Survey of surgical emergencies in a rural population in the Northern Areas of Pakistan

Tropical Medicine and International Health

volume 4 no 12 pp 846–857 december 1999

© 1999 Blackwell Science Ltd846

Survey of surgical emergencies in a rural population in theNorthern Areas of Pakistan

Mushtaq Ahmed1, Mehboob Ali Shah2, Stephen Luby2, Philomena Drago-Johnson3 and Sifat Wali4

1 Department of Surgery, The Aga Khan University, Karachi, Pakistan

2 Department of Community Health Sciences, The Aga Khan University, Karachi, Pakistan

3 Kunri Christian Hospital, Kunri, Pakistan

4 Aga Khan Health Services (AKHS), Gilgit, Pakistan

Summary objective To determine the incidence of specific surgical emergencies in a mountainous rural community

in the Northern Areas of Pakistan and to assess use of existing health services, and outcomes related to acute

surgical illness events.

method A cross-sectional population-based survey was conducted. Interviewers visited each of 118 villages

in the study area (population 100000), selected a random sample from a total of 9900 households, and inter-

viewed the oldest premenopausal female member (n 5 836). Questions were focused on injury, acute

abdomen, and/or maternal morbidity occurring in the past year. Cases were included as surgical emergencies

when one or more index clinical features indicating a potential for surgical intervention were present.

Mortality from a wider range of surgical emergencies was also elicited based on the respondent’s lifetime

knowledge of the household.

results The incidence rates were 1531/100000 persons per year for injuries; 1364/100000 for acute

abdomen, and 16462/100000 for maternal morbidity. The rate of injuries was 2.7 times higher and that of

acute abdomen twice as high in males as in females. The injury rate decreased with advancing age, being 13

times higher in children , 5 years than in adults . 40. By contrast, the rate for acute abdomen showed a rise

with advancing age, being 8 times higher in the . 40 age group than in under-fives. Burns, falls and road

accidents, in that order, were the commonest forms of injury accounting for 82% of 138 cases. Of 43 burn

casualties, 46% were in the age group , 5 years; there was no gender bias. Of 71 casualties from falls and

road accidents, 85% were aged 6–40 years; there was 6 : 1 male predominance. The maternal morbidity rate

was highest in the age group 25–35 years and may be attributed to the high pregnancy rate in this age

bracket. Of 408 patients with acute surgical illness, 85% were managed initially at home or close to home in

a health centre, dispensary or civil hospital; 32% eventually sought specialist surgical care. The overall rate

for minor and major surgical procedures was 411/100000 persons per year (lowest estimate), and appeared to

be low. The rate of operative deliveries at 11.8/1000 deliveries (lowest estimate) was particularly low. The

mortality rates were correspondingly high: 55/100000 persons per year for injuries and for acute abdomen

(lowest estimates). The maternal mortality ratio was particularly high at 8.9/1000 deliveries (lowest esti-

mate). Annual mortality rates derived from deaths recalled during the respondent’s lifetime in the household

(mean period 5 26 years), tended to corroborate the results of the 1-year survey.

conclusion The incidence rates for broad categories of serious acute surgical illness in the study popula-

tion far exceeded the rates of acute surgical intervention. Mortality rates were correspondingly high. Such

evidence points to a large unmet surgical need and ought to spur improvements in the health service.

keywords cross-sectional studies, surgical emergencies, rural populations, Pakistan

correspondence Dr Mushtaq Ahmed, Department of Surgery, The Aga Khan University, Karachi,

Pakistan. E-mail: [email protected]

Introduction

In Pakistan, rural communities do not have adequate access

to emergency surgical care. In 1983, Blanchard et al. (1987)

conducted a survey of 12 district hospitals providing 100% of

the surgical cover for the entire population of Northern

TMIH490

Tropical Medicine and International Health volume 4 no 12 pp 846–857 december 1999

M. Ahmed et al. Survey of surgical emergencies in rural Pakistan

Sindh, Northern Balochistan, and the Hazara district of the

North-west Frontier Province, totaling 11 million. The

overall rate of surgery in these rural areas of Pakistan was

124/100000 persons per year. The operations were related to

the specialties of general surgery, urology, orthopaedics, and

obstetrics-gynaecology. By comparison the rate of operations

in similar specialties in the USA in 1978 was 8,253/100000

persons per year. (Rutkow & Zuidema 1981). The situation in

rural Pakistan is not unique and has also been observed in

rural Kenya (Nordberg et al. 1996) and rural Mozambique

(McCord 1987).

A comparison of the rates of specific operations such as

caesarian section and groin hernia repair is perhaps more

valid. The annual rates per 100000 persons for caesarian sec-

tion were 9 in rural Pakistan, 129 in rural Kenya, 42 in rural

Mozambique and 236 in the USA (Rutkow & Zuidema 1981;

Blanchard et al. 1987; McCord 1987; Nordberg et al. 1996).

For groin hernia repair the rates were 9, 6, 124 and 236 per

100000 persons per year, respectively. Nordberg et al. (1996)

concluded that the surgical output of a rural hospital in the

developing world does not reflect the true burden of surgical

disease in its catchment population. Barriers exist to seeking

health care including lack of education and awareness, cul-

tural factors, poverty, and inadequate health sector capacity.

The establishment of primary health care in a region cre-

ates the need for a first-level referral centre for management

of clinical conditions including those requiring surgery. In

1986, the Aga Khan Health Services, an NGO, established

a primary health care program in the Northern Areas of

Pakistan. Following introduction of the programme, the

infant mortality rate (IMR) decreased from 158 at baseline to

52 per 1000 live births by 1997 in the population served (Aga

Khan Health Services 1997). In 1992, a first-level referral cen-

tre with a surgical facility was established in the Ghizar dis-

trict of the Northern Areas of Pakistan (population 100000).

The aim was to meet essential needs such as obstetrical and

gynaecological emergencies, trauma, and other surgical emer-

gencies. A trained surgeon was posted at Singal Medical

Centre (SMC), the referral centre. The surgeon imparted clin-

ical training by rotation to Lady Health Visitors (LHV)

staffing the 13 Health Centres in the district, which in coordi-

nation with 2 field modules are responsible for providing pri-

mary health care to the entire Ghizar population.

