title: Variability in mortality following caesarean delivery, appendectomy, and groin hernia repair in low-income and middle-income countries: a systematic review and analysis of published data.
abstract: BACKGROUND
  Surgical interventions occur at lower rates in resource-poor settings, and complication and death rates following surgery are probably substantial but have not been well quantified. A deeper understanding of outcomes is a crucial step to ensure that high quality accompanies increased global access to surgical care. We aimed to assess surgical mortality following three common surgical procedures--caesarean delivery, appendectomy, and groin (inguinal and femoral) hernia repair--to quantify the potential risks of expanding access without simultaneously addressing issues of quality and safety.
  
  
  METHODS
  We collected demographic, health, and economic data for 113 countries classified as low income or lower-middle income by the World Bank in 2005. We did a systematic review of Ovid, MEDLINE, PubMed, and Scopus from Jan 1, 2000, to Jan 15, 2015, to identify studies in these countries reporting all-cause mortality following the three commonly undertaken operations. Reports from governmental and other agencies were also identified and included. We modelled surgical mortality rates for countries without reported data using a two-step multiple imputation method. We first used a fully conditional specification (FCS) multiple imputation method to establish complete datasets for all missing variables that we considered potentially predictive of surgical mortality. We then used regression-based predictive mean matching imputation methods, specified within the multiple imputation FCS method, for selected predictors for each operation using the completed dataset to predict mortality rates along with confidence intervals for countries without reported mortality data. To account for variability in data availability, we aggregated results by subregion and estimated surgical mortality rates.
  
  
  RESULTS
  From an initial 1302 articles and reports identified, 247 full-text articles met our inclusion criteria, and 124 provided data for surgical mortality for at least one of the three selected operations. We identified 42 countries with mortality data for at least one of the three procedures. Median reported mortality was 7·9 per 1000 operations for caesarean delivery (IQR 2·8-19·9), 2·2 per 1000 operations for appendectomy (0·0-17·2), and 4·9 per 1000 operations for groin hernia (0·0-11·7). Perioperative mortality estimates by subregion ranged from 2·8 (South Asia) to 50·2 (East Asia) per 1000 caesarean deliveries, 2·4 (South Asia) to 54·0 (Central sub-Saharan Africa) per 1000 appendectomies, and 0·3 (Andean Latin America) to 25·5 (Southern sub-Saharan Africa) per 1000 hernia repairs.
  
  
  CONCLUSIONS
  All-cause postoperative mortality rates are exceedingly variable within resource-constrained environments. 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.affiliation: Department of Surgery, Stanford, CA, USA.
authors.forename: Tarsicio
authors.initials: T
authors.lastname: Uribe-Leitz
authors.affiliation: Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Joshua
authors.initials: J
authors.lastname: Jaramillo
authors.affiliation: Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Lydia
authors.initials: L
authors.lastname: Maurer
authors.affiliation: Management Science and Engineering, Stanford University, Stanford, CA, USA.
authors.forename: Rui
authors.initials: R
authors.lastname: Fu
authors.affiliation: Department of Surgery, Stanford, CA, USA.
authors.forename: Micaela M
authors.initials: MM
authors.lastname: Esquivel
authors.affiliation: Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA; Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: Atul A
authors.initials: AA
authors.lastname: Gawande
authors.affiliation: Ariadne Labs: a Joint Center for Health System Innovation, Boston, MA, USA; Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA; Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Alex B
authors.initials: AB
authors.lastname: Haynes
authors.affiliation: Department of Surgery, Stanford, CA, USA. Electronic address: tweiser@stanford.edu.
authors.forename: Thomas G
authors.initials: TG
authors.lastname: Weiser
mesh_terms: D000328:Adult; D001062:Appendectomy / Q000706:statistics & numerical data; D001064:Appendicitis / Q000401:mortality* / Q000601:surgery; D002585:Cesarean Section / Q000401:mortality*; D003906:Developing Countries; D005260:Female; D006119:Groin / Q000601:surgery; D006547:Hernia / Q000401:mortality*; D059685:Herniorrhaphy / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D011184:Postoperative Period; D011247:Pregnancy