Safety of Essential Surgery Performed by Non-Physicians in Low and Middle Income Countries

BACKGROUND: A lack of surgically trained providers in low and middle income countries (LMICs) is a major contributor to high morbidity and mortality from surgical conditions in these settings. Some countries train non-physician clinicians (NPCs) in surgery to help solve this problem. The World Health Organization recommends this practice in some cases, although data on its safety is limited. HYPOTHESIS: Complication rates of NPCs and physicians practicing essential surgery in LMICs are similar. METHODS: A literature search using PubMed and OvidMEDLINE identified studies reporting complication rates of NPCs when performing essential surgery in LMICs. RESULTS: I identified 28 articles and 2 abstracts reporting the complication rates of 57,578 procedures performed by NPC and MD surgeons in LMICs, as well as 4 systematic reviews and/or meta-analyses on the safety of NPC surgery. Studies came from 4 world regions and the majority were from sub-Saharan Africa. Studies addressed 5 areas: major general surgery (13,253 procedures), medical male circumcision (14,248 procedures, 70% in adults), emergency obstetric surgery (18,853 procedures), tubal ligation (7,179 procedures) and first-trimester abortion (4,045 procedures). Complication and mortality rates for NPC and MD surgeons were similar when performing a variety of general surgery procedures, tubal ligation, and abortion. One out of 7 studies on circumcision found increased complications when NPCs performed the procedure. One out of seven studies found increased maternal and perinatal mortality when NPCs performed emergency obstetric surgery, although these differences were not found in meta-analysis. Meta-analysis did find increased rates of wound healing problems and wound infection in patients of NPCs after obstetric surgery. The majority of studies in this review are limited by factors related to study design. CONCLUSION: NPC surgeons contribute significantly to surgical practice in at least 7 LMICs, all in sub-Saharan Africa. In the majority of cases, NPC and MD surgeons had similar complication rates when performing essential surgery. In areas with large unmet need for surgical care, NPC providers offer a significant mortality and morbidity benefit by increasing access. More research is needed to define the scope of NPC surgical practice that will maximize this benefit and to develop the proper supervision and support mechanisms that MDs must provide to these clinicians.