International Journal of Gynecology and Obstetrics 127 (2014) 229–233
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REVIEW ARTICLE
Defining the anesthesia gap for reproductive health procedures in resource-limited settings R. Eleanor Anderson a,b,⁎, Roy Ahn a,b, Brett D. Nelson a,b, Jean Chavez a, Emily de Redon a, Thomas Burke a,b a b
Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA
a r t i c l e
i n f o
Article history: Received 23 February 2014 Received in revised form 18 June 2014 Accepted 6 August 2014 Keywords: Anesthesia Low-income countries Reproductive health
a b s t r a c t Background: In resource-limited settings, severe shortages of anesthetists and anesthesiologists lead to surgical delays that increase maternal and neonatal mortality and morbidity. Objectives: To more clearly understand the individual components of the anesthesia gap pertaining to reproductive health surgeries and procedures in resource-limited settings. Search strategy: Medline, the Cochrane Library, CINAHL, Embase, and POPLINE were systematically searched for reports published before December 31, 2013. Search terms were related to obstetric surgery, resource-limited settings, and anesthesia. Selection criteria: Studies that addressed the use of anesthesia in reproductive procedures in resource-limited settings were included. Data collection and analysis: Reviewers independently evaluated the full text of identified studies, extracted information related to study objectives and conclusions, and identified the anesthesia gap. Main results: Overall, 14 publications met the inclusion criteria. A significant lack of infrastructure, equipment and supplies, and trained personnel were identified as key factors responsible for a lack of anesthesia services. Conclusions: A shortage of trained anesthesia providers, equipment, supplies, medications, and infrastructure, along with limitations in transportation in resourcelimited settings have produced a wide gap between available anesthesia services and the demand for them for reproductive health surgeries and procedures. Safe, affordable, and scalable solutions to address the anesthesia gap are urgently needed. © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Worldwide, 287 000 mothers die every year of pregnancy-related causes, and 20–50 times this number become disabled [1,2]. The overwhelming majority of these maternal deaths and injuries occur in resource-limited settings. For example, in Sub-Saharan Africa, the maternal mortality ratio (MMR) stands unacceptably at 920 maternal deaths for every 100 000 live births, compared with 8 maternal deaths per 100 000 live births in high-income nations [3]. Most maternal deaths could be prevented by ensuring the wide availability of contraception (including tubal ligation), presence of trained birth attendants during labor, and access to uterotonics, magnesium, antibiotics, blood transfusion, and emergency operative management [4–7]. In high-income countries, anesthetists and anesthesiologists play a crucial part in averting maternal and newborn death and disability by supporting critical surgeries such as cesareans, emergency hysterectomy, removal of ectopic pregnancies, tubal ligation, and even dilation and curettage. However, in resource-limited settings, severe shortages of anesthetists and anesthesiologists frequently lead to surgical delays, ⁎ Corresponding author at: Zero Emerson Place, Suite 104, Boston, MA 02114, USA. Tel.: +1 617 643 4294; fax: +1 617 643 8772. E-mail address: [email protected] (R.E. Anderson).
often resulting in death or disability of the mother and/or newborn [2]. Additionally, the frequencies of some procedures are reduced, probably partly because of poor availability of anesthesia services. For example, the frequency of cesarean delivery in Sub-Saharan Africa is often between 1% and 5% of births, and sometimes lower, whereas WHO maintains that the optimum frequency should be 5%–15% [8,9]. The lack of anesthesia services in obstetrics is fully recognized [10]. The global anesthesia crisis is well documented and cannot be overstated [11–13]. Although WHO and others have called for urgent expansion of anesthesia and anesthetist training programs, the severity of the need and matching solutions remain to be defined [14]. The number of anesthesia providers in low-income countries is difficult to track: although WHO monitors the numbers of doctors and other healthcare providers in each country, they do not specifically report on specialists, such as anesthesiologists, anesthetists, and technologists who provide anesthesia under the supervision of an anesthesiologist. While it is recognized that the global shortage of anesthesia providers is even more extreme in low-income countries, an optimum number of anesthetists per population has not yet been established (K. A. McQueen, MD; written communication, February 2014). The lack of access to safe anesthesia—the anesthesia gap—for lifesaving obstetric procedures such as cesarean delivery, tubal ligation, surgery for ectopic pregnancy, emergency hysterectomy, and dilatation
http://dx.doi.org/10.1016/j.ijgo.2014.06.023 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
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and curettage is under-recognized as a contributing factor to maternal mortality and morbidity. The aim of the present review was to more clearly understand the individual components of the anesthesia gap pertaining to vital reproductive health surgeries and procedures in resource-limited settings. 2. Materials and methods In December 2013, a systematic literature search was done in Medline, the Cochrane Library, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, and POPLINE. The following search term was used: “‘cesarean section’ OR ‘tubal ligation’ OR ‘manual vacuum aspiration’ OR ‘hysterectomy’ OR ‘dilation and curettage’ AND ‘poverty’ OR ‘limited resource’ OR ‘low resource’ OR ‘developing country’ OR ‘resource-poor’ AND ‘anesthesia’”. Two reviewers (J.C. and E.d.R.) independently conducted these searches. The searches were restricted to human studies but were not limited by language, and included all articles published before December 31, 2013. In addition to the studies identified through the search, key references from included studies were also examined for inclusion. Two reviewers (J.C. and E.d.R) conducted preliminary screening of the titles and abstracts of identified studies for eligibility. All articles in which the use of anesthesia in reproductive health procedures in resource-poor settings was assessed were included. Randomized controlled trials, prospective and retrospective observational studies, case series, and reports were eligible. Studies that addressed the administration of anesthesia by individuals who were not anesthetists for reproductive surgical procedures in resource-poor settings were also included. Studies that did not directly relate to the review question (e.g. articles on the use of anesthesia for reproductive health procedures in settings where resources are not limited) were excluded from the review. Furthermore, editorials and other opinion-based, non-empirical articles were excluded from the review. If either reviewer considered an article eligible for inclusion, both reviewers independently evaluated the full text. In the event that the two reviewers disagreed about whether a study should be included after reviewing the full text, R.E.A. examined it, and the group deliberated until consensus was achieved. Information about the study objective, conclusions, and the identified anesthesia gap was then extracted by J.C., E.d.R., and R.E.A. 3. Results 3.1. Results of the search The literature review identified 14 reports meeting the inclusion criteria (Table 1). In general, the studies revealed a significant lack of infrastructure, equipment and supplies, and trained personnel as the key factors responsible for a lack of anesthesia services. 3.2. Infrastructure Poor health system design and a lack of general community infrastructure inhibit the development of functioning comprehensive emergency obstetric and newborn care facilities, which, by definition, include cesarean capabilities. To manage obstetric complications requiring surgery, a comprehensive emergency obstetric and newborn care facility must be equipped with a functional operating theater, adequate support staff, and the capability to perform blood transfusions and emergency anesthesia [14]. Providing anesthesia services for emergency obstetric care relies on components of infrastructure that are currently lacking in many lowresource nations [16,19,20,25,27]. Lapses in electricity and intermittent running water often prevent the use of equipment even when it is available [20]. In Uganda, 41% of anesthesia providers work in an environment where electricity or a generator is not always available and
