Scaling up Mumbai's Maternal Health Referral System through Implementation Research

UN Photo/Mark Garten

Seema* (name changed) aged 24 years old, rocks her baby as she recalls how fortunate she is to have a healthy baby. "I went to a nearby hospital, and I was told go to another hospital due to complications. The umbilical cord was around my baby’s neck. The hospital organized my referral and I had a caesarean section and delivered a healthy 3.5 kg baby." smiles Seema.

Barriers accessing care

While multiple barriers exist for women to access antenatal care, one of the causes is the lack of an efficient referral system. In India, as in many other countries, public health systems are pyramidal in structure with several levels ranging from community health posts to tertiary hospitals. Weak referral systems can delay expectant mothers from seeking health care which can, in some cases affect the survival of both mother and baby.

Dr Shanti Pantvaidya, Executive Director for the Society for Nutrition, Education and Health Action (SNEHA), a non-profit organization that works to address the health needs of women and children in Mumbai explains, “In many heath facilities, referrals are often done ad-hoc, with little documentation to track referred clients and their outcomes. Many patients would bypass their local clinic and go directly to a tertiary hospital, which often causes overcrowding. In other cases patients due to long waiting times, do not go back for treatment."

Adding further, Dr Pantvaidya notes that in these settings there is no pre-referral communication between facilities. Facilities can accuse each other of inappropriate referrals but in many cases there was is no evidence either way. Outpatient referrals in emergencies are typically sent without a clinical summary which means that staff in the receiving facility had to repeat examinations, thus delaying treatment for the patient. Cases that could be treated at the secondary-level were often escalated leading to unnecessary referrals and increasing the workload of tertiary hospitals.

Alliance’s Implementation Research Grant in action

To improve this situation, SNEHA entered into a partnership with the Municipal Corporation of Greater Mumbai, in 2004 to develop and implement a participatory referral model. This model improved referral processes leading to a 22% decrease in the utilization of tertiary hospitals. As a result, SNEHA was invited to expand this model in three other municipalities in the greater Mumbai region.

“Too often interventions that work in small-scale pilot studies fail to live up to expectations when rolled-out to other settings due to contextual differences and other factors. The Alliance’s implementation research grants allow for researchers and programme implementers to jointly identify health system bottlenecks and find practical solutions to improve and expand a health programme to other areas,” explains Dr Abdul Ghaffar, Executive Director of the Alliance.

Working with the Alliance, SNEHA used implementation research and systems thinking to develop an appropriate, context sensitive referral system in the three municipalities.

Research Process

The implementation research study used both qualitative and quantitative research methods to understand how the model was scaled-up in the three municipalities. The study sought to understand impact, in terms of referral patterns, but more importantly processes by which referral linkages were established between different levels of the health system and the factors that influenced how these linkages were developed including the challenges faced.

Research Findings

A total of nine referral linkages were established between facilities in the three municipalities. Findings revealed that there was a need to produce standardised referral criteria including, clear and coordinated processes to track cases and follow-up on a patient’s status across the various referral pathways. Also, regular cross-facility provider meetings were held to jointly troubleshoot problems, find solutions and document progress.

“Many providers engaged in the project, agreed that the referral project had a positive outcome because of the interaction between researchers and implementers, which allowed for richer findings. They felt that better documentation, standardized referral forms, and guidelines improved communication with other health facilities. Peripheral hospitals accepted referral patients, which contributed immensely to improving antenatal and postnatal care, especially to high-risk pregnant women,” says Ms Sushma Shende, former Head of SNEHA’s Maternal and Newborn Health programme and who is currently leading its Child Health and Nutrition programme.

This model has not only improved ANC for pregnant women but is also reducing overcrowding in public tertiary hospitals, which is enabling the entire system to run more efficiently.

Benefits of Implementation Research

"Investing in implementation research is an investment rather than a cost, because the evidence found is context specific and if addressed in real-time provides important insights that will ultimately reduce wastage and improve the overall efficiency of the health system,” explains Dr Nhan Tran who leads the Alliance’s work on implementation research. To reap these benefits, implementation research should be used more regularly and embedded in the overall design, planning and decision-making process," adds, Dr Tran.

Through the Alliance’s grant and technical support, SNEHA has been able to use this knowledge to expand its referral model to more than 100 health facilities across four corporations in and around Mumbai, enabling more mothers, such as Seema to access ANC with greater ease.