Characteristics of included studies
Seventeen articles were included in this review. We have summarised each article according to study aim, context, methodology and relevant findings (see Table 1). Most studies (n=13) investigated the quality of referral from the perspective of healthcare providers either through interviews or audit of health facility records [1, 8, 29-37, 38, 39]. Two studies explored women’s experiences of maternal and newborn referral [40, 41]. One study included both healthcare providers and women’s perspectives [42] whilst one South Sudan based study included the perspectives of stakeholders from the local government sector, Faith-Based Organisations (FBOs), non-governmental organisations (NGOs), and community religious leaders in addition to healthcare providers [43]. The common conditions that prompted referral included premature rupture of membranes, obstructed labour and postpartum complications, such as haemorrhage and fistula [8, 32, 38, 39, 41- 44] . The outcomes identified in these studies are summarised in Table 2.
Provision of maternity referral
All the 17 articles reported on various aspects of maternal and newborn referral and are presented under the sub-themes as outlined by the supply side of the framework for assessing the quality of maternal referrals (Figure 1).
Referral system
Two studies indicated use of standard maternal and newborn referral procedures, availability of standardised referral forms and health provider escorts [1, 33]. Awoonor-Williams & Bailey [1] indicated that such procedures were accompanied by telephoning ahead to prompt the receiving hospital about referral.
In that study in 16 facilities in Ghana, healthcare providers escorted by ambulance all referred women and their newborns from health centres to BEmOC and CEmOC facilities. Details about the specific providers who escorted women, however, were not reported [1]. In two other studies in Ghana, health care providers rarely escorted women to the next facility [37, 42]. Some referrals were even unaccompanied because they were not emergencies [42]. Unaccompanied women sometimes arrived late in the receiving facility, but details about the socio-demographics or their circumstances were not provided [42].
Elmusharaf, Byrne identified four referral pathways: 1. zigzag referral (where a woman was sent back and forth between two healthcare providers), 2. late referral to appropriate health facility, 3. multiple referral (referring a woman to a number of non-functioning facilities before arrival in an appropriate health facility) and 4.0 by-passing (where health care providers at the first facility refer directly to a specific well-functioning facility)[43]. One woman narrated her zigzag referral:
Family members lifted the pregnant woman onto a donkey-driven cart and went to the village’s medical assistant. When they arrived, her water broke. The medical assistant prescribed drugs and told them that she was in labour and that the midwife should deliver her straight away. He sent them back to the midwife for birth. After spending three hours with the midwife without progress, the pregnant woman was exhausted. The midwife advised them to go back to the medical assistant. They spent most of the night going back and forth between a midwife and a medical assistant until the midwife insisted on the medical assistant referring them to Renk hospital (5JMD) [43].
In a study from Angola delays of up to 13.7 hours were noted in the triage of a referred woman upon arrival in the receiving facility [34]. Referred women and their newborns were simply added to the queue with other patients. When healthcare providers were alerted about this issue, a meeting was held to better identify referred women and prioritise them upon arrival. After this strategy was implemented, referred women and their newborns spent an average of nine minutes to meet a midwife and 71 minutes to be assessed by a doctor.
In Ghana, triage initiation for women in labour was found to vary by shift or timing of the day in Ridge Regional Hospital [32]. Average waiting time in the morning was 35 minutes, 28 minutes in the evening and 55 minutes in the night. Women in the first stage of labour were triaged within 35 minutes and moved to labour ward within 24 minutes. Those in the second stage were evaluated in 30 minutes and moved to the labour ward within 10 minutes [32].
In Burundi a 15% higher chance of neonatal deaths was observed for women who took three or more hours to arrive in the next facility. Facilities had to call for an ambulance from another facility with sometimes delays [35]. In a Nigerian teaching hospital 11 of 123 referred women die, 10 of them from severe pre-eclampsia. One died before labour commenced, five died during the intrapartum period whilst five died during the postpartum period. Of these women, seven were referred from secondary health facilities, three from private hospitals and one from a maternity home [29].
