https://orcid.org/0000-0002-8907-182X
Figures
Abstract
Background
Emergency Medical Services (EMS) systems exist to reduce death and disability from life-threatening medical emergencies. Less than 9% of the African population is serviced by an emergency medical services transportation system, and nearly two-thirds of African countries do not have any known EMS system in place. One of the leading reasons for EMS utilization in Africa is for obstetric emergencies. The purpose of this systematic review is to provide a qualitative description and summation of previously described interventions to improve access to care for patients with maternal obstetric emergencies in Africa with the intent of identifying interventions that can innovatively be translated to a broader emergency context.
Methods
The protocol was registered in the PROSPERO database (International Prospective Register of Systematic Reviews) under the number CRD42018105371. We searched the following electronic databases for all abstracts up to 10/19/2020 in accordance to PRISMA guidelines: PubMed/MEDLINE, Embase, CINAHL, Scopus and African Index Medicus. Articles were included if they were focused on a specific mode of transportation or an access-to-care solution for hospital or outpatient clinic care in Africa for maternal or traumatic emergency conditions. Exclusion criteria included in-hospital solutions intended to address a lack of access. Reference and citation analyses were performed, and a data quality assessment was conducted. Data analysis was performed using a qualitative metasynthesis approach.
Findings
A total of 6,457 references were imported for screening and 1,757 duplicates were removed. Of the 4,700 studies that were screened against title and abstract, 4,485 studies were excluded. Finally, 215 studies were assessed for full-text eligibility and 152 studies were excluded. A final count of 63 studies were included in the systematic review. In the 63 studies that were included, there was representation from 20 countries in Africa. The three most common interventions included specific transportation solutions (n = 39), community engagement (n = 28) and education or training initiatives (n = 27). Over half of the studies included more than one category of intervention.
Interpretation
Emergency care systems across Africa are understudied and interventions to improve access to care for obstetric emergencies provides important insight into existing solutions for other types of emergency conditions. Physical access to means of transportation, efforts to increase layperson knowledge and recognition of emergent conditions, and community engagement hold the most promise for future efforts at improving emergency access to care.
Citation: Joiner A, Lee A, Chowa P, Kharel R, Kumar L, Caruzzo NM, et al. (2021) Access to care solutions in healthcare for obstetric care in Africa: A systematic review. PLoS ONE 16(6): e0252583. https://doi.org/10.1371/journal.pone.0252583
Editor: Limakatso Lebina, University of the Witwatersrand, SOUTH AFRICA
Received: January 22, 2021; Accepted: May 18, 2021; Published: June 4, 2021
Copyright: © 2021 Joiner et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: AJ acknowledges support from the Society for Academic Emergency Medicine Foundation (SAEMF)/Global Emergency Medicine Academy (GEMA) Research Pilot Grant, RF2019-004. The funders had no role in the study design, data collection, analysis, decision to publish or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
There is a lack of access to healthcare for a range of emergent conditions on the continent of Africa. Much of this impaired access can be traced back to a paucity of available or reliable transportation resources; less than 9% of the African population is serviced by an emergency medical services (EMS) transportation system, and nearly two-thirds of African countries do not have any known EMS system in place [1]. Many Africans must resort to using personal or public transportation in his or her time of greatest need [2–7]. This is further complicated when emergent conditions occur at inconvenient times of day or night, when commonly used means of transportation may be unavailable. Lack of transportation or access to care can lead to delays in care or an inability to receive care for emergent conditions [8,9]. This lack of access may also limit the ability to provide timely treatment for less-emergent or non-emergent continuing care for a range of health conditions.
Healthcare access to care and transportation solutions in low- and middle-income countries (LMICs) are defined as specific interventions that aid the ability of a patient in accessing a healthcare facility, either by provision of a transportation solution, social or financial intervention, or education-based training interventions. Access-to-care solutions, including the development of prehospital and EMS care systems in all socioeconomic settings, have demonstrated a reduction in mortality from time-dependent conditions [9–13]. Given the value of these interventions in reducing morbidity and mortality, the World Health Organization has called for a need to increase access to healthcare, specifically the availability of prehospital care systems in LMICs [14].
