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To the editor,
With interest we read the recent paper by Caviglia et al, describing the relation between prehospital ambulance time and outcome in terms of maternal and perinatal outcomes in the setting of Sierra Leone1. Sierra Leone has one of the highest rates of maternal (1360 in 100.000 life births) and infant (87 in 1.000 births) mortality worldwide2. The National Emergency Medical Service (NEMS) was designed and started in this country, an effort by or in collaboration with part of the authors of the current manuscript3. The results show that longer prehospital ambulance times are associated with poor outcome. Furthermore, only in the capital and its surroundings the 2-hour target is met in a high percentage of patients, with only 24-65% of patients meeting this mark in the more rural areas of the country. The authors conclude that there are still major geographical barriers for timely access to care, and that any intervention to strengthen the existing primary health system may help reduce maternal and perinatal mortality.
The elaborate NEMS system, including 81 fully equipped and staffed ambulances with a centralized operations centre, was operational since 2018, with the last districts connected to the service in 2019. The system was managed by the local ministry of health and sanitation (MoHS) and funded through the governmental budget, with help from the World Bank, Doctors with Africa (CUAMM, Padua, Italy), the Regional Government of Veneto (Ita...
The elaborate NEMS system, including 81 fully equipped and staffed ambulances with a centralized operations centre, was operational since 2018, with the last districts connected to the service in 2019. The system was managed by the local ministry of health and sanitation (MoHS) and funded through the governmental budget, with help from the World Bank, Doctors with Africa (CUAMM, Padua, Italy), the Regional Government of Veneto (Italy) and the Research Center in Emergency and Disaster Medicine (CRIMEDIM, Università del Piemonte Orientale, Italy)3. According to the triage classifications, most “red” indications were maternal/perinatal emergencies, making this the most important focus of the service3.
We have seen the contribution of NEMS in our rural 80-bed hospital in Yele, Tonkolili district, with a catchment population of 150.000. The 2 ambulances stationed in our catchment area, together with ambulances sending referrals from elsewhere, presented an average of over 2 patients per 24 hours to our hospital for emergency services. We used NEMS ourselves for referrals to third-line indications upon indication. As a response to this well-functioning service, have scaled down our ambulance services with the number of drivers and vehicles reduced as they were no longer needed. In line with the NEMS-focus, the majority of presentations were maternal/perinatal admissions; we saw frequent advanced stage diseases due to first delays and in some cases second delays in light of the Three Delays framework. Still, despite the impressive pathology, there were many mothers that could receive proper care and return home in stable condition with a healthy newborn.
Fast forward not even 2 years after the connection of the last district, when the NEMS service was released to the MoHS on the first of January 2021. While ambulances frequented the hospital in December 2020, this came to a total stillstand one month later. As of that moment, the number of presentations by NEMS dropped from over 2 patients per day to one patient in the 9 months after. Due to financial troubles, the whole service collapsed. NEMS ambulances are currently gathering dust on the parking lots of governmental hospitals. Inquiry with hospitals in other districts showed a comparable drop in NEMS presentations after release of the service.
The case of NEMS may be a positive and negative example at the same time. The development of a nationwide ambulance service in a low-income country with high maternal and neonatal mortality is to be applauded. During the time NEMS was in service, the authors demonstrate that a respectable percentage of patients can be transferred to a hospital in time despite large distances and poor road conditions. Furthermore, as shorter prehospital times lead to improved outcome, the service was an important part of the health infrastructure of Sierra Leone.
The current situation with a powerless ambulance service is worse than when NEMS came into service. Before, hospitals had their own ambulance services and drivers, and were sometimes able to pick up patients from peripheral health units through intensified communication. Nowadays, hospitals have scaled down on their number of drivers and ambulances due to the presence of NEMS, and NEMS itself is unavailable for transportation of the needy. To us, it is unclear whether mismanagement, a premature program release, actual financial constraints or perhaps even corruption brought the NEMS-program to its current state. As such, the contrary of the research implications came true: due to the unavailability of the service, a lower percentage of mothers is able to reach hospitals, which will inevitably lead to an increase in maternal and neonatal mortality.
In conclusion, the authors demonstrate the NEMS-service has resulted in swift transport of patients to the proper health facilities, thereby reducing the maternal and perinatal mortality. The premature program release to the local government however has resulted in the unavailability of ambulance services, both by NEMS and local hospitals, thereby likely increasing the already worrisome maternal and perinatal mortality. The important lessons are that the development and deployment of an elaborate ambulance service is possible in sub-Saharan African countries, but premature release of such programs to local government that lack sustainable and durable resources to continue programs, may result in a situation that is worse than before the service started.
1 Caviglia M, Putoto G, Conti A, et al. Association between ambulance prehospital time and maternal and perinatal outcomes in Sierra Leone: a countrywide study. BMJ Glob Heal 2021; 6: e007315.
2 Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization; 2015. , 2015.
3 Caviglia M, Dell’aringa M, Putoto G, et al. Improving access to healthcare in sierra leone: The role of the newly developed national emergency medical service. Int J Environ Res Public Health 2021; 18: 1–12.