Effectiveness of Maternal Referral System in Tanzania: A Mixed Method Study

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Mbekenga This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1799859/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Poor accessibility of emergency obstetric care services contributes to severe morbidity and high maternal mortality. Variations in the capacity of providing Emergency obstetric care by different levels of public health facilities highlights the fundamental role of maternal referral system. There has being no significant changes in the maternal mortality for the past 15 years despite the feasibility of interventions within the limited resources hospital settings. There is still a paucity of evidence on the effectiveness of the obstetric referral process in reducing maternal mortality. This study was conducted to determine referral reasons, referral delays and communication barriers influencing referrals of women with obstetric complications in order to evaluate the effectiveness of the maternal referral system. Methods: A descriptive cross-sectional design employing mixed methods approach was used to evaluate effectiveness of the maternal referral system. A 7 weeks prospective study was conducted at Muhimbili National Hospital. Quantitative data were collected through reviewing referral slips of 426 women referred from various health facilities due to obstetric complications in the peripartum period and admitted in the labour ward, postnatal ward, ICU and high dependant ward. Analysis was done using SPSS. Qualitative data was collected using 9 semi-structured in-depth interviews with nurse-midwives and obstetricians who were selected purposively, and data was analysed with qualitative content analysis. Results: A total of 426 records of referred women with obstetric complications were reviewed. Most documented reasons for referral were hospital based (62%), which included theatre being busy (25.1%), unavailability of blood (11.3%) and lack of equipment and inadequate supplies (10.3%). 60.3% accounted for delayed referrals. The study identified referral-receiver communication barriers which include inconsistent use of phones before referral, unsatisfactory referral form documentation and inadequate feedback mechanism. Conclusion: The study demonstrates lack of both human and non-human resources required for provision of health care services in the referring facilities. It identifies high proportion of late referrals and deficiencies in the referral process which illustrate ineffective referral system. Obstetric referral maternal referral system reasons for referral referral delays referral communication Figures Figure 1 Figure 2 Background Tanzania health system is decentralized and assumes a pyramid structure which reflects the referral pathway from primary level to tertiary level. Linking different levels of health care has been regarded as an important element of primary health care(1). Ability of different levels of health facilities to provide Emergency Obstetric services vary tremendously with some being Comprehensive Emergency Obstetric Care(CEmOC) facilities while others function at or less than Basic Emergency Obstetric Care level (BEmOC) (2). A well-functioning referral system is considered to be an essential domain of successful Safe Motherhood programmes (3). Worldwide 287,000 women die because of complications arising due to pregnancy and childbirth, whereby Sub-Saharan Africa accounts for about half of these deaths(4). According to a national survey, Tanzania has a maternal mortality ratio of 556 per 100,000 live births. Many of these deaths are due to direct and indirect obstetric complications hence remain a major public health concern(5). World Health Organization estimates that between 88 and 98% of undesirable occurrence of maternal deaths can be prevented with timely and adequate accessibility to emergency obstetric care through an effective referral system (6). Obstetric referral system is a crucial component of the health care system in providing access to emergency obstetric care when complications arise (7). Estimates shows that 15% of all pregnant women develop pregnancy and childbirth related complications which require access to advanced care (8). In these circumstances, most life threatening obstetric complications occur during delivery or immediately after delivery (9). Among the three components of delays model developed by Thaddeus and Maine, one is the delay in receiving adequate care at a health facility (10). Here the referral system failures have been identified as a main contributing factor to substandard care. A study by (11) showed that poor connections between different levels of the referral system are an integral part of an ineffective referral system in health care provision. Delays in transfer of women who get complications within the health care system leads to many women arrive at an Emergency Obstetric Care (EmOC) facility in critical condition (12). In a study which looked into delays in receiving obstetric care and poor maternal outcomes showed that 25.7% of delays were related to quality of medical care which reflects ineffective referral system, whereby frequency of delay contributed to 84.1% of maternal mortality (10). Promising referral linkages within the referral system which enhances accessibility to advanced health services within a continuum of care have shown a positive outcome on maternal health. Hence effectiveness of the referral system at all levels of health care facilities plays a great role in preventing adverse outcomes of pregnancy and childbirth (2). However even with the feasibility of interventions within the limited resources hospital settings, most maternal deaths in Tanzania occur after women have had contact with health care facilities (13), making referral systems a critical domain for the survival of such women. Current levels of maternal deaths are still unacceptably high for Tanzania to contribute significantly to achieving Sustainable Development Goal 3; the referral system is still facing a significant number of barriers in terms of its functioning. The study aimed to provide information about the current referral system, which would offer a better understanding of what really happens on the ground when things are beyond the expected norms within the hospital setting thus informing policy makers to act accordingly. There is still a paucity of evidence on the effectiveness of the obstetric referral process in reducing maternal mortality, in particular at MNH and general in Dar es Salaam. Therefore this study aimed to determine referral reasons, referral delays and communication barriers in order to evaluate the effectiveness of the obstetric referral system. Methods Study design A descriptive cross sectional design employing both qualitative and quantitative approaches was carried and involved the review of files of women referred due to obstetric complications and in-depth interview of healthcare providers during the study period Study setting The study was conducted in Dar-es-Salaam region at the Maternity block of Muhimbili National Hospital (MNH). Dar es Salaam is among the highly populated cities in Tanzania located along the coast of Indian Ocean, it has an approximate population of 4 million people with three districts namely Ilala, Temeke and Kinondoni. Muhimbili National Hospital serves as a tertiary level health facility and it is also a teaching hospital for the Muhimbili University of Health and Allied Sciences (MUHAS). The maternity block receives about 600 maternal referrals per month from three Regional hospitals in Dar es Salaam namely Amana, Temeke and Mwananyamala, including other hospitals. . Study population Quantitatively, study participants were women referred during the peripartum period due to obstetric complications and admitted in the labour ward, high dependent ward, Intensive Care Unit (ICU) ward and postnatal ward. The study population for the qualitative part of the study included health care providers (nurse-midwives and obstetricians) working at the Maternity block. Inclusion Criteria For quantitative part All women referred during the peripartum period due to obstetric complications and admitted at labour ward, high dependent ward, ICU ward and postnatal ward For qualitative part Nurse - midwives Obstetricians Exclusion Criteria For quantitative part Women with gestation age of less than 28 weeks (Women of gestation age less than 28 weeks were excluded because the pregnancies have not reached viability and hence are considered as abortion, whereby my study focused on women who are in the peripartum period.) Women with self-referral For qualitative part Nurse – midwives and obstetricians with less than 3 years of experience Sample Size Quantitatively, the sample size was estimated by using the following formula (Naing, Winn, & Rusli, 2006). Adjusted sample size was 426 Whereby; N=Estimated minimum sample size Z=Standard normal deviate set at 1.96(corresponding to the 95% confidence level) P=proportion=50% (Since the proportion of peripartum referral is unknown, it was set at 50% in order to observe the minimum sample size) E=Acceptable margin of error (5%) Qualitatively, the researcher interviewed 9 health care providers: - (7 nurse - midwives and 2 doctors), with the sample size being determined by reaching of data saturation point. Study duration The study was conducted for a period of 7 weeks, from 5 th April to 23 rd May, 2017. Sampling technique Quantitatively, simple random sampling using lottery method was used, whereby files of women with obstetric complications were collected from the four wards (labour ward, high dependant ward, ICU ward and postnatal). Selection was based on the available files forming a sampling frame. 