JOURNAL OF TROPICAL PEDIATRICS, VOL. 59, NO. 2, 2013
Using Three Delays Model to Understand the Social Factors
Responsible for Neonatal Deaths in Rural Haryana, India
by Ravi Prakash Upadhyay, Sanjay K. Rai, and Anand Krishnan
Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
Correspondence: Anand Krishnan, Centre for Community Medicine, All India Institute of Medical Sciences, Ansari Nagar, New
Delhi 110029, India. Tel: þ91-011-26594253/þ91-9811500667. E-mail <[email protected]>.
Summary
Objective: To investigate causes of and contributors to newborn deaths in rural Haryana using a three
delays audit approach.
Methods: The study was conducted in 28 villages under the rural field practice area of the
Comprehensive Rural Health Services Project, All India Institute of Medical Sciences situated in
Ballabgarh, Haryana. Data were collected through house visits and analysed using the three delays
model.
Results: Of the 50 newborn deaths investigated, 44% occurred within the first 24 h after birth. The
leading causes of death were pre-term/low birthweight (32%), birth asphyxia (28%) and neonatal sepsis
(14%). Major contributing delays to neonatal death were caretaker’s delay in deciding to seek care
(44%, 22/50) and delay in reaching a health care facility, i.e. the transport delay (34%, 17/50).
Conclusions: Household and transport-related delays were the major contributors to newborn deaths,
and efforts to improve newborn survival need to address both concurrently.
Key words: neonatal deaths, social audit, three delays model, rural, north India.
Introduction
Globally 4 million deaths occur every year in the first
month of life [1, 2]. Almost all (99%) neonatal deaths
arise in low-income and middle-income countries,
and most deaths occur at home, the causes for
which largely remain unexplored [1, 3]. It is important to understand and document the causes and contextual factors surrounding these newborn deaths.
Attempts to obtain data on causes of death of
Acknowledgements
The authors would like to thank the late Dr Bir Singh
for his constant guidance and constructive suggestions since the inception of the study. A.K. and
S.K.R. conceived the idea, planned the study and
provided overall supervision. R.P.U. did the review
of literature, prepared the protocol, developed questionnaires and collected the data. R.P.U. and A.K.
did the analysis and prepared the manuscript. All the
authors read and approved the final manuscript. No
external funding was required.
The work should be attributed to Centre for
Community Medicine, All India Institute of
Medical Sciences, New Delhi, India.
newborns have relied on verbal autopsy (VA) [4–8].
Routine death investigation and VA do not include
questions on care-seeking before death, and information on any inadequacies or modifiable factors in the
home, community, health facilities and referral mechanisms is missed, which could probably guide future
programs and policies [9].
For exploring maternal deaths, the three delays
model developed by Thadeus and Maine has been
widely used [10]. The model comprises delay in deciding to seek care on the part of the individual, family
or both (Delay 1), delay in reaching an adequate
health care facility (Delay 2) and delay in receiving
adequate care at the health facility (Delay 3). This
model helps to identify community and health services factors contributing to maternal deaths and is
useful in devising strategies for preventive measures.
Maternal death audits have helped in reducing maternal mortality indicators as can be seen in Rwanda,
located in eastern central Africa, where the maternal
mortality ratio has fallen from 750 per 100 000 live
births in 2005 to 540 per 100 000 live births in 2008
[11, 12]. The government of Rwanda, to accelerate
the reduction of maternal mortality and morbidity,
had developed a road map with United Nations
Population Fund (UNFPA) support that took into
ß The Author [2012]. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]
doi:10.1093/tropej/fms060
Advance Access published on 21 November 2012
100
R. P. UPADHYAY ET AL.
account the maternal death audit at health facilities
and at the community level. These audits provided a
better understanding of the major causes of death
and the changes needed to address them. Another
example is from Tamil Nadu, a state in south
India, where through initiatives such as establishment
of maternal death registration and audit and establishment of comprehensive emergency obstetrics care
centres, there has been a reduction in the maternal
mortality ratio from 380 in 1993 to 90 in 2007 [13].
Similar to how maternal death audits have helped
in reducing maternal morbidity and mortality, neonatal deaths can possibly be reduced through identification of the existing gaps by means of audits and
taking the necessary steps. Although the medical
causes underlying neonatal deaths have been studied
in detail, both at the global and national level, no
sizeable literature exists on the social factors that
play a role in these deaths. The purpose of the current study was to provide a better understanding of
the barriers to timely access to neonatal care in case
of neonatal deaths in rural Ballabgarh, Haryana.
