Malawi Medical Journal 28 (3): September 2016

College of Medicine Silver Jubilee Special Issue Outcomes of emergency obstetric surgery 94

Research Article (Human Resources for Health)

Postoperative outcome of caesarean sections and
other major emergency obstetric surgery by clinical
officers and medical officers in Malawi
Garvey Chilopora1, Caetano Pereira2,3, Francis Kamwendo1, Agnes Chimbiri4, Eddie Malunga1 and
Staffan Bergstrm3
1. Department of Obstetrics and Gynaecology, University of Malawi, College of Medicine, Blantyre, Malawi
2. Instituto Superior de Cincias de Sade, Maputo, Mozambique,
3. Division of International Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
4. Centre for Reproductive Health, University of Malawi, College of Medicine, Blantyre, Malawi

Correspondence to: Staffan Bergstrm (staffan.bergstrom@ki.se)

Abstract
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.
Conclusions
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.

Background
Malawi, like many other countries in sub-Saharan Africa
is facing a critical shortage of human resources across
all cadres in the health sector. Due to the high cost of
training medical doctors and other health personnel, the
country has been faced with a chronic underproduction of
health care personnel. At 1:62 000, the present doctor-to-
population ratio is one of the worlds lowest.1 The Ministry
of Health declared this shortage a crisis in early 2004.2 With
the help of donor funds, the government embarked on a
six year Emergency Human Resource Programme aimed
at improving staff recruitment and retention in the public
sector.2,3
HIV/AIDS has taken a significant toll on health care
providers. An initial Human Resources Development Plan
1999 to 2004 assumed an annual HIV/AIDS-related attrition
of 2.8%.4 However, this is thought to be an underestimate.
In addition to AIDS-related deaths, health personnel have
This article originally appeared in Human Resources for Health
Citation: Chilopora G, Pereira C, Kamwendo F, Chimbiri A, Malunga E,
Bergstrm S. Postoperative outcome of caesarean sections and other major
emergency obstetric surgery by clinical officers and medical officers in Malawi.
Hum Resour Health. 2007 Jun 14;5:17.
doi: 10.1186/1478-4491-5-17
(Published 14 June 2007)
2007 Chilopora et al; licensee BioMed Central Ltd.
Open access article republished under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0)
left the profession for other less risky professions for fear
of being exposed to the disease. A lot of staff time has
also been lost through prolonged periods of illness, funeral
attendance and caring for sick relatives.3,5 The migration of
health professionals, notably doctors and nurses, to high
income countries has also had a large contribution to the
worsening human resource situation in countries that can
least afford the depletion of human resources for health,
including Malawi.5 However this raises a conflict between
the individuals right to travel and the countrys need for an
adequate health workforce.6
Against this background, Malawi has to live up to the
challenge of meeting the Millennium Development Goal
(MDG) number 5, i.e. to reduce maternal mortality by
75% based on the level in 1990 within the next eight
years. Success stories from Sri Lanka7 and Malaysia8 point
to human resources as a crucial factor in reducing maternal
mortality. In order to cope with the ever-increasing demand
for health care, Malawi introduced a cadre of mid-level
health care providers called clinical officers (COs) as early
as 1976. These are non-doctors trained locally for three
years. After completing a year of internship either at the
central or district hospital, they (like medical officers (MOs))
are licensed to practice independently and perform major
emergency and elective surgery.
Unlike in Mozambique9,10 and Tanzania,11 the delegation
of major surgery to non-doctors in Malawi has not been
scientifically validated. The purpose of this study was
therefore to elucidate the extent of major surgical work
Hum Resour Health. 2007 Jun 14;5:17
 occurred among MO interventions (20%) than among Eclampsia 49 (0.7%)
COMedical
interventions The outcome figures for newborns were similar in the two (10%)
Malawi Journal 28(12%). The diagnoses
(3): September 2016 prescribing sur-
gery were cephalopelvic disproportion,
College of Medicine Silver Jubilee Special Issue obstructed labour, groups (Table 5). TheOutcomes same overall patternobstetric
of emergency was also noted95
surgery rates b
previous caesarean section, fetal distress, suspected rup- for maternal outcomes, being almost identical by compar- CS pat
carried out by COs and MOs, respectively, in Malawi and Table(Table
1: Type6).of operation and category of surgeon (C/S = for eclamp
tured uterus, ante partum haemorrhage, cord prolapse, ison Of the patients, 83% stayed in hospital
to find out the quality of surgical care as observed in the caesarean section) highes
prolonged labour, breech presentation and eclampsia two days or less prior to surgery. There was no significant
postoperative outcome of patients operated upon by these
(Table 2). The distribution of these diagnoses in the two difference in the number
Type of operation of days required
Clinical Medical for Total
hospitaliza-
two categories of staff.
categories of surgeons did not differ significantly. tion in the two groups of surgeons.
officers Unknown HIV status
officers
Methods was almost universal (98%) and 65% received preopera- Table 3
internsh
TheOfstudy the was conducted
operations (n =prospectively
256) performed in allbygovernment
MOs, 199 C/S only
tive antibiotics. The 1569 (89.5%) 185
immediate (10.5%) 1754outcome
postoperative (100.0%)
district
(77.7%) hospitals
wereand done CHAM
by MOs (Christian
who hadHealth done theirAssociation
intern- C/S + subtotal 11 (57.9%) 8 (42.1%)
was evaluated, followed by a repeat evaluation at 24 hours 19 (100.0%)
Insti
hysterectomy
of Malawi)
ship at the hospitals
centralin Malawi.Of
hospital. A these
total of 25638interventions,
health facilities 55 after surgery. A gross
C/S + total
categorization
7 (70.0%) 3 (30.0%)
was 10established
(100.0%)
int
were(21.5%)
under study were over a perioddoctors
by foreign of three who months
had had (October
their (Tables 6 and 7), indicating no major difference between
hysterectomy
to December
internship 2005). outside Fourthe referral
country.hospitals
Of the (Zomba operations Central
(n = cases
C/S + operated
repair of upon 59 by(89.4%)
COs and7 MOs,
(10.6%)respectively.
