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

Background
Worldwide, an estimated 5 billion people lack access to safe, affordable surgical care when needed. This leads to millions of deaths and avertable morbidity each year, due to complicated pregnancies, congenital malformations, hernias, open fractures, and many other treatable surgical conditions. Yet, data and credible metrics have been lacking to guide improvement.

Aim
Based on the indicator framework of the Lancet Commission on Global Surgery, 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. Specifically, the thesis aims to quantify global unrealized access to emergency obstetric care (I); the global distribution of specialist surgeons, anaesthesiologists and obstetricians (II); the volume and perioperative mortality of caesarean sections in Sierra Leone, a country with the world’s highest maternal mortality (III); to propose a new methodology for collecting data on surgical outcomes (IV); to examine the cost-effectiveness of surgical care, as exemplified by Ponseti club foot repair (V); and to critically review the global data collection efforts of the six Lancet global surgery indicators (VI).

Method
National and sub-national data were collected, reviewed and analysed on emergency obstetric care (I), and the number and distribution of the specialist surgical workforce (II). Outcomes of caesarean sections in Sierra Leone were analysed based on data from facilities and from the national Maternal Death Surveillance and Response system (III); a protocol for collecting data on perioperative mortality of emergency abdominal surgery was developed (IV); cost effectiveness analysis was carried out for club foot repair (V); and data on the six indicators proposed by the Lancet Commission on Global Surgery in 2015 were analysed and critically reviewed (VI).

Results
The global met need for emergency obstetric care was 45% [interquartile range 28–57%], and the met need is significantly correlated with GDP and the proportion of births attended by skilled birth attendants (I). There were an estimated two million specialist surgeons, obstetricians and anaesthesiologists, of which only 20% serve the poorest half of the world (II). 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%] (III). A multicentre, international, prospective cohort study protocol for the measurement of perioperative mortality of emergency abdominal surgery was published (IV). The cost effectiveness ratio for clubfoot repair by the Ponseti method was 22.46 USD per averted Disability Adjusted Life Year (V). 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 (VI).

Significance
High quality indicators are paramount for planning and tracking progress towards increased access to safe, affordable and timely surgical, obstetric and anaesthesia care when needed. This research has contributed to better understanding of the met need for Emergency Obstetric Care, and it has led to the inclusion of surgical workforce in the WHO 100 Core Health Indicators, the World Bank World Development Indicators, and in the Sustainable Development Goals target 3.8.1. The studies have helped guide the development of indicators for global surgery, with potential impact for surgical patients, families and societies today and in the future.