Perspective Chapter: Epidural Anaesthesia Service Delivery in Anaesthesia Workforce Constrained Regions

Abstract

Epidural anaesthesia is often under-utilized in our environment. This could be linked to scarcity of specialist anaesthesia providers in anaesthesia workforce constrained regions. To have an effective and safe surgical and obstetric intervention, there is need to have specialist anaesthesia providers that proffer effective leadership in anaesthesia services and delivery of emergency and essential patient care, to help combat the extremely high avoidable anaesthesia-related morbidities and mortalities. Epidural anaesthesia can offer both intraoperative and postoperative analgesia, with the potential to reduce morbidity and mortality. It’s use in labour analgesia has been found to be very effective, with good obstetric outcome. Nevertheless, epidural anaesthesia requires the availability of human, technical and economic resources. But, despite the fact that healthcare is given a strategic priority in the life of people, delivery of safe surgical and non-surgical services is linked to anaesthesia workforce capacity and its impact in the society.

1. Introduction

Epidural anaesthesia and analgesia services is a technique for perioperative and procedural pain management with multiple applications that may be used as a primary surgical anaesthetic, resource for postoperative pain management, chronic pain relief or labour and obstetric delivery analgesia [1]. It is safe and relatively easy to perform by trained personnel. Nevertheless, it requires adequate training and high level of skill acquisition. Epidural anaesthesia and analgesia services takes into consideration the anatomy of the patient’s spine, procedural indications and contraindications, in the view of the interprofessional teams’ role in providing and improving care for patients who undergo surgery or require pain management. Irrespective of the benefit of potentially providing excellent analgesia, its use reduces the exposure of patient to other anaesthetics and analgesics, decreasing side effects [2]. Nevertheless, the importance of collaboration and communication amongst the health care team involved in the care of patients who receive epidural anaesthesia or analgesia service is important in improving outcomes. Epidural anaesthesia or analgesia can be administered as a single shot, intermittent/programmed bolus or a continuous infusion for long-term pain relief. Many beneficial aspects of epidural analgesia or anaesthesia have been reported, including better suppression of surgical and labour stress, positive effect on postoperative nitrogen balance, more stable cardiovascular haemodynamic, reduced blood loss, better peripheral vascular circulation, better labour analgesia and postoperative pain control [2].

Epidural anaesthesia and analgesia services is one of the unique facets of anaesthesia service delivery, which forms an important part of medical services in any country and undeniably strengthens the healthcare systems. Nevertheless, irrespective of the strategic priority given to healthcare in the life of the global population, the delivery of safe surgical and non-surgical services is linked to anaesthesia workforce capacity and its impact in the society. The epidural analgesia and anaesthesia services in any region of the world are particularly susceptible to the level of socio-economic development of such region, and like any other anaesthesia service delivery, the practice faces numerous challenges exclusively related to high number of pathologies, shortage of materials and drugs, infrastructure and human resources [3]. In many developing countries, especially sub-Saharan Africa, there is a critical shortage of healthcare workers and very limited resources. The health systems are stretched by diseases such as HIV/AIDS, tuberculosis, diarrhoea diseases and malaria and the loss of trained staff to the developed world and insecurities. Furthermore, economic effects of long-term conflict continue to rampage most of the developing countries.

Epidural anaesthesia and analgesia service are particularly vulnerable to development pressures and the quality of epidural anaesthesia and analgesia services is highly correlated with perioperative mortality and morbidity of the patients [4]. Hence, the presence of adequate infrastructure, skilled anaesthesia providers and the use of effective sanitation are paramount to improving the epidural anaesthesia and analgesia service, which will have a pro-founding positive effect on acute and chronic pain management services, obstetric services and perioperative outcome.

2. Shortage of physician anaesthesia specialist

Effective and safe pain care, surgical and obstetric intervention requires the presence of specialist anaesthesia providers that proffer quality leadership in epidural anaesthesia and analgesia services during elective, emergency and essential patient care, to help combat the extremely high avoidable anaesthesia-related morbidities and mortalities. This remains elusive in developing countries because of shortage of anaesthesia specialist among other healthcare workers [5, 6]. The number of surgical conditions contributing to the global burden of disease and the potential impact of such on basic surgical services continue to rise. It is estimated that 11% of the world’s disability-adjusted life years are from conditions that are very likely to require surgery. Increasing evidence is beginning to emerge that maternal and infant survival is proportionately correlated to the number of health workers including physician anaesthetist providing obstetric care [5, 6]. Physician anaesthetists are scarce in many resource limited countries and they are not available at most referral health facilities and non-existent in remote and rural areas [3].

