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Barriers and Technologies of Maternal and Neonatal Referral System in

Developing Countries: A Narrative Review

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DOI: 10.1016/j.imu.2019.100184

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 Informatics in Medicine Unlocked 15 (2019) 100184

Contents lists available at ScienceDirect

Informatics in Medicine Unlocked

journal homepage: www.elsevier.com/locate/imu

Barriers and technologies of maternal and neonatal referral system in T

developing countries: A narrative review
Nabila Clydea Harahap∗, Putu Wuri Handayani, Achmad Nizar Hidayanto
Faculty of Computer Science, University of Indonesia, Depok, 16424, Indonesia

ARTICLE INFO ABSTRACT

Keywords: There is a lack of studies concerning the maternal and neonatal referral system in troubled contexts, and the
Referral number of maternal and neonatal mortality deaths is considered high in developing countries. This study aims to
Maternal understand the current conditions of the maternal and neonatal referral system in developing countries, in the
Neonatal context of barriers and technologies. We conducted a narrative literature review based on journals and con-
Barrier
ference papers in the last five years (2014–2018) from selected databases (MEDLINE, CINAHL, Science Direct,
Technologies
Scopus, Wiley Online, PMC, and ProQuest). The results of the study selection show that 40 studies identified
barriers or challenges in maternal or neonatal referral systems, and eight studies discussed technology to support
referral. Based on the results, barriers in maternal and neonatal referral systems can be divided into two main
factors: 1. the healthcare system and 2. the patient. Some technologies are used in developing countries to
support maternal and neonatal referral. However, these technologies still do not address all of the barriers
described in the referral system. A study from different perspectives is needed, such as community involvement
or government programs, to improve the current conditions of the maternal and neonatal referral system.

1. Introduction
Health is an important individual need and it is one of the de-
terminants of the level of welfare of a nation. Improving maternal and
child health is one of the important healthcare goals throughout the
world. This is because mother and child are highly important members
of society. This is also in accord with the United Nations goals listed in
the Sustainable Development Goals (SDG). One of the SDG goals is to
“ensure healthy lives and promote well-being for all at all ages”, in-
cluding maternal and child health [1].
In 2030, SDG targeted reduction in the global maternal mortality
ratio to less than 70 per 100,000 live births, under-5 mortality to at
least as low as 25 per 1000 live births, and neonatal mortality to at least
as low as 12 per 1000 live births [1]. The facts showed that 17,000
fewer children die each day than in 1990 and maternal mortality has
fallen by 37% since 2000 [1]. However, the maternal mortality ratio in
developing regions is still 14 times higher than in the developed re-
gions, and 5.4 million children still die in the first five years of life, with
around half of them being newborns [1,2].
Inadequate access to quality of care is one of the factors that can
elevate the risk of maternal and neonatal death. According to Thaddeus
and Maine (1994), there are three delay models that women face when
trying to access care that contributes to maternal death [3]. These
delays are: delay on the decision to seek care, delay on the arrival at a
healthcare facility, and delay on the provision of adequate care [3].
Several factors contributing to these delays include socioeconomic or
cultural factors, accessibility of facilities, and quality of care [3].
Some improvements need to be made to reduce maternal and
newborn mortality. One of the improvements can be made by
strengthening the referral mechanism and linkages between the various
levels of the facility [2]. This is because the referral can be seen as a
metric for the overall functioning of the health system and it reflects the
ability of governments to manage all subsystems and actors that con-
tribute to the referral process [4]. In referrals, transportation and
communication are the most important issues in the success of the re-
ferral system, especially in the cases of obstetrical emergencies [4–6].
Maternity referral systems have been under-documented, under-
researched, and under-theorized, and no study of the referral system in
troubled contexts has been found in the literature [5,7]. To understand
current conditions in maternal and neonatal referral systems, there is a
need to understand barriers or challenges that hinder patients from
complying with referral, as the factors that cause a delay in accessing
the quality of care. In addition, current technological developments can
help solve problems in various fields, including healthcare. Therefore, it
is also necessary to understand how technology can facilitate referrals.
Thus, this study aims to understand the current conditions of the

∗
Corresponding author.
E-mail addresses: nabila.clydea@ui.ac.id (N.C. Harahap), putu.wuri@cs.ui.ac.id (P.W. Handayani), nizar@cs.ui.ac.id (A.N. Hidayanto).

