Background The impact of the COVID-19 pandemic on surgical care delivery in low- and middle-income countries (LMIC) has been challenging to assess due to a lack of data. This study examines the impact of COVID-19 on pediatric surgical volumes at four LMIC hospitals. Methods Retrospective and prospective pediatric surgical data collected at hospitals in Burkina Faso, Ecuador, Nigeria, and Zambia were reviewed from January 2019 to April 2021. Changes in surgical volume were assessed using interrupted time series analysis. Results 6078 total operations were assessed. Before the pandemic, overall surgical volume increased by 21 cases/month (95% CI 14 to 28, p p = 0.014). Patients during the pandemic were younger (2.7 vs. 3.3 years, p p = 0.003). Additionally, they experienced lower rates of post-operative sepsis (0.3% vs 1.5%, p p p Conclusions During the COVID-19 pandemic, children’s surgery in LMIC saw a sharp decline in total surgical volume by a third in the month following March 2020, followed by a slow recovery afterward. Patients were healthier with better post-operative outcomes during the pandemic, implying a widening disparity gap in surgical access and exacerbating challenges in addressing the large unmet burden of pediatric surgical disease in LMICs with a need for immediate mitigation strategies.