Quantitative findings
A total of 718 cases, (94% of response rate) which fulfilled the inclusion criteria were included in this study. The study found that many deliveries which should have been managed at health center level were managed by hospitals. Three quarters of cases, (74.23%; n = 533) who visited the selected hospitals could have been managed at the health center level. The descriptive analysis showed that close to two-thirds of inappropriate cases for hospitals were young, (15 to 25 years old) and had more than four ANC visits. Close to half of the inappropriate referrals reported one to three live deliveries and had their ANC visits at a catchment health center of the primary hospital. The analysis of the data showed no major difference as to the appropriateness of hospital level care in relation to age of mothers, previous medical and obstetrics history as well as danger signs at admission. On the other hand, number of parities (chi-square = 9.3; p-value = 0.010), frequency of ANC, (chi-square = 6.7; p-value = 0.037) and timing of seeking ANC, (chi-square = 12.9; p-value = 0.005) were found to be associated with appropriateness of the case for hospital level care.
The study also found close to two-thirds of the cases which should have been managed at health centers were self-referrals. The findings also demonstrated a significant association with appropriateness of referrals at chi-square = 13.3 and p-value of < 0.001, (Table 1). Moreover, further inventory of the referred cases revealed that approximately 33.2% of referred cases were appropriate for hospital level care. The comparative analysis showed that distance to hospitals, (chi-square = 9.3; p-value = 0.010) has an influence on the appropriateness of referrals. In addition, use of referral slips, (chi-square = 17.97; p-value < 0.001) and ability to determine the cause, (chi-square = 6.4; p-value = 0.011) were associated with appropriateness of referrals. The latter is directly related to the competence of the provider as well the availability of the necessary gadgets at the health center level which boosts the confidence of providers to select appropriate cases for referrals.
Table 1
Description of factors related to appropriateness of referral status
Variables | Can this case be managed at the health center level? | Total | Chi-square | P-value |
Yes | No |
Age group of mothers | | | | | | | | |
15–25 | 333 | 63% | 105 | 57% | 438 | 62% | 3.10 | 0.211 |
26–35 | 181 | 34% | 71 | 39% | 252 | 36% | | |
> 35 | 11 | 2% | 7 | 4% | 18 | 3% | | |
Total | 525 | 100% | 183 | 100% | 708 | 100% | | |
Number of parities | | | | | | | | |
Nullipara | 197 | 39% | 65 | 37% | 262 | 39% | 9.29 | 0.010 |
Para 1 to 3 | 240 | 48% | 73 | 41% | 313 | 46% | | |
Para 4 and above | 65 | 13% | 40 | 22% | 105 | 15% | | |
Total | 502 | 100% | 178 | 100% | 680 | 100% | | |
Any pregnancy danger signs at admission | | | | | | | | |
Yes | 26 | 5% | 10 | 5% | 36 | 5% | 0.05 | 0.830 |
No | 494 | 95% | 175 | 95% | 669 | 95% | | |
Total | 520 | 100% | 185 | 100% | 705 | 100% | | |
Previous obstetrics problems | | | | | | | | |
Yes | 106 | 20% | 37 | 20% | 143 | 20% | 0.0005 | 0.982 |
No | 426 | 80% | 148 | 80% | 574 | 80% | | |
Total | 532 | 100% | 185 | 100% | 717 | 100% | | |
Previous medical problems | | | | | | | | |
Yes | 90 | 17% | 34 | 18% | 124 | 17% | 0.21 | 0.643 |
No | 443 | 83% | 151 | 82% | 594 | 83% | | |
Total | 533 | 100% | 185 | 100% | 718 | 100% | | |
Number of ANC follow up visits | | | | | | | | |
No ANC visits | 10 | 3% | 3 | 4% | 13 | 4% | 6.70 | 0.035 |
1–3 ANC visits | 96 | 32% | 12 | 17% | 108 | 29% | | |
4 + ANC visits | 193 | 65% | 57 | 79% | 250 | 67% | | |
Total | 299 | 100% | 72 | 100% | 371 | 100% | | |
Institution of ANC follow up | | | | | | | | |
In this hospital | 52 | 29% | 6 | 14% | 58 | 26% | 12.90 | 0.005 |
In the referring facility | 29 | 16% | 17 | 40% | 46 | 21% | | |
From the catchment health center | 88 | 49% | 17 | 40% | 105 | 47% | | |
Other institutions | 10 | 6% | 3 | 7% | 13 | 6% | | |
Total | 179 | 100% | 43 | 100% | 222 | 100% | | |
Referral status | | | | | | | | |
