The Open Public Health Journal




ISSN: 1874-9445 ― Volume 12, 2019
RESEARCH ARTICLE

Current Status of Obstetric Anaesthesia Services (OASIS); A Cross-sectional Survey of Public Hospitals in Khartoum State, Sudan



Sohel M G Ahmed*, 1, Amna Mustafa Ali2, 3, Tayseer Salih Mohamed4, Mohamed Sayed M Hajnour5, 6, Hayat O. Elfil1, Samahir F M Hussein2, 3, Dalia Abdelrahman7, Abdelrahman Eltegani8, 9, Ahmed M A A Abusalab2, Aala F Elhadi10, Amna Eljak11, 12, Hadab Ahmed Mohamed13, 14
1 Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
2 Department of Anaesthesia, University of Khartoum, Khartoum, Sudan
3 Soba University Hospital, Khartoum, Sudan
4 Saad Abu Alela Hospital, Khartoum, Sudan.
5 King Khalid University Hospital, Riyadh, KSA
6 King Saud University, Riyadh, KSA
7 Rotunda Maternity Hospital, Dublin, Ireland
8 Alzaaiem Alazhary University, Khartoum, Sudan
9 Alshaab Teaching Hospital, Khartoum, Sudan
10 Rashid Trauma Centre, Dubai, UAE
11 Khartoum Academy Charity Hospital, Khartoum, Sudan
12 University of Technology and Medical Science. Khartoum, Sudan
13 Faculty of Medicine, University of Khartoum, Khartoum, Sudan
14 Department of Anaesthesia, The National Centre for Neurological Sciences (NCNS), Khartoum, Sudan

Abstract

Background:

Medical services in general, and anaesthetic services in particular, in Sudan have been vulnerable to changes secondary to the socio-economic factors over the last few decades.

Objective:

This cross-state survey aims to identify the current set up of obstetric anaesthesia services in 19 hospitals - representing all public hospitals in Khartoum State with maternity units- and audit them against internationally set standards.

Methodology:

This is a cross-sectional descriptive non-interventional study. Questionnaires- based on the World Federation of Societies of Anaesthesiologists (WFSA) Safe Anaesthesia Standards- were distributed to Anaesthetic departments’ heads at the time of the study (first to fourteenth of May 2016) of 19 public hospitals. This is the total number of public hospitals delivering obstetric services in Khartoum State. All filled out questionnaires were returned (response rate 100%). Collected information/data provided were subsequently entered into an Excel sheet and analysed. Results were tabulated.

Results:

There was a considerable variation in the capacity of the surveyed hospitals in terms of human resources, caseload and set up. Improper utilisation of already deficient anaesthesiologist in covering high load obstetrics services was also noticed. All the hospitals fell short of recommendations for minimum standards set by the World Federation of Societies of Anaesthesiologists (WFSA).

Conclusion:

There is a vast gap between international set standards and the current set up of obstetric anaesthesia in Khartoum State public hospitals. Necessary concerted efforts from governmental, non-governmental and professional bodies are warranted to improve obstetric anaesthetic services in Khartoum State.

Keywords: Obstetrics, Anaesthesia, Setup, State, Hospitals, Khartoum.


Article Information


Identifiers and Pagination:

Year: 2019
Volume: 12
First Page: 294
Last Page: 299
Publisher Id: TOPHJ-12-294
DOI: 10.2174/1874944501912010294

Article History:

Received Date: 12/02/2019
Revision Received Date: 21/05/2019
Acceptance Date: 14/06/2019
Electronic publication date: 30/06/2019
Collection year: 2019

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© 2019 Ahmed et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Hamad General Hospital, Hamad Medical Corporation, PO Box 11340, Doha, Qatar; Tel: +97450586481; Email: sohelm@yahoo.com





1. INTRODUCTION

In 2015, the WHO estimated that over 303,000 women died of complications in childbirth [1 Global health Observatory (GHO) Data, WHO [online] accessed 29th July 2016 http://www.who.int/gho/maternal_health/mortality/maternal/en/]. The maternal mortality rate in Sudan in the same year was calculated to be 311 per 100,000 live births, ranking it the 40th worst place globally [1 Global health Observatory (GHO) Data, WHO [online] accessed 29th July 2016 http://www.who.int/gho/maternal_health/mortality/maternal/en/]. Ninety-nine percent of maternal deaths occurs in resource-poor countries [2WHO. (2010) Trends in Maternal Mortality: 1990 to 2008. Geneva: World Health Organization [online]. Accessed 29th July 2016 https://apps.who.int/iris/bitstream/handle/10665/44423/9789241500265_eng.pdf] where access to family planning, antenatal care and emergency obstetric services is limited.

