Findings from hospital record data
Data from one of the 12 facilities were not included in the analysis, because few records were available. The 11 remaining facilities varied considerably in RH workload (average deliveries varied from 56 to 687 per month). Two facilities had no operating theatre, and five lacked a gynaecologist.
The survey findings generally were corroborated by the hospital data. General records and information from the facility in-charges and facility CORH confirmed that CORH were mostly used as consultants, in all areas of obstetrics and gynaecology. Survey findings and hospital data both indicated that the participation of CORH in RH surgery varied. In facilities where the CORH had worked many years, he or she appeared regularly in records for elective operations and uncommon emergency procedures and less than expected for common procedures, such as CS. They functioned as de facto consultants and supervisors of medical officers and medical officer interns for common procedures such as CS and MVA. In other facilities, CORH, medical officers, and medical officer interns shared common RH surgery. In a few facilities, tension appeared to exist between medical officers and CORH in allocating the CORH surgical responsibilities. In one facility, this appears to have resulted in a sharp decline in participation by the CORH in theatre accompanied by an observable increase in delivery-related referrals.
Some procedures, although outlined in the curriculum, were never performed by CORH. For example, during the period studied, no vacuum extraction was mentioned in the labour ward records and no vasectomy was recorded in the theatre records. For two procedures, findings from the hospital data were different from the survey results. Examination under anaesthesia for cervical cancer staging was commonly recorded as being performed by CORH, but fewer than 75% of the CORH reported doing so. In contrast, survey data showed that 94% of the CORH engaged in manual removal of the placenta, but this procedure was rarely mentioned in the hospital records.
In none of the 10 facilities with a theatre was the CORH consistently the only RH surgeon. Four of the facilities had relatively numerous staff who performed RH surgery; in six facilities, the CORH worked on a team of two to five RH surgeons. In two of the facilities, the CORH supervised medical officer interns and newly posted medical officers. Overall, CORH contributed much to RH surgery, with most CORH performing at least 25% of them in their facilities.
From the nine theatre records, we analysed data for a total of 118 months (Table
2). The number of CS that the CORH performed each month varied from zero to 31, with a mean of six per month. Most months that the CORH did not perform CS were because they were on leave or out for training. Having a CORH on staff improved CS availability; CORH performed more than half of the CS in almost 40% of the months. Theatre records showed that CORH performed more than 25% of three other obstetric emergency procedures in those facilities (Table
3).
Table 2
Caesarean sections per month by clinical officers–reproductive health in nine facilities over 118 months
No CS | 15 | 16.0 |
1–4 CS (max. 1/week) | 38 | 40.4 |
5–8 CS (max. 2/week) | 20 | 21.3 |
More than 9 CS | 21 | 22.3 |
| 94* | 100 |
Table 3
Other emergency obstetric procedures done during 118 months in nine facilities
Repair perineal tear* | 12 | 4 | 33.3 |
Repair ruptured uterus | 9 | 3 | 33.3 |
Manual removal of the placenta | 31 | 8 | 25.8 |
Repair cervical tear | 40 | 8 | 20.0 |
Re-laparotomy after CS (“burst abdomen”) | 30 | 3 | 10.0 |
We collected data on 641 complicated deliveries from 8 labour ward records. However, analysis of the contribution of the CORH in managing complications during delivery was only possible in one facility. In all other facilities, it was hampered by inconsistencies in, and incompleteness of, the data, including torn and tattered records, many blanks, and failure to record consultations during delivery.
The hospital records showed, on average, between one and two laparotomies for suspected ectopic pregnancy every month. Some theatre records did not record any, whereas the largest facility had 2 months with nine laparotomies for ectopic pregnancy. In the 118 months, 183 laparotomies for ectopic pregnancies were performed, 28 (15%) of these by a CORH.
Only five facilities kept MVA records; even those were scanty. Only one facility kept records in accordance with government guidelines. The five facilities reported between 4 and 47 (a mean of 15) MVAs per month. Only three facilities recorded details about the MVA (indication, who performed the procedure, complications, or referral). The CORH performed 24% of the MVAs in those facilities.
Ten of the 11 hospitals did not have a gender-based violence clinic, but called upon the CORH or a medical officer when a rape case or sexual assault case was reported. It was not possible to get quantitative data that specified the involvement of the CORH.
In the facilities, theatre records were used to assess the frequency with which CORH performed various procedures (Table
4). It was not possible to get substantive quantitative information on nonsurgical consultations by the CORH from the hospital records. In addition to the curriculum-derived competencies, two procedures were clearly within the scope of CORH and frequently performed: marsupialization of Bartholin cyst and avulsion of cervical polyps. No vasectomy was documented. Hydatiform mole, as an indication for MVA, was mentioned once.
Table 4
Theatre procedures in nonemergency reproductive health care over the 118 months in nine facilities
Avulsion of cervical polyp | 0 | 4 | 0.10 | 0 | 1 | 0.04 | 40.0 |
Bilateral tubal ligation | 0 | 13 | 1.92 | 0 | 8 | 0.75 | 39.1 |
Staging of cervical cancer—examination under anaesthesia | 0 | 10 | 1.34 | 0 | 5 | 0.36 | 26.9. |
Dilatation and curettage | 0 | 11 | 1.44 | 0 | 4 | 0.35 | 24.3 |
Inserting MacDonald stitch | 0 | 9 | 1.06 | 0 | 5 | 0.25 | 23.6 |
Marsupialization of Bartholin cyst | 0 | 6 | 0.69 | 0 | 3 | 0.16 | 23.2 |
Removal of lost intrauterine contraceptive device | 0 | 3 | 0.13 | 0 | 1 | 0.01 | 7.7 |
In line with the survey results, the theatre books displayed records of several procedures performed by CORH beyond the scope of their training curriculum (Table
5). These advanced procedures were mainly carried out by experienced CORH.
Table 5
Advanced procedures by clinical officers–reproductive health over the 118 months in nine facilities
Hysterectomy (both subtotal and total) | 6 | 17 |
Myomectomy | 3 | 4 |
Ovarian cystectomy | 2 | 3 |
Incision haematocolpos | 2 | 2 |
Vulvectomy | 1 | 1 |
Fistulectomy | 1 | 1 |
Intra-abdominal abscess | 1 | 1 |
Prostatectomy | 1 | 5 |
Herniorrhaphy | 1 | 1 |