Obstetrics Referral System

Maternal mortality in 2008

104/100000
life births

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 systems 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.

2. 3.

4. 5. 6.

parenteral (given intravenously or by injection) antibiotics parenteral oxytocic drugs parenteral anti-convulsants (for pre-eclampsia and eclampsia), Manual removal of placenta removal of retained products 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 Definition Recommended Indicator 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 Definition Recommended Indicator 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 Definition Recommended Indicator 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 Definition Recommended Indicator Level 4. Met need for EmOC services Proportion of 100% (Estimated women with as 15% of expected births) obstetric complications treated in EmOC facilities

The Six UN Process Indicators and Recommended Levels UN Process Definition Recommended Indicator Level 5. Caesarean sections as a percentage of all births Caesarean Minimum 5% deliveries as a Maximum 15% proportion of all births in the populations

The Six UN Process Indicators and Recommended Levels UN Process Definition Recommended Indicator Level 6. Case fatality rate Proportion of Maximum 1% women with obstetric complications admitted to a facility who die

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