Surgical Gowns Level AAMI 3 Market Size, Share & Trends Analysis By Gown Type (Fabric Reinforced, Non-fabric Reinforced), By Surgery (Orthopedic Surgery, General Surgery), By Usability, By End Use, By Region, And Segment Forecasts, 2025 - 2033

Surgical Gowns Level AAMI 3 Market Summary

The aging global population further supports the market expansion, the growing demand for moderate barrier protection gowns in inpatient and outpatient settings, and heightened awareness of surgical safety, particularly post-pandemic. In addition, innovation in gown materials and healthcare infrastructure improvements in emerging economies are anticipated to boost market adoption further over the forecast period. According to a study by the CDC, approximately 1 in every 31 hospitalized patients in the U.S. acquires a healthcare-associated infection, translating to an estimated 633,300 cases annually. In 2023, the Pennsylvania Patient Safety Reporting System recorded 23,970 HAI incidents reported by long-term care facilities across the state, highlighting the ongoing challenge of infection control in acute and extended care settings.

The rising incidence of healthcare-associated infections, including Surgical Site Infections (SSIs), Methicillin-Resistant Staphylococcus aureus (MRSA), Clostridium difficile infections, and Central Line-Associated Bloodstream Infections (CLABSIs), is a significant factor fueling the demand for AAMI Level 3 surgical gowns. These infections compromise patient safety, leading to longer hospital stays, increased morbidity, and higher healthcare costs. Among these, CLABSIs are particularly concerning in surgical and intensive care settings, where patients require invasive devices like central venous catheters. Proper use of personal protective equipment, including surgical gowns with moderate barrier protection, is critical in reducing contamination risk during line insertions and surgical procedures. In response to these risks, healthcare institutions are adopting more stringent infection prevention and control protocols supported by CDC, WHO, and ECDC recommendations. AAMI Level 3 gowns, known for their balance of comfort and fluid resistance, are increasingly used in settings with moderate exposure to blood and bodily fluids, including operating rooms and intensive care units. The global focus on reducing HAIs, especially in light of rising antimicrobial resistance, continues to drive strong demand for high-standard protective apparel, boosting the market. According to the Australian Institute of Health and Welfare, 2023-2024, 1,699 SABSI cases were reported across public hospitals, occurring over 22.7 million patient care days, equating to a national rate of 0.75 cases per 10,000 patient days.

The data below highlights the top 15 U.S. states most affected by Central Line-Associated Bloodstream Infections (CLABSIs) in 2022. These high-capacity healthcare hubs perform a significant volume of invasive procedures involving central lines, increasing the risk of bloodstream infections. As a result, hospitals in these states are under greater pressure to implement rigorous infection prevention protocols, including the mandatory use of AAMI Level 3 surgical gowns that offer essential fluid and microbial barrier protection during central line insertions and maintenance.

Top 15 States of the U.S. With Central Line-Associated Bloodstream Infections, 2022

Source: U.S. Centers for Disease Control and Prevention

“Any patient who is treated for a long time using a catheter, a ventilator, central lines, or antibiotics is at increased risk. This is because anything that lowers someone’s immunity while potentially increasing the presence and duration of foreign bodies during their care can predispose them to a healthcare-associated infection.”- Syed Husain, MD, at ID Care.

The rising aging population is a key driver of growth in the surgical gowns level AAMI 3 market, as older adults are more prone to chronic conditions and require surgical interventions such as cardiovascular procedures, orthopedic surgeries, and gastrointestinal operations. With advancing age, the possibility of developing multiple comorbidities increases, leading to higher hospital admissions and surgical care rates. This demographic shift has significantly increased the demand for protective surgical apparel, particularly AAMI Level 3 gowns that offer moderate barrier protection for common procedures involving moderate fluid exposure. Moreover, elderly patients are more susceptible to hospital-acquired infections (HAIs), prompting healthcare providers to strictly adhere to infection control protocols, including high-performance surgical gowns. As global healthcare systems adapt to accommodate the medical needs of a growing geriatric population, the demand for reliable and standardized surgical PPE continues to rise, supporting the market growth for AAMI Level 3 gowns.

