A comparison of clinical officers with medical doctors on outcomes of caesarean section in the developing world: meta-analysis of controlled studies

BMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.d2600 (Published 13 May 2011)
Cite this as: BMJ 2011;342:d2600

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The recent meta-analysis by Wilson et al (1) underscores the potential of clinical staff other than medical doctors to fill human resource gaps in emergency obstetric care in low resource countries, a finding that is consistent with our research across several African countries. However, we are concerned by the authors' use of the term "clinical officers" through which a disparate set of cadres providing a range of clinical functions is conflated. Bergstrom's editorial (2) in the same issue seeks to rectify this, recommending the preferred "non- physician clinician" (NPC) label - a label we endorse for use in global discussions while recognizing that designation by a negation is a less than ideal way to characterise a valued category of health professionals.

As an umbrella term, 'non-physician clinician' encompasses different levels of provider within different countries. By way of illustration, we present Table 1, drawn from data collected through key informant interviews with NPC trainers as part of a large study conducted in sub- Saharan Africa in 2010. Information from these six countries exemplifies the complexity of the NPC landscape. It suggests the wealth of cadres who might be called upon to provide emergency obstetric care while also highlighting distinctions with respect to trainings and competencies within and between countries.

Evidence from our field research supports Wilson et al. and Bergstrom's call for an increased volume of NPC graduates together with standardization of these cadres' training in emergency obstetric care. We are pleased to confirm that this work is already underway; the Africa Network for Non-Physician Clinician Training was formed in August 2010, based at Chainama College of Health Sciences in Lusaka, Zambia.(http://my.ibpinitiative.org/NPC) Led by representatives from training institutions in countries with existing NPC programmes, this unique regional coalition aims to share knowledge, expertise and innovations in NPC training and education, and thereby to improve maternal and neonatal health, as articulated in MDGs 4 & 5.

Yet, as identified in the Health System Strengthening for Equity: The Power and Potential of the Mid-Level Provider (HSSE) project, training alone is an insufficient means for reducing maternal mortality. NPCs, like all clinicians, provide medical care in the context (or absence) of available resources and supports. To provide high quality and life-saving care to women in historically underserved areas, NPCs need an enabling environment--one in which supply levels, infrastructure, management and supervision structures facilitate rather than inhibit their performance. In enhancing the capacity of these proven and valuable health care workers, our attention must also, and will, remain focused on the support and strengthening of the health system itself.

Helen de Pinho, Judy Austin, Lynn Freedman, Libby Abbott - Averting Maternal Death and Disability Program (AMDD), Columbia University, New York, USA

David Lusale, Annel Bowa – Chainama College of Health Sciences, Lusaka, Zambia

Eilish McAuliffe – Centre for Global Health, Trinity College Dublin, Ireland

Suzanne Stalls – American College of Nurse Midwives, Silver Spring, Maryland, USA.

Jody Lori, University of Michigan, Ann Arbor, Michigan, USA

1. Wilson A, Lissauer D, Thangaratinam S, Khan KS, Macarthur C, Coomarasamy A. A comparison of clinical officers with medical doctors on outcomes of caesarean section in the developing world: meta-analysis of controlled studies. BMJ. 2011;342:d2600.

2. Bergstrom S. "Non-physician clinicians" in low income countries. BMJ 2011; 342:d2499

Table 1.Categories of NPC cadres in 6 sub-Saharan African countries.

Competing interests: None declared

de Pinho, Assistant Professor

Judy Austin, Lynn Freedman, Libby Abbott - Averting Maternal Death and Disability Program (AMDD), Columbia University, New York, USA; David Lusale, Annel Bowa - Chainama College of Health Sciences, Lusaka, Zambia; Eilish McAuliffe - Centre for Globa

HSSE Project

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I applaud Wilson et al for their meta-analysis of clinical officers in the developing world(1). It is unfortunate that there was such inherent bias in the studies included in the analysis, and that none of the studies attempted to randomise their trials (although the logistics and ethics of doing so would have been problematic). They were therefore right to be tentative in their conclusions, but have brought attention to the unique role of the clinical officer in Sub-Saharan Africa.