66 (100.0%)The District
CHAM
Hospital, Mzuzu Central Hospital, Lilongwe Central Hospital
1,875) performed by COs, only one fourth were done by uterine rupture
subjectivity of these evaluations is a limitation of this
C/S + bilateral tubalthe more
224 (80.9%) Centra
and Queen Elizabeth Hospital) were not studied. They
COs with internship at the central hospital. Half of all the study; however, specific 53 (19.1%)
classification277 (100.0%)
elaborated Outsid
Human Resources for Health 2007, 5:17 ligation
http://www.human-resources-health.com/content/5/1/17
performed
CO operations together were anperformed
estimated by800COscaesarean
with internshipsections at inNotTable 8 would seem
indicated
to confirm0the
5 (100.0%)
findings5 in
(0.0%)
Tables 6
(100.0%) Not ind
during the study period. The respective proportions carried
district hospital level (Table 3). and
Total7. 1875 (88.0%) 256 (12.0%) 2131 (100.0%) Total
out by COs and MOs is not known.
The
All 1).
women post-internship
undergoing surgical
caesarean experience had a duration of There were numerically more maternal deaths in the CO
Of these, 1875 (88%) were section
done byduring COs whilethe study256 Table 2: Indications motivating surgery
four years or more in 44% of COs and in 59% of MOs, group (n = 22/1875; 1.2%) than in the MO group (n = 1/
period
(12%) werewere included
done in bythe MOs.study. COsTheperformed
vast majority of such
as many as
while the figures for three years or less were 46% and 256; 0.4%) but the difference is not statistically
Indication Numbersignificant
of cases
operations
93% of these surgical operations in government elective
were carried out to cater for emergencies, district
37%, respectively (Table 4). It should, however, be noted by Fisher's exact test. Broken down by type of interven-
caesareans
hospitalsconstituting
and 78% inaCHAM small minority.
hospitals. We recruited one Cephalopelvic disproportion
that as much as 9% of COs admitted no post-internship tion, the distribution of or obstructed
maternal 1230 (22%)
deaths was: 4/18
qualified nurse midwife working in the maternity unit as labour
surgical experience at the moment of interview. died after CS and hysterectomy, whereas only 11/1569
a research assistant ofat interventions
The distribution each of the was hospitals.
comparable All womenin the Previous caesarean section 452
(0.7%) died after CS only. Of uterine rupture cases, 6/59
undergoing
two groupscaesarean of surgeons. section were operations
Of all 1875 followed carried up from out Fetal distress 264
The outcome figures for newborns were similar in the two (10%) died postoperatively (Table 9). The case 87 fatality
the bytimeCOs the1569decision
(84%)towere do aCSscaesarean
only, while
groups (Table 5). The same overall pattern was also noted
section
this was
figuremade was Suspected
rates
ruptured
by specific
uterus
preoperative morbidity in this77group of
Antepartum haemorrhage
untilsomewhat
dischargeless from for hospital.
MOs (72%) Women (Table were asked to come
1). Hysterectomies
CS
Cord patients
prolapse are presented in Table 10, indicating 62 that
backoccurred
for review
in aroundseven 1%days after
of all discharge.
interventions
Table 1: Type of operation and category of surgeon (C/S =
A COs,
by structured
while Failure to progress
eclampsia and clinical signs of uterine rupture60had the
datathiscollection
figure
caesarean section) sheet
was 4% was amongused to
MOs. retrieve
More information
tubal ligationson Breech inrates
highest primigravida
at around 6 % 53
admission
occurreddiagnosis,
among MO indication
interventionsfor surgery,
(20%) than preoperative
among Eclampsia 49
CO Type
condition, ofdesignation
operation (12%).
interventions ofClinical
surgeon Medical
and
The diagnoses type of Total
surgery.
prescribing sur-
officers officers
gery were cephalopelvic disproportion,
We also assessed the competence of the two types of obstructed labour, Table 3: Institution where the clinical officers did their
previous caesarean
professionals section, fetal distress, suspected rup- for maternal outcomes, being almost identical by compar-
C/S only that were the 1569 performing
(89.5%) 185 (10.5%) surgeons, 1754by(100.0%)
noting internship against the
tured uterus, ante partum haemorrhage, cord prolapse, ison (Table 6). Of the patients, 83% stayed in hospital for
information
C/S + subtotalabout the 11 institution
(57.9%) at8 (42.1%)
which they did their
19 (100.0%)
prolonged
hysterectomy labour, breech presentation and eclampsia twoInstitution of prior
days or less Number of
to surgery. Proportion
There wasofnooperations
significant
internship as well as the number of years of practice each intership operations done by clinical officers(%)
(Table 2). The distribution
after a completed of
C/S + total 7 (70.0%) these diagnoses10in
3 (30.0%) the two
(100.0%) difference in the number of days required for hospitaliza-
of them had
hysterectomy internship. Although medical
categories of surgeons did not differ significantly. tion in the two groups948 of surgeons. Unknown HIV status
doctorsC/S +play
repaira role
of in the59training
(89.4%) of7 COs, (10.6%)much66of the on-
(100.0%) District Hospital 50.5
was almost universal (98%) and 65% received25.4 preopera-
the-job practical
uterine rupture experience is passed on from CO to CO, CHAM Hospital 476
Of the operations
tubal (n =(80.9%)
256) performed by277MOs, 199 tive antibiotics.
Central Hospital The 447 immediate postoperative 23.8 outcome
sinceC/S the+ bilateral
newly qualified 224COs often53are sent straight
(19.1%) to the
(100.0%)
(77.7%)
ligation were done by MOs who had done their intern- was evaluated,
Outside Malawi followed1 by a repeat evaluation 0.1 at 24 hours
district
ship
hospital
Not at
for their5internship
the central hospital.
indicated (100.0%)Of these
to fill the gaps
256 interventions,
0 (0.0%)
in human
5 (100.0%) 55 Not indicated
after surgery. A gross4 categorization was 0.2 established
resources.