https://doi.org/10.1016/j.imu.2019.100184
Received 22 January 2019; Received in revised form 11 April 2019; Accepted 15 April 2019
Available online 16 April 2019
2352-9148/ © 2019 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
N.C. Harahap, et al.
maternal and neonatal referral system in developing countries. This is
because the number of maternal and neonatal mortality deaths is con-
sidered high in the developing countries, especially in Sub-Saharan
Africa and Southeast Asia [2,8,9]. This study will answer the following
research questions: 1) What are some barriers or challenges in maternal
and neonatal referral systems in developing countries? 2) What are
some technologies that can be applied to support maternal and neonatal
referral systems?
Several studies had been conducted to discuss the referral systems in
developing countries. Murray and Pearson (2006) conducted a litera-
ture review to identify key requisites for successful maternity referral
systems in developing countries [5]. Krasovec (2004) discussed some
programs to improve transportation and technologies for communica-
tion to support obstetrical referrals in developing countries [6]. Some of
the issues discussed were related to increasing collaboration between
different levels of care, increasing the availability of transportation, and
the use of technologies in communication, such as radio communica-
tions and cell phone use.
This study will benefit several parties. First, it will be useful for
healthcare facilities to understand potential challenges or barriers re-
lated to process and implementation of maternal and neonatal referral
systems. Second, this study will be useful for researchers to obtain an
overview of the current implementation of maternal and neonatal re-
ferral systems. Third, this study will be useful for application vendors or
developers as considerations for planning and assessment, before im-
plementing the application to facilitate maternal and neonatal referral
systems.
This study consists of six chapters. The first chapter is an in-
troduction, which explains the research background. The second
chapter is a literature review to provide an overview of the maternal
and neonatal referral system in a general context. The third chapter will
introduce the methodology to conduct this literature review. The fourth
chapter will present results and discussion from the literature review.
The fifth chapter will discuss the conclusions from the fourth chapter,
and the last chapter will discuss the limitations and future work.
2. Literature review
2.1. Referral system
One of the important aspects of healthcare facilities is the referral
system, especially in the case of obstetric and newborn emergencies.
According to the World Health Organization (WHO), a referral can be
defined as “a process in which a health worker at one level of the
healthcare system, having insufficient resources (drugs, equipment,
skills) to manage a clinical condition, seeks the assistance of a better or
differently resourced facility at the same or higher level to assist in, or
take over the management of, the client's case”. A referral system
consists of four main components: initiating facility, receiving facility,
health system, and supervision and capacity building [10].
Fig. 1 above elucidates the flows of a referral system according to
WHO [10]. It consists of initiating facility, receiving facility, super-
vision and capacity building, and health system issues. The facility that
starts the referral process is called the initiating facility, while the fa-
cility that accepts the referred case is called the receiving facility. Su-
pervision and capacity building can be done by facility managers and
supervisors at all levels, to monitor the effectiveness and efficiency of
all referrals made in their facilities or area.
When patients arrive, the initiating facility provides appropriate
treatment and stabilize patient conditions based on the protocol of care.
If a referral is needed, the initiating facility will provide a referral form,
communicate with the receiving facility to make referral arrangements,
and provide information to patients or their family about the referral.
The receiving facility anticipates the arrival and receives the patients
with their referral form; then the receiving facility provides care and
follow-up for the patients, and sends back the referral form and
2
Informatics in Medicine Unlocked 15 (2019) 100184
Fig. 1. Referral system flows [10].
feedback to the initiating facility on the appropriateness of referral.
Each facility also requires a referral register to track and monitor all of
the referrals made and received.
All levels of the health system need to be functioning appropriately,
including the primary healthcare system. They need to be clear about
their role, responsibilities, and limitations, having readily available
protocols of care for conditions for that level of service, and having
suitable means of communication and transport. Facility managers and
supervisors at all levels should monitor all referrals made to and from
facilities in their area each month to identify what is needed to im-
prove, such as providing clinical training or strengthening of particular
parts of the referral system or its procedures.
There are several standards that need to be made to ensure the
success of referral, especially in the case of emergencies referral [11].
Referral to the higher level of care should be in line with standard
operating procedures, and covers emergencies, including obstetric
emergencies, and may include elective cases. Arrangements for referral
should be made with the district or regional national referral hospitals
that offer comprehensive obstetric and surgical care, and ambulance
services should be available 24/7.
2.2. Maternal and neonatal referral system
Maternal health refers to the health of women during pregnancy,
childbirth and the postpartum period [12]. A newborn infant, or neo-
nate, is a child under 28 days of age [13]. The first 28 days of life is the
most vulnerable and at this time the child has the highest risk of dying
[9,13]. To improve the quality of care for mothers and newborns
around the time of childbirth, WHO has defined a framework that
consists of eight standards that should be assessed, improved, and
monitored within the health system. One of those standards is related to
referral: “Every woman and newborn with condition(s) that cannot be
dealt with effectively with the available resources are appropriately
referred” [14].
The aim of the standards is to ensure timely, appropriate referral of
all patients who need care that cannot be provided in the healthcare
facility. This standard consists of three quality statements: (1) Every
woman and newborn is appropriately assessed on admission, during
labor, and in the early postnatal period, to determine whether referral is
required, and the decision to refer is made without delay. (2) For every
woman and newborn who requires referral, the referral follows a pre-
established plan that can be implemented without delay at any time. (3)
For every woman and newborn referred within or between healthcare
N.C. Harahap, et al.
Fig. 2. Levels of care [15].
facilities, there is appropriate information exchange and feedback to
relevant healthcare staff [14].
In any referral system, a referral starts from a lower level to a higher
level of care. The structure or level of care for referrals varies across
countries. However, in general, the following levels of care have been
identified as the family/village/community, healthcare center, and
district/referral hospital. Fig. 2 below shows the common levels of care
in a referral system. Moreover, there are several ways to do referral in
pregnancy and childbirth. This can be categorized as institutional or
self-referral, depending on the involvement of the first line services,
antenatal, delivery or postnatal referral, and elective or emergency
referral [15].
2.3. Issues in maternal and neonatal referral systems
A good referral system helps to ensure patients receive optimal care
at the appropriate level and is not unnecessarily costly, hospital facil-
ities are used optimally and cost-effectively, patients who most need
specialist services can access them in a timely way, and primary
healthcare services are well utilized and their reputation is enhanced
[11]. However, there are some common issues in the referral system
that hinder patients to receive the appropriate care at a referral facility.
These issues are lack of transportation, communication, and poorly
documented referral flows [7,15].
To ensure the success of referral, some qualities need to be made
including availability of referral protocols and guidelines that reflect a
facility's capacity and resources, availability of adequately equipped
transportation that operate 24 h a day and 7 days a week, and a func-
tioning communication system (e.g. radio, telephone), and formal ar-
rangements for communication and consultations [14]. In addition,
some interventions can be made at the community level concerning
educational activities to raise awareness of danger signs and encourage
the use of obstetric services, to reduce geographical and financial bar-
riers through emergency loans, and to improve transport and commu-
nication [15].
3. Methodology
This study is a narrative literature review based on journals and
conference papers in the last five years (2014–2018). This type of re-
view is useful in gathering together a volume of literature in a specific
subject area and summarizing and synthesizing it [16]. Narrative Re-
views are aimed at identifying and summarizing what have been pre-
viously published, avoiding duplications, and seeking new study areas
not yet addressed [17]. In the narrative review, a literature search is
conducted by defining the searching strategy, inclusion and exclusion
criteria, verifying the availability of all the selected studies, and citing
and listing the researched references [17].
3
Informatics in Medicine Unlocked 15 (2019) 100184
3.1. Search strategy
The searching strategy is conducted by determining the databases
and keywords [17]. For journals and conference papers, the search is
conducted using the online databases MEDLINE, CINAHL, Science Di-
rect, Scopus, PMC, Wiley Online, and ProQuest. Terms or keywords
used to search the articles include “referral”, “referral system”, “referral
process”, “maternal”, “obstetric”, “neonatal”, “newborn”, “barrier”,
“challenge”, “technology”, and “application".
3.2. Eligibility criteria
Defining the inclusion/exclusion criteria for literature selection can
be helpful in focusing on the relevance of the studies to the topic [17].
Inclusion or exclusion criteria can be defined based on the types of
studies, languages, time periods, among others [17]. The inclusion
criteria for this study: articles written in English, published in the past
five years (2014–2018), and studies aimed at identifying barriers in
maternal and neonatal referral system, or technologies to support the
referral of maternal and neonatal health in developing countries. If the
sample size of some studies reviewed is relatively small, the result may
not be generalizable and applied to other settings [75]. However, we
ensured the validity of the conclusion of these studies from their
methods or techniques to overcome bias, such as triangulation, the use
of quotations from the participants, or coding of transcripts. The ex-
clusion criteria for this study: articles for which full text was not
available, and studies of the maternal and neonatal referral system in
developed countries.
3.3. Study selection
Based on the literature collected, assessments are conducted to en-
sure that the literature is relevant and suitable for the review scope.
After the search is carried out based on keywords and predetermined
databases, screening is done from the title and abstract, to eliminate
duplication of the same articles in different databases. Thereafter, full-
text screening is done to ensure it is appropriate for the review scope of
this study. Fig. 3 below describes the flow of the literature selection
process.
Fig. 3. Literature search process.
N.C. Harahap, et al. Informatics in Medicine Unlocked 15 (2019) 100184

4. Result and discussion Table 2

Sources of selected study.
4.1. Study selection Article Source Number of Publication(s)

Search results based on keywords in the selected databases gener- BMC Pregnancy and Childbirth 7
PLoS One 7
ated (MEDLINE (n = 275), CINAHL (n = 83); ScienceDirect (n = 601);
BMC Health Services Research 6
Scopus (n = 262); WileyOnline (n = 142); PMC (n = 1524); and BMJ Open 4
ProQuest (n = 388)). The articles that cannot be fully accessible by Global Health Action 4
authors and not published in the past five years were eliminated. Next, Reproductive Health 4
the articles were screened based on title and abstract, and duplications Journal of Health, Population and Nutrition 2
Maternal and Child Health Journal 2
were removed (same articles in different databases), resulting in 121
Midwifery 2
articles utilized for initial analysis. Next, the articles were reviewed Asian Journal of Nursing Education and Research 1
based on full text for potential inclusion. From the articles retrieved, 4 Cogent Medicine 1
references were identified among the cited references. 78 studies were Global Public Health 1
Healthcare (Amsterdam, Netherlands) 1
excluded for: the studies were not related to barriers or technologies of
International Journal for Equity in Health 1
maternal and neonatal referral system or the studies were conducted in International Journal of Health Planning and 1
developed countries. Finally, 48 articles were selected in this study. Management
Rural and Remote Health 1
Sexual and Reproductive Healthcare 1
Wetland Science 1
4.2. Study characteristics
IET Conference Proceedings 1

The results of the study selection show that 40 studies identified

barriers or challenges in maternal and neonatal referral system and
eight studies discussed technology to support maternal or neonatal re-
ferral systems. Based on United Nations (UN) Country Classification
(2014), developed countries consist of European countries and other
countries such as Australia, Canada, Japan, New Zealand, and the
United States, while developing countries consist of other countries in
Africa, Asia, and Latin America and the Caribbean [42]. The studies
selected come from developing countries in Asia such as India (5 stu-
dies), Bangladesh (2 studies), Indonesia (2 studies), and Pakistan (1
study); Africa, such as Ghana (8 studies), Tanzania (7 studies), Uganda
(4 studies), Kenya (3 studies), Ethiopia (3 studies), Sudan (3 studies),
Malawi (2 studies), Burkina Faso (1 study), Eritrea (1 study), Mo-
zambique (1 study), and Somaliland (1 study); and Latin America, such
as Guatemala (2 studies) and Honduras (1 study). Table 1 below pre-
sents the countries of selected study and Table 2 presents the sources of
selected study.
Table 1, regarding countries of selected study, is useful to show that
the results of the literature search process follow the scope of the review
for developing countries, and Table 2 describes sources of selected
study, and is useful to provide information regarding journals that
discuss these topics, so that it can be useful as another reference for
researchers when looking for literature on similar issues.

