An ambulance referral network improves access to emergency obstetric and neonatal care in a district of rural Burundi with high maternal mortality.

OBJECTIVES: In 2006, Médecins sans Frontières (MSF) established an emergency obstetric and neonatal care (EmONC) referral facility linked to an ambulance referral system for the transfer of women with obstetric complications from peripheral maternity units in Kabezi district, rural Burundi. This study aimed to (i) describe the communication and ambulance service together with the cost; (ii) examine the association between referral times and maternal and early neonatal deaths; and (iii) assess the impact of the referral service on coverage of complicated obstetric cases and caesarean sections. METHODS: Data were collected for the period January to December 2011, using ambulance log books, patient registers and logistics records. RESULTS: In 2011, there were 1478 ambulance call-outs. The median referral time (time from maternity calling for an ambulance to the time the patient arrived at the MSF referral facility) was 78 min (interquartile range, 52-130 min). The total annual cost of the referral system (comprising 1.6 ambulances linked with nine maternity units) was € 85 586 (€ 61/obstetric case transferred or € 0.43/capita/year). Referral times exceeding 3 h were associated with a significantly higher risk of early neonatal deaths (OR, 1.9; 95% CI, 1.1-3.2). MSF coverage of complicated obstetric cases and caesarean sections was estimated to be 80% and 92%, respectively. CONCLUSION: This study demonstrates that it is possible to implement an effective communication and transport system to ensure access to EmONC and also highlights some of the important operational factors to consider, particularly in relation to minimising referral delays.

Achieving the millennium development goal of reducing maternal mortality in rural Africa: an experience from Burundi.

OBJECTIVES: To estimate the reduction in maternal mortality associated with the emergency obstetric care provided by Médecins Sans Frontières (MSF) and to compare this to the fifth Millennium Development Goal of reducing maternal mortality. METHODS: The impact of MSF's intervention was approximated by estimating how many deaths were averted among women transferred to and treated at MSF's emergency obstetric care facility in Kabezi, Burundi, with a severe acute maternal morbidity. Using this estimate, the resulting theoretical maternal mortality ratio in Kabezi was calculated and compared to the Millennium Development Goal for Burundi. RESULTS: In 2011, 1385 women from Kabezi were transferred to the MSF facility, of whom 55% had a severe acute maternal morbidity. We estimated that the MSF intervention averted 74% (range 55-99%) of maternal deaths in Kabezi district, equating to a district maternal mortality rate of 208 (range 8-360) deaths/100,000 live births. This lies very near to the 2015 MDG 5 target for Burundi (285 deaths/100,000 live births). CONCLUSION: Provision of quality emergency obstetric care combined with a functional patient transfer system can be associated with a rapid and substantial reduction in maternal mortality, and may thus be a possible way to achieve Millennium Development Goal 5 in rural Africa.

Sexual violence in post-conflict Liberia: survivors and their care.

Using routine data from three clinics offering care to survivors of sexual violence (SV) in Monrovia, Liberia, we describe the characteristics of SV survivors and the pattern of SV and discuss how the current approach could be better adapted to meet survivors' needs. There were 1500 survivors seeking SV care between January 2008 and December 2009. Most survivors were women (98%) and median age was 13 years (Interquartile range: 9-17 years). Sexual aggression occurred during day-to-day activities in 822 (55%) cases and in the survivor's home in 552 (37%) cases. The perpetrator was a known civilian in 1037 (69%) SV events. Only 619 (41%) survivors sought care within 72 h. The current approach could be improved by: effectively addressing the psychosocial needs of child survivors, reaching male survivors, targeting the perpetrators in awareness and advocacy campaigns and reducing delays in seeking care.

Emergency obstetric care in a rural district of Burundi: What are the surgical needs?

OBJECTIVES: In a rural district hospital in Burundi offering Emergency Obstetric care-(EmOC), we assessed the a) characteristics of women at risk of, or with an obstetric complication and their types b) the number and type of obstetric surgical procedures and anaesthesia performed c) human resource cadres who performed surgery and anaesthesia and d) hospital exit outcomes. METHODS: A retrospective analysis of EmOC data (2011 and 2012). RESULTS: A total of 6084 women were referred for EmOC of whom 2534(42%) underwent a major surgical procedure while 1345(22%) required a minor procedure (36% women did not require any surgical procedure). All cases with uterine rupture(73) and extra-uterine pregnancy(10) and the majority with pre-uterine rupture and foetal distress required major surgery. The two most prevalent conditions requiring a minor surgical procedure were abortions (61%) and normal delivery (34%). A total of 2544 major procedures were performed on 2534 admitted individuals. Of these, 1650(65%) required spinal and 578(23%) required general anaesthesia; 2341(92%) procedures were performed by 'general practitioners with surgical skills' and in 2451(96%) cases, anaesthesia was provided by nurses. Of 2534 hospital admissions related to major procedures, 2467(97%) were discharged, 21(0.8%) were referred to tertiary care and 2(0.1%) died. CONCLUSION: Overall, the obstetric surgical volume in rural Burundi is high with nearly six out of ten referrals requiring surgical intervention. Nonetheless, good quality care could be achieved by trained, non-specialist staff. The post-2015 development agenda needs to take this into consideration if it is to make progress towards reducing maternal mortality in Africa.

