Phone calls make a difference in referral of labour cases in West Gonja

Esther wakes up every morning wondering what difference she can make and be remembered for in the Mole-Larabanga community. She has attended midwifery training, as well as many other training sessions, so she can provide better quality care for pregnant women and newborns.

She was posted to the health centre to provide skilled and safe delivery for women in labour. However, she was afraid of losing her midwifery skills due to lack of practice; from January to June 2008, Esther conducted only one labour case. She might have passed the blame on the community, local beliefs, and challenges regarding transport. Instead, Esther and her team kept trying various methods to increase the rate of skilled delivery in her community.

Using the QI methodology

In July 2008, “Project Fives Alive!” began work in the Northern Region, using quality improvement (QI) to reduce maternal and child mortality (MDG four and five). Esther was invited to participate in the first Learning Session in Tamale. Using the QI methodology, she identified the root causes of the low skilled delivery in her facility and learned about testing changes on a small scale using the Model for Improvement (Plan-Do-Study-Act), which uses repeated cycles of testing changes, learning, and revising your approach. 

She also learned that, rather than reinventing the wheel, she could borrow change ideas that were effective for others. Esther started by sharing her telephone number with pregnant women and their caregivers, so they could call when labour sets in. She monitored this change for a while and observed that some caregivers called when labour was too advanced and problems had already developed. Learning from this, Esther ensured that her field bag was well packed with the things needed to conduct a domiciliary delivery. She also documented and analysed phone call data to assess its effectiveness. 

Analysis of the data showed that, at Esther’s facility, deliveries increased from 18 per cent in 2008 to 90 per cent in 2012. Current data show that they have exceeded the performance of 2012.

Learning from the use of mobile phone, Esther next initiated a change around efficient transport systems to ensure that labour cases were transported to the hospital, especially for those cases she was unable to manage or when she was on other assignments.

 She began by initiating a discussion with her district director and medical superintendent on the need to support her request for transport any time there was an emergency because her community is 18 kilometres from the district hospital. They accepted her request, and shared her phone number with the drivers in the district.

Unrestricted access to vehicles  

She therefore had unrestricted access to the vehicles at the hospital and the District Health Management Team (DHMT) for such purposes. Due to the level of poverty in the area, patients and caregivers were not required to have any money before transportation was provided.

The good relationship Esther established with the drivers also accounted for the quick response whenever she called a driver to carry a labouring woman to the hospital. In fact, the drivers contributed significantly to the success of the interventions. 

Having realised that the phone calls made a difference in the referral of labour cases, Esther met with her team to explore how to spread the change idea to improve referral compliance for children less than five years (Under-5) in the community. 

She started by assessing the default rate for referral by collecting baseline data on all cases referred in the past six months and the outcome of referral. Specifically, she was looking forward to see whether patients complied early (within 24 hours), complied late (after 24 hours), or never complied. She observed from the baseline that only 17 per cent of all cases referred actually complied. She found this unacceptable and decided to initiate changes to improve compliance. 

Improving counselling 

The first idea the team tested was improving counselling of caregivers about the reasons for the referral. Some people felt that if a child was referred to the hospital, the child was likely to die. They started with counselling and documented all the referred cases. They also followed up with the hospital to check their records to confirm compliance. 

Although they saw improvement in the first three months of testing, thereafter the rate of referral compliance started decreasing. Discouraged, they considered giving up on the changes, but with the support of “Project Fives Alive!” improvement advisors they agreed to do thorough analysis of the data to see what might have accounted for the decrease. 

Ensuring compliance

They discovered that the referral rate decreased when counselling was either done poorly or not done at all; patients simply returned to their homes and no follow-up was carried out. The QI team then decided to include additional changes to ensure compliance. 

A referred patient was kept in the health facility for observation to allow the caregiver to go home and get prepared while they called for a vehicle from the hospital or the DHMT. 

For those they were convinced would go to the  referred hospital, they allowed them to take the child home, but quickly contacted the community health  volunteer to follow  up to the home of the patient to ensure that the child was taken to the hospital. They also called the hospital OPD to find out if the patient had been brought there. 

The writer is a Senior Project Officer of “Project Fives Alive!”