Staffing needs for unscheduled activity in obstetrics and gynecology.

INTRODUCTION: To determine a minimum threshold of medical staffing needs (obstetricians-gynecologists, anesthesiologists-resuscitation specialists, nurse-anesthetists, pediatricians, and midwives) to ensure the safety and quality of care for unscheduled obstetrics-gynecology activity. MATERIALS AND METHODS: Face to face meetings of French healthcare professionals involved in perinatal care in different types of practices (academic hospital, community hospital or private practice) who belong to French perinatal societies: French National College of Gynecologists-Obstetricians (CNGOF), the French Society of Anesthesia and Resuscitation Specialists (SFAR), the French Society of Neonatology (SFN), the French Society of Perinatal Medicine (SFMP), the National College of French Midwives (CNSF), and the French Federation of Perinatal Care Networks (FFRSP). RESULTS: Different minimum thresholds for each category of care provider were proposed according to the number of births/year in the facility. These minimum thresholds can be modulated upwards as a function of the level of care (Level 1, 2 or 3 for perinatal centers), existence of an emergency department, and responsibilities as a referral center for maternal-fetal and/or surgical care. For example, an obstetrics-gynecology department handling 3000-4500 births per year without serving as a referral center must have an obstetrician-gynecologist, an anesthesiologist-resuscitation specialist, a nurse-anesthetist, and a pediatrician onsite specifically to provide care for unscheduled obstetrics-gynecology needs and a second obstetrician-gynecologist available within a time compatible with security requirements 24/7; the number of midwives always present (24/7) onsite and dedicated to unscheduled care is 5.1 for 3000 births and 7.2 for 4500 births. A maternity unit's occupancy rate must not exceed 85 %. CONCLUSION: The minimum thresholds proposed here are intended to improve the safety and quality of care of women who require unscheduled care in obstetrics-gynecology or during the perinatal period.

Understanding the gap in emergency obstetric and neonatal care in Ghana through the PREventing Maternal And Neonatal Deaths (PREMAND) study.

OBJECTIVE: To explore basic and comprehensive emergency obstetric service provision across four districts in rural northern Ghana, and whether women were more likely to deliver at facilities with more skilled care. METHODS: Field workers geo-coded all health facilities in East Mamprusi, Sissala East, Kassena Nankana Municipal, and Kassena Nankana West districts, and administered surveys to assess providers and emergency obstetric care available. Data were also prospectively collected on delivery locations of women and neonates who died, or nearly died (near misses), between September 1, 2015 and April 30, 2017. RESULTS: There were 14 physicians for a population of nearly 360 000 women. Six (6%) facilities could provide basic emergency care, and 3 (3%) could provide comprehensive care. Services were distributed unequally, with 6 (67%) of the emergency facilities located in the least populated district. Among the sample of women and neonates who died or nearly died, 175 (39%) delivered at locations unable to provide basic emergency services. CONCLUSION: Access to emergency obstetric and neonatal care was distributed inequitably across these districts, suggesting the need to revisit geographic placement of facilities relative to population. The study also raised the question of how to ensure facilities are equipped to respond to emergencies.

Reconceptualizing the role of emergency care in the context of global healthcare delivery.

Since the adoption of the Sustainable Development Goals in 2015, innovation in global healthcare delivery has been recognized as a vital avenue for strengthening health systems and overcoming present implementation bottlenecks. In the recent rapid development of the science of global health-care delivery, emergency care-a critical element of the health system-has been widely overlooked. Emergency care plays a vital role in the health system through providing immediately responsive care and serving as one of the main entry points for those with symptomatic disease. We present a new perspective on emergency care's role in the health system within the context of global health-care delivery, and argue that, if properly integrated, emergency care has the potential to add significant value across the healthcare continuum. Capitalizing on emergency care as a shared delivery infrastructure presents opportunities to increase efficiency not only in treatment of time-sensitive conditions, but also for secondary prevention through its capacity to promote early disease detection and enhance coordination of care. We propose an integrated emergency care delivery value chain, demonstrating emergency care's critical position as a point of access to the greater health system and its key connections to longitudinal care delivery, which remain under-developed in low- and middle-income country health systems. As emergency care systems are created within emerging and established health systems, this role can be more effectively leveraged by policy makers and healthcare leaders globally to promote progress towards the Sustainable Development Goals.

Lifesaving emergency obstetric services are inadequate in south-west Ethiopia: a formidable challenge to reducing maternal mortality in Ethiopia.