access to running water and bedside laboratory investigations is also quite limited [19]. Additionally, in a review of 132 facilities in eight low-income countries [20], every facility reported frequent interruptions in water supply, electricity, and oxygen. Additional infrastructure weaknesses frequently identified in reports include lack of transportation and roads, poor community education and preparedness, and the multiple effects of poverty (including general vulnerability, isolation, and lack of access to social and financial assets) [5,16,19,20,22,24,25,29]. 3.3. Equipment and supplies In resource-limited settings, essential surgical equipment and supplies, equipment for the management of airways, antibiotics, and medications for intubation, anesthesia, and analgesia are often unavailable [11,18,19,26,27,30,31]. The present literature search also revealed that basic safety monitoring equipment—e.g. pulse oximetry, blood pressure devices, and heart rate monitors—are commonly in disrepair or unaffordable [14,17,18,26,28,32,33]. The most common types of anesthesia used in resource-limited settings are general anesthesia (halothane and ether), spinal anesthesia (bupivacaine), and dissociative anesthesia (ketamine) [24,34]. A survey of half the anesthesia providers in Uganda [19] revealed that only 6% of anesthesia providers are able to provide both spinal and general anesthesia for cesarean deliveries at any one time, mostly because of a lack of medications and supplies. A separate survey in Uganda [35] found that all hospitals were missing essential equipment and frequently had shortages of WHO Essential Medications, none had pulse oximeters, and there was no mechanism for reporting outcomes. Similar results were found in Rwanda and Ethiopia [30,31]. Over the past two decades, cesarean deliveries in well-resourced countries have been increasingly performed using spinal anesthesia, with outcomes reportedly improved over general anesthesia [36]. Trends of decreased mortality with spinal anesthesia have been reported in Malawi and Zimbabwe [18,23], although widespread adoption is lacking [23]. However, the 2005–2007 South African Confidential Enquiry into Maternal Death report [37] showed that implementation of spinal anesthesia in cesarean deliveries in resource-limited settings may not be as safe as hoped: 74 direct anesthesia deaths were described, of which 53 (72%) were associated with spinal anesthesia and 18 (24%) with general anesthesia. In the deaths directly related to spinal anesthesia, the most common causes were a high spinal (41%) and intraoperative hypotension (14%). Possible causes include inadequate training [16,17,21]. A few studies have compared different anesthesia regimens for cesarean delivery to determine safety profiles in low-income countries [21,23]. Although no rigorous studies have been done in resourcelimited settings, ketamine seems to be one of the most commonly used anesthetic and sedation agents around the world, primarily because of its high therapeutic index [21,38]. Ketamine rarely suppresses ventilatory or cardiovascular systems, is considered safe in overdose, and is inexpensive [39]. A report of its use in 64 cases during civil war in Somalia and Uganda for surgeries lasting up to 2 hours showed no complications [15]. 3.4. Trained personnel Only recently have data begun to emerge on specific numbers of anesthesia providers in low-income countries. What is known has come from local and national ministries of health, non-governmental organizations, and providers in regions with unmet anesthesia needs [13,14]. In summary, the poorest regions in the world have the lowest density of anesthesiologists and anesthetists [11,12]. In Uganda, there are 0.05 anesthetists for every 100 000 people [19]. In Rwanda, the corresponding number is 0.09 [30], and in Ethiopia 0.02 [31]. Factors responsible for this paucity of anesthesia providers include political instability, corruption, emigration of trained providers, and
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Table 1 Summary of the 14 studies identified in the literature review. Author, year
Objective
Bonanno, 2001 [15]
Case study of 64 patients in whom ketamine was used as an anesthetic agent for surgeries (including cesarean delivery) performed in war and low-resource settings.
Clyburn et al., 2007 [16]
Dyer, 2010 [17]
Fenton, 2003 [18]
Hodges et al., 2007 [19]
Kushner et al., 2010 [20]
Kwawukume, 2001 [21]
McKenzie, 1998 [22]
Okafor et al., 2009 [23]
Conclusions
Respiratory and heart rates were maintained within the accepted range in all patients. Patients who received diazepam prior to ketamine had hallucinations of shorter duration than did those who did not receive diazepam. To review challenges in obstetric anesthesia in Many women lack access to basic obstetric low-income countries. analgesia and others present with life-threatening complications that anesthetic providers are unprepared to handle. Although the WHO recommended frequency of cesarean is 5%–10%, the frequency in the poorest populations in 20 countries is less than 1%, partly because of inadequate anesthesia provision. Review of interventions required to improve In South Africa, anesthesia is the seventh most obstetric anesthesia in low-resource settings. common direct cause of maternal mortality. There is no current standard in terms of equipment and medicine for adequately safe anesthesia, and in many instances in resource-poor settings, providers do not have the necessary skills to use donated material from high-income countries. To examine potentially modifiable factors that Obstructed labor was significantly associated may influence high maternal and perinatal with both maternal and perinatal mortality. Other mortality associated with cesarean delivery potentially modifiable risk factors identified through questionnaires given to anesthetists who included anesthetist training, blood loss, and type perform cesarean deliveries. of anesthetic. Most maternal deaths occurred postoperatively, within 72 hours of birth and while patients were on the wards. To examine difficulties in providing anesthesia in There was only one physician anesthetist among Uganda through a questionnaire distributed to 97 the population of anesthesia providers sampled. anesthesia providers at an anesthesia refresher Most non-physician anesthetists had attended course. training courses that lasted 1–2 years. Only 6% could provide anesthesia services for cesarean deliveries by both general and spinal anesthesia. Intermittent mains electricity was reported by 41% of respondents, who also said that a generator was not always available. Access to running water, gloves, disinfectant, laboratory investigations, and other general hospital needs were limited. Anesthesia was largely ketamine-based. A standardized WHO tool was used in 30 low- and In no country did 100% of facilities report middle-income countries to assess infrastructure, continuous supply of water, electricity, and supplies, and procedures essential to surgical and oxygen, with most reporting less than 50% anesthetic capacity as they relate to Millennium availability. Only 44% of facilities were able to Development Goals 4, 5, and 6. offer cesareans. Other emergency and elective reproductive procedures were available only 48% and 39% of the time, respectively. To report difficulties with performing cesareans Poor communication and transportation systems and other infrastructure deficits delay maternal in low-income countries. care. Lack of anesthetic equipment and machines is prevalent. Poverty and poor education of patients and their families further delay patient care. Lack of anesthesia providers causes obstetricians to act as surgeon and anesthetist. Traditional healers/birth attendants compete with hospitals for delivery. In most rural areas, anesthesia is given without muscle relaxants. Ketamine, which has high therapeutic index and no known maternal circulatory or fetal neurological depression, is appropriate for low-resource settings where there are few providers. Prospective review of anesthetic-associated 9833 operative obstetric procedures were deaths, defined as death within 24 hours of performed under anesthesia, with 1.73 avoidable anesthesia or failure to regain consciousness, deaths per 1000 anesthetics administered. within the maternity unit of Harare Central Emergency procedures were followed but all Hospital in Harare, Zimbabwe. avoidable deaths were associated with general anesthesia. Seven deaths were directly attributable to anesthesia, and all instances of substandard anesthesia occurred at hands of junior anesthetists. Ten deaths were due to hemorrhage, and lack of availability of beds in an intensive care unit contributed to two deaths. Retrospective survey of hospital records of 2968 women delivered in the hospital during the cesarean deliveries in southeastern Nigeria in a study period. 24.0% of births were via caesarean, 4-year period to determine the trend of different and of anesthetics administered, 47.6% were forms of anesthesia for cesarean. general anesthetics, 51.3% were spinal anesthesia,
The anesthesia gap identified The simplicity of the anesthetic technique allowed surgery to be performed despite an anesthesia gap created by civil war.
