Measuring delay in high-risk obstetric referrals in Accra, Ghana: How long does it really take?

Abstract Background In Ghana, inefficient referral systems for managing obstetric emergencies is an obstacle to receiving optimal care. The timeliness of referral for comprehensive emergency obstetric care (CEmOC) from district or sub-district facilities to referral hospitals is unknown. The Greater Accra Regional Hospital (GARH) conducts approximately 8,000 deliveries per year that includes 70% high-risk referrals. Our aim was to characterize referrals for obstetric patients seeking care at the GARH in Accra, Ghana. Methods Data was collected on obstetric patients referred to the GARH from September 1 to November 30, 2017. A descriptive analysis was conducted on the following variables: location of referring facility, time from referral to arrival at GARH, mode of transport, referring diagnosis and members accompanying the patient. Data are presented as number, percent or median (IQR). Results Data were collected for 652 obstetric patient referrals to the GARH from 123 surrounding facilities. Transportation modes included: taxi (76.4%), ambulance (8.1%), private car (8.0%), public van (5.5%) and unknown (2.0%). Of 652 referrals, 303 (46.5%) were received during labour. The median time (IQR) from referral to arrival at GARH for 280 labouring patients was 307 (170, 1778) minutes. Midwives accompanied patients in only 71 (10.9%) of referrals; however, in these, median (IQR) referral times were 73 (34, 268) minutes. The leading referral indications included: Arrest of labour (26.3%), prior uterine scar (11.6%) and hypertensive disorders of pregnancy (11.5%). There were seven (1%) maternal deaths; four died the day of arrival. For 110 (17%) pregnancies, prolonged hospitalization was required for complications. There were 32 stillbirths (5%), including six intrapartum deaths. Conclusions The obstetric referral process for CEmOC is suboptimal. Most intrapartum referrals relied on public transport to reach the CEmOC facility and were unaccompanied by healthcare personnel. There is significant delay in the referral process, even in an urban setting. Delay may contribute to poor maternal and newborn outcomes.