The infrastructural needs for surgical care and safe anesthesia have been surveyed and categorized as essential since early in the advocacy efforts for safe surgery within the global health agenda. Essential to surgical systems, infrastructure includes everything from the bricks and mortar of operating rooms, to scalpels and cautery, and anesthesia machines and monitoring devices. Additionally, the infrastructure must be accessible to the population in need. For essential surgery, which is considered basic surgery without a high degree of specialization, the ideal access cadence is within 2 hours. The “Essential Surgery” section of the World Bank Disease Control Priorities , 3rd edition (DCP3), recommends that 44 cost-effective surgical procedures should be accessible within 2 hours of seeking care, including cesarean delivery, dilation and curettage, and surgical treatment for hemorrhage. Beyond the infrastructure to provide surgery, it is essential to have the ability to monitor high-risk mothers to improve decision-making about when to intervene with surgical delivery. Additionally, oxygen and blood product availability must be considered.

Many LMICs have too few practicing physicians to serve the populations in need. The availability of cesarean delivery in LMICs is an essential feature of obstetric care, but availability is often limited by lack of anesthesia and obstetric or surgical providers. Many factors contribute to physician shortages, including poor access to medical education and residency training, and the exodus of LMIC physicians to higher-income countries (HICs), so-called brain drain. Specialty trained physicians are limited in most LMICs, and this is especially true for anesthesiologists in the lowest-income countries. The shortage of anesthesiologists and nonphysician anesthesia providers (NPAPs) has impacted surgical and obstetric care in many LMICs, but most notably in sub-Saharan Africa, where the crisis in anesthesia provision is most significant and the burden of surgical disease is the greatest ( Table 15.2 ).

Until recently, little was known about the numbers of practicing anesthesiologists and NPAPs in LMICs, apart from reports by anesthesia and surgical missionaries noting that limitations in anesthesia care negatively impacted safety during surgery. Documentation of the number of anesthesia and surgical providers in LMICs began by a small group of interested researchers, and this eventually became a priority for the World Federation of Societies of Anesthesiologists (WFSA) and the WHO. Nicholas M. Greene advocated for training of NPAPs in sub-Saharan Africa after working in the harsh conditions of East Africa in the 1980s, where surgical access and safety were limited by the few trained anesthesia providers. Dr. Greene lobbied the American Society of Anesthesiologists (ASA) for many years before convincing the prestigious society to support the Overseas Teaching Program (OTP), whose initial aim in 1990 was to train nonphysicians to safely conduct anesthesia. The OTP continues today as the ASA Global Humanitarian Outreach Committee, which remains committed to the education and training of anesthesiologists and NPAPs in sub-Saharan Africa.

Anesthesia workforce surveys have been conducted since the late 2000s and are ongoing. The WFSA Global Workforce Survey, the most comprehensive to date, has informed the global community and influenced planning for the education and training of physicians and NPAPs alike ( Table 15.3 and Fig. 15.2 ). The anesthesiology workforce crisis in LMICs was clearly illuminated in 2015 when several important bodies of work were published, namely the DCP3 Essential Surgery volume, the Lancet Commission on Global Surgery (LCOGS), and the World Health Assembly resolution on strengthening emergency and essential surgical care and anesthesia. These reports underscored the anesthesia workforce crisis as the rate-limiting step for surgical access and patient safety and called for a commitment to workforce development to achieve safe anesthesia. It will take decades to train an adequate workforce of anesthesiologists to meet the needs of LMICs, but improving access and patient safety for patients in LMICs is an urgent need.

Fortunately, in many LMICs, there is a commitment to training nonphysician providers, including NPAPs. Both task shifting and task sharing have been successfully applied to maternal and reproductive health in LMICs. Task shifting is the deliberate shifting of a task or tasks that are specifically described and defined. The shift in responsibility frees up more highly trained individuals to provide more complex care. Task sharing involves a team of providers working together to deliver a procedure or service that they may not have delivered previously as individuals. Endorsed by the WHO, these strategies maximize health worker capacity and optimize performance in low-resource settings. Both task shifting and sharing are historically common in LMICs, where fully trained providers are scarce. The shifting or sharing may be an informal process that occurs out of necessity; however, a formal process that involves training, certification, and support offers better and safer options.