There is lack of access to anesthetists capable of handling basic obstetric analgesia or obstetric life-threatening complications, especially in rural areas. This is due to complex social and economic factors, including lack of trained staff, essential medicine, and equipment.
Predisposing factors for anesthesia-related mortality include failed airway management, inadequate supervision of junior or non-physician anesthetists, insufficient patient monitoring, and lack of equipment that staff are trained to use. These issues are especially prevalent in rural areas. Ruptured uterus, blood loss, general (versus spinal) anesthesia, and inadequate training of the anesthetist are factors that contribute to the high rate of maternal and perinatal deaths related to cesarean delivery.
Ugandans are severely limited in their access to the most basic forms of health care, along with a severe shortage of medical providers, especially anesthetists. International standards of anesthesia are unattainable within this resource-poor environment. Logistical difficulties in ordering, finance, and transport of medical supplies is common.
There is a massive shortfall in resources and infrastructure required to provide basic surgical support in obstetrics.
Lack of adequately trained personnel means that underqualified physicians or nurses provide anesthetic services. Inadequate drug supply and poor infrastructure complicate obstetric surgical procedures. Delays in patients reaching hospitals leads to increased incidence of anesthesia-related complications.
Lack of resources, education, and guidelines contributes to avoidable maternal deaths. Spinal anesthesia is safer than general anesthesia, and monitoring during recovery should be improved.
In low-income countries such as Nigeria, there is a trend toward the use of regional anesthesia for cesareans because of its ease of use and economic practicality, a trend already seen in many (continued on next page)
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Table 1 (continued) Author, year
Objective
Okafor et al., 2009 [23]
and 1.1% were epidurals. This represents an increase in the use of spinal anesthesia relative to general anesthesia over the 4-year study period. Review of population-based studies with Two strategies have been promoted for the maternal mortality as the outcome variable. reduction of maternal mortality: a package known as emergency obstetric care and the promotion of delivery by a skilled birth attendant. Promotion of emergency obstetric care packages better prevent maternal mortality, but the evidence for emergency obstetric care packages versus evidence for a skilled attendant at work is often difficult to separate. A study of the association between population Births in health facilities exceeded those with a indicators of access to obstetric care and levels of skilled attendant, reflecting that not all facilities maternal mortality in urban and rural West Africa are staffed by skilled staff, and nearly all home based on two population-based studies. births are conducted without a skilled attendant. Most women in rural areas give birth at home in the absence of skilled care, whereas those in urban areas tend to give birth in hospital with skilled attendants. Maternal mortality is extremely high in rural areas and substantially lower in urban areas. However, within urban or rural areas, there is no specific or obvious association between maternal mortality and skilled obstetric care, hospital births, or cesareans. To highlight the regional underutilization of Drugs are in short supply in Sub-Saharan Africa anesthesia techniques. partly because of inconsistent funding as well as less-than-optimal drug storage. Lack of equipment or inadequate equipment is an ongoing problem for regional anesthesia use. Equipment can be expensive. Furthermore, anesthesia is usually performed by non-physician providers who mostly have training in spinal but not regional anesthesia. There is limited access to further training in regional anesthesia. To document infrastructure, personnel, Three qualified surgeons and two obstetricians procedures performed, and supplies and work in Liberia. There are no anesthesiologists. equipment available at 16 all county hospitals in Thirteen (81.2%) facilities reported being able to Liberia using the World Health Organization Tool provide spinal or examine anesthesia, 4 (25%) for Situational Analysis of Emergency and were able to provide general anesthesia, and 2 Essential Surgical Care. (12.5%) could perform regional blocks. Supplies and equipment were severely limited. To examine population-based cesarean rates by Frequency of cesarean deliveries was below 1% for socioeconomic groups in various low-income the poorest 20% of the population in 20 countries countries (including four of the 10 most populous low-income countries [Bangladesh, Pakistan, Nigeria, and Ethiopia]). Rates were below 1% in 80% of the population in Chad, Madagascar, Niger, Ethiopia, Burkina Faso, and Mali. This is partly due to the unmet obstetric surgical needs.
