Assessment of Maternal Referral Systems used for a Rural Zambian Hospital: The Development of Setting Specific Protocols for the Identification of Complications

In resource-limited countries, it is estimated that up to 75% of maternal deaths are preventable. Efficient maternal referral systems are an effective measure to help prevent these deaths.  Delineating criteria that healthcare workers use to both identify obstetrical emergencies and make referrals aids in evaluating the effectiveness of an established referral system and implementing improvements.

Using a qualitative descriptive cross-sectional design the individuals with the highest level of formal obstetrics training at 10 health posts that refer to a rural Zambian hospital were surveyed regarding their referral protocols. Data were analyzed through open-coding. At the conclusion of the interview, standardized referral protocols for obstetric emergencies derived from published guidelines and local practices were distributed.

Identified complications resulting in referral most commonly included post-partum hemorrhage (70%), prolonged labor (70%), malpresentation (50%), antepartum hemorrhage (40%), and retained placenta (40%); some health posts named multiple complications as the most common. While numerous reasons for referral were identified, there was little consensus on the referral protocol used for each complication.  Obstacles to successful referral most commonly included cellular network disruptions (70%), distance (50%), and lack of transportation (30%).

While the referral protocols distributed to health posts covered multiple topics, they only covered 11 of the 23 complications cited as the most common reason for referral. At the conclusion of this study, the referral criteria and protocols were updated to include all of these complications. We propose this document for others working in resource-limited settings attempting to establish or evaluate a maternal referral systems.