Assessment of efficiency of the Maternity Referral System in Uasin Gishu County, Kenya

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.