Referred | 187 | 35.1% | 93 | 50.3% | 280 | 40.0% | 13.31 | < 0.001 |
Self-referral | 346 | 64.9% | 92 | 49.7% | 438 | 60.0% | | |
Total | 533 | 100% | 185 | 100% | 718 | 100% | | |
Time it takes to reach the primary hospital by ambulance (min) | | | | | | | | |
< 20 | 36 | 19.3% | 13 | 14.0% | 49 | 17.5% | 9.28 | 0.010 |
30–45 | 97 | 51.9% | 36 | 38.7% | 133 | 47.5% | | |
> 45 | 54 | 28.9% | 44 | 47.3% | 98 | 35.0% | | |
Total | 187 | 100% | 93 | 100% | 280 | 100% | | |
Referral slip attached | | | | | | | | |
Yes | 100 | 53.7% | 74 | 79.6% | 174 | 62.1% | 17.97 | < 0.001 |
No | 87 | 46.3% | 19 | 20.4% | 106 | 37.9% | | |
Total | 187 | 100% | 93 | 100% | 280 | 100% | | |
Cause for referral established | | | | | | | | |
Yes | 62 | 60.2% | 55 | 78.6% | 117 | 67.6% | 6.43 | 0.011 |
No | 41 | 39.8% | 15 | 21.4% | 56 | 32.4% | | |
Total | 103 | 100% | 70 | 100% | 173 | 100% | | |
Qualitative findings
Respondents’ gender and qualification
Of the respondents, 61.54% were male and 38.46% were female. 46% had a BSc degree, 38.5% had a Diploma in nursing, 7.69% had a MSc degree, and 7.69% had a certificate in short health related trainings, (see Fig. 1). The respondents’ mean number of months in their current position was 31.2.
The qualitative phase of the study attempted to uncover the reasons behind the referral of inappropriate cases by health centers to hospital care. Although there might be causal factors at both ends, this study scanned factors associated with the referral initiation site. As a result, it found three major themes and 11 categories. The following paragraphs describe each category.
Theme 1: capability of identifying appropriate cases for referral
Category 1: prior relationship with the health center
Health workers establish relationships with mothers during the antenatal (ANC) period. Interactions with mothers help health workers build good rapport with them and identify potential risks. Strong working relationships between health extension workers and midwives at the health center level facilitates to establishment of relationships with mothers. According to a respondent,
The first and fourth ANC are provided at health center level. The fourth ANC is used to provide further counseling the mother and her family about birth preparation and labor signs. As we do not have maternity homes, we try to make sure mothers are coming when they are close to labor. Even though we inform them to come late, if they come early, we find a room at the health center and allow them to stay there.
Category 2: high caseload at health center level
The health centers provide services to a designated catchment population of approximately 25,000 people. Most of the visited facilities provide services to a wider catchment population, and an increasing number of clients for institution-based care for various reasons. The number of health workers providing the services however did not match the rise in number of visits to the health centers and some health workers were not available due to having to attend meetings and training. According to a respondent,
The caseload we encounter is not in accordance with our plan. People are coming from neighboring kebeles and woredas. Our plan is to provide services for 20 mothers per week, but we may see more than 20 and sometimes, up to 40 cases. When there is no case, we at least have ten cases.
Category 3: competent health workforce
The respondents stressed that health worker competence is related to their skills. According to them, short-term BEmONC in-service training, weekly peer mentorship and team consultations were available but limited to one staff member assigned to health a center and regular updates were not available. The respondents emphasized the impact of trainings on seeing improvements. According to a respondent,
I think we are referring the appropriate cases now. When we compare it to the last year’s performance, there are lots of improvements. Last year, there were lots of referrals, but after the health workers got more experience and were trained in BEmONC, they easily diagnose and refer appropriate cases.
The lack of skills was also linked with wrong diagnosis for referrals, complications such as referred hypothermia in newborn cases, lack of clarity in referral slips, limited pre-referral management, and delays in referral. The respondents underlined that not having the required skills undermined providers’ confidence and increased inappropriate care practices. One respondent stated,
The person who is referring may not be capable of diagnosing and writing referral slips. In some of the health centers where they have GPs, this doesn’t occur as often. In other facilities however, it is not uncommon to find wrong information on the referral slips.
Category 4: logistical limitations leading to referrals
Due to logistical limitations, health center staff refer cases to the next level of the referral system, namely hospitals or a nearby facility. The reasons included shortage of power, lack of water, limited space and equipment, shortage of supplies and drugs, and laboratory reagents. The respondents reported that there was limited practice of introducing alternative power and water sources at health center level. Lack of laboratory services also forced health workers to rely solely on physical examination and thus empirical treatment, which led to unnecessary referral and practices at the health center level. A respondent described the situation and health worker frustration at health center saying,
We do not have any of the important supplies such as glucose, vitamin A, calcium gluconate, hydralazine, epileptic drugs, option B for HIV positive cases, and misoprostol. The shortage is because of budget limitations. It is annoying that because of these simple items, we are having to refer cases to other places.
Category 5: motivated health workforce
The respondents pointed out that many factors affected health worker motivation, including, availability of necessary materials and equipment and relationships with the community. The respondents indicated that low salaries, untimely payments of benefit packages, exclusion of some health workers from benefit packages, poor inter-professional support structures, and relationships among staff members affected their motivation. According to respondents,
There are lots of challenges. My pay is very low. I have a third-grade driving license, and I would earn more working as a driver for a private company than I currently do as a civil servant. I work long hours - often a full 24 hours and don’t receive benefit packages. They also say we are entitled to per diem payments when we go to hospitals but even that we don’t receive on time.
The health center has a standard. We have 13 health workers currently. Some staff on maternity leave, and one is breast-feeding. Out of eight staff on active duty, five are expected to support health posts. How does anyone think the remaining health workers are able to provide the required quality services? With all these limitations, we still provide services 24/7. Sometimes services are provided with no protective gear and we don’t receive duty payments. On top of this, we only have one midwife who works with other health workers assigned to provide services in the delivery case team unit. However, as per the government guidance, the risk payment is only payable to the midwife. This affects the referral of services. In addition, the health center does not have a phone, so we are using our personal phones for which we don’t receive any reimbursement
In relation to the health system support, the respondents added that ill equipped facilities, lack of essential drugs and supplies, management inability to establish good relationships among staff and impartiality of the facility management were factors influencing staff motivation at the health center level. According to respondents,
The management is not strong and it is biased. I expect the management to be fair to all. some of the decisions made in our day to day life are based on the individual’s relationship with the management. Many of the staff are wanting to leave the facility early.
When talking to the health officers, they tell me that when they enter delivery case team unit, the midwives are not happy. The midwives say that the health officers should have fixed schedules. In addition, all the drugs and supplies in the delivery room are taken out on behalf of the midwives and the health officers may not be as cautious as they are. I think if they work in a committee and if we have a strong referral committee, they can easily work together.
The respondents also discussed the relationship they have with the community. Most of the respondents underlined that the main factor for their commitment to serve was their relationship with the community. The respondents indicated that praise from the community that followed quality care and outcomes, the willingness of the community to contribute to improved services, and their acceptance of the health workers’ advice were key factors in their motivation.
The respondents indicated that health worker motivation was key to further improve the quality of service provided at the health center level. Some factors that affected motivation included long contact hours with clients, a clean work environment, sharing of costs borne by clients due to unavailability of drugs and supplies, strong follow up of the referred cases, and minimal or no negligent practices. According to respondents,
When they send the patient, if possible, they ask for the phone numbers of the recipient health workers at the hospital level. If they are unable to get that information, they record the phone number of the attendant and check the status of the referral. The follow up includes the place where they were referred to and tracks if there are further referrals. We reserve a copy of the referral paper and also have a referral registry to document the cases.
