Barriers and Enablers to Task Shifting for Caesarean Sections in sub-Saharan Africa: A Scoping Review

Sheillah Matinhure, Moses J. Chimbari


Task shifting of Caesarean-sections to non-physician clinicians (NPCs) has raised concerns over NPCs‘ competences and rationale of using them in facilities where medical doctors (MDs) are scarce to provide mentorship. We conducted a scoping
review to provide an update on NPCs‘ contribution to C-sections including barriers and enablers to task shifting. Using the PRISMA Flow Diagram, we identified 15 eligible articles from Google Scholar, PubMed and Africa Index Medicus using
specific search terms and a pre-established inclusion criterion. All 15 studies characterised NPCs: their names, training, challenges and enablers to task shifting. NPCs performed 50%-94% C-sections. Outcomes of such C-sections were comparable to those performed by MDs. Enablers included supportive policies, pre-existing human resources for health shortage, wellresourced
health facilities and supervision of NPCs. Weak health systems were major barriers. While NPCs make a significant contribution to accessing C-sections services, there is need to address challenges to fully realize benefits. (Afr J Reprod Health 2019; 23[3]: 149-160).

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World Health Organisation. Trends in Maternal Mortality: 1990 to 2015 Estimates by the WHO, UNICEF, UNFPA, the World Bank and the United Nations Population Division. [WHO Website]. 2015. WHO_RHR_15.23_eng.pdf?ua=1 Accessed July

, 2017

Sharma G, Mathai M, Dickson KE, Weeks A, Hofmeyr

GJ, Lavender T, Day LT, Mathews JE, Fawcus S, Simen-Kapeu A and de Bernis L. Quality care during labour and birth: a multi-country analysis of health system bottlenecks and potential

solutions. BMC Pregnancy and Childbirth. 2015;15(Suppl 2): S2

Ellard DR, Shemdoe A, Mazuguni F, Mbaruku G,

Davies D, Kihaile P, Pemba S, Bergström S, Nyamtema A, Mohamed H and O‘Hare JP. Can training non-physician clinicians/associate clinicians (NPCs/ACs) in emergency obstetric, neonatal care and clinical leadership make a difference to practice and help towards reductions

in maternal and neonatal mortality in rural Tanzania? The ETATMBA project. BMJ Open. 2016;6(2):e008999.

Chilopora G, Pereira C, Kamwendo F, Chimbiri A

Malunga E and Bergström S. Postoperative outcome of caesarean sections and other major emergency obstetric surgery by clinical officers and medical officers in Malawi.Malawi Med J. 2016;28(3):94-98.

Gessessew A, Barnabas GA, Prata N and Weidert K.

Task shifting and sharing in Tigray, Ethiopia, to

achieve comprehensive emergency obstetric care.

Int J Gynaecol Obstet. 2011;113(1):28-31.

McCord C, Mbaruku G, Pereira C, Nzabuhakwa C and

Bergstrom S. The quality of emergency obstetrical

surgery by assistant medical officers in Tanzanian

district hospitals. Health Aff. 2009;28(5):876-85.

Mullan F and Frehywot S. Non-physician clinicians in

sub-Saharan African countries. Lancet. 2007;


Pereira C, Cumbi A, Malalane R, Vaz F and McCord C,

Bacci A and Bergstrom S. Meeting the need for emergency obstetric care in Mozambique: work performance and histories of medical doctors and assistant medical officers trained for surgery BJOG. An Int. J. of Obstet & Gynaecol.


World Health Organization. The world health report:

Working together for health. [WHO Website]. 2006. Accessed December 15, 2014.

Galukande M, Kaggwa S, Sekimpi P, Kakaire O and

Katamba A, Munabi I, Runumi FM, Mills E, Hagopian A, Blair G, Barnhart S and Luboga S. Use of surgical task shifting to scale up essential surgical services: a feasibility analysis at facility

level in Uganda. BMC Health Services research.


