General surgical services at an urban teaching hospital in Mozambique

A qualitative study on midwives' identity and perspectives on the occurrence of disrespect and abuse in Maputo city

BACKGROUND

Midwifery care plays a vital role in the reduction of preventable maternal and newborn mortality and morbidity. There is a growing concern about the quality of care during facility based childbirth and the occurrence of disrespect and abuse (D&A) worldwide. While several studies have reported a high prevalence of D&A, evidence about the drivers of D&A is scarce. This study aims to explore midwives' professional identity and perspectives on the occurrence of D&A in urban Mozambique.

METHODS

A qualitative study took place in the central hospital of Maputo, Mozambique. Nine focus group discussions with midwives were conducted, interviewing 54 midwives. RQDA software was used for analysing the data by open coding and thematic analysis from a grounded theory perspective.

RESULTS

Midwives felt proud of their profession but felt they were disrespected by the institution and wider society because of their inferior status compared to doctors. Furthermore, they felt blamed for poor health outcomes. The occurrence of D&A seemed more likely in emergency situations but midwives tended to blame this on women being "uncooperative". The involvement of birth companions was a protective factor against D&A together with supervision.

CONCLUSION

In order to improve quality of care and reduce the occurrence of D&A midwives will need to be treated with more respect within the health system. Furthermore, they should be trained in handling obstetric emergency situations with respect and dignity for the patient. Systematic and constructive supervision might be another promising strategy for preventing D&A.

Disrespect and abuse during facility-based childbirth in southern Mozambique: a cross-sectional study

BACKGROUND

Evidence suggests that many women experience mistreatment during childbirth in health facilities across the world, but the magnitude of the problem is unknown. The occurrence of disrespect and abuse (D&A) in maternity care services affects the overall quality of care and may undermine women's trust in the health system. Studies about the occurrence of disrespect and abuse in Mozambican health facilities are scarce. The aim of this study was to explore the experience of women giving birth in hospital in different settings in Maputo City and Province, Mozambique.

METHODS

A cross sectional descriptive survey was conducted between April and June 2018 in the Central Hospital of Maputo (HCM) and district hospitals of Manhiça and Marracuene, Maputo Province, Mozambique. Five hundred seventy-two exit interviews were conducted with women leaving the hospital after delivery. The questionnaire consisted of the following components: socio-demographic characteristics, the occurrence of disrespect and abuse, male involvement during labor and childbirth and intrapartum family planning counselling and provision.

RESULTS

Prevalence of disrespect and abuse ranged from 24% in the central hospital to 80% in the district hospitals. The main types of D&A reported were lack of confidentiality/privacy, being left alone, being shouted at/scolded, and being given a treatment without permission. While very few women's partners attended the births, the majority of women (73-80%) were in favor of involving their partner as a birth companion. Intrapartum counseling of family planning was very low (9-17%).

CONCLUSION

The occurrence of disrespect and abuse was much higher in the district hospitals compared to the central hospital, emphasizing the high need for interventions outside Maputo City. Allowing male partners as birth companions should be explored further, as women seem in favor of involving their partners. Investing in intrapartum counselling for family planning is currently a missed opportunity for improving the uptake of contraception in the country.

Clinical and Pathologic Profiles of Esophageal Cancer in Mozambique: A Study of Consecutive Patients Admitted to Maputo Central Hospital

PURPOSE

Eastern Africa was recently described as a high-incidence geographic area for esophageal cancer. Mozambique is included in this region. This study aimed to characterize this malignant disease at Maputo Central Hospital (MCH) to develop a global program for esophageal cancer management in Mozambique.

METHODS

MCH records from between 2012 and 2016 were used to assess the clinical, pathologic, and outcome profiles of esophageal tumors. A descriptive analysis of data collected was performed. Overall survival was evaluated using Kaplan-Meier curves.