Paxton, 2005 [24]
Ronsmans, 2003 [25]
Schnittger, 2007 [26]
Sherman, 2011 [27]
Ronsmans, 2006 [28]
Conclusions
devastation of the labor force by HIV/AIDS, tuberculosis, and malaria [40]. A study of migration issues in six African countries [41] found that up to two-thirds of recent medical graduates emigrate (68% of health workers in Zimbabwe, 49% in Cameroon, and about 60% in Ghana and South Africa). Although recently receiving WHO attention, there generally remains little incentive to become an anesthetist or anesthesiologist in resource-limited settings: there are few training positions, and remuneration and working conditions are usually poor [1,16]. Most anesthesia in cesarean deliveries is administered by individuals who are not physicians but have 1–3 years of training [2,19,29]. Often, the provider performing the surgery is also responsible for anesthesia, making additional tasks (e.g. providing intensive care to critically ill mothers or airway management) nearly impossible [19,21,28]. The education of non-physician anesthetists varies considerably, from no formal qualification to training for 1–3 years [17]. In a report from a rural area of South Africa [42], only 3% of 105 doctors administering obstetric anesthesia in 2005 were specialist anesthetists. Most had been trained in anesthesia for at most 4 weeks, and in 13% of respondents this training did not include obstetric anesthesia [42]. Additionally, anesthesia providers in resource-limited settings who complete training
The anesthesia gap identified high-income countries. This trend is slower than in high-income countries as a result of the paucity of physician anesthetists. The health system in countries with high maternal mortality ratios function at low levels in terms of personnel, supplies, and infrastructure. Deaths due to direct obstetric complications can be avoided by improving access to adequate obstetric services.
The major difference between rural and urban maternal mortality is due to differential access to high-quality maternal care.
Widespread uptake of regional anesthesia is prevented by the combination of lack of drugs, equipment, training, and institutional practice/ surgical preference. Lack of training is due in part due to lack of textbooks/training materials. Shortage of anesthetic drugs is another barrier. Economic factors influence anesthesia technique.
Gaps in essential personnel need to be filled as well as bettering hospital infrastructure and access to resources and basic amenities such as electricity, running water.
In the poorest quintile in low-income countries, there is almost no access to potentially lifesaving obstetric surgery such as cesareans, which is partly a result of inadequate access to treatment, a poor referral system, and a lack of basic facilities, fees, and unskilled birth attendants.
either as a physician or mid-level provider (e.g. clinical officer, nurse, or midwife) have almost no access to mentorship, continuing education, and professional development [24,26]. 4. Discussion The present literature review has shown that the components of the anesthesia gap fall into three categories: infrastructure, equipment and supplies, and trained personnel. Given the emergent findings of widespread deficits across all components within each of the three categories, the three categories will have to be addressed together to develop a systems solution. In low-income countries, there are urgent requirements to establish and expand training for anesthesia providers, continue education programs, increase motivation to pursue specialty training (perhaps through remuneration), improve surgical infrastructure (e.g. electricity), and increase the availability of necessary anesthesia equipment and supplies. The consequences of the gap in available anesthesia and its contribution to morbidity and mortality in low-income countries is currently being assessed by WHO and the World Federation of Societies of
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Anaesthesiologists [14,29]. In addition, The Global Oximetry initiative has been advocating for the provision and use of pulse oximetry as a minimum [43], and the WHO Patient Safety Pulse Oximetry Project is responding to the lack of basic monitoring devices by providing a Surgical Safety Checklist, pulse oximetry, and training to hospitals in low-income countries, while tracking patient outcomes [32]. WHO has developed a Guide to Anaesthetic Infrastructure and Supplies at Various Levels of Health Care Facilities as well as a Model List of Essential Medications, which is updated every 2 years and serves as a guide for the development of national and institutional lists of essential medicines. These guides describe the minimum essential equipment and drugs required to deliver basic anesthesia care. However, it is clear that many hospitals in low-income countries do not meet these requirements and often have shortages of essential medications [14,17,26,28]. Although increased training and improvements across all components of the anesthesia delivery system are clearly needed and should be a development priority, the task at hand is massive and will probably take decades in many areas of the world. However, the need is now and is, by many reports, of crisis proportions. Each of the components within the described three categories should receive immediate attention and investment, but investigators should think in new and innovative ways to close the anesthesia gap. Action-oriented and perhaps out-of-thebox research should be undertaken to identify cost-effective and safe solutions to close the anesthesia gap in a rapid and high-impact fashion. Examples might include the development of more effective and affordable monitoring devices as well as simpler ultra-safe anesthesia clinical protocols, designed with the resource-limited setting in mind. In terms of limitations, this literature search was restricted by the paucity of research on the topic of anesthesia in obstetrics in resourceconstrained settings. In summary, the shortages of trained anesthesia providers, equipment, supplies, medications, and basic infrastructure, along with limitations in transportation in resource-limited settings have produced a wide gap between available anesthesia services and the demand for them in reproductive health surgeries and procedures. In addition to immediate investment in widespread strengthening of anesthesia systems, innovators need to seek safe, affordable, and scalable new solutions that will rapidly address the crisis and close the anesthesia gap. Mothers deserve no less. Conflict of interest The authors have no conflicts of interest. References [1] Mavalankar DV, Rosenfield A. Maternal mortality in resource-poor settings: policy barriers to care. Am J Public Health 2005;95(2):200–3. [2] Burkhalter BR. Consequences of Unsafe Motherhood in Developing Countries in 2000: Assumptions and Estimates from the REDUCE Model. In: Murray C, Lopez A, editors. The Global Burden of Disease and Injury 3: Health Dimensions of Sex and Reproduction. Boston, MA: Harvard University Press; 1998. p. 170–4. [3] World Health Organization, United Nations Children’s Fund, United Nations Population Fund, The World Bank. Trends in maternal mortality: 1990 to 2010. http://whqlibdoc.who.int/publications/2012/9789241503631_eng.pdf?ua=1. Published 2012. Accessed August 1, 2014. [4] Ronsmans C, Graham WJ. Lancet Maternal Survival Series steering group. Maternal mortality: who, when, where, and why. Lancet 2006;368(9542):1189–200. [5] Campbell OM, Graham WJ, Lancet Maternal Survival Series steering group. Strategies for reducing maternal mortality: getting on with what works. Lancet 2006;368(9543): 1284–99. [6] Koblinsky M, Matthews Z, Hussein J, Mavalankar D, Mridha MK, Anwar I, et al. Going to scale with professional skilled care. Lancet 2006;368(9544):1377–86. [7] Borghi J, Ensor T, Somanathan A, Lissner C, Mills A, Lancet Maternal Survival Series steering group. Mobilising financial resources for maternal health. Lancet 2006; 368(9545):1457–65. [8] United Nations Children’s Fund, World Health Organization, United Nations Population Fund. Guidelines for monitoring the availability and use of obstetric services. http://www.childinfo.org/files/maternal_mortality_finalgui.pdf. Published August 1997. Accessed January 15, 2014.
