Nonphysician Surgeons Save Lives In Low-Income Countries

Training nurses in caesarean sections and other life-saving surgery could save millions of lives in low and middle-income countries, according to a recent doctoral thesis.

The thesis by obstetrician Caetano Pereira, M.D., presented at the Karolinska Institutet (Stockholm, Sweden) during March 2010, examined the hospital records of 2,071 caesarean sections in Maputo (Mozambique) Central Hospital during one year, to assess the outcomes of major obstetric surgery performed by either formally trained medical specialists or assistant medical officers (AMOs) and técnicos de cirurgia (TCs, surgical technicians). The cost of training and deploying the different cadres of health workers were derived from budget reviews, annual expenditure reports, enrolment registers, accounting statements from training institutions, and interviews with directors and administrators. The researcher also examined hospital records of all deliveries in 2003 at rural, district, provincial, and central hospitals with an operating theatre in Mozambique to determine who was responsible for treatment and outcome for the mother, comparing TCs and AMOs to medical officers.

The results show that the mothers and babies in both groups fared equally well, in that they had an equally low number of complications and the same post-delivery survival rate. The thesis showed that in 2002, TCs and AMOs performed 57% of the 12,178 operations for a caesarean section, ruptured uterus, or ectopic pregnancy for all hospitals with a theatre in Mozambique. In rural (district level) hospitals, they performed 92% of 3,246 operations for these conditions. In provincial and general (urban) hospitals, they performed 34% of 4,175 such operations; and in the three central hospitals, they performed 53% of 4,757 such operations. Almost 90% of the TCs and AMOs included in the studies were still active at these district hospitals in Mozambique seven years after starting there, while all formally trained doctors had left.

"TCs and AMOs carry most of the burden of emergency obstetric surgery in Mozambique and Tanzania; the quality of work is comparable to that of medical officers,” concluded Dr. Pereira in his dissertation. "In Mozambique they are cost-effective and their retention in rural areas, where they are needed most, reaches almost 90% at seven years after graduation, while the corresponding percentage for medical officers is zero.”

In Mozambique and Tanzania, TCs and AMOs, who lack formal medical training, receive 3-years' basic training as nurses, and usually have an average of 7 years practical experience, often of surgery. When calculated in terms of a full working life (30 years), the nonmedically trained health-workers were three times more cost-effective than the doctors.

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Karolinska Institutet