Understanding family-level decision-making when seeking access to acute surgical care for children: Protocol for a cross-sectional mixed methods study.

BACKGROUND: There is limited understanding of how social determinants of health (SDOH) impact family decision-making when seeking surgical care for children. Our objectives of this study are to identify key family experiences that contribute to decision-making when accessing surgical care for children, to confirm if family experiences impact delays in care, and to describe differences in family experiences across populations (race, ethnicity, socioeconomic status, rurality). METHODS: We will use a prospective, cross-sectional, mixed methods design to examine family experiences during access to care for children with appendicitis. Participants will include 242 parents of consecutive children (0-17 years) with acute appendicitis over a 15-month period at two academic health systems in North Carolina and Virginia. We will collect demographic and clinical data. Parents will be administered the Adult Responses to Children's Symptoms survey (ARCS), the child and parental forms of the Adverse Childhood Experiences (ACE) survey, the Accountable Health Communities Health-Related Social Needs Screening Tool, and Single Item Literacy Screener. Parallel ARCS data will be collected from child participants (8-17 years). We will use nested concurrent, purposive sampling to select a subset of families for semi-structured interviews. Qualitative data will be analyzed using thematic analysis and integrated with quantitative data to identify emerging themes that inform a conceptual model of family-level decision-making during access to surgical care. Multivariate linear regression will be used to determine association between the appendicitis perforation rate and ARCS responses (primary outcome). Secondary outcomes include comparison of health literacy, ACEs, and SDOH, clinical outcomes, and family experiences across populations. DISCUSSION: We expect to identify key family experiences when accessing care for appendicitis which may impact outcomes and differ across populations. Increased understanding of how SDOH and family experiences influence family decision-making may inform novel strategies to mitigate surgical disparities in children.

Impact of the COVID-19 pandemic on perinatal care and outcomes: A retrospective study in a tertiary hospital in Northern Ghana.

BACKGROUND: Perinatal mortality remains a global challenge. This challenge may be worsened by the negative effects of the COVID-19 pandemic on maternal and child health. OBJECTIVES: Examine the impact of the COVID-19 pandemic on perinatal care and outcomes in the Tamale Teaching Hospital in northern Ghana. METHODS: A hospital-based retrospective study was conducted in the Tamale Teaching Hospital. We compared antenatal care attendance, total deliveries, cesarean sections, and perinatal mortality before the COVID-19 pandemic (March 1, 2019 to February 28, 2020) and during the COVID-19 pandemic (March 1, 2020 to February 28, 2021). Interrupted time series analyses was performed to evaluate the impact of the COVID-19 pandemic on perinatal care and outcomes at TTH. RESULTS: A total number of 35,350 antenatal visits and 16,786 deliveries were registered at TTH from March 2019 to February 2021. Antenatal care, early neonatal death, and emergency cesarean section showed a rapid decline after the onset of the pandemic, with a progressive recovery over the following months. The total number of deliveries and fresh stillbirths showed a step change with a marked decrease during the pandemic, while the macerated stillbirths showed a pulse change, a temporary marked decrease with a quick recovery over time. CONCLUSION: The COVID-19 pandemic had a negative impact on perinatal care and outcomes in our facility. Pregnancy monitoring through antenatal care should be encouraged and continued even as countries tackle the pandemic.

Impact of the COVID-19 pandemic in childhood and adolescent cancer care in northern Tanzania: a cross-sectional study.

