A health systems analysis of non-compliance to the maternity referral system by health facilities in Uganda: Findings from a mixed-methods study

IntroductionA fully functional referral system is central to achieving quality maternal and newborn care. In 2018, Uganda established Kawempe National Referral hospital (KRNH) as the highest level of care for maternity services. There is a dearth of data examining if the referral function for which it was established has been met. The objectives of this study were two fold; i) to assess the appropriateness of in-coming referrals at KRNH ii) to examine factors underpinning referral decisions at lower referring facilities across Uganda. MethodsThis was a two-phased, mixed-methods study involving 76 health facilities across Uganda. In Phase One, we conducted a cross-sectional study examining incoming referrals at KNRH between July 2019 and August 2020 based on routinely collected data in the Health Information System (HMIS) in-patient registers. In Phase Two, we qualitatively explored factors underpinning maternity referrals at 75 purposively selected facilities. Descriptive statistics were managed in STATA (v14) while qualitative data were analyzed by thematic approach. ResultsA total of 461,226 referrals were made to KNRH during the period under review. The three most common indications for referral at KNRH were; previous caesarian scar, premature rupture of membranes and obstructed labour. Facilities mandated to offer comprehensive emergency obstetric care such as general hospitals (84%) and sub-district hospitals or Health Centre IVs (18%) were the two leading sources of referrals at KNRH. Shortage of basic commodities, poorly equipped theatres, deficiencies in skills for labour, study leaves for maternity workforce at lower facilities contributed to unnecessary referrals. ConclusionSeveral of the indications of referrals at KNRH are ideally manageable at lower referring facilities such as district and sub-district hospitals levels suggesting deficiencies in the national obstetric referral system. Interventions for strengthening basic clinical skills in the management of labour at lower referring facilities and addressing underpinning health system constraints is recommended.