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Assessment of cesarean delivery availability in 26 low- and middle-income countries: a cross-sectional study

  • Rele Ologunde
    Correspondence
    Reprints: Rele Ologunde, Faculty of Medicine, School of Public Health, Imperial College London, St Mary's Hospital, Praed Street, London, W2 1NY, United Kingdom.
    Affiliations
    Faculty of Medicine, School of Public Health, Imperial College London, St Mary's Hospital, London, United Kingdom

    Emergency and Essential Surgical Care Program, Health Systems and Innovation
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  • Joshua P. Vogel
    Affiliations
    Department of Reproductive Health and Research, United Nations Development Programme/United Nations Fund for Population Activities/United Nations International Children's Emergency Fund/World Health Organization (WHO)/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction

    Faculty of Medicine, Dentistry and Health Sciences, School of Population Health, University of Western Australia, Crawley, Australia
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  • Meena N. Cherian
    Affiliations
    Emergency and Essential Surgical Care Program, Health Systems and Innovation
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  • Mariam Sbaiti
    Affiliations
    Faculty of Medicine, School of Public Health, Imperial College London, St Mary's Hospital, London, United Kingdom
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  • Mario Merialdi
    Affiliations
    Department of Reproductive Health and Research, United Nations Development Programme/United Nations Fund for Population Activities/United Nations International Children's Emergency Fund/World Health Organization (WHO)/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction
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  • James Yeats
    Affiliations
    Faculty of Medicine, School of Public Health, Imperial College London, St Mary's Hospital, London, United Kingdom
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      Objective

      We sought to assess the capacity to provide cesarean delivery (CD) in health facilities in low- and middle-income countries.

      Study Design

      We conducted secondary analysis of 719 health facilities, in 26 countries in Africa, the Pacific, Asia, and the Mediterranean, using facility-based cross-sectional data from the World Health Organization Situational Analysis Tool to Assess Emergency and Essential Surgical Care.

      Results

      A total of 531 (73.8%) facilities reported performing CD. In all, 126 (17.5%) facilities did not perform but referred CD; the most common reasons for doing so were lack of skills (53.2%) and nonfunctioning equipment (42.9%). All health facilities surveyed had at least 1 operating room. Of the facilities performing CD, 47.3% did not report the presence of any type of anesthesia provider and 17.9% did not report the presence of any type of obstetric/gynecological or surgical care provider. In facilities reporting a lack of functioning equipment, 26.4% had no access to an oxygen supply, 60.8% had no access to an anesthesia machine, and 65.9% had no access to a blood bank.

      Conclusion

      Provision of CD in facilities in low- and middle-income countries is hindered by a lack of an adequate anesthetic and surgical workforce and availability of oxygen, anesthesia, and blood banks.

      Key words

      Following the adoption of the Millennium Declaration by the United Nations in 2000, the Millennium Development Goals (MDGs) were established. These 8 international development goals, agreed on by all 189 Member States, were aimed to be achieved by the year 2015. Although much attention has been focused on meeting the MDGs, the role of strengthening surgical capacity to achieve these goals, notably MDG4 (reducing child mortality) and MDG5 (improving maternal health), has received relatively less attention.
      PloS Medicine Editors
      A crucial role for surgery in reaching the UN millennium development goals.
      Surgical disease has been estimated to account for 11% of the world's disability-adjusted life years
      • Debas H.T.
      • Gosselin R.
      • McCord C.
      • Thind A.
      Surgery.
      and is predicted to eclipse those of human immunodeficiency virus, tuberculosis, and malaria by the year 2026.
      • Bae J.Y.
      • Groen R.S.
      • Kushner A.L.
      Surgery as a public health intervention: common misconceptions versus the truth.
      However, according to current estimates, the poorest third of the world's population receive only 3.5% of the 234 million surgical procedures undertaken worldwide.
      • Weiser T.G.
      • Regenbogen S.E.
      • Thompson K.D.
      • et al.
      An estimation of the global volume of surgery: a modeling strategy based on available data.
      In 2010, the global maternal mortality ratio was 210 deaths per 100,000 births, which corresponds to a total of 287,000 maternal deaths worldwide.

      WHO, UNICEF, UNFPA, The World Bank. Trends in maternal mortality: 1990 to 2010. Geneva (Switzerland): World Health Organization; 2012.

      Major complications due to obstetric conditions such as antepartum hemorrhage, obstructed labor, and eclampsia can be prevented or managed with timely access to cesarean delivery (CD).

      WHO, UNFPA, UNICEF, Mailman School of Public Health. Monitoring emergency obstetric care. Geneva (Switzerland): World Health Organization; 2009.

      However, access to and use of CD varies widely both geographically and between low- and middle-income countries (LMICs)
      • Betran A.P.
      • Merialdi M.
      • Lauer J.A.
      • et al.
      Rates of cesarean section: analysis of global, regional and national estimates.
      • Souza J.P.
      • Gulmezoglu A.
      • Lumbiganon P.
      • et al.
      Cesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004-2008 WHO Global Survey on Maternal and Perinatal Health.
      with rates <1% for many of the poorest populations.
      • Ronsmans C.
      • Holtz S.
      • Stanton C.
      Socioeconomic differentials in cesarean rates in developing countries: a retrospective analysis.
      To reduce the unacceptably high levels of maternal mortality in LMICs,

      WHO, UNICEF, UNFPA, The World Bank. Trends in maternal mortality: 1990 to 2010. Geneva (Switzerland): World Health Organization; 2012.

      efforts to improve the availability and accessibility of emergency obstetric care must be facilitated. This care encompasses all care related to the treatment of peripartum complications, including the ability to perform safe CD.

