Knowledge, beliefs and practices regarding osteoporosis among female medical school entrants in Pakistan.

BACKGROUND: Osteoporosis is a growing health problem around the world. The increasing incidence of osteoporotic fractures coupled with the lack of knowledge about the disease in the general community means that the disease is continuously increasing the burden on health sector and the general population. The purpose of the study is to assess knowledge, attitudes and practices about osteoporosis among female medical school entrants in Karachi. METHODS: This is a descriptive cross-sectional study conducted amongst 400 female medical school entrants of DOW University of Health Sciences (DUHS) and Jinnah Sindh Medical University (JSMU). A pre validated questionnaire, Osteoporosis Knowledge Assessment Tool (OKAT), was distributed amongst the participants. A food frequency questionnaire was also distributed to determine calcium intake. Descriptive statistics and Chi square test were used to compare the two groups of students with SPSS (20.0) being utilized for analysis. A p value of <0.05 was considered as significant. RESULTS: The mean age of the participants was 19.4 ± 1.2 years. Only 8.0% of the participants had a good score pertaining to knowledge about osteoporosis whereas majority of the participants (49.0%) had a poor score. Perceived susceptibility was low as only 14.0% of the participants believed that they were at a high risk for osteoporosis. The RDA for calcium was equal to or greater than 700 mg per day which was met by only 29.0% of the participants despite of the high motivation towards consuming a calcium rich diet. Exercise levels were insufficient in terms of both, duration and the recommended type of exercise. Only 12.0% of the participants engaged in exercises according to the recommended guidelines. Moreover, only 5.5% subjects were involved in definitive behaviors to improve bone health. CONCLUSIONS: Participants possessed an insufficient knowledge of the disease and that too was not adequately applied in preventative practices. There is a serious lack of adoption of preventative practices for osteoporosis. This was primarily due to little appreciation of the seriousness of osteoporosis. Hence, this study highlights the dire need for awareness about practices and attitudes related to the disease. Furthermore, it could be of paramount importance to future studies conducted on practices and beliefs related to osteoporosis.

Prevalence and characteristics of resistant hypertensive patients in an Asian population.

BACKGROUND: Resistant hypertension is a well-recognized clinical challenge yet there are no reported data on its prevalence in Pakistan. These patients are subjected to a higher risk of developing hypertensive complications. The objective of our study was to evaluate the prevalence and determinants of resistant hypertension in an Asian cohort of hypertensive patients. METHODS: This cross-sectional study was carried out among hypertensive patients visiting a tertiary care hospital in Karachi from September-December 2015. Patient data and characteristics were recorded using a pre-coded questionnaire. Morisky and Berlin questionnaires were used to assess compliance to medications and determine the risk of developing obstructive sleep apnea, respectively. Pearson's chi-square test was used to analyze statistical differences between hypertensive patients and related factors. RESULTS: A total of 515 patients were included in the study. Overall, 12% of the total patients (n=62) were resistant hypertensives and 25% (n=129) had pseudo-resistant hypertension. Resistant patients were more often females, older and had a higher body mass index (all P<0.001). Use of painkillers and noncompliance to dietary recommendations were found to be significant determinants of resistant hypertension. Prevalence of comorbid conditions, including diabetes (p=0.33), hyperlipidemia (p=0.46), and chronic kidney disease (p=0.23), was not significantly higher in patients with resistant hypertension. CONCLUSION: Nearly one in ten hypertensive patients had true resistant hypertension, and twenty-five percent of patients had pseudo-resistance. Resistance hypertensions is significantly associated with female gender, older age, obesity, dietary noncompliance and increased use of NSAIDs.

Self-Medication with Antibiotics among People Dwelling in Rural Areas of Sindh.

