The author together with Ms. Neema, NPAP nurse during emergency caesarean section at St. Benedict’s Ndanda Referral Hospital, Ndanda, Tanzania.
Dear Dr Kietzmann, then let us start: how do non-physician anaesthesia providers help improve access to safe care in remote areas?
In many low- and lower-middle-income countries (LICs and LMICs), there are very few physician anaesthetists (anaesthesiologists). For example, Tanzania has approximately one physician anaesthetist per million inhabitants, compared with roughly one specialist anaesthetist per 50,000–100,000 people in India and one per 1,000–10,000 people in many European countries.
Without anaesthesia, surgery cannot be performed. In many countries and regions, the majority of operations would simply not take place without non-physician anaesthesia providers (NPAPs), and many more patients would die without treatment. NPAPs are essential to making surgery possible, particularly emergency procedures such as caesarean sections, operations for complications during and after childbirth, emergency abdominal surgery, and trauma care. Well-trained and skilled NPAPs save countless lives; however, their numbers remain far too low, especially across sub-Saharan Africa.
What are the main challenges to providing safe anaesthesia in low-resource settings, especially for maternal care?
The main challenges are shortages of trained staff, oxygen, equipment, and blood for transfusion. Maternal care is particularly demanding because clinicians are often caring for two patients simultaneously—the mother and the newborn. In many low-resource settings, anaesthesia care is provided by a single clinician. This can be extremely challenging in emergencies where multiple hands are needed. Obstetric emergencies, such as severe haemorrhage, can occur suddenly and require immediate intervention to prevent life-threatening shock. One of the most difficult situations is managing both a critically ill mother and a compromised newborn at the same time, especially when there is no paediatrician or trained assistant available to help.
A further major challenge is the lack of a reliable oxygen supply. Oxygen is often lifesaving, and without access to concentrated oxygen, patients may quickly deteriorate. Equally important is access to functioning equipment for airway management, mechanical ventilation, and patient monitoring. Essential monitoring includes capnography, which measures exhaled carbon dioxide and helps confirm adequate ventilation. Blood transfusion services may also be unavailable or unable to provide enough compatible blood at short notice. Severe haemorrhage may require multiple units of blood within a short period. For a lone NPAP, simultaneously administering blood products, vasoactive medications, anaesthetic drugs, and respiratory support can be extraordinarily difficult while the patient's condition is rapidly deteriorating.
How can training be improved for providers who often learn on the job?
On-the-job learning should be supported by regular auditing, supervision, mentorship, and clinical tutoring. Structured workshops are also valuable, particularly when they include essential basic sciences such as physiology and pharmacology relevant to everyday anaesthesia practice. Training should also incorporate simulation and case-based learning, alongside opportunities to develop practical skills. These include safe airway management through endotracheal intubation and the safe administration of spinal anaesthesia. Continuous professional development is essential to building competence, confidence, and patient safety.
How do simple tools like checklists and dosage tables help make care safer and more equitable?
Daily operating theatre checklists, as well as pre-procedure checklists for every patient, can be lifesaving without adding significant costs. To be most effective, these checklists should be adapted to local circumstances and resources. Many preventable complications result from inadequate preparation of the clinical environment, medications, or equipment. Dosage tables are another simple but powerful tool. They help prevent medication errors, particularly in high-stress situations, during emergencies, or when clinicians are working long hours and experiencing fatigue.
What changes are needed to better support providers working in remote hospitals?
A fundamental priority is ensuring the continuous availability of electricity, clean water, oxygen, and essential medications and consumables. These supplies should be affordable and readily accessible, especially during emergencies. Clear referral pathways are also essential. Hospitals should have defined plans for when patients need to be transferred and where they should be referred. Standard operating procedures (SOPs) should be developed and adapted to local realities. Anaesthesia services in a small remote hospital cannot be delivered in the same way as those in a large teaching hospital with extensive staffing, equipment, medications, and intensive care facilities. In many settings, it may be preferable to concentrate major surgical services in well-equipped regional centers rather than distributing them across multiple under-resourced facilities. Transferring a patient a reasonable distance is often safer than attempting to manage severe complications such as circulatory shock in an understaffed and under-equipped hospital. Safe anaesthesia depends on adequately trained providers, and complex surgical or obstetric cases may exceed the capabilities of clinicians who lack specialist training.
Thanks for sharing these insights originating from years of field experience!
#obstetrics #maternalhealth #anesthesiology #low-resource #LICS #LMCIS #NPAPs #SOPs #SSA