The data below shows a consistent rise in the elderly population aged 65 years and above in Canada, growing from 6.57 million in 2019 to over 7.56 million in 2023. This demographic includes significant growth across all age brackets, particularly among those aged 75 years and older, who are more likely to require surgical procedures due to age-related health issues such as cardiovascular diseases, orthopedic conditions, and cancers. As the demand for surgeries among older adults increases, so does the need for high-quality protective surgical apparel. AAMI Level 3 surgical gowns offer moderate barrier protection and are especially critical during procedures with moderate fluid exposure risk, which is standard in elderly surgical patients.

The data below shows that total hospital admissions across all U.S. hospitals have remained consistently high, rising from approximately 33.36 million in January 2022 to 33.68 million by January 2024, with community hospitals accounting for over 93% of total admissions. This sustained volume of hospitalizations reflects a high and ongoing demand for inpatient care, including many surgical procedures requiring strict infection prevention protocols. As a result, the consistent flow of admissions drives the demand for AAMI Level 3 surgical gowns, particularly in community hospitals, where most surgeries are performed.

Hospitalization statistics for 2022, 2023, and 2024

Source: American Hospital Association, U.S. CDC, FDA, Grand View Research

Market Concentration & Characteristics

The market growth stage is high, and the pace of growth is accelerating. The surgical gown level AAMI 3 industry is characterized by high growth owing to the rising number of surgical procedures, growing launches of novel products, and increasing prevalence of healthcare-associated infections.

The market shows a significant level of innovation, primarily driven by advancements in nonwoven fabric technologies, breathable barrier materials, and eco-friendly disposable solutions. Innovations include antimicrobial coatings, reusable gowns with enhanced fluid resistance, and ergonomically designed gowns for better mobility and comfort during lengthy procedures. Players are investing in R&D for multilayer fabric systems that provide AAMI Level 3 protection while optimizing weight and breathability.

The market has witnessed moderate mergers and acquisitions as larger PPE and surgical gown manufacturers seek to expand their product portfolios, geographic reach, and technological capabilities. Strategic acquisitions have been focused on integrating local manufacturers and specialty fabric suppliers. In high-growth regions, M&A activity is also driven by efforts to comply with evolving regulatory standards and consolidate market share in a fragmented landscape.

Regulations have a high impact on the market. Surgical gowns, especially those rated AAMI Level 3, are subject to strict regulatory requirements from agencies such as the U.S. FDA, European CE Marking authorities, and ISO standards. Compliance with 510(k) premarket notifications in the U.S. and EN 13795 standards in the EU ensures consistent product safety and performance.

The threat of product substitutes is low to moderate. While alternatives like aprons, coveralls, or lower-level surgical gowns (AAMI Level 1 or 2) may be used in specific low-risk environments, they do not offer the same barrier protection required for moderate-risk procedures. In settings where AAMI Level 3 protection is mandated, substitutes are generally not viable, making demand relatively inelastic.

Regional expansion is a key growth strategy for market players, with Asia Pacific, Latin America, and the Middle East & Africa presenting substantial opportunities. In Asia Pacific, countries like India, China, and Southeast Asian nations are witnessing increased surgical volumes, improving healthcare infrastructure, and heightened awareness of infection control. Similarly, public-private healthcare investments across emerging economies encourage local production and adoption of AAMI-rated gowns.

Gown Type Insights

The fabric reinforced gowns segment dominated the market in 2024 in the gown type segment and is expected to register the highest CAGR of 11.73% during the forecast period. This growth is attributed to their superior protection, durability, and performance during high-risk surgical procedures. These gowns are typically made from multi-layered materials with reinforcement in critical zones such as the chest and sleeves, where fluid exposure is most likely. Their ability to offer enhanced barrier protection against blood, bodily fluids, and pathogens makes them the preferred choice in surgeries with moderate to high fluid contact, especially in orthopedic, general, cardiovascular, and trauma surgeries. Healthcare providers favor fabric-reinforced gowns for their reliability and compliance with AAMI Level 3 standards, which balance safety with comfort and breathability. The growing emphasis on healthcare worker safety, combined with rising surgical volumes globally, has accelerated the adoption of these gowns.