Fig. 4. Barriers in maternal and neonatal referral systems.

Table 1
Countries of selected study. 4.3. Barriers in maternal and neonatal health referral system

Country Number of Publication(s)

Based on the literature reviewed [18–36,48–68], barriers in ma-
Asia India 5 ternal and neonatal referral systems can be divided into two main
Bangladesh 2 factors: 1. the health system and 2. patients. Fig. 4 and Table 3 below
Indonesia 2 summarize the barriers in maternal and neonatal referral systems.
Pakistan 1
Timor-Leste 1
Africa Ghana 8
Tanzania 7 4.3.1. Health system factors
Uganda 4 Health system factors are related to accessibility of health facilities
Kenya 3 and the inability of health providers to manage patient conditions or to
Ethiopia 3
refer patients appropriately. Cost and access to transport is an important
Sudan 3
Malawi 2 barrier in many low-resource areas in developing countries [6]. Several
Burkina Faso 1 studies showed that unavailability of the ambulance or and inadequate
Eritrea 1 transport [19–24,28,30,32–34,36,49,51,53,54,56,57,61–63,65,67,68]
Mozambique 1 are barriers related to transportation. Patients or their families have to
Somaliland 1
make their own way to reach the referral facilities, such as using public
Latin America Guatemala 2
Honduras 1 transportation [20,22,23,51,53,64] which will be of high cost in some
areas [22,28,30,32,34,35] and this also makes it difficult to ensure

4
 Table 3
Barriers in maternal and neonatal referral systems.
No Barriers Countries Number of References
Publications
N.C. Harahap, et al.

Health System Factors

1 Transportation India, Pakistan, Ghana, Ethiopia, Tanzania, Uganda, Honduras, Indonesia, 28 [19–26,28,30,32,34–36,49,51–54,56,57,61–65,67,68].
- unavailability of ambulance or inadequate transportation system Kenya, Somaliland, Sudan, Eritrea, Timor-Leste, Malawi
- lack of coordination of transportation between facilities
- poor management and maintenance of ambulance
- lack or unavailability of drivers
- poorly equipped ambulances
- lack of quality of ambulance personnel to provide appropriate
treatment to patients during travel
- late ambulance arrival
2 Quality of Care India, Pakistan, Ghana, Tanzania, Honduras, Uganda, Indonesia, Ethiopia, 16 [18,21,22,24,26–29,49,52,53,55,56,60,61,66].
- lack of quality to handle complicated cases Mozambique, Timor-Leste, Sudan
- poor quality or skill of health workers in the lower levels of care
- no training of health workers to manage sick mother and newborns for
referral
- poorly staffed facility
3 Communication India, Ghana, Ethiopia, Uganda, Honduras, Somaliland, Sudan, Eritrea, 12 [18,22,23,25,26,29,33,34,49,51,54,63].
- lack of pre-referral communication Malawi
- no standard system for communication
- lack of feedback or follow-up about current condition of patients
4 Standard and Monitoring India, Ghana, Ethiopia, Uganda, Indonesia 8 [19,22,23,25,36,49,51,62].
- no uniformity in defining cases of complications and indications for
referral
- poor referral system

5
- no system to refer patients from higher facility to lower level facility
- low adherence to referral guidelines
- lack of monitoring on the success of referral system
5 Referral Documentation India, Ghana, Honduras, Tanzania 7 [18,19,22,26,35,48,67].
- inadequate or no documentation of referrals
- lack of maintenance of referral records
- loss of referral slips or written documentations
6 Network Infrastructure Ghana, Ethiopia 3 [22,23,53].
- poor mobile network connectivity
- lack of dedicated phone lines and communication infrastructure
Patient Factors
1 Knowledge about Referral Ghana, Tanzania, Uganda, Indonesia, Somaliland, Sudan 12 [22,27,28,31,33,34,48,57–60,62].
- no understanding about hierarchy, capacities, and limitations of each
health facilities and why they need to be referred
- lack of knowledge about referral system
- lack of knowledge are about danger signs or complications during
pregnancy
- believe that referral would automatically lead to caesarean section
2 Poverty India, Uganda, Tanzania, Ghana, Sudan, Indonesia, Burkina Faso, Eritrea, 12 [20,27,31,32,34,36,49,50,54,57,59,61].
- lack of money Timor-Leste
- inability to pay for transportation, hospital bills, and other living
expenses in hospital
(continued on next page)
Informatics in Medicine Unlocked 15 (2019) 100184
N.C. Harahap, et al. Informatics in Medicine Unlocked 15 (2019) 100184

appropriate care during travel [22]. Moreover, unavailability of the

ambulance made patients have to wait a long time to arrange transport
[49,53,57]. This barrier can occur due to lack of a coordination of
transport between facilities to facilitate referral [26,32,64]. However,
even when ambulances are available, there can be other problems, such
as poor management and maintenance of the ambulance, so that patients
have to pay for the fuel in order to be transported [25,68], lack or un-
availability of drivers [23,24,26,56], poorly equipped ambulances [26],
[22,25–28,30,32,36,51,54,61]

lack of quality of ambulance personnel to provide appropriate treatment

to patients during travel [20], and the late ambulance arrival, which can
result in patients dying on the way to the referral facility [52,64].
Lack of pre-referral communication or coordination between in-
itiating and receiving facilities [18,23,29,33,34,51,54,63], resulted in
References

patients to be referred several times, because the initiating facility did

[27,28].

[28,31].

not receive information concerning bed availability in the receiving

facilities [23], and sometimes patients arrived when the facilities were
already closed [29]. Other barriers related to communication are lack of
a standard system for communication between the initiating and re-
ceiving facilities, and lack of feedback or follow-up from receiving fa-
Publications
Number of

cilities to sending facilities concerning the current condition of the re-

ferred patients to evaluate the success of referral [22,25,26,49,63].
In most developing countries, telecommunications infrastructure is
11

underdeveloped, and there is a lack of sufficient electrical supplies [43].

Ghana, Uganda, Honduras, Kenya, Indonesia, India, Eritrea, Timor-Leste

Some studies have shown that there is a problem in network infra-

structure, such as poor mobile network connectivity, especially in more
rural areas, and a lack of dedicated phone lines and communication
infrastructure [22,23,53]. These barriers contribute to the lack of pre-
referral communication between initiating and receiving facilities.
Another reason for the non-compliance of patients to follow the
referral system is due to the quality of care. Some barriers including
lack of quality of some facilities to handle complicated cases [18,21]
and poor quality or skills of healthcare workers in the lower levels of
care [22,60], such as lack of knowledge of health workers to identify
risk in pregnancy [55,66], which can result in late referral [66]. Some
healthcare workers also have no training to manage a sick mother and
newborn in the context of referral [26]. Some patients also had bad
experiences with healthcare facilities related to poor quality of care,
such as rude healthcare workers [27,28,49,52,61], out of stock medi-
Indonesia, Tanzania
Indonesia, Uganda

cines [27,28], and unavailability of healthcare workers [27,28].