The delivery of peripartum care through task shifting is a sustainable option in LMICs. Examples include the shifting of responsibility from an obstetrician to a midwife, or from a midwife to a skilled birth attendant, freeing up the obstetrician or surgeon to provide cesarean delivery when needed. Similarly, anesthesia care delivery by a nurse anesthetist, general physician, or anesthesia technician allows critical surgery to continue in the absence of an anesthesiologist. Both examples are common in many LMICs. Task sharing is less common because of the shortage of anesthesiologists, especially in LMICs, thus limiting the availability of teams functioning together to provide anesthesia care.

Consistent with many operating spaces in LMICs, the labor and delivery areas and operating rooms for cesarean delivery frequently lack safety monitoring equipment, essential medicines, and access to blood products. A cross-sectional survey was conducted among 86 anesthesia providers working in national referral hospitals in five countries in East Africa (Uganda, Kenya, Tanzania, Rwanda, Burundi) to assess the ability to provide safe obstetric anesthesia. None of the respondents worked in a facility that metall the requirements listed in the WFSA guidelines for safe anesthesia care. Although drugs for general and spinal anesthesia were generally present, the availability of safety monitors and airway supplies was limited. Even pulse oximetry and oxygen are not ubiquitous in LMICs. While governments may emphasize the need for basic safety monitoring, it may take years for every operating room and high acuity unit to be suitably equipped, as shown in a separate survey of cesarean delivery infrastructure in 26 LMICs (see Table 15.2 ). International initiatives such as Lifebox ( www.lifebox.org ) are committed to providing durable, inexpensive, portable pulse oximeters with education to LMICs. Importantly, blood banks are also lacking in LMICs. For the care of women with peripartum or postpartum hemorrhage, the lack of access to transfusable blood is often catastrophic.

Consistent access to essential medicines is also a barrier to the anesthesia and obstetric care of women in the peripartum period. Essential medicines for the peripartum period include antibiotics, antihypertensive and antiemetic medications, general and local anesthetic agents, magnesium sulfate, and tocolytic agents. The WHO endorses an updated list of essential medicines every 2 years, but these medicines may not readily be available in every setting, and an absence of any of the essential medicines, including oxygen, can compromise the care of vulnerable patients, including the care of the mother and baby. The WHO Essential Medicine List represents guidance to ministries of health and health systems, but these medications are not mandated. Similarly, there is no international governing body that requires ministries of health or local health systems to invest to ensure the availability of equipment, monitoring capability, basic surgical supplies, blood products, and essential medicines.

The fourth “S” in Farmer’s guidance for successful healthcare delivery is “systems.” The role of the system is often overlooked by many physicians from HICs who are committed to global health. Farmer noted that while space, staff, and stuff are essential for the delivery of healthcare, it is the system—operational processes, referral services, and medical records—that reorients the resources to provide quality medical care. This need to focus on the system was proven true for addressing the HIV/AIDS epidemic; it is also true for the delivery of surgery and safe anesthesia, and especially true when addressing access to cesarean delivery and other life-saving obstetric procedures.

The evaluation of national surgical systems became a priority after the significant reports published in 2015, and the unanimous commitment to emergency and essential surgery at the World Health Assembly. The WHO and the Harvard Medical School Program in Global Surgery and Social Change (PGSSC) partnered to create guidance for a process that would empower countries to perform their own evaluations, followed by the design of processes and systems to address the common barriers to safe surgical, obstetric, and anesthesia care. The National Surgery, Obstetric and Anesthesia Plans (NSOAPs) address infrastructure, workforce, and reusable and disposable resources for the care of surgical and obstetric patients. The healthcare system is central to the ultimate success of the NSOAP process, and implementing the process has the potential to result in significant expansion of surgical, obstetric, and anesthesia care in LMICs (see later discussion).

Anesthesia disproportionately contributes to maternal mortality in LMIC, primarily during cesarean delivery; therefore it is important to understand the attribution to death by the type of anesthetic. In a 2016 systematic review and meta-analysis of 140 studies from LMICs, investigators observed that complications from anesthesia related to cesarean delivery contributed to 13.8% (95% CI, 9.0 to 20.7) of all maternal deaths occurring during or after cesarean delivery. The administration of general anesthesia tripled the odds of maternal death, with case fatality rates of 5.9 per 1000 and 1.2 per 1000 for general and neuraxial anesthesia, respectively. General anesthesia also doubled the risk of perinatal death.

