Are bicycle ambulances and community transport plans effective in strengthening obstetric referral systems in Southern Malawi?

SETTING: Nsanje District in the Southern Region of Malawi. OBJECTIVES: - To determine the time taken, cost-effectiveness and cultural acceptability of bicycle ambulances (BAs) and established community transport plans (CTPs) in the referral of obstectric cases. - To determine whether the presence of bicycle ambulances and established plans decrease home delivery rates. METHODS: We conducted a community-based case control study in Traditional Authority Tengani in Nsanje District. We used both qualitative and quantitative methods to collect data from ten villages within a 5-kilometre radius of three Basic Essential Obstetric Care (BEOC) facilities. Four villages were enrolled as 'cases' while the other six were controls. Of the four 'case' villages, two were provided with bicycle ambulances and two developed community transport plans; the six control villages lacked both bicycle ambulances and community transport plans. Prior to the intervention, 30 homogenous focus group discussions (FGDs) explored experiences and perceptions of modes of transport with elders, chiefs, women of child bearing and their partners. Retrospective interviews were conducted with women delivering six months prior to the study (n=92) to obtain baseline data, whilst prospectively 157 deliveries were registered. RESULTS: Approximately 90 minutes of travel time was required with all forms transportation studied. Important cultural beliefs deterred most pregnant women from using the bicycle ambulances. People believe that publicising the onset of labour summons evil spirits resulting in obstructed labour. This explains why general medical cases used BAs more frequently than obstetric cases. However, home delivery rates in case villages decreased from 37% to 18% (P<0.005). CONCLUSIONS: In this study we were unable to demonstrate any benefit for obstetric referral systems when BAs and CTPs were introduced. The dearth of international literature coupled with these findings highlight the need for further detailed studies prior to wide-scale adoption of transport schemes.