The government, which is the only other health care

provider in the region, does not offer surgical facilities. Its

health personnel in 12 first aid posts, 12 dispensaries, and 4

civil hospitals were informed about the surgical facilities

available at SMC. With the institution of primary health care

in the region, along with health education and clinical train-

ing of paramedical staff, it was fair to expect an improved

referral of patients for emergency surgical care. Yet despite

these measures, the number of emergency surgical procedures

for Ghizar inhabitants remained low; 19 caesarian sections

were performed at SMC in 1993. Two additional patients

from Ghizar underwent caesarian section at the District

Headquarters (DHQ) Hospital in Gilgit, which is a sec-

ondary-level hospital in the adjacent district, 2.5 h away by

jeep ride from SMC.

It was obvious that there were large unmet surgical needs

in the Ghizar community. As knowledge of the burden of sur-

gical disease in the community is important for organizing a

cost-effective service, we undertook a population-based sur-

vey in Ghizar in 1995. Our objectives were to estimate

• the prevalence of specific surgical emergencies;

• use of existing health services;

• outcomes related to acute surgical illness.

We focused on emergency surgical conditions that would

represent the commonest risk of death or disability to the

population, and that a surgical centre in a remote rural area

should be able to address (Nundy 1984).

Methods

Study area and population

Ghizar is one of 5 districts in the Northern Areas of Pakistan

situated amid the Hindu Kush, Karakoram, and Himalayan

mountain ranges. The region, which is situated at 9000 feet

above sea level, has been called ‘the rooftop of the world’. Its

scenic splendor is matched only by the inhospitability of its

living conditions: the terrain is extremely rough and winters

are severe. The majority of the people are subsistence farmers

whose annual per capita income is $200, half the national per

capita income. The population is scattered in small clusters of

10–400 households connected by dirt tracks, jeep roads and

makeshift motor vehicles. The inaccessibility of the area had

been a strong impediment to development until the construc-

tion of the Karakoram Highway in the late 1970s linked

Pakistan to China through the Northern Areas. Further

development has taken place as a result of the establishment

of community institutions and the promotion of income-

generating activities, beginning in the early 1980s, by the Aga

Khan Rural Support Programme, an NGO.

Sampling

AKHS provided the baseline information for the study: the

total population of Ghizar is distributed in 118 villages and

9900 households. The main study variable was the proportion

of inhabitants who had suffered an acute surgical illness

during one year. The estimated prevalence of acute surgical

illness was 0.9 based on knowledge of the number of de-

liveries during one year (2994 in 1992); an assumed 10% rate

© 1999 Blackwell Science Ltd 847




of caesarian sections and an assumed rate of procedures for

other acute surgical illnesses estimated to be twice that of

caesarian sections. Accepting 0.02 as the tolerable range of

error and a 95% level of confidence, it was necessary to enroll

850 households for the study. The actual number of house-

holds enrolled was 836.

Interviewers visited each of the 118 villages in the Ghizar

district. To select the households, a map of the village with

important landmarks was prepared. Shops, schools and

mosques served as landmarks. A landmark in each village was

randomly selected as the starting point where the study team

placed a soda bottle on its side on the ground and spun it.

They approached the closest house in the direction where the

mouth of the bottle pointed. After completing the interview,

the study team then approached every third house and con-

tinued this process until a sufficient number of houses were

enrolled proportionate to the size of the village.

Measurement

The incidence of acute surgical illnesses was assessed by

administering a structured questionnaire to the oldest woman

in the study household who was still in her reproductive

years. In the extended families that characterize the study vil-

lages, these women would be most likely to know the health

conditions of the family members in the preceding year. If an

appropriate respondent could not be identified, the house-

hold was not enrolled in the study. The Lady Health Visitors

(LHV) who were trained to administer the questionnaire had

a minimum of 3 years experience of providing maternal and

childcare in the region. The LHVs visited the women in their

homes and conducted the interviews in the language of the

respondents.

Section 1 of the questionnaire was related to demographic

details: number of people in the household and their age and

sex distribution. Section 2 sought to elicit deaths from surgi-

cal causes in the household during the respondent’s lifetime

in the household. Respondents were asked whether death had

occurred in association with injury including burn injury,

acute abdomen, a complication of pregnancy or childbirth,

gastro-intestinal haemorrhage, acute groin-scrotal swelling,

superficial spreading infection, limb gangrene or airway

obstruction by a foreign body. Section 3 was divided into 5

modules: injury, burns, acute abdomen, complication of preg-

nancy and complication of childbirth. This section of the

questionnaire was designed to capture only those acute surgi-

cal illness events that had occurred during the past year. The

survey was conducted around Eid-ul-Baqr, an Islamic feast,

and the previous Eid-ul-Baqr was taken as the reference point

marking one year. Once it was established that an acute ill-

ness event had occurred, respondents were asked whether

any of the index clinical features from a predetermined list

had been observed indicating the potential for surgical inter-

vention. Cases were included in the study only if one or more

index clinical features were present. Additionally, in each

module, questions were asked about risk factors, care

received, and outcome of illness.

An interview took approximately 30 min to complete. Five

percent of completed interviews were checked for reliability

by one of the authors (MAS), who re-visited the home of the

respondent and asked a few questions from the questionnaire

to verify the accuracy of the responses. No fake interviews

were detected.

To determine rates related to injury and acute abdomen

based on the 1-year survey, we totaled the number of persons

living in the visited households for denominator (n 5 9012).

For maternal morbidity only the population of women

between the ages of 15 and 44 (n 5 1713) was used as de-

nominator. The numerator in relation to incidence, mortality

and operative procedure rates in each module included cases

with unequivocal answers. If answers were left blank or the

respondent answered ‘don’t know’, cases were not included in

Table 1 Incidence of injury and acute abdomen according to age group and sex during a 1-year household survey in Ghizar district

Age in years Sex

––––––––––––––––––––––––––––––––––––––––––––––––––– ––––––––––––––––––––––––

<5 6–15 16–40 >40 M F Total

Illness n 5 1441 n 5 2786 n 5 3094 n 5 1691 n 5 4645 n 5 4367 n 5 9012

All injuries 32 (2221) 55 (1974) 48 (1551) 03 (177) 102 (2196) 36 (824) 138 (1531)

Burns 20 (1388) 11 (395) 11 (356) 01 (59) 021 (452) 22 (504) 043 (476)

Falls 09 (625) 23 (826) 22 (711) 00 044 (947) 10 (229) 054 (598)

Road accidents 00 07 (251) 08 (259) 02 (18) 017 (366) 00 017 (189)

Assault 00 01 (36) 01 (32) 00 002 (43) 00 002 (22)

Others 03 (208) 13 (467) 06 (194) 00 018 (386) 04 (92) 022 (244)

Acute abdomen 04 (277) 28 (1005) 52 (1681) 39 (2306) 084 (1808) 39 (893) 123 (1365)

Figures in brackets give rates per 100000 persons per year.




the numerator. As a result the lowest rate estimates were

obtained.

