The Obulamu Mama framework: development of an evidence-informed implementation framework for community obstetric referral systems in rural Uganda

BACKGROUND: Preventable maternal deaths remain disproportionately concentrated in low- and lower-middle-income countries. In rural Uganda, delayed recognition of obstetric emergencies, transportation barriers, fragmented referral pathways, and inconsistent communication continue to limit timely access to emergency obstetric care. OBJECTIVE: To develop an evidence-informed implementation framework for strengthening community obstetric referral systems in rural Uganda. METHODS: We conducted a framework development study using a structured, iterative five-phase process informed by maternal and newborn health evidence, implementation science, systems thinking, international health-system guidance, and Ugandan health policy. Evidence was identified through purposive, targeted searches of PubMed, World Health Organization resources, and Uganda Ministry of Health policy and guidance repositories. Development included problem identification, identification of evidence-informed implementation strategies, preliminary framework development, contextual refinement through in-country review by a Ugandan academic collaborator, and final framework integration. RESULTS: The Obulamu Mama Framework comprises six interdependent implementation domains: community workforce strengthening; standardized community midwifery resources; closed-loop digital referral communication; coordinated referral networks; continuous quality improvement and supportive supervision; and monitoring, evaluation, and adaptive learning. The domains are designed as complementary components of an integrated maternal referral system aligned with existing community and district health structures. CONCLUSIONS: The framework translates existing evidence and health-systems principles into an implementation roadmap for community obstetric referral systems in rural Uganda. It provides a foundation for feasibility testing, implementation research, and prospective evaluation and may inform adaptation of referral-system strengthening approaches in other resource-constrained settings.