An Evaluation of Maternal Referrals in the Sissala East District

Abstract

Background The referral system is an integral part of maternal health care and is particularly crucial to patients living in rural areas, where vast distances and bad road network, make access to district hospitals an expensive and time-consuming challenge. Ensuring skilled attendance at birth requires developing a responsive referral system which provides links between levels of health care. It is widely accepted that substantial reductions in maternal mortality and severe morbidity are impossible to achieve without an effective referral system for cases with complications. Objective: To evaluate the referral system for pregnancy- related complications in the Sissala East district. Methods: A mixed-tool was developed for the evaluation using the Ghana Health Service referral policies and guidelines, the National Reproductive Health Service Protocols, tools for monitoring maternity referral system in developing countries by Murray et al and Guidelines for Monitoring the Availability and Use of Essential Obstetric Services. Medical records were reviewed for patients who were referred with pregnancy- related complications from the subdistricts to the district hospital between January 2007 and April 2008. Six (6) health centres, one Community-Based Health Planning and Services (CHPS) zone and the district hospital records were used for the study from May to August 2008. In-charges of the maternity units at the time of the study were interviewed on issues concerning the challenges with maternal referrals. Questionnaires were used to assess the availability of Essential Obstetric Care (EOC) in the various health facilities. Monitoring guide was used to check for availability and use of standard referral forms and referral registers. The data was analysed using Microsoft excel 2007 version to create tables and graphs. Content analysis was done for data collected by indepth interview. Results: A total of 72 patients with pregnancy-related complications were referred from the subdistricts to the district hospital between January 2007 and April 2008. Majority of the patients were referred due to prolonged labour (23.6 %,), incomplete abortion (16.7%) and risk pregnancy (16.7%). Five (5) maternal deaths and seven (7) still births were recorded out of the referrals. The annual intrapartum referral rate for 2007 was 10.53% and the maternal case fatality rate among referred patients was 12.5%. Referral forms and referral registers were not available in the health facilities. Feedback was given in only 19.4% patients referred to the district hospital. None of the health facilities assessed offered Basic Essential Obstetric Care services except the hospital which offered comprehensive EOC services. Lack of emergency community transport and communication were major challenges to the referral system in the district. Conclusion: The referral system for pregnancy-related complications was found to be ineffective in the Sissala East district and needs improvement. Keywords: Referral system, maternal complications, Sissala East district, Ghana