In the urban setting of Accra, Ghana, we have shown that significant delay occurs in the obstetric referral process. Among the 303 (46.5%) patients referred intrapartum, the median time from referral decision to arrival was over five hours, confirming our earlier suspicions. Previously, we reported that of 1082 obstetric patients referred to GARH, 200 (18%) arrived in advanced labour (> 7 cm dilation) and 83 (8%) were completely dilated, suggesting that delay had occurred along the referral pathway . These findings prompted us to conduct the current study. Research on emergency obstetric referrals in Ghana, and in other countries, is limited, particularly in the quantitative measure of delay in reaching secondary and tertiary levels of care. Many studies discuss the negative implications of referral delays, but few studies measure or quantitate it [9, 22, 23].
A study in Mozambique found that delay encountered during transport and referral accounted for 60% of the 712 maternal deaths . The authors, however, did not define delay or provide detail on timeliness, although the times of arrival at the initial health facility, treatment initiation, arrival at the referral (secondary) facility and death were reportedly collected . In Ghana, a questionnaire was administered to directors or in-charge maternity unit officers in 120 health facilities in the Upper East region on emergency obstetric interventions . One hundred and four individuals responded to a question regarding travel time, but this was not measured quantitatively. The mean travel time to the nearest referral facility was stated to be 37 min (range 5 to 120 min) using various means of transport, including a car (52%), an ambulance (21%), or a motorbike (10%). Nearly 20% of these facilities had no standard procedures for transporting patients . According to the 2017 Ghana Maternal Health Survey, of 107 pregnant women who died from direct obstetric complications, data from interviewed family members found that the median travel time to a health facility was 29.8 min . It is important to note that data from interviews of either medical staff or family members remote from the occurrence are subject to recall bias, and as such, may be inaccurate. Twenty years ago, Nkyekyer assessed peripartum referrals to KBTH, Ghana’s largest hospital . He described the indications for referral, modes of transport, who accompanied patients and referral sources but timeliness was inadequately assessed. Data were available for only 46 of 396 (11.6%) referred patients regarding transport timeliness and the average time needed to reach KBTH was 78 min. The decision time for referral until facility departure could only be determined for seven women and was not stated .
Delay is influenced by more than just the physical distance to a health facility. In fact, women in the Greater Accra Region were least likely to report distance to a health facility as a barrier to care . Simply, reaching any health facility is not good enough. Recently, a study of 119,244 pregnancies in the Brong Ahafo region of Ghana, found that facility delivery and shorter travel distance did not improve survival benefits for women or newborns, unless births occurred in high quality or CEmOC facilities . Others have shown similar results [26–28]. It is imperative that high risk obstetric patients reach the right facility, in a timely manner. The geographic analysis shown in Fig. 1 reveals an expansive catchment area that is not well defined with respect to other CEmOC facilities in Accra. The longest travel distant in our patient sample was 145.8 km, a distance that would take several hours. Distance, however, is not the only factor, as many patients represented in our study arrived from facilities located in close proximity to GARH, yet had long referral to arrival times. Our study found that in patients accompanied by a midwife, the median referral time was shorter. We did not address which factors were responsible for the delay, which is a limitation of our study. Other studies, however, have described numerous barriers in accessing appropriate care beyond distance alone, including: delay in the recognition of a problem; needing to collect money for treatment or transport; waiting for relatives; needing permission; patient preferences for traditionalist and spiritual practices; refusal of referral due to fear of disrespectful care, medical procedures, or surgery; waiting for transport; and traffic congestion [1–3, 5, 6, 11, 22, 23, 26, 27, 29]. Also, in some cases, pregnant women are referred from one facility to another on the basis of no bed availability or lack of resources, until it is too late [28, 29]. Fortunately, in the present report, this occurred for only 9 (1.4%) patients. One advantage of the present study, is that we determined delay from the point in time the referral decision was made, which likely extends beyond the time required for transport alone.
In the present study, the leading referral indications were failure to progress (26.3), prior uterine scar (11.6%), and hypertensive disorders of pregnancy (11.5%). This is in agreement with other reports, which have similarly found obstructed labour to be the most common indication for referral [3, 11, 21, 24, 29]. In Nkyekyer’s 2002 report, only 2% of patients were referred for prior uterine scar . In 2012, we found that 9.1% of patients were referred for this indication and the trend continues to increase . A rising cesarean delivery rate, particularly in Accra, may worsen the existing burden on CEmOC hospitals [1, 25, 29]. A better understanding of labour management practices in lower level facilities is needed to stem the tide of increasing surgical deliveries . For example, Nkyekyer found that 37.6% of patients referred for failure to progress had intact membranes, similar to our previous study [21, 24]. Even more troubling was that only 17.9% of patients requiring an intravenous line actually had one, including 55.6% of bleeding patients. Similarly, we found that treatment was rendered in only 19.3% of patients prior to departure. In addition, high-risk obstetric referrals are frequently unaccompanied by healthcare staff, consistent with the current report [2, 6, 24, 29].
Nkyekyer found that 65.8% of referred patients utilized taxis or small public buses for transport . Sadly, more than 20 years later, little has changed. In the current study, we found that 81.9% of referred patients arrived by means of public transport. This has been corroborated by others [2, 3, 6, 16, 29, 30]. Even when ambulances are utilized, delay is often encountered as patients may need wait for ambulances to arrive from other locations or are asked to provide funds to fuel the vehicle [2, 4–6, 24, 29]. Indeed, our results demonstrate that transport by ambulance was only marginally better than by taxi and interestingly, even the general public has the perception that taxis are a faster form of transport than are ambulances, which needs to be addressed . The facilities most likely to refer are least likely to have transport mechanisms and proper means of communication with the receiving hospital [3, 4, 6]. Lack of advance warning that a patient is coming and omitting a referral slip further hampers preparedness at the receiving hospital [2, 6]. Communication is frequently deficient between facilities, including feedback to the referring institution regarding patient outcome [2, 3, 6, 29]. Furthermore, patients have been shown to self-refer, bypassing the usual referral chain to seek higher levels of care [3, 6, 21, 24, 28]. They will travel farther and pay more for what they perceive to be better care [3, 6, 24, 28, 29].
There is controversy as to whether referral system barriers constitute Phase II or Phase III delays. Although some authors classify referral barriers as primarily transport-related and therefore Phase II delays, others consider these as Phase III barriers since the patient has already reported to a health facility [11, 26, 28]. It is important to identify and categorize referral related barriers, whether considered Phase II or Phase III delay, in the provision of timely CEmOC in low resource countries and this topic remains vastly under-researched [2, 6, 26, 27]. A strong referral system is characterized by communication and coordination along the referral pathway, with tailored referral protocols, patient support, protection against costs, and efficient transportation [2, 6, 16]. Having an effective and efficient referral system can reduce stillbirth, neonatal and maternal deaths [9, 31].