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High-Risk Obstetric Referrals in Accra, Ghana: Understanding the Second Delay
Abstract Number: F1A-4
Abstract Type: Original Research
Introduction: Of the estimated 300,000 maternal deaths worldwide each year, 98% occur in low-resource countries. In Ghana, weak referral systems, particularly for managing obstetric emergencies, are sited as a leading challenge to achieving the millennium development goals. Yet, little is known about the characteristics of patient referrals from district to tertiary level facilities for advanced care. In 2000, a paper assessed peripartum referrals to Korle Bu teaching hospital in Accra, Ghana, including causes of referral, who accompanied the patients and sources of referrals but did not adequately address transit time.1 Similar to Korle Bu, the Greater Accra Regional Hospital (GARH) is a large referral hospital with 9,000 deliveries per year of which 70% are high-risk referrals.2 Our aim was to characterize aspects of the referral system after nearly two decades and determine the timelines of transport to GARH in Accra, the capital city.
Methods: Data was collected on obstetric patients referred to the GARH from September 1 to October 31, 2017. A descriptive analysis was conducted on the following variables: time taken to reach GARH, modes of transportation, referring diagnosis and members accompanying the patient. Data are presented as number, percent or median (IQR).
Results: There were 552 obstetric patients referred to the GARH from 115 surrounding facilities. Modes of transportation included: taxi (81%), ambulance (9%), private car (8%), and unknown (2%). Patients were accompanied by husbands (51%), other relatives (35%), no one (12%), unknown (2%). Midwives accompanied patients in only 13% of referrals. Out of 552, there were 242 (44%) patients referred during labour. The time required to reach GARH was available for 164 laboring patients with a median (IQR) of 239 (127, 345) minutes to reach the facility. There was no difference in arrival time between the day or night. The top three indications for referral during labor were: Failure to progress (30%), hypertensive disorders of pregnancy (11%), and prior uterine scar (9%). There were seven (1.3%) maternal deaths within the dataset, all of whom died within 24 hours of arrival at GARH. For 103 (19%) pregnancies, prolonged hospitalization was required due to complications. There were 28 stillbirths (5.1%), seven of which were intrapartum deaths.
Discussion: As shown, it took nearly four hours for laboring women to reach the referral hospital. The majority arrived by public transport unaccompanied by a health care provider. The modes of transport and the causes of referral were similar to the previous study published in 2000. We conclude that there is significant delay that occurs within the referral process in Accra, Ghana and inappropriate modes of transport remain for high-risk women in labor. This may contribute to poor maternal and newborn outcomes.
Reference: 1Tropical Medicine and International Health 2000;5(11):811-17.2 2BMC Pregnancy Childbirth 2017;17:216.