Enhancing accountability in maternal and newborn health referrals through a network of care: A mixed methods implementation research in Makueni, Kenya

Effective coordination and timely action are crucial for preventing and managing maternal and newborn health (MNH) complications. In low- and middle-income countries, these elements are often inadequate given complexity in health systems dynamics. A major challenge is the lack of accountability for actions and outcomes across interconnected health facilities alongside inefficient MNH referral systems. This study assessed changes in accountability within a broader implementation research effort assessing the feasibility, acceptability, and effectiveness of integrating a Network of Care (NoC) in Kenya. This mixed methods study assessed whether establishing a County-level NoC enhanced accountability in MNH referrals and relationships among health facilities. Quantitative data were collected through six rounds of phone surveys with MNH healthcare providers, while qualitative data was collected from focus group discussions with MNH healthcare providers and key informant interviews with county health managers at baseline, midline, and endline. Accountability outcomes were categorized under three themes: Proactive and Efficient MNH Referral Systems, Collaboration and Communication, and Trust among providers. Quantitative analysis indicated significant improvements (p < 0.05) in 12 out of 17 accountability measures. Qualitative data highlighted enhanced referral systems, clarity of roles, peer learning, teamwork, respect, confidence and transparency within and across facilities, presenting an opportunity to enhance inter-facility accountability through a well-coordinated NoC. Study findings suggest that NoCs, which support efficient collaborative health systems decision-making and action to optimize person-centered outcomes, can enhance accountability in MNH and offer a transferable model for similar settings. • Mixed methods study explores referral accountability in a maternal health network. • Health worker perspectives show perceived gains in communication and collaboration. • Findings reflect improved clarity of roles and strengthened inter-facility linkages. • Networks of Care perceived to support peer learning and mutual trust. • Study offers insights on structuring referral coordination in low-resource settings