BACKGROUND: Most maternal deaths take place during labour and within a few weeks after delivery. The availability and utilization of emergency obstetric care facilities is a key factor in reducing maternal mortality; however, there is limited evidence about how these institutions perform and how many people use emergency obstetric care facilities in rural Ethiopia. We aimed to assess the availability, quality, and utilization of emergency obstetric care services in the Gamo Gofa Zone of south-west Ethiopia. METHODS: We conducted a retrospective review of three hospitals and 63 health centres in Gamo Gofa. Using a retrospective review, we recorded obstetric services, documents, cards, and registration books of mothers treated and served in the Gamo Gofa Zone health facilities between July 2009 and June 2010. RESULTS: There were three basic and two comprehensive emergency obstetric care qualifying facilities for the 1,740,885 people living in Gamo Gofa. The proportion of births attended by skilled attendants in the health facilities was 6.6% of expected births, though the variation was large. Districts with a higher proportion of midwives per capita, hospitals and health centres capable of doing emergency caesarean sections had higher institutional delivery rates. There were 521 caesarean sections (0.8% of 64,413 expected deliveries and 12.3% of 4,231 facility deliveries). We recorded 79 (1.9%) maternal deaths out of 4,231 deliveries and pregnancy-related admissions at institutions, most often because of post-partum haemorrhage (42%), obstructed labour (15%) and puerperal sepsis (15%). Remote districts far from the capital of the Zone had a lower proportion of institutional deliveries (<2% of expected births compared to an overall average of 6.6%). Moreover, some remotely located institutions had very high maternal deaths (>4% of deliveries, much higher than the average 1.9%). CONCLUSION: Based on a population of 1.7 million people, there should be 14 basic and four comprehensive emergency obstetric care (EmOC) facilities in the Zone. Our study found that only three basic and two comprehensive EmOC service qualifying facilities serve this large population which is below the UN's minimum recommendation. The utilization of the existing facilities for delivery was also low, which is clearly inadequate to reduce maternal deaths to the MDG target.

Prenatal care and basic emergency obstetric care services provided at primary healthcare facilities in rural Nigeria.

OBJECTIVE: To assess the availability of prenatal care and basic emergency obstetric care services at primary healthcare (PHC) facilities in rural Nigeria. METHODS: In total, 652 PHC facilities enrolled in the Midwives Service Scheme, a government-funded program designed to reduce the national shortage of skilled birth attendants, were surveyed. RESULTS: In all, 44.0% of the PHC facilities evaluated did not provide all components of prenatal care, and only 39.0% of all pregnant women nationwide attended prenatal care clinics 4 or more times. In addition, 52.2% of the facilities were not distributing insecticide-treated nets to pregnant women, while only 36.8% of the PHC facilities provided services to prevent mother-to-child transmission of HIV. By contrast, 70.0% of the PHC facilities had access to antibiotics for the treatment of uncomplicated sepsis. Only 11.0% of clinics reported the use of vacuum extraction during labor and 36.8% provided post-abortion care services. Treatment for pre-eclampsia and eclampsia was initiated at 40.0% and 28.0% of PHC facilities, respectively, prior to referral. CONCLUSION: The present study provides useful information on the state of prenatal and basic emergency obstetric care in rural Nigeria. The data obtained indicate that changes are needed to achieve related Millennium Development Goals.

Assessment of surgical and obstetrical care at 10 district hospitals in Ghana using on-site interviews.

BACKGROUND: For most of the population in Africa, district hospitals represent the first level of access for emergency and essential surgical services. The present study documents the number and availability of surgical and obstetrical care providers as well as the types of surgical and obstetrical procedures being performed at 10 first-referral district hospitals in Ghana. MATERIALS AND METHODS: After institutional review board and governmental approval, a study team composed of Ghanaian and American surgeons performed on-site surveys at 10 district hospitals in 10 different regions of Ghana in August 2009. Face-to-face interviews were conducted documenting the numbers and availability of surgical and obstetrical personnel as well as gathering data relating to the number and types of procedures being performed at the facilities. RESULTS: A total of 68 surgical and obstetrical providers were interviewed. Surgical and obstetrical care providers consisted of Medical Officers (8.5%), nurse anesthetists (6%), theatre nurses (33%), midwives (50.7%), and others (4.5%). Major surgical cases represented 37% of overall case volumes with cesarean section as the most common type of major surgical procedure performed. The most common minor surgical procedures performed were suturing of lacerations or episiotomies. CONCLUSIONS: The present study demonstrates that there is a substantial shortage of adequately trained surgeons who can perform surgical and obstetrical procedures at first-referral facilities. Addressing human resource needs and further defining practice constraints at the district hospital level are important facets of future planning and policy implementation.

Actividad de los equipos de emergencias extrahospitalarios / Activity of the out of hospital emergency teams

No disponible

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International pediatric emergency care: establishment of a new specialty in a developing country.