In many developing countries, especially sub-Saharan Africa, there is a critical shortage of healthcare providers and minimal resources [3WHO. https://www.who.int/whr/2006/en/ Working together for health. The World Health Report 2006 [online] accessed on 29th July 2016]. Sudan is no exception. Decades of “brain drain”, insecurity and the economic toll of long-term conflicts impacted negatively the country’s development in general and healthcare, in particular [4Isam Mohammed Abdel-Maged. Isam Mohammed Abdel-Maged, Brain drain in the Sudan: pros and cons [Online]. accessed 31 December 2016. https://www.researchgate.net/publication/287196399].

Anaesthesia services have not been immune to these factors. Nationally, there are too few physician anaesthetists. At the time of this survey, the number of consultant anaesthetists registered with the Sudan Medical Council (SMC) was 378, not all of these are currently practising in Sudan, and some of them passed away in recent years [5Personal communication with Sudan Medical council (SMC). ]. This led to frequent delivery of anaesthesia by non-physicians (technicians and assistants). Anaesthetic technicians are high school graduates who proceed to receive four years of training in college. Anaesthetic assistants, on the other hand, are nurses who receive further two years training in anaesthesia. Throughout Sub-Saharan Africa, anaesthesia services are deemed by many, including senior healthcare management, as a low priority specialty and often lacks the voice to demand additional resources [6Bharati Sachidanand Jee, Chowdhury Tumul, Gupta Nishkarsh, et al. Nigerian Medical Journal. Anaesthesia in underdeveloped world: Present scenario and future challenges. 2014 Jan-Feb; 55(1): 1-8].

To our knowledge, there has been no survey, to date, that quantifies and describes challenges faced by anaesthetists delivering obstetric services in Khartoum State. We believe this is an essential step in planning comprehensive and optimum service delivery, and in effective utilisation of current resources, in addition to adopting a training curriculum which matches the needs and is based on local settings.

2. METHODOLOGY

The study was a cross-sectional survey conducted in Khartoum State from the first until the fourteenth of May 2016. All public hospitals providing obstetric anaesthesia in Khartoum State were included in the survey. The list of the hospitals was provided by the Khartoum State Ministery of Health. We developed a survey tool based on WFSA safe standards and the WHO Safety Checklist [16American Society of Anaesthesiologists (ASA). https://www. asahq. org/ about- asa/ newsroom/ news- releases/ 2009/03/asa-supports-ihi-sprint-action-day-for-who-surgical-safety-checklist Retrieved on 10th February 2016. , 7Merry AF, Cooper JB, Soyannwo O, Wilson IH, Eichhorn JH. International Standards for a Safe Practice of Anesthesia 2010. Can J Anaesth 2010; 57(11): 1027-34.
[http://dx.doi.org/10.1007/s12630-010-9381-6] [PMID: 20857254]
]. We also assessed other parameters, such as the number and experience of service providers, equipment availability and medications. Data was collected in a pre-set questionnaire filled by anaesthesia head department in each enrolled hospital (Annex A). All the questionnaires were filled and returned (response rate 100%). The data was entered into an Excel sheet and analysed by one of the investigators (TSM). As this survey was non-interventional and did not include human subjects, the need for ethical approval was waived away by the Ethics and Research Committee of the State Ministry of Health, Khartoum State.

3. RESULTS

There are nineteen public state hospitals which currently deliver obstetric services. Their names and locations were provided by the State Ministry of Health (Table 1). Hospitals affiliated to armed forces (police, military, internal security forces) and privately-owned hospitals were not included in this study, as they enjoy different set of governing systems, financial revenues, set-up and staffing levels. We could not establish how many deliveries occur in these facilities.

