High proportions of obstetric referrals in Addis Ababa: The case of term premature rupture of membranes Emergency Medicine

Background: The Public Health Centers (HCs) provide basic obstetric and neonatal care to about 80 % of the eligible population in Addis Ababa. Hospitals provide comprehensive services and are referral centers for complications that cannot be managed at the HCs. This study assessed the proportion of obstetric referrals in general and referrals due to premature rupture of membranes (PROM) at term in particular, from the HCs in Addis Ababa and explored its appropriateness and management in hospitals. Methods: The study used a sequential explanatory mixed methods design. Routine retrospective data were collected from ten randomly selected HCs in 2012. Key informant interviews were conducted using a guide developed following a preliminary analysis of the quantitative data. Ten head midwives, one from each health center participated in the interviews. Results: Of the 9340 mothers who sought skilled birth care in the ten HCs in 2012, 2820 (30.3 %) were diagnosed with obstetric complications and referred to hospital. Term PROM accounted for 557 (19.7 %) of the referrals and it was widely varied across the HCs. Fifteen (7.8 %) mothers who were referred for PROM, had intact membranes upon hospital examinations. Forty-two (77.8 %) of the referred mothers who had spontaneous labour and delivery could have been misclassified as not having labour upon referral. In the interviews, variations in diagnosing and managing term PROM were identified as themes. Three HCs relayed solely on mothers’ self reports of amniotic fluid leakage to diagnose, two HCs did complementary speculum/vaginal examination, three HCs monitored sign of labour on top of confirming the leakage. Regarding management, two HCs practiced expectant management, three referred mothers after 30 min of observation while others issued referral right away. All providers reported the lack of clinical guidelines for most common obstetric problems in their HC. Conclusions: The study reported large proportion of obstetric referrals in general and PROM referrals in particular as well as variations in diagnosing and managing term PROM. These could largely be attributed to lack of clinical guidelines for most common obstetric complications at the HCs and competency gap among providers. Addressing the identified gaps and strengthening the primary care settings could contribute to improved quality of obstetric care and outcomes. The study was conducted in Addis Ababa, the capital of Ethiopia as part of an intervention project that intends to improve maternal and neonatal health outcomes through intensive knowledge and skills training for midwives/nurses on basic EmONC. The city is home for about 3.5 million people and is administratively divided in 10 sub-cities. Under the City Administration, Health Bureau, there are over 90 public primary HCs, which provide basic EmONC and four regional public hospitals providing comprehensive EmONC. These hospitals are Zewditu Memorial, Ghandi Memorial, Tirunesh Beijing and Yekatit 12. Ghandi Memorial is a maternity hospital while the other three are general hospitals that receive referrals from all over the city. Moreover, there are federal specialized referral hospitals in the city, which also provide comprehensive EmONC. Generally speaking availability, accessibility and acceptability of EmONC services are quite high in the city [11, 12]. The numbers of basic and comprehensive EmONC facilities outnumber the WHO minimum standard and the median distance to the nearest comprehensive EmONC facility is 5 km. Eight five percent of mothers in the city give birth in health facilities with the great majorities at public facilities. Using a mixed methods approach, this study collected quantitative and qualitative data. The study employed a sequential explanatory design. Routine retrospective data were collected from registers and preliminary analyses were made. This was followed by qualitative interviews to explore the issues behind the numbers and come up with plausible explanations. The study used Consolidated Criteria for Reporting Qualitative Research (COREQ) guideline for the qualitative findings [17] (see Additional file 1). To have a representative sample, ten well-established primary public HCs were randomly selected one from each sub-city using a lottery system. All the selected HCs are primary care facilities providing basic EmONC and have a similar staffing profile. The HCs provide delivery services free of charge and serve heterogeneous, low-income group of women as many women from high-income strata opting for private facilities. Hospital data were collected from two regional and one federal referral hospitals, which all together attend about two-thirds of the deliveries in the public health facilities in Addis Ababa. Zewditu Memorial and Ghandi Memorial hospitals were selected randomly from the four hospitals under the Addis Ababa City Administration Health Bureau. The third hospital was Tikur Anbessa, a federal referral hospital randomly selected from the two federal referral hospitals, catering obstetric and neonatal care services in Addis Ababa. This review retrieved retrospective data from labour, delivery and intrapartum referral logbooks from the selected HCs. These included total number of women who sought care during labour and delivery, number of total referrals, referrals due to term PROM and number of full-time skilled providers from January 1st, 2012 to December 30, 2012. To identify women who were