Should midwives be trained to perform caesarean sections?
Mar 16, 2008
LIKE any new mother, Tereza was looking forward to the arrival of her baby with much anticipation. She had attended the antenatal clinics faithfully and the midwives had told her everything was fine.
By Irene Nabusoba
LIKE any new mother, Tereza was looking forward to the arrival of her baby with much anticipation. She had attended the antenatal clinics faithfully and the midwives had told her everything was fine.
However, her blood pressure shot up during labour and there was no doctor to perform an emergency caesarean birth at the centre where she was booked. Tereza was referred to the regional hospital, which was 28km away from the health centre.
But a combination of the distance and the poor means of transport could not allow her or her baby a second lease on life. Both died on the way.
This is the sad reality for many women, especially in rural areas, where becoming pregnant is not a cause for joy but for fear, not a celebration of new life but an acceptance that death in childbirth is a very real possibility.
But participants at the just concluded First Global Forum on Human Resources for Health conference in Munyonyo believe there could be a solution to this problem.
They believe that training midlevel health professionals such as clinical officers and midwives to provide essential clinical and surgical services could save mothers’ lives.
Delegates at the conference argued that employment of well-trained midlevel health workers would ease human resource constraints caused by loss of doctors to international migration or reluctance to be deployed to rural areas. It is also cheaper.
Training one doctor alone costs18m, says Dr Daniel Zaake, the vice president of Uganda Medical Association. By contrast, training a nurse costs 2.5m a year.
There is indeed cause for concern. In Uganda, 15% of all pregnancies end up with life- threatening complications, many of which cannot be detected or predicted during antenatal care.
They include obstructed or prolonged labour, high blood pressure and bleeding. As a result, about 16 pregnant women die everyday while for very woman that dies, six survive with complications.
Unfortunately, while many of these deaths can be prevented through emergency obstetric care, which includes caesarean sections, blood transfusion, and administration of drugs to stop bleeding, many of the primary providers of health care are only trained to provide the basics but not to carry out life-saving caesarean sections and blood transfusions.
Margaret Kabanga, the principle of Mulago School of Nursing and Midwifery says that midwives and nurses’ training does not include C-sections.
“Only doctors do it.
But other emergency obstetric care, we teach it to midwives and diploma comprehensive nurses. Nonetheless, if they trained our nurses well, they would deliver the same services.â€
Dr. Pius Okong, a gynecologist from St. Francis Hospital Nsambya explains that the failure of health professionals at lower level to provide obstetric care means that they have to refer mothers to bigger hospitals like Nsambya.
“Unfortunately such referrals push up maternal and neonatal deaths at our facility because they are often late. Even most of the admissions in the neonatal intensive care unit are a result of these referrals,†Okong says.
The picture is even graver in upcountry and hard- to- reach areas where transport and communication is a nightmare.
But research shows that obstetric care can be performed safely by well-trained midlevel providers. Research in Malawi Mozambique and Tanzania found no differences between emergency care provided by doctors and clinical officers or midwives, according to Dr. Staffan Bergstrom, of the department of health at the Karolinska Institute in Sweden,and one of the authors of the research report.
The one-year study of all public hospitals in Malawi and Mozambique, as well as two regions in Tanzania showed that over 80% of Caeserean-sections and other obstetric surgery is performed by mid level professionals.
The research is part of a four-year project launched in 2007 by Realising Rights – a part of a global partnership led by the ‘Averting Maternal Death and Disability program at Columbia University.
The programme, Health Systems Strengthening for Equity: The Power and Potential of the Mid-level Provider is an innovative research and advocacy initiative to highlight the role of mid-level providers in health care delivery.
It’s meant to strengthen health systems in Africa by building evidence on the role of mid-level providers in maternal and newborn health.
Dr. Sam Luboga, the deputy dean of Makerere University’s medical school believes the research findings are significant. “There are real challenges of convincing these people to go upcountry even to just do the monitoring role.
Most of our health centres are manned by clinical officers, midwives, and nurses who are not well qualified to provide services like caesarean-sections. With adequate training, it’s worth considering this model,†Luboga says.
Dr. Zaake adds that training midlevel providers to provide obstetric care would be effective in improving maternal and neonatal health.
“We are only 100 gynaecologists,†he says of a country with about 1.2m pregnancies every year.
“Of course it would take policy and training but supervision is most important. If gynaecologists can go there (rural facilities) at least once a week or twice a month to monitor their activities, it would immensely cut the maternal mortality rates,†he says.
There are many reasons to justify training midwives and clinical officers to handle more comprehensive obstetric care. Of all the doctors who graduate in Uganda, 30% migrate to work abroad.
According to the 2007-2015 Road Map for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity in Uganda, a government policy framework on maternal health, only 24% of pregnant women who need obstetric care receive it.
The World Health Organisation estimates that 5%-15% of all pregnant women should receive caesarean sections to save their lives- only 2.7%, of women in Uganda do so.
But while many health professionals are in support of training mid level professionals, others fear that there may be poorer clinical decision-making for complex cases, lack of practice regulation and inter-professional conflict.
They argue that any proposal to use non-physicians for surgical procedures or any medical role is unlikely to be widely accepted without scepticism . Kabanga acknowledges this but argues that with changes in the training curriculum such concerns would be addressed.
“Our rural mothers are dying because the doctors are not enough and available,†she says.
Dr. Anthony Mbonye, assistant commissioner for reproductive health in the ministry of health says that employing mid level professionals could help reduce maternal and infant deaths if health facilities are well equipped and supervision is serious.
“It is a good approach because it would mean that more mothers would access quality services at lower levels. We are working on a policy called task shifting where some of the roles that were executed by doctors can be done by midlevel providers.