Moreover, some health facilities are poorly staffed [24,29,53,56] and
Countries

the overload of patients resulted in difficulties to determine which

mothers need referral [24,56].
The barrier in referral documentation is related to inadequate
documentation of referrals [22,26] and lack of maintenance of referral
- maternal weakness after childbirth to bring their neonates to referral

records or no proper referral documents provided to the pregnant

- involvement of family member in decision making to follow referral

women [19,48,67]. Lack of documentation in receiving facilities could

be caused by the lack of detailed information about treatment that had
been given to patients [18,19,22]. This could occur because of the lack
of accompanying documentation, such as a referral letter when
- the need to take care of children or families at home

healthcare workers accompany a patient to receiving facilities [22,48].

Some healthcare workers did not document the required information
about the patient to the referral facility [48,67] and they only refer
patients orally [67]. In addition, lack of documentation resulted in the
loss to follow-up referred patients due to loss of referral slips or written
documentation about the referred patients [35].
Several studies also showed that there are some barriers regarding
the adequacy or adherence to referral guidelines. Lack of standard in
- bad weather conditions

referral including no uniformity in defining cases of complications and

Health Status of Mother
- poor road network

indications for referral and no referral guidelines, render decision-

making related to referrals complicated and confusing [19,62]. Poor
Table 3 (continued)

Environments

referral systems resulted in patients to be referred several times [36].

facilities
- distance

Another study showed that there is no system to refer patients from a

Barriers

Culture

higher facility to lower level facility, resulting in overcrowding of pa-

tients in some referral facilities [23]. Other barriers are related to ad-
herence, such as very few facilities adhering to referral guidelines [22]
No

and weak implementation of referral guidelines [25]. This problem

6
N.C. Harahap, et al.
resulted in some healthcare workers not accompanying patients during
referral [49], and healthcare workers did not immediately examine the
patients before referring to another facility [51]. Moreover, the lack of
monitoring of the success of the referral system and poor accountability
of the system to users [18,25] contributed to failures in the referral
system.
4.3.2. Patient factors
Patient factors are related to patient considerations or the decision
to follow the referral. Barriers in maternal and neonatal referral from
patient factors mostly related to socioeconomic or cultural factors such
as poverty and decision-making culture, that potentially cause a delay
in deciding to seek care. However, physical accessibility factors can also
be a reason for the non-compliance of patients to follow referral. Many
low-resource areas have poor roads and infrastructure [6]. Distance to
the healthcare facility is shown to be an important barrier, especially in
rural areas [3]. Based on the literature reviewed, environmental factors
such as poor road network [22,25,26,30,32] and bad weather condi-
tions such rain the entire day or storms [27,28] can hinder patients
from reaching referral facilities. Furthermore, distance to healthcare
facilities in some areas caused patients to prefer seeking care at home
by traditional healthcare workers, rather than seeking more appropriate
and sophisticated care at referral facilities [28,36,51,54,61].
Another barrier in the referral system is related to knowledge of
patients about the referral. Some patients did not understand the
hierarchy, capacities, and limitations of each healthcare facilities, and
why they need to be referred [22]. They were convinced that the re-
ferral was not necessary [31] and believed that some conditions could
be handled by traditional healers or community specialists [27]. They
only desired to transport to the healthcare facilities when traditional
healers or community specialists failed to deal with complicated cases
[27] or when the conditions become severe [57]. This is due to their
lack of understanding about referral systems [28], lack of knowledge
about danger signs or complications during pregnancy [33,48,62], and
lack of knowledge about safe and skilled deliveries [59]. Their per-
ception that their baby was not severely ill and would improve also
hinder them from following referral [58]. Moreover, some women re-
fused to follow referral to healthcare facilities because they believed
referral would automatically lead then to Caesarean section [34,60].
Other barriers in referral system include poverty, the health status
of the mother, and culture. Barriers related to poverty including the
inability of patients or their families to follow referral due to financial
constraints. The reasons women did not follow referral also includes a
lack of money [49,50,57], inability to pay for transportation cost
[27,31,32,34,36,54,59], hospital bills, and other living expenses in
hospital [31,36]. Some families also prefer to save their money for
funeral preparation rather than spend it for referral [61]. Other barriers
are maternal weakness after childbirth to bring their neonates to re-
ferral facilities [27,28], and cultural barrier such as involvement of
family members like the husband and mother in decision-making to
follow referral [28,31] and the need to take care of children or families
at home, so that women did not want to follow referral to health fa-
cilities [31].
4.4. Technology to support referral of maternal and neonatal health
Based on the review result, there are not many studies
[37–41,69–71] that discussed the use or implementation of technology
to support maternal and neonatal health services with referral support.
These technologies came from several countries, including Kenya,
Bangladesh, Tanzania, Ghana, and Guatemala. These technologies
provide several functions to help healthcare workers to identify com-
plication cases, link healthcare workers to health facilities, and facil-
itate or coordinate referral if emergency cases occurred. Table 4 below
summarizes some technologies used to support maternal and neonatal
referral systems.
7
Informatics in Medicine Unlocked 15 (2019) 100184
In Kenya [37], a mobile application: Maternal Newborn and Child
Health (mPAMANECH), aims to improve the responsiveness of ma-
ternal and child health services. mPAMANECH utilizes short message
service (SMS) and hotlines to access important information and co-
ordinate referral. This application helps community health volunteers
(CHV) in the identification of high-risk and complicated cases of ma-
ternal and newborns, and to make timely and correct decisions con-
cerning referral. Moreover, this application replaced paper-based
forms, so it allows integration of patient data for better referral and
management of patients.
A study in Kenya also showed the combined use of telehealth and
call centers to improve the effectiveness of referral [69]. The telehealth
provides consultation support between clinicians and pediatricians,
which can facilitate timely decision-making for the referral. The call
center links the special care units to the midwives and mothers of
newborns, and supports follow-up of patients after discharge. The
follow-up data obtained from the call center is uploaded to the tele-
health system to support clinicians, and pediatricians understand the
newborns' health situation in that community.
A toll-free mobile communication in Bangladesh [38], serves to
facilitate communication among mothers, community skill birth at-
tendants (CSBA), and a solution linked group (SLG). The toll-free mo-
bile communication helps mothers in seeking care to the appropriate
facility, including facilitating referral if a complication has occurred.
The mobile communication also provides a complication guide and
helps CSBA in making a decision for the referral. The mobile commu-
nication should provide availability of services every day at any hour.
However, sometimes the mobile phone is switched off by CSBA (espe-
cially on weekends), and there can be lack of involvement of SLG, and
network problems.
One of the challenges in the implementation of technologies in
developing countries is an inadequate communication network, for
example, toll-free communication in Bangladesh. There is a correlation
between network communication and wealth of a country [72,73].
Countries with better economic conditions tend to have a better com-
munication network as compared with countries with lower economic
situations. If technology like toll-free communication in Bangladesh is
implemented in a country with a better economy, this technology may
run better. However, the problem in this implementation is not only in
