Obstetric referrals from a rural clinic to a community hospital in Honduras
Introduction
When analysing obstetric care in low-resource settings, it has been shown that maternal/neonatal morbidity and mortality are strongly linked to healthcare access during intrapartum events (Lee et al., 2009). Numerous studies note that complications during labour and childbirth are responsible for an estimated one-half of maternal deaths, one-third of stillbirths, and one-fourth of neonatal deaths (McClure et al., 2007, Lawn et al., 2009, Cousens et al., 2011, Oestergaard et al., 2011, Pasha et al., 2013). Several studies suggest a large potential reduction in intrapartum-related neonatal deaths and implementation of widespread comprehensive emergency obstetric care with improvements in facility delivery (Lawn et al., 2009, Kamath-Rayne et al., 2015). However, access to basic emergency obstetric care (intravenous administration of antibiotics, oxytocics and anticonvulsants; assisted vaginal childbirth; manual removal of retained placenta; and removal of retained products) is challenged by delays in decision-making associated with referral, transport, care and communication. Delays in decision-making thereby lead to associated increase in morbidity and an increase in healthcare spending for reproductive care (Lee et al., 2009).
Honduran healthcare is decentralised, such that small rural clinics refer and transport patients to facilities with more experienced staff and more advanced technology to care for sick patients. A decentralised healthcare model is not unique to Honduras, and guidelines already exist for targeted improvement of these systems in low-resource areas. The Mesoamerican Health Initiative in Latin America aims to address deficiencies in access to certain targeted interventions for maternal and newborn health (Lozano et al., 2011). These include skilled childbirth care, emergency obstetric care, neonatal care, and contraceptive family planning. A Honduran specific study from the 1990s by Omaha, et al., suggested four points to improve the linkages between clinics and hospitals in Honduras to better manage overall patient load: first, increase awareness regarding the importance of a referral system; second, ensure that key patient information is efficiently communicated between institutions; third, allow open crosstalk between institutions regarding referral cases and patient load; and finally, educate patients and staff on the efficient use of healthcare services in Honduras (Omaha et al., 1998).
Despite these recommendations, little detailed information exists that describes the full referral process from a rural setting to a regional community hospital, and the outcomes of the patients involved, to determine whether these recommendations are being achieved. According to 2012 census data, 83% of births in Honduras take place in the presence of a professional healthcare worker, such as a licensed nurse, auxiliary nurse, or doctor (Instituto Nacional de Estadística, 2013). Although this percentage gives an indication of the availability of healthcare, it fails to reveal the condition in which pregnant women arrive at healthcare facilities, the quality of care in the facilities, and the complications that arise along the continuum of care.
Therefore, the purpose of this retrospective study was to characterise the obstetrical referrals from a rural clinic to community referral hospital in Honduras, and to describe subsequent maternal and neonatal outcomes.
Section snippets
Methods
The study setting was Intibucá, a mountainous rural department in southwest Honduras with a population of about 180,000, 86.6% living in rural conditions (Censo De Poblacion Y Vivienda, 2001). The annual birth rate is 40.5 live births per 1000 people and the infant mortality rate is 42.1 deaths per 1000 live births (Censo De Poblacion Y Vivienda, 2001). The neonatal mortality rate is 18 deaths per 1000 live births (Instituto Nacional de Estadística, 2013). The estimated maternal mortality ratio
Findings
Between July 2012 and May 2013, a total of 199 pregnant women presented for care at the rural clinic. One-hundred-seven women delivered in the rural clinic, all singleton and vaginal deliveries. There were 92 documented obstetric referrals from the rural clinic to the community hospital (Fig. 1). Of these 92 referrals, 66 (72%) referrals had full data regarding arrival times, delivery times, and diagnoses. These 66 patients were included in our analysis. The remaining 26 (28%) referral patients
Discussion
Strengthening healthcare systems so that comprehensive and high-quality clinical care is provided to mothers and babies is a high priority in maternal and child health (Dickson et al., 2014). To do so, health care systems must improve links between rural clinics and community hospitals, so that referral pathways can increase the availability of emergency obstetric care to at-risk mothers. Ideally, both mother and baby should be matched with adequate resources and personnel for the complexity of
Conclusion
Challenges with personnel and infrastructure are barriers to timely referral in obstetrical emergencies and delivery of quality care. Understanding the barriers that cause delays in the decision to refer and the transport of the high-risk pregnant women to a higher level of care is the first step towards improving the situation. This study points out the need for targeted reform in two general areas: personnel and infrastructure. Future personnel reform should target our observations regarding
Conflict of interest
The authors have no conflicts of interest to disclose.
Acknowledgements
The authors thank the Division of Neonatology, Cincinnati Children׳s Hospital Medical Centre, for the financial support of this project. We also thank Dr. Ramon Dario Argueta (Director of Paediatrics), Dr. Domingo Amador (Hospital Director), and Dr. Juan Carlos Vasquez (Hospital Assistant Director) for their support of the project.
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Barriers and technologies of maternal and neonatal referral system in developing countries: A narrative review
2019, Informatics in Medicine UnlockedCitation Excerpt :Distance to the healthcare facility is shown to be an important barrier, especially in rural areas [3]. Based on the literature reviewed, environmental factors such as poor road network [22,25,26,30,32] and bad weather conditions such rain the entire day or storms [27,28] can hinder patients from reaching referral facilities. Furthermore, distance to healthcare facilities in some areas caused patients to prefer seeking care at home by traditional healthcare workers, rather than seeking more appropriate and sophisticated care at referral facilities [28,36,51,54,61].
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