Obstetric referral processes and the role of inter-facility communication: the district-level experience in the Greater Accra region of Ghana.

Abstract

To describe the capacity of primary health care facilities to manage obstetric referrals, the reasons, and processes for managing obstetric referrals, and how an enhanced inter-facility communication system may have influenced these. Mixed methods comparing data before and during the intervention period. Three districts in the Greater Accra region, Ghana from May 2017 to February 2018. Referred pregnant women and their relatives, health workers at referring and referral facilities, facility and district health managers. An enhanced inter-facility communication system for obstetric referrals. Twenty-two facilities and 673 referrals were assessed over the period. The major reason for referrals was pregnancy complications (85.5%). Emergency obstetric medicines - oxytocin and magnesium sulfate (MgSO4) were available in 81.8% and 54.5% facilities, respectively, and a health worker accompanied 110(16.3%) women to the referral centre. Inter-facility communication about the referral occurred for 240 (35.7%) patients. During the intervention period, referrals joining queues at the referral facility decreased (7.8% to 0.0%; p=0.01), referrals coming in with referral notes improved (78.4% to 91.2%) and referrals with inter-facility communication improved (43.1% to 52.9%). Health workers and managers reported improvement in feedback to lower-level facilities and better filling of referral forms. Facilities had varying levels of availability of infrastructure, protocols, guidelines, services, equipment, and logistics for managing obstetric referrals. Enhanced inter-facility communication for obstetric referrals which engages health workers and provides requisite tools, can facilitate an efficient referral process for desired outcomes. This study was funded by the WHO/TDR Postdoctoral grant number B40347 to the NMIMR.