network connection but also the lack of healthcare workers’ engage-
ment in using the technology. When implementing technology, the
motivation and commitment of users must be maintained to ensure the
success of implementation, especially when the technology is intended
to manage emergency cases, which indeed requires responsiveness from
healthcare workers.
Bangladesh also uses a GIS-based transport system for emergency
referral system which helps transport women, newborns, or children
under five years old [70]. A call center coordinated the transport
system. The call center help determined the need for referral by asking
some questions of the caller. If a referral is needed, the GIS-based
transport system will arrange transport for patients. This transport
system helps to ensure the continuous availability of transportation,
identifying the fastest route, and selecting the most appropriate vehicles
based on the road types. However, there are some areas which not
correctly mapped in the system. Therefore, future improvement is
needed to include all areas accurately.
A study in Ghana [39] used a call center to link frontline providers
to specialists and consultants to obtain expert advice and facilitate and
coordinate referrals. To coordinate referral, the call center helps ar-
range bed availability, arranges transportation with the National Am-
bulance Service, and follow-up of patients after arriving at the referral
hospital. However, some challenges occurred in the actual im-
plementation of this technology, such as a continuing problem related
to rejection from referral hospitals to receive emergency cases with “no
beds” as a reason, and mistrust of the referral hospitals among call
center staff.
N.C. Harahap, et al.
Table 4
Technologies to support maternal and neonatal referral systems.
No Technology Countries
1 Mobile application or mobile health (mHealth) Kenya, Guatemala, Tanzania
2 Call-center or toll free mobile communication Bangladesh, Ghana, Kenya
3 Telehealth Kenya
4 GIS-based transport system Bangladesh
5 Monitoring system Guatemala
In Guatemala [40], mobile health (mHealth) is used to provide
support and guidance to traditional birth attendants (TBAs) when they
evaluate patients, including providing a complication guide and link to
health facilities to make the referral. To facilitate referral, mHealth
provides an on-call medical team to coordinate transport to the hospital
with a local ambulance or private car, and communicates with the
hospital about the referral. Moreover, mHealth also facilitates updates
to TBA and the patient's family about the current condition of the pa-
tient. However, non-compliance to referral still occurs, such as lack of
permission from the family to follow referral, a patient's fear of the
hospital due to cultural or language barriers, and lack of a patient's
knowledge to recognize the complication as an emergency.
Guatemala also developed a low-cost perinatal monitoring system to
be used by traditional birth attendants [71]. This system is intended to
improve screening of complicated cases, advice seeking, and timely and
relevant referrals to higher levels. This technology uses devices such as
the shelf sensors, 1D Doppler fetal heart monitor, and a pulse oximeter
to monitor the mother's condition. The devices are connected to a
smartphone to record monitoring data. However, some participants still
have difficulties in using this technology, which is generally due to lack
of experience or familiarity in using technology and education levels.
Therefore, to use the technology more optimally in the future, more
training is needed.
In Tanzania [41], an mHealth for Safer Deliveries program was
developed, with aims to overcome delays in receiving care and in-
creasing levels of postnatal care at the health facility. The mHealth
provides a decision-support application for community health workers
(CHWs) to support some activities. One of the functions of decision-
support is to provide guidance to CHWs in screening complications of
women and their babies and refer them as needed to the health facility.
Although this decision-support function helps CHW to increase their
confidence to make decisions about the referral, the cost to be incurred
can be a barrier for mothers to receive care in the health facility.
When implementing technologies, social or human-related factors
should be considered to ensure the success of the implementation. An
mHealth for safer deliveries in Tanzania seems to be successful because
this program can address social or cultural issues in the community. For
example, healthcare workers took the initiative to hold community
meetings to increase facility attendance awareness [41]. Moreover, this
program also provided education and encouragement to families to
seek care at the facility; financial incentives that are given to healthcare
workers to ensure their motivation in this project, and continuous do-
nation support from certain parties to ensure the continuity of this m-
health implementation [74].
5. Conclusion and recommendations
5.1. Conclusion
Barriers in maternal and neonatal referral system can be summar-
ized into two main factors: healthcare systems and patient factors.
8
Informatics in Medicine Unlocked 15 (2019) 100184
Function(s) References
- Complication and referral guidance [37,40,41]
- Referral coordination
- Referral form
- Patients follow-up
- Complication and referral guidance [38,39,69]
- Referral coordination
- Patients follow-up
- Consultation support [69]
- Referral decision
- Transportation arrangement for referral [70]
- Patients monitoring and complication detection [71]
Healthcare system factors are related to accessibility of health facilities
and the inability of health providers to manage patient conditions or to
refer patients appropriately, while patient factors are related to patient
considerations or decision to follow the referral which are often related
to socioeconomic or cultural factors. Barriers from the healthcare
system include transportation, communication, quality of care, referral
documentation, standard and monitoring, and network infrastructure.
Barriers from patients include environments, knowledge about the re-
ferral, poverty, health status of the mother, and culture.
According to the three delays model of Thaddeus and Maine (1994)
[3], healthcare system factors are more important than patient factors.
Barriers from patient factors showed that these factors are related to
socioeconomic and cultural factors. Based on the model, these barriers
can cause phase 1 delay, that is, deciding to seek care. Barriers from
healthcare system factors indicate that these factors are related to ac-
cessibility and quality of care. These factors can not only cause phase 1
delay, that is deciding to seek care but can also cause phase 2 delay,
reaching an adequate health care facility, and phase 3 delay, receiving
adequate care at the facility. Therefore, barriers in healthcare system
factors are more important factors to be considered as compared with
patient factors, because healthcare system factors can cause more de-
lays in the referral system, thus contributing to maternal or neonatal
death.
Some developing countries have used technologies to improve ma-
ternal and neonatal healthcare, including referral. These technologies
are mobile technologies and call centers, to assist healthcare workers in
identifying cases of complications in pregnant women, with referral as
needed. These technologies can address some barriers of maternal and
neonatal referral from healthcare system factors, such as coordination
and communication to the referral facility, transportation arrange-
ments, and follow-up of patient conditions after being referred.
However, some of these technologies still cannot address barriers from
patient factors. Some patients do not follow the referral advice due to
lack of knowledge about the referral, poverty, and cultural factors.
Network problems and lack of involvement or mistrust of healthcare
workers and healthcare facilities to use these technologies also was
exhibited in some literature.
5.2. Solutions and recommendations
Some interventions can be made to address barriers in the maternal
and neonatal healthcare systems of developing countries. The use of
technologies, as reviewed in the previous section, can be used to sup-
port pre-referral communication and to coordinate referral, including
transportation arrangements and detection of complicated cases. In
addition to addressing the transportation barrier, in India, there is a
Janani Express Yojana scheme that provides 24/7 emergency transport
services to patients in rural Madhya Pradesh [44]. The use of technol-
ogies in the previous section can also be used to improve quality of care
by providing complication guidelines, and helps healthcare workers in
making the decision of referral. To address the documentation barrier,

