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Anesthesia for Cesarean Delivery: A Cross-Sectional Survey of Provincial, District, and Mission Hospitals in Zimbabwe

Lonnée Herman A. FCA(SA); Madzimbamuto, Farai FRCA(UK); Erlandsen, Ole R. M. MBChB; Vassenden, Astrid MBChB; Chikumba, Edson MMED; Dimba, Rutenda RN(DA); Myhre, Arne K. DrMED; Ray, Sunanda FFPH(UK)
doi: 10.1213/ANE.0000000000002733
Research Report: PDF Only

BACKGROUND:

Cesarean delivery is the most common surgical procedure in low- and middle-income countries, so provision of anesthesia services can be measured in relation to it. This study aimed to assess the type of anesthesia used for cesarean delivery, the level of training of anesthesia providers, and to document the availability of essential anesthetic drugs and equipment in provincial, district, and mission hospitals in Zimbabwe.

METHODS:

In this cross-sectional survey of 8 provincial, 21 district, and 13 mission hospitals, anesthetic providers were interviewed on site using a structured questionnaire adapted from standard instruments developed by the World Federation of Societies of Anaesthesiologists and the World Health Organization.

RESULTS:

The anesthetic workforce for the hospitals in this survey constituted 22% who were medical officers and 77% nurse anesthetists (NAs); 55% of NAs were recognized independent anesthetic providers, while 26% were qualified as assistants to anesthetic providers and 19% had no formal training in anesthesia. The only specialist physician anesthetist was part time in a provincial hospital. Spinal anesthesia was the most commonly used method for cesarean delivery (81%) in the 3 months before interview, with 19% general anesthesia of which 4% was ketamine without airway intubation. The mean institutional cesarean delivery rate was 13.6% of live births, although 5 district hospitals were <5%. The estimated institutional maternal mortality ratio was 573 (provincial), 251 (district), and 211 (mission hospitals) per 100,000 live births. Basic monitoring equipment (oximeters, electrocardiograms, sphygmomanometers) was reported available in theatres. Several unsafe practices continue: general anesthesia without a secure airway, shortage of essential drugs for spinal anesthesia, inconsistent use of recovery area or use of table tilt or wedge, and insufficient blood supplies. Postoperative analgesia management was reported inadequate.

CONCLUSIONS:

This study identified areas where anesthetic provision and care could be improved. Provincial hospitals, where district/mission hospitals refer difficult cases, did not have the higher level anesthesia expertise required to manage these cases. More intensive mentorship and supervision from senior clinicians is essential to address the shortcomings identified in this survey, such as the implementation of evidence-based safe practices, supply chain failures, high maternal morbidity, and mortality. Training of medical officers and NAs should be strengthened in leadership, team work, and management of complications.

Accepted for publication November 2, 2017.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org).

Funding: The study was funded by grants from the Norwegian University of Science and Technology, St Olav’s Hospital, Trondheim Norway, and the Norwegian Association of Anesthetists. The funders had no role in the study design, data collection, data analysis or interpretation, writing, or publication process of this report.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Herman A. Lonnée, FCA(SA), Department of Anesthesia and Intensive Care, St Olav’s Hospital, Postbox 3250 Sluppen, NO 7006 Trondheim, Norway. Address e-mail to hlonnee@gmail.com.

© 2018 International Anesthesia Research Society