APPROPRIATENESS OF MATERNAL REFERRAL SYSTEM AND ITS ASSOCIATED FACTORS AND BARRIERS AMONG WOMEN REFERRED TO SELECTED REFERRAL HOSPITALS IN EASTERN ETHIOPIA: A CROSS-SECTIONAL STUDY

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 XII with appropriate maternal referrals. Improving communication between facilities, availing emergency transportation, and resilient health systems are essential for improving maternal referral system