Abstract:
The three distinct attributes of referral appropriateness are referral necessity, referral destination
and referral quality. Although the occurrence of obstetric complications is often unpredictable,
prevention of maternal mortality requires an effective maternity referral system that provides
timely treatment to effectively respond to complications. Despite this fact, there is a paucity of
research on the appropriateness of maternal referral systems in Ethiopia.
Objective: To assess appropriateness of maternal referral system and associated factors among
women referred to selected referral hospitals in eastern Ethiopia from July 1 to July 31, 2021.
Methods: A facility-based cross-sectional mixed-method study was conducted. Simple random
sampling method was applied to recruit 422 maternal referral documents, and review them using
a pretested structured questionnaire. In addition, key informant interviews were held with
relevant stakeholders involved in the referral system. Collected data were entered into EpiData
3.1 and exported to SPSS 20 for analysis. Referrals were rated as appropriate if all four
components of the referral system are met and coded as “1’’. If one of the referral components is
missed, it was categorized as inappropriate, and coded as “0’’. Binary and multiple logistic
regression analyses were performed to identify factors associated with appropriate referrals.
Model fitness was checked using the Hosmer-Lemeshow goodness of fit test. The Adjusted odds
ratio (AOR) at 95% confidence interval (CI) and p-values <0.05 were used to declare significant
association. In-depth interviews were analyzed thematically.
Results: Of a total 422 maternal referral papers reviewed, only 40 (10.1%; 95% CI=7.14-13.11)
were appropriate. Appropriate referral was more likely among women arriving on working days
(AOR=4.50; 95% CI= 1.37-14.78), working time (AOR=4.34; 95% CI=1.70-11.09), referred
from private/ nongovernmental organizations (AOR=4.12; 95% CI=1.39-12.22), written in
standard referral form (AOR=9.56; 95% CI=2.59-35.33), patients with life-threatening
complications (AOR=14.82; 95% CI=5.29-41.52), and return referral feedback (AOR=6.04; 95%
CI=2.03-17.97). In the qualitative analysis, the main barriers to inappropriate maternal referral
system were reported to be gaps on communication, transportation and the overall health care
system.
Conclusions: The appropriateness of maternal referral system in the study area is low. Being
referred to working day and time, from private facilities, using a standard referral form, having
life-threatening maternal complications and return referral feedback were found to be associated
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with appropriate maternal referrals. Improving communication between facilities, availing
emergency transportation, and resilient health systems are essential for improving maternal
referral system
