Meaningful progress has been made in reducing maternal mortality during the years of the Millennium Development Goals with global maternal deaths declining by nearly half (44%) since 1990, accompanied by a marked increase in the use of maternity services.1 In countries where the changes in maternal health have been significant, there has been improvement in health care generally, with systemic strengthening of health care infrastructure. However, progress has been uneven, and the Millennium Development Goal 5 target of a 75% reduction in maternal mortality is still to be met. Most of these deaths occur in low- and middle-income countries (LMICs). Many of the major causes of maternal death are amenable to emergency surgical treatment, including hemorrhage (18%),1 obstructed labor (8%),1 unsafe abortion (18%),1 in addition to uterine rupture, genital tract trauma, retained placenta, and ectopic pregnancy. Anesthetic providers are also integral to the resuscitation and management of critically ill pregnant and postpartum women including sepsis and preeclampsia/eclampsia, responsible for 9% and 12% of maternal deaths, respectively.1
Furthermore, the World Health Organization (WHO) recommends that countries should achieve cesarean delivery (C-section) rates of 10% at a population level, to achieve reductions in maternal and newborn mortality rates.2 In most low-income countries (LICs), the C-section rates are typically lower than 5%, except for pockets of private care, where, ironically, the rates are sometimes much higher than recommended. In LICs, women may wait for many hours for an emergency C-section due to lack of availability of anesthesia personnel.3
The global distribution of fully trained surgeons, anesthesiologists, and obstetricians (SAO) is not only critically inadequate in many parts of the world but also grossly inequitable between and within countries.4 Many of the greatest gaps in care are in Sub-Saharan Africa (SSA) and South Asia.
IDENTIFYING THE BARRIERS TO SAFE OBSTETRIC SURGERY
Global Surgery 2030, commissioned by the Lancet and published in 2015, identified several key components of the problem.5 At least 143 million additional surgical procedures are needed in LICs to save lives and prevent disabilities. Included in this number is the need for timely surgical intervention for many more pregnant women, known as the “third delay.” Data from the WHO SAT database show that only 64% of first-level hospitals could provide a cesarean delivery, even if the first and second delays are addressed.5 (The 3 delays model is the conceptual framework that describes the avoidable factors leading to failure to prevent or treat complications. The 3 delays are as follows: first, delay in deciding to seek care; second, delay in reaching a health facility after the decision to seek care has been made; and third, delay in getting effective care having reached a health facility.)5
An estimated 951 million women are without access to emergency obstetric care should they become pregnant.6 Cesarean delivery is one of the 3 Bellwether procedures for assessing access to timely essential surgery.5 In addition to C-section, the Lancet Commission indicates that a basic emergency obstetric surgical package should include hysterectomy, salpingectomy, and dilation and curettage.5
The most important barrier to the provision of preoperative, intraoperative, and postoperative surgical and anesthetic services in LICs, especially in SSA, is the shortage of trained staff.7 In LMICs, anesthesia for obstetric cases is provided by specialist anesthetists, general medical officers, and nurse anesthetists (NAs) (nonphysician anesthetists). Specialist anesthetists generally work in regional referral hospitals and hardly ever in rural district hospitals. Sometimes, general medical officers in district and regional hospitals become competent in anesthesia through on-the-job training, but it is NAs who are the backbone of the service in SSA.7 The NAs will either be certified or will have received on-the-job training.