      WHO, UNFPA, UNICEF, Mailman School of Public Health. Monitoring emergency obstetric care. Geneva (Switzerland): World Health Organization; 2009.

      A checklist of 9 signal functions defines the minimum requirements of a facility to be considered a provider of comprehensive emergency obstetric care services.

      WHO, UNFPA, UNICEF, Mailman School of Public Health. Monitoring emergency obstetric care. Geneva (Switzerland): World Health Organization; 2009.

      These signal functions are indicators for a group of interventions that are used to manage the obstetric complications that contribute to the majority of maternal deaths worldwide.

      World Health Organization. Maternal health around the world. Geneva (Switzerland): WHO 1997.

      The ability to perform surgery (including CD) and to deliver a blood transfusion are the 2 indicators that distinguish a comprehensive emergency obstetric care facility from a basic emergency obstetric care facility. In the absence of a CD, women with obstructed labor are at increased risk of death or developing a fistula during childbirth, in addition to risk of perinatal morbidity and mortality.

      World Health Organization. Essential elements of obstetric care at first referral level. Geneva (Switzerland): WHO; 1991.

      There is, however, evidence showing that basic surgical care provision and investment in obstetric capacity, particularly in LMICs, can be a cost-effective public health intervention.
      • Laxminarayan R.
      • Chow J.
      • Shahid-Salles S.A.
      Intervention of cost-effectiveness: overview of main messages.
      • Spiegel D.A.
      • Abdullah F.
      • Price R.R.
      • Gosselin R.A.
      • Bickler S.W.
      World Health Organization Global Initiative for Emergency and Essential Surgical Care: 2011 and beyond.
      • McCord C.
      • Chowdhury Q.
      A cost effective small hospital in Bangladesh: what it can mean for emergency obstetric care.
      Effective intrapartum care is not limited to the capacity to perform CD; it also requires trained skilled birth attendants able to prevent, recognize, and manage obstetric complications and deliver a range of interventions. This study is the largest cross-sectional survey of availability of CD in LMICs to date and provides the most comprehensive assessment of provision of this procedure yet from a sample of a number of facilities around the world rather than a single geographic location.
      This study focuses on the critical aspect of provision of CD as a lifesaving surgical intervention for women with obstetric complications. We aimed to quantify CD capacity in health facilities in LMICs based on availability of the procedure, infrastructure and human resources, and reasons for referral using the World Health Organization (WHO) Situational Analysis Tool (SAT) to assess emergency and essential surgical care.

      Materials and Methods

      WHO SAT to assess emergency and essential surgical care

      The main outcome of this study was to determine the proportion of health facilities in LMICs performing CD. Secondary exposures of interest are reasons for referral of CD in those facilities that do not perform the procedure, availability of essential surgical elements in facilities performing and not performing CD, and availability of human personnel in facilities performing and not performing CD.
      The standardized WHO SAT to assess emergency and essential surgical care, developed by the WHO Global Initiative for Essential and Emergency Surgical Care research group in November 2007, has been used to collect data from health facilities in 44 LMICs from December 2008 through the present. The SAT is a paper-based cross-sectional survey form used to quantify surgical capacity, including trauma, obstetrics, and anesthesia, within participating facilities. The analysis tool collects information on the name, location, and type of participating facilities. The WHO SAT was pilot tested in 8 facilities in The Gambia and United Republic of Tanzania
      • Kushner A.L.
      • Cherian M.N.
      • Noel L.
      • Spiegel D.A.
      • Groth S.
      • Etienne C.
      Addressing the millennium development goals from a surgical perspective essential surgery and anesthesia in 8 low- and middle-income countries.
      and has been validated for assessing surgical capacity in health facilities in LMICs.
      • Osen H.
      • Chang D.
      • Choo S.
      • et al.
      Validation of the World Health Organization tool for situational analysis to assess emergency and essential surgical care at district hospitals in Ghana.
      The WHO SAT has 108 data points divided into 4 sections: (1) 25 questions on infrastructure and health facility demographics, including the availability of essential surgical services such as oxygen, an anesthesia machine, and a blood bank; (2) 8 questions on the availability of health care personnel (including the number of personnel for each relevant category); (3) 34 questions assessing the availability of surgical interventions; and (4) 41 questions on the availability of surgical equipment and supplies. Section 4 of the SAT is based on the WHO Essential and Emergency Equipment list.

      World Health Organization. WHO generic essential emergency equipment list 2006. Available at: www.who.int/surgery/publications/EEEGenericListFormatted 06.pdf. Accessed May 7, 2013.

