ArticlePDF AvailableLiterature Review

Improvement of maternal health services through the use of mobile phones



To analyse, on the basis of the literature, the potential of mobile phones to improve maternal health services in Low and Middle Income Countries (LMIC). Wide search for scientific and grey literature using various terms linked to: maternal health, mobile telecommunication and LMIC. Applications requiring an internet connection were excluded as this is not widely available in LMIC yet. Few projects exist in this field and little evidence is available as yet on the impact of mobile phones on the quality of maternal health services. Projects focus mainly on the delay in receiving care--that is in recognizing the need and making the decision to seek care--and the delay in arriving at the health facility. This is achieved by connecting lesser trained health workers to specialists and coordination of referrals. Ongoing projects focus on empowering women to seek health care. There is broad agreement that access to communication is one of several essential components to improve maternal health services and hence the use of mobile phones has much potential. However, there is a need for robust evidence on constraints and impacts, especially when financial and human resources will be invested. Concurrently, other ways in which mobile phones can be used to benefit maternal health services need to be further explored, taking into consideration privacy and confidentiality.
Improvement of maternal health services through the use
of mobile phones
A. Camielle Noordam
, Barbara M. Kuepper
, Jelle Stekelenburg
and Anneli Milen
1Royal Tropical Institute, Amsterdam, The Netherlands
2Medical Centre, Leeuwarden, The Netherlands
3National Institute for Health and Welfare, Helsinki, Finland
Summary objective To analyse, on the basis of the literature, the potential of mobile phones to improve
maternal health services in Low and Middle Income Countries (LMIC).
methods Wide search for scientific and grey literature using various terms linked to: maternal health,
mobile telecommunication and LMIC. Applications requiring an internet connection were excluded as
this is not widely available in LMIC yet.
results Few projects exist in this field and little evidence is available as yet on the impact of mobile
phones on the quality of maternal health services. Projects focus mainly on the delay in receiving care –
that is in recognizing the need and making the decision to seek care – and the delay in arriving at the
health facility. This is achieved by connecting lesser trained health workers to specialists and coordi-
nation of referrals. Ongoing projects focus on empowering women to seek health care.
discussion There is broad agreement that access to communication is one of several essential com-
ponents to improve maternal health services and hence the use of mobile phones has much potential.
However, there is a need for robust evidence on constraints and impacts, especially when financial and
human resources will be invested. Concurrently, other ways in which mobile phones can be used to
benefit maternal health services need to be further explored, taking into consideration privacy and
keywords maternal health, mobile phones, mHealth eHealth, communication
Progress in achieving Millennium Development Goal
(MDG) 5, to improve maternal health by reducing mater-
nal mortality and improving access to reproductive health,
is lagging behind the targets. New impulses are needed to
attain the goals. Two recent international initiatives
recommend mobile phones as a means to improve maternal
health services (ITU 2010; mHealth Alliance 2010).
Maternal health
Every 90 seconds a woman dies of complications related to
pregnancy and childbirth, resulting in more than 340 000
maternal deaths a year (Hogan et al. 2010). Millions of
women suffer from pregnancy-related illnesses or experi-
ence other severe consequences such as infertility, fistula
and incontinence (UNICEF 2009). Delay is considered the
key factor leading to women not accessing health services.
There are three phases of delay: (i) recognizing the need for
health care and in the decision-making process; (ii) arrival
at a health facility; and (iii) receiving appropriate and
adequate care at the health facility (Maine 1994). Under-
lying determinants that cause the delays are the position of
women in society, large geographical distances, weak
health systems, poverty and lack of education (Ronsmans
& Graham 2006; UNICEF 2009).
Mobile phones
MDG 8 addresses the need to make benefits of new
technologies available, especially those related to infor-
mation and communication. The fastest growing new
technology worldwide is the mobile phone. In Africa and
Asia, where the burden of maternal mortality is greatest
(WHO & UNICEF 2010), the expectations are that by
2012, 50% of the people will have access to a mobile
phone (ITU 2009). The uptake of mobile phones varies; it
is inversely proportional to poverty rates, but also influ-
enced by the competitiveness and thus the price levels of
the relevant markets (UNCTAD 2010). The use of mobile
phones in health systems is called mHealth. This article
Tropical Medicine and International Health doi:10.1111/j.1365-3156.2011.02747.x
volume 16 no 5 pp 622–626 may 2011
622 ª2011 Blackwell Publishing Ltd
discusses the potential of mobile phones to improve
maternal health services in LMIC by strengthening com-
munication throughout different levels of the health
Our literature search limited to English publications
combined terms linked to: maternal health, mobile tele-
communication, and LMIC. Only publications considering
the basic use of mobile devices (without requiring internet
access) were included, as poor internet coverage, high
illiteracy rates and low levels of experience in using
technology make more advanced use of mobile technology
difficult in LMIC.