Although many EMS systems remain underdeveloped in Africa, obstetric conditions are among the top two causes of EMS transports in the continent [1]. A global focus on improving maternal mortality has resulted in numerous programs aimed at strengthening emergency obstetric care in LMICs. Many of these interventions follow the three-delay model, which delineates 3 primary delays that contribute to maternal deaths in LMICs: 1) delays in the decision to seek care; 2) the time from when the decision to seek care is made to the time of arrival to the most appropriate facility; and 3) the delay in receiving care due to facility delays [15]. Applying lessons learned from addressing maternal mortality in these settings and translation of these concepts to a broader emergency care perspective has been previously proposed [16].
This systematic review attempts to perform a qualitative metasummary of known, evidence-based interventions to address healthcare access to care and transportation problems for patients with emergency obstetric conditions in Africa. Through summarizing the available literature on emergency obstetric interventions in this region, we aim to define the quality and scope of these interventions as well as to provide a foundation for the translation of these interventions to a more holistic emergency care lens.
Methods
Protocol and registration
This systematic review is reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) Statement S1 Table. and is registered in the PROSPERO database (International Prospective Register of Systematic Reviews) under the number CRD42018105371 [17].
Eligibility criteria
Inclusion criteria included: 1) transportation or access to care solutions for prehospital or follow up care; 2) trauma or maternal and obstetric conditions; 3) interventions in African countries. Exclusion criteria were interfacility transportation solutions. Language was not excluded and all types of studies were included. All manuscripts, regardless of year of publication, were included.
Information sources
Articles in reference to transportation for hospital or clinic access in an African country were searched in the following electronic databases: PubMed/MEDLINE, Embase, CINAHL, Scopus and African Index Medicus. No language limitations were placed on initial article selection. We performed citation trailing for all included articles by screening both the references and citing articles identified through Web of Science and Google Scholar. A qualified librarian with prior experience in systematic review methodology performed the searches and assisted in refining search criteria (MV).
Literature search
The initial search strategy is outlined in S2 Table. All studies up to the date of 10/19/2020 were included. All results were blindly screened by two authors in Covidence™ for the initial search and Endnote for the citation trailing. Disagreements were adjudicated by a third author.
Study selection
Eight reviewers evaluated titles and abstracts of the retrieved articles (AJ, AL, PC, AY, LV, LR, RK, LK). Each abstract was reviewed independently by at least two reviewers. Full-text articles of the selected abstracts were then independently evaluated by at least two reviewers. Any disagreement was resolved by a third reviewer’s opinion (AJ).
Risk of bias
Risk of bias was determined using study quality assessment tools from the National Heart, Blood and Lung Institute for controlled intervention, cohort, cross-sectional, and pre- and post- with no control group studies [18]. Quality assessment for qualitative studies was performed using the Joanna Briggs Critical Appraisal Checklist for Qualitative Research, which appraises 10 items specific to qualitative methodology through “yes”, “no”, “unclear” or “not applicable” responses [19]. Three authors (NC, TR, AJ) categorized risk of bias as either low risk or high risk based on the number of indicators with unclear specifications on the quality assessment. Those studies categorized as low risk of bias had 3 or less indicators with unclear specifications that were not directly related to the provision of raw data or analysis. Those studies with 3 or more items with unclear classifications or at least one low-quality indicator was classified as having a high risk of bias. Studies that were classified as descriptions of programs with no analysis were excluded from risk assessment.
Data extraction
Two reviewers (NM and TR) independently conducted data extraction by reviewing each full text manuscript. Disagreements were solved by consensus and a third reviewer’s opinion (AJ) was sought if the disagreement could not be resolved. Data collected included general characteristics of the studies, including type of study, year of publication, location of the study, type of intervention, and study outcome. Type of study was classified into one of the following categories: cross-sectional, cohort/case control (observational), controlled intervention, uncontrolled intervention, economic evaluation, qualitative, mixed methods, or intervention development. Intervention development studies were defined as those that included a formative evaluation or description of an intervention without a formal study component or outcome data; the description of the intervention was the key focus of these studies.