INTRODUCTION: The SARS-CoV-2 (COVID-19) pandemic has strained healthcare systems and presented unique challenges for children requiring cancer care, particularly in low- and middle-income countries. This study aimed to assess the impact of the COVID-19 pandemic on access to cancer care for children and adolescents in Northern Tanzania. METHODS: In this cross-sectional study, we assessed the demographic and clinical characteristics of 547 pediatric and adolescent cancer patients (ages 0-19 years old) between 2016 and 2022 using the population-based Kilimanjaro Cancer Registry (KCR). We categorized data into pre-COVID-19 (2016-2019) and COVID-19 (2020-2022) eras, and performed descriptive analyses of diagnostic, treatment, and demographic information. A secondary analysis was conducted on a subset of 167 patients with stage of diagnosis at presentation. RESULTS: Overall admissions nearly doubled during the pandemic (n = 190 versus 357). The variety of diagnoses attended at KCMC increased during the pandemic, with only five groups of diseases reported in 2016 to twelve groups of diseases in 2021. Most patients were diagnosed at a late stage (stage III or IV) across eras, with the proportion of under-five years old patients increasing late-diagnoses from 29.4% (before the pandemic), 52.8% (during the pandemic), when compared to the overall cohort. Around 95% of children in this age category reported late-stage diagnosis during the pandemic. Six out of the twelve cancer site groups also reported an increase in late-stage diagnosis. During the pandemic, the proportion of children receiving surgery increased from 15.8 to 30.8% (p < 0.001). CONCLUSION: Childhood and adolescent cancer care changed in Northern Tanzania during the COVID-19 pandemic, with increased late-stage diagnoses presentations among younger patients and the increased use of surgical therapies in the context of a growing practice. Understanding the impact of the COVID-19 pandemic on pediatric and adolescent cancer care can help us better adapt healthcare systems and interventions to the emerging needs of children and adolescents with cancer in the midst of a health crisis.

Modeling the global impact of reducing out-of-pocket costs for children's surgical care.

Over 1.7 billion children lack access to surgical care, mostly in low- and middle-income countries (LMICs), with substantial risks of catastrophic health expenditures (CHE) and impoverishment. Increasing interest in reducing out-of-pocket (OOP) expenditures as a tool to reduce the rate of poverty is growing. However, the impact of reducing OOP expenditures on CHE remains poorly understood. The purpose of this study was to estimate the global impact of reducing OOP expenditures for pediatric surgical care on the risk of CHE within and between countries. Our goal was to estimate the impact of reducing OOP expenditures for surgical care in children for 149 countries by modeling the risk of CHE under various scale-up scenarios using publicly available World Bank data. Scenarios included reducing OOP expenditures from baseline levels to paying 70%, 50%, 30%, and 10% of OOP expenditures. We also compared the impact of these reductions across income quintiles (poorest, poor, middle, rich, richest) and differences by country income level (low-income, lower-middle-income, upper-middle-income, and high-income countries).Reducing OOP expenditures benefited people from all countries and income quintiles, although the benefits were not equal. The risk of CHE due to a surgical procedure for children was highest in low-income countries. An unexpected observation was that upper-middle income countries were at higher risk for CHE than LMICs. The most vulnerable regions were Africa and Latin America. Across all countries, the poorest quintile had the greatest risk for CHE. Increasing interest in financial protection programs to reduce OOP expenditures is growing in many areas of global health. Reducing OOP expenditures benefited people from all countries and income quintiles, although the benefits were not equal across countries, wealth groups, or even by wealth groups within countries. Understanding these complexities is critical to develop appropriate policies to minimize the risks of poverty.

Childhood and Adolescent Cancer Care at a Tertiary Hospital in Northern Tanzania: A Retrospective Study.

PURPOSE: Over 400,000 children are diagnosed with cancer around the world each year, with over 80% of these children residing in low- and middle-income countries. This study aims to summarize the epidemiology and care patterns of newly diagnosed childhood cancer patients in Northern Tanzania. METHODS: Data from all children and adolescents (age 0-19 years) with newly diagnosed cancers were collected from the Kilimanjaro Cancer Registry located at the Kilimanjaro Christian Medical Centre. Descriptive and inferential analyses were used to compare the demographic and clinical characteristics of the participants over time, stage, and status at last contact. Statistical significance was set at P < .05. Secondary descriptive analysis was conducted on a subset sample with available staging data. RESULTS: A total of 417 patients were diagnosed with cancer between 2016 and 2021. There was an increase in the rate of patients with newly diagnosed pediatric cancer each year, particularly among children under age 5 years and 10 years. Leukemias and lymphomas were the leading diagnoses and accounted for 183 (43.8%) of all patients. Over 75% of patients were diagnosed at stage III or above. From a subset analysis of patients with available staging data (n = 101), chemotherapy was the most common treatment (87.1%), compared with radiotherapy and surgery. CONCLUSION: There is a significant burden of children with cancer in Tanzania. Our study fills crucial gaps in the literature related to the large burden of disease and survival for children with cancer in the Kilimanjaro region. Furthermore, our results can be used to understand the regional needs and guide research and strategic interventions to improve childhood cancer survival in Northern Tanzania.

