Paediatric surgical outcomes in sub-Saharan Africa: a ...

1PaedSurg Africa Research Collaboration. BMJ Global Health 2021;6:e004406. doi:10.1136/bmjgh-2020-004406

Paediatric surgical outcomes in sub- Saharan Africa: a multicentre, international, prospective cohort study

PaedSurg Africa Research Collaboration

Original research

To cite: PaedSurg Africa Research Collaboration. Paediatric surgical outcomes in sub- Saharan Africa: a multicentre, international, prospective cohort study. BMJ Global Health 2021;6:e004406. doi:10.1136/bmjgh-2020-004406

Handling editor Seye Abimbola

Received 9 November 2020Revised 23 January 2021Accepted 26 January 2021

Correspondence toNaomi Jane Wright; naomiwright@ doctors. org. uk

© Author(s) (or their employer(s)) 2021. Re- use permitted under CC BY. Published by BMJ.

ABSTRACTIntroduction As childhood mortality from infectious diseases falls across sub- Saharan Africa (SSA), the burden of disease attributed to surgical conditions is increasing. However, limited data exist on paediatric surgical outcomes in SSA. We compared the outcomes of five common paediatric surgical conditions in SSA with published benchmark data from high- income countries (HICs).Methods A multicentre, international, prospective cohort study was undertaken in hospitals providing paediatric surgical care across SSA. Data were collected on consecutive children (birth to 16 years), presenting with gastroschisis, anorectal malformation, intussusception, appendicitis or inguinal hernia, over a minimum of 1 month, between October 2016 and April 2017. Participating hospitals completed a survey on their resources available for paediatric surgery.The primary outcome was all- cause in- hospital mortality. Mortality in SSA was compared with published benchmark mortality in HICs using χ2 analysis. Generalised linear mixed models were used to identify patient- level and hospital- level factors affecting mortality. A p<0.05 was deemed significant.Results 1407 children from 51 hospitals in 19 countries across SSA were studied: 111 with gastroschisis, 188 anorectal malformation, 225 intussusception, 250 appendicitis and 633 inguinal hernia. Mortality was significantly higher in SSA compared with HICs for all conditions: gastroschisis (75.5% vs 2.0%), anorectal malformation (11.2% vs 2.9%), intussusception (9.4% vs 0.2%), appendicitis (0.4% vs 0.0%) and inguinal hernia (0.2% vs 0.0%), respectively. Mortality was 41.9% (112/267) among neonates, 5.0% (20/403) in infants and 1.0% (7/720) in children. Paediatric surgical condition, higher American Society of Anesthesiologists score at primary intervention, and needing/receiving a blood transfusion were significantly associated with mortality on multivariable analysis.Conclusion Mortality from common paediatric surgical conditions is unacceptably high in SSA compared with HICs, particularly for neonates. Interventions to reduce mortality should focus on improving resuscitation and timely transfer at the district level, and preoperative resuscitation and perioperative care at paediatric surgical centres.

INTRODUCTIONThe global focus on reducing childhood mortality from infectious diseases is reflected in improved outcomes.1 However, lack

of focus on surgical diseases in children means the proportion of deaths attributed to surgical conditions is increasing.1–3 Glob-ally, 1.7 billion children do not have access to safe, affordable, timely surgical care when needed.2 Sub- Saharan Africa (SSA), where up to 50% of the population are children, has almost one- third of the worlds burden of

Key questions

What is already known? ► 1.7 billion children worldwide do not have access to safe, affordable, timely surgical care when needed.

► Emergency abdominal surgical outcomes in children are poor in low- income and middle- income coun-tries, compared with high- income countries (HICs), globally.

► Sub- Saharan Africa (SSA), where up to 50% of the population are children, has the greatest burden of surgical disease, but limited data exist on paediatric surgical management and outcomes in the region.

What are the new findings? ► In a prospective cohort study of 1407 children presenting to 51 hospitals in 19 low- income and middle- income countries across SSA, the mortality from common paediatric surgical conditions was significantly higher than reported in HICs.

► The majority of deaths occurred in neonates. ► Mortality was associated with indicators of poor sys-temic condition at presentation to the paediatric sur-gery centre and at the time of primary intervention.

What do the new findings imply? ► Mortality from common paediatric surgical condi-tions is unacceptably high in SSA compared with HICs, particularly for neonates.

► Sustainable Development Goal 3.2 to ‘end prevent-able deaths in neonates and children under 5 by 2030’ is unachievable without urgent action to im-prove access to quality paediatric surgical care in SSA.

► Interventions to reduce mortality should focus on improving resuscitation and timely transfer at the district level, and preoperative resuscitation and perioperative care at paediatric surgical centres.

on October 3, 2021 by guest. P

rotected by copyright.http://gh.bm

j.com/

BM

J Glob H

ealth: first published as 10.1136/bmjgh-2020-004406 on 2 S

eptember 2021. D

ownloaded from

on O

ctober 3, 2021 by guest. Protected by copyright.

http://gh.bmj.com

/B

MJ G

lob Health: first published as 10.1136/bm

jgh-2020-004406 on 2 Septem

ber 2021. Dow

nloaded from



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

on O


http://gh.bmj.com

/B

MJ G



ber 2021. Dow

nloaded from



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

on O


http://gh.bmj.com

/B

MJ G



ber 2021. Dow

nloaded from



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

on O


http://gh.bmj.com

/B

MJ G



ber 2021. Dow

nloaded from



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

on O


http://gh.bmj.com

/B

MJ G



ber 2021. Dow

nloaded from



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

on O


http://gh.bmj.com

/B

MJ G



ber 2021. Dow

nloaded from



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

on O


http://gh.bmj.com

/B

MJ G



ber 2021. Dow

nloaded from



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

on O


http://gh.bmj.com

/B

MJ G



ber 2021. Dow

nloaded from



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

on O


http://gh.bmj.com

/B

MJ G



ber 2021. Dow

nloaded from



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

on O


http://gh.bmj.com

/B

MJ G



ber 2021. Dow

nloaded from



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

on O


http://gh.bmj.com

/B

MJ G



ber 2021. Dow

nloaded from



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

on O


http://gh.bmj.com

/B

MJ G



ber 2021. Dow

nloaded from



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

on O


http://gh.bmj.com

/B

MJ G



ber 2021. Dow

nloaded from



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

on O


http://gh.bmj.com

/B

MJ G



ber 2021. Dow

nloaded from



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

on O


http://gh.bmj.com

/B

MJ G



ber 2021. Dow

nloaded from



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

on O


http://gh.bmj.com

/B

MJ G



ber 2021. Dow

nloaded from



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

on O


http://gh.bmj.com

/B

MJ G



ber 2021. Dow

nloaded from



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

on O


http://gh.bmj.com

/B

MJ G



ber 2021. Dow

nloaded from



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

http://gh.bmj.com/

http://crossmark.crossref.org/dialog/?doi=10.1136/bmjgh-2020-004406&domain=pdf&date_stamp=2021-09-02

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

http://gh.bmj.com/

2 PaedSurg Africa Research Collaboration. BMJ Global Health 2021;6:e004406. doi:10.1136/bmjgh-2020-004406

BMJ Global Health

surgical disease and half of the worlds under-5 deaths.4–6 A population- based study in Uganda highlighted that almost one- third of childhood deaths resulted from surgical conditions.7 Current evidence from SSA on paediatric surgical outcomes comes mainly from single- institutions, small case series and retrospective reviews. Multicentre, multinational prospective data are lacking.8

This study sought to address this gap by collecting prospective data from hospitals providing paediatric surgical care across SSA on five of the most common paediatric surgical conditions in the neonatal, infant and childhood periods: gastroschisis, anorectal malforma-tion (ARM), intussusception, appendicitis and inguinal hernia. Gastroschisis is one of the most common congen-ital anomalies with a rising global incidence. An interna-tional survey estimated many paediatric surgical centres in SSA have a mortality of 75%–100% from gastroschisis, compared with under 25% in high- income countries (HICs).9–12 Associated anomalies are rare in neonates with this condition and in HICs the vast majority live a full life with minimum disability. ARM, also known as imperforate anus, is one of the most frequent neonatal surgical emergencies presenting to hospitals in SSA with a mortality up to 20% in Nigeria compared with 3% in HICs.13–15 Intussusception is the leading cause of intestinal obstruction in children, typically infants, with reported mortality rates of 9.4% in SSA compared with 0.1% in Europe.16 Appendicitis is one of the the most common causes of acute abdomen in children world-wide. Research from SSA suggests deaths (extremely rare in HICs) still occur, and morbidity is high.17–19 Inguinal hernia repair is the most commonly performed paedi-atric operation worldwide; morbidity is low in HICs and mortality close to nil.20 Reports from SSA suggest delayed treatment and limited care facilities result in preventable deaths and disability.21

The study aim was to collect mortality and morbidity outcomes data for neonates and children presenting with these common paediatric surgical conditions to paedi-atric surgical centres across SSA, to compare mortality with published HIC benchmark data, and to identify factors associated with mortality that could be modified to improve survival.

METHODSStudy design and participantsA multicentre, international prospective cohort study was undertaken at paediatric surgery centres across SSA. Health-care professionals involved in the care of children with the study conditions in SSA, including surgeons, anaesthetists and allied health professionals, were invited to participate in the study through professional organisations, conference presentations, social media and designated ‘Country Leads’. At each participating hospital, data was collected by one or more teams, consisting of up to three local investigators per team, over 1- month or multiple 1- month study periods between October 2016 and April 2017. During each month

of study participation, prospective data were collected on consecutive patients, under the age of 16 years, presenting for the first time with gastroschisis, ARM, intussusception, appendicitis and inguinal hernia. This included patients managed operatively and non- operatively for gastroschisis, ARM, intussusception and appendicitis. Children with an inguinal hernia required an operation to be included because, unlike the other conditions, patients can present electively and surgery is the only definitive intervention. Patients who had previously been operated and re- pre-sented with complications or requiring further surgery were excluded.

Data were collected on patient demographics, condition on arrival, perioperative resuscitation and care, surgical interven-tion and outcomes (online supplemental appendix methods 1) using Research Electronic Data Capture (REDCap).22 Data collection consisted of generic variables, relevant to all the study conditions, and condition specific variables. Patients were followed up until discharge and 30 days post- intervention where locally feasible. The study protocol and data collection form were available in English, French and Portuguese. A pilot study was undertaken at five hospitals to optimise the study design and data collection. Data entered into REDCap was assessed for congruency and complete-ness. Local investigators were individually contacted for clar-ification of any discrepancies, and to complete missing data.

Local investigators were asked to complete a survey on the resources available for paediatric surgery at their hospital. This contained four categories: (1) personnel, (2) infrastructure, (3) procedures, (4) anaesthesia and resuscitation (online supplemental appendix methods 2). This was developed through modification of the PediPIPES institutional capacity assessment survey with a reduced number of questions for feasibility and to reflect the conditions being studied.23 24

OutcomesThe primary outcome was all- cause in- hospital mortality. For patients still in hospital, a 30- day post primary inter-vention mortality was used (including operative and non- operative interventions). Secondary outcomes included surgical site infection, wound dehiscence, need for unplanned reintervention, length of hospital stay and 30- day post primary intervention mortality.

Statistical analysisWe aimed to include a minimum of 50 hospitals (online supplemental appendix methods 3). Differences between all- cause, in- hospital mortality in SSA and expected mortality from published HIC benchmark data were compared using χ2 analysis or Fisher’s exact test if less than five patients per group. Results are presented with 95% CI. HIC benchmark studies were selected based on the most representative population and largest sample size at the time of protocol development (online supple-mental appendix table 1).10 15 16 20 25 HIC gastroschisis mortality of 2.0% (6/302) within the neonatal period, was reported in a UK national ‘whole population’



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

https://dx.doi.org/10.1136/bmjgh-2020-004406








http://gh.bmj.com/

PaedSurg Africa Research Collaboration. BMJ Global Health 2021;6:e004406. doi:10.1136/bmjgh-2020-004406 3

BMJ Global Health

cohort study.10 ARM HIC mortality of 2.9% (12/410) was reported from a case- series in Finland (270 high ARM; 140 low ARM).15 The HIC intussusception mortality of 0.2% (18/9186) constitutes a meta- analysis of ‘case- fatality among children hospitalised with intussuscep-tion’ in Australia, Europe, New Zealand and USA.16 Paediatric appendicitis mortality of 0.004% (1/24 665) in HICs, is from a meta- analysis of three hospital based studies in Canada, UK and USA containing both paedi-atric and general surgeon operators.25 HIC paediatric inguinal hernia mortality of 0% (0/6361) was reported from a 35- year case- series in Canada.20

A generalised linear mixed model (GLMM) with a bino-mial family specification and random intercept for hospitals was used to identify patient- level factors associated with all- cause in- hospital mortality for the three study conditions with highest mortality: gastroschisis, ARM and intussusception. A second GLMM was used to identify both patient- level and hospital- level factors associated with mortality for these three conditions combined. Variables significantly associated with mortality at univariable analysis (p<0.05) were included in the multivariable models, with adjustment for confounders: paediatric surgical condition, weight and American Society of Anesthesiologists (ASA) score. Exploratory analyses involved univariable analysis (including a random intercept for hospitals) of factors associated with all- cause, in- hospital mortality for gastroschisis, ARM and intussusception, indi-vidually. Multivariable analysis was not possible for the indi-vidual conditions due to low event rates per variable.

To facilitate analysis, hospital variables within each of the four domains (personnel, infrastructure, procedures and anaesthesia/resuscitation) were categorised into low, medium or high availability. For each hospital, the number of paediatric surgeons per population of children was calcu-lated using the reported number of paediatric surgeons and population served in the hospital survey, and a published mean proportion of children in the SSA population of 43%.26 We used the IQR to categorise personnel availability as follows: low, <0.2 paediatric surgeons per 1 000 000 chil-dren; medium, ≥0.2 and <1.5 paediatric surgeons per 1 000 000 children; high, ≥1.5 paediatric surgeons per 1 000 000 children. For the infrastructure, procedures and anaes-thesia/resuscitation domains, each variable was categorised as ‘Always available’ or ‘Sometimes or never available’. Each domain was then categorised as follows: low, indicating 30% or less of the variables within the domain were ‘always avail-able’; medium, indicating between 31% and 69% of the variables within the domain were ‘always available’; high, indicating 70% or more of the variables within the domain were ‘always available’. Since a number of collaborators had independently completed the survey at each hospital, the mean for each variable was used for categorisation and analysis.

Data validationTen per cent of study hospitals were randomly selected to validate patient data. A local investigator, who did not participate in the original data collection, but also cared

for the study patients, was asked to independently collect data on all eligible patients presenting during 1 month of the study. Cohen’s kappa coefficient was used to evaluate the level of agreement between the main study and vali-dation datasets. The validating investigator was asked to confirm how many eligible patients presented during the study period to determine if any were missed. A validation survey was undertaken by all local investigators at vali-dating hospitals regarding the quality of the patient data. The hospital data were validated by analysing the level of agreement between local investigators independently completing the survey from the same hospital. Interclass correlation coefficients were used because the number of survey respondents per hospital was not consistent. Observed agreement was also reported.

Analyses were undertaken in Stata V.14, Stata V.15, R V.4.0 and SAS V.9.4. A p<0.05 was deemed significant.

Patient and public involvementPatients and public were not involved in the design of the study. However, patient support groups (One in 5000 Foundation and CDH International) are assisting in the dissemination of the findings.27 28

RESULTSPatient characteristics and exposuresData were collected on 1407 children from 51 hospitals across 19 countries in SSA (figures 1 and 2): 111 patients with gastroschisis (7.9%), 188 with ARM (13.4%), 225 with intussusception (16.0%), 250 with appendicitis (17.8%) and 633 with inguinal hernia (45.0%). The data were collected over 75 one- month study periods. The median number of months of data collection per hospital was 1 month (range 1–4). The patient characteristics and perioperative management relevant to all conditions are presented in table 1. The condition- specific patient char-acteristics and management are reported in the online supplemental appendix tables 2a–e.

Few neonates with gastroschisis were diagnosed ante-natally (n=5 (4.5%)) or born at the study hospital (n=8 (7.3%)). They frequently arrived without health service transportation (n=50 (45.5%)). Most presented on day 1 of life (IQR 1–2), but many were already septic (n=60 (54.5%)), hypovolaemic (n=64 (57.7%)) and hypo-thermic (n=84 (75.7%)). Similarly, there were high rates of sepsis at presentation for patients with ARM, intussus-ception and appendicitis (n=41 ((21.9%), n=102 (45.3%) and n=140 (56.0%), respectively) with median times to presentation of 3–5 days. ASA scores at primary interven-tion were high (3 or above), particularly in patients with gastroschisis, ARM and intussusception (n=63 (63.6%), n=41 (23.7%) and n=76 (35.2%), respectively) and a high proportion required blood transfusions (n=23 (29.7%), n=39 (21.1%) and n=91 (40.5%), respectively). Surgical pathology was frequently advanced: 31 (27.9%) patients with gastroschisis were complex, 118 (52.4%) patients with intussusception had a contraindication to



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from



http://gh.bmj.com/


BMJ Global Health

non- operative management and 140 (57.1%) patients with appendicitis had perforated. In contrast, patients with an inguinal hernia had lower ASA scores (3% ASA 3–5). Of the 633 patients with an inguinal hernia, 59 (9.3%) were complicated (57 (9.0%) incarcerated, obstructed or strangulated and 2 (0.3%) fistulated).

Deficiencies in primary resuscitation were identified: 19 (22.6%) hypothermic neonates with gastroschisis were not warmed, while 20 (11.4%) patients with intussuscep-tion and 13 (7.7%) patients with appendicitis were not given intravenous fluids for sepsis or hypovolaemia prior to surgical intervention. Ventilation was not available when required for 36 (32.4%) patients with gastroschisis

and 60 (32.0%) with ARM. 85 (76.6%) patients with gastroschisis had no or insufficient parenteral nutrition. Some patients with gastroschisis, ARM and intussuscep-tion were palliated without a surgical intervention (n=20 (18.2%), n=7 (3.8%) and n=7 (3.1%), respectively). Mini-mally invasive or non- operative techniques were used infrequently: 25 (10.0%) of patients with appendicitis were managed laparoscopically and 58 (25.8%) patients with intussusception had an air enema or hydroenema reduction (successful in 40 (69.0%)). Of patients under-going laparotomy for intussusception, 63 (35.6%) under-went manual reduction only. Management of gastroschisis and ARM varied widely.

Figure 1 Flow chart of patient inclusion. ARM, anorectal malformation; SSA, sub- Saharan Africa.

Figure 2 Countries in the study depicted by number of participating hospitals and patients (n). *The higher study population in Nigeria reflects the high population of the country (18% of the sub- Saharan Africa population) and the high number of paediatric surgeons (87 compared to a median of 4/country in sub- Saharan Africa).



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

http://gh.bmj.com/


BMJ Global Health

Tab

le 1

P

atie

nt c

hara

cter

istic

s an

d p

erio

per

ativ

e ca

re s

trat

ified

by

cond

ition

(gen

eric

var

iab

les

only

)

Vari

able

All,

n=14

07, n

(%)

Gas

tro

schi

sis,

n=11

1, n

(%)

AR

M,

n=18

8, n

(%)

Intu

ssus

cep

tio

n,n=

225,

n (%

)A

pp

end

icit

is,

n=25

0, n

(%)

Ing

uina

l her

nia,

n=63

3, n

(%)

Sex

: mal

e10

25 (7

2.9)

47 (4

2.3)

103

(54.

8)14

8 (6

5.8)

161

(64.

4)56

6 (8

9.4)

Ges

tatio

nal a

ge a

t b

irth*

38, 3

7–40

37, 3

5–38

38, 3

7–39

39, 3

8–40

39, 3

8–40

38, 3

7–40

Wei

ght

(kg)

on

arriv

al*

10.0

, 5.0

–20.

02.

3, 2

.0–2

.73.

3, 2

.7–6

.57.

4, 6

.4–8

.630

.0, 2

3.0–

38.0

12.5

, 7.9

–18.

0

Age

*†14

, 4–7

2 (m

onth

s)1,

1–2

(day

s)5,

2–9

2 (d

ays)

7, 5

–10

(mon

ths)

10, 8

–12

(yea

rs)

25, 8

–59

(mon

ths)

Con

diti

on o

nset

to

pre

sent

atio

n (d

ays)

*7,

2–1

271,

1–2

5, 2

–92

3, 2

–53,

2–5

120,

30–

700

Pat

ient

’s h

ome

to h

osp

ital d

ista

nce

(km

)*20

, 10–

5559

, 18–

182

47, 2

3–15

020

, 10–

4517

, 9–4

415

, 8–3

5

Mod

e of

tra

nsp

ort

to h

osp

ital:

A

mb

ulan

ce o

r ot

her

heal

th s

ervi

ce t

rans

por

t20

8 (1

4.9)

52 (4

7.3)

31 (1

6.5)

20 (9

.0)

58 (2

3.7)

47 (7

.5)

P

atie

nt’s

ow

n tr

ansp

orta

tion

1168

(84.

0)50

(45.

5)15

3 (8

1.8)

203

(91.

0)18

7 (7

6.3)

575

(91.

9)

B

orn

in s

tud

y ho

spita

l15

(1.1

)8

(7.3

)3

(1.6

)N

AN

A4

(0.6

)

AS

A s

core

:‡

I-

norm

al o

r II-

mild

sys

tem

ic d

isea

se11

38 (8

2.9)

36 (3

6.4)

132

(76.

