1.
E-Referral Systems for Maternal Health
Mumbai, India
Health Information Systems to
Improve Quality of Care in Resource Poor Settings
May 13, 2011
Presented by:
Rachel Koffman
Crystal Lawrence
Tseli Mohammed
S a n a
|
P a r t n e r s
i n
H e a l t h |
M I T
O p e n C o u r s e W a r e
H e l l e r
S c h o o l
f o r
S o c i a l
P o l i c y
a n d
M a n a g e m e n t ,
B r a n d e i s
U n i v e r s i t y

2. E-Referral Systems for Maternal Health | Mumbai, India
Initial Problem
There are great disparities in the provision and access to maternal
healthcare worldwide, most often attributed to differences in socioeconomic
factors. This issue is most apparent in the divide between standards of maternal
health between the developed and developing world. Developing countries
account for 99% of all maternal deaths, as over a thousand women die daily
from preventable complications during pregnancy and childbirth.1
Latest estimates reveal that in the developed world, the maternal
mortality ratio2 (MMR) was estimated at 14 per 100,000 births, whilst in
developing regions, it was estimated at 290 per 100,000 births (2008)3. Though
this demonstrated gap, related to access to care and information, poverty, and
sociocultural norms and practices, has been declining (2.3% per year1).
India, a country with one of the fastest growing economies today, has
had a similar decline in its MMR over time, yet in its most populous city, Mumbai
this is not the case. The MMR of Mumbai has been estimated to he as high as
450 deaths per 100,000 births4.
“…in the heart of Mumbai last year over 200 women died at childbirth beating
the figure of 154 last year. This shows how maternal mortality in the city is rising at
an alarming pace each year.” (February, 2011)5
One suggested mechanism to help mitigate this rising issue in Mumbai, is
the development and implementation of an e-referral system, to efficiently and
effectively link primary level maternal healthcare to appropriate secondary and
tertiary level care when necessary.
1
World
Health
Organization.
Maternal
Health
Factsheet.
November
2010.
Retrieved
from:
http://www.who.int/mediacentre/factsheets/fs348/en/index.html
2
Maternal
Mortality
Ratio
is
defined
as
“the
number
of
maternal
deaths
in
a
population
divided
by
the
number
of
live
births.
It
depicts
the
risk
of
maternal
death
relative
to
the
number
of
live
births.”
(WHO)
2008.
3
WHO,
UNICEF,
UNFPA
and
the
World
Bank.
Trends
in
Maternal
Mortality:
1990-­‐2008.
Retrieved
from:
http://www.who.int/reproductivehealth/publications/monitoring/9789241500265/en/index.html
Society
for
Nutrition,
Education
and
Health
Action.
Retrieved
from:
http://www.snehamumbai.org/index.php
4
New
Delhi
Television
(ndtv.com):
News.
Mumbai’s
Rising
Maternal
Mortality
Rate.
Retrieved
from:
5
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3. E-Referral Systems for Maternal Health | Mumbai, India
Within the current maternal healthcare system of Mumbai, there are a few
issues specific to the contextual setting and acceptable standard procedures:
• Lack of coordination between primary, secondary and tertiary care:
o Patients often referred to tertiary, skipping secondary care, even if appropriate.
o Results in bottlenecks at tertiary care, and unused secondary care.
o Providers lack expertise and confidence to refer to secondary care (sociocultural
issues within primary care organizations).
• Inefficient and ineffective patient tracking – within each and amongst the
three different levels of care.
• Lack of patient follow-up after referral.
An integrated e-referral system that connects the three levels of maternal
healthcare can target these challenges of the current system, improving
communication and coordination between the varying levels. The system would
not only increase efficiency and improves competencies, but also reduce
mismanagement of paper records, and improves legibility of clinical notes.
Additionally, it doubles as a form of electronic data collection, which can be
used for monitoring and evaluation purposes and inform future
recommendations for the system.
Background
Maternal mortality and morbidity is a severe and prevalent problem in
India. The maternal mortality ratio estimated at 500 per 100,000 live births is as
much as fifty times higher than many developing countries and six times higher
than neighboring developing country, Sri Lanka6. Causes of maternal death in
order of most prevalent are hemorrhage, infection, hypertension, and
obstructed delivery. Maternal mortality in India accounts for 25% of all maternal
death worldwide7.
6
Pachauri,
Saroj.
Defining
a
Reproductive
Health
Package
for
India:
A
Proposed
Framework
7
Goldie
SJ,
Sweet
S,
Carvalho
N,
Natchu
UCM,
Hu
D,
2010
Alternative
Strategies
to
Reduce
Maternal
Mortality
in
India:
A
Cost-­‐Effectiveness
Analysis
| Health Information Systems to Improve Quality of Care in Resource Poor Settings | 3