Does reducing out-of-pocket costs for children's surgical care protect families from poverty in Somaliland? A cross-sectional, national, economic evaluation modelling study.

OBJECTIVES: An estimated 1.7 billion children around the world do not have access to safe, affordable and timely surgical care, with the financing through out-of-pocket (OOP) expenses being one of the main barriers to care. Our study modelled the impact of reducing OOP costs related to surgical care for children in Somaliland on the risk of catastrophic expenditures and impoverishment. DESIGN AND SETTING: This cross-sectional nationwide economic evaluation modelled several different approaches to reduction of paediatric OOP surgical costs in Somaliland. PARTICIPANTS AND OUTCOME MEASURES: A surgical record review of all procedures on children up to 15 years old was conducted at 15 surgically capable hospitals. We modelled two rates of OOP cost reduction (reduction of OOP proportion from 70% to 50% and from 70% to 30% reduction in OOP costs) across five wealth quintiles (poorest, poor, neutral, rich, richest) and two geographical areas (urban and rural). The outcome measures of the study are catastrophic expenditures and risk of impoverishment due to surgery. We followed the Consolidated Health Economic Evaluation Reporting Standards. RESULTS: We found that the risk of catastrophic and impoverishing expenditures related to OOP expenditures for paediatric surgery is high across Somaliland, but most notable in the rural areas and among the poorest quintiles. Reducing OOP expenses for surgical care to 30% would protect families in the richest wealth quintiles while minimally affecting the risk of catastrophic expenditure and impoverishment for those in the lowest wealth quintiles, particularly those in rural areas. CONCLUSION: Our models suggest that the poorest communities in Somaliland lack protection against the risk of catastrophic health expenditure and impoverishment, even if OOP payments are reduced to 30% of surgical costs. A comprehensive financial protection in addition to reduction of OOP costs is required to prevent risk of impoverishment in these communities.

Delays in cancer care for children in low-income and middle-income countries: development of a composite vulnerability index.

BACKGROUND: Early access to diagnosis and care is essential to improve rates of survival from childhood cancer, particularly in low-income and middle-income countries (LMICs). Composite indices are increasingly used to compare country performance in many health fields. We aimed to develop a composite vulnerability index of risk of mortality associated with delays in care for childhood cancer in LMICs, and to compare the vulnerability index scores across countries. METHODS: The composite vulnerability index was built in ten steps. A previous systematic review of determinants of delays in cancer care for children guided data selection. We collected exposure variables (determinants of delays in care) and outcome variables (childhood cancer-related mortality) from several large datasets. Data were analysed with regression models to identify determinants of delays in care that contribute to childhood cancer mortality. Significant indicators were aggregated into domains according to the socio-ecological model. We used geospatial tools to summarise and compare the composite vulnerability index scores across countries. FINDINGS: We found that life expectancy, maternal education, fertility rate, availability of pathology services, bone marrow transplantation capacity, availability of treatment services (chemotherapy, radiotherapy, or surgery), number of pharmacists per 10 000 population, country income level, and out-of-pocket health expenditure were significantly associated with cancer mortality for children in LMICs. The highest levels of vulnerability were found in sub-Saharan Africa. INTERPRETATION: Our composite vulnerability index can potentially serve as a valuable policy decision tool to help monitor country performance and guide interventions to reduce delays in care for children with cancer in LMICs. FUNDING: None. TRANSLATIONS: For the Chinese, Portuguese, Arabic, Spanish and Swahili translations of the abstract see Supplementary Materials section.

Determinants of delayed childhood cancer care in low- and middle-income countries: A systematic review.

