Referral and counter-referral practices in obstetric emergencies among health-care providers in selected health facilities in Plateau state, Nigeria

Alberta David NSEMO, Samuel Mahan Zakka MALAU, Idang Neji OJONG

1Department of Nursing Science, University of Calabar, Calabar, Cross River State, Nigeria; 2Department of Midwifery, College of Nursing and Midwifery, Vom, Plateau State, Nigeria

Referral and counter-referral practices in obstetric emergencies among health-care providers in selected health facilities in Plateau state, Nigeria

Alberta David NSEMO1, Samuel Mahan Zakka MALAU2, Idang Neji OJONG1

1Department of Nursing Science, University of Calabar, Calabar, Cross River State, Nigeria;2Department of Midwifery, College of Nursing and Midwifery, Vom, Plateau State, Nigeria

ABSTRACTObjective:This study aimed to examine the referral and counter-referral practices in obstetric emergencies among health-care providers in selected health facilities in Plateau state of Nigeria.Materials and Methods:A concurrent embedded descriptive mixed method consisting of both quantitative and qualitative methods was adopted for the study. Participants (104) were recruited using multistage sampling and 8 participants using purposive sampling techniques for quantitative and qualitative aspects of the study, respectively. The three-phase delay model directed the study. A self-developed structured questionnaire and an in-depth interview guide were used to elicit quantitative and qualitative responses from the participants. Quantitative instrument was tested for reliability, while the qualitative instrument went through the rigors of qualitative data.Results:Findings revealed low level of referral and counter-referral practices as only 19 (18.27%) and 30 (28.85%), respectively, of care providers referred patients above 10 times in a year. The study also revealed inadequate human and material resources for referrals and counter-referrals. The mean on barriers to referral was 2.90, which was above the cutoff of mean of 2.50, which indicates that the barriers are militating against referral and counter-referral in obstetric emergencies.Conclusions:Low levels of referral and counter-referral practices are identified with inadequate resources among others posing as barriers. Therefore, provision of standard operational procedures/protocols in every health-care facility as well as provision of adequate material and skilled human resources among others is recommended to enhance referral and counter-referral network in obstetric emergencies. There is also a need for teamwork and synergy among all stakeholders in the referral chain.

Keywords:Challenges, counter-referral, health-care facilities, health-care providers, obstetric emergencies, practices, referral

Address for correspondence:Dr. Alberta David NSEMO, Department of Nursing Science, University of Calabar, Calabar, Cross River State, Nigeria.

E?mail: albertansemo@yahoo.com

Submitted:29-Mar-2022

Revised:25-Jun-2022

Accepted:28-Jul-2022

Published:29-Sep-2022

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

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How to cite this article:Nsemo AD, Zakka Malau SM, Ojong IN. Referral and counter-referral practices in obstetric emergencies among health-care providers in selected health facilities in Plateau state, Nigeria. J Integr Nurs 2022;4:127-36.

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INTRODUCTION

In Sub-Saharan Africa, the Nigerian maternal mortality ratio in 2017 was 917 deaths per 100,000 live births.[1]Women’s chances of dying from pregnancy and childbirth in Nigeria are 1 in 13.[2]Reducing maternal mortality has been rolled on into the Sustainable Development Goal (SDG) 3 which seeks to ensure healthy lives and promote well-being for all at all ages.[2]This goal targets to reduce the global maternal mortality ratio to ＜70 per 100,000 live births by 2030.[2]Weak referral and counter-referral systems are serious factors threatening the achievement of the maternal health SDG particularly in low- and middle-income countries including Nigeria. The World Health Organization (WHO) through its safe motherhood initiatives noted that for woman with emergency obstetric complication(s) such as bleeding or severe hypertensive disorders, the dysfunction of the referral system to timely and safely transfer to an appropriate level of care and expertise may have devastating maternal and fetal outcomes including death.[3]It is assumed that in terms of diagnostics and skilled attendance, high-level facilities are better equipped than those from which the referral was initiated.