Searches initiated in PubMed, Embase, Cochrane Li-
brary, Scopus, Science Direct and African Journals Online
retrieved a large amount of mHealth-related publications,
of which only eight were relevant; these articles address
maternal health services in LMIC, the use of mobile devices
and reported preliminary results. The search was subse-
quently expanded to grey literature, and reference lists
were also screened for further relevant sources.
Literature findings
A recently published paper on mobile phone technology for
health care in LMIC (Mechael et al. 2010) reviewed
literature on mHealth, such as treatment compliance, data
collection and disease prevention. The authors see great
potential for mHealth; however, there is not much evidence
of actual and wide-scale impacts yet. We analysed
resources for the particular area of maternal mHealth and
confirmed a lack of evidence-based studies focusing on
the efficacy and effectiveness of interventions. Most
documentation referred to pilot studies and often lacked
baseline data, a control group and clear outcome
Accessing emergency obstetric care
Before the wider use of mobile phones, several project
publications considered improved communication through
radio systems as one component among several aimed at
improving access to emergency obstetric care and referral
systems. These projects mainly focused on reducing the
second phase of delay. Traditional Birth Attendants (TBAs)
and or midwives were equipped with walkie-talkies,
enabling them to contact supervisors and ambulances when
facing difficult situations. Concurrently, other components
such as the overall quality of the health services were
improved through more reliable transport means, increased
capacity, medical equipment and reduction of financial
Projects in Mali, Uganda, Malawi, Sierra Leone and
Ghana, which implemented the above mentioned com-
ponents, noted a significant reduction in maternal deaths
and an increase in supervised births when comparing the
situation before and after the interventions. Faster modes
of communication and transport were named as impor-
tant factors in improving access to emergency obstetric
care (Samai & Sengeh 1997; Musoke 1999, 2002;
Matthews & Walley 2005; Lungu & Ratsma 2007;
Fournier et al. 2009). The projects in Uganda and
Ghana additionally considered the first phase of delay
by connecting traditional health providers to the bio-
medical health system. As TBAs are frequently at the
homes of pregnant women, they can speed up the
process there.
Krasovec (2004) concluded that studies provided only
weak empirical evidence regarding the actual impact of
communication systems and that access to tools of com-
munication is not the solution for decreasing maternal
deaths in isolated areas. The tight timeframe in which a
woman requires emergency obstetric care (due to e.g.
severe bleeding) implies that quality services need to be
accessible at short notice and supported by effective
infrastructure management. In a more recent review, Lee
et al. (2009) confirm the need for more rigorous assess-
Information regarding plans for scaling-up projects that
use radio systems was only found for the pilot project in
Uganda. These plans were not realized due to high costs,
inability to maintain equipment and lack of integration
into the health system. However, in this project the radio
system was later replaced by mobile phones, which were
found to be a cheaper and a more practical solution
(UNFPA 2007).
Improving the capacity of lesser trained health workers
More recent projects introduced mobile phones to improve
the capacity of lesser trained health workers by connecting
them to better trained medical staff, thus aiming to reduce
the third phase of delay. In Indonesia, Chib et al. (2008)
selected 15 health facilities through random sampling;
midwives in eight of the facilities received a mobile phone.
Perceived benefits reported were that: (i) mobile phones
made it easier to contact patients, midwives and supervi-
sors, (ii) time efficiency increased due to the ability to
coordinate visits, and (iii) if complications occurred assis-
tance was only a call away. Despite these advantages,
constraints included the costs, poor mobile phone network
infrastructure in rural areas, increased demand for
Tropical Medicine and International Health volume 16 no 5 pp 622–626 may 2011
A. C. Noordam et al. Better maternal health services through mobile phones
ª2011 Blackwell Publishing Ltd 623
consultation, difficulties in uptake of higher technology
programmes for data analysis, and hesitation in contacting
supervisors due to organizational hierarchy (Chib et al.