RESULTS

In the study, 522 consecutive patient cases of esophageal cancer were recorded. The median patient age was 56.1 years (range, 27 to 97 years); 291 (55.7%) patients were women, and 230 (44.1%) were men. Regarding tumor site, 113 patients (21.6%) had a tumor in the lower third, 154 (29.5%) in the middle, and 50 (9.6%) in the upper third of the esophagus; in the remaining 196 (37.5%), tumor site was unknown. Squamous cell carcinoma comprised 94.4% of cases with documented histopathology (74.9% of the sample). Surgical treatment was possible in 32 patients (6.1%). Disease stage was documented only in these 32 surgical patients; 28.1%, 53.1%, and 18.8% had stage I, II, and III disease, respectively. The remaining patient cases seemed to involve clinically advanced tumors. The median follow-up time was of 1.6 months. The median survival time was of 3.5 months for all patients; for patients treated with curative intent, it was of 8.7 months.

CONCLUSION

Esophageal carcinoma is a common malignant tumor at MCH and is diagnosed in the advanced stages resulting in poor prognosis. Therefore, implementation of an Esophageal Cancer Program in Mozambique is essential.

Identifying barriers and finding solutions to implement best practices for cancer surgery at Maputo Central Hospital, Mozambique

Purpose

The aim of this study was to assess the surgical resources and surgical oncology team skills at the Surgical Department of Maputo Central Hospital (MCH) in Mozambique in order to define an educational program to support surgical oncology practice.

Methods

From January 2017 to December 2017, a general evaluation of the resources of MCH was carried out, as well as its offerings in oncological care in different services. Data were obtained by reviewing documents, visiting surgical services and interviewing key-informants and others informally. In addition, a group of seven surgeons of the Surgical Department of MCH answered a questionnaire about the quality of the cancer units (The Cancer Units Assessment Checklist for low- or middle-income African countries). Subsequently, surgical, anaesthesiology and intensive care facilities were evaluated according to the Portuguese-speaking African Countries Assessment of Surgical Oncology Capacity Survey (PSAC-Surgery). All the data were triangulated in order to identify gaps, develop an action plan and define an educational program.

Results

Breast, oesophagus and colorectal cancers were the most commonly treated neoplasms in MCH. A range of technical and resource needs as well as the gaps in knowledge and skills were identified. All surgeons recognised the need to create a training program in oncology at the undergraduate level, specific training for residents and continuing oncological education for general surgeons to improve the practice of surgical oncology. It was evident that all these interventions needed to be formalised, appropriately certified and count for professional career progression. Based on the local epidemiological data and on these study findings, oncology education programs were developed for surgeons.

Conclusions

The findings of this study contributed to the development of an educational program in surgical oncology, considered essential to the training of surgeons at MCH. The cancer educational programs and the mobilisation of adequate resources will ensure the provision of adequate surgical oncology treatments for MCH. The training requirements should be tailored to suit the local needs based on the most prevalent malignancies diagnosed in the region. In our view, this methodology may apply to other countries with similar realities in the formation of surgical oncologists.

A profile of surgical burden and anaesthesia services at Mozambique's Central Hospital: A review

BACKGROUND

Surgical and anaesthesia data, including outcomes, remain limited in low-income countries (LIC). This study reviews the surgical burden and anaesthesia services at a tertiary care hospital in Mozambique.

METHODS

Information on activities within the department of anaesthesia at Maputo Central Hospital for 2014-15 was collected from its annual report and verified by the Chairman of Anaesthesia. Personnel information and health care metrics for the hospital in 2015 were collected and verified by hospital leadership.

RESULTS

Maputo Central Hospital has 1423 beds with 50.1% allocated to primary surgical services. 39.7% of total admissions were to surgical services, and in 2015 the hospital performed 10,049 major operations requiring anaesthesia. The OB/GYN service had the most operations with 2894 (28.8%), followed by general surgery (1665, 16.6%). Inpatient surgical mortality was 4.1% and surgical-related diagnoses comprised two of the top 9 causes of death, with malignant neoplasms and hemorrhage from trauma causing the highest mortality. In 2014-15, Maputo Central Hospital employed 15 anesthesiologists, with 4 advanced and 23 basic mid-level anaesthesia providers. Of 10,897 total anaesthesia cases in 2014, 6954 were general anaesthesia and 3925 were neuraxial anaesthesia. Other anaesthesia services included chronic pain and intensive care consultation. Anaesthesia department leadership noted a strong desire to improve data collection and analysis for anaesthesia outcomes and complications, requested an additional administrator for statistical analysis.