      Administration of the WHO SAT

      Identification of health facilities for administration of the SAT was left to the discretion of Ministry of Health, WHO country office, and Global Initiative for Essential and Emergency Surgical Care representatives in individual countries. As such, the data represent a sample of convenience. Representatives from these organizations, during site visits to health facilities, performed data collection. Where this was not possible medical or surgical directors at respective hospitals took over administration of the SAT. Survey responses were kept anonymous. The data were entered into and stored on the WHO DataCol SQL global database at WHO headquarters in Geneva, Switzerland, from December 2008 through the present. The hard copies of the paper-based information were stored securely. In March 2013, a database query was performed to extract information on CD capacity.

      Data analysis

      Countries providing data on <5 health facilities were excluded from the aggregated data to reduce potential bias of including nationally unrepresentative data, in line with previous studies employing the WHO tool.
      • Kushner A.L.
      • Cherian M.N.
      • Noel L.
      • Spiegel D.A.
      • Groth S.
      • Etienne C.
      Addressing the millennium development goals from a surgical perspective essential surgery and anesthesia in 8 low- and middle-income countries.
      • Vo D.
      • Cherian M.N.
      • Bianchi S.L.
      • et al.
      Anesthesia capacity in 22 low and middle income countries.
      Health facilities were included if they had ≥1 operating rooms. A total of 719 health facilities met the inclusion criteria (Table 1). Health facilities included health centers, district/rural/community hospitals, provincial hospitals, general hospitals, and private/nongovernmental organization (NGO)/mission hospitals. Results were grouped for aggregate analysis to avoid intercountry comparisons. Health centers are often present at the subdistrict level where they provide both preventive and curative services for their population
      • Choo S.
      • Perry H.
      • Hesse A.A.J.
      • et al.
      Assessment of capacity for surgery, obstetrics and anesthesia in 17 Ghanaian hospitals using a WHO assessment tool.
      and often represent the lowest level of health facility. District hospitals tend to represent the largest level of health facility and are a first referral point for patients who present with conditions that require surgical intervention.
      • Abdullah F.
      • Choo S.
      • Hesse A.A.
      • et al.
      Assessment of surgical and obstetrical care at 10 district hospitals in Ghana using on-site interviews.
      District, rural, and community hospitals were grouped together in keeping with previous studies using the WHO SAT.
      • Kushner A.L.
      • Cherian M.N.
      • Noel L.
      • Spiegel D.A.
      • Groth S.
      • Etienne C.
      Addressing the millennium development goals from a surgical perspective essential surgery and anesthesia in 8 low- and middle-income countries.
      • Contini S.
      • Taqdeer A.
      • Cherian M.
      • et al.
      Emergency and essential surgical services in Afghanistan: still a missing challenge.
      • Penoyar T.
      • Cohen H.
      • Kibatala P.
      • et al.
      Emergency and surgery services of primary hospitals in the United Republic of Tanzania.
      • Iddriss A.
      • Shivute N.
      • Bickler S.
      • et al.
      Emergency, anesthetic and essential surgical capacity in the Gambia.
      Provincial hospitals in many LMICs are typically tertiary teaching hospitals. General hospitals are similar to district hospitals and in some countries the terms are used interchangeably.
      • Iddriss A.
      • Shivute N.
      • Bickler S.
      • et al.
      Emergency, anesthetic and essential surgical capacity in the Gambia.
      Private/NGO/mission hospitals are large well-resourced and typically well-equipped institutions.
      Table 1Characteristics of countries included in study and number of facilities contributed by each
      No.CountryLIC/MIC
      As defined by the World Bank Classification System based on 2011 Gross National Income per capita with LIC making ≤$1025 and MIC making $1026-12,475
      MMR per 100,000
      Figures derived from trends in maternal mortality: 1990 through 20105
      Births by CD, %
      See Appendix for sources of CD rates.
      No. of facilities completing a surveyNo. of facilities includedData
      1AfghanistanLIC4603.626223.06%
      2ArgentinaMIC7722.7981.11%
      3ChinaMIC4027.0870.97%
      4Democratic Republic of CongoLIC5407.216152.09%
      5EthiopiaLIC3501.519192.64%
      6The GambiaLIC3602.575233.20%
      7GhanaLIC3506.922223.06%
      8HaitiLIC3503.051486.68%
      9IndiaLIC2008.117111015.30%
      10KenyaLIC3606.254537.37%
      11LiberiaLIC7703.523162.23%
      12MalawiLIC4604.616152.09%
      13MongoliaLIC6321.043294.03%
      14MyanmarLIC20032.120202.78%
      15NigerLIC5901.021212.92%
      16NigeriaLIC6301.812111515.99%
      17PakistanLIC2607.3981.11%
      18Papua New GuineaLIC2304.725243.34%
      19Sao Tome and PrincipeLIC705.3510.14%
      20Sierra LeoneLIC8904.512111.53%
      21Solomon IslandsMIC936.2970.97%
      22SomaliaLIC10001–214141.95%
      23Sri LankaMIC3523.839182.50%
      24UgandaLIC3105.338314.31%
      25United Republic of TanzaniaLIC4604.549435.98%
      26VietnamLIC5920.019192.64%
      Total914719100.00%
      CD, cesarean delivery; LIC, low-income country; MIC, middle-income country; MMR, maternal mortality ratio.
      Ologunde. Cesarean delivery availability in 26 LMICs. Am J Obstet Gynecol 2014.
      a As defined by the World Bank Classification System based on 2011 Gross National Income per capita with LIC making ≤$1025 and MIC making $1026-12,475
      b Figures derived from trends in maternal mortality: 1990 through 2010

