Interventions to reduce postoperative mortality in Low- and Middle-Income Countries: a systematic review

INTRODUCTION: Postoperative mortality is the third leading cause of death worldwide and disproportionately affects patients in LMICs. Although many deaths are potentially preventable, evidenced-based interventions remain limited. The aim of this systematic review was to consolidate randomised trial evidence on interventions designed to reduce postoperative mortality in LMICs. METHODS: Medical databases from database inception to February 2025 were systematically searched for randomised trials evaluating interventions in any aspect of the patient pathway from admission to discharge to reduce postoperative mortality within 90 days of surgery in LMIC patients. Eligible studies included elective and emergency operations across all surgical specialities. RESULTS: From 10,877 search results, some 18 trials involving 95,521 patients were included. Three were multi-country trials and half were conducted in China. Trials spanned multiple specialities with only four of 18 assessed as having low risk of bias. Four trials showed significant mortality reduction although these were largely context specific. These included 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 following caesarean deliveries in Senegal and Mali. Adherence to interventions was generally high, and similar between simple and complex interventions (93.6% vs 96.8%), although adherence varied substantially across trials. CONCLUSIONS: Few RCTs have targeted postoperative mortality in LMICs, and no intervention demonstrated consistent effectiveness across multiple contexts. To maximise clinical impact, future research should prioritise 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.