There was a huge variation in the capacity of the studied hospitals. Three of the hospitals (TRK, OMH and SAU,all being stand-alone obstetric hospitals) accounted for 66.3% of all in-hospital deliveries. Some units were much smaller with less than 1000 deliveries per annum. One particular hospital (JBT) had only 40 births in 2015. The majority of the obstetric units had a delivery rate between 2000 and 4000 (Table1)

The number of senior physicians available varied significantly cross these units so did the availability of junior doctors and non-physician staff (Table 1). While all the hospitals had one or more consultant obstetricians among its staff, five of these hospitals had no consultant anaesthetists affiliated to them, head departments in these institutions were either anaesthetic technicians or assistants or had none. There was also considerable variation in the ratio of consultant physicians to deliveries, indicating that human resources were probably not uniformly distributed throughout the state. Only six of these hospitals were allocated anaesthetic trainees.

Availability of anaesthetic equipment was uniformly deficient throughout the different hospitals. While almost all the hospitals had an anaesthetic machine per room, the obstetric hospital with the highest case load (OMH) reported that none of their 12 machines was fit for purpose. The caesarean section rate in OMH is around 30% [8Carlson VM, Omer MI, Ibrahim SA, et al. Fifty years of Sudanese hospital-based obstetric outcomes and an international partnership. BJOG 2011; 118(13): 1608-16.
[http://dx.doi.org/10.1111/j.1471-0528.2011.03092.x] [PMID: 2191 7111]
]. Accordingly, there are more than 10,000 caesarean deliveries per annum without adequate anaesthesia resources. Six of the hospitals had no ventilators, indicating that lung ventilation was carried out via manual bagging. Fifty-two out of the fifty-eight operating rooms (ORs) designated for obstetric surgeries had one or more pulse oximeters. 12 of the 19 hospitals had a ready access to a defibrillator. Five of the investigated hospitals had no facilities to ensure ECG monitoring intraoperatively, while another three reported the occasional presence of same.

Only three anaesthetic departments were equipped with a difficult airway setup; however, 6 of the other departments did not have necessary airway adjuncts, such as bougies and stylets. Suction apparatus was available in all ORs albeit on-demand basis in some of them.

The setup for neuraxial anaesthesia seemed to be better established. All the anaesthetic departments studied had access to spinal needles. Four hospitals, however, reported using size 23G and larger size needles. These needles are associated with higher incidences of post-dural puncture headaches (PDPH), and their routine use is discouraged [9Reynolds F. Dural puncture and headache. BMJ 1993; 306(6882): 874-6.
[http://dx.doi.org/10.1136/bmj.306.6882.874] [PMID: 8490408]
]. Both lignocaine and bupivacaine were observed to be equally available. However, ephedrine was the main vasoconstrictor used, as phenylephrine has not been licensed in Sudan [10National Medical Supplies Fund. http://nmsf.gov.sd/prices/medicines Accessed 13 February 2017].

Table 1
Distribution of health care staff and equipment in the surveyed hospitals.


Most anaesthetic departments had emergency medications available. Only three, however, believed that access to blood and blood products was consistent and reliable. WHO regional analysis of maternal mortality in Africa identified haemorrhage, along with hypertensive disorders, sepsis, and pulmonary embolism as the predominant ailments [11Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet 2006; 367(9516): 1066-74.
[http://dx.doi.org/10.1016/S0140-6736(06)68397-9] [PMID: 1658 1405]
].

None of the hospitals investigated had an incubator to transfer neonates in place, only two had a Post-Anesthetic Care Unit (PACU), and six had an Intensive Care Unit (ICU) within the premises.

4. DISCUSSION

To our knowledge, this is the first survey that analysed obstetric anaesthesia services in Khartoum state. The reason we only included Khartoum state in this study was that it is the most populated state in Sudan. The population census conducted in 2008 showed that over 5 million inhabited the capital [12Central Bureau of Statistics (Sudan). 5th Sudan population and housing census - 2008 - Priority results, 26 April 2009 [online]. Accessed 8th February 2017], many believe that this number has doubled in recent years [13World Population Review. http://world-population-review. com/ countries/ sudan- population Accessed on 8th February 2017, 14World Health Organization (WHO). Working together for health. The World Health Report 2006. [Online]. //http://www. Who. International /Whr //en Accessed on 01/02/2017].

