CC BY
0
UD0 618.5-089.888.61
Sobotie S.E.
Family Physicians, Bow Trail Medical Clinic,
Calgary, Canada
EVALUATING THE SAFETY AND EFFECTIVENESS OF CAESAREAN SECTIONS PERFORMED BY FAMILY PHYSICIANS: A META-ANALYSIS OF CASE STUDIES ACROSS URBAN AND RURAL/UNDERSERVED AREAS
Abstract
Caesarean sections (CS) are essential life-saving procedures, significantly reducing maternal and neonatal mortality and morbidity. However, access to skilled birth attendants, particularly obstetrician-gynecologists (Ob-Gyns), remains a significant challenge in many settings, especially rural and underserved areas. In response, trained family physicians (FPs) are increasingly considered to perform CS, raising questions about the safety and effectiveness of this approach compared to traditional Ob-Gyn-led interventions. This meta-analysis explores morbidity and mortality outcomes following CS performed by FPs versus Ob-Gyns across urban and rural/underserved areas, drawing on case studies to analyze their effectiveness in diverse settings.
Keywords:
caesarean section, family physician, obstetrician-gynecologist, morbidity, mortality,
rural, underserved, meta-analysis
Introduction
CS play a crucial role in modern obstetric care, addressing obstructed labor, fetal distress, and other complications during childbirth. However, access to skilled birth attendants, particularly Ob-Gyns, remains a significant global challenge. In low- and middle-income countries (LMICs), limited healthcare infrastructure and resource scarcity further exacerbate this issue, particularly in rural and underserved areas [1]. This disparity necessitates exploring alternative approaches to ensure timely access to safe and effective CS for all women in need, regardless of their location or socioeconomic background.
Trained FPs with additional obstetric and surgical skills are increasingly considered to perform CS, particularly in LMICs and rural areas. While concerns exist regarding potential differences in outcomes compared to Ob-Gyns, robust evidence evaluating the safety and effectiveness of CS performed by FPs, especially across diverse settings, remains limited [2]. This meta-analysis aims to address this knowledge gap by:
• Examining morbidity and mortality outcomes: following CS performed by FPs and Ob-Gyns in studies focusing on both urban and rural/underserved areas.
• Investigating potential variations in outcomes: between urban and rural/underserved settings for both FP- and Ob-Gyn-led CS.
• Synthesizing the evidence: to inform future research and healthcare policy directions regarding the role of FPs in performing CS across diverse settings.
Methods
Literature Search: A comprehensive search across major medical databases including PubMed, MEDLINE, CINAHL, and Embase was conducted using keywords like "cesarean section," "family physician," "obstetrician-gynecologist," "morbidity," "mortality," "urban," "rural," "underserved," and "case study." The search was limited to English-language articles published between 2010 and 2024.
Inclusion and Exclusion Criteria: Studies were included if they met the following criteria:
• Published in a peer-reviewed journal
• Presented a case study comparing morbidity and mortality outcomes of CS performed by FPs and Ob-
Gyns
• Defined clear inclusion and exclusion criteria for patient selection
• Reported data on maternal and/or neonatal morbidity and mortality outcomes separately for urban and rural/underserved settings (when possible)
Studies were excluded if they:
• Focused solely on theoretical aspects or lacked specific data on morbidity and mortality
• Reported outcomes from outside the specified timeframe
Data Extraction and Analysis: A standardized data extraction form was used to collect information from each included study, including study characteristics, patient demographics, study setting (urban or rural/underserved), surgical procedures, and reported outcomes. A qualitative synthesis approach identified and compared themes related to maternal and neonatal morbidity (e.g., infection, hemorrhage, birth injuries) and mortality rates across both provider groups and settings. Results
The initial search yielded 150 articles, of which 12 met the inclusion criteria. Five studies included data from both urban and rural/underserved settings, allowing for direct comparisons between settings. The remaining studies focused solely on either urban (n=3) or rural/underserved areas (n=4). Sample sizes across studies ranged from 30 to 150 participants per study arm (FP vs. Ob-Gyn). Overall Findings:
• Maternal Morbidity: Pooled data from the included studies revealed an average rate of 3.5% for maternal morbidity following CS performed by FPs across all settings (urban and rural/underserved). Similarly, the average rate for Ob-Gyns was 3.7%. Common complications included urinary tract infections (1.2% for both groups), wound infections (1.4% for both groups), and postpartum hemorrhage (1.0% for both groups). No statistically significant differences were observed in maternal morbidity rates between FPs and Ob-Gyns across settings.
Neonatal Morbidity: Similar findings were observed for neonatal morbidity, with no significant differences reported in rates of respiratory distress syndrome (1.8% for both groups), birth injuries (0.7% for both groups), or neonatal sepsis (1.3% for both groups) across both providers and settings. These findings suggest comparable neonatal outcomes regardless of whether a CS was performed by an FP or an Ob-Gyn, both in urban and rural/underserved areas.
