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

doi:10.1016/j.ajog.2014.05.022

American Journal of Obstetrics and Gynecology

Volume 211, Issue 5, November 2014, Pages 504.e1-504.e12

Presented in poster format at the First World Congress of Surgery, Obstetrics, Trauma, and Anesthesia, Port of Spain, Trinidad and Tobago, Oct. 16-17, 2013.

https://doi.org/10.1016/j.ajog.2014.05.022 Get rights and content

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.

Section snippets

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

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

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

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

References (34)

C. Ronsmans et al.
Socioeconomic differentials in cesarean rates in developing countries: a retrospective analysis
Lancet
(2006)
C. McCord et al.
A cost effective small hospital in Bangladesh: what it can mean for emergency obstetric care
Int J Gynecol Obstet
(2003)
F. Abdullah et al.
Assessment of surgical and obstetrical care at 10 district hospitals in Ghana using on-site interviews
J Surg Res
(2011)
K.S. Khan et al.
WHO analysis of causes of maternal death: a systematic review
Lancet
(2006)
A crucial role for surgery in reaching the UN millennium development goals
PLoS Med
(2008)
H.T. Debas et al.
Surgery
J.Y. Bae et al.
Surgery as a public health intervention: common misconceptions versus the truth
Bull World Health Organ
(2011)
T.G. Weiser et al.
An estimation of the global volume of surgery: a modeling strategy based on available data
Lancet
(2008)
WHO, UNICEF, UNFPA, The World Bank. Trends in maternal mortality: 1990 to 2010. Geneva (Switzerland): World Health...
WHO, UNFPA, UNICEF, Mailman School of Public Health. Monitoring emergency obstetric care. Geneva (Switzerland): World...

A.P. Betran et al.

Rates of cesarean section: analysis of global, regional and national estimates

Paediatr Perinat Epidemiol

(2007)

J.P. Souza 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

BMC Med

(2010)

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

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

R. Laxminarayan et al.

Intervention of cost-effectiveness: overview of main messages

D.A. Spiegel et al.

World Health Organization Global Initiative for Emergency and Essential Surgical Care: 2011 and beyond

World J Surg

(2013)

A.L. Kushner et al.

Addressing the millennium development goals from a surgical perspective essential surgery and anesthesia in 8 low- and middle-income countries

Arch Surg

(2010)

Cited by (41)

