Anaesthesia facility evaluation: a Whatsapp survey of hospitals in Burundi

Background: Data regarding the capacity to provide safe anaesthesia is lacking in many low-income countries. With the increasing popularity of WhatsApp for both personal and professional communication in Africa, we sought to test the feasibility of using this platform to administer a brief survey of anaesthesia equipment availability in Burundi. The aims of the study were to survey a subset of anaesthesia equipment availability in Burundi and to assess the suitability of using a WhatsApp chat group to administer such a survey.

Methods: The survey was distributed via WhatsApp by ATSARPS (Agora des Techniciens Supérieurs Anesthésistes Réanimateurs pour la Promotion de la Santé), an association of anaesthesia providers in Burundi. The questions focused on the presence of five pieces of anaesthesia equipment recommended by the World Health Organization – World Federation of Societies of Anesthesiologists (WHO–WFSA) International Standards for a Safe Practice of Anesthesia, namely a Lifebox pulse oximeter, anaesthesia machine, capnograph, ECG and defibrillator. Questions were sent as free text, and responses were received as a reply or as a personal message to the president of ATSARPS who sent the survey.

Results: Responses received represented data from 55 (85%) of the 65 hospitals that offer anaesthesia care across Burundi. Eightynine per cent of hospitals had a Lifebox pulse oximeter, 91% had an anaesthesia machine, 16% had capnography, 24% had an ECG and 14% had a defibrillator. Among hospitals which responded to our survey, only 60% reported perfoming general endotracheal anaesthesia on a monthly basis.

Conclusion: Data collection in low- and middle-income countries (LMICs) can be challenging; therefore, simple, low-cost methods of data collection need to be developed. We have demonstrated the feasibility of using a WhatsApp chat group among a national society of anaesthesia providers in Burundi to perform an initial abbreviated audit of anaesthesia facilities. We have also identified significant deficits in anaesthesia equipment in Burundi.

Inequalities in caesarean section in Burundi: evidence from the Burundi Demographic and Health Surveys (2010–2016)

Background
Despite caesarean section (CS) being a lifesaving intervention, there is a noticeable gap in providing this service, when necessary, between different population groups within a country. In Burundi, there is little information about CS coverage inequality and the change in provision of this service over time. Using a high-quality equity analysis approach, we aimed to document both magnitude and change of inequality in CS coverage in Burundi over 7 years to investigate disparities.

Methods
For this study, data were extracted from the 2010 and 2016 Burundi Demographic and Health Surveys (BDHS) and analyzed through the recently updated Health Equity Assessment Toolkit (HEAT) of the World Health Organization. CS delivery was disaggregated by four equity stratifiers, namely education, wealth, residence and sub-national region. For each equity stratifier, relative and absolute summary measures were calculated. We built a 95% uncertainty interval around the point estimate to determine statistical significance.

Main findings
Disparity in CS was present in both survey years and increased over time. The disparity systematically favored wealthy women (SII = 10.53, 95% UI; 8.97, 12.10), women who were more educated (PAR = 8.89, 95% UI; 8.51, 9.26), women living in urban areas (D = 12.32, 95% UI; 9.00, 15.63) and some regions such as Bujumbura (PAR = 11.27, 95% UI; 10.52, 12.02).

Conclusions
Burundi had not recorded any progress in ensuring equity regarding CS coverage between 2010 and 2016. It is important to launch interventions that promote justified use of CS among all subpopulations and discourage overuse among high income, more educated women and urban dwellers.

Availability, procurement, training, usage, maintenance and complications of electrosurgical units and laparoscopic equipment in 12 African countries

Background: Strategies are needed to increase the availability of surgical equipment in low- and middle-income countries (LMICs). This study was undertaken to explore the current availability, procurement, training, usage, maintenance and complications encountered during use of electrosurgical units (ESUs) and laparoscopic equipment.

Methods: A survey was conducted among surgeons attending the annual meeting of the College of Surgeons of East, Central and Southern Africa (COSECSA) in December 2017 and the annual meeting of the Surgical Society of Kenya (SSK) in March 2018. Biomedical equipment technicians (BMETs) were surveyed and maintenance records collected in Kenya between February and March 2018.

Results: Among 80 participants, there were 59 surgeons from 12 African countries and 21 BMETs from Kenya. Thirty-six maintenance records were collected. ESUs were available for all COSECSA and SSK surgeons, but only 49 per cent (29 of 59) had access to working laparoscopic equipment. Reuse of disposable ESU accessories and difficulties obtaining carbon dioxide were identified. More than three-quarters of surgeons (79 per cent) indicated that maintenance of ESUs was available, but only 59 per cent (16 of 27) confirmed maintenance of laparoscopic equipment at their centre.

Conclusion: Despite the availability of surgical equipment, significant gaps in access to maintenance were apparent in these LMICs, limiting implementation of open and laparoscopic surgery.

Postoperative Airway Obstruction in a Low Resource Setting: A Case Report.

A 2-month-old girl with abnormal facial features and malnutrition presented for placement of a gastrostomy tube. The surgery was performed under general anesthesia using a laryngeal mask airway (LMA); however, after removal of the LMA, the patient had recurrent airway collapse, requiring repeated insertion of the LMA. The authors describe the management of this problem with the use of a tongue suture and anterior traction in the postoperative period in a resource-limited setting.

Surgical consent in sub-Saharan Africa: a modern challenge for the humanitarian surgeon.

Surgical consent is one of the pillars of ethical conduct in Western world surgical practice. Recent studies have described the consenting processes for clinical trials in low- and middle-income countries (LMICs), but only a few have explored its practice before surgical procedures. The recent World Medical Association (WMA) Declaration of Lisbon recommends autonomy and independent decision-making. However, informed consent is influenced by cultural background, family structure, socioeconomic status, religion and education. The authors of the paper support the WMA recommendations, but agree the process for obtaining informed consent should be reviewed and developed to integrate in a culturally appropriate manner. This commentary reports the author’s personal experience of surgical consent in Burundi and reviews the literature describing its practice and the specific challenges faced in Sub-Saharan Africa. Its aim is to encourage a debate among surgeons as to how surgical consent can be undertaken in different scenarios of LMICs.