Materials and Methods
A community-based, cross-sectional study was conducted in all 28 villages under the intensive field
practice area (IFPA) of the Comprehensive Rural
Health Services Project (CRHSP). These villages
are nearly 50 km away from Delhi and represent a
typical rural community of Haryana. There are two
primary health centres (PHCs) under the project at
Dayalpur and Chhainsa, each with six subcentres.
These two PHCs served a population of 87 008, as
of 31 December 2009. Households with neonatal
deaths in 2010 were identified through the health
management information system. The health management information system is a computerized database of all individuals residing in the 28 villages
under CRHSP, which is regularly updated with
birth, death and migration records [14]. Visits were
made to the families with neonatal deaths. Mothers
(preferably) or any other reliable older family members were interviewed after obtaining written
informed consent. Two more visits were made if a
reliable informant was not available for the interview
during the first visit.
Study instrument
The interview guide used was developed by the
INDEPTH Network [15]. Areas covered under
social audit included ‘factors at the family level’,
i.e. knowledge of the mothers/caregivers about neonatal danger signs, gender-based difference in treatment seeking, type of treatment done at home and
causes of delay in seeking ‘outside home’ care;
‘socio-economic and geographical factors’, i.e.
affordability of hospital and transport expenses,
availability of transport facilities, distance from the
Journal of Tropical Pediatrics
Vol. 59, No. 2
hospital and travel time; ‘factors related to health
system’, i.e. availability of qualified doctors in the
village, treatment provided by the health care provider (included waiting time and the management
done) and details of referrals, if made. These three
areas conform to the three levels of delay.
A Verbal autopsy (VA) tool was used to document
the probable cause of death (COD). The VA tool that
was used has been developed by CRHSP and validated against the INDEPTH tool. It has five portions
and includes an open narrative portion and a 42symptom checklist [16].
Ethical aspects
The study was conducted with ethical approval from
the Institutional Ethical Review Board of the All
India Institute of Medical Sciences. Written consent
was obtained from the participants in a consent form,
which was in the local language, i.e. Hindi.
Data analysis
Initially, the three study researchers (R.P.U., S.K.R.
and A.K.) discussed a few case studies together to
achieve uniformity. Subsequently, two researchers
(R.P.U. and S.K.R.) independently reviewed each
audit form and looked for the presence of delay
and assigned the type of delay, if present. In case of
disagreement, a third experienced researcher (A.K.)
reviewed the forms, and the final decision on any
delay and level of delay was ascertained by him.
A delay was supposed to have occurred if, in the
perception of the reviewers, the delay seemed to
have partially contributed to the death or if the
delay was ‘avoidable’ by some action by either the
caregiver or health professional. Based on review of
the case history, a subjective assessment of the different levels of delay being a critical determinant of outcome was made. Delay was defined based on the
model proposed by Thadeus and Maine [10]: Delay
1, which is the delay to recognize illness and the
need to seek medical care; Delay 2 included newborn
babies whose caregivers expressed problems in reaching a health facility; and Delay 3, the delay in receiving
quality care after reaching a health facility (as judged
by the person conducting the audit). Delay 1 included
seeking care both ‘outside home’ and from a lower to
higher health facility, while Delay 2 could include referral from a lower to higher health facility. Each
death could be attributed to one or more delays.
Data were entered in Epi-info software version
3.5.1. Data were transferred to SPSS version 17
(Chicago, IL, USA) for statistical analysis. Descriptive analysis was performed, and wherever applicable, proportions were reported.
Results
There were 56 neonatal deaths in the study area
during the study period. Of these, an audit of 50
101
R. P. UPADHYAY ET AL.
deaths could be done. In three cases, the family had
moved, and in the remaining three, there was no reliable informant present on three visits.
Descriptive characteristics
Of the 50 newborn deaths investigated, 58% (29/50)
were girls. Forty-four percent of the deaths (22/50)
occurred within the first 24 h after birth and 76% in
the first week. The median age at the time of death
was 3.00 (Interquartile range, IQR 1.00–7.25) days.
Of the 50 newborns who died, 17 were born in a
government hospital or a health centre, 13 in a private clinic with a qualified doctor, 12 at home and 8
at clinics run by unqualified personnel (Table 1).
