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The fee exemption policy for EmONC in Mali aims to lower the financial barrier to care. The objective of the study was to evaluate the direct and indirect expenses associated with caesarean interventions performed in EmONC and the factors associated with these expenses. Data sampling followed the case control approach used in the large project (deceased and near-miss women). Our sample consisted of a total of 190 women who underwent caesarean interventions. Data were collected from the health workers and with a social approach by administering questionnaires to the persons who accompanied the woman. Household socioeconomic status was assessed using a wealth index constructed with a principal component analysis. The factors significantly associated with expenses were determined using multivariate linear regression analyses. Women in the Kayes region spent on average 77,017 FCFA (163 USD) for a caesarean episode in EmONC, of which 70 % was for treatment. Despite the caesarean fee exemption, 91 % of the women still paid for their treatment. The largest treatment-related direct expenses were for prescriptions, transfusion, antibiotics, and antihypertensive medication. Near-misses, women who presented a hemorrhage or an infection, and/or women living in rural areas spent significantly more than the others. Although abolishing fees of EmONC in Mali plays an important role in reducing maternal death by increasing access to caesarean sections, this paper shows that the fee policy did not benefit to all women. There are still barriers to EmONC access for women of the lowest socio-economic group. These included direct expenses for drugs prescription, treatment and indirect expenses for transport and food.

Background Albania, as with all Central and Eastern European countries whose health systems were highly centralized, has undertaken a number of reforms aiming to transform, among many items, the financing and delivery of primary health care services. Objective This study assesses the practice activities of general practitioners working in the region of Tirana, over a period of 12 months. Methods Production is measured by the number of monthly visits carried out by the practitioner, and practice profiles are determined by referral rates for specialist care and prescription rates per visit. Multi-level regression analyses, taking into account the hierarchical structure of the data, were performed to identify the factors associated with productivity and profiles of practice. Results Results show large urban-rural variations with respect to practice conditions, characteristics of practitioners, productivity, and profiles of practice. Productivity was weak in the city of Tirana (an average of 277 monthly visits), 18% of patients were referred to specialists, and 66% received prescriptions. In rural areas, productivity was weaker (an average of 179 monthly visits), referral rates were lower (11%), and the prescription rate was 74%. In urban and rural areas, productivity and profiles of practice were related to the characteristics of both the client and the health centre and to the type of practice. Conclusion There are only a few available epidemiological studies documenting the ongoing health transition and the concomitant increase in demand for primary health care services; therefore, we are unable to (causally) link the reported low productivity of general practitioners with population needs. Physician productivity and patient care is better for certain groups and in health care settings where a wide range of services and sophisticated medical technologies are available. The capacity to efficiently plan for medical manpower is limited - this may be attributed to deficiencies of the patient registration system on the lists of physicians who are paid on the basis of capitation. Additional studies examining utilization of health services, and satisfaction of patients and providers, is needed in order to provide sound recommendations for improving Albania's health care system.

To estimate effective strategies for implementing clinical practice guidelines in obstetric care and to identify specific barriers to behavior change and facilitators in obstetrics.The Cochrane Library, EMBASE, and MEDLINE were consulted from January 1990 to June 2005. Additional studies were identified by screening reference lists from identified studies and experts' suggestions.Studies of clinical practice guidelines implementation strategies in obstetric care and reviews of such studies were selected. Randomized controlled trials, controlled before-after studies, and interrupted time series studies were evaluated according to Effective Practice and Organization of Care criteria standards.Studies were reviewed by two investigators to assess the quality and the efficacy of each strategy. Discordances between the two reviewers were resolved by consensus. In obstetrics, educational strategies with medical providers are generally ineffective; educational strategies with paramedical providers, opinion leaders, qualitative improvement, and academic detailing have mixed effects; audit and feedback, reminders, and multifaceted strategies are generally effective. These findings differ from data on the efficacy of clinical practice guidelines implementation strategies in other medical specialties. Specific barriers to behavior change in obstetrics and methods to overcome these barriers could explain these differences. The proportion of effective strategies is significantly higher among the interventions that include a prospective identification of barriers to change compared with standardized interventions.Prospective identification of efficient strategies and barriers to change is necessary to achieve a better adaptation of intervention and to improve clinical practice guidelines implementation. In the field of obstetric care, multifaceted strategy based on audit and feedback and facilitated by local opinion leaders is recommended to effectively change behaviors.