4. E-Referral Systems for Maternal Health | Mumbai, India
In order to meet Millennium Development Goal 5 there needs to be a
global reduction in maternal mortality of 5% annually. Between 1990 and 2005,
global maternal deaths decreased by only 1%; in India, the decrease in
maternal deaths between 1990 and 2005 was about 1.8%.
Mumbai, India, has a population of approximately 12.5 Million. The most
populous city in India, it is also generally accepted as the richest, with the
highest GDP in the country. The densely populated, urbanized city has an
average of literacy rate 89.7%, higher than the national average of 71.7%8.
The city has vast and robust healthcare infrastructure, with specific
facilities and providers in place to supply maternal healthcare services:
• 3 tertiary hospitals (also medical colleges)
• 13 peripheral hospitals with maternity wards
• 25 maternity hospitals
• 167 health posts - primary health centers in slums
• 150 dispensaries
Although more than 95% women register in the
antenatal period, almost 50% of those women visit a hospital
for the first time in the last three months of their pregnancy.
Additionally, although 91% of pregnant women deliver in
hospitals, almost one-third of them arrive on average only
half an hour before delivery. From this, we can imply that in
such circumstances, there is little time to diagnose and
respond to any preventable complications that may arise.
“Public infrastructure is often sub-optimally utilized. It is the product of a range of
interrelated factors such as… , poor referral systems.., attitudinal and
management challenges, inappropriateness and inefficiency of data
management systems.”9
8
Census
of
India,
2001.
Basic
Data
Sheet:
District
Mumbai
and
Mumbai
(Suburban)
Retrieved
from:
http://www.censusindia.gov.in/Tables_Published/Basic_Data_Sheet.aspx
Society
for
Nutrition
Education
and
Health
Action
(sNEHA).
City
Initiative
for
Newborn
Health,
Mumbai:
Overview
and
Protocol.
Pg
4.
9
| Health Information Systems to Improve Quality of Care in Resource Poor Settings | 4

5. E-Referral Systems for Maternal Health | Mumbai, India
Pilot System: E-Referral Software for Maternal Health
Launched in 2010 Sana MRS Mumbai© is an e-referral, patient tracking
software system being piloted by 2 Primary, 1 Secondary and 1 Tertiary
healthcare facilities. The software aims to improve coordination, tracking, and
patient follow-up between the provider institutions, especially in terms of
maternal health referrals.
System Overview:
• Each doctor registers with username and password, needed to securely
access the system (screenshot 1).
• Primary care doctors complete patient forms (screenshot 2).
• Referrals inputted into system when necessary, and referred provider
(secondary or tertiary facility) sent automatic notification (screenshot 3).
• Patient given information regarding referral, including patient tracking ID #.
• Patient tracked to ensure visit to referred provider (screenshot 4).
1 2
3
4
| Health Information Systems to Improve Quality of Care in Resource Poor Settings | 5

6. E-Referral Systems for Maternal Health | Mumbai, India
Research
Our research highlighted the significant problem area of inadequate
health care for pregnant women both in India and in most developing
countries. The use of referral systems as a way to ensure adequate care once
women have access to essential services, when successfully implemented, has
been linked to reductions in pregnancy related morbidity and mortality.
Often, the most significant problems associated with maternal mortality
occur before any referral system could have been useful in intervening to help
save a mother’s life – these are problems associated with access. Much of the
literature suggests that strengthening the health system to create greater access
is the most important tool to combat high maternal mortality rates. However, the
importance of adequate and functioning referral systems are consistently
mentioned as complimentary intervention to garnering health system access.
Findings
The Real Effects of Maternal Mortality and Morbidity
Maternal mortality and morbidity has extensive and detrimental effects on
families and communities beyond the death and sickness of the mothers
themselves. Effects of high rates of maternal mortality are linked to:
• Family disintegration and psychological problems
• Economic and social problems in the community and the country
• Children exposed to social risk
• Increased financial burdens on other family members
• Increases in health problems of children, i.e. increased prevalence of
childhood diseases, malnutrition, diarrhea etc.
| Health Information Systems to Improve Quality of Care in Resource Poor Settings | 6

