Patient referrals among health facilities are initiated to maximize receipt of quality care at a proper level within the health system. This study explored the processes, factors that influence, and strategies for referral of children from Ndirande Health Centre to Queen Elizabeth Central Hospital in Blantyre, Malawi. We drew a purposive sample comprising health care workers, mothers, fathers, ambulance drivers, and Health Center Advisory Committee (HCAC) members and held 19 in-depth interviews and 1 focus group discussion in August 2020. The referral process is influenced by the availability of motor and bicycle ambulances that are well equipped with medical equipment, delay in seeking health services, uptake of referral, and community support. Education and communication with the community and parents respectively optimize the process of referral. There is a need to improve the referral system of under-five children by instituting a policy that is functional while addressing the main barriers.

Background Adolescent pregnancy remains a public health problem as it contributes to maternal mortality and morbidity. There is poor utilization of maternal health services among adolescent women, and they do not gain maximum benefits of the services, by either reporting late to book for ANC, for labour and delivery, and for their postnatal checkups or partially using them. This situation increases the risk of infant and maternal morbidity and mortality. Hence, this study explored the factors that influence and strategies for improving the utilization of maternal health services among adolescents in Malawi. Methods We conducted an exploratory longitudinal qualitative study at Matawale Health Center from August 2021 to January 2022 among pregnant adolescent women to explore the factors that influence and strategies for improving the utilization of maternal health services among adolescents. We drew a purposive sample of 12 adolescent women between 15 and 19 years of age and collected data using in-depth interviews, vignettes and pictorial diaries. All recordings were audio-recorded, translated, and transcribed verbatim. Data were analysed using thematic content analysis, with NVivo 12 software. Additionally, we used Andersen’s behavioral theoretical framework to guide the study. Findings Factors that influence the uptake and utilization of maternity health services among adolescent women include distance, embarrassment/fear, healthcare workers' attitudes, resource availability, support, and operation times. The strategies for promoting the utilization of services include having adolescent-friendly operational times, community outreach, and awareness. Conclusion The optimization of maternity services among adolescents will require restructuring the way the current services are provided so that the perspectives of adolescents are incorporated. Strategies to address fear and embarrassment, which are specific to adolescents, need to be addressed, and this could be done through community awareness and flexibility in the delivery of services to align with the needs of adolescents.