The number of Physician anaesthetists serving the looming population in the developing and resource limited countries has continued to decline irrespective of the soaring population, due to lack of political will, poor wages, conflicts and insecurities and migration to developed countries with better wage packages and incentives [3]. Mavalankar and coworkers [7], reported that in Afghanistan with population of 32 million persons, there are only 9 physician anaesthetists and only 8 in Bhutan with population less than 700,000. Another study observed that only 13 physician anaesthetist are available in Uganda to serve a surging population of 27 million persons [3]. Different studies conducted in Zimbabwe [8] and Nigeria [9, 10] identified that there are no specialist anaesthetists in public or provincial hospitals that serve as the referral centres in Zimbabwe and Nigeria respectively. World Health Organization (WHO) has encouraged member states to ensure that anaesthesia is properly prioritized within the health system and that support, follow-up, reporting, and bench-marking take place [11].

A report from the World Federation of Societies of Anaesthesiologist (WFSA) shows that there was a total of 436,596 physician anaesthesia provider in the 153 countries serving a population of more than 7 billion persons. This represents a workforce density of 6.09 per 100,000 population. The study also showed that 355,381 (81.4%) were specialist anaesthetists, 71,990 trainee specialist anaesthetists (16.5%), and 9225 (2.1%) non-specialist physician providers [12]. However, this figure is mainly dominated by developed country statistics. Most countries in Africa like Nigeria, Angola, Burkina Faso, Ethiopia, Zimbabwe and Niger has a workforce of <1 per 100,000 physician anaesthesia providers [12]. Indicating that resource limited and developing countries are still unable to meet the WFSA recommendation of at least 5 physician anaesthesia providers per 100,000 population, in other to ensure an effective leadership in anaesthesia services and delivery of emergency and essential patient care.

The scarcity of specialist anaesthesia physician can have a negative impact on the implementation of epidural anaesthesia and analgesia service in terms of the safety of perioperative, obstetric and pain patients, as well as the quality of healthcare services that will be delivered to the patients. The specialist anaesthesia physician in resource limited countries are over-worked irrespective of their limited number. For example, in Nigeria the physician anaesthetists in the public hospitals are involved in perioperative patient care, patient’s resuscitation, critical care medicine, transportation of critically ill patients, acute and chronic pain management, sedation services, as well as healthcare system management, advocacy, simulation and medical education and research [13]. Furthermore, the private hospitals also depend on the services of this constrained specialist anaesthetists to sustain safe and quality healthcare services in their institutions. Thus, making them prone to burnouts and unable to sustain epidural anaesthesia and analgesia services.

3. Obstetrics epidural analgesia service challenges

Epidural analgesia is widely regarded as the gold standard for pain relief during labour. It involves the titration of low-dose and low-concentration local anaesthetics, to produce safe and reliable analgesia during labour and delivery. A properly monitored labour epidural service has a low incidence of side effects or serious complications to the parturient or foetus [14, 15]. However, in order for this service to be safe and efficacious, epidural labour analgesia need to be accessible 24 hours, every day. But the evaluation of this service in resource limited countries of the world shows that it is reluctantly or grossly low, or even not available in most health institutions that serves as referral healthcare facilities [16, 17, 18]. Furthermore, literature search on the utilization rate of epidural analgesia in labour in resource limited countries shows dearth of data in this region of the world, and it is associated with limited anaesthesia workforce, time constraint, limited anaesthesia materials and equipment, lack of advocacy and awareness of such service (see Table 1).

