Emergency obstetric referrals in public primary health care centres in Benin City, Nigeria: a qualitative study

Abstract

The aim of this study was to assess the mechanisms, procedures, and processes of the referral system for emergency obstetric care (EmOC) in public primary health care centres (PHCs) in Benin City, Edo State, Nigeria, with recommendations offered to address the challenges. A qualitative study was conducted in Egor Local Government Area (LGA), purposively selected from the three LGAs in Benin City. From the 11 public PHCs in Egor LGA, nine were selected based on their provision of maternal care and performance of EmOC in the three months preceding this study. Nine key informant interviews were conducted using a semi-structured interview guide, with one nurse or midwife, serving as a senior health care provider or health facility manager, selected as the participant per PHC. Data saturation was achieved with this sample. The interviews were audio-recorded, transcribed verbatim, and analysed thematically using NVivo V.12.0 software. From the responses of all the participants, three themes emerged following data analysis: (1) mechanisms, procedures, and processes for the referral of obstetric emergencies. From many of the participants’ responses, the associated categories were availability of emergency transport vehicles; process for receiving feedback and follow-up, among others; (2) Challenges encountered with the referral system. From many of the participants’ responses, the associated categories were infrastructural deficits such as nonavailability of ambulances. For some participants, other challenges mentioned were presence of bad roads leading to the PHCs; logistics constraints such as shortage of staff and stock-out of referral letters; and patient-related challenges such as financial constraints, and preference for traditional care; and (3) recommendations for improving the referral systems. From many of the participants’ responses, the associated categories were strengthening the infrastructure through addressing logistics and resource challenges. Public PHCs in Egor LGA have existing procedures for referring obstetric emergencies. However, challenges exist in terms of nonavailability of written referral protocols and emergency transportation, poor two-way communication, inadequate staffing and logistics, thereby limiting its effectiveness. Strengthening these health system components could improve the quality of referrals and contribute to reducing preventable maternal mortality in Edo State, with implications for the rest of Nigeria.