Hakon Angell Bolkan

Sub-Saharan Africa and Sierra Leone bear one of the world's highest maternal mortality rates. In rural Sierra Leone, 19% of births occur at home, contributing to high maternal mortality ratios. This study aims to identify characteristics and reasons for home births among women in the rural Mathonkara Catchment area in Sierra Leone. A cross-sectional survey was conducted among 555 women of childbearing age in the Mathonkara Catchment area, Tonkolili district. Data was collected between February 25 and May 12, 2023. A structured questionnaire assessed birthplaces, demographic characteristics, maternal health indicators, care seeking behaviours, and previous experiences of care at health facilities. The prevalence of home births was 26.67%. Characteristics associated with home births include the experience of feeling like health care workers did not care about your life (AOR = 19.11; 95% CI:1.57-799.61), a distance of > 1 km to the nearest health facility (AOR = 7.15; 95% CI:3.12-16.51), ≤ 3 antenatal care visits (AOR = 4.84; 95% CI:2.37-10.14), and previous homebirths (AOR = 4.17; 95% CI:2.42-7.30). Common reasons for home births were labour occurring at nighttime, transportation costs and availability, and health care service costs. The factors influencing home births in rural Sierra Leone are multifaceted. To improve maternal outcomes, it is crucial to address the challenges that impede facility-based births, including quality of care and respectful care at health facilities, distance, economic costs of reaching facilities, and transportation challenges such as quality of roads and availability of transportation.

Objective: Maternal and neonatal mortality remain high in Sierra Leone despite significant decline in the last decade. The aim of the present study was to evaluate obstetric care delivery using the Robson Ten Group Classification System (TGCS), focusing on caesarean delivery (CD) and task‐sharing. Methods: This cross‐sectional study analyzed maternity and surgical registry data from nine governmental hospitals, collected over 4 months in 2021 or 2022. Variables included mode and outcome of delivery, TGCS parameters, and provider cadre: associate clinician (AC) or medical doctor (MD). Results: Of 5748 women included in the study, 3806 (66.2%) delivered vaginally, 156 (2.7%) by assisted vaginal delivery and 1786 (31.1%) by CD. The largest TGCS groups were low risk primipara (28.8%) and multipara (47.0%). In the low risk primipara group, 450/1656 (27.2%) underwent CD; in the low risk multipara group, 604/2702 (22.4%) underwent CD. MDs performed 876 (49.1%) of the total CDs and ACs 830 (46.5%). ACs performed more CDs with the indication of twin pregnancy, previous CD, or malpresentation, whereas MDs performed more with the indication of breech, uterine rupture, and fetal distress. Conclusion: Facility‐based CD rates in Sierra Leone are high, particularly among low risk primi‐ and multipara‐Robson groups, while assisted vaginal delivery rates remain low. Nearly half of all CDs are performed by ACs, highlighting the importance of task‐sharing in this context. Further in‐depth analysis is warranted to understand the factors influencing CD decision making and the collaborative processes between ACs and MDs to improve maternal and neonatal outcomes.

Objective To assess challenges and enablers in accessing paediatric inguinal hernia surgical care at governmental hospitals in Sierra Leone. Methodology A qualitative exploratory interview study was conducted using semistructured interviews with 16 healthcare providers and 19 guardians of 17 children at four governmental secondary-level and tertiary-level hospitals in Sierra Leone. All interviews were analysed using thematic analysis within a constructivist paradigm, with subsequent framework-based interpretation using the WHO health system building blocks. Results The study identified five interrelated themes describing barriers to accessing surgical care across household and health system levels: (1) access to equipment, consumables and medicines; (2) health-seeking behaviour; (3) financial considerations; (4) workforce; and (5) management and hospital structure. These themes illustrate how health system constraints and household-level barriers interact to delay or impede access to surgery. Key enablers included task-sharing within the surgical workforce, community trust and financial protection through the Free Healthcare Initiative or non-governmental organisations. Conclusion Access to paediatric inguinal hernia surgery in Sierra Leone is hindered by economic barriers, limited awareness and shortages of staff, equipment and medicines. Targeted community outreach, expansion of the Free Healthcare Initiative beyond age 5 and securing dedicated paediatric surgical instrument sets emerged as feasible strategies to reduce delays and improve equity of care.

