title: Rates of caesarean section and total volume of surgery in Sierra Leone: a retrospective survey.
abstract: BACKGROUND
  Surgical services are essential components of health-care systems. Monitoring of surgical activity is important, but resource demanding. Simpler tools to estimate surgical volume, particularly in low-income countries, are needed. Previous work hypothesises that the relative frequency of caesarean sections, expressed as a proportion of total operative procedures, could serve as a proxy measure of surgical capacity. We aimed to establish nationwide and district-wide rates of surgery and caesarean sections, and to explore correlations between districts rates for caesarean sections and corresponding rates for total volume of surgery in Sierra Leone in 2012.
  
  
  METHODS
  A nationwide, exhaustive, retrospective, facility-based study of all surgical providers and surgical procedures was performed in Sierra Leone. Between Jan 14, and May 20, 2013, four teams of 12 medical students collected data on the characteristics of the institutions and of the surgeries performed in 2012. Data were retrieved from operation, anaesthesia, and delivery logbooks.
  
  
  RESULTS
  Of 60 facilities performing surgery, complete annual data for 2012 was collected from 58 (97%) institutions. 24 152 surgical procedures identified, gave a national rate of 400 surgeries per 100 000 inhabitants (district range 32-909 per 100 000 [IQR 95-502 per 100 000]). National caesarean section rate was 2·1% (district range 0·3-4·0% [IQR 0·8-2·1]). District caesarean sections rate significantly correlated with the rate of total surgical procedures per 100 000 population (p<0·01). With known caesarean section rate, total volume of surgeries per 100 000 can be calculated with the equation: -9·8 + 4·68 × caesarean sections per 100 000.
  
  
  CONCLUSIONS
  The close correlation between rate of caesarean section and population rates of total volume of surgery at district level in Sierra Leone indicates that rate of caesarean section should be further explored as a proxy indicator for overall surgical volume in low performing settings. By collecting data from three sources, missing procedures was considered less likely.
  
  
  BACKGROUND
  Norwegian University of Science and Technology.
authors: CapaCare, Trondheim, Norway; Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Surgery, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway. Electronic address: hakon.bolkan@capacare.org.
authors: Håkon A
authors: HA
authors: Bolkan
authors: Department of Public Health Sciences, Health system and Policy, Karolinska Institute, Stockholm, Sweden.
authors: Johan
authors: J
authors: von Schreeb
authors: College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone.
authors: Mohamed M
authors: MM
authors: Samai
authors: Ministry of Health and Sanitation, Freetown, Sierra Leone.
authors: Donald A
authors: DA
authors: Bash-Taqi
authors: College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone; Department of Surgery, Connaught Hospital, Freetown, Sierra Leone.
authors: Thaim B
authors: TB
authors: Kamara
authors: Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
authors: Øyvind
authors: Ø
authors: Salvesen
authors: CapaCare, Trondheim, Norway; Department of Surgery, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
authors: Brynjulf
authors: B
authors: Ystgaard
authors: CapaCare, Trondheim, Norway; Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Surgery, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
authors: Arne
authors: A
authors: Wibe