There may be as many as 5 billion people who do not have access to safe surgical and anesthesia care when they need it. An estimated 17 million people will die each year of preventable surgical conditions. And, without additional investments in surgical care, low- and middle-income countries will lose $12.3 trillion in GDP by 2030.

The provision of safe surgical care, which includes safe obstetric, anesthesia and trauma care, is affordable. It not only saves lives but also promotes economic growth. For every $1 invested in strengthening local surgical systems, $10 is returned in improved health and increased productivity. By focusing on coverage of the “bellwether procedures,” which include cesarean sections, laparotomies (abdominal surgery) and management of open fractures, 80% of emergency surgical needs can be met at the district hospital level, where we primarily work.

Safe surgery means that the “staff, stuff, space and systems” are in place to provide timely, safe and affordable surgical care. Surgical care includes the continuum of care from admission to recovery, and incorporates evidence-based practices, surgical techniques, infection prevention practices, the World Health Organization Surgical Safety Checklist and appropriate postoperative care.

At the district hospital level in low- and middle-income countries, most major surgical procedures are cesarean sections, and most surgical teams manage all surgical cases. Therefore, strengthening surgical teams’ management of cesarean sections carries over to other surgical care.

There is concern over the global trend of increasing rates of cesarian sections, which was estimated at 21.1% in 2015, nearly double the rate in 2000, and represents overuse (“too much, too soon”). The World Health Organization has stated that cesarean sections are “effective in saving maternal and infant lives, but only when they are required for medically indicated reasons” and that cesarean section rates higher than 10% are not associated with reductions in maternal and newborn mortality rates.

However, this statistic disguises the significant variation in cesarean section rates between and within countries. In many parts of the world, lack of access or underuse (“too little, too late”) is the prevailing situation. For example, in Ethiopia, the national cesarean section rate is about 2%. In many contexts, overuse and underuse co-exist. This is seen in the large disparities between urban and rural populations, rich and poor, and private and public institutions.