil war

2014; Informa; Volume: 94; Issue: 1 Linguagem: Inglês

10.1111/aogs.12540

1600-0412

Maria Milland, Håkon A. Bolkan,

Health and Conflict Studies

The Millennium Development Goals expire in 2015, and extensive efforts to ensure access to quality emergency obstetric care are required on a global scale. Maternal mortality is still a major problem worldwide. In 2013 alone, an estimated 289 000 women died due to causes related to pregnancy and childbirth 1. The large majority of these deaths are preventable, as reflected by massive inequities in maternal mortality ratios (MMR), which amount to 100-fold higher in less privileged compared to affluent countries. Access to skilled care before, during and after childbirth has been defined as a prerequisite to save women's lives 2, 3. Only 15 countries have an MMR of less than 5/100 000 live births, while figures at the other end of the scale for 16 countries are above 500, Sierra Leone being one of them. The challenge for Sierra Leone is a serious shortage of skilled health workers in combination with massive health needs, such as an unacceptably high maternal disease burden. This serious lack of human resources, along with massive health needs and weak capacities in training institutions, led to the establishment of a surgical training program in 2011. The aim is to provide physicians as well as community health officers with knowledge and skills for handling the most common life-threatening obstetrical and surgical conditions. Current evidence suggests that surgical task shifting is cost-effective and safe for selected procedures, and is recommended to improve access to key maternal interventions. The present Ebola epidemic has overwhelmed an already very fragile health system, and women's health issues are at risk of being left even further behind. In this guest editorial we discuss the present experience and evidence for surgical task shifting in low resource settings. Sierra Leone is still recovering from a 10-year period of civil war ending in 2002, during which thousands of people were killed, almost one-third of the population displaced, and most of the country's infrastructure, including its health services, was destroyed 4. A 2008 assessment of the health workforce concluded that the country had a total of 95 doctors, of which seven were obstetricians and 14 surgeons, serving a population of 5.7 million 5. A doctor density of less than 2/100 000 is among the lowest in the world, and is far from meeting the WHO recommendation of at least 230 qualified health workers per 100 000 population. The acute nature of obstetrics requires functioning operating facilities around the clock. The majority of government hospitals is still lacking sufficient supplies of electricity and running water, as well as equipment and supplies essential to perform emergency obstetric procedures. The health indicators for Sierra Leone clearly point towards lack of access to health care; life expectancy at birth is 48 years, nearly one in five children die before their fifth birthday, and the MMR ranks as highest in the world at 1100/100 000 6. While the country has shown some progress between 1990 and 2013 with an average annual decline in MMR of 3.3%, this modest progress is likely to be reversed. The Ebola outbreak has undermined the health sector and most likely changed the health-seeking behavior of pregnant women 7. Fear of contracting Ebola in hospitals may influence pregnant women to stay at home and deliver without skilled attendance 8. To address the need for skilled staff, mainly at district level, a three-year postgraduate surgical training program was established in 2011, targeting physicians and community health officers alike. The Norwegian non-governmental organization CapaCare initiated the program in collaboration with the national Ministry of Health and Sanitation (www.capacare.org). The curriculum is based on the WHO Integrated Management for Emergency and Essential Surgical Care program. During their training the students have been exposed to rotating expatriate teams for periods of 2–6 weeks, six times per year. Between rotations the candidates have been working under the supervision of obstetricians and surgeons at selected major hospitals throughout the country 9. So far 31 students have been enrolled, 26 males and five females. Eleven have passed an examination following their initial two-year training, of whom eight at present are in junior medical training posts, two have started working at district hospitals, and a medical doctor is in surgical specialist training in Ghana. Fourteen are in the initial two years of training and six have dropped out of the program, either due to slow progress in acquiring clinical skills, upon personal request or death. By August 2014, three and half years after the start of the program, the students had collectively participated in just above 15 000 major surgeries in 15 hospitals all over Sierra Leone; 3150 cesarean sections made that operation the second most performed procedure after hernia repairs. Surgical task-shifting programs have been in place since the 1980s, mainly in East Africa. The training of mid-level providers to perform selected obstetrical procedures such as manual removal of the placenta, cesarean section and postpartum hysterectomy, have proven to be not only cost-effective but also to have the valuable side-effect of contributing to retention of staff 10, 11. The WHO recommends that health workers’ functions can be optimized through task shifting