Obstetric Referral Practices and Health System Factors in Public Health Centres of Addis Ababa, Ethiopia: A Mixed-Methods Study

ObjectiveTo determine the magnitude of obstetric referral and to explore contextual factors influencing referral practices in public health centres of Addis Ababa, Ethiopia. DesignExplanatory sequential mixed-methods study. Setting and periodFifty public health centres in Addis Ababa City Administration, January-April 2021. MethodsDelivery and referral registers from 50 health centres were reviewed retrospectively for 12 months (8 July 2019-7 June 2020). Facility observations and interviews with maternity unit heads were conducted in all selected centres. In-depth interviews were conducted with 20 midwives and 13 health-centre managers. Quantitative data were analysed descriptively, and qualitative data were analysed thematically using Colaizzis method. ResultsEighty percent of health centres had a functional referral system. The overall obstetric referral rate was 32%, with substantially higher referral rates in facilities without caesarean section (CS) services compared with those providing CS (39% vs 21%). Qualitative findings indicated that high referral rates were associated with limitations in the predictive capacity of the partograph, variability in providers clinical skills, and risk-averse practices driven by accountability concerns related to maternal and perinatal outcomes. ConclusionAlthough referral systems were largely functional, obstetric referral rates were high, suggesting potential over-referral. Updating labour monitoring tools, strengthening provider competencies, and clarifying accountability mechanisms may reduce unnecessary referrals.