Objective: To determine the factors associated with obstetric competency and clinical practice among obstetric care providers in referral health centers in Mali. Methods: The present cross-sectional study was conducted between March and May 2012 among 140 obstetric care providers (obstetric nurses, midwives, and physicians) working in referral health centers in Mali. Emergency obstetric care knowledge and skills were evaluated with clinical vignettes developed using national Malian guidelines. The vignettes covered 5 areas of emergency obstetric care, and the results were used to generate a competency score. A backward stepwise random-effects model using a maximum likelihood estimator was applied to evaluate variables independently associated with competency score. Results: Out of 100, the mean +/- SD score was 57.8 +/- 11.2 for obstetric nurses, 66.4 +/- 14.7 for midwifes, and 78.6 +/- 13.4 for physicians (P < 0.001). Three variables were significantly associated with a higher competency score: professional qualification, working in an urban setting, and working in a health center with a smaller number of obstetric care providers. Conclusion: Increasing the in-service training of both rural staff and lower-level healthcare workers working in larger health centers via facility-based maternal death reviews might help to improve clinical practice and maternal health outcomes.

INTRODUCTION: Several countries have instituted fee exemptions for caesareans to reduce maternal and newborn mortality. OBJECTIVES: To evaluate the effect of fee exemptions for caesareans on population caesarean rates taking into account different levels of accessibility. METHODS: The observation period was from January 2003 to May 2012 in one Region and covered 11.7 million person-years. Exemption fees for caesareans were adopted on June 26, 2005. Data were obtained from a registration system implemented in 2003 that tracks all obstetrical emergencies and interventions including caesareans. The pre-intervention period was 30 months and the post-intervention period was 83 months. We used an interrupted time series to evaluate the trend before and after the policy adoption and the overall tendency. FINDINGS: During the study period, the caesarean rate increased from 0.25 to 1.5% for the entire population. For women living in cities with district hospitals that provided caesareans, the rate increased from 1.7% before the policy was enforced to 5.7% 83 months later. No significant change in trends was observed among women living in villages with a healthcare centre or those in villages with no healthcare facility. For the latter, the caesarean rate increased from 0.4 to 1%. CONCLUSIONS: After nine years of implementation policy in Mali, the caesarean rate achieved in cities with a district hospital reached the full beneficial effect of this measure, whereas for women living elsewhere this policy did not increase the caesarean rate to a level that could contribute effectively to reduce their risk of maternal death. Only universal access to this essential intervention could reduce the inequities and increase the effectiveness of this policy.

To investigate the frequency of catastrophic expenditures for emergency obstetric care, explore its risk factors, and assess the effect of these expenditures on households in the Kayes region, Mali.Data on 484 obstetric emergencies (242 deaths and 242 near-misses) were collected in 2008-2011. Catastrophic expenditure for emergency obstetric care was assessed at different thresholds and its associated factors were explored through logistic regression. A survey was subsequently administered in a nested sample of 56 households to determine how the catastrophic expenditure had affected them.Despite the fee exemption policy for Caesareans and the maternity referral-system, designed to reduce the financial burden of emergency obstetric care, average expenses were 152 United States dollars (equivalent to 71 535 Communauté Financière Africaine francs) and 20.7 to 53.5% of households incurred catastrophic expenditures. High expenditure for emergency obstetric care forced 44.6% of the households to reduce their food consumption and 23.2% were still indebted 