OVERVIEW OF MNCH BURDEN OF DISEASE &

EMERGENCY REFERRAL FOR MOTHERS AND NEWBORNS

Emily Keyes 27 September 2012

MDGs 4&5 – counting down to 2015

MDG 4: reduce under 5 child mortality by 2/3Global rate fallen by 41% since 19906.9 million deaths in 2011 (down from 12 million in 1990)Rate of decline is increasing (from 1.8% in 1990s to 3.2% from 2000 to 2011)Deaths are increasingly concentrated in SSA and S. Asia (more than 80% of <5 deaths)

MDG 5: reduce maternal mortality by 75%Very few countries on track to meet goal (16 on track, 25 insufficient

or no progress))

287,000 maternal deaths in 2010 (declined by 47% since 1990)

56% of maternal deaths in SSA, 29% in S Asia

3.3 million neonatal deaths occur each year

75% occur in the first week (2.3 million)

Source: Oestergaard MZ, Inoue M, Yoshida S, Mahanani W et al. Neonatal Mortality Levels for 193 Countries in 2009 with Trends since 1990: A Systematic Analysis of Progress, Projections, and Priorities. PLOS Medicine. 2011; 8(8): 13 pages.

Asphyxia

Preterm/LBW

50% occur in the first 24 hours

When do women die?

Rates and absolute numbers

Laos (<5) Malawi (<5) Nepal (<5) Bangladesh (<5 + M) Egypt (M) Romania (M) India (M) China (M)

India Nigeria Dem. Rep. of

Congo Afghanistan Ethiopia Pakistan Bangladesh

Rapid rates of decline Highest absolute numbers (M+Neo)

Sources: UNICEF 2009; WHO 2007

India – annual statistics

117,000 maternal deaths

0.9 million newborn deaths (28% global deaths)

20% of global births 49% of global

underweight children 34% stunted children 46% of wasted

children

Evidence-based interventions for children Supplementary

feeding (6-9 months)

DPT3 Measles Vitamin A (2

doses) Sleeping under

insecticide-treated bednets

Care seeking for pneumonia

Malaria treatment

Diarrhea treatment

Improved sanitation

Improved drinking water

Evidence-based interventions for newborns

Folic acid Tetanus toxoid Syphilis screening Intermittent preventive

Rx malaria Detection, Rx

bacteriuria Antib for PPROM Corticosteriods preterm

labor Detection,

management of breech, twins

Labor surveillance Clean birth practices Newborn

resuscitation Breastfeeding Prevention,

management of hypothermia

Kangaroo mother care

Community-based pneumonia case managementSource: Darmstadt et al. 2008

Evidence-based interventions for women

Contraception Antenatal care Skilled birth attendant Postnatal care for mothers Cesarean delivery Safe abortion Active management of the third stage of

labor Magnesium sulfate for

pre-eclampsia/eclampsia Blood transfusion

Tracked in DHS

Drivers of maternal mortality reduction

Declines in fertility Increases in income per head Greater educational attainment among

females Increases in access to skilled care at

birth and emergency obstetric care

In the absence of HIV infection, declines would have been more dramatic in last 2 decades

Emergency Referral for Women and Children

Why referral? The continuum of care

Preconception Pregnancy Delivery Postnatal Care Infant and Child Care

Terminology and concepts Referral – any upwards movement of health

care seeking by individuals in the health system

Categorizations Point of initiation: Front line provider or self-

referral Urgency: Elective (cold) or emergency Timing: Antenatal, delivery and postpartum

referrals Acceptance vs. compliance with referral Appropriateness of referral

The 3 Delays Model

Onset of Recovery or deathComplication

DELAY #1

Deciding to seek care

DELAY #2

Reaching a facility

DELAY #3Receiving adequate

care

Referral has the potential to reduce all 3 delays

Time between the onset of a complication and

deathComplication Hours DaysHemorrhage

Postpartum 2

Antepartum 12

Ruptured uterus 1

Eclampsia 2

Obstructed labor 3Infection 6

Pyramidal structure & bypassing

Health center/post/dispensary

District Hospital

Regional Hospital

Adapted from Jahn & De Brouwere, 2001

Receiver

Sender

Transport

Resources to treatClinical judgmentProtocolsFeedbackQOCFinancial accessibilityTransportCommunication

Perceived • risk• etiology• QOCCosts• transport• careDistances & roadsSocio-culturalpreferences

Community

Requisites of a well functioning system

Communication

Functioning referral center

Transport

Source: Murray SF, Pearson SC. Maternity referral systems in developing countries: Current knowledge and future research needs. Soc Sci & Med 62, 2006.

Requisites of a well functioning system

Transport

Communication

Functioning referral center

Protocols for senders &receivers

Requisites of a well functioning system

Transport

Communication

Functioning referral center

Protocols for senders &receivers

Collaboration across levels and sectors

Supportive supervision

Monitoring system

Requisites of a well functioning system

Transport

Communication

Functioning referral center

Protocols for senders &receivers

Collaboration across levels and sectors

Supportive supervision

Monitoring system

Referral strategy informed by population needs and HS capabilities

Pro-poor protection for referral & transport

Policy support

Referral in Bo North, Sierra Leone 2007

What to do at the community level?

Birth preparedness includes planning for delivery attendant and (emergency) transport

Increasing family and male involvement in the awareness of danger signs and where to seek care -- to reduce gender driven barriers to care

Community mobilization for support of pregnant women and their infants

How to address the cost of referral?

Strategic solutions to cover transport + services Community-based health insurance Community loans Conditional cash transfers: NGO /

government incentives to pay for referral

Voucher schemes targeted at poor / fee waivers

How to address transportation?

All terrain vehicles are costly Need for greater accountability

Exclusive use for emergency transport Regular maintenance and repair

Driver coverage and training Solutions

Less costly transport options – ex. Motorcycle ambulances

Private-public partnerships – ex. Dondo, Mozambique

Operational guidelines / protocols Use of transport unions & on-call rotations

How to improve feedback?

Where feedback/counter-referral doesn’t exist, does it make sense to phase it in by ensuring feedback for those cases where follow up is critical?

Whose responsibility is it – patient or provider?

Solutions: Tie feedback to financial reimbursement Make forms simple Use telephones

Unmet need for referral

Non-compliance with referral can be high Compliance for fetal, newborn (and child)

referral may be particularly low Fear, discrimination, male providers,

poverty, etc. Provider reluctance to refer

Over confident / fear of losing credibility Poor diagnostic skills / poor patient

monitoring Lack of communication skills to overcome

patient reluctance

Bypassing when seeking treatment for obstetric complications Bypassing highlights the relative

importance of distance or cost as opposed to internal facility factors Quality of care – HR, drugs, supplies, open

24/7 Provider attitudes, greater privacy

First level referral sites sometimes refuse referrals, reportedly because they don’t want a maternal death on their books Pervasive or anecdotal? A problem of private referring to public

facilities?

How do we ensure the appropriateness of referral? Consequences of “too much” referral

Overburdening referral centers with normal cases (false positives), thus, increasing cost of care

Travel and opportunity costs increase for families Overmedicalization

Solutions Clinical criteria for referral (decision trees) Upgrade sending facilities to be more self

sufficient Penalize patients for accessing tertiary facilities

without a formal referral?

Key Messages

Successful referral systems are multifaceted and tailored to suit specific environmental contexts; all require careful consideration of what is needed in addition to affordable transport

A functioning referral system promotes equity and trust in the health system

Referral will reduce morbidity and mortality only if the care at the receiving end is of high quality