Early access to care is essential to improve survival rates for childhood cancer. This study evaluates the determinants of delays in childhood cancer care in low- and middle-income countries (LMICs) through a systematic review of the literature. We proposed a novel Three-Delay framework specific to childhood cancer in LMICs by summarizing 43 determinants and 24 risk factors of delayed cancer care from 95 studies. Traditional medicine, household income, lack of transportation, rural population, parental education, and travel distance influenced most domains of our framework. Our novel framework can be used as a policy tool toward improving cancer care and outcomes for children in LMICs.

Prevalence and outcomes of pediatric surgical conditions at Connaught Hospital in Freetown: a retrospective study.

Background: Sub-Saharan Africa experiences a disproportionate amount of pediatric surgical disease, with 80% of children lacking access to timely, affordable, and safe surgical care. This study aims to characterize the burden of disease and outcomes of pediatric surgical conditions at Connaught Hospital, the main pediatric referral hospital in Sierra Leone. Methods: This retrospective and hospital-based study included children up to 15 years old who were operated on between 2015 and June 2016 at Connaught Hospital in Freetown, Sierra Leone. Descriptive and inferential statistics were used to characterize the distribution of disease and compare all variables against age category and mortality. Findings: A total of 215 patients were included in this study of which 72.5% (n=132) were male and 27.5% (n=50) were female. Most of the patients were diagnosed with congenital anomalies (60.9%; n=131). However, infection was the leading diagnosis (60.5%; n=23) among patients aged 5-10 years (n=38). Inguinal hernia was the leading condition (65.0%; n=85) among patients presenting with a congenital anomaly. The condition with the highest mortality was infections (17.0%; n=8), followed by other conditions (9.1%; n=2) and congenital anomalies (3.1%; n=4). Based on the results of this study, over 7000 children with inguinal hernias remain untreated annually in Freetown, Sierra Leone. Conclusion: This study quantifies the burden of surgical disease among children, a foundational step toward the prioritization of pediatric surgical care in national health agendas, the development of evidence-based interventions, and the strategic allocation of resources in Sierra Leone.

Delays in care for hydrocephalus and spina bifida at a tertiary hospital in Somaliland.

Background: Childhood neurosurgical conditions such as hydrocephalus and spina bifida represent a significant burden of death and disability worldwide, particularly in low and middle-income countries. However, there are limited data on the disease prevalence and delays in care for pediatric neurosurgical conditions in very low-resource settings. This study aims to characterize the delays in access to care for pediatric neurosurgical conditions in Somaliland. Methods: We performed a retrospective review of all children with congenital hydrocephalus and spina bifida admitted to the Edna University Hospital (EAUH) in Somaliland between 2011 and 2018. Patient demographics were analyzed with descriptive statistics and χ2 test statistics. We defined delays in care for each condition based on standard care in high-income settings. Univariate and multivariate logistic regression were performed to evaluate predictors of delay in care. Statistical significance was set at p<0.05. Results: A total of 344 children were admitted to EAUH with neurosurgical conditions from 2011 to 2018. The most common condition was congenital hydrocephalus (62%). Delays in care were found for 90% of patients and were associated with the type of diagnosis and region. The longest delay among children with spina bifida was 60 months, while the longest delay for children with congenital hydrocephalus was 36 months. Children with congenital hydrocephalus or spina bifida traveling from foreign countries had the highest waiting time to receive care, with a median delay of 8 months (IQR: 5-11 months) and 4 months (IQR: 3-7 months), respectively. Conclusion: We found significant delays in care for children with neurosurgical conditions in Somaliland. This country has an urgent need to scale up its surgical infrastructure, workforce, and referral pathways to address the needs of children with hydrocephalus and spina bifida.

Factors contributing to delayed childhood cancer care in low- and middle-income countries: A systematic review protocol.

