Utilisation of private general practitioners to provide caesarean deliveries in five rural district public hospitals in South Africa: a mixed-methods study

Objective Researching how public-private engagements may promote universal access to safe obstetric care including caesarean delivery is essential. The aim of this research was to document the utilisation of private general practitioners (GPs) contracted to provide caesarean delivery services in five rural district hospitals in the Western Cape, the profile and outcomes of caesarean deliveries. We also describe stakeholder experiences of these arrangements in order to inform potential models of public-private contracting for obstetric services. Design We used a mixed-methods study design to describe rural district hospitals’ utilisation of private GP contracting for caesarean deliveries. Between April 2021 and March 2022, we collated routine data from delivery and theatre registers to capture the profile of deliveries and maternal outcomes. We conducted 23 semistructured qualitative interviews with district managers, hospital-employed doctors and private GPs to explore their experiences of the contracting arrangements. Setting The study was conducted in five rural district hospitals in the Western Cape province, South Africa. Results The use of private GPs as surgeon or anaesthetist for caesarean deliveries differed widely across the hospitals. Overall, the utilisation of private GPs for anaesthetics was similar (29% of all caesarean deliveries) to the utilisation of private GPs as surgeons (33% of all caesarean deliveries). The proportion of caesarean deliveries undertaken by private GPs as the primary surgeon was inversely related to size of hospital and mean monthly deliveries. Adverse outcomes following a caesarean delivery were rare. Qualitative data provided insights into contributions made by private GPs and the contracting models, which did not incentivise overservicing. Conclusion The findings of this study suggest that private GPs can play an important role in filling gaps and expanding quality care in rural public facilities that have insufficient obstetric skills and expertise. Different approaches to enable access to safe caesarean delivery are needed for different contexts, and contracting with experienced private GP’s is one resource for rural district hospitals to consider. We undertook descriptive health systems research using a mixed-methods study design to describe rural district hospitals’ utilisation of private GP contracting for caesarean deliveries in the Western Cape province and the profile and maternal outcomes of these deliveries in five hospitals. We chose a mixed-methods study design incorporating both quantitative and qualitative data collection as this approach is well suited to applied health systems research.11 12 The setting for this research was the Western Cape province where existing public–private contracting for caesarean delivery services was occurring due to human resource shortages in rural district hospitals. Five rural district hospitals within one rural district were chosen following engagement with provincial managers and obstetric clinical managers. In SA, women with low-risk pregnancies receive antenatal care at primary care clinics and community health centres. District hospitals provide level 1 (generalist) services to inpatients and outpatients including obstetric care for women with low-risk pregnancies. District hospitals have between 30 and 200 beds, a 24-hour emergency service and an operating theatre. Generalists (medical officers) provide the services together with nursing staff and allied health professionals; some district hospitals have specialist family physicians serving as clinical managers but there are no obstetric or anaesthetic specialists at district hospital level. Most district hospitals also have community service doctors. These are doctors who have completed a 2-year internship and are required to complete a further 1 year of community service.13 None of the five hospitals had newly qualified intern medical doctors who are generally not placed within district hospitals. For obstetric services at district hospital level, normal vaginal deliveries are performed by midwives, assisted vaginal deliveries are performed by advanced midwives or medical officers and caesarean deliveries (surgery and anaesthesia) are performed by medical officers. Pregnant women with pre-existing morbidities such as diabetes, autoimmune disorders, thyroid disease, and cardiac disease or obstetric complications such as anticipated preterm delivery, suspected intrauterine growth restrictions, pre-eclampsia, placenta praevia, abruptio placentae, multiple pregnancy, two previous caesarean sections, body mass index over 35–40 kg/m², and severe anaemia are referred for delivery to a secondary or tertiary level hospital. Public health facilities are permitted to contract the services of private providers where needed. There are three mechanisms by which private providers can be contracted to the public service: through a locum agency, through a sessional contract which is limited to a maximum of 39 hours per month or as a service provider in response to a tender for specific services. In all three contracting models, the remuneration is time based and not related to the number of patients or theatre cases performed. In the case of obstetric services, private providers are mainly used for theatre services either as a GP surgeon or GP anaesthetist to undertake caesarean deliveries or for obstetric surgery including ectopic pregnancy, termination of pregnancy and dilatation and curettage following spontaneous miscarriage. They may also be called for an assisted delivery if the establishment doctor is unable to manage a complicated delivery. For GPs contracted