Research in context
Evidence before this study
Safe, accessible, and affordable surgery is a global health priority. An estimated 5 billion people do not have access to safe and affordable surgery, and an additional 143 million surgeries each year are needed in low-income and middle-income countries (LMICs) to address this need. However, there are few surgical outcome data from LMICs, and particularly few data from Africa. Two observational cohort studies only included a few African countries, with a small range of surgeries reported. Increasing access to surgery is a priority in Africa; however, it is essential to ensure that the surgery is safe, and that unnecessary perioperative morbidity and mortality are prevented. Because of the scarcity of surgical outcomes data in Africa, there is an urgent need for a robust epidemiological study of perioperative patient outcomes to inform the global surgery initiative.
Added value of this study
The African Surgical Outcomes Study provided data from 25 African countries for all in-patient surgeries. Our findings showed that one in five surgical patients in Africa developed a perioperative complication, following which, one in ten patients died. Our findings also showed that, despite being younger with a low-risk profile, and lower occurrences of complications, patients in Africa were twice as likely to die after surgery when compared with outcomes at a global level. African surgical hospitals are under-resourced with a median combined total of specialist surgeons, obstetricians, and anaesthesiologists of 0·7 (IQR 0·2–1·9) per 100 000 population, far below the recommended number identified by the Lancet Commission on Global Surgery. The number of surgical procedures in Africa was also very low at 212 (65–578) per 100 000 population each year. Most surgical procedures were done on an urgent or emergency basis, and a third were caesarean deliveries. Importantly, 95% of deaths occurred after surgery, indicating the need to improve the safety of perioperative care.
Implications of all the available evidence
Previous studies have presented only few data on surgical outcomes in Africa, because of limited country participation and inclusion of selected surgical procedures. The African Surgical Outcomes Study provided a detailed insight into this problem. Our findings suggest a high incidence of potentially avoidable deaths among low-risk patients after surgery, largely caused by a failure to identify and treat life-threatening complications in the perioperative period. Limited availability of human and hospital resources might be a key factor in this problem. Despite the positive effect of the global safe surgery campaign, our findings showed that surgical outcomes will remain poor in Africa unless the perioperative care of patients with deteriorating physiological function is addressed and sufficient resources are available to provide this care. A continent-wide quality improvement strategy to promote effective perioperative care might save many lives after surgery in Africa.