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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.
