A comparison of clinical officers with medical doctors on outcomes of caesarean section in the developing world: meta-analysis of controlled studies

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Abstract

Objective To review the effectiveness and safety of clinical officers (healthcare providers trained to perform tasks usually undertaken by doctors) carrying out caesarean section in developing countries compared with doctors.

Design Systematic review with meta-analysis.

Data sources Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, BioMed Central, the Reproductive Health Library, and the Science Citation Index (inception-2010) without language restriction.

Study selection Controlled studies.

Data extraction Information was extracted from each selected article on study characteristics, quality, and outcome data. Two independent reviewers extracted data.

Results Six non-randomised controlled studies (16 018 women) evaluated the effectiveness of clinical officers carrying out caesarean section. Meta-analysis found no significant differences between the clinical officers and doctors for maternal death (odds ratio 1.46, 95% confidence interval 0.78 to 2.75; P=0.24) or for perinatal death (1.31, 0.87 to 1.95; P=0.19). The results were heterogeneous, with some studies reporting a higher incidence of both outcomes with clinical officers. Clinical officers were associated with a higher incidence of wound infection (1.58, 1.01 to 2.47; P=0.05) and wound dehiscence (1.89, 1.21 to 2.95; P=0.005). Two studies accounted for confounding factors.

Conclusion Clinical officers and doctors did not differ significantly in key outcomes for caesarean section, but the conclusions are tentative owing to the non-randomised nature of the studies. The increase in wound infection and dehiscence may highlight a particular training need for clinical officers.

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Using mid-level cadres as substitutes for internationally mobile health professionals in Africa. A desk review

Delanyo Dovlo (2004)

Background Substitute health workers are cadres who take on some of the functions and roles normally reserved for internationally recognized health professionals such as doctors, pharmacists and nurses but who usually receive shorter pre-service training and possess lower qualifications. Methods A desk review is conducted on the education, regulation, scopes of practice, specialization, nomenclature, retention and cost-effectiveness of substitute health workers in terms of their utilization in countries such as Tanzania, Malawi, Mozambique, Zambia, Ghana etc., using curricula, evaluations and key-informant questionnaires. Results The cost-effectiveness of using substitutes and their relative retention within countries and in rural communities underlies their advantages to African health systems. Some studies comparing clinical officers and doctors show minimal differences in outcomes to patients. Specialized substitutes provide services in disciplines such as surgery, ophthalmology, orthopedics, radiology, dermatology, anesthesiology and dentistry, demonstrating a general bias of use for clinical services. Conclusions The findings raise interest in expanding the use of substitute cadres, as the demands of expanding access to services such as antiretroviral treatment requires substantial human resources capacity. Understanding the roles and conditions under which such cadres best function, and managing the skepticism and professional turf protection that restricts their potential, will assist in effective utilization of substitutes.

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Postoperative outcome of caesarean sections and other major emergency obstetric surgery by clinical officers and medical officers in Malawi

Garvey Chilopora, Caetano Pereira, Francis Kamwendo … (2007)

Background Clinical officers perform much of major emergency surgery in Malawi, in the absence of medical officers. The aim of this study was to validate the advantages and disadvantages of delegation of major obstetric surgery to non-doctors. Methods During a three month period, data from 2131 consecutive obstetric surgeries in 38 district hospitals in Malawi were collected prospectively. The interventions included caesarean sections alone and those that were combined with other interventions such as subtotal and total hysterectomy repair of uterine rupture and tubal ligation. All these surgeries were conducted either by clinical officers or by medical officers. Results During the study period, clinical officers performed 90% of all straight caesarean sections, 70% of those combined with subtotal hysterectomy, 60% of those combined with total hysterectomy and 89% of those combined with repair of uterine rupture. A comparable profile of patients was operated on by clinical officers and medical officers, respectively. Postoperative outcomes were almost identical in the two groups in terms of maternal general condition – both immediately and 24 hours postoperatively – and regarding occurrence of pyrexia, wound infection, wound dehiscence, need for re-operation, neonatal outcome or maternal death. Conclusion Clinical officers perform the bulk of emergency obstetric operations at district hospitals in Malawi. The postoperative outcomes of their procedures are comparable to those of medical officers. Clinical officers constitute a crucial component of the health care team in Malawi for saving maternal and neonatal lives given the scarcity of physicians.

