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

Introduction A 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. Methods This 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. Results A 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. Conclusion Several 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. ### Competing Interest Statement The authors declare they have no competing interests ### Funding Statement This study was funded by the Uganda Ministry of Health ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Makerere University, School of Public Health, Institutional Review Board I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors