Reducing maternal, fetal, and neonatal mortality requires broad access to the essential obstetric and neonatal services described in Chapters 2 and 3. The availability and quality of these services is inadequate in most countries. Also needed are referral structures to address major barriers to provision of referral care. The “four delays” in responding to maternal or neonatal complications were introduced in Chapter 2 (Lawn et al., 2001). These delays—in recognizing the problem; deciding to seek care; getting to a facility that can provide it; and receiving appropriate treatment—confront every medical emergency. Several determinants of the use of referral care may need to be addressed to increase referrals for complicated births, such as the ability of pregnant women and their families to recognize symptoms of complications (The Prevention of Maternal Mortality Network, 1992; Bloom et al., 1999); distance to the referral facility (The Prevention of Maternal Mortality Network, 1992) (see Figure 5-1), the availability and cost of transportation (Eades et al., 1993; Fraser and Meli, 1990; Fawcus et al., 1996; The Prevention of Maternal Mortality Network, 1992) and the cost of care (Bloom et al., 1999; Asowa-Omorodion, 1997).

Many women do not recognize the benefits of receiving higher-level care, are wary of the attitude of providers toward patients, and do not understand the medical causes of complications or the importance of specific treatments (Mathur et al., 1979; The Prevention of Maternal Mortality Network, 1992; Thaddeus and Maine, 1994; National Research Council, 1997). The signs of complications during pregnancy and labor and after delivery are not always recognized by women and their families as causes for concern. Recognizing complications and promptly seeking skilled care can be taught during antenatal care. Geographical and financial accessibility also present major barriers to referral care (Thaddeus and Maine, 1994; Bouillin et al., 1994; Haddad and Fournier, 1995). When deciding whether to seek referral care in an emergency, patients and their families tend to weigh the potential expense and effort involved against the perceived benefit of hospital care (Thaddeus and Maine, 1994; Oosterbaan and da Costa, 1995; Asowa-Omorodion, 1997). These decisions are often influenced by fears of discrimination, loss of privacy, and the lack of emotional and social support in a hospital setting.

Where access to referral care is less a problem than the quality of care available, improving provider skills and the availability of drugs and other medical supplies may increase the number of emergency referrals (Jahn and De Brouwere, 2001). However, in the more common situation, where skilled attendants are likely to remain scarce for the foreseeable future, improving referral mechanisms, communication capability, and transportation, so that those who need emergency care receive it, is an alternative means to reduc-