In a subset of studies, contributing factors were reported in 124 maternal deaths: over half of the deaths were attributed to airway complication and/or pulmonary aspiration; nearly one-third were related to staff incompetency, poor preoperative assessment, limited intraoperative monitoring, and equipment failure; and one-tenth were due to high spinal anesthesia or a drug-related event. The risk of death associated with anesthesia was higher in rural than in urban settings, and in low-income and lower-middle income than in upper-middle income countries.

Many of the studies in the 2016 meta-analysis were based in sub-Saharan Africa and may not reflect the full spectrum of anesthetic complications in LMICs. A secondary analysis of two large WHO surveys (data from 2004 to 2005 and 2010 to 2011 ) assessed associations between anesthetic technique and pregnancy outcomes for 129,742 cesarean deliveries in LMICs. For each of the WHO surveys, well-trained research assistants used pretested, standardized data collection forms to obtain data across various LMICs in Africa, Asia, Latin America, and the Middle East. The World Health Organization Global Survey (WHOGS) on Maternal and Perinatal Health included 370 health facilities in 24 countries, and the World Health Organization Multicountry Survey (WHOMCS) on Maternal and Newborn Health included 359 health facilities in 29 countries. In each country, the capital city and two randomly selected provinces were sampled to identify seven facilities with over 1000 annual deliveries and the capacity to perform cesarean delivery. Spinal anesthesia was the most common anesthetic technique in both databases, accounting for 48.9% in the WHOGS and 57.1% in the WHOMCS. Compared with general anesthesia, intended neuraxial anesthesia was associated with lower odds of maternal death, maternal near-miss events, severe maternal outcome, and intensive care unit admission ( Fig. 15.3 ).

In a 6-year retrospective review, Médecins Sans Frontières (MSF, also known as Doctors Without Borders) found that in over 75,000 surgeries conducted in low-resource settings, cesarean delivery was the most commonly performed surgery (35%), and spinal anesthesia was the most frequently administered type of anesthesia (46%). The authors similarly reported a significantly lower odds of death associated with spinal than with general anesthesia with tracheal intubation (adjusted OR, 0.10; 95% CI, 0.05 to 0.18).

Although studies in low-resource settings have demonstrated better maternal outcomes when cesarean delivery is conducted with spinal anesthesia, neuraxial techniques are not without risks. The 2008 to 2010 NCCEMD audit found that deaths due to spinal anesthesia had steadily increased over the preceding decade, accounting for more than half of the maternal deaths attributed to anesthesia. The most recent NCCEMD audit (2017 to 2019) reported that over one-third of the 921 maternal deaths in women who received anesthesia were conducted using spinal anesthesia. The author speculated that this finding is likely related to the increasing cesarean delivery rate across South Africa, the promotion of spinal anesthesia as a “safer” anesthesia technique, administration by physicians not fully trained or competent to manage complications of spinal anesthesia (such as hypotension, reflex bradycardia, and hemodynamic collapse), and use of spinal anesthesia for inappropriate conditions because it was the only form of anesthesia that the provider felt competent to provide. There have been additional reports of substandard care and mortality in situations where a physician administered spinal anesthesia and then left the patient in the care of an unqualified person while the physician performed or assisted in the surgery or conducted neonatal resuscitation. Sadly, maternal mortality from this practice has been reported in a country as advanced as Japan, where obstetricians often conduct both anesthesia and surgery on the same patient.

The decision to use neuraxial or general anesthesia may be influenced by the severity of the indication for cesarean delivery. This may confound the observed association between mode of anesthesia and pregnancy outcome. Large database studies have not controlled for indication or patient comorbidities when comparing outcomes associated with neuraxial and general anesthesia, but audits have identified preventable morbidity and mortality. Whether general or spinal anesthesia is administered for cesarean delivery in low-resource settings, maternal morbidity and mortality related to substandard anesthesia practices are likely underreported.

Intravenous Ketamine Anesthesia

Intravenous ketamine administered as the sole anesthetic agent for cesarean delivery by minimally trained, unsupervised anesthesia officers has been described. Little data exist on the safety and outcomes of this technique. In Kenya, no maternal deaths were reported in a prospective case series of 401 emergency cesarean deliveries conducted with the use of intravenous ketamine without tracheal intubation by 54 trained, nonanesthesia providers. A survey conducted in Sierra Leone found that intravenous ketamine without tracheal intubation was the second most common anesthetic technique administered for cesarean delivery, with spinal anesthesia the most common. Similar findings have been reported in Zimbabwe.

