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

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 quantifi ed. 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 classifi ed 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 identifi ed and included. We modelled surgical mortality rates for countries without reported data using a two-step multiple imputation method. We fi rst used a fully conditional specifi cation (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, specifi ed within the multiple imputation FCS method, for selected predictors for each operation using the completed dataset to predict mortality rates along with confi dence intervals for countries without reported mortality data. To account for variability in data availability, we aggregated results by subregion and estimated surgical mortality rates. Findings From an initial 1302 articles and reports identifi ed, 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 identifi ed 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. Interpretation All-cause postoperative mortality rates are exceedingly variable within resource-constrained environments. Eff orts to expand surgical access and provision of services must include a strong commitment to improve the safety and quality of care