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Maternal mortality ratios remain alarmingly high in much of sub-Saharan Africa. Burundi has one of the highest in the world at 800 deaths/100 000 live births in 2010 (WHO, UNICEF, The World Bank & UN Population Division Maternal Mortality Estimation Interagency Group (MMEIG) 2012) (NB: While lower estimates have been submitted to the MMEIG, these have yet to be validated). Lack of access to emergency obstetric care (EOC) is one of the major factors contributing to this mortality.
In 2006, Médecins sans Frontières (MSF) – an international Non-Governmental Organisation (NGO) – began working in a rural province in Burundi, with the aim of reducing maternal and neonatal mortality. To tackle the problem of lack of access to emergency obstetric services, MSF set up a central emergency obstetric and neonatal care (EmONC) facility, coupled with a 24-h communication network to facilitate ambulance referrals for the transfer of women with obstetric complications from peripheral maternity units to the EmONC facility. In a recently published study, this combination of interventions was estimated to reduce maternal mortality by 74% (Tayler-Smith et al. 2013).
In many cases, efforts to improve access to EOC focus on establishing a minimum number of EOC facilities, improving quality of care in such facilities, and mobilising communities to encourage women to use these services. But, overcoming transport barriers is a relatively neglected area (Hofman et al. 2008). In most sub-Saharan settings, ambulances are available, but often poorly managed, badly maintained and have frequent break downs. Their performance remains largely unevaluated (Somigliana et al. 2011). In view of this and the high impact that the MSF intervention had on reducing maternal mortality (Tayler-Smith et al. 2013), using routine programme data from a rural district in Burundi, we aimed to (i) describe the MSF communication and ambulance service with the related costs incurred; (ii) examine the association between referral times and maternal and early neonatal deaths; (iii) assess the impact of the referral service on coverage of complicated obstetric cases and caesarean sections.
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This study from a rural setting with high maternal mortality shows that an efficient ambulance system facilitates the transfer of women who urgently require emergency obstetric care. Timeliness of transfer was associated with a reduced risk of early neonatal deaths and still births.
One important strength of this study is that an efficient ambulance monitoring system was in place in CURGO, which ensured that ambulance use and timing were systematically recorded, and all running costs documented. As the data were also reviewed and supervised regularly by the logistics and medical departments, we believe they are robust.
The study has several limitations: it was not possible to control for all potential confounding factors when assessing the association between referral times and early neonatal deaths (such as the severity of the mother's condition when arriving at the health centre maternity unit, comorbidities or possible delays in treatment response at the CURGO facility). Due to reliance on estimates, we may have under or over estimated MSF coverage of complicated obstetric cases and caesarean sections. There was no monitoring of how the communication system functioned at the level of the referring health centres (e.g. how many times the communication system broke down, batteries went flat). While transfer times were most likely directly related to the distance travelled, it was not possible to investigate other factors, such as poor roads, that may also have been associated with longer transfer times, and whether 1.6 centralised ambulances were sufficient to meet the referral demand. Despite these limitations, our findings raise a number of important points for discussion.
First, timely access to quality EmONC for women with obstetric complications is recognised as being essential for reducing maternal mortality (Paxton et al. 2005; Campbell & Graham 2006; WHO 2006a) ensuring that an effective referral system is in place to help achieve this fits within the framework of the Minimal Initial Services Package for reproductive health (Inter-agency Working Group on Reproductive Health in Crises 2010). As only one maternal death was recorded among all of the women transferred to CURGO, it would suggest that MSF's maternity referral system functions in an acceptable manner. The main factors that are likely to underpin the effectiveness of the MSF maternity referral system are highlighted in Box 3. To be effective overall, each of the components must function well; the maternity care chain is only as strong as its weakest link. These factors are similar to those that have previously been described as being important for ensuring an effective maternity referral system (Murray et al. 2001). The importance of ensuring timely access to EmONC through such a referral system is similar to the improvements in survival that have been associated with earlier access to health care for other forms of medical emergencies such as cardiac arrest (Cummins et al. 1991). Survival from cardiac arrest is more likely if there is (i) a recognition of early warning signs, (ii) rapid activation of the emergency medical system, (iii) basic cardiopulmonary resuscitation, (iv) availability of defibrillation, (v) intubation and (vi) intravenous administration of medications – a process described by the concept of ‘chain of survival’. Similar principles apply to obstetric emergencies and an effective referral system is key for strengthening this ‘chain of survival’.
Box 3. The main factors that likely underpin the effectiveness of the MSF maternity referral system, Kabezi, Burundi
- An adequately resourced referral facility offering good quality EmONC.
- Robust protocols for the effective identification of obstetric complications, together with health centre staff trained in the proficient use of these protocols.
- A functional and efficient communication system using a two-way solar-powered radio system or cell phones.
- Medically equipped ambulances including a trained midwife or nurse as part of the ambulance team to enhance stabilisation and preparation of women for emergencies interventions.
