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Obstetrics and Gynecology in Low-Resource Settings: A Practical Guide

George, Ronald B. MD, FRCPC

doi: 10.1213/ANE.0000000000002340
Books, Multimedia, and Meeting Reviews

Department of Women’s & Obstetric Anesthesia, IWK Health Centre, Halifax, Nova Scotia, Canada,

Dissemination of high-quality medical knowledge to areas of low resources is critical to the care of millions of people. Obstetrics and Gynecology in Low-Resource Settings: A Practical Guide delivers on its goal to provide evidence-informed practical guidance to care providers working in low-resource countries. The editor of the book, Dr Nawal M. Nour, gives readers practical management strategies for problems faced in low-income countries: human immunodeficiency virus–complicated pregnancy, obstetric fistula, unsafe abortions, violence against women, and anesthesia-related morbidity. These topics are important to an anesthesiologist who plans to work in a low-resource environment.

Dr Nour is director of the Division of Global Obstetrics and Gynecological Health at Brigham and Women’s Hospital in Boston, Mass, and associate professor at Harvard Medical School. She established the African Women’s Health Center, which focuses on care for women who have undergone female genital mutilation. The African Women’s Health Center also provides outreach programs to the African community in Boston. Nour wrote this book to “present an epidemiologic picture of their subject and practical approaches to treating real-world patients.” Dr Nour lends her expertise to chapter 11, “Female Genital Cutting.”

I have been an active participant in a number of global health efforts to improve anesthesia conditions and to help organize a meeting to prepare anesthesiologists working and educating in low-resource environments. For this reason, I had a strong appreciation for the sections written by Nour: “Are You Doing This for the Right Reasons?”; “Is Global Health Right for You?”; and “How Do You Fit Into the Picture of Global Women’s Health?” These sections enticed me to reflect on my own motivations; as Nour says, “improving the health and well-being of women worldwide is worth the effort.” The chapter titled “Maternal Mortality in Low-Resource Countries” was another highlight for me. Lalonde and Miller provide readers with a well-indexed history of the struggle to reduce maternal mortality worldwide. They discuss the unsurprising major causes of maternal mortality and practical considerations, but they also provide readers with observations on how we may continue to reduce the direct causes of maternal mortality.

Part IV of the book comprises 2 chapters focusing on the teamwork challenges of obstetric and gynecology practice in low-resource environments. In Chapter 13, Dinesh Jagannathan and Bhavani Kodili describe a detailed picture of what it is like to provide anesthesia in these environments and the importance of safe anesthesia to reduce maternal and newborn mortality. They emphasize the need for essential equipment, drugs, protocols, and, perhaps most important, well-trained anesthesia providers. This chapter illustrates the benefits of educational initiatives developed by nonprofit organizations to enhance the safety of anesthesia for childbirth. In Croatia, the nonprofit organization Kybele provided a program of education for cesarean delivery anesthesia that increased the use of regional anesthesia from 18% to 59%.1 It also highlights the anesthesia fellowship training programs from the World Federation of Societies of Anaesthesiologists and their web-based educational programs.2

The chapter on anesthesia for childbirth provides a necessary summary of the limitations of monitoring, medication, transfusion medicine, and anesthesia equipment that affect clinicians in low-resource environments. Jagannathan and Kodili also provide readers with practical protocols for the management of women’s care during childbirth. These include protocols for neuraxial and general anesthesia for cesarean delivery, as well as postoperative pain management. They adapted a World Health Organization reference table (Table 13.1) to describe the minimum requirements for the provision of obstetric anesthesia. There is also a concise section on labor analgesia. Neuraxial labor analgesic techniques are used infrequently in low-resource environments, and are often overlooked in many texts regarding anesthesia care in low-resource environments. Jagannathan and Kodili briefly mention nonneuraxial aspects of labor analgesia, including parenteral opioids and nitrous oxide. My personal experience might suggest a need to expand on labor analgesia in future editions.

As an obstetric anesthesiologist who has worked alongside local clinicians in many low-resource environments, I would recommend this book to colleagues and students who have worked or are planning to work in these challenging environments. I believe this book has value in providing greater insight to anesthesiologists working as part of a global health mission that targets maternal and newborn health. We are rarely involved with isolated obstetric anesthesia projects in low-resource environments. It is important for us to recognize some of the problems faced by our obstetrician teammates to improve how we work alongside one another. In the current era, I hope a digital version will be available for easy access and transportability. The practical aspects of this book will be of value to friends working in low-resource environments. My own copy is now packed in my travel bag, both for review during a long flight and to pass forward to a global health colleague on my next trip abroad.

Ronald B. George, MD, FRCPCDepartment of Women’s & Obstetric AnesthesiaIWK Health CentreHalifax, Nova Scotia,

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1. Kopic D, Sedensky M, Owen M. The impact of a teaching program on obstetric anesthesia practices in Croatia. Int J Obstet Anesth. 2009;18:4–9.
2. Enright A, Wilson IH, Moyers JR. The World Federation of Societies of Anaesthesiologists: supporting education in the developing world. Anaesthesia. 2007;62Suppl 167–71.
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