Despite surgery patients in Africa being younger, with a lower risk, having minor surgery, and having fewer complications, their risk of death is double the global average (2.1% vs 1% of patients die), according to the most comprehensive study of surgery in Africa published in The Lancet.
The observational study, which was conducted by a group of more than 30 African researchers and includes 247 hospitals in 25 African countries, suggests that scarce workforce and resources mean surgery is less safe across the region. To improve these outcomes it calls for improved monitoring of patients during and soon after their surgery.
Surgery is a cost-effective and important component of universal healthcare, however, it is estimated that five billion people worldwide are unable to access safe surgical treatment, and 94% of these people live in low- and middle-income countries.
“Approximately one in five surgery patients in our African cohort developed a complication, and, overall, 2% of all patients died,” says lead author Professor Bruce Biccard, Groote Schuur Hospital and the University of Cape Town, South Africa.
“Our study reveals the scarce workforce resources available to provide safe surgical treatment. Although increased access to surgery is important, it is essential that these surgical treatments are safe and effective. Importantly, 95% of deaths in our study occurred in the postoperative period, suggesting that many lives could be saved by effective monitoring of patients who have developed complications and increasing the resources necessary to achieve this objective. Surgical outcomes will remain poor in Africa until the problem of under-resourcing is addressed.”
The study includes data from 11422 people who underwent an inpatient surgical procedure during a set week at each of the 247 hospitals included across 25 African countries. Data on complications were missing for 537 people and data on mortality were missing for 229 people.
As well as documenting each patient’s health before surgery, the study monitored their health after the surgery, tracking any complications, admission to critical care, or deaths. The study also reviewed hospital resources, such as numbers of beds, operating rooms, critical care beds, anesthetists, surgeons, and obstetricians.
Overall, most patients (87.3%) had a good physical status and were low-risk for surgery, and were young (average age of 38.5 years). The majority of surgeries in the study were urgent or emergent (57.1% of surgeries) and the most common procedure was the caesarean section (33.3% of all surgeries).
Complications following surgery occurred in 18.2% of all patients (1977/10885 people), and the most common complications were infections, accounting for 58.7% of all complications (1156/1970). Around 16.3% of patients (321/1972 people) were admitted to critical care to treat complications. One in ten patients with complications died (9.5%, 188/1970 people), and these deaths were spread equally across infectious (112 deaths), cardiovascular (110 deaths) and other complications (112 deaths).
Overall, 2.1% of patients died after surgery (239/11193), which is double the global rate of 1%. Of these, 14 people (5.9%) died on the day of their surgery, and the average time to death was five days. With most deaths occurring in the days following surgery, the authors note that it is likely that these deaths are preventable, and that the safety of surgery may be improved through increased monitoring of patients on the ward.
However, resources are scant, with each hospital included in the study serving an average population of 810000 people, with an average of 300 beds, four operating rooms, and three critical care beds.
Having few specialists and low procedural volumes also contributes to the low safety of surgery across African countries. Typically, each hospital completed 29 surgeries in a week, equivalent to 212 operations per 100000 people. The authors note that this is low, and indicates that services are not meeting the need.
Overall, there were 0.7 specialists (a combined total of surgeons, obstetricians, and anesthesiologists) to every 100000 people in the hospital population, which the authors note is well below the recommended levels of 20-40 specialists per 100000 patients needed to reduce mortality. On average, each hospital had three specialist surgeons, one specialist anesthetist and two specialist obstetricians.
The study furthers the work of The Lancet Commission on Global Surgery which was published in 2015 and called for robust data on surgical activity and patient outcomes. The Commission states that structures, processes, and outcomes are important parts to improve the quality of surgery worldwide.
“Our study highlights the importance of effective perioperative care to achieve better surgical outcomes in Africa. A continent-wide quality improvement programme might reduce the number of preventable deaths following surgery in Africa,” adds Professor Biccard.
The authors note some limitations, including that the study does not include data for all African countries, including many low-income countries, or for smaller, more remote hospitals, and so the findings might not be applicable for detailed health policy decisions in individual countries or hospitals.
Additionally, the week-long period of data collection means that wider changes, which may influence health care access – such as seasonal weather, industrial action, available workforce, armed conflict, workload, and when people choose to access healthcare – may not be accounted for.
