Steps in Improving the Referral System

Referral can only be justified if the referral facility provides a reasonable level quality of care. Therefore, as a first step, the quality of obstetric care at referral level needs to be ascertained, monitored and improved. The next steps would include raising awareness of complications and danger signs at the community level and assessing locally available resources for emergency transport and communication. These include private cars, buses, lorries and all potential means of communication (e.g. radio call of police station). In a process involving the community and local health workers, feasible and sustainable options for referral can be identified as described earlier. Examples from literature (Essien et al . 1997) include arrangements with local owners of transport, provision of means of transport and emergency loan schemes. Then institutional referral policies and guidelines need to be reviewed and rationalised. The long-term objective should be to establish an operational referral system for emergencies and elective referrals as part of the district health system. This should not be restricted to pregnancy-related complications. However, obstetric referral provides a good starting point because maternal emergencies are most often a felt need, because they comprise a considerable part of overall emergencies, because most maternal deaths can be prevented by timely intervention and because unmet obstetric needs can be better quantified and monitored than other life-threatening emergency conditions (De Brouwere et al . 1996)