The non-fabric reinforced gowns segment is anticipated to witness significant growth during the forecast period, driven by the rising demand for cost-effective and lightweight protective apparel in low- to moderate-risk surgical procedures. These gowns, which meet AAMI Level 3 standards without added reinforcement, are commonly used in routine operations, diagnostic procedures, and ambulatory care settings where fluid exposure is limited, but barrier protection is still necessary. Their growing adoption is also fueled by the increasing number of outpatient surgeries and the expansion of day-care surgical facilities, particularly in emerging markets. Non-fabric reinforced gowns offer improved mobility, breathability, and affordability, making them suitable for extended wear by healthcare personnel without compromising essential protection.

Surgery Insights

The general surgery segment accounted for the largest market share of 24.40% in 2024. This growth is primarily driven by the high volume of surgical procedures performed globally across hospitals and surgical centers. General surgeries including appendectomies, hernia repairs, cholecystectomies, and bowel resections-are among the most commonly conducted procedures, requiring strict adherence to sterile techniques to minimize the risk of surgical site infections. AAMI Level 3 gowns are particularly suited for general surgical settings as they provide moderate fluid and microbial barrier protection, essential for procedures involving moderate blood or bodily fluid exposure. Moreover, the demand for general surgeries continues to grow due to the increasing burden of lifestyle-related diseases, aging populations, and trauma cases, particularly in developing regions. Hospitals and outpatient surgical facilities prioritize using reliable protective apparel in operating rooms to comply with infection control protocols and ensure patient and staff safety. As a result, the general surgery segment continues to drive substantial demand for AAMI Level 3 gowns.

The endoscopic surgery segment is projected to grow at the fastest CAGR from 2025 to 2033. The increasing demand for surgical gowns in this segment is primarily driven by the rising adoption of minimally invasive procedures across various medical specialties. These surgeries necessitate highly sterile environments and precision instruments, increasing the need for high-quality, fluid-resistant surgical gowns to ensure contamination control and patient safety. Furthermore, the growing prevalence of gastrointestinal, gynecological, and urological conditions has contributed to the global rise in endoscopic procedures. According to data published by the National Institutes of Health (NIH) in September 2024, over 20 million gastrointestinal endoscopies are performed annually in the U.S. alone. This high procedural volume, coupled with advancements in endoscopic technology, is expected to drive the growth of the surgical gown level AAMI 3 industry within this segment over the coming years.

Usability Insights

The disposable gowns segment dominated the market in 2024 and was expected to grow at the fastest CAGR during the forecast period. The rising preference for disposable gowns is driven by their single-use nature, significantly reducing the risk of cross-contamination and healthcare-associated infections, critical concerns in surgical and high-risk clinical settings. Disposable gowns offer enhanced convenience, eliminate the need for laundering and sterilization, and ensure compliance with stringent infection control protocols. Moreover, the growing number of surgical procedures, heightened awareness of personal protective equipment, and pandemic preparedness strategies have further boosted the adoption of disposable gowns across hospitals, ambulatory surgical centers, and intensive care units, boosting the demand for convenient, ready-to-use protective solutions.

The reusable gown segment is expected to grow significantly in the surgical gown level AAMI 3 market over the forecast period. The increasing focus on sustainability, cost-effectiveness, and environmental impact reduction in healthcare settings primarily drives this growth. Reusable gowns, made from durable and high-performance fabrics such as polyester or polyester-cotton blends with fluid-resistant coatings, can withstand multiple laundering and sterilization cycles while maintaining AAMI Level 3 barrier protection standards. As a result, they are becoming an attractive long-term investment for hospitals and surgical centers, especially in regions with established sterilization infrastructure.

End Use Insights

The operating room segment led the end-use market with a revenue share of over 40.67% in 2024. This significant share is primarily attributed to the increasing number of surgical procedures, rising awareness about infection prevention, and strict adherence to safety standards in healthcare settings. AAMI Level 3 gowns are widely preferred in operating rooms due to their moderate barrier protection against fluid penetration, making them ideal for various surgical interventions. The growing burden of hospital-acquired infections and regulatory emphasis on sterile environments further drive demand for high-performance gowns in surgical settings.

The Intensive Care Unit (ICU) segment is expected to experience significant growth during the forecast period. This growth is primarily fueled by the increasing incidence of life-threatening conditions such as sepsis, respiratory failure, and multi-organ dysfunction, which require intensive medical care and prolonged hospital stays. Moreover, the global surge in infectious diseases has highlighted the critical importance of infection control in ICU settings. ICUs are high-risk environments where patients are immunocompromised and require frequent invasive procedures such as central line insertions, mechanical ventilation, and catheterization. These procedures significantly increase the risk of hospital-acquired infections, necessitating high-performance, fluid-resistant gowns. AAMI Level 3 gowns are particularly suited for ICUs, offering moderate barrier protection against blood, bodily fluids, and pathogen transmission while maintaining comfort and breathability for extended use by healthcare professionals.

