Table 1 Recommendations made and implemented

1. Two ambulances were stationed in two health centres to serve the other nearby health centres

2. Health care providers (from both the district hospital and health centres) trained on the resuscitation, particularly the management of hypovolemic shock

3. Health care providers briefed on the need to handle emergencies urgently and properly

4. Ambulance drivers briefed on the need to handle emergencies urgently

5. All necessary preparations made to receive and treat the patient when a health centre calls to inform the district hospital about an emergency referral

6. Midwives on duty allowed to call the clinicians and anaesthetic technicians directly thereby bypassing the bureaucracy of calling first the senior midwife in-charge of the maternity who will decide whether to call for additional staff.