Incentives to yield to Obstetric Referrals in deprived areas of Amansie West district in the Ashanti Region, Ghana

The progress towards fulfilling the fifth UN Millennium Development Goal (MDG 5), to reduce maternal mortality by three quarters by 2015, is still far off the track in most countries of the world [1]. Despite evidence of effective interventions to promote safe motherhood, morbidity and mortality related to pregnancy and childbirth remain major challenges to stakeholders in health in low-and- middle-income countries. Developed countries have actually succeeded in improving maternal health and reducing maternal mortality. Developing countries on the other hand, are still faced with big inequalities in health within and between different segments of the populations. Disadvantaged groups of women tend to have higher rates of both morbidity and mortality, and less access to safe, affordable and acceptable health care services to enable safe pregnancy and childbirth [1, 2].

Obstetric referral is an important component of emergency care, necessary in reducing maternal mortality. Inability to timely refer expectant mother and refusal of the referred client to honour such referral leads to development of life-threatening complications, often resulting in preventable maternal deaths. Referrals systems connect the lowest level of care to the highest level and ensure access to specialist and continuum of care, as patients are referred from dispensaries and health centers in communities to a secondary level of care [3]. Previous evidence suggests that effective and efficient referral system could reduce stillbirth by 27 %, neonatal deaths by 18 % and maternal deaths by 50 % [4].

In Ghana, the community level represents the largest continuum of the health system and this comprises the community health clinic and the Community-based Health Planning and Services (CHPS), which mainly offer preventive care. This strategy was adopted in 1999 to extend quality Primary Health Care (PHC) to all Ghanaians, especially those in remote areas. It functions in galvanizing local leadership and empowering communities to engage in health outreach activities. A Community Health Officer (CHO) and a nurse are delegated to distant village locations (CHP zones), where they follow clients to their communities and homes to deliver basic health services. The CHO initiates referral to the next level of care during emergencies [5, 6]. The next level of care is the sub-district level, which entails the sub-district management team and health center for managing basic Emergency Obstetric and Neonatal Care (EmONC). From this point, patients are referred to the district referral hospital and then further to the regional hospital.

Maternal health referral systems in Ghana is however fraught with gaps in service proficiency, leading to increased maternal risk. These are exacerbated by socio-economic characteristics, distance to health facility, financial constraints, access to reliable transport services, quality of care and unstructured referral systems [7]. The interplay of these factors influence physician referrals [8‐11] and patients’ acceptance to go to the next level [12, 13]. Alter [9], for example, found individuals with high socio-economic status to be more likely to be referred. However, the role of these factors in ensuring smooth referrals in this setting appears to be overlooked.

It is important to note that, the outcome of late obstetric referrals could be detrimental to both the pregnant mother and unborn baby. Pregnancy complications are unpredicted and have the potential to develop rapidly to become severe and life threatening. Previous literature suggests that about two-thirds of women in developing countries deliver at home, without having access to health professionals [14]. Effective referral could prevent the phase II delays (delays in reaching the appropriate facility), as postulated by the three delays model, which describes factors influencing the timely arrival to appropriate care in obstetric emergencies [15]. This study is important, to provide insight into the current obstetric referrals in the Amansie West district. It also adds to existing knowledge on factors that influence obstetric referrals to secondary level of care. This is important to understand which individuals are likely to honour referrals to secondary level of care to help address disparities in access to healthcare.

The protocols of this research were reviewed and cleared by the Committee for Human Resource Publications and Ethics of Kwame Nkrumah University of Science and Technology, Kumasi, Ghana, before the commencement of the study. Prior informed consent was also sought from all participants. All recruited patients and health personnel signed an informed consent and permission was sought from the District Health Directorate, Amansie West and the opinion leaders of study communities.

Efficient referral systems are very essential in maternal healthcare to ensure a smooth linkage between the lower levels of care, which provides mainly preventive services with the higher specialized healthcare delivery. This study sought to gain insight into the referral systems at the Amansie West district in Ghana, and to assess the influence of socio-economic factors, transport availability and pregnancy history on obstetric referrals. This study had two main findings. First, the study found transportation as an important factor in effective referral system. Access to ambulance was quite low and difficulty in accessing transportation barred some pregnant women from accepting and honouring referrals. Second, socio-economic status significantly influenced community health worker’s decision of who should be referred for secondary care and to a large extent who honours referral. Respondents in the higher wealth quintile were more likely to be referred and honoured as compared to those in the lowest quintile. Obstetric referrals were found to be low in the Amansie West district, with only 21.7 % of the women interviewed ever being referred to the next level of care.

