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.
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.
Management and outcomes of sellar, suprasellar, and parasellar masses in low-and middle- income countries: a scoping review
Background: There are several studies which describe the current management strategies and outcomes of SMs in High-Income Countries (HICs). However, there is little known the situation regarding SMs in Low and Middle-Income Countries (LMICs) apart from studies describing the experience from tertiary centres. With this study, we identified the epidemiology, diagnosis, management, and outcomes of SMs, SSMs, and PSMs in LMICs while reviewing and synthesising the relevant literature. Methods: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis extension for Scoping Review (PRISMA-ScR) guidelines were used to report the findings. MEDLINE, Embase, Global Index Medicus, and African Journals OnLine were the databases of choice. Cases were included if the pathology was related to the sellar, parasellar or suprasellar regions. The dataset was analysed using descriptive statistics via SPSS. Results: We have includedn=16589 patients from 49 LMICs. LMICs with the most studies were in China (n=49, 4.9%). Headache was the most reported symptomn=3995 with a mean of 29.82 cases per study (Range 0–130). Most reported tumour location was the sellar regionn=12933 (85%). Somatotroph adenomas was the most diagnosed pituitary adenoma (n=3297). The most frequently diagnosed non-pituitary adenomatous mass was arachnoid cysts (n=282). Endoscopic approaches were far more utilised compared to microsurgical approaches, n=3418 and n=1730, respectively. Hormonal therapies with Cabergoline were administered in 1700 patients with prolactinoma. Radiosurgery was performed in n=357 patients. The average follow-up duration was 33.26 months. Conclusion: Neuro-oncology and pituitary research in LMICs remains under-reported. Our understanding of the current landscape of the management and outcomes of sellar, suprasellar and parasellar masses show that there is similarity to the management approaches utilised compared to HICs. The surgical outcomes, although largely underreported, were worse in LMICs compared to HICs, highlighting the need for more research and education.
State of African neurosurgical education: a protocol for an analysis of publicly available curricula
Background
Africa bears >15% of the global burden of neurosurgical disease. Yet to date, Africa still has the lowest neurosurgical workforce density globally, and efforts to fill this gap by 2030 need to be multiplied. Although the past decade has seen an increase in neurosurgery residency programs in the continent, it is unclear how these residency programs are similar or viable. This study aims to highlight the current status of neurosurgical training in Africa as well as the differences within departments, countries or African regions.
Methods
A literature search using keywords related to ‘neurosurgery’, ‘training’, and ‘Africa’ and relevant names of African countries will be performed on PubMed and Google Scholar. If unavailable online, the authors will contact local neurosurgeons at identified training programmes for their curricula. The residency curricula collected will be analysed against a standardized and validated medical education curriculum viability tool.
Results
The primary aim will be the description of African neurosurgical curricula. In addition, the authors will perform a comparative analysis of the identified African neurosurgical curricula using a standardized and validated medical education curriculum viability tool.
Discussion
This study will be the first to evaluate the current landscape of neurosurgery training in Africa and will highlight pertinent themes that may be used to guide further research. The findings will inform health system strengthening efforts by local training programme directors, governments, policymakers and stakeholders.Background
Africa bears >15% of the global burden of neurosurgical disease. Yet to date, Africa still has the lowest neurosurgical workforce density globally, and efforts to fill this gap by 2030 need to be multiplied. Although the past decade has seen an increase in neurosurgery residency programs in the continent, it is unclear how these residency programs are similar or viable. This study aims to highlight the current status of neurosurgical training in Africa as well as the differences within departments, countries or African regions.
Methods
A literature search using keywords related to ‘neurosurgery’, ‘training’, and ‘Africa’ and relevant names of African countries will be performed on PubMed and Google Scholar. If unavailable online, the authors will contact local neurosurgeons at identified training programmes for their curricula. The residency curricula collected will be analysed against a standardized and validated medical education curriculum viability tool.
Results
The primary aim will be the description of African neurosurgical curricula. In addition, the authors will perform a comparative analysis of the identified African neurosurgical curricula using a standardized and validated medical education curriculum viability tool.