To calculate annual mortality rates based on the respon-

dents’ lifetime experience in study households, we determined

the mean period of recall for 836 respondents (26 years) and

the total number of deaths recalled in each acute surgical ill-

ness category. Annual mortality was the total number of

deaths in a given category divided by 26; the annual mortality

rate was annual mortality times 100000 divided by the rel-

evant population denominator. The mean 26-year recall

period included the last year of study, during which the inci-

dence rates of acute surgical illness were established.

Results

Demographic composition of the study population

The demographic composition of the study population con-

formed to the pyramidal shape identified for developing

countries (Figure 1). However, the relative sizes of the first

two age-groups, , 5 years and 5–9 years, suggests a decreas-

ing fertility rate and reduced IMR.

Geographical distribution of acute surgical illness

A total of 549 acute surgical illness events occurred during

one year. A single event occurred in 448 households (54%), 2

events in 40 households (4.8%), and 3 events in 7 households

(0.8%). There was no acute surgical illness event in 341

households (41%). There was a uniform distribution of

affected households throughout the district. Adequate

documentation was available of 543 illness events in as many

patients, forming the material for further analyses.

Incidence of acute surgical illness events

Table 1 shows the incidence of injuries and acute abdomen.

The incidence of burns decreased with age, being highest in

the age group , 5 years. However, falls, road accidents and

other forms of injury were more common between 6 and

40 years of age. There was male predominance in all forms of

injury except burns, which had affected both sexes equally.

The majority of the burn injuries in young children were

scalds sustained accidentally in their homes. In contrast to

injuries, there was a rising incidence of acute abdomen with

increasing age. There was also a male bias for acute abdomi-

nal pain.

The incidence of pregnancy and childbirth related compli-

cations seemed particularly high in the age group 25–34 years

(Table 2). However, this simply reflected a higher incidence of

pregnancies in this age group. A little more than half (51%)

of the women who were pregnant (n 5 493) or had delivered

a child (n 5 338) were between 25 and 34 years of age; 31%

were 15–24 and 18% were . 35 years old. The complication

rate did not differ significantly between the different age

groups. The parity status of the women also did not seem to

significantly influence predisposition to complications.

Severity of acute surgical illness

Details of associated clinical features indicating a potential

for surgical intervention were available in 90 of 95 patients

0 200Female

400 600 8000200Males

400600800

>65

0–55–9

10–1415–1920–2425–2930–3435–3940–4445–4950–5455–5960–65

Number of population

Figure 1 Demographic structure of the

study population in Ghizar district,

Northern Areas, Pakistan (1996).




Table 3 Frequency of occurrence of index clinical features in association with each type of acute surgical illness: results of a 1-year household

survey in Ghizar

Type of illness Associated clinical feature No of cases

Non-burn injury (n 5 90) Open wound . size of outstretched hand 043

Fracture long bone, skull, spine, ribs, pelvis 061

External blood loss . volume of cupped hand 049

Loss of consciousness 043

Breathing difficulty 013

Abdominal pain, distension, vomiting, GI bleed, urinary retention, haematuria 013

Penetrating injury 002

Burn injury (n 5 40) Breathing difficulty 013

Decreased urine output 003

GI bleed 001

Eschar formation 010

Pus formation & fever 035

Acute abdomen (n 5 123) Duration . 6 h 123

Profuse vomiting 109

Gross abdominal distention 078

Diarrhoea 060

Fever & sweating 057

Signs of shock 076

GI bleed 033

Complete stoppage of faeces & flatus . 24 h 008

Tender groin swelling 008

Complications of pregnancy (n 5 102) Pre-term acute abdominal pain 080

Pre-term bleeding per vagina 005

Pre-term passage of conceptus 001

Shock, abdominal pain/distension 012

Pre-term fits 001

Passage of grape like forms per vagina 003

Complications of childbirth (n 5 151) . 16 h strong contractions 059

. 40 weeks gestation 006

Ante-partum haemorrhage 015

Post-partum haemorrhage 068

Puerperal fever 062

Abdominal distension & vomiting 036

Urinary/faecal incontinence 015

Breech presentation 007

Baby born dead 008

Baby had deformity 004

Baby was blue / had fits 019

Age in years

————————————————————————————

15–24 25–34 35–44 Total

Complication n 5 75 n 5 530 n 5 468 n 5 1713

All complications 91 (12727) 146 (27547) 45 (9615) 282 (16462)

Pregnancy-related 44 (6153) 061 (11509) 26 (5556) 131 (7647)

Child birth-related 47 (6573) 085 (16037) 19 (4059) 151 (8815)

Figures in brackets give rates per 100000 persons per year.

Table 2 Incidence of maternity-related

complications according to age group during

a 1-year household survey in Ghizar district




with nonburn injuries, 40 of 43 with burn injuries, all 123

with acute abdomen, 102 of 131 with complications of preg-

nancy and all 151 with complications of childbirth (Table 3).

Pattern of health services use

Only 91 (25%) of 367 pregnant women were receiving ante-

natal care from an LHV and 159 (43%) from a Trained Birth

Attendant (TBA). The Health Centres of AKHS staffed by

LHVs attracted 37 (47%) of 79 women developing compli-

cations during pregnancy (Table 4). By contrast, only 22

(22%) of 98 women who developed complications during

delivery reported initially to the health centres. The tendency

to manage childbirth complications at home in 65 (66%) of

98 women may be attributed to dependence on TBAs who

facilitate home deliveries. Thirty-five (41%) of 86 patients,

the highest proportion with nonburn injuries, were managed

initially at the Civil Hospital where radiological facilities are

available. As expected, the majority of patients with acute

abdominal pain of . 6 h duration, 42 (39%) of 109, were

managed initially at home. It is likely that patients with an

acute surgical illness who reported initially to SMC were seen

by the specialist surgeon. Very few patients with an acute sur-

gical illness went initially to the DHQ Hospital in Gilgit.

Eventually, only 131 (32%) of 408 patients who had a serious

acute surgical illness were able to see a specialist surgeon.

Sixty-three (15%) of 408 patients who suffered an acute sur-

gical illness were delayed by 3–7 days before reaching the final

care provider. In 14 (3%) of cases the delay was . 7 days.

Sixty-one of 90 patients with nonburn injuries had sus-

tained a major fracture and seemed to be candidates for

surgery (Table 3). By contrast, based on information available

about surgical care on 85 patients in this subgroup, only 46

were X-rayed, 30 were hospitalized, 4 received blood trans-

fusion, and 17 had a surgical procedure under spinal/general

anaesthesia. Thirty-five of 40 burn injury patients appeared

to have had infected wounds. Only 3 were hospitalized and

underwent surgery under spinal/general anaesthesia.

