Referral reasons and communication barriers influencing referrals of women with obstetric complications during peripartum period at Muhimbili national hospital, Dar es salaam

Abstract

Background: World Health Organization (WHO) emphasises that the referral process should follow a pre- established plan that can be put into action without delay at any given time. While obstetric referral has continued to be a challenge in the health care system, adherence to referral guidelines reflects the effectiveness of maternal referral system in influencing quality of care for reduction of maternal morbidity and mortality. Objective: The aim of this study was to assess the obstetric referral process among women with obstetric complications during the peripartum period referred to Muhimbili National Hospital (MNH) for advanced obstetric management Materials and methods: This was a cross-sectional study that was conducted at the maternity block in MNH, Dar es Salaam. Both qualitative and quantitative research methods were employed. Quantitatively, the study population was women admitted in the labour ward, high dependency ward, ICU ward and postnatal ward, who were selected by convenience sampling. Qualitatively the study population was health care providers (nurse-midwives, and obstetricians) working at the Maternity block in MNH, who were selected purposively.Quantitative data was collected by review of files of women with obstetric complications which were collected from the four wards (labour ward, high dependant ward, ICU ward and postnatal). File numbers were written on small pieces of paper, then the pieces of papers were mixed together and then half the number of pieces of papers was selected randomly each day. Qualitative data was obtained through in depth interviews using semi-structured interview guide to explore means of communication during the referral process. Data generated were analysed using univariate statistics when summarizing background characteristics. Qualitative data were analysed by using content analysis framework. The study was conducted in a one month period from 5st April to 23rd May. Results: A total of 426 records of referred women were reviewed.95.8% came from public health facilities in which73.2% were referred from regional hospitals.Most documented reasons to refer women were hospital related factors 62%, among which theatre busy had 25.1%, unavailability of blood 11.3% and lack of equipment and supplies 10.3%. Late referrals (after two hours) were observed in60.3% of women. In-depth interviews indicated barriers in the referral process with the most commonly identified including:- use and non-use of phones before referral, unsatisfactory referral form documentation and inadequate feedback mechanisms. Conclusion: The study demonstrates lack of both human and non-human resources required for provision of health care services, and identifies high proportion of late referrals influenced by significant deficiencies in referral process. Recommendations: These findings calls for the undivided attention of stakeholders in enhancing effectiveness of referral system by strengthening peripheral facilities and creating sustainable coordination between all levels of the referral system.