Ghana Health Service conducted an audit to strengthen the referral system for
pregnant or recently pregnant women and newborns in northern Ghana. The audit took
place in 16 facilities with two 3-month cycles of data collection in 2011. Midwife-led
teams tracked 446 referred women until they received definitive treatment. Between
the two audit cycles, teams identified and implemented interventions to address gaps
in referral services. During this time period, we observed important increases in
facilitating referral mechanisms, including a decrease in the dependence on taxis in
favour of national or facility ambulances/vehicles; an increase in health workers
escorting referrals to the appropriate receiving facility; greater use of referral slips and
calling ahead to alert receiving facilities and higher feedback rates. As referral systems
require attention from multiple levels of engagement, on the provider end we found
that regional managers increasingly resolved staffing shortages; district management
addressed the costliness and lack of transport and increased midwives’ ability to
communicate with pregnant women and drivers; and that facility staff increasingly
adhered to guidelines and facilitating mechanisms. By conducting an audit of maternal
and newborn referrals, the Ghana Health Service identified areas for improvement that
service providers and management at multiple levels addressed, demonstrating a
platform for problem solving that could be a model elsewhere.