Anaesthesia providers and maternal mortality in Africa
Authors: J Matthew Kynes, Mark W Newton
Journal: The Lancet Global Health (2019)

In The Lancet Global Health, David Bishop and colleagues1Bishop 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 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. However, we believe that their comparison of experience level of anaesthesia provider warrants closer inspection. The authors state that “it is unclear…whether the level of the anaesthesia provider contributes directly to maternal mortality in Africa” but go on to use a point estimate of mortality (15% specialist vs 45% non-physician anaesthesia provider; p=0·108) unsubstantiated by regression analysis to suggest that experience level of anaesthesia provider does contribute to mortality. Although the meta-analysis cited to support this finding did identify a higher mortality for non-physician anaesthesia providers (9·8 per 1000 anaesthetics) compared with physician anaesthesia providers (1·8 per 1000),2Sobhy 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 no study included in the meta-analysis directly compared non-physician anaesthesia providers and physician anaesthesia providers, which is problematic for several reasons. Similarly to other specialties,3Lemiere C Herbst CH Jahanshah N Smith E Reducing geographical imbalances of health workers in Sub-Saharan Africa: a labor market perspective on what works, what does not, and why (English). World Bank, Washington, DC2010Crossref Google Scholar physicians who are anaesthesia specialists tend to be concentrated in urban centres, as shown in a survey of obstetric anaesthesia care in east Africa, which showed an anaesthesia specialist density of 4·6 per 100 000 population in Nairobi and 0·03 per 100 000 in the rest of the country.4Epiu I Tindimwebwa JV Mijumbi C et al.Challenges of anesthesia in low- and middle-income countries: a cross-sectional survey of access to obstetric anesthesia in East Africa.Anesth Analg. 2017; 124: 290-299Crossref PubMed Scopus (48) Google Scholar This survey also showed deficiencies in critical infrastructure, supplies, and safety systems necessary for effective anaesthesia at referral hospitals—deficiencies that are more obvious at the district level at centres that are more commonly staffed by non-physician anaesthesia providers.5LeBrun 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 Anaesthesia complications such as failed intubation and cardiac arrest might be due to inadequate skill or training, but might also be due to other factors such as unavailability of advanced airway equipment or blood for transfusion. Further exploration of these resource deficiencies by Bishop and colleagues, and the potential disproportionate burden these deficiencies place on non-physician anaesthesia providers, would shed light on root causes of outcome disparities and inform strategies to improve them. As the authors appropriately conclude, access to caesarean delivery needs to increase but this endeavour will only be successful if we increase the education quality and numbers of non-physician anaesthesia providers who practice in the rural areas of low-income and middle-income countries. Mid-level anaesthesia providers in Africa play an important role in settings where health-care providers are scarce but need for caesarean delivery is high. We 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 Africa – Authors' replyWe thank J Matthew Kynes and Mark W Newton for their interest in our Article describing the obstetric cohort1 of the African Surgical Outcomes Study (ASOS).2 In the ASOS cohort, no difference was seen in maternal mortality between physician and non-physician anaesthesia providers.1 However, anaesthesia complications were independently associated with maternal mortality, and the point estimate for maternal mortality favoured risk associated with non-physician anaesthesia providers.1 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. Full-Text PDF Open Access