Abstract
BackgroundMaternity referral systems have been under-documented, under-researched, and under-theorised. Responsive emergency referral systems and appropriate transportation are cornerstones in the continuum of care and central to the complex health system. The pathways that women follow to reach Emergency Obstetric and Neonatal Care (EmONC) once a decision has been made to seek care have received relatively little attention. The aim of this research was to identify patterns and determinants of the pathways pregnant women follow from the onset of labour or complications until they reach an appropriate health facility.MethodsThis study was conducted in Renk County in South Sudan between 2010 and 2012. Data was collected using Critical Incident Technique (CIT) and stakeholder interviews. CIT systematically identified pathways to healthcare during labour, and factors associated with an event of maternal mortality or near miss through a series of in-depth interviews with witnesses or those involved. Face-to-face stakeholder interviews were conducted with 28 purposively identified key informants. Diagrammatic pathway and thematic analysis were conducted using NVIVO 10 software.ResultsOnce the decision is made to seek emergency obstetric care, the pregnant woman may face a series of complex steps before she reaches an appropriate health facility. Four pathway patterns to CEmONC were identified of which three were associated with high rates of maternal death: late referral, zigzagging referral, and multiple referrals. Women who bypassed nonfunctional Basic EmONC facilities and went directly to CEmONC facilities (the fourth pathway pattern) were most likely to survive. Overall, the competencies of the providers and the functionality of the first point of service determine the pathway to further care.ConclusionsOur findings indicate that outcomes are better where there is no facility available than when the woman accesses a non-functioning facility, and the absence of a healthcare provider is better than the presence of a non-competent provider. Visiting non-functioning or partially functioning healthcare facilities on the way to competent providers places the woman at greater risk of dying. Non-functioning facilities and non-competent providers are likely to contribute to the deaths of women.
Highlights
Maternity referral systems have been under-documented, under-researched, and under-theorised
Underpinning all the pathways was the functionality of Basic emergency obstetric and neonatal care (BEmONC) facilities and competency of their health providers
Functionality of BEmONC Depending on the geographical location, the nearest healthcare facility at the level of the community for a pregnant woman could be a village Primary Health Care Units (PHCUs) serviced by a professional midwife or a nurse, or a Primary Health Care Centres (PHCCs) serviced by a medical assistant
Summary
Maternity referral systems have been under-documented, under-researched, and under-theorised. Responsive emergency referral systems and appropriate transportation are cornerstones in the continuum of care and central to the complex health system. A peak in maternal mortality occurs during the intrapartum period around childbirth and the first day postpartum [4]. The main reasons for maternal deaths are the lack of skilled birth attendants, remoteness of health facilities in relation to catchment area, delays in referral for emergency obstetric care, and poor implementation of interventions at the facility level [4, 6]. Responsive emergency referral systems, clear referral protocols and appropriate transportation at the first level of care are cornerstones in the continuum of care and a crucial part of the health system to ensure timely and appropriate transfer to comprehensive emergency obstetric and neonatal care (CEmONC)
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