Early initiation of breastfeeding is inversely associated with public and private c-sections in 73 lower- and middle-income countries

Although studies in low- and middle-income countries (LMICs) have examined the effects of c-sections on early initiation of breastfeeding (EIBF), the role of the place of birth has not yet been investigated. Therefore, we tested the association between EIBF and the type of delivery by place of birth. Data from 73 nationally representative surveys carried out in LMICs between 2010 and 2019 comprised 408,013 women aged 15 to 49 years. Type of delivery by place of birth was coded in four categories: home vaginal delivery, institutional vaginal delivery, c-section in public, and c-section in private health facilities. We calculated the weighted mean prevalence of place of birth and EIBF by World Bank country income groups. Adjusted Poisson regression (PR) was fitted taking institutional vaginal delivery as a reference. The overall prevalence of EIBF was significantly lower among c-section deliveries in public (PR = 38%; 95% CI 0.618–0.628) and private facilities (PR = 45%; 95% CI 0.54–0.566) compared to institutional vaginal deliveries. EIBF in c-sections in public facilities was slightly higher in lower-middle (PR = 0.650, 95% CI 0.635–0.665) compared to low (PR = 0.544, 95% CI 0.521–0.567) and upper-middle income countries (PR = 0.612, 95% CI 0.599–0.626). EIBF was inversely associated with c-section deliveries compared to institutional vaginal deliveries, especially in private facilities compared to public ones.

International pediatric transplant association (IPTA) guidance on developing and/or expanding pediatric solid organ transplantation programs in low- and middle-income countries

Pediatric solid organ transplantation (SOT) is a preferred treatment for medically suitable children with end-stage organ failure. Still, many of them have no access to transplantation owing to socioeconomic constraints or lack of transplant facilities in low- and middle-income countries (LMIC). Establishing pediatric SOT programs in LMIC offers children the opportunities to receive transplant care in more familiar home environments as well as help curtail transplant tourism and improve transplant outcomes as pediatric transplantation would be performed ethically and legally. The International Pediatric Transplant Association (IPTA) is a professional organization aiming to promote safe, ethical, and high-quality pediatric transplantation worldwide. This society paper describes major obstacles to pediatric SOT in LMIC and provides guidance on developing and/or expanding pediatric SOT programs in such countries. We also summarize available resources from the IPTA Outreach Program to help establish and support pediatric SOT programs in LMIC.

Duration of the patient interval in breast cancer and factors associated with longer delays in low-and middle-income countries: A systematic review with meta-analysis

Objective
Breast cancer survival is lower in low- and middle-income countries (LMICs) partially due to many women being diagnosed with late-stage disease. The patient interval refers to the time elapsed between the detection of symptoms and the first consultation with a healthcare provider and is considered one of the core indicators for early diagnosis and treatment. The goal of the current research was to conduct a meta-analysis of the duration of the patient interval in LMICs and investigate the socio-demographic and socio-cultural factors related to longer delays in presentation.

Methods
We conducted a systematic review with meta-analysis (pre-registered protocol CRD42020200752). We searched seven information sources (2009–2022) and included 50 articles reporting the duration of patient intervals for 18,014 breast cancer patients residing in LMICs.

Results
The longest patient intervals were reported in studies from the Middle East (3–4 months), followed by South-East Asia (2 months), Africa (1–2 months), Latin America (1 month), and Eastern Europe (1 month). Older age, not being married, lower socio-economic status, illiteracy, low knowledge about cancer, disregarding symptoms or not attributing them to cancer, fear, negative beliefs about cancer, and low social support were related to longer delays across most regions. Longer delays were also related to use of alternative medicine in the Middle East, South-East Asia, and Africa and distrust in the healthcare system in Eastern Europe.

Conclusions
There is large variation in the duration of patient intervals across LMICs in different geographical regions. Patient intervals should be reduced and, for this purpose, it is important to explore their determinants taking into account the social, cultural, and economic context.

A global study of the association of cesarean rate and the role of socioeconomic status in neonatal mortality rate in the current century

Introduction
Caesarean section (C/S) rates have significantly increased across the world over the past decades. In the present population-based study, we sought to evaluate the association between C/S and neonatal mortality rates.

Material and methods
This retrospective ecological study included longitudinal data of 166 countries from 2000 to 2015. We evaluated the association between C/S rates and neonatal mortality rate (NMR), adjusting for total fertility rate, human development index (HDI), gross domestic product (GDP) percentage, and maternal age at first childbearing. The examinations were also performed considering different geographical regions as well as regions with different income levels.

