Timely referral saves the lives of mothers and newborns: Midwifery led continuum of care in marginalized teagarden communities – A qualitative case study in Bangladesh

Introduction

Globally 830 maternal deaths occur every day, 99% of which occur in developing countries^1,2. According to the World Health Organization, roughly 303,000 maternal deaths are caused as a result of pregnancy and childbirth related complications^3,4. Globally, about 3.7 million neonatal deaths occurred within the first 28 days, with 75% in the first week of life⁵. Only 19 out of 186 countries have achieved the Millennium Development Goal-5, related to reduction in maternal mortality⁶; unfortunately, Bangladesh is not one of them. Estimations suggest that about 87% of maternal deaths occurred in South Asian and Sub-Saharan African regions⁷. According to the Demographic and Health Survey, neonatal mortality rates range from 28 to 54 per 1000 live births in Bangladesh, India and Pakistan⁸. In 2010 the Bangladesh Maternal Mortality and Health Care Survey (BMMS) claimed that the lifetime risk of maternal death is 1 in 500 due to pregnancy and delivery related complication, and two third of these deaths occurred in the postpartum period. A study in Bangladesh found that 38% of the maternal deaths occurred by haemorrhage, which is the most common cause, 20% occurred by eclampsia, and 8.1% occurred by sepsis⁹. Another study in the teagarden area of Bangladesh revealed that maternal death in teagarden areas is higher due to lack of knowledge on maternal complication. Ignorance, traditional myths, family restriction on seeking better care, and dependency on traditional birth attendants and village doctors also influence these maternal deaths in teagarden communities¹⁰.

Referral is the process of coordinated movement of health care seeker to reach a high-level care within a small window of time¹¹. The goal of timely referral is to minimize or prevent the delay for transportation (called second delay), and ensure pre-hospital care while transporting a patient to the referral facility^12,13. In 2014, Directorate General of Health Services (DGHS) reported that out of 120 maternal deaths 47 deaths occurred in the teagarden area of Moulvibazar district of Bangladesh. Estimations suggest that about 46.4% of maternal deaths occurred at home, and 7.1% while the women were on route towards a facility; this indicated the delay occurred as a result of delay in decision making of which facility to take the mothers for management, and arranging transport to go to the facility ¹⁴. Another study stated that 22.2% of maternal deaths occurred with more than 6 hours delay in decision-making and 12.9% of deaths occurred with 1–2 hours transportation delay⁹. In light of this, it can be assumed that ensuring emergency obstetric care services, and quick referral during the perinatal period can help reduce maternal deaths. To safeguard the reproductive age (15–49 years) of a woman, continuous care from family and community, along with support in getting easy access to referral healthcare facilities, is needed¹⁵. Transportation support, timeliness of referral, and inter-facility transfer are major contributing factors found to reduce the rate of maternal deaths^12,16. A social autopsy study of maternal deaths found that very few mothers sought facility based care during complications, and that ensuring timely referral through transportation saved the lives of many of them¹⁴. It is recommended that five Emergency Obstetric and Newborn Care (EmONC) services, including four basic EmONC (BEmONC) and one Comprehensive EmONC (CEmONC), should be available and geographically distributed for each 500,000 individuals of a population¹⁷. The component of care (consisting of antenatal care, identification of high risk mothers, safe delivery conduction by skilled birth attendant, timely referral of complicated mothers and postnatal care including essential newborn care.) with high quality services can be ensured by the good referral system at all levels, both in facilities as well as in communities by the trained health care providers⁹. A shifting process is developed after the identification of high-risk pregnancies from a risk based approach to provide skilled care during delivery, and emergency obstetric care when complications occur^18,19. This approach is not adequate to reduce maternal and neonatal mortality as the capacity is limited at the primary level of care, and is difficult to access in the referral facilities remaining in most of the low-income countries²⁰. Professionally, a referral transport system must be managed for providing some basic intervention to the patient before reaching the referral facility²¹.