In 2010, the World Federation of Societies of Anaesthesiologists (WFSA) described a list of essential equipment and drugs requirements for delivery of safe anaesthesia [7Merry AF, Cooper JB, Soyannwo O, Wilson IH, Eichhorn JH. International Standards for a Safe Practice of Anesthesia 2010. Can J Anaesth 2010; 57(11): 1027-34.
[http://dx.doi.org/10.1007/s12630-010-9381-6] [PMID: 20857254]
]. Recommendations specific to the delivery of safe obstetric anaesthesia was endorsed by the Anaesthetists Association of Great Britain and Ireland (AAGBI) [15Association of Anaesthetists of Great Britain and Ireland (AAGBI) Online.. http://www.aagbi.org/sites/default/files/obstetric_anaesthetic_services_2013.pdf Retrieved on 10th February 2016] and the American Society of Anesthesiologists (ASA) [16American Society of Anaesthesiologists (ASA). https://www. asahq. org/ about- asa/ newsroom/ news- releases/ 2009/03/asa-supports-ihi-sprint-action-day-for-who-surgical-safety-checklist Retrieved on 10th February 2016. ]. In 2018, the WHO and WFSA published an updated version regarding the safe practice of anesthesia [17Adrian W. Gelb, MBChB, FRCPC • Wayne W. Morriss, MBChB, FANZCA • Walter Johnson, MD. World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia. Canadian Journal of Anesthesiology 2018; 65(6): 698-708.
[http://dx.doi.org/10.1007/s12630-018-1111-5]
].

For caesarean section, the most common obstetric surgery, the requirement was to be able to safely provide adult general anaesthesia and spinal anaesthesia, and to have access to blood transfusion and drugs for the treatment of common obstetric problems such as haemorrhage, pre-eclampsia and eclampsia [18Anonymous . International standards for a safe practice of anaesthesia. Eur J Anaesthesiol 1993; 10: 12-5.].

Effective obstetric anaesthesia services are closely related to maternal well-being and pregnancy outcomes. In setting its safety standards, the WFSA recommends that facilities providing caesarean sections, have to be able to provide adult general anaesthesia and spinal anaesthesia safely and should provide access to blood transfusion and drugs for the treatment of common obstetric problems such as haemorrhage, pre-eclampsia and eclampsia [3WHO. https://www.who.int/whr/2006/en/ Working together for health. The World Health Report 2006 [online] accessed on 29th July 2016, 7Merry AF, Cooper JB, Soyannwo O, Wilson IH, Eichhorn JH. International Standards for a Safe Practice of Anesthesia 2010. Can J Anaesth 2010; 57(11): 1027-34.
[http://dx.doi.org/10.1007/s12630-010-9381-6] [PMID: 20857254]
, 18Anonymous . International standards for a safe practice of anaesthesia. Eur J Anaesthesiol 1993; 10: 12-5.].

Women fertility in Sudan is estimated by the World Bank to be around 4.4 per woman [19World Bank. http://data.worldbank.org/indicator/SP.DYN.TFRT.IN Accessed on 25/01/2017.]; this, in addition to the exponentially growing urban population resulting from rural to city migration, puts a burden on an already overextended service. When it comes to deliveries, only 18% of births in Sudan are delivered in a healthcare facility, and only 13.2% are delivered in a public hospital [20World Health Organization. 2017. Sudan: Country Profile. Geneva: Department of Making Pregnancy Safer, 2011. Online. www.who.int/making_ pregnancy_safer/countries/sud.pdf Accessed on 25/01/2017].

Human resources are the backbone of any service. In this study, anaesthetic, and human resources are both insufficient and ill-distributed (Table 1). Currently, a significant portion of obstetric anaesthetic services is delivered by anaesthetic assistants (nurses with 2-year training in anaesthesia) and the newly introduced anaesthetic technicians. This is deemed by many as an unsafe practice; national anaesthetic and perioperative organisations recommend that they are “to be supervised at all times” [21Royal College of Anaesthetists (UK). Joint statement from the RCoA and AAGBI on the Scope of Practice of Physicians’ Assistants (Anaesthesia). 18 April 2016, 22Medical Sciences Council of New Zealand. Guideline for the professional relationship between anaesthesia technicians and anaesthetist. August 2014]. The presence of a trained anaesthesiologist is a cornerstone in patient safety. Anaesthetic technicians’ job plan and scope of responsibilities remain to be clearly defined by the Ministry of Health in Sudan [10National Medical Supplies Fund. http://nmsf.gov.sd/prices/medicines Accessed 13 February 2017]. Clear obligatory regulations should be released by the health authorities to limit the unsupervised practice of anaesthetic assistants in locations privileged by physician-anaesthetist-based service

