Objective: Kapit is the largest division of Sarawak which occupies one third total area of Sarawak (38,934 sq. km) and surrounded by dense primary forest and mountainous region. Kapit Hospital is the only category B district hospital that provides health care service for whole of Kapit population. Nevertheless, O&G (Obstetrics and Gynaecology) specialist posting in this remote hospital is inconsistent despite being well known for geographical difficulties and not accessible by road to the nearest hospital with O&G specialist service. Those unfortunate suffer from obstetric emergencies or considerable risk pregnancy are transferred to nearest referral center by three-hour express boat journey, after hours of challenging journey from further remote longhouses to reach Kapit Hospital. The main objective of this retrospective study is to demonstrate the impact of O&G specialist on O&G service in Kapit Hospital.
Method: A retrospective data collection was performed to study workload of O&G service in Kapit Hospital from 2008 to 2016. Source of data collection was retrieved from discipline manual registry from O&G ward and operation theatre. These were then counter checked with the electronic registry Sistem Maklumat Rekod Pesakit (Patient Record Information System). Annual statistics of total hospital admission to O&G ward, total obstetrics delivery, total case referral to nearest hospital with O&G specialist and total O&G procedures were analyzed. This information was subdivided into two groups namely year of study with and without presence of in-house O&G specialist in Kapit Hospital for comparison.
Results: Total of 13,035 cases were admitted to O&G discipline during study period 2008 – 2016 (annual mean 1,448.3, SD 189.91). Total O&G case referrals were 735 (annual mean 81.7, SD 33.76). There were accumulated 7,864 obstetrics deliveries, in which 798 cases were delivered via caesarean section (caesarean rate 10%). Surgical procedures under O&G discipline was 1,489 cases, which was 832 and 657 cases for obstetrics and gynaecology respectively. The commonest obstetrics surgery performed in Kapit was caesarean section (annual mean 88.7, SD 53.56), and open permanent sterilization (annual mean 41.1, SD 15.05) for gynaecological procedure. There were 46 cases of ruptured ectopic presented to Kapit hospital between 9 years that required emergency exploratory laparotomy for damage control. On comparison between years with O&G specialist service and years with medical officers only service, there were significant increase inpatient O&G case referral during absence of in-house specialist (p=0.015), more caesarean deliveries (p=0.019), more obstetrics procedures (p=0.04) and more gynaecological procedures (p=0.038) in both elective and emergency situations. Indication for O&G cases referral (as outpatient or inpatient) during year 2016 with O&G specialist placement in Kapit in 2016 mainly due to specialist not physically available in Kapit (48.8%), followed by lack of O&G subspecialty service (15.9%), absence of other multidisciplinary such as anaesthetist or surgeon (14.6%), inadequate O&G service such as minimal invasive procedure instrument (12.2%) and patient’s preference (8.5%). All O&G cases referred as inpatient required escort by medical staffs.
Conclusion: O&G specialist service carries an utmost important duty in this remote hospital with unresolved issue related to time limited transportation for transfer. Many undetected substantial risk cases which often presented in emergency required immediate attention by O&G specialist to handle the on-going complications. Presence of O&G specialist service in Kapit Hospital confers significant impact to the workload in O&G discipline. More obstetrics cases can be conducted in this hospital with availability of paediatrician. Equipment and facilities in operation theatre are sufficient to perform common O&G procedures that would further benefit local women under supervision and guidance of O&G specialist. Reduction of case referral to nearest hospital with O&G specialist again decrease financial burden to patients and potential hazardous risk for both medical staffs and patient during transfer by boat. In return, that will reduce the patient load in receiving hospital. Expenditure during escorting case for both parties can be exceptionally high in long term accumulation. In summary, distance of transfer and geographical challenge in Kapit warrants a continuous placement of O&G specialist, for both staff training and welfare of local population.