title: Variability in mortality after caesarean delivery, appendectomy, and groin hernia repair in low-income and middle-income countries: implications for expanding surgical services.
abstract: BACKGROUND
  While surgical interventions occur at lower rates in resource-poor settings, rates of complication and death after surgery are substantial but have not been well quantified. A deeper understanding of outcomes is a crucial step to ensure that quality accompanies increased global access to surgical care. We aimed to assess mortality following surgery to assess the risks of such interventions in these environments.
  
  
  METHODS
  We collected the most recent demographic, health, and economic data from WHO for 114 countries classified as low-income or lower-middle-income according to the World Bank in 2005. We searched OVID, MedLine, PubMed, and SCOPUS to identify studies in these countries reporting all-cause mortality after three commonly performed operations: caesarean delivery, appendectomy, and groin hernia repair. Reports from governmental and other agencies were also identified. We modelled surgical mortality rates for countries without reported data with the lasso technique that performs continuous variable subset selection to avoid model overfitting. We validated our model against known case fatality rates for caesarean delivery. We aggregated mortality results by subregion to account for variability in data availability. We then created collective surgical case fatality rates by WHO region.
  
  
  RESULTS
  We identified 42 countries with mortality data for at least one of the three procedures. Median reported mortality rates were 7·7 per 1000 operations for caesarean delivery (IQR 3-14), 4·0 per 1000 operations for appendectomy (IQR 0-17), and 4·7 per 1000 operations for hernia groin (IQR 0-13); all recorded deaths occurred during the same admission to hospital as the operation. Based on our model, case fatality rate estimates by subregion ranged from 0·7 (central Europe) to 13·9 (central sub-Saharan Africa) per 1000 caesarean deliveries, 5·6 (central Asia) to 6·4 (central sub-Saharan Africa) per 1000 appendectomies, and 3·5 (tropical Latin America) to 33·9 (central sub-Saharan Africa) per 1000 hernia repairs.
  
  
  CONCLUSIONS
  All-cause postoperative mortality rates are exceedingly variable within resource-constrained environments, and substantially higher than those in middle-income and high-income settings. Efforts to expand surgical access and provision of services must include a strong commitment to improve the safety and quality of care.
  
  
  BACKGROUND
  None.
authors: Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: tweiser@stanford.edu.
authors: Thomas G
authors: TG
authors: Weiser
authors: Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
authors: Tarsicio
authors: T
authors: Uribe-Leitz
authors: Management Science and Engineering, Stanford University, Stanford, CA, USA.
authors: Rui
authors: R
authors: Fu
authors: Stanford University School of Medicine, Stanford, CA, USA.
authors: Joshua
authors: J
authors: Jaramillo
authors: Stanford University School of Medicine, Stanford, CA, USA.
authors: Lydia
authors: L
authors: Maurer
authors: Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
authors: Micaela M
authors: MM
authors: Esquivel
authors: Ariadne Labs, Boston, MA, USA; Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
authors: Atul A
authors: AA
authors: Gawande
authors: Ariadne Labs, Boston, MA, USA; Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Surgery, Massachussetts General Hospital, Boston, MA, USA.
authors: Alex B
authors: AB
authors: Haynes