INTRODUCTION: Self-medication with antibiotics is becoming increasingly common due to multiple factors. The public who are using these antibiotics generally do not have full information regarding their proper use, especially the dosages and possible side-effects. Hence, unregulated use of such medicines may cause dangerous adverse effects in the patients. AIM: The study was aimed to evaluate the prevalence and practice of self-medication with antibiotics among people dwelling in the rural areas of province Sindh. MATERIALS AND METHODS: A cross-sectional survey was performed at Outpatient Department of Civil Hospital Karachi, from January to March 2015. Four hundred rural dwellers who lived in the outskirts of Karachi city area of province Sindh were recruited for the study in the aforementioned time period through non-probability convenience sampling. RESULTS: The investigation reported a prevalence of 81.25% among rural dwellers of Sindh with regards to self-medication of antibiotics. The most common reason behind self-medication were economic reasons (88.0%). Amoxicillin (52.0%) was found to be the most self-prescribed antibiotic. Majority of the participants (74.7%) didn't know about the phenomena of antibiotic resistance associated with inadequate use of antibiotics and only 25 subjects identified correctly that the situation would lead to increase resistance. CONCLUSION: The self-medication rates with antibiotic are higher in rural areas of Sindh. There is an urgent need for the government to enforce stricter laws on pharmacies dispensing medications, especially antibiotics, without prescriptions. Lastly, provision of cost effective treatment from public sector can significantly reduce self-medication with antibiotics among rural dwellers of Sindh.

Effects of colchicine on pericardial diseases: a review of the literature and current evidence.

Colchicine, extracted from the colchicum autumnale plant, used by the ancient Greeks more than 20 centuries ago, is one of the most ancient drugs still prescribed even today. The major mechanism of action is binding to microtubules thereby interfering with mitosis and subsequent modulation of polymorphonuclear leukocyte function. Colchicine has long been of interest in the treatment of cardiovascular disease; however, its efficacy and safety profile for specific conditions have been variably established in the literature. In the subset of pericardial diseases, colchicine has been shown to be effective in recurrent pericarditis and post-pericardiotomy syndrome (PPS). The future course of treatment and management will therefore highly depend on the results of the ongoing large randomized placebo-controlled clinical trial to evaluate the efficacy and safety of colchicine for the primary prevention of several postoperative complications and in the perioperative period. Also, given the positive preliminary outcomes of colchicine usage in pericardial effusions, the future therapeutical use of colchicine looks promising. Further study is needed to clarify its role in these disease states, as well as explore other its role in other cardiovascular conditions.

Impact of Mode of Curriculum on Knowledge and Attitudes of Medical Students towards Health Research.

INTRODUCTION: Equipping students with skills in medical research should be an integral part of medical education systems. This study is designed to gauge the difference in knowledge and attitudes towards health research between two sets of undergraduate medical students; those enrolled in the new Problem Based Learning (PBL) education system versus those of the conventional Lecture Based Learning (LBL) curricula. MATERIALS AND METHODS: From the 4(th) and 5(th) years of medical university students, 90 participants were recruited from the Aga Khan University (PBL group) and Dow University of Health Sciences (LBL group) and were presented with structured and pre-validated questionnaire. Responses obtained for knowledge and attitudes of each group were recorded on a scale and graduated in percentages to be compared statistically for differences to identify the effectiveness of each curriculum. RESULTS: The score on the knowledge scale for the PBL group was found to be 44.77% against the 31.55% of the LBL students (p-value<0.001). Furthermore, the mean attitude score of AKU students was 72.22% as opposed to the 56.11% of the DUHS participants (p-value<0.001). CONCLUSION: The PBL group achieved significantly higher scores in all aspects than the LBL group, showing healthier attitudes towards health science research along with better knowledge. Hence, the apparent positive influence of PBL curricula on attitudes towards research may be helpful in improving research output of medical students in Pakistan.

Assessment of Blood Glucose and Electrolytes during Cardiopulmonary Bypass in Diabetic and Non-Diabetic Patients of Pakistan.

INTRODUCTION: Perioperative hyperglycemia has been shown to be related to higher levels of morbidity and mortality in patients on cardiopulmonary bypass (CPB) undergoing coronary artery bypass grafting (CABG), both diabetic and non-diabetic. Blood electrolytes, like sodium, potassium, calcium, and chloride play a very important role in the normal functioning of the body and can lead to a variety of clinical disorders if they become deficient. A minimal number of studies have been conducted on the simultaneous perioperative changes in both blood glucose and electrolyte levels during CPB in Pakistan. Therefore, our aim is to record and compare the changes in blood glucose and electrolyte levels during CPB in diabetic and non-diabetic patients. MATERIALS & METHODS: This was a prospective, observational study conducted on 200 patients who underwent CABG with CPB, from October 2014 to March 2015. The patients were recruited from the Cardiac Surgery Ward, Civil Hospital Karachi after they complied with the inclusion criteria. Repeated-measures analysis of variance (ANOVA) was used to compare the trend of the changes perioperatively for the two groups. RESULTS: There was no significant difference in changes in blood glucose between the two groups (P = 0.62). The only significant difference detected between the two groups was for PaCO2 (P = 0.001). Besides, further analysis revealed insignificant group differences for the trend changes in other blood electrolytes (P > 0.05). CONCLUSION: Our findings highlighted that there is no significant difference in blood electrolytes changes and the increase in blood glucose levels between diabetic and non-diabetic patients.