7. E-Referral Systems for Maternal Health | Mumbai, India
Referral Systems Worldwide: Room for Improvement
Many countries both developing and developed have protocols for
referral systems for obstetric care. These guidelines provide examples of when
women should be referred to higher levels of care. Full implementation of
referral systems worldwide would result in between 30-50% more referrals of
pregnant women to antenatal or delivery care.10 The current global averages
for referral rates are between 6-12%, and significantly lower in rural areas where
maternal mortality rates are likely to be higher than in urban areas.
Significant Issue: The Three Delays Model11
The Three Delays Model gave us an interesting lens through which to view
the areas for technological intervention in reducing maternal mortality. The first
delay is defined as a delay in recognition of a health problem and the decision
to seek care. The second delay is related to reaching the appropriate facility,
either improper referral or transportation issues. The third delay is in the health
care actually provided and wait times/understaffing issues once the woman
reaches the facility. This model pinpoints the specific areas in need of
intervention to reduce maternal mortality. The pilot referral system in Mumbai
currently deals mostly with the second delay. If it is furthered to include
considering capacity at the partner health centers it could also combat
problems in the third delay arena.
Transportation: Referral Systems Main Challenge
Research has shown that transportation to referred health centers is
significant barrier to women obtaining the care they should receive. Even with a
computerized referral system in place, such as the Mumbai Pilot project, there is
no way of ensuring that the women will end up in her scheduled center for care.
Albrecht,
Jahn
and
Vincent
De
Brouwere
Referral
in
Pregnancy
and
Childbirth:
Concepts
and
Strategies
10
www.dfid.gov.uk/.../SystematicReviews/FINAL-­‐Q35-­‐Aberdeen_maternal_mortality.pdf
11
| Health Information Systems to Improve Quality of Care in Resource Poor Settings | 7

8. E-Referral Systems for Maternal Health | Mumbai, India
The literature suggests that adequate referral systems are complemented by
improvements in emergency transport coordination systems.
Technology in Referral Systems: Case Study Zambia
A report published by Research Triangle Institute (RTI) in 2010 on a study of
e-referral systems in Zambia advocates for electronic patient referral systems as
a precursor for full-scale electronic medical record systems (EMR). In comparison
to India, Zambia has a significantly higher MMR at 750 per 100,000 births. The
project moved the referral and recording system of pregnant women from hand
written booklets to an integrated e-referral system.
The project has yielded positive outcomes for both patients and
physicians. Physicians and staff now have immediate access to reports
concerning patients’ referrals, care received, patient preparation, and patient
discharging to close the care loop.12 Diagram 1 (see Appendix) shows the
schematic of how the system was set up. RTI concludes that in implementing a
referral system in a resource poor setting, lack of human capital, lack of physical
and material resources, and low usage need to be considered to have a
successful program.
Other Viable Technology Applications for Referral Systems
Many studies have highlighted telecommunications as an important tool
in referring women with high-risk pregnancies to hospitals for treatment. Many
systems have been set up in such a way that community health workers make
home visits to pregnant women and use technology (radios, cell phones, PDAs)
to refer and call ahead to facilities to ensure care for the women in danger of
pregnancy related complications.
12
Darcy,
N.,
Kelley,
C.,
Reynolds,
E.,
Cressman,
G.,
and
Killam,
P.
(2010).
An
Electronic
Patient
Referral
Application:
A
Case
Study
from
Zambia.
RTI
Press
publication
No.
RR-­‐0011-­‐1003.
Research
Triangle
Park,
NC:
RTI
International.
Retrieved
from:
http://www.rti.org/rtipress
| Health Information Systems to Improve Quality of Care in Resource Poor Settings | 8

