|12. Referral in Pregnancy and Childbirth: Concepts and Strategies|
The typical referral pattern among users of hospital-based obstetric care - many self referrals and few emergency referrals - has been outlined in the introductory part.
In order to make referral meaningful and improve survival chances for mother and child, the referral hospital has to provide good quality obstetric care. This is often not the case and a considerable proportion of maternal and perinatal mortality has been attributed to substandard referral level care (Fawcus et al . 1996, Urassa et al . 1995, Jahn et al . 2000). Thus, ensuring quality obstetric care at referral level is a precondition for successful referral.
Accessibility and perceived quality of care have been identified as important determinants for the use of hospital-based obstetric care. One option to increase accessibility is to increase service outlets for obstetric care according to population size and distribution. Distances in large rural districts are often too large to be covered by one district hospital. Strategically located existing structures, such as health centres, can be up-graded with limited input. Many Safe Motherhood Programmes include this intervention in their programmes (Inter-agency group for safe motherhood 1997, Chiwuzie et al . 1997, Nwakoby et al . 1997). An additional option is to link health centres and hospital via radio call and send the hospital ambulance in the event of an emergency. However, this intervention needs to be accompanied by measures to ensure financial accessibility. In Burkina Faso, the costs for obstetric emergency transports are covered by the health services through fuel vouchers.
However, utilisation of obstetric care can also be improved with less capital investment through a set of interventions making it more user friendly and receptive to the social and medical needs of potential users (Sabitu et al . 1997). These may include interventions such as preferential treatment for referred patients, 24-hours service, culturally appropriate attitudes, provision of privacy and allowing for an accompanying support person (Kowalewski et al . 2000).
As mentioned earlier, cost is a crucial factor in referral decision making. It is very difficult to make general statements on cost of referral. In any case these are substantial for users and providers alike. In Tanzania on average 2 US$ was spend on transport with a maximum of 12 US$, depending on distance and means of transport (Kowalewski 1996). Hiring a car (if possible at all) is extremely expensive in local terms. The situation in Nepal is similar with average transport costs of 1,5 US$ and a maximum of 11 US$ against a basic salary of 1 US$/day (Dar Iang 1999). In addition to these costs, further costs are incurred for treatment, drugs and food which add up to 96 US$ on average (maximum 230 US$). In 1997 in Mali, the average cost of transportation with an ambulance called by radio was 63 US$ and the additional cost of a caesarean section 84 US$ (De Brouwere 1997). But the cost varies depending on the district; in Kolondieba for instance, the total cost for an emergency referral was 100 US$ including transportation by ambulance, intervention kit and post-intervention care. Cost was covered by public sources (35%-58%), the community-funded association of health centres (21%-35%) and the patient herself (21%-30%) (Maiga et al . 1999)Based on experiences from Uganda, health service capital costs for establishing and maintaining a referral system are estimated to be 22% of overall capital costs or 100.000 US$ per district per year (Weissman et al . 1999).