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. 2021 Apr 29;21(1):402.
doi: 10.1186/s12913-021-06402-7.

Assessing the functionality of an emergency obstetric referral system and continuum of care among public healthcare facilities in a low resource setting: an application of process mapping approach

Bernice Ofosu  1 , Dan Ofori  2 , Michael Ntumy  1   3 , Kwaku Asah-Opoku  1   3 , Theodore Boafor  4   5
Affiliations

Assessing the functionality of an emergency obstetric referral system and continuum of care among public healthcare facilities in a low resource setting: an application of process mapping approach

Bernice Ofosu et al. BMC Health Serv Res. .

Abstract

Background: Weak referral systems remain a major concern influencing timely access to the appropriate level of care during obstetric emergencies, particularly for Low-and Middle-Income Countries, including Ghana. It is a serious factor threatening the achievement of the maternal health Sustainable Development Goal. The objective of this study is to establish process details of emergency obstetric referral systems across different levels of public healthcare facilities to deepen understanding of systemic barriers and preliminary solutions in an urban district, using Ablekuma in Accra, Ghana as a case study.

Methods: The study is an analytical cross-sectional study. Nine [1] targeted interviews were carried out for a three-week period in June and July 2019 after informed written consent with two [2] Obstetrics & Gynaecology consultants, two [2] Residents, one family physician, and four [3] Midwives managing emergency obstetric referral across different levels of facilities. Purposeful sampling technique was used to collect data that included a narration of the referral process, and challenges experienced with each step. Qualitative data was transcribed, coded by topics and thematically analysed. Transcribed narratives were used to draft a process map and analyze the defects within the emergency obstetric referral system.

Results: Out of the 34 main activities in the referral process within the facilities, the study identified that 24 (70%) had a range of barriers in relation to communication, transport system, resources (space, equipment and physical structures), staffing (numbers and attitude), Healthcare providers (HCP) knowledge and compliance to referral policy and guideline, and financing for referral. These findings have implication on delay in accessing care. HCP suggested that strengthening communication and coordination, reviewing referral policy, training of all stakeholders and provision of essential resources would be beneficial.

Conclusion: Our findings clearly establish that the emergency obstetric referral system between a typical teaching hospital in an urban district of Accra-Ghana and peripheral referral facilities, is functioning far below optimum levels. This suggests that the formulation and implementation of policies should be focused around structural and process improvement interventions, strengthening collaborations, communication and transport along the referral pathway. These suggestions are likely to ensure that women receive timely and quality care.

Keywords: Access; Emergency; Ghana; Improve; Obstetric; Quality; Referral system; Women.

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Conflict of interest statement

Ethical clearance was granted by the KBTH Institutional Review Board, Accra Ghana (Protocol ID NO: KBTH-IRB/00099/2019). Administrative approval was obtained from the Accra Regional Health Directorate to pretest in Ussher polyclinic and collect data in Dansoman and Mamprobi polyclinics. Confidentiality, anonymity and privacy of respondents were maintained at all times. The researchers removed names and other identifying information in the responses to ensure anonymity, and this was explained to respondents before seeking their written informed consent. Study participants were also given the right to withdraw and this could be exercised at any time during the study and debriefing. Data files were password protected and hard copies locked and access was limited to the three main authors and the data analyst of the study. Data is being used for research purposes only. The researchers have no conflict of interest so far as this study is concerned.

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Map of Ablekuma district showing the facilities included in the study. Source: Google (n.d.)
Fig. 2
Fig. 2
Process Map of Emergency Obstetric Referral System showing major barriers: (colored boxes) in referral processes in Ablekuma District (Attached)
See this image and copyright information in PMC

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