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

  • BMC Pregnancy and Childbirth, Volume 17, No. 1, Year 2017

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Study Justification:
– Despite advances in surgery and anesthesia, many health facilities in low-income countries are under-resourced and unable to effectively manage obstetric complications.
– This study aimed to assess the factors contributing to maternal mortality related to anesthesia in Uganda and the magnitude of these issues.
– The study aimed to identify the specific deficiencies in anesthesia services and provide recommendations for improvement.
Highlights:
– The study surveyed 64 hospitals in Uganda, including regional referral, district, private for-profit, and private not-for-profit hospitals.
– Only 5% of the hospitals had all the requirements to meet international guidelines for safe obstetric anesthesia.
– 84% of the hospitals did not have a trained physician anesthetist, and 8% had no trained providers for anesthesia at all.
– Shortages of essential drugs and outdated anesthesia machines were common.
– Continuous ECG was available in only 5% of hospitals.
– The study concludes that there is a significant lack of essential equipment and trained providers for safe anesthesia in Uganda.
Recommendations:
– Strengthen anesthesia services by addressing deficiencies in equipment and staffing.
– Improve training of associate clinicians and increase the number of physician anesthetists.
– Provide the basic equipment required for safe and effective care.
– These improvements are crucial for comprehensive emergency obstetric care and managing critically ill mothers.
Key Role Players:
– Ministry of Health: Responsible for policy-making and resource allocation.
– Hospital Directors: Responsible for implementing changes and ensuring adequate resources.
– Anesthesia Associations and Professional Societies: Provide guidance and support for training and standards.
– Training Institutions: Responsible for training and education of anesthesia providers.
Cost Items for Planning Recommendations:
– Training Programs: Budget for training more physician anesthetists and associate clinicians.
– Equipment Procurement: Budget for purchasing essential equipment, such as anesthesia machines, monitors, and drugs.
– Infrastructure Upgrades: Budget for improving operating and recovery rooms to meet international guidelines.
– Continuous Monitoring: Budget for implementing continuous ECG and other monitoring systems.
– Drug Supply: Budget for ensuring a consistent supply of essential drugs for anesthesia.
Please note that the cost items provided are general categories and not actual cost estimates.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on a cross-sectional survey conducted in Uganda, which included a total of 64 hospitals. The survey used pre-set questionnaires and checklists to gather data from anaesthetists and hospital directors. The response rate was 100%, and the study found that only 5% of the hospitals had all the requirements for safe obstetric anaesthesia according to international guidelines. The study also identified shortages of trained providers, essential drugs, and outdated equipment. The conclusion suggests actionable steps to improve the situation, such as strengthening anaesthesia services, improving training, and providing necessary equipment. However, the abstract does not provide specific details about the methodology used in data analysis, which could be improved.

Background: Despite 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. Methods: We 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. Results: Response 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. Conclusion: We 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.

This was a cross-sectional survey conducted in Uganda from September 2014 to August 2015. A total of 64 hospitals across Uganda were selected based on the criteria that they provided obstetric anaesthesia. At least 15 hospitals from each region; East, West, North and Central were included for representativeness. This study was part of a larger comprehensive survey of the emergency and anaesthesia services in Uganda conducted during the corresponding authors’ National Institutes of Health (NIH) funded fellowship in Global Health where peri-operative data was collected following the World Federation of Societies’ of Anaesthesiologists (WFSA) international guidelines for safe anaesthesia. A survey tool to evaluate compliance was developed based on WFSA Guidelines and the WHO Safe surgery checklist. Additionally we evaluated demographic data on staffing, availability of equipment, monitors, and drugs. These included pre-operative assessment of patients, staffing and continuous monitoring intra-operatively and post-operatively. In this report we have included the peri-operative components of staffing, availability of equipment, monitors, and drugs recommended for safe anaesthesia by the WFSA. We purposefully selected all the 12 regional referral hospitals because these are level 3 centres and the lower health centres usually refer patients here for surgery. We also randomly selected hospitals from the other groups to include general (government district hospitals), private for profit and private not for profit hospitals. The survey tool comprised of 3 components, the first was an interviewer-administered questionnaire to one Anaesthetist available at each hospital with the aim of understanding the quality of anaesthesia care. The second was a checklist to objectively assess the obstetric theatres. The third was another interviewer-administered questionnaire with the Directors of the hospital in order to document other challenges faced in delivery of anaesthesia care at the government and private hospitals. Data on caesarean sections and anaesthetists countrywide was obtained from the ministry of health. With the help of the statistician, data was subsequently cleaned and, coded, into Epidata version 3.1. Range, consistency and validity checks were built in to minimize errors. Data was exported and analyzed using STATA version 14 (Statcorp, College Station, Texas, USA). We dichotomised according to drugs and 15 facility variables available in theatre and postoperative recovery areas including functional anaesthesia machine, oxygen source, reservoir oxygen source, continuous Blood Pressure, Continuous ECG, and Continuous pulse oximetry, suction machine, laryngoscope, Endotracheal tubes (ETT), Face Masks and Laryngeal Mask Airways (LMA), Stethoscope, Difficult Airway Cart, Defibrillator, Capnograph and availability of ICU facilities for post-operative care of complicated cases. Ethical approval was obtained from Makerere University School of Medicine Research and Ethics Committee (SOMREC), the appropriate hospital ethics committees for participating hospitals, and the Uganda National Council for Science and Technology Ethics Committee. Informed consent was obtained from all individuals participating in the study.

