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ORIGINAL ARTICLE
Year : 2023 | Volume
: 22
| Issue : 3 | Page : 265-270
Audit of emergency obstetric referrals at a tertiary center in Kano
Idris Usman Takai1, Murtala Yusuf1, Halima Bashir2
1 Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital; Department of Obstetrics and Gynaecology, Bayero University, Kano, Nigeria
2 Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Kano, Nigeria
Correspondence Address:
Murtala Yusuf
Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital / Bayero University, Kano
Nigeria
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/aam.aam_8_22
Abstract
Introduction: Maternal and perinatal deaths could be prevented if functional referral systems are in place to allow pregnant women to get appropriate services when complications occur. Methodology: The study was a 1-year retrospective study of obstetric referrals in Aminu Kano Teaching hospital, from 1st January to 31st December 2019. Records of all emergency obstetrics patients referred to the hospital for 1 year were reviewed. A structured proforma was used to extract information such as sociodemographic characteristics of the patients, indications for referral, and pre-referral treatment. The care given at the receiving hospital was extracted from the patients' folders. An Audit standard was developed and the findings were compared with the standards in order to determine how the referral system in the study area perform in relation to the standard. Results: There were total of 180 referrals, the mean age of the women was 28.5 ± 6.3 years. Majority (52%) of the patients were referred from Secondary Centres and only 10% were transported with an ambulance. The most common diagnosis at the time of referral was severe preeclampsia. More than half of the patients (63%) had to wait for 30 to 60 minutes before they see a doctor. All the patients were offered high quality care and majority (70%) were delivered via caesarean section. Conclusion: There were lapses in the management of patients before referral; failure to identify high risk conditions, delay in referral, and lack of treatment during transit to the referral centre.
Abstract in French Résumé
Introduction: Les décès maternels et périnatals pourraient être évités si des systèmes de référence fonctionnels étaient en place pour permettre aux femmes enceintes d'obtenir des services appropriés en cas de complications. Méthodologie: L'étude était une étude rétrospective d'un an sur les références obstétricales à l'hôpital universitaire Aminu Kano, du 1er janvier au 31 décembre 2019. Les dossiers de toutes les patientes en obstétrique d'urgence référées à l'hôpital pendant 1 an ont été examinés. Un formulaire structuré a été utilisé pour extraire des informations telles que les caractéristiques sociodémographiques des patients, les indications de référence et le traitement pré-référence. Les soins prodigués à l'hôpital d'accueil ont été extraits des dossiers des patients. Une norme d'audit a été élaborée et les résultats ont été comparés aux normes afin de déterminer comment le système d'aiguillage dans la zone d'étude fonctionne par rapport à la norme. Résultats: Il y avait un total de 180 références, l'âge moyen des femmes était de 28,5 ± 6,3 ans. La majorité (52%) des patients ont été référés depuis des centres secondaires et seulement 10% ont été transportés en ambulance. Le diagnostic le plus courant au moment de la référence était la prééclampsie sévère. Plus de la moitié des patients (63%) ont dû attendre 30 à 60 minutes avant de voir un médecin. Tous les patients ont reçu des soins de haute qualité et la majorité (70%) ont accouché par césarienne. Conclusion: Il y avait des lacunes dans la prise en charge des patients avant la référence ; incapacité à identifier les conditions à haut risque, retard dans la référence et absence de traitement pendant le transit vers le centre de référence.
Mots-clés: Audit, Obstétrique, référence, Kano
Keywords: Audit, Kano, obstetrics, referral
Introduction 
Pregnancy and childbirth are physiological processes that are not free of risks and complications.[1] A woman can come across a number of health-related problems during pregnancy and she can become a victim of death during the process. Two regions, sub-Saharan Africa and South Asia, account for 86% of maternal death worldwide.[2] The vast majority of these deaths occurred in low-resource settings and most could have been prevented.[1],[3]
The treatments for most obstetric complications are well known and the availability of appropriate emergency obstetric and newborn care (EmONC) services would prevent death from most of the complications.[4] Although emergency obstetric and newborn care have been identified as an important health-care intervention toward reducing maternal and newborn morbidity and mortality, the strategy cannot function optimally without its integration with a functional referral system which allows for early diagnoses and treatment at both referring and referral hospitals.[4] The main factors identified as being responsible for poor quality of care were failure to offer 24-h services, lack of drugs, and low-competent birth attendants.[5]
A referral system is a process in which a health worker at one level of the health system having insufficient resources to manage a clinical condition seeks the assistance of a different resourced facility at the same or higher level to assist in or to take over the management of the client case.[6] The process of directing a patient to an appropriate specialist or agency should use a systematic process from a unit of lower capacity to a unit with a higher capacity. The importance of referral in an obstetric emergency is related to the unpredictability of pregnancy complications and their potential to progress rapidly to become severe and threatening. Maternal and neonatal deaths could therefore be prevented if functional referral systems are in place to allow pregnant women to reach appropriate health services when complications occur.[7]
The three-delay model provides a conceptual framework of factors influencing the timely arrival of appropriate care in obstetric emergencies.[7],[8],[9] An efficient referral system is still wanting in Nigeria, as evidenced by the late presentation of women requiring emergency obstetric care.[4] The major causes of maternal mortality predominate the indications for referrals from lower levels to tertiary institutions from numerous reviews.[4],[5],[6],[7],[8],[9] In addition, health system factors constitute a key component of the three-delay model that underlie adverse outcomes including maternal mortality. Thus, identifying referral indications that could otherwise be managed at the referring level are the key to isolating health system deficiencies that could be addressed to make health more accessible to the population.[4],[5],[6],[7],[8],[9]
This audit will seek to identify the indications/reasons for referrals as well as diagnosis at presentation and mode of management offered to the patient. This hopefully might provide a basis for developing training modules for workers at the primary and secondary levels of the health-care system as well as possibly define basic hospital equipment needed to achieve improved maternal outcomes at the hospitals nearest to the population. The aim of the audit is therefore to assess the characteristics of emergency obstetric referral in Aminu Kano Teaching Hospital (AKTH) and to determine the appropriateness and timelines of emergency obstetric referral, the quality of care given at the receiving hospital, and the maternal and perinatal outcomes of patients referred to the hospital.