Discussion
This study will be the first to evaluate the current landscape of neurosurgery training in Africa and will highlight pertinent themes that may be used to guide further research. The findings will inform health system strengthening efforts by local training programme directors, governments, policymakers and stakeholders.
Inspirational Women in Surgery: Professor Kokila Lakhoo, South Africa
“Imagine growing up in apartheid South Africa as a woman of color, wanting to do academic surgery.” This was the world in which Kokila Lakhoo began her surgical journey in pre-Mandela South Africa in the 1980’s during a time when the government was not supportive of the educational ambitions of black and brown communities. Now, as Professor of Pediatric Surgery at Oxford University, Prof Lakhoo remembers her own fight for social justice and remains one of the world’s strongest advocates for children and surgical health care providers in low-and-middle-income-countries (LMICs). She owes her early interest in medicine and social justice to her grandmother who was a community health care advocate in the hamlet (Bethal, South Africa) where there were no affordable facilities for people of color. She inculcated a strong sense of right and wrong in the young Kokila Lakhoo, who would go on to fight for the same rights for billions of people around the world as a global surgery advocate.
She completed medical school at the University of Natal in 1982 and discovered a burgeoning love for surgery as an intern. There was an immediate backlash to her nascent ambitions. She recalls, “Everybody thought I was mad… they would say ‘You have no chance… This is suicide… they won’t let you do it.” Professor Lakhoo remained resolute and pushed her case, without mentors, and with nothing but a quiet determination and her trademark resourcefulness to keep her going. This continued during her move to her first position at one of the segregated “apartheid hospitals.” She continued to face discouraging resistance to her career ambitions and was alone in her surgical aspirations. When against the odds, and contrary to expectations she fulfilled the academic criteria for admission by excelling in the part 1 exams, she again encountered resistance. During her first position as senior house officer in surgery at Baragwanath hospital (tertiary center for black and brown communities) there was a movement to reduce the number of doctors. She found herself in the line of fire. She was the only one in her cohort with the intent of becoming a surgeon and had passed part 1 of the surgical exams. It was then that her trademark tenacity shone through. She defied the insistence that she should give up her dreams and refused to leave the medical director’s office for 6 hours. She proclaimed “I’m not leaving–I want my job, because I have passed the exams and I want to be a surgeon, you have to give me the job.” Her insistence paid off when she was allowed to enter surgical training.
Her perseverance to educate herself did not stop. During her post-graduate studies, she traveled 35 km to attend lectures daily, attended extra surgical lectures at neighboring hospitals and pursued her PhD simultaneously with the grueling residency. “I did my experiments at night and weekends and took call in the morning.” After successfully completing her surgical training and PhD, she completed advanced training in pediatric surgery at Red Cross Children’s Hospital in Cape Town, South Africa, and then in Great Ormond Street in London. She completed her adult surgical training in 1989 and pediatric surgery in 1992. At the time of her completion of pediatric surgery training in 1992, she was the first qualified female pediatric surgeon and the first qualified female pediatric surgeon of color in South Africa.
Professor Lakhoo’s most impactful contribution to global health has been her role in developing pediatric surgery in Tanzania with little to no funding. She used her own funds and annual leave to help set the rudimentary building blocks of what would eventually become a longstanding partnership with Tanzanian surgeons [1]. She worked closely with the surgical team there to develop academic tools such as various aspects of scholarship and leadership. She also fostered clinical advances as well as career development alongside the local team [2, 3].
She is also a co-founder and past President of the Global Initiative in Children’s Surgery (GICS) and has been a strong advocate uplifting the voices of children and providers of surgery in LMICs [4]. She has led global efforts through the British Association of Pediatric Surgeons and provided leadership and support to the Pan-African Association of Pediatric Surgeons (PAPSA) and served as lead pediatric surgery external examiner for the College of Surgeons of East, Central, and Southern Africa (COSECSA) [5]. Professor Lakhoo believes the one of the most significant problems in the surgical community that needs to be addressed are the pervasive inequalities in the field with need for leadership, mentorship, role models, and advocacy.
In her spare time, she finds joy in making miniatures that she often gifts to her trainees.