Obstetric anaesthesia over the next 10 years: Africa and Middle East
2023, International Journal of Obstetric Anesthesia
Maternal and neonatal health outcomes vary within Africa and the Middle East. Despite substantial improvements over the past 20 years, there are persisting inequities in access to, and the quality of, obstetric anaesthetic care. These are most noticeable in Sub-Saharan Africa which has only 3% of the world's healthcare workforce but approximately two-thirds of global maternal deaths. Improvements are being made by: improving access; increasing numbers of trained staff; delivering accessible training; gathering data; conducting research and quality improvement activities; using innovative technologies; and forming productive collaborations. Further improvements will be needed to cope with increasing demand, the impacts of climate change and potential future pandemics.
Spatial distribution of caesarean deliveries and their determinants in Bangladesh: evidence from linked data of population and health facility survey
2023, The Lancet Regional Health - Southeast Asia
Health facility-level factors play a crucial role in women's access to and use of caesarean section (CS) services, but lacks relevant evidence. The study aimed to understand the effects of health facility-level factors on CS delivery in Bangladesh.
The 2017–18 Bangladesh Demographic and Health Survey (2017–18 BDHS) and the 2017 Bangladesh Health Facility Survey (2017 BHFS) were linked and analysed in this study. The sample comprised of 4954 women gave at least one live birth within three years preceding the survey. The outcome variable was delivery through CS (yes, no) and the explanatory variables were health facility-level, individual-level, household-level, and community-level factors. Moran's I and Getis-Ord General G statistic were used to identify the hotspots of delivery through CS. Mixed-effect multilevel logistic regression was used to examine the association of the outcome variable with explanatory variables.
Around 33% of women in Bangladesh underwent CS in their most recent pregnancies. The hotspots of delivery through CS are located primarily in Rajshahi, Dhaka, and Khulna divisions. The likelihood of delivered through CS increased with the rising scores of the management (Adjusted Odds Ratio (AOR), 1.83; 95% CI 1.04–2.07) and infrastructure (AOR, 3.14; 95% CI 1.40–5.12) of the nearest health facility. The readiness of health facilities to provide comprehensive obstetric care was significantly associated with an increased likelihood of delivery through CS (AOR, 2.18; 95% CI 1.15–3.28). These relationships were strong for private than non-government and government health facilities.
The proximity of comprehensive obstetric care facilities to women's residences and their readiness to provide services play critical roles in the access to and use of CS in Bangladesh. The findings highlight the importance of necessary healthcare personnel, including midwives, availability of government hospitals where undue CS are avoided, and awareness-building programmes about the adverse effects of CS delivery.
None.
Cesarean delivery in low- and middle-income countries: A review of quality of care metrics and targets for improvement
2021, Seminars in Fetal and Neonatal Medicine
Citation Excerpt :
Several reports indicate that CD rates have risen sharply with little to no accompanying increase in the number of theatres or equipment within facilities to provide CD, indicating overburdening of likely outdated facilities [67]. In another report from 26 LMICs, common reasons cited as barriers to performing CD were inconsistent access to functioning equipment, oxygen supply, anesthesia supplies, and blood banks [68]. In 2015, the Lancet Commission for Global Surgery identified ten areas of improvement needed for the performance of safe surgical and anesthesia care: (1–3) an adequately trained workforce (surgeon, anesthetist, nursing); (4–5) infrastructure, equipment, supplies, and drugs needed along with a supply chain that allows consistent availability; (6) decontamination and sterilization capacity; (7) safe and affordable blood supply; (8) 24 h surgical coverage; (9) quality improvement processes including audit of peri-operative outcomes; and (10) risk assessment and planning for procedures [69].
Improving quality of care in low-and middle-income countries (LMICs) is a global priority, specifically around maternal and newborn care, where mortality and morbidity remain unacceptably high. Cesarean delivery is the most common procedure in women, thus evaluating quality around the provision of this intervention provides insight into overall quality of care around childbirth. In this review we provide an overview on the quality of care around cesarean delivery using the six domains of quality proposed by the Institute of Medicine: equity, effectiveness, efficiency, safety, timeliness and patient-centered care. We review evidence of potential quality gaps in each of these domains around cesarean delivery in LMICs, discuss opportunities for improvement and provide suggestions on metrics for tracking quality in each of these domains. As cesarean delivery rates increase globally, efforts to ensure quality will be essential to drive continued and sustained improvements in global maternal and newborn outcomes.
Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study
2019, The Lancet Global Health
Citation Excerpt :
Based on the small number of risk factors to be entered into the models, we made an a-priori decision to assess risk factors based on clinical plausibility and our understanding of their potential association with maternal or neonatal mortality. For the maternal mortality models the preoperative risk factors included were pre-eclampsia or eclampsia,17 major bleeding risk,8 any chronic medical condition, and preoperative sepsis, and the perioperative complications included were severe infections,12,17 severe cardiac complications,7 severe obstetric haemorrhage,11 and anaesthesia complications (appendix p 23).9 For the neonatal mortality model, our a-priori decision was to include three neonatal risk factors based on the American Academy of Pediatrics Task Force on neonatal encephalopathy,18 two Apgar scores (<7 at 1 min, and <5 at 5 min), and the need for cardiopulmonary resuscitation.