Total
(21.5%)
The senior
were by foreign
COs therefore
1875 (88.0%)doctors
take
256 who the
(12.0%)had responsibility
2131
had (100.0%)
their Total 6 and 7), indicating
(Tables 1876 100.0
no major difference between
of teaching,
internshipasoutside in mostthe cases there isOfnothe
country. doctor available
operations (n at= cases operated upon by COs and MOs, respectively. The
the 1,875)
station.performed by COs, only one fourth were done by interventions
subjectivity of (12%).
theseThe diagnosesisprescribing
evaluations a limitation surgery were
of this
Outcome
COs with measures
internship included
at theneonatal condition,
central hospital. Half immediate
of all the cephalopelvic disproportion, obstructed labour,
study; however, the more specific classification elaborated previous
andCO 24 hour maternal
operations were condition,
performed post-operative
by COs with fever, internshipwound at caesarean
in Table 8section,
would seemfetal to
distress,
confirm suspected
the findingsruptured
Page 3uterus,
in Tables
of 6
6
sepsis and hospital
district mortality. levelOutcomes
(Table 3).of surgery by COs were ante partum
and 7. haemorrhage, cord prolapse,
(page number notprolonged labour,
for citation purposes)

compared with those of surgery performed by MOs. breech presentation and eclampsia (Table 2). The distribution
Thewas post-internship ofThere
thesewere
diagnoses in the more
two categories
maternal of surgeons
in thedid
COnot
Data entered in surgical experiencepackage
SPSS statistical had a durationand the of numerically deaths
four years or more differ significantly.
unpaired chi square testinwas44% of COs
used to test and forinsignificance
59% of MOs, of group (n = 22/1875; 1.2%) than in the MO group (n = 1/
the while the figures
differences in outcomefor three years or
between COs lessandwereMOs. 46% and
When Of
256;the0.4%)
operations
but the(ndifference
= 256) performed by MOs,significant
is not statistically 199 (77.7%)
37%, respectively
appropriate, Fishers exact(Tabletest 4).was
It should,
used. however, be noted were done by
by Fisher's MOs
exact test.who had down
Broken done their internship
by type at the
of interven-
that as much as 9% of COs admitted no post-internship central
tion, thehospital. Of these
distribution 256 interventions,
of maternal deaths was: 554/18
(21.5%) were
(22%)
Results
surgical experience at the moment of interview. bydied
foreign
after doctors who had had whereas
CS and hysterectomy, their internship outside
only 11/1569
A total of 2131 emergency obstetric operations were the country.
(0.7%) diedOf
afterthe
CSoperations (n = 1,875)
only. Of uterine ruptureperformed
cases, 6/59by
performed
The outcomein thefigures
38 centres during the
for newborns werestudy period
similar (Table
in the two COs, only one fourth were done by COs with internship
(10%) died postoperatively (Table 9). The case fatality
1). Of these,
groups 18755).
(Table (88%) were done
The same bypattern
overall COs while 256 (12%)
was also noted at the central hospital. Half of all the CO operations were
rates by specific preoperative morbidity in this group of
were done by MOs. COs performed as many as 93% of these performed by COs with internship at district hospital level
CS patients are presented in Table 10, indicating that
surgical
Tableoperations in government
1: Type of operation district
and category hospitals
of surgeon and
(C/S = 78% (Table 3). and clinical signs of uterine rupture had the
eclampsia
in CHAM
caesareanhospitals.
section) highest rates at around 6 %
The Type
distribution of interventions was comparable The post-internship surgical experience had a duration of
of operation Clinical Medical Total in the
two groups of surgeons.officersOf all 1875officers
operations carried out four years or more in 44% of COs and in 59% of MOs,
by COs 1569 (84%) were CSs only, while this figure was while
Tablethe figures for
3: Institution three
where theyears orofficers
clinical less were 46% and 37%,
did their
somewhat
C/S only less for MOs (72%)
1569 (89.5%)(Table 1). Hysterectomies
185 (10.5%) 1754 (100.0%) respectively (Table
internship against the4). It should, however, be noted that as
C/S + subtotal
occurred in around 1%11of(57.9%) 8 (42.1%) by19
all interventions (100.0%)
COs, while much as 9% of COs admitted no post-internship surgical
Institution of Number of Proportion of operations
hysterectomy
this C/S
figure was 4% among MOs. More tubal ligations experience
intershipat the moment
operationsof interview.
done by clinical officers(%)
+ total 7 (70.0%) 3 (30.0%) 10 (100.0%)
occurred among MO interventions (20%) than among CO
hysterectomy The outcome figures for newborns were similar in the two
C/S + repair of 59 (89.4%) 7 (10.6%) 66 (100.0%) District Hospital 948 50.5
http://dx.doi.org/10.1186/1478-4491-5-17
uterine rupture CHAM Hospital 476 Hum Resour Health.
25.42007 Jun 14;5:17
C/S + bilateral tubal 224 (80.9%) 53 (19.1%) 277 (100.0%) Central Hospital 447 23.8
ligation Outside Malawi 1 0.1
 Human Resources
Human forfor
Resources Health 2007,
Health 5:17
2007, 5:17 http://www.human-resources-health.com/content/5/1/17
http://www.human-resources-health.com/content/5/1/17
Malawi Medical Journal 28 (3): September 2016
College of Medicine Silver Jubilee Special Issue Outcomes of emergency obstetric surgery 96

Table 4: Duration
Table of of
4: Duration surgeons' post-internship
surgeons' surgical
post-internship practice
surgical practice Table 6: Immediate
Table 6: Immediate post-operative maternal
post-operative general
maternal condition
general condition
in relation to to
in relation category of of
category surgeon.
surgeon.
Duration
Duration Clinical
Clinical Medical
Medical Total
Total
officers
officers officers
officers Condition
Condition Clinical officer
Clinical officerMedical
Medical Total
Total
officers
officers
Four
Fouryears or or
years more
more832832(44.4%)
(44.4%) 151151(59.0%)
(59.0%) 963963
(46.1%)
(46.1%)
Two
Two to to
three years
three years 456456
(24.3%)
(24.3%) 61 61(19.9%)
(19.9%) 507507
(23.8%)
(23.8%) FairFair 1700 (90.7%)
1700 (90.7%) 235235 (91.8%)
(91.8%) 1935 (90.8%)
1935 (90.8%)
Human Resources for Health 2007, 5:17 http://www.human-resources-health.com/content/5/1/17
SickSick 105105(5.6%) 17 17
(6.6%) 122122
(5.7%)
Less than
Less oneone
than year
year 401401
(21.4%)
(21.4%) 44 44(17.2%)
(17.2%) 445445
(20.9%)
(20.9%) (5.6%) (6.6%) (5.7%)
None
None 175175
(9.3%)
(9.3%) - - 175175
(8.2%)
(8.2%) Very
Verysicksick 27 27
(1.4%)
(1.4%) 3 (1.2%)
3 (1.2%) 30 30
(1.4%)
(1.4%)
NoNoinformation
information 11 11
(0.6%)
(0.6%) 10 10
(3.9%)
(3.9%) 21 21(1.0%)
(1.0%) NoNo information
information43 43(2.3%)
(2.3%) 1 (0.4%)
1 (0.4%) 44 44
(2.1%)
(2.1%)
Total
Total 1875 (100.0%)
1875 (100.0%) 256256
(100.0%)
(100.0%)2131 (100.0%)
2131 (100.0%) Total
Total 1875 (100.0%)
1875 (100.0%) 256256 (100.0%)
(100.0%) 2131 (100.0%)
2131 (100.0%)
Table 4: Duration of surgeons' post-internship surgical practice Table 6: Immediate post-operative maternal general condition
in relation to category of surgeon.