Thus, 60% (30/50) of the births were reportedly attended by skilled personnel (Table 1). Twenty-seven
(54%) newborns were reported to be born at ‘term’,
and 92% were delivered through normal vaginal delivery. Of those newborns who were reported to have
been weighed after birth (n ¼ 40), 21 (52.5%) weighed
2500 g. Nineteen deaths (38%) occurred at private
nursing homes or clinics and 12 deaths (24%)
occurred at home. Deaths at government hospitals
and health centres constituted 20% (n ¼ 10) of the
total neonatal deaths. Nine deaths (18%) occurred
on the way to a health facility.
Cause of neonatal deaths
The COD for the neonatal deaths included in the
audit were pre-term/low birthweight in 32%
(n ¼ 16), birth asphyxia/meconium aspiration syndrome in 28% (n ¼ 14), neonatal sepsis in 14%
(n ¼ 7) and congenital malformation in 12% (n ¼ 6).
In four neonatal deaths, the cause was labelled as
‘others’ (included neonatal jaundice, birth-related
injury and seizures); in the remaining three, the
COD was ‘unclassified’.
Delay(s) involved based on the review of audit forms
Distribution of the deaths according to the levels of
delay involved: Of the 50 neonatal deaths audited,
37 had at least one type of delay involved (74%). In
13.5% (5/37) delay was present at all three levels; in
35.1% (13/37) delay was observed at two levels; and
in 51.4% (19/37) only one type of delay was present.
There were 13 (26%) neonatal deaths that did not
have any delay in treatment seeking, transport or initiation of treatment.
First delay—delay in decision making: Of the 50
neonatal deaths audited, delay in decision making
was present in 44% (22/50). In 8 of these 22, the
delay was due to the belief that the home treatment
would benefit the baby, and in another 7, the delay
was due to the inability of the caregivers/mother in
recognizing danger signs (Table 2). In five of the
deaths, the caregivers perceived that seeking care
102
TABLE 1
Descriptive statistics of the delivery related factors in
the context of the neonates who had died (n ¼ 50)
Delivery-related factors
Gestational age
Term (37 weeks)
Pre-term (<37 weeks)
Place of delivery
Private nursing home/clinic
having qualified doctor
Home
Clinic run by a local practitioner
without a formal medical degreea
PHC
Sub-district hospital
District hospital
First referral unit (FRU)/CHC
Personnel conducting delivery
Skilled (doctor, nurse or auxiliary
nurse midwife)
Unskilled (includes traditional birth
attendants/dais, family members
or neighbours)
Mode of delivery
Normal vaginal
Caesarean
Birthweight recording
Yes
No
Birthweight categories (g) (n ¼ 40)b
<1500
1500–1999
2000–2499
2500
n (%)
27 (54.0)
23 (46.0)
13 (26.0)
12 (24.0)
8 (16.0)
6
5
5
1
(12.0)
(10.0)
(10.0)
(2.0)
30 (60.0)
20 (40.0)
46 (92.0)
4 (8.0)
40 (80.0)
10 (20.0)
6
5
8
21
(15.0)
(12.5)
(20.0)
(52.5)
a
Assessed after interacting with the Accredited Social
Health Activist and the health workers in the particular
village.
b
Only 40 neonates had their weight recorded at the time
of birth or within 24 h of birth by the Accredited Social
Health Activist during the visit to the house.
would not benefit the baby, whereas concerns regarding the cost of treatment delayed care seeking in two
cases.
Second delay—delay in reaching a health care
facility: Delay in reaching a health facility was present in 34% (17/50) of the neonatal deaths. In seven
neonates, the delay was ascribed to the absence of an
accompanying member of the family, preferably a
male; in four deaths, it was due to the unavailability
of transport. The need to travel a long distance
because of a lack of a health facility in the vicinity
(4/17) and a lack of funds to bear the cost involved
in transport and treatment (2/17) were other reasons for the delay in reaching a health care facility
(Table 2).
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Vol. 59, No. 2
R. P. UPADHYAY ET AL.
TABLE 2
Reason(s) for the delay at the level of decision making,
delay in transport and delay in initiation of care
(n ¼ 50)
Reason(s)
n (%)
Delay in decision making to seek care
Over reliance on home treatment
Inability to recognize danger signs
Apathy/deliberate neglect/no
perceived use of treatment seeking
Concerns about possible expenditure
Delay in reaching a health care facility
No accompanying member
Unavailability of transport
Long distance traversed to reach
health facility
Lack of funds for transport/treatment
Delay in initiation of treatment from
arrival at health facility
Non-availability of drugs, equipments
Absence of a doctor/trained personnel
Referral without treatment
Inadequate assessment of the condition
of the neonate
Systems delay (no directions,
complicated admission process etc.)
