Interventions to reduce postoperative mortality in low- and middle-income countries: systematic review.

BACKGROUND

Postoperative mortality is the third leading cause of death worldwide and disproportionately affects patients in low- and middle-income countries (LMICs). Although many deaths are potentially preventable, evidenced-based interventions remain limited. The aim of this systematic review was to consolidate randomized trial evidence on interventions designed to reduce postoperative mortality in LMICs.

METHODS

Medical databases from database inception to February 2025 were systematically searched for randomized trials evaluating interventions in any aspect of the patient pathway from admission to discharge that were designed to reduce postoperative mortality within 90 days of surgery in LMIC patients. Eligible studies included elective and emergency operations across all surgical specialties. The protocol was preregistered in PROSPERO, the international prospective register of systematic reviews (CRD42024604760).

RESULTS

From 10 877 search results, some 18 trials involving 95 521 patients were included. Three were multicountry trials and half were conducted in China. Trials spanned multiple specialties, with only 4 of 18 assessed as having a low risk of bias. Four trials showed a significant reduction in mortality, although the interventions were largely context specific (two neurosurgical trials centred on operative technique in China, one Brazilian trial investigating patient blood management, and one study evaluating maternal death reviews and implementation of best practice after caesarean deliveries in Senegal and Mali). Adherence to interventions was generally high and similar between simple and complex interventions (93.6% versus 96.8% respectively), although adherence varied substantially across trials.

CONCLUSION

Few RCTs have targeted postoperative mortality in LMICs and no intervention demonstrated consistent effectiveness across multiple contexts. To maximize clinical impact, future research should prioritize the development of interventions in regions with the greatest need, particularly sub-Saharan Africa, and ensure they are co-developed with LMIC interest holders and evaluated across diverse clinical environments.