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Impact of Medical Doctors Global Health and Tropical Medicine on decision-making in caesarean section: a pre- and post-implementation study in a rural hospital in Malawi.

ABSTRACT: BACKGROUND:Medical doctors with postgraduate training in Global Health and Tropical Medicine (MDGHTM) from the Netherlands, a high-income country with a relatively low caesarean section rate, assist associate clinicians in low-income countries regarding decision-making during labour. Objective of this study was to assess impact of the presence of MDGHTMs in a rural Malawian hospital on caesarean section rate and indications. METHODS:This retrospective pre- and post-implementation study was conducted in a rural hospital in Malawi, where MDGHTMs were employed from April 2015. Indications for caesarean section were audited against national protocols and defined as supported or unsupported by these protocols. Caesarean section rates and numbers of unsupported indications for the years 2015 and 2016 per quarter for different staff cadres were assessed by linear regression. RESULTS:Six hundred forty-five women gave birth by caesarean section in the study period. The caesarean rate dropped from 20.1 to 12.8% (p < 0.05, R2 = 0.53, y = - 0.0086x + 0.2295). Overall 132 of 501 (26.3%) auditable indications were not supported by documentation in medical records. The proportion of unsupported indications dropped significantly over time from 47.0 to 4.4% (p < 0.01, R2 = 0.71, y = - 0.0481x + 0.4759). Stratified analysis for associate clinicians only (excluding caesarean sections performed by medical doctors) showed a similar decrease from 48.3 to 6.5% (p < 0.05, R2 = 0.55, y = - 0.0442x + 0.4805). CONCLUSIONS:Our results indicate that presence of MDGHTMs was accompanied by considerable decreases in caesarean section rate and proportion of unsupported indications for caesarean section in this facility. Their presence is likely to have influenced decision-making by associate clinicians.

SUBMITTER: Bakker W

PROVIDER: S-EPMC7650186 | biostudies-literature | 2020 Nov

REPOSITORIES: biostudies-literature

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Impact of Medical Doctors Global Health and Tropical Medicine on decision-making in caesarean section: a pre- and post-implementation study in a rural hospital in Malawi.

Bakker Wouter W Bakker Emma E Huigens Christiaan C Kaunda Emily E Phiri Timothy T Beltman Jogchum J van Roosmalen Jos J van den Akker Thomas T

Human resources for health 20201109 1

<h4>Background</h4>Medical doctors with postgraduate training in Global Health and Tropical Medicine (MDGHTM) from the Netherlands, a high-income country with a relatively low caesarean section rate, assist associate clinicians in low-income countries regarding decision-making during labour. Objective of this study was to assess impact of the presence of MDGHTMs in a rural Malawian hospital on caesarean section rate and indications.<h4>Methods</h4>This retrospective pre- and post-implementation ...[more]

PMID: 33168014

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Project description:BackgroundCaesarean section (CS) is not recommended for PMTCT in Malawi HIV Guidelines, contrary to most high-income countries where CS is indicated if viral suppression is sub-optimal pre-delivery. We describe patterns of CS in HIV-infected and uninfected women in Malawi and explored if insight into the use of Elective CS (ECS) for PMTCT could be obtained.MethodsWe used routinely collected data from individual medical records from 17 large health facilities in the central and southern regions of Malawi, from January 2010 to December 2013. We included data from maternity registers from all HIV-positive women, and randomly selected around every fourth woman with negative or unknown HIV status. We used multivariable logistic regressions and cluster-based robust standard errors to examine independent associations of patient- and facility characteristics with CS and ECS.ResultsWe included 62,033 women in the analysis. The weighted percentage of women who had a spontaneous vaginal delivery was 80.0% (CI 95% 79.5-80.4%); 2.4% (95% CI 2.3-2.6%) had a vacuum extraction; 2.3% (95% CI 2.2-2.5%) had a vaginal breech delivery; 14.0% (95% CI 13.6-14.4%) had a CS while for 1.3% (95% CI 1.2-1.4%) the mode of delivery was not recorded. Prevalence of CS without recorded medical or obstetric indication (ECS) was 5.1%, (n = 3152). Presence of maternal and infant complications and older age were independently associated with CS delivery. HIV-positive women were less likely to have ECS than HIV negative women (aOR 0.65; 95%-CI 0.57-0.74). Among HIV-positive women, those on antiretrovirals (ARV's) for ≥4 weeks prior to delivery were less likely to have ECS than HIV-positive women who had not received ARVs during pregnancy (aOR 0.81; 95% CI 0.68-0.96).ConclusionsThe pattern of CS's in Malawi is largely determined by maternal and infant complications. Positive HIV status was negatively associated with CS delivery, possibly because health care workers were concerned about the risk of occupational HIV transmission and the known increased risk of post-operative complications. Our results leave open the possibility that CS is practiced to prevent MTCT given that ECS was more common among women at high risk of MTCT due to no or short exposure to ARV's.

