World Journal of Surgery

, Volume 37, Issue 7, pp 1526–1529 | Cite as

Ratio of Cesarean Deliveries to Total Operations and Surgeon Nationality Are Potential Proxies for Surgical Capacity in Central Haiti

  • Christopher D. HughesEmail author
  • Craig D. McClain
  • Lars Hagander
  • Jean Hamiltong Pierre
  • Reinou S. Groen
  • Adam L. Kushner
  • John G. MearaEmail author



The World Health Organization has a standardized tool to assess surgical capacity in low- and middle-income countries (LMICs), but it is often resource- and time-intensive. There currently exists no simple, evidence-based measure of surgical capacity in these settings. The proportion of cesarean deliveries in regard to the total operations (C/O ratio) has been suggested as a way to assess quickly the capacity for emergency and essential surgery in LMICs. This ratio has been estimated to be between 23.3 and 41.5 % in LMICs, but the tool’s utility has not been replicated.


We reviewed operative logbooks for the Partners In Health/Zanmi Lasante hospital in Cange, Haiti. We recorded data on all consecutive surgical patients from July 2008 to 2010 and calculated the C/O ratio by dividing the number of cesarean deliveries by the total number of operations performed. We also analyzed surgical data by surgeon nationality to provide additional information about local surgical capacity.


A total of 3,641 operations were performed between 2008 and 2010. The C/O ratio decreased significantly between 2008–2009 and 2009–2010 (13.4 vs. 10.7 %, p = 0.001) as the surgical volume and resources increased. Nationality analysis demonstrated that Haitian surgeons were able to provide a spectrum of general and specialist surgical care.


In its inherent relation to essential surgical procedures and to the overall rate of cesarean deliveries in the region, the C/O ratio can provide an accessible assessment of regional surgical resources. In Haiti, the change in the C/O ratio demonstrated a relative increase in surgical capacity from 2008 to 2010. An additional analysis of surgeon nationality ensured that C/O ratio estimates more accurately reflect local practitioner activity, but deficiencies in the regional capacity to address the local burden of surgical disease may still exist.


Cesarean Delivery Centre District Local Health Care System Public Health Development District Facility 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors thank Thierry Pauyo, MD and David Bayne for their assistance in collecting a portion of the operative data. We also acknowledge the Pyrtek Fund at Hartford Hospital and the Department of Surgery, University of Connecticut School of Medicine, for their educational support.


  1. 1.
    Natuzzi ES, Kushner A, Jagilly R et al (2011) Surgical care in the Solomon Islands: a roadmap for universal surgical care delivery. World J Surg 235:1183–1193. doi: 10.1007/s00268-011-1097-4 CrossRefGoogle Scholar
  2. 2.
    Kingham TP, Kamara TB, Cherian MN et al (2009) Quantifying surgical capacity in Sierra Leone: a guide for improving surgical care. Arch Surg 144:122–127PubMedCrossRefGoogle Scholar
  3. 3.
    Osen H, Chang D, Choo S et al (2011) Validation of the World Health Organization tool for situational analysis to assess emergency and essential surgical care at district hospitals in Ghana. World J Surg 35:500–504. doi: 10.1007/s00268-010-0918-1 PubMedCrossRefGoogle Scholar
  4. 4.
    Sherman L, Clement PT, Cherian MN et al (2011) Implementing Liberia’s poverty reduction strategy: an assessment of emergency and essential surgical care. Arch Surg 146:35–39PubMedCrossRefGoogle Scholar
  5. 5.
    Spiegel DA, Choo S, Cherian MN et al (2011) Quantifying surgical and anesthetic availability at primary health facilities in Mongolia. World J Surg 35:272–279. doi: 10.1007/s00268-010-0904-7 PubMedCrossRefGoogle Scholar
  6. 6.
    Kushner AL, Cherian MN, Noel L et al (2010) Addressing the Millennium Development Goals from a surgical perspective. Arch Surg 145:154–160PubMedCrossRefGoogle Scholar
  7. 7.
    Surgeons OverSeas Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) tool. Available at: Accessed 5 Dec 2011
  8. 8.
    Notrica MR, Evans FM, Knowlton LM et al (2011) Rwandan surgical and anesthesia infrastructure: a survey of district hospitals. World J Surg 35:1770–1780. doi: 10.1007/s00268-011-1125-4 PubMedCrossRefGoogle Scholar
  9. 9.
    Kwon S, Kingham TP, Kamara TB et al (2012) Development of a surgical capacity index: opportunities for assessment and improvement. World J Surg 36:232–239. doi: 10.1007/s00268-011-1385-z PubMedCrossRefGoogle Scholar
  10. 10.
    Kushner AL, Groen RS, Kingham TP (2011) Percentage of cesarean sections among total surgical procedures in sub-Saharan Africa: possible indicator of the overall adequacy of surgical care. World J Surg 34:2007–2008. doi: 10.1007/s00268-010-0653-7 CrossRefGoogle Scholar
  11. 11.
    World Health Organization (2007) Haiti country profile. Available at: Accessed 14 Dec 2011
  12. 12.
    Anonymous (2009) Monitoring emergency obstetric care: a handbook. World Health Organization, GenevaGoogle Scholar
  13. 13.
    Anonymous (1985) Appropriate technology for birth. Lancet 2(8452):436–437Google Scholar
  14. 14.
    McIntyre T, Hughes CD, Pauyo T et al (2011) Emergency surgical care delivery in post-earthquake Haiti: partners in health and Zanmi Lasante experience. World J Surg 35:745–750. doi: 10.1007/s00268-011-0961-6 PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2012

Authors and Affiliations

  • Christopher D. Hughes
    • 1
    • 2
    Email author
  • Craig D. McClain
    • 2
    • 3
  • Lars Hagander
    • 1
    • 2
    • 4
  • Jean Hamiltong Pierre
    • 5
  • Reinou S. Groen
    • 6
  • Adam L. Kushner
    • 6
    • 7
  • John G. Meara
    • 1
    • 2
    Email author
  1. 1.Department of Plastic and Oral SurgeryChildren’s Hospital BostonBostonUSA
  2. 2.Program in Global Surgery and Social ChangeHarvard Medical SchoolBostonUSA
  3. 3.Department of AnesthesiologyChildren’s Hospital BostonBostonUSA
  4. 4.Department of Pediatric SurgeryLund University Medical FacultyLundSweden
  5. 5.Zanmi LasanteCangeHaiti
  6. 6.Surgeons OverSeasNew YorkUSA
  7. 7.Department of SurgeryColumbia University Medical CenterNew YorkUSA

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