Improving Emergency Obstetric Referrals: A Mixed Methods Study of Barriers and Solutions in Assin North, Ghana

Abstract

Background: Women in developing countries often face serious health risks during pregnancy and delivery due to poor access to early and appropriate referrals. Despite studies that show clear linkages between timely referrals and improved maternal outcomes, challenges still remain in the referral process, particularly in rural communities.

Objectives: To investigate baseline referral systems in obstetrics in rural Ghana with a focus on describing barriers, solutions and the value of healthcare workers (HCW) in identifying system based bottlenecks.

Design: A mixed methods approach: for the quantitative component, we reviewed health facility registers; for the qualitative section, we used semi-structured interviews to obtain provider narratives.

Setting: Referral systems in obstetrics in Assin North Municipal Assembly, a rural district in Ghana. This included 1 district hospital, 6 health centers, and 4 local health posts. This work was embedded in an ongoing quality improvement project in the district addressing barriers to existing referral protocols to lessen delays. Eighteen HCWs (8 midwives, 4 community health officers, 3 medical assistants, 2 ER nurses, 1 doctor) at different facility levels within the district were interviewed for the qualitative section.

Results: Between January – June 2012, the leading causes for obstetric referrals to the district hospital were prolonged labor, retained placenta, postpartum hemorrhage, malpresentation of baby, and premature rupture of membranes. From the district hospital to tertiary care hospitals, the leading cause of referrals was severe eclampsia. Delay indicators were not able to be obtained due to poor documentation. From the qualitative study, we identified important gaps in referral processes in Assin North, with the most commonly noted including recognizing danger signs, alerting receiving units, accompanying critically-ill patients, documenting referral cases, and giving and obtaining feedback on referred cases. Main root causes identified by providers were in five domains: 1) individual and socio-cultural factors 2) transportation, 3) communication, 4) clinical skills and management, and 5) standards of care and monitoring, and suggested interventions that target these barriers. Mapping these challenges allowed for better understanding of next steps for developing comprehensive, evidence-based solutions to identified referral gaps within the district.

Conclusions: Addressing referral processes may hold better promise for reducing maternal mortality if frameworks for designing solutions target multiple referral challenges concurrently. Providers are an important source of information on local referral delays and should be better engaged in identifying the challenges and in the development of approaches to improvement responsive to these gaps. Similar work is needed to integrate their perspectives with those of patients and their communities.