Project description:ObjectiveSurgical informed consent is essential prior to caesarean section, but potentially compromised by insufficient communication. We assessed the association between a multicomponent intervention and women's recollection of information pertaining to informed consent for caesarean section in a low-resource setting, thereby contributing to respectful maternity care.DesignPre-post implementation survey, conducted from January to June 2018, surveying women prior to discharge.SettingRural 150-bed mission hospital in Southern Malawi.ParticipantsA total of 160 postoperative women were included: 80 preimplementation and 80 postimplementation.InterventionBased on observed deficiencies and input from local stakeholders, a multicomponent intervention was developed, consisting of a standardised checklist, wall poster with a six-step guide and on-the-job communication training for health workers.Primary and secondary outcome measuresIndividual components of informed consent were: indication, explanation of procedure, common complications, implications for future pregnancies and verbal enquiry of consent, which were compared preintervention and postintervention using χ2 test. Generalised linear models were used to analyse incompleteness scores and recollection of the informed consent process.ResultsThe proportion of women who recollected being informed about procedure-related risks increased from 25/80 to 47/80 (OR 3.13 (95% CI 1.64 to 6.00)). Recollection of an explanation of the procedure changed from 44/80 to 55/80 (OR 1.80 (0.94 to 3.44)), implications for future pregnancy from 25/80 to 47/80 (1.69 (0.89 to 3.20)) and of consent enquiry from 67/80 to 73/80 (OR 2.02 (0.73 to 5.37)). After controlling for other variables, incompleteness scores postintervention were 26% lower (Exp(β)=0.74; 95% CI 0.57 to 0.96). Recollection of common complications increased with 0.25 complications (β=0.25; 95% CI 0.01 to 0.49). Recollection of the correct indication did not differ significantly.ConclusionRecollection of informed consent for caesarean section changed significantly in the postintervention group. Obtaining informed consent for caesarean section is one of the essential components of respectful maternity care.

Project description:BackgroundCaesarean section rates are increasing worldwide and are a growing concern with limited explanation of the factors that influence the rising trend. Understanding obstetricians' and midwives' views can give insight to the problem. This systematic review aimed to offer insight and understanding, through aggregation, summary, synthesis and interpretation of findings from studies that report obstetricians' and midwives' views on the factors that influence the decision to perform caesarean section.MethodsThe electronic databases of PubMed (1958-2016), CINAHL (1988-2016), Maternity and Infant Care (1971-2016), PsycINFO (1980-2016) and Web of Science (1991-2016) were searched in September 2016. All quantitative, qualitative and mixed methods studies, published in English, whose aim was to explore obstetricians' and/or midwives' views of factors influencing decision-making for caesarean section were included. Papers were independently reviewed by two authors for selection by title, abstract and full text. Thomas et al's 12 assessment criteria checklist (2003) was used to assess methodological quality of the included studies.ResultThe review included 34 studies: 19 quantitative, 14 qualitative, and one using mixed methods, involving 7785 obstetricians and 1197 midwives from 20 countries. Three main themes, each with several subthemes, emerged. Theme 1: "clinicians' personal beliefs"-('Professional philosophies'; 'beliefs in relation to women's request for CS'; 'ambiguous versus clear clinical reasons'); Theme 2: "health care systems"-('litigation'; 'resources'; 'private versus public/insurance/payments'; 'guidelines and management policy'). Theme 3: "clinicians' characteristics" ('personal convenience'; 'clinicians' demographics'; 'confidence and skills').ConclusionThis systematic review and metasynthesis identified clinicians' personal beliefs as a major factor that influenced the decision to perform caesarean section, further contributed by the influence of factors related to the health care system and clinicians' characteristics. Obstetricians and midwives are directly involved in the decision to perform a caesarean section, hence their perspectives are vital in understanding various factors that have influence on decision-making for caesarean section. These results can help clinicians identify and acknowledge their role as crucial members in the decision-making process for caesarean section within their organisation, and to develop intervention studies to reduce caesarean section rates in future.

