Characteristics of included studies
Seventeen articles were included in this review. Study aim, context, methodology and relevant findings are summarised in 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, 29-39]. 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 Sudanese 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]. 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 S2.
Table 1. Summary of Included Articles
Reference
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Country/Setting
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Aim
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Methods
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Sample
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Findings
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Abodunrin et al, 2010
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Nigeria (urban and rural communities in Ilorin, the capital of Kwara State)
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To assess factors that determine the referral practices of Traditional Birth Attendants (TBAs).
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Descriptive quantitative survey: pre-tested semi-structured questionnaire
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162 Registered TBAs (mean age= 46 years, 89.5% females, 71.6% married, 92% Islam, 64.2% had at least primary school education, 85.8% were part-time TBAs)
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§ Identified timely and appropriate referrals among TBAs with more than one re-training (69.2%) and TBAs who have ever been visited by a supervisor (45%). The authors explained timely and appropriate referral as referring very high-risk cases such as previous stillbirths, bleeding in previous or current pregnancies, multiple pregnancies, abnormal lie and not interfering with them. It also comprised immediate referral of women who had complications (such as bleeding during labour, prolonged labour, tiredness or loss of strength, seizures and retained placenta) during labour management.
§ Inappropriate referral comprised three conditions; delayed referral irrespective of the reason, wrong referral and non-referral. Delayed referral was defined as "not referring immediately any identified very high-risk pregnancy and complicated labour."
§ Wrong referrals were the ones made to any other place instead of a modern health facility.
§ A significant relationship was found between age, marital status, educational status, initial source of skill acquisition, re-training, supervision and prompt/appropriate referral of high-risk pregnancies.
§ Young and unmarried TBAs with higher education had a higher tendency of appropriate and timely referral.
§ Most TBAs who started through inheritance usually refer late or do not refer.
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Afari et al, 2014
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Ghana (4 health posts, 6 health centres and 1 district hospital in the Assin North Municipality)
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To describe healthcare workers (HCW) identified systemic challenges and the significance of local engagement in developing strategies to enhance emergency obstetric care referral related processes.
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Qualitative study: semi-structured interviews
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18 HCWs (1 doctor, 2 emergency room nurses, 3 medical assistants, 4 community health
officers, 8 midwives)
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§ Gaps in existing referral protocols-signal function recognition for referral, stabilising patients, initiating a referral, transportation arrangement for referral:
“Sometimes they hire commercial vehicles and sometimes too they use the motorbike. If there is no commercial vehicle at the station, they will beg someone to use their motorbike to convey them to the nearest health center or hospital, and then maybe somebody’s private car. The person might sacrifice.” CHO, Health Post
§ Few facilities adhered to national referral protocols. Papers reported poor referral documentation and a lack of communication between sending and receiving facilities although national referral protocols existed. Some of these manifest in the following expressions:
“Apart from that [one] guy (HCW) who calls, the others don’t call so you’ll be here and such a case comes in. And […] with no…nobody accompanying… it’s really a challenge. Because if you know […] somebody is coming with eclampsia… you know you’re supposed to prepare first so that you receive [appropriately].” Emergency Nurse, District Hospital
“Somebody who is fitting (or convulsing), a pregnant woman who is fitting… somebody (HCW) needs to accompany. But this is someone who is coming with relatives. They don’t know they have to turn the head to the side, [or] the person can aspirate saliva and any other thing[s].” Nurse, District Hospital
§ HCWs recommendations: standardising implementation of the referral protocol, enhancing the transportation system, ensuring dependable data reporting and management systems, actively engagement of community and offering continuous training for health staff.
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Akaba & Ekele, 2018
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Nigeria (from either a primary, secondary, tertiary or private health facility to University of Abuja Teaching Hospital, Gwagwalada)
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To determine maternal and fetal outcomes of emergency obstetric referrals and reasons for these referrals.
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Prospective longitudinal study-November 2015 to March 2016, data retrieved from case-notes, cross-checked with referral documentation when available.
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All women requiring emergency obstetric care and referred from primary, secondary, tertiary or private health facility to University of Abuja Teaching Hospital, aged less than 20 to 44.
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§ Nine cases (7.3%) were transported by ambulance.
§ There was 8.9% emergency referral fatality rate (i.e. 11 maternal deaths).
§ 63.6% maternal deaths occurred among women referred from secondary health facilities.
§ Poor emergency obstetric referrals and fetal outcomes were reported: 14 (11.5%) fresh stillbirths and six (4.9%) macerated stillbirths) due to late presentation.
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Awoonor-Williams et al, 2015
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Ghana (Upper East Region)
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Obstetric and newborn referral audit to strengthen the referral system for
pregnant women and newborns in northern Ghana.
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Quantitative, two-cycle prospective referral audit in March-May 2011; September-November, 2011; questionnaire, 32 facilities in all-16 facilities, 15 home facilities (comprising 12 health centres and 3 district hospitals) and a Regional Hospital.
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223 referred women and their newborns (223 in each of the two cycles)
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§ Observed enhanced referral facilitative mechanisms-increased use of ambulances/vehicles for referrals (48% to 63%); higher usage of referral forms (66% to 77%); alerting receiving facilities through phone calls (38% to 65%); increment in feedback from receiving facilities (58% to 70%); all 6 women referred twice in the 2nd cycle were accompanied by health staff.
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Carnahan et al, 2016
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Tanzania (14 government facilities providing maternal health services, Ilala Municipality)
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To investigate healthcare providers regarding the prevention and management of postpartum haemorrhage (PPH).
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Quantitative cross-sectional survey, questionnaire
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115 healthcare providers (102(88.7%) nurses with midwifery training, 9(7.8%) nurses without midwifery training, 4(3.5%) doctors/medical/clinical officers) from 13 facilities (10 dispensaries (60.9% respondents), 2 hospitals (18.3% respondents), 1 health centres (20.9% respondents).
104 (90.4%) females, 71(62.8%) with more than 6-year experience.
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§ All 14 facilities had referred 42.6% of maternal cases within the past 3 months.
§ Forty-nine (42.6%) providers had referred at least one woman in the 3 months preceding the survey.
§ 67.8% of all 13 health facilities have consultation and referral communication systems in place.
§ 65.2% had established maternal referral transport system.
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Elmusharaf et al, 2017
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South Sudan (Renk County, Upper Nile State)
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To ascertain patterns and contributory factors of pregnant women's pathways from the onset of labour or complications until arriving at the suitable health facility.
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Qualitative, Critical Incident Technique (CIT), Stakeholder Interviews.
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28 key informants (2 from local government, 4 from county health department, 14 healthcare providers, 2 NGO employees, 3 Faith-Based Organisation (FBO) employees, 3 community religious leaders).
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§ Identified four referral pathways-late referral, zigzagging referral, multiple referrals and bypassing non-functioning facilities.
§ Women who directly went to appropriate health facilities and by-passed non-functioning facilities survived.
§ Competencies of healthcare providers and functionality of the initial point of service determined the pathway to further healthcare.
§ Trained midwives were found to be competent but TBAs were not.
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Goodman et al, 2017
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Ghana (Ridge Regional Hospital (RRH), Accra)
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To describe obstetric referrals received at Ridge Regional Hospital (RRH) and explore the timeliness with which women enter CEmOC.
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10-week prospective cohort study gathered time-sequence information at woman arrival and from their records and logbooks in 10-week period (September 9-November 11, 2012).
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1,082 women with pregnancy complications, 15-46 years, 0-8 parity range, 24-49 weeks gestation age.
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§ Long waiting time upon arriving at receiving facility-40 minutes on average.
§ The most distant referral facilities were 50 km from RRH.
§ Gaps were identified in how maternal vital signs and labour assessment were recorded with 25 of 90 referrals found to be inappropriate. The most common reason for referral was for fetal-pelvic disproportion however, the fundal height was less than 40 cm, which does not support this diagnosis.
