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Postnatal Care Module: 9. Making a Referral for Postnatal Care

Study Session 9  Making a Referral for Postnatal Care


As you reach the end of this Module, you will have to come to realise just how vital your role is in providing effective postnatal care. Health Extension Practitioners (HEPs) like you not only promote the health of mothers and newborn babies in your community, but you save lives too. The postnatal care you provide is part of the continuum of maternal and child health care.

The continuum of care begins even before the women in your community become pregnant; it then continues through the antenatal care you give them during their pregnancy and the skill and support you bring to their labour and delivery. It merges seamlessly into your role in the postnatal period. Of course the continuum does not stop there: later you will study the Module on the Integrated Management of Newborn and Childhood Illness, which teaches you how to preserve and protect the health of infants and older children. So you can see this continuum as an ongoing process of giving support at all stages of from birth through to childhood, including support to their mothers.

A health facility.

One final teaching point remains to be covered in this Module – making the referral link. Knowing how to refer mothers and newborns for specialist attention and treatment is as crucially important for the success of postnatal care as knowing when to refer. Early detection of life-threatening conditions is critical, but following up your diagnosis with a successful referral of mother and baby to a health facility for advanced treatment and life support is just as crucially important.

Learning Outcomes for Study Session 9

When you have studied this session, you should be able to:

9.1  Define and use correctly all of the key words printed in bold. (SAQ 9.1)

9.2  Explain why an effective referral link has to be a ‘two-way street’ between the health facility and the Health Extension Practitioner, and give examples of ways in which you can support this link. (SAQ 9.1)

9.3  Describe how you make sure that referrals happen effectively when you refer critical cases, and give reasons why referrals may fail to be managed correctly. (SAQ 9.2)

9.4  List the information that should be included in a clear and complete referral note. (SAQ 9.2)

9.1  Effective referral

Whether or not a sick mother or sick newborn can reach a fully functional health facility in time can literally be the difference between life and death. It helps a great deal if:

  • You have taken care to develop and establish strong links with the health facilities that you use (and the health workers in them), so that referrals can be dealt with quickly and efficiently.
  • You have mobilised the community to be alert to the need for psychosocial, financial and practical support in cases where critically sick mothers and newborns must reach the health facility urgently.
  • You have convinced the mother and family to trust your judgement before the emergency happens, so they are ready to follow your advice if an emergency occurs.
  • You are active in following up and checking that the mother and baby get to the health facility. The traditional way of telling the mother or the caregivers to go to the health facility, or just writing a referral note and doing nothing else, is never a sufficient solution.

9.2  The referral link: a two-way street

The referral link between a higher-level health facility and you, the Health Extension Practitioner (HEP) at the Health Post, is a two-way street (Figure 9.1). For this system to be fully functional, you have to know the health workers in the nearby health centre or hospital, and they should know all the HEPs at the Health Posts in their catchment area.

A diagram showing the higher health facility should refer/give feedback to the health post and vice-versa.
Figure 9.1  The referral link: a two-way street.
  • Why do you think it is important to know the health workers at the higher-level facilities?

  • One reason is that it is so much easier to write an effective referral note to people you know than to people you don’t. Another reason is that if they know you, they will be more able to trust your judgment and act quickly on it when you refer a mother or baby to them.

9.2.1  Receiving feedback

Of course, it is not just a case of referring the mother/baby to the health facility and that is the end of it. For example, if you refer a sick mother, the health facility staff should write a note to you when the mother is discharged back to the village, giving you feedback about what happened to her while she was in their care, and giving you instructions on how to manage her health problem in the future. That way you can continue to care for the mother and newborn in the most optimum way possible.

9.2.2  Knowing about local health facilities

To be really effective in your referrals you will need a list of all the health centres and any hospitals in your catchment area, together with information about the services each of them offers. This is so that if, for example, you deliver a very low birth weight baby, you immediately know which health facility has the right capacity, equipment and trained staff to give emergency care to very tiny babies. This information enables you to refer the mother and baby quickly to the right place.

  • What could happen if you don’t have information about the services offered at a higher-level health facility?

  • The main risk is of sending a sick mother or baby on a difficult and expensive journey, only for them to discover that the health facility does not have the appropriate care services. This could be disastrous because it means so much precious time will have already been lost on the road.