Deaths Attributable to Accidental Spinal Injection of Tranexamic Acid

An alarming increase in maternal deaths has been attributed to the accidental intrathecal administration of tranexamic acid (TXA). TXA is recommended for the treatment of postpartum hemorrhage and has quickly become a mainstay of care worldwide. It is heat-stable and inexpensive; if stored in the operating room alongside local anesthetic solutions, similarly appearing glass ampules or vials can lead to drug administration errors. Intrathecal TXA is a potent neurotoxin, presenting with severe back and leg pain, refractory seizures, hypertension, tachycardia, and hemodynamic instability. There have been numerous case reports of accidental spinal TXA injection; death has resulted in approximately 50% of cases. Accordingly, the WHO has issued a safety alert warning about this alarming trend.

Eastern Europe

Even in relatively well-resourced middle-income countries with adequate numbers of anesthesia providers, the provision of neuraxial labor analgesia is limited. Collaborations between nongovernmental organizations (NGO) and host institutions in LMICs have demonstrated some effectiveness in increasing the availability of neuraxial labor analgesia; however, use of these techniques remains limited. The NGO, Kybele, Inc., has worked in collaboration with several Eastern European countries and countries of the former Soviet Union to promote neuraxial anesthesia and analgesia use for cesarean and vaginal delivery with favorable results. In Croatia, a single 10-day training intervention in eight hospitals increased the average annual use of epidural labor analgesia from 1.2% to 2.3% across all sites for the year preceding and following the program. In Serbia, a neighboring country with similar healthcare demographics, a training intervention conducted from 2012 to 2015 in a single regional hospital with 6500 annual births resulted in an increase of neuraxial labor analgesia from 1.2% in 2011 (baseline) to 10.5% in 2015. Staffing constraints were cited as a barrier to the provision of neuraxial labor analgesia. All anesthesia staff members were available during the 8-hour workday, but only one anesthesiologist provided call coverage beginning midafternoon. This staffing model limited personnel available to perform labor analgesia at night, because the on-call person was also responsible for anesthesia for cesarean delivery. In addition, some obstetricians were resistant to change and did not support the distribution of patient informational brochures on analgesia and anesthesia options for vaginal and cesarean delivery. In the former Soviet county of Georgia, five hospitals were selected for participation in a multiyear project integrating clinical education, protocol development, quality improvement, and supply chain logistics. Prior to 2007, 10% lidocaine was the only local anesthetic agent available and the antiquated technique of caudal labor analgesia was practiced. The program sought approval from the Health Ministry to bring bupivacaine, vasopressors, and supplies into the country for teaching demonstrations. Through continued engagement and early positive results, the Health Ministry approved the addition of bupivacaine to the national formulary. Additionally, the First Lady of Georgia became a strong advocate and proponent for more modern childbirth practices. The epidural kit supply chain improved and costs decreased, making labor analgesia more affordable. Consequently, the use of epidural labor analgesia increased from 20% in 2005 to over 40% in 2008 in participating hospitals, accounting for one-third of all deliveries in the capital city.

Kybele conducted six visits to neighboring Armenia between 2006 and 2015 to observe healthcare practices and to establish higher standards of obstetric anesthesia care. Spinal anesthesia for cesarean delivery increased markedly across the country, but the use of epidural labor analgesia remained limited. Although epidural analgesia initially increased in seven hospitals from 2006 to 2012, by 2015, the use declined to less than 5% in all but two hospitals where labor epidural analgesia was sustained or increased. Epidural labor analgesia was not utilized outside the capital city, as there was typically only one anesthesiologist practicing in each hospital.

China.

In China, the NGO, No Pain Labor & Delivery– Global Health Initiative, as well as recent governmental policies, have resulted in tremendous strides in promoting administration of neuraxial labor analgesia. A 2007 study reported that the estimated rate of neuraxial labor analgesia use in China was less than 1%. Concomitantly, China also had one of the highest cesarean delivery rates in the world, which had grown to approximately half of the 16.4 million annual deliveries by 2010. In essence, operative deliveries had become an accepted norm. The increase in the cesarean delivery rate occurred during the era of the one-child national policy and was driven by factors that included fear of malpractice litigation, cultural and superstitious beliefs, and fear of labor pain due to the limited availability of neuraxial labor analgesia. These factors were compounded by a shortage of anesthesiologists and limited training in epidural labor analgesia, and wide disparity in care practices across urban and rural parts of the country.