Table 5
Recommendations to address barriers in maternal and neonatal referral systems.
No Barrier
1 Transportation
2 Communication
9
3 Quality of Care
4 Referral Documentation
5 Referral Monitoring
6 Knowledge about Referral
7 Poverty
Solution
Transportation Arrangements
Communication Technology
Complication guide
Digitalized documentation
Referral Monitoring Feature
Health Education Program
Health Insurance Program
N.C. Harahap, et al.
Example(s) References
A call center in Ghana helps arrange transportation for referral with National Ambulance Service. [39]
mHealth in Guatemala provides the on-call medical team to coordinate transport to the hospital with a local ambulance or private cars. [40]
Janani Express Yojana scheme that provides 24/7 emergency transport services in India. Patients can use a call center to request a vehicle to take them to the [44]
hospital for emergency cases and drop them back home after treatment.
GIS-based transport system in Bangladesh to arrange transportation for patients when referral is needed. [70]
mPAMANECH in Kenya utilizes short message service (SMS) and hotlines to coordinate referral. [37]
Toll-free mobile communication in Bangladesh helps mothers in seeking care to the appropriate facility, including facilitating referral if a complication [38]
occurred.
A call center in Ghana facilitate and coordinate referrals. [39]
mHealth provides the on-call medical team to help traditional birth attendants (TBAs) communicate with the hospital about the referral and facilitate updates to [40]
TBA and the patient's family about the current condition of the patient.
The call center links the special care units to the midwifes and mothers of newborns and support follow up patients after discharge. [69]
mPAMANECH in Kenya helps community health volunteers (CHV) to identify high risk and complication cases of maternal and newborns and make timely and [37]
correct decisions on referral.
Toll-free mobile communication in Bangladesh provides complication guide and help in taking decision for the referral. [38]
A call center in Ghana link frontline providers to specialists and consultants to get expert advice. [39]
mHealth in Guatemala provide support and guidance to traditional birth attendants (TBAs) when evaluating patients, including complication guide. [40]
mHealth for Safer Deliveries program in Tanzania provides a decision-support application to guide community health workers (CHWs) in screening [41]
complications of women and their babies.
The telehealth in Kenya provides consultation support between clinicians and pediatricians to facilitate timely decision making for referral [69]
A low-cost perinatal monitoring system in Guatemala can help traditional birth attendants (TBAs) to monitor patients' conditions and detect complications. [71]
mPAMANECH helps in documentation by replacing paper-based forms and allows integration of patient data for better referral and management of patients. [37]
SijariEMAS in Indonesia provides a feature for referral monitoring that can be done by PSC Call Center staff or Health Office staff. [45]
In Kenya, Jacaranda Health using SMS to engage women and husbands to improved uptake of antenatal and postnatal care. [46]
Enfants du Monde program provides free health education to pregnant women and their family to improve the health of mothers and babies in El Salvador and [47]
Burkina Faso.
Janani Suraksha Yojana (JSY) program in India to support the poor woman to deliver at health facilities. [18]
Health insurance program like Jaminan Kesehatan Masyarakat (Jamkesmas) in Indonesia can increase poor woman access to deliver at a health facility. [36]
However, this program did not provide coverage for referral transport and hospital stay.
Informatics in Medicine Unlocked 15 (2019) 100184
N.C. Harahap, et al.
mPAMANECH in Kenya helps in replacing paper-based forms and al-
lows integration of patient data for better referral and management of
patients.
The use of technologies should also be used to monitor the effec-
tiveness of the referral. For example, the Sistem Informasi Jejaring
Rujukan Maternal & Neonatal (SIJARIEMAS) Referral Exchange System
in Indonesia provides a feature to monitor referral communication that
can be done by PSC Call Center staff or Health Office staff. Some pro-
grams are held to improve patient knowledge about the health of mo-
thers or babies. Other examples include the Jacaranda Health Program
in Kenya and Enfants du Monde program in El Salvador and Burkina
Faso. Although these programs do not directly discuss the referral, the
same approach might be used to educate patients about the referral
system. Some health insurance programs like Jaminan Kesehatan
Masyarakat (Jamkesmas) in Indonesia and Janani Suraksha Yojana
(JSY) in India can support poor woman to deliver at health facilities
[18,36]. Furthermore, government support to provide the investment in
network infrastructure to maximize the use of technologies and the
investment in road infrastructure should also be considered. Table 5
below summarizes some examples of technologies or healthcare pro-
grams to address some barriers in maternal and neonatal referral sys-
tems.
6. Limitations and future work
This study has some limitations. This study has the limited number
of articles reviewed due to a small number of keywords and database
used. In addition, this studies only discuss the maternal and neonatal
referral system from patient and healthcare system perspectives. Future
research can be done to understand the maternal and neonatal referral
system from different views, such as community involvement or gov-
ernment programs, to address the barriers of the maternal and neonatal
referral system in developing countries.
Consent
Written and signed consent: none.
Author contribution
Nabila Clydea Harahap: designing, writing, and revising the article.
Putu Wuri Handayani: concepting the study, writing assistance, and
approving the final version to be submitted.
Achmad Nizar Hidayanto: writing assistance and approving the final
version to be submitted.
Acknowledgement
This work was supported by PITTA-A grant University of Indonesia
with contract number: NKB-0351/UN2.R3.1/HKP.05.00/2019.
References
[1] Health - United Nations Sustainable Development. United Nations sustainable de-
velopment (n.d.). https://www.un.org/sustainabledevelopment/health/ (accessed
19 January 2019).
[2] A child under 15 dies every five seconds around the world – UN report. Unicef.Org.;
2018 accessed 19 January 2019 https://www.unicef.org/press-releases/child-
under-15-dies-every-five-seconds-around-world-un-report.
[3] Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med
1994;38:1091–110. https://doi.org/10.1016/0277-9536(94)90226-7.
[4] Giovine, Ostrowski C. Improving transportation and referral for maternal health:
knowledge gaps & recommendations. Woodrow Wilson International Center for
Scholars; 2010 accessed 1 December 2018 https://www.wilsoncenter.org/sites/
default/files/Transport%20Referral%20Meeting%20Technical%20Report.pdf.
[5] Murray S, Pearson S. Maternity referral systems in developing countries: current
knowledge and future research needs. Soc Sci Med 2006;62:2205–15. https://doi.
org/10.1016/j.socscimed.2005.10.025.
[6] Krasovec K. Auxiliary technologies related to transport and communication for
10
Informatics in Medicine Unlocked 15 (2019) 100184
obstetric emergencies. Int J Gynecol Obstet 2004;85:S14–23. https://doi.org/10.
1016/j.ijgo.2004.02.007.
[7] WHO. Module 9. Studying the health network, Who.Int (n.d.). https://www.who.
int/hac/techguidance/tools/disrupted_sectors/module_09/en/index4.html (ac-
cessed 1 December 2018).
[8] Maternal mortality. UNICEF DATA. UNICEF DATA; 2017https://data.unicef.org/
topic/maternal-health/maternal-mortality/ (accessed 1 December 2018).
[9] Neonatal mortality. UNICEF DATA. UNICEF DATA; 2018https://data.unicef.org/
topic/child-survival/neonatal-mortality/ (accessed 1 December 2018).
[10] WHO. Management of health facilities: referral systems, Who.Int (n.d.). https://
