Skip to main content

Advertisement

SpringerLink
Log in

Waiting Too Long: The Contribution of Delayed Surgical Access to Pediatric Disease Burden in Somaliland

  • Surgery in Low and Middle Income Countries
  • Published:
World Journal of Surgery Aims and scope Submit manuscript

Abstract

Background

Delayed access to surgical care for congenital conditions in low- and middle-income countries is associated with increased risk of death and life-long disabilities, although the actual burden of delayed access to care is unknown. Our goal was to quantify the burden of disease related to delays to surgical care for children with congenital surgical conditions in Somaliland.

Methods

We collected data from medical records on all children (n = 280) receiving surgery for a proxy set of congenital conditions over a 12-month time period across all 15 surgically equipped hospitals in Somaliland. We defined delay to surgical care for each condition as the difference between the ideal and the actual ages at the time of surgery. Disability-adjusted life years (DALYs) attributable to these delays were calculated and compared by the type of condition, travel distance to care, and demographic characteristics.

Results

We found long delays in surgical care for these 280 children with congenital conditions, translating to a total of 2970 attributable delayed DALYs, or 8.4 avertable delayed DALYs per child, with the greatest burden among children with neurosurgical and anorectal conditions. Over half of the families seeking surgical care had to travel over 2 h to a surgically equipped hospital in the capital city of Hargeisa.

Conclusions

Children with congenital conditions in Somaliland experience substantial delays to surgical care and travel long distances to obtain care. Estimating the burden of delayed surgical care with avertable delayed DALYs offers a powerful tool for estimating the costs and benefits of interventions to improve the quality of surgical care.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Abdelgadir J, Punchak M, Smith ER et al (2018) Pediatric traumatic brain injury at Mbarara Regional Referral Hospital, Uganda. J Clin Neurosci Off J Neurosurg Soc of Australas 47:79–83

    Google Scholar 

  2. Butler EK, Tran TM, Fuller AT et al (2016) Quantifying the pediatric surgical need in Uganda: results of a nationwide cross-sectional, household survey. Pediatr Surg Int 32(11):1075–1085

    Article  PubMed  PubMed Central  Google Scholar 

  3. Butler EK, Tran TM, Nagarajan N et al (2017) Epidemiology of pediatric surgical needs in low-income countries. PLoS ONE 12(3):e0170968

    Article  PubMed  PubMed Central  Google Scholar 

  4. Bhide P, Gund P, Kar A (2016) Prevalence of congenital anomalies in an Indian maternal cohort: healthcare, prevention, and surveillance implications. PLoS ONE 11(11):e0166408

    Article  PubMed  PubMed Central  Google Scholar 

  5. Vos T, Kyu HH, Pinho C et al (2016) Global and national burden of diseases and injuries among children and adolescents between 1990 and 2013 findings from the global burden of disease 2013 study. JAMA Pediatr 170(3):267–287

    Article  PubMed  Google Scholar 

  6. Wang H, Bhutta ZA, Coates MM, Coggeshall M, Dandona L, Diallo K, Franca EB, Fraser M, Fullman N, Gething PW, Hay SI (2016) Global, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 388(10053):1725–1774

    Article  Google Scholar 

  7. LA Murray CJL (1996) The Global Burden of Disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Harvard University Press, Cambridge

    Google Scholar 

  8. Bickler S, Ozgediz D, Gosselin R et al (2010) Key concepts for estimating the burden of surgical conditions and the unmet need for surgical care. World J Surg 34(3):374–380. https://doi.org/10.1007/s00268-009-0261-6

    Article  PubMed  Google Scholar 

  9. Poenaru D (2016) The burden of pediatric surgical disease in low-resource settings: discovering it, measuring it, and addressing it. J Pediatr Surg 51(2):216–220

    Article  PubMed  Google Scholar 

  10. Poenaru D, Ozgediz D, Gosselin RA (2014) Burden, need, or backlog: a call for improved metrics for the global burden of surgical disease. Int J Surg 12(5):483–486

    Article  PubMed  Google Scholar 

  11. Concepcion T, Mohamed M, Dahir S et al (2019) Prevalence of pediatric surgical conditions across Somaliland. JAMA Netw Open 2(1):e186857