      WHO, UNICEF, UNFPA, The World Bank. Trends in maternal mortality: 1990 to 2010. Geneva (Switzerland): World Health Organization; 2012.

      c See Appendix for sources of CD rates.
      To minimize potential bias as a result of nonresponse, all reasonable attempts were made to contact health facilities with missing data points. When health facilities were contacted, verification of previously submitted data was also conducted, to minimize potential bias from possible response errors. Where a response for a data point was unobtainable, it was reported as missing and the health facility was excluded from the subanalysis pertaining to that data point.
      Computerized spreadsheet tools were used to generate descriptive statistics using Microsoft Excel for Mac 2011, version 13.3.4 (Microsoft, Redmond, WA). We used SPSS, version 21.0 (IBM Corp, Armonk, NY) to perform χ2 tests. We employed descriptive statistical analysis to compare individual elements of the survey between facilities performing CD and those not performing CD. We performed bivariate analysis using χ2 test to compare the results of facilities performing CD and those not performing CD with a P value of < .05 set as statistically significant.
      Data used in this study did not require ethics approval because no patient records or information was included. The data analyzed are for assessing the availability of surgical services for each health facility.

      Role of the funding source

      The sponsors of the study had no role in study design, data collection, data interpretation, data analysis, or writing of the report. The corresponding author had full access to all the data in the study; all authors had final responsibility for the decision to submit for publication.

      Results

      A total of 18 countries were excluded from the aggregated data for providing information on <5 health facilities (Figure 1). Of the remaining 914 facilities, 195 did not have an operating room and were excluded from the study. Of these, 29 were district/rural/community hospitals, 9 were general hospitals, 126 were health centers, 14 were private/NGO/mission hospitals, 4 were provincial hospitals, and 13 did not provide a response for this data point. The 719 health facilities included in our analysis represent 14 African countries, 5 Western Pacific countries, 3 Southeast Asian countries, 2 Eastern Mediterranean countries, and 2 North American countries. Demographic and study data for included countries are shown in Table 1. Country classifications were based on WHO classification of world regions.

      WHO. World health statistics 2013, Geneva, Switzerland. Available at: http://apps.who.int/iris/bitstream/10665/81965/1/9789241564588_eng.pdf. Accessed May 16, 2013.

      Figure thumbnail gr1
      Figure 1Study flowchart
      Ologunde. Cesarean delivery availability in 26 LMICs. Am J Obstet Gynecol 2014.

      Health facility characteristics

      In all, 244 (33.9%) of the included facilities were district/rural/community hospitals, 202 (28.1%) were private/NGO/mission hospitals, 100 (13.9%) were general hospitals, 78 (10.8%) were health centers, and 78 (10.8%) were provincial hospitals. All health facilities surveyed had at least 1 operating room, with 233 (32.4%) reporting ≥2.

      CD provision and referral

      In all, 531 (73.8%) of the 719 facilities surveyed reported performing CD, whereas 167 (23.2%) did not perform the procedure and 21 (2.9%) did not provide information on this. Of the 167 facilities that did not perform the procedure, 36 did not state what they did with regards to women requiring a CD and were thus excluded from the analysis. Of the 719 facilities, 126 (17.5%) facilities reported that they referred the procedure to another facility. It is possible that a number of the facilities not providing information on referral of CD actually do not provide it because it is not within the remit of procedures they perform (ie, a small rural health post) and thus pregnant women would likely be aware not to seek such a facility in the event of labor. Establishments performing and referring CD were stratified by facility type and are illustrated in Figure 2. Provision of CD was highest in private/NGO/mission hospitals, whereas referral was most common in health centers.
      Figure thumbnail gr2
      Figure 2Availability of CD in health facilities
      Facilities excluded for not providing data on performance of CD (n = 21) and not indicating whether or not they referred CD (n = 36).
      CD, cesarean delivery; NGO, nongovernmental organization.
      Ologunde. Cesarean delivery availability in 26 LMICs. Am J Obstet Gynecol 2014.
      Of the facilities that did not perform but referred CD, the most common reason for doing so was a lack of skills (n = 67, 53.2%). The next most common reasons were nonfunctioning equipment (n = 54, 42.9%) and lack of supplies/drugs (n = 42, 33.3%). However, in general hospitals and private/NGO/mission hospitals the most common reason for referring CD was nonfunctioning equipment. Reasons for referring CD were stratified by facility type among those not performing the procedure (Figure 3).
      Figure thumbnail gr3
      Figure 3Reasons for referring cesarean delivery
      Facilities excluded for not providing data on reasons for referral (n = 14).
      NGO, nongovernmental organization.
      Ologunde. Cesarean delivery availability in 26 LMICs. Am J Obstet Gynecol 2014.