In 2016, a national two-child policy was adopted, raising new concerns regarding advanced maternal age at childbirth and risks associated with prior uterine surgery. In an effort to decrease cesarean delivery rates and improve women’s health, concerted efforts have been made to improve the provision of labor analgesia. The No Pain Labor & Delivery– Global Health Initiative began in 2008 with the goal of increasing the epidural labor analgesia rate by 10% by establishing 10 obstetric anesthesia-training centers over a 10-year period. The program used annual 1-week visits by international expert clinicians with didactic and bedside education, daily debriefing and conferences, patient education books and social media education, and professional forums and the Journal of No Pain Labor & Delivery– Global Health Initiative . By 2020, 109 Chinese hospitals had been visited by over 1000 volunteer healthcare professionals from around the world. Four large-impact studies with approximately 74,465 parturients have confirmed that the implementation of 24-hour epidural pain relief services correlated with lower cesarean delivery rates in three hospital settings (a municipal maternity hospital, two academic institutions, and a rural hospital).

In addition to the NGO collaboration, the National Health Commission in China issued two policies in 2018 to promote neuraxial labor analgesia. The national policies aimed to improve neuraxial labor analgesia technical skills, promote a more scientific rationale for selecting the delivery mode, raise awareness regarding labor analgesia for hospital personnel, strengthen health education for pregnant women and their families, and make full use of training demonstrations in pilot hospitals. Accordingly, 913 pilot hospitals were selected for implementation.

A study was undertaken to assess changes in the rates of neuraxial labor analgesia with data from China’s National Maternal Near Miss Surveillance System. Data were reviewed for 438 hospitals in 326 urban districts and rural counties in 30 provinces across China. Over the study period (2012 to 2019), 620,851 parturients received neuraxial labor analgesia from a population of 6,023,046 women who delivered vaginally. The estimated national neuraxial labor analgesia rate increased from 8.4% in 2012 to 16.7% in 2019. Most provinces experienced a rapid rise in neuraxial labor analgesia use during this period, which was accelerated after 2018 with the introduction of the national pilot policy ( Fig. 15.4 ).

Multiple-group interrupted time series analysis (ITSA) for comparisons on national monthly changes of labor neuraxial analgesia rates after initiation of the national policy promoting neuraxial labor analgesia in China (January 2019, dotted line ). Promotion of neuraxial labor analgesia was officially implemented in 913 hospitals in China (primarily level-3 hospitals). The uptake of neuraxial labor analgesia increased in both pilot (light dots) and nonpilot (primarily level-2 hospitals) (dark dots) . The ITSA was adjusted for time-varying covariates, including proportion of maternal age ≥ 35 years old, women with college education or above, number of antenatal visits ≥ 7, and women with antepartum complications or medical diseases.

From Mu Y, Wang X, Wang Y, et al. The trends and associated adverse maternal and perinatal outcomes of labour neuraxial analgesia among vaginal deliveries in China between 2012 and 2019: real-world observational evidence. BMC Med . 2021;19:74.

The studies also evaluated the association between labor neuraxial analgesia and adverse maternal and perinatal outcomes in China. There were no differences between women with and without neuraxial labor analgesia in the incidence of uterine atony, retained placenta, intrapartum fetal demise, and 1- and 5-minute Apgar scores < 7. However, women with neuraxial labor analgesia had higher incidences of genital tract trauma (adjusted relative risk [aRR], 1.53; 95% CI, 1.04 to 2.26) and maternal near miss (aRR, 1.35; 95% CI, 1.08 to 1.69) in nonpilot hospitals; these hospitals may have lacked sufficient equipment and personnel.

