Health Care Workers' Experiences, Challenges of Obstetric Referral Processes and Self-Reported Solutions in South Western Uganda: Mixed Methods Study.

Introduction: In resource limited settings, the highest burden of adverse maternal-fetal outcomes at referral hospitals is registered from emergency obstetric referrals from lower health facilities. Implementation of referral protocols has not been optimally successful possibly attributed to lack of understanding of profile of obstetric referrals and local challenges faced during implementation process. Objective: This study described the profile of emergency obstetric referrals, challenges faced in implementation of obstetric referral processes and explored self-reported solutions by health workers. Methods: This was a mixed methods study done at Mbarara Regional Referral Hospital (MRRH) and health centre IVs in South-Western Uganda. We consecutively recruited emergency obstetric referrals from Isingiro district for delivery at MRRH. Using a pre-tested questionnaire, we collected demographics, obstetric and referral characteristics. We described the profile of referrals using frequencies and proportions based on demographics, obstetric and referral characteristics. We conducted focus group discussions and in-depth interviews with health workers using discussion/interview guides. Using thematic analysis, we ascertained the challenges and health worker self-reported solutions. Results: We recruited 161 referrals: 104(65%) were below 26 years, 16(10%) had no formal education, 11(7%) reported no income, 151(94%) had no professional-escort, 137(85%) used taxis, 151(96%) were referred by midwives. Common diagnoses were previous cesarean scar (24% [n=39]) and prolonged labour (21% [n=33]). There was no communication prior to referral and no feedback from MRRH to lower health facilities. Other challenges included inconsistencies of ambulance and anesthesia services, electric power, medical supplies, support supervision, and harassment by colleagues. Self-reported solutions included the use of phone call technology for communication, audit meetings, support supervision and increasing staffing level. Conclusion: Most referrals are of poor social-economic status, use taxis, and lack professional-escort. Health workers suffer harassment, lack of communication and shortage of supplies. We need to experiment whether mobile phone technology could solve the communication gap.