To sum up, for there to be the best chance of a positive outcome, all health workers in the community need to know how to refer their patients and exactly where to refer them so they can receive appropriate services to meet their needs.

9.3  What prevents referrals from happening effectively?

There are many reasons why a referral doesn’t happen at all, or does not happen in time, including the following:

  • Lack of proper counselling to the mother, father and other caregivers, so they don’t realise how serious the problem is.
  • Far distance and lack of means of transportation to the health facility.
  • The family has not saved the financial resources to make the journey.
  • Health facilities are not attractive to some patients. Often they don’t have proper supplies of essential medicines and equipment, or they lack the correctly trained person for the service required. Hence, due to the poor reputation of some health facilities, parents may be reluctant to go to them.
  • Is there anything you can do to help reduce the chances of a failed referral?

  • You might look back to Study Session 13 in the Antenatal Care Module and the discussion about Focused Antenatal Care (FANC). Remember that emergency care planning is a key part of the counselling you should have conducted with every expectant mother and her family before the birth. They should have saved money for the journey and arranged transport.

In addition to the antenatal counselling you have done with pregnant mothers and families, you will also have been mobilising community involvement to support them in the postnatal period. Study Session 1 of this Module discussed how to do this effectively. Remember that it is in the emergency situation that you can really see your work with the community bearing fruit.

  • Think of an example of how you might turn to the community for help with a postnatal emergency.

  • You may have thought of many different examples. Here is just one. The family is not financially prepared and doesn’t have a plan for transport. You persuade someone locally who has a vehicle to take the mother and newborn to the health facility, because it is a matter of life and death. Based on your earlier involvement with the community you are able to get agreement in advance from the kebele leaders that money will be found from a community fund to pay for the transport if the family cannot afford it. You thank the community leaders for their support and recognition that emergencies can often be successfully treated in a higher health facility, provided that the patient arrives in good time.

9.4  How to make referrals happen

Writing a referral note and telling people to go to the health facility is not the problem. As we have discussed already, the problem is getting them to the appropriate facility where they will receive the right care. What else helps to make a referral happen effectively?

9.4.1  Good documentation

During pregnancy, every mother should be advised to get prepared for birth, including what to do if emergency problems occur either in the baby or herself. You should have the standard counselling card from your Region to help you convince the mother and other caregivers to agree to a referral if necessary. In other words, if you tell them she or the baby needs specialist help and treatment from a higher-level health facility, they should be ready to trust your judgement and go.

You should also have a well prepared format to write referral notes to the health facility. You learned how to do this in the Antenatal Care Module, Study Session 13.

  • What information should a referral note contain?

  • It should cover the following:

    • Date of the referral and time
    • Name of the health facility you are sending the patient to
    • Name, date of birth, ID number (if known) and address of the patient
    • Relevant medical history of the patient
    • Your findings from physical examinations and tests
    • Your suspected diagnosis
    • Any treatment you have given to the patient
    • Your reason for referring the patient
    • Your name, date and signature
    • Your address, so the health facility can communicate back to you.

9.4.2  Transport and the emergency evacuation plan

Ideally, each village or community will have an emergency evacuation system in place that will automatically be triggered by a health crisis. That way it should be possible to ensure ready transport to enable critically sick mothers or babies to get to the health facility in time.

  • Quickly write down two actions that you would take when you have a mother or baby who needs to get to a health facility for specialist care.

  • You would write the referral note; and support the family in mobilising the necessary human and financial resources to transport mother and baby to the nearest appropriate health facility.

Once you have ensured that mother and baby have transport, check that there is adequate support for any other children or frail dependents who remain at home while the mother and any other caregivers are away.

Important! If the mother may need a blood transfusion, send one or two healthy adults with her who could act as blood donors.

If possible, aim to accompany the critically sick mother or baby to the health facility. If you cannot go with them, make sure that a responsible adult accompanies them instead. Remember to ask this person to contact you as soon as he or she gets back to the village, so that you know that the patient reached the health facility safely. She or he can also tell you how the mother or baby is being treated. If you do not hear anything within a day or two, visit the home to check whether they have returned from the health facility, and how they are progressing.

