Caesarean Sections in Sierra Leone An Evaluation in the Light of the Lancet Global Surgery Indicators

Background: Two third of the world’s population does not have adequate access to timely safe and affordable surgical services. The Lancet Commission on Global Surgery has defined a framework with six indicators and targets to evaluate preparedness, service delivery and financial impact of surgical services. In Sierra Leone, insufficient access to emergency obstetric and surgical services has led to poor maternal and perinatal outcomes. To improve access to caesarean sections, the Free Health Care Initiative was implemented to abolish user fees for obstetric and paediatric care. In addition, a task-sharing training programme for associate clinicians has been introduced to increase the surgical workforce. Aims: The aim of thesis was to evaluate caesarean sections in Sierra Leone performed by associate clinicians and medical doctors using the framework of the Lancet Commissions on Global Surgery indicators. The thesis specifically aimed to: I. compare the outcome of caesarean sections performed by associate clinicians and medical doctors, II. analyse factors associated with perinatal death, III. evaluate catastrophic expenditure, impoverishment and the impact of the Free Health Care Initiative, and IV. assess patient reported and geospatial modelled travel time. Methods: A prospective observational multicentre non-inferiority study was applied in all hospitals where both associate clinicians and medical doctors performed caesarean sections in 2016. Women undergoing caesarean section, either performed by associate clinicians or medical doctors, were included in the study and were followed with home visits after 30 days. Data on obstetric history, indication, travel time, household characteristics, health expenditure, and maternal and neonatal outcomes were collected. Individual income was estimated based on household characteristics and further used to determine impoverishing and catastrophic expenditure. The impact of the Free Health Care Initiative was assessed using a counterfactual scenario. Geospatial modelled travel times were generated based on two models and compared with patient reported travel time. Findings: Between October 2016 and May 2017, 1,728 caesarean sections were done by either associate clinicians or medical doctors in the nine study hospitals. Of those, 1,274 women and 1,376 babies were included in the study and 1,161 women (91.1%) were successfully followed up with a home visit. Medical doctors performed a higher proportion of caesarean sections outside office hours, while associate clinicians did more surgeries for twin pregnancies. The 30-day perioperative maternal mortality was 0.2% (1 of 443) in the associate clinician group and 1.8% (15 of 831) in the medical doctor group (crude odds ratio 0.12, 90% confidence interval 0.01 to 0.67). Of the 1,376 babies, 261 (19.0%) were perinatal deaths. Indications with the highest perinatal mortality were uterine rupture, abruptio placentae, and antepartum haemorrhage. The median expenditure was 23 international dollars, with travel and food being the largest expenses. Patients in the poorest quintile had significantly higher healthcare related expenses compared to patients in the richest quintile. Catastrophic expenditure was encountered by 12.0% and 4.0% (10% and 25% threshold, respectively) of the women and without the Free Health Care Initiative, 66.1% and 28.8% of the women would have encountered catastrophic expenditure. The median reported travel time was 60 minutes, compared with 13 and 34 minutes estimated by the two models, respectively. Longer travel times were associated with poverty, low or no education, transport by ambulance or boat, and visiting one or two health facilities before reaching the final hospital where the caesarean section war performed. Higher perinatal mortality was identified in the group with a reported and modelled travel time of 2 hours or more. Significance.: Caesarean sections in Sierra Leone - an evaluation in the light of the Lancet Global Surgery Indicators has provided more insight in the preparedness, service delivery and financial impact of caesarean sections in Sierra Leone. This thesis has documented noninferiority of caesarean sections performed by associate clinicians compared to medical doctors based on prospective data collection. It has also provided new insights in the associated factors of the high perinatal mortality related to caesarean sections. In addition, it has expanded the understanding of modelled travel time compared to patient-reported travel time. Finally, it has shown the effect of the Free Health Care Initiative on catastrophic expenditure and impoverishmen

Caesarean birth experiences. A qualitative study from Sierra Leone.