22
8
7
5
(44)
(36.4)
(31.8)
(22.7)
2
17
7
4
4
(9.1)
(34)
(41.2)
(23.5)
(23.5)
2 (11.8)
14 (28)
4
3
3
2
(28.6)
(21.4)
(21.4)
(14.3)
2 (14.3)
Third delay—delay in initiation of treatment: As
compared with the first and the second delay, the
delay in initiation of treatment from arrival at the
health facility was present in a fewer number of neonates who died, i.e. 28% (14/50). Non-availability of
drugs and equipment (4/14), lack of a skilled care
provider (3/14) and referral without providing any
treatment (3/14) were factors in the majority of the
neonatal deaths in which third-level delay was reported. Delay in the admission process because of
lack of guidelines/complicated admission process
(which reflects poor organization of the health facility) and inadequate assessment of the condition of
the neonate each resulted in two neonatal deaths.
Causes of death by type of delay
The major causes of death by main contributing
delay were as follows (Fig. 1): Delay 1—prematurity
(8/22, 36.4%) followed by sepsis (6/22, 27.3%);
Delay 2—birth asphyxia (6/17, 35.3%) followed by
prematurity (4/22, 23.5%); Delay 3—prematurity (4/
14, 28.7%) followed by birth asphyxia (3/14, 21.4%)
and sepsis (3/14, 21.4%).
Discussion
This study is the first in the study area and among the
few studies in India in which the three delays model,
originally developed for maternal deaths, has been
used to explore the social determinants of newborn
Journal of Tropical Pediatrics
Vol. 59, No. 2
deaths at the community level in a rural setting. In
our study, we found that delay in decision making to
seek care (Delay 1) and delay in reaching an adequate
health facility (Delay 2) were the major contributors
to newborn deaths.
Our results on the contribution of delays to newborn death differ from those in the Tanzanian study
by Mbaruku, et al. [17], in which most newborns
were reported to have died because of Delay 3
(third delay occurred in 72.5%). This difference can
be due to the fact that in the Mbaruku, et al. study,
the data were collected from the hospital and did not
include older neonates (>1 week), and therefore
would have overestimated the third delay. On the
other hand, our findings largely relate with the
study done by Nandan, et al. [18] in rural areas of
Agra in Uttar Pradesh, India where delay in the recognition of the seriousness of a problem and deciding
to seek care (47.9%) and delay in reaching a health
facility (36.4%) were major contributors to neonatal
deaths.
To reduce the number of newborn deaths, addressing Delay 1, or a delay in problem recognition and in
deciding to seek quality care, will be critical, as it was
a key contributor in the neonatal deaths in this study.
The major reasons for delay in seeking care were
belief in home treatment and an inability to recognize
danger signs. Although home treatment should not
be labelled ‘inappropriate’ indiscriminately, the fact
that it could delay quality treatment seeking is an
area of concern. Considering that the time frame
for seeking appropriate medical treatment of neonatal illnesses is short, delayed care-seeking practices,
often owing to the inability to recognize danger signs/
symptoms of illness, can lead to poor newborn survival. Community-based interventions can address
delays in problem recognition of sick newborns
(Delay 1) by including neonatal health counselling
during antenatal check-ups, promoting supervised
deliveries and raising awareness of the mothers/
family members/other caregivers regarding newborn
danger signs. This approach was adopted by Dongre,
et al. [19] in rural Wardha, which resulted in a significant improvement in mothers’ knowledge regarding newborn illness danger signs and subsequent
health care-seeking behaviour. Similar improvements
in recognition of danger signs and early care seeking
owing to behaviour change communications were
observed in Nepal and Bangladesh [20, 21].
Absence of a male member of the family to accompany the ill neonate was cited as an important cause
of delay in reaching a health facility. A feasible way
to address this issue is to practise ‘birth preparation
and planning’, which is an educational process to
enable women and their families to prepare for a
complication should it arise [22, 23]. With such a
plan in place, if a neonatal complication does
occur, crucial time may be saved, especially if the
husband is absent. Alternatively, the community
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R. P. UPADHYAY ET AL.
FIG. 1. Causes of neonatal deaths by major contributing delay in rural Haryana, India.
may appoint members to take responsibility of a
newborn’s health, if the husband/father or an elder
is absent.