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 were selected randomly each day. Qualitatively, purposive sampling was used to select key informants who were considered to be knowledgeable and could best contribute to the information needs of the study. Data Collection Data were collected through review of patients’ files whereby information concerning socio-demographic characteristics such as age, education level, occupation, marital status, parity, gestation age, payment category, type of referral, presence of referral form, time of admission at MNH, referral diagnosis, reasons for referral, time of referral and working diagnosis at MNH was obtained using data abstraction form. Information concerning communication and feedback system was obtained qualitatively by conducting face to face individual in depth interviews using semi-structured interview guide. The guide consisted of questions aiming at exploring informant’s experience on means of communication during the obstetric referral process. The principal researcher together with the research assistant collected data and conducted all interviews that were audio-taped after obtaining consent from participants. Field notes were written during and immediately after the interviews. Pilot A pilot study was done to women with obstetric complications referred to Mwananyamala hospital prior to data collection by abstracting numerous patient records so as to test the data abstraction form. Mwananyamala hospital was considered to have close settings as those of MNH. Results of the pilot study were used to ensure clarity and understanding of questions to modify content and wording of the data abstraction form. Pilot study results are not included in the study results. Validity and Reliability For quantitative study Validity The data abstraction form was reviewed by an expert midwife; obstetrician and statistician to check for content validity of the tool which was achieved by evaluating each question and provide opinion on how well answers the research objective. Their opinions were compared and analyzed to determine the degree of content validity. Reliability Two abstractors collected data from the same file. A Cohen’s kappa (Kappa) rating was used to measure reliability, with the minimum acceptable level of 80% and preferably 95% For qualitative study Trustworthiness Credibility was achieved by triangulation of methods. That is using both quantitative and qualitative methods to ensure richness of the data gathered. Data triangulation was used during data collection by using multiple data sources which was achieved by going through patients’ files; interviewing health care providers’ of different professions and different cadres about the same topic. Member checking was done throughout the data collection process, during the conversations to confirm the accuracy of the investigator’s interpretations. To ensure dependability the same researcher was used to conduct the interview and asked the same questions in the same order, using an interview guide to ensure consistency during data collection and questioned the same areas for all participants. Questions were re-phrased and modified as the researcher continued to collect data so as to make sure that participants understood the information they were required to give. Transferability was achieved through detailed description of the characteristics of study participants, study setting and study methods, so that a reader can compare them to a similar setting that they are more familiar with and apply the research results. Confirmability was achieved by describing data collection, analysis, and presentation methods to create an audit trail and by retaining study data and making them available for use by another researcher in order to be able to verify the study when presented with the same data. Training of Research Assistants Prior to data collection a two days training of the research assistants was conducted by the principal researcher on how to obtain informed consent from the informants, to retrieve data from the patient’s files, to fill the data abstraction form and how to collect data consistently to avoid biases and errors so as to come up with clean data. Data Management Control of data quality was achieved through training of research assistants on standardized data collection tool. Data abstraction forms were reviewed daily in the field by the investigators. All incomplete and missing data were identified and rectified by the researcher and errors were corrected at the study site, by daily reviewing of data abstraction forms and filling of missing information. Data processing and analysis Quantitatively collected data was entered and cleaned to remove inconsistencies and out-of-range values. Data was analysed using statistical software (SPSS software version 21). Univariate analysis was performed to summarize background characteristics using frequency tables. All categorical variables such as marital status, employment status, etc. were summarized using proportions. Qualitatively, field notes from the interviews on the health care provider’s experiences on communication and feedback system in maternal referral system were read several times to obtain a sense of the wholeness and audio- taped information was transcribed verbatim and later translated into English to facilitate analysis by the research team. Qualitative content analysis was used to analyze the data. Transcripts were read several times to obtain a sense of wholeness and familiarize with the data. The texts containing information about the participants’ experiences on communication and feedback system were selected into ‘meaning units’ then condensed meaning units were obtained from the original meaning units. The condensed meaning units were then abstracted and labeled with codes. The codes were later grouped into categories reflecting the content of the text then similar categories were organized and formulated a theme. Quantitative data were presented using tables and figures of relevant variables while Qualitative data were presented in terms of themes with backup of participants quotes. Results Background characteristics Table 1 shows the socio-demographic characteristics of the referred patients. A total of 426 records of women referred were reviewed. 408 (95.8%) came from public health facilities, of these 73.2% were from regional referral hospitals.The age range between 20 and 34 years accounted for 312 (73.2%) of the referrals. Majority of the women, 414 (97.2%), were married. Almost two third of the women 269 (63.1%) had some primary education. By occupation, half of the women, 214 (50.2%), were unemployed. 153 (35.9%) of referred women were nulliparous and gestation age of 37-44weeks accounted for 264 (62.0%) of the referrals. Table 1: Background characteristics of study participants, MNH (n=426) Background characteristic Number (%) Source of the sample Public facilities Private facilities Age group ( years) 15 – 19 20 – 24 25 – 29 30 – 34 35+ Current marital status Not married* Married** Education status No formal Some primary Some secondary Above secondary Employment status Unemployed Employed Parity 0 1 2+ Gestation age (Weeks) 28 – 36 37 – 44 423 (99.3) 3 (0.7) 53 (12.4) 106 (24.9) 113 (26.5) 93 (21.8) 61 (14.3) 12 (2.8) 414 (97.2) 32 (7.5) 269 (63.1) 112 (26.3) 13 (3.1) 214 (50.2) 212 (49.8) 153 (35.9) 121 (28.4) 152 (35.7) 162 (38.0) 264 (62.0) * Widow, Divorce, Separate; ** Married or Cohabiting Reasons for referrals Most documented reasons to refer women based on hospital factors, 265 (62%), among which theatre being busy accounted for (25.1%), followed by unavailability of blood (11.3%) and lack of equipment and inadequate supplies (10.3%). Foetal-based reasons included premature care (20.4%) and neonatal care (1.2%). Obstetric reasons were only (2.6%) of the referred cases while other reasons (11%) included further management and in (2.8%) of the referrals the reasons where not documented. (This information can be found in figure 1) Time since decision to refer and actual admission at MNH Referral within two hours accounted for only 29 (6.8%) of the referred women whereas 257 (60.3%) were referred after 2 hours. Mean time among referred women was 4.9 (SD=3.1) hours. Among women referred early, the average time was 1.3 (SD=0.4) hours as compared to 5.3 (SD=3.0) hours for women referred late. However, 140 (33%) of the referred women had undocumented duration of time. (This information can be found in figure 2) Experiences on means of communication Health care providers working at the maternity block in Muhimbili national hospital were interviewed. From analysis of the data a main theme “Inadequate connection between different levels of health facilities” emerged that reflected the health care provider’s experiences of obstetric referral process. The theme included 3 categories: - (1) Use and non-use of phones before referral (2) Unsatisfactory referral form documentation (3) Inadequate feedback mechanism Inadequate connection between different levels of health facilities Use and non-use of phones before referral Health care providers interviewed explained that there is inconsistent and poor information exchange between health facilities, as despite a mobile phone being available for communication but it’s only one and is placed in one ward. Moreover some of other peripheral health facilities do not have the phones for communication and still even with those facilities with phones not all of them make calls before they refer the patients. “For now the communications are done through mobile phone which is in the labor ward, others make phone calls before referring the mothers and others just refer without making any phone calls. Not all referring health facilities make phone calls”. (Nurse-midwife, P1) Health Care Providers (HCPs) described how the lack of advance notice from referring health facilities makes it difficult for hospital staff to make early preparations adequately. “A patient can come intubated, very sick. She arrives and you have other stuffs, you start to run here and there so information before patient’s arrival is very important because of preparation”. (Nurse-midwife, P5) Unsatisfactory referral form documentation Health care providers interviewed reported