Cesarean Section Ratio: A Practical Tool to Assess Surgical Access and Resource Availability in Low- and...

Access and availability of timely, quality surgical services remain a problem in low- and middle-income countries. Easily obtainable measures, such as the facilities cesarean section ratio and whether a facility can complete and care for a patient undergoing a damage control laparotomy, are needed to evaluate access to surgical services. This current study aims to evaluate surgical access and resource allocation at primary, district, and tertiary level facilities (public and private) throughout Botswana. These data have the potential to help guide future surgical resource allocation in other low- and middle-income countries throughout the world.

Cesarean section ratio was calculated based on the ratio of cesarean sections to total surgical procedures completed during the data collection timeframe (June 1, 2022-May 31, 2023). Total surgical procedures included all procedures performed in an operating theater requiring local, general, spinal, or regional anesthesia. Data were collected from a selection of primary, district, and tertiary facilities throughout Botswana.

A total of eight primary, three district, and two tertiary facilities were included. Most facilities (11 of 13) were public. More surgical procedures were completed at tertiary compared to primary and district level facilities, 4889 (785) versus 162 (962), and median (range), respectively. The median (range) cesarean section ratio among all facilities was 66.1 (85). The two private facilities (Kanye Seventh-day Adventist and Bokamoso Private hospitals) had lower cesarean section ratios than all public facilities, 20.7% and 6.4%, respectively. Only tertiary level facilities were able to complete damage control laparotomies.

The cesarean section ratio can be easily obtained and dynamically followed to provide feedback on surgical resource utilization. The high cesarean section ratio seen in public facilities demonstrates an unmet surgical need, with resources asymmetrically devoted to perinatal care. Tertiary level facilities can complete damage control laparotomies, showing that surgical resources are available in Botswana.