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Mid-level providers in emergency obstetric and newborn health care: factors affecting their performance and retention within the Malawian health system

Susan Bradley, Eilish McAuliffe (2009)

Background Malawi has a chronic shortage of human resources for health. This has a significant impact on maternal health, with mortality rates amongst the highest in the world. Mid-level cadres of health workers provide the bulk of emergency obstetric and neonatal care. In this context these cadres are defined as those who undertake roles and tasks that are more usually the province of internationally recognised cadres, such as doctors and nurses. While there have been several studies addressing retention factors for doctors and registered nurses, data and studies addressing the perceptions of these mid-level cadres on the factors that influence their performance and retention within health care systems are scarce. Methods This exploratory qualitative study took place in four rural mission hospitals in Malawi. The study population was mid-level providers of emergency obstetric and neonatal care. Focus group discussions took place with nursing and medical cadres. Semi-structured interviews with key human resources, training and administrative personnel were used to provide context and background. Data were analysed using a framework analysis. Results Participants confirmed the difficulties of their working conditions and the clear commitment they have to serving the rural Malawian population. Although insufficient financial remuneration had a negative impact on retention and performance, the main factors identified were limited opportunities for career development and further education (particularly for clinical officers) and inadequate or non-existent human resources management systems. The lack of performance-related rewards and recognition were perceived to be particularly demotivating. Conclusion Mid-level cadres are being used to stem Africa's brain drain. It is in the interests of both the government and mission organizations to protect their investment in these workers. For optimal performance and quality of care they need to be supported and properly motivated. A structured system of continuing professional development and functioning human resources management would show commitment to these cadres and support them as professionals. Action needs to be taken to prevent staff members from leaving the health sector for less stressful, more financially rewarding alternatives.

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Author and article information

Contributors

: Role: doctoral researcher

: Role: clinical research fellow

: Role: senior lecturer in obstetrics and maternal medicine

: Role: professor of women’s health and clinical epidemiology

: Role: professor of maternal and child epidemiology

: Role: reader in reproductive medicine and gynaecology

Journal

Journal ID (nlm-ta): BMJ

Journal ID (publisher-id): bmj

Title: BMJ : British Medical Journal

Publisher: BMJ Publishing Group Ltd.

ISSN (Print): 0959-8138

ISSN (Electronic): 1756-1833

Publication date Collection: 2011

Publication date (Print): 2011

Publication date (Electronic): 13 May 2011

Volume: 342

Electronic Location Identifier: d2600

Affiliations

[1 ]School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK

[2 ]Centre for Health Sciences, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK

[3 ]School of Health and Population Sciences, College of Medical and Dental Sciences, University of Birmingham, UK

Author notes

Correspondence to: A Coomarasamy, Academic Unit (University of Birmingham), Birmingham Women’s Foundation Trust, Birmingham B15 2TG, UK a.coomarasamy@ 123456bham.ac.uk

Article

Publisher ID: wila825091

DOI: 10.1136/bmj.d2600

PMC ID: 3272986

PubMed ID: 21571914

SO-VID: 30edabcb-88fa-47bd-847d-b766b0032c26

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

A comparison of clinical officers with medical doctors on outcomes of caesarean section in the developing world: meta-analysis of controlled studies

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Most cited references 10

Using mid-level cadres as substitutes for internationally mobile health professionals in Africa. A desk review

Postoperative outcome of caesarean sections and other major emergency obstetric surgery by clinical officers and medical officers in Malawi

Mid-level providers in emergency obstetric and newborn health care: factors affecting their performance and retention within the Malawian health system

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