Comparison of the Postprocedural Quality of Life between Coronary Artery Bypass Graft Surgery and Percutaneous Coronary Intervention: A Systematic Review.

The treatment of choice between coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) has remained unclear. Considering quality of life (QOL) increases life expectancy, we believe QOL should be important in determining the optimum treatment. Thus the objective of this review was to illustrate the comparative effects of CABG and PCI on postprocedural QOL. Methods. We searched PubMed (Medline) and Embase from inception of the databases to May 2014 using "PCI versus CABG quality of life", "Percutaneous Coronary intervention versus Coronary artery bypass graft surgery Quality of life", "PCI versus CABG health status", "Angioplasty versus CABG", "Percutaneous coronary intervention versus coronary artery bypass surgery health status", and different combinations of the above terms. 447 articles were found. After applying strict exclusion criteria, we included 13 studies in this review. Results. From the 9 studies that compared QOL scores at 6 months after procedure, 5 studies reported CABG to be superior. From the 10 studies that compared QOL among patients at 1 year after procedure, 9 reported CABG to be superior. Conclusion. It can be established that CABG is superior to PCI in improving patient's QOL with respect to all scales used to determine quality of life.

Factors associated with patient visits to the emergency department for asthma therapy in Pakistan.

BACKGROUND: Acute asthma is a chronic condition affecting people of all ages around the world and hence, is one of the leading causes of emergency department (ED) visits and hospital admissions globally. Most of them are related to poor patient practices and a weak healthcare system. The aim of our study was to assess the reasons for the increased usage of the ED by asthmatic patients in Pakistan. METHODS: A cross-sectional study was conducted on 600 asthmatic patients reporting to the ED of Civil Hospital Karachi over a 6-month period. The consenting patients were given a questionnaire to fill and the following data was collected: demographic information, duration of the disease, medications prescribed the, frequency of and reasons for outpatient clinic and ED visits for issues related to asthma. RESULT: According to our results most of the participants visited the ED to obtain a nebulized bronchodilator (90 %) or oxygen (79.5 %). Moreover, 44.8 % of the people visited the ED to get treatment without any delay and 24.0 % considered that the severity of asthma does not allow the patient to wait for clinic visits. Strikingly, 92.8 % claimed that inhaled corticosteroid therapy treatment should be stopped when patients feel better. Irregular follow ups with clinics, low education about asthma and an education level higher than a Bachelors degree were the most important factors associated with three or more ED visits per year, p values = 0.0289, 0.0110 and 0.0150 respectively. CONCLUSION: This study identifies several preventable risk factors responsible for recurrent visits to the ED by asthmatic patients in Pakistan.

Acute Kidney Injury Recognition and Management: A Review of the Literature and Current Evidence.

Acute renal failure is defined as a rapid decrease in the glomerular filtration rate, occurring over a period of hours to days and by the inability of the kidney to regulate fluid and electrolyte homeostasis appropriately. AKI is a catastrophic, life-threatening event in critically ill patients. AKI can be divided into pre-renal injury, intrinsic kidney disease (including vascular insults) and obstructive uropathies. The prognosis of AKI is highly dependent on the underlying cause of the injury. Children who have AKI as a component of multisystem failure have a much higher mortality rate than children with intrinsic renal disease. Treatment of AKI is subjected to risk stratification and ongoing damage control measures, such as patients with sepsis, exposure to nephrotoxic agents, ischemia, bloody diarrhea, or volume loss, could be helped by optimizing the fluid administrations, antibiotics possessing least nephrotoxic potential, blood transfusion where hemoglobin is dangerously low, limiting the use of nephrotoxic agents including radio contrast use, while maximize the nutrition. Acute kidney injury remains a complex disorder with an apparent differentiation in pathology between septic and nonseptic forms of the disease. Although more studies are still required, progress in this area has been steady over the last decade with purposeful international collaboration.