Unavailability of transport was also reported as
the primary reason for delay in reaching a health
facility. In the study area, usually it is difficult to
get a vehicle such as auto rickshaw or bus at night,
and considering this, the Haryana government has
recently started a 24 7 ambulance service [24].
This service caters to maternal obstetric and neonatal
emergencies. Community-led arrangements could
also be made for transport, as seen in rural
Tanzania [25]. Developing a community loan fund
to address the problem of lack of money to pay for
transportation and/or health service could be a workable option, and this has been successful in lowincome settings, such as Nigeria and Sierra Leone
[26, 27].
In the present study, most newborns died on the
day of birth or within the first week. Forty-four percent of deaths occurred within the first 24 h after
birth. These findings probably reflect the poor quality of intra-partum and immediate post-partum care
provided, which is similar to that documented by
Pattinson, et al. [28] in South Africa. Our findings
confirm the lack of capacity for newborn care in
this setting. The lack of skilled health personnel
and drugs/equipment was one of the primary reasons
for delay in initiation of treatment after reaching a
health facility. Similar results were reported by
Waiswa, et al. in rural Uganda [9].
Inadequate management often makes a difference
when it comes to survival of the baby. Referral without providing initial treatment to stabilize the condition of the neonate was reported in the current study.
This convincingly documents the existing mismanagement, which, if not addressed, could lead to
more fatal outcomes. The rural population in
Haryana is served by a large number of private
104
health providers, typically through a single-doctor
clinic. There is a wide range of quality of health
care provided by these doctors. Thus, it would be
useful to standardize the services of these providers
by providing assistance to these clinics in the form of
training and technical support.
The strength of the study lies in being one of the
few studies in India to document the social factors
surrounding neonatal deaths based on the three
delays model. The study had limitations, too. As
the study captured the neonatal deaths that occurred
in 1 year only, i.e. in 2010, the sample size might seem
insufficient, but the nature of the results can be confidently generalized to the rural north India because
of a similar socio-economic and cultural milieu.
Because the survey was administered a few months
after the death had occurred, the respondents may
not have accurately remembered how they perceived
neonatal illness or what actions they took in caring
for the newborn.
There were problems in categorizing the third level
of delay. The actual quality of treatment received at
the health facility could not be assessed and was
taken as reported by the respondents. Moreover, in
cases when the ill baby was taken by the family members to Ballabgarh in time but needed mechanical
ventilation (not expected to be available) and was
referred to an equipped health facility, deciding for
the presence of level three delay could be arguable.
Conclusion
The three delays model, which was originally developed for maternal death, can help in the understanding of neonatal deaths in low-resource settings,
thereby providing useful information for guiding
programmes and policy making. Household and
transport-related delays were the major contributors
to newborn deaths, and efforts to improve newborn
survival need to address both concurrently.
Journal of Tropical Pediatrics
Vol. 59, No. 2
R. P. UPADHYAY ET AL.
Strengthening different levels of the health care
system for the provision of quality neonatal services
would be beneficial.
17.
References
18.
1. Lawn JE, Cousens S, Zupan J. 4 million neonatal
deaths: when? where? why? Lancet 2005;365:891–900.
2. Lawn J, Cousens S, Bhutta Z, et al. Why are 4 million
babies dying each year? Lancet 2004;364:399–401.
3. Jha P, Gajalakshmi V, Gupta PC, et al. Prospective
study of 1 million deaths in India: rationale, design,
and validation results. PLoS Med 2006;3:e18.
4. Kulkarni R, Chauhan S, Shah B, et al. Investigating
causes of perinatal mortality by verbal autopsy in
Maharashtra, India. Indian J Community Med 2007;
32:259–63.
5. Shrivastava SP, Kumar A, Ojha AK. Verbal autopsy
determined causes of neonatal deaths. Indian Pediatr
2001;38:1022–5.
6. Khanal S, Gc VS, Dawson P, et al. Verbal autopsy to
ascertain causes of neonatal deaths in a community setting: a study from Morang, Nepal. JNMA J Nepal Med
Assoc 2011;51:21–7.
7. Baghel B, Bansal AK. Use of verbal autopsy as a proxy
to determine the possible cause of neonatal deaths. J
Nepal Paedtr Soc 2011;31:44–48.
8. Thatte N, Kalter HD, Baqui AH, et al. Ascertaining
causes of neonatal deaths using verbal autopsy: current
methods and challenges. J Perinatol 2009;29:187–94.
