Prioritise anaesthesia on the health agenda

By Isabella Epiu

Globally, about 1000 maternal deaths occur every day, with the vast majority (99%) occurring in low resource settings.

This statistic is hardly surprising, considering that every year tens of millions of patients worldwide suffer disabling injuries or death due to unsafe medical care.

In spite of the fact that improving maternal health was one of the eight “Millennium Development Goals” (MDGs) adopted by the international community in 2000, global rates of change suggest that only 16 countries have achieved this MDG target by 2015.
 
We also know that anaesthesia death rates in low- and middle-income countries (LMICs) are reported to be 100 to 1,000 times higher than in high-income countries and represent data more commonly seen in developed countries in the 1940s.

It is this inequality and the lack of access to safe surgical interventions in LMICs, which remains a significant factor in these unacceptable rates of morbidity and mortality.

Sub-Saharan Africa is one of the most risky places to be pregnant as the lifetime risk of dying during pregnancy is one in 40 compared to one in 3,700 in developed countries.

The fifth Millennium Development Goal (MDG) aimed to reduce the maternal mortality ratio by 75% between 1990 and 2015.

To-date, the global rates have declined by 45% with 10 countries accounting for around 60% of all maternal deaths: India, Nigeria, Democratic Republic of the Congo, Ethiopia, Indonesia, Pakistan, Tanzania, Kenya, China and Uganda.
 
For every maternal death in Uganda, at least six survive with chronic and debilitating ill health.

Most maternal deaths are due to causes directly related to pregnancy and childbirth, unsafe abortion and obstetric complications

such as severe bleeding, infection, high blood pressure and obstructed labour. Many of these deaths are preventable.

Inadequate access to appropriate health care means many women still do not survive pregnancy and childbirth.

Quality obstetric anaesthesia is key to reducing maternal and fetal deaths.

According to the World Federation of Societies of Anesthesiologists (WFSA), quality obstetric anaesthesia includes general anesthesia and spinal anesthesia, along with access to blood transfusion and drugs for the treatment of common obstetric problems such as hemorrhage, pre-eclampsia and eclampsia.

The WFSA international standards for safe practice of anaesthesia are intended to provide guidance to anesthesia professionals, their professional societies, hospital, facility administrators and governments for improving and maintaining the quality and safety of anesthesia care.
 
A basic requirement of the WFSA is availability of a fully trained anesthetist throughout surgery.

However, our study revealed that only 7% of anesthetists reported adequate anaesthesia personnel in their hospitals.

In Uganda, for example, there are only 40 physician anaesthetists for 40 million people (one anaesthesiologist for one million Ugandans).

At the teaching hospitals, students ultimately provide most of the anesthesia services with little or no supervision.

The path to better and safer care, which will ultimately lead to reduction in morbidity and mortality, needs support and implementation at all levels.

The solution is multifactorial, involving capacity, workforce, advocacy and the implementation of existing standards through clearly defined and robustly implemented guidelines.

Local guidelines for safety should be drafted and implemented while being sensitive to the culture and expectations of the providers.

The use of a surgical checklist and adherence to basic international standards for the provision of care, is paramount, especially in this setting, where the presence of trained personnel may be limited, medications absent or equipment or other resources likely to be faulty and poorly serviced.

For long, surgery has been the neglected stepchild of Global health, with anaesthesia being the invisible friend of the neglected stepchild. Across the world, many people die from lack of access to safe surgery.

However on May 22nd 2015, at the World Health Assembly in Geneva, ministers for health from around the globe approved the World Health Organisation (WHO) resolution, entitled “Strengthening Emergency and Essential Surgical Care and Anaesthesia as a Component of Universal Health Coverage”
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The resolution urges member states, for the first time ever, to “identify and prioritise a core set of emergency and essential surgery and anaesthesia services at the primary health care and first referral hospital level” and furthermore to “develop methods and financing systems for making quality, safe, effective and affordable emergency and essential surgical care and anaesthesia services accessible to all who need it”.

Hopefully this will be implemented in Uganda to strengthen surgery and anaesthesia.

There is urgent need to train more anaesthesiologists in the region and to provide the necessary equipment and drugs to ensure quality anaesthesia, obstetric and neonatal resuscitation services for better maternal and neonatal outcomes.

The writer is a medical doctor and specialist in anaesthesia, who is currently a Global Health Fellow with University of California Global Health Institute. She is based at Makerere University College of Health Sciences.