Barriers to proper maternal referral system of health facilities: a qualitative study in Eastern Ethiopia

Background: Appropriate referral system plays an essential role in curbing maternal mortality. Although the occurrence of obstetric complications is often unpredictable, addressing bottlenecks of the referral system is crucial to facilities the women have access to timely lifesaving interventions. Nonetheless, little is known about the barriers to maternal referral system in the eastern part of Ethiopia. Therefore, this study aimed to explore the barriers to maternal referral system at selected referral hospitals in eastern Ethiopia. Methods Key informant interviews and in-depth interviews were conducted among purposively selected respondents who had a role in the maternal referral processes. A total of 12 key informants that comprised of liaisons officers, healthcare providers and three in-depth interviews with referred women were conducted. Semi-structured interview guide was developed and used to facilitate the interviews. All the interviews were tape recorded, complemented by note taking. Then audio recorded interviews were transcribed as per verbatim of participants, and imported to NVivo for coding and merging. The data were thematically synthesized. Results The study identified a range of barriers that affect the maternal referral system in Eastern Ethiopia. The main barriers are grouped into three domains, such as: communication, transportation, and healthcare system. The most commonly reported barriers were lack of pre referral communication and feedback, using informal communication, incomplete referral communication, poor ambulance service including misuse of ambulances, lack of skilled healthcare, escort, and lack of medical equipment, at emergency, unnecessary self-referrals, poor referral skills, and limited number of health professions. Conclusions The maternal referral system is overwhelmingly affected by lack of skill, logistics (referral form), misuse of available ambulance, poor communication, and limited seeking of feedback. We suggest a regular consultative meeting with relevant stakeholders and uptake of feedbacks are crucial to improve referral communication, proper use of ambulance and building capacity of health workforce about referral, management that will improve the maternal referral system in the study area.