2008; Chib 2010).
A recently launched project in Rwanda went a step
further by using text messaging to facilitate and coordinate
the communication as well as data exchange between
community health workers, health centres and hospitals.
Preliminary data suggested a positive effect on access to
maternal health services and consequently lower death
rates (Holmes 2010).
An initiative in Tanzania designed a phone-based
application that contained forms and protocols meant to
support pregnant women before, during and after delivery
(Svoronos et al. 2010). The results of a pilot project
seemed positive; however, the authors mentioned the need
to further assess the impact of the project.
Empowering women to contact health services and
access information
To decrease the first phase of delay, several programmes
aimed to empower women to contact health services and
access information; however, data was still being processed
at the time this article was written. In Zanzibar, a study
following 2 500 women investigated the impact of both
voice and text messages on maternal health (Lund 2009,
2010a). Text messages were sent to pregnant women
containing basic health education and reminders for
routine health care appointments. Expectant mothers
received vouchers and phone numbers that they could use
to contact services for questions and emergencies. The
study assessed the impact on quality of services, health
seeking behaviour and maternal morbidity and mortality.
The data was being processed at the time of writing this
article; the study promised to yield useful information
(Lund 2010b).
MoTECH is an ongoing project in Ghana aiming to
determine how mobile phones can best be used to increase
the quantity and quality of antenatal care (Mechael 2009).
Results from randomized treatment and control groups
were not yet available (Mailman School of Public Health
Gender discrepancies in access to and use of the technology
The analysis of the potential of mobile phones for maternal
health requires examining how mobile phones may relate
to the root cause of poor maternal health, namely the
position of women in society (UNICEF 2009). Globally, a
woman is 21% less likely to own a mobile phone than a
man (GSMA et al. 2010). This discrepancy in the uptake of
mobile phones is highest in South Asia, followed by Sub-
Saharan Africa.
Women who do have access to a mobile phone often use
it for business, banking and employment opportunities
(GSMA et al. 2010; Hellstro
¨m 2010; Macueve et al. 2009)
and thus to make themselves more independent. Several
projects use mobile phones to improve access to basic
education for women, for example text message-based
literacy programmes (GSMA et al. 2010).
The main reason for not owning a mobile phone lies in
the associated costs, illiteracy and lack of electricity
(GSMA et al. 2010; Hellstro
¨m 2010). Being practical,
especially women in Africa are likely to borrow a phone if
they do not own one (Macueve et al. 2009). Other
discrepancies in the ownership of mobile phones exist
between countries and in rural areas versus urban areas,
mainly due to poor network coverage (Comfort & Dada
Robust studies providing evidence on the impact of
introducing mobile phones to improve the quality or
increase the use of maternal health services are lacking.
However, there is broad agreement that access to com-
munication is an essential component of improving the use
and quality of maternal health services. The mobile phone
has a high potential as it is small, portable, widely used,
relatively cheap and the extending network coverage
increasingly enables communication with rural and iso-
lated areas.
The extremely quick uptake of mobile phones world-
wide can shorten delays in seeking and receiving health
care. The available literature suggests great potential in
connecting traditional and biomedical health care, as well
as connecting the different levels within a health care
system, provided that women are not restricted due to their
position in society, lack of finance or means of transport.
To fully realize the benefits of mobile communication,
research needs to generate the evidence-basis for scaling up
mHealth and enabling informed mHealth policy-making,
and to analyse its benefit in ensuring timely delivery of
medical equipment, provide health education and improve
access to reproductive health services, e.g. for family
So far, projects mainly focus on acute, life threatening
situations, but mobile phones can also be used to deliver
mass health messages to pregnant women, recalling women
with risk factors to present themselves at an antenatal
clinic or referring women who suffer from complications
such as fistula, incontinence and infertility. Possibilities
related to connecting them to specialized hospitals need to
Tropical Medicine and International Health volume 16 no 5 pp 622–626 may 2011
A. C. Noordam et al. Better maternal health services through mobile phones
624 ª2011 Blackwell Publishing Ltd
be integrated into research and project designs. In addition,
all the different applications, best practices, constraints and
lessons learned need to be documented.