An intervention named “Bagan Mayer Jonno” has been implemented in the selected teagardens in the Moulvibazar district. The project ran through counseling and courtyard meetings of pregnant mothers, as well as an advocacy meeting with their guardians regarding quick referral of complicated mother. This project also supported the communities in detecting high-risk mothers by the active participation of volunteer and professional midwives. It also managed the provision of transportation and assistance of volunteers to ensure a quick and safe referral procedure. The present qualitative study describes the referral system using the midwifery led service delivery in five selected teagardens of Moulvibazar district in Bangladesh.

Methods

Qualitative method was used to collect information in this study. The referral records of 2016 in selected five teagardens were reviewed retrospectively and qualitative information of selected 15 referral cases were collected though in-depth interviews at the community.

Results

From the review of records from 2016, Bagan Sebika identified the complicated mothers and immediately informed the project midwife. Then the project midwife decided whether the case needed to be referred. The project midwife also identified mothers as high risk during their routine ANC for referral. A total number of 72 complicated pregnancies (16%) were identified from a total of 450 pregnant mothers. These complicated mothers were identified at different stages during their antenatal visit, or during delivery, or immediately after delivery. Mothers informed the Bagan Sebika if any complication arose. Bagan Sebika also identified complicated mothers during their regular household visit. Then Bagan Sebika immediately informed to the project midwife. Professional midwives ensured immediate referral to the higher center after consultation, and coordinated with garden midwives, doctors and Bagan authorities. Unregistered workers in all cases directly referred to the Upazila or District facility, whereas registered workers were taken immediately to the garden’s existing referral system. In about 85% of cases, the transportation support was provided for referral of the complicated mothers, and of them in 75% of cases the Bagan Sebika (Volunteer) participated during referral of the mothers [Figure 1].

Figure 1. Referral process from the selected five teagardens to the higher referral centre.

Place and time of referral

With project support, about 60% mothers were referred to Upazila Health Complex and 28% referred to Sadar district hospital. Only 13% of registered mothers or dependent workers of the teagardens were referred to teagarden referral center [Figure 2]. The time range at which most of the mothers (about 42%) were referred was between 10 a.m. to 2 p.m., where usually doctors, nurses and midwives are available in the government facilities. The remaining referrals occurred at times when only nurses and midwives are available in the facilities. But about 28% and 30% of mothers were referred within the period of 6 a.m. to before 10 a.m., and after 2 p.m. to 8:30 p.m. which is the vital period when doctors or service providers may not be found at government facilities [Table 3].

Figure 2. Place of referral of complicated women.

Cause of referral

Most frequent causes for referral were due to prolonged labour (31%) and after that pre-eclampsia (about 18%). Moreover, another cause of referral found were retained placenta with post-partum haemorrhage, premature rupture of membrane, severe anaemia, breech presentation, twin pregnancy and others (~11%, ~9%, ~7%, ~7%, ~4% and ~13% respectively) [Figure 3].

Figure 3. Distribution of referred mothers by cause of referral.

Delay to start treatment at referral center after complication arises

The delay includes first (decision), second (transportation) and third (treatment) delays, which started from the complication arising, up to receiving treatment. In about 46% of cases family members needed more than 4 hours to make a decision as whether to seek care at a facility or not. Whereas about 60% cases reached from teagarden dispensary to the referral center (UHC) within one hour, and 74% cases women received treatment within one hour after arriving at the facility. Midwifery counseling as well as transportation support from the project influenced much in reducing the community delays mainly first and second delay [Figure 4].

Figure 4. Analysis of the three delays reported for referral of complicated mothers.

(A) First (decision) delay- delay indecision to seek care. (B) Second (transportation) delay- delay in reaching to the facility, Third (treatment) delay- delay in receiving treatment.