      Essential surgical elements

      In facilities performing CD, there was consistent availability of an oxygen supply (cylinder or concentrator), an anesthesia machine, and a blood bank at 417 (78.7%), 350 (66.7%), and 199 (39.8%) facilities, respectively (Figure 4). In facilities referring CD because of nonfunctioning equipment, only 21 (39.6%) facilities had a consistent availability of oxygen (cylinder or concentrator), 18 (35.3%) an anesthesia machine, and 4 (8.3%) a blood bank (Figure 4). A statistically significant difference was found in the availability of essential surgical elements between facilities performing and those not performing but referring CD (Table 2).
      Figure thumbnail gr4
      Figure 4Availability of essential surgical elements in facilities performing CD, and those referring CD due to nonfunctioning equipment
      Facilities performing CD excluded for not providing data on oxygen supply (n = 1), anesthesia machine (n = 6), and a blood bank (n = 31). Facilities referring CD excluded for not providing data on oxygen supply (n = 1), anesthesia machine (n = 3), and a blood bank (n = 6).
      CD, cesarean delivery.
      Ologunde. Cesarean delivery availability in 26 LMICs. Am J Obstet Gynecol 2014.
      Table 2Availability of infrastructure
      ItemTotal (n = 719)Facilities performing CD (n = 531)Facilities referring CD
      Refer CD due to nonfunctioning equipment.
      (n = 54)
      P value
      Oxygen525 (73.3%)417 (78.7%)21 (39.6%)< .001
      Anesthesia machine415 (58.9%)350 (66.7%)18 (35.3%)< .001
      Blood bank228 (33.8%)199 (39.8%)4 (8.3%)< .001
      CD, cesarean delivery.
      Ologunde. Cesarean delivery availability in 26 LMICs. Am J Obstet Gynecol 2014.
      a Refer CD due to nonfunctioning equipment.
      An anesthesia machine and a blood bank were the most common essential surgical elements that were lacking in facilities performing CD and in those referring due to nonfunctioning equipment (Figure 4). Of all the facilities surveyed, 67 (9.4%) reported not having an oxygen supply, 243 (33.8%) reported not having an anesthesia machine, and 345 (48.0%) reported not having a blood bank.

      Human resources

      The most common providers of anesthetic care in facilities performing CD, and in those referring due to lack of skills, were nurses or nonphysician medical practitioners (Table 3). In health facilities referring CD due to a lack of skills at the facility, only 4 (6.0%) facilities had at least 1 anesthesiologist and only 6 (9.0%) facilities had at least 1 nurse or nonphysician medical practitioner providing anesthesia. In all, 57 (85.1%) of the facilities referring CD due to a lack of skills did not report the presence of any type of anesthesia provider (Table 3). In addition, 251 (47.3%) of the facilities reporting that they performed CD did not report the presence of any type of anesthesia provider.
      Table 3Availability of anesthetic care providers
      PersonnelTotal (n = 719)Facilities performing CD (n = 531)Facilities referring CD
      Refer CD due to lack of skills.
      (n = 67)
      P value
      Anesthesiologist172 (23.9%)145 (27.3%)4 (6.0%)< .001
      General doctor providing anesthesia66 (9.2%)62 (11.7%)0 (0.0%).003
      Nurse or NMP providing anesthesia229 (31.8%)202 (38.0%)6 (9.0%)< .001
      None present389 (54.1%)2 (47.3%)57 (85.1%)< .001
      CD, cesarean delivery; NMP, nonphysician medical practitioner.
      Ologunde. Cesarean delivery availability in 26 LMICs. Am J Obstet Gynecol 2014.
      a Refer CD due to lack of skills.
      Surgeons were the most common providers of obstetric or surgical care in facilities performing CD, whereas general doctors were the most common surgical care providers in facilities that referred CD due to a lack of skills (Table 4). Additionally, of the facilities performing CD, 95 (17.9%) did not report the presence of any type of obstetric/gynecological or surgical care provider (Table 4).
      Table 4Availability of obstetrical and surgical care providers
      PersonnelTotal (n = 719)Facilities performing CD (n = 531)Facilities referring CD
      Refer CD due to lack of skills.
      (n = 67)
      P value
      Obstetrician/gynecologist215 (29.9%)187 (35.2%)3 (4.5%)< .001
      Surgeon358 (49.8%)307 (57.8%)7 (10.4%)< .001
      General doctor performing surgery254 (35.3%)195 (36.7%)38 (56.7%).002
      NMP performing surgery154 (21.4%)86 (16.2%)5 (7.5%).061
      None present168 (23.4%)95 (17.9%)21 (31.3%).009
      CD, cesarean delivery; NMP, nonphysician medical practitioner.
      Ologunde. Cesarean delivery availability in 26 LMICs. Am J Obstet Gynecol 2014.
      a Refer CD due to lack of skills.

      Comment

      This study aimed to assess the surgical capacity of facilities providing CD in LMICs, and the reasons for referral in those facilities unable to provide CD. We found that 73.8% of facilities analyzed performed CD, with 17.5% not performing but referring the procedure. Lack of skills and nonfunctioning equipment were found to be major barriers to provision of CD. Even in facilities where CD was performed, our data demonstrate a lack of essential equipment and skilled anesthesia, obstetric, and surgical care providers. This raises concerns about patient safety and the quality of care being delivered in these facilities. To our knowledge this is the largest study to assess availability of CD, referrals, and barriers to provision of the procedure, using a standardized tool across a large number of LMICs.