10 months to two and a half years later. Living in remote rural areas was associated with the risk of catastrophic spending, which shows the referral system's inability to eliminate financial obstacles for remote households. Women who underwent Caesareans continued to incur catastrophic expenses, especially when prescribed drugs not included in the government-provided Caesarean kits.The poor accessibility and affordability of emergency obstetric care has consequences beyond maternal deaths. Providing drugs free of charge and moving to a more sustainable, nationally-funded referral system would reduce catastrophic expenses for households during obstetric emergencies.Étudier la fréquence des dépenses catastrophiques en soins obstétricaux d'urgence, explorer leurs facteurs de risque et évaluer l'effet de ces dépenses sur les ménages dans la région de Kayes, au Mali.Les données de 484 urgences obstétricales (242 décès et 242 accidents évités de justesse) ont été recueillies sur la période 2008-2011. Les dépenses catastrophiques en soins obstétricaux d'urgence ont été évaluées à différents niveaux, et leurs facteurs associés ont été étudiés par régression logistique. Une enquête a ensuite été effectuée auprès d'un échantillon imbriqué de 56 ménages, afin de déterminer comment les dépenses catastrophiques les avaient affectés.Malgré la politique d'exonération de frais pour les césariennes et le système de maternité de référence, conçu pour réduire la charge financière des soins obstétricaux d'urgence, les dépenses moyennes étaient de 152 dollars des États-Unis (équivalent à 71 535 francs de la Communauté financière africaine), et 20,7 à 53,5% des ménages faisaient face à des dépenses catastrophiques. Des dépenses élevées pour les soins obstétricaux d'urgence ont forcé 44,6% des ménages à réduire leur consommation alimentaire, et 23,2% d'entre eux étaient encore endettés, dix mois à deux ans et demi plus tard. Vivre dans des zones rurales reculées était associé au risque de dépenses catastrophiques, ce qui montre que le système de référence ne peut éliminer les obstacles financiers pour les ménages éloignés. Les femmes ayant subi une césarienne ont continué à faire face à des dépenses catastrophiques, en particulier lorsque les médicaments prescrits n'étaient pas inclus dans les kits de césarienne fournis par le gouvernement.Le fait que les soins obstétricaux d'urgence soient difficilement accessibles et peu abordables a des conséquences au-delà des décès maternels. Fournir gratuitement des médicaments et passer à un système de référence plus durable, financé au niveau national, permettrait de réduire les dépenses catastrophiques pour les ménages en situation d'urgence obstétricale.Investigar la frecuencia de los gastos catastróficos en la atención obstétrica de urgencia, examinar los factores de riesgo y evaluar el efecto de dichos gastos en los hogares de la región de Kayes en Malí.Se recogieron los datos de 484 situaciones obstétricas de urgencia (242 fallecimientos y 242 errores evitados) entre 2008 y 2011. El gasto catastrófico de la atención obstétrica de urgencia se evaluó en umbrales diferentes y los factores relacionados se examinaron por medio de una regresión logística. Posteriormente, se realizó una encuesta en una muestra jerarquizada de 56 hogares a fin de determinar los efectos de dicho gasto catastrófico.A pesar de la política de exención de pago para las cesáreas y el sistema de derivación para la atención de maternidad, diseñado para reducir la carga financiera de la atención obstétrica de urgencia, el gasto medio fue de 152 dólares estadounidenses (71 535 francos CFA) y del 20,7 al 53,5% de los hogares incurrieron en gastos catastróficos. El gasto elevado de la atención obstétrica de urgencia obligó al 44,6% de los hogares a reducir su consumo de alimentos, y el 23,2% seguía endeudado entre 10 meses y dos años y medio más tarde. Vivir en un área rural remota estuvo asociado con el riesgo de gasto catastrófico, lo que muestra la incapacidad del sistema de derivación de eliminar los obstáculos financieros para los hogares de zonas remotas. Las mujeres que se sometieron a una cesárea continuaron acumulando gastos catastróficos, en particular en los casos en los que se prescribieron medicamentos no incluidos en los botiquines para cesáreas proporcionados por el gobierno.La mala accesibilidad y asequibilidad de la atención obstétrica de urgencia tiene consecuencias más allá de las muertes maternas. Suministrar medicamentos gratuitos y el cambio a un sistema de derivación financiado a nivel nacional y más sostenible reduciría los gastos catastróficos de los hogares en los casos de emergencias obstétricas.