title: Challenges of management and outcome of neonatal surgery in Africa: a systematic review.
abstract: BACKGROUND
  Disparity still exists in the outcome of neonatal surgery between high-income countries and low-income and middle-income countries. This study reviews publications on neonatal surgery in Africa over 20 years with a focus on challenges of management, trends in outcome, and potential interventions to improve outcome.
  
  
  METHODS
  We did a literature review by searching PubMed and African Index Medicus for original articles published in any language between January 1995 and September 2014. A data extraction sheet was used to collect information, including type of study, demographics, number of cases, outcome, challenges, and suggestions to improve outcome.
  
  
  RESULTS
  A total of 51 studies from 11 countries met the inclusion criteria. The 16 studies in the first 10 years (1995-2004; group A) were compared with the 35 in the last 10 years (2005-2014; group B). Nigeria (n = 32; 62.7 %), South Africa (n = 7; 13.7 %), Tanzania (n = 2; 3.9 %), and Tunisia (n = 2; 3.9 %) were the predominant sources of the publications, which were retrospective in 38 (74.5 %) studies and prospective in 13 (25.5 %) studies. The mean sample size of the studies was 95.1 (range 5-640). Overall, 4849 neonates were studied, with median age of 6 days (range 1-30 days). Common neonatal conditions reported were intestinal atresia in 28 (54.9 %) studies, abdominal wall defects in 27 (52.9 %), anorectal malformations 25 in (49.0 %), and Hirschsprung's disease, necrotising enterocolitis, and volvulus neonatorum in 23 (45.1 %) each. Mortality was lowest (<3 %) in spina bifida and facial cleft procedures, and highest (>50 %) in emergency neonatal surgeries involving bowel perforation, bowel resection, congenital diaphragmatic hernia, oesophageal atresia, and ruptured omphalocele or gastroschisis. Overall average mortality rate was higher in group A than group B (36.9 vs 29.1 %; p < 0.001), and varied between the groups for some conditions. The major documented challenges were delayed presentation and inadequate facilities in 39 (76.5 %) studies, dearth of trained support personnel in 32 (62.7 %), and absence of neonatal intensive care in 29 (56.9 %). The challenges varied from country to country but did not differ in the two groups.
  
  
  CONCLUSIONS
  Improvement has been achieved in outcomes of neonatal surgery in Africa in the past two decades, although several of the studies reviewed are retrospective and poorly designed. Cost effective adaptations for neonatal intensive care, improved health-care funding, coordinated neonatal surgical care via regional centres, and collaboration with international partners are potential interventions that could help to address the challenges and further improve outcome.
authors.affiliation: Sub-Department of Pediatric Surgery, College of Medicine, University of Nigeria, Enugu Campus, 400001, Enugu, Nigeria. soekenze@yahoo.com.
authors.forename: Sebastian O
authors.initials: SO
authors.lastname: Ekenze
authors.affiliation: Department of Anesthesia, University of Nigeria Teaching Hospital, Enugu, Nigeria.
authors.forename: Obinna V
authors.initials: OV
authors.lastname: Ajuzieogu
authors.affiliation: Nationwide Children's Hospital, Columbus, OH, USA.
authors.forename: Benedict C
authors.initials: BC
authors.lastname: Nwomeh
mesh_terms: D000349:Africa; D000013:Congenital Abnormalities / Q000401:mortality* / Q000601:surgery*; D003906:Developing Countries; D006801:Humans; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications / Q000453:epidemiology*
keywords: Africa; Challenges; Congenital anomalies; Developing countries; Neonatal surgery; Outcome