    Article  PubMed  PubMed Central  Google Scholar 

  12. Bank W(2018) New World Bank GDP and Poverty Estimates for Somaliland. http://www.worldbank.org/en/news/press-release/2014/01/29/new-world-bank-gdp-and-poverty-estimates-for-somaliland. Accessed 1 July 2018

  13. Global Health Repository data (2018) World Health Organization. http://www.who.int/gho/database/en/. Accessed 2 April 2018

  14. Murray CJ (1994) Quantifying the burden of disease: the technical basis for disability-adjusted life years. Bull World Health Organ 72(3):429–445

    CAS  PubMed  PubMed Central  Google Scholar 

  15. Warf BC, East African Neurosurgical Research C (2010) Pediatric hydrocephalus in East Africa: prevalence, causes, treatments, and strategies for the future. World Neurosurg 73(4):296–300

    Article  PubMed  Google Scholar 

  16. Surgeons AAoN (2018) Spina Bifida. 2018; https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Spina-Bifida

  17. Control CfD (2018) Birth defects: Facts about Encephalocele 2017; https://www.cdc.gov/ncbddd/birthdefects/encephalocele.html

  18. Service NH. Treatment (2018) Cleft lip and palate. 2016; https://www.nhs.uk/conditions/cleft-lip-and-palate/treatment/

  19. Templeton PA, Flowers MJ, Latz KH, Stephens D, Cole WG, Wright JG (2006) Factors predicting the outcome of primary clubfoot surgery. Can J Surg 49(2):123–127

    PubMed  PubMed Central  Google Scholar 

  20. Ishitani MB (2018) Anorectal malformation. 2016; http://www.eapsa.org/parents/conditions/a-e/anorectal-malformation/

  21. Chan YY, Durbin-Johnson B, Kurzrock EA (2016) Pediatric inguinal and scrotal surgery—practice patterns in US academic centers. J Pediatr Surg 51(11):1786–1790

    Article  PubMed  PubMed Central  Google Scholar 

  22. Clearinghouse EAoUatNG (2018) Guidelines and measures. 2009; www.guideline.gov/content.aspx?id=12594

  23. Smith ER, Concepcion T, Lim S et al (2018) Disability weights for pediatric surgical procedures: a systematic review and analysis. World J Surg 42:3021–3034. https://doi.org/10.1007/s00268-018-4537-6

    Article  PubMed  Google Scholar 

  24. Salomon JA, Haagsma JA, Davis A et al (2015) Disability weights for the Global Burden of Disease 2013 study. Lancet Global Health 3(11):e712–723

    Article  PubMed  Google Scholar 

  25. Shrime MG, Alkire BC, Grimes C, Chao TE, Poenaru D, Verguet S (2017) Cost-effectiveness in global surgery: pearls, pitfalls, and a checklist. World J Surg 41:1401–1413. https://doi.org/10.1007/s00268-017-3875-0

    Article  PubMed  Google Scholar 

  26. Murray CJ, Ezzati M, Flaxman AD et al (2012) GBD 2010: design, definitions, and metrics. Lancet 380(9859):2063–2066

    Article  PubMed  Google Scholar 

  27. Davé DR, Nagarjan N, Canner JK, Kushner AL, Stewart BT, Group SR (2018) Rethinking burns for low & middle-income countries: differing patterns of burn epidemiology, care seeking behavior, and outcomes across four countries. Burns 44:1228–1234

    Article  PubMed  Google Scholar 

  28. Abdelgadir J, Smith ER, Punchak M et al (2017) Epidemiology and characteristics of neurosurgical conditions at Mbarara regional referral hospital. World Neurosurg 102:526–532

    Article  PubMed  Google Scholar 

  29. Abdelgadir J, Smith E, Punchak M et al (2017) Outcomes and predictors of mortality in neurosurgery patients at Mbarara regional referral hospital, Mbarara, Uganda. Ann Global Health 83(1):18–19

    Article  Google Scholar 

  30. Murray CJ, Lopez AD (1997) Global mortality, disability, and the contribution of risk factors: global Burden of Disease Study. Lancet 349(9063):1436–1442

    Article  CAS  PubMed  Google Scholar 

  31. Saxton AT, Poenaru D, Ozgediz D et al (2016) Economic analysis of children’s surgical care in low- and middle-income countries: a systematic review and analysis. PLoS ONE 11(10):e0165480