Throughout her career, Professor Lakhoo has maintained a preserving outlook—“There are no failures in life, there are only setbacks. I hope more women and people from challenging backgrounds can be encouraged to take up surgical careers. Challenges in acknowledgement of the pioneering advances by women, especially those of color, still persist even up to now. The field still lacks sufficient workforce diversity in South Africa. I found I was able to have greater impact and career growth outside the country I trained and that remains the case for many other women globally as well.” She grounds herself in being able to separate her home (her husband and two children) and professional life, and she encourages trainees to strive for their dreams, never accept “no” and not be afraid to make mistakes along the way.
The Role and Duty of Global Surgery in Increasing Sustainability and Improving Patient Care in Low and Middle-Income Countries
Global health is one of the most pressing issues facing the 21st century. Surgery is a resource and energy-intensive healthcare activity which produces overwhelming quantities of waste. Using the 5Rs (Reduce, Reuse, Recycle, Rethink, and Research) provides the global surgical community with the pillars of sustainability to develop strategies that are scalable and transferable in both low and middle-income countries and their high-income counterparts.
Reducing energy consumption is necessary to achieving net zero emissions in the provision of essential healthcare. Simple, easily transferrable, high-income country (HIC) technologies can greatly reduce energy demands in low-income countries. Reusing appropriately sterilized equipment and reprocessing surgical devices leads to a reduction of costs and a significant reduction of unnecessary potentially hazardous waste. Recycling through official government-facilitated means reduces ‘informal recycling’ schemes, and the spread of communicable diseases whilst expectantly reducing the release of carcinogens and atmospheric greenhouse gases. Rethinking local surgical innovation and providing an ecosystem that is both ethical and sustainable, is not only beneficial from a medical perspective but allows local financial investment and feeds back into local economies. Finally, research output from low-income countries is minimal compared to the global academic output. Research from low and middle-income countries must equal research from high-income countries, thereby producing fruitful partnerships. With adequate international collaboration and awareness of the lack of necessary surgical interventions in low and middle-income countries (LMICs), global surgery has the potential to reduce the impact of surgical practice on the environment, without compromising patient safety or quality of care.
Outcomes of Children With Low-Grade Gliomas in Low- and Middle-Income Countries: A Systematic Review
PURPOSE
Pediatric CNS tumors are increasingly a priority, particularly with the WHO designation of low-grade glioma (LGG) as one of six index childhood cancers. There are currently limited data on outcomes of pediatric patients with LGGs in low- and middle-income countries (LMICs).
METHODS
To better understand the outcomes of LGGs in LMICs, this systematic review interrogated nine literature databases.
RESULTS
The search identified 14,977 publications. Sixteen studies from 19 countries met the selection criteria and were included for data abstraction and analysis. Eleven studies (69%) were retrospective reviews from single institutions, and one (6%) captured institutional data prospectively. The studies captured a total of 957 patients with a median of 49 patients per study. Seven (44%) of the studies described the treatment modalities used. Of 373 patients for whom there was information, 173 (46%) had a gross total or near total resection, 109 (29%) had a subtotal resection, and 91 (24%) had only a biopsy performed. Seven studies, with a total of 476 patients, described the frequency of use of radiotherapy and/or chemotherapy in the cohorts: 83 of these patients received radiotherapy and 76 received chemotherapy. The 5-year overall survival ranged from 69.2% to 93.5%, although lower survival rates were reported at earlier time points. We identified limitations in the published studies with respect to the cohort sizes and methodologies.
CONCLUSION
The included studies reported survival rates frequently exceeding 80%, although the ultimate number of studies was limited, pointing to the paucity of studies describing the outcomes of children with LGGs in LMICs. This study underscores the need for more robust data on outcomes in pediatric LGG.
Neurotrauma clinicians’ perspectives on the contextual challenges associated with traumatic brain injury follow up in low-income and middle-income countries: A reflexive thematic analysis
Background
Traumatic brain injury (TBI) is a major global health issue, but low- and middle-income countries (LMICs) face the greatest burden. Significant differences in neurotrauma outcomes are recognised between LMICs and high-income countries. However, outcome data is not consistently nor reliably recorded in either setting, thus the true burden of TBI cannot be accurately quantified.
