A referral system is a process in which health workers at one level of the health system, having insufficient resources (drugs, equipment, skills) to manage a clinical condition, seeks the assistance of a better or differently resourced facility at the same or higher level to assist in, or take over the management of the client’s case (1). Theoretically, health posts [the primary or first level] refer cases to health centers, as the health care professionals have at their disposal a minimal number of materials and drugs. Then, health workers are advised to refer cases from health centers to district hospitals; the last step of the referral pathway may include regional and possibly national referral hospitals. The referral system is most likely to be effective when there is a clearly articulated process between the referring/sending and receiving facilities, bypassing can result in higher costs and inefficiencies of the health system (2).
The three delays–deciding to seek health services, reaching a health facility, and receiving treatment after reaching the referral facility has been recognized as one of the main factors that lead to poor outcomes among women who have obstetric emergencies including maternal death (3). Recently, a “fourth delay” that results when patients are not timely referred to the next higher level of care due to delay in making referral decisions by providers is getting attention. This is indicating that time is a significant modifiable factor that negatively affected patient experience and outcome and it is invaluable to saving lives (4). Hence, the time spent between referring and receiving health facilities is an important determinant of the outcome of the referred patients/clients because time is essential in obstetric care as the onset of complications and proper initiation of management makes a difference between life and death, and timely referrals are important in making sure of this a difference in the outcome (5).
The longer it takes to reach the receiving health facilities, the poorer the outcome whereas the shorter time spent between referring and receiving health facility the better outcome given that referral is initiated timely and the condition is reversible (6). However, this could be affected by several factors that are related to the referring and receiving health facility, health care providers, the referred patient/client, and referral system (7,8). Thus, a well-functioning referral system: the ability of the health care providers to timely identify cases in need of referral, readiness of the clients/patients or their family being referred to take timely action, availability of conducive infrastructures (e.g. all-weather roads), distance between the two health care facility, vital resources (Ambulance or vehicles, lifesaving material needed to quickly transfer people with need of higher/specialized maternal and newborn health care to higher levels of care (2,9).
Women in low income countries often face serious health risks during pregnancy and delivery due to poor access to early and appropriate referrals. Despite studies that show clear linkages between timely referrals and improved maternal outcomes, challenges still remain in the referral process, particularly in rural communities (10). Also, women may face with a number of barriers related with referral and health workers who have difficulty in complying with guidelines for referral. The relative importance of these barriers is limitedly known to health planners. Consequently, interventions to improve caretaker compliance with referral system are difficult to develop where caretakers may be faced with much communication and transportation barriers (2,3).
Evidence from Tanzania revealed that from the referred 1538 women 70% were referred for demographic risks, 12% for obstetric historical risks, 12% for prenatal complications and 5.5% for natal and immediate postnatal complications. Five or more pregnancies and age < 20 years were the most common referral indications (11). A descriptive survey on 5060 pregnancies in eastern Zaire, showed that the referral success rate in the region was only 33%, despite some favorable conditions, such as a strong emphasis on community participation, a complementary health centers and hospital, and the absence of financial barriers within the health services system (12). A study conducted in Zambia indicates that 32% of the patients were referred (of which 97% referred to hospital); of the referred cases 73% were referred because they were too sick and 17% need specialized care; 19% of patients had taken some course of action (like self-medication (40%) before coming to the centre. The study found that 60% of all patients were self-referral. There was a higher self-referral pattern for children (only 44% had been referred) compared with adults (70% had been referred)(13).
In another study only 10% of patients were referred and majority of (74%) patients in the hospital were referred by a health center whereas among those who were referred to the health center, 32% came from a nearby hospital and only 18% referred from health post(14). A study in Nigeria revealed that only 100 (7.1%) of patients were referred to the hospital mostly from private clinics while the rest (92.9%) were self-referral(15). Study self-referrals constitute more than 50%, institutional referral around 30% and emergency referral less than 5% of women at referral level. Distance, cost, perceived quality of obstetric care, health workers attitude and respect for women's social needs, perceived etiology of complications and socio-cultural preferences, prolonged labor, retained placenta, postpartum hemorrhage, mal-presentation of baby, severe eclampsia and premature rupture of membrane were among the determinants of obstetric care utilization at referral sites, theatre busy 25.1%, unavailability of blood 11.3% and lack of equipment and supplies 10.3%, lack of transportation and communication infrastructure, overcrowding at the referral hospital, insufficient pre-service and in-service training, and absence of supportive supervision were key barriers to provision of quality emergency obstetric care. Late referrals (after two hours) were observed in 60.3% of women the cases (5,10,16,17).
According to study in Uganda, patients spent a median time of 346 minutes in assessment center. The mean time from the vehicle being called by the PHU to the patient’s arrival at hospital was 3.1 hours(18) study done in Sierra Leone indicates that transportation cost and communication intervention were important predictors of quality of obstetric care(19). The average waiting time was found to be 44.85 minutes (17.92 minutes to 126.56 minutes in surgery and nephrology department respectively), average consultation time for all OPD was found to be 17.357 minutes (6.00 minutes in medicine department to 76.840 minutes in psychiatry department)(20). In another study ~ 70% of the population is served by facilities within a 2-hour transfer time to a hospital and spent 64.1% of their total time in waiting at the immunization clinics (21, 22). Despite the challenges in accessibility of maternal and child health service for mothers and children in Ethiopia there is paucity of information about the average time spent and its determinants in using the service; hence the current study aims to fill this gap.