India

In India, a diverse country with approximately 25 million annual births, epidural labor analgesia is infrequently used outside of private hospital settings. A recent survey conducted among 1351 anesthesiologists found that the highest rate of labor analgesia was in private (32.4%) and corporate hospitals (31.2%), followed by private medical colleges (21.1%), government medical colleges (12.4%), and government hospitals (3.0%). These results suggest that labor analgesia is more consistently available for upper- and middle-income parturients, but much less available for the majority of women from rural and lower-income backgrounds who deliver in government hospitals. Labor analgesia was primarily conducted by anesthesiologists (71.3%), followed by both anesthesiologists and obstetricians (27.3%), and least commonly by obstetricians (1.4%). Epidural analgesia with intermittent bolus injection was employed most frequently (43.5%), followed by continuous infusion with intermittent boluses (37.9%). Other techniques included single-shot spinal analgesia, combined spinal-epidural analgesia, and patient-controlled epidural analgesia techniques. Bupivacaine (64.1%) and fentanyl (83.3%) were the most common epidural medications. India promotes up-to-date refresher training at the annual meeting of the Association of Obstetric Anaesthesiologists of India, established in 1983.

In Bhutan, a 4-year retrospective study found that of 15,119 patients, only 3.5% of women received either combined-spinal epidural, epidural, or single-shot spinal analgesia during labor. Anesthesia staffing constraints and cultural beliefs were thought to limit the use of neuraxial labor analgesia.

Latin America

Latin America represents a diverse group of countries with large gaps in research, knowledge, and health services related to obstetric anesthesia care. Studies reflecting neuraxial labor analgesia use in various Latin America countries are limited. The WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS) assessed labor analgesia practices in 29 countries across Latin America, Asia, the Middle East, and Africa, using data collected on 221,345 vaginal deliveries in 359 healthcare facilities in 2010 to 2011. Pharmacologic analgesia interventions, including systemic analgesia (opioid or inhalational), neuraxial analgesia (epidural or spinal), or no pharmacologic intervention were compared by country and the Human Development Index (HDI), a composite measure of lifespan, education, and gross national income per capita. The use of epidural labor analgesia was higher among Latin American countries compared with Middle Eastern and sub-Saharan Africa countries, and in countries with a higher HDI ( Table 15.4 ). This study also found that neuraxial labor analgesia use was greater in nulliparous women, in women with higher education levels, and in women with previous cesarean delivery.

Table 15.4

Use of Analgesia for Vaginal Birth in 29 Countries According to WHO Human Development Index and Regions, 2010–11

Data from Souza MA, Cecatti JG, Guida JP, et al. Analgesia for vaginal birth: secondary analysis from the WHO Multicountry Survey on Maternal and Newborn Health. Int J Gynaecol Obstet . 2021;152:401–408.

HDI and Country	Labor Analgesia (%)
	No Analgesia	Epidural Analgesia	Spinal Analgesia
Very High HDI
Argentina	83	16	1
Japan	86	14	0.4
Qatar	82	18	0.4
High HDI
Brazil	82	14	4
Ecuador	91	2	6
Lebanon	66	34	0.9
Mexico	71	29	0.1
Peru	98	2	0
Sri Lanka	99	1	0.2
Medium HDI
Cambodia	99.6	0.1	0.3
China	94	5.6	0.1
India	99.8	0	0.1
Jordan	99	1	0
Mongolia	97	0	3
Nicaragua	99.6	0.2	0.1
OPT	94	6	0
Paraguay	89	8	3
Philippines	99.5	0.3	0.2
Thailand	99.7	0	0.3
Vietnam	86	13	1
Low HDI
Afghanistan	99.9	0	0.1
Angola	99.9	0	0.1
DR Congo	99.7	0.2	0.1
Kenya	99.8	0.2	0
Nepal	99.4	0	0.6
Niger	100	0	0
Nigeria	100	0	0
Pakistan	98.3	0.1	1
Uganda	99.8	0	0.2

DR , Democratic Republic; HDI , Human Development Index; OPT ,occupied Palestinian territories.

Educational strategies using simulation-based courses have been initiated by Confederación Latinoamericana de Sociedades de Anestesiología and the WFSA to improve obstetric anesthesia practices, and team training has been used to facilitate the management of obstetric emergencies.

Middle East

The Middle Eastern region of the world similarly lacks studies on the use of neuraxial labor analgesia. The WHOMCS database reflects labor analgesia practices within some hospitals located in Qatar, Lebanon, Jordan, Palestine, Afghanistan, and Pakistan (see Table 15.4 ). A 2019 3-month retrospective review of labor analgesia practices in Saudi Arabia was conducted in a tertiary referral hospital. Intramuscular meperidine was used most frequently (35%). Epidural analgesia was administered to 32% of women, and spinal analgesia/intrathecal morphine and nitrous oxide were used in fewer than 1% of women. Approximately one-third of women received no form of analgesia. The authors stated that the study results may not reflect practice patterns across the country and that multicenter studies are needed to determine broader practices and care standards in Saudi Arabia.