When in Ghana recently, I was surprised by the extent of care patients received from clinical officers, most notably in the community where they act as general practitioners looking after entire villages. The clinical officers I met were very experienced and did an excellent job looking after their patients. They were competent at diagnosing and treating the limited number of conditions that could be managed using the scarce resources available. Anyone who could not be treated in the clinic were referred on to the hospital, thereby triaging patients attending outpatient appointments. However I wonder how their role will change as Ghana develops, and more resources become available. Will they become better trained in order to cope with the more complex decision processes required, or will patients care suffer from their lack of expertise and training? It would of course be wonderful for all patients to be seen by a medically trained doctor, but the medical assistants provide care which is infinitely better than the traditional healers who patients would otherwise be forced to turn to.


1. Wilson A, Lissauer D, Thangaratinam S, Khan KS, Macarthur C, Coomarasamy A. A comparison of clinical officers with medical doctors on outcomes of caesarean section in the developing world: meta-analysis of controlled studies. BMJ. 2011;342:d2600.

Competing interests: None declared

Richard A. Salisbury, Medical Student

University of Manchester

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Dr Wilson et al have done good work showing what is easily observed in SubSaharan Africa, that is that well trained clinical officers do well. it is well recognised that appropriate people given the appropriate training perform well and do not need to have the professional qualifications demanded by the West.

What is missing in the discussion is what would happen if the clinical officers could not do Caesarian sections. It is acknowledged that they have high retention in rural communities compared to doctors. If they were not available to do Caesarian sections the morbidity and mortality of mothers and babies would be enormously high since the mothers in need would not have appropriate access due to the enormous distances and lack of transport and money. Another role they provide is to help take some of the pressure off a few scattered doctors who otherwise would be oncall 24 hours , 365 days a year.

I worked in Tanzania for 15 months alongside 3 assistant medical officers who did amazing good obstetric work including autotransfusion for a ruptured uterus. We had no doctors apart from myself (with no surgical skills) and I would have trusted anyone of these nondoctors with the care of any of my family.

Dr Savipanidis response is insulting to the very many highly trained nondoctor clinicians in subSaharan Africa and it suggests he should leave his Ivory Tower and spend some time in places where he could be very useful.

Competing interests: None declared

Rupert A Gude, Family doctor

Northern Provincial Hospital, Vanuatu

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Dear Editor,

It is known that there is a severe shortage of qualified surgeons in all developing Countries, especially in vast rural areas.

Desperate local Authorities have been experimenting with various projects in order to be able to provide minimal Healthcare Services for these people.

One of the latest trends is to employ local traditional health providers, euphemized to clinical officers. They are cheap, rapidly trained and already reside in the community. In developing Countries this translates into applying natural healers, shamans, curer-magicians, etc [1] [2] [3] [7] [10] [11] [12] [14]

Up to now they were only assigned to secondary supportive health tasks, mainly screening, informing, referring to Specialists, etc [5] [7] [10] [11] [15]

Results are poor, they do not seem able even to prevent diseases like tuberculosis, malaria, HIV/AIDS, or recognize others like schizophrenia, depression, autism. [1] [4] [5] [7] [8] [11] [13]

There should be no surprise. Cultural, scientific and educational gaps are enormous.

Some healers do not even agree between themselves, let alone with Western doctors! [9]

Some even only accept plants as teachers! [6]

I was astonished to read that these "clinical officers" , after briefly attending some operating theatres for a few months(!) are awarded licence to perform caesarean sections, and, I suppose, also emergency hysterectomies for a ruptured uterus.

Many years of formal education and supervised practice in Obstetrics and Gyneacology have been established for a good reason: to provide the best possible care to women!

Any shortcuts in training are unethical and dangerous!

Attempting to compare caesarean sections performed by Specialists in Obstetrics and Gyneacology to those performed by express-trained shamans is equally unethical and dangerous.

Although this review has serious limitations (which have been admitted by the Authors), is inconclusive, and any increases in maternal and perinatal mortality have been vaporized by statistical analysis, it creates a risky precedent.

In the future, any express-trained shaman, self-taught natural healer, stage magician or exorcist could dream of comparing his clinical results to those achieved by trained physicians!

They could only declare that they are cheaper and more available to distant rural areas, to start practising their charlatanisms!

