BJOG Inspired
Would you have your emergency caesarean section performed by a non‐physician surgeon? Clearly, the answer would be no for most within the medical profession; however, for a Sierra Leonean woman who has been in obstructed labour for hours or even days, it might be a choice between surgery performed by a Community Health Officer or no surgery at all.
In January 2011 an innovative 2‐year postgraduate Surgical Training Program was launched in Sierra Leone, targeting physicians as well as community health officers. Community health officers have 3 years of basic medical training oriented towards primary health care, but are increasingly found at the secondary healthcare level where they serve as physician assistants. The Norwegian NGO CapaCare established the program in collaboration with the National Ministry of Health (www.capacare.org). As of January 2015, more than 30 students have been enrolled in the Surgical Training Program, 29 Community Health Officers and one Physician. Eleven have passed their final examination and are presently doing their 1‐year housemanship in a government hospital. Two have been posted to district hospitals for clinical duties. During their initial 2‐year training, each candidate will take part in between 650 and 1000 major surgeries, approximately half being emergency obstetric procedures. In 2013 alone, the students collectively took part in 7000 major surgeries as observers (23%), assistants (40%), supervised surgeons (17%) or independent surgeons (20%).
The challenge for Sierra Leone, ranking highest in the world with a maternal mortality ratio of 1100 per 100 000 live births, is the shortage of qualified health workers in combination with a high disease burden. After 10 years of civil war, the country has fewer than 100 doctors, of which seven are obstetricians, serving a population of 6 million, with an estimated 220 000 annual deliveries (Kingham et al. Arch Surg. 2009;144:122–127). The Ebola epidemic may further worsen the human resource crisis.
WHO recommends task shifting to improve access to key maternal and newborn interventions. Surgical task shifting is not new. Since the 1980s, associate clinicians have been trained to perform selected obstetrical procedures, mainly in East Africa. These training interventions have proven cost‐effective, with superior retention of staff at district level (Chao et al. Lancet 2014;2:e334–e345). The shifting of responsibilities to less trained cadres raises ethical considerations about standards of care. A recent meta‐analysis showed equal outcomes after caesarean section performed by associate clinicians and medical doctors (Wilson et al. BMJ2011;342:d2600). While the benefits of a common training duration and defined scope of practice are shared between Sierra Leonean and East African training initiatives, the lack of legal recognition and formal regulations in Sierra Leone for community health officers who have undergone this additional training continues to be contentious.
The international community has ambitiously declared that it is possible for all countries to reach a maternal mortality ratio below 50 within the next 20 years. This will pose challenges for Sierra Leone and require profound investments and innovations in training and the development of human resources.
Disclosure of interests
MM is a trainer in CapaCare's Surgical Training Program in Sierra Leone. HB is the Chairman of CapaCare.
Contribution to authorship
MM conceived the idea and was the primary author. HB was an editing author.
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