Use of Cyclosporine Therapy in Steroid Resistant Nephrotic Syndrome (SRNS): A Review.

A chronic, progressive disorder Steroid Resistant Nephrotic Syndrome (SRNS) accounts for 10-20% of all children with Nephrotic Syndrome. It is a heterogeneous disorder comprised of persistent edema, proteinuria, hypoalbuminemia and hyperlipidemia. Treatment for steroid-resistant nephrotic syndrome (SRNS) is challenging and children who suffer from SRNS require aggressive treatment to achieve remission. Calcineurin inhibitors have been used more in an empirical manner than on the basis of clear rationale. It was in 1984 when cyclosporine was first considered for the treatment of steroid resistant nephrotic syndrome. Cyclosporin is a calcineurin inhibitor that suppresses immune response by downregulating the transcription of various cytokine genes. Till now many studies have been conducted to determine dosages, duration of therapy, side effects and advantages of cyclosporine. Treatment of SRNS remains a difficult challenge in pediatric nephrology.  Treatment should be individualized according to the underlying histopathology, and clinical and environmental conditions of the children. There is an urgent need to distinguish as soon as possible those patients who may benefit from prolonged immunosuppressive treatment from those who will not benefit from such treatment and who will just suffer from its major side effects. The emerging evidence that the majority of genetic forms of SRNS should receive symptomatic treatment only, should also be clinically tested and studies baring its significance should be evaluated in the future.

Knowledge, attitudes and perceptions among non blood donor female health care professionals.

INTRODUCTION: Blood donation is necessary in order to maintain an adequate supply of blood to patients who are suffering from any kind of disease or trauma, which requires them to have blood transfusion. Female non-blood donors are generally low in number. Therefore, this research was carried out to assess the main reasons behind the lack of blood donations made by females, and their knowledge, attitude and perceptions towards voluntary blood donation. METHODOLOGY: A cross-sectional study was conducted on 664 female health professionals, who were selected by non-probability convenience sampling from two tertiary care hospitals. A pretested questionnaire was presented to the sample population, and the data was entered and analyzed on SPSS (V17). RESULTS: 94.6 % were aware with the fact that blood is screened for AIDS, Hepatitis B and C before transfusion. Moreover, 83.7% said that they will only donate blood if a family, relative or friend would need it and similarly 83.4%  suggested that they would donate blood if blood donation camps are arranged in hospital premises. 81.8 % thought that blood donors can contract Hepatitis B after donation where as only 29.5% did not blood due already blood loss in menstrual cycle. CONCLUSION: The participants had adequate knowledge about the benefits of blood donation. The most important reason identified for not donating blood is the lack of facilities within the workplace or lack of approach by responsible authorities. The results of the study may help in minimizing the misconceptions of the participants about blood transfusion, which would increase their contribution towards blood donation.

Predictors of Mortality in Patients Undergoing Mitral Valve Replacement.

OBJECTIVE: Although mitral valve replacement is frequently performed in patients of all age groups, there are few studies available which determine the causes of operative mortality in mitral valve replacement especially in our region. Therefore, the objective of this study was to identify factors that are significantly associated with operative mortality in mitral valve replacement. METHODS: From August 2012 to March 2013, 80 consecutive patients undergoing mitral valve replacement in a single tertiary hospital were included. Patients with a history of previous coronary artery bypass graft surgery or congenital heart problems were excluded from the sample. The included patients were observed for a period of 30 days. Pre and post-operative variables were used to identify significant predictors of mortality. RESULTS: The overall hospital mortality (30 days) was 15%. High post-perative creatinine (P =0.05), high ASO titre (P=0.03), young age (P=0.011), low cardiac output (P=0.0001), small mitral valve size (P=0.002) and new onset of atrial fibrillation (P=0.007) were the significant independent predictors of operative morality. CONCLUSION: Mitral valve replacement can be performed in third world countries with limited resources with low mortality. However, optimal selection of mitral valve size can help to improve operative mortality.

Knowledge, Awareness and Self-Care Practices of Hypertension Among Cardiac Hypertensive Patients.