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Kyei-Onanjiri et al, 2018
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Ghana (120 health facilities across Upper East region)
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To investigate the availability of emergency obstetric care interventions in Upper East region.
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Quantitative cross-sectional survey, questionnaire.
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120 health facilities (9 public and private hospitals, 17 clinics, 41 health centres, 52 Community-based Health Planning and Services (CHPS) centres, 1 maternity home).
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§ 94% health facilities were having standardised or printed referral forms for obstetric referrals.
§ 83% had a standard obstetric referral procedure.
§ 64% had shortwave radio/telephone for referral communication.
§ 56% of facilities without shortwave radio/telephone could not access one within minutes in instances where it is needed.
§ Most of the facilities indicated that they always had a trained health provider.
§ 73% had a midwife or doctor either on call or present at all times.
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Mirkuzie et al, 2016
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Ethiopia (10 public health centres with similar staff profile and providing EmONC, Addis Ababa)
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To assess the proportion of obstetric referrals resulting from premature rupture of membranes and investigate its correctness and management in Healthcare centres.
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Sequential explanatory mixed methods, routine retrospective data from birth and intrapartum referral logbooks and interviews, focused interview guide.
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2,820 women with obstetric complications; 10 head midwives
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§ All healthcare centres with high referral rates had too many skilled providers per caseload.
§ 77.8% of the referred women who had had a spontaneous labour and birth could have been diagnosed incorrectly as they were not in labour when they were referred.
§ Some health centres observed women for about 8 hours before referral initiation:
“… when we get mothers saying that their water has broken, after we evaluate them, they will be admitted to our health center and observed for about eight hours. If there is no spontaneous labour in eight hours we refer them to hospital after giving them a loading dose of Ampicillin… in the referral slip we write how long the mothers had been observed in our health center.” (An informant from HC I).
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Mselle & Kohi, 2016
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Tanzania (Comprehensive Community Based Rehabilitation, a private, non-governmental organisation in Dar es Salaam)
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To use women’s narratives to demonstrate the challenges leading to failure in accessing adequate obstetric care in a timely manner
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Qualitative, narrative research, semi-structured interview guide
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16 women with obstetric fistula, aged between19 and 43 years, 82% rural dwellers, all unemployed, 88% had no or primary education
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§ Delay in making referral decision was reported:
“… it took 4 days at the village health facility, I could not give birth and then I was referred to the big hospital” (Divorced, aged 29, Kibakwe, Dodoma).
“…In the health facility, I spend the night until morning … I had pains, the day passed, I slept again until morning again, and it was when a decision was made to transfer me to another hospital. They said it was because I had urine retention. On the third day is when I was transported to a big hospital” (Divorced, aged 20, Mlandizi-Pwani).
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Nuamah et al, 2016
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Ghana (Antenatal clinics, Amansie West District in the Ashanti region)
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To evaluate the role of socio-economic factors, perception and transport availability in fulfilling obstetric referrals
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Quantitative cross-sectional study, questionnaire
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720 confirmed pregnant women from 5 sub-districts , less than 20 to over 40 year range, 65.5% cohabitating, 28.8% married, 49.6% JHS/Middle School, 17% No formal education
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§ Referral was honoured to about 21.7% of women.
§ More than 90% reported that they met the staff at the receiving facility always.
§ 76.6% disclosed that health staff at the receiving facility solved their problems.
§ Most women were referred once and were not referred further.
§ Commercial cars (88.2%) are more often used for referral than ambulances (6.6%).
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Nwameme et al, 2014
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Ghana (ante-natal care (ANC) clinics in Ga East district, Greater Accra region)
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To examines the situation faced by women when they need emergency obstetric care
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Mixed Method, Questionnaire, In-depth Interview guide, Referral and facility review checklist
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390 women attending ANC antenatal care clinic attendees and in-depth interviews with principal health care personnel, 17-46 aged women, 92% married, 44.6% Unorthodox Christians, 35.6% Orthodox Christians, 52.1% Junior High School, 12.8% no education, 76.2% traders, 43.6% parity 1, 29.7% parity 2
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§ Out of 17 women referred in their current pregnancies, none of them was sent by Ambulance, ten had public transport whilst seven made their own transport arrangement.
