{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,31]],"date-time":"2026-10-31T14:41:00Z","timestamp":1793457660899,"version":"4.5.0"},"reference-count":64,"publisher":"BMJ","issue":"2","license":[{"start":{"date-parts":[[2026,2,18]],"date-time":"2026-02-18T00:00:00Z","timestamp":1771372800000},"content-version":"unspecified","delay-in-days":17,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100019902","name":"Fakultet for medisin og helsevitenskap, Norges Teknisk-Naturvitenskapelige Universitet","doi-asserted-by":"publisher","award":["90369500"],"award-info":[{"award-number":["90369500"]}],"id":[{"id":"10.13039\/100019902","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,1,16]]},"published-print":{"date-parts":[[2026,2]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>To assess anaesthesia capacity and practice in Sierra Leone by enumerating the anaesthesia workforce by volume, training level and distribution across urban and rural areas and facility ownership; estimating the prevalence of anaesthesia methods used for common surgical procedures by provider category; and evaluating hospital infrastructure and the availability of essential anaesthesia-related medications and equipment.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>A nationwide, cross-sectional, facility-based study combining structured questionnaires administered through face-to-face interviews with facility leads and retrospective review of surgical and anaesthesia logbooks.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>Public and private hospitals and clinics in Sierra Leone providing surgical care with general, regional or local anaesthesia within an operating theatre.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>69 of 78 eligible surgical facilities nationwide were included. Facilities providing surgical services between September 2022 and August 2023 were eligible; facilities without registries or declining participation were excluded.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Across participating facilities, the anaesthesia workforce comprised 198 full-time positions, predominantly non-physician providers, with only 40.4% (80\/198) trained to administer anaesthesia independently. Ketamine-based and spinal anaesthesia were most common, while general anaesthesia with a protected airway accounted for just 5.0% (415\/8339) of procedures. Anaesthesia practices varied by provider training level. Essential infrastructure, equipment and medications fell below international minimum standards, with shortages most pronounced in rural facilities.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Severe shortages of certified anaesthesia providers, limited anaesthesia techniques and inadequate material resources remain major barriers to safe anaesthesia and surgical care in Sierra Leone. Targeted investments in workforce development, infrastructure and resource allocation\u2014particularly in rural areas\u2014are required to improve the safety, quality and equity of anaesthesia care nationwide.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-109326","type":"journal-article","created":{"date-parts":[[2026,2,18]],"date-time":"2026-02-18T15:10:43Z","timestamp":1771427443000},"page":"e109326","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Anaesthesia workforce distribution, practices and essential resources in Sierra Leone: a nationwide, cross-sectional, facility-based study"],"prefix":"10.1136","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0009-0002-1608-5232","authenticated-orcid":false,"given":"Elisabeth","family":"\u00d8vre\u00e5s","sequence":"first","affiliation":[{"name":"Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eric","family":"Vreede","sequence":"additional","affiliation":[{"name":"Teaching Hospitals Complex, Anaesthesia, University of Sierra Leone, Freetown, Sierra Leone"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6943-0100","authenticated-orcid":false,"given":"Alex J","family":"van Duinen","sequence":"additional","affiliation":[{"name":"Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway"},{"name":"CapaCare, Masanga, Sierra Leone and Trondheim, Norway"},{"name":"Clinic of