INTRODUCTION: The most prevalent form of hypertension is systolic blood pressure (SBP) and it is considered to be predisposing risk factor for cardiovascular disease. The objective of the study was to assess self-care practices, knowledge and awareness of hypertension, especially related to SBP among cardiac hypertensive patients. METHODOLOGY: A Cross sectional study was conducted on 664 cardiac hypertensive patients, which were selected by non-probability convenience sampling from cardiology outpatient department of three tertiary care hospitals. Face to face interviews were conducted using a pre designed questionnaire. Data was entered and analyzed by SPSS (V17). RESULTS: 81.8%, did not know that hypertension is defined as high blood pressure. 97.1% of the sample population did not know that top measurement of blood pressure was referred to as systolic and only 25.0% correctly recognized normal systolic blood pressure to be less than 140 mmHg. 7.4% of the patients consulted their doctor for hypertension once or twice in a month. Risk factor for high blood pressure most commonly identified by the participants was too much salt intake CONCLUSIONS: The results state that there is an inadequate general knowledge of hypertension among cardiac patients and they do not recognise the significance of elevated SBP levels. There is a need to initiate programs that create community awareness regarding long term complications of uncontrolled hypertension, particularly elevated SBP levels so that there is an improvement in self-care practices of the cardiac patients.

Sociodemographic Pattern of Depression in Urban Settlement of Karachi, Pakistan.

INTRODUCTION: Depression is a global issue prevalent among developing countries like Pakistan as compared to developed countries. We conducted a study to assess the prevalence and identify the significant predictors of depression in an elite urban settlement in Karachi, Pakistan. MATERIALS AND METHODS: This cross-sectional study was done in the elitist residential area of Karachi; Defence Housing Authority (DHA). Four hundred and twenty three participants were included by going to their residences. Self-administered questionnaires were handed out after taking informed consent. Level of depression was assessed by Patient Health Questionnaire (PHQ-9). Data were entered and analysed in Predictive Analytical Software v. 18.0. RESULTS: The mean and median total score of the scale were 5.9 ± 5.4 and 4 (7) respectively with minimum score 0 and maximum 27. In this sequence, 139 (32.86%) respondents were identified to be depressed. It was found that females were slight more depressed than males (p = 0.063). Regression Model identified only gender and marital status as significant predictors of depression. Having a female gender increased 0.658 times chance of being depressed (p = 0.047). Unmarried person had 0.296 times more likely to be depressed (p = 0.019). Boredom was considered as significant factor of depression by the participants (p< 0.0001). Odds ratio signified depression occurred 0.310 times more if one was bored. DISCUSSION: Depression should be considered as a major public health issue for the city. Public awareness should be done in all parts of the city in an attempt to reduce depression especially among the female gender.

Predictors of Knowledge of Coronary Intervention in a Group of PCI Patients.

OBJECTIVE: This study was performed to assess the knowledge of CAD risk factors and post management of coronary intervention among sample of population who were hospitalized for PCI. METHODOLOGY: A cross-sectional, descriptive survey was conducted in Cardiology ward of a tertiary care hospital from July 2013 to May 2015 on 600 patients. A structured questionnaire was used to interview the patients. In univariate analysis, t-tests were employed to assess association of knowledge of CAD risk factors with gender, education level and monthly household income. RESULTS: The mean score of participants with no education was 4.42 and patients with education of bachelors or higher was 8.59 (p-value: 0.01). Similarly, the mean score for participants with monthly household income less than 5000 was 3.32 and participants with income higher than 50,000 had a score of 8.31 (p-value: 0.01). Furthermore, only 28% (N=168) claimed aerobic exercise as a key part of angioplasty recovery. CONCLUSIONS: Our results indicate the lack of good level of knowledge of risk factors for CAD and post management of coronary intervention among PCI patients of Pakistan. There is urgent need for targeted educational programs on national basis to reduce mortality associated with CAD in Pakistani population.

Predictors of the size of prosthetic aortic valve and in-hospital mortality in aortic valve replacement.