Sudan has preserved the model of stand-alone obstetric hospital it inherited from colonial Great Britain and is found nationwide. Safety and efficiency of such a model have undergone immense criticism with more countries moving away from it [23Ministry of Health. Review of the quality, Safety and Management of Maternal services in the Wellington Area. [Online] https://www.health.govt.nz/system/files/documents/publications/maternity-services-review-oct08-v2.pdf-25Oireachtas Committee on Health and Children. 2017. Republic of Ireland. https://www.oireachtas.ie/parliament/media/committees/healthandchildren/health2015/Opening-Statement-by-Dr.-Sam-Coulter-Smith,-Master,-Rotunda-Hospital.pdf [Online]. Accessed on 27/01/2017].

Another point worth mentioning is that some health facilities had a limited number of deliveries per annum (Table 1), with one as low as 40 deliveries in total in 2015. A recent study in East Africa concluded that Hospitals with less than 1000 deliveries per year are a significant concern, as the caseloads are too low to enable the acquisition or maintenance of skills for safe operative services [26Hodges SC, Mijumbi C, Okello M, McCormick BA, Walker IA, Wilson IH. Anaesthesia services in developing countries: defining the problems. Anaesthesia 2007; 62(1): 4-11.
[http://dx.doi.org/10.1111/j.1365-2044.2006.04907.x] [PMID: 1715 6220]
]. Small volume centres are associated with worse outcomes, and we believe that the redirection of services towards high volume centres would be more resource efficient and safer practise. It has to be taken into consideration, however, that Khartoum State extends over an area of more than twenty-two thousand kilometers square. Infrastructure such as paved roads and rail service is poorly developed, with some regions partially accessible during the rainy season. For these, the presence of healthcare units in their area is of paramount importance.

Huge safety leaps in anaesthesia were only witnessed in the second half of the twentieth century and the beginning of the twenty-first. This was promoted primarily via advances in technology, such as anaesthetic delivery systems, monitoring devices and medications. Most hospitals in this study have shown critical shortages in all above mentioned domains of health care. No anaesthetic should be delivered without a fully functioning anaesthetic machine. The practise of manual bagging an anaesthetised patient is hazardous and -in the combined absence of capnography - may lead to detrimental effects secondary to hypercarbia, hypocarbia and possible barotrauma. Inadequate setup and improper application of safety measurements when utilizing regional anaesthesia, such as hand hygiene and aseptic techniques in neuraxial blocks, may have severe sequelae. Perioperative support systems, e.g. neonatal ICU backup, is a necessity if best outcomes are sought.

CONCLUSION

Obstetric anaesthesia services in Khartoum are inadequate and are unable to deliver safe service to a large portion of pregnant ladies. Substandard care remains a leading avoidable factor in many maternal deaths, particularly those due to anaesthesia, the majority of which are associated with a lack of skills in basic anaesthesia and resuscitation [27Thompson JP, Mahajan RP. Monitoring the monitors--beyond risk management. Br J Anaesth 2006; 97(1): 1-3.
[http://dx.doi.org/10.1093/bja/ael139] [PMID: 16769701]
]. An urgent national review by bodies responsible for health services in the country is warranted. As Hodges and Mujambi of Uganda nicely summarised in their article “ (studies) are the first step to quantifying and describing the problems faced by anaesthetists in developing countries, and one that can be used by national anaesthesia societies and governments in developing countries to improve management and planning of anaesthesia services, target education and enable limited resources to be used effectively” [26Hodges SC, Mijumbi C, Okello M, McCormick BA, Walker IA, Wilson IH. Anaesthesia services in developing countries: defining the problems. Anaesthesia 2007; 62(1): 4-11.
[http://dx.doi.org/10.1111/j.1365-2044.2006.04907.x] [PMID: 1715 6220]
]. Professional bodies, such as the Sudan Society of Anaesthesiologists, need to make their voices heard. Minimum standards on safe service delivery need to be agreed upon and audited regularly. This cannot and should not wait. This should happen now.