www.who.int/management/facility/referral/en/ (accessed 1 December 2018).
[11] Medical referral care standard (life-saving), Emergency.Unhcr.Org (n.d.). https://
emergency.unhcr.org/entry/115577/medical-referral-care-standard-lifesaving (ac-
cessed 1 December 2018).
[12] Maternal health, world health organization. (n.d). https://www.who.int/maternal-
health/en/ (accessed 1 December 2018).
[13] Infant, newborn, world health organization. (n.d). https://www.who.int/infant-
newborn/en/ (accessed 1 December 2018).
[14] Standards for improving quality of maternal and newborn care in health facilities.
Geneva, Switzerland: World Health Organization; 2016http://apps.who.int/iris/
bitstream/handle/10665/249155/9789241511216-eng.pdf;jsessionid=
15CCE39453B6FABD6F1351ADB33AAA88?sequence=1 (accessed 1 December
2018).
[15] Jahn V Brouwere. Referral in pregnancy and childbirth: concepts and strategies.
Studies In Health Services Organisation & Policy 2001;17:229–46.
[16] Cronin P, Ryan F, Coughlan M. Undertaking a literature review: a step-by-step
approach. Br J Nurs 2008;17:38–43. https://doi.org/10.12968/bjon.2008.17.1.
28059.
[17] Ferrari R. Writing narrative style literature reviews. Med Writ 2015;24:230–5.
https://doi.org/10.1179/2047480615z.000000000329.
[18] Chaturvedi S, Randive B, Diwan V, De Costa A. Quality of obstetric referral services
in India's JSY cash transfer programme for institutional births: a study from Madhya
Pradesh province. PLoS One 2014;9. https://doi.org/10.1371/journal.pone.
0096773. e96773.
[19] Singh S, Doyle P, Campbell O, Mathew M, Murthy G. Referrals between public
sector health institutions for women with obstetric high risk, complications, or
emergencies in India – a systematic review. PLoS One 2016;11. https://doi.org/10.
1371/journal.pone.0159793. e0159793.
[20] Vail B, Morgan M, Dyer J, Christmas A, Cohen S, Joshi M, et al. Logistical, cultural,
and structural barriers to immediate neonatal care and neonatal resuscitation in
Bihar, India. BMC Pregnancy Childbirth 2018;18. https://doi.org/10.1186/s12884-
018-2017-5.
[21] Rehman S, Ahmed J, Bahadur S, Ferdoos A, Shahab M, Masud N. Exploring op-
erational barriers encountered by community midwives when delivering services in
two provinces of Pakistan: a qualitative study. Midwifery 2015;31:177–83. https://
doi.org/10.1016/j.midw.2014.08.006.
[22] Afari H, Hirschhorn L, Michaelis A, Barker P, Sodzi-Tettey S. Quality improvement
in emergency obstetric referrals: qualitative study of provider perspectives in Assin
North district, Ghana. BMJ Open 2014;4. https://doi.org/10.1136/bmjopen-2014-
005052. e005052.
[23] Gulema Austin, H, Belizan M, Colaci D, Kendall T, Tebeka M, et al. Barriers to
providing quality emergency obstetric care in Addis Ababa, Ethiopia: healthcare
providers' perspectives on training, referrals and supervision, a mixed methods
study. BMC Pregnancy Childbirth 2015;15. https://doi.org/10.1186/s12884-015-
0493-4.
[24] Shimoda K, Leshabari S, Horiuchi S, Shimpuku Y, Tashiro J. Midwives' intrapartum
monitoring process and management resulting in emergency referrals in Tanzania: a
qualitative study. BMC Pregnancy Childbirth 2015;15. https://doi.org/10.1186/
s12884-015-0691-0.
[25] Chi P, Bulage P, Urdal H, Sundby J. Barriers in the delivery of emergency obstetric
and neonatal care in post-conflict Africa: qualitative case studies of Burundi and
northern Uganda. PLoS One 2015;10. https://doi.org/10.1371/journal.pone.
0139120.
[26] Josyula S, Taylor K, Murphy B, Rodas D, Kamath-Rayne B. Obstetric referrals from a
rural clinic to a community hospital in Honduras. Midwifery 2015;31:1054–9.
https://doi.org/10.1016/j.midw.2015.07.002.
[27] Nalwadda C, Waiswa P, Guwatudde D, Kerber K, Peterson S, Kiguli J. ‘As soon as the
umbilical cord gets off, the child ceases to be called a newborn’: sociocultural beliefs
and newborn referral in rural Uganda. Glob Health Action 2015;8:24386. https://
doi.org/10.3402/gha.v8.24386.
[28] Rosales S Sulistyo, Miko O, Hairani L, Ilyana M, Thomas J, et al. Recognition of and
care-seeking for maternal and newborn complications in Jayawijaya district, Papua
province, Indonesia: a qualitative study. J Health Popul Nutr 2017;36. https://doi.
org/10.1186/s41043-017-0122-0.
[29] Okuga M, Kemigisa M, Namutamba S, Namazzi G, Waiswa P. Engaging community
health workers in maternal and newborn care in eastern Uganda. Glob Health
Action 2015;8:23968. https://doi.org/10.3402/gha.v8.23968.
[30] Essendi H, Johnson F, Madise N, Matthews Z, Falkingham J, Bahaj A, et al.
Infrastructural challenges to better health in maternity facilities in rural Kenya:
community and healthworker perceptions. Reprod Health 2015;12. https://doi.
org/10.1186/s12978-015-0078-8.
[31] Mbekenga Pembe, C, Olsson P, Darj E. Why do women not adhere to advice on
maternal referral in rural Tanzania? Narratives of women and their family mem-
bers. Glob Health Action 2017;10:1364888. https://doi.org/10.1080/16549716.
2017.1364888.
[32] Atuoye K, Dixon J, Rishworth A, Galaa S, Boamah S, Luginaah I. Can she make it?
N.C. Harahap, et al.
Transportation barriers to accessing maternal and child health care services in rural
Ghana. BMC Health Serv Res 2015;15. https://doi.org/10.1186/s12913-015-
1005-y.
[33] Kiruja J, Osman F, Egal J, Essén B, Klingberg-Allvin M, Erlandsson K. Maternal
near-miss and death incidences – frequencies, causes and the referral chain in
Somaliland: a pilot study using the WHO near-miss approach. Sex. Reprod. Healthc.
2017;12:30–6. https://doi.org/10.1016/j.srhc.2017.02.003.
[34] Nakano K, Nakamura Y, Shimizu A, Alamer S. Exploring roles and capacity devel-
opment of village midwives in Sudanese communities. Rural Rem Health 2018.
https://doi.org/10.22605/rrh4668.
[35] Awoonor-Williams J, Bailey P, Yeji F, Adongo A, Baffoe P, Williams A, et al.
Conducting an audit to improve the facilitation of emergency maternal and new-
born referral in northern Ghana. Glob Public Health 2015;10:1118–33. https://doi.
org/10.1080/17441692.2015.1027247.
[36] Brooks M, Thabrany H, Fox M, Wirtz V, Feeley F, Sabin L. Health facility and skilled
birth deliveries among poor women with Jamkesmas health insurance in Indonesia:
a mixed-methods study. BMC Health Serv Res 2017;17. https://doi.org/10.1186/
s12913-017-2028-3.
[37] Bakibinga P, Kamande E, Omuya M, Ziraba A, Kyobutungi C. The role of a decision-
support smartphone application in enhancing community health volunteers' effec-
tiveness to improve maternal and newborn outcomes in Nairobi, Kenya: quasi-ex-
perimental research protocol. BMJ Open 2017;7. https://doi.org/10.1136/
bmjopen-2016-014896. e014896.
[38] Huq N, Azmi A, Quaiyum M, Hossain S. Toll free mobile communication: over-
coming barriers in maternal and neonatal emergencies in Rural Bangladesh. Reprod
Health 2014;11. https://doi.org/10.1186/1742-4755-11-52.
[39] Frimpong E, Oduro‐Mensah E, Vanotoo L, Agyepong I. An exploratory case study of
the organizational functioning of a decision‐making and referral support call center
for frontline providers of maternal and new born care in the Greater Accra Region of
Ghana. Int J Health Plan Manag 2018;33:e1112–23. https://doi.org/10.1002/hpm.
2595.
[40] Martinez B, Ixen E, Hall-Clifford R, Juarez M, Miller A, Francis A, et al. mHealth
intervention to improve the continuum of maternal and perinatal care in rural
Guatemala: a pragmatic, randomized controlled feasibility trial. Reprod Health
2018;15. https://doi.org/10.1186/s12978-018-0554-z.
[41] Battle J, Farrow L, Tibaijuka J, Mitchell M. mHealth for Safer Deliveries: a mixed
methods evaluation of the effect of an integrated mobile health intervention on
maternal care utilization. Healthcare 2015;3:180–4. https://doi.org/10.1016/j.
hjdsi.2015.10.011.
[42] Country classification, world economic situation and prospects. 2014 accessed 1
January 2019 http://www.un.org/en/development/desa/policy/wesp/wesp_
current/2014wesp_country_classification.pdf.
[43] Ministry of transport and communications. https://www.itu.int/en/Lists/
consultationOct2016/Attachments/66/ITU-CWG%202017.pdf (accessed 1 January
2019).
