title: An Analysis of Cesarean Section and Emergency Hernia Ratios as Markers of Surgical Capacity in Low-Income Countries Affected by Humanitarian Emergencies from 2008 - 2014 at Médecins sans Frontières Operations Centre Brussels Projects.
abstract: BACKGROUND
  Surgical capacity assessments in low-income countries have demonstrated critical deficiencies. Though vital for planning capacity improvements, these assessments are resource intensive and impractical during the planning phase of a humanitarian crisis. This study aimed to determine cesarean sections to total operations performed (CSR) and emergency herniorrhaphies to all herniorrhaphies performed (EHR) ratios from Médecins Sans Frontières Operations Centre Brussels (MSF-OCB) projects and examine if these established metrics are useful proxies for surgical capacity in low-income countries affected by crisis.
  
  
  METHODS
  All procedures performed in MSF-OCB operating theatres from July 2008 through June 2014 were reviewed. Projects providing only specialty care, not fully operational or not offering elective surgeries were excluded. Annual CSRs and EHRs were calculated for each project. Their relationship was assessed with linear regression.
  
  
  RESULTS
  After applying the exclusion criteria, there were 47,472 cases performed at 13 sites in 8 countries. There were 13,939 CS performed (29% of total cases). Of the 4,632 herniorrhaphies performed (10% of total cases), 30% were emergency procedures. CSRs ranged from 0.06 to 0.65 and EHRs ranged from 0.03 to 1.0. Linear regression of annual ratios at each project did not demonstrate statistical evidence for the CSR to predict EHR [F(2,30)=2.34, p=0.11, R2=0.11]. The regression equation was: EHR = 0.25 + 0.52(CSR) + 0.10(reason for MSF-OCB assistance).
  
  
  CONCLUSIONS
  Surgical humanitarian assistance projects operate in areas with critical surgical capacity deficiencies that are further disrupted by crisis. Rapid, accurate assessments of surgical capacity are necessary to plan cost- and clinically-effective humanitarian responses to baseline and acute unmet surgical needs in LICs affected by crisis. Though CSR and EHR may meet these criteria in 'steady-state' healthcare systems, they may not be useful during humanitarian emergencies. Further study of the relationship between direct surgical capacity improvements and these ratios is necessary to document their role in humanitarian settings.
authors.affiliation: Department of Surgery, University of Washington, Seattle, Washington, USA.
authors.forename: Barclay
authors.initials: B
authors.lastname: Stewart
authors.affiliation: Centre for Global Surgery, McGill University Health Centre, Montreal, Quebec, Canada; Surgeons OverSeas (SOS), New York, New York, USA.
authors.forename: Evan
authors.initials: E
authors.lastname: Wong
authors.affiliation: Department of Obstetrics and Gynecology, McGill University, Montreal, Quebec, Canada.
authors.forename: Jessica
authors.initials: J
authors.lastname: Papillon-Smith
authors.affiliation: Surgery, Anesthesia, Gynecology, and Emergency Medicine Unit, Médecins Sans Frontières, Brussels, Belgium.
authors.forename: Miguel Antonio
authors.initials: MA
authors.lastname: Trelles Centurion
authors.affiliation: Surgery, Anesthesia, Gynecology, and Emergency Medicine Unit, Médecins Sans Frontières, Brussels, Belgium.
authors.forename: Lynette
authors.initials: L
authors.lastname: Dominguez
authors.affiliation: Surgery, Anesthesia, Gynecology, and Emergency Medicine Unit, Médecins Sans Frontières, Brussels, Belgium; Mon General Hospital, Mon, Nagaland, India.
authors.forename: Supongmeren
authors.initials: S
authors.lastname: Ao
authors.affiliation: Surgery, Anesthesia, Gynecology, and Emergency Medicine Unit, Médecins Sans Frontières, Brussels, Belgium; Referral General Hospital of Masisi, Masisi, Democratic Republic of the Congo.
authors.forename: Basimuoneye Kahutsi
authors.initials: BK
authors.lastname: Jean-Paul
authors.affiliation: Surgery, Anesthesia, Gynecology, and Emergency Medicine Unit, Médecins Sans Frontières, Brussels, Belgium; Timurgara DHQ Hospital, Timurgara, Pakistan.
authors.forename: Mustafa
authors.initials: M
authors.lastname: Kamal
authors.affiliation: Surgery, Anesthesia, Gynecology, and Emergency Medicine Unit, Médecins Sans Frontières, Brussels, Belgium; Ahmad Shah Baba General Hospital, Kabul, Afghanistan.
authors.forename: Rahmatullah
authors.initials: R
authors.lastname: Helmand
authors.affiliation: Surgery, Anesthesia, Gynecology, and Emergency Medicine Unit, Médecins Sans Frontières, Brussels, Belgium; Dargai DHQ Hospital, Dargai, Pakistan.
authors.forename: Aamer
authors.initials: A
authors.lastname: Naseer
authors.affiliation: Surgeons OverSeas (SOS), New York, New York, USA; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Department of Surgery, Columbia University, New York, New York, USA.
authors.forename: Adam L
authors.initials: AL
authors.lastname: Kushner