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Obstetric Care During and After COVID-19

A Conversation with Jhpiego's Dr. John Varallo

A webinar organized by the G4 Alliance and taking place Sept. 17 during the virtual meeting of the United Nations General Assembly, features Dr. John E. Varallo, Jhpiego’s Global Director of Safe Surgery, as co-moderator of a panel discussing “Obstetrics During and After COVID-19: Delivering for Mothers and Babies.”

The pandemic notwithstanding, 5 billion people do not have access to safe surgical and anesthesia care when needed and 18 million die annually from preventable surgical conditions. Access to timely and safe surgery, including cesarean section, is not a luxury, but rather a critical piece of the continuum of care, Varallo insists, adding that safe surgery needs to be integrated into all maternal and newborn health programs. Consider that timely access to safe cesarean section can prevent approximately 25% of maternal deaths and anywhere between 30% and 70% of newborn deaths.

Committed before, during and after COVID-19 to tackling the myriad issues that underpin such daunting statistics, Jhpiego has been working with public and private partners in Ethiopia, Tanzania, Cambodia and Kenya to promote safe surgery. We talked with Varallo about his work with Jhpiego’s safe surgery program.

Q: The specific focus of the panel that you’re co-moderating is obstetrics—which seems near and dear to your heart, in terms of safe surgery.

JV: That’s Jhpiego’s strength—leveraging our work in our maternal newborn health platforms. In addition, though, an important aspect we want to highlight with safe surgery is that there are a number of key principles that cut across technical areas; not only surgical technical areas but all technical areas.

Q: Which are?

JV: A focus on health provider teams rather than on the individual, as well as the importance of non-technical skills, like teamwork and communication and building a culture of patient safety These are key principles that we try to illustrate and focus on in any of our capacity building activities and all of our programs.

Q: These teams—who’s on them?

JV: Typically, when we talk about this kind of team-based performance, it tends to focus on the perioperative surgical team, which includes a surgeon (who tends to be a non-specialist in most of the places we work) or surgical provider; an anesthesia provider; a midwife; a circulating nurse; an Operating Room tech and postoperative ward nurse. Some may have shared responsibilities in some settings.

Q: How has the safe surgery team responded to the COVID-19 pandemic?

JV: Even before the pandemic, we were exploring blended learning and blended capacity-building approaches for health workers that incorporate not only in-person support but also virtual support.

We are working with countries and health facility teams to keep essential health services going, including surgery, while keeping patients and health workers safe. This includes organizing  services and patient flow, screening, developing elective surgery triage processes and rational and proper use of protective personal equipment.

Q: What about the issue of postponing surgeries?  

JV: In higher resource settings, postponing elective surgeries is easier to manage since once your system is up and running, you can catch up on the backlog. But in the low- and middle-income countries where Jhpiego works, there’s a real challenge already with the surgical backlog. Delays and postponements ultimately have significant repercussions on patient health and the health system. Cesarean section, though, is not a surgery that can be postponed, so it is essential to maintain those services.

Q: As you look at continuing to provide essential services safely amid the pandemic, what’s in your way?

JV: We are certainly working with our Ministry of Health counterparts and other stakeholders to ensure that essential surgical services continue. In addition to the systems and backlog  challenges we discussed earlier, fear is a big issue—among patients and health workers. Some providers aren’t showing up to work because of the fear of COVID-19. More patients are avoiding visiting hospitals, opting instead to give birth at home, which can pose hazards for mom and baby if complications arise. At these most fundamental levels, COVID-19 is disrupting access to basic obstetric care and safe surgery. It’s a huge challenge.

Q: Yet you sound upbeat. What gives you hope?

JV: In part, there seems to be more awareness of the basic, essential need for safe surgery—that it is an integral component to a functional health system. And what seems to be increased awareness of the need for safe obstetric surgical services to improve maternal and newborn outcomes. Much of Jhpiego’s focus is on improving access to safe cesarean section, which helps complete the continuum of care for many pregnant women. That means linking with midwifery-led management of labor and birth, as well as newborn care.

Dr. John Varallo with the happy, healthy results of high quality obstetric care.

Q: You’ve led Jhpiego’s safe surgery efforts for a couple years now. Any light-bulb moments?

JV: What has become really crystal clear to me is the importance of focusing on surgical teams: team cohesion and team performance. There’s the tendency to focus on individuals, or just on the surgical or anesthesia provider, especially in a setting such as surgery, which requires complex skills and takes place in a high-stress environment. But the team is much more than that. It includes the midwife in obstetric cases, the scrub tech, the circulating nurse, the post-op ward nurse, etc. And teamwork, communication and building a culture of patient safety are so incredibly important. We need to break down the hierarchies that tend to occur in the operating theater and that carry over outside of it, onto the wards and to other teams.  

Q: Where is that happening and to what extent?

JV: Tanzania is one example where the concept of surgical teams has been embraced and is also informing the way forward for Jhpiego safe surgery. In those facilities with higher team cohesion and a culture of patient safety, we are seeing improved outcomes. As a result, we are seeing greater adherence to the surgical safety checklist and other best practices, leading to reductions in surgical site infections by around 40% overall—and by 90% following cesarean section in the Tanzania project. Additionally, we are seeing decreasing perioperative mortality rates following cesarean section of around 50%. That is quite remarkable! It is really encouraging to see that teamwork and adherence to patient safety measures and best practices are linked to such positive outcomes.

Q: What about the woman and her family? Are they on the team?

JV: That’s a really important point. We are looking at building into our programing shared decision-making in labor management/birth and including cesarian section, which includes the woman and her family, as well as incorporating patient reported outcomes/experience of care measures to evaluate the quality of our programs.

Jhpiego believes that when women are healthy, families and communities are strong. We won’t rest until all women and their families—no matter where they live—can access the health care they need to pursue happy and productive lives.

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