Referral and counter-referral in obstetric emergencies

As the crow flies, Kédougou is located in the extreme south-east of Senegal, 739km from the capital Dakar. Most of its departmental roads leading to the regional capital are unpaved, with dilapidated traditional bridges. At the last census, Kédougous maternal mortality ratio was the highest in Senegal, with 921 deaths per 100,000 live births in 2013 and 340 deaths per 100,000 live births in 2023. Obstetric referral is particularly problematic in Kédougou, where 67% of cases involve delivery haemorrhage, generally unaccompanied by a qualified provider, without a medical ambulance, and with undocumented procedures. This article highlights the effects of the dysfunctional referral and counter-referral system in the Kédougou health district on womens vital prognosis. It is based on an emic approach, starting from health care providers whose information provides an embedded theory of the local health infrastructure.