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

Burundi

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

MSF intervention

Emergency Obstetrics and Neonatal Care (EmONC) facility

Emergency patient transfer service from peripheral facilities → hospital

Research question

Does an ambulance referral network effectively improve access to emergency obstetrics and neonatal care?

Study objectives

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 setting: Kabezi district

• Population ~ 198,000

• ~9900 expected deliveries/yr

• One district hospital

• 9 health centre maternities: 1-70km from hospital

Location of the district’s maternities covered by the

referral network

o 4 on the main roado 5 on hillside dirt

tracks o Furthest centre: 3 hours awayo Altitudes: 800 –

2000 meters.

Communication & ambulance network

(24 hours, all days)

• Referral criteria: At risk deliveries/Obstetric

complications

• VHF Radio • Three ambulances (3 health districts)

Referral criteria to CURGO

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

Communication system – VHF Radio

• 8 maternities use VHF for calling an ambulance

• 1 MU uses a cell phone

Communication system –Radio operator

o Records all incoming calls

o Passes on to medical transfer team

o Criteria met; ambulance goes out.

Communication system – Ambulance driver

o Keeps in contact with maternity and CURGO

o Records arrival/departure time at/from MU

The ambulance

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

The ambulance transfer nurse

o Nurse trained in obstetrics evaluates the patient at the maternity and confirms diagnosis made by the maternity nurse

o Observes and provides essential care to the patient during transfer until arrival at hospital

Data Sources

Data sources Ambulance call books

Logistic recordsHospital medical database

Study period Jan – Dec 2011

Ethics Burundi Ethics Committee & MSF Ethics Review Board

Median time: call out to dispatch and return

Total ambulance call outs 1478 for 1385 women

Maternity call – Ambulance dispatched* 30 minIQR(15-65)

Ambulance dispatch – Roundtrip to hospital*

78 minIQR (52- 130)

* for 86 occasions time unknown

Main Reasons

Referral times in association with early adverse neonatal

outcomes

Ambulance call –return to hospital Hospital

deliveriesNeonates

Stillborn & Death < 24hrs after birth

n (%)

< 3 hours 840 858 75 (9)> 3 hours 136 137 21 (15)Unknown 57 57 8 (14)

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

Transport CostsCosts in Euros Annual costsVehicles (Toyota land Cruiser)Stretcher and oxygen on board ambulanceDrugs on board ambulanceVehicle tax and insurance / yearVehicle repair and maintenance / yearFuel / yearDrivers – gross salariesAccompanying nurses – gross salaries

Total

10 008485

361912913968

124141797620585

70 346

Communication Costs

Costs in EurosAnnual

costs

Radio system Radio operators – gross salariesRadio VHF kits for the health centresSolar panel kits for the health centresAmbulance radiosTotal

20012 732

5401 672

9615 240

Costs - per case & capita

Costs in Euros Annual costs

Communication totalTransport totalTotal

15 24070 34685 586

Cost per obstetric case: € 61

Cost per capita / year: € 0.43

Conclusion

o A medicalised ambulance was key to starting care early

o Strong association between

referral time and early neonatal death – this needs to be reduced

o Overall per-capita costs are low

o Motorbike ambulances ?

AcknowledgementsMany thanks to the patients and clinical staff at Kabezi hospital

and maternities and to the relevant Health authoritiesLuxor Operational Research Team