that referred patients are accompanied with referral notes which should facilitate communication about the patient’s condition but the referral forms have no enough information to help in the patient’s management and hence hinders continuation of patients care. “………………..No documentation of what was done as primary management to the patient. So when the patient arrives here you cannot continue with management from where they ended you have to start afresh” . (Obstetrician, P6) Another health care provider said “............. referral forms don’t have information to help in patient’s management. Below the form you will find the name and number of the referring doctor but for my experience most of the times you find it’s a wrong number”. (Obstetrician, P9) Inadequate feedback mechanisms Informants explained that there is no feedback given to referring health facilities instead only complaints are being given when things have not being done appropriately or as expected. Immediate feedback given through phone calls depends on the initiative of individual providers, whereby during patients’ admission they can call and inquire about stuffs which have not being done as required but this is not done on a regular basis. “No, we don’t give any feedback. few times we can call to complain or to ask but from there if a patient dies or recovers it’s not common to give feedback”. (Obstetrician, P9) Other informants also explained the inconsistent use of forms for giving feedback. “For almost one month now we give feedback through forms, but they are not yet being used effectively, emphasis on their use has not being made”. (Nurse-midwife, P2) Discussion Study results obtained have shown that the referral system is still facing a considerable number of challenges and hence not implemented as required. Results from this study indicate that hospitals are not able to manage most of the obstetric complications due to hospital related reasons which accounted for more than 60% of all referral reasons, more than a quarter pointing to the theatre being busy, more than 10%each stating of unavailability of blood and lack of equipment and supplies (10.3%) and others. Likewise a study by( 14 ) showed that most hospitals were not capable of managing obstetric emergencies due to lack of resources/supplies, and hence questioned the performance of hospitals which provide CEmOC. Similarities of the findings may be due to the fact that both settings are in developing countries in which most public hospitals that are supposed to offer EmOC are not able to function at that level. More than half (60%) of women reached MNH after two hours since the decision to refer them was made. These results signify that lives of most women could have been lost if they were referred due to severe Post-Partum Haemorrhage (PPH) since this complication is well known to cause immediate death of women in less than an hour. Delay is a lethal enemy to women with obstetric complications hence time is a vital component when dealing with emergency conditions in which rescuing two lives is the outmost goal. A study done by( 15 ) showed that maternal referral system decreased the risk of death among women who had obstetric complications by relating to whether proper care was received within two hours or not in those women who had haemorrhagic complications. Standards portrays that a patient is supposed to be referred immediately after the decision is made. Although this study did not look into the causes of delays but studies done elsewhere indicated that reasons for delay include lack of fuel for ambulances, absence of escorting nurse, presence of one ambulance hence the driver has to wait for all expected referrals so that they can all be transferred at once( 16 ). Qualitative findings of the study on assessment of obstetric referral process from the experiences of healthcare providers working in a tertiary level hospital offer extra proof about the barriers which impede effectiveness of the referral system. Non-use of mobile phones for exchanging information, unsatisfactory referral form documentation and inadequate feedback mechanisms all contribute to inadequate linkage between different levels of health facilities. Study results reveal that there is inconsistency in information exchange before referral of patients as illustrated by the non-use of phones by the referring health facilities despite their availability. Communication aims at calling for transportation, seeking advice and providing a room for the receiving facility to make early preparations for the emergency, making appropriate communication vital. These findings coincide with a study done by( 17 ) which explored referral system links between lower and higher level facilities. It showed that even with the presence of phones still the referring facilities were not calling the receiving facility each time they wanted to refer patients. This study has shown that the quality of referral forms remains to be questionable in a sense that they do not offer adequate information to facilitate patient’s management hence act as a barrier in continuation of care. During the interviews several health care providers reported that due to poor documentation of the referral forms it makes them unaware of what has being done to the patient and hence have to start giving care from the beginning. Results of this study were consistency with the study done by( 18 ) which showed that at one point in time improper documentation can lead to treatment repetition. This finding is different from our study whereby all referred patients were accompanied with referral letters, and this is due to the fact that our study didn’t focus on self referrals which according to the established rules they could be accepted at the receiving facility without referral forms if there payment category is either by health insurance or cash. Another unique finding revealed from this study is the lack of standard organization for giving feedback. Feedback provides a means through which challenges facing maternal referral system can be addressed by providing an opportunity for evaluation. Similar to our findings, lack of feedback has been noted to affect the referral process and undermine proper management of patients( 11 ). High level facilities are obligated to keep records of management and outcomes of all patients referred and give recommendations to the referring facilities so as to improve patients care by reducing overcrowding of patients who are critically ill. Referrals can be reasonably accepted if the referral facilities provide quality care. The goal of establishing a referral system was to deliver best medical care by skilled personnel timely. The current referral system is more of a transfer system rather than referral system due to the influence of referral system barriers which hinders smooth delivery of health services. There is a significant difference between the referral pyramid found in policy documents and the realities women face when they try to access maternal care especially in developing countries. The effectiveness of obstetric care at referral levels need to be ascertained supervised and enhanced. Further research Further research needs to be conducted at lower level facilities to assess barriers affecting the referral system, as this study focused only on a tertiary level facility. Conclusion The study demonstrates lack of both human and non-human resources required for provision of health care services in the referring facilities, and identifies high proportion of late referrals influenced by significant deficiencies in referral process. Abbreviations BEmOC Basic Emergency Obstetric Care CEmOC Comprehensive Emergency Obstetric Care EmOC Emergency Obstetric Care ICU Intensive Care Unit MNH Muhimbili National Hospital MUHAS Muhimbili University of Health and Allied Sciences PPH Postpartum Haemorrhage SPSS Statistical Package for Social Sciences TDHS Tanzania Demographic and Health Survey HCP Health Care Providers Declarations Ethics approval and consent to participate Ethical approval to conduct the study was obtained from the MUHAS Institutional Review Board # IX/75 and permission to collect data was obtained from Participants were informed of study procedures; those who agreed to participate in the study were asked to complete a written informed consent form. One copy of the signed consent form remained with the researcher, and a second copy was given to the study participant. The study was conducted in accordance with the Declaration of Helsinki. Consent for publication Not applicable Availability of data and materials The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Iam not able to submit data to a repository because informed consent to share data publicly was not obtained from the study participants and also approval from the Institutional Review Board was also not obtained. Competing interests The authors declare that they have no competing interests Funding The design of the study, collection, analysis, interpretation of data and in writing the manuscript was funded by the author. Author’s contributions Contributions MAB conceptualized the idea of the study, participated in its design, collected, analyzed and interpreted the data and wrote the first draft of the manuscript. SL, DM and CM assisted to draft, review and edit the manuscript. All authors revised and approved the final manuscript for publication. Acknowledgements We are grateful to all of those with whom we have had the pleasure to work with during the study. We specifically thank the study participants Authors’ information Department of Reproductive and Child Health, Hubert Kairuki Memorial University, 70 Chwaku Street-Mikocheni, P.O. Box 65300, Dar es Salaam, Tanzania Monica Alex Bugomola Department of Community Health Nursing , Muhimbili University of Health and Allied Sciences, P.O. Box 65004, Dar es Salaam, Tanzania Sebalda Leshabari School of Nursing, Muhimbili University of Health and Allied Sciences, P.O. Box 65004, Dar es Salaam, Tanzania Dickson Mkoka Department of Reproductive and Child Health, Hubert Kairuki Memorial University, 70 Chwaku Street-Mikocheni, P.O. Box 65300, Dar es Salaam, Tanzania Columba Mbekenga References Jahn A, Brouwere VD. Referral in pregnancy and childbirth: Concepts and strategies.:18. Hussein J, Kanguru L, Astin M, Munjanja S. 