When we facilitate pregnant mothers’ forums or when we accompany a mother during referrals at night, we may use our own money for transportation or may be forced to spend the night at other people’s houses or at the hospital.
Theme 2: proper initiation of the referral process determines the outcome
Category 1: knowledge of referral pathways
Referral by health workers or self-referral was determined by knowledge of referral pathways in the health system. The referral pathway, which was partly influenced by the availability of a referral directory, was affected by the community’s knowledge of the available services at various levels of the health system. The respondents identified various factors that swayed mothers to go to hospitals directly: limited knowledge of services provided at health centers, advice from family and community members and private facilities, distance, and topography. According to a respondent,
Mothers residing in the town, bring their neonate here and we review the case. Together with the health extension workers, we are educating the community during pregnant mothers’ forums about service availability.
Health worker knowledge of the services provided at neighboring health centers and referral hospitals was an important factor affecting the referral system. Regular update of the referral directory, including contact persons and available services in each referral facility, was identified an important factor in knowledge of the referral pathways. In addition, the respondents stated that proactive communication from the hospitals to health centers avoided unnecessary, multiple referrals due to unavailability of services or logistical problems at the referral hospitals. One respondent pointed out,
When the generator fails and depletes the reagents for certain investigations, we call the heads of the health centers so that they directly refer cases to the general hospital. This helps to reduce the delay which may happen due to multiple referrals.
Category 2: referral communication between facilities
As part of the referral system, a health center is expected to assign a referral focal person and a hospital needs to establish a referral liaison office. The referral focal person is contacted whenever there is a referral. Despite this, high caseloads, minimal communication between facilities, lack of a dedicated room, limited functionality of referral committees, and no accountability framework especially during night shifts are obstacles to this function at the health center level. The limited functionality of the referral focal means there are gaps in the process of initiating a call before referrals take place and ensuring all the necessary documentation and assignment of health workers with the referral case are carried out. According to a respondent,
The health centers do not value the importance of the referral focal person. They merely assign the focal person for the sake of fulfilling the standard. This person should be informed before any referrals are conducted. If the person is not trained, they should undertake the proper training. This function is very important and should receive the needed attention from the woreda health office and the health center management. I know of people who have unnecessarily travelled from facility to facility for the sake of services and have died as a result to delays in treatment. If there is adequate communication before referrals, the outcomes may have been different.
Category 3: preparation for referrals
Preparation for referrals is a stepwise approach, which includes deciding on a referral, preparing a patient, preparing a referral slip and recording the case in the register. The decision on referrals should involve a team effort and the referral committee which should be operating at the health center level should make the decision. However, the timing of the referral cases and the availability of team members is a challenge to the functionality of this team. In addition, after the placement of general practitioners at the health center level, they are now the ones who decide on referrals. Patient preparation requires knowledge of the case and confidence in the established diagnosis. Moreover, proper counselling is also an important component to make sure the patient and her family accept the referral. Considering these factors, the respondents perceive the patient preparation required for referrals as insufficient. According to a respondent,
The pre-referral management is problematic. For example, for eclampsia cases [health workers] are expected to refer the patient after administering the loading dose, but they send the patient without any pre-referral management or writing it on the referral paper. Once the protein and blood pressure levels are raised, they are expected to start the loading dose and refer the patients. Additionally, when a mother experiences bleeding instead of administering IV they refer the case as if it is like other cases.
The availability of formats and registers, the competence of the health workers, caseloads, and availability of the referral committee influenced documentation of cases and referral paper preparations. A positive practice reported by the hospitals was that all referred cases had respective referral slips or papers prepared by health center staff. However, much of the information required was missing on some of the referral slips, especially when the health workers at health center level used plain paper. According to respondents,
The person who is managing the case completes the referral slip and then I register the case in the referral register. The slip is filled in by the person who takes down the history of clients.
As [staff] are not adequately trained, we are taking steps to improve the completion of our referral slips. For example, if the case is diagnosed as perinatal asphyxia, they should at least record the APGAR score. Through repeatedly questioning staff on why they fail to complete the referral slips, we have learned that there may be capacity limitations and some have completely stopped using the slips.
