Access to pediatric surgery delivered by general surgeons and anesthesia providers in Uganda: Results from 2 rural regional hospitals.

BACKGROUND: Significant limitations in pediatric surgical capacity exist in low- and middle-income countries, especially in rural regions. Recent global children's surgical guidelines suggest training and support of general surgeons in rural regional hospitals as an effective approach to increasing pediatric surgical capacity. METHODS: Two years of a prospective clinical database of children's surgery admissions at 2 regional referral hospitals in Uganda were reviewed. Primary outcomes included case volume and clinical outcomes of children at each hospital. Additionally, the disability-adjusted life-years averted by delivery of pediatric surgical services at these hospitals were calculated. Using a value of statistical life calculation, we also estimated the economic benefit of the pediatric surgical care currently being delivered. RESULTS: From 2016 to 2019, more than 300 surgical procedures were performed at each hospital per year. The majority of cases were standard general surgery cases including hernia repairs and intussusception as well as procedures for surgical infections and trauma. In-hospital mortality was 2.4% in Soroti and 1% in Lacor. Pediatric surgical capacity at these hospitals resulted in over 12,400 disability-adjusted life-years averted/year. This represents an estimated economic benefit of 10.2 million US dollars/year to the Ugandan society. CONCLUSION: This investigation demonstrates that lifesaving pediatric procedures are safely performed by general surgeons in Uganda. General surgeons who perform pediatric surgery significantly increase surgical access to rural regions of the country and add a large economic benefit to Ugandan society. Overall, the results of the study support increasing pediatric surgical capacity in rural areas of low- and middle-income countries through support and training of general surgeons and anesthesia providers.

Demographic Trends From 2005 to 2015 Among Physicians With Accreditation Council for Graduate Medical Education-Accredited Anesthesiology Training and Active Medical Licenses.

BACKGROUND: A temporary decrease in anesthesiology residency graduates that occurred around the turn of the millennium may have workforce implications. The aims of this study are to describe, between 2005 and 2015, (1) demographic changes in the workforce of physicians trained as anesthesiologists; (2) national and state densities of these physicians, as well as temporal changes in the densities; and (3) retention of medical licenses by mid- and later-career anesthesiologists. METHODS: Using records from the American Board of Anesthesiology and state medical and osteopathic boards, the numbers of licensed physicians aged 30-59 years who had completed Accreditation Council for Graduate Medical Education-accredited anesthesiology residency training were calculated cross-sectionally for 2005, 2010, and 2015. Demographic trends were then described. Census data were used to calculate national and state densities of licensed physicians. Individual longitudinal data were used to describe retention of medical licenses among older physicians. RESULTS: The number of licensed physicians trained as anesthesiologists aged 30-59 years increased from 32,644 in 2005 to 36,543 in 2010 and 36,624 in 2015, representing a national density of 1.10, 1.18, and 1.14 per 10,000 population in those years, respectively. The density of anesthesiologists among states ranged from 0.37 to 3.10 per 10,000 population. The age distribution differed across the years. For example, anesthesiologists aged 40-49 years predominated in 2005 (47%), but by 2015, only 31% of anesthesiologists were aged 40-49 years. The proportion of female anesthesiologists grew from 22% in 2005, to 24% in 2010, and to 28% in 2015, particularly among early-career anesthesiologists. For anesthesiologists with licenses in 2005, the number who still had active licenses in 2015 decreased by 9.6% for those aged 45-49 years, by 14.1% for those aged 50-54 years, and by 19.7% for those aged 55-59 years. CONCLUSIONS: The temporary decrease in anesthesiology residency graduates around the turn of the 21st century decreased the proportion of anesthesiologists who were midcareer as of 2015. This may affect the future availability of senior leaders as well as the future overall workforce in the specialty as older anesthesiologists retire. National efforts to plan for workforce needs should recognize the geographical variability in the distribution of anesthesiologists.

Assessment of Anesthesia Capacity in Public Surgical Hospitals in Guatemala.

