Referral Systems
Referral systems for emergency obstetric and newborn care
To improve referral systems for women and newborns we must ask important questions about a woman’s experience in the system:
- Can someone in the community or a low-level health facility stabilize her before they move her or her newborn to a higher level of care?
- Are ambulances maintained and available at the ready? Are there drivers and petrol available for transport?
- Is there an IV drip or oxygen available for her while she’s riding to the next facility?
- Will her medical records go with her to the next facility, or at least documentation of what was done?
- What can communities do to facilitate referral? Do they have emergency and financial plans that help her and her family? Is there someone in the family who can donate blood?
A woman has just delivered her baby and is beginning to hemorrhage. She may have less than two hours before she dies from this treatable obstetric complication. This should be enough time to reach the emergency obstetric care (EmOC) she needs. But if she lives in the developing world – where 99% of maternal deaths occur – simply getting to a health facility able to treat her could be a considerable struggle.
Many women in developing countries give birth at home or at local health facilities that are not staffed or equipped to treat many complications. If complications arise during pregnancy or delivery, their lives depend upon getting to a health facility equipped to provide EmOC.
It is the task of the health system’s referral system to quickly and easily get these women to emergency treatment.
In developing countries the referral system for emergencies is often weak. Sometimes facilities have no vehicle or way to call for a vehicle; at other times there may be no petrol or driver available. Once en route, women may face hours of travel over nearly impassible roads. Any breakdown along the path from home to health facility, or between health facilities, can prevent women and newborns from accessing emergency care.
Making change: Researching solutions to the breakdown in referral systems
Referral in Malawi
“The problem is the transportation, the referral system. 97% of our patients are coming for antenatal care, but when it comes to the time of delivery, [transportation] is the problem. Unfortunately delivery does not wait for daybreak. Most labors that start after sunset arrive at the facilities very late because of the distances they have to cover and the transportation they have to get. So what we have done at the moment is place motorbike ambulances at our health facilities. If one health facility can’t help them, then the motorbike will take them to one that can.”
- Dr. Chisale Mhango,
Head of Health and Reproductive Unit, Ministry of Health, Malawi
Lifetime risk of dying during pregnancy and delivery in Malawi is 1 in 36.
AMDD believes that strengthening the referral system – from the moment obstetric complications begin until the moment definitive care is provided – is absolutely essential to reducing maternal and newborn mortality.
We are currently researching referral systems in developing countries to help ministries of health make informed decisions about effective mechanisms for referral. Research includes identifying gaps in the management of referral systems, training for drivers, the use of clinical protocols, a onitoring system for referral, and the availability of communication and transportation. All of these affect the condition in which women and newborns arrive at facilities that deliver quality emergency care.
Since 1999, AMDD has helped countries with high maternal mortality collect information on referral systems through needs assessments of emergency obstetric and newborn care. With those data, ministries of health can analyze referral readiness, determine where emergency transport vehicles should be prioritized, identify low-functioning hospitals and strategic health centers that should be upgraded to deliver more life-saving care.
AMDD continues to broaden expertise in emergency care delivery by actively examining the systemic challenges of the referral process. AMDD is currently studying the design, implementation, and impact of emergency referral systems in Ghana and Tanzania.
Filling the gap: Why AMDD is focusing on referral systems
The critical role that the referral system plays is recognized by virtually everyone who advocates for good maternity care programs. Yet,surprisingly little attention is given to this complex but often poorly functioning part of the health system. The evidence on how to design, implement, and sustain emergency referral systems in developing countries is scattered,and few good evaluations exist detailing the impact of interventions to improve referral systems.
AMDD is working to bring attention to the critical role referral plays in reducing maternal and newborn death and is currently helping to research, identify, and implement appropriate referral strategies in general and on the ground in Bangladesh, Ethiopia, Ghana, and Tanzania.
Where we’re working in referral systems
- Bangladesh
- Ethiopia
- Ghana
- Tanzania
All part of a larger health system
Women and newborns often need to access emergency care through a reliable and efficient referral process. But there are many other pieces of the health system that must work together to ensure access to life-saving emergency care for all women and newborns.
Learn about our work in