Referral patterns through the lens of health facility readiness to manage obstetric complications: national facility-based results from Ghana

Abstract

Introduction Countries with high maternal and newborn mortality can benefit from national facility level data that describe intra-facility emergency referral patterns for major obstetric complications. This paper assesses the relationship between referral and facilities’ readiness to treat complications at each level of the health system in Ghana. We also investigate other facility characteristics associated with referral. Methods The National Emergency Obstetric and Newborn Care Assessment 2010 provided aggregated information from 977 health facilities. Readiness was defined in a 2-step process: availability of a health worker who could provide life-saving interventions and a minimum package of drugs, supplies, and equipment to perform the interventions. The second step mapped interventions to major obstetric complications. We used descriptive statistics and simple linear regression. Results Lower level facilities were likely to refer nearly all women with complications. District hospitals resolved almost two-thirds of all complicated cases, referring 9%. The most prevalent indications for referral were prolonged/obstructed labor and antepartum hemorrhage. Readiness to treat a complication was correlated with a reduction in referral for all complications except uterine rupture. Facility readiness was low: roughly 40% of hospitals and 10% of lower level facilities met the readiness threshold. Facilities referred fewer women when they had higher caseloads, more midwives, better infrastructure, and systems of communication and transport. Discussion Understanding how deliveries and obstetric complications are distributed across the health system helps policy makers contextualize decisions about the pathways to providing maternity services. Improving conditions for referral (by increasing access to communication and transport systems) and the management of obstetric complications (increasing readiness) will enhance quality of care and make referral more effective and efficient.

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

“…In the present study, the leading referral indications were failure to progress (26.3), prior uterine scar (11.6%), and hypertensive disorders of pregnancy (11.5%). This is in agreement with other reports, which have similarly found obstructed labour to be the most common indication for referral [3,11,21,24,29]. In Nkyekyer's 2002 report, only 2% of patients were referred for prior uterine scar [24].…”

“…The region is predominately urban, and represents the most educated and wealthiest segment of the population [1]. The government health system is organized within a three-tier model, whereby care is escalated via referral from primary care and community health centers, to district hospitals, to regional and teaching hospitals [2,3,15]. Additionally, there are numerous smaller private facilities with varying capabilities.…”

“…Despite this improvement, signi cant gaps remain in the provision of quality care for high-risk obstetric patients, particularly along the referral pathway [2][3][4][5][6]. It is known that at least 15% of all pregnancies will develop complications that require advanced care, including surgery, in hospitals capable of performing comprehensive emergency obstetric care (CEmOC) [7].…”

“…Delays in reaching the appropriate health facilities contribute to poor maternal and newborn outcomes [8][9][10][11]. Ine cient referral processes can result in death during transport or soon after arrival at secondary and tertiary institutions [2,3,11]. As such, referral and teaching hospitals have maternal mortality rates that far exceed the national average [3,12,13].…”

“…Ine cient referral processes can result in death during transport or soon after arrival at secondary and tertiary institutions [2,3,11]. As such, referral and teaching hospitals have maternal mortality rates that far exceed the national average [3,12,13]. In Ghana, the country action plan for the Millennium Development Goal (MGD) Acceleration Framework identi ed weak referral systems, particularly for managing obstetric emergencies, as one of the leading challenges to achieving the MDG for maternal mortality [14].…”