This study has shown that 55.3% of deaths due to surgical conditions in Malawi occurred outside a health facility. This is higher than for deaths due to other medical conditions. Most of the surgical deaths outside health facilities happened at home. There are few studies on this topic, as most studies of surgical patients are based on hospitalized patients. However, a large study of 80,483 women of reproductive age in Mozambique indicated that 61.1% of deaths of women occurred at a health facility, 27.8% at home and 11.1% occurred somewhere else (for example on way to a health facility). These figures indicate similar problems as seen in the present study [17]. The difference in proportion of deaths happening outside a health facility, between surgical related and non-surgical related deaths can be partially explained by the fact that some road traffic injuries will lead to death at the site of injury. However, this finding still highlights a large lack of capacity for transport and health care in Malawi.
The problem with lack of access to surgery and trauma centres in low income settings has also been described in a study on acute abdominal conditions and other emergency conditions in India and lack of emergency obstetric services in Mozambique [18, 19]. A study done in Zambia demonstrated that only 16.5% of the hospitals met the WHO minimum standards of safe surgical care [20]. There is a similar situation in Malawi with low standards of safe surgery in rural health facilities [21]. In addition, the need of improvement in global surgical care, particularly in low- income and middle- income countries is described in a review from 2019 [21].
Some communities are remote, with large distances to health facilities, and family members may not have enough financial resources to help with transportation to the hospital [13]. This presents a further delay, or barrier, to patients being able to present to the health facility, which in many cases leads to loss of life. People in the rural communities of Malawi often visit a traditional healer before considering visiting a formal health care facility [22]. In our study, 12.9% of patients that died went to a traditional healer prior to visiting a formal health facility, possibly contributing to delayed presentation for surgical health care. Not all surgical conditions need operative interventions, but access to consultation with qualified health personnel can help identify those at risk and the need of surgical intervention or non-operative management.
The present study shows that surgical conditions that significantly affect mortality in Malawi were found to be 26.9% of all deaths. Overall the dominant causes of death were localised body masses, like breast mass, extremity masses and other body torso masses, representing such conditions as tumours, abscesses and hernias. Acute abdominal distension and traumatic conditions were the other dominant causes of untreated surgical condition related deaths. Though abdominal distension can arise from other medical conditions, in this survey death related to abdominal distension was defined by the interviewer as an acute death occurring within 1 week of the abdominal distension. This condition is highly suspicious of a surgical condition e.g. bowel obstruction or bowel perforation with peritonitis. There is little literature on this from Malawi. A previous study at a referral hospital in Lilongwe showed that the common aetiology for peritonitis were appendicitis and intestinal volvulus. It was also found that 11% of acute abdominal presentation with peritonitis was due to perforated peptic ulcer and small intestinal perforation respectively, and mortality from this was 15% [23]. The complications of untreated surgical conditions like bowel perforation, gangrene, dehydration and respiratory compromise can result in high morbidity and mortality rates. A study in East Africa reported morbidity rate of 24% and a mortality rate of 12.9% from abdominal surgical conditions due to bowel obstruction [24].
Children, below the age of 5, represented 18.8% of the surgical deaths with the majority of them dying from congenital disorders (40.7%). A study in a paediatric population in Malawi from 2016, reported a mortality rate of 23.3% in neonates due to different kinds of intestinal obstruction, most of which were congenital [25]. This study also showed that, in children, congenital surgical conditions, such as Hirschsprung’s disease and anorectal malformations, accounted for 29 and 18.5% of intestinal obstructions in neonate respectively [25]. This is associated with high mortality if not diagnosed promptly and treated properly in time by surgical intervention. Similarly, a Kenyan study showed that the highest mortality rates among neonates and infants were related to acute abdomen, 7% of congenital deaths [24]. In our study there were 11 neonates that died from congenital surgical conditions after being born alive. This survey did not investigate the burden of still birth, as these are culturally not registered as part of the population in Malawi. Congenital intestinal obstruction in neonates constitutes a major portion of neonatal surgical problems. Similar to our study, the Kenyan study was based on information from households. However, the Kenyan study used other categories for the reasons for death and had a longer observation period [24].
Trauma is another leading cause of death, and in our study it contributed to 21.5% of all surgical deaths, mainly in the age group 18–49. There were 16 persons (51.6% of traumatic deaths) that died from traffic related injuries. This reflects findings from another study in Malawi that showed a rapid rise in road traffic injuries in Malawi from 2009 to 2015 [26].
We registered 12 women who died during pregnancy and childbirth. However, the specific cause of death was in most cases not documented, except that bleeding was reported. Death from child birth complications was due to excessive haemorrhage associated with child delivery, i.e. post-partum haemorrhage. The Maternal Mortality Ratio in Malawi has been estimated at 675 maternal deaths/100000 live births during the period 2004–2010 [20]. It should be noted that this figure is far from Sustainable Development Goal 3.1, where the aim is to reduce maternal mortality to less than 70 per 100,000 live births (www.who.int/sdg/targets/en/).
A study done in Malawi assessing maternal mortality from delays in accessing obstetric medical care showed that the cost of transport and insufficient family finances, poor road conditions or terrain, shortage of health workers and providers, long travel to the nearest health facility and an inadequate referral system contributed significantly to delays in timely obstetric care. In this study 62.2% of maternal deaths occurred at a health facility while 21.2% of the deaths happened at home [27]. Improving health facility systems and implementing models like “saving mothers, giving life” (SMGL) initiatives may help to reduce deaths that happen from acute obstetric complications at rural or primary health care centres [28].
The absence of appropriate surgical care in LMICs results in many unnecessary deaths from curable surgical conditions. This lack of services contributes to significant disability, economic loss and ultimately compromises the quality of life for people living in these regions. Key barriers to accessing surgical services are; cost of transport, distance, poor roads, and lack of suitable transport [13]. Most people present late to health facilities as a result of the different transportation barriers they have faced [13]. Cultural issues like consulting the traditional herbalist for traditional medical intervention might also delay timely surgical intervention.
A limitation of this study was that the information of the causes of death was limited, since in many cases, no clear diagnosis was given. Data relies on the medical understanding of the informant, and this is likely to have weaknesses. However, in a validation study in Nepal, the SOSAS survey was compared with a visual examination and demonstrated high concordance with the self-reports from the participants [29]. Another limitation is that the information might be hampered by recall bias, with the informant thinking back in time over the past year, as well as specific causes of the events surrounding the deaths. However, this study also has many strengths, most obviously its sample size, response rate and covering nearly the whole geographical area of Malawi through randomization of survey sites. The interviewers were skilled and specifically trained for the study, and they used a standardized interview guide developed specifically to assess surgical need. Interviews were chosen because other sources for this information were not available in Malawi. Also, questionnaires were not an option, due to a moderately high illiteracy rate in Malawi [30], and a lack of culture for this type of data gathering.