3)14

2 (6

4.8)

215

(86.

0)61

3 (9

7.0)

III

- sev

ere

syst

emic

dis

ease

151(

11.9

)20

(20.

2)27

(15.

6)56

(25.

6)34

(13.

6)14

(2.2

)

IV

/V- l

ife t

hrea

teni

ng84

(6.1

)43

(43.

4)14

(8.1

)21

(9.6

)1

(0.4

)5

(0.8

)

N

A, n

o su

rgic

al in

terv

entio

n33

1115

60

0

Sur

gica

l saf

ety

chec

klis

t us

ed:‡

N

o63

1 (4

6.5)

60 (6

5.9)

77 (4

5.3)

125

(59.

0)11

1 (4

4.4)

258

(40.

8)

Ye

s72

5 (5

3.5)

31 (3

4.1)

93 (5

4.7)

87 (4

1.0)

139

(55.

6)37

5 (5

9.2)

N

A, n

o su

rgic

al in

terv

entio

n51

2018

130

0

Ana

esth

etic

:‡

G

ener

al a

naes

thet

ic11

01 (8

2.2)

36 (4

2.4)

152

(93.

8)17

2 (8

1.5)

239

(96.

0)50

2 (7

9.3)

N

o G

A (l

ocal

, reg

iona

l, ke

tam

ine

or n

one)

239

(17.

8)49

(57.

7)10

(6.2

)39

(18.

5)10

(4.0

)13

1 (2

0.7)

N

A, n

o in

terv

entio

n66

2626

131

0

Ana

esth

etis

t:‡

A

naes

thet

ic d

octo

r§92

3 (7

0.5)

28 (3

5.9)

114

(70.

4)13

4 (7

0.9)

175

(70.

3)47

2 (7

4.7)

A

naes

thet

ic n

urse

294

(22.

4)9

(11.

5)42

(25.

9)44

(23.

3)64

(25.

7)13

5 (2

1.4)

M

edic

al o

ffice

r, su

rgeo

n or

oth

er93

(7.1

)41

(52.

6)6

(3.7

)11

(5.8

)10

(4.0

)25

(4.0

)

N

A, n

o an

aest

hetic

giv

en96

3326

361

0

Blo

od t

rans

fusi

on:

N

o, n

ot r

equi

red

1188

(84.

6)78

(70.

3)14

6 (7

8.9)

134

(59.

6)21

9 (8

7.6)

611

(96.

5)

N

o, r

equi

red

but

not

ava

ilab

le21

(1.5

)8

(7.2

)3

(1.6

)2

(0.9

)2

(0.8

)6

(0.9

)

Ye

s19

5 (1

3.9)

25 (2

2.5)

36 (1

9.5)

89 (3

9.6)

29 (1

1.6)

16 (2

.5)

Per

cent

ages

hav

e b

een

roun

ded

and

may

not

tot

al 1

00. M

issi

ng d

ata:

ges

tatio

nal a

ge a

t b

irth

n=19

9, w

eigh

t n=

21, a

ge n

=10

, con

diti

on o

nset

to

pre

sent

atio

n n=

5, d

ista

nce

from

hom

e n=

47, m

ode

of t

rans

por

t n=

16, A

SA

sco

re n

=1,

ana

esth

etic

n=

1, a

naes

thet

ist

n=1,

blo

od t

rans

fusi

on n

=3.

*Med

ian,

IQR

.†A

ge a

t p

rese

ntat

ion

for

pat

ient

s w

ith g

astr

osch

isis

, AR

M, i

ntus

susc

eptio

n an

d a

pp

end

iciti

s. A

ge a

t th

e tim

e of

op

erat

ion

for

pat

ient

s w

ith a

n in

guin

al h

erni

a.‡A

t p

rimar

y in

terv

entio

n.§C

onsu

ltant

or

trai

nee.

AR

M, a

nore

ctal

mal

form

atio

n; A

SA

, Am

eric

an S

ocie

ty o

f Ane

sthe

siol

ogis

ts; G

A, g

ener

al a

naes

thet

ic; N

A, n

ot a

pp

licab

le.



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

http://gh.bmj.com/


BMJ Global Health

Hospital characteristicsForty- eight (94%) participating hospitals provided survey data regarding their availability of paediatric surgical resources (table 2).

The majority of hospitals had between one to three consultant paediatric surgeons for paediatric and neonatal surgery (n=30 (65%) and n=33 (72%) hospitals, respectively). Paediatric and neonatal intensive care were reliably available at just 14 (29%) and 17 (35%) hospitals, respectively. Only 14 (29%) hospitals had reliable access to parenteral nutrition. Central venous access was consis-tently available in only 16 (33%) hospitals for children and 14 (29%) hospitals for neonates. Reliable availability of specialist equipment was also limited: preformed silo use for gastroschisis (n=11 (23%) hospitals), air or hydroenema reduction for intussusception (n=14 (29%) and n=10 (21%) hospitals, respectively) and laparoscopic appendicectomy (n=9 (19%) hospitals). An anaesthetic doctor (including all levels of training) was available to undertake paediatric anaesthesia at 34 (71%) hospitals and neonatal anaesthesia at 17 (35%) hospitals.

An additional 23 hospitals (online supplemental appendix figure 1) provided survey data without patient data. Hospital characteristics were compared between these 23 hospitals and the 48 hospitals in the study using χ2 statistics and no differences were found at p<0.10.

OutcomesThere was a significant disparity in mortality between SSA and HICs for all paediatric surgical conditions: gastro-schisis (75.5% vs 2.0%, p<0.0001), ARM (11.2% vs 2.9%, p<0.0001), intussusception (9.4% vs 0.2%, p<0.0001), appendicitis (0.4% vs 0.004%, p=0.02) and inguinal hernia (0.2% vs 0.0%, p=0.008), respectively (figure 3).10 15 16 20 25 Mortality was highest among neonates (112/267, 41.9%), followed by infants (20/403, 5.0%) and children (7/720, 1.0%) (online supplemental appendix table 3).

Secondary outcomes are detailed in table 3. Eleven patients with ARM and one patient with an inguinal hernia died following discharge within 30- days of primary intervention. Hence, the 30- day post- primary interven-tion mortality for these conditions in SSA was 17.0% and 0.3%, respectively. Condition specific complications are detailed in online supplemental appendix tables 2a to 2e and patient follow- up in online supplemental appendix table 4.

On multivariable analysis of patients with gastroschisis, ARM and intussusception combined (generic patient variables only), the following were significant predictors of mortality (OR (95% CI), p value): ARM vs gastro-schisis (0.07 (0.02 to 0.18), <0.001), intussusception versus gastroschisis (0.03 (0.01 to 0.10), p<0.001), ASA score 3–5 vs 1–2 at primary intervention (3.91 (1.74 to 8.79), p=0.001), receiving a blood transfusion (3.72 (1.59 to 8.68), p=0.002) and not receiving anaesthesia due to no surgical intervention (10.48 (2.07 to 52.97), p=0.004) (online supplemental appendix table 5). In the second multivariable model incorporating hospital- level factors,

Table 2 Hospital resources available for paediatric surgery in sub- Saharan Africa (n=48 hospitals)

Hospital resource Availability, % (n)

Personnel*

Number of paediatric surgeons undertaking general paediatric surgery/hospital:

0 8.7 (4)

1–3 65.2 (30)

4 or more 26.1 (12)

Number of paediatric surgeons undertaking neonatal surgery/hospital:

0 10.9 (5)

1–3 71.7 (33)

4 or more 17.4 (8)

Number of general surgeons undertaking general paediatric surgery/hospital

0 47.8 (22)

1–3 32.6 (15)

4 or more 19.6 (9)

Number of general surgeons undertaking neonatal surgery/hospital:

0 67.4 (31)

1–3 21.7 (10)

4 or more 10.9 (5)

Number of medical officers undertaking general paediatric surgery/hospital:

0 78.3 (36)

1–3 15.2 (7)

4 or more 6.5 (3)

Number of medical officers undertaking neonatal surgery/hospital:

0 93.5 (43)

1–3 2.2 (1)

2 or more 4.3 (2)

Always available, % (n)

Sometimes/never available, % (n)

Infrastructure

Running water 93.8 (45) 6.2 (3)

Electricity 52.1 (25) 47.9 (23)

Electricity back- up generator

64.6 (31) 35.4 (17)

Laboratory for biochemistry 66.7 (32) 33.3 (16)

Laboratory for haematology 75.0 (36) 25.0 (12)

Blood bank 83.3 (40) 16.7 (8)

Functioning ultrasound machine

79.2 (38) 20.8 (10)

Fluoroscopy 27.1 (13) 72.9 (35)

Paediatric ventilation outside the operating room

31.3 (15) 68.7 (33)

Neonatal ventilation outside the operating room

31.3 (15) 68.7 (33)

PICU for children requiring surgical care

29.2 (14) 70.8 (34)

NICU for neonates requiring surgical care

35.4 (17) 64.6 (31)

Parenteral nutrition 29.2 (14) 70.8 (34)

Continued



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from








http://gh.bmj.com/


BMJ Global Health

the same patient- level factors remained significant; no hospital factors were significant.

Exploratory analysisOn univariable analysis of patients with gastroschisis, ARM and intussusception, individually, the generic variables significantly associated with mortality reflect those identified in the multivariable model of all three conditions combined (online supplemental appendix tables 6-8). Condition- specific variables associated with a higher mortality were (OR (95% CI), p value): complex gastroschisis (4.39 (1.12 to 17.20), p=0.034) and hypo-volaemia on arrival (7.84 (1.96 to 31.34), p=0.004) for patients with gastroschisis; sepsis on arrival (8.55 (2.89 to 25.34), p<0.001) and electrolyte disturbance (29.94 (6.31 to 142.05), p<0.001) and sepsis (22.20 (5.05 to 97.68), p<0.001) within 30 days of surgery, for patients with ARM; and sepsis on arrival (14.59 (3.10 to 68.70), p=0.001) and shock (8.98 (2.21 to 36.50), p=0.002) for patients with intussusception. Not having associated anomalies (0.24 (0.08 to 0.73), p=0.012) and not requiring ventilation (0.24 (0.07 to 0.82), p=0.022) were associated with a lower mortality for patients with ARM. Higher procedure score was associated with a lower mortality for gastro-schisis (0.16 (0.34 to 0.84), p=0.031); no hospital- level variables were significantly associated with mortality for ARM and intussusception.

Data validationValidation of the patient- level data showed very good agreement (observed agreement 94%; median kappa statistic 0.96) between the main study and validation data-sets (online supplemental appendix table 9). Validating investigators only identified one patient (with an inguinal



Surgical safety checklist in the operating room

43.8 (21) 56.3 (27)

Sterile gloves and gown 89.6 (43) 10.4 (5)

Autoclave for sterilising surgical equipment

89.6 (43) 10.4 (5)

Peña simulator for anorectal reconstruction

33.3 (16) 66.7 (32)

Procedures

Bianchi cotside closure of gastroschisis

27.1 (13) 72.9 (35)

Performed silo application, reduction and closure

22.9 (11) 77.1 (37)

Surgical silo application, reduction and closure

31.3 (15) 68.8 (33)

Primary closure of gastroschisis in the operating room

45.8 (22) 54.2 (26)

Sigmoid colostomy 83.3 (40) 16.7 (8)

Posterior sagittal anorectoplasty

85.4 (41) 14.6 (7)

Open appendectomy 93.8 (45) 6.3 (3)

Laparoscopic appendectomy

18.8 (9) 81.2 (9)

Ultrasound guided drainage of intra- abdominal collection

35.4 (17) 64.6 (31)

CT guided drainage of intra- abdominal collection

16.7 (8) 83.3 (40)

Personnel to diagnose intussusception on ultrasound

75.0 (36) 25.0 (12)

Air- enema reduction of intussusception

20.8 (10) 79.2 (38)

Hydro- enema reduction of intussusception

29.2 (14) 70.8 (34)

Laparotomy for intussusception

87.5 (42) 12.5 (6)

Open herniotomy 97.9 (47) 2.1 (1)

Laparoscopic herniotomy 12.5 (6) 87.5 (42)

Paediatric central line 33.3 (16) 66.7 (32)

Neonatal central line 29.2 (14) 70.8 (34)

Umbilical vein catheterisation

50.0 (24) 50.0 (24)

Anaesthesia and resuscitation

Paediatric bag, valve and mask

85.4 (41) 14.6 (7)

Bottled oxygen 77.1 (37) 22.9 (11)

Piped oxygen 56.3 (27) 43.7 (21)

Oxygen saturation monitor 75.0 (36) 25.0 (12)

Apnoea monitor 39.6 (19) 60.4 (29)

Multiparameter intraoperative monitoring

79.2 (38) 20.8 (10)

Anaesthetic machine for children

66.7 (32) 33.3 (16)

Anaesthetic machine for neonates

52.1 (25) 47.9 (23)

Ketamine anaesthesia for children

60.4 (29) 39.6 (19)

Table 2 Continued

Continued



Ketamine anaesthesia for neonates

43.8 (21) 56.2 (27)

Spinal/caudal anaesthesia for children

31.3 (15) 68.7 (33)

Spinal/caudal anaesthesia for neonates

29.2 (14) 70.8 (34)

Anaesthetic doctor to undertake paediatric anaesthesia†

70.8 (34) 29.2 (14)

Anaesthetic doctor to undertake neonatal anaesthesia†

35.4 (17) 64.6 (31)

Anaesthetic nurse to undertake paediatric anaesthesia†

56.2 (27) 43.8 (21)

Anaesthetic nurse to undertake neonatal anaesthesia†

43.8 (21) 56.2 (27)

46/48 hospitals provided data on personnel. 48/48 hospitals provided data for all other categories.*Includes consultant surgeons only.†Includes all grades/training levels.NICU, neonatal intensive care unit; PICU, paediatric intensive care unit.

Table 2 Continued



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from




http://gh.bmj.com/


BMJ Global Health

hernia) who was eligible for study inclusion, but not included. The validation survey identified the following variables as higher risk for inaccuracy: gestational age, distance from home to hospital, and time from arrival to intervention (online supplemental appendix table 10). Validation of the hospital data showed fair agree-ment between investigators independently completing the survey at each hospital (observed agreement 75%; median interclass correlation coefficient 0.58) (online supplemental appendix table 11).

DISCUSSIONThis multicentre, multinational prospective cohort study highlights significantly higher mortality rates for common paediatric surgical conditions in SSA compared with published benchmark mortality rates in HICs, particularly for neonates. The disparity in mortality was greatest in patients with gastroschisis (75.5% vs 2.0%), ARM (11.2% vs 2.9%) and intussusception (9.3% vs

0.2%), respectively. Correspondingly, overall mortality was highest among neonates (41.9%) compared with infants (5.0%) and children (1.0%). These results are consistent with the GlobalSurg Study on emergency abdominal surgery outcomes, which also reported much higher mortality rates in neonates (18%–24%) compared with infants (9%) and children (1%–4%) in low- income and middle- income countries (LMICs), globally.29 Our findings align with a systematic review of neonatal surgical outcomes in SSA, which reported an overall mortality of 31.8%, and over 50% mortality for emergency neonatal surgery involving gastrointestinal congenital anomalies such as gastroschisis.8

Congenital anomalies have recently risen to become the fifth- leading cause of death in children under 5 glob-ally (half a million annual deaths) and 11th leading cause of years of life lost for the global population.3 30 A recent study from Ghana highlighted that congenital anomalies accounted for 87% of neonatal surgical cases and 96%

Figure 3 A comparison between the mortality in sub- Saharan Africa and published benchmark mortality in high- income countries, with 95% CIs.10 15 16 20 25

Table 3 Secondary outcomes

Surgical site infection, % (number of cases/sample size)

Wound dehiscence, % (number of cases/sample size)

Unplanned reintervention, % (number of cases/sample size)

30- daypost- interventionmortality % (number of cases/sample size)*

Duration of hospital stay among patients who survived to discharge (days)†

Duration of hospital stay among patients who died in hospital (days)†

Gastroschisis 21.1 (20/95) 3.2 (3/94) 16.0 (15/94) 74.8 (83/111) 16.5, 7–24 4, 2–7

Anorectal malformation

23.1 (37/160) 9.4 (15/160) 11.2 (19/170) 17.0 (32/188) 7, 5–14 3, 2–5

Intussusception 25.4 (45/177) 7.3 (13/177) 11.6 (26/224) 9.3 (21/225) 7, 5–11 3, 2–5

Appendicitis 18.5 (45/243) 4.9 (12/243) 9.9 (24/243) 0.4 (1/250) 5, 4–8 3

Inguinal hernia 4.2 (26/625) 1.0 (6/625) 1.3 (8/624) 0.3 (2/633) 1, 1–3 1

*Study population used as denominator; 30- day post intervention mortality status unknown for 16.4% patients (online supplemental appendix table 4).†Median, IQR. One patient died in each of the appendicitis and inguinal hernia categories, hence IQR not available.



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from






http://gh.bmj.com/


BMJ Global Health

of deaths; two- thirds of the congenital anomaly deaths were in conditions involving the gastrointestinal tract.31 It is estimated that two- thirds of the deaths and disability from congenital anomalies can be prevented through surgical care.32 However, improving neonatal surgical care has received little global focus or action to date.33 Deaths from congenital anomalies fell very little from 2005 to 2015 (-3.2%) compared with the other leading causes of under 5 mortality (−25.9% preterm birth, −16.1% neonatal encephalopathy, −36.9% lower respi-ratory infections, −34.3% diarrhoeal diseases, −42.8% malaria).3 Sustainable Development Goal (SDG) 3.2 aims to ‘end preventable deaths in neonates and children under 5 by 2030’.34 The high mortality among neonates with congenital anomalies in this study, and in the system-atic review of neonatal surgical outcomes in SSA, high-light the urgent need to target improvements in neonatal surgical care for this to be achieved.

Higher ASA score at primary intervention, needing/receiving a blood transfusion and paediatric surgical condition, were significantly associated with mortality on multivariable analysis of generic variables related to patients with gastroschisis, ARM and intussusception. Exploratory analysis of the condition- specific variables for the individual conditions, although only univariable and hence less robust, provides some further insights; higher mortality was significantly associated with having complex gastroschisis and hypovolaemia on arrival for patients with gastroschisis, and sepsis on arrival for patients with ARM and intussusception. Indeed, the high proportion of patients presenting with sepsis, hypovo-laemia and other indicators of advanced disease severity, account for the large proportion of patients with high ASA scores at primary intervention. Some deficiencies were also identified in preintervention resuscitation which may also impact on the ASA score. The surgical condition determines how quickly clinical deterioration can progress without appropriate care. Patients with gastroschisis deteriorate most rapidly due to the large surface area of exposed bowel resulting in hypothermia, hypovolaemia and sepsis, within hours if plastic bowel coverage and resuscitative measures are not instigated at birth.35 Hence, interventions to improve outcomes must focus on improving resuscitation and timely referral/transportation at the district level, and preintervention resuscitation and perioperative care at paediatric surgery centres. This aligns with recommendations by Kruk et al that to achieve improved outcomes in the SDG era, enhancing access to services must be accompanied by improved quality of care within facilities.36–38 Studies from individual paediatric surgical centres in SSA have reported similar findings and conclusions.39

The hospital survey highlighted numerous deficiencies in resources required to provide high- quality paediatric surgical care; less than a third of hospitals had ventilation, parenteral nutrition and central intravenous access facil-ities for neonates. Our findings are consistent with those of the PediPIPES hospital survey undertaken in West

Africa which reported that over half of the hospitals had less than three paediatric surgeons, half had no neonatal or paediatric intensive care, life- saving equipment such as apnoea monitors were deficient, and minimally invasive interventions such as non- operative reduction of intus-susception were frequently unavailable.40 Interestingly, we found that hospital- level factors were not significantly associated with mortality on multivariable analysis. This may be related to insufficient patient numbers, but also may mirror other studies highlighting that resources alone do not determine outcomes; it is the actions undertaken by an effective workforce using the avail-able resources, that result in improved care.36 41 Indeed, higher procedure availability, incorporating both skilled healthcare personnel and resources, was associated with lower mortality on univariable analysis for patients with gastroschisis.

The Global Initiative for Children’s Surgery (GICS) provides a framework for improving children’s surgical care and outcomes in LMICs within four main domains: infrastructure, service delivery, training and research.42 GICS has produced the Optimal Resources for Children’s Surgery guidelines detailing what is required within each domain at every level of healthcare.43 This has recently been used alongside a paediatric modified WHO assess-ment tool to help integrate children’s surgical care into the Nigerian National Surgical, Obstetric and Anaes-thetic Plan (NSOAP).44 45 This can be used as a template for other SSA countries and LMICs globally, to include children’s surgical care within National Health Plans. Government engagement and investment will be essen-tial to ensure implementation of NSOAPs and ultimately improved surgical outcomes.46 This study highlights the importance of ensuring neonatal surgical care is a key focus of these plans as it is where a large proportion of the mortality burden lies.