We need a serious mechanism on training and supervision. We also need a very well equipped facility with operational theatres, anesthetists, and blood transfusion services,†he says.
LIKE any new mother, Tereza was looking forward to the arrival of her baby with much anticipation. She had attended the antenatal clinics faithfully and the midwives had told her everything was fine.
However, her blood pressure shot up during labour and there was no doctor to perform an emergency caesarean birth at the centre where she was booked. Tereza was referred to the regional hospital, which was 28km away from the health centre.
But a combination of the distance and the poor means of transport could not allow her or her baby a second lease on life. Both died on the way.
This is the sad reality for many women, especially in rural areas, where becoming pregnant is not a cause for joy but for fear, not a celebration of new life but an acceptance that death in childbirth is a very real possibility.
But participants at the just concluded First Global Forum on Human Resources for Health conference in Munyonyo believe there could be a solution to this problem.
They believe that training midlevel health professionals such as clinical officers and midwives to provide essential clinical and surgical services could save mothers’ lives.
Delegates at the conference argued that employment of well-trained midlevel health workers would ease human resource constraints caused by loss of doctors to international migration or reluctance to be deployed to rural areas. It is also cheaper.
Training one doctor alone costs18m, says Dr Daniel Zaake, the vice president of Uganda Medical Association. By contrast, training a nurse costs 2.5m a year.
There is indeed cause for concern. In Uganda, 15% of all pregnancies end up with life- threatening complications, many of which cannot be detected or predicted during antenatal care.
They include obstructed or prolonged labour, high blood pressure and bleeding. As a result, about 16 pregnant women die everyday while for very woman that dies, six survive with complications.
Unfortunately, while many of these deaths can be prevented through emergency obstetric care, which includes caesarean sections, blood transfusion, and administration of drugs to stop bleeding, many of the primary providers of health care are only trained to provide the basics but not to carry out life-saving caesarean sections and blood transfusions.
Margaret Kabanga, the principle of Mulago School of Nursing and Midwifery says that midwives and nurses’ training does not include C-sections.
“Only doctors do it.
But other emergency obstetric care, we teach it to midwives and diploma comprehensive nurses. Nonetheless, if they trained our nurses well, they would deliver the same services.â€
Dr. Pius Okong, a gynecologist from St. Francis Hospital Nsambya explains that the failure of health professionals at lower level to provide obstetric care means that they have to refer mothers to bigger hospitals like Nsambya.
“Unfortunately such referrals push up maternal and neonatal deaths at our facility because they are often late. Even most of the admissions in the neonatal intensive care unit are a result of these referrals,†Okong says.
The picture is even graver in upcountry and hard- to- reach areas where transport and communication is a nightmare.
But research shows that obstetric care can be performed safely by well-trained midlevel providers. Research in Malawi Mozambique and Tanzania found no differences between emergency care provided by doctors and clinical officers or midwives, according to Dr. Staffan Bergstrom, of the department of health at the Karolinska Institute in Sweden,and one of the authors of the research report.
The one-year study of all public hospitals in Malawi and Mozambique, as well as two regions in Tanzania showed that over 80% of Caeserean-sections and other obstetric surgery is performed by mid level professionals.
The research is part of a four-year project launched in 2007 by Realising Rights – a part of a global partnership led by the ‘Averting Maternal Death and Disability program at Columbia University.
The programme, Health Systems Strengthening for Equity: The Power and Potential of the Mid-level Provider is an innovative research and advocacy initiative to highlight the role of mid-level providers in health care delivery.
It’s meant to strengthen health systems in Africa by building evidence on the role of mid-level providers in maternal and newborn health.
Dr. Sam Luboga, the deputy dean of Makerere University’s medical school believes the research findings are significant. “There are real challenges of convincing these people to go upcountry even to just do the monitoring role.
Most of our health centres are manned by clinical officers, midwives, and nurses who are not well qualified to provide services like caesarean-sections. With adequate training, it’s worth considering this model,†Luboga says.
Dr. Zaake adds that training midlevel providers to provide obstetric care would be effective in improving maternal and neonatal health.
“We are only 100 gynaecologists,†he says of a country with about 1.2m pregnancies every year.
“Of course it would take policy and training but supervision is most important. If gynaecologists can go there (rural facilities) at least once a week or twice a month to monitor their activities, it would immensely cut the maternal mortality rates,†he says.
There are many reasons to justify training midwives and clinical officers to handle more comprehensive obstetric care. Of all the doctors who graduate in Uganda, 30% migrate to work abroad.
According to the 2007-2015 Road Map for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity in Uganda, a government policy framework on maternal health, only 24% of pregnant women who need obstetric care receive it.
The World Health Organisation estimates that 5%-15% of all pregnant women should receive caesarean sections to save their lives- only 2.7%, of women in Uganda do so.
But while many health professionals are in support of training mid level professionals, others fear that there may be poorer clinical decision-making for complex cases, lack of practice regulation and inter-professional conflict.
They argue that any proposal to use non-physicians for surgical procedures or any medical role is unlikely to be widely accepted without scepticism . Kabanga acknowledges this but argues that with changes in the training curriculum such concerns would be addressed.
“Our rural mothers are dying because the doctors are not enough and available,†she says.
Dr. Anthony Mbonye, assistant commissioner for reproductive health in the ministry of health says that employing mid level professionals could help reduce maternal and infant deaths if health facilities are well equipped and supervision is serious.
“It is a good approach because it would mean that more mothers would access quality services at lower levels. We are working on a policy called task shifting where some of the roles that were executed by doctors can be done by midlevel providers.
We need a serious mechanism on training and supervision. We also need a very well equipped facility with operational theatres, anesthetists, and blood transfusion services,†he says.