Safe anaesthesia for the South African rural obstetric patient in KwaZulu-Natal

Background: The South African National Committee for Confidential Enquiries into Maternal Deaths has shown that anaesthesia-related maternal deaths continue to increase at district hospitals. This has been attributed to substandard anaesthesia care and resuscitation. This study investigated the anaesthesia practices, work circumstances, support structure and access to training by doctors involved in obstetric anaesthesia in KwaZulu-Natal district and regional hospitals. Method: This was an observational study, which included 48 district and regional hospitals offering operative obstetrics in KwaZulu-Natal. Separate questionnaires were given to medical managers and doctors providing obstetric anaesthesia. Results: The authors assessed 254 doctors' questionnaires. Ninety-eight per cent were full-time appointments and 75% had been employed for less than five years. Almost all of the doctors routinely used spinal anaesthesia, 96% used uterine displacement and 77% measured blood pressure every 1-2 minutes. Appropriate vasopressors were used by 98% of the doctors to treat post-spinal hypotension. Thirteen per cent (32 of 254) of the doctors "frequently or always" performed or assisted with surgery after anaesthetising the patient. Only 22% (54 of 248) of the doctors had an anaesthetic-trained nurse as usual assistance. Thirty per cent (35 of 115) of the doctors in the district hospitals reported feeling insecure or having experienced difficulties during general anaesthesia. Nine per cent (22) of the doctors reported not having after-hours supervision and 53% (134 of 253) did not receive any structured training at their base hospitals. Conclusion: The majority of doctors provided safe obstetric anaesthesia according to the indicators used. The unsafe practice of administering anaesthesia and then performing other theatre duties, thus leaving the mother without dedicated medical supervision, must be stopped. Efforts should be made to improve the supervision and support of district hospital doctors. Resources to optimise safe practices need to be improved.