Regional Insights

North America dominated the market with a revenue share of 29.64% in 2024. The surgical gowns level AAMI 3 market in North America is driven by several key factors, including rising healthcare expenditures, an increase in elective and emergency surgeries, and expansion of manufacturing capacities. In addition, advancements in medical technology, the aging population, and a growing number of surgeries also contribute to the demand for high-quality surgical gowns. For instance, a study published by the National Library of Medicine in May 2023 revealed that over 2 million surgeries are conducted in Canada annually.

U.S. Surgical Gowns Level AAMI 3 Market Trends

The surgical gowns level AAMI 3 market in the U.S. is expected to dominate the North American market over the forecast period. The rising incidence of healthcare-associated infections (HAIs) is a significant driver of the U.S. surgical gown level AAMI 3 market. HAIs, such as surgical site infections (SSIs), bloodstream infections, and pneumonia, pose serious risks to patient safety and increase healthcare costs through extended hospital stays and additional treatments. In response, hospitals and surgical centers are strengthening their focus on infection prevention protocols, which include the routine use of high-barrier surgical gowns, particularly those classified under AAMI Levels 3 and 4. Regulatory bodies like the Centers for Disease Control and Prevention (CDC) and Occupational Safety and Health Administration (OSHA) mandate strict compliance with PPE usage to reduce infection risks. This has led to a growing preference for single-use, fluid-resistant, antimicrobial gowns in surgical and non-surgical settings. According to a CDC study, approximately 1 of every 31 hospitalized patients in the U.S. has an HAI, meaning that approximately 633,300 patients contract one of these infections annually. In 2023, the Pennsylvania Patient Safety Reporting System received 23,970 HAI reports from long-term care facilities in Pennsylvania.

Top 15 States Central line-associated bloodstream infections, 2022

Source: U.S. Centers for Disease Control and Prevention

Europe Surgical Gowns Market Trends

The European surgical gown level AAMI 3 market is experiencing growth, driven by a combination of advanced healthcare infrastructure, strict regulatory standards, and a rising number of surgical procedures. Countries such as Germany, France, the UK, and Italy are leading the market due to their strong hospital networks and focus on infection prevention. The growing elderly population and the increasing prevalence of chronic conditions contribute to higher surgical volumes, fueling the demand for high-quality surgical gowns. As per the European Commission, on 1 January 2024, the EU population was estimated at 449.3 million people, and more than one-fifth (21.6%) was 65 years and over.

The chart illustrates the prevalence of healthcare-associated infections in European countries from 2022 to 2023.

The UK surgical gowns Level AAMI 3 market is poised for significant growth, driven by demographic and healthcare-related factors. The rapidly aging population is contributing to a higher incidence of chronic conditions such as cardiovascular diseases, which in turn is increasing the number of surgical procedures performed across the country. In addition, the rising concern over healthcare-associated infections is prompting hospitals and surgical centers to adopt higher-barrier gowns, such as those meeting AAMI Level 3 standards, to ensure better patient and healthcare worker protection. These dynamics, stringent infection control protocols, and growing awareness around surgical safety are expected to propel strong market expansion in the forecast years.

The data below shows the significant burden of cardiovascular diseases in the UK, with 174,693 deaths recorded in 2023 and over 7.6 million people currently living with the condition. Alarmingly, 48,697 of these deaths occurred in individuals under the age of 75, indicating a substantial impact on the working-age population.

Data on deaths from and numbers living with heart and circulatory diseases (CVD) for the UK 

Source: British Heart Foundation 2025

The market for surgical gowns level AAMI 3 in France, is expected to grow during the forecast period. The rising incidence of healthcare-associated infections, increasing volume of orthopedic surgeries, and an aging population are key factors propelling the growth of the surgical gowns market in France. France, like much of Europe, is experiencing a demographic shift, with a growing proportion of elderly individuals who are more prone to chronic conditions and degenerative joint diseases, necessitating more frequent orthopedic procedures such as hip and knee replacements. As per the Royal College of Surgeons of England, hip replacement numbers vary widely. In France, between 2018 and 2050, primary hip replacement is predicted to increase by 41.9% and 114.3%. These surgeries carry a high risk of post-operative infections, prompting healthcare facilities to adopt higher-grade surgical gowns, including AAMI Levels 3 and 4, to ensure enhanced patient and medical staff protection.