Surgery, St Olav\u2019s Hospital HF, Trondheim, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-7018-8489","authenticated-orcid":false,"given":"Maria","family":"Svengaard","sequence":"additional","affiliation":[{"name":"Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-6046-567X","authenticated-orcid":false,"given":"Mali Eggen","family":"Furre","sequence":"additional","affiliation":[{"name":"Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Augustine Kamanda","family":"Kamara","sequence":"additional","affiliation":[{"name":"CapaCare, Masanga, Sierra Leone and Trondheim, Norway"},{"name":"Government of Sierra Leone Ministry of Health and Sanitation, Freetown, Sierra Leone"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Denis Akar","family":"Sesay","sequence":"additional","affiliation":[{"name":"CapaCare, Masanga, Sierra Leone and Trondheim, Norway"},{"name":"Government of Sierra Leone Ministry of Health and Sanitation, Freetown, Sierra Leone"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5613-6140","authenticated-orcid":false,"given":"Herman","family":"Lonn\u00e9e","sequence":"additional","affiliation":[{"name":"Department of Anaesthesiology and Intensive Care, St Olav\u2019s Hospital HF, Trondheim, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4984-9278","authenticated-orcid":false,"given":"Priyansh","family":"Nathani","sequence":"additional","affiliation":[{"name":"Programme for Global Surgery & Trauma, The George Institute for Global Health India, New Delhi, Delhi, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mustapha S","family":"Kabba","sequence":"additional","affiliation":[{"name":"Government of Sierra Leone Ministry of Health and Sanitation, Freetown, Sierra Leone"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9609-4093","authenticated-orcid":false,"given":"Hakon Angell","family":"Bolkan","sequence":"additional","affiliation":[{"name":"Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway"},{"name":"CapaCare, Masanga, Sierra Leone and Trondheim, Norway"},{"name":"Clinic of Surgery, St Olav\u2019s Hospital HF, Trondheim, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,2,18]]},"reference":[{"key":"2026021807101410000_16.2.e109326.1","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(15)60160-X"},{"key":"2026021807101410000_16.2.e109326.2","doi-asserted-by":"publisher","DOI":"10.1007\/s00268-015-3153-y"},{"key":"2026021807101410000_16.2.e109326.3","doi-asserted-by":"crossref","first-page":"981","DOI":"10.1213\/ANE.0000000000002258","article-title":"The WFSA Global Anesthesia Workforce Survey","volume":"125","author":"Kempthorne","year":"2017","journal-title":"Anesth Analg"},{"key":"2026021807101410000_16.2.e109326.4","doi-asserted-by":"crossref","first-page":"404","DOI":"10.1111\/aas.13736","article-title":"A survey of anaesthesia practices at all hospitals performing caesarean sections in Sierra Leone","volume":"65","author":"Lonn\u00e9e","year":"2021","journal-title":"Acta Anaesthesiol Scand"},{"key":"2026021807101410000_16.2.e109326.5","doi-asserted-by":"crossref","first-page":"213","DOI":"10.1213\/ANE.0000000000001285","article-title":"Anesthesia Practice and Perioperative Outcomes at Two Tertiary Care Hospitals in Freetown, Sierra Leone","volume":"123","author":"Koka","year":"2016","journal-title":"Anesth Analg"},{"key":"2026021807101410000_16.2.e109326.6","doi-asserted-by":"crossref","first-page":"237","DOI":"10.1001\/jamasurg.2014.2246","article-title":"An assessment of surgical and anesthesia staff at 10 government hospitals in Sierra Leone","volume":"150","author":"Vaughan","year":"2015","journal-title":"JAMA Surg"},{"key":"2026021807101410000_16.2.e109326.7","doi-asserted-by":"publisher","DOI":"10.1001\/archsurg.2008.540"},{"key":"2026021807101410000_16.2.e109326.8","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(12)60990-8"},{"key":"2026021807101410000_16.2.e109326.9","unstructured":"Statistics Sierra Leone Stats SL . 