Emergency obstetric referral and transport in low- and middle-income countries: the direction of travel

In low- and middle-income countries, adequate plans to seek care in case of an emergency are important especially if women live far away from where lifesaving care is available. Decisions to seek care can be deferred or hindered. Even if decisions are rapidly made to seek care, transport may be unavailable or slow.

Mechanisms to improve referral and transportation of mothers and babies are crucial to reduce maternal and newborn mortality, as they enable women to reach care when complications unexpectedly occur. Various forms of transport for obstetric emergencies have been put forward, from stretchers carried by volunteers to bicycles, boats, motorcycles and other forms of motorised vehicles. The type of vehicle will obviously affect the time for transportation, with geography, terrain and affordability influencing the choice.

The issue of transportation is however more complex than simply identifying the most appropriate vehicle. It has been two years since we published our systematic review, which assesses the effects of emergency obstetric referral interventions. What have we learnt since the publication of our review?

Our study called for research to understand how referral and transport interventions work. I am pleased to say that we have since come some way towards understanding some of these mechanisms. Wilson and colleagues in a systematic review have elicited key factors that affect the use and uptake of transport in obstetric emergencies, including the level of family and community support, culture and ergonomics. Of particular interest is the way the authors have distinguished between support and autonomy in relation to decision-making. Ergonomics and position of the woman being transported is another under-investigated factor revealed in the paper.

Financing the costs of transportation has been known for some time to be an important factor affecting transport. Getting community members to generate funds to support the costs of health care is not a new idea. Communities have organised the collection of funds to meet costs associated with transport and emergency obstetric care. In another systematic review, Nwolise and colleagues found that where community-based loan funds were used along with other interventions, the utilization of health facilities for childbirth increased, with indications of a potentially positive effect on women’s access to care for complications.

An international panel supported by the World Health Organization recently identified research on transport and referral solutions as a priority area to improve maternal and newborn health in low-resource settings. It is good to see that the increasing interest in such research seems to be mirrored by scaled-up implementation of programmes in several areas around the world. In India, a national ambulance service and the ‘dial 102’ system, specifically geared for obstetric care, was launched. The success of this system in India is of special interest as it has been initiated as a public-private partnership. Burundi has initiated a systemised initiative that links peripheral maternity units using an ambulance referral system. Lastly, the eRanger group should also be lauded for their sustained work in developing their motorbike ambulances engineered for use on poor roads in resource-poor situations in many parts of sub-Saharan Africa.

There is no dispute that various forms of transportation are required so that rapid transfer of women can be made in the event of an emergency. No single method will fit all situations, so we should continue developing a range of options that are feasible, acceptable, effective and matched to local needs. Apart from directly focusing on transport, broader solutions need to be explored and understood. Too little is known for example, about how obstetric first aid can be used effectively at the community level before transportation, or how maternity waiting homes can replace long travel times and be made acceptable and effective. These are unique and promising referral interventions that may provide a better map to show how to choose our ‘direction of travel’ for the safety of pregnant women in the future.

By Dr Julia Hussein, Scientific Director, Immpact, University of Aberdeen

This post is part of the Translating Research into Practice Series, which features guest posts from authors of the MHTF-PLoS open-access collections describing the impact of their research since publication. It was originally posted on the Maternal Health Task Force blog page on 30 December 2014. It is re-posted here with permission. 

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