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Sir,

Bergström1 restores my faith in your journal, which for a good number of years has not paid much attention to the realities of the third world, in particular the fact that most caesarean sections—at least in Africa—are performed by non-obstetricians who have not been trained in the procedure by obstetricians. If they have been trained at all, they have usually been trained by general surgeons who, in turn, are likely to have themselves been trained by general surgeons.

This is firstly because the specialty of obstetrics and gynaecology has not spread outside the provincial hospital, whereas the lion's share of obstetric work is at the district hospital or the sub-district health center and secondly because teaching departments of obstetrics and gynaecology still jealously protect their turf.

In my 40 years in Africa, I visited 400 hospitals located in a dozen countries and never met an obstetrician in the ‘bush’. During my years as a district surgeon, the most common operations I had to perform were ‘obstetric and gynecological’, among them caesarean sections. Subsequently, for some 30 years, I visited the countryside as a flying pilot-surgeon. I operated altogether in 120 hospitals and at least half of my workload consisted of ‘obstetrics and gynaecology’.

I recently (25th August 2005) presented my district surgeon experience in Durban, South Africa, and emphasized that a caesarean section is ‘primary surgery’ that cannot be left to obstetricians because there are too few of them and they are clustered in the cities. Several professors of obstetrics and gynaecology protested and maintained that caesarean sections must only be performed but by fully trained certified specialists.

I fully support Bergström in suggesting that the so-called paramedicals, selected clinical officers, nurses and midwives should be taught caesareans, and that if this is not done more and more women and babies will die in childbirth. Bergström may be right that the recent ‘brain drain’ has aggravated matters, although I would argue that the situation existed long before this. Finally, because obstetrics and gynaecology will remain part of district surgery for a long time to come, it would be wise to reorganize the teaching hospitals so that general surgeons can be adequately trained for that role.

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