[44] Janani express yojna: health referral transport facility. OneWorld Foundation India;
2012http://indiagovernance.gov.in/files/JananiExpressYojana.pdf (accessed 10
January 2019).
[45] Sistem Informasi dan komunikasi jejaring rujukan pelayanan kesehatan
Masyarakat, Sijariemas.Net. (n.d). http://www.sijariemas.net/ (accessed 10
January 2019).
[46] Team J. Using mobile tech to influence behavior and improve maternal health.
Jacaranda Health; 2017 accessed 10 January 2019 https://jacarandahealth.org/
using-mobile-tech-to-influence-behavior-and-improve-maternal-health/.
[47] Enfants du Monde provides better healthcare, Enfants Du Monde. (n.d) accessed 10
January 2019 https://www.edm.ch/en/health/better-health.
[48] Bremnes HS, Wiig ÅK, Abeid M, Darj E. Challenges in day-to-day midwifery prac-
tice; a qualitative study from a regional referral hospital in Dar es Salaam, Tanzania.
Glob Health Action 2018;11. https://doi.org/10.1080/16549716.2018.1453333.
[49] Nwameme AU, Phillips JF, Adongo PB. Compliance with emergency obstetric care
referrals among pregnant women in an urban informal settlement of accra, Ghana,
matern. Child Health J 2014;18:1403–12https://doi.org/10.1007/s10995-013-
1380-0.
[50] Melberg AH Diallo, Tylleskar T, Moland KM. We saw she was in danger, but couldnt
do anything: missed opportunities and health worker disempowerment during birth
care in rural Burkina Faso. BMC Pregnancy Childbirth 2016;16https://doi.org/10.
1186/s12884-016-1089-3.
[51] Bhattacharyya S, Issac A, Rajbangshi P, Srivastava A, Avan BI. “Neither we are
satisfied nor they”-users and provider's perspective: a qualitative study of maternity
care in secondary level public health facilities, Uttar Pradesh, India. BMC Health
Serv Res 2015;15:1–14. https://doi.org/10.1186/s12913-015-1077-8.
[52] Jackson R, Tesfay FH, Godefay H, Gebrehiwot TG. Health extension workers' and
mothers' attitudes to maternal health service utilization and acceptance in adwa
woreda, tigray region, Ethiopia. PLoS One 2016;11https://doi.org/10.1371/
journal.pone.0150747.
[53] Sumankuuro J, Crockett J, Wang S. Perceived barriers to maternal and newborn
health services delivery: a qualitative study of health workers and community
members in low and middle-income settings. BMJ Open 2018;8https://doi.org/10.
1136/bmjopen-2017-021223.
[54] Kifle MM, Kesete HF, Gaim HT, Angosom GS, Araya MB. Health facility or home
delivery? Factors influencing the choice of delivery place among mothers living in
rural communities of Eritrea. J Health Popul Nutr 2018;37https://doi.org/10.
11
View publication stats
Informatics in Medicine Unlocked 15 (2019) 100184
1186/s41043-018-0153-1.
[55] Windsma M, Vermeiden T, Braat F, Tsegaye AM, Gaym A, van den Akker T,
Stekelenburg J. Emergency obstetric care provision in Southern Ethiopia: a facility-
based survey. BMJ Open 2017;7https://doi.org/10.1136/bmjopen-2017-018459.
[56] Shimoda K, Leshabari S, Horiuchi S, Shimpuku Y, Tashiro J. Midwives intrapartum
monitoring process and management resulting in emergency referrals in Tanzania: a
qualitative study. BMC Pregnancy Childbirth 2015;15https://search.proquest.com/
docview/1779725128?accountid=17242.
[57] Nuamah GB, Agyei-Baffour P, Akohene KM, Boateng D, Dobin D, Addai-Donkor K.
Incentives to yield to obstetric referrals in deprived areas of amansie west district in
the ashanti region, Ghana. Int J Equity Health 2016;15https://doi.org/10.1186/
s12939-016-0408-7.
[58] Manu A, Hill Z, ten Asbroek AHA, Soremekun S, Weobong B, Gyan T, Tawiah-
Agyemang C, Danso S, Amenga-Etego S, Owusu-Agyei S, Kirkwood BR. Increasing
access to care for sick newborns: evidence from the Ghana Newhints cluster-ran-
domised controlled trial. BMJ Open 2016;6https://doi.org/10.1136/bmjopen-
2015-008107.
[59] Kananura RM, Kiwanuka SN, Ekirapa-Kiracho E, Waiswa P. Persisting demand and
supply gap for maternal and newborn care in eastern Uganda: a mixed-method
cross-sectional study. Reprod Health 2017;14https://doi.org/10.1186/s12978-017-
0402-6.
[60] Long Q, Madede T, Parkkali S, Chavane L, Sundby J, Hemminki E. Maternity care
system in Maputo, Mozambique: plans and practice? Cogent Med 2017;4https://
doi.org/10.1080/2331205X.2017.1412138.
[61] Price JA, Soares AIFS, Asante AD, Martins JS, Williams K, Wiseman VL. “I go I die, I
stay I die, better to stay and die in my house”: understanding the barriers to ac-
cessing health care in Timor-Leste. BMC Health Serv Res 2016;16https://doi.org/
10.1186/s12913-016-1762-2.
[62] Oommen A. Neonatal health care services in India. Asian J. Nurs. Educ. Res.
2015;5:545–52https://doi.org/10.5958/2349-2996.2015.00112.3.
[63] Gondwe A, Munthali A, Ashorn P, Ashorn U. Investigating preterm care at the fa-
cility level: stakeholder qualitative study in central and southern Malawi. Matern
Child Health J 2016;20:1441–7https://doi.org/10.1007/s10995-016-1942-z.
[64] Mgawadere F, Unkels R, Kazembe A, van den Broek N. Factors associated with
maternal mortality in Malawi: application of the three delays model. BMC
Pregnancy Childbirth 2017;17https://doi.org/10.1186/s12884-017-1406-5.
[65] Scanagatta Wilunda, C, Putoto G, Takahashi R, Montalbetti F, Segafredo G, Betrán
AP. Barriers to institutional childbirth in rumbek north county, south Sudan: a
qualitative study. PLoS One 2016;11https://doi.org/10.1371/journal.pone.
0168083.
[66] Elmusharaf K, Byrne E, AbuAgla A, AbdelRahim A, Manandhar M, Sondorp E,
ODonovan D. Patterns and determinants of pathways to reach comprehensive
emergency obstetric and neonatal care (CEmONC) in South Sudan: qualitative
diagrammatic pathway analysis. BMC Pregnancy Childbirth 2017;17https://doi.
org/10.1186/s12884-017-1463-9.
[67] Dillip A, Kimatta S, Embrey M, Chalker JC, Valimba R, Malliwah M, Meena J, Lieber
R, Johnson K. Can formalizing links among community health workers, accredited
drug dispensing outlet dispensers, and health facility staff increase their colla-
boration to improve prompt access to maternal and child care? A qualitative study
in Tanzania. BMC Health Serv Res 2017;17https://doi.org/10.1186/s12913-017-
2382-1.
[68] John TW, Mkoka DA, Frumence G, Goicolea I. An account for barriers and strategies
in fulfilling women's right to quality maternal health care: a qualitative study from
rural Tanzania. BMC Pregnancy Childbirth 2018;18https://doi.org/10.1186/
s12884-018-1990-z.
[69] Gitaka J, Natecho A, Mwambeo HM, Gatungu DM, Githanga D, Abuya T. Evaluating
quality neonatal care, call Centre service, tele-health and community engagement
in reducing newborn morbidity and mortality in Bungoma county, Kenya. BMC
Health Serv Res 2018;18https://doi.org/10.1186/s12913-018-3293-5.
[70] Chowdhury AI, Haider R, YousufAbdullah A, Christou A, Ali NA, Rahman AE, Iqbal
A, Bari S, Emdadul Hoque DM, El Arifeen S, Kissoon N, Larson CP. Using geospatial
techniques to develop an emergency referral transport system for suspected sepsis
patients in Bangladesh. PLoS One 2018;13https://doi.org/10.1371/journal. pone.
0191054.
[71] Stroux L, King NE, Fathima S, Hall-Clifford R, Rohloff P, Clifford GD. A low-cost
perinatal monitoring system for use in rural Guatemala. IET Conf. Proc.
2014:1–4https://doi.org/10.1049/cp.2014.0777.
[72] Communications technology in emerging and developing Nations. Pew Research
Center's Global Attitudes Project; 2015 accessed 28 March 2019 https://www.
pewglobal.org/2015/03/19/1-communications-technology-in-emerging-and-
developing-nations/.
[73] Poushter J. Internet access grows worldwide but remains higher in advanced
economies. Pew Research Center's Global Attitudes Project; 2016 accessed 28
March 2019 https://www.pewglobal.org/2016/02/22/internet-access-growing-
worldwide-but-remains-higher-in-advanced-economies/.
[74] Mitchell M, Ruben J. Saving lives of mothers & infants in zanzibar. Globalgiving;
2013 accessed 28 March 2019 https://www.globalgiving.org/projects/
safedelivery/reports/.
[75] Establishing validity in qualitative research - center for innovation in research and
teaching, Cirt.Gcu.Edu; (n.d.). https://cirt.gcu.edu/research/
developmentresources/research_ready/qualitative/validity, [Accessed 28 March
2019].