Among the patients with acute abdominal pain, 78 of 123

had alleged gross abdominal distention and were potential

surgical candidates. However, based on information about

surgical care in 105 patients, only 35 were X-rayed, 28 were

hospitalized, and 12 had a surgical procedure under

anaesthesia.

Of 102 pregnant women with complications, 80 had suf-

fered preterm acute abdominal pain. Based on information

about surgical care in 73 patients, only 11 had ultrasound

examination, 9 were hospitalized, 1 received blood trans-

fusion, and 1 had a surgical procedure. Postpartum haemor-

rhage occurred in 68 of the 151 women who had complicated

deliveries. Information about surgical care was available on 85

patients in this module: only 12 were hospitalized, 3 had

blood transfusion, and 4 underwent a surgical procedure

under anaesthesia. The operative delivery rate in this series

was 12 per 1000 births.

Outcome of acute surgical illness events

The outcome of an acute surgical illness event was recorded

as complete recovery, death or survival with residual dis-

ability. Death was recorded in 4 of 90 patients with nonburn

injury, 1 of 39 patients with burn injury, 5 of 112 patients

who had an acute abdomen, 1 of 74 patients who developed a

pregnancy-related complication and 2 of 102 patients who

developed a childbirth related complication. There were also

16 perinatal deaths. Among survivors there was evidence of

residual disability in 20 of 78 patients with nonburn injury, 5

of 36 patients with burn injury, 9 of 87 patients with acute

abdomen, 2 of 85 patients who had a pregnancy-related com-

plication and 5 of 114 patients who had a childbirth-related

complication.

Annual rates per 100000 population

Incidence rates per 100000 population per year of injury,

acute abdomen, and maternal morbidity were calculated

based on the results of the 1-year survey and compared with

corresponding rates of surgical operation and mortality

Table 4 Place of initial management of 408 patients with acute surgical illness: results of a 1-year household survey in Ghizar

Health Civil

Illness Home centre/dispensary hospital SMC DHQ

Injury (n 5 86) 23 (26) 12 (14) 35 (41) 13 (15) 3 (3)

Burn (n 5 36) 14 (39) 13 (36) 07 (19) 02 (6) 0 (0)

Acute abdomen (n 5 109) 42 (39) 30 (28) 20 (18) 14 (13) 3 (3)

Pregnancy complication (n 5 79) 23 (29) 37 (47) 02 (3) 15 (19) 2 (3)

Child birth complication (n 5 98) 65 (66) 22 (22) 02 (2) 06 (6) 3 (0)

Figures in brackets give %; SMC, Singal Medical Centre; DHQ, District Headquarters Hospital, Gilgit.




(Table 5). Although 68% of 367 women had received some

form of antenatal care, there were 834 maternity-related com-

plications per 1000 births during the study year. However, the

rate of operative deliveries was extremely low at 11.8 per 1000

deliveries. Not surprisingly, the maternal mortality ratio was

8.9 per 1000 deliveries.

The results of the mean 26-year recall (Table 6) validated

the mortality rates from injury, acute abdomen and maternity-

related complications obtained by the 1-year survey. In ad-

dition the 26-year recall was helpful in establishing annual

mortality rates for a wider spectrum of acute surgical

diseases.

Discussion

The thrust of the present study is different from previous

population-based surveys of surgical disease, which have

tended to concentrate on specific disease entities such as

injury to determine prevalence and risk factors with a view to

formulate preventive measures. As our aim was to improve

the effectiveness of a surgical service, it was necessary to elicit

acute surgical illness events, representing a spectrum of surgi-

cal diseases. We chose to elicit illness events related to injury,

acute abdomen and maternity-related complications because

they are common and demand a mix of surgical skills and

resources. Considerable emphasis was placed on describing

an illness event in terms of its associated clinical features so

that only serious events were elicited requiring surgical

attention.

Burns, road accidents and falls are the commonest causes

of injury in rural communities. This was our experience and

that of Mock et al. (1995), who reported injuries presenting

to a hospital in a rural area of Ghana. In both series burns

were commonest in children , 5 years of age. The predis-

position of the very young to burn injuries at home has also

been reported from Nigeria (Onuba 1988) and Ethiopia

Table 5 Relationship between incidence, surgical procedure and mortality rates per 100 000 persons per year for acute surgical illnesses: (The

entire study population (n 5 9012) has been used as denominator for calculating rates related to injury and acute abdomen. The population of

women between the ages of 15–44 years (n 5 1713) has been used to calculate rates related to maternity related complications). Results of a

1-year household survey in Ghizar district

Incidence Surgical procedures Mortality

––––––––––––––––––– –––––––––––––––––––– ––––––––––––––––––––

Illness n Rate n Rate n Rate

Injury 138 01531 20/115 221 5/129 055

Acute abdomen 123 01364 12/102 133 5/112 055

Maternity-related complications 282 16462 05/142 291 (11.8) 3/176 175 (8.9)

Figures in brackets give rates per 1000 deliveries.

Table 6 Annual mortality rates from acute surgical illness according to age group and sex based on a mean 26-year recall of deaths in the study

households

Distribution of mortality

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

Age (years) Sex

–––––––––––––––––––––––––––––––––––––––––––– ––––––––––––––––––––––

0–5 6–15 16–40 >40 M F Total

Nature of illness n 5 1441 n 5 2786 n 5 3094 n 5 1691 n 5 4645 n 5 4367 n 5 9012

Injury 018 (48) 16 22 070 (87) 033 (75) 107 (89) 0030 (26) 137 (59)

Acute abdomen 018 (48) 13 18 016 (20) 036 (89) 057 (47) 0026 (23) 183 (35)

Maternity-related complications 000 03 *54 (135) 003 **60 (135)

Superficial spreading infection 042 (112) 06 8 006 0(7) 004 (9) 030 (25) 0028 (25) 058 (25)

Gastrointestinal haemorrhage 009 (24) 06 8 008 (10) 016 (36) 025 (21) 0014 (12) 039 (17)

Gangrene 008 (21) 14 1 005 (6) 013 (30) 019 (16) 0008 (7) 027 (12)

Groin swelling 009 (24) 14 3 003 (4) 006 (14) 014 (12) 0006 (5) 020 (9)

Airway obstruction 007 (19) 14 000 002 (5) 009 (7) 0004 (4) 13 (6)

Total 111 86 162 113 261 0176 437 (187)

Figures in brackets give rate per 100000 persons per year; *n 5 1537; **n 5 1713.



