Perspectives on the Referral system for Obstetric Emergencies in Benin City, Nigeria
Dr. Michael Ezeanochie(Presenter)Prof A.B.A Ande17/12/2019
BENIN CITY, EDO STATE Capital city of Edo State (pop: 5 mil) UBTH is the Apex Tertiary Health Facility Between 78-95% of women deliver in Health
facilities (Nigeria 2018 DHS) 83.7% of women receive 4 or more ANC visits
(*NBS, 2017) 75% of live births in Edo State were in private
sector facilities [Nigeria 2013 DHS]
NIGERIA Estimated Population of 200 million 512 maternal deaths per 100,000 live births (2018
NDHS). Mixed Health System [Public and Private Health
Care Providers (HCPs), out of pocket payments for service is common]
University of Benin Teaching Hospital (UBTH)
650 Bed Hospital 3,000 Deliveries annually
Background
What type of Patients do we see?
While 70 to 80% of the unbookedObstetric emergencies are low Socio-economic Class
Less than 20% of our ‘booked’ clients are of low Socio-economic Status
20-30% are referredObstetricEmergencies(Unbooked)
70-80% of our clients are registered for ANC with the UBTH (Booked)
Maternal Deaths in Nigerian Teaching Hospitals
• ‘When getting there is not enough: a nationwide cross-sectional study of 998 maternal deaths and 1451 near-misses in public tertiary hospitals in a low-income country’ (Oladapo et al 2016)
• A WHO led study that investigated the burden and the quality of emergency obstetric care in 42 public tertiary hospitals in Nigeria (including UBTH)
• Relevant Results
998 Maternal deaths in the Hospitals
136 women were recorded as dead before arrival in the Hospitals
Late presentation to the hospital (35.3%), lack of health insurance/inability to pay for required services (17.5%)
Maternal Deaths in Nigerian Teaching Hospitals
• They noted that ‘women present to the tertiary facilities in Nigeria, with a higher prevalence of Severe Maternal Morbidity, compared with those in the Brazilian and WHO MCS networks’
• ‘In settings where critically ill women present late to the hospital, maternal survival is not entirely dependent on the availability and application of life-saving interventions’.
Compared to highly resourced settings, Tertiary Hospitals in under resourced settings appear to be receiving patients in a worse condition
Maternal Deaths in UBTH
Ande A, Olagbuji B and Ezeanochie M (2012)
Reviewed 184 maternal deaths from 2005 to 2009 83.2% were ‘unbooked’ emergencies 84.9% were considered to be of low socio-economic
class 62.5% were admitted in ‘critical condition’ and died
within 72 hours of admission 69.5% of the women were referred from health facilities 66.1% of the pregnancies were stillbirths
Translating Research into Policy to improve Patient care
• Our Conclusions
Majority of our ‘unbooked obstetric emergencies’ are referred from Health Care Providers (HCP’s)
Delay in receiving appropriate interventions exists after the patients encountered the Healthcare System
The pregnancy outcome is far worse for ‘unbooked’ obstetric emergencies compared to ‘booked’ patients managed in UBTH (same facility, health workforce, time period)
The referral pathway patients navigate is NOT functioning properly, and this may be a systemic impediment to good pregnancy outcomes
Government
Legal Framework
StrengthenRegulation
Access toemergencycare
Coordinationwith otherPublic hospitals
Institution (UBTH)
PrioritizeMaternalHealth
EMR System Collaborative
Research Strengthen our
internal auditprocesses onquality of care
Private HCP’s
Training Establish
Linkages Support
Priority Actions for Implementing Reform
E n ga g e m e n t
Advocacy to Government2016 Edo State Policy Dialogue• Executive Governor of Edo State,• Speaker of Edo State Parliament
Domestication of National Health Act (Passed 2018)
State-wide Health Insurance Scheme(Launched 2019)
Edo State Primary Healthcare Development Agency(Started 2019)
Institutional Engagement
Reforms Overhaul of Maternity
Unit
Electronic Medical Records
Structured Admission and Discharge Forms
Collaborative Research(UBTH/LSHTM)
Our Goal• What characterises
obstetric referral in pluralistic healthcare systems, and how can it be monitored and improved to enhance equitable and timely access to emergency Obstetric care?
Pilot Study (routine UBTH Data)
Objectives• the extent to which referral
status and components were captured in patient records
• the prevalence of key components of effective referral.
What about HCP’s?
01
06 03
02
0405
Identify Facilities
Communication
EmergencyAmbulance
Service
Cross Posting of
Resident Doctors
Paramedics Training Workshops
Inadequate Resources for Training HCP’s
Who pays for the Ambulance?
Weak RegulatoryEnvironment
Health workforceShortage
Problem poorly understood?
NetworkedHealth Ecosystem: TECHNOLOGY
Challenges Interventions
The Community• Complex Adaptive System• What are their concerns?
(Clients, HCP’s, Regulators)
Single Health Ecosystem ?• Networked Health System• Accessible medical records
(Cloud based),• Central Referral ‘clearing house’• Efficient interfacility transportMeasurement and Evaluation• Which Variables?
More Research• Understanding causes
for delayed referral in Obstetric Emergencies
• Implementation Science
What Next?
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T H A N K
YO U