Access to appropriate health care including skilled birth attendance at delivery and timely referrals to access emergency obstetric care (EmOC) services can greatly reduce maternal deaths and disabilities.[4,5]Hence, the inability of most women to access timely emergency obstetric care (EmOC) remains one major challenge in addressing the burden of maternal mortality worldwide.[6]Accordingly, the timely referral of women with obstetric emergencies from lower levels of care to higher levels for timely intervention has been identified as an integral component of a functional health-care delivery system.[7]Obstetrical emergencies are health problems that are life-threatening for pregnant women and their babies.[8]Due to the above reason, the WHO, UNICEF, and UNFPA in 1997 conceptualized EmOC as the care given to women with obstetrical emergencies.[9]Midwives provide EmOC services within the context of community- and facility-based health systems, enabling timely prevention of, and intervention for these complications to save the lives of mothers and newborns.[10]Sequel to the above, some facilities may not have the facilities to provide both basic EmOC and comprehensive EmOC; hence, the referral to a resource-rich facility is appropriate as it will facilitate continuity of quality and efficient care.[10]An effective referral of emergency obstetric conditions is an indication that the health-care delivery system is functional.[11]In addition, establishment of a referral system through a referral pathway that links the three levels (primary, secondary, and tertiary) of health care for better coordination is essential.[12]

Evidence from studies revealed that certain levels of health care are underutilized, resulting in the high volume of patients turn up at higher levels of care which should have been managed at lower levels of care.[13]The WHO further documented that for effective delivery of health care, the following building blocks of the health system must be available: health financing, leadership and governance, human resource, pharmaceutical management, and health information systems.[14]This implies that a referral is a process in which a health worker at one level of health system having insufficient resources (such as drugs, equipment, and skill) seeks assistance by referring a patient for skilled and expert management at a more resourced or better-equipped facility.[14]On the other hand, the higher facility receiving the patient should give relevant feedback about the progress of the patient to the referring facility after investigations and necessary follow up (counter-referral).[15,16]

Nigeria is currently recording the highest maternal mortality globally by contributing 14% of maternal mortality globally.[2]Although the introduction of the free maternal care policy in most Nigerian states in 2009 was geared toward increasing access to timely maternal health services across the country, Nigeria is lagging behind for various reasons. This is evidenced by the report of findings from Christian Aid Supported Communities on assessment of Primary Health Centers in selected states of Nigeria in 2015, which revealed that in Plateau state the referral system is dysfunctional as only two facilities have ambulance vehicle for emergency responses, coupled with insufficient number of healthcare providers, and unavailability of laboratory services on-site across all the thirteen facilities studied.[17]Furthermore, delays in recognizing danger and deciding to seek care (Phase 1), delays in reaching the appropriate facility (Phase 11), and delays in receiving quality care once the woman reaches the facility (Phase 111) have also been identified as some of the underlying factors contributing to high maternal mortality in Nigeria.[18]Addressing the second and third delays is vital to the proper functioning of the referral system. The referral system requires patients to first access primary care and be referred to the appropriate higher level when the need arises.[3,19]

In 2012, the Ministry of Health in Plateau state came up with a national policy to help address delays in accessing emergency care for referred patients.[19,20]This referral policy sought to ensure harmonization of the referral system for better collaboration and communication between health facilities. The implementation of this policy to achieve its intended purpose was posed with challenges. Associated factors are linked to sociocultural, human, and material resources.[21]Moreover, despite numerous researches on emergency obstetric referrals in Nigeria,[7,22]research on emergency obstetric referrals in Plateau state of Nigeria appears to be limited as most studies were focused on referrals in primary health-care (PHC) facilities without covering the aspect of counter-referrals.[17,19]It has also been observed that health-care providers working at the primary level of care who make such referrals receive very little or no feedback (counter-referral) on the outcome of their referrals (Personal communication with Nurse Midwife In-charge of Tangur PHC’s on 3/5/2018). This gap in the referral flow between the higher level of care and the referral initiation point makes it difficult to ensure that the required continuum of care for the referred mothers is achieved. This study therefore aimed to examine referral and counter-referral practices in obstetric emergencies among health-care providers in selected health-care facilities in Plateau state, Nigeria.

