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Global Health: Original Clinical Research Report

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)§,∥

Author Information
doi: 10.1213/ANE.0000000000002733



  • Question: The study seeks to identify the type of anesthesia used for cesarean delivery in provincial and district hospitals in Zimbabwe, the level of training of anesthetic providers at these hospitals, and the availability of essential anesthetic drugs and equipment.
  • Findings: Spinal anesthesia is the most commonly used anesthetic for cesarean deliveries, usually given by nurse anesthetists, but in work environments where availability of essential drugs for safe anesthesia is low, safe practice routines are not followed, and there is little physician anesthetist involvement outside the major centers.
  • Meaning: More engagement from specialist physician anesthetists in supporting anesthesia services in provincial and district hospitals, especially in adherence to international standards of care, could have a significant impact on patient safety and maternity outcomes even with limited resources.

In 2015, the World Health Assembly unanimously approved a resolution to strengthen surgery and anesthesia globally as an important and cost-effective way to achieve universal health coverage, including in low- and middle-income countries (LMICs).1 Although studies have explored infrastructure and resources, there is a paucity of evidence from LMICs on safe anesthesia and anesthetic techniques.2,3 Cesarean delivery is 1 of 3 bellwether procedures: tracer procedures for overall surgical activity in a health care system.4 It is feasible to assess access and quality of anesthesia service in relation to cesarean delivery provision because cesarean delivery is the most widespread surgical procedure in LMICs. Studies in Africa have identified deficiencies in training, routines, and equipment in relation to anesthesia for cesarean delivery, especially where the majority of providers are nonphysician clinicians (NPCs).5 A recent meta-analysis6 of anesthesia-related maternal mortality in LMICs concluded that anesthesia contributed to 13.8% of post–cesarean delivery maternal deaths, mainly due to complications arising from general anesthesia (GA). Nearly half of all anesthetic deaths resulted from airway complications such as difficult or failed airway management; 31% from pulmonary aspiration; 27% from issues related to staff competency, poor preassessment, intraoperative monitoring, and equipment failure; and 6% due to complications after spinal anesthesia (SA). The risk of maternal death in association with anesthesia was highest in sub-Saharan Africa.6 A small retrospective study of anesthesia-associated mortality in obstetric emergencies in a rural hospital in Zimbabwe showed that factors under control of the anesthetic provider accounted for 5 of 7 mortalities.7


Zimbabwe is one of the poorest countries in the world with a maternal mortality ratio (MMR) of 651 per 100,000 living births (2014).8 For comparison, in 2013, the MMR worldwide was 210, in sub-Saharan countries 510, and in high-income countries 16 per 100,000 live births.9 The national maternal deaths reporting system requires that all maternal deaths are reported within a defined timeframe. Common causes of direct maternal deaths are postpartum hemorrhage, pregnancy-induced hypertension (PIH), and sepsis. The national population cesarean delivery rate has remained stable at 6% over recent years.10 Most of the 60 or so specialist physician anesthetists in Zimbabwe are based in the capital Harare, of whom half work for the public sector. Nurse anesthetists (NAs) are the main providers of anesthetic services nationwide. After completion of 3 years of nurse training and 2 years of service, nurses can undergo a 12-month NA diploma (diplomate NAs [DNAs]) and are authorized as independent anesthesia practitioners by the Ministry of Health and Child Care (MoHCC). Other nurses complete a 6-month training course (certified NAs [CNAs]) as assistants to anesthesia providers but not as independent providers. A further group of nurses has no recognized anesthesia training but has developed skills through assisting anesthesia providers. They are not authorized to do so but may provide anesthesia. For the purpose of this study, they are called uncertified NAs (UNAs). Medical officers (MOs) may also provide anesthesia and medical supervision for NAs. After medical school, MOs spend 24 months as interns in teaching hospitals, including 4 months in surgery and 4 months in either anesthetics or psychiatry. They are subsequently sent to district hospitals for compulsory service for 1 year, but where they often remain for 3–4 years.

Of the total population of Zimbabwe (13 million),11 65% live in rural areas served by 8 provincial hospitals, 63 district, and 21 mission hospitals. Provincial and district hospitals are government facilities while mission hospitals receive funding from the government and external donors. District and mission hospitals refer complex cases to provincial hospitals that have posts for specialist obstetricians and anesthetists that are rarely filled. The MoHCC is working to meet Sustainable Development Goal 3 to reduce the MMR to <70 by 2030 by strengthening emergency obstetric services at provincial and district hospitals and the appropriate use of anesthesia. In 2013, the Zimbabwe Anesthesia Association highlighted the need for more knowledge on anesthesia for cesarean delivery outside the main cities of Harare and Bulawayo to target service improvement.12 The primary aim of this study was therefore to assess the type of anesthesia used for cesarean delivery in provincial, district, and mission hospitals in Zimbabwe. Secondary outcomes were the level of training of anesthetic staff attending these hospitals and the availability of essential anesthetic drugs and equipment.