Methodology This retrospective study is a 1-year review of emergency obstetric referrals in AKTH, Kano, a tertiary center in northwestern Nigeria. The study was carried out from January 01, 2019, to December 31, 2019. Records of all antenatal and postnatal women referred to AKTH for 1 year were reviewed. A structured pro forma was used to extract information such as sociodemographic characteristics of the patients, time of admission, time of referral, indication for referral, and prereferral treatment. The care given at the receiving hospital was extracted from the patients' folders; this includes resuscitative measures given, mode of delivery, maternal and neonatal outcome, and intensive care unit admission among others.
An audit standard was developed based on the departmental protocol and standards obtained from other similar studies.[1],[6],[8],[9] The findings from this study were then compared with the audit standards to determine how the hospital performs in relation to the standard.
Audit standards
Appropriateness of referralEvery patient referred should be accompanied by a written record from the referring facility (100%)Majority of the patients should be accompanied by a health worker (at least 80%)At least half of the patients should be transported with an ambulance (50%)There should be an accurate diagnosis at the time of referral (at least in 80% of cases)Majority of the referred patients should have received resuscitative measures before referral (at least 80%)At least half of the patients should arrive at the referral center within 2 h of referral (50%).Timeliness: All referred emergencies must be seen by a doctor within 30 min (100%)Quality of careAll women with obstetric emergencies must have a properly filled partograph except those delivered through cesarean section (100%)The receiving facility should use its resources to provide patient high quality of care (100%).OutcomeMaternal outcomeMajority of the referred patients should be alive without severe morbidity (80%)There should be no mortality.Fetal outcomeThe fetuses should be alive without severe morbidity in the majority of the referred cases (80%)There should be no mortality.Two-way referral system: At the discharge of the patient back referral to the referring facility should be provided (in at least 80% of cases).Data analysis
The data collected were then transferred into a spreadsheet on Microsoft excel and then analysed using IBM SPSS Statistics for Windows (Version 25.0) [Computer software]. Armonk, NY: IBM Corp. (2017). Both quantitative and qualitative variables were summarized. Mean and standard deviations were calculated for the qualitative variables while percentages and frequencies were used for the quantitative variables.
Results There were a total of 180 referrals within the study period. Out of which only 100 case files were retrieved giving a retrieval rate of 55.5%. The mean age of the women was 28.5 ± 6.3 years with almost 26% within the age group of 26–30 years while only 3% were above the age of 40 years.
Majority of the women (83%) were Muslims, and 81% were of the Hausa tribe. Only 22% had tertiary level of education; the majority had secondary school leaving certificates.
Of the women who delivered within the study period, 46% were primiparous, 33% were multiparous, and 21% were grand multiparous [Table 1].
As many as 52% of the patients were referred from secondary health-care centers and 48% were referred from primary health centers directly, bypassing the secondary centers or intermediate level of referral chain [Table 2]. Distance traveled by the patients before reaching the study center ranged from 2 to 100 km. Majority of the patients (90%) had no accompanying health-care personnel to escort them to the hospital and only 10% were transported with an ambulance. About 32% of the patients received some emergency care before referral. Majority of the patients (52%) presented to the study center following a delay of more than 2 h.
The most common diagnosis at the time of referral was severe preeclampsia, followed by premature rupture of fetal membranes [Table 3]. The diagnosis was found to be accurate in most of the referral (75%).
Most of the patients (76%) were monitored by an appropriately filled partograph at the referral center [Table 4]. More than half of the patients (63%) had to wait for 30–60 min before they see a doctor. All the patients were offered high-quality care with hospital resources. Majority of the patients (70%) were delivered through cesarean section, 28% had spontaneous vaginal deliveries, and 2% had vacuum deliveries.
