Africa Has Unique And Urgent Barriers To Cleft Care: Lessons From The Survey Of Practitioners Attending The Pan-African Congress On Cleft Lip And Palate
Oluwaseun A. Adetayo, MD, Mark C. Martin, MD, DMD, FRCSC, Subhas Gupta, MD, PhD, FRCSC, FACS.
Loma Linda University Medical Center, Loma Linda, CA, USA.
Purpose: Cleft care in Africa faces challenges due to a lack of established networks and treatment consensus and is additionally challenged by issues unique to its geography, cultures, and socioeconomic challenges. Issues include late presentation, lack of access to cleft teams, infrastructure deficiencies, and difficulties in building and sustaining Cleft care teams.
Methods: We conducted a survey of participants of the second Pan-African Congress on Cleft Lip and Palate which took place from February 4-7, 2007 in Ibadan, Nigeria. The conference included over 225 participants representing 17 African countries of which there were 68 responders to the survey. Information solicited included surgical specialty, access to advanced training in cleft care, team composition, patient load and demographics, provider perspectives on barriers to care, and physician perspectives on critical areas for improvement.
Results: The survey showed that majority of cleft care was provided by Plastic Surgeons (34%) and Oral and Maxillofacial Surgeons (26.9%). Most of the physicians at the congress were from West Africa (86.6%) with the vast majority of responders (91%) reporting formal training in cleft care. During training, half of the surgeons had encountered 30 cleft cases and a quarter had encountered more than 100 cases. The protocols for primary unilateral cleft lip and palate in infancy and for secondary repair of residual deformity were widely varied. One third of surgeons had no access to speech language pathologists, 22% had no access to orthodontists, and 13% had no access to audiologists. Most commonly accessible were ENT (52%), social work (30%), psychology (21%), anesthesia (50%), and dentistry (46%). The most challenging barriers to cleft care were patient awareness (31%), patient access to health care (31%), access to cleft care (37%), patient follow up (65%), ability to pay (53%), transportation (25%), and lack of speech (52%) or orthodontic services (43%).
Conclusion: Geographic separation in Africa presents a similar challenge due to isolationism as it does to surgeons in Europe. Specific to Africa are the increased barriers to care due to cultural beliefs, economic hardship at institutional (physician) and individual (patient) levels. Surgeons treating clefts in Africa report a high level of exposure to Cleft care in their training and tended not to see surgeon education as a major pathway to improving care to a significant number of patients. Instead a focus on infrastructure, funding, team building, and patient education were seen as the keys to improving the care and lives of children with facial clefts in Africa. The classic model of small visiting teams providing concentrated clinical care and individual surgical training does not appear to be the best approach at this point in this region. By communicating with African Cleft care providers and partnering with them to address these systemic issues, North American Plastic Surgeons have a unique opportunity to have a much farther reaching impact than any one surgeon could have through providing clinical service.