Introduction

Linking the different levels of care was an essential element of primary health care (PHC) from the very beginning. The referral system was meant to complement the PHC principle of treating patients as close to their homes as possible at the lowest level of care with the needed expertise (King 1966). As emphasised by the (WHO 1994), this back-up function of referral is of particular importance in pregnancy and childbirth, as a range of potentially life-threatening complications require management and skills that are only available at higher levels of care. The following levels of care have been identified: (1) family/community, (2) health centre and (3) district hospital (WHO 1996).

The first referral level is defined as district or sub-district hospital, to which a woman at high risk is referred prenatally or sent for emergency obstetric care, and where the following essential services should be available: (1) surgical obstetrics, (2) anaesthesia, (3) medical treatment, (4) blood replacement, (5) manual procedures and monitoring labour, (6) management of women at high risk, (7) family planning support and (8) neonatal special care (WHO 1991). Most countries have different types of first line facilities (e.g. dispensary, health post, basic health unit) or intermediate levels of care; however, in practical terms these provide usually similar levels of maternity care and are not qualified to manage obstetric complications adequately. Therefore, for our discussion we will use the 3-level model as outlined in Figure, whereby the category health centre comprises all first line health facilities. The paper will start with an outline of current referral patterns, then introduce a model of the referral chain (sender - transport - receiver) and discuss potential strategies and interventions along this pathway. This will be followed by a note on conceptual issues. Finally a strategy for improving obstetric referral will be outlined and put in the context of district health services in general.