Patterns and determinants of pathways to reach comprehensive emergency obstetric and neonatal care (CEmONC) in South Sudan: qualitative diagrammatic pathway analysis

Abstract

BackgroundMaternity referral systems have been under-documented, under-researched, and under-theorised. Responsive emergency referral systems and appropriate transportation are cornerstones in the continuum of care and central to the complex health system. The pathways that women follow to reach Emergency Obstetric and Neonatal Care (EmONC) once a decision has been made to seek care have received relatively little attention. The aim of this research was to identify patterns and determinants of the pathways pregnant women follow from the onset of labour or complications until they reach an appropriate health facility.MethodsThis study was conducted in Renk County in South Sudan between 2010 and 2012. Data was collected using Critical Incident Technique (CIT) and stakeholder interviews. CIT systematically identified pathways to healthcare during labour, and factors associated with an event of maternal mortality or near miss through a series of in-depth interviews with witnesses or those involved. Face-to-face stakeholder interviews were conducted with 28 purposively identified key informants. Diagrammatic pathway and thematic analysis were conducted using NVIVO 10 software.ResultsOnce the decision is made to seek emergency obstetric care, the pregnant woman may face a series of complex steps before she reaches an appropriate health facility. Four pathway patterns to CEmONC were identified of which three were associated with high rates of maternal death: late referral, zigzagging referral, and multiple referrals. Women who bypassed nonfunctional Basic EmONC facilities and went directly to CEmONC facilities (the fourth pathway pattern) were most likely to survive. Overall, the competencies of the providers and the functionality of the first point of service determine the pathway to further care.ConclusionsOur findings indicate that outcomes are better where there is no facility available than when the woman accesses a non-functioning facility, and the absence of a healthcare provider is better than the presence of a non-competent provider. Visiting non-functioning or partially functioning healthcare facilities on the way to competent providers places the woman at greater risk of dying. Non-functioning facilities and non-competent providers are likely to contribute to the deaths of women.Electronic supplementary materialThe online version of this article (10.1186/s12884-017-1463-9) contains supplementary material, which is available to authorized users.

Diagnostic accuracy of the partograph alert and action lines to predict adverse birth outcomes: a systematic review

“…In this sense, the use of the alert line alone to trigger referrals from peripheral to higher level hospitals may have unnecessarily increased referrals of women who otherwise had labours that were progressing normally. This may have had huge emotional, physical, and costs implications not only for the women, the fetus, and their families, but also for healthcare providers in referring and receiving facilities and the health system, in particular in places where referral systems are suboptimal or where higher level maternity units are overcrowded or understaffed …”

Measuring delay in high-risk obstetric referrals in Accra, Ghana: How long does it really take?

“…Recently, a study of 119,244 pregnancies in the Brong Ahafo region of Ghana, found that facility delivery and shorter travel distance did not improve survival bene ts for women or newborns, unless births occurred in high quality or CEmOC facilities [25]. Others have shown similar results [26][27][28]. It is imperative that high risk obstetric patients reach the right facility, in a timely manner.…”

“…Other studies, however, have described numerous barriers in accessing appropriate care beyond distance alone, including: delay in the recognition of a problem; needing to collect money for treatment or transport; waiting for relatives; needing permission; patient preferences for traditionalist and spiritual practices; refusal of referral due to fear of disrespectful care, medical procedures, or surgery; waiting for transport; and tra c congestion [1-3, 5, 6, 11, 22, 23, 26, 27, 29]. Also, in some cases, pregnant women are referred from one facility to another on the basis of no bed availability or lack of resources, until it is too late [28,29]. Fortunately, in the present report, this occurred for only 9 (1.4%) patients.…”

“…Communication is frequently de cient between facilities, including feedback to the referring institution regarding patient outcome [2,3,6,29]. Furthermore, patients have been shown to self-refer, bypassing the usual referral chain to seek higher levels of care [3,6,21,24,28]. They will travel farther and pay more for what they perceive to be better care [3,6,24,28,29].…”

“…There is controversy as to whether referral system barriers constitute Phase II or Phase III delays. Although some authors classify referral barriers as primarily transport-related and therefore Phase II delays, others consider these as Phase III barriers since the patient has already reported to a health facility [11,26,28]. It is important to identify and categorize referral related barriers, whether considered Phase II or Phase III delay, in the provision of timely CEmOC in low resource countries and this topic remains vastly under-researched [2,6,26,27].…”