International Journal of Health Policy and Management

International Journal of Health Policy and Management

Emergency Referral Transport for Maternal Complication: Lessons from the Community Based Maternal Death Audits in Unnao District, Uttar Pradesh, India

Document Type : Original Article

Authors
Sunil Saksena Raj 1
Suneedh Manthri 1
Pratap Kumar Sahoo 2
1 HIV/AIDS Partnership for Impact through Prevention, Private Sector and Evidence-based Programming (PIPPSE) Project, Public Health Foundation of India, New Delhi, India
2 Health Promotion Division, Public Health Foundation of India, New Delhi, India
10.15171/ijhpm.2015.14
Abstract
Background
An effective emergency referral transport system is the link between the home of the pregnant woman and a health facility providing basic or comprehensive emergency obstetric care. This study attempts to explore the role of emergency transport associated with maternal deaths in Unnao district, Uttar Pradesh (UP).
 
Methods
A descriptive study was carried out to assess the causes of and factors leading to maternal deaths in Unnao district, UP, through community based Maternal Death Review (MDR) using verbal autopsy, in a sample of 57 maternal deaths conducted between June 1, 2009, and May 31, 2010. A facility review was also conducted in 15 of the 16 block level and district health facilities to collect information on preparedness of the facilities for treating obstetric complications including referral transportation. A descriptive analysis was carried out using ratios and percentages to analyze the availability of basic facilities which may lead to maternal deaths.
 
Results
It was found that there were only 10 ambulances available at 15 facilities against 19 required as per Indian Public Health Standards (IPHS). About 47% of the deaths took place in a facility, 30% enroute to a health facility and 23% at home. Twenty five percent of women were taken to one facility, 32% were taken to two facilities, and 25% were taken to three facilities while 19% were not taken to any facility before their death. Sixteen percent of the pregnant women could not arrange transportation to reach any facility. The mean time to make arrangements for travel from home to facility-1 and facility-2 to facility-3 was 3.1 hours; whereas from facility-1 to facility-2 was 9.9 hours. The mean travel time from home to facility-1 was 1 hour, from facility-1 to facility-2 was 1.4 hours and facility-2 to facility-3 was 1.6 hours.
 