BACKGROUND: International standards for safe anesthetic care have been developed by the World Federation of Societies of Anaesthesiologists (WFSA) and the World Health Organization (WHO). Whether these standards are met is unknown in many nations, including Guatemala, a country with universal health coverage. We aimed to establish an overview of anesthesia care capacity in public surgical hospitals in Guatemala to help guide public sector health care development. METHODS: In partnership with the Guatemalan Ministry of Public Health and Social Assistance (MSPAS), a national survey of all public hospitals providing surgical care was conducted using the WFSA anesthesia facility assessment tool (AFAT) in 2018. Each facility was assessed for infrastructure, service delivery, workforce, medications, equipment, and monitoring practices. Descriptive statistics were calculated and presented. RESULTS: Of the 46 public hospitals in Guatemala in 2018, 36 (78%) were found to provide surgical care, including 20 district, 14 regional, and 2 national referral hospitals. We identified 573 full-time physician surgeons, anesthesiologists, and obstetricians (SAO) in the public sector, with an estimated SAO density of 3.3/100,000 population. There were 300 full-time anesthesia providers working at public hospitals. Physician anesthesiologists made up 47% of these providers, with an estimated physician anesthesiologist density of 0.8/100,000 population. Only 10% of district hospitals reported having an anesthesia provider continuously present intraoperatively during general or neuraxial anesthesia cases. No hospitals reported assessing pain in the immediate postoperative period. While the availability of some medications such as benzodiazepines and local anesthetics was robust (100% availability across all hospitals), not all hospitals had essential medications such as ketamine, epinephrine, or atropine. There were deficiencies in the availability of essential equipment and basic intraoperative monitors, such as end-tidal carbon dioxide detectors (17% availability across all hospitals). Postoperative care and access to resuscitative equipment, such as defibrillators, were also lacking. CONCLUSIONS: This first countrywide, MSPAS-led assessment of anesthesia capacity at public facilities in Guatemala revealed a lack of essential materials and personnel to provide safe anesthesia and surgery. Hospitals surveyed often did not have resources regardless of hospital size or level, which may suggest multiple factors preventing availability and use. Local and national policy initiatives are needed to address these deficiencies.

Clinical Challenges and Considerations in Management of Chronic Pain Patients During a COVID-19 Pandemic.

Since the coronavirus disease 2019 (COVID-19) was deemed a pandemic on 11 March 2020, we have seen exponential increases in the number of cases and deaths worldwide. The rapidly evolving COVID-19 situation requires revisions to clinical practice to defer non-essential clinical services to allocate scarce medical resources to the care of the COVID-19 patient and reduce risk to healthcare workers. Chronic pain patients require long-term multidisciplinary management even during a pandemic. Fear of abandonment, anxiety and depression may increase during this period of social isolation and aggravate pain conditions. Whilst physical consults for chronic pain patients were reduced, considerations including continuity of support and analgesia, telemedicine, allied health support and prioritising necessary pain services and interventions, were also taken to ensure biopsychosocial care for them. Chronic pain patients are mostly elderly with multiple comorbidities, and are more susceptible to morbidity and mortality from COVID-19. It is imperative to review pain management practices during the COVID-19 era with respect to infection control measures, re-allocation of healthcare resources, community collaborations, and analgesic use and pain interventions. The chronic pain patient faces a potential risk of functional and emotional decline during a pandemic, increasing healthcare burden in the long term. Clinical decisions on pain management strategies should be based on balancing the risks and benefits to the individual patient. In this commentary, we aim to discuss the basis behind some of the decisions and safeguards that were made at our tertiary pain centre over the last 6 months during the COVID-19 outbreak.

Anesthesia Infrastructure and Resources in Bangladesh.

