MATERNAL MORTALITY REDUCTION TO GLOBAL EMERGENCY HEALTH

Artículo completo
Global health priorities have long focused on vertical interventions to address health issues that tend to be easily definable, quantifiable, and measurable. The recent Ebola outbreak in Africa, cholera epidemic in Haiti, and earthquake in Nepal demonstrated that these interventions falter when acute, unexpected threats to a population’s health test healthcare systems designed around vertical interventions and do not include a rigorous systemic approach to everyday emergencies. Despite recent advances in global healthcare, emergency system development generally lags behind. The groundswell of support for creation of emergency systems has yet to materialize despite the estimate that functional emergency systems could mitigate 35-46% of all morbidity and mortality in low and middle-income countries.2 The approach to emergency system development in low and middle income countries has been evolving and some interventions to improve emergency health systems have been successfully studied.3, 4 However, these initiatives have primarily focused on pre-hospital services. A comprehensive framework to better understand the needs of a population and optimize the design of an emergency care system has not been well described in the literature. A clear framework is needed to provide a structured way of discussing emergency care systems and rally stakeholders to prioritize this issue globally.

To ascertain this framework, a review of successful global health initiatives that could be transferable to emergency systems identified the three-delay model, used to conceptualize the causes of maternal mortality, as the most applicable. This model which was part of the larger movement inspired by Millennium Development Goal 5 which has resulted in vast decrease in maternal morbidity and mortality globally. The three-delay model was constructed with the understanding that the majority of causes of maternal morbidity and mortality are preventable if the woman is able to receive appropriate care within a certain timeframe after the onset of a medical emergency. Delays were grouped into three critical time points for emergency conditions: (i) the decision to seek care, (ii)the time to reach care, and (iii) the receipt of adequate and appropriate treatment. Excessive delay in any of the three can render interventions that address the other delays ineffectual and therefore a system must be designed with specific elements to address each of the delays in a weighted manner.

The etiologies of maternal morbidity and mortality are limited and defined whereas emergency medicine encompasses all ages and specialties in its scope of practice. To distill the practice of emergency medicine into its essential presentations, over 150 practicing emergency clinicians at the 2013 African Federation of Emergency Medicine Consensus Conference concluded that six clinical syndromic presentations were the most essential to address. These were termed the sentinel emergency conditions and included shock, respiratory failure, trauma and altered mental status, severe pain, and dangerous fever.5,6 When focusing on these sentinel emergency conditions, the three-delay model can be implemented to better understand the critical time points where delay would prevent life-saving care from being delivered.

Barriers such as distance to a facility, differences in cultural status, and perceptions of quality of care at facilities have been shown to be applicable to all emergencies and been the targets of interventions to improve emergency care.7,8,9 Factors that have been established to effect the decision to seek care in the maternal health literature include the patient’s perception of the level of care available but not the cost of seeking such care.7,10 These factors have been supported in a recent study of the first delay in medical emergencies in Kenya.11 Any delay to reaching care – the second delay - has been well established to cause worsened outcomes especially with trauma care. Conversely, improvement of a pre-hospital transportation system, even in very resource limited settings such as Iraq, has showed a significant decrease in mortality.12 Receiving appropriate care in emergencies includes triage, stabilization, diagnosis and definitive care of the patient and when delivered correctly has a profound impact on morbidity and mortality; effective sepsis care is one such powerful example.13,14,15,16

Substantial infrastructure changes in emergency systems are required to minimize each of the three delays. However, the multiple changes needed for a complete overhaul of emergency systems may not be possible to implement simultaneously, particularly in low-resource settings. Recent efforts to offer a roadmap to overcome neonatal mortality in low- and middle-income countries have focused on a few key strategies.17 The same strategies could be applied more broadly to emergency systems – by advocating for universal health care, making emergency services free to all, developing a system that provides a basic level of emergency care at community level, and developing strong monitoring programmes to assure that key emergency services are being delivered at health facilities and that patients have access to these facilities. Such strategies could be pursued with those targeted practical interventions that have been shown to be markedly effective when focused on critical time points in the chain of survival. Improving emergency health systems, via an approach that address the three types of delay, has the potential to reduce mortality throughout the population in every age group and medical specialty.

Bibliografía del artículo
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