The chart indicates a significant projected increase in the geriatric population in France between 2023 and 2040. This demographic shift suggests that a larger portion of the French population will be over 65 in the coming decades. This trend is expected to drive higher adoption of surgical gowns, particularly those meeting AAMI Level 3 and 4 standards, as healthcare providers seek to minimize healthcare-associated infections and ensure the safety of vulnerable patients. Thus, France's growing elderly population is a significant factor fueling its surgical gown level AAMI 3 market expansion.

Asia Pacific Surgical Gowns Market Trends

The Asia Pacific surgical gown level AAMI 3 market is witnessing significant growth, driven by rising surgical procedures, expanding healthcare infrastructure, and increasing awareness of infection prevention. Countries such as China, India, and Japan are seeing a surge in surgeries due to a growing elderly population and a higher burden of chronic diseases like diabetes and cardiovascular conditions. Additionally, post-pandemic emphasis on infection control has led to greater adoption of high-standard protective apparel, including AAMI level 3 gowns. Government initiatives and investments in public health and hospital modernization further boost demand. Moreover, the region’s position as a cost-effective manufacturing hub enhances both domestic supply and global exports. These factors position Asia Pacific as the fastest-growing market for surgical gowns globally.

The surgical gowns level AAMI 3 market in China is experiencing growth, fueled by rapid expansion in the healthcare sector, increasing surgical volumes, and a heightened focus on infection control. The country's aging population and rising prevalence of chronic diseases such as diabetes and cancer have led to a greater demand for surgeries, subsequently driving the need for surgical gowns. According to the National Bureau of Statistics, over 15.4% of China's population was aged 65 and above in 2023. Moreover, government investments in hospital infrastructure, healthcare digitization, and stricter infection prevention protocols post-pandemic have boosted the adoption of AAMI-level-compliant gowns. Additionally, China's strong domestic manufacturing capacity and its role as a global supplier of medical textiles further accelerate market expansion. As a result, China remains a key contributor to the growth of the Asia-Pacific surgical gown level AAMI 3 market.

The India surgical gowns AAMI level 3 market is experiencing notable growth driven by healthcare infrastructure expansion, increased surgical volumes, and heightened awareness around infection control. One of the primary factors propelling the market is the growing number of surgeries performed across the country due to the rising prevalence of chronic diseases such as diabetes, cardiovascular ailments, and cancer. These procedures demand high-performance protective apparel, with AAMI Level 3 gowns being the preferred choice due to their moderate-to-high barrier protection against fluid penetration. According to the NIH, about 10-20% of admitted patients acquire nosocomial infections in India.

Latin America Surgical Gowns Level AAMI 3 Market Trends

The Latin America surgical gowns Level AAMI 3 market is experiencing growth driven by various factors. The rising burden of chronic diseases such as diabetes, cancer, and cardiovascular conditions has led to an increase in surgical procedures across the region. According to projections by the International Diabetes Federation, the number of people living with diabetes in the South and Central America (SACA) Region is expected to rise by 46%, reaching 52 million by 2050. During the same period, the prevalence of diabetes is anticipated to grow by 23%, reaching 12.3%. In 2024, diabetes-related healthcare spending in the region amounted to USD 81 billion, accounting for approximately 8% of global diabetes expenditure. In addition, greater awareness of hospital-acquired infections prompts healthcare facilities to adopt higher-standard protective apparel, including AAMI Level 3 gowns that offer moderate protection against fluid penetration. For instance, a study published by BioMed Central in January 2025 reported that out of 128,247 patients in ICUs in Brazil, 4,066 (3.2%) had at least one healthcare-associated infection (HAI) during their ICU stay, with 435 patients suffering from multiple HAIs.