2021 mid-term population and housing census - December 10, 2021. Freetown, Sierra Leone Statistics Sierra Leone; 2018. Available: https:\/\/www.statistics.sl\/index.php\/census\/mid-term-population-census.html [accessed 30 May 2023]"},{"key":"2026021807101410000_16.2.e109326.10","unstructured":"United Nations . Sustainable development goals. Country profile. Sierra Leone, New York: United Nations, Department of Economic and Social Affairs, Statistics, SDG Indicators Database; 2025. Available: https:\/\/unstats.un.org\/sdgs\/dataportal\/countryprofiles\/SLE#goal-3"},{"key":"2026021807101410000_16.2.e109326.11","unstructured":"United Nations Development Programme . Human development reports. Sierra Leone, New York UNDP; 2025. Available: https:\/\/hdr.undp.org\/data-center\/specific-country-data#\/countries\/SLE [accessed 12 Dec 2025]"},{"key":"2026021807101410000_16.2.e109326.12","unstructured":"World Health Organization . Health expenditure profile. Selected country. Sierra Leone WHO, Global Health Expenditure Database; 2023. Available: https:\/\/apps.who.int\/nha\/database\/country_profile\/Index\/en"},{"key":"2026021807101410000_16.2.e109326.13","unstructured":"Ministry of Health and Sanitation, Sierra Leone . Summary report of the 2017 SARA plus in Sierra Leone: service availability and readiness assessment (SARA), quality of care survey, and data quality review. Freetown, Sierra Leone, 2017. Available: https:\/\/mohs2017.files.wordpress.com\/2018\/05\/mohs-sierra-leone_sara-report_final.pdf [accessed 10 Jun 2023]"},{"key":"2026021807101410000_16.2.e109326.14","doi-asserted-by":"crossref","first-page":"1315","DOI":"10.1002\/bjs.10552","article-title":"Safety, productivity and predicted contribution of a surgical task-sharing programme in Sierra Leone","volume":"104","author":"Bolkan","year":"2017","journal-title":"Br J Surg"},{"key":"2026021807101410000_16.2.e109326.15","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2021-056784","article-title":"Barriers to increase surgical productivity in Sierra Leone: a qualitative study","volume":"11","author":"Bakker","year":"2021","journal-title":"BMJ Open"},{"key":"2026021807101410000_16.2.e109326.16","doi-asserted-by":"crossref","DOI":"10.1186\/s12992-018-0447-5","article-title":"Health sector fragmentation: three examples from Sierra Leone","volume":"15","author":"Barr","year":"2019","journal-title":"Global Health"},{"key":"2026021807101410000_16.2.e109326.17","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2024-018423","article-title":"The impact of surgical task-sharing in Sierra Leone: a nationwide longitudinal observational study on surgical workforce and volume, 2012-2023","volume":"10","author":"Furre","year":"2025","journal-title":"BMJ Glob Health"},{"key":"2026021807101410000_16.2.e109326.18","doi-asserted-by":"crossref","first-page":"1028","DOI":"10.4314\/ahs.v15i3.43","article-title":"Assessing unmet anaesthesia need in Sierra Leone: a secondary analysis of a cluster-randomized, cross-sectional, countrywide survey","volume":"15","author":"Harris","year":"2015","journal-title":"Afr H Sci"},{"key":"2026021807101410000_16.2.e109326.19","doi-asserted-by":"publisher","DOI":"10.1016\/j.surg.2014.12.028"},{"key":"2026021807101410000_16.2.e109326.20","doi-asserted-by":"crossref","first-page":"126","DOI":"10.1016\/j.surg.2021.02.043","article-title":"Changes in surgical volume, workforce, and productivity in Sierra Leone between 2012 and 2017","volume":"170","author":"Lindheim-Minde","year":"2021","journal-title":"Surgery"},{"key":"2026021807101410000_16.2.e109326.21","unstructured":"Surgical assessment tool (SAT) hospital walkthrough. Geneva World Health Organization; 2018. Available: https:\/\/cdn.who.int\/media\/docs\/default-source\/integrated-health-services-(ihs)\/csy\/surgical-care\/who_surgical_assessment_tool.pdf?sfvrsn=739788e4_7&Status=Master [accessed 02 Jan 2024]"},{"key":"2026021807101410000_16.2.e109326.22","unstructured":"Anaesthesia Facility Assessment Tool (AFAT). London, UK World Federation of Societies of Anaesthesiologists (WFSA); 2018. Available: https:\/\/wfsahq.org\/wp-content\/uploads\/wfsa-anaesthesia-facility-assessment-tool.pdf [accessed 03 Feb 2024]"},{"key":"2026021807101410000_16.2.e109326.23","doi-asserted-by":"publisher","DOI":"10.1213\/ane.0000000000002927"},{"key":"2026021807101410000_16.2.e109326.24","unstructured":"The World Bank . Africa health service delivery in Sierra Leone. Results of 2018 service delivery indicator survey. 