For Prisca, a woman from Kome Island in Lake Victoria, Tanzania some 100 kilometers from the district hospital, going into labor with her seventh pregnancy was scary. Her previous pregnancy resulted in an emergency caesarian section at a facility not well equipped to handle this surgery, and the loss of the baby.
At this point, if Prisca were giving birth at home, her baby’s and her own prospects for survival would not be good. Both of their lives would also be in danger at most of Tanzania’s public health facilities, the majority of which are unable to perform emergency caesarean sections. In fact, just 51% of government hospitals are ready to perform surgery of any kind. The average patient in Tanzania lives 74 miles from a facility that can provide surgery; given the state of transportation infrastructure, this often means at least six hours travel time, as well as a significant cost for rural patients.
This is not just a Tanzanian problem; it’s a global one. Today, the majority of the world’s population—five billion people—lack access to safe, timely surgery. Over 95% of people in South Asia and Africa cannot access the surgical care they need.
When it comes to maternal and infant mortality, in particular, the lack of access to safe surgery is a crisis. Sustainable Development Goal (SDG) 3 pinpoints the urgent need to drastically reduce global maternal and neonatal mortality – and obstructed labor like Prisca’s is one of the most common causes of maternal death, responsible for almost one in ten maternal deaths in developing countries. Approximately 15% of all births are complicated by a potentially fatal condition that requires emergency care. Today, maternal mortality in Tanzania is 556 deaths per 100,000 live births. To reach the SDG target of 70 maternal deaths per 100,000 live births globally by 2030, it is clear new approaches are needed.
So, what can be done to help mothers like Prisca and her baby? A recent study in Lancet Global Health estimates the cost of scaling up access to surgery in low- and middle-income countries (LMICs) by 2030 at $300 – $420 billion. This is a huge number, but momentum is growing around the importance of surgery to global health, and there is cause for optimism that funding levels will increase. Still, in the near term, we urgently need to find creative solutions for making surgery safe and accessible to many, many more people.
Around the world, organizations are trying a range of innovative approaches. Tanzania is, again, a good example. In 2013, Touch Foundation and Pathfinder launched the Mobilizing Maternal Health Program (MMH) to reduce maternal and neonatal mortality rates in two rural districts of Tanzania. The program, funded by Vodafone Foundation and others, raises community awareness and provides infrastructure such as C-section theaters and neonatal intensive care units, supplies and equipment, and comprehensive emergency maternal and newborn care (CEMONC) training across the continuum of care. The program’s Emergency Transportation System (EmTS) transfers mothers facing difficult births to referral hospitals that can provide appropriate care. In one district, during the first full year of operation, the program transported 1,430 women and 315 newborns, saving (by conservative estimate) 57 lives—or the equivalent of a 27% reduction in local maternal mortality. Yet these results just scratch the surface of the need, even in this pilot district: the vast majority of the transports originated at community and lower-level health facilities, and since 40% of births in Tanzania occur at home, there is significant room for expansion.
To address the workforce challenge, several initiatives are looking to new models that build skills for surgical officers and nurse anesthetists to use on the front lines of emergency care. As an example, Safe Surgery 2020 (SS2020), a multi-partner initiative funded by GE Foundation, has begun training surgical teams in Tanzania so that they can perform even in low-resource settings. By empowering both specialist and non-specialist surgical care providers—nurses, clinical officers, general practitioners, and midwives—to work in teams to perform some surgical procedures, SS2020 hopes to improve surgical outcomes. This approach is already showing promising results at partner hospitals in Ethiopia, where the program first launched. For example, at one district hospital in Northern Ethiopia, where SS2020 began in June 2016, safe C-sections nearly doubled in the first full year of the program and the time from “decision to incision” was cut by more than half.
Because Prisca received care at a MMH network hospital that had fully trained CEMONC staff, a dedicated and fully equipped C-section theater next to the labor ward, and trained anesthetists and providers who could perform a C-section, she received the quality care she needed when she needed it. When her condition changed and she was thought to have a uterine rupture, she was operated on within 30 minutes. The operation was a success, her uterus was repaired, and both mother and baby are doing well.
Over the next decade, large-scale investment in safe surgery has the potential to save the lives of millions of people with easily treatable conditions. In the immediate term, however, programs like Mobilizing Maternal Health, EmTS, and Safe Surgery 2020 are models for creative, low-cost solutions. Even as funders ramp up efforts to close the global safe surgery funding gap, there is much more we can and must do to build basic surgical skills, improve emergency transportation options, and encourage creative, team-based problem-solving among medical professionals around the world. These tangible steps are already saving the lives of mothers like Prisca, and their babies, every day.