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

Objectives: To describe the demographic characteristics and clinical outcomes of neonates born within 7 days of public ambulance transport to hospitals across five states in India. Design: Prospective observational study. Setting: Five Indian states using a centralised EMS agency that transported 3.1 million pregnant women in 2014. Participants: Over 6 weeks in 2014, this study followed a convenience sample of 1,431 neonates born to women utilizing 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. Results: Among 1,684 women, 1,411 gave birth to 1,431 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 41, 53 and 62 per 1000 births, respectively. The perinatal mortality rate (PMR) was 53 per 1000. Preterm birth [OR: 2.89, 95% CI: 1.67-5.00], twin deliveries (OR: 2.80, 95% CI: 1.10-7.15), and cesarean section (2.21, 95% CI: 1.15-4.23) were the strongest predictors of mortality. Conclusions: The 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 has the potential to provide more robust estimates of PMR, reduce inequities in timely access to healthcare, and increase facility-based care through service of marginalized populations

Data from: Characteristics and outcomes of women utilizing emergency medical services for third-trimester pregnancy-related complaints in India: a prospective observational study

Objectives: Characterize the demographics, management, and outcomes of obstetric patients transported by emergency medical services (EMS). Design: Prospective observational study. Setting: Five Indian states utilizing a centralized EMS agency that transported 3.1 million pregnant women in 2014. Participants: This study enrolled a convenience sample of 1684 women in third trimester of pregnancy calling with a “pregnancy-related” complaint for free-of-charge ambulance transport. Calls were deemed “pregnancy-related” if categorized by EMS dispatchers as “pregnancy”, “childbirth”, “miscarriage”, or “labor pains”. Interfacility transfers, patients absent upon ambulance arrival, and patients refusing care were excluded. Main outcome measures: Emergency medical technician (EMT) interventions, method of delivery, and death. Results: The median age enrolled was 23 years (IQR 21-25). Women were primarily from rural/tribal areas (1550/1684 (92.0%)) and lower economic strata (1177/1684 (69.9%)). Time from initial call to hospital arrival was longer for rural/tribal compared to urban patients (66 min (IQR 51-84) vs 56 min (IQR 42-73), respectively, p<0.0001). EMTs assisted delivery in 44 women, delivering the placenta in 33/44 (75%), performing transabdominal uterine massage in 29/33 (87.9%), and administering oxytocin in none (0%). There were 1411 recorded deliveries. Most women delivered at a hospital (1212/1411 (85.9%)), however 126/1411 (8.9%) delivered at home following hospital discharge. Follow-up rates at 48 hours, 7 days, and 42 days were 95.0%, 94.4%, and 94.1%, respectively. Four women died, all within 48 hours. The cesarean section rate was 8.2% (116/1411). On multivariate regression analysis, women transported to private hospitals versus government primary health centers were less likely to deliver by cesarean section (odds ratio 0.14 (0.05 to 0.43)). Conclusions: Pregnant women from vulnerable Indian populations use free-of-charge EMS for impending delivery, making it integral to the health care system. Future research and health system planning should focus on strengthening and expanding EMS as a component of EmONC

Characteristics and outcomes of pediatric patients presenting at Cambodian referral hospitals without appointments: an observational study

Abstract Background Emergency medicine is a young specialty in many low- and middle-income countries (LMICs). Although many patients seeking emergency or acute care are children, little information is available about the needs and current treatment of this group in LMICs. In this observational study, we sought to describe characteristics, chief complaints, management, and outcomes of children presenting for unscheduled visits to two Cambodian public hospitals. Methods Children enrolled in the study presented without appointment for treatment at one of two Cambodian public referral hospitals during a 4-week period in 2012. Researchers used standardized questionnaires and hospital records to collect demographic and clinical data. Patients were followed up at 48 h and 14 days after initial presentation. Multivariate logistic regression identified factors associated with hospital admission. Results This study included 867 unscheduled visits. Mean patient age was 5.7 years (standard deviation 4.8 years). Of the 35 different presenting complaints, fever (63%), respiratory problems (25%), and skin complaints (24%) were most common. The majority of patients were admitted (51%), while 1% were transferred to another facility. Seven patients (1%) died within 14 days. Follow-up rates were 83% at 48 h and 75% at 14 days. Predictors of admission included transfer or referral from another health provider, seeking prior care for the presenting problem, low socioeconomic status, onset of symptoms within 24 h of seeking care, abnormal vital signs or temperature, and chief complaint of abdominal pain or fever. Conclusions While the admission rate in this study was high, mortality was low. More effective identification and management of children who can be treated and released may free up scarce inpatient resources for children who warrant admission

An observational study of adults seeking emergency care in Cambodia

Objective To describe the characteristics and chief complaints of adults seeking emergency care at two Cambodian provincial referral hospitals. Methods Adults aged 18 years or older who presented without an appointment at two public referral hospitals were enrolled in an observational study. Clinical and demographic data were collected and factors associated with hospital admission were identified. Patients were followed up 48 hours and 14 days after presentation. Findings In total, 1295 hospital presentations were documented. We were able to follow up 85% (1098) of patients at 48 hours and 77% (993) at 14 days. The patients’ mean age was 42 years and 64% (823) were females. Most arrived by motorbike (722) or taxi or tuk-tuk (312). Most common chief complaints were abdominal pain (36%; 468), respiratory problems (15%; 196) and headache (13%; 174). Of the 1050 patients with recorded vital signs, 280 had abnormal values, excluding temperature, on arrival. Performed diagnostic tests were recorded for 539 patients: 1.2% (15) of patients had electrocardiography and 14% (175) had diagnostic imaging. Subsequently, 783 (60%) patients were admitted and 166 of these underwent surgery. Significant predictors of admission included symptom onset within 3 days before presentation, abnormal vital signs and fever. By 14-day follow-up, 3.9% (39/993) of patients had died and 19% (192/993) remained functionally impaired. Conclusion In emergency admissions in two public hospitals in Cambodia, there is high admission-to-death ratio and limited application of diagnostic techniques. We identified ways to improve procedures, including better documentation of vital signs and increased use of diagnostic techniques

Data for a Convenience Sample of Women Utilizing EMS for Obstetric Emergencies in India

This data is from a convenience sample of women in their third-trimester who used EMS across five states in India over a six week period in 2014