9. E-Referral Systems for Maternal Health | Mumbai, India
The Cost-Effectiveness of Reducing Maternal Mortality in India
A study published in 2010, estimated the cost savings of reducing
maternal mortality rates in India through specific interventions. These strategies
were based around improving coverage of effective interventions that could be
provided individually or packaged as integrated services, improved logistics
such as reliable transport to an appropriate referral facility as well as recognition
of referral need and quality of care.13 The study concluded that reducing
maternal mortality is cost effective ($500 for package of interventions compared
to India’s GDP of $1,068) and that over 5-years the combination of the above
mentioned services would save 150,000 women and over $1 billion.
Implications of Findings
Most of the literature points to sufficient referral systems as an essential
compliment to strengthened health systems. The current pilot project in Mumbai
is an important first step in increasing and adequately using secondary and
tertiary hospitals for antenatal care and obstetric emergencies.
The three delays model should be take into consideration along with the
computer based referral system. The pilot project deals mainly with the second
and third delays. It can be argued that the first level delays are most detrimental
and life threatening to mothers. Though the technology being used can’t
mitigate the consequences of the first delay, it could be suggested that the
partner health clinics using the technology partner with community health
workers to reach women before the situation becomes dire.
The computer based pilot project referral system in Mumbai creates
important linkages between levels of care. This sets up a safety net to provide
necessary care for pregnant women in the forms of antenatal care, emergency
care for complications, and postnatal care. In order to ensure that the system
13
Goldie
SJ,
Sweet
S,
Carvalho
N,
Natchu
UCM,
Hu
D
(2010)
Alternative
Strategies
to
Reduce
Maternal
Mortality
in
India:
A
Cost-­‐Effectiveness
Analysis.
| Health Information Systems to Improve Quality of Care in Resource Poor Settings | 9

10. E-Referral Systems for Maternal Health | Mumbai, India
continues to add value to the physicians using it, its capabilities could be
enhanced by providing hospital capacity, wait times, transportation options.
Including theses measures will aid the e-referral system in reducing maternal
mortality and morbidity.
Problem Reformulation
The absence of an effective referral system in Mumbai as a barrier to
adequate emergency obstetric care was the initial view of the problem.
Although this is certainly an element of the broader issue, addressing this
problem alone will not solve the issue in the long term. Upon further research
and a more in depth examination of the literature, we found that the rising MMR
in Mumbai is a multifaceted problem stemming from many sources.
As previously mentioned the Three Delays Model is a more comprehensive
framework for examining MMR in Mumbai, and in general. Delays in seeking
care for an obstetric emergency; delays in reaching an appropriate obstetric
facility; and delays in actually receiving care once arriving at the facility
represent the three most common reasons a woman would suffer maternal
morbidity and mortality.
Apart from the lack of availability and/or resources, high MMR in Mumbai
can be attributed to non-utilization of services among expectant mothers. Poor
health education and the resulting lack of awareness among expectant
mothers regarding the importance of antenatal care and importance of
delivery within a healthcare facility can affect the decision to seek care.
Additionally, a woman’s decision-making power (or lack there of) within her
household has also contributed to low utilization of health services.
| Health Information Systems to Improve Quality of Care in Resource Poor Settings | 10

11. E-Referral Systems for Maternal Health | Mumbai, India
Little awareness of healthcare facility location; poverty (inability to cover
cost of direct fees, transportation, drugs and supplies); and low service quality
are additional reasons women in India are reluctant to seek healthcare14.
Improper referral systems represent another factor contributing to high
MMR. A woman’s ability to reach the appropriate healthcare facility is
negatively affected when physicians are prone to inaccurate referrals. Mumbai
is currently experiencing underutilization of secondary healthcare centers and
patient overcrowding at tertiary centers as a result of little coordination
between primary, secondary and tertiary facilities. More specifically, primary
care doctors are referring patients directly to tertiary centers and thus not
leveraging the availability of resources at secondary centers. Diagram 2 (see
Appendix) illustrates the considerations, phases and interventions in developing
a referral system.
By developing a patient tracking software, the pilot project in Mumbai
seeks to address this facet of the broader issue. This system would entail that
primary care physicians complete a patient form and depending on the
information provided the patient would be referred if necessary. If and where
they are referred is recorded and a notification is sent to the referred care
facility where the patient uses an ID number upon admission to this facility.
Inefficient and ineffective referrals occur mostly due to lack of confidence and
expertise among the health care professionals in Mumbai. Doctors are not
confident enough in their own knowledge and diagnostic abilities to refer
patients to secondary centers and rather than risk making a mistake they refer
patients to tertiary clinics for treatment.
One reason for this could be the lack of connection between medical
professionals and the communities they serve. Medical schools are not
14
Kausar,
Rehana.
(2005)
India
Journal
for
the
Practising
Doctor.
Maternal
Mortality
in
India
–
Magnitude,
Causes
and
Concerns.
Vol.
2,
No.
2.
Retrieved
from:
http://www.indmedica.com/journals.php?journalid=3&issueid=58&articleid=722&action=article
| Health Information Systems to Improve Quality of Care in Resource Poor Settings | 11