referred with a diagnosis of PROM, routine hospital referral registers were first checked. By using their unique patient identifiers, in total 227 individual patient records were retrieved and reviewed. Women referred for other obstetric and neonatal complications were not included. The hospital data were collected using checklists to assess the standards of care for term PROM and for assessing maternal and neonatal outcomes. The checklist included maternal age, gravidity, parity, last menstrual period, gestational age, referring facility, diagnosis made by the referring primary health center, diagnosis after hospital arrival, prophylactic antibiotic, time referred from the referring facility, arrival time in hospital, admission to hospital, if a mother was not admitted to the hospital and referred again, reason for second or third referral from a hospital, time of delivery/induction or caesarean section, action at the hospital (induction, augmentation or caesarean section) and mode of delivery. Mean and range values were calculated for continuous data, while proportions and Chi square tests were calculated for categorical data. In this study a mother is said to have term PROM when she fulfils the following three criteria [1, 2]: (1) she should be at 37 completed weeks of gestation or more, (2) the amniotic membranes should have ruptured, (3) she should not be in labour. Due to the difficulty to ascertain whether the woman was in labour or not upon referral, we used the time taken from referral to delivery as a proxy indicator. By definition normal labour could take 12 h in multigravida and 18 h in primigravida mothers [18, 19]. Taking into consideration the travel time and logistic challenges to reach from HCs to hospitals or from hospitals to hospitals, we set 9 h as a cutoff. Therefore, a mother who had spontaneous labour and vaginal delivery within 9 h of referrals were considered to be in labour by the time the referral was issued and the rupture of amniotic membranes for this mother could have been a sign of labour. Those women who had ruptured amniotic membranes and who had spontaneous labour and delivery after 9 h of referral were considered to have PROM. In this study primary HCs are also referred as basic EmONC facilities or public HCs. Tertiary hospitals are also referred as comprehensive EmONC facilities or hospitals. Key informant interviews were conducted. Ten head midwives, one from each HC were approached for the interviews and all of them agreed to participate. Using a focused interview guide, the interviews were conducted after obtaining informed verbal consent. The guide explored experiences on (1) how PROM diagnosis was made? and (2) how mothers with term PROM were managed at health center? (see Additional file 2). All the interviews were conducted in Amharic, the national language fluently spoken by all the interviewees and the interviewer. The principal investigator (PI) did all the interviews in the HCs. During the interviews, dialogues were made to continue to the point where no new information was coming up and took on average 15 min. Notes taken during the interviews were transcribed and then translated to English for analyses by the PI. Doing the transcriptions and translations allowed the PI to get immersed into the data for gaining an overall impression of the findings. The interviews were analysed using content analysis. According to the principles in content analysis [20–22], the interview transcripts were first read and re-read to have an overview of the data. Then by using the two major questions from the interview guide, two themes were identified. The first theme was ‘making PROM diagnosis’ and the second theme was ‘managing PROM’. Then after the interview transcripts were sorted out and aligned with the respective themes, which then followed quantitative interpretations of the findings as shown in Table 1. In qualitative content analysis, the process of data analysis also involves interpretation of findings and can be presented in the form of frequency [20–22]. To ensure the validity of the findings, we did participant checking by calling up the informants in a consultative meeting where we presented preliminary findings. At the meeting, the informants gave us positive feedbacks that the findings presented were the main issues addressed during the in-depth interviews. Shows variable diagnostic and management approaches for term PROM explored in key informant interviews in Addis Ababa The project obtained ethical approval from the Ethics Committee of Addis Ababa City Administration, Health Bureau (AACAHB), and the Ethics Committee in Western Norway. Study permits were obtained from the AACAHB, sub-city health bureaus, hospitals and health centers. First, the AACAHB issued us a support letter for all sub-cities health bureaus. Based on the support letter, we got permission from each sub-city health bureau to access all the health facilities under them. Finally, in reference to the support letter from the sub-cities, the head of each health facility granted us access to the registers and to do the qualitative interviews. As stated in the protocol approved by the ethics committees’, informed verbal consent to participate in the in-depth interviews was secured from each informant after explaining the purpose of the study. Prior to the interviews all the informants were informed about the interview procedure and their right to opt out at any point during the interviews without any consequence. For ethical reasons, instead of their names all the HCs were de-identified using capital letters.