MATERIALS AND METHODS

Study design and setting

Concurrent embedded descriptive mixed-method design consisting of both quantitative and qualitative methods was adopted for this study. The quantitative method was employed to determine availability of resources for referrals and level of referral and counter-referral practices for obstetric emergencies, while qualitative method was used to explore barriers to referral and counter-referral practices among health-care providers.

The study area comprised primary, secondary, and tertiary health-care facilities in Plateau State. The researcher used 4 primary health facilities, 2 secondary facilities, and a tertiary facility where referred obstetric cases are managed along the referral chain, selected from Bokkos and Mangu Local Government Areas (LGAs). Plateau state has 16 secondary health facilities and three tertiary health facilities. Plateau Specialist Hospital and Jos University Teaching Hospital are tertiary hospitals in Plateau state, which render both basic and comprehensive emergency obstetric services, and most patients from Bokkos and Mangu are referred there. This study area was chosen because of the high rate of maternal mortality in the state.

Study population

The target population for the quantitative aspect of this study consisted of all health-care providers (midwives, community health extension workers [CHEWs] and doctors) who are involved in maternity care, deliveries, and referrals in the three levels of care within Plateau state. They numbered about 123. The researchers engaged PHC coordinators, unit heads, and ward charges (doctors, midwives, and community health officers) in an in-depth interview for the qualitative aspect as they constitute rich information sources on the subject matter under investigation. The researcher selected 8 of them who were willing to participate in the study.

Inclusion and exclusion criteria

Participants involved in the study were midwives, CHEWs, and doctors working in the maternity unit (antenatal, labor, postnatal, and gynecological wards) who have served in their various units for a period of 1 year and above, as well as the heads of maternity units. The health-care providers working in units other than maternity unit as well as those who served ＜1 year in the maternity unit were excluded.

Sample size determination

For the quantitative sampling, two out of the seventeen LGAs in Plateau state were randomly selected (Bokkos and Mangu), followed by the selection of health-care facilities through stratified sampling technique to have four PHC’s (Mangu central, Magun, Bokkos central and Tangur), two secondary facilities (General Hospital Bokkos and Mangu General Hospital), and the only tertiary hospital (Plateau State Specialist Hospital) selected. Then 123 respondents were selected from across the 3 levels of health-care facilities as thus: Primary level has 21, secondary level 39, and tertiary level 63. To determine the proportion of each level, the total population of the cluster was divided by the total population: the primary level 17.31%, the secondary level 30.77%, and the tertiary level 51.92%. To distribute the 123 samples proportionately, the sample size was multiplied by each level of health care: primary level has 18 providers, secondary level 32 providers, and tertiary 54 providers. Therefore, a total of 104 health-care providers were selected based on the various facilities using proportionate stratified random sampling.

Qualitative: This study employed an in-depth interview with 8 stakeholders comprising 4 health-care providers from the PHC facilities (including 2 CHOs and 2 midwives in charge of their maternity units), 2 from the secondary facilities (including 1 midwife-unit charge and 1 medical officer), and 2 from tertiary health-care facility (including 1 chief medical director and 1 assistant director nursing service) using purposive sampling technique to facilitate deepened exploration into barriers and facilitators of referral and counter-referral practices. In-depth interviews are not concerned with using a large population of respondents and do not tend to rely on hypothesis testing, but rather are more inductive and seeks to gather an in-depth understanding of a phenomenon, issue, process, or situation from a fewer rich-source population.

Data collection instrument

A self-structured questionnaire was used for the quantitative data collection. It comprises 5 sections: Section A which comprised of 6 items covered the demographic information of the respondents; Section B which comprised 20 items covered rating of availability of resources (human, material and financial resources); Section C comprising 20 items covered the level of referral practices in obstetric emergencies; Section D which comprised of 20 items solicited responses on the level of counter-referral practices in obstetric emergencies; and Section E which comprised of 15 items covered barriers to referral and counter-referral in obstetric emergencies. Item scoring ranged from 4 to 1 for “very high level” to “very low level.” Summation above 50% was considered “high,” whereas below 50% was considered “l(fā)ow.”