DISCUSSION

This profile of anaesthesia services at a large tertiary hospital in Mozambique highlights several features of anaesthesia care and surgical burden in LICs, including challenges of resource limitations, patient comorbidity, and social dynamics present in Mozambique that contribute to prolonged hospital stays. As noted, enhanced data collection and analysis within the department and the hospital may be useful in identifying strategies to improve outcomes and patient safety.

Global general pediatric surgery partnership: The UCLA-Mozambique experience

BACKGROUND/PURPOSE

There has been increasing recognition of the disparities in surgical care throughout the world. Increasingly, efforts are being made to improve local infrastructure and training of surgeons in low-income settings. The purpose of this study was to review the first 5-years of a global academic pediatric general surgery partnership between UCLA and the Eduardo Mondlane University in Maputo, Mozambique.

METHODS

A mixed-methods approach was utilized to perform an ongoing needs assessment. A retrospective review of admission and operative logbooks was performed. Partnership activities were summarized.

RESULTS

The needs assessment identified several challenges including limited operative time, personnel, equipment, and resources. Review of logbooks identified a high frequency of burn admissions and colorectal procedures. Partnership activities focused on providing educational resources, on-site proctoring, training opportunities, and research collaboration.

CONCLUSION

This study highlights the spectrum of disease and operative case volume of a referral center for general pediatric surgery in sub-Saharan Africa, and it provides a context for academic partnership activities to facilitate training and improve the quality of pediatric general surgical care in limited-resource settings.

LEVEL OF EVIDENCE

Level IV.

Analysis of trauma admission data at an urban hospital in Maputo, Mozambique

Background

Trauma is a major public health concern. Worldwide, injuries resulted in 4.8 million deaths in 2013, an increase of 11 % since 1990. The majority of deaths from trauma in low-and middle-income countries occur in a pre-hospital setting. Morbidity from trauma contributes significantly to disability in these countries. Mozambique has experienced a rise in injury-related morbidity and mortality. Efforts are underway to prioritize surgical and anesthesiology care in the post-2015 Global Surgery agenda that will build on momentum of the Millennium Development Goals. Injury surveillance remains vital to defining priorities and implementing policy changes.

Methods

We performed a cross-sectional study between June and September, 2010 at the Hospital Central de Maputo (HCM). Data were collected on all patients admitted to the HCM emergency surgical services with a diagnosis of trauma. We describe patient characteristics and mechanism of traumatic injury by calculating simple proportions (for dichotomous or categorical variables) or medians with interquartile ranges (IQR) for continuous variables. Multivariable logistic regression analysis was used to estimate the mechanisms of trauma most associated with alcohol consumption.

Results

A total of 517 patients were approached for inclusion in this study. Of these, 441 (91.5 %) participants were followed from admission until discharge. Three hundred twenty-four participants (73.5 %) were male. The most common age group was 20–29 years old. The three principal mechanisms of injury were road traffic injury, fighting, and falls, accounting for 74 % of injuries recorded. Traumatic injury involving alcohol consumption was nine times more likely to occur at a recreation/sporting event (OR 9.0, 95 % CI 3.01–27.13, p ≤ 0.0001).

Conclusions

As Mozambique prepares to respond to the post-2015 international development agenda, urgent action is required to scale-up its national injury surveillance networks. Injury prevention efforts in Mozambique should focus attention on improving road safety regulations and their implementation, as well as on interventions targeting violence reduction and the reduction of alcohol consumption at sporting events.