A Sustainable and Scalable Approach to the Provision of Cleft Care: A Focus on Safety and Quality

Evaluation of Global Cleft Care Initiatives Among the Top Searched Low- and Middle-Income Countries

OBJECTIVE

International outreach for cleft lip and/or palate care has traditionally been characterized by foreign groups and individuals holding surgical outreach trips in low- and middle-income countries. However, this "magic bullet" approach has often been criticized for prioritizing short-term results that may disrupt local workflow. The presence and impact of local organizations that support cleft care and take on capacity building initiatives has not been well explored.

DESIGN

Eight countries previously studied as having the highest Google search demand for CL/P were chosen for the scope of the study. Local NGOs in regions were identified through a web search, and information was collected regarding the location, objectives, partnerships, and work conducted thus far.

RESULTS

Countries with a strong combination of local and international organizations included Ghana, Philippines, Nepal, Kenya, Pakistan, India, and Nigeria. The country with minimal to no local NGO presence included Zimbabwe. Local NGOs often supported education and research, training of providers and staff, spreading community awareness, offering interdisciplinary care, and opening cleft clinics and hospitals. Unique initiatives included starting the first school for children with CL/P, enrolling patients in the national healthcare to cover CL/P care, and monitoring the referral system to improve efficiencies in the healthcare system.

CONCLUSIONS

Moving towards a mindset of capacity building not only involves bilateral partnerships between international host sites and visiting organizations, but also collaboration with local NGOs that have a deep understanding of local communities. Successful partnerships may help address the complex challenges regarding CL/P care faced by LMICs.

Publishing Trends in International Humanitarian Cleft Lip and Palate Care: A Systematic Review

Background: Humanitarian outreach delivers essential cleft lip and palate (CLP) care in low- and middle-income countries. Objective: To review the literature regarding humanitarian CLP care and determine if a shift toward more sustainable care delivery is observed. Methods: A systematic review was performed on articles describing CLP repair in humanitarian settings from 1985 to 2020. Publications were categorized into trip reports, outcomes, teaching, and public health. Articles were stratified into three 12-year intervals (T1-T3) for analysis. Results: A total of 246 publications were included. Average annual publications increased 15.4-fold from T1 to T3 (p < 0.001). Among publications focused on delivering CLP-related care, descriptive trip report articles trended downward (58% in T1 vs. 42% in T3), whereas outcome-focused publications trended upward (42% in T1 vs. 58% T3). Public health research represented the greatest percentage of publications in T3 (50%). There were 22 teaching-related publications in T3 and only one in prior years. Conclusion: Research trends demonstrate a shift away from focusing solely on the number of surgical cases completed and toward more sustainable models of care delivery that address barriers to receiving longitudinal care.

Quality Assurance Standards for Outreach Cleft Lip and Cleft Palate Repair Programs in Low-Resource Settings

BACKGROUND

Comprehensive cleft care is a multidisciplinary team endeavor. While untreated craniofacial conditions have multiple undue repercussions, cleft care in outreach settings can be fraught with significant perioperative morbidity risks.

AIM

Propose updated quality assurance standards addressing logistic and operational considerations essential for the delivery of safe and effective cleft lip and /or palate (CL/P) care in low and middle-income countries (LMICs) settings.

METHODS

Based on American Cleft Palate-Craniofacial Association (ACPA) quality standards, published literature, published protocols by Global Smile Foundation (GSF), and the senior author's three-decade experience, updated standards for outreach cleft care were synthesized.

RESULTS

Ten axes for safe, effective, and sustainable cleft lip and palate care delivery in underserved settings were generated: 1) site assessment, 2) establishment of community partnerships, 3) team composition and credentialing, 4) team training and mission preparation, 5) implementation of quality assurance guidelines, operative safety checklists, and emergency response protocols, 6) immediate and long-term postoperative care, 7) medical record keeping, 8) outcomes evaluation, 9) education, and 10) capacity building and sustainability. Subsequent analysis further characterized essential components of each of those ten axes to delineate experience derived and evidence-based recommendations.

DISCUSSION

Quality assurance guidelines are essential for the safe delivery of comprehensive cleft care to patients with CL/P in any setting. Properly designed surgical outreach programs relying on honest community partnerships can be effectively used as vehicles for local capacity building and the establishment of sustainable cleft care ecosystems.

The History and Mission of Smile Train, a Global Cleft Charity

Cleft lip and/or palate (CLP) is a common congenital anomaly with a global impact. One organization attempting to decrease global burden of CLPs is Smile Train. Since 1999, Smile Train has empowered local medical providers to provide comprehensive and sustainable cleft care. Partner surgeons have performed more than 1.5 million operations for patients with CLPs in more than 90 countries. This article outlines the history and mission of Smile Train and details the organization's efforts to increase hospital-wide safety, provide education and training opportunities for partners, and use technology to improve the delivery of cleft care on a global scale.

[Secondary cheiloplasty in the treatment of cleft lip and palates]

In the course of treatment of cleft lip and palates, the quality of primary cheilo-rhinoplasty is essential to limit aesthetic and functional complications. This is why these primary reconstructions come under the domain of specialised centres with multidisciplinary teams. Unfortunately, residual imperfections often remain, especially in bilateral clefts, and secondary cheiloplasties represent for us a complex challenge. They aim at functional and aesthetic correction, and the choice of time is very random and depends largely on the psychological repercussions of the deformation in the child. It often occurs at the age of school entry and is combined with alveoloplasty. We then speak of alveolar transplantation with vestibulo and labio-plastie, the GPVP. Then we propose to combine all the resources of cosmetic surgery to improve the aesthetic and functional result of these children.