groups
Duration (Table 5). The same overall
Clinical pattern was
Medical Total also noted the provision
Difference
Difference notnot of health
statistically services
significant,
statistically p =pboth
significant, 0.786 in the rural and urban
= 0.786
Discussion
for Discussion
maternal outcomes, being
officers almost identical
officers by comparison areas of the country
Condition Clinicaldue to the
officer chronic shortage
Medical Total of medical
The problem
(TableThe 6). Of of
problem high
theof high maternal
patients, 83%mortality
maternal mortality
stayed in ratios
ratios and
hospital and perina-
perina-
for two The The profile
doctors. profile of patients
Thisofmay patients operated
operated
be considered
onon
officers byby COs COs
a variant
was was found to to
of found
a two tier
tal mortality
tal mortality rates
ratesis endemic
is endemic in most
in most low-income
low-income coun-
coun- bebe comparable
comparable to tothat that of ofpatients
patients operated
operated onon byby MOs,MOs,
daysFouroryears lessor more
prior 832 to (44.4%)
surgery. There 151 (59.0%) was no significant
963 (46.1%) system of training where some health personnel are trained
tries.
tries.toMultiple
Multiple factors
factors areareinvolved in inthis 507sustained with similar indications for surgery in the two 1935 (90.8%)of of
groups
difference
Two in the
three years number of
456 (24.3%) daysinvolved
required
61 (19.9%) this sustained
for hospitalization
(23.8%) towith
Fair similar
a basic level1700 indications
and(90.7%) for
therefore 235 surgery
are (91.8%) in
more likely the two groups
to be retained
scenario.
scenario.
Less than one Such yearfactors
Such factors include
401 (21.4%) include unavailability
44unavailability
(17.2%) of of
445 a sound
a sound
(20.9%) surgeons.
surgeons.
Sick During
During105the the
(5.6%)study
study it was
it17was found
(6.6%) found thatthat 50%
122 50%
(5.7%)of ofthethe
in the two groups of surgeons. Unknown HIV status was in thesickcountry. 13,14
Our studywho found that as many as 93% of
health
None
health carecare system
system with
175with adequate
(9.3%) adequate - essential
essential supplies;
175 (8.2%)
supplies; facil-
facil- surgeries
Very
surgeries were were done
27done
(1.4%)byby COs COs 3who had
(1.2%) had donedone their
30 (1.4%)
their intern-
intern-
almost
No universal
information (98%)
11 (0.6%) and 65% 10 received
(3.9%) preoperative
21and
(1.0%) major
No emergency
information obstetricIn
43 hospital.
(2.3%) operations
1 some
(0.4%) in government
44COs(2.1%) district
ities
itiesforfor emergency
emergency obstetric
obstetric care,
care, bothboth basic
basic and compre-
compre- shipship at at
thethe district
district hospital. In some instances,
instances, COs under-
under-
antibiotics.
Total The immediate 1875 (100.0%) postoperative
256 (100.0%) outcome
2131 (100.0%) was hospitals
Total were done
1875 by
(100.0%) COs and
256 this
(100.0%) includes2131 surgery
(100.0%) on
hensive;
hensive; social,
social, cultural
cultural andandpolitical
political factors;
factors; as aswellwell as as
thethe going
going internship
internship werewere doingdoing caesarean
caesarean sections
sections onon their
their
evaluated,
absence
followed by a repeat evaluation at 24 hours after complicated conditions. This is similar to earlier findings by
absenceof ofskilled skilledattendants
attendantsat atthethetime timeof ofdelivery delivery own.own. It might
It might bebe argued
argued that,
that, even even if COs
if COs have have well welldocu-
docu-
surgery.
[11,12].
A Ingrossthe
categorization
face of the
was established
current human
(Tables
resource
6 and
crisis, Fenton
Difference
mented et al.,
not
manual where
statistically
skills 65% of
significant,
in in caesarean
performing
p = 0.786 sections at central and
even major surgery,
[11,12].
Discussion In the face of the current human resource crisis, mented manual skills performing even major surgery,
7),each
indicating
country, nopoormajor difference
ormaternal
rich, needs between
to tohave cases
a national operated
work- district
they may hospitals
not have were
skills done
in in by COs.15,16
diagnostic It is noteworthy that
The
upon
each
by
country,
problem COs of poor
high
and toMOs,
or rich, needs
mortality
respectively.
have
ratios
The
a national
and work-
perina-
subjectivity Thethey may
profile not
of have
patients skills
operated on by accuracy
diagnostic COs wascompara-
accuracy compara-
found to
force
talforce planplan
mortality shaped
shaped
rates is its
to situation
its
endemic situation
in and and
most crafted
crafted
low-incometo toaddress
address
coun- itsof
its a
ble similar
beble to tothose
comparable
study
those of of in
MOs.
toMOs.