    Article  PubMed  PubMed Central  Google Scholar 

  32. Goodman LF, St-Louis E, Yousef Y et al (2018) The global initiative for children’s surgery: optimal resources for improving care. Eur J Pediatr Surg Off J Austrian Assoc Pediatr Surg [et al] = Zeitschrift fur Kinderchirurgie 28(1):51–59

    Google Scholar 

  33. Adeyemo WL, James O, Butali A (2016) Cleft lip and palate: parental experiences of stigma, discrimination, and social/structural inequalities. Ann Maxillofac Surg 6(2):195–203

    Article  PubMed  PubMed Central  Google Scholar 

  34. Magee WP Jr, Vander Burg R, Hatcher KW (2010) Cleft lip and palate as a cost-effective health care treatment in the developing world. World J Surg 34(3):420–427. https://doi.org/10.1007/s00268-009-0333-7

    Article  PubMed  Google Scholar 

  35. Farmer D, Sitkin NA, Lofberg KP , Ozgediz D. Surgical Interventions for Congenital Anomalies. Chapter 8. DCP-3

  36. Wang H, Naghavi M, Allen C, Barber RM, Bhutta ZA, Carter A, Casey DC, Charlson FJ, Chen AZ, Coates MM, Coggeshall M (2016) Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 388(10053):1459–1544

    Article  Google Scholar 

  37. Gosselin R, Ozgediz D, Poenaru D (2013) A square peg in a round hole? Challenges with DALY-based “burden of disease” calculations in surgery and a call for alternative metrics. World J Surg 37(11):2507–2511. https://doi.org/10.1007/s00268-013-2182-7

    Article  PubMed  Google Scholar 

  38. Murray C, Lopez A (1996) The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Harvard University Press, Cambridge

    Google Scholar 

  39. Salomon JA, Vos T, Hogan DR et al (2012) Common values in assessing health outcomes from disease and injury: disability weights measurement study for the Global Burden of Disease Study 2010. Lancet 380(9859):2129–2143

    Article  PubMed  Google Scholar 

  40. World Health Organization (2015) The global burden of disease: 2004 update. http://www.who.int/healthinfo/global_burden_disease/2004_report_update/en/. Accessed 11 Aug 2015

  41. Kuznik A, Lamorde M, Hermans S et al (2012) Evaluating the cost-effectiveness of combination antiretroviral therapy for the prevention of mother-to-child transmission of HIV in Uganda. Bull World Health Organ 90(8):595–603

    Article  PubMed  PubMed Central  Google Scholar 

  42. Yap A, Cheung M, Muzira A et al (2019) Best buy in public health or luxury expense?: the cost-effectiveness of a pediatric operating room in Uganda from the societal perspective. Ann Surg

  43. Yap A, Muzira A, Cheung M et al (2018) A cost-effectiveness analysis of a pediatric operating room in Uganda. Surgery 164(5):953–959

    Article  PubMed  Google Scholar 

  44. Grabski D, Ameh E, Ozgediz D, Oldham K, Abantanga FA, Abdel-malak M, Abdulraheem N, Ade-Ajayi N, Ismail A, Ademuyiwa A, Ahmed E (2019) Optimal resources for children’s surgical care: executive summary. World J Surg 43(4):978–980. https://doi.org/10.1007/s00268-018-04888-7

    Article  Google Scholar 

  45. Global Initiative for Children’s Surgery (2019) A model of global collaboration to advance the surgical care of children. World J Surg 43(6):1416–1425. https://doi.org/10.1007/s00268-018-04887-8

    Article  Google Scholar 

  46. Butler MW, Ozgediz D, Poenaru D et al (2015) The global paediatric surgery network: a model of subspecialty collaboration within global surgery. World J Surg 39(2):335–342. https://doi.org/10.1007/s00268-014-2843-1

    Article  PubMed  Google Scholar 

  47. Ologunde R, Maruthappu M, Shanmugarajah K, Shalhoub J (2014) Surgical care in low and middle-income countries: burden and barriers. Int J Surg 12(8):858–863

    Article  PubMed  Google Scholar 

  48. Bearden A, Fuller AT, Butler EK et al (2018) Rural and urban differences in treatment status among children with surgical conditions in Uganda. PLoS ONE 13(11):e0205132

