Abstract:
Introduction: Approximately 15 percent of all births globally are complicated by
potentially fatal conditions requiring emergency care. In developing countries, high
maternal and perinatal mortality and morbidity is mainly attributed to poor access to
Emergency Obstetric and Neonatal Care (EmONC) services. This is partly due to the three
delays - deciding to seek care, reaching the health facility and receiving adequate treatment
- and the failure to bridge these delays with adequate referral interventions and systems.
Uasin Gishu County (UGC) hosts a level 6 facility, Moi Teaching and Referral Hospital
(MTRH) which conducts approximately 1200 deliveries monthly, receiving maternity
referrals from 84 health facilities from UGC alone. The MTRH reported 30 maternal deaths
in 2014. In order to achieve universal health access and coverage in reproductive health in
UGC, it is vital to have a well- functioning maternity referral system. This study also
incorporates the three delay model to analyze the three delays of accessing healthcare.
Objectives: To assess the efficiency of the maternity referral system in UGC as measured
through the implementation of national referral guidelines; and delay factors in accessing
maternal health services.
Methodology: This was a descriptive cross sectional study done between December 2016
and April 2017. The study was conducted at MTRH and ten public health facilities
referring maternity patients to MTRH maternity which were selected using purposive
sampling method. The study population was made up of in-charges or members of
management teams of facilities, clinicians or nurses involved in the maternity referral
process and referral-in forms from all the public health facilities within UGC. Stakeholder
sampling was adopted for selecting two sets of key informants including the in charge, or a
member of management team (in facilities where the in charge was absent), and a clinician
or a nurse involved in the maternity referral process in each of the 11 selected facilities.
Additionally, a census of 39 referral-in documents from the ten referring facilities were
reviewed from the period between December 1st 2016 and April 31st 2017. The first set of
key informants were interviewed using a Referral System Assessment (RSA) toolkit
adopted from MEASURE evaluation. The second set of key informants were interviewed
using an open ended questionnaire developed by the researcher. The referral-in documents
were assessed using a document review checklist developed by the researcher based on the
national guidelines on the minimum requirements of a referral document. The data
collected were processed to provide descriptive statistics using SPSS statistics for
Windows, version 23.
Results: All the eleven (11) facilities offered maternity referral services. Only 1 (9.1%)
offered EmONC services. Sixty-four (64%) percent of the facilities fulfilled the staffing
norms for reproductive services. Only 1 (9.1%) facility had documented maternity referral
protocols. Only 3 (27.3%) facilities had training of providers on referral protocols. The
most sought referral service was EmONC (81%). There did not exist standardized referral
forms. Out of 39 referral- in documents assessed at MTRH, 10(26%) were official referral
forms whose completeness varied between 50-70%. Referrals documented on Ante Natal
Card, Mother Baby booklet, Plain paper and discharge summary were 16(41%), 8(21%),
4(10.3%) and 1(2.6%) respectively. All (11) facilities had no special register for
documenting referrals back. The frequency of delays as reported by key informants include:
Delay in reaching a health facility (43.75%), Delay in receiving care at facility (37.5%),
Delay in deciding to seek care (12.5%) and No delay (6.25%).
Conclusion: The efficiency of the maternity referral system in UGC is less than optimal
and the most common delay in accessing maternity health care in UGC is that of reaching
the health facility.
Recommendations: Development of maternity referral guidelines, training of health
personnel on maternity referral protocols, adoption of standardized referral forms and clear
referral monitoring and evaluation framework.