The quick uptake of the mobile phone and its use in
health care requires policies and guidance of governments,
especially related to issues such as privacy and confiden-
tiality. An overuse of text messaging by the private and
public sector will soon be regarded as spam, making it lose
its effectiveness. In addition to privacy, governments need
to ensure confidentiality of sensitive information.
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Corresponding Author A. Camielle Noordam, Royal Tropical Institute, Mauritskade 63, 1092 AD Amsterdam, The Netherlands.
Tropical Medicine and International Health volume 16 no 5 pp 622–626 may 2011
A. C. Noordam et al. Better maternal health services through mobile phones
626 ª2011 Blackwell Publishing Ltd
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Bu çalışmada Sağlık Bakanlığı’nın Covid-19 salgınıyla mücadele kapsamında geliştirmiş olduğu “Hayat Eve Sığar (HES)” uygulamasının başarılı bir şekilde kullanılabilmesi ve yürütülebilmesi için gerekli kritik başarı faktörlerinin ortaya konulması amaçlanmıştır. Bu kapsamda toplam 20 kişi ile odak grup görüşmeleri gerçekleştirilmiştir. Bir araştırmacı İstanbul’da 5 sağlık çalışanı ve HES uygulamasını günlük hayatında kullanan 5 kişi ile odak grup görüşmesi yapmıştır. Diğer bir araştırmacı ise Ardahan’da yine 5 sağlık çalışanı ve HES uygulamasını günlük hayatında kullanan 5 kişi ile ayrı bir odak grup görüşmesi yapmıştır. Her bir odak grup görüşmesi ortalama 45 dakika sürmüştür. Yapılan odak grup görüşmeleri sonucunda elde edilen veriler çözümlenerek analiz edilmiştir. Analiz sonucunda HES uygulamasının başarılı bir şekilde kullanılabilmesi ve yürütülebilmesi için gerekli olabilecek toplam 7 kritik başarı faktörü belirlenmiştir. Bu faktörler konum bazlı etkin uyarı sistemi, bulaşı önleyici mekanizma, etkin bilgilendirme sistemi, yeni hizmetler ve kullanım deneyimi, hız, etkin ihbar yönetim sistemi ve kod güvenliğinden oluşmaktadır.
With their widespread use in the Global South, mobile phones are attracting growing interest from international aid actors and local authorities alike, who are positioning mobile technology as a growth driver and a solution to many social problems. Initiated by giants of the digital industry, these policies are reviving old questions about technological development, the relationship between the market sector and States, and the role of technology in the inequalities between the Global North and Global South. Through a multi-sited ethnography on maternal care in Ghana and India, this Element provides a first-hand look at initiatives that promise to improve poor women's health in the Global South through the use of mobile phones; a field known as Mobile Health or mHealth. Attentive to the way in which these technical objects modify power relations at both international and local levels, this Element also discusses how mHealth transforms care practices and healthcare.
Purpose Adopting digital technology could facilitate the public health response to the COVID-19 pandemic. Some analysts argue that countries that adopted digital technology in their health sector have managed to control the virus better (Whitelaw et al. , 2020). For instance, countries with more comprehensive contact tracing have significantly lower fatality rates (Yalaman et al. , 2021). Moreover, World Health Organization (WHO) believes this technology is a crucial enabler for countries to meet the current challenge (WHO. Regional Office for the Western Pacific & University of Melbourne, 2021). In this regard, this study aims to quantitatively find the relationship between the technological advancement of countries and COVID-19 health outcomes, using seven technological indices that measure technological advancement. Design/methodology/approach The authors used the multiple linear regression method to answer the research questions. The first analysis focuses on a cross section of all countries worldwide, and the second focuses on European countries for which weekly death statistics exist after the pandemic. Findings The findings support those countries with more technological abilities managed to control the virus’s mortality better, as evidenced by the negative link between the mortality rate of COVID-19 and the technological factors at the national level. Results also reveal that technology adoption decreases the death risk due to COVID-19 in countries with more elderly people. The authors may argue that technological advancement positively correlates with the number of deaths and diagnosed cases because the authors can better collect data or because the virus spreads due to higher economic and business activities. However, such technological advancement significantly decreases the death risk (lower mortality rate in the first analysis and lower mortality rate for elderly people in the second analysis). Research limitations/implications Three important conclusions could be made from the results: a lower mortality rate is generally expected for countries adopting advanced technology; technological advancement significantly decreases the death risk for elderly people; and a higher technology adoption level does not necessarily result in fewer diagnosed cases of/death due to COVID-19. Originality/value Although some studies have focused on e-health applications in the public health response to the COVID-19 pandemic, no studies, to the best of the authors’ knowledge, have tried to quantify its efficacy, most especially on the global level.