Objectives: To assess anaesthesia capacity and practice in Sierra Leone by enumerating the anaesthesia workforce by volume, training level and distribution across urban and rural areas and facility ownership; estimating the prevalence of anaesthesia methods used for common surgical procedures by provider category; and evaluating hospital infrastructure and the availability of essential anaesthesia-related medications and equipment. Design: A nationwide, cross-sectional, facility-based study combining structured questionnaires administered through face-to-face interviews with facility leads and retrospective review of surgical and anaesthesia logbooks. Setting: Public and private hospitals and clinics in Sierra Leone providing surgical care with general, regional or local anaesthesia within an operating theatre. Participants: 69 of 78 eligible surgical facilities nationwide were included. Facilities providing surgical services between September 2022 and August 2023 were eligible; facilities without registries or declining participation were excluded. Results: Across participating facilities, the anaesthesia workforce comprised 198 full-time positions, predominantly non-physician providers, with only 40.4% (80/198) trained to administer anaesthesia independently. Ketamine-based and spinal anaesthesia were most common, while general anaesthesia with a protected airway accounted for just 5.0% (415/8339) of procedures. Anaesthesia practices varied by provider training level. Essential infrastructure, equipment and medications fell below international minimum standards, with shortages most pronounced in rural facilities. Conclusions: Severe shortages of certified anaesthesia providers, limited anaesthesia techniques and inadequate material resources remain major barriers to safe anaesthesia and surgical care in Sierra Leone. Targeted investments in workforce development, infrastructure and resource allocation—particularly in rural areas—are required to improve the safety, quality and equity of anaesthesia care nationwide.

Background: Inguinal hernia repair is one of the most performed surgical procedures, but, nevertheless, there is a high unmet need, with over 200 million people worldwide living with an inguinal hernia. The aims of this study were to evaluate 5-year outcomes after anterior mesh inguinal hernia repair, to assess the safety of a training intervention, and to compare the outcomes of patients operated on by a medical doctor (MD) versus an associate clinician (AC). Methods: Adult men with a primary inguinal hernia were included either as training patients or in the randomized trial, with surgical treatment performed by an MD or an AC. Patients were followed up mostly at hospital or at home; questionnaire information was collected and physical examinations were performed. Outcomes of training and trial patients were compared and outcomes of patients who underwent surgeries performed by MDs or ACs during the trial were compared. Results: In total, 129 patients were included in the training group and 229 patients were included in the randomized trial group. At 5-year follow-up, 288 patients (80.4%) were alive, 40 patients (11.2%) had died, and 30 patients (8.4%) were lost to follow-up. The overall recurrence rate was 5.0% and the all-cause mortality rate was 11.2%. Mortality and recurrence were not significantly different between the training and trial patients or between the patients who underwent surgeries performed by MDs or ACs during the trial. Conclusion: Long-term outcomes after primary elective inguinal mesh hernia repair indicate that hands-on short-course training can be implemented effectively and that task sharing is safe and effective.

Background: To mitigate the critical surgeon shortage in Sierra Leone, a surgical training programme was launched in 2011, training associate alinicians in surgery and obstetrics through task-sharing. While graduates of this programme now perform most surgeries outside the capital, they continue to face significant barriers to integration within the national health system. Methods: We conducted 22 semi-structured interviews with surgical providers (n=12) and facilitators (n=10) to identify barriers and enablers of surgical task-sharing in Sierra Leone’s health system. Providers and facilitators were selected from three geographically diverse hospitals with varying healthcare worker densities and also included district medical officers and representatives from the Ministry of Health and United Nations Population Fund. Data were analysed using descriptive qualitative content analysis, categorising themes into institutional, interpersonal, resource-related and sociocultural factors. Results: In total, 18 barriers and 21 enablers to surgical task-sharing were identified. Associate clinicians play a critical role in surgical care in underserved regions, help alleviate physician burnout and foster teamwork. Increasing support from younger doctors and hospital administrators signals growing acceptance. Yet, challenges such as exclusion from the healthcare service scheme, inadequate compensation, lack of training accreditation, reliance on external funding, limited national engagement and medical protectionism contribute to demotivation and attrition. These findings highlight the indispensable role of associate clinicians while emphasising the need for systemic reforms to maximise the impact of task-sharing. Conclusions: Enhancing institutional support, implementing rigorous regulatory frameworks and expanding training opportunities for physicians within the surgical training programme are essential measures to optimise the benefits of task-sharing, sustain the provision of high-quality care and improve surgical outcomes.

Background: A surgical task-sharing programme was initiated by the Sierra Leonean Ministry of Health in 2011 to enhance public surgical capacity and equalise access between urban and rural populations by redistributing surgical tasks within a limited healthcare workforce.Methods: This longitudinal nationwide study, involving all healthcare facilities with an operating theatre in Sierra Leone, analysed changes in volume and population rates of surgery and distribution of surgical resources before (2012), 5 (2017) and 10 years after (2023) the initiative was introduced.Results: Surgical volume rates increased from 400 to 505 procedures per 100 000 population between 2012 and 2023. The public sector became the main provider, performing 56.0% of all operations in 2023, up from 39.6% in 2012. Rural surgeries increased by 77.6% over the decade, almost two times more than in urban areas. In rural areas, there was a transition from non-specialised physicians performing 46.2% of operations in 2012, to task-shared associate clinicians performing 55.1% (95% CI 49.5% to 60.7%) in 2023, making them the main surgical provider. Nationwide caesarean section rates increased from 1.4% (2012) to 5.3% (95% CI 4.6% to 6.0%) (2023). Caesarean sections were in 2023 mostly performed in public facilities (81.3%, 95% CI 80.1.0% to 82.5%) by associate clinicians (57.6%, 95% CI 53.2% to 61.9%).Conclusions: Over the last decade, Sierra Leone has seen a shift in surgical care, with a transition from general to obstetric surgeries, from private to public institutions, and an expansion of surgical care in rural areas, with associate clinicians as the leading provider. The introduction of a nationwide surgical task-sharing initiative to strengthen the surgical workforce at district governmental hospitals in 2011 has emerged as the major contributor to the change in surgical activity and output observed in Sierra Leone over the last decade.

