title: An ambulance referral network improves access to emergency obstetric and neonatal care in a district of rural Burundi with high maternal mortality.
abstract: OBJECTIVE
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Medical department Operational Research, Medecins sans Frontieres, Luxembourg. katie_harries@yahoo.co.uk
authors.forename: K
authors.initials: K
authors.lastname: Tayler-Smith
authors.forename: R
authors.initials: R
authors.lastname: Zachariah
authors.forename: M
authors.initials: M
authors.lastname: Manzi
authors.forename: W
authors.initials: W
authors.lastname: Van den Boogaard
authors.forename: G
authors.initials: G
authors.lastname: Nyandwi
authors.forename: T
authors.initials: T
authors.lastname: Reid
authors.forename: E
authors.initials: E
authors.lastname: De Plecker
authors.forename: V
authors.initials: V
authors.lastname: Lambert
authors.forename: M
authors.initials: M
authors.lastname: Nicolai
authors.forename: S
authors.initials: S
authors.lastname: Goetghebuer
authors.forename: B
authors.initials: B
authors.lastname: Christiaens
authors.forename: B
authors.initials: B
authors.lastname: Ndelema
authors.forename: A
authors.initials: A
authors.lastname: Kabangu
authors.forename: J
authors.initials: J
authors.lastname: Manirampa
authors.forename: A D
authors.initials: AD
authors.lastname: Harries
mesh_terms: D000328:Adult; D000552:Ambulances / Q000191:economics / Q000458:organization & administration; D002063:Burundi / Q000453:epidemiology; D003430:Cross-Sectional Studies; D004631:Emergency Medical Service Communication Systems / Q000191:economics; D004632:Emergency Medical Services / Q000379:methods / Q000706:statistics & numerical data*; D005260:Female; D017048:Health Care Costs; D006297:Health Services Accessibility; D006801:Humans; D007231:Infant, Newborn; D007390:International Agencies; D063130:Maternal Death / Q000517:prevention & control; D008427:Maternal Health Services / Q000379:methods / Q000706:statistics & numerical data*; D008428:Maternal Mortality; D007744:Obstetric Labor Complications / Q000453:epidemiology* / Q000628:therapy; D013513:Obstetric Surgical Procedures / Q000706:statistics & numerical data; D010360:Patient Transfer / Q000191:economics / Q000379:methods / Q000706:statistics & numerical data*; D054238:Perinatal Mortality; D011247:Pregnancy; D015397:Program Evaluation; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012424:Rural Population / Q000706:statistics & numerical data; D013997:Time Factors; D055815:Young Adult
keywords: Burundi; ambulance; emergency obstetric care; referral