Data analysis
We used both qualitative and descriptive approaches in analyzing the pooled data. A descriptive approach was used to provide an overview of the study characteristics whereas a qualitative approach provided an in-depth analysis of the results through grouping of interventions and outcomes. Given the significant heterogeneity amongst and between the studies and interventions performed, a meta-analysis of pooled quantitative data was not feasible.
Results
Study selection
A total of 6,457 citations from 5 databases (PubMed/MEDLINE, Embase, CINAHL, Scopus and African Index Medicus) were screened for eligibility (Fig 1). A total of 73 studies were identified for data extraction, however, given the paucity of trauma-related articles, we elected to include only obstetric and maternal health-related articles for the final descriptive analysis for a total of 63 studies.
Studies characteristics
General characteristics for the included studies are found in Table 1. As demonstrated in Fig 2, a total of 20 different African countries were represented, with a range of 1 to 19 studies per country. Uganda had the largest number of studies at 19, followed by Zambia with 10, and Tanzania with 9. The remainder of the countries had 3 or fewer studies, with the majority only having 1 per country. The majority of studies were non-controlled interventional (22) or cross-sectional (10) studies. There were 8 mixed methods, 7 qualitative, 6 intervention development and 5 controlled intervention. The remaining 5 studies were 2 controlled intervention and 3 retrospective cohorts.
Quality of studies
The vast majority of the studies (n = 51), were at a high risk of bias. Only 6 of the studies were at low risk of bias. Six of the included manuscripts were descriptions of interventions with no study performed and were therefore excluded from the quality assessment.
Synthesis of results
The majority of studies [42] had multifaceted interventions involving more than one approach to improving access to care (Table 2). Of the 63 articles, we identified 28 that had at least one intervention in the category of community engagement, 27 with an intervention in the education/training category, 18 in financial category, 39 in the transportation category, and 16 in the facility infrastructure category. Of note, given the inclusion and exclusion criteria of this review, no articles were included that utilized facility infrastructure improvements as the sole intervention; rather all such interventions were complementary to other engagement, education, financing, and transportation programs. Multiple studies evaluated different aspects of the same program or intervention.
The majority of community-based interventions (24 out of 28) involved some aspect of training and integrating community members such as village health workers or community health teams. Ten of the 27 interventions in the education/training category focused on healthcare worker education and training while the remainder focused on education to lay-people and community members. Thirteen of the financial interventions involved the use of a voucher program for maternal health services and/or transport or removal of user fees; 5 involved the development of a community loan program or cost-sharing scheme. The remaining financial interventions included the use of mobile technology to directly provide funds once patients requiring referral were identified, and a national policy change to subsidize certain aspects of maternal care, including transportation. Twenty-four transportation-focused interventions involved the development of an ambulance-based referral system or ambulance network. Eleven of the interventions focused on community supported transportation systems for obstetric emergencies and 4 involved the use of vouchers for transportation services. Interventions included the creative use of several different types of transportation vehicles (ambulances, 4-wheel drive vehicles, motorbikes, bicycles, donkey carts and boats). Finally, there were 16 interventions that included some aspect of improving facility infrastructure or providing equipment for healthcare facilities.
Discussion
This review identified a variety of obstetric access to care and transportation interventions across several African nations that could be translated to other emergency conditions. Though cases and sample sizes varied greatly from a few dozen to the thousands, several themes emerged. Many interventions utilized a “local arbiter”, midwife or otherwise, to identify cases needing interventional support. In some instances, support was in the form of financial loans or direct payments for transportation, vouchers for public transport, or existing ambulance utilization. There is a noted significant heterogeneity in the outcome measurements, from mortality measures, to the number of individuals educated, to the financial indicators of money raised/disbursed. Although high quality evidence is lacking, many of these interventions could be adapted to address other emergent conditions requiring transportation to access care.
