Person:

Meara, John

Background: Although advances in the reduction of maternal mortality have been made, up to 273,000 women will die this year from obstetric etiologies. Obstructed labor (OL), most commonly treated with Caesarean delivery, has been identified as a major contributor to global maternal morbidity and mortality. We used economic and epidemiological modeling to estimate the cost per disability-adjusted life-year (DALY) averted and benefit-cost ratio of treating OL with Caesarean delivery for 49 countries identified as providing an insufficient number of Caesarean deliveries to meet demand. Methods and Findings Using publicly available data and explicit economic assumptions, we estimated that the cost per DALY (3,0,0) averted for providing Caesarean delivery for OL ranged widely, from $251 per DALY averted in Madagascar to $3,462 in Oman. The median cost per DALY averted was $304. Benefit-cost ratios also varied, from 0.6 in Zimbabwe to 69.9 in Gabon. The median benefit-cost ratio calculated was 6.0. The main limitation of this study is an assumption that lack of surgical capacity is the main factor responsible for DALYs from OL. Conclusions: Using the World Health Organization's cost-effectiveness standards, investing in Caesarean delivery can be considered “highly cost-effective” for 48 of the 49 countries included in this study. Furthermore, in 46 of the 49 included countries, the benefit-cost ratio was greater than 1.0, implying that investment in Caesarean delivery is a viable economic proposition. While Caesarean delivery alone is not sufficient for combating OL, it is necessary, cost-effective by WHO standards, and ultimately economically favorable in the vast majority of countries included in this study.

Little is known about pediatric surgical disease in resource-poor countries. This study documents the surgical care of children in central Haiti and demonstrates the influence of the 2010 earthquake on pediatric surgical delivery. Methods. We conducted a retrospective review of operations performed at Partners in Health/Zanmi Lasante hospitals in central Haiti. Results. Of 2,057 operations performed prior to the earthquake, 423 were pediatric (20.6%). Congenital anomalies were the most common operative indication (159/423 opera- tions; 33.5%). Pediatric surgical volume increased signi cantly a er the earthquake, with524 Pediatric surgical care in Haiti 670 operations performed (23.0% post-earthquake v. 20.6% pre-earthquake, p5.03). Trauma and burns became the most common surgical diagnoses a er the disaster, and operations for non-traumatic conditions decreased signi cantly (p,.01). Conclusion. Congenital anomalies represent a signi cant proportion of baseline surgical need in Haiti. A natural disaster can change the nature of pediatric surgical practice by signi cantly increasing demand for operative trauma care for months afterward.

Background The surgical burden of disease is substantial, but little is known about the associated economic consequences. We estimate the global macroeconomic impact of the surgical burden of disease due to injury, neoplasm, digestive diseases, and maternal and neonatal disorders from two distinct economic perspectives. Methods The value of lost output (VLO) approach projects annual market economy losses during 2015-2030 by relating disease mortality to changes in the labor force and gross domestic product (GDP). The value of lost welfare (VLW) approach uses a broader measure of nonmarket losses based on a concept termed the value of a statistical life and estimates the present value of long-run welfare losses resulting from mortality and short-run welfare losses resulting from morbidity incurred during 2010. Sensitivity analyses are performed for both approaches. Findings During 2015-2030, the VLO approach projects surgical conditions to result in losses of 1·25%of potential GDP, or $20·7 trillion (2010 USD, PPP). When expressed as a proportion of potential GDP, annual GDP losses are greatest in low- and middle-income countries, with up to a 2·5% loss in output by 2030. When nonmarket losses are assessed (VLW), the present value of economic welfare losses is estimated to be equivalent to 17% of 2010 GDP, or $14.5 trillion (2010 USD, PPP). Neoplasm and injury account for greater than 95% of total economic losses in each approach, but maternal, digestive, and neonatal disorders, which represent only 4% of losses in high-income countries in the VLW approach, contribute to 26% of losses in low-income countries. Interpretation The macroeconomic impact of surgical disease is substantial and inequitably distributed. When paired with the growing number of favorable cost-effectiveness analyses of surgical interventions in low- and middle-income countries, our results suggest that building surgical capacity should be a global health priority.