Validity and reliability of the questionnaire was achieved through scrutiny by two experts in the field of maternal, neonatal, and child health who checked through the items of the questionnaire, to ensure that the questions were in line with the research objectives and questions. Test-retest and Cronbach’s alpha reliability statistics were also employed to ascertain the reliability of the instrument after being administered to 10% of the estimated sample size who were not part of the study but possessed similar characteristics with the population of interest. Reliability coefficient of 0.85 was achieved.

For the qualitative data, an in-depth interview guide was designed to augment information on challenges of referral and counter-referral practices through an in-depth interview from the units/departmental heads of all the three levels of health care selected for the study. The major themes covered were nature of counter-referral in obstetric emergencies and barriers to referral and counter-referral with subthemes (i) providers barrier, (ii) patient barrier, and (iii) system barrier.

Rigor and trustworthiness of qualitative data was achieved by the researchers adhering strictly to the rules guiding principles for personal in-depth interviews, while collecting qualitative data to enhance credibility, transferability, dependability, and confirmability of the result using Lincoln and Guba’s evaluative criteria.[23]

Data collection procedure

Following ethical approval, the quantitative instrument (questionnaire) was administered face to face to the respondents from November 2019 to May 2020, and the time required for completion of each questionnaire was between 40 and 60 min. The same was retrieved on the spot. Qualitatively, the researchers conducted one on one in-depth interview which lasted between 40 and 45 min. The sessions were recorded with the participant’s consent.

Ethical considerations

A letter of introduction was obtained from the Department of Nursing Science, University of Calabar, Calabar, and ethical approval was also obtained from the Plateau State Ministry of Health and Plateau State Research Ethics Committee (NHREC/05/01/2010b dated November 4, 2019). Furthermore, administrative permission was sorted from all the facilities used in the study. The researchers explained the purposes and methods of the study and obtained permission and written consent from the respondents.

Statistical analysis

The quantitative data were entered and analyzed using the Statistical Package for the Social Sciences (SPSS) version 21.0 by IBM Corp. Released 2012 in Armonk, NY, USA.[24]Results were expressed as number and percentage and mean and standard deviation. When calculating the frequency and percentages of the level of referral and counter-referral practices, all the responses of “very high level” and “high level” were merged to become “high level,” whereas “very low level” and “l(fā)ow level” were combined to become “l(fā)ow level.” Hence, the responses were summarized under “high level” and “l(fā)ow level,” and summation above 50% was considered “high” and below 50% was considered “l(fā)ow.” Qualitatively, data from the in-depth interview sessions were transcribed verbatim and thematic analyzed employed using NVivo 8.[25]

RESULTS

Quantitative data presentation

Table 1 shows that 19 (18.27%) were below the ages 30, 38 (36.54%) between ages 31 and 40, 31 (29.81%) ages 41 and 50, and 16 (15.38%) above age 50. Data on the gender of respondents showed that 20 (19.23%) were male, while 84 representing (80.77%) were female. Medical officers were 8 (7.69%), midwives 17 (16.35%), nurses 16 (15.38%), nurse/midwife 49 (47.12%), and CHEW 14 (13.46%). The highest years of experience was 1-9 years in 55 (52.89%), while majority had diploma 69 (66.35%).

Table 1: Demographic information of respondents (n=104)

Available resources for referral and counter-referral for obstetric emergencies

The availability of human, material, and financial resources for referral and counter-referral for obstetric emergencies as presented in Table 2 revealed that except for CHEWs, examination kit, and delivery cord, the availability of health-care resources ranged from 2.54 to 2.63 mean score, whereas nonavailability ranged from 2.51 to 2.85 mean score. This implies that there is a high level of nonavailability of human and financial resources in the facilities studied.

Level of referral practices for obstetric emergencies

Table 3 shows the extent of referral practices for obstetric emergencies among health-care providers in selected health-care facilities in Plateau state, Nigeria. Majority of the respondents, 99 (95.19%), accepted that they could not refer a woman with retained products of conception after a miscarriage, premature rupture of membranes, as well as unexpected bleeding during pregnancy from lower to higher facility. This is followed by 97 (93.27%) who agreed on inability to refer inversion of the uterus from lower to higher facility among other emergency conditions. Contrarily, the highest percentage, 19 (18.27%) of the respondents who agreed with the items that tested the level of referral practices for obstetric emergencies among health-care providers in selected health-care facilities in Plateau state was in the aspect of referring prolonged labor and referring maternal collapse from lower to higher facility. This implies that there is a low level (＜10 cases a year) of referral practices for obstetric emergencies among health-care providers in selected health-care facilities in Plateau state, Nigeria.

