In this study, we used published GBD 2019 data and a counterfactual method developed for DCP3 to estimate the number of treatable child and adolescent deaths from scaling surgical care at first-level hospitals in LMICs. Our analysis showed that scaling up surgical care at first-level hospitals in LMICs could avert almost 315,000 deaths of children and adolescents per year. This number of deaths represents approximately 22% of the 1.4 million deaths per year that were estimated by DCP3 should surgical care be scaled up at first-level hospitals to treat all age groups.
Perhaps, the most important finding of our study was that improving surgical care for pregnant females at first-level hospital in LMICs could have a profound effect on the under 20 mortality rate. Almost two-thirds of the treatable surgical deaths in the under 20 years age group were attributable to improvements in surgical care directed at pregnant females. This relationship exists because stillbirths and intrapartum-related neonatal deaths are often associated with difficult and obstructed labor . Thus, provision of assisted vaginal delivery and Caesarian delivery are vital to the reduction of perinatal morbidity and mortality. The importance here is that a substantial reduction in the neonatal death rate is possible via surgical interventions in the mother, rather than direct intervention in the neonate.
To further explore the relationship between improved surgical care for pregnant females at first-level hospital in LMICs and the under 20 years mortality rate, we calculated the fraction of the total maternal and neonatal deaths (GBD cause category A.6) that would be averted in the under 20 years age group. The 2019 GBD study reported 19,865 LMICs deaths in the under 20 years age group from maternal causes (Additional file 4). Twenty-two percent of these (4412 deaths) would be averted by scaling up surgical care at first-level hospitals in LMICs. Considering only the neonatal encephalopathy due to birth asphyxia and trauma cause category, 199,088 of 562,556 (35.3%) deaths could be averted. Thus, within specific GBD cause categories, basic surgical care delivered at first-level hospitals could be an important strategy for reducing the under-five mortality rate, and especially neonatal deaths.
Our analysis also suggests there is an important opportunity to reduce the under 20 death rates in LMICs by improving the surgical care of injuries. Treatable deaths related to injuries occurred across the span of the first 8000 days of life and account for the largest fraction of treatable deaths in the 5–19 years age group. Almost, one-third of these treatable injury deaths are due to road injuries. Road traffic injuries have long been known to be a major cause of death and disability worldwide, with the majority of deaths in LMICs occurring in pedestrians, cyclists, and children . As UN SDG 3.6 is aimed at reducing the number of global deaths and injuries from road traffic accidents, improving surgical care within LMICs can play an important role in achieving this goal.
Treatable deaths from scaling up surgical care to treat gastrointestinal causes were considerably less than the number of treatable deaths in the maternal-neonatal and injury categories. This may reflect that fewer GBD causes were examined in the gastrointestinal category. However, it is more likely that gastrointestinal conditions are less common in children relative to deaths associated with maternal and neonatal conditions and injuries [23, 24]. Nevertheless, surgical treatment of common gastrointestinal conditions is an attractive intervention for the first-level hospital as they are lifesaving, relatively easy to perform, restore health quickly and are cost-effective.
An unexpected finding of our study was that the largest number of treatable deaths from scaling up surgical care at first-level hospitals would occur in lower-middle-income, rather than in low-income countries. This occurs because the under 20 years population in lower middle-income countries is more than three times larger than the under 20 years population in the low-income countries (Additional file 2). This finding disguises the fact that the situation is worse in low-income countries (i.e., people living in LICs are more likely to die from a treatable surgical death than anywhere else). Perhaps the good news is that lower-middle-income countries have the extra fiscal space, compared to low-income countries, to scale up actions in response to recognized needs. As an example, national school meals programs increased coverage over the last 10 years by 86% in lower middle-income countries and only 36%, despite best efforts, in low-income countries . This implies that the largest treatable burden is in countries that have the greater potential to respond. It doesn’t solve the problems for the worst affected countries, but it would save a substantial number of lives.
As our analysis included only 13 of the 369 GBD causes, it is important that our estimate not be interpreted as the total number of child and adolescent deaths that could be averted if surgical care would be scaled up across all levels of the health care system. Important GBD cause categories not included in our analysis were congenital anomalies and cancer. Birth defects are now the fifth most common cause of death in children younger than 5 years with many congenital anomalies correctable with surgery [26, 27]. In 2018, there were over 200,000 cases of childhood cancers accounting for almost 75,000 deaths . Beyond preventing death, surgical care also has a role in the diagnosis and treatment of a wide variety of other healthcare problems [29, 30].
Our study has several limitations. First, it shares the limitations of the overall GBD approach [15, 31], including it being a descriptive study; limitations in data availability (e.g., reporting lags, disruptions in settings with conflict, natural disasters, or domestic governance crises); variable data granularity with respect to age and cause detail; varying quality and completeness of mortality reporting systems; and the core GBD assumption of each death having only a single underlying cause. Second, our analysis required assumptions to be made about the effect of surgery and access to health systems. As emphasized in Chapter 2 of the Essential Surgery Chapter DCP3 , estimating the effect of surgical care is challenging as the effectiveness of an operation varies by the type of operation; resources available to conduct the operation; operative skills of the surgeon; capability, and resources of anesthesia personnel; and patient factors, such as nutritional status, age and other comorbidities. For consistency, we used the adjustments for the effect of surgery and access reported in Annex 2E of the Essential Surgery Chapter of DCP3 . These adjustments are based on a combination of factors that best represent the variable effect surgical care can have on health conditions. As an example, the adjustment for the effect of surgery on neonatal encephalopathy due to birth asphyxia and trauma was based on the 40% risk reduction that was used in the World Health Organization Choosing Interventions that are Cost Effective (WHO CHOICE) project [32,33,34]. Because applying this assumption uniformly to all regions leads to an overestimation of treatable deaths, the effect was also scaled for access to healthcare. Third, our model assumes that healthcare access is equal across all age groups, which may be problematic given the variability in importance that children occupy in society in different regions of the world. Fourth, while we have described our estimates as the number of deaths that could be prevented if surgical care would be scaled up at first-level hospitals, more accurately we have estimated the number of treatable deaths from scaling up a basic surgical package across all levels of the healthcare system. Nevertheless, our estimates still likely approximate the impact of scaling up surgical care at first-level hospitals because most gaps in surgical care exist in geographic areas served by first-level hospitals and most higher-level facilities in LMICs can provide the surgical care our model. Finally, although our framework for estimating treatable surgical deaths is conceptually simple, and a powerful tool for estimating the impact of scaling up surgical care in LMICs, it is also limited by its inherently retrospective nature, and its inability to parse competing risks or factors that might influence geographical variability in surgical care.
In conclusion, our findings suggest an important opportunity exists to improve the health of children and adolescents living in LMICs by scaling up basic surgical care at first-level hospitals. As much of care is directed at women of child-bearing age, these efforts would have a dual benefit—directly improving the health of women and indirectly reducing the deaths of infants associated with obstructed labor. Future research should focus on confirming the intrinsic link between improving obstetrical care at first-level hospitals and infant survival and defining the impact of scaling up surgical care that is beyond the scope of the first-level hospital.