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Quality improvement in emergency obstetric referrals: qualitative study of provider perspectives in Assin North District, Ghana. BMJ Open. 2014 May 15;4(5):e005052. Gupta M, Mavalankar D, Trivedi P. A Study of Referral System for EmOC in Gujarat. (2009):50. Agarwal R, Chawla D, Sharma M, Nagaranjan S, Dalpath SK, Gupta R, et al. Improving quality of care during childbirth in primary health centres: a stepped-wedge cluster-randomised trial in India. BMJ Glob Health. 2018 Oct 1;3(5):e000907. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1799859","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":119298119,"identity":"ee81bdcc-15d4-4a4b-b4fa-fb97cac96089","order_by":0,"name":"Monica Alex Bugomola","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+klEQVRIiWNgGAWjYJCCA0AsA2ZJGNgAScbGA8Ro4QGzLCrSQFoaCGphgGupOHMYbghOoNvee/DAjxo7Hn6J7MQPN9vO261tPwy0pcYmGpcWszPnEg72HEvmkew5u1lyZtvt5G1nEoFajqXlNuDSciPH4DADGzOPwfHeDdKSQC1mB4BaGBsOE9Dyr57H/jDv5t9/284lm51/SIQWxrbDPAbsvdskJM4csDO7QciWM2cMDvb2HeeROHN2m4VERXKC2Q2gLQn4/HK8x/jDj2/VcvwzcjffkDCwszc7n/7wwYcaG5xaMEAiWGUCscpBwJ4UxaNgFIyCUTAyAABy4Wim75FiyAAAAABJRU5ErkJggg==","orcid":"","institution":"Hubert Kairuki Memorial University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Monica","middleName":"Alex","lastName":"Bugomola","suffix":""},{"id":119298120,"identity":"fd80fcbe-7b2b-4adf-b62e-8e5b21cb588f","order_by":1,"name":"Sebalda Leshabari","email":"","orcid":"","institution":"Muhimbili University of Health and Allied Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sebalda","middleName":"","lastName":"Leshabari","suffix":""},{"id":119298121,"identity":"885fdf8d-ef78-4e3e-bb70-487be6c5cd80","order_by":2,"name":"Dickson Mkoka","email":"","orcid":"","institution":"Muhimbili University of Health and Allied Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Dickson","middleName":"","lastName":"Mkoka","suffix":""},{"id":119298124,"identity":"4b972c79-d67b-4ea0-b6f4-dd9b29bc5168","order_by":3,"name":"Columba K. Mbekenga","email":"","orcid":"","institution":"Hubert Kairuki Memorial University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Columba","middleName":"K.","lastName":"Mbekenga","suffix":""}],"badges":[],"createdAt":"2022-06-27 12:44:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1799859/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1799859/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":23911468,"identity":"a32229d0-3749-48e0-9967-9beddba19499","added_by":"auto","created_at":"2022-07-15 16:45:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":16807,"visible":true,"origin":"","legend":"\u003cp\u003eDocumented reasons for referring women\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-1799859/v1/78167bb33323e57227debd09.png"},{"id":23911469,"identity":"0aa51af1-9443-4ab9-813a-2babfc283e4b","added_by":"auto","created_at":"2022-07-15 16:45:18","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":18959,"visible":true,"origin":"","legend":"\u003cp\u003eProportion of women according to referral time\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-1799859/v1/3f839f1e051ab01e550ab61b.png"},{"id":37964635,"identity":"a1836512-5e78-4a8b-b9da-68f0338048d3","added_by":"auto","created_at":"2023-06-03 23:14:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":585734,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1799859/v1/cb3080bb-61ef-4c0b-8a1a-a4b561987dba.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectiveness of Maternal Referral System in Tanzania: A Mixed Method Study","fulltext":[{"header":"Background","content":"\u003cp\u003eTanzania health system is decentralized and assumes a pyramid structure which reflects the referral pathway from primary level to tertiary level. Linking \u0026nbsp;different levels of health care has been regarded as an important element of primary health care(1). Ability of different levels of health facilities to provide Emergency Obstetric services vary tremendously with some being Comprehensive Emergency Obstetric Care(CEmOC) facilities while others function at or less than Basic Emergency Obstetric Care level (BEmOC)\u0026nbsp;(2).\u0026nbsp;A well-functioning referral system is considered to be an essential domain of successful Safe Motherhood programmes\u0026nbsp;(3).\u003c/p\u003e\n\u003cp\u003eWorldwide 287,000 women die because of complications arising due to pregnancy and childbirth, whereby Sub-Saharan Africa accounts for about half of these deaths(4). According to a national survey, Tanzania has a maternal mortality ratio of 556 per 100,000 live births. Many of these deaths are due to direct and indirect obstetric complications hence remain a major public health concern(5). World Health Organization estimates that between \u0026nbsp;88 and 98% of undesirable occurrence of maternal deaths can be prevented with timely and adequate accessibility to emergency obstetric care through an effective referral system\u0026nbsp;(6).\u003c/p\u003e\n\u003cp\u003eObstetric referral system is a crucial component of the health care system \u0026nbsp;in providing access to emergency obstetric care when complications arise\u0026nbsp;(7). \u0026nbsp;Estimates shows that 15% of all pregnant women develop pregnancy and childbirth related complications which require access to advanced care\u0026nbsp;(8). In these circumstances, most life threatening obstetric complications occur during delivery or immediately after delivery\u0026nbsp;(9).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong the three components of delays model developed by Thaddeus and Maine, one is the delay in receiving adequate care at a \u0026nbsp;health facility\u0026nbsp;(10). Here the \u0026nbsp;referral system failures have been identified as a main contributing factor to substandard care.\u0026nbsp;A study by\u0026nbsp;(11)\u0026nbsp;showed that poor connections between different levels of the referral system are an integral part of an ineffective referral system in health care provision. Delays in transfer of women who get complications within the health care system leads to many women arrive at an Emergency Obstetric Care (EmOC) facility in critical condition\u0026nbsp;(12). In a study which looked into delays in receiving obstetric\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ecare and poor\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ematernal outcomes showed that 25.7% of delays were related to quality of medical care which reflects ineffective referral system, whereby frequency of delay contributed to 84.1% of maternal mortality\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e(10).\u003c/p\u003e\n\u003cp\u003ePromising \u0026nbsp;referral \u0026nbsp;linkages within the referral system which enhances accessibility to advanced health services within a continuum of care have shown a positive outcome on maternal health. Hence effectiveness of the referral system at all levels of health care facilities plays a great role in preventing adverse outcomes of pregnancy and childbirth\u0026nbsp;(2). However even with the feasibility of interventions within the limited resources hospital settings, most maternal deaths in Tanzania occur after women have had contact with health care facilities\u0026nbsp;(13), making referral systems a critical domain for the survival of such women.\u003c/p\u003e\n\u003cp\u003eCurrent levels of maternal deaths are still unacceptably high for Tanzania to contribute significantly to achieving Sustainable Development Goal 3; the referral system is still facing a significant number of barriers in terms of its functioning.\u0026nbsp;The study aimed to provide information about the current referral system, which would\u0026nbsp;offer a better understanding of what really happens on the ground when things are beyond the expected norms within the hospital setting thus informing policy makers to act accordingly.\u003c/p\u003e\n\u003cp\u003eThere is still a paucity of evidence on the effectiveness of the obstetric referral process in reducing maternal mortality, in particular at MNH and general in Dar es Salaam. Therefore this study aimed to determine referral reasons, referral delays and communication barriers in order to evaluate the effectiveness of the obstetric referral system.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy design\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA descriptive cross sectional design employing both qualitative and quantitative approaches was carried and involved the review of files of women referred due to obstetric complications and in-depth interview of healthcare providers during the study period\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy setting\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in Dar-es-Salaam \u0026nbsp;region at the Maternity block of Muhimbili National Hospital (MNH). Dar es Salaam is among the highly populated cities in Tanzania located along the coast of Indian Ocean, it\u0026nbsp;has an approximate population of 4 million people with three districts namely Ilala, Temeke and Kinondoni. Muhimbili National Hospital serves as a tertiary level health facility and it is also a teaching hospital for the Muhimbili University of Health and Allied Sciences (MUHAS). The maternity block receives about\u0026nbsp;600 maternal referrals per month\u0026nbsp;from three Regional hospitals in Dar es Salaam namely Amana, Temeke and Mwananyamala, including other hospitals.\u003c/p\u003e\n\u003cp\u003e.\u003cstrong\u003e\u003cem\u003eStudy population\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitatively, study participants were women\u0026nbsp;referred during the peripartum period due to\u0026nbsp;obstetric complications and\u0026nbsp;admitted in the labour ward,\u0026nbsp;high dependent ward, Intensive Care Unit (ICU) ward\u0026nbsp;and postnatal ward. The study population for the qualitative part of the study included health\u0026nbsp;care providers (nurse-midwives and obstetricians) working at the Maternity block.