"Referral has been called an orphan cause," said Patricia Bailey, public health specialist for Family Health International and Columbia University, because it is "everybody's responsibility and therefore nobody's responsibility."

As part of the Maternal Health Dialogue Series the Woodrow Wilson International Center for Scholars' Global Health Initiative convened a small technical meeting on May 19, 2010, with 25 experts from five countries to discuss their experiences and share lessons, challenges, and recommendations for improving transportation and referral for maternal health. Following the technical meeting, a public dialogue was held on May 20, 2010, to share the knowledge gaps and recommendations identified. The formal report from the technical meeting will be available in the near future.

Mobilizing District Communities in Rural Ghana

To improve maternal health care in Ghana, "we needed to shift [services] to the community level, where 70 percent of our population lives," said Dr. John Koku Awoonor-Williams, the east regional director of Ghana Health Service. The "Community-based Health Planning and Services" (CHPS) program was created to galvanize local leadership and empower communities to engage in health outreach activities.

Through this approach, "community health officers and nurses are trained and delegated to distant village locations called CH[I]P zones, in which they are responsible for health education, treatment of minor illnesses, maternal and antenatal care, and referral to district hospitals for emergency care," said Awoonor-Williams. Community health officers use two-way Motorola walkie-talkies to communicate with traditional birth attendants and referral centers. Pregnant women are given the phone numbers so they can call in the event of complications.

"Mobilization of the community is essential," said Awoonor-Williams. Maternal health education and dialogue with local community members build consensus and support for improving transportation and referral systems. For example, in Ghana's Alokpatsa district, community members collectively pooled their resources to purchase a tractor that serves as both an emergency ambulance and farming equipment. Revenue generated from farming covers the cost of fuel for emergency transportation. While this system has improved access to emergency obstetric care, "maintenance and fuel costs for transportation vehicles, including tractor ambulances, tricycles, and other transport vehicles, is a major challenge," said Awoonor-Williams.

1-0-8 Emergency Number for Improving Maternal Health in India

Many parts of the developing world do not have a 911-style emergency response service. To address this gap, the GVK Emergency Management & Research Institute in India developed the toll-free 1-0-8 telephone number for all medical, police, and fire emergencies.

"We assure every citizen that wherever you are, [if] you call us we will be there," said Subodh Satyawadi of GVK. In order to reach the 433 million people covered by GVK, they have:

• 19,623 EMTs and 10,000 doctors and other healthcare professionals
• 2,710 ambulances
• 16,300 call-center employees

"Although we address all kinds of emergencies, we heavily focus on maternal health…31 percent of emergencies are pregnancy-related," said Satyawadi, who said that GVK's emergency response system has helped save more than 200,000 mothers. Institutional deliveries have increased in the state of Gujarat by 92 percent. "We have been able to reduce maternal mortality by 20-25 percent in different geographies," he said.

"Presence of this service has built people's trust in the overall health system, because we respond quickly, we provide affectionate care, and provide pre-hospital care," said Satyawadi. Currently GVK provides emergency services to 10 states; however, their goal is to scale up this delivery model throughout India.

Pre-Hospital Barriers: Reducing Maternal Morbidity in Bolivia

Women in Bolivia receive free maternal care. In cities like La Paz, emergency obstetric care is often available within a short distance. However, "37 percent of our maternal deaths [occur] at our hospitals," said Víctor Conde Altamirano, OB/GYN of CARE Bolivia.

To better understand this mortality rate, Altamirano evaluated whether pre-hospital barriers and routine antenatal care are associated with near-miss morbidity. He found that women who are older, have lower levels of education, lack antenatal care, are pregnant for the first time, or live in rural areas are at a greatest risk of illness or death. His results helped to identify and target interventions such as the "Integrated Model in Maternal and Neonatal Health" approach, which comprises three key players:

1. Community members
2. Health facilities and health care workers
3. Municipal leaders

"We are trying to organize our communities and service facilities, and promote improved health management by the municipalities. If our authorities can be sensitive and invest in health; invest in fuel, drugs, and human resources; we can improve near-miss morbidity rates," said Altamirano. As in Ghana, dialogue and communication with community members is imperative to promoting behavior change and improving antenatal care.

Strategies and Recommendations for Improving Transportation & Referral

The workshop participants agreed on six key topic areas for improving transportation and referral:

1. Multi-sectoral collaboration
2. Mobile phone technology
3. Public-private partnerships
4. Referral for newborns
5. Indicators for referral
6. Sharing evidence

The examples from Ghana, India, and Bolivia demonstrate the complexity of referral systems and the need for increased funding for human resources, vehicle maintenance, supervision, and accountability.

"We need to keep in mind that what is at stake for each sector can vary…roads are more likely to be built to promote business and economic growth than to service a health care facility," said Bailey. The group called for improved multi-sectoral engagement and continuous dialogue among key ministries: Health, Finance, Communication, Social Welfare, Security and Defense, Transportation, and Public Works.

Private-public partnerships, such as those demonstrated by GVK in India and the CH[I]P program in Ghana, create opportunities for collaboration. "Cell-phone technology can reduce delays in transport and treatment by identifying which facilities might be the most appropriate for referral," said Bailey. Additionally, contracts with commercial vehicles and taxi unions have been executed in some developing nations.

Monitoring and evaluation of transportation and referral systems are weak and basic standards and indicators are needed. "Developing standards will be a challenge, given how complex referral systems are, but indicators should be based on those standards," said Bailey.

The final recommendation by the group calls for increased pooling and use of existing evidence to move the transportation and referral agenda forward. Updated synthesis papers on existing evidence are needed, said Bailey. "We have a lot of data that is perhaps less than perfect, but this should not be a barrier for further action," she said.

Drafted by Calyn Ostrowski.