Association between ambulance prehospital time and maternal and perinatal outcomes in Sierra Leone: a countrywide study

Abstract

IntroductionSierra Leone, one of the countries with the highest maternal and perinatal mortality in the world, launched its first National Emergency Medical Service (NEMS) in 2018. We carried out a countrywide assessment to analyse NEMS operational times for obstetric emergencies in respect the access to timely essential surgery within 2 hours. Moreover, we evaluated the relationship between operational times and maternal and perinatal mortality.MethodsWe collected prehospital data of 6387 obstetric emergencies referrals from primary health units to hospital facilities between June 2019 and May 2020 and we estimated the proportion of referrals with a prehospital time (PT) within 2 hours. The association between PT and mortality was investigated using Poisson regression models for binary data.ResultsAt the national level, the proportion of emergency obstetric referrals with a PT within 2 hours was 58.5% (95% CI 56.9% to 60.1%) during the rainy season and 61.4% (95% CI 59.5% to 63.2%) during the dry season. Results were substantially different between districts, with the capital city of Freetown reporting more than 90% of referrals within the benchmark and some rural districts less than 40%. Risk of maternal death at 60, 120 and 180 min of PT was 1.8%, 3.8% and 4.3%, respectively. Corresponding figures for perinatal mortality were 16%, 18% and 25%.ConclusionNEMS operational times for obstetric emergencies in Sierra Leone vary greatly and referral transports in rural areas struggle to reach essential surgery within 2 hours. Maternal and perinatal risk of death increased concurrently with operational times, even beyond the 2-hour target, therefore, any reduction of the time to reach the hospital, may translate into improved patient outcomes.

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“…Second, additional time points were not captured to examine where specifically the delays in travel time occurred. For example, capturing dispatch time, response time, travel time, and prehospital time could have been additional time related variables that could have enhanced the results 22 . Due to these limitations, the result of this study needs to be interpreted carefully.…”

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“…79 Studies have found that the use of specialized vehicles such as motorlances (motorcycles modified to be used as ambulances) and helicopter Emergency Medical Services (HEMS) can lead to shorter response times than traditional ambulances, 61,69,80 which was in turn associated with improved health outcomes and lower mortality. 59,81,82 Factors that affected response times included the distance from the hospital, location, type of emergency, and ambulance mechanism. Additionally, several studies found that response times in rural areas were generally longer than those in urban areas [83][84][85] (Table 3 38,39,59,61,63,69,74,[79][80][81][82][83][84][85][86][87][88][89][90][91][92][93] ).…”

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“…In Sierra Leone, a countrywide study demonstrated that maternal risk of death increased concurrently with National Emergency Medical Service (NEMS) operational times. 37 This implies that, improved maternal outcomes are likely to be noted with reduced delays of reaching the hospital. 37,38 The emergency system should be effective, affordable and adequate.…”

“…37 This implies that, improved maternal outcomes are likely to be noted with reduced delays of reaching the hospital. 37,38 The emergency system should be effective, affordable and adequate. 39…”