Anaesthesia providers and maternal mortality in Africa – Authors' reply
Authors: Bruce M Biccard, David Bishop, Robert A Dyer, Rupert M Pearse
Journal: The Lancet Global Health (2019)

We thank J Matthew Kynes and Mark W Newton for their interest in our Article describing the obstetric cohort1Bishop D Dyer RA Maswime S et al.Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.Lancet Glob Health. 2019; 7: e513-e522Summary Full Text Full Text PDF PubMed Scopus (70) Google Scholar of the African Surgical Outcomes Study (ASOS).2Biccard BM Madiba TE Kluyts HL et al.Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.Lancet. 2018; 391: 1589-1598Summary Full Text Full Text PDF PubMed Scopus (205) Google Scholar In the ASOS cohort, no difference was seen in maternal mortality between physician and non-physician anaesthesia providers.1Bishop D Dyer RA Maswime S et al.Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.Lancet Glob Health. 2019; 7: e513-e522Summary Full Text Full Text PDF PubMed Scopus (70) Google Scholar However, anaesthesia complications were independently associated with maternal mortality, and the point estimate for maternal mortality favoured risk associated with non-physician anaesthesia providers.1Bishop D Dyer RA Maswime S et al.Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.Lancet Glob Health. 2019; 7: e513-e522Summary Full Text Full Text PDF PubMed Scopus (70) Google Scholar Kynes and Newton correctly emphasise that this association does not necessarily imply that the level of the anaesthesia provider is associated with maternal mortality in Africa, especially because this association was not explored in the ASOS cohort.2Biccard BM Madiba TE Kluyts HL et al.Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.Lancet. 2018; 391: 1589-1598Summary Full Text Full Text PDF PubMed Scopus (205) Google Scholar Previously, non-physician anaesthesia providers have been shown in a systematic review to be associated with a higher maternal mortality than physician providers,3Sobhy S Zamora J Dharmarajah K et al.Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis.Lancet Glob Health. 2016; 4: e320-e327Summary Full Text Full Text PDF PubMed Scopus (73) Google Scholar but these data did not allow for a comparative risk adjustment between the physician and non-physician anaesthesia providers, and thereby provide little context to the environment in which the non-physician anaesthesia providers were working. Kynes and Newton specifically draw attention to the difficulties that many non-physician anaesthesia providers face daily, due to infrastructural, supply, and safety constraints that might adversely affect patient outcomes, especially when working in resource-limited and remote district-level hospitals.4LeBrun DG Chackungal S Chao TE et al.Prioritizing essential surgery and safe anesthesia for the Post-2015 Development Agenda: operative capacities of 78 district hospitals in 7 low- and middle-income countries.Surgery. 2014; 155: 365-373Summary Full Text Full Text PDF PubMed Scopus (84) Google Scholar Importantly, these environmental resource limitations might independently contribute to anaesthesia-related morbidity and mortality in Africa, regardless of the level of the anaesthesia provider. Importantly, in the ASOS obstetric cohort no clear association was seen between non-physician anaesthesia providers and increased maternal mortality.1Bishop D Dyer RA Maswime S et al.Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.Lancet Glob Health. 2019; 7: e513-e522Summary Full Text Full Text PDF PubMed Scopus (70) Google Scholar We agree further exploration is necessary of the contribution of limited resources to increased maternal mortality regardless of the level of training of the anaesthesia providers. Defining the risk associated with the potential infrastructural and system deficiencies is important for the development of strategies to provide safer anaesthesia for mothers in Africa, especially because nearly a quarter of the anaesthesia workforce providing care during caesarean section in ASOS were non-physicians working in resource-limited environments.1Bishop D Dyer RA Maswime S et al.Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.Lancet Glob Health. 2019; 7: e513-e522Summary Full Text Full Text PDF PubMed Scopus (70) Google Scholar RMP has received research grants from Edwards Lifesciences, Nestlé Health Sciences, and Intersurgical, has given lectures or performed consultancy work for Nestlé Health Sciences, Medtronic, Edwards Lifesciences, Braun, and GlaxoSmithKline, and is a member of the associate editorial board of the British Journal of Anaesthesia. All other authors declare no competing interests. Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort studyMaternal mortality after caesarean delivery in Africa is 50 times higher than that of high-income countries and is driven by peripartum haemorrhage and anaesthesia complications. Neonatal mortality is double the global average. Early identification and appropriate management of mothers at risk of peripartum haemorrhage might improve maternal and neonatal outcomes in Africa. Full-Text PDF Open AccessAnaesthesia providers and maternal mortality in AfricaIn The Lancet Global Health, David Bishop and colleagues1 reported outcomes after caesarean delivery in 22 African countries and reported a maternal mortality of 543 per 100 000 operations, with anaesthesia complications identified as a significant risk factor (odds ratio 11·47, 95% CI 1·20–109·20). Prospective data on perioperative outcomes is challenging to obtain but crucial to understanding and improving patient care in low-income and middle-income countries and we applaud the authors’ efforts. Full-Text PDF Open Access