In the absence of ambulances, donkey-driven carts, tractors, pick-up trucks, public transport (taxis and lorries), motorised tricycles and motorbikes were used for referral [40, 29, 33, 36, 37, 42]. In Ghana, 15% among 720 pregnant women used approximately one hour to make arrangements to hire private vehicles for transport [40].
Some health facilities were not equipped with telephones and some healthcare providers from primary health centres in southern Ethiopia had to use their personal phones to notify receiving facilities about referrals [36]. A communication system for facilitating referrals in 14 government health facilities in Tanzania was reported without details [36]. One study from a teaching hospital in Nigeria reported the absence of initial communication with the hospital in all referrals [29].
Referring health facilities are not always given feedback so that opportunities for improvement did not reach the referring healthcare workers [37, 42]. High workload of health care workers was cited as the main reason why feedback was not given. A Medical Officer from Ghana reported:
‘‘We don’t receive any feedback from the hospitals. At least it would help us understand what we could have done better.’’ (In-depth Interview, Medical Officer) [42].
However, in one study, the referring facilities received verbal feedback from the women and/or their families [1].
International standards for the management of emergency obstetrics
Nwameme & Phillips [42] indicated that more than 75% of staff from two of the three facilities in their survey were trained on how to use national referral guidelines. Shimoda & Leshabari [38] reported that midwives in their study followed the guidelines of midwifery care in undertaking examinations leading to referral [38]. However, the study did not identify the guidelines. Two of the three studies reporting availability of national referral guidelines in Ghana indicated adherence in health facilities [1, 42] whilst one noted non-adherence [37]. Adherence includes documentation of referral indication, telephoning the referral facility ahead of time and making arrangements for means of transport, preferably ambulance. In a survey of 120 health facilities in Ghana, 94% of the facilities had standard referral forms and 83% followed a standard referral procedure [33].
In Tanzania, guidelines for midwifery care were used in the studied hospital and health centre to manage intrapartum monitoring leading to emergency referrals of 11 women with prolonged labour [38]. Unlike the WHO guidelines and recommendations [11, 45], the national guidelines of Ghana do not mention that uterotonics or oxytocics are to be applied to reduce haemorrhage.
Human resources for health
A variety of providers were involved in maternal and newborn referrals, but few details were available regarding their experience and training [1, 40, 30, 31, 33, 36-38, 42, 46]. Three papers reported that midwives and nurses had between two and 12.5 years of experience in their positions [36, 38] and doctors and nurses with midwifery training had at least 6 years [31].
In 14 government health facilities in Tanzania, 17% of 115 healthcare providers (nurses with or without midwifery training, and medical doctors) could correctly diagnose post-partum haemorrhage (blood loss of at least 500 millilitres, or blood loss of 500 millilitres with shock symptoms) [31]. Almost all healthcare providers (98.3%) knew that misoprostol can be used for post-partum haemorrhage (PPH), but 62.6% were able to state the recommended dose (600 μg) and only 36.5% were able to prescribe it, because it was not always available [31]. No significant differences were found in the mean scores of the PPH-related knowledge index between providers who had more than six years of experience or less.
Women who had been referred to a higher level facility in one Ghana (76.6%) reported that healthcare providers were competent enough to solve their problems, however, details about the providers’ competencies were not explained [40]. In Kwara State in Nigeria, 79.0% (n=128) of Trained Birth Attendants (TBAs) indicated that they did not refer in a timely manner [30]. These TBAs were not formally trained but acquired their skills through either inheritance or self-initiation. Nine of the twenty TBAs who had had at least one supervisory visit by a qualified provider were able to conduct appropriate referral. In addition, nine out of the thirteen TBAs who had attended more than one training course referred women with complications in an appropriate manner [30].
Okafor, Arinze‑Onyia [8] also reported on a Nigerian study where 155 (75.6%) of the trained TBAs delayed referral for women who showed signs of difficulty in childbirth for more than 12 hours [8]. A senior manager at the Reproductive Health and Midwifery Department in the Renk County of South Sudan complained about the competency of TBAs:
In the past, TBAs have arrived in Renk hospital with pregnant women with their babies partly delivered; parts of the foetus, such as the head, the arm or the leg, outside the woman's body and the rest of the body still inside. (Senior Manager at the Reproductive Health and Midwifery Department) [43].
