Abstract
Many low- and middle-income countries (LMICs) report low rates of regional anesthesia (RA) use for cesarean delivery (CD), despite its association with lower maternal major morbidity and mortality. Also, the prevalence of neuraxial analgesia for labor (NAL) is often low in LMICs. We report on the results of a collaboration in clinical education over a multi-year period between Kybele Inc., an international non-profit organization, and Klinicki Centar Vojvodine (CCV), a teaching hospital in Novi Sad, Serbia, to increase RA use for CD and NAL at CCV. From late 2011 through 2015, teams from Kybele participated in annual to biannual didactic conferences and week-long bedside teaching efforts involving obstetric and anesthesia staff from CCV and surrounding hospitals. Ongoing contact occurred at least weekly between Kybele and the host to discuss progress. De-identified quality improvement data on total deliveries, numbers of elective and non-elective CDs, number of vaginal deliveries, type of anesthesia for CD, and the number of NALs were collected. RA use for CD increased to 25% in year 2015 versus 14% in base year 2011 [odds ratio (OR): 2.05; 95% confidence interval (CI): 1.73,2.42; p < 0.001]. NAL increased to 10.5% of laboring women in 2015 versus 1.2% in 2011 (OR: 9.6; 95% CI: 7.2, 12.8; p < 0.001). Greater increases for RA use during non-elective CD were observed between 2011 and 2015 (1.4 versus 7.5% of total CD; OR: 5.52; 95% CI: 2.63, 8.41; p < 0.001) relative to elective CD (12.5 versus 17.5% of total CD; OR: 1.48; 95% CI: 1.23, 1.77; p < 0.001). Overall, RA for CD increased during the 4 year collaboration but was not as great as reported in other countries with similar health-care demographics utilizing a similar program. Detailed descriptions of program interventions and barriers to change at CCV are presented.
Highlights
The use of regional anesthesia (RA) for cesarean delivery (CD) has become widespread in countries in the USA and in Western Europe [1, 2]
In 2012 and 2013, the relative odds of RA use were greater by 18% and 39%, respectively
RA for CD increased from 12.5% of total CD in 2011 to 17.5% in 2015 (OR: 1.48; 95% confidence interval (CI): 1.23, 1.77; p < 0.001)
Summary
The use of regional anesthesia (RA) for cesarean delivery (CD) has become widespread in countries in the USA and in Western Europe [1, 2]. RA is associated with a lower maternal mortality risk compared to general anesthesia (GA) in both high and lowand middle-income countries (LMICs) [3,4,5,6,7] Despite this recognition, many Eastern European countries report much lower rates of RA use for CD and neuraxial analgesia for labor (NAL) [8, 9]. One report from Georgia cited lack of governmental funding for supplies, lack of familiarity of anesthesia staff with current techniques and evidence-based guidelines, and limited availability of appropriate local anesthetics as possible reasons [10] Another survey of RA use from the Czech Republic cited patient fear over the safety of RA and lack of acceptance by obstetric providers [9], similar to a report of an ongoing collaboration in China between Chinese and American anesthesia providers [11]. We describe our interventions to increase RA use and the barriers to practice change that we encountered
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