Equivalence between physicians and associate clinicians in the frequency of iatrogenic urogenital fistula following cesarean section in Tanzania and Malawi

Human Resources for Health, vol. 22, pp. 43

Abstract

BACKGROUND: Physicians and associate (non-physician) clinicians conduct cesarean sections in Tanzania and Malawi. Urogenital fistulas may occur as complications of cesarean section. Location and circumstances can indicate iatrogenic origin as opposed to ischemic injury following prolonged, obstructed labor. METHODS: This retrospective review assessed the frequency of iatrogenic urogenital fistulas following cesarean sections conducted by either associate clinicians or physicians in Tanzania and Malawi. It focuses on 325 women with iatrogenic fistulas among 1290 women who had fistulas after cesarean birth in Tanzania and Malawi between 1994 and 2017. An equivalence test compared the proportion of iatrogenic fistulas after cesarean sections performed by associate clinicians and physicians (equivalence margin = 0.135). Logistic regression was used to model the occurrence of iatrogenic fistula after cesarean section, controlling for cadre, date, maternal age, previous abdominal surgery and parity. RESULTS: Associate clinicians attended 1119/1290 (86.7%) cesarean births leading to fistulas, while physicians attended 171/1290 (13.3%). Iatrogenic fistulas occurred in 275/1119 (24.6%) cesarean births by associate clinicians and in 50/171 (29.2%) cesarean births by physicians. The risk difference and 90% confidence interval were entirely contained within an equivalence margin of 13.5%, supporting a conclusion of equivalence between the two cadres. The odds of iatrogenic fistula after cesarean section were not statistically significantly different between associate clinicians and physicians (aOR 0.90; 95% CI 0.61-1.33). CONCLUSIONS: Associate clinicians appear equivalent to physicians performing cesarean sections in terms of iatrogenic fistula risk. Lower iatrogenic proportions for associate clinicians could reflect different caseloads. The occurrence of iatrogenic fistulas illustrates the importance of appropriate labor management and cesarean section decision-making, irrespective of health provider cadre. Given the noninferior performance and lower costs of employing associate clinicians, other countries with insufficient and/or unequally distributed health workforces could consider task-shifting cesarean sections to associate clinicians.

Authors 6

1. Carrie Jane Ngongo corresponding

   RTI International

   Affiliation as printed

   RTI International, Global Health Division, Research Triangle Park, United States of America. cngongo@gmail.com

   RTI International, Global Health Division, Research Triangle Park, United States of America

2. Thomas J. I. P. Raassen
   Affiliation as printed

   Independent Consultant, Weesp, the Netherlands

3. Jos van Roosmalen Aachen

   Leiden University

   Affiliation as printed

   Leiden University Medical Centre and Athena Institute VU University, Amsterdam, Netherlands

4. Marietta M. Mahendeka

   Bugando Medical Centre

   Affiliation as printed

   Bugando Medical Centre, Mwanza, Tanzania

5. Ladeisha Lombard
   Affiliation as printed

   Independent Consultant, Cape Town, South Africa

6. Elizabeth Anne Bukusi

   University of Washington · Kenya Medical Research Institute · University of Nairobi

   Affiliation as printed

   Department of Obstetrics and Gynecology, University of Nairobi, Nairobi, Kenya

   Departments of Global Health and Obstetrics and Gynecology, University of Washington, Seattle, United States of America

   Research Care Training Program in the Center for Microbiology Research, KEMRI, Nairobi, Kenya