\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInclusion Criteria\u003c/p\u003e\n\u003cp\u003eFor quantitative part\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eAll women referred during the peripartum period due to\u0026nbsp;obstetric complications and\u0026nbsp;admitted at labour ward,\u0026nbsp;high dependent ward, \u0026nbsp;ICU ward\u0026nbsp;and postnatal ward\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eFor qualitative part\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eNurse - midwives\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eObstetricians\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eExclusion Criteria\u003c/p\u003e\n\u003cp\u003eFor quantitative part\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eWomen with gestation age of less than 28 weeks (Women of gestation age less than 28 weeks were excluded because the pregnancies have not reached viability and hence are considered as abortion, whereby my study focused on women who are in the peripartum period.)\u003c/li\u003e\n \u003cli\u003eWomen with self-referral\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eFor qualitative part\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eNurse \u0026ndash; midwives and obstetricians with less than 3 years of experience\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eSample Size\u003c/p\u003e\n\u003cp\u003eQuantitatively, the sample size was estimated by using the following formula (Naing, Winn, \u0026amp; Rusli, 2006).\u003c/p\u003e\n\u003cp\u003e\u003cimg 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G+eekiTB6+srHMdBFEW4vb3FarWC53nIsgyz2ezELSb6g3NYn9DV1dXW8ru7OziOAwBYLpfFt4C9Xg/z+fzo7SNqwsD6hB4fH9Hr9WrLbNtmD4rOFgPrk0mSBIvFouhBleXDv7Jer1eswVoul7As6yTtJKrDhaMfXJZlEEIU9y3Lqu1BRVGE5XK5Ma/lOA6WyyU0TQOA2sWnRKfCSXciUgaHhESkDAYWESmDgUVEymBgEZEyGFhEpAwGFhEpg4FFRMpgYBGRMhhYRKQMBhYRKYOBRUTKYGARkTIYWESkDAYWESmDgUVEymBgEZEyGFhEpAwGFhEpg4FFRMpgYBGRMhhYRKQMBhYRKYOBRUTKYGARkTIYWB3KsgyaphW3IAgq5VEUVcqjKNr72EEQFPsZhrGz7m3Htm17o23bns+ubQ3DgKZpsG179xMhKmFgdUjXdUgpiz//Ph6PkSRJUe44DqSUsCwLUko4jrPXcfPwKR/b87zKNkII+L5fbDMYDCp1l481n8931hkEAYQQO9ulaRpubm4gpcRsNtvr+RDlGFhnwrIsCCFwfX198LEuLy8xGo2K+9+/f0eWZcX9PJj++eefSv2vr68bx1oulzuDCABGo1ERjnWiKMJgMEAYhphMJns9D6J1DKwz8vDwAAAHD5V0Xa/cf35+xu3tbXH/77//BgA8PT1Vtvvy5Uvlvud5rYXLYDCA7/t79xKJ6jCwzoiu6wjDEPP5vHYeKEmSyrxT3W19WBcEAXq9HkzTrNTjum4xDAyCAMPhsLJNFEXo9XqtPK/y/FjeTs5f0XswsM6M4zhwXXdjPgsATNMs5pyabuXQMQwD4/EYg8FgYw5rMpnAsqxiCLre81kul631hsrDSikl4jhuDGWibRhYZ2gymbQyn7VarYp5pel0WpnHyv8fhiHG43El0NocCuZ13dzcFPNqpmnCdV38+vWrtTroc2Bgnam6+az3DAkBIE3TjceEEJhMJnAcB2maYjqdFj2e6XRaOWaaphiPx9A0rbXnd3Fx0dqx6PNgYJ2p8nzWarUC8PYhYflY5X/zOaXy477vY7FYAMDGMctLIN6j3+8XAVxWtz6MaBsG1hnL57MO5XkefN8v7l9eXgJAZQ5psVig3+8fXFedfChYrm88Hle+uSTai6RO+b4vARS3OI43trEs603HtCyrcswwDDe2ieO4so3v+43HE0JUyvN9y4+FYVg5nhBi4zi7nifRLpqU7+znExGdGIeERKQMBhYRKYOBRUTKYGARkTIYWESkDAYWESmDgUVEyvh/zmTQxl9WlsEAAAAASUVORK5CYII=\"\u003e\u003c/p\u003e\n\u003cp\u003eAdjusted sample size was 426\u003c/p\u003e\n\u003cp\u003eWhereby;\u003c/p\u003e\n\u003cp\u003eN=Estimated minimum sample size\u003c/p\u003e\n\u003cp\u003eZ=Standard normal deviate set at 1.96(corresponding to the 95% confidence level)\u003c/p\u003e\n\u003cp\u003eP=proportion=50% (Since the proportion of peripartum referral is unknown, it was set at 50% in order to observe the minimum sample size)\u003c/p\u003e\n\u003cp\u003eE=Acceptable margin of error (5%)\u003c/p\u003e\n\u003cp\u003eQualitatively, the researcher interviewed 9 health care providers: - (7 nurse - midwives and 2 doctors), with the sample size being determined by reaching of data saturation point.\u003c/p\u003e\n\u003ch2\u003eStudy duration\u003c/h2\u003e\n\u003cp\u003eThe study was conducted for a period of \u0026nbsp;7 weeks, from 5\u003csup\u003eth\u003c/sup\u003e April to 23\u003csup\u003erd\u003c/sup\u003e May, 2017.\u003c/p\u003e\n\u003ch1\u003eSampling technique\u003c/h1\u003e\n\u003cp\u003eQuantitatively, simple random sampling using lottery method was used, whereby files of women with obstetric complications were collected from the four wards (labour ward, high dependant ward, ICU ward and postnatal). Selection was based on the available files forming a sampling frame. 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 were selected randomly each day.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eQualitatively, purposive sampling was used to select key informants who were considered to be knowledgeable and could best contribute to the information needs of the study.\u003c/p\u003e\n\u003ch1\u003eData Collection\u003c/h1\u003e\n\u003cp\u003eData were collected through\u0026nbsp;review of patients\u0026rsquo; files whereby information concerning socio-demographic characteristics such as age, education level, occupation, marital status, parity, gestation age,\u0026nbsp;payment category, type of referral, presence of referral form, time of admission at MNH, referral diagnosis, reasons for referral, time of referral and working diagnosis at MNH was obtained \u0026nbsp;using data abstraction form. Information concerning communication and feedback system was obtained qualitatively by conducting face to face individual in depth interviews using semi-structured interview guide. The guide consisted of questions aiming at exploring informant\u0026rsquo;s experience\u0026nbsp;on means of communication during the obstetric referral process. The principal researcher together with the research assistant collected data and conducted all interviews that were audio-taped after obtaining consent from participants. Field notes were written during and immediately after the interviews.\u003c/p\u003e\n\u003ch2\u003ePilot\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eA pilot study was done to women with obstetric complications referred to Mwananyamala hospital prior to data collection by abstracting numerous patient records so as to test the data abstraction form. Mwananyamala hospital was considered to have close settings as those of MNH. Results of the pilot study were used to ensure\u0026nbsp;clarity and understanding of questions to\u0026nbsp;modify content and wording of the data abstraction form. Pilot study results are not included in the study results.\u003c/p\u003e\n\u003ch1\u003eValidity and Reliability\u003c/h1\u003e\n\u003cp\u003eFor quantitative study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eValidity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data abstraction form was reviewed by an expert midwife; obstetrician and statistician to check for content validity of the tool which was achieved by evaluating each question and provide opinion on how well answers the research objective. Their opinions were compared and analyzed to determine the degree of content validity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReliability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo\u0026nbsp;abstractors collected data from the same file. A Cohen\u0026rsquo;s kappa (Kappa) rating was used to measure reliability, with the minimum acceptable level of 80% and preferably 95%\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor qualitative study\u003c/p\u003e\n\u003ch2\u003eTrustworthiness\u003c/h2\u003e\n\u003cp\u003eCredibility was achieved by triangulation of methods. That is using both quantitative and qualitative methods to ensure richness of the data gathered. Data triangulation was used during data collection by using multiple data sources which was achieved by going through patients\u0026rsquo; files; interviewing health care providers\u0026rsquo; of different professions and different cadres about the same topic.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMember checking was done throughout the data collection process, during the conversations to confirm the accuracy of the investigator\u0026rsquo;s interpretations.\u003c/p\u003e\n\u003cp\u003eTo ensure dependability the same researcher was used to conduct the interview and asked the same questions in the same order, using an interview guide to ensure consistency during data collection and questioned the same areas for all participants. Questions were re-phrased and modified as the researcher continued to collect data so as to make sure that participants understood the information they were required to give.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTransferability was achieved through detailed description of the characteristics of study participants, study setting and study methods, so that a reader can compare them to a similar setting that they are more familiar with and apply the research results.\u003c/p\u003e\n\u003cp\u003eConfirmability was achieved by describing data collection, analysis, and presentation methods to create an audit trail and by retaining study data and making them available for use by another researcher in order to be able to verify the study when presented with the same data.\u003c/p\u003e\n\u003ch2\u003eTraining of Research Assistants\u003c/h2\u003e\n\u003cp\u003ePrior to data collection a two days training of the research assistants was conducted by the principal researcher on how to obtain informed consent from the informants, to retrieve data from the patient\u0026rsquo;s files, to fill the data abstraction form and how to collect data consistently to avoid biases and errors so as to come up with clean data.