BACKGROUND: Monitoring improvements in nationwide anesthesia capacity over time is critical to ensuring that population anesthesia needs are being met and identifying areas for targeted health systems interventions. Anesthesia resources in Bangladesh were previously measured using a cross-sectional nationwide hospital-based survey in 2012. No follow-up studies have been conducted since then. METHODS: A follow-up cross-sectional study was performed in 16 public hospitals; 8 of which are public district hospitals, and 8 are medical college (tertiary) hospitals in Bangladesh. A survey tool assessing hospital anesthesia capacity, developed by Vanderbilt University Medical Center, was utilized. Nationwide data were obtained from the Ministry of Health and Family Welfare and from the Bangladesh Society of Anaesthesiologists. Institutional Review Board approvals were obtained in the United States and Bangladesh, and informed consent was waived. RESULTS: Bangladesh has 952 anesthesiologists (0.58 anesthesiologists per 100,000 people), which represents a modest increase from 850 anesthesiologists in 2012. Significant improvements in electricity and clean water availability have occurred since the 2012 survey. Severe deficiencies in patient safety and monitoring equipment (eg, pulse oximetry, electrocardiography, blood pressure, anesthesia machines, and intubation materials) were noted, primarily at the district hospital level. CONCLUSIONS: Despite modest improvements in certain anesthesia metrics over the past several years, the public health care system in Bangladesh still suffers from substantial deficiencies in anesthesia care.

Are Rural Hospitals in Pakistan Responding to the Global Surgery Movement? An Analysis of the Gaps, Challenges and Opportunities.

BACKGROUND: Access to essential surgical care is vital for reduction in mortality and morbidity as a result of surgical conditions. These account for 28-32% of the overall global burden of disease, yet billions of people lack access to safe, affordable surgical and anesthesia care when needed. The purpose of this study was to assess the capacity for surgical care in rural hospitals across four provinces of Pakistan. METHODS: This was a cross-sectional study undertaken in 10 rural hospitals across four provinces of the country. Of these, six were district and four sub-district hospitals that were purposively selected in consultation with the government. Data were gathered using the WHO-PGSSC Surgical Assessment Tool. RESULTS: This study estimated 3 of the 6 indicators proposed by the Lancet Commission on Global Surgery. While most hospitals had basic provisions of infrastructure and equipment, severe shortage of specialists was observed with 0.56 specialists (surgeons, gynecologists and anesthetists) present per 100,000 population. Two-hour access was possible for the catchment population of 7 out of the 10 hospitals. Of the 43 essential surgical procedures assessed, 13 or 30% procedures were available per hospital. The three Bellwether procedures were provided by only 1 hospital. Mean number of surgeries performed was 753 ± 979 per 100,000 population. CONCLUSIONS: Our study has demonstrated major gaps in the provision of surgical care in rural hospitals in Pakistan. While developing a strategy and national action plan is necessary, implementation can immediately begin at the local level to address the gaps that need urgent attention.

Factors affecting the provision of analgesia during childbirth, Japan.

Japan's universal health-care system means that it is a very safe country in which to give birth. Perinatal outcomes in Japan are excellent, with low infant mortality and neonatal mortality. However, childbirth remains a challenge for many Japanese women, who are faced with a scarcity of places to give birth, limited availability of analgesia and social norms that favour natural birth. The number of birth facilities in Japan continues to decrease as fewer children are born. The numbers of qualified medical staff remain inadequate, with a continuing lack of female physicians, perpetuated by a pervasive negative gender bias. Recruitment efforts are underway, but few doctors want to specialize in obstetrics or gynaecology. Furthermore, around half of female obstetricians and gynaecologists in Japan's male-dominated medical system stop practising when they have their own children. The difficulty of obtaining analgesia during labour is another problem. Although low uptake of labour pain relief in Japan is said to be due to cultural influences, the root of the problem is a lack of qualified anaesthesiologists and the inflexibility of a system that will not allow other staff to be trained to administer labour analgesia. Problems with labour anaesthesia have been linked to 14 maternal deaths since 2010. Japanese policy-makers need to act to renovate the nation's obstetric facilities, reorganize regional perinatal care systems, train more obstetricians and anaesthesiologists, promote task-shifting and better integrate biomedical and traditional, non-medical care for pregnant women.

