Interventions to improve obstetric emergency referral decision making, communication, and feedback between health facilities in sub-Saharan Africa: a systematic review.

OBJECTIVE: To review the evidence on interventions to improve obstetric emergency referral decision making, communication, and feedback between health facilities in sub-Saharan Africa (SSA).

METHODS: A systematic search of PubMed, Embase, Cochrane Register and CINAHL Plus was conducted to identify studies on obstetric emergency referral in SSA. Studies were included based on pre-defined eligibility criteria. Details of reported referral interventions were extracted and categorized. The Joanna Biggs Institute Critical Appraisal checklists were used for quality assessment of included studies. A formal narrative synthesis approach was used to summarise findings guided by WHO's referral systems flow.

RESULTS: 14 studies were included, with seven deemed high quality. Overall, 7 studies reported referral decision-making interventions including training programmes for health facility and community health workers, use of a triage checklist and focused obstetric ultrasound, which resulted in improved knowledge and practice of recognising danger signs for referral. 9 studies reported on referral communication using mobile phones and referral letters/notes, resulting in increased communication between facilities, despite telecommunication network failures. Referral decision-making and communication interventions achieved a perceived reduction in maternal mortality. 2 studies focused on referral feedback, which improved collaboration between health facilities.

CONCLUSION: There is limited evidence on how well referral interventions work in sub-Saharan Africa, and limited consensus regarding the framework underpinning the expected change. This review has led to the proposition of a logic model that can serve as the base for future evaluations which robustly expose the (in)efficiency of referral interventions.