Improving surgical care for women in low- and middle-income countries is a global health priority. It's also critical for sustainable development because of the critical role women play in macro-economic growth, community well-being, and as part of the healthcare workforce.
When the inequities and disparities in obstetric outcomes between world regions came to the attention of governments and multinational organisations, maternal health initiatives were started in regions with the highest maternal mortality rates, including sub-Saharan Africa. This has contributed to an almost 40% reduction in maternal deaths in sub-Saharan Africa in the last two decades.
But the outcomes of other kinds of surgery for women in Africa have remained under-examined. Women need equitable surgical care throughout their lives - not just during childbirth.
In our recent study we compared the outcomes of non-obstetric surgery for women in African countries with the outcomes for women in countries outside Africa. We wanted to bring attention to the outcomes and establish whether there was a large disparity between the groups. At the surface the outcomes seemed similar: 2.9% of the African patients and 2.3% of the international group experienced severe complications after surgery. But when we adjusted for risk profile, African women were twice as likely to experience severe complications (including death) after surgery compared with the international incidence.
Our study reveals an important and addressable health equity issue and makes a case for expanding funding and resources for women's health and global surgery. The findings point to the urgent need to improve healthcare and surgical care for women in Africa.
Comparing surgery outcomes
The study was an analysis of data from two large, similar studies: the African Surgical Outcomes Study (ASOS and the International Surgical Outcomes Study (ISOS. There were 1,671 women in the African cohort and 18,449 in the international cohort (from low-, middle- and high-income countries elsewhere in the world).
We focused on the outcomes of operations such as orthopaedic and bowel surgery. We excluded obstetric and gynaecological surgeries such as caesarean sections and hysterectomies.
At first glance, the rates of severe complications appeared to be similar: 2.9% of women in the African cohort developed a severe complication and 2.3% of women in the international cohort did.
But the African cohort was almost a decade younger. The African women also had significantly fewer comorbidities such as diabetes and hypertension. And they typically underwent more minor and fewer major surgeries. One would therefore expect their outcomes to be significantly better. This means the African outcomes were disproportionately worse.
Our analysis then adjusted for these differences in health status and type of surgical procedure. The analysis confirmed that, if the risk profiles were equal, women in the African cohort would have twice the odds of dying or having a severe complication after surgery.
This indicates that health system factors, such as staffing and infrastructure, are severely affecting women's surgical care and health in Africa. This not only affects the patients, but has ripple effects for their families, communities and the macroeconomic development of their countries.
Almost half - 48% - of the women who developed severe complications in the African cohort died while in hospital (versus 18% in the international cohort). This is a particular cause for concern.
The percentage of severe complications that result in death is known as the "failure-to-rescue" rate. It's largely determined and prevented by the early detection of potentially serious postoperative complications in hospital - and fast and effective clinical action in response. Where there are staff shortages, high patient loads and limited funding, doctors and nurses are stretched. Many hospitals in these settings don't have the resources and warning systems to pick up these complications and act early enough. This is currently a major issue in African health systems.
Women at all life stages and from all backgrounds deserve access to safe and comprehensive surgical care. Our study highlights the need for further research and investment into women's surgical care in African countries.
Africa is not a monolith. There are vast differences between and within African countries' health systems. Therefore there's a need for country-specific and condition-specific research into women's surgical care and ways to improve these outcomes on the African continent.
Authors: Amy Paterson - DPHIL STUDENT, University of Oxford | Salome Maswime - Professor of Global Surgery, University of Cape Town