Le système de soins de santé universel du Japon en fait un pays très sûr pour les accouchements. Les résultats en matière de santé périnatale au Japon sont excellents, avec une mortalité infantile et une mortalité néonatale faibles. Néanmoins, l'accouchement reste problématique pour de nombreuses Japonaises, qui doivent faire face à un manque d'établissements adaptés pour les accouchements, à une disponibilité limitée de l'analgésie et à des normes sociales qui favorisent les accouchements naturels. Le nombre de maternités au Japon ne cesse de baisser, à mesure de la diminution du nombre de naissances. Les effectifs en personnel médical qualifié restent inappropriés, avec une pénurie persistante de femmes médecins, perpétuée par des préjugés négatifs généralisés liés au genre. Des efforts de recrutement sont en cours, mais peu de médecins souhaitent se spécialiser en obstétrique ou en gynécologie. Par ailleurs, dans le système médical japonais dominé par les hommes, près de la moitié des femmes obstétriciennes et gynécologues cessent de pratiquer dès qu'elles ont elles-mêmes des enfants. La difficulté à bénéficier d'une analgésie obstétricale pendant l'accouchement constitue un autre problème. Même si, au Japon, le faible recours au soulagement de la douleur pendant le travail est généralement imputé à des influences culturelles, le fond du problème est une pénurie d'anesthésistes qualifiés et le manque de souplesse d'un système qui ne permet pas de former d'autres professionnels de santé pour pouvoir pratiquer l'analgésie obstétricale. Les problèmes liés à la réalisation d'une analgésie obstétricale ont donné lieu à 14 décès maternels depuis 2010. Au Japon, les décideurs politiques doivent agir pour rénover les installations obstétricales du pays, réorganiser les systèmes régionaux de santé périnatale, former davantage d'obstétriciens et d'anesthésistes, promouvoir le transfert des tâches et mieux intégrer les soins biomédicaux et les soins traditionnels, non médicaux, pour les femmes enceintes.

El sistema universal de atención sanitaria de Japón hace que sea un país muy seguro para dar a luz. Los resultados perinatales en Japón son excelentes, con baja mortalidad infantil y mortalidad neonatal. Sin embargo, el parto sigue siendo un problema para muchas mujeres japonesas, que se enfrentan a la escasez de lugares para dar a luz, la limitada disponibilidad de analgesia y las normas sociales que favorecen el parto natural. El número de centros de maternidad en Japón sigue disminuyendo a medida que nacen menos niños. El número de personal médico cualificado sigue siendo insuficiente, con una continua falta de mujeres médicas, perpetuada por un prejuicio de género negativo generalizado. Los esfuerzos de reclutamiento están en marcha, pero pocos médicos quieren especializarse en obstetricia o ginecología. Además, alrededor de la mitad de las obstetras y ginecólogas del sistema médico japonés dominado por los hombres dejan de ejercer cuando tienen sus propios hijos. La dificultad para obtener analgesia durante el trabajo de parto es otro problema. Aunque se dice que la baja aceptación del alivio del dolor del trabajo de parto en Japón se debe a influencias culturales, la raíz del problema es la falta de anestesiólogos calificados y la inflexibilidad de un sistema que no permitirá que otro personal esté capacitado para administrar la analgesia del trabajo de parto. Los problemas con la anestesia del trabajo de parto se han relacionado con 14 muertes maternas desde 2010. Los responsables de formular políticas en Japón deben actuar para renovar las instalaciones obstétricas del país, reorganizar los sistemas regionales de atención perinatal, capacitar a más obstetras y anestesiólogos, promover el cambio de tareas e integrar mejor la atención biomédica y la atención no médica tradicional para las mujeres embarazadas.

Provision of Surgical Care for Children Across Somaliland: Challenges and Policy Guidance.