Mozambique
thatThis This
of aspect
aspect
patients
revealed
is operated
not
is not the
investigated. figure
investigated.
on by MOs,
of
The The92%
these
health evaluations
health needs
needs [5]. is
[5].
a limitation of this study; however, the [Pereira
issue
issue of etpreoperative
al, unpublished
preoperative
of diagnostic results].
diagnostic skills
skills willwilltherefore
therefore bebe the the
tries. Multiple factors are involved in this sustained with similar indications for surgery in the two groups of
more specific classification elaborated in Table 8 would seem The profile offorthcoming
patients operated on by that COs50% was offound
scenario. Such factors include unavailability of a sound focus
focus
surgeons. of ofour ourforthcoming
During the study research.
research.
it was found the to
toFor
confirm theyears
findings inhasTables 6 and 7. be comparable to that of patients
For
healthmany careyears
many system Malawi
Malawi
with adequate hasbeenbeen dependent
dependent
essential onon
supplies; COs COs forfor
facil- surgeries were done by COs who hadoperated done their onintern-
by MOs,
There
the the were
provision
provision numerically
of of health
health more
servicesmaternal
services
ities for emergency obstetric care, both basic and compre- bothboth deaths
in inthe the in
rural the
rural and CO
and with
Monitoring similar
Monitoring
ship and
at the district indications
evaluating
andhospital.
evaluating for surgery
quality
quality
In some of in
care the
is
of care isCOs
instances, two
subject groups
subject to to
under- a aof
group
hensive; social, cultural and political factors; as well as the=
urban
urban (n =
areas
areas22/1875;
of the
of thecountry1.2%)
country duethan
due to in
the
to the
the MO
chronic
chronic group
shortage
shortage (nof of surgeons.
certain
certain degree During
degree of the
subjectivism.
of study
subjectivism.
going internship were doing caesarean sections on their it Itwasmay
It mayfound
be be that
argued
argued 50%
thatthat of
the thethe
1/256;
medical
medical0.4%) but
doctors.
doctors. the
This difference
This may may be be
absence of skilled attendants at the time of delivery is not
considered
considered statistically
a variant
a variant significant
of a
of two
a two surgeries
positioning
positioning wereof a
ofdone
local
a by
local
own. It might be argued that, even if COs have COs
nurse
nurse who
midwife
midwifehad done
with with their
well well internship
known
known
docu-
bytier
Fishers
system
tier
[11,12]. system
Inexact
of
theof test.
training Broken
training
face of where
the down
where some
current some byhealth
human type
health of intervention,
personnel
personnel
resource areare
crisis, atcompetence
mentedthe district
competence manual as ashospital.
anskills
an inIn
'impartial'
'impartial' some(though
performing instances,
(though non-blinded
even COs surgery,
non-blinded
major undergoing
as asfarfar
the distribution
trained
trained to a
to basic
a of
basic maternal
levellevel andand deaths
therefore
therefore
each country, poor or rich, needs to have a national work- was:
areare 4/18
more
more (22%)
likely
likely to died
bebe
to they may not have skills in diagnostic accuracy compara- It
asinternship
type
as typeof were
surgeon
of surgeon doing
was was caesarean
concerned)
concerned) sections
individual
individual on
might their
might own.
imply
imply
after CS
retained
retained and
in in hysterectomy,
the thecountry
country whereas
[13,14].
[13,14]. Our
force plan shaped to its situation and crafted to address its Our only
study
study11/1569
found
found (0.7%)
thatthatas as might
ablebias.
a bias. beAlthough
argued
Although
to those of MOs. that,
assessment
assessment
This even of
aspectifof COs
postoperative have
postoperative
is not well documented
outcome
investigated. outcome The is is
died
many after
many as CS
93%
as
health needs [5]. only.
93% of Of
major
of uterine
major rupture
emergency
emergency cases,
obstetric
obstetric 6/59 (10%)
operations
operations died
in in issue of preoperative diagnostic skills will therefore be themay
manual
largely
largely a skills
subjective
a in
subjective performing
matter,
matter, we even
we attemptedmajor
attempted surgery,
to tomake make they
it as
it as
postoperatively
government
government (Table
district
district 9).
hospitalsThe were
hospitals casewere fatality
donedone byrates
byCOs COsbyand specific
and this this not
objective have
objective as skills
possible
as in
possible
focus of our forthcoming research. diagnostic
by byasking
asking accuracy
themthem to comparable
collect
to collect such such to
objec-
objec-those
preoperative
includes
For manysurgery
includes morbidity
surgery
years onon
Malawi inhas
complicatedthis
complicatedbeen group of CSThis
conditions.
conditions.
dependent onpatients
Thisis is
COs simi- are
simi-
for oftivedata
tive MOs.
data asThis
blood
as bloodaspect
pressure is not
pressure level, investigated.
level, pulse
pulse rate,
rate, The
amount
amount issueof ofof
presented
lar
the toprovision
lar to in Table
earlier
earlier of 10,
findings
findings
health indicating
by Fenton
by Fenton
services that al.,eclampsia
et both
et where
al., where
in the 65% and
65%
rural ofclinical
cae-
of
and cae- vaginal
preoperative
vaginal
Monitoring bleeding,
bleeding,
and post
diagnostic post
evaluatingoperative
skills
operative
quality pyrexia,
will therefore
pyrexia,
of care wound is be
wound infection,
the
subject focus
to a of
infection,
signs
sarean of areas
sarean
urban uterine
sections of rupture
sections at at
the central hadand
central
country the
and
due highest
district
district
to rates
thehospitals
hospitals
chronic at shortage
around
werewere done6of%.
done wound
our
wound
certain dehiscence
forthcoming
dehiscence
degree and
research.
and
of subjectivism. needneed forfor
Itre-operation
mayre-operation
be argued in in addition
addition
that the
by COs [15,16]. It is noteworthy that a similar study in
by COs
medical [15,16].
doctors. It may
This is noteworthy that aavariant
be considered similarofstudy
a twoin to thethe
to
positioning general
general of clinical
aclinical
local condition
condition
nurse of of
midwife thethepatient.
patient.
with well known
Discussion Monitoring and evaluating quality of care is subject to a certain
Mozambique
Mozambique
tierproblem revealed
system ofrevealedthethefigure
training of of
figure 92%
92%[Pereira
where mortality[Pereira
some health et et
al,al,
personnel are competence as an 'impartial'
The ofresults].
high maternal ratios and perinatal degree of subjectivism. It may(though be argued non-blinded
that the positioningas far
unpublished
unpublished
trained to a basicresults].
level and therefore are more likely to be The
as The
typecasecase
offatality
fatality
surgeon rates
rates
was (CFRs)
(CFRs)
concerned) of of a few defined
aindividual
few defined morbidities,
mightmorbidities,
imply
mortality rates is endemic in most low-income countries. of a local nurse midwife with well known competence as
suspected
suspected ruptured
ruptured uterus,
uterus,of eclampsia
eclampsia and obstructed
andoutcome
retained in the country [13,14]. Our study found that as
Multiple factors are involved in this sustained scenario. aanbias.