Patients’ perception of their disease conditions influenced their willingness to accept referral to the next level of care in this study. The most cited disease condition was oedema followed by cough and malaria. Malaria was however the leading cause of OPD attendance in the district in 2013 [16]. In a similar vein, most of the women indicated that they were referred to the next level of care for conditions other than malaria. The district has only one (1) district hospital and six (6) health centres. The health centres are however not well equipped and the chances are that they may make unnecessary referrals.

Transportation is an important factor in healthcare delivery, especially in cases of emergency. Rural and remote regions in developing countries have limited access to regular and suitable transport, making physical access to specialized healthcare difficult or impossible in some cases. Many developing countries’ studies, identified transport cost, availability of transport and travel time as strong correlates of health care utilization [19, 20]. Rural dwellers often have greater distances to cover in order to reach health care services [21] and transport costs are relatively higher [19]. Under the current CHPS strategy in Ghana, transportation is paramount since the services provided at the CHPS zones are basically preventive and there is the need to ensure reliable means for referrals.

In this study, access to reliable transportation appeared to be an issue for most of the women. Although majority indicated that transport services were available, most of these were commercial vehicles and only a few had access to ambulances during emergencies. Arranging for transport could take about 30 min to an hour for some of the respondents. This finding is parallel with previous evidence where participants narrated their difficulties in having access to transportation and in some instances, were forced to deliver at home [22, 23]. This has been cited as a drawback of the CHPS strategy; failing to take into consideration all the important aspects of health delivery and most importantly making provision for effective referrals. For this reason, some patients are forced to refuse referrals to the next level of care, which is very characteristic of a health care with weak ambulatory system. The Amansie west district has very poor road network in most parts of the district such that when distances to facilities are even short, vehicles would not like to ply those roads.

The role of socio-economic disparities in health care in limited resource settings has long been confirmed through research. Investigating into the socio-economic differences in different aspects of health delivery is important to ensure equitable distribution of healthcare to all people. This study found that wealth status could have influence on who is being referred to the next level of care and whether the referred patient will honour such referrals. The distribution of respondents according to wealth quintiles was quite uniform in this study and majority of the women rated themselves as moderately rich. As compared to women in the lowest wealth quintile, belonging to the second and fourth wealth quintiles significantly increased the likelihood of being referred to the next level of care.

As suggested in previous studies, this could be explained that women with high socio-economic status tend to be more knowledgeable about their illness, have greater expectations of the level of care and could better negotiate with their primary care physician to maximize their referral and access the next level of care [9]. From another viewpoint,, community healthcare workers refer mothers they believe have the financial resources to make it to the secondary level, putting those in the lowest wealth quintile at a disadvantage. Studies from other settings have also reported physicians’ lack of motivation to refer patients who are not on medical insurance, with the belief that they could not afford cost of care at the next level [10, 11]. This is however, discriminatory and should be discouraged by addressing the structural problems of road network and ambulatory system. It is expensive in terms of transportation and cost of healthcare to be referred to the next level and those in the high wealth quintiles honoured obstetric referrals because they had the means to [9]. As put forward by Buor [19], the use of health services depends on one’s ability to pay. Low incomes had been captured as a barrier to seeking healthcare and can create a devastating financial burden for some people [24], especially in a setting with inequitable access to healthcare. A lack of finance could therefore have adverse effect on health care seeking [25, 26]. That is although the willingness to pay for services might exist [27], the means to do so, may not. On the other hand, Chan [8], found physician referrals to be higher among low socio-economic status individuals and this they explained that this group of patients were likely to have more illness.

The age, educational, employment, length of stay in community being an active member of NHIS appeared not to be important in health workers decision to refer patients to the next level. The implications for these in the attainment of maternal health targets could be devastating. Probably implementing pro-distance and referral intervention health care delivery strategy could be helpful.

The choice of cross-sectional study design could not permit us to make direct inferences on the relationship between maternal referrals and the covariates studied. This study might also have suffered some recall bias in responses from participants. We however believed that this was not much and could not affect the findings and conclusions of the study, since most of the questions pertained to their recently past pregnancies.

Incentives to yield to obstetric referrals to the next level in deprived areas were found to depend on health staff’s decision as to who to refer, clients’ perception about severity of health condition, availability of transportation and high-income level of the client. The absence of these are disincentives to honour obstetric referrals to the next level in a setting with inequitable access to healthcare. Implementing social interventions and improving ambulatory system could improve the situation and help attain maternal health targets in deprived areas. The health centres are faced with logistical constraints and are unable to manage primary health conditions. The CHPS compounds, CHCs, community clinics and maternity homes must therefore be well equipped to offer the requisite primary health care for pregnant women and refer to the district hospital only when appropriate.