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Introduction: Countries with high maternal and newborn mortality can benefit from national facility level data that describe intra-facility emergency referral patterns for major obstetric complications. This paper assesses the relationship between referral and facilities’ readiness to treat complications at each level of the health system in Ghana. We also investigate other facility characteristics associated with referral. Methods: The National Emergency Obstetric and Newborn Care Assessment 2010 provided aggregated information from 977 health facilities. Readiness was defined in a 2-step process: availability of a health worker who could provide life-saving interventions and a minimum package of drugs, supplies, and equipment to perform the interventions. The second step mapped interventions to major obstetric complications. We used descriptive statistics and simple linear regression. Results: Lower level facilities were likely to refer nearly all women with complications. District hospitals resolved almost two-thirds of all complicated cases, referring 9%. The most prevalent indications for referral were prolonged/obstructed labor and antepartum hemorrhage. Readiness to treat a complication was correlated with a reduction in referral for all complications except uterine rupture. Facility readiness was low: roughly 40% of hospitals and 10% of lower level facilities met the readiness threshold. Facilities referred fewer women when they had higher caseloads, more midwives, better infrastructure, and systems of communication and transport. Discussion: Understanding how deliveries and obstetric complications are distributed across the health system helps policy makers contextualize decisions about the pathways to providing maternity services. Improving conditions for referral (by increasing access to communication and transport systems) and the management of obstetric complications (increasing readiness) will enhance quality of care and make referral more effective and efficient.
This is a secondary analysis of the National Emergency Obstetric and Newborn Care Assessment conducted by the Ghana Ministry of Health (MOH) and Ghana Health Service (GHS) in 2010. A detailed description of the assessment methods can be found elsewhere [24]. The assessment targeted public and private health facilities; the original selection criterion was based on the number of deliveries per month, where the minimum number eligible for inclusion ranged from 1 to 5 deliveries, depending on the geographic region. In the 3 Northern regions (Upper East, Upper West and Northern) one or more births per month was the cut off level while 5 was the cut off level for all other regions. A total of 1268 facilities were assessed, but in this paper, we selected only those facilities that had on average 5 or more deliveries per month based on the last 3 months before the survey, leaving 977 facilities in the sample. The data collection instruments, used in more than 40 countries, were adapted to the Ghanaian health system [25]. Specific instruments covered facility infrastructure; availability of human resources; availability of drugs, equipment and supplies; performance of the emergency obstetric care signal functions; and retrospective service statistics. Service statistics included the number of women who delivered, number of women with obstetric complications, by type, and of these, the number of women referred to another facility. They also included the number of maternal deaths by cause of death. These tools were completed at all health facilities; tracer items were observed by data collectors but availability of most items was reported by facility staff. Data collectors reviewed service logbooks, labor and delivery registers, admissions and discharge records, and referral logbooks. They tallied events for the 12-month period April 2009 to March 2010 in the Upper East Region, and from July 2009 to June 2010 for the rest of the country. No other data sources were used. We focused on complications that lead to the direct causes of maternal mortality: antepartum hemorrhage (placenta praevia or abruption), postpartum hemorrhage, retained placenta, severe pre-eclampsia and eclampsia, sepsis, prolonged/obstructed labor, ruptured uterus, ectopic pregnancy, and severe complications due to abortion (hemorrhage, infection, perforation, etc.). Women with multiple complications were counted only once; data collectors were trained to select the most life-threatening complication. Safe induced abortions were not included. Operational definitions of major direct obstetric complications were included in the data collectors’ manual and were drawn from Monitoring emergency obstetric care: a handbook [26]. Of primary interest was the extent to which facilities referred women experiencing a specific complication. We created a referral ratio where the numerator was based on the annual number of referrals out for each complication and the denominator was the annual number of women admitted with each complication. This ratio is an indicator of the level of referral occurring in each facility, though it is not a true proportion since the numerator was not always in the denominator because the data for each were sometimes gathered from different sources. Many Ghanaian facilities use referral registers, documenting whom they sent, when, where, and the indication for referral. Women who were admitted in labor or with a complication during pregnancy or postpartum, or developed a complication after admission were registered generally in labor and delivery logbooks. It was possible for a ratio to exceed 100% when the number of referrals for a complication exceeded the number of admissions with the same complication. For purposes of the regression analyses, we treated ratios that exceeded 100% as simply 100%. We used a two-step process to classify whether each facility was ready to treat each of the complications of interest. First, a facility was defined as ready to provide each of the emergency obstetric care (EmOC) signal functions (newborn resuscitation with bag and mask was dropped given our focus on maternal complications) if it had both a health worker who could perform the signal function and the minimum package of health technologies (Table 1). Health worker performance was determined by a series of questions in the human resources module where we asked if each health worker category present at the facility provided each of the signal functions. Readiness to provide tracer drugs, supplies and equipment to perform the signal functions Second, we mapped the eight signal functions to nine complications (Table 2), sometimes adjusting for facility type by assuming: 1) all hospitals had the potential to provide the comprehensive EmOC signal functions, and 2) health centers, health clinics, maternity homes and CHPS had the potential to provide the basic EmOC signal functions. For example, at hospital level, treatment of antepartum hemorrhage might entail the use of assisted vaginal delivery, surgery, and blood transfusion, whereas, at health center/clinic level, the only signal function expected would be assisted vaginal delivery. For two complications – ectopic pregnancy and uterine rupture – we assumed definitive treatment required surgery and thus no lower level facility could be considered ready to treat those complications. Mapping complications to signal functions Readiness to treat complications and readiness to provide the signal functions were informed by the Ghana National Safe Motherhood Service Protocol that specified care at community level, health center level and first referral or district level care [27]. The descriptive results are reported as means, ranges, ratios, and percentages. We used simple linear regression of the referral ratio. All analyses were performed using STATA v. 13 software [28]. Statistical tests were shown only for the regression results, with significance measured at the 0.05 level. No patient or staff names or other personal identifiers were recorded on the data collection instruments and were never part of the electronic database. Access to the facilities was facilitated with a letter from GHS and medical directors granted data collectors permission to talk to staff and view facility records. The Navrongo Health Research Centre in Ghana provided ethical approval.
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