Results
The C/S rate and NMR in the 166 included countries were 19.97% ± 10.56% and 10 ± 10.27 per 1000 live birth, respectively. After adjustment for confounding variables, C/S rate and NMR were found correlated (r = -1.1, p < 0.001). Examination of the relationship between C/S rate and NMR in each WHO region resulted in an inverse correlation in Africa (r = -0.75, p = 0.005), Europe (r = -0.12, p < 0.001), South-East Asia (r = -0.41, p = 0.01), and Western Pacific (r = -0.13, p = 0.02), a direct correlation in America (r = 0.06, p = 0.04), and no correlation in Eastern Mediterranean (r = 0.01, p = 0.88). Meanwhile, C/S rate and NMR were inversely associated in regions with upper-middle (r = -0.15, p < 0.001) and lower-middle (r = -0.24, p < 0.001) income levels, directly associated in high-income regions (r = 0.02, p = 0.001), and not associated in low-income regions (p = 0.13). In countries with HDI below the centralized value of 1 (the real value of 0.9), the correlation between C/S rate and NMR was negative while it was found positive in countries with HDI higher than the mentioned cut-off.

Conclusions
This study indicated that NMR associated with C/S is dependent on various socioeconomic factors such as total fertility rate, HDI, GDP percentage, and maternal age at first childbearing. Further attentions to the socioeconomic status are warranted to minimize the NMR by modifying the C/S rate to the optimum cut-off.

Global surgery and global health: One size does not fit all

Global surgery is interpreted differently and may lack an in-depth understanding which is complicated by socio-economy and culture. Global surgery and global health have become part of health care service following the report of the Lancet Commission. Sustainability, ethical principles, and decolonization are some important ongoing issues for recipient societies. Incorporating societal dimensions, socio-cultural values, patients’ needs, and affordability requires a tailored approach and not blindly pursuing the best technology. The recent COVID-19 has exposed the unethical and inequity in terms of equitable healthcare, vaccine rollout and its access, and unprecedented high mortality observed in some societies. Surgery has been a neglected stepchild of global health and in addition global surgery must not be a slave of technology for the promotion of the ‘gold standard’, especially corporate-led commercialized services because a sustainable and effective surgical service at a reduced cost is desirable for all, be resource-rich or poor. Global surgery and global health include health security and universal health coverage. Stakeholders of global surgery need to be aware that ‘one size does not fit all’ and are required to consider the diverse conditions.

Pediatric renal tumor epidemiology: Global perspectives, progress, and challenges

Pediatric renal tumors account for 3%–11% of childhood cancers, the most common of which is Wilms tumor or nephroblastoma. Epidemiology plays a key role in cancer prevention and control by describing the distribution of cancer and discovering risk factors for cancer. Large pediatric research consortium trials have led to a clearer understanding of pediatric renal tumors, identification of risk factors, and development of more risk-adapted therapies. These therapies have improved event-free and overall survival for children. However, several challenges remain and not all children have benefited from the improved outcomes. In this article, we review the global epidemiology of pediatric renal tumors, including key consortium and global studies. We identify current knowledge gaps and challenges facing both high and low middle-incomes countries.

Highlights from Choosing Wisely 2022 for Resource Limited Settings: Reducing Low Value Cancer Care for Sustainability conference, 17th–18th September, Mumbai, India

The ‘Choosing Wisely 2022’ conference, organised by the ecancer foundation, was held at the Tata Memorial Hospital, Mumbai, India, on 17 and 18 September. It was a successful event with 159 delegates attending it in person and around 328 delegates attending online. Thirty oncology experts from across the world shared their thoughts during this meeting. The theme of the conference was to focus on cancer care, in low- and middle-income countries (LMICs). The emphasis of discussion was on ways to select more cost-effective and high value treatments and interventions and minimise financial toxicity. In addition, cancer research from LMICs needs to be improved substantially. Collaboration and networking amongst cancer institutions in LMICs is essential.

War, Politics, Pandemic, and a Failed Assassination: 117 Years of World Congresses of Surgery

I am fascinated by history. As an undergraduate English major, I loved poetry, novels, and short stories. As a 20-year old, I thought history dull, dim, and irrelevant. Oh, how wrong I was! The drama created by real-life stories are far more unpredictable and riveting than fiction. In holding 48 previous world congresses, the International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC) has participated in a few stories I’d like to share with you.

Many of the stories of the ISS/SIC are a little like the story of Switzerland, the home of our beloved society, an oasis of neutrality surrounded by a chaotic world, punctuated with pandemics, wars, and global politics. Our Swiss leaders, whether their last names were deQuervain, Nissen, Allgower, Harder, or Givel, have served as neutral intermediaries in many critical negotiations over the years, holding this society together against strong global currents and nationalistic ideology which—in some circumstances—led to major wars between nations and created rifts between close professional friends within our society. Yes, there was even an attempted assassination of a world leader at a World Congress of Surgery, one that would have changed the 20th century, had it been successful. So hang on and bear with me for a few minutes.

