Putting faith in mid-level workers paying off

Presenters from Mozambique, Tanzania and Malawi at the 14th FIGO (International Federation of Gynecology & Obstetrics) World Congress of Gynecology and Obstetrics yesterday (SUBS: MONDAY) shared details of how mid-level health workers are performing caesareans and other emergency surgical procedures in hospitals where there are simply no doctors and often no professional nurses.

In Mozambique, 92 percent of all Caesarean sections at the district hospital level are carried out my mid-level providers ‘€“ Tecnicos de Cirugia. In Tanzania the percentage is 84 percent.

Studies in all three countries have shown that with the right training these mid-level providers ‘€“ some trained straight after school while other have some experience of working in the health sector ‘€“ have similar outcomes to doctors when providing life-saving emergency obstetric surgical care.

Compared to doctors their retention rates, especially in rural and district areas where the need is desperate, are excellent.

Globally, 75 percent of maternal deaths are the result of five direct causes ‘€“ hemorrhage, obstructed labor, sepsis, eclampsia (high blood pressure accompanied by fluid retention which leads to seizures of a coma) and unsafe abortion. Many more women suffer serious, permanent injuries and disabilities during pregnancy and delivery.

It has been shown that where women suffering from obstetric complications are quickly connected to care, maternal death is extremely rare, and injury and disability often prevented.

Worldwide, over half a million women die each year due to pregnancy-related complications, while between three and four million babies are stillborn and over three million neonatal deaths are caused by maternal disease and poor delivery care.

In Ethiopia, 94 percent of women giving birth do not have a skilled attendant at birth.

Steffan Bergstrom of the Karolinska Institute in Sweden revealed that some of the mid-level providers were performing advanced emergency surgery, not all related to pregnancy, with no statistically significant difference in outcomes when compared to medical doctors.

‘€œMany of these workers have more than 10 years of work training and at least three years of surgery training, which is more than a newly qualified doctor,’€ said Bergstrom.

Caetano Pereira of the Eduardo Mondlane University in Maputo presented data showing that 88% of the Tecnicos de Cirugia’€™s were still working in the rural areas seven years after starting while not one doctor who ‘€œgraduated’€ in the same period, was working in these areas.

Godfrey Mbaruku presented evidence from Tanzania showing that their assistant medical officers were performing 85 percent of operations in district hospitals, ranging from trauma to general surgery and emergency obstetric care. Tanzania currently has one doctor for every 20 000 people and one nurse or midwife for every 8 000 people.

Malawi only started training doctors in 1992, starting with an intake of 18. It is currently training 60 doctors every year, but it is not enough to meet the need. Clinical officers have been filling the critical gap in this country since 1976 with 88 percent of all emergency obstetric surgery performed by these workers. The biggest challenge is finding the necessary drugs, medical supplies and functioning equipment needed to perform the lifesaving interventions, according to Garvey Chilopara.

Mid-level providers have now been trained and deployed in 25 of 47 sub-Saharan countries.

The Health Systems Strengthening for Equity project, an innovative partnership for research and advocacy, has picked up the baton and aims to highlight and strengthen the crucial role of mid-level providers, using research to build evidence based case for the expansion of this critical service.


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