BACKGROUND: Existing data suggest a large burden of surgical conditions in low- and middle-income countries (LMICs). However, surgical care for children in LMICs remains poorly understood. Our goal was to define the hospital infrastructure, workforce, and delivery of surgical care for children across Somaliland and provide policy guidance to improve care. METHODS: We used two established hospital assessment tools to assess infrastructure, workforce, and capacity at all hospitals providing surgical care for children across Somaliland. We collected data on all surgical procedures performed in children in Somaliland between August 2016 and July 2017 using operative logbooks. RESULTS: Data were collected from 15 hospitals, including eight government, five for-profit, and two not-for-profit hospitals. Children represented 15.9% of all admitted patients, and pediatric surgical interventions comprised 8.8% of total operations. There were 0.6 surgical providers and 1.2 anesthesia providers per 100,000 population. A total of 1255 surgical procedures were performed in children in all hospitals in Somaliland over 1 year, at a rate of 62.4 surgical procedures annually per 100,000 children. Care was concentrated at private hospitals within urban areas, with a limited number of procedures for many high-burden pediatric surgical conditions. CONCLUSIONS: We found a profound lack of surgical capacity for children in Somaliland. Hospital-level surgical infrastructure, workforce, and care delivery reflects a severely resource-constrained health system. Targeted policy to improved essential surgical care at local, regional, and national levels is essential to improve the health of children in Somaliland.

Relationship Between State Policy and Anesthesia Provider Supply in Rural Communities.

BACKGROUND: There is a significant geographic variation in anesthesia provider supply. Lower supply in rural communities raises concerns about access to procedures that require anesthesia in rural areas. State policies related to certified registered nurse anesthetist (CRNA) practice may help to alleviate rural supply concerns. OBJECTIVES: To estimate the association between state CRNA policy and anesthesia provider supply especially in rural communities. RESEARCH DESIGN: Repeated cross-sectional design using ordinary least squares and 2-stage least squares regressions. SUBJECTS: All counties in the United States from 2010 to 2015. MEASURES: Dependent variables include anesthesia provider counts per 100,000 people, calculated separately for anesthesiologists, CRNAs, and their sum. Key variables of interest include state-level CRNA policy based on scope of practice (SOP) regulations and Medicare opt-out status. RESULTS: Opt-out status and less restrictive SOP regulations were consistently correlated with a greater supply of CRNAs, especially in rural counties. Furthermore, we found that anesthesiologists and CRNAs tend to be complements to each other, but less restrictive SOP and opt-out status tend to weaken the importance of this relationship. CONCLUSIONS: State regulations may lead to increased supply of CRNAs in rural communities. However, the design of our study makes causality difficult to assert. So, it is also possible that states set CRNA policy as a response to counts of anesthesia providers in rural areas. Furthermore, given supply of anesthesiologists and CRNAs are complementary to one another, improving access to anesthesia services may require addressing issues pertaining to the supply of all anesthesia provider types.

Twenty Years of Collaboration Between Belgium and Benin in Training Anesthesiologists for Africa.

Belgium has been collaborating for 20 years with Abomey-Calavi University in Cotonou, Republic of Benin, to train anesthesiologists for Sub-Saharan, French-speaking African countries. With 123 graduates from 15 countries and 46 residents still in training, this program has succeeded in reversing the trend of a decreasing anesthesiology workforce in those countries, thus improving the quality of anesthesia and patient safety. Belgian government sources, as well as hospitals and anesthesia teams, provided most of the financial resources. Reasons for success, positive outcomes, and shortcomings are discussed, as well as future perspectives and threats. Failure to enroll enough female residents (15%) and brain drain (18% of alumni) are of concern. Alumni are capable of importing and adapting modern technology and practice. Graduates increase the impact of the Cotonou program by getting involved in teaching nonphysician anesthesia providers and by supporting new anesthesiology training programs being launched in several countries. Other African countries with training programs, by following this example, could accelerate anesthesiology progress by accepting foreign residents from the region. The role of anesthesiologists as anesthesia team leaders must be better defined, and residency training programs adapted accordingly. Continuing international support remains of critical importance, especially in the form of resident rotations to high-income countries. The development of structured anesthesiology programs should be encouraged by African governments as developing anesthesia is a prerequisite for surgical development in every discipline.

