Factors influencing referrals for ultrasound-diagnosed complications during prenatal care in five low and middle income countries

Abstract

BackgroundUltrasound during antenatal care (ANC) is proposed as a strategy for increasing hospital deliveries for complicated pregnancies and improving maternal, fetal, and neonatal outcomes. The First Look study was a cluster-randomized trial conducted in the Democratic Republic of Congo, Guatemala, Kenya, Pakistan and Zambia to evaluate the impact of ANC-ultrasound on these outcomes. An additional survey was conducted to identify factors influencing women with complicated pregnancies to attend referrals for additional care.MethodsWomen who received referral due to ANC ultrasound findings participated in structured interviews to characterize their experiences. Cochran-Mantel-Haenszel statistics were used to examine differences between women who attended the referral and women who did not. Sonographers’ exam findings were compared to referred women’s recall.ResultsAmong 700 referred women, 510 (71%) attended the referral. Among referred women, 97% received a referral card to present at the hospital, 91% were told where to go in the hospital, and 64% were told that the hospital was expecting them. The referred women who were told who to see at the hospital (88% vs 66%), where to go (94% vs 82%), or what should happen, were more likely to attend their referral (68% vs 56%). Barriers to attending referrals were cost, transportation, and distance. Barriers after reaching the hospital were substantial. These included not connecting with an appropriate provider, not knowing where to go, and being told to return later. These barriers at the hospital often led to an unsuccessful referral.ConclusionsOur study found that ultrasound screening at ANC alone does not adequately address barriers to referrals. Better communication between the sonographer and the patient increases the likelihood of a completed referral. These types of communication include describing the ultrasound findings, including the reason for the referral, to the mother and staff; providing a referral card; describing where to go in the hospital; and explaining the procedures at the hospital. Thus, there are three levels of communication that need to be addressed to increase completion of appropriate referrals-communication between the sonographer and the woman, the sonographer and the clinic staff, and the sonographer and the hospital.Trial registrationNCT01990625.

Obstetric care navigation: results of a quality improvement project to provide accompaniment to women for facility-based maternity care in rural Guatemala

“…In addition, Guatemala is a particularly challenging environment for obstetric referrals. A recent study of the Global Network for Women and Children’s Health—conducted in the Democratic Republic of the Congo, Pakistan, Kenya, Zambia and Guatemala—tested community-based antenatal ultrasound screening as a strategy to improve pregnancy outcomes through detection and referral 31. Guatemala had the lowest rate of referral completion at 52%, compared with more than 90% in the African nations.…”

Investigating the use of ultrasonography for the antenatal diagnosis of structural congenital anomalies in low-income and middle-income countries: a systematic review

“…In an additional survey by the same group, barriers to referral attendance included cost, distance and lack of transportation. 18 For women who did attend referral, barriers included not being connected to the correct provider and being told to return at a later time. 18 The authors conclude that without improvement of subsequent care, antenatal ultrasound offered limited impact.…”

“…18 For women who did attend referral, barriers included not being connected to the correct provider and being told to return at a later time. 18 The authors conclude that without improvement of subsequent care, antenatal ultrasound offered limited impact. 17 Hence, to reduce neonatal morbidity and mortality, detection of an anomaly must be followed by referral for antenatal counselling and delivery at a tertiary centre which can provide the necessary surgical care at birth where required.…”

Working with lay midwives to improve the detection of neonatal complications in rural Guatemala

“…We also addressed the financial disincentives lay midwives face for taking on additional clinical work with neonates, which many may feel is outside their scope or interest. Multipronged continuum of care interventions like this is especially important in Guatemala where the extensive literature on obstetrical referrals has shown that the decision to refer is complex and often fear-laden, given the prevalence of disrespect and low-quality care that both lay midwives and their indigenous patients often experience within referral facilities 12 31–34…”