An article published in The Lancet Global Health this month reported that 250,000 women die every year during or after pregnancy and childbirth, and 99% of these women are from low and middle income countries. Many of these deaths result from conditions that require surgery, such as obstructed labour.
It is impossible to perform safe surgery without safe anaesthesia, making anaesthetic interventions an integral part of obstetric care. However, there is a crisis in the anaesthesia workforce with an estimated one physician anaesthesiologist per one million women in many of the poorest countries.
Therefore anaesthesia contributes disproportionately to maternal mortality in low and middle income countries with one in seven (1/7) maternal deaths during or after caesarean section due to anaesthesia related complications, according to the article.
The report highlighted the administration of anaesthesia by non-physicians, especially those with no formal training, as a major risk factor for maternal deaths from anaesthesia.
The increased mortality and morbidity from general anaesthesia was identified as possibly due to inadequate training and resources, poor general condition of the mother, or associated complications such as post-partum haemorrhage.
What is being done?
In 2015, and again this month, the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the World Federation of Societies of Anaesthesiology (WFSA) were awarded grants from the Tropical Health Education Trust (THET) to develop obstetric and paediatric anaesthesia in East Africa.
The grants have allowed the SAFE (Safer Anaesthesia from Education) obstetric and paediatric training courses for anaesthetic officers to be introduced in Kenya, Malawi and Ethiopia, and to be expanded in Uganda and Zambia this year.
The three day courses focus on small group teaching with content based on clinical conditions that currently cause 80% of maternal deaths.
SAFE Impact – Malawi
The latest award of funding will go towards launching the SAFE obstetric courses in Malawi.
According to the zonal reports in Malawi’s National Plan data from district maternal death audits:
“sepsis and post-partum haemorrhage are the most likely causes of death in the majority of mortality cases based at health facilities. As such, an improvement in maternal and newborn care requires access to safe Emergency Obstetric Care (EmOC) for many more pregnant women.”
It is clear that there is a great need to scale up investment and increase resources for improved obstetric care in Malawi. The WFSA and AAGBI will run three SAFE Obstetric courses this year; two in Blantyre and one course in Lilongwe or Nzuzu.
The courses will collectively target at least 90 out of the current 195 anaesthetic officers in Malawi, and will be taught in such a way that some of these anaesthetic officers will have the tools to teach others in hospitals across the country.
SAFE Impact - Kenya
The impact of the SAFE courses in East Africa so far this year have been incredible.
Kenya has successfully implemented the new SAFE programme in recent months. The WFSA is extremely proud of the success of courses and how well they have been taught and adopted across the country.
Three SAFE Obstetrics courses have run in Kenya since January 2016, training 117 anaesthetic officers and physicians. On average each participant will treat at least 150 obstetric patients every year, meaning that more than 17,500 pregnant women will receive safer anaesthesia care in the next 12 months.
The first Kenyan SAFE Course in Nairobi also trained 24 participants on how to deliver the SAFE course, so they were able to go back to their regional hospitals and train others. This sustainable approach encourages Kenyan anaesthesia providers to lead the way in improving anaesthetic care across the country.
According to The Lancet article on maternal deaths, strategies to reduce maternal mortality should focus on increasing the number of anaesthetic practitioners managing pregnancy, enhancing the resources available to them, and increasing their level of training in low and middle income countries. The authors argue:
“Governmental and non-governmental organisations should prioritise investment in obstetric anaesthesia, to implement the WHO’s Resolution calling on decision makers to include emergency and essential surgical care and anaesthesia as a component of universal health coverage (UHC).”
This is in line with the position of the World Health Organisation, the WFSA, as well as a number of other global organisations. In 2015 the World Health Assembly unanimously approved a resolution entitled “Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage,” in a landmark decision to address this huge global health crisis that has previously been ignored.
Globally there is a shortage of more than 1 million specialist surgeons, anaesthetists and obstetricians, a number set to rise to 2.2 million by 2030 if there is not a substantial scale up in surgical care.
The WFSA’s education programmes, including SAFE, increase access to formal education for anaesthesia providers in low resource countries, reducing the global gap in healthcare and improving patient care worldwide.