BACKGROUND: Significant disparities exist for timely access to cancer care for children, with the highest disparities in low- and middle-income countries (LMICs). This study aims to conduct a systematic review that identifies the factors contributing to delayed care of childhood cancers in LMICs. METHODS: We will conduct a systematic review with search strings compliant with the PICO framework: (1) the Population-children (aged 0-18 years) from LMICs; (2) the Exposure-factors contributing to timely childhood cancer care; (3) the Outcome-delays in childhood cancer care. DISCUSSION: Our study is an essential step to guide strategic interventions to assess the myriad of factors that prevent children from accessing timely cancer care in LMICs. The results will be submitted for publication in a peer-reviewed journal and shared with institutions related to the field.

Application of theoretical frameworks on human papillomavirus vaccine interventions in the United States: systematic review and meta-analysis.

PURPOSE: Theoretical frameworks are useful tools to explain the dynamics of behavioral change, develop, and implement intervention studies. The purpose of this systematic review and meta-analysis is to evaluate the application of theoretical frameworks and models to HPV vaccination intervention studies in the United States (US) from January 2006 to December 2019. METHODS: A comprehensive search across databases, including PubMed, EMBASE, ERIC, CINAHL, Academic Search Complete, Scopus, Web of Science, and PsycINFO, was conducted. Articles were included in the systematic analysis if at least one theory was used to develop the intervention phase. All intervention studies targeting populations in the US without restrictions of age, income, sex, and ethnicity were included. Articles were included in the meta-analysis if vaccine uptake and/or vaccine completion was addressed. RESULTS: The Health Belief Model, Motivational Interviewing, Theory of Planned Behavior, and Information-Motivation-Behavioral Skills were the most used theories. Based on theory integrity, theory rationale, and theory operationalization, most of the studies (60%) were rated high for the application of the theoretical frameworks. Our results suggest a preference for theoretical frameworks targeting individual change rather than community change and the existence of gender disparities in the application of theoretical frameworks. The association between theory and increase of likelihood in vaccine uptake and completion was not supported. CONCLUSION: This review spotlights common issues in the application of theoretical frameworks in HPV vaccine interventions in the US. Our results suggest we are still in a developmental phase on several aspects of theory application to HPV vaccination.

Geospatial analysis of pediatric surgical need and geographical access to care in Somaliland: a cross-sectional study.

BACKGROUND: The global burden of disease in children is large and disproportionally affects low-income and middle-income countries (LMICs). Geospatial analysis offers powerful tools to quantify and visualise disparities in surgical care in LMICs. Our study aims to analyse the geographical distribution of paediatric surgical conditions and to evaluate the geographical access to surgical care in Somaliland. METHODS: Using the Surgeons OverSeas Assessment of Surgical Need survey and a combined survey from the WHO's (WHO) Surgical Assessment Tool-Hospital Walkthrough and the Global Initiative for Children's Surgery Global Assessment in Paediatric Surgery, we collected data on surgical burden and access from 1503 children and 15 hospitals across Somaliland. We used several geospatial tools, including hotspot analysis, service area analysis, Voronoi diagrams, and Inverse Distance Weighted interpolation to estimate the geographical distribution of paediatric surgical conditions and access to care across Somaliland. RESULTS: Our analysis suggests less than 10% of children have timely access to care across Somaliland. Patients could travel up to 12 hours by public transportation and more than 2 days by foot to reach surgical care. There are wide geographical disparities in the prevalence of paediatric surgical conditions and access to surgical care across regions. Disparities are greater among children travelling by foot and living in rural areas, where the delay to receive surgery often exceeds 3 years. Overall, Sahil and Sool were the regions that combined the highest need and the poorest surgical care coverage. CONCLUSION: Our study demonstrated wide disparities in the distribution of surgical disease and access to surgical care for children across Somaliland. Geospatial analysis offers powerful tools to identify critical areas and strategically allocate resources and interventions to efficiently scale-up surgical care for children in Somaliland.

Global and regional overview of the inclusion of paediatric surgery in the national health plans of 124 countries: an ecological study.