(Courtright et al. 1993). In our study and in the Ghanian and

Nigerian series, burns from scalds were commoner, while in

the Ethiopian series flame burns predominated. The urban

burn pattern in developing countries appears to be different.

In a burns study in Karachi (Marsh et al. 1996), young

women were observed to be most commonly affected and

were predisposed to flame burns sustained while cooking.

In the present study, falls caused injury three times more

often than road accidents. Both forms of injury were com-

monest in males in the age group 6–40 years. The predis-

position of young men to road accidents and falls reflects

their involvement with activities such as travel and climbing

trees in order to stack hay. Falls from trees have been reported

as the leading cause of serious injury in rural areas of other

developing countries, where the products of tall trees are

important sources of food and income (Smith & Barss 1991).

The highest risk group is young boys, and in some areas,

young adult males (Ebong 1978; Barss et al. 1984). In the

Ghanaian series (Mock et al. 1995) however, road accidents

were 2.5 times as common as falls and while road accidents

occurred at all ages beyond 5 years, falls were most commonly

observed in the age group . 60 years; males predominated in

both types of injury. Falling in the elderly has a different

aetiology and is known to be associated with reduced daily

physical activity (Cooper et al. 1988; Lau et al. 1988, 1990;

Wickham et al. 1989). Injuries related to assault were uncom-

mon in the Ghanian series and ours. By contrast, assault was

the leading cause of injury in an urban hospital based series

in Eldoret, Kenya (Odero & Kibosia 1995).

It is difficult to explain the predominance of older men in

acute abdominal pain cases. In neighbouring districts of

northern Pakistan, volvulus of the sigmoid colon was ob-

served to be a common surgical emergency, particularly dur-

ing Ramzan, which is the holy month of fasting (Blanchard

& Maguire 1985; Bokhari 1985). In Bokhari’s series the

majority of the patients were males between 40 and 80 years

of age.

With respect to maternal morbidity it seemed from the

clinical descriptions that complications such as haemorrhage,

obstructed labour and sepsis, which are amenable to surgical

intervention, frequently occurred in our patients. These three

complications together accounted for 43% of 77.6 million

obstetric morbidity events and 47% of 0.5 million obstetric

deaths occurring worldwide during 1993 (WHO 1994). It

seemed that complications such as obstetric fistulae and

pelvic inflammatory disease also occurred in our patients.

However, we did not elicit complications from unsafe

abortion, which are surgical in nature, probably reflecting a

weakness in questionnaire design.

The injury incidence rate of 1531/100000 persons per year

in the current study is likely to be an underestimate because it

did not take into account injuries which were not serious. In

addition, events such as poisoning, drowning, suffocation and

animal and insect bites, which are included under the rubric

of injury in the ICD 9 code, were not given specific import-

ance in our questionnaire. By comparison, Gordan et al.

(1962), who included all forms of external injury in their

community-based survey, determined the incidence rate to be

116/1000 persons per year in 11 rural villages in northern

India (study population 12022). These authors defined injury

quite simply as causing a disruption of normal daily activity.

Only 4% of the injuries in their study resulted in permanent

disability, a rate of 5/1000 persons per year. A comparable

rate of injury in the United States is about 270/1000 persons

per year allowing for some variation in injury definition

(Collins 1990). Most studies of distribution of injury in a

population focus on hospital admissions or attendances (Zwi

1993). Hospital-based rates of injury are much lower than

those based on community survey (Bangdiwala et al. 1990). In

the Ghanian series, the rate of serious injuries in a rural

population requiring hospital admission was 0.6/1000 per-

sons per year (Mock et al. 1995). In the Eldoret series (Odero

& Kibosia 1995), the rate of injuries in an urban population,

based on injured persons registering at a hospital, was

2.6/1000 persons per year. Only 20% of the injured persons

required hospital admission. The Eldoret study represents an

urban injury pattern with a predominance of motor vehicle

and assault-related injuries. The incidence rates of uninten-

tional injury, excluding injury caused by motor vehicles, are

said to be relatively similar across developing countries, even

though the importance of specific injuries varies from

country to country and from one area to the next (Smith &

Barss 1991).

Our incidence rate for acute abdomen was 1,364/100000

persons, per year. It is more difficult to compare the incidence

rates for acute abdomen, as there is a greater possibility of

geographical variation in disease pattern and diagnostic

capability. There is an estimated minimum need for 133

appendicectomies (Rutkow & Zuidema 1981) and 30 strangu-

lated inguinal hernia repairs (Nordberg 1984) per 100000

persons per year. For every person requiring operative inter-

vention for acute abdomen, many more require to be

screened. In one study (Thompson & Jones 1986), only 39%

of 220 admissions for acute abdomen resulted in operative

intervention. There was a 5% negative laparotomy rate. In

another study (Irvin 1989), 47% of 1190 admissions for acute

abdomen resulted in surgery with a 16% rate of unnecessary

appendicectomy. Ambulatory patients with acute abdominal

pain have a much lower rate of surgical intervention (White

et al. 1975; Wasson et al. 1981; Britt et al. 1994).

The maternal morbidity ratio of 834/1000 births during the

current study year seemed excessive. The maternal mortality

ratio was correspondingly high at 8.9/1000 births per year.

Unpublished estimates of worldwide maternal complications




and deaths in 1993 were 77.6 million and 0.5 million, respect-

ively (WHO Maternal Health and Safe Motherhood

Program, unpublished estimates 1994). There were 33 million

complications related to haemorrhage, sepsis and obstructed

labour. The ratio of the number of surgical type compli-

cations to death was 137:1 in the worldwide estimate com-

pared to 94:1 in our study.

Incongruity between the occurrence of serious acute surgi-

cal illness events and the surgical care patients receive has

also been observed by others in developing countries. Delay

in reaching the final care provider is corroborated in the

Ghanian series on rural injuries (Mock et al. 1995). In our

study, 54% of 85 injured patients who were taken to hospital

had X-rays; 57% of 30 who were hospitalized underwent

surgery. To our knowledge, comparable population-based

data on rates of radiological investigation and surgical inter-

vention for injury are not available from any other rural area

in a developing country. However, in an urban hospital based

series from Eldoret, Kenya, only 27% of 1304 injured patients

brought to hospital had X-rays; only 4% of 275 patients who

were hospitalized underwent surgery (Odero & Kibosia

1995). It seems that in rural areas as compared with the city,

patients attend hospital for relatively serious injuries.

