The problem of high maternal mortality ratios and perinatal mortality rates is endemic in most low-income countries. Multiple factors are involved in this sustained scenario. Such factors include unavailability of a sound health care system with adequate essential supplies; facilities for emergency obstetric care, both basic and comprehensive; social, cultural and political factors; as well as the absence of skilled attendants at the time of delivery [11, 12]. In the face of the current human resource crisis, each country, poor or rich, needs to have a national workforce plan shaped to its situation and crafted to address its health needs .
For many years Malawi has been dependent on COs for the provision of health services both in the rural and urban areas of the country due to the chronic shortage of medical doctors. This may be considered a variant of a two tier system of training where some health personnel are trained to a basic level and therefore are more likely to be retained in the country [13, 14]. Our study found that as many as 93% of major emergency obstetric operations in government district hospitals were done by COs and this includes surgery on complicated conditions. This is similar to earlier findings by Fenton et al., where 65% of caesarean sections at central and district hospitals were done by COs [15, 16]. It is noteworthy that a similar study in Mozambique revealed the figure of 92% [Pereira et al, unpublished results].
The profile of patients operated on by COs was found to be comparable to that of patients operated on by MOs, with similar indications for surgery in the two groups of surgeons. During the study it was found that 50% of the surgeries were done by COs who had done their internship at the district hospital. In some instances, COs undergoing internship were doing caesarean sections on their own. It might be argued that, even if COs have well documented manual skills in performing even major surgery, they may not have skills in diagnostic accuracy comparable to those of MOs. This aspect is not investigated. The issue of preoperative diagnostic skills will therefore be the focus of our forthcoming research.
Monitoring and evaluating quality of care is subject to a certain degree of subjectivism. It may be argued that the positioning of a local nurse midwife with well known competence as an 'impartial' (though non-blinded as far as type of surgeon was concerned) individual might imply a bias. Although assessment of postoperative outcome is largely a subjective matter, we attempted to make it as objective as possible by asking them to collect such objective data as blood pressure level, pulse rate, amount of vaginal bleeding, post operative pyrexia, wound infection, wound dehiscence and need for re-operation in addition to the general clinical condition of the patient.
The case fatality rates (CFRs) of a few defined morbidities, suspected ruptured uterus, eclampsia and obstructed labour, are well above the level WHO has suggested, less than 1% . It should be noted, however, that the WHO target refers to the "crude" CFR, implying all deaths divided by all morbidities, which we consider gives too blunt a picture of the quality of emergency care. We consider morbidity-specific CFR a more appropriate measure of quality of care than the "crude" CFR.
The major cause of maternal death (where clearly identifiable) was sepsis. This is similar to the findings of the confidential inquiry into institutional maternal deaths in the southern region of Malawi by Ratsma .
Other factors than events surrounding the surgery come into play. Most of these patients will have spent a number of days on the way to hospital, some even coming from abroad. In addition, unknown HIV status was almost universal and only slightly more than half of the patients received preoperative antibiotics.