AUTHORS’ CONTRIBUTIONS

  • SMGA helped to design the study, conduct the study and write the manuscript, seen the original study data, reviewed the analysis of the data, approved the final manuscript
  • AMA helped to design the study, conduct the study and write the manuscript, collected the original study data, reviewed the analysis of the data and approved the final manuscript.
  • TSM helped to design the study, conduct the study and write the manuscript, collected the original study data, reviewed the analysis of the data, approved the final manuscript and is the author responsible for archiving the study files.
  • MSMH helped to design the study, conduct the study and write the manuscript, has seen the original study data, reviewed the analysis of the data, approved the final manuscript.
  • HOE helped to design the study, conduct the study and write the manuscript, seen the original study data, reviewed the analysis of the data, approved the final manuscript.
  • SFMH helped to design the study, conduct the study and write the manuscript, collected the original study data, reviewed the analysis of the data and approved the final manuscript.
  • DOA helped to design the study, conduct the study and write the manuscript, seen the original study data, reviewed the analysis of the data, approved the final manuscript.
  • AE helped to design the study, conduct the study and write the manuscript, collected the original study data, reviewed the analysis of the data and approved the final manuscript.
  • AMAAA helped to design the study, conduct the study and write the manuscript, collected the original study data, reviewed the analysis of the data and approved the final manuscript.
  • AFE helped to design the study, conduct the study and write the manuscript, has seen the original study data, reviewed the analysis of the data, approved the final manuscript.
  • AFE helped to design the study, conduct the study and write the manuscript, collected the original study data, reviewed the analysis of the data and approved the final manuscript.
  • HAM helped to design the study, conduct the study and write the manuscript, collected the original study data, reviewed the analysis of the data and approved the final manuscript.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

As this survey was non-interventional and did not include human subjects, the need for ethical approval was waived away by the Ethics and Research Committee of the State Ministry of Health, Khartoum State.

HUMAN AND ANIMAL RIGHTS

No animals/ humans were used in the study that is basis of this research.

CONSENT FOR PUBLICATION

Not applicable.

AVAILABILITY OF DATA AND MATERIALS

The data supporting the findings of the article is available in a secured file password protected in the main investigator's computer.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

ANNEX (A) HOSPITAL DATA COLLECTION SHEET

  1. Name of hospital ……………………….
  2. Number of operating theatres in hospital …………………………………………..
  3. Number of operating rooms delivering obstetric services ……………………………………
  4. Number of consultant obstetricians affiliated to the hospital ……………………………….
  5. Number of consultant anaesthetists affiliated to the hospital………………………………………
  6. Number of anaesthetic registrars ………………….
  7. Number of anaesthetic technicians ………………..
  8. Number of anaesthetic assistants ………………….
  9. Number of maternal deliveries in 2015 ……………
  10. Number of beds in labour ward ……………
Are the following equipment and monitors available in your institution for obstetric surgeries around the clock?


