Obstetrics Referral System

104/100000 life births

Maternal mortality in 2008

307/100000 life births

Background

• woman has just delivered her baby and is beginning to hemorrhage. She may have less than two hours before she dies from this treatable obstetric complication. This should be enough time to reach the emergency obstetric care (EmOC) she needs.

• But …… • if she lives in the developing world – where 99% of

maternal deaths occur – simply getting to a health facility able to treat her could be a considerable struggle.

• In developing countries, sometimes facilities have no vehicle or way to call for a vehicle; at other times there may be no petrol or driver available. Once en route, women may face hours of travel over nearly impassible roads.

• Any breakdown along the path from home to health facility, or between health facilities, can prevent women and newborns from accessing emergency care.

Referral system

It is the task of the health system’s referral system to quickly and easily get these women to emergency treatment.

A referral system is a vehicle to get a high quality basic emergency obstetrics care and comprehensive obstetrics care

The target of reducing maternal mortality by 75% by 2015 is a key UN Millennium Development Goal (MDG)

Because obstetric complications cannot be predicted or prevented, all pregnant women need access to good quality EmOC.

What is emergency obstetrics(EmOC) care?

Key ‘signal functions’ have been identified as necessary to the provision of basic EmOC( BEOC) and comprehensive EmOC (CEOC)

Basic EmOC services must be able to provide the following signal functions:

1. parenteral (given intravenously or by injection) antibiotics

2. parenteral oxytocic drugs 3. parenteral anti-convulsants (for pre-eclampsia and

eclampsia), 4. Manual removal of placenta 5. removal of retained products 6. assisted vaginal delivery.

• Comprehensive EmOC includes all above functions plus: 7. ability to perform surgery (Caesarian

section) 8. blood transfusion.

Six UN process indicators to evaluate emergency obstetrics care (EmOC)

In 1997 UNICEF, WHO and UNFPA issued a set of indicators called ‘UN Process Indicators’ to monitor the availability, utilisation and quality of EmOC

The UN Process Indicators offer a systematic approach to assessing health care systems and for planning sustainable maternal health interventions

The Six UN Process Indicators and Recommended Levels

UN Process Indicator

Definition Recommended Level

1. Amount of

EmOC services Number of facilities that provide EmOC

Minimum: 1 available EmOC Comprehensive facility for every 500,000 people Minimum: 4 Basic EmOC facilities per 500,000

The Six UN Process Indicators and Recommended

Levels UN Process

Indicator Definition Recommended

Level

2. Geographical distribution of Facilities providing EmOC

Facilities providing EmOC well distributed at subnational level

Minimum: 100% of sub-national areas have the minimum acceptable numbers of basic and comprehensive EmOC facilities

The Six UN Process Indicators and Recommended

Levels UN Process

Indicator Definition Recommended

Level

3. Proportion of all births in EmOC facilities

Proportion of all births in the population that take place in EmOC

Minimum: 15%

The Six UN Process Indicators and Recommended

Levels UN Process

Indicator Definition Recommended

Level

4. Met need for EmOC services

Proportion of women with obstetric complications treated in EmOC facilities

100% (Estimated as 15% of expected births)

The Six UN Process Indicators and Recommended

Levels UN Process

Indicator Definition Recommended

Level

5. Caesarean sections as a percentage of all births

Caesarean deliveries as a proportion of all births in the populations

Minimum 5% Maximum 15%

The Six UN Process Indicators and Recommended

Levels UN Process

Indicator Definition Recommended

Level

6. Case fatality rate

Proportion of women with obstetric complications admitted to a facility who die

Maximum 1%

Three delays in referral system

Timing proves to be critical in preventing maternal death and disability: Although post-partum haemorrhage can kill a woman in under two hours, for most other complications, a woman has between 6 and 12 hours or more to get life-saving emergency care. Similarly, most perinatal deaths occur during labour and delivery, or within the first 48 hours thereafter.

The ‘three delays’ model (see below) has proved to be a useful tool to identify the points at which delays can occur in the management of obstetric complications, and to design programmes to address these delays.

The first two "delays" (delay in deciding to seek care and delay in reaching appropriate care) relate directly to the issue of access to care, encompassing factors in the family and the community, including transportation.

The third "delay" (delay in receiving care at health facilities) relates to factors in the health facility, including quality of care.

Unless the three delays are addressed, no safe motherhood programme can succeed. In practice, it is crucial to address the third delay first, for it would be useless to facilitate access to a health facility if it was not available, well-staffed, well equipped and providing good quality care.

Criteria based audit for Referral System

1. All referred patients come with a referral form filled by the referring facility

2. Ambulances are available at all times to transport referred patients

3. Health centre staff inform the district hospital through the short-wave radio when a patient is referred

5. Health centre staff receive feedback on all patients referred

6. All patients are adequately resuscitated before referral

7. A delay of less than 2 hours from the time an ambulance was called to when the ambulance brought the patient to the district hospital

8. All patients referred are attended to by a clinician within 30 minute of arrival in the district hospital

Examples of referral system function

Pregnant women in developing countries posed greater risk for dying because of postpartum haemorrhage

Why ???

the prevalence of severe anaemia is substantial, so

that a given degree of blood loss is more likely to cause haemodynamic instability

many women deliver at home and are often attended by unskilled providers (traditional birth attendants, family members) who are unable to recognize the signs of excessive bleeding

gender relations can present barriers to care seeking; for example, it might not be possible to arrange transfer to a health facility without the authority of male relatives Type 1

once the problem is recognized and the decision to take the woman to a health facility is made, emergency transport might not be available or affordable, and distances might be long Type 2

even if a woman arrives at a health facility or hospital in time, the facility might not have the trained staff available or the necessary supplies and equipment to treat her Type 3