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Published 2006. Accessed 16 February, 2014. [40] Tawfik L, Kinoti SN. The impact of HIV/AIDS on the health workforce in developing countries: background paper prepared for The World Health Report 2006—working together for health. http://www.who.int/hrh/documents/Impact_of_HIV.pdf. Published March 2006. Accessed 28 December, 2013. [41] Awases M, Gbary A, Nyoni J, Chatora R. Migration of health professionals in six countries: a synthesis report. http://info.worldbank.org/etools/docs/library/206860/ Migration%20study%20AFRO.pdf. Published 2004. Accessed August 1, 2014. [42] Lamacraft G, Kenny PJ, Diedericks BJ, Joubert G. Obstetric anaesthesia: the source of the crisis. S Afr Med J 2008;98(2):123–4. [43] Thoms GM, McHugh GA, O’Sullivan E. The Global Oximetry initiative. Anaesthesia 2007;62(Suppl. 1):75–7.
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International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
REVIEW ARTICLE
Defining the anesthesia gap for reproductive health procedures in resource-limited settings R. Eleanor Anderson a,b,⁎, Roy Ahn a,b, Brett D. Nelson a,b, Jean Chavez a, Emily de Redon a, Thomas Burke a,b a b
Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA
a r t i c l e
i n f o
Article history: Received 23 February 2014 Received in revised form 18 June 2014 Accepted 6 August 2014 Keywords: Anesthesia Low-income countries Reproductive health
a b s t r a c t Background: In resource-limited settings, severe shortages of anesthetists and anesthesiologists lead to surgical delays that increase maternal and neonatal mortality and morbidity. Objectives: To more clearly understand the individual components of the anesthesia gap pertaining to reproductive health surgeries and procedures in resource-limited settings. Search strategy: Medline, the Cochrane Library, CINAHL, Embase, and POPLINE were systematically searched for reports published before December 31, 2013. Search terms were related to obstetric surgery, resource-limited settings, and anesthesia. Selection criteria: Studies that addressed the use of anesthesia in reproductive procedures in resource-limited settings were included. Data collection and analysis: Reviewers independently evaluated the full text of identified studies, extracted information related to study objectives and conclusions, and identified the anesthesia gap. Main results: Overall, 14 publications met the inclusion criteria. A significant lack of infrastructure, equipment and supplies, and trained personnel were identified as key factors responsible for a lack of anesthesia services. Conclusions: A shortage of trained anesthesia providers, equipment, supplies, medications, and infrastructure, along with limitations in transportation in resourcelimited settings have produced a wide gap between available anesthesia services and the demand for them for reproductive health surgeries and procedures. Safe, affordable, and scalable solutions to address the anesthesia gap are urgently needed. © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Worldwide, 287 000 mothers die every year of pregnancy-related causes, and 20–50 times this number become disabled [1,2]. The overwhelming majority of these maternal deaths and injuries occur in resource-limited settings. For example, in Sub-Saharan Africa, the maternal mortality ratio (MMR) stands unacceptably at 920 maternal deaths for every 100 000 live births, compared with 8 maternal deaths per 100 000 live births in high-income nations [3]. Most maternal deaths could be prevented by ensuring the wide availability of contraception (including tubal ligation), presence of trained birth attendants during labor, and access to uterotonics, magnesium, antibiotics, blood transfusion, and emergency operative management [4–7]. In high-income countries, anesthetists and anesthesiologists play a crucial part in averting maternal and newborn death and disability by supporting critical surgeries such as cesareans, emergency hysterectomy, removal of ectopic pregnancies, tubal ligation, and even dilation and curettage. However, in resource-limited settings, severe shortages of anesthetists and anesthesiologists frequently lead to surgical delays, ⁎ Corresponding author at: Zero Emerson Place, Suite 104, Boston, MA 02114, USA. Tel.: +1 617 643 4294; fax: +1 617 643 8772. E-mail address: [email protected] (R.E. Anderson).
often resulting in death or disability of the mother and/or newborn [2]. Additionally, the frequencies of some procedures are reduced, probably partly because of poor availability of anesthesia services. For example, the frequency of cesarean delivery in Sub-Saharan Africa is often between 1% and 5% of births, and sometimes lower, whereas WHO maintains that the optimum frequency should be 5%–15% [8,9]. The lack of anesthesia services in obstetrics is fully recognized [10]. The global anesthesia crisis is well documented and cannot be overstated [11–13]. Although WHO and others have called for urgent expansion of anesthesia and anesthetist training programs, the severity of the need and matching solutions remain to be defined [14]. The number of anesthesia providers in low-income countries is difficult to track: although WHO monitors the numbers of doctors and other healthcare providers in each country, they do not specifically report on specialists, such as anesthesiologists, anesthetists, and technologists who provide anesthesia under the supervision of an anesthesiologist. While it is recognized that the global shortage of anesthesia providers is even more extreme in low-income countries, an optimum number of anesthetists per population has not yet been established (K. A. McQueen, MD; written communication, February 2014). The lack of access to safe anesthesia—the anesthesia gap—for lifesaving obstetric procedures such as cesarean delivery, tubal ligation, surgery for ectopic pregnancy, emergency hysterectomy, and dilatation
http://dx.doi.org/10.1016/j.ijgo.2014.06.023 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
