Background: While recommendations for the optimal distribution of surgical services in high-income countries (HICs) exist, it is unclear how these translate to resource-limited settings. Given the significant shortage and maldistribution of surgical workforce and infrastructure in many low- and middle-income countries (LMICs), the optimal role of decentralization versus regionalization (centralization) of surgical care is unknown. The aim of this study is to review evidence around interventions aimed at redistributing surgical services in LMICs, to guide recommendations for the ideal organization of surgical services. Methods: A narrative-based literature review was conducted to answer this question. Studies published in English between 1997 and 2017 in PubMed, describing interventions to decentralize or regionalize a surgical procedure in a LMIC, were included. Procedures were selected using the Disease Control Priorities’ (DCP3) Essential Surgery Package list. Intervention themes and outcomes were analyzed using a narrative, thematic synthesis approach. Primary outcomes included mortality, complications, and patient satisfaction. Secondary outcomes included input measures: workforce and infrastructure, and process measures: facility-based care, surgical volume, and referral rates. Results: Thirty-five studies were included. Nine (33%) of the 27 studies describing decentralization showed an improvement in primary outcomes. The procedures associated with improved outcomes after decentralization included most obstetric, gynecological, and family planning services as well as some minor general surgery procedures. Out of 8 studies on regionalization (centralization), improved outcomes were shown for trauma care in one study and cataract extraction in one study. Conclusion: Interventions aimed at decentralizing obstetric care to the district hospital and health center levels have resulted in mortality benefits in several countries. However, more evidence is needed to link service distribution to patient outcomes in order to provide recommendations for the optimal organization of other surgical procedures in LMICs. Considerations for the optimal distribution of surgical procedures should include the acuity of the condition for which the procedure is indicated, anticipated case volume, and required level of technical skills, resources, and infrastructure. These attributes should be considered within the context of each country.

Large gaps exist between instrument reprocessing practices in LMICs and recommended policies/procedures. Identified areas for improvement include instrument cleaning and decontamination, sterilization aspects of instrument reprocessing, and verification of sterilization. Education and training of staff responsible for reprocessing instruments and realistic, defined policies and procedures are critical, and lend themselves to improvement interventions.

BackgroundIn low-and middle-income countries (LMICs), c-section is the most commonly performed operation, and surgical site infection (SSI) is the most common post-operative complication following all surgical procedures performed. Whilst multiple interventions have been rolled out to address high SSI rates, strategies for optimal care of patients at risk of developing SSIs need to include an understanding of the general care seeking behaviors, facilitators, and barriers among high-risk groups, including mothers delivering via c-section. This study explores the healthcare experiences of women who delivered by c-section section, from giving birth through recovery, and their associated decision-making, perceptions of care, and social and financial supports. MethodsWe conducted protocol-guided interviews in rural Kirehe District, Rwanda with twenty-five mothers who delivered by c-section at Kirehe District Hospital between February-April 2018, exploring their experience with delivery, hospitalization, recovery, and complications. Coded interviews were analyzed using the Grounded Theory approach to identify emergent themes. Thematic saturation was achieved. ResultsOverall, women largely followed the tiered referral system, as it was designed. A majority faced financial barriers to returning to care, and a majority were not able to describe the reason for their c-section, the complications experienced, or the treatment prescribed. We constructed a process map to summarize key steps where interventions should be designed to promote facilitators, to reduce barriers, and to identify and target the women being diverted from this designated path. ConclusionsUnderstanding the existing healthcare pathway and the associated facilitators and barriers among postpartum women is critical to designing appropriate interventions that properly serve their needs. Our findings strongly suggest that moving or complimenting post-operative wound assessments from the health center into home-based care, and ensuring unified messaging around c-section indications, care, and complications at the community-level are two of the areas that may improve utilization of existing healthcare infrastructure for women who deliver by c-section in rural districts in Rwanda.Cesarean section (c-section) is the most common major surgical procedure conducted in low-and middle-income countries (LMICs). 1,2 C-section poses inherent risks to patients, many of which occur at higher rates in LMICs. For all surgical procedures conducted, the most common postoperative complication is surgical site infection (SSI), with incidence estimated as high as 30.9% in some low-resource settings, [3][4][5][6][7][8][9][10][11][12] where high SSI rates have been associatedPowell BL, Nkurunziza T, Kateera F, et al. Synthesizing postpartum care pathways, facilitators, and barriers for women after cesarean section: a qualitative analysis from rural Rwanda.