Sub-Saharan Africa

Neuraxial epidural analgesia use is extremely limited in sub-Saharan Africa (see Table 15.4 ). A 2012 audit performed in an urban South African teaching hospital with over 7000 annual births found that only 2.2% of laboring patients had received epidural analgesia. The primary reason was the posting of a single anesthesia provider who was simultaneously responsible for emergency surgery and labor analgesia. An epidural service was initiated in June 2014, whereby one anesthesia trainee was assigned to the labor ward during daytime hours, along with a staff nurse trained to manage epidural top-up doses and infusion adjustments. Following initiation, a 19-month audit was conducted from July 2014 to December 2015; 5.2% of women received epidural labor analgesia during this period. The authors surmised that the small number of patients who requested labor analgesia likely reflects a lack of patient knowledge about labor analgesia options. Overall use of epidural analgesia, however, remained low due to human resource allocation, nursing staff training, and patient education.

In contrast to epidural analgesia, single-shot spinal analgesia may be a viable option for providing pain relief for labor in low-resource settings. It is simple to perform compared to an epidural technique, and it avoids the risk of unintentional dural puncture with a large-bore epidural needle and the associated risk of postdural puncture headache. The use of single-shot spinal analgesia minimizes the risk of local anesthetic systemic toxicity and high spinal anesthesia. It also requires less equipment (catheters, low-resistance syringes, infusion devices), all of which are generally unavailable in low-resource settings. Spinal analgesia has risks that must be discussed with the patient and anticipated; however, spinal labor analgesia services can be established with the development of simple protocols, staff education, and a few basic medications. Resuscitative agents (e.g., vasopressors) and equipment (e.g., self-inflating bag, face masks, endotracheal tubes) must be readily available. In labor and delivery suites that require parturients to walk to a separate delivery room, motor weakness from residual spinal analgesia must be considered.

Single-shot spinal labor analgesia is commonly utilized in some HICs, such as Finland, where studies have shown patient satisfaction and effectiveness. In a study of 209 parturients, single-shot spinal labor analgesia with bupivacaine 2.5 mg and fentanyl 25 μg *

provided pain relief for 101 ± 34 minutes (mean ± standard deviation [SD]) and 81% of women stated that they would request the same regimen again. Single-shot spinal analgesia was also shown to be superior to paracervical block. In a 2016 meta-analysis of five randomized, placebo-controlled trials, including 286 patients from HICs, the addition of intrathecal morphine (50 to 250 μg) extended the duration of the bupivacaine-fentanyl or sufentanil mixture by an average of 60 minutes. A 2023 1-year retrospective review of 535 patients found that single-shot spinal labor analgesia was efficacious for most parturients; however, inadequate duration of analgesia was more frequent in nulliparous parturients and in parous women when analgesia was initiated early in labor. The authors recommended this technique for use in resource-limited settings where other options for pain relief are unavailable.

Table 15.5 summarizes studies from LMICs utilizing single-shot spinal labor analgesia. Many studies utilized spinal bupivacaine alone or in combination with fentanyl. A study from Nigeria found that the mean (± SD) duration of bupivacaine analgesia was shorter (62 ± 6 minutes) than bupivacaine combined with fentanyl (129 ± 22 minutes). More patients receiving bupivacaine alone (52%) required a second spinal dose compared with those receiving bupivacaine with fentanyl (18%). The duration of labor and newborn outcomes were similar. Pruritus was more common with fentanyl administration (22% versus 0%); however, satisfaction was higher in the group that received fentanyl.

In a small study from Ghana describing the initiation of a labor analgesia service, 46 women received spinal bupivacaine; 6 (13%) required a second dose. Protocol deviations were noted in 26 (57%) patients who received higher than the recommended dose of bupivacaine 2.5 mg (range 3 to 6 mg), likely administered with the intent to extend the duration of pain relief. Opioid availability was limited; only four patients received bupivacaine combined with opioid (fentanyl 25 μg or meperidine 10 mg). Motor block was minimal and patients ambulated to an adjacent delivery room. Unfortunately, efforts to sustain the analgesia service were hampered by prolonged staff shortages and attrition.