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The state of maternal health is an important indicator of a nation's health care delivery system and the level of the society's development. Previous efforts to meet the Millennium Development Goals (MDGs) on the reduction of maternal mortality in Nigeria have shown only marginal reductions in the last five years, making the MDGs targets by 2020 clearly unachievable using current strategies alone (Mid-Point Assessment Overview, MDGs Nigeria, 2008), hence this study; The methodology adopted for this study is Object-oriented analysis and design methodology that starts with understanding the domain, locating proper data sources, preparing the raw data, applying advanced analysis techniques, and extracting and validating the resulting knowledge from a quality registry for maternal mortality. The results will be to develop an integrated IT solution that is suitable for Nigeria, focused on the maternity care conditions and control the rate of maternal mortality in Nigeria using knowledge discovery in database (KDD).
Background Persuasive design principles are increasingly employed in mHealth apps for motivating users and promoting healthy behaviours among individuals. However, how the persuasive design principles are perceived by the mHealth app users remains unclear. Aim To develop and validate the content validity of an instrument designed to measure the user’s perceptions of the persuasive design principles assimilated in a breastfeeding mHealth app. Methods A critical review of the literature guided the development of the research instrument. The developed instrument was refined and validated through a two-round modified Delphi process. Ten experts drawn from academic and clinical settings evaluated the items through two content validity indicators, relevance, and clarity and provided narrative feedback. The content validity of the instrument was determined by calculating the Content Validity Index (CVI). Content validity indicators at the scale-level (S-CVI) and item-level (I-CVI) were calculated. Results The results demonstrated high content validity index of individual items in the instrument. All items in the instrument reached an excellent I-CVI ≥ 0.78 for both relevance and clarity except one item. The overall content validity index of the instrument using the average approach was moderate to high (S-CVI/Ave was 0.89 and 0.92 for relevance and clarity, respectively). The developed research instrument is composed of 5 constructs representing 24 items: (1) primary task support, (2) dialogue support, (3) system credibility support, (4) social support and (5) perceived persuasiveness. Conclusions Using a modified Delphi approach, the development and validation of the research instrument demonstrated moderate to high content validity for measuring users’ perceptions of the persuasive design principles assimilated in a breastfeeding mHealth app. The evidence from this study supports that the research instrument is valid, relevant, and clear.
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Information-Communication Technologies (ICT) are the general technology impacting the economy universally. The analysis of these processes was done within the framework of the Information Society concept. Standard statistical indicators had been insufficient to evaluate its development, so it was proposed to calculate the composite ICT Development Index (IDI). IDI ranges from 0 to 1. The top ten countries are headed by Korea. Its IDI is 8.4; Chad scored the lowest – 0.83. This indicates a significant gap in Information Society development between the countries. On the one hand, this could be explained by the model of the index constructing, on the other, ICT implementation is directly influenced by their value. Nevertheless, the level of IDI in the CIS countries is higher than expected, taking into account their income per capita. This indicates that national strategies can facilitate their transition to the Information Society (IS). These strategies should be coordinated with the current level of ICT implementation and economic development. Therefore, the objective of the study was to form the priorities for IS strategy according to the particular stage of its development. To define these stages statistically we set the following tasks: to create a list of the indicators, to analyze statistical data, and to identify the clusters of the countries which are on the same IS stage.
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Community Health Worker (CHW) programs have potential to improve the health of the millions living in extreme poverty by serving as a liaison between a household and the formal health system. Yet despite many attempts, CHW programs consistently fall short due to inconsistent care, lack of supervision and feedback, and high staff turnover. Quality Improvement (QI) tools have great potential to mitigate these shortcomings. We are evaluating the possibility of inserting QI tools into CHW practice through CommCare, a phone-based application. Each CHW is equipped with a low-cost phone running CommCare to help manage their day and report data in real time. By making checklists, decision support protocols, and reminders a part of CHWs' routines, we can reinforce the target behavior that a successful CHW program requires. CHWs using CommCare have reported a significant improvement in their management of pregnancies. Additionally, CommCare is paired with a set of supervisory tools to ensure regular feedback from health officers, though these tools have yet to be appropriately piloted.
