|12. Referral in Pregnancy and Childbirth: Concepts and Strategies|
|The Crucial Issues|
Given the diversity of health systems, geographical conditions and infrastructure it is impossible to develop a generally applicable blue print for referral systems. However, we can identify the following crucial issues that need to be addressed early on and that require strategic decisions:
The importance of access to obstetric emergency care is undisputed (WHO 1996). However, there is also evidence to justify elective referral for maternal and perinatal reasons, as outlined earlier (Villar & Bergsjo 1997). This is also acknowledged by the Safe Motherhood Initiative by stating that a minimum of 15% of all pregnant women should deliver in obstetric referral level facilities (Inter-agency group for safe motherhood 1997). Most of these will not be emergencies. In addition there is often no clear line between emergency and elective referral, as in the case of mild antepartum haemorrhage. It may be sensible to start with a focus on emergency referral. Yet, there is a need to also improve and rationalise referral for all pregnancy-related conditions. This could be done, for instance, through locally adapted and operational referral guidelines and related tools such as referral forms and feedback reports, transport arrangements and special admission routines in the referral centre.
There is a general lack of emergency care, which contributes considerably to the high adult mortality in Africa (Nordberg 1984, Adult Morbidity and Mortality Project [AMMP] 1997). As shown earlier, many Safe Motherhood Projects restrict the eligibility to use their emergency referral arrangements to obstetric complications and exclude other medical or surgical emergencies. None of the reported case studies cited earlier comments on conflicts arising form this rule, although they are likely to occur. From a district health perspective, a restrictive approach has several shortcomings: There are maternal emergencies, which are often not recognised as such; e.g. ectopic pregnancy with an estimated prevalence of 1/100 pregnancies (Amoko & Buga 1995). Given the transport problems in most rural African communities, it may simply be unethical to deny assistance in case of any life-threatening condition. Maintaining a system for emergency care (e.g. ambulance, radio call) needs constant attention and inputs, even if it is idle. The rarity of referrals in most of the studies (1-2 per month) indicates that the emergency referral arrangements are often under-utilised. Our own experience in a series of village meetings on Safe Motherhood in Southern Tanzania suggests that access to emergency care has a very high priority at the community level but comprises all sorts of emergencies.
There are also projects that have focused on emergency referrals in general. Macintyre & Hotchkiss (Macintyre & Hotchkiss 1999) report on an 8 years experience with a health insurance scheme, covering emergency referral. The most frequent causes for referral were trauma, pregnancy-related, complicated malaria, and severe diarrhoea. Therefore we suggest, expanding Safe Motherhood emergency referral initiatives to other areas of emergency care.
Referral by health workers is often handled in a rather directive way. Instead, there should be a mutual understanding about the need for, and purpose of the referral between health worker and patient (Paine & Siem Tjam 1988). The mother baby package (WHO 1996) suggests the antenatal care should be used to help women and their families to develop an appropriate delivery plan (including place of delivery), based on the women's history and health status. The Safe Motherhood Initiative emphasises that women's choices should be respected and ensured (Inter-agency group for safe motherhood 1997). This adds another dimension to the discussion on antenatal risk assessment and referral, because it implies involving the mother in defining the need for referral and shifts the focus from predictive power of risk factors to the risk as perceived by the individual mother. There is a wide gap between these approaches as evidenced by the high rates of self-referral and the low compliance with referral advice given by health workers. Thus a mother with her first uncomplicated pregnancy may prefer to deliver in hospital for safety reasons (and many do so) while a mother with her tenth pregnancy may prefer to deliver at home, because she feels better cared for in her domestic environment. Taking informed decision making seriously would imply to move from rigid application of referral criteria to individual counselling based on professional needs assessment and women's preferences.