REFERENCES

[1] Global health Observatory (GHO) Data, WHO [online] accessed 29th July 2016 http://www.who.int/gho/maternal_health/mortality/maternal/en/
[2] WHO. (2010) Trends in Maternal Mortality: 1990 to 2008. Geneva: World Health Organization [online]. Accessed 29th July 2016 https://apps.who.int/iris/bitstream/handle/10665/44423/9789241500265_eng.pdf
[3] WHO. https://www.who.int/whr/2006/en/ Working together for health. The World Health Report 2006 [online] accessed on 29th July 2016
[4] Isam Mohammed Abdel-Maged. Isam Mohammed Abdel-Maged, Brain drain in the Sudan: pros and cons [Online]. accessed 31 December 2016. https://www.researchgate.net/publication/287196399
[5] Personal communication with Sudan Medical council (SMC).
[6] Bharati Sachidanand Jee, Chowdhury Tumul, Gupta Nishkarsh, et al. Nigerian Medical Journal. Anaesthesia in underdeveloped world: Present scenario and future challenges. 2014 Jan-Feb; 55(1): 1-8
[7] Merry AF, Cooper JB, Soyannwo O, Wilson IH, Eichhorn JH. International Standards for a Safe Practice of Anesthesia 2010. Can J Anaesth 2010; 57(11): 1027-34.
[http://dx.doi.org/10.1007/s12630-010-9381-6] [PMID: 20857254]
[8] Carlson VM, Omer MI, Ibrahim SA, et al. Fifty years of Sudanese hospital-based obstetric outcomes and an international partnership. BJOG 2011; 118(13): 1608-16.
[http://dx.doi.org/10.1111/j.1471-0528.2011.03092.x] [PMID: 2191 7111]
[9] Reynolds F. Dural puncture and headache. BMJ 1993; 306(6882): 874-6.
[http://dx.doi.org/10.1136/bmj.306.6882.874] [PMID: 8490408]
[10] National Medical Supplies Fund. http://nmsf.gov.sd/prices/medicines Accessed 13 February 2017
[11] Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet 2006; 367(9516): 1066-74.
[http://dx.doi.org/10.1016/S0140-6736(06)68397-9] [PMID: 1658 1405]
[12] Central Bureau of Statistics (Sudan). 5th Sudan population and housing census - 2008 - Priority results, 26 April 2009 [online]. Accessed 8th February 2017
[13] World Population Review. http://world-population-review. com/ countries/ sudan- population Accessed on 8th February 2017
[14] World Health Organization (WHO). Working together for health. The World Health Report 2006. [Online]. //http://www. Who. International /Whr //en Accessed on 01/02/2017
[15] Association of Anaesthetists of Great Britain and Ireland (AAGBI) Online.. http://www.aagbi.org/sites/default/files/obstetric_anaesthetic_services_2013.pdf Retrieved on 10th February 2016
[16] American Society of Anaesthesiologists (ASA). https://www. asahq. org/ about- asa/ newsroom/ news- releases/ 2009/03/asa-supports-ihi-sprint-action-day-for-who-surgical-safety-checklist Retrieved on 10th February 2016.
[17] Adrian W. Gelb, MBChB, FRCPC • Wayne W. Morriss, MBChB, FANZCA • Walter Johnson, MD. World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia. Canadian Journal of Anesthesiology 2018; 65(6): 698-708.
[http://dx.doi.org/10.1007/s12630-018-1111-5]
[18] Anonymous . International standards for a safe practice of anaesthesia. Eur J Anaesthesiol 1993; 10: 12-5.
[19] World Bank. http://data.worldbank.org/indicator/SP.DYN.TFRT.IN Accessed on 25/01/2017.
[20] World Health Organization. 2017. Sudan: Country Profile. Geneva: Department of Making Pregnancy Safer, 2011. Online. www.who.int/making_ pregnancy_safer/countries/sud.pdf Accessed on 25/01/2017
[21] Royal College of Anaesthetists (UK). Joint statement from the RCoA and AAGBI on the Scope of Practice of Physicians’ Assistants (Anaesthesia). 18 April 2016
[22] Medical Sciences Council of New Zealand. Guideline for the professional relationship between anaesthesia technicians and anaesthetist. August 2014
[23] Ministry of Health. Review of the quality, Safety and Management of Maternal services in the Wellington Area. [Online] https://www.health.govt.nz/system/files/documents/publications/maternity-services-review-oct08-v2.pdf
[24] National Health Services (NHS) UK. 2017. . Better Births, Improving Outcomes of Maternity Services in England. [Online]. https://www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity-review-report.pdf Accessed on 27/01/2017
[25] Oireachtas Committee on Health and Children. 2017. Republic of Ireland. https://www.oireachtas.ie/parliament/media/committees/healthandchildren/health2015/Opening-Statement-by-Dr.-Sam-Coulter-Smith,-Master,-Rotunda-Hospital.pdf [Online]. Accessed on 27/01/2017
[26] Hodges SC, Mijumbi C, Okello M, McCormick BA, Walker IA, Wilson IH. Anaesthesia services in developing countries: defining the problems. Anaesthesia 2007; 62(1): 4-11.
[http://dx.doi.org/10.1111/j.1365-2044.2006.04907.x] [PMID: 1715 6220]
[27] Thompson JP, Mahajan RP. Monitoring the monitors--beyond risk management. Br J Anaesth 2006; 97(1): 1-3.
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Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


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