Critical comparative analysis of data sources toward understanding referral during pregnancy and childbirth: three perspectives from Nigeria

Abstract

Background The highest risk of maternal and perinatal deaths occurs during and shortly after childbirth and is preventable if functional referral systems enable women to reach appropriate health services when obstetric complications occur. Rising numbers of deliveries in health facilities, including in high mortality settings like Nigeria, require formalised coordination across the health system to ensure that women and newborns get to the right level of care, at the right time. This study describes and critically assesses the extent to which referral and its components can be captured using three different data sources from Nigeria, examining issues of data quality, validity, and usefulness for improving and monitoring obstetric care systems. Methods The study included three data sources on referral for childbirth care in Nigeria: a nationally representative household survey, patient records from multiple facilities in a state, and patient records from the apex referral facility in a city. We conducted descriptive analyses of the extent to which referral status and components were captured across the three sources. We also iteratively developed a visual conceptual framework to guide our critical comparative analysis. Results We found large differences in the proportion of women referred, and this reflected the different denominators and timings of the referral in each data source. Between 16 and 34% of referrals in the three sources originated in government hospitals, and lateral referrals (origin and destination facility of the same level) were observed in all three data sources. We found large gaps in the coverage of key components of referral as well as data gaps where this information was not routinely captured in facility-based sources. Conclusions Our analyses illustrated different perspectives from the national- to facility-level in the capture of the extent and components of obstetric referral. By triangulating across multiple data sources, we revealed the strengths and gaps within each approach in building a more complete picture of obstetric referral. We see our visual framework as assisting further research efforts to ensure all referral pathways are captured in order to better monitor and improve referral systems for women and newborns.

Travel of pregnant women in emergency situations to hospital and maternal mortality in Lagos, Nigeria: a retrospective cohort study

“…However, both data are not routinely reported inpatient records in many SSA health systems. 35 Furthermore, being a facility-based study, our study does not include pregnant women who died in transit. Finally, we observed wide CIs around the travel time and distance estimates for referred women.…”

“…Moreover, we could not fully capture women’s socio-economic and educational characteristics, which are also essential factors that influence access to care. However, both data are not routinely reported inpatient records in many SSA health systems 35. Furthermore, being a facility-based study, our study does not include pregnant women who died in transit.…”

Use of motorised transport and pathways to childbirth care in health facilities: Evidence from the 2018 Nigeria Demographic and Health Survey

“…The NDHS asked the childbirth care-seeking questions used in this analysis only of women with a live birth. There is evidence that many women needing emergency obstetric care experience stillbirth (and some women die), but these women and the pathways and modes of transport they use, if any, are not captured in this dataset [9,22,35]. Our study also did not provide details on the number of stops women might have made before arriving at their final facility [36,37].…”

“…Thus far, there is limited availability of large-scale data, such as the periodically reported Demographic and Health Surveys in LMICs, to understand pathways and mode of transport to care. Where these data exist, there are large gaps in key components of referral, mainly because this information is not captured routinely [22]. Understanding travel to reach health facilities and factors that influence transport and referral mechanisms is a critical step needed to develop an effective obstetric transport and referral system [12].…”

The potential utility of an augmented data collection approach in understanding the journey to care of pregnant women for maternal and perinatal death surveillance and response

“…11 However, while patient records have copious detail to understand factors that might have contributed to delays after the woman arrived at the health facility, they typically contain minimal information on the journey she travelled to care. 14,15 The WHO recommends that though it is more difficult to obtain, such additional information could be sourced from the woman's family. 11 In practice, this might mean conducting post-mortem interviews for MPDSR purposes, as in Indonesia.…”