MORES Intervention:
Following baseline collection of referral data, a two-day interactive
obstetric triage and MORES referral training was conducted with the
nurses and midwives at 20 RHFs and two district hospitals in Bong
County, Liberia. The training focused on recognition and management of
acutely ill pregnant woman, managing obstetric emergencies, and
prioritization of care. The healthcare providers were provided with an
overview of MORES, assigned unique ID, and messaging templates for RHF
referrals to the district hospitals (Figure 1) and templates for
received hospital referrals back to the RHF provider were designed to
ensure bi-directional communication (Figure 2). Templates for referrals
from providers at RHFs included information such as patient initials,
reasons for referral, time of referral, and type of transportation.
Templates for providers at the district hospitals to communicate back to
RHFs providers included information such as unique ID, patient initials,
referral received confirmation, patient’s arrival time and maternal and
newborn outcomes. Prior to the implementation of the MORES intervention,
referrals were handwritten at the RHF and carried by the women’s family
to the district hospital. Furthermore, these handwritten referrals would
often get misplaced and forgotten, causing the necessary information to
never reach the hospital.
Data collection and procedures :
Research assistants (RAs) from the Bong County health team obtained
permission from the RHFs and district hospitals to conduct chart reviews
and collect transfer data. A retrospective review of the hospital labor
and delivery logs for baseline referrals sent from the 20 RHFs to the
two district hospitals was conducted prior to implementation of the
MORES intervention. Data collection was repeated at endline, during the
final six months of the study. Identifying data was collected to link
data from hospital labor and delivery log and patient charts to data
from RHF logs. The linking document, and identifiable data, were
destroyed after clinical data were collected. Deidentified data
collected and used for analysis included date and time of departure from
RHF and hospital arrival, type of delivery, and maternal and newborn
outcomes. The hospital logs contained more referral records than those
recorded in the RHF logs, as not all women referred arrived at the
district hospital. Thus, data were sorted as complete (hospital data
linked to RHF data) or incomplete (hospital records only).
Data management and analysis :
Referral data were collected via paper and pen, entered into Excel and
exported into Stata 17 (StataCorp, College Station, TX, USA) for
analysis. All paper copies were stored in a locked cabinet at the county
health office in Bong County. All digital data were stored in an
encrypted DropBox folder only accessible to the research team.
Descriptive analyses were conducted for all baseline and endline data
and analyzed as separate cohorts (complete and incomplete). Frequency
and percentage were tabulated for RHFs, referrals to district hospitals,
reasons for referral, and outcome variables including mode of delivery,
maternal outcome, newborn outcome, and transfer time from RHF to
district hospital. Transfer time was further presented as mean with
(SD), as well as the median time, and categorized into two hours or
less, between two hours and twelve hours, and more than 12 hours. The
two hours or less category was included per The Lancet’sdefinition of geographic accessibility, with access to a health facility
with the capacity to provide essential surgical and anesthesia services,
including CS, within two hours (14). Furthermore, the 12 hours or less
and more than 12 hours were included because despite a referral from a
RHF, woman often go back home before going to the referred hospital.
Binary logistic regression models and linear regression models were fit
to assess the relationship between the timepoint of the data (baseline,
endline), mode of delivery, maternal outcome, newborn outcome, and
transfer time. All models accounted for the clustering of individuals
within hospital and RHF. All logistic regression models provided odds
ratios (ORs) and 95% confidence intervals (95% CIs) and linear
regression models provided coefficient and standard error (SE).
Ethics :
Ethical approval for the study was obtained from the Institutional
Review Boards of the University of Michigan and University of Liberia.
The study used retrospective medical records, the data were fully
anonymized before analysis, and the ethics committee waived the
requirement for the informed consent.