9. Waiswa P, Kallander K, Peterson S, et al. Using the
three delays model to understand why newborn babies
die in eastern Uganda. Trop Med Int Health 2010;15:
964–72.
10. Thadeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med 1994;38:1091–110.
11. UNFPA. Maternal mortality reduction programme in
Rwanda http://rwanda.unfpa.org/drive/MaternalMor
talityReductioninRwanda%28VLR%29.pdf (12 June
2012, date last accessed).
12. USAID. MCH program description: Rwanda July
2008.
http://pdf.usaid.gov/pdf_docs/PDACP019.pdf
(13 June 2012, date last accessed).
13. Padmanaban P, Raman PS, Mavalankar DV. Innovations and challenges in reducing maternal mortality in
Tamil Nadu, India. J Health Popul Nutr 2009;27:
202–19.
14. Krishnan A, Nongkynrih B, Yadav K, et al. Evaluation
of computerized health management information
system for primary health care in rural India. BMC
Health Serv Res 2010;10:310.
15. Kallander K, Kadobera D, Williams TN, et al. Social
autopsy: INDEPTH Network experiences of utility,
process, practices and challenges in investigating
causes and contributors to mortality. Popul Health
Metr 2011;9:44.
16. Krishnan A, Kumar R, Nongkynrih B, et al. Adult
mortality surveillance by routine health workers using
Journal of Tropical Pediatrics
Vol. 59, No. 2
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
a short verbal autopsy tool in rural north India. J
Epidemiol Community Health 2012;66:501–6.
Mbaruku G, van Roosmalen J, Kimondo I, et al.
Perinatal audit using the 3-delays model in western
Tanzania. Int J Gynaecol Obstet 2009;106:85–88.
Nandan D, Misra SK, Jain M, et al. Social audits for
community action: a tool to initiate community action
for reducing child mortality. Indian J Community Med
2005;30:78–80.
Dongre AR, Deshmukh PR, Garg BS. A community
based approach to improve health care seeking for newborn danger signs in rural Wardha, India. Indian J
Pediatr 2009;76:45–50.
Sood S, Chandra U, Mishra P, et al. Measuring the
Effects of Behavior Change Interventions in Nepal
with Population-Based Survey Results. Baltimore,
MD: Jhpiego, 2004, http://pdf.usaid.gov/pdf_docs/
PNADA614.pdf (15 June 2012, date last accessed).
Rahman A, Leppard M, Nasreen HE, et al.
Acceptability, comprehensibility and reported influence
of behaviour change communication tools: experience
from MNCH programme in Nilphamari district of
Bangladesh. RED working Paper no. 21. BRAC; 2011.
http://www.bracresearch.org/workingpapers/
RED%20Working_ Paper_21.pdf (15 June 2012, date
last accessed).
Kakaire O, Kaye DK, Osinde MO. Male involvement
in birth preparedness and complication readiness for
emergency obstetric referrals in rural Uganda. Reprod
Health 2011;8:12.
Hailu M, Gebremariam A, Alemseged F, et al. Birth
preparedness and complication readiness among pregnant women in Southern Ethiopia. PLoS One 2011;6:
e21432.
Sundararaman T, Chakraborty G, Nair A, et al.
Publicly financed emergency response and patient
transport systems under NRHM. National Health
Systems Resource Centre, Policy Support Report,
May 2012. http://nhsrcindia.org/pdf_files/resources_
thematic/Financing_and_PPP/NHSRC_Contribution/
Publicly%20Financed%20Emergen_492.pdf (18 June
2012, date last accessed).
Schmid T, Kanenda O, Ahluwalia I, et al.
Transportation for maternal emergencies in Tanzania:
empowering communities through participatory problem solving. Am J Public Health 2001;91:1589–90.
Essien E, Ifenne D, Sabitu K, et al. Community loan
funds and transport services for obstetric emergencies in
northern Nigeria. Int J Gynaecol Obstet 1997;59(Suppl
2):S237–44.
Fofana P, Samai O, Kebbie A, et al. Promoting the use
of obstetric services through community loan funds, Bo,
Sierra Leone. The Bo PMM Team. Int J Gynaecol
Obstet 1997;59(Suppl 2):S225–30.
Pattinson R, Woods D, Greenfield D, et al. Improving
survival rates of newborn infants in South Africa.
Reprod Health 2005;2:4, doi:10.1186/1742-4755-2-4.
105