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Direct causes of maternal deaths are responsible for about 80% of maternal mortality in developing regions of the world. Death from any one of these can be prevented by the use of relatively inexpensive, simple medical interventions which includes the use of anesthesia and anesthetic techniques. Lack of anesthetic care and anesthesia has been recognized as a limiting factor to successful provision of life saving interventions that could prevent maternal deaths in low resource settings. Doctor anesthetists are few and the anesthetic care has been adequately provided by non doctor anesthetist in many of these settings. Increasing the numbers of non doctor anesthetists and strengthening their capacity where they exist, is a strategy which will contribute to maternal mortality reduction in such settings. Several UK based organizations have contributed to increasing the capacity to deliver anesthesia in developing countries over the past 15-20 years. Learning from their experiences, a high level of training in anesthesia for non doctors can be introduced or existing programmes improved upon. This article proposes a mechanism to achieve this through national and international links for resource poor settings.
Each year, more than 536 000 women die from the complications of pregnancy and childbirth; this equates to more than one per minute.1 There are a greater number of survivors who suffer ill health and disability in the longer term. It is estimated that four million neonatal deaths occur each year and these account for 40% of deaths in children under the age of 5 years.2,3 Neonatal welfare is inextricably linked to maternal welfare.
Three-quarters of all these deaths occur in Sub Saharan Africa and South Asia.1,4 About 80% of maternal deaths are due to haemorrhage, sepsis, eclampsia, obstructed labour and complications of abortion.5 Relatively inexpensive, simple medical and surgical interventions are recognised to be life saving in the management of these conditions. These skills are taught in the Royal College of Obstetricians and Gynaecologists and Liverpool School of Tropical Medicine Life Saving Skills—Essential Obstetric Care and Newborn Care course.6 It is recognised however, that their optimal management regularly requires anaesthesia or anaesthetic related skills; general or good regional (spinal or epidural) anaesthesia can be required to gain control of haemorrhage, which otherwise could quickly become catastrophic and life threatening, slick management of the airway, blood pressure and fluid balance and timely anaesthesia are needed in the proper care of the eclamptic patient, anaesthetic skills allow very sick and septic patients to be identified, operated on and given high dependency care readily. In these ways, the availability, practice, quality and effectiveness of anaesthesia significantly influence outcome and impact on maternal mortality and morbidity. Without the availability of anaesthetic skills, mothers and their newborns die.
Access to anaesthesia not only saves lives, but relieves maternal distress and pain and thereby restores dignity to women. The anaesthetist has to be able to deliver anaesthesia, to cope with complications of anaesthesia, to resuscitate and deliver perioperative care and should be able to provide good analgesia. Anaesthesia must be timely and must pay exquisite attention to detail.
The need for good anaesthetic care cannot be argued. It is disturbing therefore to read that obstetric care in low resource countries is compromised by the lack of anaesthetic care, and anaesthesia is a limiting factor in maternal and neonatal welfare.7,8
Historically anaesthesia was administered by the surgeon or their assistant. There has been a move away from this and the medical specialty of anaesthesia has become independent, distinct and respected. However, in many parts of the world and including some well-resourced countries, such as the USA, the Netherlands and Sweden, anaesthetics are administered by non doctor anaesthetists working to strict protocol and with adequate training and ongoing supervision. These countries have set the precedent of allowing a move away from the ‘anaesthesia only by anaesthetists’ paradigm and embracement of the expansion of professional roles.
In sub-Saharan Africa and Southern Asia, the doctor can be a rare commodity and delivery of medical care falls to non doctors. It is unlikely that a doctor trained and dedicated to the administration of anaesthetics would be a frequently available resource, particularly in rural settings.8 Anaesthesia is instead delivered by non doctor anaesthetists. McAuliffe et al. found that in a survey of 200 countries, 107 used non doctor anaesthetists.9 It is recognised that their skills can be adequate and they form a more permanent resource as they are less likely to be poached or lured to well-resourced countries. It is further recognised that this may be a venture away from the ‘individual highest quality care’ model to treating a greater number, overall with a greater number of survivors.
The non doctor anaesthetist resource is itself scarce; demand for anaesthesia outstrips availability and results in death and morbidity.8 This imbalance must be corrected.
Internationally and within the UK, there are many more projects, which address the provision of anaesthesia in low resource countries. There are links at organisation/institution level such as the Nottingham-Jimma (Ethiopia) programme (set up by Tropical Health and Education Trust (THET) over 15 years ago),10 Bristol—Uganda, Middlesborough—Malawi, Scotland-Malawi, South Manchester-Uganda, and more examples of individual doctor anaesthetists working for varying periods of time in low resource settings. Such initiatives are supported by the Crisp report.11 The Royal College of Anaesthetists has a curriculum for doctor anaesthetists delivering anaesthesia in low resource countries. An integral part of the contribution of any visiting doctor anaesthetists is to impart skills and teach.