    Article  PubMed  PubMed Central  Google Scholar 

  49. Smith ER, van de Water BJ, Martin A et al (2018) Availability of post-hospital services supporting community reintegration for children with identified surgical need in Uganda. BMC Health Serv Res 18(1):727

    Article  PubMed  PubMed Central  Google Scholar 

  50. Fuller AT, Haglund MM, Lim S et al (2016) Pediatric neurosurgical outcomes following a neurosurgery health system intervention at Mulago Hospital in Uganda. World Neurosurg 95:309–314

    Article  PubMed  Google Scholar 

  51. Smith ER, Vissoci JRN, Rocha TAH et al (2017) Geospatial analysis of unmet pediatric surgical need in Uganda. J Pediatr Surg 52:1691–1698

    Article  PubMed  Google Scholar 

  52. Concepcion TL, Smith ER, Mohamed M et al (2019) Provision of surgical care for children across Somaliland: challenges and policy guidance. World J Surg 43:2934–2944. https://doi.org/10.1007/s00268-019-05079-8

    Article  PubMed  Google Scholar 

  53. New World Bank GDP and Poverty Estimates for Somaliland. http://www.worldbank.org/en/news/press-release/2014/01/29/new-world-bank-gdp-and-poverty-estimates-for-somaliland. Accessed 25 May 2019

  54. Smith ER, Concepcion TL, Mohamed M et al (2019) The contribution of pediatric surgery to poverty trajectories in Somaliland. PLoS ONE 14(7):e0219974

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  55. Poenaru D, Pemberton J, Cameron BH (2015) The burden of waiting: dALYs accrued from delayed access to pediatric surgery in Kenya and Canada. J Pediatr Surg 50(5):765–770

    Article  PubMed  Google Scholar 

  56. Wilson J, Hodges A (2012) Cleft lip and palate surgery carried out by one team in Uganda: Where have all the palates gone? Cleft Palate-Craniofacial J Off Publ Am Cleft Palate-Craniofacial Assoc 49(3):299–304

    Article  Google Scholar 

  57. Smith ER, Concepcion TL, Niemeier KJ, Ademuyiwa AO (2019) Is global pediatric surgery a good investment? World J Surg 43(6):1450–1455. https://doi.org/10.1007/s00268-018-4867-4

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

We want to thank the Global Initiative for Children’s Surgery (GICS) for its support of this work. GICS (www.globalchildrenssurgery.org) is a network of children’s surgical and anesthesia providers from low-, middle-, and high-income countries collaborating for the purpose of improving the quality of surgical care for children globally.

Funding

The funding was provided by the Duke Global Health Institute, Duke University, and by the Robbins College of Health and Human Sciences, Baylor University.

Author information

Authors and Affiliations

  1. Duke Global Health Institute, Duke University, Durham, NC, USA

    Emily R. Smith, Tessa L. Concepcion & Henry E. Rice

  2. Department of Public Health, Robbins College of Health and Human Sciences, Baylor University, MMGYM Room 218, One Bear Place #97313, Waco, TX, 76798-7313, USA

    Emily R. Smith & Kelli Niemeier

  3. Center for Global Surgery Evaluation, Massachusetts Eye and Ear Infirmary, Boston, MA, USA

    Mark Shrime

  4. Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA

    Mark Shrime

  5. Edna Adan University Hospital, Hargeisa, Somaliland, Somalia

    Mubarak Mohamed, Shugri Dahir & Edna Adan Ismail

  6. McGill University, Montreal, QC, Canada

    Dan Poenaru

Authors
  1. Emily R. Smith
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Tessa L. Concepcion
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Mark Shrime
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Kelli Niemeier
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Mubarak Mohamed
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Shugri Dahir
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Edna Adan Ismail
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Dan Poenaru
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Henry E. Rice
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

the Global Initiative for Children’s Surgery

Corresponding author

Correspondence to Emily R. Smith.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Smith, E.R., Concepcion, T.L., Shrime, M. et al. Waiting Too Long: The Contribution of Delayed Surgical Access to Pediatric Disease Burden in Somaliland. World J Surg 44, 656–664 (2020). https://doi.org/10.1007/s00268-019-05239-w

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00268-019-05239-w

Search

Navigation