- Twenty-four hour availability of functional and dedicated ambulances, with independent ambulance teams, providing transport free of charge
CURGO – Centre d'Urgence Gyneco-Obstetric; EmONC, emergency obstetric and neonatal care.
Second, the annual running cost of the MSF communication and ambulance referral system in Kabezi district came to just over € 85 000, which equated to € 61/obstetric case transferred or € 0.43/capita/year (NB: the gross domestic product (GDP) per capita in Burundi in 2011 was US$ 271 – approximately € 200, World Bank 2013). In a previous study (Tayler-Smith et al. 2013), it was estimated that the MSF intervention in Kabezi (i.e. the EmONC referral facility backed up by a functional patient transfer system) led to a 74% reduction in maternal mortality. In this respect, the annual running cost of the MSF communication and ambulance service would seem well justified, although a better appreciation of the cost-effectiveness of this service would require a more formal analysis which was beyond the scope of this study. A recent study from a remote setting in Uganda has demonstrated that, within the framework of reproductive health, an ambulance service is highly cost-effective (Somigliana et al. 2011). That said, alternative initiatives, such as that described from Malawi (Hofman et al. 2008), which uses motorcycle ambulances based at the health centres, do have the potential to reduce costs further. The average operating costs of a motorcycle ambulance were over 20 times less than for a car ambulance. A combination of such approaches might be most effective, depending on what is required in terms of distance, geographic terrain and weather conditions. With the growing use and decreasing costs of cell phones in many poor settings, this form of technology may also provide a cheaper and possibly more practical option than VHF radio communication.
Third, while we were not able to examine the association between referral times and maternal deaths (due to so few maternal deaths at CURGO), there is already evidence to indicate that for certain obstetric complications, prognosis is directly related to whether appropriate care is received promptly (for example – within 2 h for post-partum haemorrhage) (WHO 2005). What we did demonstrate was that longer referral times (>3 h) were associated with a higher frequency of early neonatal deaths, particularly in relation to prolonged/obstructed labour and abnormal foetal presentation. This further supports the importance both of keeping referral times to a minimum (Murray et al. 2001; WHO 2006b; Fauveau 2007), particularly in the case of prolonged/obstructed labour and abnormal foetal presentation, and factoring them in when delineating an appropriate catchment area for an emergency obstetric referral facility. The median time from the maternity unit calling CURGO to the ambulance being dispatched from CURGO was 30 min. While we would argue that this was acceptable, it draws attention to the need for good coordination between the radio communication room receiving the referral calls and the ambulance teams, in order that time delays during this part of the referral process are kept to a minimum, and ensuring that there are enough ambulances available to meet the referral demand.
Fourth, with the ambulances stationed at the CURGO base, each call-out required an ambulance to travel to the peripheral health centre maternity unit and back again to CURGO. For those maternity units located as far as a 3 h drive away from CURGO, this led to significantly long transfer times. While the ideal might have been to have stationed an ambulance at each of the nine maternity units, this would have required a far greater and unrealistic investment of resources and costs (more ambulances, more ambulance drivers, difficulties with vehicle maintenance, etc.). The initiative reported from Malawi (Hofman et al. 2008), which used motorcycle ambulances (consisting of a 250 cc Yamaha motorcycle with sidecar) placed at rural health centres and a car ambulance based at the district hospital, provides a possible solution around this. Not only did this significantly reduce referral times, but motorcycle ambulances were much less likely to be misused for non-health-related purposes than the car ambulances. Another study in Malawi assessed the effectiveness of bicycle ambulances to strengthen an obstetric referral system. However, they found that cultural beliefs deterred pregnant women from using bicycle ambulances (Lungu et al. 2001). Thus, some consideration needs to be given to cultural acceptance before an innovative transport intervention is introduced.
Fifth, coverage of complicated obstetric cases and caesarean sections by the MSF referral system was high – an essential requirement if any referral system is to have a maximum impact on maternal outcomes at the population level (Campbell & Graham 2006). This first implies that there is good utilisation of healthcare facilities by women with complicated pregnancies/deliveries in Kabezi, and, secondly, that women with complications are being effectively identified at the level of the health centres. Strategies to increase coverage of complicated deliveries are essential for reducing maternal and neonatal mortality (Fournier et al. 2009).
Finally, although not part of the referral and transfer system in place for trying to ensure timely access to EmONC, upon discharge from CURGOMSF offered free transport for women back to the health centre from which they had initially been referred. Knowledge of this service may have positively influenced a woman's decision to agree to be transferred to CURGO, especially when the health centre was far from CURGO.
In conclusion, our findings demonstrate that implementing an effective communication and ambulance system to ensure access to EmONC in a setting with very high maternal mortality, results in acceptable referral coverage of complicated deliveries and caesarean sections. We also highlight some of the important operational factors to consider, particularly in relation to minimising referral delays and reducing costs.