A study from Turkey utilized bupivacaine 2.5 mg alone or in combination with fentanyl 15 or 25 μg in 105 patients. The overall duration of analgesia was difficult to ascertain from the report; however, 21% of parturients in the bupivacaine-alone group required intravenous opioid supplementation compared with 9% in the fentanyl 15 μg group and 11% in the fentanyl 25 μg group. Pruritus was the most commonly reported side effect in all groups (9% to 11%) and Apgar scores were similar.

Several studies have compared single-shot spinal labor analgesia to an intermittent-bolus epidural technique. In a study of 80 multiparous women in Egypt, parturients were allocated to receive intrathecal hyperbaric bupivacaine 3.75 mg with fentanyl 25 μg or epidural bupivacaine 0.125% with 50 μg fentanyl (8 to 10 mL). The block onset was slower (9 versus 5 minutes) in the epidural group but the mean (± SD) duration was longer (163 ± 17 versus 120 ± 3 minutes). Breakthrough pain in 25% of patients in the spinal group was treated with intravenous ketamine and perineal local infiltration, while in the epidural analgesia group it was treated with epidural top-up doses of bupivacaine 0.125% (30% of parturients in the epidural group). The spinal group had a shorter duration of labor, but pain scores, side effects, and satisfaction were similar between groups. The authors concluded that single-dose spinal analgesia is an effective alternative to epidural analgesia.

In an Iranian study, women were randomized to receive intrathecal bupivacaine 2.5 mg with fentanyl 50 μg or epidural bupivacaine 0.125% with fentanyl 50 μg (16 mL). Breakthrough pain was treated with intramuscular meperidine in the spinal group and an epidural top-up dose in the epidural group. Initial pain scores were lower, and satisfaction was higher in the spinal group, although 13% of women in the spinal group reported pruritus. The authors found a longer mean (± SD) duration of analgesia in the spinal group (225 ± 19 versus 159 ± 37 minutes) and fewer women in the spinal group required supplemental analgesia (4% versus 28%). Labor duration and mode of delivery were similar. The authors recommended single-dose spinal analgesia as a simple and fast technique with high maternal satisfaction.

The addition of spinal morphine has been shown to extend the duration of spinal bupivacaine-fentanyl analgesia when used in laboring women in LMICs. In Kenya, the duration of analgesia was approximately 2 hours in women who received spinal bupivacaine-fentanyl compared with nearly 3 hours in women who received bupivacaine-fentanyl with intrathecal morphine. The incidence of breakthrough pain was lower and satisfaction was greater in the women who received morphine. The incidence of adverse effects was higher in the women who received morphine, although the absolute incidence was low (nausea [8% versus 4%], pruritus [15% versus 6%], shivering [6% versus 2%], hypotension [10% versus 4%]).

In another study from Ghana, spinal bupivacaine 2.5 mg, fentanyl 25 μg, and morphine 200 μg were administered to 332 patients; 28 (8%) required a second dose. The primary outcome was ability to ambulate; no motor impairment was observed in 88% of parturients, and mild weakness occurred in 12%, allowing most women to walk to the delivery room. Pruritus occurred in 31% of parturients and nausea occurred in 27%; 14.5% of women received naloxone treatment. Fetal bradycardia occurred in 4% of women following the initiation of spinal analgesia.

A study from India compared intrathecal bupivacaine-fentanyl-morphine to the standard institutional systemic analgesia regimens consisting of intravenous and intramuscular pentazocine, diazepam, and tramadol. If the visual analog scale (VAS) (0 to 10) pain score exceeded 5, intravenous ketamine was provided to supplement analgesia. Labor duration, mode of delivery, and Apgar scores were similar, but the pain scores were markedly lower in the spinal analgesia group ( Fig. 15.5 ). The mean (± SD) duration of analgesia in the spinal group was 249 ± 24 minutes, similar to the reported length of labor (245 ± 20 minutes). Only two (5%) patients in the spinal group required rescue analgesia. Ninety-eight percent of parturients in the spinal group had a moderate to severe (Grade 2 to 3) motor block within 5 minutes of the intrathecal injection; however, this resolved within 30 minutes.