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Health Solutions International began as a platform to advocate for increased access to safe surgery and safe anaesthesia in Low-and Middle-Income countries following a 2013 World Federation of Societies of Anaesthesiologists (WFSA) Research Grant for a study of the challenges of anaesthesia care in developing countries, specifically Sub Saharan Africa. Travelling to 5 separate East African Countries Dr. Epiu evaluated the provision for anesthetic care according to the WFSA guidelines. Her results identified specific shortages of personnel and equipment needed to provide safe anesthetic care for obstetric surgical cases in tertiary referral hospitals across East Africa.

Access to safe surgery and safe anesthesia is a basic human right for health. However, it is far from being achieved in many low- and middle-income countries (LMICs) where lack of trained providers and poor infrastructure, utilizing a variety of often poorly maintained donated equipment, contributes to unacceptably high morbidity and mortality rates. Reports from Sub-Saharan Africa (SSA) describe anaesthesia mortality ranging from 1:133 to 1:1900 for adult and pediatric practice.


These rates are closer to those seen in high-income countries more than fifty years ago and while the rates in these high income countries reflect a one hundred-times improvement in anesthesia safety, little has changed in the intervening period in many LMICs. Safe anaesthesia and safe surgery are an essential but neglected element of good maternal outcomes. We therefore set out to assess the main referral hospitals in the East African Community (EAC) to obtain a snapshot of the capacity to provide safe anesthetic care for mothers and babies in this region. Objective: To determine the quality of anaesthesia care offered to obstetric patients undergoing surgery in the National Referral Hospitals of the East African Region. Methodology: The study was a cross-sectional survey conducted at the main referral hospitals in East Africa – Mulago - Uganda, Kenyatta - Kenya, Muhimbili - Tanzania, Center Hospitalier Universite de Kigali (CHUK) – Rwanda and Centre Hospitalier Universitaire de Kamenge (CHUK) - Burundi. Using a questionnaire based on the (WFSA) World Federation of the Societies of Anaesthesiologists guidelines for safe anaesthesia, we assessed demographic, administrative, pre-anesthetic, intra-operative, post-anesthetic variables by interviewing anaesthetists in these hospitals, key informants from the Ministry of Health and the heads of the National Society of Anaesthesia in each country.


Results: Results from the 85 anesthetists interviewed were analyzed and 58% of the anaesthesia providers had heard about the WFSA international guidelines for safe anaesthesia. Only 25% regularly used the pre-anesthetic surgical checklist mainly because it was not available. Although Muhimbili hospital had a locally designed checklist, 54% said it was not available for use. Using the WFSA checklist as a guide, 4 % of the anesthetists were able to provide safe obstetric anaesthesia, 19% provided intermediate and 78% provided poor quality anaesthesia. Conclusion: This study of anaesthesia capacity in the EAC identified shortages of personnel and equipment needed to provide safe anesthetic care for obstetric surgical cases.


1. Epiu, I: Tindimwebwa, JV; Mijimbi, C; Chokwe, T; Lugazia, E; Ndarugirire, F; Twagirumugabe, T; Dubowitz, G; Anaesthesia In Developing Countries; Value in Health Vol 18 No. 7; 2015. Elsevier 

2. Epiu, I: Tindimwebwa, JVB; Mijumbi, C; Ndarugirire, F; Twagirumugabe, T; Lugazia, E; Gerald, D; Chokwe, T; Working towards safer surgery in Africa; a survey of utilization of the WHO safe surgical checklist at the main referral hospitals in East Africa; BMC anesthesiology 16, 1, Page 60; 2016. BioMed Central 


3. Epiu, I: Tindimwebwa, JVB; Mijumbi, C; Chokwe, T; Lugazia, E; Ndarugirire, F; Twagirumugabe, T; Gerald, D; Challenges of Anesthesia in Low-and Middle-Income Countries: A Cross-Sectional Survey of Access to Safe Obstetric Anesthesia in East Africa. Anesthesia & Analgesia, 124, 1, Page 290-299; 2017. LWW 

4. Isabella Epiu: Putting safety anesthesia at the center of the Global Health Agenda;


5.Isabella Epiu: Agnes Wabule, Kambugu Andrew, Harriet Mayanja-Kizza, Jossy Verel Bahe Tindimwebwa,Gerald Dubowitz; Key bottlenecks to the provision of safe obstetric anaesthesia in low- income countries; a cross-sectional survey of 64 hospitals in Uganda. November 2017. BMC Pregnancy and Childbirth DOI: 10.1186/s12884-017-1566-3. BioMed Central


6. Epiu Isabella, Josaphat Byamugisha, Andrew Kwikiriza, and Meg Amy Autry. "Health and sustainable development; strengthening peri-operative care in low income countries to improve maternal and neonatal outcomes." Reproductive Health (2018) 15:168  PMC6173895 

7. Epiu Isabella,Godfrey Alia, John Mukisa, Paula Tavrow, Mohammed Lamorde, and Andreas Kuznik. "Estimating the cost and cost-effectiveness for obstetric fistula repair in hospitals in Uganda: a low-income country." Health Policy and Planning, Volume 33, Issue 9, 1 November 2018, Pages 999–1008, University of Oxford Press 

8.Isabella Epiu. Why improving access to surgery in childbirth makes economic sense.  The conversation.January 2019.


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