Strengthening South African public sector obstetric emergency medical services (EMS) systems
The Foundation for Professional Development (FPD), in partnership with the National Department of Health (NDoH) and MSD for Mothers is leading the MSD for Mothers: Strengthening South African Public Sector Obstetric Emergency Medical Services (EMS) Systems Project. The aim of this project is to improve maternal and infant survival by improving the quality of emergency care for pregnant mothers and/ or new born babies during ambulance transit to health facilities. The three-year project commenced in April 2016 and was implemented in five health districts in South Africa, namely Amathole in the Eastern Cape, Capricorn in Limpopo, and Ehlanzeni, Gert Sibande and Nkangala in Mpumalanga.
FPD developed standardised EMS protocols, Standard Operating Procedures (SOPs) and monitoring data collection tools for all emergency call centres to ensure that obstetric emergencies are prioritised and correctly triaged during transit. In addition to this, FPD developed an online course for call centre staff which was made available to all call centre staff nationally (Short Course in EMS Call Centre Communications - Obstetric Emergencies). To ensure that EMS personnel are adequately prepared for obstetric emergencies, FPD developed training material for Advanced Life Support (ALS), Intermediate Life Support (ILS) and Basic Life Support (BLS) personnel in identifying and managing obstetric emergencies in-transit. The training courses developed and implemented by FPD include the Essential Steps in Managing Obstetric Emergencies In-transit (ESMOE-IT) Master Training Course and the Short Course in the Management of Obstetric Emergencies in Transit - BLS Cadre. The training included interactive workshops that combined theoretical concepts and in-depth practical drills on managing such emergencies. As the project is drawing to a close in April 2019, an evaluation was conducted at the end of 2018 to determine if it had resulted in the indented objectives and outcomes.
As of December 2018, 692 people had been trained under the MSD programme. In total, 182 people were trained by FPD on the ESMOE-IT Master Training course, far exceeding the target of 100. In addition, FPD trained 50 other National Department of Health personnel, including doctors, nurses and midwives. They were included as a result of specific requests from the districts, to ensure that there is adequate understanding between all sectors on the realities of the EMS sector and the challenges they face. The ESMOE-IT Master Training Course was implemented with the main aim of ensuring that the delegates who attended the training be declared competent to cascade the training to their own districts, ensuring that the training intervention is sustainable. The cascaded training in Amathole district and the rest of the Eastern Cape was very successful, with 868 EMS personnel being trained by the master trainers. 332 BLS personnel were trained on the Short Course in the Management of Obstetric Emergencies in transit. A total of 101 Call Centre operators were trained on the Short Course in EMS Call Centre Communications, five times more than the target of 20. An additional 27 healthcare professionals completed this course online.
Training participants were asked to complete a pre- and post-course questionnaire before and after they completed the courses to determine if the training was successful in transferring knowledge. From Figure 1 we can see that the post-course average scores increased by 16% to 20% in all three courses.
Participants who were trained found the training to be extremely valuable and said that it improved the care that they were able to provide to obstetrics patients. One of the major improvements was in the ability of EMS personnel to ask patients the right questions, obtain a full history and hand over the patient properly. It also gave them the knowledge and confidence to discuss the patients’ treatment and care with the healthcare workers in the transferring and receiving facilities. Trainees highlighted that they now know more about obstetrics and the responsibilities of the various role-players during the transport of an obstetrics patient.
47 EMS facilities (in the five districts) were surveyed, 44 EMS Stations and four Communication Centres, an 88% response rate. The survey found that the EMS system is still faced with a number of challenges, including a shortage of obstetric ambulances, as well as essential and obstetrics equipment. There was a severe shortage of obstetric ambulances in the districts surveyed, with 74% of the EMS stations having no functioning obstetric ambulance. Obstetrics patients in these cases are transported in general ambulances, which do not have the equipment needed to respond to an obstetric emergency. A total of 80% of the EMS stations reported that their ambulances are not sufficiently equipped to respond to medical emergencies. Interview respondents reported that EMS personnel often bring their own equipment (e.g. blood pressure machines) to work in order to do their job.
Data from the District Health Barometer1 show that the Maternal Mortality Rate decreased over the last three years in four of the five districts where the project was implemented (Figure 2). While this cannot be directly attributed to the project, it is an interesting observation. The national early neonatal mortality rate remained relatively stable between 2016/17 and 2017/18, at around 10 deaths per 1 000 live births.
The evaluation of the MSD for Mothers Programme found that the programme did meet its objective to train communication centre and EMS personnel so that they can provide high-quality, standardised care and management of obstetric emergencies in-transit. The potential for this programme to have a significantly positive impact on maternal and infant mortality was highlighted by the beneficiaries and stakeholders, provided that the challenges still faced by the EMS system are also addressed. It was recommended that the National Department of Health explore strategies to expand this training to all provinces in South Africa and provide EMS personnel with the equipment and resources they need to provide high-quality emergency medical services. The full evaluation report will be ready for dissemination in April 2019.