Task-shifting for saving mothers – Vital Strategies shows the way

Non-physician clinicians can be trained in obstetric surgery and anaesthesia to save mothers, a US-based public health experts’ platform, Vital Strategies, has showed to the world.

“It’s possible. We have done it successfully,” Dr Nguke Mwakatundu, said Vital Strategies Country Director in Tanzania, where the experiment had been done.

He was talking to bdnews24.com on Thursday on the sidelines of the ‘Women Deliver’ conference in Copenhagen, where Vital Strategies, formally known as the World Lung Foundation, displayed its works.

It set out to upgrade rural Tanzanian health centre to provide comprehensive emergency obstetric and neonatal care (CEmONC) with the support of Bloomberg Philanthropies since 2008 and the Fondation H&B Agerup since 2012.

At that time, CEmONC services were only available at hospitals, located hours away for most rural women facing potentially life-threatening obstetric complications.

Vital Strategies trained non-physician clinicians, known globally as ‘associate clinicians’, in obstetric surgery and anaesthesia, built operating theatres, set up facilities with equipment, supplies and medication.

They also provided mentoring, supervision and continuing medical education to health providers.

Delivering CEmONC services in rural health centres had not been tried in Tanzania at that time and most people were sceptical that it would work.

But the Vital Strategies team proved them wrong.  A recent article published in PLOS ONE journal shows that: “It can be done.  You can completely transform a health centre to provide surgery!”

The article shows, between 2009 and 2014, the use of supported facilities by the local population increased dramatically; deliveries increased by 151 percent in the first year after CEmONC services were introduced.

At the same time, health providers at the health centres raised their competency. Over the five years, they performed 2,890 caesarean sections and their obstetric referral rate decreased by 67 percent.

During the study period, health centres had lower institutional maternal mortality ratios than their corresponding district hospitals.

The country director, Dr Mwakatundu, said there was “no error, no malpractice because we follow them up every month.”

“We audit them (providers) on a monthly basis and we hold meetings with them and look into the cases they managed, so that they understand how to do better the next time.”

“We did not find any deaths because of the providers,” he said.

Bangladesh is grappling to keep Emergency Obstetric Care (EmOC) facilities at sub-district level functional, which is needed to manage complicated referral cases.

The biggest challenge is to keep pairs of surgeons and anaesthetists at those EmOC facilities. Now, in most of the places, women have to travel to far-off district facilities.

There is also a national shortage of anaesthetists prompting some experts to suggest the training of nurses by the government to administer spinal anaesthesia for caesarean deliveries.

But doctor anaesthetics have blocked such efforts, arguing nurses will not be up to the job and there will be chances of malpractices. But the Tanzanian experience can be an eye-opener for them.

Dr Mwakatundu said the Tanzania health ministry was “very supportive” of the introduction of the new system, “so they (non-physician clinicians) are allowed to do C-section, though they are not called specialists.”

“It has been proven in other areas of the world that task-shifting works,” he said. Besides, the medical association was also “receptive”, something, he said, was “very important”.

Dr Mwakatundu said they also trained providers to use ‘vacuum extraction’ when needed to avoid unnecessary caesarean section.

In vacuum extraction, a health care provider applies the vacuum — a soft or rigid cup with a handle and a vacuum pump — to the baby's head to help guide the baby out of the birth canal.