Prevalence and factors related to inappropriate referrals during intrapartum care – a mixed method study

Abstract

Background: Complications during delivery are responsible for half of all maternal deaths, one-third of stillbirths and a quarter of neonatal deaths. The care necessitates emergency care, and it is a known fact that reductions in maternal mortality and morbidity are not possible without an effective referral system. This study is aimed at measuring the prevalence of inappropriate referrals and identifying factors that contribute to it. Methods: The study employed a sequential explanatory mixed research design. In the first phase, a retrospective cross-sectional quantitative study was done, 718 medical records were reviewed. The second phase involved a qualitative study of 26 key informants being interviewed. Results: Three quarters of cases, (74.23%; n=533), who visited the selected hospitals could have been managed at the health center level. Sixty-five percent of them, (n=436), sought care at the hospital level with no referral from the lower level. Further 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 the institution where ANC was sought, (chi-square = 12.9; p-value = 0.005) were found to be associated with appropriateness of the case for hospital level care. Further inventory of the referred cases revealed that 33.2% of referred cases were appropriate for hospital level care. In addition, the qualitative study identified three major themes in relation to appropriateness of referrals: capability of identifying appropriate cases for referral, proper initiation of the referral process determining the outcome and functional cross-facility support platforms for better collaboration and coordination between facilities. Conclusion: Referral, which is the coordination between facilities, requires readiness of the facilities at both ends as well as a transportation system. The governance system should also be strengthened to ensure the emergency management system in the country is effective.