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Skip to 0 minutes and 13 seconds DR MATTHEW STREHLOW: Hello. My name is Matthew Strehlow, and welcome to the Lancet maternal Health Series Call to Action. This session is on linking women to routine and emergency care. System integration is imperative around the time of delivery to improve both the provision of routine and emergency obstetric care. Central to effective timely care delivery is the organised movement of the patient and key health information through the system. Our goal during the peripartum period is timely access for all patients to routine and emergency obstetric care. Worldwide access to routine obstetric care at the time of delivery, as defined by the presence of a Skilled Birth Attendant, has increased dramatically in the past few decades and is now estimated at 74%.

Skip to 1 minute and 6 seconds In contrast, the global met need for Emergency Obstetric Care or EmOC was recently estimated to be a paltry 25%. Currently then, we continue to struggle with substantial gaps in the delivery of both routine and emergency obstetric care during the peripartum period. A significant contributor to these gaps are challenges with the efficient movement of the patient through the system, often overly simplified and referred to as transport. Let’s take an example of a woman who goes into routine labour requiring non-emergent, but still swift transport on the order of hours as opposed to minutes or days. She then shifts by readily available means to a facility. The means available may range from walking all the way up to ambulance transportation.

Skip to 2 minutes and 3 seconds Whether she arrives in an appropriate time depends on distance, mode of transport, terrain, and choice of facility. Not infrequently, women will choose to bypass the nearest facility for perceived poor quality, time of day, or lack of staff. Alternatives to this approach are to have the Skilled Birth Attendant shift to the patient’s home or to utilise maternity waiting homes. Maternity waiting homes are shelter-like facilities close to definitive care facilities where women in the later stages of pregnancy, but prior to the onset of labour, come and stay. This reduces transport times and ensures rapid access to care. Although generally recommend as a means to improve access for patients in remote areas, there is little scientific evidence to support their use.

Skip to 2 minutes and 56 seconds At any point in the peripartum period, a woman may require emergency obstetric care. She then must access these services at an appropriate facility regardless of where she began. Care may be delivered during transport and bypassing lower-level facilities may be appropriate to avoid unnecessary delays at facilities where services may not be offered or despite the services being offered are not truly functional. When thinking about the different steps in managing a health emergency, we often refer to the “Chain of Survival”. This begins with recognition of the need for care and system activation. Once the system has been activated, the patient must be transported to a care facility, or less commonly, the resources are transported to the patient.

Skip to 3 minutes and 48 seconds Upon arrival, the patient must be appropriately received and triaged to rapidly identify the acuity or urgency of her condition. Appropriate quality care is provided by a skilled practitioner who assesses the patient, delivers care, and determines if further resources, human or otherwise, are required. If further resources are required, the provider must be able to swiftly activate these resources, whether they are within or outside the facility in which they are at currently. This may again involve shifting the patient. The end goal then is to rapidly move the patient to a functional emergency care facility where life-saving interventions can be performed. As you can see, the patient flows through this chain of survival, hopefully in an organised manner.

Skip to 4 minutes and 45 seconds Further, information regarding the patient’s status, prior care, and needs must flow rapidly through the chain to ensure timely and appropriate resources are mobilised and interventions delivered. Throughout this chain, the quality of service delivery must be assessed and quality improvement approaches integrated that cut across the different silos and highlight the weak points in the Chain of Survival. Other global strengtheners must be in place as well, such as health system financing for emergency care and appropriate leadership and governance. In conclusion, linking women to routine and emergency obstetric care during the time of delivery is critical. Unfortunately, substantial gaps exist, including a lack of evidence for specific interventions.

Skip to 5 minutes and 36 seconds Understanding the “Chain of Survival”, however, can elucidate specific areas of weakness, such as a lack of an integrated communication and transport system. Thank you.

Linking women to routine and emergency care

What challenges do pregnant women face accessing timely routine and emergency obstetric care?

In this step Dr Matthew Strehlow (Stanford University) addresses a critical point in health systems using the Chain of Survival concept, namely how women get to childbirth care. The step explores women in labour who need to travel to get skilled care, and those that need to be referred in case of complications. The step refers to factors contributing to delays, using the Three Delays Paradigm, and some of the transport obstacles to accessing care.

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This video is from the free online course:

The Lancet Maternal Health Series: Global Research and Evidence

London School of Hygiene & Tropical Medicine