Gender equity in pediatric surgical care in Central and South Asia: A systematic review and meta-analysis

OBJECTIVE: We assessed gender based access to pediatric surgical care in Central and South Asia (CSA) by reviewing published clinical studies. METHODS: A PRISMA-guided systematic review and meta-analysis of 99 pediatric surgical studies from CSA (2004-2023) included 10,508 children. Nineteen conditions grouped as acquired, congenital, or tumor related. After adjusting for minor sex based incidence differences using global and regional rates, we compared adjusted sex distributions with those in high-income countries. RESULTS: Boys were overrepresented in acquired conditions compared with high-income country M:F ratios, including appendicitis (2:1 vs 1.4:1, p < 0.001) and intussusception (1.9:1 vs 1.5:1, p < 0.001). Congenital conditions showed similar excess boys' predominance: anorectal malformations (1.6:1 vs 1.3:1, p < 0.05), Hirschsprung disease (4.6:1 vs 4:1, p > 0.05), congenital diaphragmatic hernia (2.6:1 vs 1.5:1, p < 0.001), esophageal atresia (3.6:1 vs 1.3:1, p < 0.001), and biliary atresia (2.2:1 vs 0.6:1, p < 0.001). Tumors also showed higher boys' predominance; neuroblastoma (1.8:1 vs 1.2:1, p < 0.05), Wilms' tumor (1.4:1 vs 0.9:1, p < 0.001), and hepatoblastoma (1.6:1 vs 1.2:1, p > 0.05). Meta-analysis confirmed strongest boys' predominance in acquired conditions (n = 3465; log OR 0.75, 95 % CI 0.66-0.84), followed by congenital (n = 2780; log OR 0.43, 95 % CI 0.35-0.50). Tumors showed no significant overall difference (n = 1234; log OR 0.10, p = 0.13). Adjusting for regional sex ratio at birth reduced odds ratios by only 5-6%. CONCLUSION: A significant boys' predominance in pediatric surgical care in CSA was identified. This potential healthcare inequity warrants further investigation and action.