labour,
Although
impartial
are well
assessment
(though
above
non-blinded
the level
postoperative
WHO
as has
far as typeobstructed
suggested,
of surgeon
less
is
many as 93% of major emergency obstetric operations in labour,
largely a are well above
subjective matter, the we level WHO hastosuggested,
attempted make it less
as
Such factors include unavailability of a sound health was 1%
than
concerned)
[17].
individual
It should
might imply that a bias. Although
government district hospitals were done by COs and this than 1%
objective
assessment as[17].
possibleIt should
of postoperative by be noted,
be
asking noted,
them
outcome
however,
however,
to collect
is largely
that thethe
such WHO WHO
a objec-
subjective
care
Tablesystem
Table with adequate
5: Postoperative
5:surgery
Postoperative neonatal essential
neonataloutcomes supplies;
outcomes in relation facilities
in relation to to for
includes on complicated conditions. This is simi- tive
matter, data as blood pressure level, pulse rate, amount of
emergency
category
category of obstetric
surgeon care, both basic and comprehensive;
surgeon
of Table
Table 7:we
7: Maternal attempted
Maternal general
general to make 24
condition
condition it 24as
hoursobjective
hours after
after as
operation possible
operation in in by
lar to earlier findings by Fenton et al., where 65% of cae- vaginal
asking
relation bleeding,
them
to post
to collect
category of operative
surgeon pyrexia, wound
such objective data as blood pressure infection,
social, cultural and political factors; as well asTotal the absence relation to category of surgeon
sarean
Neonatal sections at central
Neonatal Clinical and district
Clinical Medicalhospitals
Medical 11,12 were
Total done wound dehiscence and need for re-operation in addition
of outcome
skilled attendants at the time of delivery. In the face level,
Condition pulse rate, amount
Clinical of vaginal
Medical bleeding,Total post operative
COs [15,16]. Itofficers
by outcome isofficers
noteworthy officers
officers
that a similar study in to Condition
the general clinical Clinical condition Medical
of the patient. Total
ofMozambique
the current human resource crisis, each country, pyrexia, woundofficers
poor or infection,
officers wound
officersdehiscence and need for
officers
revealed the figure of 92% [Pereira et al,
rich, needs
Alive andand
Alive to
well have a national
1604
wellresults]. (85.5%)
1604 workforce
(85.5%) 213213
(83.2%)plan shaped
(83.2%) 1817 re-operation in addition to the general clinical condition of
to its
(85.2%)
1817 (85.2%)
unpublished The case fatality1765rates(94.1%)
(CFRs) of a few defined 2008
morbidities,
situation
Alive and
andand
Alive crafted70to70
unwell
unwell address
(3.7%) its9 health
(3.7%) 9 (3.5%)needs.
(3.5%) 79 79
(3.7%) 5
(3.7%) the patient.
FairFair 1765 (94.1%) 243243 (94.9%)
(94.9%) (94.2%)
2008 (94.2%)
Stillbirth 160160
(8.5%) 29 29
(11.3%)
suspected
Sick
Sick ruptured
59 59 uterus,
(3.1%)
(3.1%) eclampsia
9 (3.5%)
9 (3.5%) and 68obstructed
(3.2%)
68 (3.2%)
Stillbirth (8.5%) (11.3%) 189189(8.9%)
(8.9%) The case
ForEarly
many years
neonatal
Early
Malawi
death
neonatal death41 41
has been4 (1.6%)
(2.2%)
(2.2%)
dependent45on
4 (1.6%)
COs for labour,
(2.1%)
45 (2.1%) Very
Very arefatality
sicksick
rates
well20above
(1.1%)
20
(CFRs)
the
(1.1%) levelof
1WHO
a few defined
(0.4%) has suggested,
1 (0.4%) 21 21
morbidities,
(1.0%)less
(1.0%)
NoNo information
information - - 1 (0.0%)
1 (0.0%)
suspected
than
No 1%
informationruptured
[17]. It
31shoulduterus,
(1.7%)
No information 31 (1.7%) be eclampsia
noted,
3 (1.2%)
3 (1.2%) and
however, obstructed
that
34 the WHO
(1.6%)
34 (1.6%) labour,
Table
Total 5: Postoperative
Total neonatal
1875 outcomes
(100.0%)
1875 (100.0%) 256256 in relation
(100.0%)
(100.0%)2131to(100.0%)
2131 (100.0%) Total
Total 1875 (100.0%)
1875 (100.0%) 256256 (100.0%)
(100.0%) 2131 (100.0%)
2131 (100.0%)
category of surgeon Table 7: Maternal general condition 24 hours after operation in
relation to category of surgeon
Difference notnot
Difference statistically significant,
statistically p =Medical
significant, p0.709
= 0.709 Difference notnot
Difference statistically significant,
statistically p =p 0.564
significant, = 0.564
Neonatal Clinical Total
outcome officers officers Condition Clinical Medical Total
officers officers
Alive and well 1604 (85.5%) 213 (83.2%) 1817 (85.2%) Page 4 of
Page 6 6
4 of
Alive and unwell 70 (3.7%) 9 (3.5%) 79 (3.7%) Fair 1765 (94.1%) (page
243 (94.9%)
number
(page notnot
number for for2008
citation (94.2%)
purposes)
citation purposes)
Stillbirth 160 (8.5%) 29 (11.3%) 189 (8.9%) Sick 59 (3.1%) 9 (3.5%) 68 (3.2%)
Early neonatal death 41 (2.2%) 4 (1.6%) 45 (2.1%) Very sick 20 (1.1%) 1 (0.4%) 21 (1.0%)
No information - 1 (0.0%) No information 31 (1.7%) 3 (1.2%) 34 (1.6%)
Total 1875 (100.0%) 256 (100.0%) 2131 (100.0%) Total 1875 (100.0%) 256 (100.0%) 2131 (100.0%)

Difference not statistically significant, p = 0.709 Difference not statistically significant, p = 0.564

http://dx.doi.org/10.1186/1478-4491-5-17 Hum Resour Health. 2007 Jun 14;5:17

Page 4 of 6
 Human
Human Resources
Resources forfor Health
Health 2007,
2007, 5:17
5:17 http://www.human-resources-health.com/content/5/1/17
http://www.human-resources-health.com/content/5/1/17
Malawi Medical Journal 28 (3): September 2016
College of Medicine Silver Jubilee Special Issue Outcomes of emergency obstetric surgery 97

Table
Table 8: 8: Specific
Specific maternal
maternal post-operative
post-operative outcomes
outcomes in in relation
relation Table
Table 10:10: Maternal
Maternal death
death byby pre-operative
pre-operative diagnosis.