Let’s start 130 years ago, here in this most beautiful city of Vienna. Most of you know of Theodor Billroth, the patriarch of Viennese surgery depicted in the famous painting by Adalbert Seligmann (Fig. 1). Billroth attracted surgeons from around the world to his operating theater, many of whom would later become surgical giants in their home countries. From the USA, William Stewart Halstead spent time in Billroth’s theater, also appearing in the Seligmann painting to the left of the cabinet of instruments. Halsted returned to Baltimore and—with William Osler—started the first university-based program of medical education in the USA, at Johns Hopkins in Baltimore, Maryland.

Additionally, Billroth was a good friend of Johannes Brahms, whose music you heard as you came in this morning. I thought about focusing my address on music and medicine, but would a violin concerto in d major capture your attention as well as the story an Irishwoman attempting the assassination of a tyrant? Or waves of global epidemics and pandemics forcing the cancelation of two world congresses in Asia, 16 years apart? Or controversies over which surgeons from which countries would be invited to the World Congress, the result of two great 20th century world wars.

With apologies to our Viennese hosts, the story of the ISS/SIC does not start in Vienna, and Billroth wasn’t even a member of our society. Nonetheless, Vienna has played an important role in our history, never so important as today, when Albert Tuchmann and a dedicated team from the ISS/SIC office (thank you Mike, Chris, Laurie, and Denise!) committed to bringing us back together in this lovely city, our first in person meeting since 2019, in Krakow. It was only 3 years ago, but so much has happened. It’s hard to remember.

Much of the history that I will be recounting here comes from a book by Dorothea Liebermann-Meffert [1] (Fig. 2). If you want to learn more of the history, the ISS/SIC office still has copies of Dr Liebermann-Meffert’s book, also available through our website. The more recent history, in the 21st century, has been collected and collated by our former secretary general, Felix Harder and former executive director, Victor Bertschi of Basel. Many of the early papers and letters are in the hands of Professor Ulrich Tröhler and Professor Hubert Steinke of Berne. To them, I owe a great debt of gratitude for helping me with this address.

Embracing robotic surgery in low- and middle-income countries: Potential benefits, challenges, and scope in the future

Robotic surgery has applications in many medical specialties, including urology, general surgery, and surgical oncology. In the context of a widespread resource and personnel shortage in Low- and Middle-Income Countries(LMICs), the use of robotics in surgery may help to reduce physician burnout, surgical site infections, and hospital stays. However, a lack of haptic feedback and potential socioeconomic factors such as high implementation costs and a lack of trained personnel may limit its accessibility and application. Specific improvements focused on improved financial and technical support to LMICs can help improve access and have the potential to transform the surgical experience for both surgeons and patients in LMICs. This review focuses on the evolution of robotic surgery, with an emphasis on challenges and recommendations to facilitate wider implementation and improved patient outcomes.

Global Learning for Health Equity: A Literature Review

Background: In high income countries struggling with escalating health care costs and persistent lack of equity, there is growing interest in searching for innovative solutions developed outside national borders, particularly in low- and middle-income countries (LMICs). Engaging with global ideas to apply them to local health equity challenges is becoming increasingly recognized as an approach to shift the health equity landscape in the United States (US) in a significant way. No single name or set of practices yet defines the process of identifying LMIC interventions for adaptation; implementing interventions in high-income countries (HIC) settings; or evaluating the implementation of such projects.

Objectives: This paper presents a review of the literature describing the practice of adapting global ideas for use in the US, particularly in the area of health equity. Specifically, the authors sought to examine; (i) the literature that advocates for, or describes, adaption of health-related innovations from LMICs to HICs, both generally and for health equity specifically, and (ii) implementation practices, strategies, and evidence-based outcomes in this field, generally and in the area of health equity specifically. The authors also propose terminology and a definition to describe the practice.

Methods: The literature search included two main concepts: global learning and health equity (using these and related terms). The search consisted of text-words and database-specific terminology (e.g., MeSH, Emtree) using PubMed, Embase (Elsevier), CINAHL (Ebsco), and Scopus in March 2021. The authors also contacted relevant experts to identify grey literature. Identified sources were categorized according to theme to facilitate analysis. In addition, five key interviews with experts engaged with global ideas to promote health equity in the United States were conducted to develop additional data.

Results: The literature review yielded over ninety (n = 92) sources relating to the adaptation of global ideas from low resource to higher resource settings to promote health equity (and related concepts). Identified sources range from those providing general commentaries about the value of seeking health-related innovations outside the US border to sources describing global projects implemented in the US, most without implementation or outcome measures. Other identified sources provide frameworks or guidance to help identify and/or implement global ideas in the US, and some describe the role of the World Health Organization and other international consortia in promoting a global approach to solving domestic health equity and related challenges.

Conclusions: The literature review demonstrates that there are resources and commentary describing potential benefits of identifying and adapting novel global ideas to address health equity in the US, but there is a dearth of implementation and evaluation data. Terminology is required to define and frame the field. Additional research, particularly in the area of implementation science and evidence-based frameworks to support the practice of what we define as ‘global learning’ for health equity, is necessary to advance the practice.