§ Of the 17, fourteen (14) got to the referral centre within 24 hours, two (2) within 48 hours and one (1) woman got there after 10 days.
§ 15 (88.2%) were issued referral letters in their current pregnancies, but only 1 (5.9%) was accompanied by staff.
§ Only one hospital had information computerized for easy access.
§ Referring health facilities hardly receive feedback from the referral centre on the women's status:
‘‘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)
§ During obstetric emergencies, they contact referral centres by mobile phone to find out if beds are available:
“There are hindrances between the two hospitals, no beds, no doctors…all these contribute to the delays.” (In-depth Interview, Nursing Administrator).
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Okafor et al, 2015
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Nigeria (Semino Hospital and Maternity (SHM), Enugu State)
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To audit childbirth emergency referrals by trained TBAs
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Quantitative, retrospective study, case records (folders) retrieved and relevant data extracted with case record forms (data entry pro forma)
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205 women with childbirth emergencies, less than 20 to 50 years, 41.5% rural dwellers, 58.5% urban dwellers, 90.2% married, 58.5% unemployed, 56.1% nullipara
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§ 155 (75.6%) of the women were delayed for more than 12 hours before referral.
§ 75.6% (155/205) arrived walking unsupported prior to admission whilst 24.4% (50/205) could not walk on admission.
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Shimoda et al, 2015
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Tanzania (urban, one regional referral hospital and one health centre in Dar es Salaam city)
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To describe how midwives monitor and manage childbirth in order to achieve early consulting and timely referral to obstetricians
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Qualitative, semi-structured interviews
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11 midwives, 12.5 average year experience, 6 at the regional referral hospital, 5 at the health centre during the day, 4 with certificate, 4 with diploma, 2 with bachelor's degree, 1 with master's degree, 30-80 daily average births for their wards.
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§ Care of Midwives concerning intrapartum management and monitoring/examination to arrive at referral decision consisted of 3 phases: 1) initial encountering, 2) monitoring, and 3) acting that finally resulted in referral.
§ Prompt referral upon identifying signal function beyond the facility's capacity:
“When she put in the catheter, we saw some blood starting to pass. That is the sign of obstructed labor. That’s why I decided to refer immediately.” (F)
§ In instances where mother and fetus conditions are worsening, midwives decide earlier without taking time to confirm labour.
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Strand et al, 2009
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Angola (3 peripheral birth units-Cazenga, Palanca and Sambizanga)
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To assess the efficacy of the newly established network of peripheral birth units and their linkage to hospitals.
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Two-phase quantitative survey, review of maternal records
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249 referred women (157 for first and 92 for second phase of the study), 24.1 mean age in both phases, 36% less than 20 years, 43% primiparous, 32% grand multiparous (≥ 4 previous births) in the first phases, in second phase 29% less than 20 years, 40% primiparous, 22% grand multiparous,
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§ 27/157 deaths occurred among the traced referrals in the first phase, i.e. 17.8% case fatality rate but no maternal death in the second phase.
§ There was a reduction in the proportion of referred women who were left without medical evaluation/treatment observed from the women's records (45% in the first phase of the study to 27% in the second phase (p=0.007).
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Tayler‐Smith et al, 2013
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Burundi (rural district, Kabezi)
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To describe Medecins sans Frontieres (MSF)’s
communication and ambulance service, examine the relationship between referral times and maternal and early neonatal deaths and explore the effect of referral service on coverage of complicated obstetric cases and caesarean sections.
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Cross-sectional study, retrospective analysis
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1,478 ambulance call-outs/referrals.
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§ Median referral time (time between call-out to the ambulance returning with the patient at CURGO) was 78 min.
