A woman’s worth: an access framework for integrating emergency medicine with maternal health to reduce the burden of maternal mortality in sub-Saharan Africa

Abstract

Background Within each of the Sustainable Development Goals (SDGs), the World Health Organization (WHO) has identified key emergency care (EC) interventions that, if implemented effectively, could ensure that the SDG targets are met. The proposed EC intervention for reaching the maternal mortality benchmark calls for “timely access to emergency obstetric care.” This intervention, the WHO estimates, can avert up to 98% of maternal deaths across the African region. Access, however, is a complicated notion and is part of a larger framework of care delivery that constitutes the approachability of the proposed service, its acceptability by the target user, the perceived availability and accommodating nature of the service, its affordability, and its overall appropriateness. Without contextualizing each of these aspects of access to healthcare services within communities, utilization and sustainability of any EC intervention-be it ambulances or simple toll-free numbers to dial and activate EMS-will be futile. Main text In this article, we propose an access framework that integrates the Three Delays Model in maternal health, with emergency care interventions. Within each of the three critical time points, we provide reasons why intended interventions should be contextualized to the needs of the community. We also propose measurable benchmarks in each of the phases, to evaluate the successes and failures of the proposed EC interventions within the framework. At the center of the framework is the pregnant woman, whose life hangs in a delicate balance in the hands of personal and health system factors that may or may not be within her control. Conclusions The targeted SDGs for reducing maternal mortality in sub-Saharan Africa are unlikely to be met without a tailored integration of maternal health service delivery with emergency medicine. Our proposed framework integrates the fields of maternal health with emergency medicine by juxtaposing the three critical phases of emergency obstetric care with various aspects of healthcare access. The framework should be adopted in its entirety, with measureable benchmarks set to track the successes and failures of the various EC intervention programs being developed across the African continent.

Closing the gaps in defining and conceptualising acceptability of healthcare: A synthesis review and thematic content analysis

“…Our findings agree with other publications describing acceptability as a dimension of access to healthcare [15][16][17]. This is particularly important and could help in resolving some misunderstandings surrounding the definition of acceptability.…”

“…Five-dimension Framework of Access to Healthcare comprising (1) Approachability; (2) Acceptability; (3) Availability and Accommodation; (4) Affordability; and (5) Appropriateness [15]. Anto-Ocrah et al [17] applied this framework to develop an adapted framework for integrating emergency medicine with maternal health to reduce the maternal mortality in sub-Saharan Africa.…”

“…It is beyond the scope of this paper to discuss the definition of access to healthcare and different conceptual frameworks, but it is important to note that acceptability is included in all of these aforementioned frameworks of access to healthcare. Therefore, acceptability is widely recognised as one of the different dimensions of access and it should be considered within the context of access to healthcare [4,14,17,20].…”

Measuring the availability and geographical accessibility of maternal health services across sub-Saharan Africa

“…Furthermore, the 2-h travel time recommended by the indicator has been critiqued as a benchmark for geographical accessibility, and literature references a "golden hour" where access to emergency obstetric care within the first hour can dramatically decrease adverse outcomes and improve chances of survival for women and their children [53]. Reducing the 2-h benchmark to consider this "golden hour" would have shown a reduction in service coverage, resulting in an increase in the number of areas not meeting this target and number of women at risk.…”

“…Furthermore, using a minimum threshold of at least 80% population coverage within this 2-h travel time is problematic, where in the context of the SDG "leave no one behind" agenda, it implies that it is acceptable that a fifth of population at risk do not have access to critical services. It is additionally important to note that any measure of geographical accessibility does not consider barriers related to the availability, affordability, acceptability, and appropriateness of services; factors which have shown to contribute substantially to delays in receiving care [54][55][56], even when geographical accessibility might otherwise be considered adequate.…”