Objective
To explore the specific contextual challenges of, and possible solutions to improve, long-term follow-up following TBI in low-resource settings.
Methods
A cross-sectional, pragmatic qualitative study, that considered knowledge subjective and reality multiple (i.e. situated within the naturalistic paradigm). Data collection utilised semi-structured interviews, by videoconference and asynchronous e-mail. Data were analysed using Braun and Clarke’s six-stage Reflexive Thematic Analysis.
Results
18 neurosurgeons from 13 countries participated in this study, and data analysis gave rise to five themes: Clinical Context: What must we understand?; Perspectives and Definitions: What are we talking about?; Ownership and Beneficiaries: Why do we do it?; Lost to Follow-up: Who misses out and why?; Processes and Procedures: What do we do, or what might we do?
Conclusion
The collection of long-term outcome data plays an imperative role in reducing the global burden of neurotrauma. Therefore, this was an exploratory study that examined the contextual challenges associated with long-term follow-up in LMICs. Where technology can contribute to improved neurotrauma surveillance and remote assessment, these must be implemented in a manner that improves patient outcomes, reduces clinical burden on physicians, and does not surpass the comprehension, capabilities, or financial means of the end user. Future research is recommended to investigate patient and family perspectives, the impact on clinical care teams, and the full economic implications of new technologies for follow-up.
Virtual reality technology in linked orthopaedic training in Ethiopia
Introduction
We describe the feasibility of delivering a live orthopaedic surgical teaching session with virtual reality (VR) technology simultaneously for trainee surgeons in Ethiopia and the UK.
Methods
Forty-three delegates from the Severn Deanery in the UK (n=30) and Bahir Dar in Ethiopia (n=13) attended a live training session in February 2021. During the session, participants watched a surgical operation (recorded earlier that week with a 360° VR camera) alongside live commentary. A qualitative questionnaire was distributed to gauge feasibility, connectivity and educational value of the session as well as its VR component.
Results
The majority of delegates from both the UK and Ethiopia felt that the use of VR technology to aid surgical training is feasible, that it is useful for learning surgical approaches, that it aids surgical performance and that it is superior to conventional resources. Bahir Dar residents strongly agreed that VR simulation videos would allow trainees to supplement reduced learning opportunities as a result of the COVID-19 pandemic and help to counteract their reduced operating experience. For Bahir Dar trainees, a lack of a stable internet connection for large VR files was the predominant issue.
Conclusions
This study demonstrates that there are infrastructure challenges in low and middle income countries (LMICs) in terms of the reliable delivery of VR teaching in orthopaedics at the current time. Despite this, our findings better inform the potential role of VR technology in surgical education, and shed light on the possibility for it to feed into and enrich surgical training in both LMICs and high income countries.
Access to training in neurosurgery (Part 2): The costs of pursuing neurosurgical training
Introduction
Opportunities for in-country neurosurgical training are severely limited in LMICs, particularly due to rigorous educational requirements and prohibitive upfront costs.
Research question
This study aims to evaluate financial barriers aspiring neurosurgeons face in accessing and completing neurosurgical training, specifically in LMICs, in order to determine the barriers to equitable access to training.
Material and methods
In order to assess the financial costs of accessing and completing neurosurgery residency, an electronic survey was administered to those with the most recent experience with the process: aspiring neurosurgeons, neurosurgical trainees, and recent neurosurgery graduates. We attempted to include a broad representation of World Health Organization (WHO) geographic regions and World Bank income classifications in order to determine differences among regions and countries of different income levels.
Results
Our survey resulted in 198 unique responses (response rate 31.3%), of which 83% (n = 165) were from LMICs. Cost data were reported for 48 individual countries, of which 26.2% were reported to require trainees to pay for their neurosurgical training. Payment amounts varied amongst countries, with multiple countries having costs that surpassed their annual gross national income as defined by the World Bank.
Discussion and conclusions
Opportunities for formal neurosurgical training are severely limited, especially in LMICs. Cost is an important barrier that can not only limit the capacity to train neurosurgeons but can also perpetuate inequitable access to training. Additional investment by governments and other stakeholders can help develop a sufficient workforce and reduce inequality for the next generation of neurosurgeons worldwide.