to improve access to key maternal and newborn interventions 12. However, it is crucial to provide sufficient training and supervision and have referral systems. To shift responsibility from higher to lower cadres may raise considerations about lowering the standards of care, as the imperative question is whether surgical task shifting is safe. A meta-analysis of six controlled non-randomized studies from Tanzania, Malawi, Mozambique, Zaire and Burkina Faso compared outcomes of cesarean section performed by non-physician surgeons and medical doctors, respectively, and showed no significant differences with regard to maternal and perinatal death. An increased risk of wound infection was found in relation to surgery performed by non-physicians, pointing towards surgical techniques of inferior quality 13. Shortage of skilled staff along with alarming maternal health indicators demands unconventional approaches in post-conflict countries such as Sierra Leone. While surgical task shifting may serve as a short- to mid-term solution, one may question whether it compromises quality of care in the long run. On the contrary, academic degrees in surgery and obstetrics for associate clinicians have been established in Tanzania, Mozambique and Malawi 14; (personal communication from Peter Jiskoot, 22 August 2014). The present Ebola outbreak is of unprecedented dimensions, and has forced us to revise our educational activities. In August 2014, one student in the surgical training program contracted Ebola and died a few days later, most likely after treating a non-isolated severely sick patient who later turned out to have Ebola. This incident together with another two unprotected students exposed to Ebola while performing a cesarean section, led us to put all clinical rotations on hold. Furthermore, we stopped sending expatriate trainers, as safety could not be maintained. The intake of new students has been postponed until the epidemic is brought under control. Some theoretical e-learning is being offered continuously. The students in training posts come under the responsibility of the Ministry of Health and Sanitation in Sierra Leone and have to continue work, even in the midst of the crisis. The difficulties of being a front line health worker amid the Ebola tragedy may be illustrated by the following quotation from Amara Conteh. Amara completed his training this summer and is currently working in a governmental district hospital: “Practicing medicine today in our society has become a mystery to our people, as they are now afraid of coming closer to health personnel because of fear of being infected, as their thinking is that we are carrying the Ebola viruses in our pocket from the hospital into the communities due to the increased death rates of the medical personnel. Practising medicine has become like working with a computer by asking, looking and filling in information without touching the informant. By that I mean that we are now practicing telemedicine using the ABC method “Avoid Body Contact or Touch.” At the time of submission (early November 2014) Amara's hospital is closed and has been put under a 21-day quarantine. A presumed healthy pregnant woman with specific complications during labor had a cesarean section performed and died a few days later. She tested positive for Ebola. Since proper infection protection measures had not been taken, the whole hospital had to be put under quarantine. Since the first confirmed Sierra Leonean cases of Ebola in May 2014, numbers have increased rapidly due to widespread transmission of the disease and an initial slow execution of control measures 15, 16. The true extent of the outbreak is unknown and future projections vary 17. The widespread consequences of the Ebola outbreak may easily reverse the modest improvements made in maternal health through the last decade. Dedicated health workers are being lost while striving to save others’ lives; resources are being drawn from other urgent medical needs to contain the outbreak, along with changed health-seeking behavior among pregnant women resulting from fear of contracting the disease. In a country with such a dire scarcity of human resources, every lost health worker exhausts a very weak healthcare system, including life-saving maternal health services. As of 26th of November 2014, Ebola has affected 136 health workers, and 105 have died in Sierra Leone alone 15. Several government hospitals have been forced to provide space for treatment of suspected and confirmed Ebola cases, leaving less room for routine services. The reluctance of pregnant women to seek care is reflected by reduced attendance at antenatal visits. Until the onset of the Ebola outbreak, national process indicators were promising; the proportion of deliveries taking place in institutions had increased from 25% in 2008 to 50% in 2012, and 75% of pregnant women attended for at least four antenatal visits in 2012 6, 18. These improvements were partly due the free health care initiative instituted in 2010, which granted pregnant women, lactating mothers and children under five years access to health care without charge at government facilities 4. Preliminary reports from the UNFPA state that the number of women attending antenatal services is going down by 50%. The full implications of the Ebola outbreak for women are hard to determine in the midst of the crisis. Our fear is that too many of the estimated 220 000 women giving birth in Sierra Leone the next 12 months, will be left alone in the dark, unnoticed. None.