1. 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

2. Burundi

3. 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

4. MSF intervention Emergency Obstetrics and Neonatal Care (EmONC) facility Emergency patient transfer service from peripheral facilities → hospital

5. Research question Does an ambulance referral network effectively improve access to emergency obstetrics and neonatal care?

6. 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

7. Study setting: Kabezi district Population ~ 198,000 ~9900 expected deliveries/yr One district hospital 9 health centre maternities: 1-70km from hospital

8. 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.

9. Communication & ambulance network (24 hours, all days) Referral criteria: At risk deliveries/Obstetric complications VHF Radio Three ambulances (3 health districts)

10. 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

11. Communication system – VHF Radio 8 maternities use VHF for calling an ambulance 1 MU uses a cell phone

12. Communication system – Radio operator o Records all incoming calls o Passes on to medical transfer team o Criteria met; ambulance goes out.

13. Communication system – Ambulance driver o Keeps in contact with maternity and CURGO o Records arrival/departure time at/from MU

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

15. 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

16. Data Sources Data sources Ambulance call books Logistic records Hospital medical database Study period Jan – Dec 2011 EthicsBurundi Ethics Committee & MSF Ethics Review Board

17. Median time: call out to dispatch and return Total ambulance call outs1478 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

18. Main Reasons

19. Referral times in association with early adverse neonatal outcomes Ambulance call – return to hospital Hospital deliveries Neonates Stillborn & Death < 24hrs after birth n (%) < 3 hours84085875 (9) > 3 hours 136137 21 (15) Unknown 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

20. Transport Costs Costs in EurosAnnual costs 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 10 008 485 3619 1291 3968 12414 17976 20585 70 346

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

22. Costs - per case & capita Costs in EurosAnnual costs Communication total Transport total Total 15 240 70 346 85 586 Cost per obstetric case:€ 61 Cost per capita / year:€ 0.43

23. 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 ?

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