Objective: The purpose of this study was to examine the association between the implementation of a mobile obstetric emergency system (MORES) and referral time for obstetric emergencies as well as maternal/newborn outcomes. Design: Pre/post intervention descriptive study. Setting: Liberia’s caesarean section (CS) coverage is about 5%, lower than 9-19% coverage associated with decreased maternal mortality. Delays in the referral process from a rural health facility (RHF) to a district hospital for comprehensive emergency obstetric and newborn care (CEmONC) services such as CS contribute to the high maternal mortality. Sample: Women with referral data from both RHFs (n=20) and hospitals (n=2) within Bong County, Liberia. Methods: A pre/post descriptive analysis was conducted on data collected from RHFs and two hospitals in Bong County, Liberia. Descriptive analysis and logistic regression models examined the relationship between the intervention’s implementation and mode of delivery, maternal outcome, newborn outcome, and transfer time from RHF to district hospital. Main outcome measures: Mode of delivery, maternal outcome, newborn outcome, and transfer time. Results: Women had higher odds of undergoing a CS at endline (OR: 1.86 95%; CI: 0.99- 3.46) compared to baseline. Additionally, newborns had lower odds of showing depressive symptoms (OR: 0.31; 95%CI: 0.14-0.68), defined as a non-vigorous newborn with poor respiratory effort, muscle tone or heart rate <100 beats per minute. Conclusion: MORES is a promising means to increase timely care seeking along the referral pathway which may enhance access to caesarean section as well as improved newborn outcomes in low- and middle-income countries.

Objective: To report on the effectiveness of a standardized core Maternity Waiting Home (MWH) model to increase facility deliveries and access to reproductive health services among women living farthest from a health facility (>10km) using facility-based data. Design: Quasi-experimental design. Setting: Seven rural districts in Zambia. Population: Women delivering at 40 health facilities between June 2016 to August 2018. Methods: 20 intervention sites and 20 comparison sites were used to test if MWHs increased access to reproductive health services for women living in rural Zambia. The difference-in-differences (DID) methodology was used to examine the effectiveness of the core MWH model on our primary outcomes. Main Outcome Measures: Differences in the change from baseline to endline in the percentage of women who: 1) traveled greater than 10 km for delivery, (2) attended a postnatal visit at 6 days postpartum, and (3) were referred to a higher-level health facility between intervention and comparison group. Results: We detected a significant difference for the percentage of deliveries at intervention facilities with the core MWH model for all women living >10km away (p=0.03), adolescent women (<18 years) living >10km away (p=0.002), and primigravida women living >10km away (p=0.01). There were no significant differences for women attending a postnatal care visit at 6 days postpartum (p=0.07) or for women referred to the next level of care (p=0.29). Conclusion: The core MWH model was successful in reaching women with historically low rates of facility delivery, those living >10km from a healthcare facility, including adolescent women and primigravidas.