Reducing early infant mortality in India: results of a prospective cohort of pregnant women using emergency medical services

Abstract

ObjectivesTo describe the demographic characteristics and clinical outcomes of neonates born within 7 days of public ambulance transport to hospitals across five states in India.DesignProspective observational study.SettingFive Indian states using a centralised emergency medical services (EMS) agency that transported 3.1 million pregnant women in 2014.ParticipantsOver 6 weeks in 2014, this study followed a convenience sample of 1431 neonates born to women using a public-private ambulance service for a ‘pregnancy-related’ problem. Initial calls were deemed ‘pregnancy related’ if categorised by EMS dispatchers as ‘pregnancy’, ‘childbirth’, ‘miscarriage’ or ‘labour pains’. Interfacility transfers, patients absent on ambulance arrival, refusal of care and neonates born to women beyond 7 days of using the service were excluded.Main outcome measures: death at 2, 7 and 42 days after delivery.ResultsAmong 1684 women, 1411 gave birth to 1431 newborns within 7 days of initial ambulance transport. Median maternal age at delivery was 23 years (IQR 21–25). Most mothers were from rural/tribal areas (92.5%) and lower social (79.9%) and economic status (69.9%). Follow-up rates at 2, 7 and 42 days were 99.8%, 99.3% and 94.1%, respectively. Cumulative mortality rates at 2, 7 and 42 days follow-up were 43, 53 and 62 per 1000 births, respectively. The perinatal mortality rate (PMR) was 53 per 1000. Preterm birth (OR 2.89, 95% CI 1.67 to 5.00), twin deliveries (OR 2.80, 95% CI 1.10 to 7.15) and caesarean section (OR 2.21, 95% CI 1.15 to 4.23) were the strongest predictors of mortality.ConclusionsThe perinatal mortality rate associated with this cohort of patients with high-acuity conditions of pregnancy was nearly two times the most recent rate for India as a whole (28 per 1000 births). EMS data have the potential to provide more robust estimates of PMR, reduce inequities in timely access to healthcare and increase facility-based care through service of marginalised populations.

Bleeding during pregnancy as a reason for interventions by emergency medical services teams in Poland

“…At the time of the first EMS call, most pregnant patients were at term. The most common reasons for the call were abdominal pain and spasm, followed by rupture of membranes, contractions, and vaginal bleeding [29]. Findings similar to those by Bills et al (2018) [29] were reported by Singh et al (2017) in their study on pregnant women transferred to healthcare centres by emergency medical services in five statinf India [30].…”

“…They found that approximately one in three of the women studied had a high-risk pregnancy or pregnancy complications [28]. Bills et al (2018) published a study on decreases in the early neonatal mortality rate in India in the context of EMS use by pregnant women. Most newborns included in the analysis had been born to mothers living in rural areas.…”

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“…For example, organising a low-cost prehospital system was associated with a substantial decrease in trauma mortality in Cambodia and Iraq 41. A prehospital care service improved access42 and utilisation in Nepal 43. A review and meta-analysis of mortality in LMICs estimated a 25% reduction in risk of death from trauma in areas with prehospital trauma systems 40…”

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“…IFTs were the focus of the study as they require EMTs to both receive and give signout, resulting in two data points per call. Further, the sample was confined to a single chief complaint because a) it required a uniform set of signout elements and b) calls for pregnancy-related transfers are a major focus for EMS agencies in LMICs -pregnancyrelated transfers comprise over 30% of total transfers by the Indian EMS agency studied with over 30% of these being IFTs [16].…”