Understanding barriers to implementing referral procedures in the rural and semi-urban district hospitals in Tanzania: Experiences of healthcare providers working in maternity units

Abstract

Introduction Maternal and perinatal deaths occurring in low and middle income countries could be prevented with timely access to maternal and new-born care. In order to increase access to maternal and child health services, a well-functioning referral system that allows for continuity of care across different tiers of healthcare is required. A reliable healthcare system, with adequate numbers of skilled staff, resources and mechanisms, is critical to ensuring that access to care is available when the need arises. Material and methods This descriptive, qualitative study design was used to explore barriers to implementing a reliable referral system. Twelve individual qualitative interviews were conducted with health care providers working in rural and semi-urban district hospitals in the Northern, Western, Eastern and Southern zones of Tanzania. Thematic analysis guided analysis of data. Results Three (3) main and interconnected themes were abstracted from the data relating to participants’ experiences of referring women with obstetric complications to adequate obstetric care. These were: 1. Adhering to a rigid referral protocol; 2. Completing the referral of women to an adequate health facility and 3. Communicating the condition of the woman with obstetric complications between the referring and receiving facilities. Conclusion Because of referral regulations, assistant medical officers were unable to make referral decisions even when they felt that a referral was needed. The lack of availability of hospital transport as well as the lack of a reliable feedback mechanism, prohibited effective referrals of patients. The Ministry of Health should revise the referral protocol to allow all clinicians to provide referrals, including assistant medical officers- who make up the majority of clinical staff in rural health care facilities. A mechanism to ensure effective communication between the referral facility and the tertiary care hospital should be instituted for quality and continuity of care. Furthermore, health care facilities should put aside budget for fuelling the ambulance for effective referrals.

Challenges of the Integrated Information System (SINA) in Maternity Care

“…One of the problems related to processes, as a sub-theme of management problem, was the insu ciency of pregnant mothers' referral process/ ow, making a gap in the continuity of care. Similarly, Jafari et al and Mselle et al have pointed out the di culty of referring to higher levels of the center, such as referral to a specialist (12,20). Mohammad also considered the lack of appropriate referral policies and solutions as one of the obstacles at the organizational level in examining the barriers to using maternal and child health services (21).…”

“…Mohammad also considered the lack of appropriate referral policies and solutions as one of the obstacles at the organizational level in examining the barriers to using maternal and child health services (21). Mselle et al have con rmed the inability to exchange information about mothers' conditions with pregnancy complications as the main referral problem in rural and suburban hospitals (20). Harahap et al expressed the weak referral system and its monitoring, insu cient documentation, information loss, or the loss of related documents and papers were health system-related obstacles to the maternal and newborn referral system in developed countries (22).…”

Collaborative training of regulators as an approach for strengthening regulatory systems in LMICs: experiences of the WHO and Swissmedic

“…Data analysis was carried out by inductive thematic analysis as previously described by Braun and Clarke ( 10 ). This was based on the large nature of the dataset, the scarcity of literature on similar aspects, and the need for higher flexibility in the identification, analysis and reporting of the possible themes and patterns ( 10 , 11 ). To familiarise with the data, the video records were watched and listened to once before they were subsequently transcribed verbatim.…”

Women's experiences with hypertensive disorders of pregnancy from a national referral hospital in Tanzania: A qualitative study

“…One study in a different region of Tanzania suggested that it took over 2 hr to transfer women from a clinic or hospital to the final facility, partly due to a lack of available transportation (Schmitz et al, 2019). This situation is very common in not only Tanzania (Mselle et al, 2021;Shimoda et al, 2015) but also in other low-and middle-income countries where they have similar referral, transportation, and human resource challenges (Ameyaw et al, 2020). Adequate and timely referral is necessary to decrease preventable maternal mortality (WHO, 2015); the success of adequate referral needs capacity-building based on the skills and knowledge of HCPs, communication between referral hospitals and preparations of pregnant women which includes help provided by their family.…”