Caesarean sections in rural Burundi: how well are mothers doing two years on?

SETTING: A caesarean section (C-section) is a life-saving emergency intervention. Avoiding pregnancies for at least 24 months after a C-section is important to prevent uterine rupture and maternal death. OBJECTIVES: Two years following an emergency C-section, in rural Burundi, we assessed complications and maternal death during the post-natal period, uptake and compliance with family planning, subsequent pregnancies and their maternal and neonatal outcomes. METHODS: A household survey among women who underwent C-sections. RESULTS: Of 156 women who underwent a C-section, 116 (74%) were traced; 1 had died of cholera, 8 had migrated and 31 were untraceable. Of the 116 traced, there were no post-operative complications and no deaths. At hospital discharge, 83 (72%) women accepted family planning. At 24 months after hospital discharge (n = 116), 23 (20%) had delivered and 17 (15%) were pregnant. Of the remaining 76 women, 48 (63%) were not on family planning. The main reasons for this were religion or husband's non-agreement. Of the 23 women who delivered, there was one uterine rupture, no maternal deaths and three stillbirths. CONCLUSIONS: Despite encouraging maternal outcomes, this study raises concerns around the effectiveness of current approaches to promote and sustain family planning for a minimum of 24 months following a C-section. Innovative ways of promoting family planning in this vulnerable group are urgently needed.

Contexte : Une césarienne est une intervention d'urgence destinée à sauver une vie. Eviter une nouvelle grossesse pendant au moins 24 mois après une césarienne est important afin de prévenir une rupture utérine et un décès maternel.Objectifs : Deux ans après une césarienne en urgence, dans le Burundi rural, nous avons évalué : les complications et les décès maternels pendant la période post-natale ; la couverture de la planification familiale et son adhérence ; les grossesses suivantes et leur devenir pour la mère et le nouveau-né.Méthodes : Enquête à domicile auprès de femmes qui ont bénéficié d'une césarienne.Résultat : Sur 156 femmes qui ont bénéficié d'une césarienne, 116 (74%) ont pu être retrouvées ; 1 était décédée du choléra, 8 avaient déménagé et 31 n'ont pas pu être localisées. Sur les 116 femmes retrouvées, il n'y a eu aucune complication post-opératoire et aucun décès. Lors de leur sortie de l'hôpital, 83 (72%) femmes ont accepté une contraception. A 24 mois après leur sortie (n = 116), 23 (20%) avaient accouché et 17 (15%) étaient enceintes. Sur les 76 femmes restantes, 48 (63%) n'avaient pas de contraception. Les motifs principaux étaient la religion ou le désaccord du mari. Parmi les 23 qui avaient accouché, il y a eu une rupture utérine, aucun décès maternel, mais il y a eu trois mort-nés.Conclusion : En dépit de résultats encourageants pour les mères, cette étude pose la question de l'efficacité des approches actuelles de la promotion et de la pérennité de la planification familiale pendant un minimum de 24 mois. Il est urgent de trouver des manières innovantes de promouvoir la planification familiale dans ce groupe vulnérable.

Marco de referencia: La cesárea es una intervención de urgencia que salva vidas. Es importante evitar un embarazo por lo menos durante los 24 meses que siguen a la operación, con el fin de evitar la ruptura uterina y la mortalidad materna.Objetivos: El seguimiento durante 2 años después de una cesárea de urgencia en una zona rural de Burundi tuvo por objeto evaluar las complicaciones y la mortalidad materna durante el período posnatal, la aceptación y el cumplimiento del método de anticoncepción y examinar los siguientes embarazos con su desenlace materno y neonatal.Método: Se llevó a cabo una encuesta domiciliaria de las mujeres en quienes se había practicado una cesárea.Resultados: Se evaluaron 116 de las 156 mujeres (74%) que se sometieron a una cesárea; una paciente falleció por cólera, 8 migraron y fue imposible localizar 31 mujeres. Durante el seguimiento de las 116 mujeres no se observaron complicaciones postoperatorias ni defunciones. En el momento del alta hospitalaria, 83 mujeres aceptaron practicar un método anticonceptivo (72%). Veinticuatro meses después del alta hospitalaria, 23 mujeres habían tenido un parto (20%) y 17 estaban embarazadas (15%). De las 76 mujeres restantes, 48 no seguían ningún método de planificación familiar (63%); las principales razones aducidas fueron religiosas o el desacuerdo del cónyuge. En los 23 casos de mujeres que tuvieron un parto, ocurrió una ruptura uterina sin mortalidad materna, pero hubo tres mortinatos.Conclusión: Pese a la buena perspectiva de los desenlaces maternos favorables, el estudio pone de manifiesto inquietudes con respecto a la eficacia de las estrategias vigentes de promoción y mantenimiento de los métodos anticonceptivos durante un mínimo de 24 meses. Se precisan con urgencia estrategias innovadoras que estimulen la planificación familiar en este grupo vulnerable de mujeres.