Obstetric referrals in Addis Ababa’s public health centres

Abstract

To determine the rate of obstetric referral and explore contextual factors influencing referral practices in public health centres of Addis Ababa, Ethiopia.

Explanatory sequential mixed-methods study.

Fifty public health centres in the Addis Ababa City Administration, January–April 2021.

Delivery and referral registers from 50 health centres were reviewed retrospectively for 12 months (8 July 2019–7 June 2020). Facility observations and interviews with maternity unit heads were conducted in all selected centres. In-depth interviews were conducted with 20 midwives and 13 health centre managers. Quantitative data were analysed descriptively, and qualitative data were analysed thematically using Colaizzi’s method.

Only 13 (26%) of the 50 health centres have met all eight standards assessed for functionality of the referral system. The main gaps of the referral system were a lack of ambulance (12%), absence of formal agreement with referral centers, and lack of timely case-by-case feedback from referral centers(64%). The overall obstetric referral rate was 32%, with substantially higher referral rates in health centers without caesarean section (CS) services compared with those providing CS (39% vs 21%). Qualitative findings indicated that high referral rates were associated with limitations in the predictive capacity of the partograph, variability in providers’ clinical skills, and risk-averse practices driven by accountability concerns related to maternal and perinatal outcomes.

Improving functionality of referrals and reducing unnecessarily high referrals requires adopting and training providers on the new WHO labour guide and partograph, improving referral feedback, and clarifying accountability mechanisms.

Introduction

Most pregnancies and births are uneventful. However, around 15% of all pregnant women will develop a potentially life-threatening complication that calls for skilled care, and some will require a major obstetrical intervention to survive [1]. Consequently, about 15% of all pregnant women are expected to develop life-threatening obstetric complications, and must be promptly referred from lower levels of care to facilities capable of providing comprehensive emergency obstetric care, including caesarean section delivery [2,3].

Effective referral systems are essential for reducing delays in accessing appropriate care. However, referral capacity at the primary care level remains weak in many sub-Saharan African countries. Analysis of service availability data from five countries showed that only 38% of primary care facilities had adequate referral capacity [4].

The World Health Organization (WHO) quality-of-care standard identifies a functional referral system as one of the eight core domains of quality maternal and newborn care [5].The standards emphasize that every woman and newborn with conditions beyond the capacity of a facility should be appropriately and promptly referred. The standard includes timely assessment at admission, during labour, and in the early postnatal period; rapid decision-making and a functioning referral system. A functional referral system that has standard referral forms and procedures, a list of pre-established referral networks, a readily available ambulance, and effective communication and feedback between referring and receiving facilities [5].