Counting caesarean sections is not enough: a framework for measuring obstetric anaesthesia readiness in resource-constrained settings

Availability of caesarean delivery is not equivalent to access to safe and effective operative obstetric care. Caesarean-section rates, procedure volumes, geographical-access measures, and facility designations are essential for identifying underuse, overuse, and inequalities, and they are often used because they are more readily available than detailed measures of perioperative quality. However, these indicators do not establish whether a facility has the personnel, monitoring, oxygen, suction, medicines, blood access, postoperative observation, and escalation systems required to provide anaesthesia safely and respond effectively when complications occur. We propose an evidence-informed Obstetric Anaesthesia Readiness Framework that makes these capabilities an explicit component of maternal-health performance rather than an assumed feature of caesarean capability. The framework was developed through a focused, non-systematic synthesis of international anaesthesia standards, emergency obstetric-care guidance, obstetric anaesthesia literature, facility-readiness evidence, and evidence from Somalia and comparable resource-constrained settings. Candidate readiness components were organised by clinical function and mapped across structure, clinical processes, rescue capacity, and organisational learning. Five interconnected domains emerged: workforce and clinical competency; infrastructure, monitoring, and documentation; airway management, resuscitation, and essential medicines; haemorrhage response and referral capacity; and recovery, surveillance, and safety governance. Somalia is used as an illustrative fragile health-system context in which workforce concentration, uneven facility readiness, and limitations in emergency and critical-care capacity make the distinction between nominal access and effective safe access particularly important. The framework is intended to complement, rather than replace, caesarean monitoring, comprehensive emergency obstetric and newborn care indicators, international anaesthesia standards, and maternal and perinatal death surveillance. The proposed framework is an evidence-informed measurement model that has not yet undergone formal consensus development or empirical validation. Its candidate domains and indicators require expert consensus, feasibility assessment, inter-rater reliability testing, and evaluation against meaningful measures of maternal safety before routine, accreditation, or regulatory use. Maternal-health systems should measure not only whether caesarean delivery is available, but whether the personnel, monitoring, rescue capacity, haemorrhage response, postoperative care, team preparedness, and governance processes required to provide it safely are reliably available and functioning when needed.