Medical Research Council of South Africa.

Background Maternal and neonatal mortality is high in Africa, but few large, prospective studies have been done to investigate the risk factors associated with these poor maternal and neonatal outcomes. Methods A 7-day, international, prospective, observational cohort study was done in patients having caesarean delivery in 183 hospitals across 22 countries in Africa. The inclusion criteria were all consecutive patients (aged ≥18 years) admitted to participating centres having elective and non-elective caesarean delivery during the 7-day study cohort period. To ensure a representative sample, each hospital had to provide data for 90% of the eligible patients during the recruitment week. The primary outcome was in-hospital maternal mortality and complications, which were assessed by local investigators. The study was registered on the South African National Health Research Database, number KZ_2015RP7_22, and on ClinicalTrials.gov, number NCT03044899. Findings Between February, 2016, and May, 2016, 3792 patients were recruited from hospitals across Africa. 3685 were included in the postoperative complications analysis (107 missing data) and 3684 were included in the maternal mortality analysis (108 missing data). These hospitals had a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0•7 per 100 000 population (IQR 0•2-2•0). Maternal mortality was 20 (0•5%) of 3684 patients (95% CI 0•3-0•8). Complications occurred in 633 (17•4%) of 3636 mothers (16•2-18•6), which were predominantly severe intraoperative and postoperative bleeding (136 [3•8%] of 3612 mothers). Maternal mortality was independently associated with a preoperative presentation of placenta praevia, placental abruption, ruptured uterus, antepartum haemorrhage (odds ratio 4•47 [95% CI 1•46-13•65]), and perioperative severe obstetric haemorrhage (5•87 [1•99-17•34]) or anaesthesia complications (11•47 (1•20-109•20]). Neonatal mortality was 153 (4•4%) of 3506 infants (95% CI 3•7-5•0). Interpretation Maternal 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.

SummaryDeaths following surgery are the third largest contributor to deaths globally, and in Africa are twice the global average. There is a need for a peri‐operative research agenda to ensure co‐ordinated, collaborative research efforts across Africa in order to decrease peri‐operative mortality. The objective was to determine the top 10 research priorities for peri‐operative research in Africa. A Delphi technique was used to establish consensus on the top research priorities. The top 10 research priorities identified were (1) Develop training standards for peri‐operative healthcare providers (surgical, anaesthesia and nursing) in Africa; (2) Develop minimum provision of care standards for peri‐operative healthcare providers (surgical, anaesthesia and nursing) in Africa; (3) Early identification and management of mothers at risk from peripartum haemorrhage in the peri‐operative period; (4) The role of communication and teamwork between surgical, anaesthetic, nursing and other teams involved in peri‐operative care; (5) A facility audit/African World Health Organization situational analysis tool audit to assess emergency and essential surgical care, which includes anaesthetic equipment available and level of training and knowledge of peri‐operative healthcare providers (surgeons, anaesthetists and nurses); (6) Establishing evidence‐based practice guidelines for peri‐operative physicians in Africa; (7) Economic analysis of strategies to finance access to surgery in Africa; (8) Establishment of a minimum dataset surgical registry; (9) A quality improvement programme to improve implementation of the surgical safety checklist; and (10) Peri‐operative outcomes associated with emergency surgery. These peri‐operative research priorities provide the structure for an intermediate‐term research agenda to improve peri‐operative outcomes across Africa.

Background: Children comprise a large proportion of the population in sub-Saharan Africa. The burden of paediatric surgical disease exceeds available resources in Africa, potentially increasing morbidity and mortality. There are few prospective paediatric perioperative outcomes studies, especially in low-and middle-income countries (LMICs). Methods: We conducted a 14-day multicentre, prospective, observational cohort study of paediatric patients (aged <16 yrs) undergoing surgery in 43 government-funded hospitals in South Africa. The primary outcome was the incidence of in-hospital postoperative complications. Results: We recruited 2024 patients at 43 hospitals. The overall incidence of postoperative complications was 9.7% [95% confidence interval (CI): 8.4e11.0]. The most common postoperative complications were infective (7.3%; 95% CI: 6.2e8.4%). In-hospital mortality rate was 1.1% (95% CI: 0.6e1.5), of which nine of the deaths (41%) were in ASA physical status 1 and 2 patients. The preoperative risk factors independently associated with postoperative complications were ASA physcial status, urgency of surgery, severity of surgery, and an infective indication for surgery. Conclusions: The risk factors, frequency, and type of complications after paediatric surgery differ between LMICs and high-income countries. The in-hospital mortality is 10 times greater than in high-income countries. These findings

Summary Background Risk of mortality following surgery in patients across Africa is twice as high as the global average. Most of these deaths occur on hospital wards after the surgery itself. We aimed to assess whether enhanced postoperative surveillance of adult surgical patients at high risk of postoperative morbidity or mortality in Africa could reduce 30-day in-hospital mortality. Methods We did a two-arm, open-label, cluster-randomised trial of hospitals (clusters) across Africa. Hospitals were eligible if they provided surgery with an overnight postoperative admission. Hospitals were randomly assigned through minimisation in recruitment blocks (1:1) to provide patients with either a package of enhanced postoperative surveillance interventions (admitting the patient to higher care ward, increasing the frequency of postoperative nursing observations, assigning the patient to a bed in view of the nursing station, allowing family members to stay in the ward, and placing a postoperative surveillance guide at the bedside) for those at high risk (ie, with African Surgical Outcomes Study Surgical Risk Calculator scores ≥10) and usual care for those at low risk (intervention group), or for all patients to receive usual postoperative care (control group). Health-care providers and participants were not masked, but data assessors were. The primary outcome was 30-day in-hospital mortality of patients at low and high risk, measured at the participant level. All analyses were done as allocated (by cluster) in all patients with available data. This trial is registered with ClinicalTrials.gov , NCT03853824 . Findings Between May 3, 2019, and July 27, 2020, 594 eligible hospitals indicated a desire to participate across 33 African countries; 332 (56%) were able to recruit participants and were included in analyses. We allocated 160 hospitals (13 275 patients) to provide enhanced postoperative surveillance and 172 hospitals (15 617 patients) to provide standard care. The mean age of participants was 37·1 years (SD 15·5) and 20 039 (69·4%) of 28 892 patients were women. 30-day in-hospital mortality occurred in 169 (1·3%) of 12 970 patients with mortality data in the intervention group and in 193 (1·3%) of 15 242 patients with mortality data in the control group (relative risk 0·96, 95% CI 0·69–1·33; p=0·79). 45 (0·2%) of 22 031 patients at low risk and 309 (5·6%) of 5500 patients at high risk died. No harms associated with either intervention were reported. Interpretation This intervention package did not decrease 30-day in-hospital mortality among surgical patients in Africa at high risk of postoperative morbidity or mortality. Further research is needed to develop interventions that prevent death from surgical complications in resource-limited hospitals across Africa. Funding Bill & Melinda Gates Foundation and the World Federati...