Factors and outcomes associated with self and institution maternal referrals in Dar es Salaam districts and national Hospitals

Abstract

Background: Improving maternal health by reducing maternal mortality constitutes the fifth Millennium Development goal and represents a key public health challenge in the United Republic of Tanzania. Despite national and global commitments and efforts to reverse the current maternal mortality rate in Tanzania, the ratio has continued to remain unacceptably high and the figures continue to rise year after year. (5291100,000 in 1996 against 5781100,000 live births in 2005). Among other factors, referral system that is efficient and of good quality, together with provision of appropriate and timely emergency obstetric care plays a crucial role in the reduction of both maternal morbidity and mortality. Objectives: Several studies done in Africa and rural parts of Tanzania have found weaknesses in the maternal referral system. This study was therefore conducted to assess the factors and outcomes associated with self and institutional maternal referrals in Dar-es- Salaam districts and National Hospitals, with the assumption that the outcome of maternal referrals reflects the effectiveness of the maternal referral system in the reduction of maternal mortality. Materials and methods: This analytical cross sectional study used both qualitative and quantitative methods of research design and was conducted in the national and district hospitals in Dar-es-Salaam region from April to May 2009. Data was collected using questionnaires and hospital based obstetric records and database checklists. A total of 392 women who were admitted and had just delivered in the four hospitals were interviewed and their antenatal cards checked for any referral advice or documentation given. Qualitative interview on assessment of the current maternal referral system was also conducted to sixteen selected healthcare workers responsible for maternal care delivery in the four hospitals. Data on maternal referrals for the year 2008 was collected from the obstetric registry books and database at districts and national hospitals respectively. Results: This study revealed a state of poor functioning of maternal referral system in the city public hospitals with a high percentage of self referrals (51.2%). A strong association was also found between educational level and economic status with referral status of women. (P<O.OS). A high maternal mortality ratio of 1,046 per 100,000 live births was found among mothers referred from the district hospital to MNH. Lack of referral guidelines and inadequate human and non human resources were among factors associated with poor functioning of the system. Conclusion and Recommendations: Urgent review of the current health system policies to address underlying causal factors for poor functioning of the system and provision of maternal referral guidelines to all health facilities is needed. Avoidance of unnecessary maternal referrals due to bad outcomes, together with implementation of emergency obstetric care functions to every facility providing maternal services is recommended.