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Reducing early infant mortality in India: results of a prospective cohort of pregnant women using emergency medical services
  1. Corey B Bills1,
  2. Jennifer A Newberry2,
  3. Gary Darmstadt3,
  4. Elizabeth A Pirrotta2,
  5. G V Ramana Rao4,
  6. S V Mahadevan2,
  7. Matthew C Strehlow2
  1. 1 Department of Emergency Medicine, University of California, San Francisco, California, USA
  2. 2 Department of Emergency Medicine, Stanford University, Stanford, California, USA
  3. 3 Department of Pediatrics, Stanford University, Stanford, California, USA
  4. 4 GVK Emergency Management and Research Institute, Secunderabad, Telangana, India
  1. Correspondence to Dr. Corey B Bills; corey.bills{at}


Objectives To describe the demographic characteristics and clinical outcomes of neonates born within 7 days of public ambulance transport to hospitals across five states in India.

Design Prospective observational study.

Setting Five Indian states using a centralised emergency medical services (EMS) agency that transported 3.1 million pregnant women in 2014.

Participants Over 6 weeks in 2014, this study followed a convenience sample of 1431 neonates born to women using a public-private ambulance service for a ‘pregnancy-related’ problem. Initial calls were deemed ‘pregnancy related’ if categorised by EMS dispatchers as ‘pregnancy’, ‘childbirth’, ‘miscarriage’ or ‘labour pains’. Interfacility transfers, patients absent on ambulance arrival, refusal of care and neonates born to women beyond 7 days of using the service were excluded.

Main outcome measures: death at 2, 7 and 42 days after delivery.

Results Among 1684 women, 1411 gave birth to 1431 newborns within 7 days of initial ambulance transport. Median maternal age at delivery was 23 years (IQR 21–25). Most mothers were from rural/tribal areas (92.5%) and lower social (79.9%) and economic status (69.9%). Follow-up rates at 2, 7 and 42 days were 99.8%, 99.3% and 94.1%, respectively. Cumulative mortality rates at 2, 7 and 42 days follow-up were 43, 53 and 62 per 1000 births, respectively. The perinatal mortality rate (PMR) was 53 per 1000. Preterm birth (OR 2.89, 95% CI 1.67 to 5.00), twin deliveries (OR 2.80, 95% CI 1.10 to 7.15) and caesarean section (OR 2.21, 95% CI 1.15 to 4.23) were the strongest predictors of mortality.

Conclusions The perinatal mortality rate associated with this cohort of patients with high-acuity conditions of pregnancy was nearly two times the most recent rate for India as a whole (28 per 1000 births). EMS data have the potential to provide more robust estimates of PMR, reduce inequities in timely access to healthcare and increase facility-based care through service of marginalised populations.

  • Maternal Medicine
  • India
  • Emergency Medical Services (ems)
  • Neonatal Mortality

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  • Contributors MCS, EAP, GVRR and SVM contributed to the study design, implementation, data analysis and manuscript production. CBB and JAN contributed to data analysis and manuscript production. GD contributed to manuscript production. CBB, MCS and SVM accept full responsibility for the work and conduct of the study, had access to the data and controlled the decision to publish.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval The study was approved by the Institutional Review Board at Stanford University (IRB#18185) and the Ethics and Research Committee at GVK EMRI.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Extra data can be accessed via the Dryad data repository at with the doi:10.5061/dryad.38n0n.

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