تحري تواتر الإنفاق الباهظ للرعاية التوليدية الطارئة، واستعراض عوامل اختطاره، وتقييم تأثير هذا الإنفاق على الأسر في إقليم كايس في مالي.تم جمع بيانات حول 484 حالة طوارئ توليدية (242 حالة وفاة و242 حالة وشيكة) في الفترة من 2008 إلى 2011. وتم تقييم الإنفاق الباهظ على الرعاية التوليدية الطارئة على عتبات مختلفة واستعراض العوامل المرتبطة به من خلال الارتداد اللوجيستي. وبعد ذلك، أُجريت دراسة استقصائية على عينة متداخلة تتألف من 56 أسرة لتحديد مدى تأثير الإنفاق الباهظ عليها.على الرغم من سياسة الإعفاء من الرسوم الخاصة بالولادات القيصرية ونظام الإحالة للأمهات، الذي تم تصميمه للحد من العبء المالي للرعاية التوليدية الطارئة، كان متوسط النفقات 152 دولاراً أمريكياً (ما يعادل 71535 فرنكاً بعملة الجماعة المالية الأفريقية) وتكبدت نسبة 20.7 % إلى 53.5 % من الأسر نفقات باهظة. وأجبر الإنفاق المرتفع على الرعاية التوليدية الطارئة 44.6 % من الأسر على تقليل استهلاكها من الطعام وظلت 23.2 % من الأسر مدينة لفترة من 10 أشهر إلى سنتين ونصف السنة بعدها. وارتبطت المعيشة في المناطق الريفية النائية بمخاطر الإنفاق الباهظ، التي تبين عجز نظام الإحالة عن التخلص من العقبات المالية التي تعترض الأسر النائية. واستمر تكبد النساء اللاتي أُجريت لهن ولادات قيصرية لنفقات باهظة، لاسيما مع عدم إدراج الأدوية الموصوفة لهن في مجموعات أدوات الولادة القيصرية التي تقدمها الحكومة.يتسبب ضعف الوصول وعدم القدرة على تحمل تكاليف الرعاية التوليدية الطارئة في عواقب تتعدى وفيات الأمهات. وسوف يقلل تقديم الأدوية بالمجان والانتقال إلى نظام إحالة أكثر استدامة يتم تمويله على المستوى الوطني من النفقات الباهظة للأسر أثناء حالات الطوارئ التوليدية.调查产科急症护理灾难性支出的频率，探索其风险因素，评估这些支出对马里凯斯地区家庭的影响。收集2008–2011 年484 例产科急症护理（242 人死亡和242 人濒危）的数据。对产科急症护理的灾难性支出进行不同阈值的估计，并通过逻辑回归探讨其相关的因素。随后在包含56 个家庭的嵌套样本中展开调查，确定灾难性支出如何对其产生影响。尽管有旨在减少产科急症护理财政负担的剖腹产、产妇转诊系统的费用豁免政策，平均费用仍有152 美元（相当于71535 非洲金融共同体法郎），20.7-53.5%的家庭蒙受灾难性支出。产科急症护理的高支出迫使44.6%的家庭减少其食品消费，23.2%的家庭在10 个月至2 年半后仍然负债。生活在偏远农村地区与灾难性支出风险相关，这显示了转诊系统无法消除偏远地区家庭的财务障碍。接受了剖腹产的女性继续承担灾难性的支出，当政府提供的剖腹产护理包中不包含处方药物时尤其如此。产科急症护理看病难、看病贵所造成的后果不仅仅在于孕产妇死亡。提供免费的药品，转为更具可持续性、全国统筹的转诊系统可望减少产科急症中家庭的灾难性支出。Исследовать периодичность чрезвычайно высоких расходов на неотложную акушерскую помощь, изучить связанные с ними факторы риска и оценить влияние этих расходов на домохозяйства в регионе Каес (Мали).Были собраны данные по 484 экстренным акушерским случаям (242 смертельных случая и 242 угрозы жизни) за период с 2008 по 2011 гг. Оценка чрезвычайно высоких расходов на неотложную акушерскую помощь проводилась на разных пороговых уровнях, и исследовались связующие факторы с помощью логистической регрессии. Впоследствии было проведено исследование методом вложенной выборки 56 домохозяйств для определения влияния на них чрезвычайно высоких расходов.Несмотря на политику предоставления льгот женщинам, перенесшим кесарево сечение, и реферальную систему пособий в связи с родами, которые направлены на сокращение финансового бремени неотложной акушерской помощи, средний размер расходов составлял 152 доллара США (что составляет 71 535 франков Африканского финансового сообщества), что для 20,7-53,5% домохозяйств представляло собой чрезвычайно высокие расходы. Высокие расходы на неотложную акушерскую помощь вынудили 44,6% семей сократить расходы на продукты питания, а 23,2% были обременены долгами в последующий период от девяти месяцев до двух с половиной лет. Проживание в отдаленных сельских районах было связано с риском чрезвычайно высоких затрат, что демонстрирует неспособность реферальной системы устранить финансовые трудности для удаленных домохозяйств. Женщины, перенесшие кесарево сечение, продолжали нести чрезвычайно высокие расходы, особенно при назначении лекарственных средств, не включенных в наборы медикаментов для родов с помощью кесарева сечения, оплачиваемые государством.Недостаточная доступность неотложной акушерской помощи, помимо материнских смертей, влечет за собой и другие последствия. Бесплатное предоставление лекарственных средств и переход к более рациональной реферальной системе, финансируемой государством, снизили бы уровень расходов для домохозяйств при экстренных акушерских случаях.

