Obstetric referral practices and health system factors in public health centres of Addis Ababa, Ethiopia: A mixed-methods study

OBJECTIVE: To determine the rate of obstetric referral and explore contextual factors influencing referral practices in public health centres of Addis Ababa, Ethiopia. DESIGN: Explanatory sequential mixed-methods study. SETTING AND PERIOD: Fifty public health centres in the Addis Ababa City Administration, January-April 2021. METHODS: Delivery 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 Colaizzi's method. RESULTS: Only 13 (26%) of the 50 health centres have met all eight standards assessed for functionality of the referral system. The main gaps of the referral system were a lack of ambulance (12%), absence of formal agreement with referral centers, and lack of timely case-by-case feedback from referral centers(64%). The overall obstetric referral rate was 32%, with substantially higher referral rates in health centers 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. CONCLUSION: Improving functionality of referrals and reducing unnecessarily high referrals requires adopting and training providers on the new WHO labour guide and partograph, improving referral feedback, and clarifying accountability mechanisms.