The study is a cross-sectional survey of all provincial hospitals and selected district and mission hospitals using an interviewer-administered questionnaire. Hospitals performing cesarean delivery and located outside the main centers of Harare and Bulawayo were eligible for study. Figures 1 and 2 display the selection process and geographical distribution of sites. All 8 provincial hospitals were included. District and mission hospitals performing cesarean delivery were listed per province. Two district and 2 mission hospitals were randomly selected from each province list using an online random number generator (, giving 21 district and 13 mission hospitals (total 42 hospitals). If there were no anesthetic providers available for interview at a selected facility, a substitute was randomly selected from the province list. Mission hospitals serving as acting district hospitals were classified as mission hospitals. In 1 province, a mission hospital serving as an acting provincial hospital was classified as the provincial hospital.

Figure 1.
Figure 1.:
Flow diagram for selection of interview sites. First, all eligible hospitals were allocated into district or mission hospitals by province. Using a random number generator, each hospital was numbered D1, D2, M1, M2, etc, by province. Two district and 2 mission hospitals per province were selected. If a D1/D2 or M1/M2 was not available, the next available one (D3, D4, etc) was chosen as a replacement. Two provinces had no or insufficient numbers of mission hospitals, so district hospitals replaced them. Three additiononal hospitals were included because they were part of the distance to a selected or replacement hospital. CS indicates cesarean section; DH, district hospital; MH, mission hospital.
Figure 2.
Figure 2.:
Map of Zimbabwe with geographical distribution of included hospitals. The area of each circle (hospital) is proportional to the total number of deliveries in 2014: the smallest 269, the largest 5579 deliveries. The colored border indicates the type of institution: red is provincial, blue is district, and green is a mission hospital. The degree of grey shading indicates the cesarean delivery rate: white <5%, grey 5%–15%, and black >15%. The 2 main cities, Harare and Bulawayo, served as reference points and were not part of the study. Data from 1 provincial and 2 district hospitals were missing.

The questionnaire was developed by modifying and merging standard questions from the World Health Organization’s (WHO’s) Tool for Situational Analysis to Assess Emergency and Essential Surgical Care and the World Federation of Societies of Anaesthesiologists (WFSA) Anaesthesia 2010 Questionnaire.2,3 It included 154 questions (Supplemental Digital Content 1, Appendix A, Similar questions in the 2 tools were merged with phrasing modified for clarity. Pilot interviews were performed with 8 separate NAs using the draft questionnaire, which went through 5 iterations before being finalized. The first part of the questionnaire covered hospital data from 2014 (number of cesarean delivery, total deliveries, live births, maternal deaths) and questions on infrastructure and human resources. The second part comprised questions to the interviewee about practices in relation to anesthesia for cesarean delivery and the availability of drugs and equipment over the previous 3 months.

The interviews were performed between September 29 and October 30, 2015. The interviewer-administered questionnaire was used during face-to-face interviews conducted by one of the coauthors (R.D., A.V., O.E.) with 1 anesthetic provider at each hospital. Smaller facilities had 2–3 anesthetic providers while bigger district hospitals and provincial hospitals had 5–7. The anesthetic provider was assigned by the hospital medical superintendent or administrator, or identified by the anesthetic providers, as the most knowledgeable respondent. Institutional data were provided by the hospital administrator from the hospital records. All other data were collected from interviewees. Gaps in information were followed up later by telephone.

Descriptive statistics were used to summarize the information. Analyses of variance was used for SA per type of hospital versus type of provider. Spearman’s correlation tests were used with trends of MMR and cesarean delivery. The significance threshold was set at 0.05. Data were analyzed using SPSS version 23.0 (IBM Corp, Armonk, NY).

This study was approved by the Joint Research Ethics Committee for the University of Zimbabwe College of Health Sciences, the Parirenyatwa Group of Hospitals, the Medical Research Council of Zimbabwe, and the Research Council of Zimbabwe (MRCZ/A/1970). Information on the study was sent to each Provincial Medical Director, and approval was gained before approaching the selected hospitals. Medical superintendents were then informed, and permission was obtained to interview anesthetic providers and to collect hospital statistics for the year 2014. Each participating anesthetic provider signed informed consent before the interview.