Background Positive birth experiences lead to better postnatal functioning, and influence mode of delivery choice for subsequent pregnancies. Healthcare workers can influence the birth experience through relevant support and care. This study seeks to explore the experience of Sierra Leonean women in relation to ante-natal, intrapartum and post-partum care with special reference to their experience of caesarean section. Methods In November 2016, individual semi structured interviews were performed with sixteen women of varying age from different geographical areas, levels of schooling, and parity. The interviews were analysed by systematic text condensation. Results During interviews, participants mentioned a fear of dying or losing their baby. This fear was managed by praying and putting trust in a higher power. However, placing trust in healthcare workers was also described by some participants. Moreover, the present study demonstrates that women experienced a great deal of pain and discomfort after the caesarean section was performed, and that they found it difficult to return to expected activities. This was managed by a large amount of practical assistance from their social network. Healthcare workers were described as providing medicines, advice, and practical care. Negative experiences in which healthcare workers took money for medicines and refused to help women were also described. Conclusions This study indicates that women locate resources to cope with pain and fear within themselves, while also utilising extended support from social networks and healthcare workers. This confirms that women from all backgrounds in Sierra Leone have access to resources for health and well-being

”For this one, let me take the risk”: why surgical staff continued to perform caesarean sections during the 2014–2016 Ebola epidemic in Sierra Leone

Introduction: Routine health service provision decreased during the 2014-2016 Ebola virus disease (EVD) outbreak in Sierra Leone, while caesarean section (CS) rates at public hospitals did not. It is unknown what made staff provide CS despite the risks of contracting EVD. This study explores Sierra Leonean health worker perspectives of why they continued to provide CS. Methods: This qualitative study documents the experiences of 15 CS providers who worked during the EVD outbreak. We interviewed surgical and non-surgical CS providers who worked at public hospitals that either increased or decreased CS volumes during the outbreak. Hospitals in all four administrative areas of Sierra Leone were included. Semistructured interviews averaged 97 min and healthcare experience 21 years. Transcripts were analysed by modified framework analysis in the NVivo V.11.4.1 software. Results: We identified two themes that may explain why providers performed CS despite EVD risks: (1) clinical adaptability and (2) overcoming the moral dilemmas. CS providers reported being overworked and exposed to infection hazards. However, they developed clinical workarounds to the lack of surgical materials, protective equipment and standard operating procedures until the broader international response introduced formal personal protective equipment and infection prevention and control practices. CS providers reported that dutifulness and sense of responsibility for one's community increased during EVD, which helped them justify taking the risk of being infected. Although most surgical activities were reduced to minimise staff exposure to EVD, staff at public hospitals tended to prioritise performing CS surgery for women with acute obstetric complications. Conclusion: This study found that CS surgery during EVD in Sierra Leone may be explained by remarkable decisions by individual CS providers at public hospitals. They adapted practically to material limitations exacerbated by the outbreak and overcame the moral dilemmas of performing CS despite the risk of being infected with EVD

Evaluation of a surgical task sharing training programme's logbook system in Sierra Leone

Background Personal logbooks are universally applied for monitoring and evaluation of surgical trainees; however, the quality and accuracy of such logbooks in low income countries (LICs) are poorly examined. Logbooks are kept by the individual trainee and detail every surgical procedure they perform and their role during the procedure. The aim of this study was to evaluate the quality of such a logbook system in Sierra Leone and to identify areas of improvement. Methods The last 100 logbook entries for students and graduates participating in a surgical task sharing training programme were compared with hospital records (HRs). The logbook entries were categorized as matching, close matching or over-reported. Moreover, HRs were checked for under-reported procedures. Semi-structured interviews were conducted with the study participants on logbook recording routines. The results were analysed using mixed effects logistic regression models. Results Three thousand one hundred sixty-nine database entries from 35 participants were analysed. Of that amount, 62.2% of the entries matched the HRs, 10.4% were close matches and 26.9% were over-reported. 20.7% of the investigated HRs were under-reported. Conclusions Information gathered from surgical logbook systems must be applied with care, and great efforts must be made to ensure that the logbook systems used provide reliable data. Based on analysis of the logbook data and interviews, focus areas are suggested to ensure reliable logbook data in LICs. Clear instructions and proper training should be provided when introducing the logbook system to the users. The importance of logging all procedures, including minor ones, should be emphasized. The logbook system should be user friendly and only as extensive as necessary. Lastly, keeping the logbooks exclusively digital is recommended, combined with sufficient IT equipment and training

Assessing geographical and economic inequalities in caesarean section rates between the districts of Bihar, India: a secondary analysis of the National Family Health Survey