Middle East and Africa Surgical Gowns Level AAMI 3 Market Trends

The Middle East and Africa surgical gowns Level AAMI 3 market is anticipated to grow significantly over the forecast period. This growth is primarily driven by the rising number of surgical procedures, increasing awareness about infection prevention, and the adoption of higher safety standards in healthcare settings. Governments and private healthcare providers across the region are investing in hospital infrastructure upgrades and implementing stricter infection control protocols, which is boosting the demand for AAMI Level 3 surgical gowns-known for their moderate fluid and microbial barrier protection. In addition, the growing medical tourism industry in countries like the UAE and South Africa and the increasing prevalence of chronic diseases requiring surgical interventions further support market expansion. For instance, the UAE Government reserves a substantial share of the federal budget for the healthcare sector every year.

Key Surgical Gowns Level AAMI 3 Company Insights

Cardinal Health, Medline Industries, LP, Mölnlycke Health Care AB, Medicom, Encompass Group, LLC, Taromed, Cortex Products Solution Pvt. Ltd, Nippon Encon Manufacturing Co., Ltd., Owens & Minor, Medilivescare Manufacturing Pvt. Ltd., Boston Scientific Corporation, Henry Schein, Inc., among others, are some of the major players in the surgical gowns level AAMI 3 market. Companies are expanding their portfolios of surgical gowns and increasing their production capacities to meet the growing demand. Moreover, industry players are also launching antimicrobial and smart gowns to gain a competitive advantage.

Recent Developments

• In March 2025, TDSC.com, powered by Henry Schein, announced a new affiliate partnership with the Pennsylvania Dental Association (PDA). This collaboration aims to expand access to dental supplies for PDA members through TDSC.com’s online marketplace, offering competitive pricing and streamlined procurement solutions tailored for dental professionals. This collaboration enhances the accessibility of Henry Schein’s product portfolio, potentially increasing the adoption of Level 1-3 surgical gowns in dental practices.

“This partnership represents a shared commitment to supporting dental professionals with top-quality products. Together, we’re helping practices across the state thrive and continue delivering great care to their patients.” - Dr. D. Scott Aldinger, Chair of Pennsylvania Enterprise Resource Corporation (PERC)

• In May 2024, Medline Industries, LP announced a collaboration with 3M to standardize surgical warming gowns, promoting patient comfort and care.

• In November 2023, Cardinal Health introduced the SmartGown EDGE Breathable Surgical Gown with ASSIST Instrument Pockets, designed to enhance the efficiency and safety of surgical procedures in the operating room. This exclusive product from Cardina is a recommended instrument per pocket, allowing for easy and convenient access during surgeries. The gown’s unique design helps streamline handling and enables clinical teams to focus on delivering high-quality patient care.

Surgical Gowns Level AAMI 3 Market Report Scope

Global Surgical Gowns Level AAMI 3 Market Report Segmentation

This report forecasts revenue growth at the global, regional, and country levels and provides an analysis of the latest industry trends in each of the sub-segments from 2021 to 2033. For the purpose of this study, Grand View Research has segmented the global surgical gowns level AAMI 3 market report on the basis of gown type, surgery, end use, usability, and region:

• Gown Type Outlook (Revenue, USD Million; Volume Unit, Price USD; 2021 - 2033)

  • Fabric Reinforced

  • Non-fabric Reinforced

• Surgery Outlook (Revenue, USD Million; Volume Unit, Price USD; 2021 - 2033)

  • General Surgery

  • Orthopedic Surgery

  • Endoscopic Surgery

  • Gynecological Surgery

  • Mastectomy

  • Others

• Usability Outlook (Revenue, USD Million; Volume Unit, Price USD; 2021 - 2033)

  • Disposable Gowns

  • Reusable Gowns

• End Use Outlook (Revenue, USD Million; Volume Unit, Price USD; 2021 - 2033)

  • Operating Room

  • Emergency Room

  • Intensive Care Unit (ICU)

  • Others

• Regional Outlook (Revenue, USD Million; Volume Unit, Price USD; 2021 - 2033)

  • North America

    • U.S.

    • Canada

    • Mexico

  • Europe

    • Germany

    • U.K.

    • France

    • Italy

    • Spain

    • Denmark

    • Sweden

    • Norway

  • Asia Pacific

    • Japan

    • China

    • India

    • South Korea

    • Australia

    • Thailand

  • Latin America

    • Brazil

    • Argentina

  • Middle East & Africa

    • South Africa

    • Saudi Arabia

    • UAE

    • Kuwait