Surgery is an essential component of healthcare in all settings, even in the most resource-limited countries. Worldwide, the volume of surgery is large and there is a growing recognition of the importance of surgical disease 1.
Paediatric surgery is a small and relatively new surgical speciality in many countries, especially within the developing world. Little is known about the workload of paediatric surgeons in many countries, particularly in low and middle income countries (LMICs) 2. It is highly likely that there is a huge variation in what constitutes paediatric surgery practice across different countries.
The aim of this study was to create a snapshot picture of the workload of paediatric surgeons worldwide, specifically in terms of the volume and type of surgical conditions. Gaining insights into the epidemiology of paediatric surgery globally is essential to help define areas where resources are needed, in terms of both workforce and training 3.
A global prospective epidemiological study was undertaken. Paediatric surgical units across the Pan-African Paediatric Surgery Association (PAPSA) network were identified and members were contacted and invited to participate. Those that responded positively, consenting to take part, were subsequently included in the study. Each unit was requested to register the study locally according to individual local policies. As the data did not require any patient-identifiable information or any change in usual practice, formal ethical approval was not required.
Each unit was asked to document all admissions to their paediatric surgical service over a 24-h time period. Information recorded included basic epidemiological data (sex and age), basic clinical information (diagnosis or reason for admission) and type of admission (elective or emergency). Alongside the admissions data, each unit was asked to provide an estimate of the size of the local population of the catchment area served by the unit. Data were documented using a standardized excel spreadsheet (Fig. 1) sent out through email to each unit before the data collection period.
Data collection began at 8 a.m. on 23 May 2012 and finished at 8 a.m. the following day, 24 May 2012.
Data were returned through email and collated centrally. Analysis was undertaken using Excel software (Microsoft Corporation), and admission data by country were represented graphically using StatPlanet online software (StatPlanet, StatSilk, Sydney, Australia). Units were divided into two groups: those situated in LMICs and those in high-income countries (HICs). The volume of admissions, proportion of emergency admissions and most frequent reasons for admission were then compared between the two groups.
In total, 13 paediatric surgical units participated in the study, each based in a different country across the world (Fig. 2). Eleven units were based in LMICs, whereas only two units were based in HICs. These countries ranged in population size, with Malawi having the smallest population of 16 million and India having the largest population of 1.2 billion. Each participating unit’s estimated catchment area also ranged in population size. Canberra Hospital in Australia served the smallest population of only 550 000, whereas Ahmadu Bello Hospital in Nigeria served the largest population of 25 million. Table 1 demonstrates the individual results for all participating units.
The mean number of admissions to the paediatric surgical service in 24 h across all of the units was 21.8. Total number of admissions in each unit is demonstrated in Fig. 3. Muhimbili Hospital in Dar es Salaam, Tanzania, had the highest number of admissions of 38. However, Ahmadu Bello Hospital, Nigeria, had the lowest number of admissions of only three admissions. However, it happened that the staff at the Ahmadu Bello Hospital were on strike during this 24-h period, resulting in an unusually low number of admissions for that department. Excluding this unit as an outlier, the two units in HICs, Oxford Children’s Hospital in the UK and Canberra Hospital in Australia, had the lowest number of admissions of 10 and 13, respectively.
The mean age for paediatric surgery admissions across all units was 4.6 years, with a range of 1 day to 16 years, as would be expected. The majority of admissions comprised male patients in all units, with an average male-to-female sex ratio of 1.8 : 1.
The proportion of admissions that constituted emergency or unplanned work ranged from 38% (Canberra Hospital, Australia) to 83% (Tanta University Hospital, Egypt). Those units that had the highest total number of admissions also tended to have the highest proportion of emergency work. Figure 4 illustrates the percentage of emergency admissions across all units.
Comparison between the units in HICs and those in LMICs is shown in Table 2. Units in LMICs all served a larger population than those in the HICs. The majority of LMIC units had more than 15 admissions during the 24-h period, whereas the two units in HICs both had under 15 admissions. On average, the units in LMICs had a higher proportion of emergency workload compared with those in HICs (60 and 44%, respectively).
The most frequent reason for admission across all units was trauma, accounting for 18% of all admissions. However, there were no cases of trauma in either of the two units in HICs within this 24-h period. The most frequent reason for admission in the HICs was anorectal malformations, and overall this was the second most common presentation, resulting in 8% of admissions. Another commonly observed reason for admission within the LMICs was hydrocephalus (5% of admissions); however, this was not seen in either of the two HICs. There was a wide spectrum of reasons for admission and many conditions were only seen once across all units. Alongside general surgical conditions, many speciality surgery conditions were being managed by paediatric surgery units, including oncology, urology, neurosurgery, ear, nose and throat (ENT) surgery, orthopaedics and plastic surgery. However, within the HIC units, admissions in oncology and urology were seen, whereas there were no admissions relating to neurosurgery, orthopaedics, ENT or plastic surgery. Figure 5 shows a full breakdown of the reasons for admission across all units. Conditions that were seen infrequently have been broadly grouped together into categories for simplicity.