The rate of operative deliveries in our study seemed to be

low; there were only 12 minor and major interventions per

1000 births. In another population-based study in rural

Morocco, Belghiti et al. (1998) showed that only 111 of 21392

mothers who were expected to deliver during 1995 underwent

a major obstetrical intervention – a rate of 5.2 per 1000

expected births. Another 135 mothers with life-threatening

conditions did not benefit from the major obstetrical inter-

vention they required – a rate of 6.3 per 1000 expected births.

By contrast, in a hospital-based series from rural Nigeria

(Harrison 1985), the rate of surgical intervention was 60 per

1000 deliveries in booked healthy women, 250 per 1000 deliv-

eries in booked women with complications, and 310 per 1000

births in unbooked emergencies. It seems that in rural areas

an alarmingly large proportion of women with serious

maternal complications requiring surgery does not reach hos-

pital. Those that do, as in the Nigerian study, require a high

rate of operative intervention.

Outcomes such as mortality ought to shed more light on

the seriousness of the illness events elicited in our study. The

annual death rate of 55 per 100000 persons from acute

injuries was very high and suggests that we were successful in

identifying serious injuries. High death rates from injury have

been observed in other population-based surveys of rural

areas in developing countries. In 1959, Gordan et al. (1962)

reported an annual death rate from unintentional injury of 63

per 100000. The study population was 12022 from 11 rural

villages in northern India. Besides burns and falls, the causes

of fatal injury included injuries from animals, drowning,

poisoning, suffocation, and lack of infant care. In the Matlab

study in Bangladesh (Zimicki et al. 1985), the causes of death

were determined through verbal autopsies from relatives.

There were 51 injury-related deaths per 100000 persons per

year, the majority from drowning in the age group 1–4 years.

Barss (1991) in another verbal autopsy study in a remote area

of the highlands of Papua New Guinea (population 25000),

observed that injury was the leading cause of death in the age

group 15–44 years. The annual mortality rates per 100000

population in this age group were 105 for males and 79 for

females. The deaths included homicide, suicide, drowning

and poisoning in addition to those caused by burns, falls

and falling objects and motor vehicles. In contrast with

community-based mortality rates, the hospital-based mortal-

ity rate from rural Ghana was 4.5/100000 persons per year

(Mock et al. 1995). It can be assumed that many patients with

serious injury died before reaching hospital.

The maternal mortality ratio of 8.9 per 1000 deliveries we

observed was much higher than that reported by AKHS for

Ghizar district in 1997. According to the AKHS report there

were only 9 maternal deaths in 1997, giving a ratio of 2.4

deaths per 1000 deliveries. The causes of maternal death,

according to the report, were: retained placenta 3, post-

partum haemorrhage 3, sepsis 2, and postoperative death 1,

following prolonged labour. No deaths in early pregnancy,

especially as a result of abortion, were reported and none

from indirect causes. Most significantly, because of the

absence of a trained surgeon that year, there were no

caesarian sections conducted at Singal Medical Centre, while

there were 3661 deliveries in the district. The implication of a

low rate of caesarian section is a higher incidence of death

and disability. A 6–8% rate of caesarian sections should be

expected provided that known and agreed indications for the

operation are strictly observed (Francome & Savage 1993).

One of the lowest rates of caesarian section achieved in an

urban community in the USA was 11.5 per 1000 live births

(Myers & Gleicher 1988).

The preliminary results of the community-based maternal

and infant mortality survey undertaken by the Community

Health Sciences department of Aga Khan University suggests

variation in maternal mortality ratio depending on access to

health care facilities in rural Balochistan and North-west

Frontier provinces of Pakistan (Midhet 1994). In rural

Balochistan (4 districts; 20 486 households in all), rates varied

between 3.64 and 6.30/1000 live births. In rural North-west

Frontier Province (3 districts; 7500 households in all),

rates varied between 3.60 and 5.23/1000 live births. In a

population-based survey in urban squatter settlements in

Karachi, Fikree et al. (1994) estimated a maternal mortality

ratio of 2.8 per 1000 live births. A report from the obstetrics

and gynaecology department of the Jinnah Postgraduate

Medical Centre in Karachi (Jaffery & Korejo 1993), which




delivers 7000 indigent women per year (60% unbooked) was

in striking contrast. The centre acknowledged that 23% of all

maternal deaths occurred in women before they arrived at the

hospital and another 26% died within half an hour of arrival.

Its estimate of maternal mortality was 7.1 per 1000 deliveries.

Maternal mortality estimates from rural population-based

surveys are also available from other developing countries. In

rural Burkina Faso, the maternal mortality ratio declined

from 5.7 to 3.0 per 1000 live births during the period 1941–87

(Garenne et al. 1997). In coastal Kenya it was 6.6 (Boerma &

Mati 1989), in rural Bangladesh 5.5–6.2 (Koenig et al. 1988),

in southern India 8.3 (Bhatia 1986), and in The Gambia 10.2

per 1000 live births (Billewicz & McGregor 1981).

The perinatal mortality rate in our survey was 48 per 1000

deliveries (16/335). Awan (1979) in a prospective investigation

of pregnant women residing in an area of Lahore cantonment

in Pakistan, had observed a perinatal mortality rate of

61/1000 births. In the hospital-based Zaria study (Harrison

1985), the perinatal mortality rate per 1000 singleton births

was 22 in booked healthy women, 74 in the booked compli-

cation group, and 243 in unbooked emergencies. It seems that

maternal and child health in Ghizar was infinitely better than

in a section of the Zaria community producing a high pro-

portion of unbooked emergencies, but it did not compare

favourably with the healthier and better attended section of

that community. Birth asphyxia and birth trauma cause 32%

of newborn deaths in developing countries and can poten-

tially be prevented through improved surgical access (WHO

Maternal Health and Safe Motherhood Program; unpub-

lished estimates 1994).

An important limitation of our study was that elicitation

of an acute surgical illness depended entirely on the ability of

the interviewer to describe the event, and of the respondent

to comprehend and recall the occurrence of such an event.

Careful selection of interviewer and respondent may have

reduced the chances of error. However, no attempt was made

to corroborate the occurrence of every illness event in the

household with its detection and management by a health

care provider. Nor was there an attempt to obtain objective

evidence of an illness event in the form of a residual deform-

ity or debility. A 12-month recall period was used to produce

higher frequencies of events for analyses, but had the draw-

back of possible memory decay (Harel et al. 1994). To reduce

recall bias, the inquiry was limited to specific illness events of

serious import. Repeated surveys of study households at fre-

quent intervals during the study period may have further

reduced inaccuracies resulting from memory decay, but were

not feasible.

