Can innovative ambulance transport avert pregnancy-related deaths? One-year operational assessment in Ethiopia.

BACKGROUND: To maximise the potential benefits of maternity care services, pregnant women need to be able to physically get to health facilities in a timely manner. In most of sub-Saharan Africa, transport represents a major practical barrier. Here we evaluate the extent to which an innovative national ambulance service in Ethiopia, together with mobile phones, may have been successful in averting pregnancy-related deaths. METHODS: An operational assessment of pregnancy-related deaths in relation to utilisation of the new national ambulance service was undertaken in six randomly selected Districts in northern Ethiopia. All 183 286 households in the six randomly selected Districts were visited to identify live-births and deaths among women of reproductive age that occurred over a one-year period. The uptake of the new ambulance transport service for women's deliveries in the same six randomly selected Districts over the same period was determined retrospectively from ambulance log books. Pregnancy-related deaths as determined by the World Health Organization (WHO 2012) verbal autopsy tool [13] and the InterVA-4 model [14] were analysed against ambulance utilisation by District, month, local area, distance from health facility and mobile network coverage. FINDINGS: A total of 51 pregnancy-related deaths and 19 179 live-births were documented. Pregnancy-related mortality for Districts with above average ambulance utilisation was 149 per 100 000 live-births (95% confidence interval CI 77-260), compared with 350 per 100 000 (95% CI 249-479) for below average utilisation (P = 0.01). Distance to a health facility, mobile network availability and ambulance utilisation were all significantly associated with pregnancy-related mortality on a bivariable basis. On a multivariable basis, ambulance non-utilisation uniquely persisted as a significant determinant of mortality (mortality rate ratio 1.97, 95% CI 1.05-3.69; P = 0.03). CONCLUSIONS: The uptake of freely available transport in connection with women's obstetric needs correlated with substantially reduced pregnancy-related mortality in this operational assessment, though the design did not allow cause and effect to be attributed. However, the halving of pregnancy-related mortality associated with ambulance uptake in the sampled Districts suggests that the provision of transport to delivery facilities in Africa may be a key innovation for delivering maternal health care, which requires wider consideration.

Avoiding 40% of the premature deaths in each country, 2010-30: review of national mortality trends to help quantify the UN sustainable development goal for health.

BACKGROUND: The UN will formulate ambitious Sustainable Development Goals for 2030, including one for health. Feasible goals with some quantifiable, measurable targets can influence governments. We propose, as a quatitative health target, "Avoid in each country 40% of premature deaths (under-70 deaths that would be seen in the 2030 population at 2010 death rates), and improve health care at all ages". Targeting overall mortality and improved health care ignores no modifiable cause of death, nor any cause of disability that is treatable (or also causes many deaths). 40% fewer premature deaths would be important in all countries, but implies very different priorities in different populations. Reinforcing this target for overall mortality in each country are four global subtargets for 2030: avoid two-thirds of child and maternal deaths; two-thirds of tuberculosis, HIV, and malaria deaths; a third of premature deaths from non-communicable diseases (NCDs); and a third of those from other causes (other communicable diseases, undernutrition, and injuries). These challenging subtargets would halve under-50 deaths, avoid a third of the (mainly NCD) deaths at ages 50-69 years, and so avoid 40% of under-70 deaths. To help assess feasibility, we review mortality rates and trends in the 25 most populous countries, in four country income groupings, and worldwide. METHODS: UN sources yielded overall 1970-2010 mortality trends. WHO sources yielded cause-specific 2000-10 trends, standardised to country-specific 2030 populations; decreases per decade of 42% or 18% would yield 20-year reductions of two-thirds or a third. RESULTS: Throughout the world, except in countries where the effects of HIV or political disturbances predominated, mortality decreased substantially from 1970-2010, particularly in childhood. From 2000-10, under-70 age-standardised mortality rates decreased 19% (with the low-income and lower-middle-income countries having the greatest absolute gains). The proportional decreases per decade (2000-10) were: 34% at ages 0-4 years; 17% at ages 5-49 years; 15% at ages 50-69 years; 30% for communicable, perinatal, maternal, or nutritional causes; 14% for NCDs; and 13% for injuries (accident, suicide, or homicide). INTERPRETATION: Moderate acceleration of the 2000-10 proportional decreases in mortality could be feasible, achieving the targeted 2030 disease-specific reductions of two-thirds or a third. If achieved, these reductions avoid about 10 million of the 20 million deaths at ages 0-49 years that would be seen in 2030 at 2010 death rates, and about 17 million of the 41 million such deaths at ages 0-69 years. Such changes could be achievable by 2030, or soon afterwards, at least in areas free of war, other major effects of political disruption, or a major new epidemic. FUNDING: UK Medical Research Council, Norwegian Agency for Development Cooperation, Centre for Global Health Research, and Bill & Melinda Gates Foundation.

Time series analysis of trends in malaria cases and deaths at hospitals and the effect of antimalarial interventions, 2001-2011, Ethiopia.

BACKGROUND: The Government of Ethiopia and its partners have deployed artemisinin-based combination therapies (ACT) since 2004 and long-lasting insecticidal nets (LLINs) since 2005. Malaria interventions and trends in malaria cases and deaths were assessed at hospitals in malaria transmission areas during 2001-2011. METHODS: Regional LLINs distribution records were used to estimate the proportion of the population-at-risk protected by LLINs. Hospital records were reviewed to estimate ACT availability. Time-series analysis was applied to data from 41 hospitals in malaria risk areas to assess trends of malaria cases and deaths during pre-intervention (2001-2005) and post-interventions (2006-2011) periods. FINDINGS: The proportion of the population-at-risk potentially protected by LLINs increased to 51% in 2011. The proportion of facilities with ACTs in stock exceeded 87% during 2006-2011. Among all ages, confirmed malaria cases in 2011 declined by 66% (95% confidence interval [CI], 44-79%) and SPR by 37% (CI, 20%-51%) compared to the level predicted by pre-intervention trends. In children under 5 years of age, malaria admissions and deaths fell by 81% (CI, 47%-94%) and 73% (CI, 48%-86%) respectively. Optimal breakpoint of the trendlines occurred between January and June 2006, consistent with the timing of malaria interventions. Over the same period, non-malaria cases and deaths either increased or remained unchanged, the number of malaria diagnostic tests performed reflected the decline in malaria cases, and rainfall remained at levels supportive of malaria transmission. CONCLUSIONS: Malaria cases and deaths in Ethiopian hospitals decreased substantially during 2006-2011 in conjunction with scale-up of malaria interventions. The decrease could not be accounted for by changes in hospital visits, malaria diagnostic testing or rainfall. However, given the history of variable malaria transmission in Ethiopia, more data would be required to exclude the possibility that the decrease is due to other factors.