Nyamtema AS, Mwakatundu N, Dominico S, Mohamed

H and Pemba S, Rumanyika R, Kairuki C, Kassiga I, Shayo A, Issa O, Nzabuhakwa C, Lyimo C and van Roosmalen. Enhancing Maternal and Perinatal Health in Under-Served Remote Areas in Sub-Saharan Africa: A Tanzanian Model. PLoS One. 2016;11(3):e0151419.

Dovlo D. Using mid-level cadres as substitutes for

internationally mobile health professionals in

Africa. A desk review. Human resources for health.


Gobeze AA, Kebede Z, Berhan Y and Ghosh B. Clinical

Performance of Emergency Surgical Officers in Southern Ethiopia. Ethiop J Health Sci. 2016;26(5):463-470.

Milland M and Bolkan H. Surgical task shifting in Sierra

Leone: a controversial attempt to reduce maternal

mortality. BJOG: An International Journal of

Obstetrics & Gynaecology. 2015;122(2):155-.155.

Pereira C. Task-shifting of major surgery to midlevel

providers of health care in Mozambique and

Tanzania: A solution to the crisis in human

resources to enhance maternal and neonatal

survival. Institutionen för

folkhälsovetenskap/Department of Public Health

Sciences; 2010

Grant MJ and Booth A. A typology of reviews: an

analysis of 14 review types and associated

methodologies. Health Information & Libraries

Journal. 2009;26(2):91-108.

Colquhoun H. Current best practices for the conduct of

Scoping Reviews: Impactful Biomedical Research:

Achieving quality and transparency. 2016.


May-12.pdf Accessed June 20, 2016

Database Search Tips: Boolean operators. [MIT


Accessed November 12, 2016.

Gajewski J, Mweemba C, Cheelo M, McCauley T, Kachimba J, Borgstein E, Bijlmakers L and Brugha R. Non-physician clinicians in rural Africa: lessons from the Medical Licentiate programme in Zambia. Hum Resour Health. 2017;15(1):53. Published 2017 Aug 22. doi:10.1186/s12960-017- 0233-0

Hounton SH, Newlands D, Meda N and De Brouwere V.

A cost-effectiveness study of caesarean-section deliveries by clinical officers, general practitioners and obstetricians in Burkina Faso. Human Resources for Health. 2009;16;7(1):34

Pereira C, Mbaruku G, Nzabuhakwa C, Bergström S and

McCord C. Emergency obstetric surgery by nonphysician

clinicians in Tanzania. Int J Gynaecol Obstet. 2011;114(2):180-3.

Kouanda S, Coulibaly A, Ouedraogo A, Millogo T,

Meda BI and Dumont A. Audit of cesarean delivery

in Burkina Faso. Int J Gynaecol Obstet. 2014;125(3):214-8.

Kruk ME, Pereira C, Vaz F, Bergström S and Galea S.

Economic evaluation of surgically trained assistant

medical officers in performing major obstetric surgery in Mozambique. BJOG: An International Journal of Obstetrics & Gynaecology. 2007;114(10):1253-60.

Shrime MG, Verguet S, Johansson KA, Desalegn D,

Jamison DT and Kruk ME. Task-Sharing or Public

Finance for Expanding Surgical Access in Rural Ethiopia: An Extended Cost-Effectiveness Analysis. In: Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, eds. Essential Surgery: Disease Control Priorities, Third Edition (Volume

. Washington (DC). The World Bank; 20. Chapter

Nyamtema AS, Pemba SK, Mbaruku G, Rutasha FD and

van Roosmalen J. Tanzanian lessons in using nonphysician

clinicians to scale up comprehensive emergency obstetric care in remote and rural areas. Human resources for health. 2011;9(1):28.

Pemba SK, Meckel M and Cobb N. The United Republic

of Tanzania‘s Clinical Officers and Assistant Medical Officers. Transformative Education for Health Professionals; 2015

UNDP Sustainable development Goals: Goal 3, Good

health and well-being able-development-goals/goal-3-good-health-andwell- being.html Accessed July 12, 2017


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