The validity of the death rate estimates obtained from the

mean 26-year recall should also be examined. It is highly

likely that the respondents would accurately recall circum-

stances of death of a household member unless the event had

occurred during the respondents’ childhood in the household.

In the latter case, the death could potentially be either

wrongly classified or forgotten. A forgotten death would tend

to lower the rate estimate. The likelihood of misclassification

of a maternal or injury-related death seems low, even though

a maternal death preventable by surgical intervention would

not be differentiated. On the other hand, misclassification of

deaths from acute abdomen and other categories of acute

surgical illness seems more likely. Yet despite these reser-

vations, there was considerable consistency between the

results of the mean 26-year recall and the 1-year survey in our

study in relation to death rates from injury, acute abdomen

and maternal causes.

Our community-based survey of surgical need, undertaken

with a view to streamline a surgical service, prevented us from

using standardized definitions of injury and maternal mor-

bidity which include nonsurgical conditions. This is partly

responsible for the differences in incidence rates compared

with other community-based studies. Acute abdomen does

not have a standardized definition. However, its inclusion

from the viewpoint of the study’s objective was important.

While mortality rates from injury and pregnancy elicited in

our study broadly agree with other studies, death rates from

the other categories of acute surgical illness, lacking standard

definitions, could not. However, the relatively high death

rate from superficial spreading infection in the age group

, 5 years can be explained by the high rate of home deliveries

and prevalent unsterile home delivery practices leading to

umbilical stump sepsis. The high death rate from tetanus

neonatorum in Pakistan, the highest in the eastern

Mediterranean region (EMRO & WHO 1995), reflects such

practices. Umbilical stump sepsis is also known to cause por-

tal venous thrombosis leading to death from GI haemorrhage

in the young, as observed in our study. Although frostbite

might account for the limb gangrene observed in the young in

our study, it does not generally cause death (Hashmi et al.

1998). Neglected strangulated hernias can certainly explain

deaths associated with acute groin swellings at all ages. The

high death rate from acute abdomen in the present study is

reminiscent of the 85% mortality from secondary peritonitis

observed in the west at the turn of the century, when surgery

was not indicated for this condition (Kirschner 1926).

Lastly, our limitation is also that we derived the lowest rate

estimates of mortality and operative procedures in each

module because of missing data. However, in a way, under-

estimation of mortality rates is likely to compensate for

underestimation of surgical procedure rates.

Conclusion

We have shown that a population-based survey can provide

valid estimates of the incidence of broad categories of acute




surgical illness in a rural community. Such estimates from

rural areas in developing countries are hard to come by in the

literature. Yet, population-based estimates are much more

sensitive than hospital-based information in eliciting the bur-

den of acute surgical illness. Estimates of acute surgical inter-

vention rates based on population studies are even harder to

find. Along with estimates of acute surgical mortality rates,

they are important for understanding the burden of unmet

emergency surgical needs. From our study, it was clear that

the incidence rates of injury, maternal complications and

acute abdomen in the Ghizar community far exceeded the

rates of acute surgical intervention for these conditions; the

mortality rates were correspondingly high. The evidence

clearly points to a significant deficiency in emergency surgical

care in Ghizar.

Such evidence could provide the stimulus for an organized

provider like AKHS to improve the health service. For in-

stance, it would be necessary to introduce injury-preventive

measures, enhance the quality of antenatal care, encourage

family planning, and train LHVs at the health centres to deal

effectively with obstetrical complications and refer appropri-

ate cases in a timely fashion to SMC. It would also be neces-

sary to remove cultural, physical and fiscal barriers to seeking

surgical care, ensure continuous posting of a surgeon at

SMC, who is trained to manage general surgical, orthopedic,

and obstetrical emergencies, and make arrangements for the

transfer of complex cases to a secondary care facility.

Acknowledgements

This project was funded by a seed money grant from the Aga

Khan University. The authors are grateful to Dr Imam Yar

Baig, General Manager AKHS, Northern Areas for facili-

tating the survey, to Dr Agha Jamil for help with data

analyses and Messers Sarwat Hussain and Nizar Nooruddin

for assistance in preparing the manuscript.

References

Aga Khan Health Services (1997) Annual report. Northern Areas

Health Care Program, Pakistan.

Awan AK (1979) Perinatal mortality. In Proceedings of the confer-

ences on child health. 17–22 February 1979. Ministry of Health

Social Welfare and Population, Government of Pakistan in collab-

oration with WHO and UNICEF, Geneva, pp. 70–73.

Bangdiwala SI, Anzola-Perez E, Romer C et al. (1990) The incidence

of injuries in young people: 1. Methodology and results of a col-

laborative study in Brazil, Chile, Cuba and Venezuela. Inter-

national Journal of Epidemiology 19, 115–124.

Barss P, Dakulala P & Doolan M (1984) Falls from trees and tree-

associated injuries in rural Melanesians. British Medical Journal

289, 1717–1720.

Barss PG (1991) Health impact of injuries in the highlands of Papua

New Guinea: A verbal autopsy study. Doctoral Dissertation, The

Johns Hopkins School of Hygiene and Public Health, Baltimore.

Belghiti A, De Brouwere V, Kegels G & Van Lerberghe W, (1998)

Monitoring unmet obstetric need at district level in Morocco.

Tropical Medicine and International Health 3, 584–591.

Bhatia JC (1986) A study of maternal mortality in Ananthpur

District, Andhra Pradesh, India. India Institute of Management,

Bangalore.

Billewicz WZ & McGregor IA (1981) The demography of two West

African (Gambian) villages. 1951–75. Journal of Biosocial Science

13, 219–240.

Blanchard RJW & Maguire D (1985) Intestinal obstruction during

Ramazan. Pakistan Journal of Surgery 1, 17–20.

Blanchard RJW, Blanchard MEE, Toussignant P, Ahmed M &

Smythe CM (1987) The epidemiology and spectrum of surgical

care in district hospitals of Pakistan. American Journal of Public

Health 77, 1439–1445.

Boerma JT & Mati JKG (1989) Identifying maternal mortality

through networking: results from coastal Kenya. Studies in Family

Planning 20, 245–253.

Bokhari H (1985) Volvulus of the sigmoid colon: pathogenesis and

review of treatment. Pakistan Journal of Surgery 1, 13–16.

Britt H, Bridges-Webb C, Sayer CP et al. (1994) The diagnostic diffi-

culties of abdominal pain. Australian Family Physician 23,

375–381.