2018. Available: https:\/\/share.google\/zTyAvxqgf6qFAYvjS"},{"key":"2026021807101410000_16.2.e109326.25","unstructured":"Ministry of Health and Sanitation Sierra Leone . Human resources for health country profile (2016). Freetown, Sierra Leone Ministry of Health and Sanitation; 2016. Available: https:\/\/www.afro.who.int\/publications\/human-resources-health-country-profile-2016 [accessed 12 Apr 2024]"},{"key":"2026021807101410000_16.2.e109326.26","unstructured":"Human resources for health strategy 2017-2021. Freetown, Sierra Leone Ministry of Health and Sanitation Sierra Leone; 2017. Available: https:\/\/www.afro.who.int\/sites\/default\/files\/2017-05\/hrhstrategy2017.pdf [accessed 05 Dec 2023]"},{"key":"2026021807101410000_16.2.e109326.27","doi-asserted-by":"crossref","first-page":"1246","DOI":"10.1002\/bjs5.50349","article-title":"Impact of surgical infrastructure and personnel on volume and availability of essential surgical procedures in Liberia","volume":"4","author":"Adde","year":"2020","journal-title":"BJS Open"},{"key":"2026021807101410000_16.2.e109326.28","unstructured":"Mock C , Lormand JD , Goosen J , et al . Guidelines for essential trauma care. Geneva World Health Organization; 2004. Available: https:\/\/iris.who.int\/bitstream\/handle\/10665\/42565\/9241546409_eng.pdf?sequence=1"},{"key":"2026021807101410000_16.2.e109326.29","unstructured":"World Health Organization . WHO generic essential emergency equipment list. 2012. Available: https:\/\/cdn.who.int\/media\/docs\/default-source\/integrated-health-services-(ihs)\/csy\/surgical-care\/eeegenericlist_revaug2012.pdf"},{"key":"2026021807101410000_16.2.e109326.30","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2018-001005","article-title":"What is the minimum number of specialist anaesthetists needed in low-income and middle-income countries?","volume":"3","author":"Davies","year":"2018","journal-title":"BMJ Glob Health"},{"key":"2026021807101410000_16.2.e109326.31","doi-asserted-by":"publisher","DOI":"10.1007\/s00268-009-0192-2"},{"key":"2026021807101410000_16.2.e109326.32","doi-asserted-by":"crossref","DOI":"10.1186\/s12960-017-0248-6","article-title":"Bridging the human resource gap in surgical and anesthesia care in low-resource countries: a review of the task sharing literature","volume":"15","author":"Ashengo","year":"2017","journal-title":"Hum Resour Health"},{"key":"2026021807101410000_16.2.e109326.33","doi-asserted-by":"crossref","unstructured":"Craven R , Edgcombe H , Gupta B , eds. Global anaesthesia, oxford specialist handbooks in anaesthesia. Oxford: Oxford University Press, 2020.","DOI":"10.1093\/med\/9780198809821.001.0001"},{"key":"2026021807101410000_16.2.e109326.34","doi-asserted-by":"crossref","first-page":"611","DOI":"10.7196\/SAMJ.2017.v107i7.12056","article-title":"Management of failed spinal anaesthesia for caesarean section","volume":"107","author":"Jones","year":"2017","journal-title":"S Afr Med J"},{"key":"2026021807101410000_16.2.e109326.35","doi-asserted-by":"crossref","first-page":"e513","DOI":"10.1016\/S2214-109X(19)30036-1","article-title":"Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study","volume":"7","author":"Bishop","year":"2019","journal-title":"Lancet Glob Health"},{"key":"2026021807101410000_16.2.e109326.36","doi-asserted-by":"crossref","first-page":"1229","DOI":"10.4314\/ahs.v20i3.26","article-title":"Type of anaesthesia for caesarean section and failure rate in Princess Marina Hospital, Botswana\u2019s largest referral hospital","volume":"20","author":"Kassa","year":"2020","journal-title":"Afr Health Sci"},{"key":"2026021807101410000_16.2.e109326.37","doi-asserted-by":"crossref","first-page":"2056","DOI":"10.1213\/ANE.0000000000002733","article-title":"Anesthesia for Cesarean Delivery: A Cross-Sectional Survey of Provincial, District, and Mission Hospitals in Zimbabwe","volume":"126","author":"Lonn\u00e9e","year":"2018","journal-title":"Anesth Analg"},{"key":"2026021807101410000_16.2.e109326.38","doi-asserted-by":"crossref","first-page":"e320","DOI":"10.1016\/S2214-109X(16)30003-1","article-title":"Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis","volume":"4","author":"Sobhy","year":"2016","journal-title":"Lancet