Using the World Federation of Societies of Anes thesiologists guidelines on safe anesthesia, a survey in 5 East African countries demonstrated significant shortages of both personnel and equipment needed to provide safe anesthesia for obstetric surgical cases.8 Using the World Federation of Societies of Anesthesiologists checklist as a guide, none of the respondents of the study in the tertiary institutions surveyed had all the necessary requirements available to provide safe obstetric anesthesia. The workforce density of anesthetists in these 5 countries per 10,000 population was 0.08 in Uganda, 0.39 in Kenya, 0.05 in Tanzania, 0.13 in Rwanda, and 0.02 in Burundi. In contrast, the targeted specialist workforce density set by the Lancet Commission on Global Surgery is 20 each of SAO care providers per 100,000 population by 2030, noting that lower rates of maternal survival are correlated with lower surgical workforce densities than 20 per 100,000.5 The authors also noted that countries with increased densities of providers per 100,000 population have improved maternal survival with decreases in maternal mortality of 13.1% (95% confidence interval [CI], 11.3–14.8) for each 10-unit increase in SAO density.5
However, increasing the number of surgeries is not enough. In many countries, the cost for any intervention is still borne by the patient and her family, with user fees, including surgical gloves, supplies, and intravenous fluids, a common barrier to care in LMICs. Meara et al5 state that 25% of those needing emergent surgical procedures will incur financial catastrophe. Universal health coverage, as outlined in the Sustainable Development Goals, must include access to surgical solutions.
TRAINING ANESTHESIA PROVIDERS
In almost all LICs and middle-income countries, specialist training in anesthesia exists at postgraduate university level, leading to a Master’s degree or similar qualification. However, the opportunities and facilities for training are limited, and the annual output of these specialists is very low compared to the need. Many of those trained in specialty programs are lost to the system, either through emigration or through work outside the public system.
Some countries have shorter courses meant for doctors who will provide anesthesia in rural areas and the qualification will be a postgraduate diploma. NAs’ training usually takes 1–2 years for those already qualified as nurses but will be longer for those going straight from high school. Training of midlevel providers such as NA has been advocated as a way of reaching the goal of safe surgery by the year 2030.7 In Ghana, an expanded training program for NAs resulted in greater availability of safe anesthesia in several districts of the country.3 A unique feature of the program, which improved retention of the NAs, was that they were sent for training by those districts that needed the service, and this increased their likelihood of remaining in those districts. This strategy has been used with success in several countries. Task shifting (typically delegating certain medical responsibilities to less specialized health workers) is sometimes deployed by necessity when no trained specialists are available, but task sharing is preferable and cost-effective when 1 or more trained physicians are also present to maximize the surgical workforce.5
Training of NAs in obstetric surgery should include simulations or drills in comprehensive emergency obstetric care (CEOC). When training in CEOC was introduced for obstetric physicians and midwives, NAs and other anesthetic staff were left out.9 Safe anesthesia should be one of the signal functions of CEOC and should include management of the difficult airway.
REGIONAL VERSUS GENERAL ANESTHESIA
In most areas, all providers are trained in both regional and general anesthesia techniques. Epidural analgesia in labor is rare in LICs, and national level data on the use of epidural/spinal analgesia and anesthesia are almost nonexistent, including in high-income countries.10 The types of anesthetics available fluctuate widely both geographically and over time. Ketamine remains a mainstay of general anesthesia globally for several reasons. It is safe, stable, and provides some pain control. Most C-sections are generally performed under spinal when spinal needles and local anesthetic are available and when skills permit, but the lack of postoperative opioids and other pain medication remains a concern in many parts of Africa.
The safety of general compared to regional anesthesia has been documented in a systematic review. Exposure to general anesthesia increased the odds of maternal (odds ratio, 3.3; 95% CI, 1.2–9) and perinatal deaths (odds ratio, 2.3; 95% CI, 1.2–4.1).11 All cadres providing anesthesia in LICs and middle-income countries should be trained in regional anesthesia. This is especially important for NAs. The same review quoted above showed that the rate of any maternal death was 9.8 per 1000 anesthetics when managed by nonphysician anesthetists compared with 5.2 per 1000 when managed by physician anesthetists. This may reflect many other complexities, including suboptimal training, fragile infrastructure, suboptimal preoperative stabilization, patient acuity, transport issues, etc.