Table 2: The extent of availability of referral resources (n=104)

Level of counter-referral practices for obstetric emergencies

The information shown in Table 4 is the item descriptions of the level of counter-referral practices of treated obstetric emergencies from the higher level of care back to the referral point among health-care providers in selected health-care facilities in Plateau state, Nigeria. These results generally pointed to the fact that a significant number of the respondents as high as 94 (90.38%) indicated that there is a low level (no counter-referral up to ten cases) of counter-referral practices for obstetric emergencies among health-care providers in the aspect of referring treated umbilical cord prolapse from higher to lower facility, while 30 (28.85%) was the highest number of respondents who accepted that there is high level of counter-referral practices for obstetric emergencies among health-care providers in selected health-care facilities in the study area. This was in the aspect of referring treated conception products from higher to lower facility. The findings indicated a low level of counter-referral practices for treated obstetric emergencies back to the referral facility. An effective counter-referral system helps the lower health-care facility to have good knowledge of how the obstetric emergency referred case was treated by the higher facility and thus learn to improve in the health-care service delivery throughout the care continuum.

Barriers militating against effective referral and counter-referral practices for obstetric emergencies

Table 5 shows the means and standard deviations of the responses to barriers militating against effective referral and counter-referral practices for obstetric emergencies in selected health-care facilities of Plateau state. Lack of motivation for health-care providers (3.45) had the highest mean score and could be considered the most contributing barrier against effective referral and counter-referral practices for obstetric emergencies, followed by poor funding of obstetric equipment (3.41). The grand mean was seen to be 2.90, which was also above the cutoff mean. This indicates acceptance that the individual items contributed as barriers militating against effective referral and counter-referral practices for obstetric emergencies in selected health-care facilities at different weights in the study area, which is based on the mean of each item. The higher the mean, the more the item is perceived as a contributing factor. Contrarily, lack of policy framework on referral practices (2.49) was seen to have a mean less than the cutoff mean of 2.50. This item was, however, not accepted as a barrier militating against effective against effective referral and counter-referral practices for obstetric emergencies in selected health-care facilities studied in Plateau state.

Table 3: The level of referral practices for obstetric emergencies in selected health facilities in Plateau state, Nigeria (n=104)

Table 4: The level of counter-referral practices for obstetric emergencies among health-care providers in selected health-care facilities in Plateau state, Nigeria (n=104)

Table 5: The responses to barriers militating against effective referral practices (n=104)

Table 6: Demographic data of in-depth interview participants

Table 7: The emerging themes and subthemes from the qualitative analysis

Qualitative data presentation

As shown in Table 6, a total of 8 participants were engaged in an in-depth interview; 2 males and 6 females, 4 of the participants were within the ages of 20-30 and 4 within the age range of 30-40 years. Four were married, 2 single and 1 widow.

Four of them were practicing in the Primary level of healthcare, 2 in secondary level and 2 tertiary level of health care. Two of the participants were medical officers, 4 were nurses and 2 were Community Health Officers. Data presentation was based on the themes that were developed during analysis of the interview scripts as shown on Table 7. Thus, this analysis reveals the account of participants’ perspective on the nature and barriers of referral and counter-referral practices in obstetric emergencies. The major findings are presented and some of the verbal accounts from the scripts are also quoted. The participants’ verbatim quotes are identified as I-P 1….8, where I represent interviewee,Prepresents participant, and 1-8 representing the interview sessions held.