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and curettage is under-recognized as a contributing factor to maternal mortality and morbidity. The aim of the present review was to more clearly understand the individual components of the anesthesia gap pertaining to vital reproductive health surgeries and procedures in resource-limited settings. 2. Materials and methods In December 2013, a systematic literature search was done in Medline, the Cochrane Library, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, and POPLINE. The following search term was used: “‘cesarean section’ OR ‘tubal ligation’ OR ‘manual vacuum aspiration’ OR ‘hysterectomy’ OR ‘dilation and curettage’ AND ‘poverty’ OR ‘limited resource’ OR ‘low resource’ OR ‘developing country’ OR ‘resource-poor’ AND ‘anesthesia’”. Two reviewers (J.C. and E.d.R.) independently conducted these searches. The searches were restricted to human studies but were not limited by language, and included all articles published before December 31, 2013. In addition to the studies identified through the search, key references from included studies were also examined for inclusion. Two reviewers (J.C. and E.d.R) conducted preliminary screening of the titles and abstracts of identified studies for eligibility. All articles in which the use of anesthesia in reproductive health procedures in resource-poor settings was assessed were included. Randomized controlled trials, prospective and retrospective observational studies, case series, and reports were eligible. Studies that addressed the administration of anesthesia by individuals who were not anesthetists for reproductive surgical procedures in resource-poor settings were also included. Studies that did not directly relate to the review question (e.g. articles on the use of anesthesia for reproductive health procedures in settings where resources are not limited) were excluded from the review. Furthermore, editorials and other opinion-based, non-empirical articles were excluded from the review. If either reviewer considered an article eligible for inclusion, both reviewers independently evaluated the full text. In the event that the two reviewers disagreed about whether a study should be included after reviewing the full text, R.E.A. examined it, and the group deliberated until consensus was achieved. Information about the study objective, conclusions, and the identified anesthesia gap was then extracted by J.C., E.d.R., and R.E.A. 3. Results 3.1. Results of the search The literature review identified 14 reports meeting the inclusion criteria (Table 1). In general, the studies revealed a significant lack of infrastructure, equipment and supplies, and trained personnel as the key factors responsible for a lack of anesthesia services. 3.2. Infrastructure Poor health system design and a lack of general community infrastructure inhibit the development of functioning comprehensive emergency obstetric and newborn care facilities, which, by definition, include cesarean capabilities. To manage obstetric complications requiring surgery, a comprehensive emergency obstetric and newborn care facility must be equipped with a functional operating theater, adequate support staff, and the capability to perform blood transfusions and emergency anesthesia [14]. Providing anesthesia services for emergency obstetric care relies on components of infrastructure that are currently lacking in many lowresource nations [16,19,20,25,27]. Lapses in electricity and intermittent running water often prevent the use of equipment even when it is available [20]. In Uganda, 41% of anesthesia providers work in an environment where electricity or a generator is not always available and
access to running water and bedside laboratory investigations is also quite limited [19]. Additionally, in a review of 132 facilities in eight low-income countries [20], every facility reported frequent interruptions in water supply, electricity, and oxygen. Additional infrastructure weaknesses frequently identified in reports include lack of transportation and roads, poor community education and preparedness, and the multiple effects of poverty (including general vulnerability, isolation, and lack of access to social and financial assets) [5,16,19,20,22,24,25,29]. 3.3. Equipment and supplies In resource-limited settings, essential surgical equipment and supplies, equipment for the management of airways, antibiotics, and medications for intubation, anesthesia, and analgesia are often unavailable [11,18,19,26,27,30,31]. The present literature search also revealed that basic safety monitoring equipment—e.g. pulse oximetry, blood pressure devices, and heart rate monitors—are commonly in disrepair or unaffordable [14,17,18,26,28,32,33]. The most common types of anesthesia used in resource-limited settings are general anesthesia (halothane and ether), spinal anesthesia (bupivacaine), and dissociative anesthesia (ketamine) [24,34]. A survey of half the anesthesia providers in Uganda [19] revealed that only 6% of anesthesia providers are able to provide both spinal and general anesthesia for cesarean deliveries at any one time, mostly because of a lack of medications and supplies. A separate survey in Uganda [35] found that all hospitals were missing essential equipment and frequently had shortages of WHO Essential Medications, none had pulse oximeters, and there was no mechanism for reporting outcomes. Similar results were found in Rwanda and Ethiopia [30,31]. Over the past two decades, cesarean deliveries in well-resourced countries have been increasingly performed using spinal anesthesia, with outcomes reportedly improved over general anesthesia [36]. Trends of decreased mortality with spinal anesthesia have been reported in Malawi and Zimbabwe [18,23], although widespread adoption is lacking [23]. However, the 2005–2007 South African Confidential Enquiry into Maternal Death report [37] showed that implementation of spinal anesthesia in cesarean deliveries in resource-limited settings may not be as safe as hoped: 74 direct anesthesia deaths were described, of which 53 (72%) were associated with spinal anesthesia and 18 (24%) with general anesthesia. In the deaths directly related to spinal anesthesia, the most common causes were a high spinal (41%) and intraoperative hypotension (14%). Possible causes include inadequate training [16,17,21]. A few studies have compared different anesthesia regimens for cesarean delivery to determine safety profiles in low-income countries [21,23]. Although no rigorous studies have been done in resourcelimited settings, ketamine seems to be one of the most commonly used anesthetic and sedation agents around the world, primarily because of its high therapeutic index [21,38]. Ketamine rarely suppresses ventilatory or cardiovascular systems, is considered safe in overdose, and is inexpensive [39]. A report of its use in 64 cases during civil war in Somalia and Uganda for surgeries lasting up to 2 hours showed no complications [15]. 3.4. Trained personnel Only recently have data begun to emerge on specific numbers of anesthesia providers in low-income countries. What is known has come from local and national ministries of health, non-governmental organizations, and providers in regions with unmet anesthesia needs [13,14]. In summary, the poorest regions in the world have the lowest density of anesthesiologists and anesthetists [11,12]. In Uganda, there are 0.05 anesthetists for every 100 000 people [19]. In Rwanda, the corresponding number is 0.09 [30], and in Ethiopia 0.02 [31]. Factors responsible for this paucity of anesthesia providers include political instability, corruption, emigration of trained providers, and
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Table 1 Summary of the 14 studies identified in the literature review. Author, year
Objective
Bonanno, 2001 [15]
Case study of 64 patients in whom ketamine was used as an anesthetic agent for surgeries (including cesarean delivery) performed in war and low-resource settings.
