Emergency Transportation Interventions for Reducing Adverse Pregnancy Outcomes in Low- and Middle-Income Countries: A Systematic Review.

Halimatou Alaofe,Linda Kimaru,Abidemi Okechukwu,Breanne Lott,Babasola Okusanya,Joy Chebet,John Ehiri,Martin Meremikwu

doi:10.5334/aogh.2934

Abstract

Objective:To assess the effect of emergency transportation interventions on the outcome of labor and delivery in low- and middle-income countries (LMICs).Methods:Eleven databases were searched through December 2019: Medline/PubMed, EMBASE, Web of Science, EBSCO (PsycINFO and CINAHL), SCIELO, LILACS, JSTOR, POPLINE, Google Scholar, the Cochrane Pregnancy and Childbirth Group’s Specialized Register, and the Cochrane Central Register of Controlled Trials. Methodological quality of included studies was assessed using the ROBINS-I tool.Results:Nine studies (three in Asia and six in Africa) were included: one cluster randomized controlled trial, three controlled before-and-after (CBA) studies, four uncontrolled before and after studies, and one case-control study. The means of emergency obstetric transportation evaluated by the studies included bicycle (n = 1) or motorcycle ambulances (n = 3), 4-wheel drive vehicles (n = 3), and formal motor-vehicle ambulances (n = 2). Transportation support was offered within multi-component interventions including financial incentives (n = 1), improved communication (n = 7), and community mobilization (n = 2). Two controlled before-and-after studies that implemented interventions including financial support, three-wheeled motorcycles, and use of mobile phones reported reduction of maternal mortality. One cluster-randomized study which involved community mobilization and strengthening of referral, and transportation, and one controlled before-and-after that implemented free-of-charge, 24-hour, 4 × 4 wheel ambulance and a mobile phone showed reductions in stillbirth, perinatal, and neonatal mortality. Six studies reported increases in facility delivery ranging from 12–50%, and one study showed a 19% reduction in home delivery. There was a significant increase of caesarian sections in two studies; use of motorcycle ambulances compared to car ambulance resulted in reduction in referral delay by 2 to 4.5 hours. Only three included studies had low risk of bias on all domains.Conclusion:Integrating emergency obstetric transportation with complimentary maternal health interventions may reduce adverse pregnancy outcomes and increase access to skilled obstetric services for women in LMICs. The strength of evidence is limited by the paucity of high-quality studies.

Highlights

Pregnancy and childbirth are normal physiological processes
In resource-poor settings, where many women deliver at home or in inadequately equipped health facilities, ensuring that those who develop obstetric emergencies during childbirth are quickly transported to facilities where they can receive quality emergency obstetric care can be the difference between life and death for the pregnant woman and her fetus
This review focused on assessment of the effects of emergency transportation interventions that were implemented to address Phase II delays aimed at reducing adverse pregnancy and birth outcomes in low- and middle-income countries (LMICs)

Summary

Introduction

Pregnancy and childbirth are normal physiological processes. For most women in high-income countries, pregnancy is associated with a feeling of pride and immense joyous expectation [1]. For millions of women and their families in low- and middle-income countries (LMICs), where emergency obstetric care is limited, pregnancy and childbirth are a major cause of fear and anxiety [2]. While most women have normal pregnancies and safe deliveries, unanticipated obstetric complications and emergencies sometimes occur. In resource-poor settings, where many women deliver at home or in inadequately equipped health facilities, ensuring that those who develop obstetric emergencies during childbirth are quickly transported to facilities where they can receive quality emergency obstetric care can be the difference between life and death for the pregnant woman and her fetus. Referral to needed emergency obstetric care may not be possible for a plethora of reasons, including geography, cost, and lack of transportation [4]

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