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Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Training programs for associate clinicians: Implementing training programs to enhance the skills and knowledge of associate clinicians in providing safe obstetric anesthesia. This would help address the shortage of trained providers and improve the quality of care.

2. Training more physician anaesthetists: Increasing the number of physician anaesthetists through targeted training programs. This would help address the shortage of trained providers and ensure that there are enough skilled professionals to manage critically ill mothers during childbirth.

3. Providing essential equipment: Ensuring that hospitals have the necessary equipment for safe obstetric anesthesia, such as functional anaesthesia machines with safety alarms and mechanical ventilators. This would help improve the quality of care and reduce the risk of complications during childbirth.

4. Addressing drug shortages: Developing strategies to address frequent shortages of drugs, particularly those needed for regional/neuroaxial anesthesia. This could involve improving supply chain management, increasing local production, or exploring alternative drug options.

5. Strengthening supervision: Implementing systems for adequate supervision of anesthesia services to ensure that protocols and guidelines are followed, and quality of care is maintained. This could involve regular monitoring and evaluation of anesthesia practices and providing feedback to healthcare providers.

6. Improving access to monitoring equipment: Increasing the availability of essential monitoring equipment, such as continuous ECG, continuous blood pressure, and continuous pulse oximetry. This would help healthcare providers monitor patients more effectively during childbirth and detect any complications early on.

7. Collaboration and partnerships: Encouraging collaboration and partnerships between government, private, and not-for-profit hospitals to share resources, expertise, and best practices. This could help improve access to maternal health services and enhance the overall quality of care.

These innovations, if implemented effectively, could help address the key bottlenecks identified in the study and improve access to safe obstetric anesthesia in low-income countries like Uganda.
AI Innovations Description
Based on the description provided, the key recommendation to improve access to maternal health is to strengthen anaesthesia services by addressing specific deficiencies. This includes:

1. Improved training of associate clinicians: There is a shortage of trained providers for anaesthesia in many hospitals. By providing training to associate clinicians, they can be equipped with the necessary skills to assist in anaesthesia procedures, thereby increasing the availability of anaesthesia services.

2. Training more physician anaesthetists: Only a small percentage of hospitals surveyed had a trained physician anaesthetist. Increasing the number of physician anaesthetists through training programs can help ensure that there are qualified professionals available to provide safe and effective anaesthesia care.

3. Providing basic equipment required for safe and effective care: Many hospitals lacked essential equipment for safe anaesthesia, such as functional anaesthesia machines, safety alarms, mechanical ventilators, and continuous ECG monitors. It is crucial to provide these basic equipment to ensure the delivery of safe anaesthesia services.

By implementing these recommendations, access to maternal health can be improved by ensuring that adequate and safe anaesthesia services are available in low-income countries like Uganda.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthening anaesthesia services: Address the deficiencies in essential equipment, such as outdated anaesthesia machines without safety alarms and mechanical ventilators. Ensure the availability of necessary drugs, including regional/neuroaxial anaesthesia drugs, antacids, and antihypertensives. Improve training for associate clinicians and increase the number of physician anaesthetists.

2. Enhancing supervision: Provide adequate supervision to ensure safe and effective care during obstetric anaesthesia. This can help address the shortage of trained providers and improve surgical outcomes.

3. Comprehensive emergency obstetric care: Recognize that anaesthetists play a crucial role in managing critically ill mothers and ensuring good surgical outcomes. Strengthening anaesthesia services is an essential component of comprehensive emergency obstetric care.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify specific indicators that can measure the impact of the recommendations, such as the availability of essential equipment, the number of trained providers, and the quality of care during obstetric anaesthesia.

2. Collect baseline data: Gather data on the current state of access to maternal health, including the availability of equipment, the number of trained providers, and the quality of care. This can be done through surveys, interviews, and data collection from hospitals and healthcare facilities.

3. Implement the recommendations: Introduce the recommended interventions, such as strengthening anaesthesia services, enhancing supervision, and promoting comprehensive emergency obstetric care.

4. Monitor and evaluate: Continuously monitor the implementation of the recommendations and collect data on the indicators identified in step 1. This can involve regular surveys, interviews, and data collection from hospitals and healthcare facilities.

5. Analyze the data: Use statistical analysis to assess the impact of the recommendations on improving access to maternal health. Compare the baseline data with the data collected after the implementation of the recommendations to identify any changes or improvements.

6. Draw conclusions and make recommendations: Based on the analysis of the data, draw conclusions about the impact of the recommendations on improving access to maternal health. Identify any gaps or areas for further improvement and make recommendations for future interventions.

7. Communicate the findings: Share the findings of the simulation study with relevant stakeholders, such as healthcare providers, policymakers, and organizations working in maternal health. This can help inform decision-making and guide future efforts to improve access to maternal health.


Statistics:
Citations: 17
Identifiers:
DOI: 10.1186/s12884-017-1566-3
Research Areas:
Health System and Policy, Maternal and Child Health, Noncommunicable Diseases, Quality of Care, Social Determinants, Technology and Innovations
Study Countries:
Multi-Countries, Uganda
Study Design:
Cross Sectional Study
Study Approach:
Quantitative
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