Author	Objective	Country	Findings	Conclusion
Fyneface-Ogan et al. [15]	To ascertain the outcome of labour and the views of multiparous Nigerian women in labour under epidural analgesia or parenteral opioids/sedatives.	Nigeria	Epidural analgesia in labour offers 80% satisfaction and 8% inadequate analgesia in women in labour.	Epidural labour analgesia is acceptable to women in our setting, with high level of satisfaction with the experience of labour.
Jacobs-Martin et al. [16]	To establish the incidence of epidural analgesia in women in labour in a tertiary referral centre in the Western Cape	South Africa	Incidence of labour epidural analgesia was 2.2%, with complication rate of 32.3%.	Only 2.2% of women in labour received epidural analgesia, most likely because of time constraints on the limited available personnel.
Okojie et al. [17]	To assess the knowledge and perception of pregnant women regarding epidural analgesia for labour	Nigeria	About 79.5% of pregnant women are not aware of epidural analgesia service in labour.	There is poor awareness and acceptance of epidural analgesia in labour in this environment.
Imarengiaye et al. [18]	To determine the clinical correlates of the demand and utilization of labour analgesia resources by Nigerian women in labour	Nigeria	About 37.5% patients were aware that the pain of labour can be relieved but only 26.0% had prenatal information on labour analgesia. A total of 38.9%) did receive analgesia during labour.	There is poor utilization of labour analgesia services.
Leonard et al. [19]	To describe the labour epidural analgesia experience in a health institution in South Africa.	South Africa	Epidural analgesia in labour had an utilization rate of 1.6% and complication rate of 22.6%.	There is low incidence of labour epidural analgesia.
Ezeonu et al. [20]	To determine the awareness and utilization of epidural analgesia in labour in pregnant women Teaching Hospital.	Nigeria	About 43.3% of the patients were aware of epidural analgesia in labour, but only 7.5% had used it, with 95% satisfaction rate.	The knowledge and practice of epidural analgesia among parturients are low.
Nabukenya et al. [21]	To determine the knowledge, attitudes and use of labour analgesia among women attending the antenatal clinic.	Uganda	Only 7% of the participants had knowledge of labour analgesia, with only 20.9% of the fraction being aware of epidural analgesia in labour. Total of 79.2% of such women had their child birth in a national referral hospital.	There is a wide gap between the desire for labour analgesia and its availability.
Waldum et al. [22]	To assess disparities in the provision of epidural analgesia in planned vaginal birth according to maternal region of birth.	Sub-Saharan Africa	Primiparous women had epidural analgesia utilization rate of 33.8%, while the multiparous women had the rate of 9% for vaginal delivery respectively.	There are some disparities in the provision of epidural analgesia based on maternal birthplace.
Waldum et al. [22]	To assess disparities in the provision of epidural analgesia in planned vaginal birth according to maternal region of birth.	North Africa/Middle East	Primiparous women had epidural analgesia utilization rate of 39.4%, while the multiparous women had the rate of 13.7% for vaginal delivery respectively.	There are some disparities in the provision of epidural analgesia based on maternal birthplace.
Waldum et al. [22]	To assess disparities in the provision of epidural analgesia in planned vaginal birth according to maternal region of birth.	East Asia/Pacific	Primiparous women had epidural analgesia utilization rate of 31.0%, while the multiparous women had the rate of 11.2% for vaginal delivery respectively.	There are some disparities in the provision of epidural analgesia based on maternal birthplace.
Waldum et al. [22]	To assess disparities in the provision of epidural analgesia in planned vaginal birth according to maternal region of birth.	South Asia	Primiparous women had epidural analgesia utilization rate of 38.1%, while the multiparous women had the rate of 14.8% for vaginal delivery respectively.	There are some disparities in the provision of epidural analgesia based on maternal birthplace.
Ojiakor et al. [23]	To determine the rate of demand, indications, post-dural puncture headache rate and factors affecting demand for epidural analgesia among women in labour.	Nigeria	The demand for labour epidural in the study centre was low with a demand rate of 2.6%	The demand for labour epidural analgesia in the study was low and there is a need for an enhanced awareness programs on obstetrics epidural analgesia.

Table 1.

Global epidural anaesthesia and analgesia indices and characteristics.

When Jacobs-Martin et al. [16] evaluated the utilization of epidural analgesia services in labour in South Africa women, they observed that the rate was abysmally low, with the incidence of 2.2%, compared with the rate of 23.4% and 90% in developed countries like United Kingdom and United State of America, respectively [24, 25]. They accrued the low rate of epidural analgesia in labour to limited number of available skilled anaesthesia personnel, time constraint, knowledgeable support staff, materials and equipment. Another study conducted by Okojie et al. [16] and Imaregiaye et al. [18] in Nigeria showed that the awareness of this service is grossly low, although with high level of acceptability among the educated and those with previous birth experience. Nevertheless, access to this service was very low, because of unavailability of 24 hours service as a result of low staff strength. In this region of the world, the ratio of physician anaesthesia provider is 0.58 per 100,000 population, instead of the recommended 5 per 100,000 population by WFSA [12]. This could be a determining factor to the lack of advocacy and effective epidural analgesia services in labour, as the limited available specialist anaesthetists are overwhelmed with perioperative and critical care services even at the referral health institutions.

