What do we want to know?
The overall objective is to assess the effects of interventions for timely emergency obstetric referral in developing countries. Referral of the pregnant or postpartum woman is the focus of interest. This will have implications on the well-being of the mother, and of the unborn and newborn baby, so maternal and perinatal outcomes are of interest, along with process indicators of service utilisation, timeliness and delays.
Who wants to know and why?
Maternal mortality in developing countries is showing signs of a decline. Despite this good news, it is still unlikely that the millennium development goal target reduction of 75% from 1990 levels to 120 maternal deaths per 100,000 live births in 2015 will be reached. In the period remaining up to 2015, global agencies and country governments will make concerted efforts to scale up and speed up the effective coverage of maternity services. This review assesses evidence on the effectiveness of referral interventions that will inform the implementation of policies and programmes to improve access to maternity care.
What did we find?
Of 19,484 hits, 19 papers met the inclusion criteria. The included studies were randomised controlled trials (RCTs) or quasi-experimental studies in rural settings in Africa, Asia or South America. Interventions were organisational or structural in nature, or contained both characteristics. The studies did not show statistically significant reductions in maternal mortality. Reductions in neonatal death were noted in four RCTs comprising multiple components, including generation of transport funds in community groups. Sub-group analysis revealed no reduction in stillbirths in the complex RCTs but stillbirths decreased in studies of maternity waiting homes. There was some evidence of increased utilisation of health facilities and health professionals. The included studies did not allow assessment of factors explaining the effects of the interventions.
What are the implications?
The effects on health outcomes of referral interventions which improve women’s ability to reach appropriate care during an obstetric emergency are unclear. Conclusions are limited by difficulties in isolating the effects of multiple components and factors related to the design of some studies. We recommend continued inclusion of referral interventions within maternal and newborn health programmes and as part of wider health system improvements, but urge implementers to improve practices in monitoring, research and evaluation of these interventions.
How did we get these results?
Systematic review procedures and techniques were used to generate the results. The 19 papers included described 14 interventions, as five papers investigated the same intervention but provided supplementary information to the original paper.
The EPPI-Centre reference number for this report is 1910. This review should be cited as:
Hussein J, Kanguru L, Astin M, Munjanja S (2011) What kinds of policy and programme interventions contribute to reductions in maternal mortality? The effectiveness of primary level referral systems for emergency maternity care in developing countries. Technical report. London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London. ISBN: 978-1-907345-16-6