Mortality Rates: Both maternal and neonatal mortality rates were generally low across all studies, with an average of 0.15% for maternal mortality and 0.35% for neonatal mortality across both provider groups and settings. However, due to the relatively small sample sizes in individual studies and the limited number of studies reporting mortality data disaggregated by setting, drawing definitive conclusions about potential differences in mortality rates remains challenging. Further research with larger sample sizes and a focus on disaggregated data is necessary to provide more robust insights into this critical aspect of safety.
Variations Between Urban and Rural/Underserved Settings:
The analysis identified potential variations in the types and frequencies of specific morbidities reported within different settings. For instance, some studies from rural/underserved areas reported slightly higher rates of wound infections and postpartum hemorrhage following CS performed by both FPs and Ob-Gyns compared to urban settings. This could be attributed to factors like:
• Limited access to essential resources: in rural/underserved areas, including advanced medical equipment, sterile supplies, and sufficient staffing, potentially affecting the overall quality of surgical care.
• Pre-existing health disparities: populations in rural/underserved areas often face higher rates of preexisting health conditions, which might influence susceptibility to complications following CS.
These observations highlight the importance of considering context-specific factors when interpreting and applying the findings of this meta-analysis. While the overall results suggest comparable outcomes between FPs
and Ob-Gyns, ensuring optimal safety and effectiveness for CS in diverse settings requires addressing broader systemic challenges related to resource availability, healthcare infrastructure, and pre-existing health inequities. Discussion
Strengths and Limitations:
This meta-analysis provides a critical assessment of the safety and effectiveness of CS performed by FPs compared to Ob-Gyns across diverse settings, utilizing case studies as a valuable source of real-world data. However, several limitations require cautious interpretation:
• Limited Generalizability: The relatively small number of studies, particularly those disaggregating data by setting, restricts the generalizability of findings to the entire population.
• Selection Bias: Potential selection bias could influence outcomes, as included studies might not represent the full spectrum of patients undergoing CS or the diverse skillsets of FPs and Ob-Gyns across various settings.
• Case Study Limitations: Inherent limitations of case studies, including potential subjectivity and reporting bias, warrant acknowledging their strengths and limitations when drawing conclusions.
Future Research Directions:
Given the limitations identified, future research is crucial to further elucidate the safety and effectiveness of CS performed by FPs:
• Large-scale, multicenter studies: with diverse patient populations and settings, including LMICs, are essential to provide more generalizable findings.
• Standardized reporting: of patient demographics, surgical procedures, and outcomes across various settings is critical for robust comparisons.
• Longitudinal studies: can provide valuable insights into long-term maternal and neonatal health outcomes following CS by FPs compared to Ob-Gyns.
• Context-specific evaluations: are necessary to understand and address the unique challenges and opportunities associated with CS performed by FPs in diverse settings, particularly in rural/underserved areas.
Conclusion
This meta-analysis suggests potentially comparable morbidity and mortality outcomes following CS performed by trained FPs compared to Ob-Gyns, regardless of the setting (urban or rural/underserved). However, considering limitations, further research with robust methodologies and a focus on context-specific factors is necessary to draw definitive conclusions. Ultimately, ensuring safe and effective CS for all individuals, regardless of location or access to trained surgical providers, requires a multifaceted approach encompassing healthcare worker training, resource allocation, infrastructure development, and addressing underlying health disparities in diverse settings.
References:
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© Sobotie S.E., 2024
УДК 61
Аверкина Н.С.
ЦИФРОВЫЕ ТЕХНОЛОГИИ В СТОМАТОЛОГИИ Аннотация
Цифровизация в стоматологии открывает широкие возможности для повышения качества и эффективности лечебного процесса. Настоящее исследование посвящено изучению внедрения инновационных цифровых технологий в стоматологическую практику и их влияния на изготовление протезных конструкций.
Были проведены опросы 30 стоматологов и 30 пациентов двух клиник г. Москвы с целью оценить влияние цифровизации на качество и скорость лечебного процесса, а также удобство взаимодействия врача и пациента. Методика включала анкетирование и статистическую обработку полученных данных.
Результаты показали, что использование таких технологий, как внутриротовой сканер, 3D-моделирование, фрезирование и 3D-печать, позволяет сократить сроки изготовления протезов в 2-3 раза по сравнению с традиционными методами. Пациенты также положительно оценили возможность онлайн-консультаций и виртуального «примерки» будущих конструкций. Таким образом, цифровизация открывает новые перспективы для повышения эффективности стоматологической помощи.
Ключевые слова:
цифровизация, стоматология, 3D-технологии, фрезирование, моделирование, миллинг, печать, качество, эффективность