Conclusion
The public health facility review and MDR, clearly indicates that the inter-facility transfers appropriateness and timeliness of referral are major contributing factor for maternal deaths in Unnao district, UP. The UP Government, besides strengthening Emergency Obstetric and Newborn Care (EmONC) and Basic Emergency Obstetric and Newborn Care (BEmONC) services in the district and state as a whole, also needs to focus on developing a functional and effective referral system on a priority basis to reduce the maternal deaths in Unnao district.
Keywords
Referral Transport
Maternal Deaths
Facility Review
Maternal Death Review (MDR)
Subjects
1. World Health Organization (WHO), United Nations Population Fund (UNFPA), Children's Rights and Emergency Relief Organization (UNICEF) and The World Bank estimates. Trends in maternal mortality: 1990 to 2010 [Internet]. WHO; 2012. [cited 28 Nov 2014]. Available from: http://whqlibdoc.who.int/publications/2012/9789241503631_eng.pdf?ua=1
2. Lozano R, Wang H, Foreman KJ, Rajaratnam JK, Naghavi M, Marcus JR, et al. Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis. Lancet 2011; 378: 1139-65.  doi: 10.1016/S0140-6736(11)61337-8
3. Trends in Maternal Mortality: 1990 to 2013 [Internet]. World Health Organization; 2014. [cited 2014 Nov 24]. Available from: http://apps.who.int/iris/bitstream/10665/
112697/1/WHO_RHR_14.13_eng.pdf
4. Registrar General, India. SRS Bulletin, Sample Registration System. New Delhi: Office of the Registrar General, Ministry of Home Affairs, Government of India; 2012.
5. Lim SS, Dandona L, Hoisington JA, James SL, Hogan MC, Gakidou E. India's Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation. Lancet 2010; 375: 2009-23.  doi: 10.1016/S0140-6736(10)60744-1
6. National Rural Health Mission, Ministry of Health and Family Welfare, Government of India. Third Common Review Mission Report. New Delhi, India; 2009.
7. National Family Health Survey - 3 [Internet]. International Institute of Population Sciences;  2005-06. [cited 2013  Jan 10]. Available from: http://www.rchiips.org/NFHS/pdf/UttarPradesh.pdf
8. Project Implementation Plan: Uttar Pradesh Health Systems Strengthening Project [Internet]. Department of Medical Health and Family Welfare, Government of Uttar Pradesh; 2011. [cited 2013 Sep 15]. Available from: http://uphealth.up.nic.in/uphssp/documents/
Revised_PIP_Final_30_AUG_2011_version.pdf
9. Rural Health Statistics in India, 2011 [Internet]. National Rural Health Mission, Ministry of Health and Family Welfare, Government of India; 2011. [cited 2013 Feb 10]. Available from: http://nrhm-mis.nic.in/UI/RHS/RHS2011
/RHS-March2011-Tables-Final9.4.2012.pdf
10. World Health Organization (WHO), United Nations Population Fund (UNFPA), Children's Rights and Emergency Relief Organization (UNICEF) and Averting Maternal Death and Disability (AMDD). Monitoring emergency obstetric care: a handbook. Geneva: WHo; 2009.
11. Ministry of Health and Family Welfare (MoHFW). National Rural Health Mission (NRHM): Mission Document. New Delhi: Ministry of Health and Family Welfare; 2005.
12. Operating perinatal referral transport services in rural India : a tool kit [Internet]. UNICEF;  2010. [cited 2013 August 15]. Available from: http://www.unicef.org/india/Referral_Transport_book-Final_PDF.pdf
13. Technical report on Improving Transportation and Referral for Maternal Health: Knowledge Gaps and Recommendations [Internet]. Wilson Center; 2010. [cited 2013 Sep 9]. Available from: http://www.wilsoncenter.org/sites/default/files/
TransportReferralMeetingTechnicalReport.pdf
14. Potluri P. Emergency Services in India: Counting on betterment. Asian Hospital and Healthcare Management [serial on the Internet]. 2009. Available from: http://www.asianhhm.com/healthcare_management/emergency_services_india.htm
15. Yousuf AM. Emergency healthcare: Taking off to the next level. Modern Medicare [serial on the Internet]. 2011. Available from: http://modernmedicare.co.in/articles/
emergency-healthcaretaking-off-to-the-next-level/
16. Ministry of Health and Family Welfare (MoHFW), Government of India. Operational Guidelines on Maternal and Newborn Health. New Delhi: NRHM, MoHFW; 2010.
17. Maine D. Safe Motherhood Programs: Options and Issues.  Center for Population and Family Health. New York: Columbia University; 1991. p. 42-51.
18. Special bulletin on maternal mortality in India: 2007-2009 [Internet]. Office of Registrar General, India, Ministry of Home Affairs, Government of India; June 2011. [cited 2013 Feb 10]. Available from: http://www.censusindia.gov.in/vital_statistics/
SRS_Bulletins/Final-MMRBulletin-2007-09_070711.pdf
19. Jansankhya Sthirta Kosh: National Population Stabilisation Fund. District level health facility GIS maps and indices [Internet]. Jansankhya Sthirta Kosh; 2007. [cited 2012 Nov 20]. Available from: http://www.jsk.gov.in/district_health.asp
20. Census of India [Internet]. Ministry of Home Affairs, Government of India; 2011. [cited 2013 Feb 12]. Available from: http://www.censusindia.gov.in/2011-prov-results/
paper2/census2011_paper2.html
21. Sample Registration System [Internet]. Ministry of Home Affairs, Government of India; 2012. [cited 2013 Jan 20]. Available from: http://www.censusindia.gov.in/vital_statistics/
SRS_Bulletins/SRS_Bulletin-October_2012.pdf