Project description:OBJECTIVES:To explore the reasons that doctors choose to leave UK medicine after their foundation year two posts. SETTING:All four regions of Scotland. PARTICIPANTS:Foundation year two doctors (F2s) working throughout Scotland who were considering leaving UK medicine after foundation training were recruited on a volunteer basis. Maximum variation between participants was sought. PRIMARY AND SECONDARY OUTCOME MEASURES:Semistructured interviews were coded using template analysis. Six perspectives, described by Feldman and Ng, were used as the initial coding template. The codes were then configured to form a framework that explores the interplay of factors influencing Foundation Year 2 (F2) doctors' decisions to leave UK medicine. RESULTS:Seventeen participants were interviewed. Six perspectives were explored. Structural influences (countrywide and worldwide issues) included visas, economic and political considerations, structure of healthcare systems and availability of junior doctor jobs worldwide. Organisational influences (the National Health Service (NHS) and other healthcare providers) included staffing and compensation policies, the working environment and the learning environment. Occupational influences (specific to being a junior doctor) comprised the junior doctor contract, role and workload, pursuit of career interests and the structure of training. Work group influences (relationships with colleagues) included support at work, task interdependence and use of locums. Personal life influences consisted of work-life balance, and support in resolving work-life conflict. The underlying theme of 'taking a break' recurred through multiple narratives. CONCLUSIONS:F2s give reasons similar to those given by any professional considering a change in their job. However, working within the NHS as an F2 doctor brought specific challenges, such as a need to make a choice of specialty within the F2 year, exposure to workplace bullying and difficulties in raising concerns. Despite these challenges, most F2s did not view their decision to leave as a permanent job change, but as a temporary break from their current working lives.

Project description:BackgroundCaesarean section rates are rising across all geographical regions. Very high rates for some groups of women co-occur with very low rates for others. Both extremes are associated with short and longer term harms. This is a major public health concern. Making the most effective use of caesarean section is a critical component of good quality, sustainable maternity care. In 2018, the World Health Organization published evidence-based recommendations on non-clinical interventions to reduce unnecessary caesarean section. The guideline identified critical research gaps and called for formative research to be conducted ahead of any interventional research to define locally relevant determinants of caesarean birth and factors that may affect implementation of multifaceted optimisation strategies. This generic formative research protocol is designed as a guide for contextual assessment and understanding for anyone planning to take action to optimise the use of caesarean section.MethodsThis formative protocol has three main components: (1) document review; (2) readiness assessment; and (3) primary qualitative research with women, healthcare providers and administrators. The document review and readiness assessment include tools for local mapping of policies, protocols, practices and organisation of care to describe and assess the service context ahead of implementation. The qualitative research is organized according to twelve identified interventions that may optimise use of caesarean section. Each intervention is designed as a "module" and includes a description of the intervention, supporting evidence, theory of change, and in-depth interview/focus group discussion guides. All study instruments are included in this protocol.DiscussionThis generic protocol is designed to underpin the formative stage of implementation research relating to optimal use of caesarean section. We encourage researchers, policy-makers and ministries of health to adapt and adopt this design to their context, and share their findings as a catalyst for rapid uptake of what works.

Dataset Information

Impact of Medical Doctors Global Health and Tropical Medicine on decision-making in caesarean section: a pre- and post-implementation study in a rural hospital in Malawi.

Publications

Impact of Medical Doctors Global Health and Tropical Medicine on decision-making in caesarean section: a pre- and post-implementation study in a rural hospital in Malawi.

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