      CD provision and referral

      Kushner et al
      • Kushner A.L.
      • Cherian M.N.
      • Noel L.
      • Spiegel D.A.
      • Groth S.
      • Etienne C.
      Addressing the millennium development goals from a surgical perspective essential surgery and anesthesia in 8 low- and middle-income countries.
      reported CD provision in 44% of facilities in a cohort of 132 facilities, with at least 1 minor or major operating room, from 8 LMICs. A number of single-country surveys have also been conducted. A study by Contini et al
      • Contini S.
      • Taqdeer A.
      • Cherian M.
      • et al.
      Emergency and essential surgical services in Afghanistan: still a missing challenge.
      in Afghanistan reported that 88% of facilities performed CD. In the United Republic of Tanzania, 67% of surveyed health facilities reported performing CD
      • Penoyar T.
      • Cohen H.
      • Kibatala P.
      • et al.
      Emergency and surgery services of primary hospitals in the United Republic of Tanzania.
      and in The Gambia 58.8% of facilities, all containing at least 1 operating room, reported performing the procedure.
      • Iddriss A.
      • Shivute N.
      • Bickler S.
      • et al.
      Emergency, anesthetic and essential surgical capacity in the Gambia.
      The difference between our estimate and previous ones may reflect differences in sampling. It may also be due to the limitations of the data used for these types of estimates, or may reflect genuine variability in the provision of CD across countries. We found that 17.5% of facilities surveyed referred CD; this is comparable with previous findings from single-country surveys of 30% by Abdullah et al
      • Abdullah F.
      • Choo S.
      • Hesse A.A.
      • et al.
      Assessment of surgical and obstetrical care at 10 district hospitals in Ghana using on-site interviews.
      and 18% by Choo et al.
      • Choo S.
      • Perry H.
      • Hesse A.A.J.
      • et al.
      Assessment of capacity for surgery, obstetrics and anesthesia in 17 Ghanaian hospitals using a WHO assessment tool.
      Although our findings suggest that over three quarters of facilities sampled provide CD, the availability of CD as a proportion of all health facilities in LMICs will be much lower given that we only included health facilities that had an operating room and excluded those that do not.

      Essential surgical elements

      Oxygen is crucial to the provision of safe surgical procedures and emergency resuscitation,
      • Brook M.H.
      • Brook J.
      • Wyant G.M.
      Emergency resuscitation.
      yet our findings suggest that it is not universally available even in settings where CD is being performed. We found that 21.3% of facilities performing CD reported not having a reliable supply of oxygen and 26.4% of those referring CD due to nonfunctioning equipment did not have any supply. Previous analyses have demonstrated that critical surgical services, such as oxygen, anesthetic machines, and blood banks, are often not available in LMICs.
      • Belle J.
      • Cohen H.
      • Shindo N.
      • et al.
      Influenza preparedness in low-resource settings: a look at oxygen delivery in 12 African countries.
      A survey of 590 facilities in 22 LMICs found that 35% of facilities did not report having access to any source of oxygen
      • Vo D.
      • Cherian M.N.
      • Bianchi S.L.
      • et al.
      Anesthesia capacity in 22 low and middle income countries.
      and a survey of 231 health facilities in 12 African countries reported that 24.8% of facilities lacked access.
      • Belle J.
      • Cohen H.
      • Shindo N.
      • et al.
      Influenza preparedness in low-resource settings: a look at oxygen delivery in 12 African countries.
      We found that 9.4% of all facilities surveyed reported not having an oxygen supply, which is much lower than previously published reports. While these 2 studies were methodologically similar to ours, possible reasons for the differences in findings may be differences in sampled facilities and classification of responses, or they may reflect real differences in the surgical capacity of facilities surveyed. Nevertheless, our study is the largest to date to quantify oxygen and anesthesia capacity and will be more representative of global capacity. It is also a significant finding that <100% of all facilities providing CD lack an oxygen supply.
      Ability to provide anesthesia is typically subsumed with the ability to perform CD.

      WHO, UNFPA, UNICEF, Mailman School of Public Health. Monitoring emergency obstetric care. Geneva (Switzerland): World Health Organization; 2009.

      Our findings however, suggest that this should not be assumed as over a quarter of facilities that reported providing CD stated that an anesthesia machine was not available at their facility. However, our study only assessed the availability of an anesthesia machine. Alternative forms of anesthesia such as spinal anesthesia and regional blocks, which are commonly used in CD,
      • Petropoulos G.
      • Siristatidis C.
      • Salamalekis E.
      • Creatsas G.
      Spinal and epidural versus general anesthesia for elective cesarean section at term: effect on the acid-base status of the mother and newborn.
      may have been available in participating health facilities. Availability of a blood bank was also low with almost half of all facilities reporting that this was unavailable. Postpartum hemorrhage is a leading cause of maternal mortality in LMICs
      • Khan K.S.
      • Wojdyla D.
      • Say L.
      • Gulmezoglu A.M.
      • Van Look P.F.
      WHO analysis of causes of maternal death: a systematic review.
      making the lack of a blood bank at a health facility an urgent priority for action to improve obstetric outcomes. Previous studies describing the availability of essential surgical elements using the WHO tool have reported similar findings to ours. In Afghanistan, a third of hospitals surveyed did not have a blood bank.
      • Contini S.
      • Taqdeer A.
      • Cherian M.
      • et al.
      Emergency and essential surgical services in Afghanistan: still a missing challenge.
      A study by Vo et al
      • Vo D.
      • Cherian M.N.
      • Bianchi S.L.
      • et al.
      Anesthesia capacity in 22 low and middle income countries.
      found that >25% of facilities surveyed did not have an anesthesia machine. In the United Republic of Tanzania, 23% of facilities surveyed did not have a blood bank and 33% lacked an anesthesia machine.
      • Penoyar T.
      • Cohen H.
      • Kibatala P.
      • et al.
      Emergency and surgery services of primary hospitals in the United Republic of Tanzania.

