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close this book12. Referral in Pregnancy and Childbirth: Concepts and Strategies
View the document(introduction...)
View the documentSummary
View the documentIntroduction
View the documentReferral and Its Function in District Health Systems
View the documentReferral situation and interventions at community level
View the documentReferral Situation and Interventions on the Level of First Line Health Services
View the documentReferral Situation and Interventions on First Referral Level
Open this folder and view contentsThe Crucial Issues
View the documentSteps in Improving the Referral System
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Summary

The referral system is an essential component of district health systems. It is particularly important in pregnancy care and childbirth for providing access to emergency obstetric care and for backing up antenatal and delivery care in first line facilities. However, referral patterns, as reported from referral hospitals in developing countries, show that the actual use of a referral system for obstetric care is inversely related to professional needs assessment. Usually, self-referrals constitute more than 50%, institutional referral around 30% and emergency referral less than 5% of women at referral level. Known determinants of the use of obstetric care at referral include distance, cost, perceived quality of obstetric care, health workers attitude and respect for women's social needs, perceived etiology of complications and socio-cultural preferences. Interventions to improve access and use of the referral system target different elements of the referral chain. Priority should be given to the quality of obstetric care at referral level and this needs to be monitored and improved. Then, local solutions should be sought in participation with the community to secure transport whenever an evacuation is required. Finally, health staff should dialogue with the community in order to raise awareness of complications and danger signs at family level. The long-term objective should be to establish an operational referral system for emergencies and elective referrals as part of the district health system. The referral system should not be restricted to pregnancy-related complications. However, obstetric referral provides a good starting point for improvement, because maternal emergencies comprise a considerable part of overall emergencies, because most maternal deaths can be prevented by timely intervention, and because this is commonly a felt need in the community.