Table 1 in Supplemental Digital Content 2,, summarizes the main results of the study, including the relative proportion of anesthetic providers in each type of facility, cesarean delivery rates, anesthetic method preferences, and maternal deaths surveillance data. Table 1 in Supplemental Digital Content 2,, also shows reasons given for referral to the next level for provincial versus district/mission hospitals in the 3 months before interview. PIH-related conditions were the most frequently referred by provincial and district/mission hospitals, especially those requiring intensive care. Hemorrhage-related conditions were the second most frequent for district/missions, especially where blood supplies were problematic, which affected provincial hospitals less. Seven interviewees cited ruptured uterus as reason for referral from district/mission hospitals. A major reason given for transfer was lack of resources.

Anesthetic Providers

The 42 hospitals studied used 152 anesthesia providers. Of these, 33 (22%) were MOs and 118 (77%) NAs; 55% of the NAs were DNAs, 26% were CNAs, and 19% UNAs (see definitions in Introduction). DNAs formed the highest proportion of providers in all 3 facility types. MOs were more likely to be main anesthetic providers in mission hospitals, especially where there were no DNAs. In 4 district and 4 mission hospitals, MOs were occasional providers, there were no DNAs, so CNAs and UNAs were the main anesthetic providers rather than assistants. Provincial hospitals, which are the referral hospitals for district/missions, did not have higher level expertise except for 1 provincial hospital that had a part-time physician anesthetist. Only 1 provincial hospital anesthetic provider, a DNA, had attended an Emergency Obstetric and Newborn Care (EmONC) course compared to 8 from district hospitals and 9 from mission hospitals (Supplemental Digital Content 2, Table 1,

Method of Anesthesia

SA was the most common method of anesthesia used in the 3 months before interview (81%), followed by 19% using GA, of which 4% was with ketamine without airway intubation. Seventy-one percent of providers reported using SA for 90%–100% of cesarean delivery cases. There was no significant difference in the choice of SA between the different hospitals (P = .3) or for the different types of anesthetic providers interviewed (P = .7).

Equipment, Perioperative Routines, and Drugs

Figure 3.
Figure 3.:
Summary of equipment and other resources for anesthesia. WHO indicates World Health Organization; ZAA, Zimbabwe Anesthesia Association.
Figure 4.
Figure 4.:
Summary of drug availability for all hospitals combined. NSAID indicates nonsteroidal anti-inflammatory drug.

All hospitals had some form of oxygen supply, while 36% had an oxygen concentrator available (Figure 3). There were no blood-storage units in 14% of district and 23% of the mission hospitals; 15% of both district and mission hospitals lacked a functioning anesthetic machine. A wide range of machine makes were recorded; all were of the “plenum” type, with only 1 “draw over” anesthetic apparatus in use. The WHO “Safe Surgery Checklist” and the “Recommended Standard of Anesthetic Care in Zimbabwe” guidelines were absent in 80%–100% of institutions. Of the 34 (81%) hospitals with a designated recovery area, 36% always used it, 42% mostly or sometimes, and 24% never used it. Six (15%) hospitals routinely used a “wedge” or “table tilt,” 30 (70%) occasionally, and 6 (15%) never used 1, to avoid aorta-caval compression during surgery. There was nearly 100% reported use of pulse oximeters, electrocardiogram, and blood pressure measuring equipment. Three (7%) hospitals (district and mission) routinely used a “laryngeal mask” instead of an endotracheal tube for primary airway management during a GA. Dedicated spinal needles (22 or 25 gauge) were routinely used by 52% of interviewees. However, 10% would always and 38% would sometimes perform an SA using 18- or 20-gauge intravenous (IV) cannulas, even when spinal needles were available. All hospitals routinely had Ringer’s lactate solution or normal saline available for cesarean delivery; 7 interviewees “sometimes” used colloids (12%) or dextrose-containing solutions (5%). Guidelines for postoperative analgesia were only available in 5 hospitals (12%). Multimodal postoperative analgesia (combinations of nonsteroidal anti-inflammatory drugs, paracetamol, opioids, or tramadol) was prescribed by 43% of interviewees, with single drugs at regular intervals by 43%. Figure 4 shows the availability of anesthesia-related drugs. Essential drugs for SA and GA were not always available. Drugs used to treat postpartum hemorrhage (misoprostol, ergometrine, and tranexamic acid) or PIH (hydralazine, nifedepine, and labetalol) were lacking, although magnesium sulfate was available. Analgesics were poorly available with the exception of oral paracetamol and pethidine.