Glob Health"},{"key":"2026021807101410000_16.2.e109326.39","doi-asserted-by":"crossref","first-page":"81","DOI":"10.7196\/SAMJ.6308","article-title":"\u201cBut it\u2019s just a spinal\u201d: combating increasing rates of maternal death related to spinal anaesthesia","volume":"103","author":"Farina","year":"2012","journal-title":"S Afr Med J"},{"key":"2026021807101410000_16.2.e109326.40","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijoa.2015.06.008"},{"key":"2026021807101410000_16.2.e109326.41","doi-asserted-by":"crossref","first-page":"965","DOI":"10.4103\/ija.IJA_756_19","article-title":"The path to safe and accessible anaesthesia care","volume":"63","author":"Law","year":"2019","journal-title":"Indian J Anaesth"},{"key":"2026021807101410000_16.2.e109326.42","doi-asserted-by":"crossref","first-page":"103646","DOI":"10.1016\/j.ijoa.2023.103646","article-title":"Global obstetric anaesthesia: bridging the gap in maternal health care inequities through partnership in education","volume":"55","author":"Fernandes","year":"2023","journal-title":"Int J Obstet Anesth"},{"key":"2026021807101410000_16.2.e109326.43","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1016\/j.bpa.2012.02.004","article-title":"Developing a curriculum for anaesthesia training in low- and middle-income countries","volume":"26","author":"Dubowitz","year":"2012","journal-title":"Best Pract Res Clin Anaesthesiol"},{"key":"2026021807101410000_16.2.e109326.44","unstructured":"Livingston P , Nyirigira G , Mossenson A . Anesthesia curriculum design for the global setting. In: Update in anaesthesia world federation of societies of anaesthesiologists, 36. 2022: 54\u20139."},{"key":"2026021807101410000_16.2.e109326.45","doi-asserted-by":"crossref","first-page":"1291","DOI":"10.1213\/ANE.0000000000002722","article-title":"Strengthening the Anesthesia Workforce in Low- and Middle-Income Countries","volume":"126","author":"Kudsk-Iversen","year":"2018","journal-title":"Anesth Analg"},{"key":"2026021807101410000_16.2.e109326.46","doi-asserted-by":"crossref","DOI":"10.1186\/s12909-016-0781-3","article-title":"Specialty preferences among final year medical students in medical schools of southeast Nigeria: need for career guidance","volume":"16","author":"Ossai","year":"2016","journal-title":"BMC Med Educ"},{"key":"2026021807101410000_16.2.e109326.47","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2018-026218","article-title":"Training non-physician anaesthetists in sub-Saharan Africa: a qualitative investigation of providers\u2019 perspectives","volume":"9","author":"Edgcombe","year":"2019","journal-title":"BMJ Open"},{"key":"2026021807101410000_16.2.e109326.48","doi-asserted-by":"crossref","first-page":"908","DOI":"10.1213\/ANE.0000000000001104","article-title":"The Role of Ketamine in Low- and Middle-Income Countries: What Would Happen if Ketamine Becomes a Scheduled Drug?","volume":"122","author":"Joshi","year":"2016","journal-title":"Anesth Analg"},{"key":"2026021807101410000_16.2.e109326.49","doi-asserted-by":"crossref","DOI":"10.1186\/s12913-024-11040-w","article-title":"The impact of scheduling ketamine as an internationally controlled substance on anaesthesia care in Sub-Saharan Africa: a case study and key informant interviews","volume":"24","author":"Ooms","year":"2024","journal-title":"BMC Health Serv Res"},{"key":"2026021807101410000_16.2.e109326.50","unstructured":"World Health Organization Sierra Leone . National essential medicines list Sierra Leone 2021 edition. 2021. Available: https:\/\/share.google\/RByUuo0FjhJzlB1by"},{"key":"2026021807101410000_16.2.e109326.51","unstructured":"Ministry of Health and Sanitation Sierra Leone . Sierra Leone basic package of essential health services 2015 -2020 Freetown, Sierra Leone governement of Sierra Leone, ministry of health and sanitation Sierra Leone. 2015. Available: https:\/\/mohs2017.wordpress.com\/wp-content\/uploads\/2017\/06\/gosl_2015_basic-package-of-essential-health-services-2015-2020.pdf [Accessed 22 Apr 2024]."