Majority of the patients (96%) were alive following treatment [Table 5], however, 30% of them had some complications which were managed before discharge. During the study, there were 4 maternal mortalities among the referred patients, 2 of the deaths were from severe preeclampsia, 1 from eclampsia, and 1 from antepartum hemorrhage (abruptio placentae). Majority of the fetuses (79%) were alive, out of which 12% had some complications that required neonatal intensive care admission. Perinatal mortality was found to be 9%, and all of them were cases of intrauterine fetal deaths. At the end of the treatment before discharge, none of the patients was given back referral form to the referring center.
When the audit result was compared with the standard, only 4 of the referral characteristics were in line with the standards, those characteristics include the presence of written record from the referral facility, utilization of hospital resources, and maternal and foetal outcomes [Table 6].
Discussion The main indicators of quality of health care in any country include maternal mortality ratio and perinatal or neonatal death, therefore, provision of basic EmONC (BEmONC) will reduce poor maternal and neonatal outcome and also reduce the rate of referrals. In this study, we found suboptimal or poor management of patients before referral in nearly 68% of the referred cases. This was lower than the reported rate of 75% in a study conducted by Neelam et al.[9] In our study, there was failure in giving antihypertensives and/or magnesium sulfate in case of eclampsia, antibiotics in case of prolonged rupture of fetal membranes or in cases of infections.
Majority of the patients were referred in conditions requiring the presence of a health-care personnel, but only 10% of the patients were accompanied by health-care workers. This is in contrast with the study conducted in Tunisia where majority of the patients were accompanied by health personnel (64.7%).[10] Before referring a patient, emergency treatment should be ensured (intravenous fluids, oxygen, and emergency drugs), this was lacking in most of the cases.
More than half of the referrals were from secondary facilities and considered unnecessary because the required infrastructure and manpower were known to be available at some of the referring centers. Unnecessary referrals can result in congestion and overcrowding of the referral center and a significant increase in workload in addition to increase the financial cost to the patients. In some of the referred cases, the diagnosis was wrong (25%), and most of the errors were in the diagnosis of abnormal labor. This was especially from some of the primary centers as they lack the experienced staff to make accurate diagnosis of labor. Nearly 48% of the patients were referred from primary centers directly to AKTH which is a tertiary center, thus breaching the hierarchy of referral chain. Although, sometimes bypassing the Secondary level of care is necessary if the desired facility is available only at the tertiary centre.
The means of transporting the patients in this study were inappropriate as only 10% of the women were brought to the referral center by an ambulance. This was lower than what was obtained in a similar study in Tunisia (64.9%).[9]
Most of the patients had cesarean section and only 28% had vaginal deliveries; this is similar to a study in Ogun state in Southwestern Nigeria where most of the patients also had cesarean section.[11] The two most common diagnoses for referral were severe preeclampsia and premature rupture of fetal membranes. The diagnosis at the referring hospitals did not conform to the diagnosis established on admission in 25% of the referred patients; this is likely to be due to the lack of well-experienced staff at the referring hospital who can make an appropriate diagnosis. Majority of the referrals were because of a lack of expertise or inability to perform surgery which underscores the need for skill and infrastructure acquisition to be able to meet the BEmONC criteria as recommended by the WHO.[12] Studies from different part of Nigeria have shown that EmONC services are deficient in many centers, especially at primary and secondary levels.[13],[14],[15],[16]
All the referred patients were offered high-quality care with hospital resources at the referral hospital. Partograph was opened for some of them which had been a valuable tool for monitoring the progress of labor. Third-degree delays are factors that prevent adequate treatment at referral centres,[16],[17] but in this study, majority of the patients were seen within 30 min–1 h. However, none of the patients were offered a referral form back to the referring facility. The importance of a two-way referral system cannot be over-emphasized. Two-way referral system can help health-care workers at the lower level to learn from the management of the patients referred to the higher center. In many places, referral system is more like a transfer system rather than a referral and as such, the patients tend to lose their confidence on the lower-level centers resulting in underutilization of those centers.[18]
During the study, four maternal deaths were reported among the referred patients, and about 30 of the patients had severe complications such as acute kidney injury and puerperal sepsis; those complications were managed before the patients were discharged. Furthermore, about 21 perinatal mortalities were recorded and 12 neonatal morbidities; this is likely due to delay in the referral, as about 52% of the patients presented more than 2 h after referral, this results in a delay in treatment at the tertiary center which can lead to irreversible complications and death.
Conclusion The audit of the obstetric referral system in the study area brought out many deficiencies at the level of the referring centers. A lot of the audit standards were not achieved. Most of the patients were not accompanied to the referral center by a health-care worker. There was inadequate treatment before referral and lack of treatment during the transit to the referral center.
Recommendations
Provision of ambulances by the government to facilitate referralsEmphasis should be made on training and retraining of health workers at primary and secondary centers, this will improve appropriateness of referrals; there should be specific guidelines for “whom to refer,” “how to refer,” “when to refer,” and “where to refer” in case of emergenciesThe receiving facility should have a back referral form to let the referring facility know what was done for their patients, this completes the loop between the two facilitiesMechanism to monitor referral by policymakers should be put in place so as to reduce unnecessary referral to tertiary centers.Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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