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Perioperative mortality rates in low-income and middle-income countries: a systematic review and meta-analysis
  1. Joshua S Ng-Kamstra1,2,3,
  2. Sumedha Arya4,
  3. Sarah L M Greenberg2,3,5,
  4. Meera Kotagal2,3,6,
  5. Catherine Arsenault7,
  6. David Ljungman2,3,8,
  7. Rachel R Yorlets3,
  8. Arnav Agarwal9,
  9. Claudia Frankfurter9,
  10. Anton Nikouline10,
  11. Francis Yi Xing Lai11,
  12. Charlotta L Palmqvist12,
  13. Terence Fu13,
  14. Tahrin Mahmood9,
  15. Sneha Raju1,
  16. Sristi Sharma2,3,14,
  17. Isobel H Marks2,3,15,
  18. Alexis Bowder2,3,16,
  19. Lebei Pi17,
  20. John G Meara2,3,
  21. Mark G Shrime2,18
  1. 1Department of Surgery, University of Toronto, Toronto, Ontario, Canada
  2. 2Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
  3. 3Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
  4. 4Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  5. 5Division of General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Washington, USA
  6. 6Department of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
  7. 7Department of Global Health and Population, Harvard T.H. Chan school of Public Health, Boston, Massachusetts, USA
  8. 8Department of Surgery, Sahlgrenska Academy, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
  9. 9Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  10. 10Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
  11. 11Skin and Cancer Foundation, Melbourne, Victoria, Australia
  12. 12Faculty of Medicine, Lund University, Lund, Sweden
  13. 13Department of Otolaryngology, University of Toronto, Toronto, Ontario, Canada
  14. 14Department of Surgery, University of Colorado, Denver, Colorado, USA
  15. 15Imperial College London, London, UK
  16. 16Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
  17. 17Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
  18. 18Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
  1. Correspondence to Dr Joshua S Ng-Kamstra;{at}


Introduction The Lancet Commission on Global Surgery proposed the perioperative mortality rate (POMR) as one of the six key indicators of the strength of a country’s surgical system. Despite its widespread use in high-income settings, few studies have described procedure-specific POMR across low-income and middle-income countries (LMICs). We aimed to estimate POMR across a wide range of surgical procedures in LMICs. We also describe how POMR is defined and reported in the LMIC literature to provide recommendations for future monitoring in resource-constrained settings.

Methods We did a systematic review of studies from LMICs published from 2009 to 2014 reporting POMR for any surgical procedure. We extracted select variables in duplicate from each included study and pooled estimates of POMR by type of procedure using random-effects meta-analysis of proportions and the Freeman-Tukey double arcsine transformation to stabilise variances.

Results We included 985 studies conducted across 83 LMICs, covering 191 types of surgical procedures performed on 1 020 869 patients. Pooled POMR ranged from less than 0.1% for appendectomy, cholecystectomy and caesarean delivery to 20%–27% for typhoid intestinal perforation, intracranial haemorrhage and operative head injury. We found no consistent associations between procedure-specific POMR and Human Development Index (HDI) or income-group apart from emergency peripartum hysterectomy POMR, which appeared higher in low-income countries. Inpatient mortality was the most commonly used definition, though only 46.2% of studies explicitly defined the time frame during which deaths accrued.

Conclusions Efforts to improve access to surgical care in LMICs should be accompanied by investment in improving the quality and safety of care. To improve the usefulness of POMR as a safety benchmark, standard reporting items should be included with any POMR estimate. Choosing a basket of procedures for which POMR is tracked may offer institutions and countries the standardisation required to meaningfully compare surgical outcomes across contexts and improve population health outcomes.

  • perioperative mortality
  • surgical outcomes
  • global surgery
  • systematic review

This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

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  • Handling editor Seye Abimbola

  • Contributors JNK, SLMG, MK and JGM conceived the study. JNK wrote the study protocol, reconciled duplicate data and ensured overall consistency in data extraction and drafted the manuscript. JNK, SLMG and MK developed the search strategy, completed searches and screened titles and abstracts. JNK, SA, AA, CF, AN, FYXL, CLP, TF, TM, SR, SS, IHM, AB and LP extracted data. JNK, CA, DL, RRY and MGS analysed the data. JNK, CA and RRY developed the figures and tables. All authors critically reviewed the manuscript and approve of its content.

  • Funding This study was funded in part by Boston Children’s Hospital.

  • Competing interests MS holds grant funding from the GE Foundation and the Damon Runyon Cancer Research Foundation, which had no bearing on this work.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement We include primary data alongside the manuscript as supplementary material. Additional data are available upon request; please contact the corresponding author.

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