Background In Bihar, one of the most populous and poorest states in India, caesarean sections have increased over the last decade. However, an aggregated caesarean section rate at the state level may conceal inequities at the district level. Objectives The primary aim of this study was to analyse the inequalities in the geographical and socioeconomic distribution of caesarean sections between the districts of Bihar. The secondary aim was to compare the contribution of free-for-service government-funded public facilities and fee-for-service private facilities to the caesarean section rate. Setting Bihar, with a population in the 2011 census of approximately 104 million people, has a low GDP per capita (US$610), compared with other Indian states. The state has the highest crude birth rate (26.1 per 1000 population) in India, with one baby born every two seconds. Bihar is divided into 38 administrative districts, 101 subdivisions and 534 blocks. Each district has a district (Sadar) hospital, and six districts also have one or more medical college hospitals. Methods This retrospective secondary data analysis was based on open-source national datasets from the 2015 and 2019 National Family Health Surveys, with respective sample sizes of 45 812 and 42 843 women aged 15–49 years. Participants Secondary data analysis of pregnant women delivering in public and private institutions. Results The caesarean section rate increased from 6.2% in 2015 to 9.7% in 2019 in Bihar. Districts with a lower proportion of poor population had higher caesarean section rates (R2=0.45) among all institutional births, with 10.3% in private and 2.9% in public facilities. Access to private caesarean sections decreased (R2=0.46) for districts with poorer populations. Conclusion Marked inequalities exist in access to caesarean sections. The public sector needs to be strengthened to improve access to obstetric services for those who need it most

Admissions and surgery as indicators of hospital functions in Sierra Leone during the west-African Ebola outbreak

Background In an attempt to assess the effects of the Ebola viral disease (EVD) on hospital functions in Sierra Leone, the aim of this study was to evaluate changes in provisions of surgery and non-Ebola admissions during the first year of the EVD outbreak. Methods All hospitals in Sierra Leone known to perform inpatient surgery were assessed for non-Ebola admissions, volume of surgery, caesarean deliveries and inguinal hernia repairs between January 2014 and May 2015, which was a total of 72 weeks. Accumulated weekly data were gathered from readily available hospital records at bi-weekly visits during the peak of the outbreak from September 2014 to May 2015. The Mann-Whitney U test was used to compare weekly median admissions during the first year of the EVD outbreak, with the 20 weeks before the outbreak, and weekly median volume of surgeries performed during the first year of the EVD outbreak with identical weeks of 2012. The manuscript is prepared according to the STROBE checklist for cross-sectional studies. Results Of the 42 hospitals identified, 40 had available data for 94% (2719/2880) of the weeks. There was a 51% decrease in weekly median non-Ebola admissions and 41% fewer weekly median surgeries performed compared with the 20 weeks before the outbreak (admission) and 2012 (volume of surgery). Governmental hospitals experienced a smaller reduction in non-Ebola admissions (45% versus 60%) and surgeries (31% versus 53%) compared to private non-profit hospitals. Governmental hospitals realized an increased volume of cesarean deliveries by 45% during the EVD outbreak, thereby absorbing the 43% reduction observed in the private non-profit hospitals. Conclusions Both non-Ebola admissions and surgeries were severely reduced during the EVD outbreak. In addition to responding to the EVD outbreak, governmental hospitals were able to maintain certain core health systems functions. Volume of surgery is a promising indicator of hospital functions that should be further explored

Perinatal outcomes of cesarean deliveries in Sierra Leone: A prospective multicenter observational study

Objective To analyze the indications for cesarean deliveries and factors associated with adverse perinatal outcomes in Sierra Leone. Methods Between October 2016 and May 2017, patients undergoing cesarean delivery performed by medical doctors and associate clinicians in nine hospitals were included in a prospective observational study. Data were collected perioperatively, at discharge, and during home visits after 30 days. Results In total, 1274 cesarean deliveries were included of which 1099 (86.3%) were performed as emergency surgery. Of the 1376 babies, 261 (19.0%) were perinatal deaths (53 antepartum stillbirths, 155 intrapartum stillbirths, and 53 early neonatal deaths). Indications with the highest perinatal mortality were uterine rupture (45 of 55 [81.8%]), abruptio placentae (61 of 85 [71.8%]), and antepartum hemorrhage (8 of 15 [53.3%]). In the group with cesarean deliveries performed for obstructed and prolonged labor, a partograph was filled out for 212 of 425 (49.9%). However, when completed, babies had 1.81‐fold reduced odds for perinatal death (95% confidence interval 1.03–3.18, P‐value 0.041). Conclusion Cesarean deliveries in Sierra Leone are associated with an exceptionally high perinatal mortality rate of 190 per 1000 births. Late presentation in the facilities and lack of adequate fetal monitoring may be contributing factors

