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.
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.
Surgical disease has been estimated to account for 11% of the world’s disability-adjusted life years and is predicted to eclipse those of human immunodeficiency virus, tuberculosis, and malaria by the year 2026. 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. 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. 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). However, access to and use of CD varies widely both geographically and between low- and middle-income countries (LMICs) with rates <1% for many of the poorest populations.
To reduce the unacceptably high levels of maternal mortality in LMICs, 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. A checklist of 9 signal functions defines the minimum requirements of a facility to be considered a provider of comprehensive emergency obstetric care services. 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. 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. 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.
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 and has been validated for assessing surgical capacity in health facilities in LMICs.
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.
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. 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 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. District, rural, and community hospitals were grouped together in keeping with previous studies using the WHO SAT. 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. Private/NGO/mission hospitals are large well-resourced and typically well-equipped institutions.
| No. | Country | LIC/MIC a | MMR per 100,000 b | Births by CD, % c | No. of facilities completing a survey | No. of facilities included | Data |
|---|---|---|---|---|---|---|---|
| 1 | Afghanistan | LIC | 460 | 3.6 | 26 | 22 | 3.06% |
| 2 | Argentina | MIC | 77 | 22.7 | 9 | 8 | 1.11% |
| 3 | China | MIC | 40 | 27.0 | 8 | 7 | 0.97% |
| 4 | Democratic Republic of Congo | LIC | 540 | 7.2 | 16 | 15 | 2.09% |
| 5 | Ethiopia | LIC | 350 | 1.5 | 19 | 19 | 2.64% |
| 6 | The Gambia | LIC | 360 | 2.5 | 75 | 23 | 3.20% |
| 7 | Ghana | LIC | 350 | 6.9 | 22 | 22 | 3.06% |
| 8 | Haiti | LIC | 350 | 3.0 | 51 | 48 | 6.68% |
| 9 | India | LIC | 200 | 8.1 | 171 | 110 | 15.30% |
| 10 | Kenya | LIC | 360 | 6.2 | 54 | 53 | 7.37% |
| 11 | Liberia | LIC | 770 | 3.5 | 23 | 16 | 2.23% |
| 12 | Malawi | LIC | 460 | 4.6 | 16 | 15 | 2.09% |
| 13 | Mongolia | LIC | 63 | 21.0 | 43 | 29 | 4.03% |
| 14 | Myanmar | LIC | 200 | 32.1 | 20 | 20 | 2.78% |
| 15 | Niger | LIC | 590 | 1.0 | 21 | 21 | 2.92% |
| 16 | Nigeria | LIC | 630 | 1.8 | 121 | 115 | 15.99% |
| 17 | Pakistan | LIC | 260 | 7.3 | 9 | 8 | 1.11% |
| 18 | Papua New Guinea | LIC | 230 | 4.7 | 25 | 24 | 3.34% |
| 19 | Sao Tome and Principe | LIC | 70 | 5.3 | 5 | 1 | 0.14% |
| 20 | Sierra Leone | LIC | 890 | 4.5 | 12 | 11 | 1.53% |
| 21 | Solomon Islands | MIC | 93 | 6.2 | 9 | 7 | 0.97% |
| 22 | Somalia | LIC | 1000 | 1–2 | 14 | 14 | 1.95% |
| 23 | Sri Lanka | MIC | 35 | 23.8 | 39 | 18 | 2.50% |
| 24 | Uganda | LIC | 310 | 5.3 | 38 | 31 | 4.31% |
| 25 | United Republic of Tanzania | LIC | 460 | 4.5 | 49 | 43 | 5.98% |
| 26 | Vietnam | LIC | 59 | 20.0 | 19 | 19 | 2.64% |
| Total | 914 | 719 | 100.00% |
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
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 χ 2 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 χ 2 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.
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.
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 ).
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 ).
| Item | Total (n = 719) | Facilities performing CD (n = 531) | Facilities referring CD a (n = 54) | P value |
|---|---|---|---|---|
| Oxygen | 525 (73.3%) | 417 (78.7%) | 21 (39.6%) | < .001 |
| Anesthesia machine | 415 (58.9%) | 350 (66.7%) | 18 (35.3%) | < .001 |
| Blood bank | 228 (33.8%) | 199 (39.8%) | 4 (8.3%) | < .001 |
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