Undoubtedly, if the Authors still believe that their scientific quest is legitimate, they should proceed to a large randomized controlled trial, comparing surgical short term and long term results.

I challenge them, this time to perform this trial using their own patients, in Birmingham, and not unfortunate African women.

Would they dare have half of the women chosen from NHS Hospitals in Birmingham operated by non medical personnel?

Are they prepared to having half of the women chosen from NHS Hospitals in Birmingham operated through a vertical abdominal incision? (as in their review)

I also think that Ammalife and Birmingham Women's NHS foundation should have spent their money more wisely.

A single surgeon, properly funded, can operate successfully on thousands of patients each year, and be responsible for a whole busy Hospital! [16]

I suggest that next time Ammalife and Birmingham Women's NHS foundation decide to offer funds to help African women find better healthcare, they should consider providing logistic support for Aira Hospital or any other similar project.

[1 ] Genetics and congenital malformations: interpretations, attitudes and practices in suburban communities and the shamans of ecuador. Paz-Y-Mi?o C, S?nchez ME, Sarmiento I, Leone PE. Community Genet. 2006;9(4):268-73.

[2 ] Chronic illness and Hmong shamans. Helsel D, Mochel M, Bauer R. J Transcult Nurs. 2005 Apr;16(2):150-4.

[3 ] Shamans in a Hmong American community. Helsel DG, Mochel M, Bauer R. J Altern Complement Med. 2004 Dec;10(6):933-8.

[4 ] Conflicting perspectives on shamans and shamanism: points and counterpoints. Krippner SC. Am Psychol. 2002 Nov;57(11):962-78.

[5 ] Shamans and conventional care: are we prepared? Plotnikoff GA, Numrich C, Yang D, Wu CY, Xiong P. HEC Forum. 2002 Sep;14(3):271-8.

[6 ] The concept of plants as teachers among four mestizo shamans of Iquitos, northeastern Peru. Luna LE. J Ethnopharmacol. 1984 Jul;11(2):135-56.

[7 ] Biomedical colonialism or local autonomy? Local healers in the fight against tuberculosis. Ortega Martos AM. Hist Cienc Saude Manguinhos. 2010 Dec;17(4):909-924.

[8 ] From the stage to the laboratory: magicians, psychologists, and the science of illusion. Lachapelle S. J Hist Behav Sci. 2008 Fall;44(4):319-34.

[9 ] Rivalry and diversity among Thai curer-magicians. Golomb L. Soc Sci Med. 1986;22(6):691-7.

[10 ] The role of ethnography in STI and HIV/AIDS education and promotion with traditional healers in Zimbabwe. Simmons D. Health Promot Int. 2011 Feb 22.

[11 ] 'Whether you like it or not people with mental problems are going to go to them': a qualitative exploration into the widespread use of traditional and faith healers in the provision of mental health care in Ghana. Ae-Ngibise K, Cooper S, Adiibokah E, Akpalu B, Lund C, Doku V, Mhapp Research Programme Consortium. Int Rev Psychiatry. 2010;22(6):558-67.

[12 ] HIV/AIDS and traditional healers: a blessing in disguise. Meel BL. Med Sci Law. 2010 Jul;50(3):154-5.

[13 ] Traditional Healers (mor pheun baan) in Southern Thailand: The Barriers for Cooperation With Modern Health Care Delivery. Suwankhong D, Liamputtong P, Runbold B. J Community Health. 2011 Jun;36(3):431-7.

[14 ] Traditional healers in Riyadh region: reasons and health problems for seeking their advice. A household survey. Al-Rowais N, Al-Faris E, Mohammad AG, Al-Rukban M, Abdulghani HM. J Altern Complement Med. 2010 Feb;16(2):199-204.

[15 ] Walking apart but towards the same goal? The view and practices of Tongan traditional healers and western-trained Tongan mental health staff. Vaka S, Stewart MW, Foliaki S, Tu'itahi M. Pac Health Dialog. 2009 Feb;15(1):89-95.

[16 ] http://www.airahospital.org/?page_id=20

Competing interests: None declared

Stavros Saripanidis, Consultant in Obstetrics and Gyneacology in Greece

Private Sector, 55131

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