BackgroundThe burden of disease, disability, and mortality that could be averted by surgery is growing. However, few low and middle income countries (LMICs) have the infrastructure or capacity to provide surgical services to meet this growing need. Equally, few of these countries have been assessed for key infrastructural capacity including surgical and anesthesia providers, equipment, and supplies. These assessments are critical to revealing magnitude of the evolving surgical and anesthesia workforce crisis, related morbidity and mortality, and necessary steps to mitigate the impact of the crisis.MethodsA pilot Internet-based survey was conducted to estimate per-capita anesthesia providers in LMICs. Information was obtained from e-mail respondents at national health care addresses, and from individuals working in-country on anesthesia-related projects.ResultsWorkers from 6 of 98 countries responded to direct e-mail inquiries, and an additional five responses came from individuals who were working or had worked in-country at the time of the survey. The data collected revealed that the per-capita anesthesia provider ratio in the countries surveyed was often 100 times lower than in developed countries.ConclusionsThis pilot study revealed that the number of anesthesia providers available per capita of population is markedly reduced in low and lower middle income countries compared to developed countries. As anesthesia providers are an integral part of the delivery of safe and effective surgical care, it is essential that more data is collected to fully understand the deficiencies in workforce and capacity in low and middle income countries.

BACKGROUND: Placenta accreta spectrum is well known for its association with catastrophic maternal outcomes. However, its pathophysiology is not well defined. There have been emerging data that in vitro fertilization may be a risk factor for placenta accreta spectrum. OBJECTIVE: We investigated the hypothesis that in vitro fertilization is an independent risk factor for placenta accreta spectrum. STUDY DESIGN: A retrospective analysis of all deliveries in a prospective, population-based cohort (2012e2019) was performed in a tertiary academic center. Primary outcome variable was placenta accreta spectrum. Univariate analysis was performed on potential risk factors for predicting placenta accreta spectrum, and a multivariate model was designed to best fit the prediction of placenta accreta spectrum adjusted for risk factors such as cesarean delivery, placenta previa, age, and parity. History of previous cesarean delivery was known as a risk factor for both placenta previa and placenta accreta spectrum; hence, the interaction between "placenta previa" and "previous cesarean delivery" was included in the final model. Odds ratios were calculated as exponential of beta coefficients from the multivariate regression analysis. RESULTS: A total of 37,461 deliveries were included in this analysis, 5464 (15%) of which had a history of cesarean delivery, 281 (0.7%) had placenta previa in their index pregnancy, and 571 (1.5%) had in vitro fertilization pregnancy. The frequency of placenta accreta spectrum was 230 (0.6%). Independent risk factors for placenta accreta spectrum were in vitro fertilization pregnancy (adjusted odds ratio, 8.7; 95% confidence interval, 3.8e20.3), history of previous cesarean delivery (adjusted odds ratio, 21.1; 95% confidence interval, 11.4e39.2), and presence of placenta previa (adjusted odds ratio, 94.6; 95% confidence interval, 29.3e305.1). After adjustment for number of previous cesarean deliveries, the correlation persisted for in vitro fertilization (adjusted odds ratio, 6.7; 95% confidence interval, 2.9e15.6). CONCLUSION: Our data suggested that in vitro fertilization is an independent risk factor for placenta accreta spectrum, although its relative clinical importance compared with that of the presence of placenta previa and history of cesarean delivery is small. The pathophysiology behind this relationship remains to be investigated.

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W hile the US Food and Drug Administration has issued a warning about the neurodevelopmental effects of anesthetic drugs in the third trimester of pregnancy and children under the age of 3, no clinical study has evaluated long-term neurodevelopmental outcomes following prenatal exposure to anesthetics. Since anesthetic drugs cross the placenta and the brain is particularly vulnerable in the prenatal period, it is plausible that prenatal anesthetic exposure could lead to adverse neurodevelopmental effects. This study examined the effects of prenatal exposure to general anesthetic agents and neuropsychological and behavioral survey scores at age 10.Data for this study was sourced from the Raine Study cohort, which consists of mothers and their children born in Western Australia between 1989 and 1992. The data includes detailed medical records, self-reported data, assessments for medical illness in the second generation throughout childhood, and comprehensive neuropsychological testing of the children at age 10. Maternal exposure to general anesthesia during pregnancy was determined using surveys from ∼18 to 34 weeks' gestation. Study authors determined the likelihood of mothers receiving anesthesia based on their response and knowledge of clinical practices in Western Australia at the time, and categorized potential exposure as likely general anesthetic, likely intravenous sedation, or unlikely to have required a general anesthetic or intravenous sedation. Neurodevelopmental outcomes were assessed using the Symbol Digit Modality Test (SDMT), the Raven's Colored Progressive Matrices (CPM), the McCarron Assessment of Neuromuscular Development (MAND), the Clinical Evaluation of Language Fundamentals receptive language, expressive language, and total language scores (CELF-R, CELF-E, and CELF-T), the Peabody Picture Vocabulary Test (PPVT), and Child Behavior Checklist (CBCL). Multivariable linear regression models compared the outcomes of exposed children to unexposed children, adjusting for demographic and clinical factors.Outcome data was available for 2024 children, 22 (1.1%) of whom were exposed to general anesthesia during the prenatal period. Of the 11 scores over 6 tests, only one score was significantly different among the 2 groups. The CBCL Externalizing behavioral scores were higher in children with prenatal exposure to general anesthesia compared with unexposed children (score difference 6.1; 99.17% confidence interval, 0.2-12.0; P = 0.006). Clinical threshold analysis found 36.4% of prenatally exposed children crossed the clinical threshold for deficit in CBCL Externalizing scores, compared with 10.5% of unexposed children. The adjusted increased risk for clinical deficit in externalizing behavioral scores in prenatally exposed children was 4.6 (99.17% confidence interval, 1.3-16.0; P = 0.001). Both groups of children had similar rates of health care utilization in their first 10 years. The majority of prenatal general anesthesia exposure occurred in the first trimester.At age 10, children who had been expos...