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.