Key bottlenecks to the provision of safe obstetric anaesthesia in low- income countries; a cross-sectional survey of 64 hospitals in Uganda

Abstract

BackgroundDespite recent advances in surgery and anaesthesia which significantly improve safety, many health facilities in low-and middle-income countries (LMICs) remain chronically under-resourced with inability to cope effectively with serious obstetric complications (Knight et al., PLoS One 8:e63846, 2013). As a result many of these countries still have unacceptably high maternal and neonatal mortality rates. Recent data at the national referral hospitals in East Africa reported that none of the national referral hospitals met the World Federation of Societies of Anesthesiologists (WFSA) international standards required to provide safe obstetric anaesthesia (Epiu I: Challenges of Anesthesia in Low-and Middle-Income Countries. WFSA; 2014 http://wfsa.newsweaver.com/Newsletter/p8c8ta4ri7a1wsacct9y3u?a=2&p=47730565&t=27996496). In spite of this evidence, factors contributing to maternal mortality related to anaesthesia in LMICs and the magnitude of these issues have not been comprehensively studied. We therefore set out to assess regional referral, district, private for profit and private not-for profit hospitals in Uganda.MethodsWe conducted a cross-sectional survey at 64 government and private hospitals in Uganda using pre-set questionnaires to the anaesthetists and hospital directors. Access to the minimum requirements for safe obstetric anaesthesia according to WFSA guidelines were also checked using a checklist for operating and recovery rooms.ResultsResponse rate was 100% following personal interviews of anaesthetists, and hospital directors. Only 3 of the 64 (5%) of the hospitals had all requirements available to meet the WFSA International guidelines for safe anaesthesia. Additionally, 54/64 (84%) did not have a trained physician anaesthetist and 5/64 (8%) had no trained providers for anaesthesia at all. Frequent shortages of drugs were reported for regional/neuroaxial anaesthesia, and other essential drugs were often lacking such as antacids and antihypertensives. We noted that many of the anaesthesia machines present were obsolete models without functional safety alarms and/or mechanical ventilators. Continuous ECG was only available in 3/64 (5%) of hospitals.ConclusionWe conclude that there is a significant lack of essential equipment for the delivery of safe anaesthesia across this region. This is compounded by the shortage of trained providers and inadequate supervision. It is therefore essential to strengthen anaesthesia services by addressing these specific deficiencies. This will include improved training of associate clinicians, training more physician anaesthetists and providing the basic equipment required to provide safe and effective care. These services are key components of comprehensive emergency obstetric care and anaesthetists are crucial in managing critically ill mothers and ensuring good surgical outcomes.

Benefits and Barriers to Increasing Regional Anesthesia in Resource-Limited Settings

“…The deficits in anesthesia infrastructure, equipment, and drugs that severely limit anesthesia capacity in most low-resource countries have been well documented in multiple studies. 1 – 4 , 43 , 56 , 57 Few hospitals in LMICs can reliably satisfy even the minimum monitoring, medication, and equipment for safe anesthetic practice recommended by the WHO and WFSA in their international guidelines. 58 This is especially a problem in Sub-Saharan African district-level hospitals where essential surgical services are meant to be provided for the predominantly rural population.…”

Mixed methods analysis of factors influencing change in clinical behaviours of non‐physician anaesthetists in Kenya following obstetric anaesthesia training

“…The course was delivered to mainly non‐physician clinical officer anaesthetists working in rural areas, who form the backbone of the anaesthesia workforce in Kenya. Lack of quality training, supervision and CME for non‐physician providers is known to contribute to professional isolation , unsafe practices, high anaesthesia‐related mortality and provider burnout; this highlights the importance of courses such as SAFE in this context .…”

“…The main contributors to anaesthesia‐related deaths included: airway complications; aspiration of gastric contents; inadequate staff training; poor pre‐operative evaluation; lack of intra‐operative monitoring; and equipment failure . The quality of existing anaesthesia training, low number of educators and limited opportunities for continuous medical education (CME) to maintain knowledge and skills are significant barriers to the provision of quality anaesthesia services . In Kenya, the density of physician anaesthesia providers per 100,000 population is 0.44 (compared with 18 per 100,000 in the UK), and most doctors work only in the urban areas .…”

Health and sustainable development; strengthening peri-operative care in low income countries to improve maternal and neonatal outcomes

“…As published in by Epiu et al** survey tool to evaluate compliance to the World Federation of Societies’ of Anaesthesiologists (WFSA) international guidelines for safe anaesthesia was developed [ 19 ]. These included quantitative and qualitative data on pre-operative assessment of patients, staffing and continuous monitoring intra-operatively and post-operatively.…”