Epidural analgesia is a technical procedure, performed under aseptic technique, where medications like local anaesthetics with or without an additive is injected into the epidural space with the intention of providing analgesia to a specific region of sensory dermatomes [26]. This is followed by subsequent intermittent or programmed top ups, until the mother delivers her baby in a pain free and safe scenario. The availability epidural analgesia service helps to conveys a level of safety to woman in labour and the foetus. Epidural analgesia service has traditionally been viewed as expensive, resource-intensive, time consuming and requiring highly specialized training for the doctors and support staff in resource limited clime. Thus, making it underutilized in this environment.

To deliver an effective and safe epidural analgesia service in labour, personnel, as well as some minimum equipment, materials and medications are required. This includes the availability of physician anaesthetist, obstetrician, trained nursing staff skilled with handling of epidural services and other support staff. There is also need for the availability of supplemental oxygen source, suction machine, related equipment, self-inflating bag and mask device that is able to provide positive pressure ventilation, airway materials like oropharyngeal airway, nasopharyngeal airway, endotracheal tubes for resuscitation, patient monitors with the capability for non-invasive blood pressure, electrocardiographic, pulse oximetry and capnographic monitoring. Furthermore, there is need to have intravenous catheters, crystalloids, infusion sets, syringes, needles, emergency drugs like vasopressors (ephedrine, phenylephrine, epinephrine), atropine, and intralipids, and defibrillators or crash cart [27].

The minimum equipment and medications required for obstetric epidural analgesia services are often not available in most health institutions in developing countries, making it difficult for the limited number of anaesthesia physicians to function and provide effective safe labour epidural analgesia services. The environment is associated with poor operation theatre infrastructure and unavailability of equipment, lifesaving drugs and anaesthetic agents [3, 28]. Furthermore, the physicians face problems of unreliable electricity, unavailability of compressed oxygen and other gases, sophisticated machines and modern drugs [3, 28]. Safe provision of labour epidural analgesia service necessitates the ability to manage any potential complications or emergencies that may arise. There should be resuscitative equipment and drugs in the event of bradycardia, hypotension, high or total spinal anaesthesia, local anaesthetic toxicity or cardiopulmonary arrest, but these are either not available or in limited supplies.

The development of an epidural analgesia service should encompass patients’ safety as part of its working protocols. Although the barriers to safe and effective administration of labour analgesia service like inadequate practitioner training, staff reserves, and unavailability of the proper technologies and medicines continue to rampage low resource countries, the desire for such services appears to exist, with evidence that when it is offered, some women chose to accept the service [16, 24].

4. Epidural anaesthesia service for surgeries and safety challenges

Epidural anaesthesia involves the injection of high volume and dose of local anaesthetic agent into the epidural space to achieve a reversible loss of sensation adequate to allow surgical procedures. It is usually administered for surgeries in the lower abdomen, perineum and lower extremities. Studies have shown that thoracic epidural anaesthesia can be used to perform major upper abdominal and thoracic surgeries, including cardiac and major thoracic vascular surgeries [29, 30]. Although epidural anaesthesia onset of action is slow, and sometimes associated with patchy sensory blocks, when properly performed, it can offer good anaesthesia and outlast the duration of prolonged surgeries. Nevertheless, the epidural anaesthetic effect on reducing intraoperative and postoperative morbidity and mortality varies with the type of surgery performed. Epidural anaesthesia can be performed as a sole anaesthetic or in combination with spinal or general anaesthesia. Its duration of anaesthesia is prolonged with the use of epidural catheters that allows for top ups or continuous injections of local anaesthetic and mixture with additive or local anaesthetic alone, to improve the overall surgical outcome. When used for abdominal aortic surgery, it can shorten the intubation time and intensive care stay [15, 31].

