Despite the fall in the global maternal mortality ratio (MMR) by nearly 44%, from an average MMR of 385 maternal deaths per 100 000 live births in 1990 to an estimated average of 216 maternal deaths per 100 000 live births in 2015 , this rate is still unacceptably high. Between the years 2000 and 2017, the MMR dropped by 38% however, 94% of all global maternal deaths emanated from low and lower-middle-income countries (LMICs) . The differences in regional maternal death rates reflect inequalities in access to health services and reveal the underlying gap between the rich and the poor.
While most of the pregnancy and childbirth complications are unpredictable though preventable or treatable, nearly 75% of all maternal deaths can be attributed to severe bleeding (post-childbirth), infections (post-childbirth), preeclampsia and eclampsia, complication of delivery as well as unsafe abortions . High maternal and perinatal mortality rates in LMICs can be attributed to three delays . The first delay entails the time taken in recognizing danger and deciding to seek care, the second delay includes time taken in reaching the appropriate facility and the third delay is the time taken in receiving quality care once the woman reaches the facility. A functional referral system is critical in addressing the second and third delays.
The capacity to deal with the unpredictable complications of pregnancy and childbirth at the primary level of care is limited due to the lack of skilled human resources and facilities hence the need to refer patients to higher levels of care. Key requisites for successful maternity referral systems in developing countries include a referral strategy informed by the assessment of population needs and health system capabilities, a well-resourced referral center, good collaboration between referral levels, formalized communication, and transport arrangements between peripheral and referral centers. Furthermore, an effective referral system has agreed upon area-specific protocols for referrer and receiver, supervision and accountability for provider performance, affordable service costs, the capacity and ability to monitor effectiveness, and policy support [5, 6].
Rural-urban health inequities result from weaker health systems and adverse social and environmental determinants experienced by the poor living in rural areas . A study conducted in Zambia reported that women from remote and poorest districts of the country only attended a single antenatal clinic (ANC) visit even when the facilities were closer to their homes because of inadequate staff and low quality of services at these facilities . The same study also cited the women’s livelihoods such as the nomadic lifestyles and household chores influenced maternal decision to go for subsequent ANC visits after the first one. Another study noted that punitive measures imposed on women by the health workers and/or incentives provided by the nongovernmental organizations prompted women to attend ANC only once .
In 2017, Zimbabwe was ranked among the 15 countries that were considered to be ‘very high alert’ or ‘high alert’ with MMRs ranging from 31 to 1150 on the Fragile States Index in 2017 . Maternal mortality in Zimbabwe remains pervasive and some women opt for community delivery due to negative labels attached to health facilities . Such labels include exorbitant costs of services, poor attitudes of health providers, extended waiting times, and long distances. Rural women at a significantly higher risk of dying from pregnancy when compared to women living in urban settings [11, 12]. The MMR in Zimbabwe shows an intolerably high and oscillating trend of 694 maternal deaths per 100 000 live births in 1999 , 729 in 2009 , 614 in 2014  to 650 in 2016 . Such trends also suggest a deficiency of sustainable solutions to the problem.
The rural health center which offers the basic emergency obstetric care package is the first line of care for the pregnant woman. In Zimbabwe, all eight rural provinces have provincial hospitals. According to the WHO levels of obstetric care, the district, provincial and central hospitals are all level 2 health centers, and these act as referral centers for the primary healthcare facilities. Besides referrals from rural institutions, the city of Harare also has urban health facilities that refer complicated obstetric cases to the central hospitals, but for this study, only referrals from the rural provinces were considered.
The majority of Zimbabweans (67%) live in rural areas  where it is difficult to access and afford health services. Approximately 23% live within 5 to 10 km and 17% reside more than 10 km from the nearest health center  while some have to walk between 10 km and 50 km to access the nearest health facility . The deficiencies of professional skills, medical supplies, and equipment particularly in the rural parts of the country limit the health workers’ options to provide care and treatment [19, 20], thus the need to refer to higher levels of care.
Rural health facilities in the Northern Region of the country refer their complicated pregnancy-related cases to Harare Central Hospital and Parirentyatwa Group of Hospitals. A preliminary review of maternal mortality registers revealed that during the first quarter of 2017, Parirenyatwa Group of Hospitals recorded a total of 24 maternal deaths and 13 (54%) of these were patients referred from rural health facilities outside Harare City. Although there are guidelines to regulate the referral pathway for the potentially life-threatening pregnancy-related complications, these are poorly utilized in Zimbabwe with little to no information being given on communicating transfers and giving feedback. A local study on the effectiveness of the referral system for antenatal and intrapartum problems reported that health professionals failed to comply with the referral recommendations . Thus, there is limited empirical evidence on the outcomes of pregnancy-related referrals from rural health facilities to various tertiary facilities. It is also not clear whether referring obstetric patients from primary health centers, district, and provincial institutions can improve the pregnancy outcomes among the referred women.
This study aimed to determine the outcomes of pregnancy-related referrals to Harare Central Hospital and Parirenyatwa Group of Hospitals from rural health facilities outside Harare. The quality of obstetric care provided by facilities can be assessed using either process indicators like the referral system or outcome indicators like the maternal mortality ratio . Establishing the outcomes of the pregnancy-related referrals would help in understanding the lived experiences of patients on emergency referrals to the two central hospitals targeting improving and sustaining the referral pathway while enhancing pregnancy outcomes.