Factors influencing use of essential surgical services in North-East India: a cross-sectional study of obstetric and gynaecological surgery

Introduction There continues to be a large gap between need and actual use of surgery in low-resource settings. While policy frequently focuses on expanding the supply of services, demand-side factors are at least as important in determining under utilisation and over utilisation. The aim of this study is to understand how these factors influence the use of selected essential obstetric and gynaecological surgical procedures in the underserved and remote setting of North-East India. Methods The study combines and makes use of data from a variety of surveys and routine systems. Descriptive analysis of variations in caesarean section, hysterectomy and sterilisation and then multivariate logit analysis of demand-side and supply-side factors on access to these services is undertaken. Results Surgical rates vary substantially both across and within North-East India, correlated with service capacity and socioeconomic status. Travel times to surgical facilities are associated with rates of caesarean section and hysterectomy but not sterilisation where services are much more deconcentrated. Travel is less important for surgery in private facilities where capacity is much more dispersed but dominated by the non-poor. The presence of non-doctor medical staff is associated with lower levels of surgical activity. Conclusion In low resource, remote settings policy interventions to improve access to services must recognise that surgical rates in low-resource settings are heavily influenced by demand-side factors. As well as boosting services, mechanisms need to mitigate demand-side barriers particularly distance and influence practice to encourage surgical intervention only where clinically indicated.

Ethics considerations and statement is unclear Page 5 line 50: Please use surgical procedures or operations consistently rather than interchangeably throughout. Page 8 line 11..'The NFHS reported...rather than 'finds... The citation of footnotes and the referencing style conflict. It is unclear if 1, 2, 3 etc in the text refers to the 1, 2, 3 etc in the reference list or the footnote.

Results
The presentation of results is mixed with the interpretation of results that should be in the discussion section. To improve this section, please consider the use of sub-headings such as Essential reproductive/obstetric surgical rates Factors associated with the availability of reproductive/obstetric surgical procedures 1) supply side. 2) demand-side Discussion I suggest state the key results in the first paragraph, other clear subsections are interpretation of findings, strengthens and limitations, the implication for research and practice, and conclusion. The finding of non-medical staff associated with lower levels of surgical activity is not surprising unless there is any other cadre expected to perform surgery.

REVIEWER
Chiara Pittalis Royal College of Surgeons in Ireland REVIEW RETURNED 07-Jul-2020

GENERAL COMMENTS
The study examines a number of demand-side factors affecting obstetric surgical care delivery in NE India. While findings may not be generalisable to other countries, they provide important insights to inform context-specific policy interventions.
in general the manuscript is clear and well written, the only suggestions would be: -to define the term 'substantial surgical facility' for the benefit of the reader -Line 54 pg. 4: explicitly list the individual and household characteristics considered in the study for the benefit of the reader -it may be interesting to have a comparison between elective and emergency procedures if data are available

VERSION 1 -AUTHOR RESPONSE
Reviewer 1 Thank you for this interesting Research Thank you

Reviewer 2
There are a few grammatical issues throughout the manuscript.
Thank for noticing this. We have read through the manuscript and corrected some issues.
In the introduction, the can improve the understanding of readers.
Changed to 'aims to examine' "This takes pairs of coordinates (longitude and latitude) and accesses the HERE mapping database [1] to compute the total travel time using available roads adjusted for speed of traffic." Page 6 line 38-Please be explicit: No role in the design of NFHS, DHS, HMIS and Census surveys. This way it is different from the study design of your manuscript (which is unclear at present) I have modified the sentence: " The funder of the research had no role in the of the NFHS, HMIS or District Census nor any role in the study design, collection, analysis and interpretation of data, writing the report or the decision to submit the paper for publication." Ethics considerations and statement is unclear Sentence added: "The data used in this study are all anonymised and in the public domain and no additional ethics approval was required in order to undertake the study." Page 5 line 50: Please use surgical procedures or operations consistently rather than interchangeably throughout. 4 occurrences of 'operations' changed to 'surgical procedures' Page 8 line 11..'The NFHS reported...rather than 'finds...

Changed to 'reported'
The citation of footnotes and the referencing style conflict. It is unclear if 1, 2, 3 etc in the text refers to the 1, 2, 3 etc in the reference list or the footnote.
I have converted the footnotes into references so there is now no conflict.
The presentation of results is mixed with the interpretation of results that should be in the discussion section.
I have moved a couple of the interpretations of results in the results section to the discussion section.
Results To improve this section, please consider the use of sub-headings such as Essential reproductive/obstetric surgical rates Factors associated with the availability of reproductive/obstetric surgical procedures 1) supply side. 2) demand-side I have considered sub-sections but don't think the section would easily divide like this as the focus is first on the descriptive and then the multivariate results.
Discussion I suggest state the key results in the first paragraph, other clear subsections are interpretation of findings, strengthens and limitations, the implication for research and practice, and conclusion.
Key results are presented in the first paragraph. I have added the sub headings as suggested The finding of non-medical staff associated with lower levels of surgical activity is not surprising unless there is any other cadre expected to perform surgery.
Not surprising perhaps but it does have a policy implication since a greater density of doctors is likely to increase both essential and unnecessary surgery. So we felt it was important to report this finding. Reviewer 3 to define the term 'substantial surgical facility' for the benefit of the reader We have taken out the word 'substantial' because in fact we look at facilities with varying surgical capacity from 1 of fewer a day up to 2000 or more a year Line 54 pg. 4: explicitly list the individual and household characteristics considered in the study for the benefit of the reader A list has been added in the methods (description of variables) section. it may be interesting to have a comparison between elective and emergency procedures if data are available Thank you for this good suggestion. Unfortunately this is not possible given the data available

REVIEWER
Chiara Pittalis Royal College of Surgeons in Ireland, Ireland REVIEW RETURNED 17-Aug-2020 GENERAL COMMENTS Improved version. You could have elaborated a bit more on the approach statistical analysis in the methods section (e.g. choice of significance levels, etc.) but overall the paper is in order. Applicable international reporting guidelines (such as STROBE) such be applied and reported against.

Reviewer
You could have elaborated a bit more on the approach statistical analysis in the methods section (e.g. choice of significance levels, etc.) but overall the paper is in order.
We have a little more detail on significance, types of variables and commands used to analyse individual associations.
Applicable international reporting guidelines (such as STROBE) such be applied and reported against.
We have gone through the 22 point STROBE checklist and ensured the paper complies with the criteria although the individual criteria are not fully used to structure the sections of the paper.