Conclusion
Timely and high-quality obstetric emergency care such as caesarean section significantly reduces maternal mortality and morbidity. While Liberia has experienced increased facility-based deliveries in the past decade, it has not been accompanied by timely referral to hospitals capable of performing emergency obstetric services. Prior to implementation of the MORES intervention, unidirectional communication from RHFs to district hospitals prevented feedback to providers making the referral. While the focus of this study was not to examine quality improvement at RHFs, providing feedback to healthcare providers has the potential to examine clinical decision-making in real time and increase connectedness for providers working in rural settings. Given that the MORES intervention was associated with a significant increase in CS and a reduction in depressed newborns at birth, it may be an innovative solution to communicate emergency referral information, improve treatment upon arrival at the hospital, and improve bi-directional communication to ultimately reduce maternal and newborn morbidity and mortality. Future studies should examine the reasons for delays after referral has been made as well as interventions to overcome these challenges.