22. Ministry of Health and Family Welfare (MoHFW). About Accredited Social Health Activist (ASHA) [internet]. National Health Mission; 2013 [cited 2014 Dec 10]. Available from: http://nrhm.gov.in/communitisation/
asha/about-asha.html
23. Maternal and Child Health Sustainable Technical Assistance and Research (MCH-STAR) Project, USAID. Technical Assistance to the Government of Jharkhand to Operationalize First Referral Units (FRUs) [internet].  2010. [2012 Nov 30]. Available from: http://www.mchstar.org/technicalAssistance/
projects/communicationCampaign.htm
24. Maternal and perinatal death inquiry and response: empowering communities to avert maternal deaths in India [Internet]. UNICEF; 2009 [cited 2013 Sep 15]. Available from: http://www.mapedir.org/MDAC-Maternal.pdf
25. Raj SS, Maine D, Sahoo PK, Manthri S, Chauhan K. Meeting the community halfway to reduce maternal deaths? Evidence from a community-based maternal death review in Uttar Pradesh, India. Global Health: Sci Pract 2013; 1: 84-96. doi: 10.9745/GHSP-D-12-00049
26. Guidelines for operationalising First Referral Units [Internet]. Ministry of Health and Family Welfare, Government of India; 2004. [cited 2015 Jan 7]. Available from: http://www.medbox.org/in-nh-guides/
guidelines-for-operationalising-first-referral-units/preview?q=
27. Indian Public Health Standards (IPHS) Guidelines for Community Health Centers, Revised 2012 [Internet]. Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India; 2012. [cited 2015 Jan 7]. Available from: http://health.bih.nic.in/Docs/Guidelines/
Guidelines-Community-Health-Centres.pdf
28. Indian Public Health Standards (IPHS): Guidelines for District Hospitals, Revised 2012 [nternet]. Directorate General of Health Services Ministry of Health and Family Welfare, Government of India; 2012. [cited 2015 Jan 7]. Available from: http://health.bih.nic.in/Docs/Guidelines/
Guidelines-District-Hospitals-2012.pdf
29. Rogi Kalyan Samities/Hospital Management [Internet]. National Rural Health Mission; 2012. [cited 14 November 2012]. Available from: http://mohfw.nic.in/NRHM/RKS.htm#intro
30. Emergency Medical Service (EMS) in India: a concept paper [Internet]. National Health Systems Resource Centre; 2011. [cited 2013 Sep 15]. Available from: http://nhsrcindia.org/pdf_files/resources_thematic/Financing_and_PPP/
NHSRC_Contribution/Others/EMS_Concept_Paper.pdf
31. Murray SF, Pearson SC. Maternity referral systems in developing countries: current knowledge and future needs. Soc Sci Med 2006; 62: 2205-15. doi: 10.1016/j.socscimed.2005.10.025
32. Evaluation Study of National Rural Health Mission (NRHM) in 7 States [Internet]. Planning Commission, India; 2011. [cited 2013 Sep 15]. Available from: http://planningcommission.nic.in/reports/
peoreport/peoevalu/peo_2807.pdf
33. Sahoo Pk, Raj SS, Manthri S. Improved access to safe blood must be prioritized as a core component of comprehensive efforts to prevent maternal deaths in Uttar Pradesh, India. Int J Med Sci Public Health 2014; 3: 1208-14. 
34. Gupta M, Mavalankar D, Poonam Trivedi. A study of referral system for EmOC in Gujarat. Research and publications: Working paper series; 2009.
35. Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sc Med 1994; 38: 1091-110.  doi: 10.1016/0277-9536(94)90226-7
36. Jahn A, de Brouwere V. Referral in pregnancy and childbirth: concepts and strategies. In: Brouwere VD, Lerberghe W V, editors. Safe motherhood strategies : a review of the rvidence. Antwerp, Belgium: ITG Press; 2001.
37. Sundararaman T, Chakraborty G, Nair A, Mokashi T, Ved R. Publicly Financed Emergency Response and Patient Transport Systems Under NRHM. National Health Systems Resource Centre, New Delhi (India); 2012.
38. Murray SF, Davis S, Phiri KR, Ahmed Y. Tools for monitoring the effectiveness of district maternity referral systems. Health Policy Plan 2001; 16: 353-61. 
39. Publicly Financed Emergency Response and Patient Transport Systems Under NRHM. National Health Systems Resource Centre; 2012.
40. Prinja S, Manchanda N, Aggarwal AK, Kaur M, Jeet G, Kumar R. Cost & efficiency evaluation of a publicly financed & publicly delivered referral transport service model in three districts of Haryana State, India. Indian J Med Res 2013; 138: 1003-11. 
41. Sundararaman T, Nair A, Mokashi T, Chakraborthy G. Business models of public private partnerships in publicly-financed emergency response services. BMC Proc 2012; 6: P8. doi:  10.1186/1753-6561-6-S5-P8
42. Documentation of “JE Management Models by SHG, Federations and NGO” in Orissa. National Rural Health Mission; 2011.
43. Prinja S, Jeet G, Kaur M, Aggarwal AK, Manchanda N, Kumar R. Impact of referral transport system on institutional deliveries in Haryana, India. Indian J Med Res 2014; 139: 883-91. 
44. Hussein J, Kanguru L, Astin M, Munjanja S. The Effective of Emergency obstetric Referral Interventions in Developing Country Settings: A Systematic Review. PLoS Med 2012; 9: e1001264. doi: 10.1371/journal.pmed.1001264  
45. Sloan NL LA, Hernandez B, Romero M, Winikoff B. The etiology of maternal mortality in developing countries: what do verbal autopsies tell us? Bull World Health Organ 2001; 79: 805–10.

  • Received Date 26 August 2014
  • Revised Date 07 January 2015
  • Accepted Date 08 January 2015
  • First Published Date 01 February 2015
  • Published Date 01 February 2015