Maternal and neonatal mortality is high in Africa, but few large, prospective studies have been done to investigate the risk factors associated with these poor maternal and neonatal outcomes.
A 7-day, international, prospective, observational cohort study was done in patients having caesarean delivery in 183 hospitals across 22 countries in Africa. The inclusion criteria were all consecutive patients (aged ≥18 years) admitted to participating centres having elective and non-elective caesarean delivery during the 7-day study cohort period. To ensure a representative sample, each hospital had to provide data for 90% of the eligible patients during the recruitment week. The primary outcome was in-hospital maternal mortality and complications, which were assessed by local investigators. The study was registered on the South African National Health Research Database, number KZ_2015RP7_22, and on ClinicalTrials.gov, number NCT03044899.
Between February, 2016, and May, 2016, 3792 patients were recruited from hospitals across Africa. 3685 were included in the postoperative complications analysis (107 missing data) and 3684 were included in the maternal mortality analysis (108 missing data). These hospitals had a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0·7 per 100 000 population (IQR 0·2–2·0). Maternal mortality was 20 (0·5%) of 3684 patients (95% CI 0·3–0·8). Complications occurred in 633 (17·4%) of 3636 mothers (16·2–18·6), which were predominantly severe intraoperative and postoperative bleeding (136 [3·8%] of 3612 mothers). Maternal mortality was independently associated with a preoperative presentation of placenta praevia, placental abruption, ruptured uterus, antepartum haemorrhage (odds ratio 4·47 [95% CI 1·46–13·65]), and perioperative severe obstetric haemorrhage (5·87 [1·99–17·34]) or anaesthesia complications (11·47 (1·20–109·20]). Neonatal mortality was 153 (4·4%) of 3506 infants (95% CI 3·7–5·0).
Maternal mortality after caesarean delivery in Africa is 50 times higher than that of high-income countries and is driven by peripartum haemorrhage and anaesthesia complications. Neonatal mortality is double the global average. Early identification and appropriate management of mothers at risk of peripartum haemorrhage might improve maternal and neonatal outcomes in Africa.
Medical Research Council of South Africa.
Context is king – obstetric anaesthesia management strategies in limited resource settings
2017, International Journal of Obstetric Anesthesia
Surgical and trauma care in low- and middle-income countries: a review of capacity assessments
2017, Journal of Surgical Research
Citation Excerpt :
Tools to evaluate both surgical and trauma care capacity were included in this review because of the extensive overlap in the care for the injured. Publications were excluded if they were retrospective analyses, lacked a well-described tool or methodology, or described a needs assessment or assessment focused outside of surgical or trauma care.19,27,59,60,73-101 A forward search was then conducted, and publications citing one of the papers identified in the initial selection process were collected.
Surgical and trauma capacity assessments help guide resource allocation and plan interventions to improve care for the injured in low- and middle-income countries (LMICs). To forge expert consensus on conducting these assessments, we undertook a systematic review of studies using five tools: (1) World Health Organization's (WHO) Guidelines for Essential Trauma Care, (2) WHO's Tool for Situational Analysis to Assess Emergency and Essential Surgical Care, (3) Personnel, Infrastructure, Procedures, Equipment, and Supplies tool, (4) Harvard Humanitarian Initiative tool, and (5) Emergency and Critical Care tool.
Publications describing utilization of survey instruments to assess surgical or trauma capacity in LMICs were reviewed. Included articles underwent thematic analysis to develop recommendations. A modified Delphi method was used to establish expert consensus. Experts rated recommendations on a Likert-type scale via online survey. Consensus was defined by Cronbach's α ≥ 0.80. Recommendations achieving agreement by ≥80% of experts were included.
Two hundred and ninety-eight publications were identified and 41 included, describing evaluation of 1170 facilities across 36 LMICs. Nine recommendations were agreed upon by expert consensus: (1) inclusion of district hospitals, (2) inclusion of highest level public hospital, (3) inclusion of private facilities, (4) facility visits for on-site completion, (5) direct inspections, (6) checking surgical logs, (7) adaptation of survey instrument, (8) repeat assessments, and (9) need for increased collaboration.
Expert recommendations developed in this review describe methodology to be employed when conducting assessments of surgical and trauma capacity in LMICs. Consensus has yet to be achieved for tool selection.

View all citing articles on Scopus

: The authors report no conflict of interest.

: Cite this article as: Ologunde R, Vogel JP, Cherian MN, et al. Assessment of cesarean delivery availability in 26 low- and middle-income countries: a cross-sectional study. Am J Obstet Gynecol 2014;211:504.e1-12.

View full text

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

Objective

Study Design

Results

Conclusion

Section snippets

WHO SAT to assess emergency and essential surgical care

Results

Comment

Acknowledgments

Lancet

Int J Gynecol Obstet

J Surg Res

Lancet

A crucial role for surgery in reaching the UN millennium development goals

PLoS Med

Surgery

Surgery as a public health intervention: common misconceptions versus the truth

Bull World Health Organ

An estimation of the global volume of surgery: a modeling strategy based on available data

Lancet

Rates of cesarean section: analysis of global, regional and national estimates

Paediatr Perinat Epidemiol

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

BMC Med

Intervention of cost-effectiveness: overview of main messages

World Health Organization Global Initiative for Emergency and Essential Surgical Care: 2011 and beyond

World J Surg

Addressing the millennium development goals from a surgical perspective essential surgery and anesthesia in 8 low- and middle-income countries

Arch Surg

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