      Human resources

      The 2006 World Health Report called for a rapid scaling up of the global health workforce.

      WHO. Rapid scaling up of health workforce production 2006. Available at: http://www.who.int/hrh/resources/WHA_59-23_EN.pdf. Accessed May 19, 2013.

      Despite this, <10% of the countries classified as low-income country by the World Bank actually meet the minimum threshold of health workers deemed necessary to deliver maternal and child health services.

      WHO. WHO global atlas of the health workforce 2010. Available at: http://www.who.int/hrh/fig_density.pdf. Accessed May 19, 2013.

      We found that paraprofessionals and nurses were the most commonly available providers of anesthesia. Similar findings have been reported elsewhere in the literature with Iddriss et al
      • Iddriss A.
      • Shivute N.
      • Bickler S.
      • et al.
      Emergency, anesthetic and essential surgical capacity in the Gambia.
      documenting that anesthesia was delivered by nonphysicians in 72.2% of facilities surveyed in The Gambia and Vo et al
      • Vo D.
      • Cherian M.N.
      • Bianchi S.L.
      • et al.
      Anesthesia capacity in 22 low and middle income countries.
      finding that nurses and clinical assistants made up the majority of anesthesia providers in the 590 facilities they surveyed across 22 LMICs. Surgeons were the most common providers of obstetric or surgical care in the facilities we surveyed, however this varied between facilities performing CD and those referring with general doctors being the most common provider in the latter. Previous reports of surgical providers in the literature suggest that paramedical professionals, including nonphysicians and nurses, make up the bulk of the surgical workforce in LMICs.
      • Abdullah F.
      • Choo S.
      • Hesse A.A.
      • et al.
      Assessment of surgical and obstetrical care at 10 district hospitals in Ghana using on-site interviews.
      • Iddriss A.
      • Shivute N.
      • Bickler S.
      • et al.
      Emergency, anesthetic and essential surgical capacity in the Gambia.
      The lack of specialists in obstetrics and gynecology in LMICs, both in the facilities we surveyed and in previous reports in literature, may have significant adverse effects in terms of the management of obstetric complications in these facilities. Surprisingly, >50% of all facilities included in our study did not report the presence of any of the types of anesthesia providers surveyed and almost a quarter of all facilities did not report the presence of a surgical provider. Given that all facilities surveyed reported having an operating room at the facility, the reasons hindering surgical capacity are likely to be due to a lack of personnel able to perform CD at the facility. Where this is the case there is the potential for task shifting, which may reduce inequalities by extending care to underserved populations. Task shifting in surgery has already been shown to be effective in a number of LMICs including Niger,
      • Sani R.
      • Nameoua B.
      • Yahaya A.
      • et al.
      The impact of launching surgery at the district level in Niger.
      where general practitioners are trained in “district surgery,” and in Malawi, where nonphysician clinical officers have on-the-job training in surgery.
      • Jiskoot P.
      On-the-job training of clinical officers in Malawi.
      A recent review of task shifting in maternal and reproductive health suggests that it is cost-effective and may increase access and availability of services without compromising on patient outcomes.
      • Dawson A.J.
      • Buchan J.
      • Duffield C.
      • Homer C.S.
      • Wijewardena K.
      Task shifting and sharing in maternal and reproductive health in low-income countries: a narrative synthesis of current evidence.
      WHO guidelines on task shifting in maternal and newborn health recommended that advanced-level associate clinicians could be used to perform CD in well-equipped facilities, in the context of targeted monitoring and evaluation.

      World Health Organization. Optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting. Geneva (Switzerland): WHO; 2012.

      Limitations

      The Essential and Emergency Surgical Care database is a sample of convenience and is susceptible to selection bias. The facilities in the data set are not demographically or geographically representative of their country. The data were aggregated, and countries were not weighted by their contribution. In addition, surveys completed without site visits lack response integrity validation and may be vulnerable to reporting bias.

      Applications and future research

      While the majority of facilities analyzed performed CD, issues of the availability, accessibility, equity, quality, and safety of CD remain unanswered. Supporting the training and continuing education of health care personnel is paramount to improving safe surgical practices in LMICs. Future research should focus on developing the surgical capacity of health facilities through frugal technologies that are appropriate for the LMIC setting: for example, low maintenance, electricity-independent oxygen concentrators that meet the needs of remote health facilities. Furthermore, to address the critical health worker shortages in many LMICs, shifting of tasks, such as CD, may improve access to the procedure.