Surgical Human Resources According to Types of Health Care Facility: An Assessment in Low- and Middle-Income Countries.

BACKGROUND: A robust health care system providing safe surgical care to a population can only be achieved in conjunction with access to competent surgical personnel. It has been reported that 5 billion people do not have access to safe, affordable surgical and anaesthesia care when needed. This study aims to fill the existing gap in evidence by quantifying shortfalls in trained personnel delivering safe surgical and anaesthetic care in low- and middle-income countries (LMICs) according to the type of health care facility. METHODS: We conducted secondary analysis of 1323 health facilities, in 35 low- and middle-income countries using facility-based cross-sectional data from the World Health Organization Situational Analysis Tool to Assess Emergency and Essential Surgical Care. RESULTS: The majority of surgical and anaesthetic care in LMICs was provided by general doctors (range 13.8-41.1%; mean 27.1%). Non-physicians made up a significant proportion of the surgical workforce in LMICs. 26.76% of the surgical and anaesthetic workforce was provided by clinical medical officers and nurses. Private/NGO/mission hospitals, large, well-resourced institutions had the highest proportion of surgeons compared to any other type of health care facility at 27.92%. This compares to figures of 18.2 and 19.96% of surgeons at health centres and subdistrict/community hospitals, respectively, representing the lowest level of health facility. CONCLUSIONS: We highlight the significant proportion of non-physicians delivering surgical and anaesthetic care in LMICs and illustrate wide variations according to the type of health care facility.

An Evaluation of Preparedness, Delivery and Impact of Surgical and Anesthesia Care in Madagascar: A Framework for a National Surgical Plan.

BACKGROUND: The Lancet Commission on Global Surgery (LCoGS) described the lack of access to safe, affordable, timely surgical, and anesthesia care. It proposed a series of 6 indicators to measure surgery, accompanied by time-bound targets and a template for national surgical planning. To date, no sub-Saharan African country has completed and published a nationwide evaluation of its surgical system within this framework. METHOD: Mercy Ships, in partnership with Harvard Medical School and the Madagascar Ministry of Health, collected data on the 6 indicators from 22 referral hospitals in 16 out of 22 regions of Madagascar. Data collection was by semi-structured interviews with ministerial, medical, laboratory, pharmacy, and administrative representatives in each region. Microsimulation modeling was used to calculate values for financial indicators. RESULTS: In Madagascar, 29% of the population can access a surgical facility within 2 h. Surgical workforce density is 0.78 providers per 100,000 and annual surgical volume is 135-191 procedures per 100,000 with a perioperative mortality rate of 2.5-3.3%. Patients requiring surgery have a 77.4-86.3 and 78.8-95.1% risk of incurring impoverishing and catastrophic expenditure, respectively. Of the six LCoGS indicator targets, Madagascar meets one, the reporting of perioperative mortality rate. CONCLUSION: Compared to the LCoGS targets, Madagascar has deficits in surgical access, workforce, volume, and the ability to offer financial risk protection to surgical patients. Its perioperative mortality rate, however, appears better than in comparable countries. The government is committed to improvement, and key stakeholder meetings to create a national surgical plan have begun.

Factors Influencing the Choice of Anesthesia as a Career by Undergraduates of the University of Rwanda.

BACKGROUND: Rwanda currently faces a severe shortage of trained medical personnel, including physician anesthesiologists. The recruitment of residents into the anesthesia program has been consistently low. This study aimed at determining the factors that influence undergraduates' decision to pursue anesthesia as a career choice. METHODS: A questionnaire was created and administered to final year undergraduate medical students at the University of Rwanda. The questionnaire was created based on factors identified from literature review and key informant interviews. The questionnaire was translated, field-tested, and refined. The final survey questionnaire contains 27 4-point Likert scale items and 4 free-text questions. RESULTS: Seventy-nine final year undergraduate medical students responded to the survey. Only 2 students (2.5%) chose anesthesia as their top choice for postgraduate training. The most frequently named factors for not choosing anesthesiology were long work hours and high stress level, insufficient mentorship, and low job opportunity. CONCLUSIONS: The issues identified by our survey must be considered when making efforts toward increasing anesthesia recruitment in Rwanda. Factors such as lack of material resources and high workload will not be easily addressed. Others can be addressed through changes in medical student anesthesiology rotations and better mentorship by anesthesiologists during formative years. Focusing on factors that can be changed now may increase enrollment into anesthesiology. Future studies will include broadening the survey population and further investigating the influencing factors elucidated by this study.

