Where referral networks aimed at reducing maternal mortality already exist, through Safe Motherhood projects or similar efforts, postabortion care and referral can be added to the network. In many settings improved postabortion care can be developed as part of an overall strategy to improve emergency obstetric care. By linking postabortion care to other reproductive health services, health systems can take advantage of existing services rather than create a new, vertical service. Integrating postabortion services with existing emergency or obstetric services can be an effective way to provide needed care with minimal added costs. In Ghana, for example, a project is underway to train 40 midwives and the physicians who back them up to provide MVA as well as family planning counseling and services as part of an overall strategy aimed at reducing maternal deaths and expanding care to the primary level (36).

Maintaining links between levels. Arranging reliable communication among and transportation to medical facilities is crucial to making the postabortion referral system work (186, 293). Improving and formalizing communication and transportation between levels of the health care system is important to improving care for all obstetric complications, as well as all other medical emergencies. Again, strategies aimed at improving postabortion can be part of a larger initiative to improve emergency care.

Making arrangements may be challenging at the primary level, especially in rural areas. District hospitals should have established systems of radio or telephone communication with regional hospitals, but, again, many do not. At all health care levels, where ambulances are available, they must be kept in running order. If none is available, making formal arrangements with community members or businesses who own vehicles is another way to make sure that women can reach appropriate care in time (293).