There are examples, within and out with the literature of training programmes for non doctor anaesthetists with greater of lesser degrees of formality.8,10
Could this training be enhanced and expanded by international linkage of those practising and delivering training to non doctor anaesthetists, perhaps in partnership with major healthcare delivery organisations and Non Government Organisations? The overarching objective of such a network would be to introduce high standard training where there is none, using the experience of those who train non doctor anaesthetists and to increase the amount of training where there is some already happening.
Potential functions could include:
To share the experience of providers of non doctor anaesthetist training
To draw benefit from the best models of training and standardise training as much as in country practice allows
To create a training package available to providers or potential providers of non doctor anaesthetist training
To create a training faculty database to provide training in country at request
To offer advocacy to promote recognition and practice of non doctor anaesthesia, to influence areas such as accreditation and provision of drugs, equipment and assistance
To encourage and assist individual or groups of doctor anaesthetists working in resource poor countries to provide non doctor anaesthetist training
To create generic monitoring and evaluation systems of training for providers of training to access
To create generic quality control systems for providers of training to access which would give training a degree of rigour which would promote confidence and demand respect for the local practice of anaesthesia
To liaise with the Ministry of Health and other professional organisations on behalf of individual or small groups of providers of training
To offer ongoing supervision and mentoring for ‘qualified’ non doctor anaesthetists
To offer Continuing Professional Development programmes for ‘qualified’ non doctor anaesthetists
To provide ‘training of trainers’ programmes for doctor anaesthetists and possibly non doctor anaesthetists
To provide support and defence against unwarranted criticism of non doctor anaesthetist training from local doctor anaesthetists
Training could be delivered to nurses, medical assistants, medical officers and clinical officers depending on local policy, policy barriers and legislation.
The detail of such a course would have to be in keeping with local practice but likely would have a theoretical, knowledge base, component and ‘hands on’ in the operating theatre/delivery suite based training, in country. It could involve, perhaps for the more senior, trained anaesthetic practitioners sabbaticals in other parts of the world.
Training would cover the delivery of anaesthesia, the management of complications of anaesthesia, resuscitation in its broadest sense, perioperative care and an appreciation and ability in the provision of good analgesia.
Regional anaesthesia i.e. spinal and epidural anaesthesia is recognised as being safer than general anaesthesia particularly in the obstetric setting. There are occasions however where general anaesthesia would be preferred to regional anaesthesia or where regional anaesthesia might fail or be inadequate and general anaesthesia has to be employed. Practising anaesthetists therefore need to be able to deliver both regional and general anaesthesia. General anaesthesia for the pregnant patient carries significantly greater risk, morbidity and mortality than in the non pregnant patient and training must reflect this. In UK practice trainee anaesthetists first learn to deliver anaesthesia to the non pregnant population, progressing to the obstetric patient. Ideally, those training to deliver anaesthesia in the resource poor world too would gain experience with the non pregnant patient before moving to the obstetric setting.
As is the case with the practice of many clinical skills, the skill itself is relatively straightforward but dealing with the complications of the technique is more challenging but essential to the practice of the skill itself. To be able to manage such complications, there must be a knowledge base of what can happen, why (physiological mechanisms) and how to be effective in treating those.
Perioperative care and resuscitation refers to correction of life threatening physiological disturbance and covers a spectrum of critical illness. All providers of anaesthesia must be adept in this.
Analgesia may be thought of as a luxury and at the admission of the author comes second to the provision of anaesthesia, perioperative care and resuscitation. However, our aims and respect for women must be wider than saving lives and must embrace the provision of good pain relief and thereby the restoration of dignity to the distressed woman.
Once trained in the practice of anaesthesia, given the recognised shortage of personnel available to provide anaesthesia, it is likely that the non doctor anaesthetist would be working in relative anaesthetic isolation. It is important within any training programme, to build in mentoring and professional and personal support, to guard against decay in skills and provide updating and professional development. Alongside training and supervision, the provision of medicines, equipment and assistance for the non doctor anaesthetist must also be addressed.
The author proposes the creation of national and international networks and links for those involved in the training of non doctor anaesthetists in low resource settings. Such networks would serve to share and foster good practice in the delivery of anaesthesia by non doctors through exemplary and accessible training packages and associated systems. An ultimate aspiration might be to deliver a very practical formal anaesthetic training programme for anaesthesia for obstetric procedures, to strict protocol, to a specified level of expertise, to a middle cadre of professionals of a specified background.