The Lancet Global Health
Jun 2014 Volume 2 Number 6 e301 – 363
http://www.thelancet.com/journals/langlo/issue/current

Detention, denial, and death: migration hazards for refugee children
Mina Fazel, Unni Karunakara, Elizabeth A Newnham
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Organised violence, persecution, and community instability cause millions of children to flee their native countries every year. About 7•6 million people were newly displaced by conflict or persecution in 20121 (the highest number in a decade), of which approximately half were younger than 18 years. Regions prone to disaster and adversity often have disproportionately young populations, and thus larger numbers of children and adolescents are now moving across country borders, with or without their families.

Global causes of maternal death: a WHO systematic analysis
Dr Lale Say MD a, Doris Chou MD a, Alison Gemmill MPH a b, Özge Tunçalp MD a, Ann-Beth Moller MSc a, Jane Daniels PhD c, A Metin Gülmezoglu MD a, Marleen Temmerman MD a, Leontine Alkema PhD d
Summary
Background
Data for the causes of maternal deaths are needed to inform policies to improve maternal health. We developed and analysed global, regional, and subregional estimates of the causes of maternal death during 2003—09, with a novel method, updating the previous WHO systematic review.
Methods
We searched specialised and general bibliographic databases for articles published between between Jan 1, 2003, and Dec 31, 2012, for research data, with no language restrictions, and the WHO mortality database for vital registration data. On the basis of prespecified inclusion criteria, we analysed causes of maternal death from datasets. We aggregated country level estimates to report estimates of causes of death by Millennium Development Goal regions and worldwide, for main and subcauses of death categories with a Bayesian hierarchical model.
Findings
We identified 23 eligible studies (published 2003—12). We included 417 datasets from 115 countries comprising 60 799 deaths in the analysis. About 73% (1 771 000 of 2 443 000) of all maternal deaths between 2003 and 2009 were due to direct obstetric causes and deaths due to indirect causes accounted for 27•5% (672 000, 95% UI 19•7—37•5) of all deaths. Haemorrhage accounted for 27•1% (661 000, 19•9—36•2), hypertensive disorders 14•0% (343 000, 11•1—17•4), and sepsis 10•7% (261 000, 5•9—18•6) of maternal deaths. The rest of deaths were due to abortion (7•9% [193 000], 4•7—13•2), embolism (3•2% [78 000], 1•8—5•5), and all other direct causes of death (9•6% [235 000], 6•5—14•3). Regional estimates varied substantially.
Interpretation
Between 2003 and 2009, haemorrhage, hypertensive disorders, and sepsis were responsible for more than half of maternal deaths worldwide. More than a quarter of deaths were attributable to indirect causes. These analyses should inform the prioritisation of health policies, programmes, and funding to reduce maternal deaths at regional and global levels. Further efforts are needed to improve the availability and quality of data related to maternal mortality.
Funding
USAID, the US Fund for UNICEF through a grant from the Bill & Melinda Gates Foundation to CHERG, and The UNDP/UNFPA/UNICEF/WHO/The World Bank Special Programme of Research, Development, and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research.