\u003c/p\u003e\n\u003ch2\u003eData Management\u003c/h2\u003e\n\u003cp\u003eControl of data quality was achieved through training of research assistants on standardized data collection tool. Data abstraction forms were reviewed daily in the field by the investigators. All incomplete and missing data were identified and rectified by the researcher and errors were corrected\u0026nbsp;at the study site, by daily reviewing of data abstraction forms and filling of missing information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData processing and analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitatively collected data was entered and cleaned to remove inconsistencies and out-of-range values. Data was analysed using statistical software (SPSS software version 21). Univariate analysis was performed to summarize background characteristics using frequency tables. All categorical variables such as marital status, employment status, etc. were summarized using proportions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eQualitatively,\u0026nbsp;field notes from the interviews on the health care provider\u0026rsquo;s experiences on communication and feedback system in maternal referral system were read\u0026nbsp;several times to obtain a sense of the wholeness and audio- taped information was\u0026nbsp;transcribed verbatim and later translated into English to facilitate analysis by the research team. Qualitative content analysis was used to analyze the data. Transcripts were read several times to obtain a sense of wholeness and familiarize with the data. The texts containing information\u0026nbsp;about the participants\u0026rsquo; experiences\u0026nbsp;on communication and feedback system were selected into \u0026lsquo;meaning units\u0026rsquo; then condensed meaning units were obtained from the original meaning units. The condensed meaning units were then abstracted and labeled with codes. The codes were later grouped into categories reflecting the content of the text then\u0026nbsp;similar categories were organized and formulated a theme.\u003c/p\u003e\n\u003cp\u003eQuantitative data were presented using tables and figures of relevant variables while Qualitative data were presented in terms of themes with backup of participants quotes.\u003c/p\u003e"},{"header":"Results","content":"\u003ch1\u003eBackground characteristics\u003c/h1\u003e\n\u003cp\u003eTable 1 shows the socio-demographic characteristics of the referred patients. A total of 426 records of women referred were reviewed. 408 (95.8%) came from public health facilities, of these 73.2% were from regional referral hospitals.The age range between 20 and 34 years accounted for 312 (73.2%) of the referrals. Majority of the women, 414 (97.2%), were married. Almost two third of the women 269 (63.1%) had some primary education. By occupation, half of the women, 214 (50.2%), were unemployed. 153 (35.9%) of referred women were nulliparous and gestation age of 37-44weeks accounted for 264 (62.0%) of the referrals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Background characteristics of study participants, MNH (n=426)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"48.336594911937375%\"\u003e\n \u003cp\u003eBackground characteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"51.663405088062625%\"\u003e\n \u003cp\u003eNumber (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"48.336594911937375%\"\u003e\n \u003cp\u003e\u003cem\u003eSource of the sample\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePublic facilities\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePrivate facilities\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eAge group ( years)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e15 \u0026ndash; 19\u003c/p\u003e\n \u003cp\u003e20 \u0026ndash; 24\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e25 \u0026ndash; 29\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e30 \u0026ndash; 34\u003c/p\u003e\n \u003cp\u003e35+\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eCurrent marital status\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eNot married*\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMarried**\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eEducation status\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eNo formal\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSome primary\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eSome secondary\u003c/p\u003e\n \u003cp\u003eAbove secondary\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eEmployment status\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eUnemployed\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eParity\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2+\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eGestation age (Weeks)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e28 \u0026ndash; 36\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e37 \u0026ndash; 44\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"51.663405088062625%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e423 (99.3)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e3 (0.7)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e53 (12.4)\u003c/p\u003e\n \u003cp\u003e106 (24.9)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e113 (26.5)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e93 (21.8)\u003c/p\u003e\n \u003cp\u003e61 (14.3)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12 (2.8)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e414 (97.2)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e32 (7.5)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e269 (63.1)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e112 (26.3)\u003c/p\u003e\n \u003cp\u003e13 (3.1)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e214 (50.2)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e212 (49.8)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e153 (35.9)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e121 (28.4)\u003c/p\u003e\n \u003cp\u003e152 (35.7)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 162 (38.0)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 264 (62.0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e*\u003c/sup\u003e\u003cstrong\u003eWidow, Divorce, Separate; \u003csup\u003e**\u003c/sup\u003eMarried or Cohabiting\u003c/strong\u003e\u003c/p\u003e\n\u003ch2\u003eReasons for referrals\u003c/h2\u003e\n\u003cp\u003eMost documented reasons to refer women based on hospital factors, 265 (62%), among which theatre being busy accounted for (25.1%), followed by unavailability of blood (11.3%) and lack of equipment and inadequate supplies (10.3%). Foetal-based reasons included premature care (20.4%) and neonatal care (1.2%). Obstetric reasons were only (2.6%) of the referred cases while other reasons (11%) included further management and in (2.8%) of the referrals the reasons where not documented. (This information can be found in figure 1)\u003c/p\u003e\n\u003ch2\u003eTime since decision to refer and actual admission at MNH\u003c/h2\u003e\n\u003cp\u003eReferral within two hours accounted for only 29 (6.8%) of the referred women whereas 257 (60.3%) were referred after 2 hours. Mean time among referred women was 4.9 (SD=3.1) hours. Among women referred early, the average time was 1.3 (SD=0.4) hours as compared to 5.3 (SD=3.0) hours for women referred late. However, 140 (33%) of the referred women had undocumented duration of time. (This information can be found in figure 2)\u003c/p\u003e\n\u003ch2\u003eExperiences on means of communication\u003c/h2\u003e\n\u003cp\u003eHealth care providers working at the maternity block in Muhimbili national hospital were interviewed. From analysis of the data a main theme \u0026ldquo;Inadequate connection between different levels of health facilities\u0026rdquo; emerged that reflected the health care provider\u0026rsquo;s experiences of obstetric referral process. The theme included 3 categories: - (1) Use and non-use of phones before referral (2) Unsatisfactory referral form documentation (3) Inadequate feedback mechanism\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInadequate connection between different levels of health facilities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eUse and non-use of phones before referral\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHealth care providers interviewed explained that there is inconsistent and poor information exchange between health facilities, as despite a mobile phone being available for communication but it\u0026rsquo;s only one and is placed in one ward. Moreover some of other peripheral health facilities do not have the phones for communication and still even with those facilities with phones not all of them make calls before they refer the patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;For now the communications are done through mobile phone which is in the labor ward, others make phone calls before referring the mothers and others just refer without making any phone calls. Not all referring health facilities make phone calls\u0026rdquo;.\u0026nbsp;\u003c/em\u003e(Nurse-midwife, P1)\u003c/p\u003e\n\u003cp\u003eHealth Care Providers (HCPs) described how the lack of advance notice from referring health facilities makes it difficult for hospital staff to make early preparations adequately.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;A patient can come intubated, very sick. She arrives and you have other stuffs, you start to run here and there so information before patient\u0026rsquo;s arrival is very important because of preparation\u0026rdquo;.\u003c/em\u003e(Nurse-midwife, P5)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eUnsatisfactory referral form documentation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHealth care providers interviewed reported that referred patients are accompanied with referral notes which should facilitate communication about the patient\u0026rsquo;s condition but the referral forms have no enough information \u0026nbsp;to help in the patient\u0026rsquo;s management and hence hinders continuation of patients care.