Clyburn et al., 2007 [16]
Dyer, 2010 [17]
Fenton, 2003 [18]
Hodges et al., 2007 [19]
Kushner et al., 2010 [20]
Kwawukume, 2001 [21]
McKenzie, 1998 [22]
Okafor et al., 2009 [23]
Conclusions
Respiratory and heart rates were maintained within the accepted range in all patients. Patients who received diazepam prior to ketamine had hallucinations of shorter duration than did those who did not receive diazepam. To review challenges in obstetric anesthesia in Many women lack access to basic obstetric low-income countries. analgesia and others present with life-threatening complications that anesthetic providers are unprepared to handle. Although the WHO recommended frequency of cesarean is 5%–10%, the frequency in the poorest populations in 20 countries is less than 1%, partly because of inadequate anesthesia provision. Review of interventions required to improve In South Africa, anesthesia is the seventh most obstetric anesthesia in low-resource settings. common direct cause of maternal mortality. There is no current standard in terms of equipment and medicine for adequately safe anesthesia, and in many instances in resource-poor settings, providers do not have the necessary skills to use donated material from high-income countries. To examine potentially modifiable factors that Obstructed labor was significantly associated may influence high maternal and perinatal with both maternal and perinatal mortality. Other mortality associated with cesarean delivery potentially modifiable risk factors identified through questionnaires given to anesthetists who included anesthetist training, blood loss, and type perform cesarean deliveries. of anesthetic. Most maternal deaths occurred postoperatively, within 72 hours of birth and while patients were on the wards. To examine difficulties in providing anesthesia in There was only one physician anesthetist among Uganda through a questionnaire distributed to 97 the population of anesthesia providers sampled. anesthesia providers at an anesthesia refresher Most non-physician anesthetists had attended course. training courses that lasted 1–2 years. Only 6% could provide anesthesia services for cesarean deliveries by both general and spinal anesthesia. Intermittent mains electricity was reported by 41% of respondents, who also said that a generator was not always available. Access to running water, gloves, disinfectant, laboratory investigations, and other general hospital needs were limited. Anesthesia was largely ketamine-based. A standardized WHO tool was used in 30 low- and In no country did 100% of facilities report middle-income countries to assess infrastructure, continuous supply of water, electricity, and supplies, and procedures essential to surgical and oxygen, with most reporting less than 50% anesthetic capacity as they relate to Millennium availability. Only 44% of facilities were able to Development Goals 4, 5, and 6. offer cesareans. Other emergency and elective reproductive procedures were available only 48% and 39% of the time, respectively. To report difficulties with performing cesareans Poor communication and transportation systems and other infrastructure deficits delay maternal in low-income countries. care. Lack of anesthetic equipment and machines is prevalent. Poverty and poor education of patients and their families further delay patient care. Lack of anesthesia providers causes obstetricians to act as surgeon and anesthetist. Traditional healers/birth attendants compete with hospitals for delivery. In most rural areas, anesthesia is given without muscle relaxants. Ketamine, which has high therapeutic index and no known maternal circulatory or fetal neurological depression, is appropriate for low-resource settings where there are few providers. Prospective review of anesthetic-associated 9833 operative obstetric procedures were deaths, defined as death within 24 hours of performed under anesthesia, with 1.73 avoidable anesthesia or failure to regain consciousness, deaths per 1000 anesthetics administered. within the maternity unit of Harare Central Emergency procedures were followed but all Hospital in Harare, Zimbabwe. avoidable deaths were associated with general anesthesia. Seven deaths were directly attributable to anesthesia, and all instances of substandard anesthesia occurred at hands of junior anesthetists. Ten deaths were due to hemorrhage, and lack of availability of beds in an intensive care unit contributed to two deaths. Retrospective survey of hospital records of 2968 women delivered in the hospital during the cesarean deliveries in southeastern Nigeria in a study period. 24.0% of births were via caesarean, 4-year period to determine the trend of different and of anesthetics administered, 47.6% were forms of anesthesia for cesarean. general anesthetics, 51.3% were spinal anesthesia,
The anesthesia gap identified The simplicity of the anesthetic technique allowed surgery to be performed despite an anesthesia gap created by civil war.
There is lack of access to anesthetists capable of handling basic obstetric analgesia or obstetric life-threatening complications, especially in rural areas. This is due to complex social and economic factors, including lack of trained staff, essential medicine, and equipment.
Predisposing factors for anesthesia-related mortality include failed airway management, inadequate supervision of junior or non-physician anesthetists, insufficient patient monitoring, and lack of equipment that staff are trained to use. These issues are especially prevalent in rural areas. Ruptured uterus, blood loss, general (versus spinal) anesthesia, and inadequate training of the anesthetist are factors that contribute to the high rate of maternal and perinatal deaths related to cesarean delivery.
Ugandans are severely limited in their access to the most basic forms of health care, along with a severe shortage of medical providers, especially anesthetists. International standards of anesthesia are unattainable within this resource-poor environment. Logistical difficulties in ordering, finance, and transport of medical supplies is common.
There is a massive shortfall in resources and infrastructure required to provide basic surgical support in obstetrics.
Lack of adequately trained personnel means that underqualified physicians or nurses provide anesthetic services. Inadequate drug supply and poor infrastructure complicate obstetric surgical procedures. Delays in patients reaching hospitals leads to increased incidence of anesthesia-related complications.
Lack of resources, education, and guidelines contributes to avoidable maternal deaths. Spinal anesthesia is safer than general anesthesia, and monitoring during recovery should be improved.
In low-income countries such as Nigeria, there is a trend toward the use of regional anesthesia for cesareans because of its ease of use and economic practicality, a trend already seen in many (continued on next page)
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Table 1 (continued) Author, year
Objective
Okafor et al., 2009 [23]
and 1.1% were epidurals. This represents an increase in the use of spinal anesthesia relative to general anesthesia over the 4-year study period. Review of population-based studies with Two strategies have been promoted for the maternal mortality as the outcome variable. reduction of maternal mortality: a package known as emergency obstetric care and the promotion of delivery by a skilled birth attendant. Promotion of emergency obstetric care packages better prevent maternal mortality, but the evidence for emergency obstetric care packages versus evidence for a skilled attendant at work is often difficult to separate. A study of the association between population Births in health facilities exceeded those with a indicators of access to obstetric care and levels of skilled attendant, reflecting that not all facilities maternal mortality in urban and rural West Africa are staffed by skilled staff, and nearly all home based on two population-based studies. births are conducted without a skilled attendant. Most women in rural areas give birth at home in the absence of skilled care, whereas those in urban areas tend to give birth in hospital with skilled attendants. Maternal mortality is extremely high in rural areas and substantially lower in urban areas. However, within urban or rural areas, there is no specific or obvious association between maternal mortality and skilled obstetric care, hospital births, or cesareans. To highlight the regional underutilization of Drugs are in short supply in Sub-Saharan Africa anesthesia techniques. partly because of inconsistent funding as well as less-than-optimal drug storage. Lack of equipment or inadequate equipment is an ongoing problem for regional anesthesia use. Equipment can be expensive. Furthermore, anesthesia is usually performed by non-physician providers who mostly have training in spinal but not regional anesthesia. There is limited access to further training in regional anesthesia. To document infrastructure, personnel, Three qualified surgeons and two obstetricians procedures performed, and supplies and work in Liberia. There are no anesthesiologists. equipment available at 16 all county hospitals in Thirteen (81.2%) facilities reported being able to Liberia using the World Health Organization Tool provide spinal or examine anesthesia, 4 (25%) for Situational Analysis of Emergency and were able to provide general anesthesia, and 2 Essential Surgical Care. (12.5%) could perform regional blocks. Supplies and equipment were severely limited. To examine population-based cesarean rates by Frequency of cesarean deliveries was below 1% for socioeconomic groups in various low-income the poorest 20% of the population in 20 countries countries (including four of the 10 most populous low-income countries [Bangladesh, Pakistan, Nigeria, and Ethiopia]). Rates were below 1% in 80% of the population in Chad, Madagascar, Niger, Ethiopia, Burkina Faso, and Mali. This is partly due to the unmet obstetric surgical needs.