International and local partnerships can help support the government with specific NSOAP goals. For example, the KidsOR Charity is investing in building children’s operating facilities, and training paediatric surgeons and anaesthetists, across SSA.47 The hub and spoke model used in India whereby multidisciplinary teams (MDTs) from paediatric surgical centres provide outreach teaching to district hospital teams and create referral networks, is an excellent example of how local partner-ships can help to optimise district level care.48 However, to enable fast and safe transfer when needed, this must be coupled with investment into the transport system. In response to the results of this study, a multicentre, multi-national interventional study has been funded aimed at reducing mortality from gastroschisis in SSA.49 50 In addi-tion to outreach teaching and establishment of referral networks, it incorporates evidence- based protocolised care at the paediatric surgical centres with a focus on resuscitation at presentation, perioperative care and MDT collaboration; a model that could benefit neonatal and paediatric surgical conditions more broadly.51 Locally sourced parenteral nutrition and low- cost preformed silos



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

http://gh.bmj.com/


BMJ Global Health

were included, highlighting the importance of investing in vital resources alongside workforce interventions.

Further partnerships are required with obstetric teams to optimise antenatal diagnosis and delivery of neonates with congenital anomalies such as gastroschisis, at paedi-atric surgery centres. Just 4.5% of neonates with gastro-schisis were antenatally diagnosed in this study and 7.3% born at a tertiary centre; these interventions, which are standard practice in HICs, would avoid clinical deterio-ration before reaching paediatric surgical care. Partner-ships with existing child health programmes, such as the WHO Every Newborn Action Plan, are required to opti-mise early recognition, resuscitation and safe transfer of surgical neonates and children at the community and district level.46 52 53 In addition, there is a need for further research into the management and outcomes of a wider selection of congenital anomalies requiring surgical care in SSA, particularly congenital anomalies involving the gastrointestinal tract which are commonly fatal without timely access to quality neonatal surgical care following birth. Following on from this study, the PaedSurg Africa Research Collaboration has been expanded to form the Global PaedSurg Research Collaboration with the first study focused on the management and outcomes of a wider selection of common gastrointestinal congenital anomalies in low, middle and HICs, globally.54

LimitationsAlthough this study provides some of the most comprehen-sive, high- quality, validated paediatric surgical outcome data from SSA, there are limitations. The study covered just 19 of the 48 countries in SSA. However, the sample was reasonably representative containing 9 low- income countries (LICs), 9 lower- middle income countries and 1 upper- middle income country (UMIC) compared with 14 LICs, 9 lower- middle income countries, 4 UMICs and 2 HICs that were not included. All geographical regions (West, East, Central and South Africa) were represented. Nigeria accounted for 644 (45.8%) of the study patients. This reflects the high population in Nigeria (18% of the SSA population) and high number of paediatric surgeons (87 compared with a median of 4/country across SSA).5 The overall 30- day post intervention mortality was 6.2% (40/644) in Nigeria and 13.0% (99/763) among the other 18 countries. Hence, mortality rates for the paedi-atric surgical conditions across all SSA countries could be slightly higher than reported. Although some countries in chronic conflict, such as the Democratic Republic of the Congo and Sudan were included, the study was not specifically designed to address the unique challenges faced in these regions, which may have an impact on mortality.

There are a number of additional reasons why the mortality and morbidity may be underestimated. Data collection was at an institutional level rather than popu-lation level and some patients may have died before reaching the study centres.55 56 In contrast, the hospital data from HICs likely reflects the population mortality

due to better access and higher- quality antenatal services, district- level care and transportation. Indeed the HIC comparator mortality rates used may be an overestimate of the current mortality in these regions due to further reductions over time, particularly for the ARM data, which was published in 2008.15 30- day post interven-tion mortality status was not known for 16.4% patients and hence some deaths following discharge could have been missed, as could complications. A convenience sample of self- selected paediatric surgery centres was used, which could represent the more academic hospi-tals with better outcomes. Participating hospitals with greater human resource capacity could have been more likely to contribute a greater number of months of data to the study. Bias was minimised by adjusting both the univariable and multivariable analyses for clustering at a hospital level. Patients with appendicitis and inguinal hernia could also be managed at district hospitals where paediatric surgical and anaesthetic expertise are likely lower and less resourced.

For feasibility reasons, the study included just five common paediatric surgical conditions rather than all paediatric surgical cases. Inclusion of gastroschisis in the selection of study conditions, with such a high mortality, may have elevated the overall neonatal mortality in comparison to the broader range of neonatal surgical conditions in SSA. However, our results are similar to the systematic review of all neonatal surgical conditions in SSA.8 In contrast, the true mortality from the broader range of paediatric surgical conditions among children over 1 year of age in SSA may be higher. This is because acute abdomen in children in HICs is mostly related to appendicitis, but in SSA typhoid perforation is also prev-alent, with reported mortality of 14.7%.57 To optimise feasibility, data collection was limited to information that would be known to the team caring for the study patients without the need for additional measurements. Hence, variables such as weight- for- length/height z- score to clas-sify nutritional status were not included, but could have an impact on outcomes.

Finally, HIC benchmark data were used as the compar-ator. The HIC studies selected had reasonable compara-bility in terms of duration of follow- up, patient population and study setting, however it would be more accurate to compare observed outcomes in SSA directly with HIC outcomes collected simultaneously within the same study. This has been incorporated into our follow- on study, Global PaedSurg, where outcomes from gastrointestinal congenital anomalies will be collected globally.54 The latter will also facilitate collection of larger sample sizes to provide greater insights into factors affecting mortality that can be modified to improve outcomes.

CONCLUSIONSThis study highlights unacceptably high mortality from common paediatric surgical conditions in SSA compared with HICs, particularly for neonates. It provides data to



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

http://gh.bmj.com/


BMJ Global Health

support the assertion that SDG 3.2 to end preventable deaths in neonates and children under 5 by 2030 will not be achieved without global focus, considerable invest-ment and action to improve paediatric surgical care in SSA.

Acknowledgements Thank you to Bolaji Coker and Ruth Owen who managed the REDCap data collection tool at King’s College London.

Collaborators Benin Republic: Houessou Gandjehou (Centre Hospitalier Departemental du Zou et des Collines), Ebassa Karl (National Teaching Hospital, University of Abomey- Calari, Cotonou). Botswana: Goutam Chowdhury (University of Botswana). Gambia: Alagie Manneh (Edward Francis Small Teaching Hospital, Banjul). Ghana: Michael Amoah, Boateng Nimako (Komfo Anokye Teaching Hospital, Kumasi). Kenya: Allan Kochi (Coast General Hospital, Mombasa), Rashmi Kumar, Intisar Hisham (Kenyatta National Hospital, University of Nairobi), Connie Keung, Robert Kuremu (Moi University, Eldoret). Madagascar: Heuric Rakotomalala (Bethany Kids Hospital). Niger: Habou Oumarou (Université de Zinder). Nigeria: Okafor David (Federal Teaching Hospital, Abakaliki, Ebonyi State), Faruk A Suleiman (Federal Teaching Hospital, Gombe), Faturoti Olubukola (General Hospital Lagos Island), Innocent Igwilo (Imo State Specialist Hospital, Owerri), Alwanlehi Eighemhenrio (Irrua Specialist Teaching Hospital, Irrua, Edo State), Andrew Shitta (Jos University Hospital), Musa Ibrahim Zarenawa (Murtala Muhammed Specialist Hospital, Kano), Iyekeoretin Evbuomwan (University of Benin Teaching Hospital, Benin City), Wabada Samuel (University of Maiduguri Teaching Hospital). Rwanda: Emmanuel Kayibanda (King Faisal Hospital, Kigali), Ainhoa Costas- Chavarri, Joseph Lule (Rwanda Military Hospital, Kigali). Somaliland: Riikka Valjakka (Boroma Regional Hospital, Awdal Region). Uganda: Anne Wesonga (Hoima Regional Referral Hospital).

Contributors Author Contributions: Naomi J Wright (Principal Investigator and Study Guarantor) conceived the study, designed, wrote and registered the protocol, gained ethical approval, designed the data collection tool, established the PaedSurg Africa Research Collaboration, co- ordinated data collection and validation, undertook data analysis, write- up and dissemination. Niyi Ade- Ajayi, Emmanuel Ameh, Kokila Lakhoo, Dan Poenaru and Andrew JM Leather (Steering and Writing Committee) provided critical input and revisions to the study design, protocol, data collection and validation tools, data analysis and write- up. Taiwo Akeem Lawal, Justine Seyi- Olajide and Stephen Tabiri also contributed as writing committee members. Emily Rose Smith and Alessandra Bisquera undertook data analysis, validation and interpretation, and contributed to the manuscript write- up. Lawal Abdullahi, Elisee Bake, Jacques Fadhili Bake, Bernadette Béré, Nwokoro Collins, Sharon Cox, Bertille Ki, Luc Malemo, Aminu Mohammad, Aberibigbe M.O. Shonubi, Albert Wandaogo (Lead Investigators) undertook pilot studies of the data collection tools and validation tools; provided feedback and critical input to the study design; and contributed to the write- up and dissemination of findings. All were also Local Investigators. Anyanwu Lofty John Chukwuemeka, Sharon Cox, Bip Nandi, Daniel Sidler, Stephen Tabiri (Country Leads) recruited local investigators from across their country and other countries in sub- Saharan Africa and provided support and guidance to Local Investigators, particularly with gaining ethical approval. Local investigators recruited and co- ordinated a local team or several mini- teams of researchers; used the study protocol to gain local ethical approval; selected patients for study inclusion and undertook patient consent when required; collected and uploaded data to REDCap electronic data capture software; ensured complete and accurate datasets without duplications; completed a survey regarding local resources available for paediatric surgical care; and disseminated the results through local, national and international presentations. 10% of centres participated in data validation. All authors read the manuscript, contributed revisions as required and approved the final manuscript. Collaborator Contributions: Study collaborators completed a survey regarding their local resources for paediatric surgical care and participated in dissemination of the study results through local, national and international conference presentations.

Funding This study was funded by the Royal College of Surgeons (RCS) of England. Naomi J Wright currently receives funding from the Wellcome Trust to undertake a Clinical PhD in Global Health at King’s Centre for Global Health and Health Partnerships, King’s College London (Funder Reference: 203905/Z/16/Z). Andrew Leather receives funding from the NIHR Global Health Research Unit on Health System Strengthening in Sub- Saharan Africa, King’s College London (GHRU 16/136/54) and by the ASPIRES research programme in LMICs (Antibiotic use across Surgical Pathways—Investigating, Redesigning and Evaluating Systems), funded by the Economic and Social Research Council. The views expressed are those of the authors and not necessarily those of the RCS, Wellcome Trust,

the NIHR or the Economic and Social Research Council. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Map disclaimer The depiction of boundaries on this map does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. This map is provided without any warranty of any kind, either express or implied.

Competing interests None declared.

Patient consent for publication Not required.

Ethics approval Ethical approval was granted by the host institution (Ref: LRS-15/16–2949) and at all participating hospitals.

Provenance and peer review Not commissioned; externally peer reviewed.

Data availability statement Once published, the full anonymous, de- identified patient and hospital datasets will be made publicly available via the Centre for Open Science website: https:// osf. io/ 72pkj/.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer- reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Open access This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https:// creativecommons. org/ licenses/ by/ 4. 0/.

Author note Principal investigator (PI) and study guarantor: Naomi Wright (King’s College London, UK). Steering committee: Niyi Ade- Ajayi (King’s College Hospital, UK), Emmanuel Ameh (National Hospital, Abuja, Nigeria), Kokila Lakhoo (Oxford University Hospitals, UK), Dan Poenaru (McGill University, Montreal, Canada), Andrew JM Leather (King’s College London, UK). Data analysis: Emily Rose Smith (Baylor University, Texas, USA), Alessandra Bisquera (King’s College London, UK) and PI. Writing committee: Anyanwu Lofty John Chukwuemeka (Aminu Kano Teaching Hospital, Nigeria), Taiwo Akeem Lawal (University College Hospital, Ibadan, Nigeria), Justine Seyi- Olajide (Lagos University Teaching Hospital), Stephen Tabiri (Tamale Teaching Hospital, Ghana), PI, steering committee and data analysis teams. Lead investigators: Aminu Mohammad, Lawal Abdullahi (Aminu Kano Teaching Hospital, Nigeria), Bertille Ki, Albert Wandaogo, Bernadette Béré (Charles De Gaulle Pediatric University Teaching Hospital, Ouagadougou), Luc Malemo, Elisee Bake (HEAL Africa Hospital, Democratic Republic of the Congo), Nwokoro Collins, Aberibigbe M. O. Shonubi (Olabisi Onabanjo University Teaching Hospital, Nigeria), Sharon Cox (Red Cross War Memorial Children’s Hospital, South Africa). Country leads: Anyanwu Lofty John Chukwuemeka (Aminu Kano Teaching Hospital, Nigeria), Sharon Cox (Red Cross War Memorial Children’s Hospital, South Africa), Bip Nandi (Kamuzu Central Hospital, Malawi), Daniel Sidler (Tygerberg Hospital, South Africa). Local investigators: Benin Republique: Houégban Romeo, Gbenou Antoine Seraphin, Eugene Zoumenou (Centre Hospitalier Universitaire de la Mère et de l'Enfant, Cotonou). Burkina Faso: Bernadette Béré, Bandré Emile, Bertille Ki, Tapsoba W. Toussaint, Albert Wandaogo, Kabre Yvette (Charles De Gaulle Pediatric University Teaching Hospital, Ouagadougou). Cote D’ivoire: Rouma Bankole, Manuela Ehua, Agbara Kouame, Moulot Olivier (Teaching Hospital Treichville, Abidjan), Nandiolo Rose (University Hospital De Bouaké). Democratic Republic of the Congo: Jacques Fadhili Bake (HEAL Africa Hospital, Goma). Ethiopia: Mesay Hailemariam Asfaw, Miliard Derbew, Gudeta Didi, Hanna Getachew, Woubedil Kiflu, Samuel Negash, Tihitiena Negussie, Amezene Tadesse, Fiseha Temesgen (Tikur Anbessa Specialized Hospital, Addis Ababa). Ghana: William Appeadu- Mensah, Afua Hesse, Samuel Osei- Nketiah (Korle Bu Teaching Hospital, Accra), Francis Atidana Abantanga, Emmanuel Owusu Abem, Theophilus Teddy Kojo Anyomih, Adakudugu Ida, Osman Imoro, Martin Kyere, Anwar Sadat Seidu, Stephen Tabiri, Paul M. Wondoh (Tamale Teaching Hospital). Kenya: Thomas Kirengo (Embu Level 5 Hospital), Michael Ganey, Michael Mwachiro, Robert K Parker, Sinkeet Ranketi (Tenwek Hospital, Bomet). Malawi: Bitiel Banda, Caroline Melhado, Bip Nandi



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

https://osf.io/72pkj/

https://creativecommons.org/licenses/by/4.0/

https://creativecommons.org/licenses/by/4.0/

http://gh.bmj.com/


BMJ Global Health

(Kamuzu Central Hospital, Lilongwe), Eric Borgstein, Mohakhelha Nyamulani, Emma Thomson, Johannes Verweij (Queen Elizabeth Central Hospital, Blantyre). Niger: Moustapha Helle (Niamey National Hospital). Nigeria: Emmanuel Ameh, Paschal Anyanwu, Matthias Igoche (Abuja National Hospital), Elizabeth Ogboli- Nwasor, Baba Suleiman, Sholadoye Tunde Talib (Ahmadu Bello University Teaching Hospital, Zaria), Mustapha Abdulazeez, Lawal Abdullahi, Farinyaro Aliyu, Aminu Mohammad, Aliyu Mohammed (Aminu Kano Teaching Hospital), Bassey Edem, Terlumun Patrick, Charles Soo (Benue State University Teaching Hospital), Akinlabi Emmanuel Ajao, Olayemi Anthony Ajiboye, Michael Abel Alao (Bowen University Teaching Hospital, Ogbomoso), Odion- obomhense kesiena Helen (Delta state university teaching hospital Ogharra, Delta state), Opeoluwa Adesanya, Adenike Odewabi, Anuoluwapo Aremo (Federal Medical Centre, Abeokuta), Taiwo Jones Olaoluwa, Odi Temitope (Federal Medical Centre, Lokoja), Kayode Bamigbola, Uduehe Enono E. (Federal Medical Centre, Owo, Ondo State), Olalekan Ajai, Omolara Faboya, Abdulsalam Moruf, Roland I Osuoji, Omolara M. Williams (Lagos State University Teaching Hospital), Fatuga Adedeji, Adesoji Ademuyiwa, Felix Alakaloko, Christopher Bode, Ihediwa Chibuike, Ibironke Desalu, Olumide Abiodun Elebute, Charles Ememonu, Oluwaseun Ladipo- Ajayi, Sola Kushimo, Justina Seyi- Olajide, Kayode Olayade, Adebambo Olowu, Justine Seyi- Olajide (Lagos University Teaching Hospital), Okechukwu Hyginus Ekwunife, Victor Ifeanyichukwu Modekwe, Obiechina Sylvester Okwuchukwu, Ngozi Chidinma Osuji, Ezidiegwu Ugochukwu Stanley, Jideofor Okechukwu Ugwu, Chuka Ifeanyichukwu Ugwunne (Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State), Collins Chijioke Adumah, Oludayo Adedapo Sowande, Ademola Olusegun Talabi (Obafemi Awolowo University Teaching Hospital, Ile Ife), Lukmon Amosu, Nwokoro Collins, Ibukunolu Ogundele, Aderibigbe M. O. Shonubi (Olabisi Onabanjo University Teaching Hospital), Felix Kumolalo (Ondo State Trauma and Surgical Centre), Taiwo Akeem Lawal, Olakayode Ogundoyin, Dare Olulana (University College Hospital, Ibadan), John Chinda, Osagie Olabisi, Samson Olori (University of Abuja Teaching Hospital, Gwagwalada), Stella Eguma, Akan Inyang, Ijeoma Esther Nwachukwu (University of Calabar Teaching Hospital), Nurudeen Toyin Abdulraheem, Lukman O. Abdur- Rahman, James O. Adeniran, Muslimat A. Alada, Abdulrasheed A. Nasir, David C. Nwosu (University of Ilorin Teaching Hospital, Ilorin), Christopher C Amah, Sebastian Okwuchukwu Ekenze, Uchechukwu Obiora Ezomike, Emmanuel I. Nwangwu, Ijeoma C. Obianyo, Nene E Obianyo, Nwankwo Elochukwu Perpetua (University of Nigeria Teaching Hospital, Ituku/ Ozalla, Enugu), Alfred T Aggo, Tobin Maxwell, Philemon Okoro (University of Port Harcourt Teaching Hospital). Republic of Cameroon: James A. Brown, Moses Kasumba, Steve Kyota (Mbingo Baptist Hospital). Somaliland: Joy Robinson (Edna Adan Maternity Hospital). South Africa: Seo- Hwa Chung, Savannah smit, Stephanie Van Straten, Andre Theron (Charlotte Maxeke Johannesburg Academic Hospital), Andrew Grieve, Robert Jaich, Jerome Loveland (Chris Hani Baragwanath Hospital), Charles Carapinha (Clinton Hospital, Johannesburg), Milind Chitnis, Mie Elsen, Nayha Gautam (East London Hospital Complex, Walter Sisulu University), Damian Clarke, Shamaman Harilal, Sanele Madziba, Hansraj Mangray, Reitze Rodseth (Grey's Hospital, Pietermaritzburg Metropolitan Hospital Complex), Sharon Cox, Babalwa Nondela, Toru Shimizu (Red Cross War Memorial Children's Hospital), Roel Matos- Puig, Ria Naidoo, Arasha Thotharam (Stranger Hospital, Kwazulu- Natal), Kondjela Sara Hamunyela, Daniel Sidler, Corne De Vos (Tygerberg Hospital, Stellenbosch University). Sudan: Ali Hamad (Gezira National Center of Paediatric Surgery, Wad- Medania), Abdelbasit E Ali, Enas Musa Ismail (Soba University Hospital, Khartoum). Tanzania: Larry Akoko, Robert Bahati, Zaitun M Bokhary, Yona Ringo (Muhimbili National Hospital, Dar es Salaam), Peter Dattani, Ezekiel Kambona, Silas Msangi (Tumbi Regional Referral Hospital, Kibaha). Togo: Komla Gnassingbé, Hamza Doles Sama (Sylvanus Olympio Teaching Hospitalier, Lome). Uganda: Nasser Kakembo, Phyllis Kisa, Mary T Nabukenya, John Sekabira (Mulago National Referral Hospital, Kampala). Zambia: Bruce Bvulani, Mulewa Mulenga, Emma Lillie, Rae Oranmore- Brown, Hope Phiri, Victoria Simiyu (University Teaching Hospital (UTH) in Lusaka). Zimbabwe: Tungamirai Gwatirisa, Bothwell Mbuwayesango (Harare Central Hospital).

REFERENCES 1 Wright NJ, Anderson JE, Ozgediz D, et al. Addressing paediatric

surgical care on world birth defects day. Lancet 2018;391:1019. 2 Mullapudi B, Grabski D, Ameh E, et al. Estimates of number of

children and adolescents without access to surgical care. Bull World Health Organ 2019;97:254–8.

3 GBD 2015 Child Mortality Collaborators. 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 2016;388:1725–74.

4 Meara JG, Leather AJM, Hagander L, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015;386:569–624.

5 Krishnaswami S, Nwomeh BC, Ameh EA. The pediatric surgery workforce in low- and middle- income countries: problems and priorities. Semin Pediatr Surg 2016;25:32–42.

6 Horton R. Offline: The false narrative of "tremendous progress". Lancet 2019;394:1129.

7 Butler EK, Tran TM, Fuller AT, et al. Quantifying the pediatric surgical need in Uganda: results of a nationwide cross- sectional, household survey. Pediatr Surg Int 2016;32:1075–85.