      World Health Organization. Optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting. Geneva (Switzerland): WHO; 2012.

      Further study in to the outcome of CD in women in LMICs is also warranted to work towards improving the safety profile and quality of the procedure.

      Conclusion

      CD is a lifesaving obstetric intervention and is indicated in several complications of pregnancy and delivery. However, even when CD is available, facilities in LMICs do not necessarily have the services, staff, and capacity to perform the procedure safely. Efforts to increase surgical and obstetric capacity and thus availability of CD need to focus on addressing deficiencies in key infrastructural items and scaling up and meeting the training needs of the health workforce. The limited availability of essential services and infrastructure in many facilities that purport to provide CD raises questions about the quality and safety of the procedures being provided.

      Acknowledgments

      We are hugely grateful for the support of the health facility visit teams in the various countries included in this survey and in particular would like to thank Rev Dr Tomi Thomas (Catholic Health Association of India), Mr Bakary Jargo (WHO country office, The Gambia), Dr Ananda Gunasekera (Ministry of Health, Sri Lanka), Dr Håkon Angell Bolkan (CapaCare, Sierra Leone), Dr Tu Tran (University of California Haiti Initiative, Haiti), Dr Samuel Likasi (United Republic of Tanzania), Dr Opar Toliva (Uganda), and Dr Olayinka Ayankogbe (Nigeria). We are hugely grateful for the support of Dr Graham Cooke, Miss Florence Guida, Miss Fiona Constable, Dr Luc Noel, Dr Laksmi Govindasamy, and Miss Rikke Le Kirkegaard for their guidance and helpful discussion.

      Appendix

      Supplementary TableEstimates and sources of CS rates
      CountryYearCS, %
      Calculated as the total number of births by cesarean section over the total number of births within a given population over a given period of time, expressed as a percentage.
      Source
      Afghanistan20113.6http://apps.who.int/gho/data/view.country.3000 [Accessed May 11, 2013]
      Argentina200622.7http://apps.who.int/gho/data/view.country.3500 [Accessed May 11, 2013]
      China200827http://apps.who.int/gho/data/view.country.6400 [Accessed May 11, 2013]
      Democratic Republic of Congo20107.2http://apps.who.int/gho/data/view.country.7405 [Accessed May 11, 2013]
      Ethiopia20111.5http://apps.who.int/gho/data/view.country.8500 [Accessed May 11, 2013]
      The Gambia20102.5http://apps.who.int/gho/data/view.country.9000 [Accessed May 11, 2013]
      Ghana20086.9http://apps.who.int/gho/data/view.country.9300 [Accessed May 11, 2013]
      Haiti20063http://apps.who.int/gho/data/view.country.10000 [Accessed May 11, 2013]
      India20088.1http://apps.who.int/gho/data/view.country.10400 [Accessed May 11, 2013]
      Kenya20096.2http://apps.who.int/gho/data/view.country.11500 [Accessed May 11, 2013]
      Liberia20073.5http://apps.who.int/gho/data/view.country.12300 [Accessed May 11, 2013]
      Malawi20104.6http://apps.who.int/gho/data/view.country.12800 [Accessed May 11, 2013]
      Mongolia201021http://apps.who.int/gho/data/view.country.13900 [Accessed May 11, 2013]
      Myanmar200932.1http://www.moh.gov.mm/file/Annual%20Hospital%20Statistics%20Report%202009.pdf [Accessed May 14, 2013]
      Niger20061http://apps.who.int/gho/data/view.country.14900 [Accessed May 11, 2013]
      Nigeria20081.8http://apps.who.int/gho/data/view.country.15000 [Accessed May 11, 2013]
      Pakistan20077.3http://apps.who.int/gho/data/view.country.15300 [Accessed May 11, 2013]
      Papua New Guinea20024.7Papua New Guinea Department of Health. Information provided by Dr Nicholas Mann on 29 July 2003. Papua New Guinea Department of Health, PO Box 807, Waigani NCD, Papua New Guinea.
      Sao Tome and Principe20095.3http://apps.who.int/gho/data/view.country.17300 [Accessed May 11, 2013]
      Sierra Leone20104.5http://apps.who.int/gho/data/view.country.17800 [Accessed May 11, 2013]
      Solomon Islands20076.2http://apps.who.int/gho/data/view.country.18200 [Accessed May 11, 2013]
      Somalia20121–2Deyo NS. Cultural traditions and the reproductive health of Somali refugees and immigrants [Dissertation]. San Francisco, CA (US): University of San Francisco; 2012.
      Sri Lanka200723.8http://apps.who.int/gho/data/view.country.18600 [Accessed May 11, 2013]
      Uganda20115.3http://apps.who.int/gho/data/view.country.20300 [Accessed May 11, 2013]
      United Republic of Tanzania20104.5http://apps.who.int/gho/data/view.country.20700 [Accessed May 11, 2013]
      Vietnam201120http://apps.who.int/gho/data/view.country.21300 [Accessed May 11, 2013]
      CS, cesarean section.
      Ologunde. Cesarean delivery availability in 26 LMICs. Am J Obstet Gynecol 2014.
      a Calculated as the total number of births by cesarean section over the total number of births within a given population over a given period of time, expressed as a percentage.

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