PDF(Pubmed)
Abstract：
BACKGROUND: Physicians and associate (non-physician) clinicians conduct cesarean sections in Tanzania and Malawi. Urogenital fistulas may occur as complications of cesarean section. Location and circumstances can indicate iatrogenic origin as opposed to ischemic injury following prolonged, obstructed labor.
METHODS: This retrospective review assessed the frequency of iatrogenic urogenital fistulas following cesarean sections conducted by either associate clinicians or physicians in Tanzania and Malawi. It focuses on 325 women with iatrogenic fistulas among 1290 women who had fistulas after cesarean birth in Tanzania and Malawi between 1994 and 2017. An equivalence test compared the proportion of iatrogenic fistulas after cesarean sections performed by associate clinicians and physicians (equivalence margin = 0.135). Logistic regression was used to model the occurrence of iatrogenic fistula after cesarean section, controlling for cadre, date, maternal age, previous abdominal surgery and parity.
RESULTS: Associate clinicians attended 1119/1290 (86.7%) cesarean births leading to fistulas, while physicians attended 171/1290 (13.3%). Iatrogenic fistulas occurred in 275/1119 (24.6%) cesarean births by associate clinicians and in 50/171 (29.2%) cesarean births by physicians. The risk difference and 90% confidence interval were entirely contained within an equivalence margin of 13.5%, supporting a conclusion of equivalence between the two cadres. The odds of iatrogenic fistula after cesarean section were not statistically significantly different between associate clinicians and physicians (aOR 0.90; 95% CI 0.61-1.33).
CONCLUSIONS: Associate clinicians appear equivalent to physicians performing cesarean sections in terms of iatrogenic fistula risk. Lower iatrogenic proportions for associate clinicians could reflect different caseloads. The occurrence of iatrogenic fistulas illustrates the importance of appropriate labor management and cesarean section decision-making, irrespective of health provider cadre. Given the noninferior performance and lower costs of employing associate clinicians, other countries with insufficient and/or unequally distributed health workforces could consider task-shifting cesarean sections to associate clinicians.
METHODS: This retrospective review assessed the frequency of iatrogenic urogenital fistulas following cesarean sections conducted by either associate clinicians or physicians in Tanzania and Malawi. It focuses on 325 women with iatrogenic fistulas among 1290 women who had fistulas after cesarean birth in Tanzania and Malawi between 1994 and 2017. An equivalence test compared the proportion of iatrogenic fistulas after cesarean sections performed by associate clinicians and physicians (equivalence margin = 0.135). Logistic regression was used to model the occurrence of iatrogenic fistula after cesarean section, controlling for cadre, date, maternal age, previous abdominal surgery and parity.
RESULTS: Associate clinicians attended 1119/1290 (86.7%) cesarean births leading to fistulas, while physicians attended 171/1290 (13.3%). Iatrogenic fistulas occurred in 275/1119 (24.6%) cesarean births by associate clinicians and in 50/171 (29.2%) cesarean births by physicians. The risk difference and 90% confidence interval were entirely contained within an equivalence margin of 13.5%, supporting a conclusion of equivalence between the two cadres. The odds of iatrogenic fistula after cesarean section were not statistically significantly different between associate clinicians and physicians (aOR 0.90; 95% CI 0.61-1.33).
CONCLUSIONS: Associate clinicians appear equivalent to physicians performing cesarean sections in terms of iatrogenic fistula risk. Lower iatrogenic proportions for associate clinicians could reflect different caseloads. The occurrence of iatrogenic fistulas illustrates the importance of appropriate labor management and cesarean section decision-making, irrespective of health provider cadre. Given the noninferior performance and lower costs of employing associate clinicians, other countries with insufficient and/or unequally distributed health workforces could consider task-shifting cesarean sections to associate clinicians.
摘要：
背景：在坦桑尼亚和马拉维，医师和副医师（非医师）进行剖宫产。泌尿生殖道瘘可能是剖宫产并发症。位置和情况可以表明医源性起源，而不是长期缺血性损伤，阻碍劳动。
方法：这项回顾性研究评估了坦桑尼亚和马拉维的临床医师或医师进行剖宫产后医源性泌尿生殖道瘘的发生频率。它的重点是1994年至2017年间在坦桑尼亚和马拉维剖宫产后发生瘘管的1290名妇女中的325名患有医源性瘘管的妇女。等效性测试比较了由临床医师和医师进行剖宫产后医源性瘘的比例（等效性界限=0.135）。采用Logistic回归模型对剖宫产术后医源性瘘的发生,控制干部，date,产妇年龄,以前的腹部手术和产次。
结果：副临床医生参加了1119/1290（86.7％）剖宫产导致瘘管，而医生参加了171/1290（13.3%）。医源性瘘发生在副临床医生的275/1119（24.6％）剖宫产和医生的50/171（29.2％）剖宫产中。风险差异和90%置信区间完全包含在13.5%的等效幅度内，支持两个干部对等的结论。剖宫产后发生医源性瘘的几率在临床医师和医师之间无统计学差异(aOR0.90;95%CI0.61-1.33)。
结论：就医源性瘘风险而言，副临床医生似乎与进行剖宫产的医生相当。副临床医生的较低医源性比例可以反映不同的病例量。医源性瘘的发生说明了适当的产程管理和剖宫产决策的重要性,无论健康提供者干部如何。鉴于雇用副临床医生的表现不差，成本较低，其他卫生劳动力不足和/或分布不均的国家可以考虑将任务转移的剖宫产术交给临床医师.
方法：这项回顾性研究评估了坦桑尼亚和马拉维的临床医师或医师进行剖宫产后医源性泌尿生殖道瘘的发生频率。它的重点是1994年至2017年间在坦桑尼亚和马拉维剖宫产后发生瘘管的1290名妇女中的325名患有医源性瘘管的妇女。等效性测试比较了由临床医师和医师进行剖宫产后医源性瘘的比例（等效性界限=0.135）。采用Logistic回归模型对剖宫产术后医源性瘘的发生,控制干部，date,产妇年龄,以前的腹部手术和产次。
结果：副临床医生参加了1119/1290（86.7％）剖宫产导致瘘管，而医生参加了171/1290（13.3%）。医源性瘘发生在副临床医生的275/1119（24.6％）剖宫产和医生的50/171（29.2％）剖宫产中。风险差异和90%置信区间完全包含在13.5%的等效幅度内，支持两个干部对等的结论。剖宫产后发生医源性瘘的几率在临床医师和医师之间无统计学差异(aOR0.90;95%CI0.61-1.33)。
结论：就医源性瘘风险而言，副临床医生似乎与进行剖宫产的医生相当。副临床医生的较低医源性比例可以反映不同的病例量。医源性瘘的发生说明了适当的产程管理和剖宫产决策的重要性,无论健康提供者干部如何。鉴于雇用副临床医生的表现不差，成本较低，其他卫生劳动力不足和/或分布不均的国家可以考虑将任务转移的剖宫产术交给临床医师.