8 Ekenze SO, Ajuzieogu OV, Nwomeh BC. Neonatal surgery in Africa: a systematic review and meta- analysis of challenges of management and outcome. Lancet 2015;385 Suppl 2:S35.

9 Wright NJ, Zani A, Ade- Ajayi N. Epidemiology, management and outcome of gastroschisis in sub- Saharan Africa: results of an international survey. Afr J Paediatr Surg 2015;12:1–6.

10 Bradnock TJ, Marven S, Owen A, et al. Gastroschisis: one year outcomes from national cohort study. BMJ 2011;343:d6749.

11 Arnold M. Is the incidence of gastroschisis rising in South Africa in accordance with international trends? A retrospective analysis at Pretoria academic and Kalafong hospitals, 1981-2001. S Afr J Surg 2004;42:86–8.

12 Ford K, Poenaru D, Moulot O, et al. Gastroschisis: bellwether for neonatal surgery capacity in low resource settings? J Pediatr Surg 2016;51:1262–7.

13 Chirdan LB, Uba FA, Ameh EA, et al. Colostomy for high anorectal malformation: an evaluation of morbidity and mortality in a developing country. Pediatr Surg Int 2008;24:407–10.

14 Ameh EA, Chirdan LB. Neonatal intestinal obstruction in Zaria, Nigeria. East Afr Med J 2000;77:510–3.

15 Rintala RJ, Pakarinen MP. Imperforate anus: long- and short- term outcome. Semin Pediatr Surg 2008;17:79–89.

16 Jiang J, Jiang B, Parashar U, et al. Childhood intussusception: a literature review. PLoS One 2013;8:e68482.

17 Ameh EA, Abantanga FA, Birabwa- Male D. Surgical aspects of bacterial infection in African children. Semin Pediatr Surg 2012;21:116–24.

18 Hadley GP. Intra- abdominal sepsis--epidemiology, aetiology and management. Semin Pediatr Surg 2014;23:357–62.

19 Ademola TO, Oludayo SA, Samuel OA, et al. Clinicopathological review of 156 appendicectomies for acute appendicitis in children in Ile- Ife, Nigeria: a retrospective analysis. BMC Emerg Med 2015;15:7.

20 Ein SH, Njere I, Ein A. Six thousand three hundred sixty- one pediatric inguinal hernias: a 35- year review. J Pediatr Surg 2006;41:980–6.

21 Bamigbola KT, Nasir AA, Abdur- Rahman LO, et al. Complicated childhood inguinal hernias in UITH, Ilorin. Afr J Paediatr Surg 2012;9:227–30.

22 Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)--a metadata- driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377–81.

23 Surgeons Overseas (SOS). Pedi pipes assessment of pediatric surgical capacity. Available: http://www. adamkushnermd. com/ files/ PediPIPES. pdf [Accessed 5th Jan 2019].

24 Wright N, Ameh EA, Lakhoo K, et al. PaedSurg Africa study protocol V5, 2016. Available: https:// osf. io/ 72pkj/

25 Healy DA, Doyle D, Moynagh E, et al. Systematic review and meta- analysis on the influence of surgeon specialization on outcomes following appendicectomy in children. Medicine 2015;94:e1352.

26 Population reference bureau. Available: https:// assets. prb. org/ pdf13/ 2013- population- data- sheet_ eng. pdf [Accessed 6 Jan 2019].

27 Ryan G. One in 5000 Foundation, 2020. Available: http://www. onein5000foundation. org/ aims [Accessed 3 Nov 2020].

28 Ireland D. CDH international, 2020. Available: https:// cdhi. org/ about/ [Accessed 3 Nov 2020].

29 GlobalSurg Collaborative. Determinants of morbidity and mortality following emergency abdominal surgery in children in low- income and middle- income countries. BMJ Glob Health 2016;1:e000091.

30 GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the global burden of disease study 2015. Lancet 2016;388:1545–602.

31 Abdul- Mumin A, Anyomih TTK, Owusu SA, et al. Burden of neonatal surgical conditions in northern Ghana. World J Surg 2020;44:3–11.

32 Farmer D, Sitkin N, Lofberg K. Surgical Interventions for Congenital Anomalies. In: Debas HT, Donkor P, Gawande A, eds. Essential surgery: disease control priorities, third edition (volume 1). Washington (DC), 2015.



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

http://dx.doi.org/10.1016/S0140-6736(18)30501-4

http://dx.doi.org/10.2471/BLT.18.216028

http://dx.doi.org/10.2471/BLT.18.216028

http://dx.doi.org/10.1016/S0140-6736(16)31575-6

http://dx.doi.org/10.1016/S0140-6736(15)60160-X

http://dx.doi.org/10.1053/j.sempedsurg.2015.09.007

http://dx.doi.org/10.1016/S0140-6736(19)32208-1

http://dx.doi.org/10.1007/s00383-016-3957-3

http://dx.doi.org/10.1016/S0140-6736(15)60830-3

http://dx.doi.org/10.4103/0189-6725.150924

http://dx.doi.org/10.1136/bmj.d6749

http://www.ncbi.nlm.nih.gov/pubmed/15532615

http://dx.doi.org/10.1016/j.jpedsurg.2016.02.090

http://dx.doi.org/10.1007/s00383-008-2114-z

http://dx.doi.org/10.4314/eamj.v77i9.46702


http://dx.doi.org/10.1371/journal.pone.0068482



http://dx.doi.org/10.1186/s12873-015-0030-9

http://dx.doi.org/10.1016/j.jpedsurg.2006.01.020

http://dx.doi.org/10.4103/0189-6725.104725

http://dx.doi.org/10.1016/j.jbi.2008.08.010

http://dx.doi.org/10.1016/j.jbi.2008.08.010

http://www.adamkushnermd.com/files/PediPIPES.pdf

http://www.adamkushnermd.com/files/PediPIPES.pdf

https://osf.io/72pkj/

http://dx.doi.org/10.1097/MD.0000000000001352

https://assets.prb.org/pdf13/2013-population-data-sheet_eng.pdf

https://assets.prb.org/pdf13/2013-population-data-sheet_eng.pdf

http://www.onein5000foundation.org/aims

http://www.onein5000foundation.org/aims

https://cdhi.org/about/

http://dx.doi.org/10.1136/bmjgh-2016-000091

http://dx.doi.org/10.1016/S0140-6736(16)31678-6

http://dx.doi.org/10.1007/s00268-019-05210-9

http://gh.bmj.com/


BMJ Global Health

33 Bickler SN, Weiser TG, Kassebaum N. Global Burden of Surgical Conditions. In: Debas HT, Donkor P, Gawande A, et al, eds. Essential surgery: disease control priorities, third edition (volume 1). Washington (DC), 2015.

34 United Nations. Sustainable development goals, 2015. Available: http://www. un. org/ sust aina bled evel opment/ health/ [Accessed 12 Oct 2020].

35 Wright NJ, Sekabira J, Ade- Ajayi N. Care of infants with gastroschisis in low- resource settings. Semin Pediatr Surg 2018;27:321–6.

36 Kruk ME, Gage AD, Arsenault C, et al. High- Quality health systems in the sustainable development goals era: time for a revolution. Lancet Glob Health 2018;6:e1196–252.

37 Kruk ME, Gage AD, Joseph NT, et al. Mortality due to low- quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries. Lancet 2018;392:2203–12.

38 Roder- DeWan S, Nimako K, Twum- Danso NAY, et al. Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap. BMJ Glob Health 2020;5:e002539.

39 Tenge- Kuremu R, Kituyi PW, Tenge CN. Neonatal surgical emergencies at Moi teaching and referral hospital in Eldoret, Kenya. East and Central African Journal of Surgery 2006;12:36–9.

40 Okoye MT, Ameh EA, Kushner AL, et al. A pilot survey of pediatric surgical capacity in West Africa. World J Surg 2015;39:669–76.

41 Leslie HH, Sun Z, Kruk ME. Association between infrastructure and observed quality of care in 4 healthcare services: a cross- sectional study of 4,300 facilities in 8 countries. PLoS Med 2017;14:e1002464.

42 Global Initiative for Children’s Surgery (GICS). Global Initiative for Children’s Surgery: A Model of Global Collaboration to Advance the Surgical Care of Children. World J Surg 2019.

43 Global Initiative for Children’s Surgery. Optimal Resources for Children’s Surgical Care: Executive Summary. World J Surg 2019;43:978–80.

44 Nigeria Federal Ministry of Health. National Surgical, Obstetrics, Anaesthesia & Nursing Plan (NSOANP) for Nigeria. Strategic Priorities for Surgical Care (StraPS) Planning for a Future of Surgical Equity, Safety & Progress 2019 - 2023, 2019. Available: https:// 6cde3faa- 9fe6- 4a8d- a485- 408738b17bc2. filesusr. com/ ugd/ d9a674_ 1f7a a816 1c95 4e2d bf23 7512 13bc6f52. pdf

45 WHO, PGSSC, GICS. WHO- PGSSC- GICS Children’s surgical assessment tool (CSAT), 2018. Available: https://www. glob alch ildr

enss urgery. org/ wp- content/ uploads/ 2019/ 10/ Childrens- Surgical- Assessment- Tool_ March- 2018. pdf

46 Smith ER, Concepcion TL, Niemeier KJ, et al. Is global pediatric surgery a good investment? World J Surg 2019;43:1450–5.

47 KidsOR charity: surgery for children. Available: https://www. kidsor. org

48 Madhuri V, Stewart RJ, Lakhoo K. Training of children’s surgical teams at district level in low- and middle- income countries (LMIC): from concept to reality—a south to south initiative. International Journal of Surgery: Global Health, 2019.

49 Wright N, Abantanga F, Amoah M, et al. Developing and implementing an interventional bundle to reduce mortality from gastroschisis in low- resource settings. Wellcome Open Res 2019;4:46.

50 Wright NJ, Langer M, Norman IC, et al. Improving outcomes for neonates with gastroschisis in low- income and middle- income countries: a systematic review protocol. BMJ Paediatr Open 2018;2:e000392.

51 Meade MO, Ely EW. Protocols to improve the care of critically ill pediatric and adult patients. JAMA 2002;288:2601–3.

52 Goley SM, Sakula- Barry S, Kelly A, et al. Investigating the use of ultrasonography for the antenatal diagnosis of structural congenital anomalies in low- income and middle- income countries: systematic review protocol. BMJ Paediatr Open 2019;3:e000538.

53 World Health Organisation. Every newborn action plan., 2020. Available: https://www. who. int/ maternal_ child_ adolescent/ newborns/ every- newborn/ en/ [Accessed 16 Oct 2020].

54 Wright NJ, Global PaedSurg Research Collaboration. Management and outcomes of gastrointestinal congenital anomalies in low, middle and high income countries: protocol for a multicentre, international, prospective cohort study. BMJ Open 2019;9:e030452.

55 Concepcion TL, Dahir S, Mohamed M, et al. Barriers to surgical care among children in Somaliland: an application of the three delays framework. World J Surg 2020;44:1712–8.

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

57 GlobalSurg Collaborative. Management and outcomes following surgery for gastrointestinal typhoid: an international, prospective, multicentre cohort study. World J Surg 2018;42:3179–88.



j.com/

BM

J Glob H


eptember 2021. D

ownloaded from

http://www.un.org/sustainabledevelopment/health/


http://dx.doi.org/10.1016/S2214-109X(18)30386-3

http://dx.doi.org/10.1016/S0140-6736(18)31668-4

http://dx.doi.org/10.1136/bmjgh-2020-002539

http://dx.doi.org/10.1007/s00268-014-2868-5

http://dx.doi.org/10.1371/journal.pmed.1002464

http://dx.doi.org/10.1007/s00268-018-04888-7

https://6cde3faa-9fe6-4a8d-a485-408738b17bc2.filesusr.com/ugd/d9a674_1f7aa8161c954e2dbf23751213bc6f52.pdf



https://www.globalchildrenssurgery.org/wp-content/uploads/2019/10/Childrens-Surgical-Assessment-Tool_March-2018.pdf



http://dx.doi.org/10.1007/s00268-018-4867-4

https://www.kidsor.org

https://www.kidsor.org

http://dx.doi.org/10.12688/wellcomeopenres.15113.1

http://dx.doi.org/10.1136/bmjpo-2018-000392

http://dx.doi.org/10.1001/jama.288.20.2601

http://dx.doi.org/10.1136/bmjpo-2019-000538

https://www.who.int/maternal_child_adolescent/newborns/every-newborn/en/

https://www.who.int/maternal_child_adolescent/newborns/every-newborn/en/

http://dx.doi.org/10.1136/bmjopen-2019-030452

http://dx.doi.org/10.1007/s00268-020-05414-4

http://dx.doi.org/10.1001/jamanetworkopen.2018.6857

http://dx.doi.org/10.1007/s00268-018-4624-8

http://gh.bmj.com/

1

Paediatric Surgical Outcomes in Sub-Saharan Africa:

A Multicentre, International, Prospective Cohort Study

PaedSurg Africa Research Collaboration

SUPPLEMENTAL APPENDIX

Appendix Methods 1. Patient Data Collection Form

Appendix Methods 2. Hospital Survey

Appendix Methods 3. Power calculation

Appendix Figure 1. Additional hospitals providing survey data without patient data

Appendix Table 1. High-income country benchmark data used as a comparator to observed SSA data

Appendix Tables 2a-2e. Condition specific patient characteristics, management and outcomes

Appendix Table 3. Mortality stratified by age

Appendix Table 4. Patient follow-up

Appendix Table 5. Univariable and multivariable analysis of patient-level and hospital-level factors

associated with mortality for patients with gastroschisis, anorectal malformation and intussusception

combined (generic patient variables only)

Appendix Table 6. Univariable analysis of patient-level and hospital-level factors associated with

mortality for patients with gastroschisis (generic and condition specific variables)


mortality for patients with ARM (generic and condition specific variables)


mortality for patient with intussusception (generic and condition specific variables)

Appendix Table 9. Summary of the agreement between the main study and validation datasets

Appendix Table 10. Validation survey undertaken by local investigators at validating centers

Appendix Table 11. Validation of the hospital data

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any relianceSupplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Global Health

doi: 10.1136/bmjgh-2020-004406:e004406. 6 2021;BMJ Global Health .

2

Appendix Methods 1. Patient Data Collection Form

Generic variables for all conditions

REDCap Record ID:

Demographics

• Gestational age at birth: The number of weeks from the first day of the woman's last menstrual cycle until birth.

• Sex: Male/ Female

• Weight: In kilograms (kg) on the day of presentation. Answer to one decimal place.

• Time from onset of the condition to this presentation at your hospital (in days): For example: Number of days from birth until presentation for gastroschisis and anorectal malformation. Time from onset of symptoms to

presentation for appendicitis and intussusception. Time from first noticing the hernia to the first day of this admission at your hospital for

patients with an inguinal hernia. Please include the first day and day of presentation in your calculation, for example, a patient presenting

with appendicitis on 5th October 2016 who has had abdominal pain since 1st October 2016, please insert 5 days.

• Distance from the patient's home to your hospital: In kilometres (km). Please round to the nearest kilometer.

• Mode of transport to your hospital:

Ambulance/ Other transport method provided by the health service/ Patient's own transport/ Born within your

hospital

Peri-operative Factors

• American Society of Anesthesiologists (ASA) score at the time of primary surgery or intervention:

1. healthy person/ 2. mild systemic disease/ 3. severe systemic disease/ 4. severe systemic disease that is a

constant threat to life/ 5. a moribund patient who is not expected to survive without the operation/ Not

applicable - intervention or surgery not undertaken

• Was a Surgical Safety Checklist used at the time of primary surgery or intervention?

Yes/ No/ Surgery or intervention not undertaken

• What type of anaesthesia was used for the primary intervention?

General anaesthesia with endotracheal tube/ General anaesthesia with laryngeal airway/ Ketamine anaesthesia/

Spinal or caudal anaesthesia/ Local anaesthesia/ No anaesthesia, just analgesia/ No anaesthesia, no analgesia/

Not applicable: no surgery or intervention undertaken. For gastroschisis please enter the anaesthesia used at the time of defect closure. For intussusception please enter the anaesthesia used for the primary intervention whether it was an air- or hydro-enema or primary surgery.

• Who undertook the anaesthetic for the primary intervention?

Anaesthetic doctor/ Anaesthetic nurse/ Medical officer/ Other/ No anaesthetic undertaken

If other, please specify:

• Did the patient receive a blood transfusion during their primary admission?

No: not required/ No: it was required but not available/ Yes: not cross-matched/ Yes: cross-matched. Indications for blood transfusion: a haemoglobin level less than 80g/L associated with symptoms including tachypnoea, shortness of breath

and tachycardia.

Outcomes

• Did the patient survive to discharge? Yes/ No If the patient was still in your hospital and alive at 30 days after primary admission, please select yes.

• If you were able to follow-up the patient, were they alive at 30 days following primary surgery/

intervention? Yes/ No/ Not followed up after discharge/ Not followed up to 30 days post-intervention Follow-up includes either in person, via telephone or other means of reliable communication.

• Duration of hospital stay (days): Please include the day of admission and the day of discharge in your calculation. For example, if a patient presented with appendicitis on 1st October and was discharged on the 5th October, their duration of hospital stay would be 5 days. If the patient died, please record the number

of days from admission to death. Only include the duration of the primary admission; not subsequent admissions if the patient re-presented.

If the operation was undertaken as a daycase and the patient was discharged the same day, please enter 1.

• Did the patient have a surgical site infection? Yes/ No Surgical site infection criteria include at least one of the following: 1) purulent drainage from the superficial or deep (fascia or muscle) incision but not from within the organ/space component of the surgical site, 2) at least one of: pain or tenderness; localised swelling;

redness; heat; fever; AND the incision is opened deliberately or spontaneously dehisces, 3) there is an abscess within the wound (clinically

or radiologically detected).

• Did the patient have a full thickness wound dehiscence? Yes/ No This is defined as all wound layers opening.

• Did the patient require a further intervention within 30 days of primary surgery?

No/ Yes - percutaneous intervention/ Yes - surgical intervention



3

• If the patient had a complication, when was it diagnosed?

During the primary admission/ As an emergency re-attender/ At routine follow-up as an out-patient/ Not

applicable, no complications

• Did the patient require re-admission to hospital? Yes/ No

• If re-admission was required, what was the duration of their subsequent hospital stay (in days)? Please include the day of admission and the day of discharge in your calculation. For example, if a patient re-presented on 1st November

and was discharged on the 5th November, their duration of hospital stay would be 5 days. If the patient died, please record the number of

days from admission to death.

• Was the patient followed up at 30 days post primary surgery or intervention to assess for complications?

No: data is based on in-patient observations only/ No: follow-up was done, but prior to 30 days/ Yes: reviewed

in person/ Yes: via telephone consultation/ Yes: via other means/ Yes: still an in-patient at 30 days

• What study condition does this patient have?

Gastroschisis/ Anorectal malformation/ Appendicitis/ Intussusception/ Inguinal hernia

Condition specific variables

Gastroschisis

• Type of gastroschisis:

Simple/ Complex: associated with atresia/ Complex: associated with necrosis/ Complex: associated with

perforation

• Was the gastroschisis diagnosed antenatally? Yes/ No

• Was the neonate septic on arrival to your unit? Yes/ No Sepsis is SIRS (Systemic Inflammatory Response Syndrome) with a suspected or confirmed bacterial, viral, or fungal cause. SIRS is a

response to a stimulus, which results in two or more of the following: temperature > 38.5°C or < 36°C, tachycardia (> two standard

deviations above normal), or bradycardia in children < 1 year old (< 10th centile for age), tachypnoea (> two standard deviations above

normal), leukocyte count > 12,000 cells/mm3, < 4,000 cells/mm3, hyperglycemia, altered mental status, hyperlactemia, increased capillary refill time >2 seconds.

• Did the neonate receive broad spectrum antibiotics within an hour of arrival to your unit?

Yes/ No: not given within 1 hour, but they were given on the first day of admission/ No: not given on the first

day of admission/ Broad spectrum antibiotics cover gram negative, gram positive and anaerobic bacteria.

• Were broad spectrum antibiotics continued for at least 48 hours after abdominal wall closure? Yes/ No Or until death if the neonate did not survive until abdominal wall closure.

• If the neonate was hypothermic on arrival to your unit, were they warmed with an incubator or radiant

heater?

Yes/ No/ Not applicable - not hypothermic Hypothermia is defined as < 36.5°C core temperature.

• Was the neonate hypovolaemic on arrival to your unit? Yes/ No Hypovolaemia criteria include: prolonged capillary refill time >2 seconds, and/ or tachycardia (> two standard deviations above normal for

age), mottled skin, reduced urine output (< 1ml/kg/hr), cyanosis, impaired consciousness, hypotension (mean arterial pressure < 5th

percentile for age).

• Did the neonate receive an intravenous fluid bolus within an hour of arrival on your unit?

Yes/ No: not within 1 hour, but it was given on the first day of admission/ No: not given on the first day of

admission. Please select 'yes' only if 10ml/kg or more of intravenous fluid was administered.

• What intravenous access was achieved for the neonate within the first day of arrival on your unit?

None/ Peripheral cannula/ Umbilical vein catheter/ Central line (including all types other than via the umbilical

vein). Please tick all that apply.

