 The authors suggest that the best way to distribute surgical services in low and middle income countries, LMIX, is through either decentralization or regionalization. Decentralizing emergency obstetric services has shown promising results, while there is limited evidence of regionalization in LMIX. Principles from successful regionalization of certain services, such as trauma care in high-income countries, HICs, could be adapted to LMIC settings and provide the backbone for innovation in service delivery and safety. This article was authored by Jamie A. Henry.