The Current Landscape of US Pediatric Anesthesiologists: Demographic Characteristics and Geographic Distribution.

BACKGROUND: There is no comprehensive database of pediatric anesthesiologists, their demographic characteristics, or geographic location in the United States. METHODS: We endeavored to create a comprehensive database of pediatric anesthesiologists by merging individuals identified as US pediatric anesthesiologists by the American Board of Anesthesiology, National Provider Identifier registry, Healthgrades.com database, and the Society for Pediatric Anesthesia membership list as of November 5, 2015. Professorial rank was accessed via the Association of American Medical Colleges and other online sources. Descriptive statistics characterized pediatric anesthesiologists' demographics. Pediatric anesthesiologists' locations at the city and state level were geocoded and mapped with the use of ArcGIS Desktop 10.1 mapping software (Redlands, CA). RESULTS: We identified 4048 pediatric anesthesiologists in the United States, which is approximately 8.8% of the physician anesthesiology workforce (n = 46,000). The median age of pediatric anesthesiologists was 49 years (interquartile range, 40-57 years), and the majority (56.4%) were men. Approximately two-thirds of identified pediatric anesthesiologists were subspecialty board certified in pediatric anesthesiology, and 33% of pediatric anesthesiologists had an identified academic affiliation. There is substantial heterogeneity in the geographic distribution of pediatric anesthesiologists by state and US Census Division with urban clustering. CONCLUSIONS: This description of pediatric anesthesiologists' demographic characteristics and geographic distribution fills an important gap in our understanding of pediatric anesthesia systems of care.

Obstetric Anesthesia Workforce Survey: A 30-Year Update.

BACKGROUND: Obstetric Anesthesia Workforce Surveys were conducted in 1981, 1992, and 2001, and the 10-year update was conducted in 2012. Anesthesia providers from US hospitals were surveyed to identify the methods used to provide obstetric anesthesia. Our primary hypothesis was that the provision of obstetric anesthesia services has changed in the past 10 years. METHODS: A sample of hospitals was generated based on the number of births per year and US census region. Strata were defined as follows: I ≥ 1500 annual births (n = 341), II ≥ 500 to 1499 annual births (n = 438), and III < 500 annual births (n = 414). Contact email information for the anesthesia provider in charge of obstetric services was obtained by phone call. Electronic questionnaires were sent through email. RESULTS: Administration of neuraxial (referred to as "regional" in previous surveys) labor analgesia was available 24 hours per day in all stratum I hospitals responding to the survey. Respondents across all strata reported high rates of in-house coverage, with 86.3% (95% confidence interval [CI] = 82.7%-90%) of stratum I providers reporting that they provided in-house anesthesiology services for obstetrics. The use of patient-controlled epidural analgesia in stratum I hospitals was reported to be 35% in 2001 and 77.6% (95% CI = 73.2%-82.1%) in this survey. Independent Certified Registered Nurse Anesthetists were reported to provide obstetric anesthesia services in 68% (95% CI = 57.9%-77.0%) of stratum III hospitals. Although 76% (95% CI = 71.2%-80.3%) of responding stratum I hospitals allow postpartum tubal ligations, 14% report inadequate staffing to provide anesthesia either always or at off-hours. CONCLUSIONS: Since 2001, there have been significant changes in how responding hospitals provide obstetric anesthesia care and staff the labor and delivery ward. Obstetric anesthesia surveys, updated every 10 years, continue to provide information about changes in obstetric anesthesia practice.