• Time from admission to primary intervention (in hours): Please round to the nearest hour. If a preformed silo was used, please enter the time from admission to the first application of the performed

silo.

• Method of gastroschisis closure:

Not attempted (palliative care)/ Primary closure at the bedside (Bianchi technique)/ Preformed silo application,

reduction and closure at the bedside/ Preformed silo, reduction and closure in the operating room/ Surgical silo,

reduction and closure in the operating room/ Primary closure in the operating room/ Other.

If other, please specify:

• On what day following admission was abdominal wall closure achieved? Please include the first day of admission and the day of closure in the calculation. For example, for a neonate admitted with gastroschisis on 2nd October and had the gastroschisis reduced and closed on 4th October, please insert 3 days.

• If ventilatory support was required at any point during the care of this neonate, was it available?

Yes/ No/ Not applicable - not required

• Did this neonate receive parenteral nutrition?

Yes, until full enteral intake was established/ Yes, but for less time than was required/ No



4

• Did the neonate have any of these complications within 30 days following primary intervention?

Ischaemic bowel/ Central line sepsis/ Abdominal compartment syndrome (defined as respiratory insufficiency secondary

to compromised tidal volumes, decreased urine output caused by falling renal perfusion or any other organ dysfunction caused by increased intra-abdominal pressure) If the patient had signs of abdominal compartment syndrome, was the abdomen re-opened?


• Type of anorectal malformation:

Perineal or vestibular - able to pass stool spontaneously/ Higher malformation

• Does the neonate have an addition anomaly?

None/ Vertebral, Cardiac/ Oesophageal atresia/ Tracheoesophageal fistula/ Renal/ Limb/ Other

• Was the baby septic on arrival to your unit? Yes/ No Sepsis is SIRS (Systemic Inflammatory Response Syndrome) with a suspected or confirmed bacterial, viral, or fungal cause. SIRS is a


deviations above normal), or bradycardia in children < 1 year old (< 10th centile for age), tachypnea (> two standard deviations above normal), leukocyte count > 12,000 cells/mm3, < 4,000 cells/mm3, hyperglycemia, altered mental status, hyperlactemia, increased capillary

refill time >2 seconds.

• Were broad spectrum antibiotics given at the time of diagnosis?

Yes/ No: not within 1 hour, but they were given on the first day of admission/ No: not given Broad spectrum antibiotics cover gram negative, gram positive and anaerobic bacteria.

• Were broad spectrum antibiotics continued until at least 48 hours following surgery? Yes/ No

• If the neonate required ventilatory support at any stage during their perioperative care, was it available?

Yes/ No/ Not applicable: not required

• Did the neonate have preoperative bowel perforation? Yes/ No

• On what day following admission did the neonate receive surgical intervention? Please include the first day of admission as day 1. For example, for a neonate admitted on 2nd October with an anorectal malformation and

receiving a stoma on 4th October, please insert 3 days. Enter 0 if no intervention was undertaken.

• What was the primary operation undertaken?

None, spontaneously stooling/ Dilatation of perineal or vestibular fistula/ Loop transverse colostomy/ Divided

transverse colostomy/ Loop sigmoid colostomy/ Divided sigmoid colostomy/ Other stoma/ Anoplasty Posterior

sagittal anorectoplasty (PSARP)/ Modified PSARP/ Abdomino-perineal anorectoplasty/ Other

If 'modified PSARP' or 'other', please provide details:

• If primary anorectal reconstruction was undertaken, was a Peña stimulator or equivalent device used to

identify the position of the muscle complex intra-operatively?

• If primary anorectal reconstructive surgery was undertaken, did they have a covering stoma?

Yes/ No/ Not applicable

• Did the patient have any of the following complications within 30 days of surgery?

Electrolyte disturbance/ High output stoma (over 20mls/kg/day)/ Stoma prolapse/ Peri-stoma skin breakdown

(or perianal if primary reconstructive surgery undertaken without a covering stoma)/ Sepsis/ Anal stenosis in

those undergoing primary anorectal reconstruction without covering stoma

• What is the plan for future management?

No further operative management/ Anoplasty or pull-through planned at your hospital/ Anoplasty or pull-

through planned at another hospital/ Stoma closure planned at your hospital/ Stoma closure planned at another

hospital Please tick all that apply.

Intussusception

• Age at presentation (in months): Please round to the nearest month If born prematurely, please enter the number of months since birth.

• How was the intussusception diagnosed?

Clinically/ On ultrasound/ Other (please provide details). Tick all that apply

• Septic on arrival? Yes/ No Sepsis is SIRS (Systemic Inflammatory Response Syndrome) with a suspected or confirmed bacterial, viral, or fungal cause. SIRS is a


deviations above normal), or bradycardia in children < 1 year old (< 10th centile for age), tachypnea (> two standard deviations above

normal), leukocyte count > 12,000 cells/mm3, < 4,000 cells/mm3, hyperglycemia, altered mental status, hyperlactemia, increased capillary


• Appropriate antibiotics given within an hour of diagnosis?

Yes/ No, not within one hour, but they were given prior to intervention (or death)/ No, not given Appropriate antibiotics include those that cover common anaerobic and aerobic gut organisms.

• If hypovolaemic or septic, were intravenous fluids administered prior to the primary intervention? Hypovolaemia criteria include: prolonged capillary refill time >2 seconds, and/ or tachycardia (> two standard deviations above normal for




5

percentile for age). Please select 'yes' only if 10ml/kg or more of intravenous fluid was administered.

• Did the patient have a contraindication to air- or hydro-enema reduction?

Yes, peritonitis/ Yes, perforation/ Yes, non-responsive shock/ Yes, other/ No

• What primary management did the patient have?

None attempted (palliative care)/ Air-enema reduction without anaesthetic/ Air-enema reduction with

anesthetic/ Hydro-enema reduction without anesthetic/ Hydro-enema reduction with anesthetic/ Laparotomy/

Laparoscopy/ Other (please specify)

If laparoscopy was used, was it converted to open?

• If air or enema reduction was attempted primarily, was it successful?

Yes/ No/ Not applicable, not attempted.

• How many attempts did it take to reduce the intussusception? One attempt is defined as a series of increasing pressures, commonly up to a maximum of 120mmHg. A second attempt is considered to be a

separate episode starting at the lowest pressure again.

• If air- or hydro-enema reduction was attempted primarily, was there a complication?

No/ Yes, perforation/ Yes, cardiorespiratory compromise and deterioration/ Yes, other

• If surgical intervention was required, what procedure was undertaken?

Manual reduction only/ Bowel resection and primary anastomosis/ Bowel resection and stoma

• How many hours following admission was the intussusception successfully reduced? Please round to the nearest hour. If air- or hydro-enema reduction were attempted, but were unsuccessful, then the child had the

intussusception reduced at laparotomy, please include the number of hours from admission to reduction in the operating room.

• Recurrence of intussusception within 30 days of original reduction?

Yes, within 30-days of original reduction/ No (patient not followed-up past discharge)/ No (patient followed-up

at 30-days post original reduction)

Appendicitis

• Age at diagnosis (in years): Please round to the nearest whole year.

• Septic on arrival? Yes/ No Sepsis is SIRS (Systemic Inflammatory Response Syndrome) with a suspected or confirmed bacterial, viral, or fungal cause. SIRS is a


deviations above normal), or bradycardia in children < 1 year old (< 10th centile for age), tachypnea (> two standard deviations above

normal), leukocyte count > 12,000 cells/mm3, < 4,000 cells/mm3, hyperglycemia, altered mental status, hyperlactemia, increased capillary


• Appropriate pre-operative antibiotics given at the time of diagnosis?

Yes/ No, not within 1 hour, but they were given pre-operatively or on the day of admission if managed

conservatively/ No, not given pre-operatively or on the day of admission Appropriate antibiotics include those that cover common anaerobic and aerobic gut organisms.

• If hypovolaemic or septic, was intravenous fluid resuscitation administered pre-operatively?

Yes/ No/ Not applicable - not hypovolemic or septic Hypovolaemia criteria include: prolonged capillary refill time >2 seconds, and/ or tachycardia (> two standard deviations above normal for


percentile for age). Please select 'yes' only if 10ml/kg or more of intravenous fluid was administered.

• How many hours following admission was the surgery undertaken?

Please round to the nearest hour.

• What time of day was the operation started (to the nearest hour)?

• Operation undertaken:

Open appendicectomy (Lanz or Gridiron)/ Open appendicectomy (Laparotomy, midline incision or other)/

Laparoscopic appendicectomy/ Open right hemicolectomy/ Laparoscopic right hemicolectomy/ Appendix mass

palpated pre-operatively, surgery not undertaken/ Appendix mass palpated under anesthesia, surgery not

undertaken/ No appendix mass palpated, patient managed conservatively with antibiotics

Other (please specify)

Conversion to open procedure? Yes/ No

• Operation findings:

Simple appendicitis/ Perforated appendicitis If the appendix was gangrenous, please tick perforated.

• Was the peritoneal cavity washed out prior to closure?

• If yes, what was used to wash it out?

• Duration of appropriate intra-venous post-operative antibiotics (in days): If no intravenous antibiotics were given, please enter 0. If the patient was managed conservatively, please enter the total number of days of

intravenous antibiotics given.

• Duration of appropriate oral antibiotics given post-operatively (in days): Please round to the nearest day. If intravenous antibiotics were given primarily then changed to oral antibiotics, please just enter the number of days of oral antibiotics here. If the patient was managed conservatively, enter the total number of days of oral antibiotics given.



6

• Did the patient have a post-operative intra-abdominal collection?

No/ Yes, drained percutaneously with no imaging/ Yes, drained percutaneously with ultrasound guidance/ Yes,

drained percutaneously with CT guidance/ Yes, drained via laparoscopy/ Yes, drained via a second open

operation/ Yes, requiring a prolonged antibiotic course but no further surgical intervention/ Not applicable, not

surgical intervention undertaken

• If yes, how was the intra-abdominal collection diagnosed?

Clinically/ On ultrasound/ On CT/ At operation/ Other

• If visualised on imaging or at operation, was the collection 5cm in diameter or greater?

Inguinal hernia

• Age at the time of operation (in weeks): Please round to the nearest week. For preterm neonates please input the number of weeks they have been alive since birth.

• Hernia type (at the time of operation):

Easily reducible/ Reduced with difficulty/ Irreducible or obstructed or strangulated/ Fistulated

• Unilateral or bilateral?

• Operation type: Elective/ Emergency

• If emergency, how many hours from admission to primary surgery? Please round to the nearest hour.

• Operation technique:

Open herniotomy/ Laparoscopic herniotomy/ Laparotomy/ Other

If other, please provide details:

• Was there a conversion from laparoscopic to open?

• Was a bowel resection required at the time of surgery?

No/ Yes, via the inguinal incision with primary anastomosis/ Yes, via laparotomy with primary anastomosis/

Yes, with stoma formation/ Yes, other operation performed (please specify)

• Was the testis found to be gangrenous at the time of surgery? Yes/ No

• Were broad spectrum prophylactic antibiotics given at the time of the operation? Yes/ No Broad spectrum antibiotics cover gram negative, gram positive and anaerobic bacteria.

• Duration of broad spectrum antibiotics given following surgery (in days): If no antibiotics were given following surgery, please enter 0.

• Was there a recurrence of the hernia within 30 days of primary surgery?

Yes/ No: not followed up after discharge/ No: not at 30-day follow-up in person/ No: not at 30-day follow-up

via telephone/ No: not at 30-day follow-up via another means

• Was the patient kept in overnight for continuous apnoea and saturation monitoring?

Yes/ No: discharged the same day/ No: kept overnight but not monitored



7

Appendix Methods 2. Hospital Survey

Title:

Surname/ Last Name:

First name:

Professional position:

Specialty:

Full name of institution:

Address of institution:

Country:

Personnel:

Number of Consultant Paediatric Surgeons undertaking general pediatric surgery at your institution:

Number of Consultant Paediatric Surgeons undertaking neonatal surgery at your institution:

Number of Consultant General Surgeons (covering adults and children) undertaking general paediatric surgery

at your institution:

Number of Consultant General Surgeons (covering adults and children) undertaking neonatal surgery at your

institution:

Number of medical officers undertaking general paediatric surgery independently at your institution:

Number of medical officers undertaking neonatal surgery independently at your institution:

Population served by your institution (in millions, including children and adults):

Infrastructure:

Please state whether the following facilities are available at your institution when required (Each field requires

an answer: always, sometimes or never available):

Running water

Electricity

Electricity generator back-up

Laboratory for biochemistry

Laboratory for hematology

Blood bank

Functioning ultrasound (US) machine

Fluoroscopy

Paediatric ventilation outside the operating room (OR)

Neonatal ventilation outside the OR

Paediatric intensive care unit for surgical pediatric patients pre and post operatively if required

Neonatal intensive care unit for surgical neonates pre and post operatively (including if a stoma is present)

Parenteral nutrition

Surgical Safety Checklist in the OR

Sterile gloves and gown

Autoclave for sterilising surgical equipment

Peña stimulator or equivalent device to identify the muscle complex during anorectal reconstruction

Procedures:

Please state whether the following procedures are available at your institution when clinically appropriate/

required (Each field requires an answer: always, sometimes or never available):

Bedside primary reduction and closure of gastroschisis (Bianchi technique)

Preformed silo application, reduction and closure of gastroschisis

Surgical silo application, reduction and closure of gastroschisis

Primary closure of gastroschisis in the operating room

Sigmoid colostomy for anorectal malformation

Posterior Sagittal Anorectoplasty (PSARP) for anorectal malformation

Open appendicectomy

Laparoscopic appendicectomy

Ultrasound guided drainage of intra-abdominal collection

CT guided drainage of intra-abdominal collection

Open inguinal herniotomy



8

Laparoscopic inguinal herniotomy

Radiologist trained to diagnose intussusception on ultrasound

Air-enema reduction of intussusception

Hydro-enema reduction of intussusception

Laparotomy for intussusception

Paediatric central line insertion

Neonatal central line insertion

Umbilical vein catheterisation

Anesthesia and resuscitation:

Please state whether the following facilities are available at your institution when required (Each field requires

an answer: always, sometimes or never available):

Bottled oxygen

Piped oxygen

Oxygen saturation monitor

Apnea monitor

Multi-parameter intra-operative monitoring

Paediatric bag, valve and mask

Anaesthetic machine for neonates

Anaesthetic machine for children

Ketamine anaesthesia for children

Ketamine anaesthesia for neonates

Spinal/ caudal anaesthesia for children

Spinal/ caudal anaesthesia for neonates

Anaesthetic doctor competent to perform paediatric anesthesia

Anaesthetic doctor competent to perform neonatal anesthesia

Anaesthetic nurse competent to perform paediatric anesthesia

Anaesthetic nurse competent to perform neonatal anesthesia

Does your country have at least one children's hospital that can provide neonatal and paediatric surgery?

Any other comments:



9

Appendix Methods 3. Power calculation

Estimated patient numbers per hospital during a one month study period were: 1-2 with gastroschisis1-3, 1-2 with

anorectal malformation4-7, 1 with intussusception8, 11 with appendicitis9,10 and 14 with an inguinal hernia11-17

(29 patients per centre). Estimates were calculated using the mean number of patients presenting per month to

hospitals in sub-Saharan Africa (SSA) who have published data on these conditions as referenced below.

Power calculations were undertaken to determine the mortality rate required in SSA for there to be a significant

difference between SSA and published high-income country (HIC) benchmark data if 50 SSA hospitals

participated in the study (1450 patients). The minimum differences that can be detected at a 5% significance

level with 80% power are summarized in the table below.

The minimum detectable differences in mortality between SSA and HICs if 50 hospitals

participated in the study

High income country Sub-Saharan Africa Patient

population* Mortality

rate* Estimated

study population size

Mortality rate in SSA at minimum detectable

difference

Gastroschisis 301 4% 75 14.5%

ARM 410 3% 75 12.2%

Intussusception 9186 0.2% 50 5%

Appendicitis 24665 0.004% 550 0.43%

Inguinal hernia 10137 0% 700 0.40% * sources of benchmark data are detailed in Appendix Table 1.

All mortality rates at the minimum detectable difference are lower than previously reported in SSA suggesting

at 50 hospitals there should be adequate power to detect significant differences between observed SSA data and

benchmark HIC data.

References

1. Agugua NE, Nwako FA. Gastroschisis a fifteen-year experience. West Afr J Med, 1990;9(2):147-50.

2. Arnold M. Is the incidence of gastroschisis rising in South Africa in accordance with international trends? A retrospective

analysis at Pretoria Academic and Kalafong Hospitals, 1981-2001. S Afr J Surg, 2004;42(3):86-8. 3. Wright NJ, Zani A, Ade-Ajayi N. Epidemiology, management and outcome of gastroschisis in Sub-Saharan Africa: Results of an

international survey. Afr J Paediatr Surg, 2015;12(1):1-6.

4. Govender S, Wiersma R. Delayed diagnosis of anorectal malformations (ARM): causes and consequences in a resource-

constrained environment. Pediatr Surg Int, 2016;32(4):369-75.

5. Kigo CN, Ndung'u JM. Bowel function following primary repair of anorectal malformations at Kenyatta National Hospital. East Afr Med J, 2002;79(3):124-7.

6. Chirdan LB, Uba FA, Ameh EA, Mshelbwala PM. Colostomy for high anorectal malformation: an evaluation of morbidity and

mortality in a developing country. Pediatr Surg Int, 2008;24(4):407-10.

7. Lawal TA, Olulana DI, Ogundoyin OO. Spectrum of colorectal surgery operations performed in a single paediatric surgery unit

in sub-Saharan Africa. Afr J Paediatr Surg, 2014;11(2):128-31. 8. Jiang J, Jiang B, Parashar U, et al. Childhood intussusception: a literature review. PLoS One, 2013;8(7):e68482.

9. Derbew M, Ahmed E. The pattern of pediatric surgical conditions in Tikur Anbessa Unversity Hospital, Addis Ababa, Ethiopia.

Ethiop Med J, 2006;44(4):331-8.

10. Kong VY, Sartorius B, Clarke DL. Acute appendicitis in the developing world is a morbid disease. Ann R Coll Surg Engl,

2015;97(5):390-5. 11. Bamigbola KT, Nasir AA, Abdur-Rahman LO, Adeniran JO. Complicated childhood inguinal hernias in UITH, Ilorin. Afr J

Paediatr Surg, 2012;9(3):227-30.

12. Eeson G, Birabwa-Male D, Pennington M, Blair GK. Costs and cost-effectiveness of pediatric inguinal hernia repair in Uganda.

World J Surg, 2015;39(2):343-9.

13. Zamakhshary M, To T, Guan J, Langer JC. Risk of incarceration of inguinal hernia among infants and young children awaiting elective surgery. CMAJ, 2008;179(10):1001-5.

14. Ameh EA. Morbidity and mortality of inguinal hernia in the newborn. Niger Postgrad Med J, 2002;9(4):233-4.

15. Usang UE, Sowande OA, Adejuyigbe O, Bakare TI, Ademuyiwa OA. The role of preoperative antibiotics in the prevention of

wound infection after day case surgery for inguinal hernia in children in Ile Ife, Nigeria. Pediatr Surg Int, 2008;24(10):1181-5.

16. Ameh EA. Incarcerated and strangulated inguinal hernias in children in Zaria, Nigeria. East Afr Med J, 1999;76(9):499-501. 17. Ohene-Yeboah M, Abantanga F, Oppong J, et al. Some aspects of the epidemiology of external hernias in Kumasi, Ghana.