Outcomes After Elective Inguinal Hernia Repair Performed by Associate Clinicians vs Medical Doctors in Sierra Leone: A Randomized Clinical Trial

Importance Task sharing of surgical duties with medical doctors (MDs) without formal surgical training and associate clinicians (ACs; health care workers corresponding to an educational level between that of a nurse and an MD) is practiced to provide surgical services to people in low-resource settings. The safety and effectiveness of this has not been fully evaluated through a randomized clinical trial. Objective To determine whether task sharing with MDs and ACs is safe and effective in mesh hernia repair in Sierra Leone. Design, Setting, and Participants This single-blind, noninferiority randomized clinical trial included adult, healthy men with primary inguinal hernia randomized to receiving surgical treatment from an MD or an AC. In Sierra Leone, ACs practicing surgery have received 2 years of surgical training and completed a 1-year internship. The study was conducted between October 2017 and February 2019. Patients were followed up at 2 weeks and 1 year after operations. Observers were blinded to the study arm of the patients. The study was carried out in a first-level hospital in rural Sierra Leone. Data were analyzed from March to June 2019. Interventions All patients received an open mesh inguinal hernia repair under local anesthesia. The control group underwent operations performed by MDs, and the intervention group underwent operations performed by ACs. Main Outcomes and Measures The primary end point was hernia recurrence at 1 year. Outcomes were assessed by blinded observers at 2 weeks and 1 year after operations. Results A total of 230 patients were recruited (mean [SD] age, 43.0 [13.5] years), and all but 1 patient underwent inguinal hernia repair between October 23, 2017, and February 2, 2018, performed by 5 MDs and 6 ACs. A total of 114 patients were operated on by MDs, and 115 patients were operated on by ACs. There were no crossovers between the study arms. The follow-up rate was 100% at 2 weeks and 94.1% at 1 year. At 1 year, hernia recurrence occurred in 7 patients (6.9%) operated on by MDs and 1 patient (0.9%) operated on by ACs (absolute difference, −6.0 [95% CI, −11.2 to 0.7] percentage points; P < .001). Conclusions and Relevance These findings demonstrate that task sharing of elective mesh inguinal hernia repair with ACs was safe and effective. The task sharing debate should progress to focus on optimizing surgical training programs for nonsurgeons and building capacity for elective surgical care in low- and middle-income co

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Introduction Longer travel times are associated with increased adverse maternal and perinatal outcomes. Geospatial modelling has been increasingly used to estimate geographic proximity in emergency obstetric care. In this study, we aimed to assess the correlation between modelled and patient-reported travel times and to evaluate its clinical relevance. Methods Women who delivered by caesarean section in nine hospitals were followed up with home visits at 1 month and 1 year. Travel times between the location before the delivery and the facility where caesarean section was performed were estimated, based on two models (model I Ouma et al; model II Munoz et al). Patient-reported and modelled travel times were compared applying a univariable linear regression analysis, and the relation between travel time and perinatal mortality was assessed. Results The median reported travel time was 60 min, compared with 13 and 34 min estimated by the two models, respectively. The 2-hour access threshold correlated with a patient-reported travel time of 5.7 hours for model I and 1.8 hours for model II. Longer travel times were associated with transport by boat and ambulance, visiting one or two facilities before reaching the final facility, lower education and poverty. Lower perinatal mortality was found both in the group with a reported travel time of 2 hours or less (193 vs 308 per 1000 births, p<0.001) and a modelled travel time of 2 hours or less (model I: 209 vs 344 per 1000 births, p=0.003; model II: 181 vs 319 per 1000 births, p<0.001). Conclusion The standard model, used to estimate geographical proximity, consistently underestimated the travel time. However, the conservative travel time model corresponded better to patient-reported travel times. The 2-hour threshold as determined by the Lancet Commission on Global Surgery, is clinically relevant with respect to reducing perinatal death, not a clear cut-off