Assessment of maternal referral systems used for a rural Zambian hospital: the development of setting specific protocols for the identification of complications.

Ashley E Benson,Amy H Luke,Michael J Benson

doi:10.4314/ahs.v19i1.27

Abstract

In resource-limited countries, it is estimated that up to 75% of maternal deaths are preventable. Maternal referral systems are an effective measure to help prevent these deaths. The objective of this study was to delineate criteria that health care workers use to identify obstetrical emergencies and make referrals, in order to evaluate the effectiveness of the established referral system and to implement improvements to this system. Using a qualitative study design, the individuals with the highest level of formal obstetrics training at 10 health posts that refer to a rural Zambian hospital were surveyed using semi-structured interviews regarding their referral protocols. Data were analyzed through open-coding. At the conclusion of the interview, standardized referral protocols for obstetric emergencies derived from published guidelines and local practices were distributed. Identified complications resulting in referral most commonly included post-partum hemorrhage (70%), prolonged labor (70%), malpresentation (50%), antepartum hemorrhage (40%), and retained placenta (40%). While numerous reasons for referral were identified, there was little consensus on the referral protocol used for each complication. Obstacles to successful referral most commonly included cellular network disruptions (70%), distance (50%), and lack of transportation (30%).The referral protocols distributed to health posts covered only 11 of the 23 complications cited as the most common reason for referral. The referral criteria and protocols were updated to include all of the reported complications. We propose this document for others working in resource-limited settings attempting to establish or evaluate a maternal referral systems.

Highlights

Maternal mortality ratios are powerful expressions of health systems outcomes, and to some extent, gender discrimination throughout the world.[1,2] The United Nation’s Sustainable Development Goals (SDG) resolve to reduce the maternal mortality to less than 70 per 100,000 live births,[3] despite numerous attempts by the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), and the United Nations Population Fund (UNFPA) there has been little improvement.[4]
Health post workers were asked to identify most common complications leading to maternal referral and describe any associated protocols used in the referral process
While numerous reasons for referral were identified, there was little standardization of the protocols for referral for each complication. Of these most common reasons for referral cited by health post workers, only 11 of the 23 complications were included in the original referral criteria and protocols’ document provided to the health post workers

Summary

Introduction

Maternal mortality ratios are powerful expressions of health systems outcomes, and to some extent, gender discrimination throughout the world.[1,2] The United Nation’s Sustainable Development Goals (SDG) resolve to reduce the maternal mortality to less than 70 per 100,000 live births,[3] despite numerous attempts by the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), and the United Nations Population Fund (UNFPA) there has been little improvement.[4]. African Health Sciences Vol 19 Issue 1, March, 2019 the most common include sepsis, eclampsia, obstructed labor, unsafe abortion, and hemorrhage.[5] It is estimated that 75-90% of maternal mortalities are preventable in resource-limited settings,[6,7,8] and that essential obstetric care for hemorrhage, sepsis, eclampsia, and obstructed labor alone could prevent half of these.[8] There is extensive evidence that obstetric emergencies managed in hospitals encounter reduced maternal mortality,[9] and that providers require protocols to assist in determining at which point a woman requires referral to higher level care.[10] Various models explain gaps in referral systems, such as the ‘3 Delays Model’11 ,which which cites delays in identifying and reaching appropriate facilities as one of the main factors affecting timely care of pregnant women and contributing to complications. Assessment of maternal referral systems used for a rural Zambian hospital: the development of setting specific protocols for the identification of complications.

Objectives

Methods

Results

Conclusion