Abstract
BackgroundWeak referral systems remain a major concern influencing timely access to the appropriate level of care during obstetric emergencies, particularly for Low-and Middle-Income Countries, including Ghana. It is a serious factor threatening the achievement of the maternal health Sustainable Development Goal. The objective of this study is to establish process details of emergency obstetric referral systems across different levels of public healthcare facilities to deepen understanding of systemic barriers and preliminary solutions in an urban district, using Ablekuma in Accra, Ghana as a case study.MethodsThe study is an analytical cross-sectional study. Nine [1] targeted interviews were carried out for a three-week period in June and July 2019 after informed written consent with two [2] Obstetrics & Gynaecology consultants, two [2] Residents, one family physician, and four [3] Midwives managing emergency obstetric referral across different levels of facilities. Purposeful sampling technique was used to collect data that included a narration of the referral process, and challenges experienced with each step. Qualitative data was transcribed, coded by topics and thematically analysed. Transcribed narratives were used to draft a process map and analyze the defects within the emergency obstetric referral system.ResultsOut of the 34 main activities in the referral process within the facilities, the study identified that 24 (70%) had a range of barriers in relation to communication, transport system, resources (space, equipment and physical structures), staffing (numbers and attitude), Healthcare providers (HCP) knowledge and compliance to referral policy and guideline, and financing for referral. These findings have implication on delay in accessing care. HCP suggested that strengthening communication and coordination, reviewing referral policy, training of all stakeholders and provision of essential resources would be beneficial.ConclusionOur findings clearly establish that the emergency obstetric referral system between a typical teaching hospital in an urban district of Accra-Ghana and peripheral referral facilities, is functioning far below optimum levels. This suggests that the formulation and implementation of policies should be focused around structural and process improvement interventions, strengthening collaborations, communication and transport along the referral pathway. These suggestions are likely to ensure that women receive timely and quality care.
Highlights
Weak referral systems remain a major concern influencing timely access to the appropriate level of care during obstetric emergencies, for Low-and Middle-Income Countries, including Ghana
Process flow/map Figure 2 above presents a process map designed on the basis of frontline healthcare workers’ narratives. It articulates the steps involved during a referral for women with emergency obstetric complications from lower-level facilities to a higher-level facility in Ablekuma district
It breaks down the complex steps of the overall referral system as a woman presenting with emergency obstetric complication transits from a lower level to a higher-level public healthcare facility, highlighting the barriers and preliminary solutions that can support future policy and improvement initiatives
Summary
Weak referral systems remain a major concern influencing timely access to the appropriate level of care during obstetric emergencies, for Low-and Middle-Income Countries, including Ghana. It is a serious factor threatening the achievement of the maternal health Sustainable Development Goal. Access to appropriate levels of care through referral systems is a complex process and remains a global public health concern. For a woman with emergency obstetric complication (s) especially patients with complications such as bleeding or severe hypertensive disorders, the World Health Organization (WHO), posits through its Safe Motherhood initiatives that the incapacity of the referral system to timely and safely transit to an appropriate level of care and expertise when complication occur may have devastating consequences on the maternal [2, 3, 5] and fetal outcomes including death.
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