Cesarean Delivery and MMR

Figure 5.
Figure 5.:
Correlation between cesarean delivery rate (%) on the x-axis and estimated maternal mortality ratio (per 100,000 live births) on the y-axis. The area of each circle (=hospital) is proportional to the total number of deliveries in 2014: the smallest circle = 269, the largest = 5579 deliveries. The color indicates the type of institution: red is provincial, blue is district, and green is mission hospital. No difference of note when outlier removed. Data from 1 provincial and 2 district hospitals were missing.

The mean institutional cesarean delivery rate (13.6%) was within the WHO advised range of 5%–15% of deliveries, although 5 district hospitals demonstrated cesarean delivery rates <5%. Table 1 in Supplemental Digital Content 2,, details the number of maternal deaths and calculated institutional MMR (iMMR) by type of facility. Figure 5 shows that the iMMR was moderately correlated with the cesarean delivery rate (Spearman ρ = 0.56; P < .01), including when weighted for the number of deliveries per institution (Spearman ρ= 0.66; P < .01).


Key findings from this survey relate to the level of training of anesthetic providers, method of anesthesia used, and availability of drugs, equipment, and guidelines at provincial, district, and mission hospitals. There are no specialist anesthetists in provincial hospitals (apart from 1 part-time physician anesthetist), which are the referral centers for district/mission hospitals. Referral of complex cases to provincial hospitals was therefore at a similar level of expertise as in district/mission hospitals. MOs had a limited and secondary role in anesthesia at provincial hospitals, with DNAs being the main anesthesia providers. EmONC courses run by the MoHCC had not been completed by most of the providers interviewed at provincial hospitals, district, or mission hospitals.

This survey found that essential drugs for managing complications of SA had not been available in the preceding 3 months; intra- and postoperative patient safety routines for SA and GA were not being followed, and standard anesthesia guidelines were absent or not used. These conditions potentially increase the risk of adverse outcomes. The preferred anesthetic technique for cesarean delivery in this survey was SA, which is considered safer in competent hands than GA.6,13 GAs were sometimes conducted without any airway device or using laryngeal masks for primary airway management. This contradicts the recommended management of an obstetric airway with an endotracheal tube.13 The use of IV cannulas as spinal needles has been reported elsewhere, usually where spinal needles are in short supply.14,15

Airway-related complications during GA contribute the most to anesthesia-related mortality in cesarean delivery.6 Safe management requires adequate training in airway assessment, intubation techniques, and rescue algorithms for difficult airways. The WHO Surgical Safety Checklist has been adopted as an international initiative, with growing evidence supporting its use in reducing perioperative errors and complications.16 Small changes to current practice in line with standards of care as recommended by the WFSA17 and Zimbabwe Anesthesia Association18 could have a significant impact on patient safety and maternal outcomes.19

The mean cesarean delivery rate in this study (13.6%) was within the recommended WHO rate, but wide variation occurred between hospitals. The lower cesarean delivery rate at district hospitals could be attributed to a relative lack of trained anesthetic providers, resulting in more transfers to higher level hospitals. MOs were more often anesthetic providers at mission hospitals, which had a higher range of cesarean delivery than district hospitals. The positive correlation between the iMMR and cesarean delivery rate can be explained by the referral of women in difficulty from district/mission hospitals to provincial hospitals. These hospitals perform more cesarean delivery, but they do so more often on women who arrive in a compromised or moribund state after transfer. Because there are few specialist anesthetists in provincial posts, the expertise of providers at provincial hospitals is similar to that at district/mission hospitals, so there may be less gained from the transfer, with a higher risk of mortality due to deterioration of the woman’s condition. Complex cases should be managed by anesthetic providers with a higher level of expertise because that is the principle of an effective referral system. Similar positive correlations were found with cesarean delivery rates and perinatal mortality in earlier research in Zimbabwe.20 Research from Malawi21 demonstrated that 94% of cesarean deliveries were done as emergencies, mainly for obstructed labor, a context similar to Zimbabwe. Cesarean deliveries done as emergencies rather than elective procedures are known to have worse outcomes.22