Hernia, 2009;13(5):529-32.



http://www.ncbi.nlm.nih.gov/pubmed/?term=Agugua%20NE%5BAuthor%5D&cauthor=true&cauthor_uid=2148495

http://www.ncbi.nlm.nih.gov/pubmed/?term=Nwako%20FA%5BAuthor%5D&cauthor=true&cauthor_uid=2148495

http://www.ncbi.nlm.nih.gov/pubmed/?term=Arnold%20M%5BAuthor%5D&cauthor=true&cauthor_uid=15532615

http://www.ncbi.nlm.nih.gov/pubmed/?term=Wright%20NJ%5BAuthor%5D&cauthor=true&cauthor_uid=25659541

http://www.ncbi.nlm.nih.gov/pubmed/?term=Zani%20A%5BAuthor%5D&cauthor=true&cauthor_uid=25659541

http://www.ncbi.nlm.nih.gov/pubmed/?term=Ade-Ajayi%20N%5BAuthor%5D&cauthor=true&cauthor_uid=25659541

http://www.ncbi.nlm.nih.gov/pubmed/?term=Govender%20S%5BAuthor%5D&cauthor=true&cauthor_uid=26790675

http://www.ncbi.nlm.nih.gov/pubmed/?term=Wiersma%20R%5BAuthor%5D&cauthor=true&cauthor_uid=26790675

http://www.ncbi.nlm.nih.gov/pubmed/?term=Kigo%20CN%5BAuthor%5D&cauthor=true&cauthor_uid=12389955

http://www.ncbi.nlm.nih.gov/pubmed/?term=Ndung'u%20JM%5BAuthor%5D&cauthor=true&cauthor_uid=12389955

http://www.ncbi.nlm.nih.gov/pubmed/?term=Chirdan%20LB%5BAuthor%5D&cauthor=true&cauthor_uid=18270719

http://www.ncbi.nlm.nih.gov/pubmed/?term=Uba%20FA%5BAuthor%5D&cauthor=true&cauthor_uid=18270719

http://www.ncbi.nlm.nih.gov/pubmed/?term=Ameh%20EA%5BAuthor%5D&cauthor=true&cauthor_uid=18270719

http://www.ncbi.nlm.nih.gov/pubmed/?term=Mshelbwala%20PM%5BAuthor%5D&cauthor=true&cauthor_uid=18270719

http://www.ncbi.nlm.nih.gov/pubmed/?term=Lawal%20TA%5BAuthor%5D&cauthor=true&cauthor_uid=24841012

http://www.ncbi.nlm.nih.gov/pubmed/?term=Olulana%20DI%5BAuthor%5D&cauthor=true&cauthor_uid=24841012

http://www.ncbi.nlm.nih.gov/pubmed/?term=Ogundoyin%20OO%5BAuthor%5D&cauthor=true&cauthor_uid=24841012

http://www.ncbi.nlm.nih.gov/pubmed/?term=Jiang%20J%5BAuthor%5D&cauthor=true&cauthor_uid=23894308

http://www.ncbi.nlm.nih.gov/pubmed/?term=Jiang%20B%5BAuthor%5D&cauthor=true&cauthor_uid=23894308

http://www.ncbi.nlm.nih.gov/pubmed/?term=Parashar%20U%5BAuthor%5D&cauthor=true&cauthor_uid=23894308

http://www.ncbi.nlm.nih.gov/pubmed/?term=Derbew%20M%5BAuthor%5D&cauthor=true&cauthor_uid=17370432

http://www.ncbi.nlm.nih.gov/pubmed/?term=Ahmed%20E%5BAuthor%5D&cauthor=true&cauthor_uid=17370432

http://www.ncbi.nlm.nih.gov/pubmed/?term=Kong%20VY%5BAuthor%5D&cauthor=true&cauthor_uid=26264094

http://www.ncbi.nlm.nih.gov/pubmed/?term=Sartorius%20B%5BAuthor%5D&cauthor=true&cauthor_uid=26264094

http://www.ncbi.nlm.nih.gov/pubmed/?term=Clarke%20DL%5BAuthor%5D&cauthor=true&cauthor_uid=26264094

http://www.ncbi.nlm.nih.gov/pubmed/?term=Bamigbola%20KT%5BAuthor%5D&cauthor=true&cauthor_uid=23250245

http://www.ncbi.nlm.nih.gov/pubmed/?term=Nasir%20AA%5BAuthor%5D&cauthor=true&cauthor_uid=23250245

http://www.ncbi.nlm.nih.gov/pubmed/?term=Abdur-Rahman%20LO%5BAuthor%5D&cauthor=true&cauthor_uid=23250245

http://www.ncbi.nlm.nih.gov/pubmed/?term=Adeniran%20JO%5BAuthor%5D&cauthor=true&cauthor_uid=23250245

http://www.ncbi.nlm.nih.gov/pubmed/?term=Eeson%20G%5BAuthor%5D&cauthor=true&cauthor_uid=25270348

http://www.ncbi.nlm.nih.gov/pubmed/?term=Birabwa-Male%20D%5BAuthor%5D&cauthor=true&cauthor_uid=25270348

http://www.ncbi.nlm.nih.gov/pubmed/?term=Pennington%20M%5BAuthor%5D&cauthor=true&cauthor_uid=25270348

http://www.ncbi.nlm.nih.gov/pubmed/?term=Blair%20GK%5BAuthor%5D&cauthor=true&cauthor_uid=25270348

http://www.ncbi.nlm.nih.gov/pubmed/?term=Zamakhshary%20M%5BAuthor%5D&cauthor=true&cauthor_uid=18981440

http://www.ncbi.nlm.nih.gov/pubmed/?term=To%20T%5BAuthor%5D&cauthor=true&cauthor_uid=18981440

http://www.ncbi.nlm.nih.gov/pubmed/?term=Guan%20J%5BAuthor%5D&cauthor=true&cauthor_uid=18981440

http://www.ncbi.nlm.nih.gov/pubmed/?term=Langer%20JC%5BAuthor%5D&cauthor=true&cauthor_uid=18981440


http://www.ncbi.nlm.nih.gov/pubmed/?term=Usang%20UE%5BAuthor%5D&cauthor=true&cauthor_uid=18726104

http://www.ncbi.nlm.nih.gov/pubmed/?term=Sowande%20OA%5BAuthor%5D&cauthor=true&cauthor_uid=18726104

http://www.ncbi.nlm.nih.gov/pubmed/?term=Adejuyigbe%20O%5BAuthor%5D&cauthor=true&cauthor_uid=18726104

http://www.ncbi.nlm.nih.gov/pubmed/?term=Bakare%20TI%5BAuthor%5D&cauthor=true&cauthor_uid=18726104

http://www.ncbi.nlm.nih.gov/pubmed/?term=Ademuyiwa%20OA%5BAuthor%5D&cauthor=true&cauthor_uid=18726104


http://www.ncbi.nlm.nih.gov/pubmed/?term=Ohene-Yeboah%20M%5BAuthor%5D&cauthor=true&cauthor_uid=19301084

http://www.ncbi.nlm.nih.gov/pubmed/?term=Abantanga%20F%5BAuthor%5D&cauthor=true&cauthor_uid=19301084

http://www.ncbi.nlm.nih.gov/pubmed/?term=Oppong%20J%5BAuthor%5D&cauthor=true&cauthor_uid=19301084

10

Appendix Figure 1. Additional hospitals providing survey data without patient data

(n=23)

©

9

3

2

1

No. hospitals

Niger(n=1)

Nigeria(n=9)

Gambia(n=1)

Ghana(n=1)

Benin(n=2) Rwanda

(n=2)

Uganda(n=1)

Kenya(n=3)

Madagascar(n=1)

Botswana(n=1)

Somaliland(n=1)



11

Appendix Table 1. High-income country benchmark data used as a comparator to

observed SSA data

Condition Study(s) used as

comparator*

Study region, type and population.

Mortality rate, %

(deaths/study population)

Timeframe of mortality rate and comparability to PaedSurg Africa

study results

Gastroschisis Bradnock et al, 20111

UK. National cohort study,

whole population.

2.0% (6/302) Neonatal period and within 30-days of primary intervention (equivalent to the

PaedSurg Africa study). Of note, the study reports an overall

mortality of 4.0% (12/302) at 1-year, but 6/302 deaths were after 30-days from

primary intervention and hence were not included within the benchmark HIC

mortality used as a comparator.

ARM Rintala et al, 20082

Finland. Single author’s case series (270 high ARM, 140

low ARM)

2.9% (12/410) The author describes the mortality timeframe within ‘short-term outcomes’

prior to ‘early childhood’. Hence, the timeframe could be longer than in the

PaedSurg Africa study. Also, the data is from 1984-1998 and hence outcomes

could have improved further since. Overall, this mortality rate could be an overestimation of the current mortality

from ARM in HICs, but it is unlikely to be an underestimation. Also, the Rintala

series has a higher proportion of patients with high ARM (65.9%) than this study (50.5%) and high ARM is

associated with higher mortality. Hence, again this difference in the cohorts could

result in an underestimation of the disparity in mortality between SSA and HICs, but unlikely an overestimation.

Intussusception Jiang et al, 20133

Australia, Europe, New Zealand, USA.

Literature review of studies published

globally since 2002. Data from 34 studies:

11 national, 9 regional, 14 hospital.

0.2% (18/9186)

Mortality was defined as ‘Case-fatality among children hospitalised with intussusception’. Hence, this is

equivalent to the all-cause, in-hospital mortality utilised in this study and indeed

the 30-day post-intervention mortality since no deaths were reported following

discharge.

Appendicitis Healy et al, 20154

Canada, UK, USA. Systematic review and meta-analysis. Data for mortality were pooled from 3 hospital based

studies containing both paediatric and general

surgeon operators.

0.004% (1/24665)

One death occurred during the primary hospital admission. This is comparable with the data from this study which also

had one death during the primary admission.

Inguinal hernia†

Ein et al, 20065

Canada. Single operator case series

(n=6361) from 1969 to 2004.

0% (0/6361) 1-12 month follow-up (mean 6-months). Hence, the mortality at discharge and

30-day post primary intervention follow-up was 0% to use as a comparator.

* These represent the published HIC studies with the largest sample sizes and most representative populations at the time of study design. †The Erdogan et al study detailed as a comparator in the PaedSurg Africa study protocol was not used as it was based in Turkey, which is upper middle income rather than high-income. ARM: Anorectal malformation. HIC: High-income country. SSA: Sub-Saharan Africa. UK: United Kingdom. USA: United States of America.



12

References

1. Bradnock TJ, Marven S, Owen A, et al; BAPS-CASS. Gastroschisis: one year outcomes from national cohort study. BMJ.

2011;343:d6749.

2. Rintala R, Pakarinen M. Imperforate anus: long- and short-term outcome. Sem Pediatr Surg, 2008;17:79-89.

3. Jiang J, Jiang B, Parashar U, et al. Childhood intussusception: a literature review. PLoS One, 2013;8(7):e68482.

4. Healy DA, Doyle D, Moynagh E, et al. Systematic review and meta-analysis on the influence of surgeon specialization n outcomes

following appendicectomy in children. Medicine (Baltimore), 2015;94(32):e1352. 5. Ein SH, Njere I, Ein A. Six thousand three hundred sixty-one pediatric inguinal hernias: a 35-year review. J Pediatr Surg,

2006;41(5):980-6.



http://www.ncbi.nlm.nih.gov/pubmed/?term=Bradnock%20TJ%5BAuthor%5D&cauthor=true&cauthor_uid=22089731

http://www.ncbi.nlm.nih.gov/pubmed/?term=Marven%20S%5BAuthor%5D&cauthor=true&cauthor_uid=22089731

http://www.ncbi.nlm.nih.gov/pubmed/?term=Owen%20A%5BAuthor%5D&cauthor=true&cauthor_uid=22089731

http://www.ncbi.nlm.nih.gov/pubmed/?term=BAPS-CASS%5BCorporate%20Author%5D

http://www.ncbi.nlm.nih.gov/pubmed/?term=Jiang%20J%5BAuthor%5D&cauthor=true&cauthor_uid=23894308

http://www.ncbi.nlm.nih.gov/pubmed/?term=Jiang%20B%5BAuthor%5D&cauthor=true&cauthor_uid=23894308

http://www.ncbi.nlm.nih.gov/pubmed/?term=Parashar%20U%5BAuthor%5D&cauthor=true&cauthor_uid=23894308

http://www.ncbi.nlm.nih.gov/pubmed/?term=Ein%20SH%5BAuthor%5D&cauthor=true&cauthor_uid=16677897

http://www.ncbi.nlm.nih.gov/pubmed/?term=Njere%20I%5BAuthor%5D&cauthor=true&cauthor_uid=16677897

http://www.ncbi.nlm.nih.gov/pubmed/?term=Ein%20A%5BAuthor%5D&cauthor=true&cauthor_uid=16677897

13

Appendix Table 2a. Condition specific patient characteristics, management and

outcomes for patients with gastroschisis, n=111 (Data from 36 hospitals)

Variable Number of cases, n (%)

Type of gastroschisis: Simple Complex with atresia Complex with necrosis Complex with perforation Complex with atresia and perforation

80 (72.1) 5 (4.5) 22 (19.8) 3 (2.7) 1 (0.9)

Was it diagnosed antenatally? No Yes

106 (95.5) 5 (4.5)

Septic on arrival: No Yes Missing*

50 (45.5) 60 (54.5) 1

Broad spectrum antibiotics given within an hour of presentation? Yes Not within 1hr, but on the first day of admission Not on the first day of admission

56 (50.5) 53 (47.7) 2 (1.8)

Were broad spectrum antibiotics continued for 48-hours after abdominal wall closure? No Yes NA - palliative care*

22 (23.9) 70 (76.1) 19

If the neonate was hypothermic, were they warmed? No Yes NA - not hypothermic*

19 (22.6) 65 (77.4) 27

Was the neonate hypovolaemic at presentation? No Yes

47 (42.3) 64 (57.7)

Did the neonate receive an intravenous fluid bolus within an hour of presentation? Yes Not within 1hr, but on the first day of admission Not on the first day of admission Missing*

58 (52.7) 41 (37.3) 11 (10.0) 1

Peripheral cannula on the first day: No Yes

7 (6.3) 104 (93.7)

Umbilical vein catheter (UVC) on the first day: No Yes

104 (93.7) 7 (6.3)

Central line (excluding UVC) on the first day: No Yes

106 (95.5) 5 (4.5)

Time from admission to primary intervention (hours). Median, IQR (range)† 7, 3-18, (0-168)

Method of gastroschisis closure: Not attempted - palliative care Primary closure at the cotside (Bianchi technique) Preformed silo, reduction and closure at cotside Preformed silo, reduction and closure in the operating room Surgical silo, reduction and closure in the operating room Primary closure in the operating room Improvised silo with plastic or female condom Missing*

20 (18.2) 5 (4.5) 33 (30.0) 13 (11.8) 8 (7.3) 16 (14.5) 15 (13.6) 1

On what day following admission was abdominal wall closure achieved? Median, IQR (range)†

1, 0-3, (0-48)



14


If the neonate required ventilatory support, was it available? No Yes NA - not required*

36 (50.7) 35 (49.3) 40

Did the neonate receive parenteral nutrition? No Yes, but for less time than required Yes, until full enteral intake was established

70 (63.1) 15 (13.5) 26 (23.4)

Did the neonate develop bowel ischaemia following intervention? No Yes NA* Missing*

60 (70.6) 25 (29.4) 24 2

Did the neonate develop following intervention? No Yes NA* Missing*

54 (85.7) 9 (14.3) 43 5

If abdominal compartment syndrome developed, was the abdomen re-opened? No Yes

6 (66.7) 3 (33.3)

Did the neonate develop central line sepsis? No Yes NA* Missing*

40 (90.9) 4 (9.1) 62 5

* Excluded from percentage calculations. † One patient was missing data for each of these variables. IQR: Interquartile range. NA: Not applicable. Percentages have been rounded and may not total 100.



15

Appendix Table 2b. Condition specific patient characteristics, management and

outcomes for patients with anorectal malformation, n=188 (Data from 42 hospitals)


Type of anorectal malformation: Low High Missing*

92 (49.5) 94 (50.5) 2

Additional congenital anomaly: No Yes

136 (72.3) 52 (27.7)

Vertebral anomaly: No Yes

180 (95.7) 8 (4.3)

Cardiac anomaly: No Yes

176 (93.6) 12 (6.4)

Oesophageal atresia: No Yes

186 (98.9) 2 (1.1)

Tracheo-oesophageal fistula: No Yes

185 (98.4) 3 (1.6)

Renal anomaly: No Yes

184 (97.9) 4 (2.1)

Limb anomaly: No Yes

180 (95.7) 8 (4.3)

Other anomaly: No Yes

158 (84.0) 30 (16.0)

Septic on arrival? No Yes Missing*

146 (78.1) 41 (21.9) 1

Broad spectrum antibiotics within an hour of presentation? Yes Not within an hour, but on the first day Not on the first day of presentation Missing*

60 (32.4) 65 (35.1) 60 (32.4) 3

Broad spectrum antibiotics for 48-hours postoperatively? No Yes Missing*

31 (17.8) 143 (82.2) 14

If ventilatory support was required, was it available? No Yes NA, not required* Missing*

60 (63.8) 34 (36.2) 88 6

Preoperative bowel perforation: No Yes Missing*

179 (96.2) 7 (3.8) 2

Time from admission to primary intervention (days). Median, IQR (range)† 2, 1.5-4, (0-607)

Operation undertaken: None, palliative care

7 (3.8)



16

None, spontaneous stooling Anal dilatation only Loop transverse colostomy Divided transverse colostomy Loop sigmoid colostomy Divided sigmoid colostomy Other stoma Anoplasty Posterior Sagittal Anorectoplasty (PSARP) Abdominoperineal Anorectoplasty (APARP) Modified Posterior Sagittal Anorectoplasty (PSARP) Missing*

8 (4.3) 11 (5.9) 9 (4.9) 6 (3.2) 20 (10.8) 77 (41.6) 1 (0.5) 17 (9.2) 27 (14.6) 1 (0.5) 1 (0.5) 3

If primary anorectal reconstruction was undertaken, was the patient given a covering stoma? No Yes Missing*

32 (71.1) 13 (28.9) 1

If anorectal reconstruction was undertaken, was a Peña stimulator or equivalent used to locate the sphincter complex? No Yes No, available but not used No, not available

5 (10.9) 23 (50.0) 2 (4.3) 16 (34.8)

Electrolyte disturbance within 30 days of surgery? No Yes NA* Missing*

128 (83.1) 26 (16.9) 26 8

High stoma output above 20mls/kg/day within 30 days of surgery? No Yes NA* Missing*

120 (97.6) 3 (2.4) 62 3

Stoma prolapse within 30 days of surgery? No Yes NA* Missing*

118 (95.9) 5 (4.1) 62 3

Peri-stoma skin breakdown within 30 days of surgery? No Yes NA* Missing*

100 (82.6) 21 (17.4) 62 5

Sepsis within 30 days of surgery? No Yes NA* Missing*

132 (85.7) 22 (14.3) 26 8

Anal stenosis within 30 days of surgery in those with primary anorectal reconstruction? No Yes NA*

39 (84.8) 7 (15.2) 142

Plan for future surgical intervention:‡ Anoplasty/ pull-through at current centre Anoplasty/ pull-through elsewhere Stoma closure at current hospital Stoma closure elsewhere No further surgery planned

118 (62.8) 7 (3.7) 47 (25.0) 0 (0.0) 34 (18.1)

* Excluded from percentage calculations. † Missing data, n=5. ‡ Some patients had more than one future planned intervention; total number of patients used as denominator. NA: Not applicable. Percentages have been rounded and may not total 100.



17

Appendix Table 2c. Condition specific patient characteristics, management and

outcomes for patients with intussusception, n=225 (data from 42 hospitals)


Diagnosis of intussusception: Clinically Ultrasound Other

40 (17.8) 175 (77.8) 10 (4.4)

Septic on arrival? No Yes

123 (54.7) 102 (45.3)

Appropriate antibiotics given within an hour of diagnosis? Yes Not within an hour, but prior to intervention No, not prior to intervention

132 (58.7) 82 (36.4) 11 (4.9)

If hypovolemic or septic, were intravenous fluids administered prior to intervention? No Yes NA - not hypovolemic or septic* Missing*

20 (11.4) 156 (88.6) 48 1

Peritonitis as a contraindication for air- or hydro-enema reduction: No Yes

184 (81.8) 41 (18.2)

Perforation as a contraindication for air- or hydro-enema reduction: No Yes

209 (92.9) 16 (7.1)

Shock as a contraindication for air- or hydro-enema reduction: No Yes

213 (94.7) 12 (5.3)

Other contraindication for air- or hydro-enema reduction: No Yes

167 (74.2) 58 (25.8)

Contraindication for air- or hydro-enema reduction: No Yes

107 (47.6) 118 (52.4)

Management: Palliative care Air enema reduction Hydroenema reduction Primary laparotomy Spontaneous resolution

7 (3.1) 5 (2.2) 53 (23.6) 158 (70.2) 2 (0.9)

If air- or hydro-enema reduction were used primarily, was it successful? No Yes

18 (31.0) 40 (69.0)

If air- or hydro-enema reduction were used primarily, was there a complication? No Yes, perforation Yes, other

53 (91.4) 3 (5.2) 2 (3.5)

If surgical intervention was required, what intervention was undertaken? Manual reduction Bowel resection and primary anastomosis Bowel resection and stoma NA*

63 (35.6) 107 (60.5) 7 (4.0) 48

Recurrence within 30-days: Yes No (followed-up to 30-days) No, but not followed-up post-discharge Missing*

4 (1.8) 46 (20.7) 172 (77.5) 3

* Excluded from percentage calculations. NA: Not applicable. Percentages have been rounded and may not total 100.



18

Appendix Table 2d. Condition specific patient characteristics, management and

outcomes for patients with appendicitis, n=250 (Data from 41 hospitals)


Septic on arrival? No Yes

110 (44.0) 140 (56.0)

Appropriate antibiotics given within an hour of diagnosis? Yes Not within an hour, but on the first day Not on the first day of admission

152 (60.8) 96 (38.4) 2 (0.8)

If hypovolemic or septic, were intravenous fluids administered preoperatively? No Yes NA*

13 (7.7) 155 (92.3) 82

Time from admission to surgery (hours). Median, IQR (range) 12, 6-24 (0-150)

Time of operation (24 hour clock): Between 8am to midnight Between midnight to 8am Missing*

205 (84.7) 37 (15.3) 8

Management: Open appendicectomy (Lanz/ Gridiron) Laparotomy Laparoscopic appendicectomy Open right hemicolectomy Non-operative, mass palpated preoperatively Non-operative, mass palpated under anesthetic Other

163 (65.2) 55 (22.0) 25 (10.0) 1 (0.4) 1 (0.4) 2 (0.8) 3 (1.2)

Conversion to open from laparoscopic: No Yes

24 (96.0) 1 (4.0)

Operation findings: Simple appendicitis Perforated appendicitis NA* Missing*

105 (42.9) 140 (57.1) 3 2

Peritoneal cavity washout prior to closure? No Yes NA*

89 (36.3) 156 (63.7) 5

Washout used: Normal saline Betadine Other NA - no washout Missing*

141 (95.9) 2 (1.4) 4 (2.7) 89 14

Duration of postoperative intravenous antibiotics (days). Median, IQR (range) 3, 2-5 (0-35)

Duration of postoperative oral antibiotics (days). Median, IQR (range) 5, 2-7 (0-36)

Postoperative intra-abdominal collection: No Yes, requiring antibiotics only Yes, percutaneous drainage without imaging Yes, surgical drainage NA Missing*

225 (90.4) 5 (2.0) 2 (0.8) 14 (5.6) 3 (1.2) 1



19


If yes, how was the collection diagnosed? Clinically Ultrasound CT

7 (33.3) 13 (61.9) 1 (4.8)

If the collection was visualised on imaging or at operation, was it above 5cm in diameter? No Yes

4 (28.6) 10 (71.4)

* Excluded from percentage calculations. CT: Computer tomography. IQR: Interquartile range. NA: Not applicable.



