An exploratory case study of the organizational functioning of a decision-making and referral support call center for frontline providers of maternal and new born care in the Greater Accra Region of Ghana

Strengthening Kampala's Urban Referral System for Maternal and Newborn Care Through Establishment of an Emergency Call and Dispatch Center

INTRODUCTION

Most pregnant women living in urban slum communities in Uganda deliver at public health centers that are not equipped to provide emergency obstetric and newborn care. When obstetric emergencies occur, pregnant women are referred to a higher-level facility and are responsible for arranging and paying for their own transport. The Kampala Slum Maternal Newborn (MaNe) project developed and tested an emergency call and ambulance dispatch center and a mobile application to request, deploy, and track ambulances. We describe the development of these 2 interventions and findings on the feasibility, acceptability, and sustainability of the interventions.

METHODS

MaNe conducted a mixed-method feasibility study that included an assessment of the acceptability and demand of the interventions. In-depth interviews (N=26) were conducted with facility proprietors, health providers, ambulance drivers, Kampala Capital City Authority officers, and community members to understand the successes and challenges of establishing the call center and developing the mobile application. Thematic content analysis was done. Quantitative data from the call center dispatch logs were analyzed descriptively to complement the qualitative findings.

FINDINGS

Between April 2020 and June 2021, 10,183 calls were made to the emergency call and dispatch center. Of these, 25% were related to maternal and newborn health emergencies and 14% were COVID-19 related. An ambulance was dispatched to transfer or evacuate a patient in 35% of the calls. Participants acknowledged that the call center and mobile application allowed for efficient communication, coordination, and information flow between health facilities. Supportive district leadership facilitated the establishment of the call center and has taken over the operating costs of the center.

CONCLUSION

The call center and referral application improved the coordination of drivers and ambulances and allowed facilities to prepare for and treat cases more efficiently.

The "No bed syndrome" in Ghana - what, how and why? A literature, electronic and print media review

Objectives

"No bed syndrome" has become a familiar phrase in Ghana. Yet, there is very little in medical texts or the peer reviewed literature about it. This review aimed to document what the phrase means in the Ghanaian context, how and why it occurs, and potential solutions.

Design

A qualitative desk review using a thematic synthesis of grey and published literature, print and electronic media content covering the period January 2014 to February 2021. Text was coded line by line to identify themes and sub-themes related to the research questions. Analysis was manual and with Microsoft Excel to sort themes.

Setting

Ghana.

Participants and Intervention

Not applicable.

Results

"No bed syndrome" describes the turning away by hospitals and clinics of people seeking walk in or referral emergency care with the stated reasons "no bed available" or "all beds are full". There are reported cases of people dying while going round multiple hospitals seeking help and being repeatedly turned away because there is "no bed". The situation appears to be most acute in the highly urbanized and densely populated Greater Accra region. It is driven by a complex of factors related to context, health system functions, values, and priorities. The solutions that have been tried are fragmented rather than well-coordinated whole system reform.

Discussions and recommendations

The "no bed syndrome" describes the challenge of a poorly functioning emergency health care system rather than just the absence of a bed on which to place an emergency case. Many low and middle income countries have similar challenges with their emergency health care systems and this analysis from Ghana is potentially valuable in attracting global attention and thinking about emergency health systems capacity and reform in low and middle income countries. The solution to the "no bed syndrome" in Ghana requires reform of Ghana's emergency healthcare system that takes a whole system and integrated approach. All the components of the health system such as human resource, information systems, financing, equipment tools and supplies, management and leadership need to be examined and addressed together alongside health system values such as accountability, equity or fairness in the formulation, implementation, continuous monitoring and evaluation of policies and programs for system reform to expand and strengthen emergency healthcare system capacity and responsiveness. Despite the temptation to fall back on them as low hanging fruit, piecemeal and ad-hoc solutions cannot solve the problem.

Quality and women's satisfaction with maternal referral practices in sub-Saharan African low and lower-middle income countries: a systematic review

Background

sub-Saharan African Low and Lower-Middle Income Countries (sSA LLMICs) have the highest burden of maternal and perinatal morbidity and mortality in the world. Timely and appropriate maternal referral to a suitable health facility is an indicator of effective health systems. In this systematic review we aimed to identify which referral practices are delivered according to accepted standards for pregnant women and newborns in sSA LLMICs by competent healthcare providers in line with the needs of pregnant women.

Methods

Six electronic databases were systematically searched for primary data studies (2009–2018) in English reporting on maternal referral practices and their effectiveness. We conducted a content analysis guided by a framework for assessing the quality of maternal referral. Quality referral was defined as: timely identification of signal functions, established guidelines or standards, adequate documentation, staff accompaniment and prompt care by competent healthcare providers in the receiving facility.

Results

Seventeen articles were included in the study. Most studies were quantitative (n = 11). Two studies reported that women were dissatisfied due to delays in referral processes that affected their health. Most articles (10) reported that women were not accompanied to higher levels of care, delays in referral processes, transport challenges and poor referral documentation. Some healthcare providers administered essential drugs such as misoprostol prior to referral.

Conclusions

Efforts to improve maternal health in LLMICs should aim to enhance maternity care providers’ ability to identify conditions that demand referral. Low cost transport is needed to mitigate barriers of referral. To ensure quality maternal referral, district level health managers should be trained and equipped with the skills needed to monitor and evaluate referral documentation, including quality and efficiency of maternal referrals.

Trial registration

Systematic review registration: PROSPERO registration CRD42018114261.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12884-020-03339-3.