This study provides a snapshot into the spectrum of paediatric surgery across the globe. The data demonstrate the volume of admissions, proportion of emergency workload and reasons for admission across paediatric surgery units. This illustrates variations between countries and, in particular, provides insight into differences observed between the HICs and the LMICs, both in terms of the structure of paediatric surgical services and their workload.
The data are limited by the small number of units from HICs; therefore, comparison between data from HICs and LMICs could not be analysed statistically. As the data were collected over a single 24-h time period, the data from each unit may not always be fully representative of that unit’s true activity. For example, Ahmadu Bello Hospital in Nigeria had an unusually low number of admissions because of a staff strike during the 24-h study period. In addition, there will be a degree of hetereogeneity within the results as all hospitals and paediatric surgery units will be structured differently, and hence the results must be interpreted with this in mind.
Although the number of participating units from HICs was very small, there were still differences observed between those units in HICs and those in LMICs. More specifically, the LMIC units served a larger population and had a greater number of admissions with a higher proportion of emergency workload.
Paediatric surgery is a broad speciality, which includes a huge variety of pathology, which was demonstrated by a large range of different reasons for admissions. The units based in LMICs did tend to manage a wider variety of conditions. Paediatric subspecialization in these countries is rare. Therefore, conditions in HICs that would be managed by the surgical specialities – for example, hydrocephalus – are often managed by the general paediatric surgeon.
Overall, the most frequent reason for admission was trauma, with LMICs experiencing a particularly high volume of paediatric trauma compared with HICs. Trauma has been reported as a significant problem in LMICs. Previous epidemiological studies in sub-Saharan Africa suggest that trauma accounts for almost half of all paediatric surgical admissions and significant morbidity and mortality 4–6. South Africa has a high prevalence of trauma cases. This is the leading cause of death in children over the age of 5 years, and the rates of interpersonal violence affecting children is more than double the corresponding rates in LMICs 7–9. Data on the burden of paediatric trauma in LMICs is beginning to grow. This study supports the suggestion that paediatric trauma is a significant public health issue in LMICs. Many HICs have developed public health initiatives and trauma prevention programmes to reduce the frequency of injuries and road traffic accidents. This may account for the lower number of trauma-related admissions, which has been documented in this study. Growing evidence suggests that injury prevention strategies and management of trauma should be a particular focus for LMICs 6,10,11. Further data are still needed to understand the full impact of trauma on child health in LMICs.
Variation between HIC units and LMIC units have previously been demonstrated in some single unit comparison studies 12,13. It is recognized that the spectrum of neonatal conditions differs between HICs and LMICs. This is likely to be because of delayed presentation and poor access to neonatal intensive care in LMICs. For example, necrotizing enterocolitis is a condition that is more frequent in HICs. This usually occurs in premature babies and typically presents on day 5–7 of life and can rapidly progress to become life-threatening; therefore, in LMICs with limited neonatal intensive care, these babies sadly do not survive. Another potential reason for any disparity in neonatal conditions is the difference in access to prenatal care. Many congenital disorders, such as neural tube defects, are more commonly detected prenatally in mothers in HICs. This allows for planning for the baby to be delivered and the immediate postoperative care to be undertaken in a paediatric surgery unit. However, in addition to this, there is a higher rate of termination of pregnancies where a significant congenital abnormality has been detected, potentially resulting in lower numbers of these conditions in HICs 12. Significant differences in the spectrum of neonatal conditions were not identified here; however, this is likely due to the rarity of these conditions and the data collection time period being only 24 h, meaning the numbers of these conditions were small.
Mortality and morbidity associated with paediatric surgical conditions remain high in LMICs 14. In addition, delayed access to paediatric surgery in LMICs has been shown to result in a greater burden of disease in a comparison with HICs 13. Although paediatric surgery is likely to be a cost-effective way to reduce childhood mortality rates and significant lifelong disability 15, many LMICs have very few trained paediatric surgeons for the relative size of their population, and often limited or no training facilities 16. This study provides insight into the spectrum of paediatric surgery across the world and highlights where further research is needed to identify specific areas, such as trauma, on which to focus future initiatives. Paediatric surgery in LMICs faces many challenges, including lack of facilities, manpower shortages, late presentations and poverty 2,16,17. These countries seem to experience a greater workload, with a higher proportion of emergency work and a wider variety of condition. In addition, these countries have a much larger childhood population, often accounting for up to 40–50% of the overall population. Therefore, training specialist paediatric surgeons in LMICs are essential to provide the care needed for these children. Some developments are already happening with local initiatives, such as partnerships between paediatric surgery units from HICs and LMICs 18,19, and awareness of the problem is growing 20,21. However, further data are still needed to fully outline the global burden of paediatric surgical disease and trauma so that this can be addressed in a targeted and sustainable way. Following on from this study, PAPSA has undertaken a further survey investigating paediatric trauma admissions in more detail and is currently awaiting analysis.