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;\u0026hellip;\u0026hellip;\u0026hellip;\u0026hellip;\u0026hellip;..No documentation of what was done as primary management to the patient. So when the patient arrives here you cannot continue with management from where they ended you have to start afresh\u0026rdquo;\u003c/em\u003e. (Obstetrician, P6)\u003c/p\u003e\n\u003cp\u003eAnother health care provider said\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;............. referral forms don\u0026rsquo;t have information to help in patient\u0026rsquo;s management. Below the form you will find the name and number of the referring doctor but for my experience most of the times you find it\u0026rsquo;s a wrong number\u0026rdquo;.\u0026nbsp;\u003c/em\u003e(Obstetrician, P9)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eInadequate feedback mechanisms\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eInformants explained that there is no feedback given to referring health facilities instead only complaints are being given when things have not being done appropriately or as expected. Immediate feedback given through phone calls depends on the initiative of individual providers,\u0026nbsp;whereby during patients\u0026rsquo; admission they can call and inquire about stuffs which have not being done as required but this is not done on a regular basis.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;No, we don\u0026rsquo;t give any feedback. few times we can call to complain or to ask but from there if a patient dies or recovers it\u0026rsquo;s not common to give feedback\u0026rdquo;.\u003c/em\u003e(Obstetrician, P9)\u003c/p\u003e\n\u003cp\u003eOther informants also explained the inconsistent use of forms for giving feedback.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;For almost one month now we give feedback through forms, but they are not yet being used effectively, emphasis on their use has not being made\u0026rdquo;. \u0026nbsp;\u003c/em\u003e(Nurse-midwife, P2)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eStudy results obtained have shown that the referral system is still facing a considerable number of challenges and hence not implemented as required.\u003c/p\u003e\n\u003cp\u003eResults from this study indicate that hospitals are not able to manage most of the obstetric complications due to hospital related reasons which accounted for more than 60% of all referral reasons, more than a quarter pointing to the theatre being busy, more than 10%each stating of unavailability of blood and lack of equipment and supplies (10.3%) and others. Likewise a study by(\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e) showed that most hospitals were not capable of managing obstetric emergencies due to lack of resources/supplies, and hence questioned the performance of hospitals which provide CEmOC. Similarities of the findings may be due to the fact that both settings are in developing countries in which most public hospitals that are supposed to offer EmOC are not able to function at that level.\u003c/p\u003e\n\u003cp\u003eMore than half (60%) of women reached MNH after two hours since the decision to refer them was made. These results signify that lives of most women could have been lost if they were referred due to severe Post-Partum Haemorrhage (PPH) since this complication is well known to cause immediate death of women in less than an hour. Delay is a lethal enemy to women with obstetric complications hence time is a vital component when dealing with emergency conditions in which rescuing two lives is the outmost goal. A study done by(\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e) showed that maternal referral system decreased the risk of death among women who had obstetric complications by relating to whether proper care was received within two hours or not in those women who had haemorrhagic complications.\u003c/p\u003e\n\u003cp\u003eStandards portrays that a patient is supposed to be referred immediately after the decision is made. Although this study did not look into the causes of delays but studies done elsewhere indicated that reasons for delay include lack of fuel for ambulances, absence of escorting nurse, presence of one ambulance hence the driver has to wait for all expected referrals so that they can all be transferred at once(\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eQualitative findings of the study on assessment of obstetric referral process from the experiences of healthcare providers working in a tertiary level hospital offer extra proof about the barriers which impede effectiveness of the referral system. Non-use of mobile phones for exchanging information, unsatisfactory referral form documentation and inadequate feedback mechanisms all contribute to inadequate linkage between different levels of health facilities.\u003c/p\u003e\n\u003cp\u003eStudy results reveal that there is inconsistency in information exchange before referral of patients as illustrated by the non-use of phones by the referring health facilities despite their availability. Communication aims at calling for transportation, seeking advice and providing a room for the receiving facility to make early preparations for the emergency, making appropriate communication vital. These findings coincide with a study done by(\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e) which explored referral system links between lower and higher level facilities. It showed that even with the presence of phones still the referring facilities were not calling the receiving facility each time they wanted to refer patients.\u003c/p\u003e\n\u003cp\u003eThis study has shown that the quality of referral forms remains to be questionable in a sense that they do not offer adequate information to facilitate patient\u0026rsquo;s management hence act as a barrier in continuation of care. During the interviews several health care providers reported that due to poor documentation of the referral forms it makes them unaware of what has being done to the patient and hence have to start giving care from the beginning. Results of this study were consistency with the study done by(\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e) which showed that at one point in time improper documentation can lead to treatment repetition. This finding is different from our study whereby all referred patients were accompanied with referral letters, and this is due to the fact that our study didn\u0026rsquo;t focus on self referrals which according to the established rules they could be accepted at the receiving facility without referral forms if there payment category is either by health insurance or cash.\u003c/p\u003e\n\u003cp\u003eAnother unique finding revealed from this study is the lack of standard organization for giving feedback. Feedback provides a means through which challenges facing maternal referral system can be addressed by providing an opportunity for evaluation. Similar to our findings, lack of feedback has been noted to affect the referral process and undermine proper management of patients(\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e). High level facilities are obligated to keep records of management and outcomes of all patients referred and give recommendations to the referring facilities so as to improve patients care by reducing overcrowding of patients who are critically ill.\u003c/p\u003e\n\u003cp\u003eReferrals can be reasonably accepted if the referral facilities provide quality care. The goal of establishing a referral system was to deliver best medical care by skilled personnel timely. The current referral system is more of a transfer system rather than referral system due to the influence of referral system barriers which hinders smooth delivery of health services. There is a significant difference between the referral pyramid found in policy documents and the realities women face when they try to access maternal care especially in developing countries. The effectiveness of obstetric care at referral levels need to be ascertained supervised and enhanced.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFurther research\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFurther research needs to be conducted at lower level facilities to assess barriers affecting the referral system, as this study focused only on a tertiary level facility.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study demonstrates lack of both human and non-human resources required for provision of health care services in the referring facilities, and identifies high proportion of late referrals influenced by significant deficiencies in referral process.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBEmOC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Basic Emergency Obstetric Care\u003c/p\u003e\n\u003cp\u003eCEmOC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Comprehensive Emergency Obstetric Care\u003c/p\u003e\n\u003cp\u003eEmOC \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Emergency Obstetric Care\u003c/p\u003e\n\u003cp\u003eICU\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Intensive Care Unit\u003c/p\u003e\n\u003cp\u003eMNH\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Muhimbili National Hospital\u003c/p\u003e\n\u003cp\u003eMUHAS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Muhimbili University of Health and Allied Sciences\u003c/p\u003e\n\u003cp\u003ePPH \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Postpartum Haemorrhage\u003c/p\u003e\n\u003cp\u003eSPSS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Statistical Package for Social Sciences\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTDHS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Tanzania Demographic and Health Survey\u003c/p\u003e\n\u003cp\u003eHCP \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Health Care Providers\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval to conduct the study was obtained from the\u0026nbsp;MUHAS Institutional Review Board\u0026nbsp;# IX/75 and permission to collect data was obtained from Participants were informed of study procedures; those who agreed to participate in the study were asked to complete a written informed consent form. One copy of the signed consent form remained with the researcher, and a second copy was given to the study participant. The study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request. Iam not able to submit data to a repository because informed consent to share data publicly was not obtained from the study participants and also approval from the Institutional Review Board was also not obtained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe design of the study, collection, analysis, interpretation of data and in writing the manuscript was funded by the author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003ch3\u003eContributions\u003c/h3\u003e\n\u003cp\u003eMAB conceptualized the idea of the study, participated in its design, collected, analyzed and interpreted the data and wrote the first draft of the manuscript.