§ One maternal death occurred among referred women but it was not possible to evaluate the linkage between death and referral time.
§ 3-hour referral duration or higher was associated with increased risk of early neonatal mortality-15% as compared with 9%
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Windsma et al, 2017
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Ethiopia (20 health centres in the Eastern Gurage Zone)
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To assess basic emergency obstetric and newborn care (BEmONC), knowledge of high-risk pregnancies and referral capacity at health centres
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Cross-sectional survey
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37 healthcare providers (18 heads of health centres, 14 midwives, 3
nurses, 1 health officer, 1 other), 45 months average of professional experience among heads of health centres with 27.5 median age, median age of 24 years for other respondents with 24 months average professional experience.
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· Most staff used their own mobile phones for referral correspondence-only 5 facilities (26.3%) had a working landline telephone and 1 (5.3%) facility had a mobile phone.
· There were 5 ambulances for the Eastern Gurage Zone population: Two were stationed at health centres and three at District Health Offices.
· Distance to the referral hospital (Butajira General Hospital) used by all health centres was 16.5 km on average.
· There is the need to train staff of the health centres in the identification of signal functions and BEmONC.
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Provision of maternity referral
All 17 studies 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 referral.
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 all referred women and their newborns from health centres by ambulance to BEmOC and CEmOC facilities. Details about which specific providers 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 these were not emergencies [42]. Unaccompanied women sometimes arrived late in the receiving facility, but details about socio-demographics or their circumstances were not provided [42].
Elmusharaf et al [43] identified four referral pathways: 1. zigzag referral (where women were sent back and forth between two healthcare providers), 2. late referral to appropriate health facilities, 3. multiple referrals (referring women to a number of non-functioning facilities before arrival in an appropriate health facility) and 4. by-passing (where health care providers in 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 [name of hospital] (5JMD) [43].
In a study from Angola delays of up to 13.7 hours were noted in the triage of referred women 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 one 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 the labour ward within 24 minutes. Those in the second stage were evaluated within 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 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].
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 [31]. 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, feedback on referral were given by the women 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 how to use national referral guidelines. Shimoda et al [38] reported that midwives 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]. Adherence includes documentation of referral indication, telephoning the referral facility ahead of time and making arrangements for means of transport, preferably by 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 WHO guidelines and recommendations, the national guidelines of Ghana do not mention that uterotonics are to be applied to reduce haemorrhage [11, 15].
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 ≥500 ml, or blood loss of 500 ml 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 between providers who had more than six years of experience or less.
268 of 350 (76.6%) women who had been referred to a higher level facility in Ghana reported that healthcare providers were competent enough to solve their problems, however, details about providers’ competencies were not explained [40]. In Kwara State in Nigeria, 128 (79.0%) Traditional Birth Attendants (TBAs) indicated that they did not refer in a timely manner [30]. These were untrained TBAs who acquired their skills through self-initiation or inheritance. 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 that155 (75.6%) trained TBAs in Nigeria delayed referral for women who showed signs of difficulty in childbirth for more than 12 hours [8]. A senior manager in a Reproductive Health and Midwifery Department in 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) [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 discomfort, and 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 in 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 Centre) [37].
Maternity information systems
Some health facilities in Ghana routinely used logbooks, care plans, referral letters, referral forms or slips correctly as required by the national referral guidelines [15]. Poor documentation relating to referral was reported in Ghana where only six out of 11 sampled health facilities had referral registers and details concerning indications and treatment in the referring facilities, current status and treatment in the receiving facility were lacking and only one EmOC facility had a computerised referral information system [37, 42].
Medicines and equipment
In the seventeen studies, four included information concerning medicines and equipment such as misoprostol [1, 31, 39, 45]. A decline in correct partograph use was reported in Ghana [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. 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, Mbori Dodoma), [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]. In three urban BEmOC facilities in Ghana 180 out of 390 women 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 women's referral 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, 720 (57%) 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].