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

• 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

 Emergency Obstetrics and
Neonatal Care (EmONC) facility
 Emergency patient transfer service from peripheral facilities → hospital

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

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

• 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 road o 5 on hillside dirt tracks o Furthest centre:
.
3 hours away o 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)

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

• 8 maternities use VHF for calling an ambulance
• 1 MU uses a cell phone

 o Records all incoming calls o Passes on to medical transfer team o Criteria met; ambulance goes out .

o Keeps in contact with maternity and CURGO o Records arrival/departure time at/from MU


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

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

Total ambulance call outs 1478 for
1385 women
Maternity call – Ambulance dispatched* 30 min
IQR(15-65)
Ambulance dispatch – Roundtrip to hospital* 78 min
IQR (52- 130)
* for 86 occasions time unknown

Other
18; 19%
Abortion
21; 22%
Risk Miscarriage
6; 6%
Excessive height of uterus; 6; 6%
Rupture of membranes
8; 8%
Abnormal presentation
8; 8%
Previous C section;
16; 16%
Prolonged obstructed labour
15; 15%

Referral times in association with early adverse neonatal outcomes
Ambulance call – return to hospital
< 3 hours
> 3 hours
Unknown
Hospital deliveries
840
136
57
Neonates
858
137
57
Stillborn & Death
< 24hrs after birth n (%)
75 (9)
21 (15)
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

Costs in Euros
Vehicles (Toyota land Cruiser)
Stretcher and oxygen on board ambulance
Drugs on board ambulance
Vehicle tax and insurance / year
Vehicle repair and maintenance / year
Fuel / year
Drivers – gross salaries
Accompanying nurses – gross salaries
Total
Annual costs
10 008
485
3619
1291
3968
12414
17976
20585
70 346

Costs in Euros
Radio system
Radio operators – gross salaries
Radio VHF kits for the health centres
Solar panel kits for the health centres
Ambulance radios
Total
Annual costs
200
12 732
540
1 672
96
15 240

Costs in Euros
Annual costs
Communication total
Transport total
Total
15 240
70 346
85 586
Cost per obstetric case: € 61
Cost per capita / year: € 0.43

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 ?

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