Improving accessibility and utilization of healthcare services for urban poor through implementation of a maternity referral system in the Mumbai Metropolitan Region, India

Complications related to pregnancy and childbirth are among the leading causes of morbidity and mortality in women of childbearing age in developing nations. The MMR of Mumbai for 2010-2012 was 158 [MDG target– MMR 109]... [ view full abstract ]

Complications related to pregnancy and childbirth are among the leading causes of morbidity and mortality in women of childbearing age in developing nations. The MMR of Mumbai for 2010-2012 was 158 [MDG target– MMR 109] despite having a vast public health infrastructure. It has been estimated that 74% of maternal mortality could be averted if all women received appropriate and timely emergency obstetric care. Around 42% of Mumbai’s population constitutes urban slum population and is heavily dependent on its multi-tiered healthcare system. Lack of an organized referral system between different levels of care meant that pregnant women often travelled long distances to tertiary facilities while secondary facilities remained under-utilized.

Main contributing issues were different administrative authorities across different levels of care, lack of awareness on services available in secondary facilities, inadequate emergency obstetric care services, and absence of communication or set referral processes in place including no standardized documentation.

SNEHA partnered with Mumbai Corporation for establishing a maternity referral system, which has then been scaled up to adjacent 3 corporations. To address gaps through a participatory approach, the processes employed included buy-in from administrative authorities, mapping of referral linkages taking into account travel distances and availability of services, introducing referral documentation, regular referral meetings and feedback.

SNEHA has successfully established 6 intra-regional and 4 inter-regional referral linkages across 4 corporations. There is significant improvement in referral documentation in Mumbai from a baseline of 40% to 85% (2014-2015), improvement in utilization of secondary facilities as referral centres from 15% to 67% and subsequent reduction in utilization of tertiary facilities from 35% to 21%. Additionally, 80% cases were appropriately referred according to set protocols.

Health emergencies being unpredictable, having a strong referral system in place can prevent delays in accessing care. It has potential to reduce mortality, without requiring massive resource allocation.