Evaluating bellwether surgical outcomes in Ethiopia: insights from a multicentre 7-day prospective cohort study

INTRODUCTION: Bellwether procedures-emergency laparotomy, caesarean section, and open fracture management-are among the most cost-effective interventions for addressing diverse emergency surgical conditions. However, inequitable access and high postoperative complication rates remain major challenges, particularly in low- and middle-income countries. This study aims to provide robust epidemiological data on postoperative outcomes following bellwether surgeries in Ethiopia. METHOD: We conducted a 7-day, multicentre, national, prospective observational cohort study of adult patients undergoing bellwether surgical procedures in Ethiopia. Hospitals were recruited through convenience sampling across all twelve administrative regions. The primary outcomes were postoperative complications and mortality occurring within 7 days of surgery. We performed descriptive analyses to summarize patient demographics, perioperative characteristics, and outcome frequencies. To identify independent risk factors for postoperative complications, we applied multivariable logistic regression models, reporting adjusted odds ratios with 95% confidence intervals. RESULTS: Among 4412 surgical patients across 46 Ethiopian hospitals, 2181 procedures (49.4%) were classified as bellwether surgeries. The median age was 27 years (IQR ± 8), and most patients were ASA IIE (53.8%, 1174/2181) and ASA IE (41.2%,899/2181). The majority of procedures were of intermediate complexity (70.7%), and 77.3% were emergencies. Caesarean section was the most common bellwether procedure (61.9%), followed by emergency laparotomy (23.6%). At 7 days postoperatively, the overall complication rate was 18.7%, with 8 deaths (0.4%). After adjustment for confounders, smoking (AOR 2.5, 95% CI 1.9-3.4), comorbidity (AOR 2.8, 95% CI 2.1-3.9), and major surgery (AOR 2.4, 95% CI 1.2-4.9) were independently associated with postoperative complications. CONCLUSION: Approximately one in five patients in Ethiopia experienced postoperative complications following bellwether surgery, despite being predominantly young, low-risk, and undergoing procedures of intermediate severity. Strengthening evidence-based interventions, improving perioperative processes, and reinforcing the foundations of the surgical system are essential to achieve safe, effective, and equitable surgical outcomes nationwide.