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

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. This study employed a cross-sectional design approach. This study adopted the Interpretive/Constructive paradigm [17] to understand how the referral system operates as opposed to how it is intended. This enabled the researcher to explore the participants’ views on the referral systems and how they function instead of a theory-based approach. The researchers of this study recognised that frontline health workers and clinical leaders from varied backgrounds have their perspectives, beliefs, assumptions, and experiences that would contribute to the reality existing about the broader functionality of the referral system. This study was conducted in three public health facilities in the Ablekuma district, specifically: in the Obstetrics and Gynaecology department of Korle Bu Teaching Hospital (KBTH) the third largest hospital in Africa and the largest tertiary hospital in Accra, Ghana; Mamprobi Polyclinic (MPC); and the Dansoman polyclinic (DPC). The setting was purposively selected to include public health facilities in an urban setting that provide primary, secondary and tertiary healthcare in the capital city of Ghana, Accra. With regards to healthcare coverage, the Obstetric unit of KBTH provides specialized antenatal care, postnatal care to large and diverse population within and outside Accra and from lower levels of facilities, primary healthcare facilities, and district (secondary) hospitals both public and private. The total bed capacity for the hospital is over 2500 with 375 bed capacity for maternity services [18]. The hospital runs an antenatal clinic, has two labour wards and three theatres. The KBTH handles an estimated 27,128 new and old antenatal (ANC) attendance, 16,000 postnatal attendance and over 10,000 deliveries every year. Over 90% of cases are referred antepartum or intrapartum to KBTH and 70% of maternal deaths are referred cases [19]. For MPC and DPC, they reflect a cross-section of two levels of healthcare, primary and secondary. The KBTH and MPC are located in Ablekuma South whilst DPC is located in Ablekuma West. The map of the Ablekuma district is shown in Fig. ​Fig.11. The DPC runs only antenatal clinics with one couch for ANC, 8 adult beds and 2 cots, a total capacity of 10 beds for the entire polyclinic. The Mamprobi Polyclinic runs an antenatal clinic, has a labour ward and an operating theatre. The annual ANC attendance in MPC is 18,677, the annual PNC attendance is 3089, annual deliveries is 2678 and total bed capacity is 45. Map of Ablekuma district showing the facilities included in the study. Source: Google (n.d.) The Ablekuma South district has an estimated population of 213,914 [20]. The KBTH is about 2.66 km from MPC and about 6 Kilometers to DPC. The distance between DPC and MPC is about 4.65 km. Healthcare providers executing varied professional roles were recruited using purposive sampling technique to obtain in-depth knowledge, individualized experience, and perception of the emergency obstetrics referral system. Data was collected using semi-structured key informant interview guide (see Referral Interview Guide) designed for this study to gather feedback about the process flow, existing barriers and recommendations for improvement. Data collection was undertaken by the primary researcher (BO) who has experience in undertaking qualitative public health and clinical research. Nine targeted interviews were conducted for a three-week period between June and July 2019 until saturation was met,ie, when the interviewer begun to hear the same responses over and over. Participants were approached face-to-face by the data collector (BO) prior to the interview and were given written and verbal information about the study. After securing their written consent to participate in the study, a date, place and time was scheduled for the interview. All HCP approached accepted to participate in the study. Two Obstetrician and Gynaecology consultants, two OBGY resident doctors, one Family Physician Specialist, and four Midwives across the three facilities in Ablekuma district in Accra, Ghana, were interviewed in English. Five were staff from KBTH, two from MPC and two from DPC. Interviewing involved the act of asking the respondents questions and audio-tape recording the responses and transcribing upon completion. Targeted interviews lasted on average 15 min. All interviews were conducted in person in a private office in the healthcare facility that would ensure privacy and convenience for the participants. The transcripts were randomly checked against the audio recordings for quality assurance purposes. A qualitative analysis was conducted in five phases. First, one researcher [BO] manually transcribed the interviews. This was reviewed by two other researchers [DO, MN] to eliminate bias, ensure consistency and check reliability. Second, we independently identified referral process related data in breadth and depth, from all nine interviews. Third, we used the transcribed narratives to draft a process map for the current emergency obstetric referral system within Ablekuma district, for each of the interviews. This was done initially for the lower-level facilities (MPC and DPC), then the higher-level facility (KBTH). Fourth, we refined and confirmed the process map ensuring that details from all interviews were reflected. Particular attention was paid to uncertainties about the referral process between the specified start and end points. That is, from when a woman with an obstetric complication comes to a lower-level facility to when discharged from a higher-level facility respectively. A process map was drawn for each interview and finally a summary process map drawn, incorporating all the individual process maps. The developed process map provided explicit visualisation of the referral process which was further analysed in two steps. First, we examined the uncertainties in the sequence of steps within the process and/or lack of systematised steps, gaps [that is, discrepancies of what the process is intended to be and what it actually is], bottlenecks within the process that cause delays before the next step occurs and inefficiencies [unnecessarily repeated steps leading to delays] to uncover potential areas for improvement broadly similar to approach used by . Key themes and sub themes were also discussed and reviewed by the five researches [BO, DO, MN, KAP, TB]. A meeting was later held with the participants to confirm the findings.