A previous systematic review evaluating access barriers to obstetric care in sub-Saharan Africa identified multiple demand-side barriers including household resources or income, lack of transport availability, cost of transportation, poor information on health care services and providers, stigma and self-esteem concerns, lack of birth preparation, and cultural beliefs [83]. Wilson et al. conducted a systematic review specifically evaluating qualitative studies on maternal emergency transport in LMICs and found key issues to be the availability and speed of transport, terrain, weather, support, lack of autonomy in decision-making for women, cultural barriers, cost, and ergonomics during transport [84]. These findings are reflected in the emergency care literature as well. A more recent systematic review evaluated more broadly the barriers to out-of-hospital emergency care in low and middle-income countries, and found many of the same barriers as in the obstetric literature, including cultural and transportation barriers [85]. The interventions described in our systematic review focus specifically on access-to-care and transportation for obstetric conditions, including emergency obstetrics. We found that the interventions identified in this systematic review address many of the barriers also found more broadly in emergency care that have not been fully described in the obstetrics literature, such as communication and coordination, training of personnel, and infrastructure [85].
This review highlights broad diversity in the approaches to access-to-care interventions for obstetric care. Although rural and urban contexts have divergent needs for improving access to obstetric care, the assorted approaches taking place across the continent of Africa have varied strengths and benefits. Our study also highlights gaps in knowledge and expertise in this subset of patients. Studies were predominantly clustered in eastern and sub-Saharan Africa. Numerous countries had no representative published literature within the scope of this review and many had only one such article. In cases where the single study from a country may have a small population size, Fig 1 may visually mislead the extent of geographic spread of the reviewed literature. These findings resonate with previous literature describing the presence of EMS systems in eastern Africa, with a relative dearth of established EMS systems in West Africa [1].
Prior work by Ehiri et al. in 2018 does have some overlap, though their study was more narrowly focused on ameliorating adverse birth outcomes for both mothers and babies and focused solely on transportation solutions [86]. Our systematic review looked more comprehensively at other solutions in access-to-care, such as training and educational interventions and community engagement, more closely mirroring the three-delays model. Furthermore, their work looked at LMICs more broadly, while our review was more focused in geographic scope.
The majority of the studies included in our qualitative synthesis were classified as having a high degree of bias, indicating concerns around the quality of studies on this subject in this geographic area. There was only one randomized-control trial and most of the studies were observational or cross-sectional. This follows findings in the global emergency medicine literature, where there has been a paucity of high quality literature focusing on interventions to increase access to emergency care in LMICs [87,88]. This spurs us to creatively evaluate and assess other types of interventions that can be translated or incorporated into efforts to increase access to emergency care. Valuable lessons from literature around obstetric care can be applied towards addressing gaps in access to care for other emergent conditions. Many recent advances in emergency obstetric care are the result of a multifactorial approach to achieving appropriate care using the three-delays model as a framework [15]. This conceptual framework has been proposed as a viable model by which to approach the delivery of and access to emergency care [16].
Many of the interventions identified in this systematic review are centered around the first and second delays in the conceptual model (delays in deciding to seek care and delays in the travel/transport required to obtain care). Previous literature describing barriers to out-of-hospital emergency care have identified specific obstacles that fit within the first two delays: decision to call EMS, recognition of emergency health conditions, challenges in finding transportation, delays in transportation, and access to appropriate hospitals [85]. One must also consider that even if a patient is transported to an appropriate hospital, there may be a paucity of blood products, medications, or adequate surgical service availability. We found that several of the interventions identified in this review could be translated to the emergency care for a number of different conditions. For example, the provision of vouchers for transportation, community-supported ambulances or transportation schemes, community cost-sharing schemes, and community education are all approaches that could be applied to improving access to numerous emergency conditions and addressing known barriers.
Limitations
This review was initially meant to encompass interventions addressing both trauma and emergency obstetric interventions in Africa. However, given the paucity of trauma-specific interventions and the relative wealth of studies focusing on emergency obstetric interventions, the focus of the review was pivoted to translating emergency obstetric interventions to broader emergency care interventions. We also chose to focus only on interventions in Africa, thus we may have overlooked pertinent interventions and better quality data in other LMIC settings.
Conclusion
Interventions to improve access to emergency obstetric conditions in Africa are varied in quality and focus. Many of these interventions follow the three-delays conceptual model and can thus be translated to improving access to a broader array of emergent conditions. In particular, interventions focusing on improving the first two delays in care through education, community involvement, and improving transportation to healthcare facilities, hold the most promise for future efforts at improving emergency access to care for both obstetric as well as other conditions.
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