THE SPECIAL PROBLEM OF CESAREAN DELIVERY
The ability to intervene and perform a timely and safe C-section is critical in obstetrics today. Anesthesia is more challenging during C-section, due to metabolic and physical changes of pregnancy that create increased risk of hypoxia. In skilled hands, and with appropriate resources, C-section can be life saving for a mother and for her newborn and can also prevent horrific complications such as fistula. In the absence of availability of anesthetists and obstetric surgeons for C-section, maternal and perinatal mortality rise, with devastating effects for families and communities. Similarly, in settings where the facilities are unable to provide surgery safely or to treat surgical complications, case fatality rates for C-sections remain high, as do significant and sometimes permanent complications or disability, especially in rural areas of SSA.12
A further consequence of the decision to perform a C-section relates to the scar on the uterus of a young mother who may not be able to access care during her next pregnancy and risks uterine rupture and/or death. When a C-section is needed for an acute indication, what reassurance is there that appropriate care and counseling will be available in subsequent pregnancies? The role of vaginal birth after cesarean delivery is not well worked out in many settings. If a C-section is required for a nonurgent indication (such as a previous operative delivery), will the system be able to ensure that the procedure is available in a timely manner when required? Who will pay for it? These questions need to be addressed both locally and globally. As the 10% WHO C-section rate is reached, the issue of safe repeat C-section or vaginal birth after cesarean delivery in LMICs will be much greater than it is today.
BY 2030, WHAT WILL HAVE CHANGED TO MAKE OBSTETRIC SURGERY SAFER?
The Lancet team identifies core indicators that must be tracked to confirm progress.5 These include timely access, workforce density, surgical volume, perioperative mortality, and protection from impoverishment. Innovative approaches will be required to reduce perioperative mortality. Timely access will require changes in systemic priorities, and investment in infrastructure in the form of viable and well-supported operative programs, safe and stable water and electricity, sterile supplies, medicines, functioning equipment, laboratory and blood bank services, as well as improving transport and supply systems. Research into the development of low-cost cell savers in LMICs could be helpful.
Workforce density will require pedagogic change, as well as interventions to improve working conditions and to assure worker retention. Training models and certification that have regional/national recognition will give anesthetic providers the option of mobility and promote the status of the anesthesia provider. The interventions to improve the working conditions and promoting the retention of midlevel obstetric and anesthetic care providers include the following: financial incentives, improving supportive supervision and staff satisfaction, developing a career path for the NAs, and assisting with accommodation/living conditions.7
Low-cost, simple, innovations such as universal use of the WHO Surgical Safety Checklist, including pulse oximeters, can be drivers of efficiency, quality, and safety.5 To walk into a remote hospital in Tanzania and find pulse oximeters, and personnel trained in their use, is a credit to the great work of the international anesthesiology community!
A WHO cost-effective analysis by Hutubessy et al13 indicates that surgical and anesthesia care are a good health investment in LMICs, especially for C-sections, promoting economic growth as well as saving lives. The Lancet Commission target for all countries to reach a density of 20 SAO providers per 100,000 population by 2030 involves training an additional 1.27 million SAO providers in LMICs, projected at a cost of over $45 billion, a significant investment.5
Anesthesia for safe obstetric surgery is essential for access to universal health care, one of the targets for Sustainable Development Goal 3. It is not yet widely understood that to meet the Sustainable Development Goal 3 target for maternal mortality, rapid access to safe anesthesia for emergency obstetric care by 2030 is an urgent global imperative.
Name: Dorothy Shaw, OC, MBChB, FRCSC.
Contribution: This author helped by providing the framework for the article, writing the final draft and revisions, and providing some responses to the reviewers’ comments.
Name: Jan Christilaw, MC, MD, FRCSC, MHSc.
Contribution: This author helped by providing content for all sections including the C-section paragraph, reviewing the final draft, and discussing the reviewers’ comments and responses.
Name: Stephen Peter Munjanja, MBChB, MD, FRCOG.
Contribution: This author helped by providing content for the section on training providers and all other sections except the C-section paragraph, reviewing the final draft, and providing the majority of responses to the reviewer’s comments.
This manuscript was handled by: Angela Enright, MB, FRCPC.
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