Interpretation
It is well established that prompt and high-quality CS can significantly improve maternal and newborn outcomes(15). A study of all 194 WHO member states to examine the relationship between CS rate and maternal and newborn mortality, found a CS rate of 9-19% of the population coverage was associated with decreased maternal and neonatal mortality (8) (16) (17). While the global CS rate continues to rise with current estimates at 21.1%, the CS rate in sub-Saharan Africa is only 5% (18)(8).
Liberia’s facility-based deliveries significantly increased between 2004 and 2017, from 37% to 80% (8). Most of the increase occurred in rural areas, closing the gap between urban and rural areas. However, the CS rate did not reflect that improvement, with 6.1% born via CS in urban areas compared to 3.7% in rural areas, far below the 9-19% of the population coverage associated with a decrease in mortality(8) (16) (17). Furthermore, in 2019, about 84% of deliveries in Bong County occurred in a health facility, with 81% taking place within RHFs (13). This study found that the MORES intervention was associated with approximately 1.8 times higher CS rate, indicating that the intervention may be improving the unmet need of CS.
Relatedly, this study found that newborns were significantly less likely to exhibit poor respiratory effort and muscle tone after the intervention implementation. This may further indicate preparations to receive women being referred from RHFs due to improved communication with the MORES intervention, led to more timely care with improved newborn outcome. While the stillbirth rates were not shown to be statistically significant, a downward trend from 20.4% to 13.8% was noted.
The transfer time from RHF to district hospitals was not significantly associated with the intervention. In fact, the median time increased from 5.87 hours to 7.2 hour and no significant percentage changes were observed when time was examined as 2 hours or less versus longer than two hours. However, after the intervention, the percentage of women arriving to the hospital within 12 hours more than doubled, compared to before the intervention.
Although all RHFs in this study were located less than two hours from a CEmONC facility, it is worth noting that even post intervention close to 30% of the women took more than 12 hours to reach the district hospital following a referral. This may be due to the seasonal differences in the road conditions affecting travel time (rainy and dry season) (4). Additionally, previous literature notes that families often delay or refuse referral when recommended due to concerns about the quality of care in hospital, fear of disrespected and abusive care, financial constraints, and lack of transportation means (19)(15). Hence, future studies need to further investigate the reasons behind the delay, specifically those between 2 to 12 hours and beyond 12 hours.