Poor skills of lower level doctors and midwives were reported in Ghana:
“Last time a pregnant woman came here…. And I was saying but there is a doctor at your place, so why did you rush here without a midwife accompanying you, and she said ‘Auntie, I had been admitted there for a long time. And each time the doctor came, he said let's wait a bit more, and I was experiencing a lot of discomforts, and I insisted that they discharge me, so they finally reluctantly discharged me.' And when she arrived here, true, it was twins. But one was IUFD (macerated) already. So she was able to get the first twin, but the second twin was macerated. (Midwife, District Hospital).
Health professionals noted the need for ongoing professional development. One midwife said:
“They (staff at the district hospital) need refresher courses... They should allow them to go to workshops so that they will see what is going on…. Me, I always learn from my junior nurses and midwives because I joined it [midwifery] about 10 years ago, and things are changing. Even the instrument[s] we are using [are] changing.” (Midwife, Health Center) [37].
Midwives in an urban BEmOC facility in Addis Ababa, Ethiopia promptly referred women whenever they identified obstetric complications induced by premature rupture of membranes (PROM):
“if a mother said that her water is broken, we consider her as PROM and we will immediately refer her to hospital for management” (an informant from HC A) [39].
Maternity information systems
Some health facilities in Ghana routinely used logbooks, care plans, referral letters, referral forms or slips correctly [1, 32, 33, 42]. Documentation was reported to be correctly done if all the necessary information about a woman was captured in the facility’s records as required by the national referral guidelines [15].
Poor documentation relating to referral was reported by one study from Ghana where six out of 11 sampled health facilities had referral registers [37]. Sometimes details concerning indications and treatment of the referring facilities, current status of the referred women and treatment at the receiving end were lacking [37, 42]. This resulted in the inability of accompanying staff members to respond to specific questions about the care given before referral. Only one EmOC facility had a computerised referral information system [42].
Medicines and equipment
Of the seventeen included articles, four included information concerning medicines and equipment [1, 31, 39, 45]. In Tanzania misoprostol was used for treating post-postpartum haemorrhage [31]. However, this was not always available in some of these facilities [31]. A decline in correct partograph use was reported in Ghana in some sending and receiving facilities [1]. Audit in peripheral health facilities in Angola revealed poor quality of partographs without further detail [34]. In Tanzania, midwives correctly used catheters to enhance referral decision making:
“When she put in the catheter, we saw some blood starting to pass. That is the sign of obstructed labour. That’s why I decided to refer immediately.” (F) [38].
Experience of referral service
None of the articles provided insights into cognition and emotional support aspects of referral that formed part of the conceptual framework.
Human resources for health
In Tanzania, some women in a primary health facility indicated that doctors were not readily available to check their progress and refer them to an EmOC facility, if necessary [41]. One woman narrated her story:
“When we got to the dispensary nurses told me to wait. At 8 pm labour pains became intense, I started pushing but the baby could not come out, and the doctor was not around. Next day I continued pushing the whole day again until at around 8 pm when the doctor came…” (Divorced, aged 33, MboriDodoma), [41].
Just over 10 percent (N= 390) of women in three health facilities in Accra Ghana indicated that poor attitudes of nurses were a source constraint to referral [42].
Satisfaction with facility, commodities and cost
Sixteen of 390 women in three urban BEmOC facilities in Ghana were dissatisfied with the performance of the health facilities. Another 180 of those complained about costs while three women reported previous bad experiences as sources of dissatisfaction and constraints to referrals without further details [42].
Socio-cultural factors affecting women’s adherence to referral
While the framework did not include socio-cultural factors, these were identified as having an effect on a woman's referral to for care. In Ghana socio-cultural beliefs relating to fear of blood transfusion and fear of death in higher level facilities affected women’s desire to travel to next level facilities [37]. In a CEmOC health facility in Ghana, 57% (N=720) of the women had to consult their husbands for permission to follow the advice of health professionals [40]. Some women in rural Tanzania with obstetric fistula indicated that the decision to travel to the next facility was made by their uncles, grandmothers, husbands and mothers-in-law [41].