Rates of surgical deaths and infections at district hospitals in Malawi and Zambia: a prospective multicentre cohort study

OBJECTIVE: This paper reports perioperative mortality and postoperative infection rates of surgical patients who underwent operations at district-level hospitals in Malawi and Zambia, and the associations of these outcomes with patient characteristics based on routinely available data. DESIGN: Prospective cohort study. SETTING: Eight government district hospitals in Malawi and nine mission and government district hospitals in Zambia. OUTCOME MEASURES: Perioperative mortality and postoperative infection were used as primary outcome measures in this study. Logistic regression and penalised maximum likelihood logistic regression were used to examine the factors correlated with surgical outcomes. RESULTS: The average perioperative mortality rates were 0.19% and 0.43% in Malawi and Zambia, respectively. Penalised maximum likelihood logistic regression showed that age (OR=1.046, 95% CI 1.016 to 1.078) and American Society of Anesthesiologists physical status score II (OR=6.658, 95% CI 2.363 to 18.762) were significantly associated with perioperative deaths. General surgery procedures were significantly more likely than obstetrical procedures to result in perioperative deaths (OR=3.821, 95% CI 1.226 to 11.908). The average rates of postoperative infections in Malawi and Zambia were 2.69% and 2.24%, respectively. Age (OR=1.010, 95% CI 1.000 to 1.020) and male sex (OR=0.407, 95% CI 0.260 to 0.637) were significantly associated with postoperative infections. Additional factors, general procedures (OR=2.319, 95% CI 1.397 to 3.850) and trauma-related procedure (OR=5.490, 95% CI 2.632 to 11.449) were significantly associated with infection rates. There was no significant correlation between surgical outcomes and cadre of lead surgeon (a non-physician clinician or doctor). CONCLUSION: Rates of mortality and postoperative infections in this sample of district-level hospitals in Malawi and Zambia were relatively low, with poorer preoperative physical status as the main predictor of both greater postoperative infection and mortality. The study demonstrates that outcomes of major surgical cases do not depend on the cadre (type) of surgeon performing it, and outcomes can be monitored using routine data, at district level in these countries. TRIAL REGISTRATION NUMBER: ISRCTN66099597.