OBJECTIVE: To evaluate the effect of a national referral system that aims to reduce maternal mortality rates through improving access to and the quality of emergency obstetric care in rural Mali (sub-Saharan Africa). METHODS: A maternity referral system that included basic and comprehensive emergency obstetric care, transportation to obstetric health services and community cost-sharing schemes was implemented in six rural health districts in Kayes region between December 2002 and November 2005. In an uncontrolled "before and after" study, we recorded all obstetric emergencies, major obstetric interventions and maternal deaths during a 4-year observation period (1 January 2003 to 30 November 2006): the year prior to the intervention (P-1); the year of the intervention (P0), and 1 and 2 years after the intervention (P1 and P2, respectively). The primary outcome was the risk of death among obstetric emergency patients, calculated with crude case fatality rates and crude odds ratios. Analyses were adjusted for confounding variables using logistic regression. FINDINGS: The number of women receiving emergency obstetric care doubled between P-1 and P2, and the rate of major obstetric interventions (mainly Caesarean sections) performed for absolute maternal indications increased from 0.13% in P-1 to 0.46% in P2. In women treated for an obstetric emergency, the risk of death 2 years after implementing the intervention was half the risk recorded before the intervention (odds ratio, OR: 0.48; 95% confidence interval, CI: 0.30-0.76). Maternal mortality rates decreased more among women referred for emergency obstetric care than among those who presented to the district health centre without referral. Nearly half (47.5%) of the reduction in deaths was attributable to fewer deaths from haemorrhage. CONCLUSION: The intervention showed rapid effects due to the availability of major obstetric interventions in district health centres, reduced transport time to such centres for treatment, and reduced financial barriers to care. Our results show that national programmes can be implemented in low-income countries without major external funding and that they can rapidly improve the coverage of obstetric services and significantly reduce the risk of death associated with obstetric complications.
This chapter reviews the state of children in both rich and poor countries of the world. It examines some recent data with respect to the longterm sequelae of malnutrition. It suggests that, unless urgent improvements in protecting fetal and infant brains can be achieved in both rich and poor countries, developmental-behavioral disorders will emerge by the 21st century as an overriding health issue in many areas of the world.
Mwanza, Phalombe and Zomba districts in the Southern Region of Malawi. Radios have been installed in many health centers in the Southern Region of Malawi but communication is often indirect. Messages get re-channeled from one health center to another before reaching district hospitals. In an attempt to strengthen the obstetric referral system, the Safe Motherhood Project installed a repeater-based VHF radio communication system in three pilot districts. The overall goal of the new network was to enable the health centers to communicate directly to their district health offices (DHOs) for an ambulance when they have an emergency obstetric complication for referral to the hospital. This study aimed to determine whether or not improving the radio communications system reduces the delay in referral of obstetric emergencies from health center to hospital. Data collection was conducted between 2001 and 2003 using a range of data collection methods. Radio communications register books were placed at each participating health center to record information on all women with emergency obstetric complications referred to the hospital for further management. An obstetric referral form was completed on each woman referred to the hospital. And using the same referral form, the referral hospital was required to give feedback to the health centers on discharge of the patient. Existing maternity registers or HMIS registers were reviewed to obtain additional information not captured in radio communication registers. Interviews with health center staff were conducted to obtain their communication experiences before and after the new network was installed. The average number of obstetric admissions per month and the proportion of referrals in the participating health centers significantly increased during the post-intervention period. Significantly more emergency obstetric referrals were collected under 1 hour between decision to refer by the midwife at the health center and arrival of transport from the DHO or base station in the post-intervention period than pre-intervention period (p<0.02). However, some patients still waited for more than 13 hours for transportation in the post-intervention period. The median time interval between decision to refer and arrival of transport was 3 h. versus 2 h. 3 min. in the pre- and post-intervention periods respectively. This study has demonstrated that the new VHF radio network system has, without doubt, improved the radio communication system in the three pilot districts. However, although the time interval between the decision to refer and arrival of transport significantly improved after the intervention, the majority of transportation still took too long, particularly for someone with postpartum hemorrhage. It is very important to improve the management/control of obstetric ambulances at district level so as to complement efforts of an improved radio communication system in reducing delays in the referral of obstetric emergencies.