# Prehospital emergency response and management of pregnancy-associated haemorrhage in KwaZulu-Natal Province, South Africa: A Retrospective Cross-Sectional Study

## TL;DR

This study examines delays and management gaps in emergency care for pregnancy-related bleeding in South Africa, highlighting the need for better training and resources to reduce maternal deaths.

## Contribution

The study provides new insights into EMS response times and clinical practices for postpartum haemorrhage in a South African setting.

## Key findings

- Over half of PAH cases had ambulance response times exceeding 60 minutes.
- Only 42.6% of PPH patients had consistent vital signs monitoring during transport.
- 44.3% of PPH cases received no intravenous fluids despite signs of shock.

## Abstract

Pregnancy-associated haemorrhage (PAH) is a leading contributor to maternal mortality in KwaZulu-Natal (KZN) and the fourth most common cause in South Africa. Delays in treating PAH increase maternal mortality; prompt prehospital response is therefore critical to improve outcomes. The aim of this study was to analyse response times and clinical management of PAH by public sector Emergency Care Providers in KZN, looking specifically at postpartum haemorrhage (PPH).

A retrospective cross-sectional study was conducted in two phases. Phase 1 involved analysis of emergency call centre records (n = 4779) assessing response time patterns. Phase 2 analysed randomly selected PPH cases (n = 61) to assess clinical management practices. Descriptive statistics summarised demographics, response patterns, and clinical practice, Pearson correlation examined the relationships between time variables, and chi-square tests assessed associations between clinical variables (p < 0.05).

More than half (51.5 %) of PAH cases had ambulance response times >60 min. Median pre-response time was 30 min; overall response time was 63.5 min but both were positively skewed by extreme delays, with higher trimmed means(50.9 min and 85.7 min respectively). Most cases (81.6 %, n = 3899) were transported from primary healthcare facilities to hospitals, with Intermediate Life Support Providers managing 75.7 % of the cases. In the sampled PPH patients, compliance with vital signs monitoring was initially high (91.8 %) but declined in transit (42.6 %). Providers were largely non-compliant in documenting blood loss and patient history. Despite almost all patients showing clinical signs of shock 44.3 % of PPH cases received no intravenous fluids.

Significant time delays in EMS response and inconsistencies in PAH clinical management by EMS providers were identified. Improved resource allocation, focused training and adherence to clinical and departmental guidelines are vital to strengthening maternal emergency care in KZN.

•Obstetric haemorrhage, particularly post-partum haemorrhage, remains a leading direct cause of maternal mortality in sub-Saharan Africa where access to emergency care is limited due to lack of transport, poor infrastructure and rurality.•There is limited research regarding EMS response and clinical management of obstetric emergencies in an African setting despite a lack of transport being a key contributor to maternal mortality.•Findings of the current study highlight gaps in response times and the immediate clinical management that can be mitigated through training, policies and strategic allocation of resources (ambulances).•Lessons learnt from this study can also inform efforts to improve maternal outcomes in other resource-limited African EMS systems.

Obstetric haemorrhage, particularly post-partum haemorrhage, remains a leading direct cause of maternal mortality in sub-Saharan Africa where access to emergency care is limited due to lack of transport, poor infrastructure and rurality.

There is limited research regarding EMS response and clinical management of obstetric emergencies in an African setting despite a lack of transport being a key contributor to maternal mortality.

Findings of the current study highlight gaps in response times and the immediate clinical management that can be mitigated through training, policies and strategic allocation of resources (ambulances).

Lessons learnt from this study can also inform efforts to improve maternal outcomes in other resource-limited African EMS systems.