12. E-Referral Systems for Maternal Health | Mumbai, India
preparing medical students to address the healthcare needs of the society.
Although medical students in India are found to be adequate academically
they often have insufficient clinical and problem solving skills. This is mostly the
result of how medical education is structured in India.15
Medical education curriculum in India typically places emphasis on
absorbing knowledge rather than the development of problem-solving;
performance; attitudinal; or communication skills. Dr. Rita Sood, a doctor and
professor at the All India Institute of Medical Sciences (AIIMS) feels that
graduates should,
“…develop an ability to gather information with sensitivity and insight in order to
make sound judgment on the basis of probabilities. Investigative medicine has
largely taken over and it is not unusual to see inappropriate use of investigative
procedures, some of which may increase the cost of medical care substantially
and may even pose a risk to the patients. This is often associated with
inadequacy to make a sound clinical judgment.”15
Issues with wait times and understaffing affect a woman’s ability to
actually receive healthcare once at the facility. The aforementioned example
of overcrowding at tertiary centers in Mumbai demonstrates how this might
create an obstacle to receiving healthcare. Tertiary facilities typically do not
have the capacity to serve the influx of all referred patients from primary centers
and the resulting long wait times often deter patients from seeking care at all.
In addition, we recognize that there is a cultural aspect contributing to the
overall problem. Organizational structure in Mumbai is very hierarchical and
because doctors are perceived as a major authority within society there is
typically no structure or person to oversee or direct these Doctors as a means to
correct this problem. Socio-cultural challenges also exist. Resistance to a new
way of referring patients, as well as resistance among the patients themselves
can present challenges with regard to the new system. Financial constraints also
interfere with the pilot project being accepted.
15
All
India
Doctor
Associate
Blog:
Retrieved
from:
http://aimddadoctors.blogspot.com/2010/12/educating-­‐our-­‐doctors-­‐our-­‐doctors-­‐have.html
| Health Information Systems to Improve Quality of Care in Resource Poor Settings | 12

13. E-Referral Systems for Maternal Health | Mumbai, India
Recommendations
Based on our findings we have gained a more comprehensive
perspective on the problem of rising MMR in Mumbai. Given the extensive
information on the multitude factors that contribute to this problem we see the
need for a multifaceted approach. While the patient tracking software being
used in the pilot project will address the delays regarding improper referral and
issues with wait times, it fails to address the first delay noted in the Three Delays
Model – recognition of a health problem and the decision to seek care.
Considering the high number of maternal deaths that occur due to lack
of awareness and absence of health education we feel the project should
consider an education element as a way to increase awareness of the
importance of antenatal care.
In preparation for scale up of the pilot project we recommend an analog
system to share up-to-date information regarding capacity levels of all
participating facilities. If the referring facility could be informed of the number of
available beds at the receiving facility referred patients could avoid long wait
times that in some cases could mean one more life lost to an obstetric
emergency.
As a way to mitigate issues with transportation we suggest developing
partnerships with the state or other NGOs to provide travel stipends for those
patients without access to a vehicle. Also, a vehicle should be designated to
travel between referral facilities for emergency situations.
Finally, we recommend developing mechanisms to promote a cultural
and attitudinal shift to mitigate management challenges; the mindset toward
hierarchy within an organizational structure; and encourage communication
among staff at healthcare facilities.
| Health Information Systems to Improve Quality of Care in Resource Poor Settings | 13

14. E-Referral Systems for Maternal Health | Mumbai, India
Appendix
Diagram 1
| Health Information Systems to Improve Quality of Care in Resource Poor Settings | 14

15. E-Referral Systems for Maternal Health | Mumbai, India
Diagram 2
| Health Information Systems to Improve Quality of Care in Resource Poor Settings | 15