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      Referral patterns through the lens of health facility readiness to manage obstetric complications: national facility-based results from Ghana

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          Countries with high maternal and newborn mortality can benefit from national facility level data that describe intra-facility emergency referral patterns for major obstetric complications. This paper assesses the relationship between referral and facilities’ readiness to treat complications at each level of the health system in Ghana. We also investigate other facility characteristics associated with referral.


          The National Emergency Obstetric and Newborn Care Assessment 2010 provided aggregated information from 977 health facilities. Readiness was defined in a 2-step process: availability of a health worker who could provide life-saving interventions and a minimum package of drugs, supplies, and equipment to perform the interventions. The second step mapped interventions to major obstetric complications. We used descriptive statistics and simple linear regression.


          Lower level facilities were likely to refer nearly all women with complications. District hospitals resolved almost two-thirds of all complicated cases, referring 9%. The most prevalent indications for referral were prolonged/obstructed labor and antepartum hemorrhage. Readiness to treat a complication was correlated with a reduction in referral for all complications except uterine rupture. Facility readiness was low: roughly 40% of hospitals and 10% of lower level facilities met the readiness threshold. Facilities referred fewer women when they had higher caseloads, more midwives, better infrastructure, and systems of communication and transport.


          Understanding how deliveries and obstetric complications are distributed across the health system helps policy makers contextualize decisions about the pathways to providing maternity services. Improving conditions for referral (by increasing access to communication and transport systems) and the management of obstetric complications (increasing readiness) will enhance quality of care and make referral more effective and efficient.

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          Most cited references 26

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          Quality of basic maternal care functions in health facilities of five African countries: an analysis of national health system surveys.

          Global efforts to increase births at health-care facilities might not reduce maternal or newborn mortality if quality of care is insufficient. However, little systematic evidence exists for the quality at health facilities caring for women and newborn babies in low-income countries. We analysed the quality of basic maternal care functions and its association with volume of deliveries and surgical capacity in health-care facilities in five sub-Saharan African countries.
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            The experience of Ghana in implementing a user fee exemption policy to provide free delivery care.

            In resource-poor countries, the high cost of user fees for deliveries limits access to skilled attendance, and contributes to maternal and neonatal mortality and the impoverishment of vulnerable households. A growing number of countries are experimenting with different approaches to tackling financial barriers to maternal health care. This paper describes an innovative scheme introduced in Ghana in 2003 to exempt all pregnant women from payments for delivery, in which public, mission and private providers could claim back lost user fee revenues, according to an agreed tariff. The paper presents part of the findings of an evaluation of the policy based on interviews with 65 key informants in the health system at national, regional, district and facility level, including policymakers, managers and providers. The exemption mechanism was well accepted and appropriate, but there were important problems with disbursing and sustaining the funding, and with budgeting and management. Staff workloads increased as more women attended, and levels of compensation for services and staff were important to the scheme's acceptance. At the end of 2005, a national health insurance scheme, intended to include full maternal health care cover, was starting up in Ghana, and it was not yet clear how the exemptions scheme would fit into it.
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              Monitoring service delivery for universal health coverage: the Service Availability and Readiness Assessment

              Objective To describe the Service Availability and Readiness Assessment (SARA) and the results of its implementation in six countries across three continents. Methods The SARA is a comprehensive approach for assessing and monitoring health service availability and the readiness of facilities to deliver health-care interventions, with a standardized set of indicators that cover all main programmes. Standardized data-collection instruments are used to gather information on a defined set of selected tracer items from public and private health facilities through a facility sample survey or census. Results from assessments in six countries are shown. Findings The results highlight important gaps in service delivery that are obstacles to universal access to health services. Considerable variation was found within and across countries in the distribution of health facility infrastructure and workforce and in the types of services offered. Weaknesses in laboratory diagnostic capacities and gaps in essential medicines and commodities were common across all countries. Conclusion The SARA fills an important information gap in monitoring health system performance and universal health coverage by providing objective and regular information on all major health programmes that feeds into country planning cycles.

                Author and article information

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                Reprod Health
                Reprod Health
                Reproductive Health
                BioMed Central (London )
                18 February 2019
                18 February 2019
                : 16
                [1 ]Independent consultant, Pittsboro, NC 27312 USA
                [2 ]ISNI 0000 0001 0582 2706, GRID grid.434994.7, Policy Planning Monitoring and Evaluation Division, , Ghana Health Service, ; Accra, Ghana
                [3 ]FHI 360, 359 Blackwell Street, Suite 200, Durham, NC 27701 USA
                [4 ]ISNI 0000 0001 0582 2706, GRID grid.434994.7, Family Health Division, , Ghana Health Service, ; Accra, Ghana
                [5 ]ISNI 0000000122483208, GRID grid.10698.36, Maternal Child Health, MEASURE Evaluation/ Carolina Population Center, , University of North Carolina at Chapel Hill, ; Chapel Hill, NC USA
                [6 ]ISNI 0000000122483208, GRID grid.10698.36, Department of Maternal and Child Health, Gillings School of Global Public Health, , University of North Carolina at Chapel Hill, ; Chapel Hill, NC USA
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

                Funded by: FundRef, United States Agency for International Development;
                Award ID: cooperative agreement AID-OAA-L-14-00004
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                © The Author(s) 2019

                Obstetrics & Gynecology

                referral system, obstetrics, emergency services, maternal mortality, ghana


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