title: Inequitable Access to Timely Cleft Palate Surgery in Low- and Middle-Income Countries.
abstract: BACKGROUND
  Delayed cleft palate repair has significant implications for physical, mental, and social well-being and has been suggested to lead to an increased risk of infant and under-five mortality in low- and middle-income countries (LMICs).
  
  
  METHODS
  Using medical records from Operation Smile international programs taking place in eleven different LMICs between March and May 2014, we performed a logistic regression assessing the relationship between delayed surgery access, defined as primary palatoplasty presentation after 24 months of age, and GDP per capita across 11 countries.
  
  
  RESULTS
  Median age of presentation ranged from 13 to 24 months in upper-middle-income countries, 17 to 35 months in lower-middle-income countries, and 14 to 66 months in low-income countries. Our analysis demonstrated a 14 % increase in the odds of late surgery [OR = 0.88 (P < 0.001)] for every 1000 USD decrease of GDP per capita. In low- and lower-middle-income countries, this relationship was even stronger, with an OR of 0.59 (P < 0.001), indicating a 70 % increase in the odds of late surgery for every 1000 USD decrease in GDP per capita.
  
  
  CONCLUSIONS
  There is a strong negative correlation between national income status and delayed access to primary cleft palate surgery, indicating a high degree of inequity in access to surgery, particularly in low- and lower-middle-income countries. As the importance of surgery in global health is increasingly recognized, an equity perspective must be included in the global dialog to ensure that the world's poor have fair and equitable access to essential surgical care.
authors.affiliation: Department of Emergency Medicine, Brigham & Women's Hospital, 75 Francis St., NH-2, Boston, MD, 02115, USA. lccarlson@partners.org.|Department of Emergency Medicine, Massachusetts General Hospital, Boston, MD, USA. lccarlson@partners.org.
authors.forename: Lucas C
authors.initials: LC
authors.lastname: Carlson
authors.affiliation: Operation Smile, Inc., Virginia Beach, VA, USA.
authors.forename: Kristin W
authors.initials: KW
authors.lastname: Hatcher
authors.affiliation: Operation Smile, Inc., Virginia Beach, VA, USA.
authors.forename: Lindsay
authors.initials: L
authors.lastname: Tomberg
authors.affiliation: Department of Anesthesiology, Kenyatta National Hospital, Nairobi, Kenya.
authors.forename: Charles
authors.initials: C
authors.lastname: Kabetu
authors.affiliation: Operation Smile, Inc., Virginia Beach, VA, USA.
authors.forename: Ruben
authors.initials: R
authors.lastname: Ayala
authors.affiliation: Operation Smile, Inc., Virginia Beach, VA, USA.
authors.forename: Richard
authors.initials: R
authors.lastname: Vander Burg
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D002608:Charities; D002648:Child; D002675:Child, Preschool; D002972:Cleft Palate / Q000601:surgery*; D003906:Developing Countries / Q000191:economics / Q000706:statistics & numerical data; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D054625:Healthcare Disparities / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D012044:Regression Analysis; D061665:Time-to-Treatment / Q000706:statistics & numerical data*; D055815:Young Adult