Epidural anaesthesia service requires the availability of human, technical and economic resources. In the present clime of patient safety, people in developing countries continue to suffer due to lack of trained physician anaesthetists, as well as lack of adequate health system infrastructure and equipment, prioritization of anaesthesia and surgical care as part of national health plans. The crisis in human resources for anaesthesia care in many developing countries is contributed by the low standing of the profession, especially in sub-Saharan Africa, and the resulting problems with recruitment and retention of practitioners at all levels. Hence, making it difficult for majority of the population in resource limited areas to access safe anaesthesia services both in cities and in the rural and underprivileged areas of the region. Safe surgical and non-surgical services is a reflection of adequate anaesthesia workforce capacity. Hence, improvements in the safety and quality of anaesthesia is urgently needed, but the challenge is the deficiency in the number of trained physician anaesthetist [32, 33].

Epidural anaesthesia is often under-utilized in our environment. This could be linked to scarcity of specialist anaesthesia providers in anaesthesia workforce constrained regions. To provide guidance and assistance in maintaining and improving the quality and safety of epidural anaesthesia service, specialist physician anaesthesia providers are required. The shortage of specialist anaesthesia physician creates a major hindrance and vacuum for epidural anaesthesia services in the resource limited areas of the world. In some countries, the gap is filled by non-physician anaesthetists, who provides any form of anaesthesia for surgical procedures. Most times they work alone without any support from specialist physician anaesthetists, and they handle cases beyond their training, with the number of morbidity and mortality relating to inappropriate care rising [34, 35]. Pignaton and colleagues reported that the quality of anaesthesia services delivered is highly correlated with perioperative morbidity and mortality [34]. A study showed that the overall risk of maternal death when non-physician anaesthetists provided care was 9.8 per 1000 compared to 5.2 per 1000 in physician anaesthesia provider care [35].

A meta-analytical study on anaesthesia related maternal mortality in low-income and middle-income countries, shows that in women undergoing an obstetric procedure, the risk of death attributed to anaesthesia was 1·2 per 1000 women, with the highest rates of 1·5 per 1000 in sub-Saharan Africa women. Anaesthesia was reported as the main cause of death in 2.8% of all direct and indirect maternal deaths, with the highest rates in Middle East and North Africa (6.2%), and the lowest in east Asia and Pacific (1.5%). When neuraxial anaesthesia like epidural anaesthesia were compared with the administration of general anaesthesia, the odds of maternal death tripled, with mortality rates of 5.9 per 1000 in general anaesthesia and 1.2 per 1000 for neuraxial anaesthesia. General anaesthesia also doubled the odds of perinatal death compared with neuraxial block [35]. Availability of specialist anaesthesia physician in the resource limited regions will be effective in ensuring leadership in epidural anaesthesia services, delivery of obstetric emergencies and essential patient care. Epidural anaesthesia service use in obstetrics has been found to be very effective, with good obstetric outcome. Epidural anaesthesia service can provide safe and efficient anaesthesia for unplanned or emergent Caesarean delivery by increasing the dose and concentration of the local anaesthetics and/or the adjuvant used for labour analgesia [15, 27].

To ensure safety of lives and improve perioperative care, modern anaesthesia practice has become increasingly dependent on complex equipment and expensive drugs, but this is only obtainable in high income countries. The resource limited regions and countries depend on basic equipment and essential drugs, however, in most places even the basic anaesthesia equipment and essential drugs are not available. Hence, limiting the practice of epidural anaesthesia.

5. Conclusion

Epidural anaesthesia and analgesia service is required for safe surgical and non-surgical ministration. It provides both intraoperative and postoperative analgesia and reduces perioperative morbidity and mortality. A properly monitored labour epidural service has a low incidence of side effects or serious complications to the parturient or foetus. But this service is often under-utilized in the workforce constrained developing and resource limited countries due to scarcity of specialist anaesthesia providers, as well as unavailability of infrastructural, technical and economic resources. Hence, to achieve an effective and sustainable epidural anaesthesia and analgesia service, there is need to increase and ensure the presence of adequate infrastructure, materials and resources and skilled anaesthesia providers. Resolution of the human resource crisis for anaesthesia care in many developing and limited resource countries will require the commitment of the government and high level of political will, to facilitate the recruitment and retention of specialist physician anaesthesia practitioners and their support staff at all levels of the healthcare system.

Acknowledgments

I will like to express my deepest appreciation to God for his wisdom and to all the authors, whose work formed the foundation for this medical writing.

No funding was received for this work.

Conflict of interest

The authors declare no conflict of interest.