},{"key":"2026021807101410000_16.2.e109326.52","doi-asserted-by":"crossref","unstructured":"Raykar NP , Makin J , Khajanchi M , et al . Assessing the global burden of hemorrhage: The global blood supply, deficits, and potential solutions. SAGE Open Med 2021;9. doi:10.1177\/20503121211054995","DOI":"10.1177\/20503121211054995"},{"key":"2026021807101410000_16.2.e109326.53","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2019-001605","article-title":"The rate and perioperative mortality of caesarean section in Sierra Leone","volume":"4","author":"Holmer","year":"2019","journal-title":"BMJ Glob Health"},{"key":"2026021807101410000_16.2.e109326.54","doi-asserted-by":"crossref","first-page":"1025","DOI":"10.1007\/s00268-016-3430-4","article-title":"Anesthesia Care Capacity at Health Facilities in 22 Low- and Middle-Income Countries","volume":"40","author":"Hadler","year":"2016","journal-title":"World J Surg"},{"key":"2026021807101410000_16.2.e109326.55","doi-asserted-by":"publisher","DOI":"10.1007\/s00520-011-1200-2"},{"key":"2026021807101410000_16.2.e109326.56","article-title":"Evaluating Rapid-cycle Deliberate Practice Versus Mastery Learning in Training Nurse Anesthetists on the Universal Anaesthesia Machine Ventilator in Sierra Leone","volume":"23","author":"Tomobi","year":"2021","journal-title":"J Educ Perioper Med"},{"key":"2026021807101410000_16.2.e109326.57","unstructured":"World Health Organization . Increasing access to health workers in remote and rural areas through improved retention. Global policy recommendations. World Health Organizatio; 2010. Available: https:\/\/iris.who.int\/bitstream\/handle\/10665\/44369\/9789241564014_eng.pdf?sequence=1"},{"key":"2026021807101410000_16.2.e109326.58","doi-asserted-by":"crossref","first-page":"1049","DOI":"10.1213\/ANE.0000000000001988","article-title":"The Need for a Global Perspective on Task-Sharing in Anesthesia","volume":"125","author":"Lipnick","year":"2017","journal-title":"Anesth Analg"},{"key":"2026021807101410000_16.2.e109326.59","unstructured":"United Nations Institute for Training and Research (UNITAR) . National surgical, obstetric and anaesthesia planning manual. Edition 2020. Geneva, Switzerland United Nations Institute for Training and Research (UNITAR); 2000. Available: https:\/\/doi.org\/10.5281\/zenodo.3982869 [accessed 20 Mar 2024]"},{"key":"2026021807101410000_16.2.e109326.60","unstructured":"Citron I , Meara JG . A global surgery, obstetrics and anaesthesia metamorphosis. SAFE-T summit 2018 reports. SAFE-T summit 2018 reports, 33. 2019.6\u20138. Available: https:\/\/resources.wfsahq.org\/wp-content\/uploads\/uia33-A-global-surgery-obstetrics-and-anaesthesia-metamorphosis.pdf"},{"key":"2026021807101410000_16.2.e109326.61","doi-asserted-by":"crossref","DOI":"10.1186\/s12992-019-0531-5","article-title":"Globalization of national surgical, obstetric and anesthesia plans: the critical link between health policy and action in global surgery","volume":"16","author":"Truch\u00e9","year":"2020","journal-title":"Global Health"},{"key":"2026021807101410000_16.2.e109326.62","unstructured":"Ministry of Health Sierra Leone . National surgical, obstetric and anaesthesia plan 2026-2030. \u201cScaling quality surgical care saves lives and boosts economic development: a resilient NSOAP for Sierra Leone\u2019s future\u201d. Sierra Leone Ministry of Health; 2026."},{"key":"2026021807101410000_16.2.e109326.63","doi-asserted-by":"publisher","DOI":"10.1002\/bjs.11061"},{"key":"2026021807101410000_16.2.e109326.64","doi-asserted-by":"crossref","unstructured":"Debas HT , Donkor P , Gawande A , eds. Essential surgery: disease control priorities, third edition (volume 1). Washington (DC), 2015.","DOI":"10.1596\/978-1-4648-0346-8"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2025-109326","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,18]],"date-time":"2026-02-18T15:10:58Z","timestamp":1771427458000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2025-109326"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2]]},"references-count":64,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2026,2,18]]},"published-print":{"date-parts":[[2026,2]]}},"alternative-id":["10.1136\/bmjopen-2025-109326"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2025-109326","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2]]}}}