\u003c/p\u003e\n\u003cp\u003eSL, DM and CM assisted to draft, review and edit the manuscript. All authors revised and approved the final manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to all of those with whom we have had the pleasure to work with during the study. We specifically thank the study participants\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDepartment of Reproductive and Child Health, Hubert Kairuki Memorial University, 70 Chwaku Street-Mikocheni, P.O. Box 65300, Dar es Salaam, Tanzania\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMonica Alex Bugomola\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDepartment of Community Health Nursing , Muhimbili University of Health and Allied Sciences, P.O. Box 65004, Dar es Salaam, Tanzania\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSebalda Leshabari\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSchool of Nursing, Muhimbili University of Health and Allied Sciences, P.O. Box 65004, Dar es Salaam, Tanzania\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDickson Mkoka\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDepartment of Reproductive and Child Health, Hubert Kairuki Memorial University, 70 Chwaku Street-Mikocheni, P.O. Box 65300, Dar es Salaam, Tanzania\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eColumba Mbekenga\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eJahn A, Brouwere VD. Referral in pregnancy and childbirth: Concepts and strategies.:18.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHussein J, Kanguru L, Astin M, Munjanja S. The effectiveness of emergency obstetric referral interventions in developing country settings: A systematic review. Vol.\u0026nbsp;9, PLoS Medicine. 2012.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMurray SF, Pearson SC. Maternity referral systems in developing countries: current knowledge and future research needs. Soc Sci Med 1982. 2006;62(9):2205\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePembe AB, Paulo C, D\u0026rsquo;mello BS, van Roosmalen J. Maternal mortality at Muhimbili National Hospital in Dar-es-Salaam, Tanzania in the year 2011. BMC Pregnancy Childbirth. 2014 Sep 13;14:320.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMinistry of Health CD, MoH/Zanzibar M of H, NBS/Tanzania NB of S, OCGS/Zanzibar O of CGS, ICF. Tanzania Demographic and Health Survey and Malaria Indicator Survey 2015\u0026ndash;2016. 2016 Dec 1 [cited 2022 Jun 27]; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://dhsprogram.com/publications/publication-fr321-dhs-final-reports.cfm\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKnight HE, Self A, Kennedy SH. Why Are Women Dying When They Reach Hospital on Time ? A Systematic Review of the \u0026lsquo; Third Delay.\u0026rsquo; 2013;8(5).\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMaskey S. Obstetric Referrals to a Tertiary Teaching Hospital of Nepal. 2015;19(1):52\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePembe AB, Urassa DP, Darj E, Carlsted A, Olsson P, Carlstedt A\u0026amp; OP. Qualitative study on maternal referrals in rural Tanzania: Decision making and acceptance of referral advice. Afr J Reprod Health. 2008;12(2):120\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSingh S, Doyle P, Campbell OM, Mathew M, Murthy GVS. Referrals between Public Sector Health Institutions for Women with Obstetric High Risk, Complications, or Emergencies in India \u0026ndash; A Systematic Review. 2016;1\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePacagnella RC, Cecatti JG, Parpinelli MA, Sousa MH, Haddad SM, Costa ML. Delays in receiving obstetric care and poor maternal outcomes: results from a national multicentre cross-sectional study. 2014;1\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eManijeh Eskandari, Abbas Abbaszadeh FB. Barriers of referral system to health care provision in rural societies in iran. J Caring Sci. 2013;2(3):229\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHirose A, Borchert M, Cox J, Alkozai AS, Filippi V. Determinants of delays in travelling to an emergency obstetric care facility in Herat, Afghanistan : an analysis of cross-sectional survey data and spatial modelling. 2015;\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePembe AB, Carlstedt A, Urassa DP, Lindmark G, Nystr\u0026ouml;m L, Darj E. Effectiveness of maternal referral system in a rural setting: a case study from Rufiji district, Tanzania. BMC Health Serv Res. 2010;10(1):326.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKitilla T. Reasons for referrals and time spent from referring sites to arrival at Tikur Anbessa Hospital in emergency obstetric: A prospective study. Ethiop J Health Dev [Internet]. 2001 [cited 2022 Jun 24];15(1). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ajol.info/index.php/ejhd/article/view/9892\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eFournier P, Dumont A, Tourigny C, Dunkley G, Dram\u0026eacute; S. Improved access to comprehensive emergency obstetric care and its effect on institutional maternal mortality in rural Mali. Bull World Health Organ. 2009 Jan;87(1):30\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAfari H, Hirschhorn LR, Michaelis A, Barker P, Sodzi-Tettey S. Quality improvement in emergency obstetric referrals: qualitative study of provider perspectives in Assin North District, Ghana. BMJ Open. 2014 May 15;4(5):e005052.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGupta M, Mavalankar D, Trivedi P. A Study of Referral System for EmOC in Gujarat. (2009):50.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAgarwal R, Chawla D, Sharma M, Nagaranjan S, Dalpath SK, Gupta R, et al. Improving quality of care during childbirth in primary health centres: a stepped-wedge cluster-randomised trial in India. BMJ Glob Health. 2018 Oct 1;3(5):e000907.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Obstetric referral, maternal referral system, reasons for referral, referral delays, referral communication","lastPublishedDoi":"10.21203/rs.3.rs-1799859/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1799859/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003ePoor accessibility of emergency obstetric care services contributes to severe morbidity and high maternal mortality. Variations in the capacity of providing Emergency obstetric care by different levels of public health facilities highlights the fundamental role of maternal referral system. There has being no significant changes in the maternal mortality for the past 15 years despite the feasibility of interventions within the limited resources hospital settings. There is still a paucity of evidence on the effectiveness of the obstetric referral process in reducing maternal mortality. This study was conducted to determine referral reasons, referral delays and communication barriers influencing referrals of women with obstetric complications in order to evaluate the effectiveness of the maternal referral system.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA descriptive cross-sectional design employing mixed methods approach was used to evaluate effectiveness of the maternal referral system. A 7 weeks prospective study was conducted at Muhimbili National Hospital. Quantitative data were collected through reviewing referral slips of 426 women referred from various health facilities due to obstetric complications in the peripartum period and admitted in the labour ward, postnatal ward, ICU and high dependant ward. Analysis was done using SPSS.\u0026nbsp;Qualitative data was collected using 9 semi-structured in-depth interviews with nurse-midwives and obstetricians who were selected purposively, and data was analysed with qualitative content analysis.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eA total of 426 records of referred women with obstetric complications were reviewed. Most documented reasons for referral were hospital based (62%), which included theatre being busy (25.1%), unavailability of blood (11.3%) and lack of equipment and inadequate supplies (10.3%). 60.3% accounted for delayed referrals. The study identified referral-receiver communication barriers which include inconsistent use of phones before referral, unsatisfactory referral form documentation and inadequate feedback mechanism.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe study demonstrates lack of both human and non-human resources required for provision of health care services in the referring facilities. It identifies high proportion of late referrals and deficiencies in the referral process which illustrate ineffective referral system.\u003c/p\u003e","manuscriptTitle":"Effectiveness of Maternal Referral System in Tanzania: A Mixed Method Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-07-15 16:45:16","doi":"10.21203/rs.3.rs-1799859/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ddd1208f-a6f8-419d-b1d6-a465b96f9c6c","owner":[],"postedDate":"July 15th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-06-03T23:14:13+00:00","versionOfRecord":[],"versionCreatedAt":"2022-07-15 16:45:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1799859","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1799859","identity":"rs-1799859","version":["v1"]},"buildId":"369fNeqWncA4NS6XSWjrt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}