Introduction
Low-and middle-income countries (LMICs) have long suffered disproportionately high preventable maternal mortality and morbidity rates compared to high-income countries (1). Countries in sub-Saharan Africa (SSA) specifically, account for 2/3 of the world’s maternal deaths (2). Delays that contribute to these maternal death and injuries are often categorized using the “three delays” framework (3). The first delay refers to the delay in deciding to seek care; the second to the delay in presenting to the health center; and the third delay refers to the delay in receiving care once the woman arrives at the health facility(3). However, additional delays can further occur when a woman needs to be referred from a rural health facility (RHF) to a district hospital for emergency obstetric care services such as blood transfusion and caesarean section (CS) (4) (5).
Rural Health Facilities (RHF) in LMICs often have the capacity to perform basic emergency obstetric and newborn care (BEmONC), which includes parenteral antibiotics, parenteral uterotonic, and parenteral anticonvulsants administration, manual removal of retained placenta, vacuum aspiration, assisted vaginal delivery, and basic neonatal resuscitation (6). Alternatively, district hospitals typically offer comprehensive emergency obstetric and newborn care (CEmONC), which includes blood transfusion and CS in addition to the seven BEmONC functions (6). Hence, if a woman shows indications for a blood transfusion or a CS, healthcare providers at the RHF should refer the woman to a district hospital for additional care (4)(5). In the process of a referral, the same three delays can occur.
According to recent verbal autopsies conducted in Bong County Liberia, ineffective communication between RHFs and hospitals is a contextual cause contributing to preventable maternal deaths (7). Specifically, having no standardized referral process for communication of important information as well as the lack of feedback once the patient is referred to the hospital were identified as communication challenges (7). A study conducted in Nigeria found that women who were referred from a RHF were three times more likely to travel longer than 60 minutes to get to a hospital compared to women who went directly to a hospital bypassing the RHF (5). Furthermore, a study conducted in Rwanda found that longer travel time from RHF to a hospital was significantly associated with adverse neonatal outcome, emphasizing the need for strategies to reduce the transfer delay from health centers to district hospitals (4). Despite this need, only 40% of RHFs in Liberia were ready to make an emergency referral, defined as having access to a functional ambulance or other vehicle stationed at the facility or access to an ambulance and a functioning telephone, either a landline or a mobile phone(8). Hence, there is a great need to implement efficient and effective communication mechanisms between RHFs and hospitals to improve the referral process and ultimately maternal and newborn outcomes.
WhatsApp, one of the most popular communication platforms worldwide has been examined as a potential means to streamline the obstetric referral process between communities, RHFs, and hospitals (9)(10)(11). Several feasibility and acceptability studies conducted in Ghana and Liberia found that the use of WhatsApp as a communication platform for obstetric referral is feasible and acceptable among community health workers, nurses, and midwives with a few addressable potential challenges such as data coverage and smartphone accessibility (9)(10)(11). Building upon these studies, this study piloted a mobile obstetric emergency system (MORES) using the free WhatsApp platform as an obstetric referral intervention in Bong County, Liberia. The purpose of this study was to examine the association between the implementation of the MORES intervention and transfer times, maternal outcome, and newborn outcomes.