diagnosis.
toto category
category of of surgeon
surgeon
Diagnosis
Diagnosis Number
Number of of Number
Number Case Case
Condition
Condition Clinical
Clinical Medical
Medical p value
p value deaths(n
deaths(n = 23) with
= 23) with fatality
fatality
officers
officers officers
officers diagnosis rate
diagnosis rate

Fever
Fever 388388 (20.7%)
(20.7%) 5656 (21.9%)
(21.9%) 0.364
0.364 Eclampsia
Eclampsia 3 3 5252 5.7%
5.7%
Wound
Wound infection
infection 137137 (7.3%)
(7.3%) 1414 (5.5%)
(5.5%) 0.994
0.994 Obstructed
Obstructed labour
labour 9 9 580
580 1.6%
1.6%
Wound
Wound dehiscence
dehiscence 4040 (2.1%)
(2.1%) 4 (1.6%)
4 (1.6%) 0.315
0.315 Previous
Previous C/Section(s)
C/Section(s) 2 2 460
460 0.4%
0.4%
Human
Need
Need Resources
for
for for Health
re-operation
re-operation 2828 2007, 5:175 (2.0%)
(1.5%)
(1.5%) 5 (2.0%) 0.364
0.364 http://www.human-resources-health.com/content/5/1/17
Suspected
Suspected ruptured
ruptured uterus
uterus 5 5 8787 5.7%
5.7%
Maternal
Maternal death
death 2222 (1.2%)
(1.2%) 1 (0.4%)
1 (0.4%) 0.292
0.292 Fetal
Fetal distress
distress 1 1 264
264 0.4%
0.4%
CPD
CPD 3 3 650
650 0.5%
0.5%
are well above the level WHO has suggested, less than
1%. target
target
17 8:refers
Table referstomaternal
It should
Specific tothe
be the"crude"
noted, "crude"
however,CFR,that
CFR,
post-operative implying
implying
outcomesthe WHOinallalldeaths
deaths
relationtarget Table 10: Maternal death by pre-operative diagnosis.
Competing interests
to category
divided ofall
byby surgeon
allmorbidities,
morbidities, whichwewe considerdivided
givestoo too auniform
uniform baseofofcompetence
competence andcapacity.
capacity. Given the
refers
dividedto the crude CFR, implying
which allconsider
deaths gives by aThe base
author(s)
Diagnosis declare thatNumber and
they have
of noNumber
Given
competing the
interests.
Case
blunt
allblunt a a
morbidities,
Condition picture
picture of
whichof
thethe
we quality
quality
consider
Clinical ofof emergency
emergency
gives too
Medical care.
care.
blunt We
a We con-con-
picture
p value scarcity
scarcity ofof physicians
physicians inin Malawi,
Malawi, COs
COs
deaths(n = 23) have
have a
with a vital
vital fatality to
role
role to
sider
ofsider
the morbidity-specific
morbidity-specific
quality of emergency CFRCFR
officers a more
a more
care. appropriate
Weappropriate measure
measure
consider morbidity-
officers Authors
play contributions
playforfordecades
decades totocome
comeininthe
theprovision
provision ofoflife-saving
diagnosis life-saving
rate
ofof quality
CFRofaofcare
quality
specific care
more than
than thethe
appropriate "crude"
"crude" CFR.of quality of care
CFR.
measure GCC
major
major planned
surgery,
surgery, the study
particularly
particularly atatwith CP.
district
district CP provided the
level.
level.
thanFever
the crude CFR. 388 (20.7%) 56 (21.9%) 0.364 background
Eclampsia methodology and 3 contributed
52 with 5.7%
the design
Wound
The infection
major cause of 137
maternal(7.3%) death 14 (5.5%)
(where
The major cause of maternal death (where clearly identifi- clearly 0.994
identifi- in collaboration
Competinginterests
Obstructed
Competing labour with SB.
interests FK,9 AC and EM
580 contributed
1.6% in
The majordehiscence
Wound
able) cause
was of maternal
sepsis. This 40is death (where
(2.1%)
similar to 4
the clearly identifiable)
(1.6%)
findings of 0.315
the con- preparing
Previous
The the
author(s) documents
C/Section(s)
declare and
that 2the
they protocol
have no460for implementing
competing0.4%inter-
able) was sepsis. This is similar to the findings of the con- The author(s) declare that they have no competing inter-
was sepsis.
Need
fidential
fidential
This is into
for re-operation
inquiry
inquiry
similar
into 28to the findings
(1.5%)
institutional
institutional
of the
5 (2.0%)
maternal
maternal
confidential
deaths
deaths
0.364
ininthethe Suspected
the study.ruptured
ests.
ests. CP, GCC,uterus
SB and EM5 prepared 87 5.7%
and completed the
inquiry
Maternalinto
southern
southern
deathinstitutional
region
region ofof
22 maternal
Malawi
Malawi
(1.2%)
by by deaths
Ratsma
Ratsma
1 (0.4%) in the southern
[18].
[18].
0.292 Fetal distress
final analysis of data. 1 264 0.4%
region of Malawi by Ratsma.18 CPD 3 650 0.5%
Authors'contributions
Authors'
References contributions
OtherOther
Other
target factors
factors
refers than
factors to events
than
thanthe surrounding
events
events
"crude" surrounding
surrounding thethe
CFR, implying surgery allcome
thesurgery
surgery into
come
come
deaths GCCGCCplanned
plannedthe
thestudy
studywith
withCP. CP.CPCPprovided
providedthe theback-
back-
play.
into Most
into
divided play.
play. byofMost
these
Most
all ofofpatients
these
these
morbidities, will have
patients
patients
which spent
will
willwe have
have aspent
considernumber
spent oftoo
a number
agives
number days 1.uniform
Malawi
ground
aground Country
base ofData
methodology
methodology Profile,
and
and World
andBank
contributed
contributed
competence Group
with
with
capacity. the
the at [http://www.
design
design
Given inin
the
onblunt sciencedirect.com/science]
ofthe
ofdaysway
days onontothe
a picture hospital,
theway
of way some
to
thetoquality even
hospital,
hospital, coming
someeven
some
of emergency from
even abroad.
coming
coming
care. We from In
from
con- collaboration
collaboration
scarcity with
with
of physicians SB.