through a sessional contract, medicolegal indemnity is provided by the state but for those contracted as locums or through a service provider tender, they are required to have their own medicolegal indemnity cover. In these five hospitals, the private GPs did not have medical indemnity for private obstetric practice and only performed caesarean deliveries during their public sector contracted time. For a period of 12 months (1 April 2021–31 March 2022), we collated quantitative obstetric clinical data from all five participating hospitals. Clinical outcomes were captured from the delivery register, theatre register and obstetric transfer book. Outcomes that could be collated from these sources without individual patient folder review included: mode of delivery and caesarean delivery complications (maternal death, postpartum haemorrhage (PPH) and referral to a regional hospital). Other procedures performed at or after a caesarean delivery were also captured as a measure of complications (hysterectomy, B-lynch suture and re-look laparotomy). For each caesarean delivery, we captured whether the surgeon or anaesthetist was a hospital-employed medical officer or a private GP, the type of anaesthetic given, whether the procedure was classified as an emergency or elective and whether it was performed during daytime or evening/night-time (16:00–08:00, Monday–Sunday). Clinical data were collated from registers by research nurses recruited for the purpose of the study. The monthly data were entered into a preset Excel spreadsheet. Semistructured interview guides were developed, one for private providers and one for public providers. Qualitative interviews were undertaken by three of the investigators (TD, GS and ED) at the hospitals and district office. The investigators who conducted interviews are all senior researchers with experience in qualitative interviewing. Two were health economists and one a health systems researcher. They had no prior relationships with any of the interviewees. All interviews were conducted in a private consulting room or office and were undertaken in English. Interviews were undertaken with private GPs who had entered into public service contracts with each of the five hospitals to explore their perceptions of undertaking work in the public sector and the role they played. At each hospital, we also interviewed the hospital managers and public providers (doctors) to explore their perceptions of the public/private interface including clinical decision-making, private GP availability and remuneration models. Types of questions asked to private GPs included: ‘What has been your experience of working in government hospitals?’ and ‘How do you balance your time between private practice and government hospital work?’; types of questions asked to district managers and government doctors included: ‘What services are private GPs contracted to provide?’, ‘How are decisions about caesarean delivery made within the clinical team?’ and ‘How are private GPs remunerated for their time by the public sector?’ During interviews, we also collected information on the total number of hours per month each GP was contracted to the public hospital and used this information to calculate the number of full-time equivalent doctor posts the GPs contributed at each hospital. For example, in hospital C, there were five private GPs each contracted for 25 hours per week. A public sector doctor works 56 hours per week; therefore, in this hospital, the combined private GP hours are equivalent to 2.2 full-time equivalent establishment doctors. We undertook a total of 23 semistructured qualitative interviews including: 3 district managers (2 male, 1 female), 12 private GPs (7 male, 5 female) and 8 government-employed doctors (4 male, 4 female). Quantitative data from hospital records were analysed in Excel using simple descriptive mean and SD (mean monthly number of deliveries) and proportions (caesarean delivery rate, deliveries undertaken by a private GP, elective caesarean deliveries and caesarean deliveries occurring during daytime or evening/night-time hours) stratifying by hospital over the 12-month data collation period. We describe the proportion of total annual caesarean deliveries at each hospital undertaken by private GPs as surgeon or anaesthetist and explore the relationship between type of provider and the caesarean delivery profile (elective vs emergency and timing in terms of daytime hours or during the evening/night) and adverse outcomes (referral to a regional hospital following a caesarean delivery, maternal death, PPH and other procedures performed at caesarean deliveries). Qualitative interviews were digitally recorded and transcribed. A framework analysis14 approach was applied, which is well suited to implementation research designs. We drew on a framework previously developed by members of our research team which outlines drivers, challenges and required action for obstetric care in preparing for NHI.15 The interviews were read and reread by members of the team to familiarise ourselves with the content. Emerging categories and major themes were identified and mapped against the framework and quantitative findings. Five members of the research team (TD, ED, GS, SF and YB) read transcripts and met to discuss emerging categories and major themes. The qualitative data enhance contextual understanding of the quantitative outcomes related to caesarean section rates and outcomes by shedding light on provider experiences and perceptions of aspects such as workload and remuneration. Patients and/or the public were not involved in the design, or conduct, of this research. We will be disseminating the findings through presentations at each of the participating hospitals, which will be targeted at stakeholder groups including patients and members of the public.