Cesarean section ( CS ) is a life‐saving procedure when performed for the right indication but carries substantial risks, specifically during subsequent pregnancies. The aim of this study was to evaluate obstetric outcomes for women 5 years after a CS performed by medical doctors and associate clinicians. This was a prospective multi‐center observational study of women who had a CS at any of nine hospitals in Sierra Leone. Women and their offspring were followed up with three home visits for 5 years after surgery. Outcomes of interest included long‐term complications, mode and place of delivery, and maternal and pediatric outcomes of subsequent pregnancies. Of the 1274 women included in the study, 140 (11.0%) were lost to follow‐up. Within 5 years after the index CS , 27.0% of the women became pregnant and 2.5% had a second pregnancy. Women with perinatal death at the index CS had 5.25 higher odds of becoming pregnant within 1 year. Of the 259 women who delivered, 31 (12.0%) had a planned CS and 228 (88.0%) attempted a trial of labor after CS , resulting in either a successful vaginal birth ( n = 138; 60.5%) or an emergency CS ( n = 90; 39.5%). Peripartum and long‐term complications did not significantly differ between those that were operated on by medical doctors and associate clinicians. Within 5 years after CS , one in four women became pregnant again and more than half had a vaginal delivery. Significant differences in place and mode of birth between wealth quintiles illustrate inequities.

Objectives This study explores potential barriers and enabling factors that may influence the acceptance of implementation of a surgical task-sharing initiative targeting physician assistants (PAs) in Liberia. Design A qualitative, pre-implementation study using semistructured interviews. Data was analysed in NVivo V.12 using deductive coding and the consolidated framework for implementation research as a guide. Setting Liberia has few surgical providers and a poor surgical infrastructure resulting in a very low surgical volume. The research was conducted in the context of an already running surgical task-sharing programme for midwives. Participants In 2019, a total of 30 key stakeholders in the field of surgery and the PAs training programme were interviewed. Results The majority of the stakeholders supported the idea of training PAs in surgery. The high unemployment rate among PAs and the need for career advancement of this cadre were important enabling factors. Resistance against surgical task sharing for mid-level clinicians is multifaceted. The Ministry of Health (MOH) did not share a common vision. Opponents within the MOH believed budgetary constraints within the MOH and the lack of surgical infrastructure is a more pressing problem compared with the surgically trained human resources. Another important group of opponents are medical officers (MOs) and their professional bodies. Many of their negative beliefs around surgical task sharing reflect lessons to be drawn from the current surgical training programme for midwives. Conclusion Prior to deciding on implementation of a surgical training programme for PAs, wider support is needed. If surgical task sharing with PAs is to be considered, the intervention should focus on adapting the ‘adaptable’ periphery of the intervention to broaden the support of the MOH, MOs and their professional bodies. Failing to obtain such support should make the implementors consider alternative strategies to strengthen surgical human resources in rural Liberia.

Objectives The economic consequences of untreated surgical disease are potentially large. The aim of this study was to estimate the economic burden associated with unmet surgical needs in Liberia. Design A nationwide enumeration of surgical procedures and providers was conducted in Liberia in 2018. We estimated the number of disability-adjusted life years (DALYs) saved by operative activities and converted these into economic losses averted using gross national income per capita and value of a statistical life (VSL) approaches. The total, the met and the unmet needs for surgery were determined, and economic losses caused by unmet surgical needs were estimated. Finally, we valued the economic losses avoided by various surgical provider groups. Results A total of 55 890 DALYs were averted by surgical activities in 2018; these activities prevented an economic loss of between US$35 and US$141 million. About half of these values were generated by the non-specialist physician workforce. Furthermore, a non-specialist physician working a full-time position for 1 year prevented an economic loss of US$717 069 using the VSL approach, while a specialist resident and a certified specialist saved US$726 606 and US$698 877, respectively. The burden of unmet surgical need was associated with productivity losses of between US$388 million and US$1.6 billion; these losses equate to 11% and 46% of the annual gross domestic product for Liberia. Conclusion The economic burden of untreated surgical disease is large in Liberia. There is a need to strengthen the surgical system to reduce ongoing economic losses; a framework where specialist and non-specialist physicians collaborate may result in better economic return than a narrower focus on training specialists alone.