PURPOSE: We hypothesized that gender, age, aortic root dimension, blood group and Left Ventricular End Diastolic and Systolic Diameters may have a significant correlation with the size of mechanical valve used. METHODS: We included 48 patients retrospectively who had been operated at a single tertiary hospital. All patients with aortic stenosis or regurgitation were included in the study. Patients who had undergone previous cardiac surgery or concomitant surgical procedures, such as coronary artery bypass grafting, were excluded from the study. RESULTS: The median size of the valves used in males (23mm) and females (21mm) were significantly different (P = 0.001). Size of the valve used was significantly associated with Left Ventricular End Systolic Diameter (LVESD) (r = 0.327, P = 0.007) and aortic root dimension (r = 0.526, P < 0.001). Moreover, significantly higher values of LVESD were observed in the expired patients (P = 0.023). CONCLUSION: This study shows that aortic root dimension and gender may be important predictors for the size of the prosthetic aortic valve used in aortic valve replacement. Our study also concludes that LVESD has significant relationship with in-hospital mortality. However, more long term clinical trials should be conducted to confirm these relationships.

On pump coronary artery bypass graft surgery versus off pump coronary artery bypass graft surgery: a review.

There are two basic ways of performing coronary artery bypass graft surgery (CABG): on pump CABG and off pump CABG. Off pump CABG is relatively a newer procedure to on-pump CABG and does not require the use of the cardiopulmonary bypass machine. On pump CABG is the more traditional method of performing bypass surgery. However its resultant inflammatory effects cause renal dysfunction, gastrointestinal distress and cardiac abnormalities which have forced the surgeons to look for alternatives to the procedure. An extensive literature search revealed that on pump CABG causes better revascularization as compared to off pump CABG while off pump CABG has a much lower post operative morbidity and mortality especially in high risk patients. We suggest that the technique used should depend on the ease of the surgeon doing the operation as both the methods seem almost equally efficient according to the review.

The frequency of smoking and common factors leading to continuation of smoking among health care providers in tertiary care hospitals of Karachi.

BACKGROUND: The primary objective of the study was to find out the frequency of tobacco smoking among health care providers in tertiary care hospitals of Karachi. The secondary objective was to identify the common factors responsible for the continuation of smoking. METHOD: This cross sectional study was conducted in the wards and out-patient departments of three selected tertiary hospitals of Karachi. A total of 180 health care providers were enrolled in the study using proportionate stratified sampling. Postgraduate students, house officers and trainees were excluded from the study. Data were collected from randomly selected health care providers using survey methodology. SPSS v. 20.0 was used to enter and analyze the data. RESULTS: Fifty two participants out of 180 were smokers for past one year (28.9%). Among them, 21 (11.7%) smoked more than 5 cigarettes per day. Twenty smokers (11.1%) were found to smoke due to peer influence. It was found that those who were influenced by their peers were 8.33 times more prone to be addicted to smoking than those who were less influenced. Similarly, the likelihood of addiction increased up to 76.9% with the lack of incentives. CONCLUSION: Our results clearly indicate that a large number of health care providers smoke which should be a serious concern. Hence our health agencies should take immediate action in order to curtail the heaving burden of smoking and its related health consequences.

Barriers to accessing surgical care: a cross-sectional survey conducted at a tertiary care hospital in Karachi, Pakistan.

BACKGROUND: The need for surgical care far exceeds available facilities, especially in low income and poor countries. Limited data are available to help us understand the extent and nature of barriers that limit access to surgical care, particularly in the Asian subcontinent. The aim of this study was to understand factors that influence access to surgical care in a low-income urban population. METHODS: An observational cross-sectional study was conducted on 199 consecutive patients admitted for elective surgery from February to April 2010 to identify the presence and causes of delay in accessing surgical care. RESULTS: The median duration of symptoms were 7 and 4 months in women and men, respectively. The odds of delay between the onset of symptoms and seeking initial health care (first interval) is twice as likely for women than for men [52.7 vs. 37.5 %, odds ratio (OR) 1.9]. Lack of knowledge regarding treatment options [OR 3.8; 95 % confidence interval (CI) 1.4-10.3] and about disease implications (OR 2.4; 95 % CI 1.2-4.8) were cited most often. A second interval of delay (time from when surgery was first advised to the surgery) was reported by 123 (61.8 %) patients. Financial constraints (29.6 %) and environment-related delays (10.6 %) were cited most often. More women than men thought there was a second delay interval (73 vs. 58 %). The odds of women having more co-morbid conditions were nearly 4.7 times that of men (95 % CI 1.5-15.1). CONCLUSIONS: A complex interaction of factors limits access to surgical care in developing countries. Women appear to face greater hurdles to accessing health care. Understanding local factors is essential to make care accessible.