Smile Train-Lifebox Safe Surgery and Anesthesia Initiative

A multi-year strategic partnership to elevate the quality and safety of cleft and pediatric surgery wordlwide

Smile Train and Lifebox are united in their work to improve the safety of surgery and anesthesia globally. Smile Train is Lifebox’s longest partner, part of the Lifebox story since its founding in 2011.

In 2020 we strengthened our longstanding partnership with the launch of the Smile Train-Lifebox Safe Surgery and Anesthesia Initiative. This groundbreaking Initiative is a multi-year strategic partnership to elevate the quality and safety of cleft and pediatric surgery worldwide. Through capacity building, innovations, and research, the Initiative is strengthening the surgical systems of over 1,000 hospitals around the world – to make every surgery safer.


“I am so proud of Smile Train and Lifebox for this ground-breaking Initiative to elevate the safety of anesthesia and surgery worldwide. Together, these two leading medical organizations are strengthening surgical systems on a global scale. It will change lives. It will save lives.”
Dr. Atul Gawande, Inaugural Global Ambassador of the Smile Train-Lifebox Safe Surgery and Anesthesia Initiative, and Lifebox Co-founder

Cleft-lip and palate is a common pediatric surgical condition which causes difficulty eating, breathing, hearing, and speaking, and often leads to a child’s marginalization. More than 90% of children with untreated clefts will die before they reach the age of 19. The Initiative, through training and technological innovations, will address the gaps in cleft and pediatric surgical and anesthetic care –  strengthening the wider surgical system as a result.

“With a shared dedication to supporting safe, high-quality surgery and anesthesia, and a shared passion for scaling innovative technologies that can transform surgical care, Smile Train and Lifebox are now expanding on our history of fruitful collaborations. As a nonprofit whose goal is to empower local medical professionals to treat patients with clefts in their own communities, we are thrilled to be working with Lifebox to bring additional training, education, and other critical resources to our global network of partners.”
Susannah Schaefer, Smile Train President & CEO, Lifebox Board Member

Initiative Activities


The Lifebox-Smile Train Pulse Oximeter

The Lifebox-Smile Train Pulse Oximeter

The Lifebox-Smile Train pulse oximeter is a low-cost, high-quality device designed for use in low-resource environments.  Since 2011, Lifebox has distributed 32,000 pulse oximeters – alongside training – to healthcare providers around the world to improve anesthesia safety. Over the next three years, we plan to distribute 11,000 Lifebox-Smile Train pulse oximeters to facilities in more than 20 countries to make surgery safer for 14 million patients.

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Developing a low-cost, high-quality capnograph

Developing a low-cost, high-quality capnograph

The Smile Train-Lifebox Capnography Project seeks to find a “capnography solution” to provide comprehensive, safe cleft care through improved patient monitoring during surgery in resource-limited settings. Due to its technical requirements, as well as the cost, capnography is not available in many operating rooms globally. Smile Train and Lifebox have developed specifications for a capnography device specifically designed for the intraoperative care of children, including those having cleft surgery, in low-resource settings.

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Piloting Clean Cut for Cleft at three hospitals in Africa

Piloting Clean Cut for Cleft at three hospitals in Africa

Clean Cut for Cleft, focuses on achieving safer surgery for children with cleft lip and palate. The program aims to reduce surgical site infections as well as the main complications faced by cleft patients undergoing surgery, such as airway compromise or delayed bleeding. The program is launching at the Smile Train partner hospitals of Yekatit 12 and the African Leprosy Research (ALERT) Hospital in Ethiopia’s capital, Addis Ababa.

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This new workshop targets the three main professional groups – anesthesia providers, nurses, and surgeons –   who collaborate together as ‘Cleft teams’ to deliver cleft surgery and care in the operating room and post-operative recovery areas.

The workshop focuses on improving teamwork and communication processes during emergency events, as well as routine best practices for surgical safety.  Cleft teams from different facilities train together to learn team-to-team and across disciplines – encouraging the sharing of best practices and helping build a network of practitioners for cleft care.  This workshop is particularly important since children with cleft are at higher-risk of complications during surgery.

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Report: A Critical Gap

A Smile Train-Lifebox report on pulse oximetry in low-and middle-income countries

A Critical Gap: pulse oximetry in low- and middle-income countries

COVID-19: Lifebox and Smile Train Joint Response

In early 2020, as the COVID-19 pandemic took hold, Lifebox and Smile Train began collaborating on a coordinated global COVID-19 response to support hospitals in LMICs with tools and resources for safe surgical, anesthesia, and COVID-19 care. This included:   

Preparedness for COVID-19: In April 2020 we prepared an article on “COVID-19 preparedness within the surgical, obstetric and anesthetic ecosystem in Sub-Saharan Africa” (published in the Annals of Surgery in June 2020), its wide dissemination included an online event with global experts – the first of an ongoing learning series on COVID-19.

Pulse oximeter distribution: We distributed 8,800 pulse oximeters across 53 low-resource countries to frontline providers for the detection and management of COVID-19 patients.

COVID-19 Surgical Patient Checklist: Together with the WFSA, Lifebox and Smile Train developed a communication tool to help keep surgical teams safe from infection, by offering prompts to support key infection prevention measures. More than 130 perioperative providers have been trained as trainers through 23 workshops. 

Global survey on perioperative provider resources and safety: Published “Perioperative Provider Safety in Low- and Middle-Income Countries During the COVID-19 Pandemic: A Call for Renewed Investments in Resources and Training” in the Annals of Surgery. The article assessed gaps in access to PPE and infection prevention protocols, and pulse oximetry. The results informed our distribution plans and to advocate for greater investment and support for essential resources and training in LMICs. 


“If we want to reduce infant mortality further, we need interventions to work deeply on the surgical management of children.” Professor Miliard Derbew, Global Ambassador, Smile Train-Lifebox Safe Surgery and Anesthesia Initiative

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