Abstract
Pregnancy complications can be unpredictable and many women in developing countries cannot access health facilities where life-saving care is available. This study assesses the effects of referral interventions that enable pregnant women to reach health facilities during an emergency, after the decision to seek care is made. Selected bibliographic databases were searched with no date or language restrictions. Randomised controlled trials and quasi experimental study designs with a comparison group were included. Outcomes of interest included maternal and neonatal mortality and other intermediate measures such as service utilisation. Two reviewers independently selected, appraised, and extracted articles using predefined fields. Forest plots, tables, and qualitative summaries of study quality, size, and direction of effect were used for analysis. Nineteen studies were included. In South Asian settings, four studies of organisational interventions in communities that generated funds for transport reduced neonatal deaths, with the largest effect seen in India (odds ratio 0·48 95% CI 0·34-0·68). Three quasi experimental studies from sub-Saharan Africa reported reductions in stillbirths with maternity waiting home interventions, with one statistically significant result (OR 0.56 95% CI 0.32-0.96). Effects of interventions on maternal mortality were unclear. Referral interventions usually improved utilisation of health services but the opposite effect was also documented. The effects of multiple interventions in the studies could not be disentangled. Explanatory mechanisms through which the interventions worked could not be ascertained. Community mobilisation interventions may reduce neonatal mortality but the contribution of referral components cannot be ascertained. The reduction in stillbirth rates resulting from maternity waiting homes needs further study. Referral interventions can have unexpected adverse effects. To inform the implementation of effective referral interventions, improved monitoring and evaluation practices are necessary, along with studies that develop better understanding of how interventions work.
Highlights
The importance of referral in an obstetric emergency is related to the unpredictability of pregnancy complications and their potential to progress rapidly to become severe and life threatening
The reduction in stillbirth rates resulting from maternity waiting homes needs further study
Inclusion and Exclusion Criteria Studies of referral systems for emergency maternity care from published and grey literature were included if they were randomised controlled trials (RCTs) or other quasi experimental study designs—i.e., studies lacking randomisation such as controlled before-after (CBA) studies and interrupted time series (ITS)—provided comparison groups were available
Summary
The importance of referral in an obstetric emergency is related to the unpredictability of pregnancy complications and their potential to progress rapidly to become severe and life threatening. Maternal and neonatal deaths could be prevented if functional referral systems were in place to allow pregnant women to reach appropriate health services when complications occur. Pregnancy complications can be unpredictable and many women in developing countries cannot access health facilities where life-saving care is available. This study assesses the effects of referral interventions that enable pregnant women to reach health facilities during an emergency, after the decision to seek care is made. About 350,000 women die from pregnancy- or childbirth-related complications Almost all of these ‘‘maternal’’ deaths occur in developing countries. It is hard to predict which women will develop pregnancy complications, many complications rapidly become life-threatening and, in developing countries, women often deliver at home, far from emergency obstetric services; obstetrics deals with the care of women and their children during pregnancy, childbirth, and the postnatal period
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