20

Appendix Table 2e. Condition specific patient characteristics, management and

outcomes for patients with inguinal hernia, n=633 (Data from 50 centres)


Type of hernia: Easily reducible Reduced with difficulty Incarcerated, obstructed or strangulated Fistulated Missing*

532 (84.2) 41 (6.5) 57 (9.0) 2 (0.3) 1

Unilateral Bilateral

561 (88.6) 72 (11.4)

Operation type: Elective Emergency

570 (90.5) 63 (9.5)

Operation undertaken: Open herniotomy Laparoscopic herniotomy Laparotomy Other

619 (97.8) 5 (0.8) 7 (1.1) 2 (0.3)

Conversion from laparoscopic to open? No Yes

5 (100.0) 0 (0.0)

Bowel resection required? No Yes, with primary anastomosis via inguinal incision Yes, with primary anastomosis via laparotomy Yes, requiring a stoma Yes, other

616 (97.3) 7 (1.1) 8 (1.3) 1 (0.2) 1 (0.2)

Testis gangrenous at the time of operation? No Yes Missing*

615 (97.5) 16 (2.5) 2

Broad spectrum antibiotics given at the time of operation: No Yes Missing*

379 (60.0) 253 (40.0) 1

Duration of broad spectrum antibiotics given following surgery (days). Median, IQR (range)†

0, 0-2 (0-21)

Recurrence within 30 days of surgery: Yes No, but no follow-up post-discharge No, followed-up in person No, followed-up via the telephone No, other follow-up undertaken Missing*

8 (1.3) 82 (13.1) 405 (64.5) 93 (14.8) 40 (6.4) 5

Overnight stay at the hospital with apnoea and saturation monitoring? No, same day discharge Admitted, but not monitored Yes Missing*

160 (25.3) 132 (20.9) 340 (53.8) 1

* Excluded from percentage calculations. † Missing data, n=3. IQR: Interquartile range. Percentages have been rounded and may not total 100.



21

Appendix Table 3. Mortality stratified by age

Age Neonate (0-28 days) % (no. deaths/ no. neonates)

Infant (29 – 364 days) % (no. deaths/ no. infants)

Child (1 – 16 years) % (no. deaths/ no. children)

Gastroschisis 75.5% (83/110) 0.0% (0/0) 0.0% (0/0)


21.5% (28/130) 0.0% (0/37) 20.0% (4/20)

Intussusception 100.0% (1/1) 9.5% (18/189) 5.8% (2/34)

Appendicitis 0.0% (0/0) 0.0% (0/0) 0.4% (1/248)

Inguinal hernia 0.0% (0/26) 1.1% (2/177) 0.0% (0/418)

All patients* 41.9% (112/267) 5.0% (20/403) 1.0% (7/720) * Missing data, n=17 (Gastroschisis n=1, ARM n=1, Intussusception n=1, Appendicitis n=2, Inguinal hernia n=12)



22

Appendix Table 4. Patient follow-up

Variable All conditions (n=1407), n (%)

Gastroschisis (n=111), n (%)

Anorectal malformation (n=188), n (%)

Intussusception (n=225), n (%)

Appendicitis (n=250), n (%)

Inguinal hernia (n=633), n (%)

Was the patient alive at 30 days post-intervention? Yes No (died in hospital) No (died after discharge) Not followed-up to 30 days Missing

1037 (73.7) 127 (9.0) 12 (0.9) 211 (15.0) 20 (1.4)

16 (14.4) 83 (74.8) 0 (0.0) 11 (9.9) 1 (0.9)

118 (62.8) 21 (11.2) 11 (5.8) 35 (18.6) 3 (1.6)

166 (73.8) 21 (9.3) 0 (0.0) 33 (14.7) 5 (2.2)

206 (82.4) 1 (0.4) 0 (0.0) 39 (15.6) 4 (1.6)

531 (83.9) 1 (0.2) 1 (0.2) 93 (14.7) 7 (1.1)

Was the patient followed-up to 30 days post-intervention to assess for complications?* Yes No Missing

1030 (73.2) 358 (25.4) 19 (1.3)

78 (70.3) 26 (23.4) 7 (6.3)

108 (57.4) 75 (39.9) 5 (2.7)

152 (67.6) 72 (32.0) 1 (0.4)

190 (76.0) 58 (23.2) 2 (0.8)

502 (79.3) 127 (20.1) 4 (0.6)

* Or followed-up until death if prior to 30 days.



23

Appendix Table 5. Univariable and multivariable analysis of patient-level and hospital-level factors associated with mortality for

patients with gastroschisis, anorectal malformation and intussusception combined (generic patient variables only)

Alive (n=396),

n (%)

Dead (n=125),

n (%)

Univariable analysis Multivariable analysis of patient variables

Multivariable analysis of patient and hospital variables

OR (95% CI) P value

OR (95% CI) P value

OR (95% CI) P value

Patient level variables Condition: Gastroschisis 27 (6.8) 83 (66.4) reference reference reference Condition: ARM 166 (41.9) 21 (16.8) 0.04 (0.02,0.07) <0.001 0.07 (0.02,0.18) <0.001 0.09 (0.03, 0.25) <0.001 Condition: Intussusception 203 (51.3) 21 (16.8) 0.03 (0.02,0.06) <0.001 0.03 (0.01,0.10) <0.001 0.04 (0.01,0.14) <0.001 Gestational age at birth, median (IQR) 38 (37,40) 37 (36,38) 0.67 (0.59,0.77) <0.001 ** ** ** ** Male 229 (57.8) 67 (53.6) 0.96 (0.62,1.50) 0.87 Weight at presentation in kg, median (IQR) 6.5 (3.2,8.0) 2.5 (2.0,3.0) 0.67 (0.60,0.75) <0.001 1.00 (0.87,1.17) 0.952 1.01 (0.87,1.16) 0.926 Time to presentation in days, median (IQR) 3.0 (2.0,7.0) 1.5 (1.0,3.0) 0.86 (0.78,0.95) 0.002 0.97 (0.91,1.03) 0.313 0.97 (0.91,1.03) 0.273 Distance from home in km, median (IQR) 30 (14,81) 40 (15,140) 1.00 (1.00,1.00) 0.853 Mode of transport: Ambulance/ health vehicle 59 (15.0) 43 (34.7) reference reference reference Mode of transport: Patient’s own 329 (83.7) 75 (60.5) 0.33 (0.18,0.60) <0.001 0.73 (0.30,1.78) 0.482 0.67 (0.26,1.69) 0.393 ASA score: 1-2 278 (70.2) 31 (25.0) reference reference reference ASA score: 3-5 98 (24.7) 82 (66.1) 9.34 (5.13,17.03) <0.001 3.91 (1.74,8.79) 0.001 3.31 (1.44,7.63) 0.005 ASA score: NA, No intervention 20 (5.1) 11 (8.9) 6.65 (2.54,17.42) <0.001 0.58 (0.10,3.34) 0.539 0.58 (0.10,3.43) 0.546 WHO checklist used: No 186 (47.0) 74 (59.2) reference reference reference WHO checklist used: Yes 184 (46.5) 27 (21.6) 0.37 (0.20,0.67) 0.001 0.69 (0.3,1.59) 0.382 0.74 (0.31,1.74) 0.486 WHO checklist used: NA, no intervention 26 (6.6) 24 (19.2) 3.09 (1.49,6.43) 0.002 0.85 (0.15,4.78) 0.858 0.84 (0.15,4.75) 0.846 Anaesthetic, General Anaesthetic: Yes 311 (78.5) 48 (38.4) reference reference reference Anaesthetic, General Anaesthetic: No 55 (13.9) 43 (34.4) 4.83 (2.63,8.88) <0.001 1.11 (0.41,2.98) 0.833 1.23 (0.45,3.41) 0.685 Anaesthetic, NA, no intervention 30 (7.6) 34 (27.2) 9.86 (4.99,19.52) <0.001 10.48 (2.07,52.97) 0.004 10.33 (1.98,53.94) 0.006 Anaesthetist: Doctor 240 (60.6) 36 (28.8) reference ** ** ** ** Anaesthetist: Non-doctor 102 (25.8) 49 (39.2) 3.08 (1.67,5.68) <0.001 ** ** ** ** Anaesthetist: NA, no anaesthetic 54 (13.6) 40 (32.0) 7.35 (3.88,13.93) <0.001 ** ** ** ** Blood transfusion: Yes 107 (27.4) 42 (36.2) 1.81 (1.08,3.04) 0.024 3.72 (1.59,8.68) 0.002 3.95 (1.70,9.19) 0.001 Surgical site infection: Yes 83 (21.2) 19 (15.8) 0.73 (0.40,1.33) 0.303 Wound dehiscence: Yes 29 (7.4) 2 (1.7) 0.18 (0.04,0.82) 0.027 ** ** ** ** Further intervention: Yes 47 (12.0) 13 (11.0) 0.80 (0.39,1.64) 0.538

Hospital level variables Paediatric surgeons/million children, mean (SD) 2.18 (0.84) 2.28 (0.83) 1.10 (0.73,1.65) 0.651 Personnel: low 56 (15.8) 3 (2.7) reference ** ** Personnel: medium 255 (71.8) 96 (85.0) 6.41 (1.50,27.32) 0.012 ** ** Personnel: high 44 (12.4) 14 (12.4) 4.98 (0.97,25.57) 0.054 ** **



24

Alive (n=396),

n (%)

Dead (n=125),

n (%)

Univariable analysis Multivariable analysis of patient variables

Multivariable analysis of patient and hospital variables

OR (95% CI) P value

OR (95% CI) P value

OR (95% CI) P value

Infrastructure: low 55 (14.2) 11 (9.4) reference Infrastructure: medium 240 (62.2) 70 (59.8) 1.39 (0.50,3.91) 0.528 Infrastructure: high 91 (23.6) 36 (30.8) 1.23 (0.37,4.13) 0.732 Procedure: low 80 (20.7) 57 (48.7) reference reference Procedure: medium 268 (69.4) 47 (40.2) 0.29 (0.15,0.54) <0.001 0.44 (0.18,1.05) 0.064 Procedure: high 38 (9.8) 13 (11.1) 0.54 (0.22,1.30) 0.167 0.65 (0.18,2.32) 0.509 Anaesthetic and resuscitation: low 54 (14.0) 11 (9.4) reference Anaesthetic and resuscitation: medium 222 (57.5) 73 (62.4) 1.51 (0.54,4.22) 0.432 Anaesthetic and resuscitation: high 110 (28.5) 33 (28.2) 1.36 (0.46,4.05) 0.578

** Excluded from the multivariable model due to collinearity or low counts. ARM: Anorectal malformation. ASA: American Association of Anesthesiologists. CI: Confidence interval. IQR: Interquartile range. NA: Not applicable. OR: Odds ratio. SD: Standard deviation. WHO: World Health Organisation. Percentages have been rounded and may not total 100.



25

Appendix Table 6. Univariable analysis of patient-level and hospital-level factors

associated with mortality for patients with gastroschisis (generic and condition specific

variables)

Alive (n=27), n (%)

Dead (n=83), n (%)

Univariable analysis OR (95% CI) P value

Patient level variables: generic Gestational age at birth, median (IQR) 38 (36,40) 36 (35,38) * * Male sex 8 (30) 39 (47) 2.40 (0.86,6.74) 0.095 Weight in kg, mean (SD) 2.50 (0.46) 2.26 (0.53) 0.40 (0.14,1.10) 0.076 Time to presentation in days, median (IQR) 1 (1,1) 1 (1,2) 1.16 (0.75,1.79) 0.502 Distance from home in km, median (IQR) 60 (22,195) 58 (16,153) 1.00 (0.99,1.00) 0.472 Place of birth: Outborn 25 (93) 76 (93) 1.01 (0.17,6.19) 0.987 ASA score: 1-2 17 (63) 18 (22) reference ASA score: 3-5 9 (33) 54 (66) 7.98 (1.70,37.40) 0.008 ASA score: NA, no intervention 1 (4) 10 (12) 9.79 (0.98,98.07) 0.052 WHO Checklist used: No 8 (30) 51 (61) * * WHO Checklist used: Yes 17 (63) 14 (17) * * WHO Checklist used: NA 2 (7) 18 (22) * * Anaesthetic: General anaesthetic 16 (59) 20 (24) reference Anaesthetic: No general anaesthetic 9 (33) 39 (47) 4.48 (1.02,19.66) 0.047 Anaesthetic: NA, no intervention 2 (7) 24 (29) 13.28 (2.04,86.24) 0.007 Anaesthetist: Doctor 13 (48) 15 (18) reference Anaesthetist: Non-doctor 11 (41) 38 (46) 3.46 (0.86,13.91) 0.08 Anaesthetist: NA, no anaesthetic 3 (11) 30 (36) 12.16 (2.18,67.77) 0.004 Blood transfusion: No 9 (33) 16 (19) 0.51 (0.17,1.52) 0.226 Surgical site infection: Yes 6 (25) 14 (20) 0.68 (0.20,2.33) 0.536 Wound dehiscence: Yes 2 (8) 1 (1) 0.06 (0.00,1.26) 0.070 Further unplanned intervention: Yes 5 (21) 10 (14) 0.48 (0.12,1.97) 0.311

Patient level variables: condition specific Gastroschisis type: Complex 3 (11) 28 (34) 4.39 (1.12,17.20) 0.034 Antenatal diagnosis: Yes 2 (7) 3 (4) 0.42 (0.05,3.25) 0.407 Septic at presentation: Yes 12 (44) 48 (59) 2.33 (0.76,7.15) 0.140 Warmed if hypothermic on arrival: No 4 (15) 14 (17) reference Warmed if hypothermic on arrival: Yes 15 (56) 50 (60) 0.99 (0.23,4.18) 0.989 Warmed if hypothermic on arrival: NA 8 (30) 19 (23) 0.58 (0.12,2.72) 0.487 Hypovolaemic on arrival: Yes 9 (33) 55 (66) 7.84 (1.96,31.34) 0.004 IV bolus within 1 hour of arrival: Yes 12 (46) 46 (55) 1.87 (0.64,5.50) 0.253 Peripheral cannula day 1: Yes 24 (89) 79 (95) 2.79 (0.49,15.80) 0.245 Umbilical catheter day 1: Yes 2 (7) 5 (6) 0.63 (0.09,4.25) 0.639 Other central line day 1: Yes 3 (11) 2 (2) 0.17 (0.02,1.46) 0.106 Time to intervention in hours, median (IQR) 6.5 (2.3,15.8) 7.5 (4.0,16.5) 1.00 (0.98,1.02) 0.820 Intervention: primary closure at the cotside or in the OR or surgical silo at the cotside or OR

22 (85) 35 (42) * *

Intervention: preformed silo at the cotside 4 (15) 29 (35) * * Intervention: palliative care 0 (0) 19 (22) * * Days to closure, median (IQR) 2 (1,5) 0 (0,2) 0.90 (0.77,1.04) 0.145 Ventilation available when required: No 10 (37) 25 (30) reference Ventilation available when required: Yes 8 (30) 27 (33) 0.89 (0.20,3.96) 0.876 Ventilation available: NA, not required 9 (33) 31 (37) 0.99 (0.26,3.88) 0.994 Parenteral nutrition received: Yes 11 (41) 30 (36) 0.30 (0.06,1.43) 0.132 Ischaemic bowel following intervention: No 24 (92) 35 (43) * * Ischaemic bowel following intervention: Yes 0 (0) 25 (31) * * Ischaemic bowel following intervention: NA 2 (8) 22 (27) * * ACS following intervention: No 23 (89) 30 (38) * * ACS following intervention: Yes 0 (0) 9 (11) * * ACS following intervention: NA 3 (12) 40 (51) * * If ACS developed, abdomen re-opened: No 0 (0) 6 (60) * *



26

Alive (n=27), n (%)

Dead (n=83), n (%)

Univariable analysis OR (95% CI) P value

If ACS developed, abdomen re-opened: Yes 0 (0) 3 (30) * * If ACS developed, abdomen re-opened: NA 0 (0) 1 (10) * * Central line sepsis: No 12 (46) 28 (35) * * Central line sepsis: Yes 1 (4) 3 (4) * * Central line sepsis: NA 13 (50) 48 (61) * *

Hospital level variables Paediatric surgeons/million children, mean (SD)

2.21 (0.83) 2.42 (0.74) 1.43 (0.62,3.28) 0.399

Personnel: low 0 (0) 2 (3) * * Personnel: medium 20 (83) 66 (89) * * Personnel: high 4 (17) 6 (8) * * Infrastructure: low 1 (4) 9 (12) reference Infrastructure: medium 11 (46) 34 (45) 0.33 (0.02,4.59) 0.408 Infrastructure: high 12 (50) 33 (43) 0.13 (0.01,2.32) 0.167 Procedure: low 8 (33) 42 (55) reference Procedure: medium 7 (29) 25 (33) 0.70 (0.18,2.78) 0.610 Procedure: high 9 (38) 9 (12) 0.16 (0.03,0.84) 0.031 Anaesthesia and Resuscitation: low 4 (17) 5 (7) reference Anaesthesia and Resuscitation: medium 14 (58) 51 (67) 2.77 (0.42,18.13) 0.289 Anaesthesia and Resuscitation: high 6 (25) 20 (26) 2.58 (0.34,19.75) 0.362

* Univariable analysis not possible due to low/zero counts or singularity of random intercept. ACS: Abdominal compartment syndrome. ASA: American Association of Anesthesiologists. CI: Confidence interval. IQR: Interquartile range. NA: Not applicable. OR: Odds ratio. SD: Standard deviation. WHO: World Health Organisation. Percentages have been rounded and may not total 100.