Collins JG (1990) Type of injuries by selected characteristics, United

States 1985–87. US Department of Health and Human Services,

Hyattsville.

Courtright P, Haile D & Kohls E (1993) The epidemiology of burns

in rural Ethiopia. Journal of Epidemiology and Community

Health 47, 19–22.

Ebong WW (1978) Falls from trees. Tropical and Geographical

Medicine 30, 63–67.

EMRO & WHO (1995) Major child killers and handicapping condi-

tions. In The State of Child Health in the Eastern Mediterranean

Region (eds JK Harfouche & LJ Verhoestrate) 2nd edn. revised by

H Al-Shazali. Eastern Mediterranean Regional Organization.

Technical publication series 9. WHO Regional Office for the

Eastern Mediterranean, Alexandria. pp. 138.

Fikree FF, Gray RH & Berendes HW (1994) A community-based

nested case-control study of maternal mortality. International

Journal of Gynaecology and Obstetrics 47, 247–255.

Francome C & Savage W (1993) Caesarian section in Britain and the

United States 12% or 24%: is either the right rate? Social Science

and Medicine 37, 1199–1218.

Garenne M, Sauerborn R, Nougtara A, Borchert M, Benzler J &

Diesfeld J (1997) Direct and indirect estimates of maternal mortal-

ity in rural Burkina Faso. Studies in Family Planning 28, 54–61.

Gordan JE, Gulati PV & Wyon J (1962) Traumatic accidents in rural

tropical regions: an epidemiological field study in Punjab, India.

American Journal of Medical Science 243, 158–178.

Harel Y, Overpeck MD, Jones DH et al. (1994) The effects of recall

on estimating nonfatal injury rates for children and adolescents.

American Journal of Public Health 84, 599–605.

Harrison JA (1985) Childbearing, health and social priorities: a survey

of 22774 consecutive hospital births in Zaria, Northern Nigeria.

British Journal of Obstetrics and Gynaecology 92 (Suppl.), 1–119.

Hashmi MA, Rashid M, Haleem A, Bokhari SAH & Hussain T




Nordberg EM (1984) Incidence and estimated need of caesarian sec-

tion, inguinal hernia repair and operation for strangulated hernia

in rural Africa. British Medical Journal 289, 92–93.

Nundy S (1984) How might we improve surgical services for rural

populations in developing countries? British Medical Journal 289,

71–72.

Odero WO & Kibosia JC (1995) Incidence and characteristics of

injuries in Eldoret. Kenya. East African Medical Journal 11,

706–710.

Onuba O (1988) Pattern of burns injury in Nigerian children.

Tropical Doctor 18, 106–108.

Rutkow IM & Zuidema GD (1981) Surgical rates in the United

States: 1966–78. Surgery 89, 151–162.

Smith GS & Barss P (1991) Unintentional injuries in developing

countries: the epidemiology of a neglected problem. Epidemi-

ological Review 13, 228–266.

Thompson HJ & Jones PF (1986) Active observation in acute ab-

dominal pain. American Journal of Surgery 152, 522–525.

Wasson KH, Sox HC Jr & Sox CH (1981) The diagnosis of abdomi-

nal pain in ambulatory male patients. Medical Decision Making 1,

215–224.

WHO (1994) Mother-baby package: Implementing safe motherhood

in countries. Safe motherhood practical guide. Maternal health

and safe motherhood program, Division of Family Health,

Geneva. WHO/FHE/MSM/94.11.

White JJ, Santillana M & Haller JA (1975) Intensive in-hospital

observation: a safe way to address unnecessary appendectomy.

American Surgery 41, 793–798.

Wickham C, Cooper C, Margett BM et al. (1989) Muscle strength

activity, housing and the risk of falls in elderly people. Age and

Ageing 18, 47–51.

Zimicki S, Nahar L, Sardar AM et al. (1985) Cause of death report-

ing in Matlab: scource book of cause-specific mortality rates

1975–81. International Centre for Diarrhoeal Disease Research,

Dhaka.

Zwi AB (1993) The public health burden of injury in developing

countries: a critical review of the literature. Tropical Diseases

Bulletin 90, 11.


(1998) Frostbite: epidemiology at high altitude in the Karakoram

mountains. Annals of the Royal College of Surgeons of England

80, 91–95.

Irvin TT (1989) Abdominal pain: a surgical audit of 1190 emergency

admissions. British Journal of Surgery 76, 1121–1125.

Jaffery SN & Korejo R (1993) Mothers brought dead: an enquiry

into causes of delay. Social Science and Medicine 36, 371–372.

Kirschner M (1926) Die Behandlung der akuten eitrigen freien

Bauchfellentzuendung. Archives Klinikum Chirurgicum 142, 253.

Koenig MA, Fauveau V, Chowdhury AI, Chakraborty J & Khan MA

(1988) Maternal mortality in Matlab, Bangladesh: 1976–85.

Studies in Family Planning 19, 69–80.

Lau E, Donnan S, Barker DJP & Cooper C (1988) Physical activity

and calcium intake in fracture of the proximal femur in Hong

Kong. British Medical Journal 297, 1441–1443.

Lau EMC, Cooper C, Wickham C, Donnan S & Barker DJP (1990)

Hip fracture in Hong Kong and Britain. International Journal of

Epidemiology 19, 1119–1121.

Marsh D, Sheikh A, Khalil A et al. (1996) Epidemiology of adults

hospitalized with burns in Karachi, Pakistan. Burns 22, 225–229.

McCord C (1987) Use of surgical technicians to expand surgical ser-

vices in rural Mozambique. In USA for Africa proposal.

Midhet F (1994) Maternal mortality in rural Balochistan and the

Hazara division of North West Frontier Province. In Report of an

international workshop at the Aga Khan University on Maternal

and Infant Mortality Policy and Intervention, February 7–9, 1994.

National Institute of Health, Pakistan, UNICEF and World Bank,

pp. 43–46.

Mock CN, Adzotor E, Denno D, Conklin E & Rivara F (1995)

Admissions for injury at a rural hospital in Ghana: Implications

for prevention in the developing world. American Journal of Public

Health 85, 927–931.

Myers SA & Gleicher N (1988) A successful program to lower

caesarian section rates. Special Article. New England Journal of

Medicine 319, 1511–1516.

Nordberg E, Holmberg S & Kiugu S (1996) Rates of major surgery

by age and sex in a rural district in Kenya. Annals of Tropical

Medicine and Parasitology 90, 213–221.

Survey of surgical emergencies in a rural population in the Northern Areas of Pakistan

Documents

Transcript of Survey of surgical emergencies in a rural population in the Northern Areas of Pakistan