Theme 3: functional cross-facility support platforms for better collaboration and coordination between facilities
Category 1: feedback on referrals
Feedback to the referring facility is a means of establishing communication between health centers and hospitals. When and how it is given has an impact on its application. Most of the health workers at the hospitals reported that they provided written or on-the-spot feedback to the referring health worker. Despite this, health centers have complained about lack of feedback in the system. Some of the respondents believe that most of the cases are referred for inappropriate reasons. The respondents gave the following reasons for the lack of referral feedback: overload of cases to provide written feedback, incomplete contact information of the referring health worker, limited follow up from the health center side, lack of health center commitment to work on the feedback, no health worker accompanying most referrals, use of inappropriate referral forms, and not trusting the competencies of health workers at the hospital level. According to a respondent,
We provide feedback some of which they may not accept as they may feel we are the same as they are in terms of qualifications. However, we have more experience and have worked with many other professionals who are of with a senior rank which ultimately means that we have better experience.
The health center staff, however, believe that lack of commitment on the part of the hospital staff is the reason that they do not receive feedback. Even when they provide feedback, the tone of communication is sometimes not appropriate. According to a respondent,
The tone in which feedback is given is always negative. This may be because they think they work at hospital level. For example, in a case of a prolonged labor, we meticulously assess clients and decide to refer some cases. Then, en route, due to the nature of the roads used, the position may change, or the labor may be hastened. When such cases reach the hospital, clients may deliver normally. In such instances, we get feedback that says, “you are sending us the inappropriate cases’. Sometimes, it is good to ask the patient herself and understand our efforts rather than concluding we are unwilling to provide the care here.
The referral focal person or the health center’s head collects the referral feedback which is jointly reviewed by the delivery case team members. In some of the health centers, the feedback is used as an opportunity for coaching and filling in the missing materials which were a cause for some referrals. Respondents described meetings between staff at health centers, their respective hospital and woreda health office officials as opportunities where every stakeholder took on an assignment to improve persisting problems in the process of referrals. According to respondents,
Our relationship with the health centers should be properly guided. We need to establish a quarter-based meeting with them at a minimum. Recently we had a meeting with the MCH lead, referral focal person and midwives from the hospital and woreda health offices. We took samples from their referral feedback and held discussions with them.
Category 2: consultation and mentorship support
The relationship between health centers and hospitals can be strengthened further by initiating functional, technical support structures in the form of phone consultations and through the provision of either individual or group mentorship support to the health centers. The respondents stated that phone consultations are necessary in minimizing unnecessary referrals. According to a respondent,
When we have no one to consult here at the health center level, we call the hospital. These calls help us manage the cases here and avoid referrals. It also lets the hospitals know that they should prepare themselves to provide the services in case they are referred.
The respondents indicated that mentorship support improved health worker competence and reorganized service delivery platforms at health center level. As mentorship support requires advance preparation before the actual visit, it contributes to ensuring that health center problems are dealt with comprehensively and sends a message that, for any actions taken in the process of referred cases, the health center is accountable. This is a further opportunity for continued consultations between the health workers at the health center and hospital levels as well as an opportunity to present any administrative-related problems to woreda health office representatives. One of the respondents described the process followed in providing group mentorship saying,
A pharmacist, an IESO, a lab technician, a GP, and quality officer went to a health center where the [IESO] conducted mass U/S screening. All of the visiting staff from the hospital supported the health center in various capacities. This was a great experience as it was helpful for the health center to receive feedback. Such visits are helpful in bridging gaps in differences of skill sets. The health system grapples with lack of accountability as [heath centers] have formal relations with the woreda, but not with hospitals. Moving forward, woreda level trainings can be a means of building strong communication between the institutions.
Category 3: functional service management committees
Various management-related committees have been established at both health center and hospital levels. The respondents identified the referral, MPDSR, and quality team committees among those that have a stake in the referral system. However, the functionality of those groups is either limited to one level or is known by very few in the system. According to a respondent,
There is an MPDSR committee led by the quality unit which includes four midwives as part of the team. The committee analyzes cases to determine causes of the problems, and every team member is evaluated. The findings are then used to educate health workers at all levels. The analysis, however, does not include visits to the health center and homes of clients.