9.4.3  Making sure the health facility knows how to communicate with you

Health workers in the nearby health facilities should map and know the names of the kebeles and the HEPs (or other health workers) in the Health Posts surrounding their health facility. Check that they have all the information they need about you, especially where to find you and how best to contact you. If you find that they fail to communicate all the information you need when they discharge a patient back into your care, contact them and ask them for written feedback, setting out the diagnosis, what they have done so far and what needs to be followed up by you. Impress them with your professionalism and make sure that they see you as a valued member of the health workforce in the community.

In other words, for the whole health system to be effective, health workers in the higher-level health facilities and the health workers in the community need to work hand in hand as a single team. If everybody’s efforts are coordinated, there is a better chance of achieving the main goal – saving the lives of mothers and newborns.

And finally, we all want to see continuous improvement in the whole system of health care. One way of achieving this is through regular performance review. Bringing together everybody involved to discuss how you can better harmonise and coordinate your activities can make the continuum of care successful for all concerned.

Summary of Study Session 9

In Study Session 9, you have learned that:

  1. Referral is a two-way street. Referrals are from the health workers in the community to the higher-level health facility, and also the other way round. The two directions are highly interdependent and equally relevant for the overall success of postnatal care.
  2. The referral link should involve feedback in both directions about what has already happened to the patient (diagnosis, treatment and other health management issues), as well as how the patient should be followed up and supported in the future.
  3. Just telling people to go to the health facility or writing a referral note is a small part of the referral process, and is unlikely to be effective without careful advance preparation and follow up.
  4. What really matters is your counselling skill in persuading and convincing the family on the importance of the referral, and your role working in the community to alleviate the barriers that can prevent mothers and newborns from reaching the health facility in good time.
  5. Establishing an effective link and effective coordination between all members of maternal and newborn health services is the key to achieving the goal of a continuum of care. This starts from the household, involves you working in the community, and connects all the way up to the higher-level health facilities and advanced treatment centres, before patients return back to your care and their family in the community.

Self-Assessment Questions (SAQs) for Study Session 9

SAQ 9.1 (tests Learning Outcomes 9.1 and 9.2)

Write short definitions of the following terms and explain why they are important in how you approach the provision of postnatal care:

  • Continuum of maternal and child health care
  • Referral link.

The continuum of maternal and child health care is a way of thinking that reminds us that postnatal care is simply one phase within the context of your overall care of the people in the community where you work. So it is a reminder that the advice and care you offer prior to pregnancy may be just as important as the interventions or referrals you make after delivery, and that your care of the baby will continue through to childhood. Every stage and phase is as important as every other one in the continuum.

The referral link is best thought of as a two-way street between you and the higher health facility and back from the higher health facility to you. It suggests that the best care is when both of you are sharing and exchanging information. It works best when you take the trouble to get to know the health workers in the facilities in your area (and they know you), and when you also know precisely which facilities offer which types of health services.

SAQ 9.2 (tests Learning Outcomes 9.3 and 9.4)

You are making a referral of a very preterm baby and its mother, who already has three older children. You are extremely worried about the baby. Write a checklist for yourself of all the things you need to remember to do.


Your list probably looks something like the one below, but it may well have had some further additions:

  • Make sure that the mother and baby are wrapped up warmly (refer also to Sections 8.5 and 8.6 of Study Session 8).
  • Tell the mother (and family) that it is imperative that she and the baby go to a health facility. If you meet with resistance remind them of the seriousness of the risks to the baby without specialist care.
  • Check which health facilities offer specialist care for preterm babies and decide which one (if there is a choice) is the most easily and quickly accessible.
  • Check if the family can arrange transport. If not send one of them to a kebele leader to see if the community will help, including financial help if necessary (see Section 9.3.2).
  • While waiting for transport, write the referral note (if you can’t remember what it should include, see Section 9.3.1).
  • Check that there are family members who will look after the older children.
  • Check that there is no other impending emergency or care need, and if not, try to accompany the mother and baby to the health facility, or send a responsible adult with them.
  • If you cannot go yourself, remember to ask whoever is accompanying them to make contact with you on their return to confirm how the mother and baby are progressing.