Editorial
Cost-effectiveness and classification
Zoë Mullan a
This week the global health cynosure has been the World Health Assembly (WHA) in Geneva. On the agenda we’ve seen action plans galore: from tuberculosis control to disability to neonatal health. There have been follow-up reports on vaccination, non-communicable diseases, and nutrition. But one thing that hasn’t so far made it onto a WHA agenda is surgery. Conservative estimates dating back to 2006 put the global burden of surgically treatable disorders at 11%, and many such conditions—eg, road-traffic injuries and cancer—are rising. Why the neglect?
WHO established the Global Initiative for Emergency and Essential Surgical Care in 2005 with the aim of engendering collaboration between “health professionals, professional societies, academic institutions, non-governmental organisations, and health authorities interested in improving surgical care in LMICs”. The forum has met biennially since 2005, but strategic outputs have been difficult to identify. Similarly, the 2008 World Health Report recognised surgery as an essential spoke in the health-system wheel, with primary care as the hub. Yet calls made back in 2010 for a “World Health Assembly amendment confirming the critical role of emergency and essential surgery within the health system” have still not borne fruit.
The Lancet’s forthcoming Commission on Global Surgery aims to push the agenda forward. One of its key aims is to identify barriers to universal access to safe, affordable, high-quality surgical care, and to clarify the role of all stakeholders in attaining this goal. As well as the Commission report, which is due early next year, a number of research papers will come out of the project, and The Lancet Global Health publishes one such paper this month.
Tiffany Chao and colleagues explore one of the potential barriers to the adequate provision of surgical care in low-income countries and to its visibility on the global health agenda—its supposed high cost. In their systematic review, Chao and colleagues assessed 26 previous studies of the cost-effectiveness of a range of essential surgical procedures across 24 countries. Standardised cost-effectiveness ratios were calculated in 2012 US dollars per disability-adjusted life-year (DALY) averted, and median values were found to be $13•78 for adult male circumcision; $47•74 for cleft lip and palate repair; $82•32 for general surgery; $108•74 for hydrocephalus repair; $136•00 for ophthalmic surgery (cataract, trichiasis, and trachoma); $315•12 for caesarean deliveries; and $381•15 for orthopaedic surgery. Rather than relying on these figures in isolation, or applying WHO’s standard measures of what is “cost-effective” (one-to-three times greater than a country’s gross domestic product [GDP] per head) and “very cost-effective” (less than a country’s GDP per head), Chao and colleagues go a step further and compare these ratios against those for interventions with existing donor and government support—ie, vaccines of the Expanded Program on Immunization, bednets, BCG vaccinations, and HIV treatment. All the median values for the surgical procedures studied were well within the cost range of these accepted interventions, nicely showing that surgery is a valuable addition to the toolbox of global health policy and practice.
Maternal deaths have also been in the headlines over recent weeks, with WHO and the Institute for Health Metrics and Evaluation (IHME) both releasing new estimates for 2013. While methods differed, and it is instructive to have these alternative measurements, the number of women estimated to have died in 2013 during pregnancy or shortly after childbirth were remarkably similar: 289 000 according to WHO and 293 000 according to IHME. The findings on why mothers die, however, were not so consistent. WHO’s analysis of the causes of maternal death are published in The Lancet Global Health this month, and put indirect causes such as diabetes, malaria, HIV, and obesity on a par with haemorrhage as the major causes of maternal mortality (around 27% of deaths each), with hypertension (14%) and sepsis (11%) the next most important contributors. The IHME findings indicate that indirect causes only accounted for around 10% of deaths, with hypertension at 12% and sepsis 9%. Abortion and “other direct causes” accounted for the most deaths according to IHME (around 17% each), with haemorrhage at around 14%. The Lancet Global Health paper includes a useful panel that unpicks some of the common problems encountered when classifying cause of maternal death, which undoubtedly account for some of these differences. The main policy recommendation, then, is for data collection to be improved. Any death in pregnancy is a tragedy and ought to be recorded with the utmost care.

Comment
Essential surgery is cost effective in resource-poor countries
Elliot Marseille, Saam Morshed
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In this issue of The Lancet Global Health, Tiffany Chao and colleagues present a systematic, comprehensive, and critical assessment of published estimates of the cost-effectiveness of essential surgery,1 and thus make an important contribution to the published work on the economics of global health interventions. Their headline finding is that a wide range of surgical interventions are cost effective across a wide range of settings in low-income and middle-income countries, and are competitive with other accepted and broadly implemented interventions.

Cost-effectiveness of surgery and its policy implications for global health: a systematic review and analysis
Dr Tiffany E Chao MD a b, Ketan Sharma MD a c, Morgan Mandigo MSc a d e, Lars Hagander MD a f g, Stephen C Resch PhD h, Thomas G Weiser MD i, John G Meara MD a c d
Summary
Background
The perception of surgery as expensive and complex might be a barrier to its widespread acceptance in global health efforts. We did a systematic review and analysis of cost-effectiveness studies that assess surgical interventions in low-income and middle-income countries to help quantify the potential value of surgery.
Methods
We searched Medline for all relevant articles published between Jan 1, 1996 and Jan 31, 2013, and searched the reference lists of retrieved articles. We converted all results to 2012 US$. We extracted cost-effectiveness ratios (CERs) and appraised economic assessments for their methodological quality using the 10-point Drummond checklist.
Findings
Of the 584 identified studies, 26 met full inclusion criteria. Together, these studies gave 121 independent CERs in seven categories of surgical interventions. The median CER of circumcision ($13•78 per disability-adjusted life year [DALY]) was similar to that of standard vaccinations ($12•96—25•93 per DALY) and bednets for malaria prevention ($6•48—22•04 per DALY). Median CERs of cleft lip or palate repair ($47•74 per DALY), general surgery ($82•32 per DALY), hydrocephalus surgery ($108•74 per DALY), and ophthalmic surgery ($136 per DALY) were similar to that of the BCG vaccine ($51•86—220•39 per DALY). Median CERs of caesarean sections ($315•12 per DALY) and orthopaedic surgery ($381•15 per DALY) are more favourable than those of medical treatment for ischaemic heart disease ($500•41—706•54 per DALY) and HIV treatment with multidrug antiretroviral therapy ($453•74—648•20 per DALY).
Interpretation
Our findings suggest that many essential surgical interventions are cost-effective or very cost-effective in resource-poor countries. Quantification of the economic value of surgery provides a strong argument for the expansion of global surgery’s role in the global health movement. However, economic value should not be the only argument for resource allocation—other organisational, ethical, and political arguments can also be made for its inclusion.
Funding
Massachusetts General Hospital Department of Surgery, Boston Children’s Hospital, and Stanford University Department of Surgery