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Introduction Maternal and perinatal deaths occurring in low and middle income countries could be prevented with timely access to maternal and new-born care. In order to increase access to maternal and child health services, a well-functioning referral system that allows for continuity of care across different tiers of healthcare is required. A reliable healthcare system, with adequate numbers of skilled staff, resources and mechanisms, is critical to ensuring that access to care is available when the need arises. Material and methods This descriptive, qualitative study design was used to explore barriers to implementing a reliable referral system. Twelve individual qualitative interviews were conducted with health care providers working in rural and semi-urban district hospitals in the Northern, Western, Eastern and Southern zones of Tanzania. Thematic analysis guided analysis of data. Results Three (3) main and interconnected themes were abstracted from the data relating to participants’ experiences of referring women with obstetric complications to adequate obstetric care. These were: 1. Adhering to a rigid referral protocol; 2. Completing the referral of women to an adequate health facility and 3. Communicating the condition of the woman with obstetric complications between the referring and receiving facilities. Conclusion Because of referral regulations, assistant medical officers were unable to make referral decisions even when they felt that a referral was needed. The lack of availability of hospital transport as well as the lack of a reliable feedback mechanism, prohibited effective referrals of patients. The Ministry of Health should revise the referral protocol to allow all clinicians to provide referrals, including assistant medical officers- who make up the majority of clinical staff in rural health care facilities. A mechanism to ensure effective communication between the referral facility and the tertiary care hospital should be instituted for quality and continuity of care. Furthermore, health care facilities should put aside budget for fuelling the ambulance for effective referrals.
This study was part of a large study which adopted a case study design to explore barriers and facilitators for performance of Caesarean section by Assistant Medical Officers in Tanzania. The descriptive phenomenology study design [19] was carried out in four districts in the Northern, Western, Eastern and Southern zones of Tanzania. The zones were purposely selected because they had caesarean section rates either above or below the national average. Further, the type of health facility (run by government or a faith-based organisation), and the location of the facility (rural or urban) were considered in order to tease out the factors that determined whether the referral protocols and system facilitated women’s access to comprehensive emergency obstetric services. Specifically, this study was conducted in 6 health facilities; including both Government and Faith-based organisations, and categorised as either rural or semi-urban (see Table 1). Although the healthcare facilities involved in the study were located in rural or semi-urban areas, they provided either basic emergency obstetric and new-born care (BEmONC) or comprehensive emergency obstetric and new-born care (CEmONC). However, due to various reasons they are compelled to refer patients to other healthcare facilities for appropriate obstetric care. The common reasons for referral were; inadequate number of CEmONC trained health care providers, limited (lack) of medical equipment and insufficient supply of essential obstetric medicines such as safe blood transfusion and magnesium sulphate [18, 20]. In Tanzania all healthcare facilities whether public, private or faith-based are implementing Government policies including maternal and neonatal referral guidelines. The study participants included Medical Officers, Assistant Medical Officers (AMOs), Nurse-Midwives and Health Secretaries working in the 6 healthcare facilities and District Medical Officers (DMOs) of the 4 study districts and were conveniently recruited. Because of the limited number of medical personnel in these study settings, convenience sampling strategy was used and therefore whoever was around during data collection period and willing to participate in the study was recruited [21]. Heads of the maternity services assisted with identification of participants based on set inclusion criteria. The participants had to work in the labour ward for 3 or more years to ensure that they had adequate experience managing women with obstetric complications and utilizing the referral system or had administrative roles in the maternity unit. The researchers met the labour ward staff, then provided information about the study purpose and issues of confidentiality. Thereafter, a convenient interview time was arranged with those who agreed to participate in the study. Twelve (12) individual, qualitative interviews were conducted using an in-depth interview guide. The guide was developed from a review of the literature that explored barriers to the implementation of a referral system, and focused on the experience of healthcare providers in rural and semi-urban district healthcare facilities for women. In order to avoid interference with the activities of the healthcare facilities, interviews were conducted when the participants were off duty. Interviews were conducted in Kiswahili in a quiet and comfortable room within the healthcare facility. At the end of each session, the recorded interviews were listened to allow new emerging issues to be included in the guide before the subsequent interviews [22]. After 10 interviews were conducted, it was noted that the knowledge saturation was reached, yet, 2 more interviews were done to adhere to the recommendations that 12 interviews will be required to achieve saturation [19, 23]. The sample size for qualitative studies depend on the complexity of the research questions, the purpose of the research study, the diversity of the sample, the nature of the analysis and the time and resources available [24–26]. On average, each interview took about 50 minutes. Before the interview began, participants signed the consent form to agree to participate and to allow recording of their conversations during the interview sessions. All participants were informed on the study aim, procedures and that their participation was purely voluntary so they were free to decline or withdraw at any time in the course of the study. The study was approved by the Senate Research and Ethics Committee of the Muhimbili University of Health and Allied Health Sciences (MUHAS) and the Ministry of Health Community Development Gender Elderly and Children (MOHCDGEC). Analysis of the data was guided by Braun and Clark thematic analysis, a flexible data analysis method that focuses in identifying themes and patterns [27, 28]. The analysis followed the six-stage in thematic analysis [20]. First, the recorded interviews were listened twice and thereafter transcribed verbatim and translated into English. The translated transcripts were then cross-checked against the Kiswahili transcripts to ensure the accuracy and completeness of translations before coding. When discrepancies occurred, these were corrected accordingly. Second, initial codes were extracted from the transcripts, whereby each researcher coded one transcript. After the team agreed on the codes, the NVivo10 software was used to organise the codes and categories. As the process continued, new, emerging codes were formulated and compared with the initial codes. Third, involves sorting the codes based on their similarities and differences into potential categories and themes, and collating all the relevant coded data extracts within the identified themes. Fourth, themes were reviewed by either splitting, combining, or discarded them during the process. Fifth, the themes and categories were named and were discussed and agreed upon among the team. Final stage, the report was produced in which a few quotes were included to demonstrate the essence of a point.