27


associated with mortality for patients with ARM (generic and condition specific

variables)

Alive (n=167),

n (%)

Dead (n=21), n (%)

Univariable analysis

OR (95% CI) P value

Patient level variables: generic

Gestational age, median (IQR) 38 (37,38) 38 (37,38) 0.89 (0.66,1.20) 0.450 Male sex 88 (53) 15 (71) 2.70 (0.88,8.30) 0.082 Weight in kg, median (IQR) 3.4 (2.8,7.0) 2.9

(2.5,3.1) 0.64 (0.44,0.95) 0.025

Time to presentation in days, median (IQR) 5 (3,120) 3 (2,5) 0.94 (0.85,1.04) 0.251 Distance from home in km, median (IQR) 50 (25,150) 30 (14,59) 1.00 (0.99,1.00) 0.231 Mode of transport: Ambulance/ healthcare vehicle 28 (17) 3 (14) reference Mode of transport: Patient’s own 135 (83) 18 (86) 1.45 (0.31,6.83) 0.641 ASA score: 1-2 125 (82) 7 (35) reference ASA score: 3-5 28 (18) 13 (65) 9.84 (2.75,35.28) <0.001 WHO Checklist used: No 62 (37) 7 (33) reference WHO Checklist used: Yes 85 (51) 8 (38) 0.69 (0.21,2.25) 0.540 WHO Checklist used: NA 20 (12) 6 (29) 1.06 (0.20,5.55) 0.941 Anaesthetic: General anaesthetic 140 (84) 12 (57) reference Anaesthetic: No general anaesthetic 7 (4) 3 (14) 5.36 (1.00,28.90) 0.051 Anaesthetic: NA, no intervention 20 (12) 6 (29) 2.96 (0.82,10.76) 0.099 Anaesthetist: Doctor 106 (64) 8 (38) reference Anaesthetist: Non-doctor 41 (25) 7 (33) 2.29 (0.66,7.98) 0.194 Anaesthetist: NA 20 (12) 6 (29) 3.20 (0.82,12.49) 0.095 Blood transfusion: Yes 26 (16) 10 (50) 5.53 (1.87,16.39) 0.002 Surgical site infection: Yes 34 (23) 3 (23) 1.06 (0.22,5.25) 0.940 Wound dehiscence: Yes 14 (10) 1 (8) 0.96 (0.09,10.50) 0.973 Further intervention: Yes 18 (12) 1 (7) 0.62 (0.07,5.60) 0.668

Patient level variables: condition specific

Type: High 79 (48) 15 (71) 2.71 (0.92,7.98) 0.070 No additional anomalies: Yes 126 (75) 10 (48) 0.24 (0.08,0.73) 0.012 Septic on arrival: Yes 28 (17) 13 (62) 8.55 (2.89,25.34) <0.001 Antibiotics within an hour of arrival: Yes 52 (32) 8 (38) 1.42 (0.49,4.16) 0.521 Antibiotics for 48hours post-op: Yes 128 (83) 15 (79) 0.82 (0.20,3.41) 0.788 Ventilation available when required: No 48 (30) 12 (57) reference Ventilation available when required: Yes 30 (19) 4 (19) 0.60 (0.15,2.40) 0.469 Ventilation available: NA, not required 83 (52) 5 (24) 0.24 (0.07,0.82) 0.022 Pre-op bowel perforation: Yes 6 (4) 1 (5) 1.63 (0.14,18.54) 0.692 Time to intervention in days, median (IQR) 2 (1,4) 2 (1,2) 0.81 (0.62,1.06) 0.127 Intervention: Stoma 100 (61) 13 (62) reference Intervention: Anorectal reconstruction 44 (27) 2 (10) 0.35 (0.07,1.70) 0.194 Intervention: Other 19 (12) 2 (10) 0.72 (0.13,4.01) 0.704 Intervention: Palliative care 1 (1) 4 (19) 25.91 (2.21,303.3) 0.01 Pena stimulator used: Yes 32 (60) 2 (50) * * Electrolyte disturbance: No† 124 (78) 4 (21) reference Electrolyte disturbance: Yes† 15 (9) 11 (58) 29.94 (6.31,142.05) <0.001 Electrolyte disturbance: NA† 21 (13) 4 (21) 5.82 (1.16,29.19) 0.032 High stoma output: No† 106 (65) 8 (40) * * High stoma output: Yes† 4 (3) 0 (0) * * High stoma output: NA† 52 (32) 12 (60) * * Stoma prolapse: No† 105 (65) 8 (40) reference Stoma prolapse: Yes† 4 (3) 1 (5) 4.02 (0.32,50.68) 0.282 Stoma prolapse: NA† 53 (33) 11 (55) 2.51 (0.85,7.46) 0.097 Peri-stoma skin breakdown: No† 87 (54) 8 (40) reference Peri-stoma skin breakdown: Yes† 20 (12) 2 (10) 1.02 (0.18,5.88) 0.983 Peri-stoma skin breakdown: NA† 54 (34) 10 (50) 1.71 (0.54,5.43) 0.363 Sepsis: No† 126 (78) 6 (32) reference



28

Alive (n=167),

n (%)

Dead (n=21), n (%)


OR (95% CI) P value

Sepsis: Yes† 12 (8) 10 (53) 22.20 (5.05,97.68) <0.001 Sepsis: NA† 23 (14) 3 (16) 2.06 (0.37,11.59) 0.411 Anal stenosis: No† 77 (48) 5 (26) ref Anal stenosis: Yes† 6 (4) 1 (5) 1.85 (0.14,25.12) 0.643 Anal stenosis: NA† 77 (48) 13 (68) 2.61 (0.76,9.00) 0.128

Hospital level variables

Paediatric surgeons/million children, mean (SD) 2.13 (0.84) 2.00 (0.92) 1.03 (0.45,2.32) 0.953 Personnel: low 28 (18) 0 (0) * * Personnel: medium 105 (69) 14 (74) * * Personnel: high 20 (13) 5 (26) * * Infrastructure: low 27 (17) 1 (5) * * Infrastructure: medium 94 (58) 19 (95) * * Infrastructure: high 41 (25) 0 (0) * * Procedure: low 39 (24) 9 (45) reference Procedure: medium 104 (64) 8 (40) 0.29 (0.07,1.21) 0.089 Procedure: high 19 (12) 3 (15) 0.58 (0.09,3.84) 0.574 Anaesthesia and Resuscitation: low 23 (14) 3 (15) reference Anaesthesia and Resuscitation: medium 97 (60) 11 (55) 0.68 (0.10,4.65) 0.691 Anaesthesia and Resuscitation: high 42 (26) 6 (30) 0.83 (0.10,6.56) 0.857

* Univariable analysis not possible due to low/zero counts or singularity of random intercept. † Within 30-days of surgery. ASA: American Association of Anesthesiologists. CI: Confidence interval. IQR: Interquartile range. NA: Not applicable. OR: Odds ratio. SD: Standard deviation. WHO: World Health Organisation.



29


associated with mortality for patient with intussusception (generic and condition

specific variables)

Alive n=203, (n (%)

Dead (n=21), N (%)


OR (95% CI) P value

Patient level variables: generic Gestational age at birth, mean (SD) 39 (1) 38 (1) 0.74 (0.52,1.06) 0.103 Age at presentation in months, median (IQR) 7 [5, 10] 6 [5, 9] 0.98 (0.93,1.03) 0.418 Male sex 134 (66.0) 13 (61.9) 0.84 (0.32,2.20) 0.723 Weight in kg, median (IQR) 7.4 [6.4,

8.7] 8.0 [6.5, 8.0] 0.96 (0.83,1.11) 0.568 Onset to presentation in days, median (IQR) 3 [2, 5] 5 [4, 7] 1.00 (0.95,1.06) 0.897 Distance from home in km, median (IQR) 20 [10, 45] 23 [11, 50] * * Mode of Transport: patient’s own vs ambulance/health service vehicle

184 (91.5) 18 (85.7) 0.55 (0.14,2.24) 0.409

ASA score: 1-3 187 (94.9) 10 (47.6) * * ASA score: 4-5 10 (5.1) 11 (52.4) * * WHO Checklist used: No 111 (54.7) 13 (61.9) reference WHO Checklist used: Yes 82 (40.4) 5 (23.8) 0.45 (0.13,1.55) 0.205 WHO Checklist used: NA, no intervention 10 (4.9) 3 (14.3) 3.03 (0.62,14.82) 0.170 Anaesthetic: General anaesthetic 155 (76.7) 16 (76.2) reference Anaesthetic: No general anaesthetic 38 (18.8) 1 (4.8) 0.27 (0.03,2.22) 0.223 Anaesthetic: NA, no intervention 9 (4.5) 4 (19.0) 5.67 (1.23,26.21) 0.026 Anaesthetist: Doctor 121 (59.6) 13 (61.9) reference Anaesthetist: Non-doctor 50 (24.6) 4 (19.0) 0.69 (0.18,2.60) 0.587 Anaesthetist: NA, no anaesthetic 32 (15.8) 4 (19.0) 1.50 (0.38,5.98) 0.563 Blood transfusion: Yes 72 (35.6) 16 (80.0) 7.97 (2.33,27.24) 0.001 Surgical site infection: Yes 43 (21.3) 2 (9.5) 0.37 (0.08,1.75) 0.211 Wound dehiscence: Yes 13 (6.4) 0 (0.0) * * Further intervention: Yes 24 (11.8) 2 (9.5) * *

Patient level variables: condition specific Diagnosis: clinical 35 (17.2) 5 (23.8) reference Diagnosis: US 162 (79.8) 12 (57.1) 0.54 (0.17,1.76) 0.306 Diagnosis: other 6 (3.0) 4 (19.0) 5.16 (0.88,30.40) 0.070 Septic on arrival: Yes 82 (40.4) 19 (90.5) 14.59 (3.10,68.70) 0.001 Antibiotics given within 1hour of arrival: Yes 118 (58.1) 14 (66.7) 1.48 (0.53,4.15) 0.455 If hypovolaemic or septic: IVF given pre-intervention: No 20 (9.9) 0 (0.0)

* *

If hypovolaemic or septic: IVF given pre-intervention: Yes 135 (66.8) 20 (95.2)

* *

If hypovolaemic or septic: IVF given pre-intervention: N/A 47 (23.3) 1 (4.8)

* *

Peritonitis: Yes† 34 (16.7) 7 (33.3) 2.80 (0.93,8.40) 0.067 Perforation: Yes† 9 (4.4) 6 (28.6) * * Shock: Yes† 7 (3.4) 5 (23.8) 8.98 (2.21,36.50) 0.002 Other contraindication: Yes† 54 (26.6) 4 (19.0) 0.61 (0.18,2.01) 0.414 No contraindication† 104 (51.2) 3 (14.3) * * Intervention: laparotomy vs air or hydroenema reduction 140 (70.7) 17 (100.0)

* *

Successful air or hydroenema reduction: Yes 40 (69.0) 0 (0.0) * * Management at laparotomy: manual reduction 63 (39.6) 0 (0.0) * * Management at laparotomy: resection, primary anastomosis

93 (58.5) 14 (82.4) * *

Management at laparotomy: resection, stoma 3 (1.9) 3 (17.6) * * Time from onset to reduction/management in hours, median IQR 15 [6,24] 20 [9, 24] 1.00 (0.99,1.01) 0.848 Recurrence: Yes 3 (1.5) 1 (5.0) * *



30

Alive n=203, (n (%)

Dead (n=21), N (%)


OR (95% CI) P value

Hospital level variables† Paediatric surgeons/million children, mean (SD) 2.24 (0.84) 2.05 (0.94) 0.79 (0.42,1.50) 0.474 Personnel: low 28 (15.7) 1 (5.0) reference Personnel: medium 130 (73.0) 16 (80.0) 3.84 (0.37,39.36) 0.257 Personnel: high 20 (11.2) 3 (15.0) 4.72 (0.34,66.28) 0.250 Infrastructure: low 28 (14.0) 1 (4.8) reference Infrastructure: medium 135 (67.5) 17 (81.0) 4.23 (0.41,44.13) 0.227 Infrastructure: high 37 (18.5) 3 (14.3) 2.62 (0.19,35.51) 0.469 Procedure: low 34 (17.0) 6 (28.6) reference Procedure: medium 157 (78.5) 14 (66.7) 0.51 (0.16,1.56) 0.237 Procedure: high 9 (4.5) 1 (4.8) 0.60 (0.06,6.35) 0.674 Anaesthetic and resuscitation: low 27 (13.5) 3 (14.3) reference Anaesthetic and resuscitation: medium 112 (56.0) 11 (52.4) 0.91 (0.18,4.53) 0.904 Anaesthetic and resuscitation: high 61 (30.5) 7 (33.3) 1.02 (0.18,5.62) 0.984

* Univariable analysis not possible due to low/zero counts or singularity of random intercept. † As a contra-indication for air- or hydro-enema reduction. ASA: American Association of Anesthesiologists. CI: Confidence interval. IQR: Interquartile range. IVF: Intravenous fluid. NA: Not applicable. OR: Odds ratio. SD: Standard deviation. WHO: World Health Organisation. US: Ultrasound. Percentages have been rounded and may not total 100.



31

Appendix Table 9. Patient data validation: agreement between the study dataset and

validation dataset

Variable Observed agreement % (patients with agreement/ total patients)*

Kappa statistic†

Generic variables: Sex 90% (45/50) 0.80

Did the patient survive to discharge 98% (49/50) 0.85

Did the patient require a further intervention 96% (43/45) -

Study condition 100% (50/50) 1.00

Condition specific variables: Gestational age at birth (in patients with gastroschisis and anorectal malformation)

83% (5/6) 0.85

Type of gastroschisis - simple 100% (5/5) 1.00

Type of gastroschisis - associated with atresia 80% (4/5) -

Type of gastroschisis - associated with necrosis 80% (4/5) 0.55

Type of gastroschisis - associated with perforation 100% (5/5) 1.00

Method of gastroschisis closure‡ 60% (3/5) 0.44

Type of anorectal malformation 50% (1/2) -

Anorectal malformation primary operation 100% (2/2) 1.0

Age at presentation in patients with appendicitis 94% (17/18) 0.98

Management of appendicitis§ 94% (17/18) 0.79

Operative findings in those with appendicitis 100% (18/18) 1.00

Age at presentation in patients with intussusception 60% (3/5) 0.41

Was the intussusception diagnosed on ultrasound 100% (5/5) 1.00

Primary management in those with intussusception** 60% (3/5) -

Age at diagnosis (in weeks) in patients with an inguinal hernia 90% (18/20) 0.94

Operation type (emergency or elective) in patients with an inguinal hernia

95% (19/20) -

Operation undertaken in patients with an inguinal hernia 100% (20/20) 1.00

Total 94% (336/359) Median: 0.96

* Data from 50 patients in 3 hospitals; 2 hospitals randomly selected for validation could not participate due to unavailability of the required data retrospectively. † 0.60-0.80 is good agreement; 0.81-1 is very good agreement. For some variables the kappa statistic could not be calculated due to all data confined to one category. ‡ Two differences were between preformed and surgical silo. § Difference was ‘other’ category. ** Main dataset had air enema reduction as primary intervention for two patients and the validation dataset had laparotomy – one explanation might be the validation data was collected from the operating room logbook retrospectively and hence the prior air enema reductions undertaken outside the OR were missed.



32

Appendix Table 10. Validation survey undertaken by local investigators at validating centers

Survey Question No. of local investigators who collected study data (n=8), n (%)

No. of local investigators who collected validation data (n=4), n (%)

Do you think your team managed to identify all eligible patients for the study? Yes No Unsure

8 (100) 0 (0) 0 (0)

3 (75) 0 (0) 1 (25)

Could any of the patients have been missed from study inclusion? Yes No Unsure

3 (38) 4 (50) 1 (13)

1 (25) 3 (75) 0 (0)

If yes or unsure, how might patients have been missed from study inclusion?* Patients who are discharged against medical advice or died before paediatric surgery team review. The resident collecting data may have missed a patient, especially if the data was collected after the patient’s intervention. On nights and weekends the adult surgeons may also manage pediatric patients. Although general surgery daily service lists were checked, there is a possibility that one or two patients could be missed. Poor record keeping.

2 1 1 0

1 0 0 1

Are there any conditions that were more likely to be missed from study inclusion? Gastroschisis Anorectal malformation Appendicitis Intussusception Inguinal hernia

1 (13) 0 (0) 2 (25) 0 (0) 5 (63)

1 (25) 0 (0) 2 (50) 0 (0) 1 (25)

If any of the conditions were more likely to be missed, why was this the case?* Inguinal hernia – may be seen in out-patients only, often managed as day cases, there are lots of patients with this condition. Appendicitis – some of the older children may have been managed by adult general surgeons. Gastroschisis – more likely to discharge against medical advice than other cases.

3 2 1

1 1 0

Which patients with appendicitis did you include in the study? Just patients within the paediatric services. All eligible patients from adult and paediatric services.

4 (50) 4 (50)

4 (75) 1 (25)

How did you identify patients to include in the study? Ward round Handover Operating room logbook Planned operation lists Ward patient lists

6 (75) 5 (63) 4 (50) 4 (50) 8 (100)

0 (0) 0 (0) 3 (75) 1 (25) 4 (100)



33

Word of mouth Personal knowledge of patients Other

2 (25) 5 (63) 1 (13)

0 (0) 0 (0) 1 (25)

If none of the collaborators were present at the hospital for one or more days during the study, was the team able to identify patients eligible for the study on those days? Yes No Not applicable Unsure

6 (75) 0 (0) 2 (25) 0 (0)

3 (75) 0 (0) 0 (0) 1 (25)

How did you identify patients to be included in the study on days when study collaborators were not present at the hospital?* Handover Operating room logbook Ward patient lists Word of mouth Personal knowledge of patients Not applicable – there is never a time when a member of the pediatric surgery team is not on the ground. Emergency records Case logs/ ward book/ electronic medical record system for billing

2 1 2 3 1 3 1 1

0 2 0 0 0 0 0 3

Do you have any concerns regarding the accuracy of the data collected? Yes No Unsure

2 (25) 5 (62.5) 1 (12.5)

1 (25) 3 (75) 0 (0)

What data points might be inaccurate and what were the challenges for collecting the data?* Collecting exact distances from home to hospital. Accuracy of gestational age stated by illiterate mothers. Exact duration of time between presentation and primary intervention – these may not be documented. Poor record keeping.

2 2 2 0

0 0 0 1

Were any of the data points more difficult to collect accurately? If so, which ones and why?* Following up patients managed by the general adult surgeons to 30-days following intervention. Distance from home to hospital. Most cities are not planned and distances are not accurately stated. We used Google distance calculator in some cases and estimated some. Some patients come from ‘these parts’ and do not have an accurate name for calculating. People measure distance of travel by cost of the transport. Gestational age – illiterate mothers often estimate pregnancy in months rather than weeks. Many do not have an ultrasound for dating. Records say ‘full term baby’ which is anything from 37 to 40 weeks. Time from admission to intervention. Paediatricians may review patients first and not document the time of admission. Some cases had no timing documented on the anesthetic chart.

1 3 2 2

0 0 2 0

* Free text boxes: percentages not calculated. Percentages have been rounded and may not total 100.



34

Appendix Table 11. Validation of the hospital data (n=40)

Variable Observed agreement*, % (no. hospitals with agreement/ total no. validation hospitals)

ICC†

Personnel

Population served by the hospital in millions 23% (5/22) 1.00

No. Paediatric Surgeons undertaking general paediatric surgery per hospital 74% (28/38) 0.87

No. Paediatric Surgeons undertaking neonatal surgery per hospital 63% (24/38) 0.86

No. General Surgeons undertaking general paediatric surgery per hospital 58% (22/38) 0.80

No. General Surgeons undertaking neonatal surgery per hospital 68% (26/38) 0.71

No. Medical Officers undertaking paediatric surgery per hospital 68% (25/37) 0.48

No. Medical Officers undertaking neonatal surgery per hospital 81% (30/37) 0.06

Infrastructure and surgical resources

Running water 71% (27/38) 0.55

Electricity 63% (24/38) 0.50

Electricity generator back-up 74% (28/38) 0.44

Laboratory for biochemistry 76% (29/38) 0.53

Laboratory for hematology 71% (27/38) 0.32

Blood bank 62% (25/40) 0.12

Functioning ultrasound (US) machine 72% (29/40) 0.38

Fluoroscopy 78% (31/40) 0.58

Paediatric ventilation outside of the operating room (OR) 85% (34/40) 0.88

Neonatal ventilation outside of the OR 90% (36/40) 0.93

Availability of a Paediatric Intensive Care Unit (ICU) for surgical patients 87% (33/38) 0.67

Availability of Neonatal ICU for surgical patients 84% (32/38) 0.67

Parenteral nutrition 90% (36/40) 0.81

Surgical Safety Checklist in the OR 62% (25/40) 0.60

Sterile gloves and gown 84% (32/38) -

Autoclave for sterilising surgical equipment 87% (33/38) -

Pena stimulator for identifying the muscle complex in ARM surgery 74% (28/38) 0.67

Procedures

Cotside reduction and primary closure of gastroschisis (Bianchi technique) 95% (37/39) 0.72

Preformed silo application, reduction and closure of gastroschisis 79% (31/39) 0.6

Surgical silo application, reduction and closure of gastroschisis 59% (23/39) 0.35

Primary closure of gastroschisis in the OR 64% (25/39) 0.48

Sigmoid colostomy for anorectal malformation 75% (30/40) 0.38

Posterior sagittal anorectoplasty (PSARP) for anorectal malformation 78% (31/40) 0.49

Open appendicectomy 85% (34/40) -

Laparoscopic appendicectomy 80% (32/40) 0.56

US drainage of intra-abdominal collection 70% (26/37) 0.57

CT drainage of intra-abdominal collection 84% (32/38) 0.34

US diagnosis of intussusception 78% (31/40) 0.54

Air-enema reduction of intussusception 92% (36/39) 0.93

Hydro-enema reduction of intussusception 87% (34/39) 0.68

Laparotomy for intussusception 62% (25/40) -

Open inguinal herniotomy 98% (39/40) 0.61

Laparoscopic inguinal herniotomy 90% (35/39) 0.67

Paediatric central line insertion 75% (30/40) 0.56

Neonatal central line insertion 82% (33/40) 0.70

Umbilical catheterisation 72% (28/39) 0.69

Anaesthesia and resuscitation

Paediatric bag, value and mask 70% (28/40) 0.14

Bottled oxygen 75% (30/40) 0.40

Piped oxygen 82% (33/40) 0.60

Oxygen saturation monitor 72% (29/40) 0.27

Apnoea monitor 71% (27/38) 0.61

Multi-parameter intra-operative monitoring 66% (25/38) 0.02



35

Variable Observed agreement*, % (no. hospitals with agreement/ total no. validation hospitals)

ICC†

Anaesthetic machine for children 60% (24/40) 0.15

Anaesthetic machine for neonates 68% (27/40) 0.46

Ketamine anaesthesia for children 65% (26/40) 0.22

Ketamine anaesthesia for neonates 68% (26/38) 0.22

Spinal/ caudal anaesthesia for children 80% (32/40) 0.54

Spinal/ caudal anaesthesia for neonates 84% (32/38) 0.58

Anaesthetic doctor competent to perform paediatric anaesthesia 85% (34/40) 0.75

Anaesthetic doctor competent to perform neonatal anaesthesia 82% (33/40) 0.71

Anaesthetic nurse competent to perform paediatric anaesthesia 68% (27/40) 0.61

Anaesthetic nurse competent to perform neonatal anaesthesia 75% (30/40) 0.61

Presence of a children’s hospital within the country of the participating hospital

70% (28/40) 0.58

Total 75% (1752/2327) Median 0.58, IQR 0.41,0.69

* Observed agreement (always vs sometimes/never) between the two most senior team members who completed the survey at each hospital. Only hospitals with more than one rater were included (n=40). † Interclass Correlation Coefficients (ICCs) were calculated from mixed models with hospital as the random intercept. ICC interpretation: <0.40 poor, 0.40-0.59 fair, 0.60-0.74 good, 0.75-1.00 excellent. Results represent the level of agreement between all respondents from each hospital where more than one respondent completed the survey. For some variables the ICC could not be calculated due to all data confined to one category.



Paediatric surgical outcomes in sub-Saharan Africa: a ...

Documents

Transcript of Paediatric surgical outcomes in sub-Saharan Africa: a ...