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