Paxton, 2005 [24]
Ronsmans, 2003 [25]
Schnittger, 2007 [26]
Sherman, 2011 [27]
Ronsmans, 2006 [28]
Conclusions
devastation of the labor force by HIV/AIDS, tuberculosis, and malaria [40]. A study of migration issues in six African countries [41] found that up to two-thirds of recent medical graduates emigrate (68% of health workers in Zimbabwe, 49% in Cameroon, and about 60% in Ghana and South Africa). Although recently receiving WHO attention, there generally remains little incentive to become an anesthetist or anesthesiologist in resource-limited settings: there are few training positions, and remuneration and working conditions are usually poor [1,16]. Most anesthesia in cesarean deliveries is administered by individuals who are not physicians but have 1–3 years of training [2,19,29]. Often, the provider performing the surgery is also responsible for anesthesia, making additional tasks (e.g. providing intensive care to critically ill mothers or airway management) nearly impossible [19,21,28]. The education of non-physician anesthetists varies considerably, from no formal qualification to training for 1–3 years [17]. In a report from a rural area of South Africa [42], only 3% of 105 doctors administering obstetric anesthesia in 2005 were specialist anesthetists. Most had been trained in anesthesia for at most 4 weeks, and in 13% of respondents this training did not include obstetric anesthesia [42]. Additionally, anesthesia providers in resource-limited settings who complete training
The anesthesia gap identified high-income countries. This trend is slower than in high-income countries as a result of the paucity of physician anesthetists. The health system in countries with high maternal mortality ratios function at low levels in terms of personnel, supplies, and infrastructure. Deaths due to direct obstetric complications can be avoided by improving access to adequate obstetric services.
The major difference between rural and urban maternal mortality is due to differential access to high-quality maternal care.
Widespread uptake of regional anesthesia is prevented by the combination of lack of drugs, equipment, training, and institutional practice/ surgical preference. Lack of training is due in part due to lack of textbooks/training materials. Shortage of anesthetic drugs is another barrier. Economic factors influence anesthesia technique.
Gaps in essential personnel need to be filled as well as bettering hospital infrastructure and access to resources and basic amenities such as electricity, running water.
In the poorest quintile in low-income countries, there is almost no access to potentially lifesaving obstetric surgery such as cesareans, which is partly a result of inadequate access to treatment, a poor referral system, and a lack of basic facilities, fees, and unskilled birth attendants.
either as a physician or mid-level provider (e.g. clinical officer, nurse, or midwife) have almost no access to mentorship, continuing education, and professional development [24,26]. 4. Discussion The present literature review has shown that the components of the anesthesia gap fall into three categories: infrastructure, equipment and supplies, and trained personnel. Given the emergent findings of widespread deficits across all components within each of the three categories, the three categories will have to be addressed together to develop a systems solution. In low-income countries, there are urgent requirements to establish and expand training for anesthesia providers, continue education programs, increase motivation to pursue specialty training (perhaps through remuneration), improve surgical infrastructure (e.g. electricity), and increase the availability of necessary anesthesia equipment and supplies. The consequences of the gap in available anesthesia and its contribution to morbidity and mortality in low-income countries is currently being assessed by WHO and the World Federation of Societies of
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Anaesthesiologists [14,29]. In addition, The Global Oximetry initiative has been advocating for the provision and use of pulse oximetry as a minimum [43], and the WHO Patient Safety Pulse Oximetry Project is responding to the lack of basic monitoring devices by providing a Surgical Safety Checklist, pulse oximetry, and training to hospitals in low-income countries, while tracking patient outcomes [32]. WHO has developed a Guide to Anaesthetic Infrastructure and Supplies at Various Levels of Health Care Facilities as well as a Model List of Essential Medications, which is updated every 2 years and serves as a guide for the development of national and institutional lists of essential medicines. These guides describe the minimum essential equipment and drugs required to deliver basic anesthesia care. However, it is clear that many hospitals in low-income countries do not meet these requirements and often have shortages of essential medications [14,17,26,28]. Although increased training and improvements across all components of the anesthesia delivery system are clearly needed and should be a development priority, the task at hand is massive and will probably take decades in many areas of the world. However, the need is now and is, by many reports, of crisis proportions. Each of the components within the described three categories should receive immediate attention and investment, but investigators should think in new and innovative ways to close the anesthesia gap. Action-oriented and perhaps out-of-thebox research should be undertaken to identify cost-effective and safe solutions to close the anesthesia gap in a rapid and high-impact fashion. Examples might include the development of more effective and affordable monitoring devices as well as simpler ultra-safe anesthesia clinical protocols, designed with the resource-limited setting in mind. In terms of limitations, this literature search was restricted by the paucity of research on the topic of anesthesia in obstetrics in resourceconstrained settings. In summary, the shortages of trained anesthesia providers, equipment, supplies, medications, and basic infrastructure, along with limitations in transportation in resource-limited settings have produced a wide gap between available anesthesia services and the demand for them in reproductive health surgeries and procedures. In addition to immediate investment in widespread strengthening of anesthesia systems, innovators need to seek safe, affordable, and scalable new solutions that will rapidly address the crisis and close the anesthesia gap. Mothers deserve no less. Conflict of interest The authors have no conflicts of interest. References [1] Mavalankar DV, Rosenfield A. Maternal mortality in resource-poor settings: policy barriers to care. Am J Public Health 2005;95(2):200–3. [2] Burkhalter BR. Consequences of Unsafe Motherhood in Developing Countries in 2000: Assumptions and Estimates from the REDUCE Model. In: Murray C, Lopez A, editors. The Global Burden of Disease and Injury 3: Health Dimensions of Sex and Reproduction. Boston, MA: Harvard University Press; 1998. p. 170–4. [3] World Health Organization, United Nations Children’s Fund, United Nations Population Fund, The World Bank. Trends in maternal mortality: 1990 to 2010. http://whqlibdoc.who.int/publications/2012/9789241503631_eng.pdf?ua=1. Published 2012. Accessed August 1, 2014. [4] Ronsmans C, Graham WJ. Lancet Maternal Survival Series steering group. Maternal mortality: who, when, where, and why. Lancet 2006;368(9542):1189–200. [5] Campbell OM, Graham WJ, Lancet Maternal Survival Series steering group. Strategies for reducing maternal mortality: getting on with what works. Lancet 2006;368(9543): 1284–99. [6] Koblinsky M, Matthews Z, Hussein J, Mavalankar D, Mridha MK, Anwar I, et al. Going to scale with professional skilled care. Lancet 2006;368(9544):1377–86. [7] Borghi J, Ensor T, Somanathan A, Lissner C, Mills A, Lancet Maternal Survival Series steering group. Mobilising financial resources for maternal health. Lancet 2006; 368(9545):1457–65. [8] United Nations Children’s Fund, World Health Organization, United Nations Population Fund. Guidelines for monitoring the availability and use of obstetric services. http://www.childinfo.org/files/maternal_mortality_finalgui.pdf. Published August 1997. Accessed January 15, 2014.
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