{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,18]],"date-time":"2025-10-18T20:58:24Z","timestamp":1760821104807,"version":"3.40.5"},"reference-count":36,"publisher":"Wiley","issue":"4","license":[{"start":{"date-parts":[[2019,9,12]],"date-time":"2019-09-12T00:00:00Z","timestamp":1568246400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"funder":[{"DOI":"10.13039\/100000200","name":"United States Agency for International Development","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100000200","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100000269","name":"Economic and Social Research Council","doi-asserted-by":"publisher","award":["ES\/I903224\/1"],"award-info":[{"award-number":["ES\/I903224\/1"]}],"id":[{"id":"10.13039\/501100000269","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100000278","name":"Department for International Development","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100000278","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Birth"],"published-print":{"date-parts":[[2019,12]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Background<\/jats:title><jats:p>The Unmet Obstetric Need (UON) indicator has been widely used to estimate unmet need for life\u2010saving surgery at birth; however, its assumptions have not been verified. The objective of this study was to test two UON assumptions: (a) Absolute maternal indications (AMIs) require surgery for survival and (b) 1%\u20102% of deliveries develop AMIs, implying that rates of surgeries for AMIs below this threshold indicate excess mortality from these complications.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>We used linked hospital and population\u2010based data in central Ghana. Among hospital deliveries, we calculated the percentage of deliveries with AMIs who received surgery, and mortality among AMIs who did not. At the population level, we assessed whether the percentage of deliveries with surgeries for AMIs was inversely associated with mortality from these complications, stratified by education.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>A total of 380 of 387 (98%) hospital deliveries with recorded AMIs received surgery; an additional eight women\u00a0with no AMI diagnosis died of AMI\u2010related causes. Among the 50\u00a0148 deliveries in the population, surgeries for AMIs increased from 0.6% among women with no education to 1.9% among women with post\u2010secondary education (<jats:italic>P<\/jats:italic>\u00a0&lt;\u00a0.001). However, there was no association between AMI\u2010related mortality and education (<jats:italic>P<\/jats:italic>\u00a0=\u00a0.546). Estimated AMI prevalence was 0.84% (95% CI: 0.76%\u20100.92%), below the assumed 1% minimum threshold.<\/jats:p><\/jats:sec><jats:sec><jats:title>Discussion<\/jats:title><jats:p>Obstetric providers consider AMIs absolute indications for surgery. However, low rates of surgeries for AMIs among less educated women were not associated with higher mortality. The UON indicator should be used with caution in estimating the unmet need for life\u2010saving obstetric surgery; innovative approaches are needed to identify unmet need in the context of rising cesarean rates.<\/jats:p><\/jats:sec>","DOI":"10.1111\/birt.12452","type":"journal-article","created":{"date-parts":[[2019,9,12]],"date-time":"2019-09-12T11:05:04Z","timestamp":1568286304000},"page":"638-647","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Testing the assumptions of an indicator of unmet need for obstetric surgery in Ghana: A cross\u2010sectional study of linked hospital and population\u2010based delivery data"],"prefix":"10.1111","volume":"46","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9641-8780","authenticated-orcid":false,"given":"Francesca L.","family":"Cavallaro","sequence":"first","affiliation":[{"name":"Institut de Recherche pour le D\u00e9veloppement Institut de Recherche pour le D\u00e9veloppement Paris France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lisa S.","family":"Hurt","sequence":"additional","affiliation":[{"name":"Cardiff University Cardiff UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jenny A.","family":"Cresswell","sequence":"additional","affiliation":[{"name":"London School of Hygiene &amp; Tropical Medicine London UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Karen","family":"Edmond","sequence":"additional","affiliation":[{"name":"King's College London London UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Seeba","family":"Amenga\u2010Etego","sequence":"additional","affiliation":[{"name":"Kintampo Health Research Centre Kintampo Ghana"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Betty R.","family":"Kirkwood","sequence":"additional","affiliation":[{"name":"London School of Hygiene &amp; Tropical Medicine London UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Carine","family":"Ronsmans","sequence":"additional","affiliation":[{"name":"London School of Hygiene &amp; Tropical Medicine London UK"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2019,9,12]]},"reference":[{"key":"e_1_2_6_2_1","unstructured":"WHO.WHO statement on caesarean section rates.2015.http:\/\/apps.who.int\/iris\/bitstream\/10665\/161442\/1\/WHO_RHR_15.02_eng.pdf?ua=1. Accessed November 3 2017."},{"key":"e_1_2_6_3_1","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0152779"},{"key":"e_1_2_6_4_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1365-3016.2007.00786.x"},{"issue":"4","key":"e_1_2_6_5_1","first-page":"161","article-title":"Caesarean section in the world: a new ecological approach","volume":"52","author":"Zizza A","year":"2011","journal-title":"J Prev Med Hyg"},{"key":"e_1_2_6_6_1","doi-asserted-by":"publisher","DOI":"10.1590\/S1020-49892011000500001"},{"key":"e_1_2_6_7_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1471-0528.2004.00247.x"},{"key":"e_1_2_6_8_1","doi-asserted-by":"publisher","DOI":"10.2471\/BLT.13.117598"},{"key":"e_1_2_6_9_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(14)60789-3"},{"key":"e_1_2_6_10_1","unstructured":"Unmet Obstetric Need Network.Tackling unmet need for major obstetric interventions. Concepts General Principles and International Network.2000.http:\/\/www.uonn.org\/pdf\/Guide1.pdf. Accessed February 15 2017."},{"volume-title":"Les Besoins Obst\u00e9tricaux Non Couverts","year":"1998","author":"De Brouwere V","key":"e_1_2_6_11_1"},{"key":"e_1_2_6_12_1","doi-asserted-by":"publisher","DOI":"10.1046\/j.1365-3156.1998.00276.x"},{"key":"e_1_2_6_13_1","unstructured":"Unmet Obstetric Need Network.L'approche des Besoins Obst\u00e9tricaux Non Couverts pour les Interventions Obst\u00e9tricales Majeures \u2010 Etude comparative B\u00e9nin Burkina\u2010Faso Ha\u00efti Mali Maroc Niger Pakistan et Tanzanie.http:\/\/www.uonn.org\/wp-content\/uploads\/2016\/08\/ENGINTC00.pdf. Accessed November 3 2017."},{"key":"e_1_2_6_14_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1365-3156.2007.01909.x"},{"key":"e_1_2_6_15_1","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2393-7-16"},{"key":"e_1_2_6_16_1","unstructured":"Unmet Obstetric Need Network.Final report \u2010 part I. Synthesis.http:\/\/wwwuonnorg\/pdf\/Final%20UON%20report%20definitifpdf. Accessed February 15 2017."},{"key":"e_1_2_6_17_1","doi-asserted-by":"publisher","DOI":"10.1093\/heapol\/czh049"},{"key":"e_1_2_6_18_1","unstructured":"BossynsP Miy\u00e9H DepoorterAM Van LerbergheW.Unmet need for obstetric interventions in Niger: between failing referral systems and inadequate management of human resources. [Unpublished]."},{"key":"e_1_2_6_19_1","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0145196"},{"key":"e_1_2_6_20_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12939-014-0112-4"},{"key":"e_1_2_6_21_1","unstructured":"DieltiensG DewanH BotleroR BiswasK BegumSN ShahjahanM.Met need for life\u2010saving obstetric surgery in Bangladesh. 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