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