The West African country of Mali implemented referral systems to increase spatial access to emergency obstetrical care and lower maternal mortality. We test the hypothesis that spatial access- proxied by travel time during the rainy and dry seasons- is associated with in-hospital maternal mortality. Effect modification by caesarean section is explored. All women treated for emergency obstetrical complications at the referral hospital in Kayes, Mali were considered eligible for study. First, we conducted descriptive analyses of all emergency obstetrical complications treated at the referral hospital between 2005 and 2007. We calculated case fatality rates by obstetric diagnosis and travel time. Key informant interviews provided travel times. Medical registers provided clinical and demographic data. Second, a matched case–control study assessed the independent effect of travel time on maternal mortality. Stratification was used to explore effect modification by caesarean section. Case fatality rates increased with increasing travel time to the hospital. After controlling for age, diagnosis, and date of arrival, a travel time of four or more hours was significantly associated with in-hospital maternal mortality (OR: 3.83; CI: 1.31–11.27). Travel times between 2 and 4 h were associated with increased odds of maternal mortality (OR 1.88), but the relationship was not significant. The effect of travel time on maternal mortality appears to be modified by caesarean section. Poor spatial access contributes to maternal mortality even in women who reach a health facility. Improving spatial access will help women arrive at the hospital in time to be treated effectively.

Background In sub-Saharan Africa, maternal and perinatal mortality and morbidity are major problems. Service availability and quality of care in health facilities are heterogeneous and most often inadequate. In resource-poor settings, the facility-based maternal death review or audit is one of the most promising strategies to improve health service performance. We aim to explore and describe health workers' perceptions of facility-based maternal death reviews and to identify barriers to and facilitators of the implementation of this approach in pilot health facilities of Senegal. Methods This study was conducted in five reference hospitals in Senegal with different characteristics. Data were collected from focus group discussions, participant observations of audit meetings, audit documents and interviews with the staff of the maternity unit. Data were analysed by means of both quantitative and qualitative approaches. Results Health professionals and service administrators were receptive and adhered relatively well to the process and the results of the audits, although some considered the situation destabilizing or even threatening. The main barriers to the implementation of maternal deaths reviews were: (1) bad quality of information in medical files; (2) non-participation of the head of department in the audit meetings; (3) lack of feedback to the staff who did not attend the audit meetings. The main facilitators were: (1) high level of professional qualifications or experience of the data collector; (2) involvement of the head of the maternity unit, acting as a moderator during the audit meetings; (3) participation of managers in the audit session to plan appropriate and realistic actions to prevent other maternal deaths. Conclusion The identification of the barriers to and the facilitators of the implementation of maternal death reviews is an essential step for the future adaptation of this method in countries with few resources. We recommend for future implementation of this method a prior enhancement of the perinatal information system and initial training of the members of the audit committee – particularly the data collector and the head of the maternity unit. Local leadership is essential to promote, initiate and monitor the audit process in the health facilities.