BACKGROUND: Emergency medicine is being established as a unique and independent specialty throughout the world. Pediatric emergency medicine, however, is a relatively new subspecialty in the United States and a newer subspecialty in the rest of the world. In most of Europe and Asia, this specialty has yet to be developed. OBJECTIVE: To analyze the establishment of a new pediatric emergency care system in a developing country and identify areas of need and potential collaboration. SETTING: Pristina University Hospital, the main academic medical center in Kosovo, Federal Republic of Yugoslavia. METHODS: Data were collected using convenience sample surveys of all emergency visits in 2001, hospital admissions, health department statistics, and interviews with government officials and healthcare providers. RESULTS: Emergency care of children in Kosovo is provided by three parallel 24-hour clinic systems. During 2001, approximately 31,000 children sought emergency care (10,000 in the pediatric clinic, 5000 in an emergency facility, and 16,000 in the infectious disease clinic). There was no coordination or cooperation between these different facilities. No attempt was made to diagnose acute otitis media or urinary tract infection in young children. No records were kept. No physician in this study had pediatric emergency medicine and/or emergency medicine training. Prehospital providers had limited equipment and training. CONCLUSIONS: Hospital clinic systems in this environment provide high-volume and often a high level of acute care. Barriers to improved care include limited specialized training, lack of coordination between departments, and failure to establish a medical records system.

Accessibility and distribution of the Norwegian National Air Emergency Service: 1988-1998.

OBJECTIVE: To evaluate the accessibility and distribution of the Norwegian National Air Emergency Service in the 10-year period from 1988 to 1998. MATERIAL AND METHODS: The primary material was annual standardized activity data that included all helicopter missions. A multivariate model of determinants for use of the helicopter service was computed by linear regression. Accessibility was measured as the percentage of the population reached in different flying times, and we evaluated the service using a simulation of alternative locations for the helicopter bases. RESULTS: The helicopter service (HEMS) has short access times, with a mean reaction time of 8 minutes and a mean response time of 26 minutes for acute missions. Nearly all patients (98%) are reached within 1 hour. A simulation that tested alternative locations of the helicopter bases compared with current locations showed no increase in accessibility. The use of the service shows large regional differences. Multivariate analyses showed that the distances of the patients from the nearest helicopter base and the nearest hospital are significant determinants for the use of HEMS. CONCLUSION: Establishment of a national service has given the Norwegian population better access to highly qualified prehospital emergency services. Furthermore, the HEMS has a compensating effect in adjusting for differences in traveling distances to a hospital. Safety, cost-containment, and gatekeeper functions remain challenges.

China: lowering maternal mortality in Miyun County, Beijing.

In Miyun County in China the medical authorities registered an elevated maternal mortality ratio which needed to be verified in order to design corrective changes. A decision was taken in 1988 to start a project of pilot interventions in the organization of maternal health services and access for obstetric emergencies. A control and pilot area were chosen in order to test the validity of the interventions. The reduction in maternal mortality from the main complications (postpartum haemorrhage and eclampsia) was impressive and no more maternal deaths were registered in the pilot area with reference to these causes. The overall maternal mortality ratio per 100,000 live births dropped by more than 75% in the pilot area throughout the three-year implementation period. It was therefore shown that the synergistic effect of additional training of medical workers and traditional birth attendants, improved health education, the provision of easier access to emergency care services, the establishment of obstetric rescue teams at the county level, generally improved MCH services, and strengthened management capacity for high risk pregnancies were the most appropriate interventions to lower maternal mortality.

PIP: This account provides a description for Miyun County (outside Beijing), China, of the number of maternal deaths, access to maternal health services, and system improvements during 1985-88. Maternal health care in Miyun County is provided through local township hospitals, county hospitals, and maternity hospitals. Community education is provided locally by village doctors and birth attendants at health stations. Health procedures were changed to include the application of Ministry of Public Health rules on strengthening referrals between village health stations, township hospitals, and county hospitals. Case management procedures were established for caring for postpartum hemorrhage, severe pregnancy-induced hypertension, amniotic embolism, shock, and neonatal asphyxia. Maternal health records were standardized, monitoring procedures for perinatal care were widely promoted, and high-risk pregnancies were identified and referred according to specific procedures. Six pilot areas were identified for testing the success of program implementation. Findings of this evaluation were that 27.3% (33) of maternal deaths were not reported. Maternal mortality was adjusted to account for these deficiencies (114/100,000). 60% of deaths were obstetrically-related. The leading causes were hemorrhage, followed by postpartum infections and pregnancy-induced hypertension. 63% of deaths involved insufficient prenatal care. Almost 40% of deaths were unnecessary, and about 66% were preventable. In the pilot townships hospitals showed improvements in hospital equipment and staff training. Only in the pilot areas did mortality rates improve. The maternal mortality rate in pilot areas declined by over 75%.

A province-by-province look at Canadian EMS.

Recent elections in the United States have put politicians on notice that people are voting their dissatisfaction with this country's lack of a national health-care plan. Suddenly, Congress is flooded with health-care financing legislation, and presidential candidates are hustling to propose plans in their platforms. As we consider various health-care solutions, what can we learn from Canada's experience?