Our results confirmed that NPCs are the main anesthesia providers in Zimbabwe, as in most African countries.19,23 Where NPCs are given rigorous training and high levels of supervision, their clinical outcomes are similar to that of physicians.6 Authors have commented that in LMICs, maternal mortality rises when anesthesia is given by NPCs compared to physicians, which is attributed to less intensive training and supervision received by the former.5,6,19 Schnittger14 explains that NPCs often have little knowledge of the physiological changes that occur during SA, the possible complications, or their management. He uses examples from Zambia and Malawi to show how routine safe practices such as left lateral tilt on the operating table and supplementary oxygen for mothers intraoperatively are seldom used. Through years of practical experience, NPCs conduct routine procedures without problems but may have difficulties when complications arise. MOs are expected to have this physiological knowledge and understanding, but they may not have the practical skills to assist. From South Africa, Farina and Rout24 described MOs as a vulnerable group, inadequately trained for the multiple challenges they face. Team working between these cadres is 1 solution, with MOs being trained to work more as team leaders with the confidence to assist NPCs in managing complications.25

Study Strengths/Limitations

Our study has several strengths: use of face-to-face interviews rather than a posted questionnaire ensured a high response rate; and use of standardized questions from WHO and WFSA and a focus on cesarean delivery (the most widespread surgical procedure requiring anesthesia) allowed appraisal of anesthetic services outside the central hospitals. This study has several limitations: due to financial and logistical constraints, a sample of hospitals was surveyed rather than the total. Only 1 anesthetic provider per facility was assigned for interview and not randomly selected, which may have led to over- or underrepresentation of practices. Triangulation of data-collection methods may have given more precise information, but we believe the trends at the hospital level were reasonably represented. There was insufficient information on 29 hospitals to include them in the selection process, which may have created some selection bias; 3 hospitals were added outside of the random selection process to increase numbers and because of their proximity to selected facilities.


Based on the findings of this study, there are clear opportunities for making anesthetic practice for cesarean delivery safer. A minimal level of formal training is essential for all anesthetic providers, with upgrading and replacement of those practicing without accreditation. All anesthetic providers should be prioritized for EmONC training. Workplace training closer to areas of greatest need would ensure that MOs and NAs are trained in the environment in which they are expected to work. Establishing incentives for specialist anesthetists to take up provincial posts to supervise and mentor MOs and NAs is likely to improve patient safety in anesthesia at provincial, district, and mission hospitals. The postgraduate anesthesia training program for physicians, currently only provided at tertiary institutions, could include registrar rotations to provincial hospitals with accompanying supervisors. Relative contributions of SA and GA to anesthesia-related maternal deaths require further enquiry. The continuing high iMMRs warrant further analysis of specific underlying causes and contributory factors using maternal death reviews24,26–28 and prospective/retrospective studies.21,29 Recommendations from such reviews usually include updating of protocols and guidelines, practice drills, improved supply chain management, better team training, and a formalized chain of consultation and feedback.30 All these would be useful in the Zimbabwe context. The hazards of using IV cannulas instead of spinal needles, such as postdural puncture headaches and arachnoiditis, should be emphasized more. Refresher courses should reinforce standard recommended safe practices, such as the use of table tilt during surgery.

In conclusion, this survey has identified opportunities for improving anesthesia care at provincial, district, and mission hospitals through training; more effective supply management; and use of guidelines for patient safety practices, many of which can be addressed within existing resources in Zimbabwe and similar health systems in Africa.


The authors thank Professor Paul Fenton, Dr Nobhojit Roy, and Professor Eirik Skogvoll for their insights and critical appraisal of the document; and Charles Chihope for administrative assistance. We commend the nonspecialist anesthetic providers who are the backbone of anesthesia in Zimbabwe and who deserve credit and praise for their efforts in difficult and challenging surroundings.


Name: Herman A. Lonnée, FCA(SA).

Contribution: This author helped with designing the research, seeking ethical approval, and writing the report.

Name: Farai Madzimbamuto, FRCA(UK).

Contribution: This author helped with collecting data, designing the research article, seeking ethical approval, and writing the report.

Name: Ole R. M. Erlandsen, MBChB.

Contribution: This author helped with collecting data, designing the research article, obtaining ethical approval, and writing the report.

Name: Astrid Vassenden, MBChB.

Contribution: This author helped with collecting data, designing the research article, obtaining ethical approval, and writing the report.

Name: Edson Chikumba, MMED.

Contribution: This author helped with designing the research article, obtaining ethical approval, and writing the report.

Name: Rutenda Dimba, RN(DA).

Contribution: This author helped with collecting data, designing the research article, obtaining ethical approval, and writing the report.

Name: Arne K. Myhre, DrMED.

Contribution: This author helped with designing the research article, obtaining ethical approval, and writing the report.

Name: Sunanda Ray, FFPH(UK).

Contribution: This author helped with collecting data, designing the research article, seeking ethical approval, and writing the report.

This manuscript was handled by: Angela Enright, MB, FRCPC.


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Supplemental Digital Content

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