SB. FK,
inFK, AC AC
Malawi, and
and EM
COs EM contributed
contributed
have inin
a vital role pre-
pre-
to
addition,
abroad.
abroad.
sider unknown
InIn addition,
morbidity-specific HIV
addition, status
CFR awas
unknown
unknown almost
HIV
HIV
more status
status universal
was
appropriatewas anduni-
almost
almostmeasure only
uni- 2.paring
Palmer
paring
play fortheD:documents
the Tackling
documents
decades Malawis
to come and
and the
in human
the resource
protocol
protocol
the forfor
provision crisis. Reproductive
ofimplementing
implementing
life-saving
slightly
versal
versal
of more
qualityandand than
onlyhalf
ofonly
care slightly
than of
thethe
slightly more patients
more
"crude" than
thanCFR. received
halfofofthe
half preoperative
thepatients
patients Health
thethe
major Matters
study.
study. CP,
surgery,2006,
CP, GCC,
GCC, 14(27):27-39.
SBSB
particularly and
andat EM EM prepared
prepared
district and
level. and completed
completed
antibiotics.
received
received preoperative
preoperative antibiotics.
antibiotics. 3.the
the final
final
United analysis
analysis
Nations ofof data. Programme. The impact of HIV/AIDS
data.
Development
The major cause of maternal death (where clearly identifi- on human resources
Competing in the Malawi public sector, UNDP. Lilongwe
interests
Conclusion 2002.
Conclusion
Conclusion
able) was sepsis. This is similar to the findings of the con- Acknowledgements
Acknowledgements
The author(s) declare that they have no competing inter-
Clinical officers
Clinical constitute
officers constitutea akey category
a key category ofofof
health
health workers
work-
Clinical
fidential officers
inquiry constitute
into key
institutional category
maternal health
deaths work-
in the 4.The
The
ests. Averting
Averting
Ministry ofMaternal
Maternal Death
Death
Health and Disability
andandPopulation,
Disability (AMDD)
(AMDD) program
program
Five-Year of of
Human Mailman
Mailman
Resources
tosouthern
save womens
erserstotosave
save lives
women's
women's
region by providing
lives
lives
of Malawi byby
by advanced
providing
providing
Ratsma emergency
advancedemer-
advanced
[18]. emer- School
School of of
Development Public
Public Health,
Health,
Plan 1999Columbia
Columbia University,
University,
2004. NewNew
Lilongwe, York,
York, gave
gave
Government financial
financial sup-
of sup-
Malawi
obstetric
gency
gency care. They
obstetric
obstetric perform
care.
care. They
They the bulkthe
perform
perform oftheemergency
bulk
bulk ofof obstetric
emergency
emergency port
port to to
1998,
Authors'thethe
III:. study.
study. We Weareare
contributions
indebted
indebted to to
MrsMrs Marie-Louise
Marie-Louise Thom
Thom at at IHCAR,
IHCAR,
operations
obstetric
obstetric at district
operations
operations hospitals
at in
district
at district Malawi.
hospitals The in postoperative
hospitalstheinsurgeryMalawi.
Malawi.come The
The
Karolinska
Karolinska
GCC
Institutet,
Institutet,
planned
Stockholm,
Stockholm,
theT,study
mmforfor
with
expert
expert secretarial
secretarial
CP. CP provided
assistance.
assistance.
Other factors than events surrounding 5. Chen L, Evans Anand S, Boufford JI, Brown the back-
H, Chowdhury
outcomes
into of
postoperative
postoperative their
play. Mostoutcomes procedures
outcomes of are
their
of their will
of these patients comparable
procedures
procedures
have spent to
are numberof
those
compara-
are acompara- ground
M,References
Cueto methodology
M, Dare L, and contributed
Dussault G, ElzingawithG,the
Feedesign in D,
E, Habte
medical References
of days on the way to hospital, some even comingtofurther
blebleto toofficers.
those
those of ofHowever,
medical
medical in order
officers.
officers. to sustain
However,
However, in in and
order
order to sus-
sus-
from Hanvorayongchai
collaboration
Malawi
1. 1. Malawi with SB.
Country
Country FK,
Data
Data AC and
Profile,
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sector,
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364:1984-90.
inConclusion
Malawi, COs have a vital role to play for decades to come Acknowledgements
Table
Table 9: 9: Maternal
Maternal deaths
deaths by by operative
operative procedure
procedure UNDP.
UNDP. Lilongwe
Lilongwe
Ministryof ofHealth
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2002.
Healthand andPopulation,
Population,Five-Year
Five-YearHuman Human
4.6.4.Hagopian
Ministry A, Thompson MJ,Disability
Fordyce M, Johnson KE,
inClinical
the provision
officersof
Procedure life-saving
constituteNumbermajor
a key surgery,
category
Number particularly
of health work-at The
Procedure- Averting Maternal
Resources
Resources Death and
Development
Development Plan
Plan (AMDD)
1999
1999 program
2004.
2004. ofHart
Lilongwe,
LG: The
Mailman
Lilongwe, Govern-
Govern-
Procedure Number Number Procedure- migration of physicians from sub-Saharan Africa to United States of
district
ers to level.
save women's lives of of by providing
deaths
deaths advanced
undergoing
undergoing emer-
related
related case
case School ment
of of
Public Malawi
Health, 1998,
ment of Malawi 1998, III:. III:.
Columbia University, New York, gave financial sup-
(n =perform
23) (n = 23)
procedure procedure fatality rate 5.America:
port5. to
ChenChen
the measures
L, L, Evans
Evans
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T, the
Anand
Anand
indebtedAfrican
S, S, Mrsbrain
Boufford
Boufford
to JI, drain.
JI, Brown
Brown
Marie-Louise Human
H, H,
Thom Resources
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itC/S
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+ Total
+ Total 2 2COs like 7 all
7 MOs 28.6should
28.6
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