A doctor shortage in war-torn Mozambique paved the way for a new breed of surgeons that have slashed deaths among new mothers.
In Caia, a small truck-stop town in a remote part of Mozambique’s central Sofala province, Sebastiana Domingos has just started her shift at the district hospital. She gently examines the scar on a patient’s abdomen.
The 34-year-old pregnant woman was rushed to hospital after her uterus ruptured.
“She was bleeding heavily and was severely anaemic,” Domingos says.
The woman urgently needed a Caesarean section, which Domingos performed and saved both mother and baby.
But she’s not a doctor. She’s a surgically trained nurse, one of an army of non-physicians, or técnicos de cirurgia (Portuguese for surgery technicians), who have been performing most of the surgeries in Mozambique for more than 30 years.
When the country declared independence from Portugal in 1975, there was an exodus of Portuguese medical staff, particularly doctors. Only 80 Mozambican doctors were left, according to a study published in the British Journal of Obstetrics and Gynaecology in 2007. As the country spiralled into civil war, the shortage grew worse.
Rural areas, in particular, were in desperate need of emergency healthcare and life-saving skills, with war casualties adding to the pressure. Women who suffered serious child-birth complications often bled to death. The maternal mortality rate — the death of a woman while pregnant, or within 42 days of the end of her pregnancy — was 1 000 per 100 000 live births, more than double the country’s 2013 rate of 480 published by the World Health Organisation (WHO).
In 1984, to fill this gap, the country began training mid-level health workers like Domingos to perform emergency surgery. Candidates are recruited among the best nurses and medical practitioners with clinical and managerial skills as well as substantial experience in rural areas. They undergo two years of intensive clinical surgical training at the Maputo Central Hospital and serve a one-year internship with qualified surgeons at a provincial hospital.
According to a 2010 paper by the Karolinska Institute in Sweden, at that time the técnicos de cirurgia were performing 92% of operations for a C-section, ruptured uterus or ectopic pregnancy (when a fertilised egg implants itself outside of the womb, usually in one of the fallopian tubes) in rural district hospitals.
Before Domingos joined the team at the Caia District Hospital in central Mozambique in October, mothers-to-be who suffered birth complications often had to be transferred to Quelimane, a three-hour drive away. In the case of an emergency, such as a uterine rupture (when the uterus tears open along the scar line of a previous C-section or other major uterine surgery), three hours can be the difference between life and death.
“Some women use traditional medicine to induce their labour and this often leads to complications,” the hospital’s director, Laura Da Graca Xinavane, says.
Caia lies in the heart of the area that was affected by recent clashes between government forces and opposition group Renamo. At the end of last year, before a ceasefire was signed, even ambulances had to be escorted by military convoys on the main road between Quelimane and Beira.
“Fights erupted very close to here and we treated a lot of wounded,” says Xinavane.
In the maternity ward, a 15-year-old girl lies on her back on a nylon-covered mattress with her legs drawn up. Tiny beads of sweat form on her forehead as her breathing gets heavier. Domingos checks the dilation of the teenager’s cervix.
“There are no complications,” she says. “This should be a normal birth.”
It is a relief for Domingos and the teenager. In Mozambique, the adolescent fertility rate is particularly high, according to 2016 United Nations data, and 38% of adolescent girls between the ages of 15 and 19 are either pregnant or already mothers. In some rural areas, this figure is even higher: nearly half (45.9%) of women in this age group are mothers or about to give birth. Studies have shown that early childbearing makes it more likely for a mother or baby to be injured during delivery.
“The bodies of 15- and 16-year-old girls are simply not ready,” says Xinavane.
Women in the area may give birth to six or seven children on average, but Xinavane says it’s not unusual to see mothers who go through nine or even 10 pregnancies. The more pregnancies a woman has, the higher the risk of birth complications.
“Having nurses with surgical skills really helps save lives,” Xinavane says.
Her experience is backed up by research. In Mozambique, the number of women who die during pregnancy and childbirth has more than halved — from 1 000 per 100 000 to 480 in 2013, according to the latest data published by the WHO.
The clinical outcomes are in fact identical whether a doctor or surgically trained non-physician holds the knife, the 2007 study in the British Journal of Obstetrics and Gynaecology found.
“There’s no doubt that the surgical training of midwives and nurses has been a significant contribution to maternal survival,” says Staffan Bergström, professor emeritus of international health at the Karolinska Institute who has conducted several studies evaluating the outcome of the surgical training for non-physicians. He was director of the department of obstetrics at the Maputo Central Hospital between 1982-1986 and is now supervising a similar initiative in war-ravaged South Sudan.
His studies show that these surgically trained mid-level care providers, or clinical associates, also tend to stay longer in rural areas. Nine out of 10 técnicos de cirurgia remained at rural hospitals seven years after graduation but not a single doctor did. The physicians had all left for better-paid jobs in the cities, or moved abroad.
“Our preliminary results indicate a remarkably low complication rate. Staff retention is crucial when building a healthcare system based on skilled professionals,” Bergström says.
But the programme remains controversial, not least among doctors.
Eugenio Zacarias, the head of the Mozambique Medical Council, is one of the critics.
“It was a necessary measure when the country was in crisis. At the time there was a war but Mozambique has changed since then. We now have several medical schools, compared with only one in the early 1990s. We can’t think like we did 20 years ago,” he says.
“The funds should rather be spent on training surgeons and other specialists, and let nurses work in health centres.”
Back in Caia, Simão Magoma shrugs off any criticism as he scrubs up in a room adjacent to the hospital’s operating theatre. A 20-year-old woman with a breeched foetus came into the hospital the previous evening. After several unsuccessful attempts to reposition the baby, the team decided to deliver the baby surgically.
Like Domingos, Magoma doesn’t have a medical degree but learned to perform operations after seeing the dire need for surgeons. Magoma, a medical technician, trained in Maputo for five years and started working in Caia almost a year ago. Only two doctors serve the local population of about 50 000.
“When I was working as a medical technician in Guro [in western Mozambique], there was only one person who could perform surgery, anything from Caesarean sections to car accidents,” he says. “That’s when I decided to complete the training so that there would be at least two of us to save lives.”