title: Ratio of cesarean deliveries to total operations and surgeon nationality are potential proxies for surgical capacity in central Haiti.
abstract: BACKGROUND
  The World Health Organization has a standardized tool to assess surgical capacity in low- and middle-income countries (LMICs), but it is often resource- and time-intensive. There currently exists no simple, evidence-based measure of surgical capacity in these settings. The proportion of cesarean deliveries in regard to the total operations (C/O ratio) has been suggested as a way to assess quickly the capacity for emergency and essential surgery in LMICs. This ratio has been estimated to be between 23.3 and 41.5 % in LMICs, but the tool's utility has not been replicated.
  
  
  METHODS
  We reviewed operative logbooks for the Partners In Health/Zanmi Lasante hospital in Cange, Haiti. We recorded data on all consecutive surgical patients from July 2008 to 2010 and calculated the C/O ratio by dividing the number of cesarean deliveries by the total number of operations performed. We also analyzed surgical data by surgeon nationality to provide additional information about local surgical capacity.
  
  
  RESULTS
  A total of 3,641 operations were performed between 2008 and 2010. The C/O ratio decreased significantly between 2008-2009 and 2009-2010 (13.4 vs. 10.7 %, p = 0.001) as the surgical volume and resources increased. Nationality analysis demonstrated that Haitian surgeons were able to provide a spectrum of general and specialist surgical care.
  
  
  CONCLUSIONS
  In its inherent relation to essential surgical procedures and to the overall rate of cesarean deliveries in the region, the C/O ratio can provide an accessible assessment of regional surgical resources. In Haiti, the change in the C/O ratio demonstrated a relative increase in surgical capacity from 2008 to 2010. An additional analysis of surgeon nationality ensured that C/O ratio estimates more accurately reflect local practitioner activity, but deficiencies in the regional capacity to address the local burden of surgical disease may still exist.
authors.affiliation: Department of Plastic and Oral Surgery, Children's Hospital Boston, 300 Longwood Avenue, Enders 1, Boston, MA 02115, USA. chughes414@gmail.com
authors.forename: Christopher D
authors.initials: CD
authors.lastname: Hughes
authors.forename: Craig D
authors.initials: CD
authors.lastname: McClain
authors.forename: Lars
authors.initials: L
authors.lastname: Hagander
authors.forename: Jean Hamiltong
authors.initials: JH
authors.lastname: Pierre
authors.forename: Reinou S
authors.initials: RS
authors.lastname: Groen
authors.forename: Adam L
authors.initials: AL
authors.lastname: Kushner
authors.forename: John G
authors.initials: JG
authors.lastname: Meara
mesh_terms: D002585:Cesarean Section / Q000706:statistics & numerical data*; D003906:Developing Countries; D005260:Female; D005550:Foreign Medical Graduates / Q000706:statistics & numerical data / Q000600:supply & distribution*; D013502:General Surgery; D006205:Haiti; D006295:Health Resources / Q000458:organization & administration / Q000706:statistics & numerical data* / Q000600:supply & distribution; D006801:Humans; D011247:Pregnancy; D013043:Specialties, Surgical; D013514:Surgical Procedures, Operative / Q000706:statistics & numerical data; D000078329:Workforce