An ambulance referral network- does it improve access to emergency obstetrics?

1. An ambulance referral network- does it improve access to emergency obstetrics? Tayler-Smith K, Zachariah R, Manzi M, Van den Boogaard W,Nyandwi G, Reid T, De Plecker E, Lambert V, Nicolai M, Goetghebuer S, Christiaens B, Ndelema B, Kabangu A, Manirampa J, Harries AD Médecins Sans Frontières Burundi Ministry of Health International Union against Tuberculosis and Lung Disease London School of Hygiene and Tropical Medicine

2. Burundi

3. Background - Burundi • High maternal mortality ratio – 800 maternal deaths /100,000 live births(200x more than in Sweden) • High neonatal mortality – 42 / 1000 live births (20X more than Belgium)) • Main reasons: Poor access to and availability of Emergency Obstetric and Neonatal Care (EmONC) • Since 2006, MSF has managed an intervention in rural Burundi including setting up a referral system

4. Emergency Obstetrics and Neonatal Care (EmONC) facility Emergency patient transfer service from peripheral facilities → hospital MSF intervention

5. Does an ambulance referral network effectively improve access to emergency obstetrics and neonatal care? Research question

6. 1) Describe the ambulance & communication system 2) Assess the association between referral times and maternal & neonatal deaths 3) Describe the cost of the referral system Study objectives

7. Population ~ 198,000 ~9900 expected deliveries/yr One district hospital 9 health centre maternities: 1-70km from hospital Study setting: Kabezi district

8. Location of the district’s maternities covered by the referral network • 4 on the main road • 5 on hillsidedirttracks • Furthestcentre: 3 hoursaway • Altitudes: 800 – 2000 meters .

9. Referral criteria: At risk deliveries/Obstetric complications VHF Radio Three ambulances (3 health districts) Communication & ambulance network(24 hours, all days)

10. At risk for complicated delivery Previously > 5 deliveries First pregnancy and height < 1.5m History of obstetric fistula Obstetric Complications Complication of abortion Mal presentation of foetus Post partum haemorrhage Referral criteria to CURGO

11. Communication system – VHF Radio • 8 maternities use VHF for calling an ambulance • 1 MU uses a cell phone

12. Communication system –Radio operator • Records all incoming calls • Passes on to medicaltransfer team • Criteriamet; ambulance goes out.

13. Communication system – Ambulance driver • Keeps in contact withmaternityand CURGO • Records arrival/departure time at/from MU

14. The ambulance Equiped with emergency medication / tools including oxygen, reanimation drugs + equipment.

15. The ambulance transfer nurse • Nurse trained in obstetricsevaluates the patient at the maternity and confirmsdiagnosis made by the maternity nurse • Observes and provides essential care to the patient duringtransferuntilarrivalathospital

16. Data Sources Data sources Ambulance call books Logistic records Hospital medical database Study period Jan – Dec 2011 Ethics Burundi Ethics Committee & MSF Ethics Review Board

17. Median time: call out to dispatch and return * for 86 occasions time unknown

18. Main Reasons

19. Referral times in association with early adverse neonatal outcomes Referral times > 3 hours associated with significant higher risk of neonatal death: OR 1,9; 95% CI, 1.1-3.2) P-value: 0.02 Only 1 maternal death

20. Transport Costs

21. Communication Costs

22. Costs - per case & capita Cost per obstetric case: € 61 Cost per capita / year: € 0.43

23. A medicalised ambulance waskey to starting care early Strongassociation betweenreferral time and earlyneonataldeath – thisneeds to bereduced Overall per-capita costs are low Motorbike ambulances ? Conclusion

24. Acknowledgements Many thanks to the patients and clinical staff at Kabezi hospital and maternities and to the relevant Health authorities Luxor Operational Research Team