Caesarean Sections in Sierra Leone An Evaluation in the Light of the Lancet Global Surgery Indicators

Abstract

Background: Two third of the world’s population does not have adequate access to timely safe and affordable surgical services. The Lancet Commission on Global Surgery has defined a framework with six indicators and targets to evaluate preparedness, service delivery and financial impact of surgical services. In Sierra Leone, insufficient access to emergency obstetric and surgical services has led to poor maternal and perinatal outcomes. To improve access to caesarean sections, the Free Health Care Initiative was implemented to abolish user fees for obstetric and paediatric care. In addition, a task-sharing training programme for associate clinicians has been introduced to increase the surgical workforce. Aims: The aim of thesis was to evaluate caesarean sections in Sierra Leone performed by associate clinicians and medical doctors using the framework of the Lancet Commissions on Global Surgery indicators. The thesis specifically aimed to: I. compare the outcome of caesarean sections performed by associate clinicians and medical doctors, II. analyse factors associated with perinatal death, III. evaluate catastrophic expenditure, impoverishment and the impact of the Free Health Care Initiative, and IV. assess patient reported and geospatial modelled travel time. Methods: A prospective observational multicentre non-inferiority study was applied in all hospitals where both associate clinicians and medical doctors performed caesarean sections in 2016. Women undergoing caesarean section, either performed by associate clinicians or medical doctors, were included in the study and were followed with home visits after 30 days. Data on obstetric history, indication, travel time, household characteristics, health expenditure, and maternal and neonatal outcomes were collected. Individual income was estimated based on household characteristics and further used to determine impoverishing and catastrophic expenditure. The impact of the Free Health Care Initiative was assessed using a counterfactual scenario. Geospatial modelled travel times were generated based on two models and compared with patient reported travel time. Findings: Between October 2016 and May 2017, 1,728 caesarean sections were done by either associate clinicians or medical doctors in the nine study hospitals. Of those, 1,274 women and 1,376 babies were included in the study and 1,161 women (91.1%) were successfully followed up with a home visit. Medical doctors performed a higher proportion of caesarean sections outside office hours, while associate clinicians did more surgeries for twin pregnancies. The 30-day perioperative maternal mortality was 0.2% (1 of 443) in the associate clinician group and 1.8% (15 of 831) in the medical doctor group (crude odds ratio 0.12, 90% confidence interval 0.01 to 0.67). Of the 1,376 babies, 261 (19.0%) were perinatal deaths. Indications with the highest perinatal mortality were uterine rupture, abruptio placentae, and antepartum haemorrhage. The median expenditure was 23 international dollars, with travel and food being the largest expenses. Patients in the poorest quintile had significantly higher healthcare related expenses compared to patients in the richest quintile. Catastrophic expenditure was encountered by 12.0% and 4.0% (10% and 25% threshold, respectively) of the women and without the Free Health Care Initiative, 66.1% and 28.8% of the women would have encountered catastrophic expenditure. The median reported travel time was 60 minutes, compared with 13 and 34 minutes estimated by the two models, respectively. Longer travel times were associated with poverty, low or no education, transport by ambulance or boat, and visiting one or two health facilities before reaching the final hospital where the caesarean section war performed. Higher perinatal mortality was identified in the group with a reported and modelled travel time of 2 hours or more. Significance.: Caesarean sections in Sierra Leone - an evaluation in the light of the Lancet Global Surgery Indicators has provided more insight in the preparedness, service delivery and financial impact of caesarean sections in Sierra Leone. This thesis has documented noninferiority of caesarean sections performed by associate clinicians compared to medical doctors based on prospective data collection. It has also provided new insights in the associated factors of the high perinatal mortality related to caesarean sections. In addition, it has expanded the understanding of modelled travel time compared to patient-reported travel time. Finally, it has shown the effect of the Free Health Care Initiative on catastrophic expenditure and impoverishment