It's the Destination and the Journey—A Mapping of the Challenges in Transport and Referral for Maternal and Newborn Health in Pandemics and Beyond

There has been an abundance of work in the last few years highlighting the importance of high-quality health systems as foundational to achieving better health outcomes (1). Quality provision of care is particularly critical for women and newborn during the perinatal and the immediate postpartum period (2). Transport issues are generally considered as important for access to care, but the quality of these transport and referral systems is equally essential. Recent systematic reviews related to the provision of intrapartum and postnatal care found that women were unlikely to accept referral if they had negative perceptions of the health facility (3) and were generally unsatisfied with delays in referral processes (4). Other studies have noted poor capacity at referring facilities (5), as well as challenges with coordination, communication, documentation, and adherence to referral protocols, especially for newborns (6). The World Health Organization standards for quality of maternal and newborns care and for care of small and sick newborns include that women and newborns must be assessed and treated with available resources or appropriately referred, without delay at any time. Functional referral systems are thus integral at each stage: initial transport to the facilities, referral between facilities, and transportation whenever follow-up is required (7, 8). The COVID-19 pandemic has stretched the limits of health systems, including transport and referral pathways (9); the question of how women and their newborns reach these facilities becomes ever more urgent in this current pandemic.