OBJECTIVE: This study evaluates the priority given to surgical care for children within national health policies, strategies and plans (NHPSPs). PARTICIPANTS AND SETTING: We reviewed the NHPSPs available in the WHO's Country Planning Cycle Database. Countries with NHPSPs in languages different from English, Spanish, French or Chinese were excluded. A total of 124 countries met the inclusion criteria. PRIMARY AND SECONDARY OUTCOME MEASURES: We searched for child-specific and surgery-specific terms in the NHPSPs' missions, goals and strategies using three analytic approaches: (1) count of the total number of mentions, (2) count of the number of policies with no mentions and (3) count of the number of policies with five or more mentions. Outcomes were compared across WHO regional and World Bank income-level classifications. RESULTS: We found that the most frequently mentioned terms were 'child*', 'infant*' and 'immuniz*'. The most frequently mentioned surgery term was 'surg*'. Overall, 45% of NHPSPs discussed surgery and 7% discussed children's surgery. The majority (93%) of countries did not mention selected essential and cost-effective children's procedures. When stratified by WHO region and World Bank income level, the West Pacific region led the inclusion of 'pediatric surgery' in national health plans, with 17% of its countries mentioning this term. Likewise, low-income countries led the inclusion of surg* and 'pediatric surgery', with 63% and 11% of countries mentioning these terms, respectively. In both stratifications, paediatric surgery only equated to less than 1% of the total terms. CONCLUSION: The low prevalence of children's surgical search terms in NHPSPs indicates that the influence of surgical care for this population remains low in the majority of countries. Increased awareness of children's surgical needs in national health plans might constitute a critical step to scale up surgical system in these countries.

A retrospective review of gastroschisis epidemiology and referral patterns in northern Ghana.

PURPOSE: To describe the epidemiology and referral patterns of gastroschisis patients in northern Ghana. METHODS: A hospital-based retrospective review was undertaken at Tamale Teaching Hospital (TTH) Neonatal Intensive Care Unit (NICU) between 2014 and 2019. Data from gastroschisis patients were compared to patients with other surgical diagnoses. Descriptive and inferential statistics were performed with SAS. Referral flow maps were made with ArcGIS. RESULTS: From a total of 360 neonates admitted with surgical conditions, 12 (3%) were diagnosed with gastroschisis. Around 91% (n = 10) of gastroschisis patients were referred from other hospitals, traveling 4 h, on average. Referral patterns showed gastroschisis patients were admitted from three regions, whereas patients with other surgical diagnoses were admitted from eight regions. Only 6% (12/201) of expected gastroschisis cases were reported during the 6-year period in all regions. All gastroschisis deaths occurred within the first week of life. CONCLUSIONS: Improving access to surgical care and reducing neonatal mortality related to gastroschisis in northern Ghana is critical. This study provides a baseline to inform future gastroschisis interventions at TTH. Priority areas may include special management of low birth weight newborns, better referral systems, empowerment of community health workers, and increasing access to timely, affordable, and safe neonatal transport.

Decrease in Admissions and Change in the Diagnostic Landscape in a Newborn Care Unit in Northern Ghana During the COVID-19 Pandemic.

Background: The coronavirus disease (COVID-19) has spread worldwide with an increasing number of patients, including pregnant women and neonates. This study aims to evaluate morbidity and mortality in the COVID-19 era compared to the preceding year in the Neonatal Intensive Care Unit (NICU) at Tamale Teaching Hospital, Ghana. Methods: This is a cross-sectional study carried out on neonates admitted to NICU between March 1st to August 31st, 2019 (pre-COVID-19 era) and March 1st to August 31st, 2020 (COVID-19 era). Multivariate logistic regression was performed to identify predictors of mortality for both periods. Results: From 2,901 neonates, 1,616 (56%) were admitted before, and 1,285 (44%) were admitted during the pandemic. Admissions decreased during the COVID-19 era, reaching their lowest point between June and August 2020. Compared to the previous year, during the COVID-19 era, admissions of patients born at TTH, delivered at home, and with infections decreased from 50 to 39%, 7 to 4%, and 22 to 13%, respectively. Referred status (OR = 3.3) and vaginal delivery (OR = 1.6) were associated with an increased likelihood of mortality. For low- birth weight neonates, admissions of patients born at TTH, with vaginal and home delivery decreased from 62 to 48%, 8 to 2%, and 59 to 52%, respectively. Neonatal infections and congenital anomalies decreased from 8 to 4%, 5 to 3%, respectively. The likelihood of mortality among referred patients increased by 50%. Conclusion: We observed a marked decrease in admissions and change in the diagnosis landscape and related mortality during the pandemic. Underlying challenges, including fear, financing, and health system capacity, might intensify delays and lack of access to newborn care in northern Ghana, leading to higher rates of lifelong disabilities and mortality. Immediate damage control measures, including an improved home-based continuum of care and equipping families to participate in the newborn care with complemented m-health approaches, are needed with urgency.