Background While evaluation is, in theory, a component of training programmes in health planning, training needs in this area remain significant. Improving health systems necessarily calls for having more professionals who are skilled in evaluation. Thus, the Université de Ouagadougou (Burkina Faso) and the Université de Montréal (Canada) have partnered to establish, in Burkina Faso, a master's-degree programme in population and health with a course in programme evaluation. This article describes the four-week (150-hour) course taken by two cohorts (2005–2006/2006–2007) of health professionals from 11 francophone African countries. We discuss how the course came to be, its content, its teaching processes and the master's programme results for students. Methods The conceptual framework was adapted from Kirkpatrick's (1996) four-level evaluation model: reaction, learning, behaviour, results. Reaction was evaluated based on a standardized questionnaire for all the master's courses and lessons. Learning and behaviour competences were assessed by means of a questionnaire (pretest/post-test, one year after) adapted from the work of Stevahn L, King JA, Ghere G, Minnema J: Establishing Essential Competencies for Program Evaluators. Am J Eval 2005, 26(1):43–59. Master's programme effects were tested by comparing the difference in mean scores between times (before, after, one year after) using pretest/post-test designs. Paired sample tests were used to compare mean scores. Results The teaching is skills-based, interactive and participative. Students of the first cohort gave the evaluation course the highest score (4.4/5) for overall satisfaction among the 16 courses (3.4–4.4) in the master's programme. What they most appreciated was that the forms of evaluation were well adapted to the content and format of the learning activities. By the end of the master's programme, both cohorts of students considered that they had greatly improved their mastery of the 60 competences (p < 0.001). This level was maintained one year after completing the master's degree, except for reflective practice (p < 0.05). Those who had carried out an evaluation in the intervening 12 months reported a negative gap between their declared mastery and their actual application. However, this is only statistically significant for reflective practice (p < 0.05). Conclusion This study shows the importance of integrating summative evaluation into the learning process. Skills-based teaching is much appreciated and well-adapted. Creating a master's programme in population and health in Africa and providing training in evaluation to high-level health professionals from many countries augurs well for scaling up the practice of evaluation in African health systems.

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.

Background Since 2001, a referral system has been operating in Kayes (Mali) to reduce maternal and perinatal deaths. Normal deliveries are managed in community health centers (CHC). Complicated cases are referred to a district health center (DHC) or the regional hospital (RH). Women with obstetric emergencies can directly access the DHC and the RH. Objective To assess, in women presenting with an obstetric complication: 1) the effects of the point of entry into the referral system on joint mother-newborn survival; and 2) the effects of the configuration of healthcare team at the CHCs on joint mother-newborn survival. Method Cross-sectional study of 7,214 women users of the referral system in the region of Kayes in 2006-2009. Bivariate probit equations were fitted to estimate joint mother-newborn survival. The marginal effects of the point of entry into the referral system and of the configuration of the healthcare team at the CHCs were evaluated with a probit bivariate regression. Results Entering the referral system at the RH was associated with the best joint mother-newborn survival; the most qualified the CHCs team was, the best was mother-newborn survival. Distance traveled interacts with the point of entry and the configuration of the CHCs team. For women coming from far (over 50 km), going directly to the RH increased the probability of joint mother-newborn survival by 11.90% (p < 0.001) as compared with entry at the CHC. Entry at the CHC while coming from a distance of less than 5 km increased the likelihood of joint survival by 8.50% (p < 0.001). Among women who go first to a CHC, physician presence increased joint mother-newborn survival, compared with having no physician and fewer than three professionals. The size of the healthcare team at the CHC is significantly associated with mother-newborn survival only when distance traveled is 5 km or less. Conclusion Mother-newborn survival in the Kayes maternal referral system is influenced by combined effects of the point of care, the skill configuration of CHC personnel and distance traveled.