The authors acknowledge all of those that contributed their data to this study and the PAPSA group for their support and assistance with planning and performing the study.
PAPSA Group Contributors: Emmanuel Ameh, Ahmadu Bello Univeristy Hospital, Nigeria. Tahmina Banu, Chittagong Medical College Hospital, Bangladesh. Eric Borgstein, Queen Elizabeth Central Hospital, Malawi. David Croaker, Canberra Hospital, Australia. Milliard Derbew, Tikur Anbessa Hospital, Ethiopia. Essam Elhalaby, Tanta University Hospital, Egypt. Erik Hansen, Kijabe Hospital, Kenya. Afua Hesse, Korle Bu Hospital, Ghana. Catherine Mngongo, Muhimbili Hospital, Tanzania. Alp Numanoglu, Red Cross Children’s Hospital, South Africa. Bankole Rouma, Yopougon Teaching Hospital, Cote D’Ivoire. Shilpa Sharma, All India Institute of Medical Sciences, New Delhi, India.
Conflicts of interest
There are no conflicts of interest.
1. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, Gawande AA. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008; 372:139–144.
2. Chirdan LB, Ameh EA, Abantanga FA, Sidler D, Elhalaby EA. Challenges of training and delivery of pediatric surgical services in Africa. J Pediatr Surg 2010; 45:610–618.
3. Bickler SW, Rode H. Surgical services for children in developing countries. Bull World Health Organ 2002; 80:829–835.
4. Bickler SW, Sanno-Duanda B. Epidemiology of paediatric surgical admissions to a government referral hospital in the Gambia. Bull World Health Organ 2000; 78:1330–1336.
5. Nordberg E. Injuries as a public health problem in sub-Saharan Africa: epidemiology and prospects for control. East Afr Med J 2000; 77 (Suppl):S1–43.
6. Ademuyiwa AO, Usang UE, Oluwadiya KS, Ogunlana DI, Glover-Addy H, Bode CO, Arjan BV. Pediatric trauma in sub-Saharan Africa: challenges in overcoming the scourge. J Emerg Trauma Shock 2012; 5:55–61.
7. Norman R, Matzopoulos R, Groenewald P, Bradshawa D. The high burden of injuries in South Africa. Bull World Health Organ 2007; 85:695–702.
8. Nantulya VM, Reich MR. Equity dimensions of road traffic injuries in low- and middle-income countries. Inj Control Saf Promot 2003; 10 (1–2):13–20.
9. Krug EG, Mercy JA, Dahlberg LL, Zwi AB. The world report on violence and health. Lancet 2002; 360:1083–1088.
10. Mohan D. Childhood injuries in India: extent of the problem and strategies for control. Indian J Pediatr 1986; 53:607–615.
11. Seedat M, Van Niekerk A, Jewkes R, Suffla S, Ratele K. Violence and injuries in South Africa: prioritising an agenda for prevention. Lancet 2009; 374:1011–1022.
12. Nandi B, Mungongo C, Lakhoo K. A comparison of neonatal surgical admissions between two linked surgical departments in Africa and Europe. Pediatr Surg Int 2008; 24:939–942.
13. Poenaru D, Pemberton J, Cameron BH. The burden of waiting: DALYs accrued from delayed access to pediatric surgery in Kenya and Canada. J Pediatr Surg 2015; 50:765–770.
14. Livingston MH, Dcruz J, Pemberton J, Ozgediz D, Poenaru D. Mortality of pediatric surgical conditions in low and middle income countries in Africa. J Pediatr Surg 2015; 50:760–764.
15. Sitkin NA, Ozgediz D, Donkor P, Farmer DL. Congenital anomalies in low- and middle-income countries: the unborn child of global surgery. World J Surg 2015; 39:36–40.
16. Elhalaby EA, Uba FA, Borgstein ES, Rode H, Millar AJ. Training and practice of pediatric surgery in Africa: past, present and future. Semin Pediatr Surg 2012; 21:103–110.
17. Mhando S, Lyamuya S, Lakhoo K. Challenges in developing paediatric surgery in Sub-Saharan Africa. Pediatr Surg Int 2006; 22:425–427.
18. Lakhoo K, Msuya D. Global health: a lasting partnership in paediatric surgery. Afr J Paediatr Surg 2015; 12:114–118.
19. Azzie G, Bickler S, Farmer D, Beasley S. Partnerships for developing pediatric surgical care in low-income countries. J Pediatr Surg 2008; 43:2273–2274.
20. Ozgediz D, Langer M, Kisa P, Poenaru D. Pediatric surgery as an essential component of global child health. Semin Pediatr Surg 2016; 25:3–9.
21. Ozgediz D, Poenaru D. The burden of pediatric surgical conditions in low and middle income countries: a call to action. J Pediatr Surg 2012; 47:2305–2311.