PhD dissertation: Measuring global surgery, obstetrics and anaesthesia – from health systems to patients – University of Copenhagen

Global Health > Open events > Archive 2019 > PhD dissertation: Meas...

Measuring global surgery, obstetrics and anaesthesia – from health systems to patients

PhD dissertation by Hampus Holmer, Faculty of Medicine at Lund University

Date 18 January 2019
Time 13.00
Place Main auditorium, Kulturen in Lund, Tegnérsplatsen 6
Registration Open to all, no RSVP required


Principal supervisor
Associate professor Lars Hagander

Faculty opponent
Professor Ties Boerma

Chair of the defence
Emeritus professor Bengt Jeppsson

ABSTRACT


Background

Worldwide, an estimated 5 billion people lack access to safe, affordable surgical care when needed. This leads to millions of avertable deaths and unnecessary morbidity each year, due to complicated pregnancies, congenital malformations, hernias, fractures, and many other treatable surgical conditions. To change this situation, urgent action is needed at many levels, but indicators and data have been lacking to guide improvement.

Aims

The aim of this thesis was to describe and evaluate measurement of surgical public health, with an emphasis on access, preparedness, and quality of care. Organised according to the Lancet Commission on Global Surgery indicator framework, the thesis specifically aimed to: I. quantify global access to emergency obstetric care; II. describe the global distribution of specialist surgeons, anaesthesiologists and obstetricians; III. measure the rate and mortality of Caesarean sections in Sierra Leone, the country with the world’s highest maternal mortality; IV. to propose a new study design for collecting data on surgical outcomes; V. calculate the cost-effectiveness of surgical care, as exemplified by Ponseti club foot repair, and; VI. critically review the global data collection efforts of the six Lancet global surgery indicators.


Methods

To address these aims, a range of methodologies were employed: I. available reports of national and sub-national data on the met need for emergency obstetric care were collected, reviewed and analysed; II. national data on the number and distribution of the specialist surgical workforce were collected; III. the rate and outcomes of Caesarean sections in Sierra Leone were analysed based on data from facilities and from the national Maternal Death Surveillance and Response system; IV. a protocol for collecting data on perioperative mortality of emergency abdominal surgery was developed; V. the cost effectiveness of club foot repair was analysed, and; VI. data on the six indicators proposed by the Lancet Commission on Global Surgery in 2015 were collected, and indicators analysed and critically reviewed.


Results

The global met need for emergency obstetric care was 45% [interquartile range 28–57%], and the met need was significantly correlated with the proportion of births attended by skilled birth attendants. There were an estimated two million specialist surgeons, obstetricians and anaesthesiologists, of which 20% serve the poorest half of the world. In 2016, the Sierra Leonean Caesarean section rate was 2.9% of all deliveries, with a perioperative mortality rate of 1.5% [median 0.9% and interquartile range 0–2.0%]. A multicentre, international, prospective cohort study protocol for the measurement of perioperative mortality of emergency abdominal surgery was published. Clubfoot repair by the Ponseti method was highly cost-effective, at 22.46 USD per Disability Adjusted Life Year averted. The six indicators proposed by The Lancet Commission on Global Surgery have been implemented to varying degrees, with definitional challenges as well as lack of commitment and structures for data collection.


Significance

Measuring global surgery, obstetrics and anaesthesia – from health systems to patients explores methods of measuring surgical care in the context of a growing recognition of the need to increase access to safe, affordable surgical care around the globe. This research has provided baseline data on several indicators, some of which have been adopted by the WHO and the World Bank. Furthermore, it has critically reviewed the six indicators proposed for global implementation, and made suggestions for further improvement. Good quality indicators are paramount for guiding further efforts in global surgery, obstetrics and anaesthesia, with potential impact for surgical patients, families and societies today and in the future.