Appropriateness of maternal referral system and its associated factors in Eastern Ethiopia: a facility-based cross-sectional study

Betelhem Mengist Sharew¹Agumasie Semahegn^2,3,4Nigus Kassie Worku^5*Shegaye Yibabie⁵Abera Kenay^6,7

• ¹Department of Midwifery, College of Medicine and Health Science, Dire Dawa University, Dire Dawa, Dire Dawa, Ethiopia
• ²School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Dire Dawa, Dire Dawa, Ethiopia
• ³Center for Innovative Drug Development and Therapeutic Trials, Addis Ababa, Addis Ababa, Ethiopia
• ⁴Department of Population, Family & Reproductive Health, School of Public Health, University of Ghana, Accra, Ghana
• ⁵School of Medicine, College of Medicine and Health Science, Dire Dawa University, Dire Dawa, Dire Dawa, Ethiopia
• ⁶Department of Psychiatry, School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Harari Region, Ethiopia
• ⁷Department of Obstetrics and Gynecology, University Medical Center Groningen, Groningen, Netherlands

Background: Given majority of obstetric complications are often unpredictable, an appropriate maternal referral system is crucial to manage life-threatening obstetric complications and prevent maternal deaths. Although Ethiopia is one of the countries with high maternal deaths, there is a paucity of data on the appropriateness of maternal referrals. The aim of this study was to assess the appropriateness of maternal referrals and its associated factors in eastern Ethiopia.Methods: A facility-based cross-sectional study was conducted among randomly selected women who were referred to the major referral hospitals during pregnancy, childbirth or the postpartum. Data on maternal conditions and referral related information were collected through review of the medical records using structured checklist. Data were entered into EpiData 3.1 and exported to SPSS 20 for analysis. Bivariable and multivariable logistic regression analyses were fitted to identify factors associated with the appropriateness of referrals using adjusted odds ratio (AOR) along with 95% confidence interval (CI). Significant association was declared at p<0.05Results: Of 422 maternal referrals reviewed, only 10.1% (95% CI: 7.1-13.1%) were appropriate. Referrals on working days (AOR=3.77; 95% CI:1.29-10.99), which arrived during working time (AOR=3.64; 95% CI:1.54-8.61), referred from governmental hospitals (AOR=5.69; 95% CI:1.33-24.32) or from private/non-governmental organization facilities (AOR=2.94; 95% CI:1.09-7.93), those written on standard referral forms (AOR=5.52; 95% CI:1.71-17.85), and which contains referral feedback (AOR=4.90; 95% CI:1.93-12.47) were more likely to be appropriate maternal referral. Only one in ten maternal referrals from public health facilities in eastern Ethiopia were found to be appropriate. Referrals on working days and time, from governmental hospitals, private facilities, standard referral forms used, and those with referral feedback were found to be appropriate. Strengthening referral system through focusing on non-working hours and during weekends as well as co-creating standards forms are essential for making maternal referrals appropriate and effective in reducing maternal deaths.