The figures presented are as accurate a representation of major surgical activity in government institutions in Malawi as we were able to measure. It is recognised that there are significant limitations in the methodology, as operations not recorded in the theatre log are not measured. Minor and intermediate procedures carried out in out-patient and other departments were thus not measured. It is estimated that up to 40% of medical and surgical activity in Malawi occurs in mission hospitals and other non-governmental private facilities. Figures were not obtained from these institutions.
The single most common operation was caesarean section with a total of 9679 cases. The Malawi National Statistics Office5
estimates that there were 578,000 births in 2003. If we assume that 40% of these births take place at or under the care of mission and private institutions that leaves 346,800 births in the population covered by our survey, and a caesarean section rate of 2.8% of births. This is considerably lower than the caesarean rate in the UK which in 2003 was 22%.6
It is highly likely that many women who need caesarean section have to deliver vaginally and are a risk of complications such as vesicovaginal fistula. Malawi's high rate of maternal mortality (1100 maternal deaths per 100,000 live births) and infant mortality (110 deaths in the first year of life per 1000 live births) are also likely to be related to the low caesarean section rate.7
The first author has seen many cases of cerebral palsy in his orthopaedic practice in Malawi. The prevalence of this condition is not known, but a significant proportion of these may have been avoidable if caesarean section was more readily accessible.
At the time of performing this study, we were not aware of any other national surveys of surgical activity; however, since the study was performed, we have been alerted to a similar survey carried out by Fenton between 1993 and 1995, and published in a non-indexed journal.8
He reports on surgical activity in 18 district and mission hospitals which he estimated to cover a population of 6,100,000. He also found caesarean section to be the commonest major operation performed, with records of 7288 cases over his 2-year study period. There are no published figures on the number of births in his population over his study period; however, if an estimate of 250,000 births per year is made, then the caesarean section rate in his population is 1.5% which is just over half the rate we found 10 years later.
The second commonest procedure we recorded was dilatation and curettage with 8522 cases. Our survey does not give any indication as to why these were performed; however, in a country where abortion is illegal, it is certainly possible that a proportion of these were performed to terminate pregnancy. These two obstetric and gynaecological procedures, namely caesarean section and dilatation and curettage, comprise 37% of all operations.
Laparotomy and hernia repair comprise the two commonest general surgical procedures and these are mainly carried out in the four central hospitals. It is interesting that in 21 district hospitals equipped with theatres only 618 laparotomies are carried out in a year. This is compared to 3444 in the 4 central hospitals. One has to question why more laparotomies are not done in district hospitals. This study did not set out to answer this question but, on talking to several clinical officers in districts, most of them are happy to perform a caesarean section as they feel confident that they have the technical competence to deal with whatever pathology they may find, while few of them feel confident to open an acute abdomen for fear of encountering a condition that is beyond their level of competence. They thus refer acute abdominal cases to central hospitals. This study did not look at referral and transport delays but it is likely that both of these are major factors and cause considerable increase in morbidity and mortality in patients with acute abdominal pathology.9
It is curious that the common and simple orthopaedic procedure of Steinmann pin insertion appears to be more often done in central hospitals. This is usually associated with the management of femoral fractures and is easily performed in a district hospital. It is possible that most pin insertions in districts are done on the ward or in the emergency room on admission, and thus not recorded in this study.
More complicated procedures like burr holes are only done in central hospitals. The same goes for the more technical elective procedures such as club foot surgery, corrective osteotomies, and osteomyelitis surgery. It should be noted here that the last 5 years have seen the establishment of postgraduate surgical training in Malawi in both general and orthopaedic surgery. More technical procedures such as arthroscopy, joint replacement and spinal surgery are now being performed;10
however, the volumes are low and do not yet impact national statistics.