Abstract
BackgroundTimely intrapartum referral between facilities is pivotal in reducing maternal/neonatal mortality and morbidity but is distressing to women, resource-intensive and likely to cause delays in care provision. We explored the complexities around referrals to gain understanding of the characteristics, experiences and outcomes of those being transferred.MethodsWe used a mixed-method parallel convergent design, in Tanzania and Zambia. Quantitative data were collected from a consecutive, retrospective case-note review (target, n = 2000); intrapartum transfers and stillbirths were the outcomes of interest. A grounded theory approach was adopted for the qualitative element; data were collected from semi-structured interviews (n = 85) with women, partners and health providers. Observations (n = 33) of transfer were also conducted. Quantitative data were analysed descriptively, followed by binary logistic regression models, with multiple imputation for missing data. Qualitative data were analysed using Strauss’s constant comparative approach.ResultsIntrapartum transfer rates were 11% (111/998; 2 unknown) in Tanzania and 37% (373/996; 1 unknown) in Zambia. Main reasons for transfer were prolonged/obstructed labour and pre-eclampsia/eclampsia. Women most likely to be transferred were from Zambia (as opposed to Tanzania), HIV positive, attended antenatal clinic < 4 times and living > 30 min away from the referral hospital. Differences were observed between countries. Of those transferred, delays in care were common and an increase in poor outcomes was observed. Qualitative findings identified three categories: social threats to successful transfer, barriers to timely intrapartum care and reparative interventions which were linked to a core category: journey of vulnerability.ConclusionAlthough intrapartum transfers are inevitable, modifiable factors exist with the potential to improve the experience and outcomes for women. Effective transfers rely on adequate resources, effective transport infrastructures, social support and appropriate decision-making. However, women’s (and families) vulnerability can be reduced by empathic communication, timely assessment and a positive birth outcome; this can improve women’s resilience and influence positive decision-making, for the index and future pregnancy.
Highlights
Intrapartum referral between facilities is pivotal in reducing maternal/neonatal mortality and morbidity but is distressing to women, resource-intensive and likely to cause delays in care provision
Intrapartum transfers were less common in Tanzania (11%) compared to in Zambia (37%)
Women most likely to be transferred were from Zambia, HIV positive, attended antenatal clinic < 4 times and living > 30 min away from the referral hospital (Table 2)
Summary
Intrapartum referral between facilities is pivotal in reducing maternal/neonatal mortality and morbidity but is distressing to women, resource-intensive and likely to cause delays in care provision. Intrapartum referrals between facilities are an essential part of obstetric management in low-income settings, aimed at ensuring that women get the appropriate emergency care in hospitals that have skilled birth attendants and adequate resources. Multiple reasons for transfer in labour exist; reflecting some of the major causes of maternal/neonatal mortality and morbidity and include obstructed labour, pre-eclampsia and haemorrhage [1]. Researchers [4, 5] have demonstrated the impact of poor referral systems on high perinatal mortality rates, which undoubtedly contribute to the 4.8 million perinatal deaths annually; 98% of which occur in low and middle income settings [6]. Reasons proposed for poor referral systems include staff shortages, inadequate staff training, and lack of transport [7]; women themselves are sometimes reluctant to be referred [7]
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