Discussions

The study revealed that among the referred mothers around 51% were unregistered workers who referred with the support of the project Bagan Mayer Jonno as they were not entitled to get any referral support from teagarden authorities. About 76% of mothers were referred during the period of delivery and 31% referred with the complication of prolonged labour. Most of the mothers (about 60%) were referred to the Upazila Health Complex and after referral about 14% mothers delivered by Caesarian-section at the facilities. A study conducted in rural Tanzania showed that about 28% of pregnant women were referred from primary level of care to tertiary level to ensure their better pregnancy outcome.

The same study also concluded that the most common referral complications found were multiparity (35%), young age of mother (30%), obstetric complications mostly due to prior history of caesarean section (12%), and previous existed prenatal risks like high blood pressure, severe anaemia etc. (12%)²⁰. On the other hand, our study found that 31% of mothers referred with prolonged labour, 18% with pre-eclampsia, 11% with post-partum haemorrhage (PPH) due to retained placenta, 9% with premature rupture of membrane (PROM), 18% with severe anaemia, breech presentation & twin pregnancy, and remaining 13% with other complications.

Proper transportation with cost support along with a good communication technology is the prime concerns in establishing an effective referral¹⁷. Our study is also consistent with the findings that almost all referral occurs with transportation support, along with extra assistance from a midwife or volunteer, ensure the lives of many vulnerable mothers. The counseling of the midwife about the severe condition of the mother, as well as its dreadful consequences, and assistance of volunteers during referral motivated the family to quickly make their decision on referral.

Our study showed that about 50% of referred mothers received treatment within 6 hours of referral and 10.6% within 2 hours. Addressing of second delay, or transportation delay, has a significant role in reducing maternal mortalities. Many studies showed that referral transportation should be available within 30 minutes of worsening condition of a mother, so that the complicated mother can be taken to a referral center as early as possible to initiate her treatment²⁴. A mechanism needs to be established for the proper utilization of easily accessible functional transport services, which could be either from government, or from a private referral transport services^24,25. Our study found that availability of transport support and assistance of volunteers from that teagarden enhanced quick referral, which consequently reduced the first and second delay.

This study found that quality ANC support by a midwife from respective gardens not only helped to identify high-risk mothers, but also further assisted the family to make a decision and prepare to delivery at a facility. Projections show that the Government of Bangladesh (GoB) already started midwifery education in all nursing institutes from 2012 and the GoB have the mandate to continue this midwifery led service delivery system until 2021, with the vision to serve hard to reach communities of the country. Another study revealed that to ensure basic and life-saving intervention to the patient, consistent support of a skilled staff should be available until the patient reaches referral facilities. However, several studies stated that it is difficult to pre-determine complication occurrence during pregnancy or childbirth^17,24. The government mandate to continue the midwifery led service delivery until 2021, it is therefore necessary to regularly review the referral indicators and counsel on complication readiness, as well as birth planning by a health attendant to improve compliance on maternal referral²⁰.

Conclusions

Early detection of complicated mothers and quick transfer to the referral center can ensure the survival of many mothers and neonates. The GoB has plans to scale up the unique midwife led service delivery (both basic and emergency health care services) system to support high-risk mothers of under privileged communities including the teagardens. The teagarden board, owners of the teagardens and local government, including policy makers of every level, must come forward to work together in finding out the best possible way to support the mothers of teagarden. At the community level, professional midwives play a key role in timely referral of a complicated mother to the facility. An integrated approach based on existing government health care delivery system with support from garden health facilities for timely referral of complicated mothers can be beneficial in reducing maternal and neonatal mortality in Bangladesh which in turn will be effective in reaching sustainable developmental goal on time.

Data availability

Data is stored at the CIPRB. Due to sensitivity of the data (contains identifying information), permission is required from the Ethical Review Committee (ERC) of CIPRB, Dhaka, Bangladesh for sharing data with a third party. Data can be requested from the CIPRB, who will contact the Ethical Committee to gain approval to share the data. The conditions for gaining data access are a formal request with a clear objective and formal permission from the Ethical Committee. Please contact the corresponding author in order to request the data though email at info@ciprb.org.