Timing and causes of neonatal mortality in Tamale Teaching Hospital, Ghana: A retrospective study.

Neonatal deaths now account for more than two-thirds of all deaths in the first year of life and for about half of all deaths in children under-five years. Sub-Saharan Africa accounts up to 41% of the total burden of neonatal deaths worldwide. Our study aims to describe causes of neonatal mortality and to evaluate predictors of timing of neonatal death at Tamale Teaching Hospital (TTH), Ghana. This retrospective study was conducted at TTH located in Northern Ghana. All neonates who died in the Neonatal Intensive Care Unit (NICU) from 2013 to 2017 were included and data was obtained from admission and discharge books and mortality records. Bivariate and multivariate logistic regression were used to assess predictors of timing of neonatal death. Out of the 8,377 neonates that were admitted at the NICU during the 5-year study period, 1,126 died, representing a mortality rate of 13.4%. Of those that died, 74.3% died within 6 days. There was an overall downward trend in neonatal mortality over the course of the 5-year study period (18.2% in 2013; 14.3% in 2017). Preterm birth complications (49.6%) and birth asphyxia (21.7%) were the top causes of mortality. Predictors of early death included being born within TTH, birth weight, and having a diagnosis of preterm birth complication or birth asphyxia. Our retrospective study found that almost 3/4 of neonatal deaths were within the first week and these deaths were more likely to be associated with preterm birth complications or birth asphyxia. Most of the deaths occurred in babies born within health facilities, presenting an opportunity to reduce our mortality by improving on quality of care provided during the perinatal period.

Interpreting the Lancet surgical indicators in Somaliland: a cross-sectional study.

BACKGROUND: The unmet burden of surgical care is high in low-income and middle-income countries. The Lancet Commission on Global Surgery (LCoGS) proposed six indicators to guide the development of national plans for improving and monitoring access to essential surgical care. This study aimed to characterise the Somaliland surgical health system according to the LCoGS indicators and provide recommendations for next-step interventions. METHODS: In this cross-sectional nationwide study, the WHO's Surgical Assessment Tool-Hospital Walkthrough and geographical mapping were used for data collection at 15 surgically capable hospitals. LCoGS indicators for preparedness was defined as access to timely surgery and specialist surgical workforce density (surgeons, anaesthesiologists and obstetricians/SAO), delivery was defined as surgical volume, and impact was defined as protection against impoverishment and catastrophic expenditure. Indicators were compared with the LCoGS goals and were stratified by region. RESULTS: The healthcare system in Somaliland does not meet any of the six LCoGS targets for preparedness, delivery or impact. We estimate that only 19% of the population has timely access to essential surgery, less than the LCoGS goal of 80% coverage. The number of specialist SAO providers is 0.8 per 100 000, compared with an LCoGS goal of 20 SAO per 100 000. Surgical volume is 368 procedures per 100 000 people, while the LCoGS goal is 5000 procedures per 100 000. Protection against impoverishing expenditures was only 18% and against catastrophic expenditures 1%, both far below the LCoGS goal of 100% protection. CONCLUSION: We found several gaps in the surgical system in Somaliland using the LCoGS indicators and target goals. These metrics provide a broad view of current status and gaps in surgical care, and can be used as benchmarks of progress towards universal health coverage for the provision of safe, affordable, and timely surgical, obstetric and anaesthesia care in Somaliland.