The impact of comprehensive training on safe cesarean delivery on non-physician surgeons' knowledge in Tigray, Ethiopia: a pre- and post-test embedded mixed-methods study.

Abstract

Background: In Ethiopia, non-physician surgeons, such as Integrated Emergency Surgical Officers (IESOs) and MSc Clinical Midwives, provide critical comprehensive emergency obstetric and surgical care in areas, where physician shortages persist. Although task shifting has improved access to maternal healthcare services in many low-resource settings, maternal and newborn mortality remain high, particularly in the conflict-affected Tigray region. This study aimed to assess the impact of a comprehensive training program on safe cesarean delivery, essential newborn care, and obstetric anesthesia on IESOs' knowledge.

Methods: An embedded mixed-methods design was employed. Quantitative data included a pre-post-test on safe cesarean delivery, early neonatal care, and obstetric anesthesia, as well as a before-and-after training assessment of seven core domains (historical background of cesarean delivery, indications for and safe prevention of cesarean delivery, preoperative preparation, surgical technique, difficult cesarean delivery, early neonatal care, and obstetric anesthesia). Fifty-nine IESOs in Tigray were enrolled. Qualitative data were obtained from two focus group discussions and five in-depth interviews that explored training adequacy and professional competency. Quantitative data were analyzed using R (version 4.6.2), and qualitative data were thematically analyzed using ATLAS.ti (version 7).

Results: A total of 59 participants took part in the quantitative component, 94.9% of whom were male. The mean pre-training knowledge test score on safe cesarean delivery, early neonatal care, and obstetric anesthesia was 60.1 (± 8.7). This increased to 75.7 (± 10.58) on post-training test (mean difference 15.6, 95% CI 13.31-17.9, p < 0.001). The self-reported understanding of the seven domains improved from 17.1 (± 4.2) to 21.5 (± 4.3) (p < 0.001). Qualitative findings confirmed high appreciation of the training's relevance and possible practical application but also highlighted concerns about long-term support, career and skills advancement, and resource constraints in the post-conflict environment.

Conclusions: Comprehensive and context-specific training significantly enhanced the knowledge of non-physician surgeons in safe cesarean delivery, early neonatal care, and obstetric anestehsia in Tigray. Ongoing mentorship, career development opportunities, and system-level support are crucial for sustaining these gains and rebuilding maternal and newborn health services in conflict-affected and other resource-limited settings.