DISCUSSION

Availability of referral and counter-referral resources

The finding from our study revealed that there are poor referral and counter-referral resources in the selected health facilities of Plateau state. This was also confirmed through the themes that emerged from the qualitative study as captured verbatim:“Wedon’thaveanyguideorprocedureforreferralandcounterreferral”(I-P 1, 4, and 8).“Wedon’thavereferralandcounter-referralprotocolsbutthecriteriaforreferralandcounter-referralisbasedontheseverity.”“Referralisdoneforbettercarebutsometimesitmaynotyieldthat”(I-P 2 and 3)“Referralisdonewithoutbetterarrangementoftransferofcare”(I-P 1 and 4). This implies that there must have been a lack of communication and feedback system, lack of protocol for identification of obstetric emergencies, and lack of unified health record systems in the health facilities. The finding is in consonant with the finding of Diazet al.[16]in 2011 and Kapooret al.[26]in 2017, which revealed that poor communication facilities for utilization by hospital professionals can sometimes result in unnecessary costly referrals and late transfers that can prove deadly. The finding is also consistent with the finding of Vargaset al.[27]in 2016 and Senitanet al.[28]in 2017, who found that the lack of electronic medical records hinders patients’ referral and counter-referral processes. The reason behind this finding is that poor referral of patients/referral criteria, communication between different levels of health-care delivery to facilitate the proper referral, lack of transportation of referred patients, and lack of equitable distribution of resources to improve the management of referrals may likely maximize duplication of health-care providers’ efforts and increase overcrowding in most of the hospitals, thereby hindering accessibility, affordability, equality, and equity in health.

Level of referral practices for obstetric emergencies

On the level of referral practices, findings revealed that the extend of referral practices between primary and secondary health-care facilities in Plateau state is low. This implies that the PHC providers might not have been able to diagnose obstetric emergencies on arrival as to make referrals. The finding of this study is in line with the finding of Senitanet al.[28]in 2017, which revealed that none of the 12 PHC providers studied could identify factors of a good referral system. Other referral problems identified by this study included patients’ unnecessary requests for referral, unstructured referral letters, and unclear dissemination guidelines for referral. This was confirmed in the qualitative findings as reported verbatim:

“Wedon’thaveastandardreferralprocedure”(I-P 8).“Higherlevelofcaredoesn’treferpatientsorgivefeedback”(I-P 7, 8 and 9). The finding is also in agreement with the finding of Erdmannet al.[29]in 2013, and Yuet al.[30]in 2017, whose findings showed that only 20.8% of doctors were willing to accept referrals from lower level of care, although this proportion was higher among patients (37.6%). Furthermore, the willingness of doctors was associated with education, understanding of referral, and perception of health resources in hospitals, while that of the patients was influenced by marital status, economic factors, and recognition of the community’s first treatment system. It is mostly assumed that patients depend on the medical information available to their health-care providers. Therefore, the need for a referral, its appropriateness, timing, and to whom the referral is made, mostly depends on the attending physician. This should be done after due consultation with the patient’s family and appropriate consent obtained. It is believed that a health practitioner should make a referral when he/she thinks that it will be of benefit to the patient.

Level of counter-referral practices for obstetric emergencies

Findings show that the extent of counter-referral practices between the receiving facility back to the initiating referral point is very low. This is also supported by the qualitative findings as quoted verbatim: “Ourstaffreferpatientstohealthcenters,andIamnotsureiftheyusuallygivefeedbacktothelowerfacilities”(I-P 7 and 8).“Higherlevelofcaredoesn’treferpatientsorgivefeedback”(I-P 7, 8, and 9).“Referralisdoneforbettercarebutsometimesitmaynotyieldthat”(I-P 2 and 3).This finding implies that the primary and secondary health-care providers involved in referral hardly receive feedback. It reveals that health-care providers at lower levels of care would not have the opportunity to improve their skills based on the outcome of management rendered to the referred. This finding is in consonance with the work of Giveet al.[31]in 2019, which considered lack of feedback as a barrier to a functional referral system. It also corroborates the findings of Austinet al.[32]in 2015, who identified a lack of transportation and communication infrastructure, overcrowding at the referral hospital, insufficient preservice and in-service training, and absence of supportive supervision as key barriers to the provision of quality EmOC.

Barriers to referral and counter-referral practices

Barriers identified by our study that militate against referral and counter-referral include failure to educate patients on conditions that require referral, institutional, patients, and staff factors. Verbatim quotes from the qualitative aspect of our study confirmed this: “Inadequatestaffinghashamperedreferralandcounter-referral”(I-P 2 and 4). “Thereispoorfundingfromgovernment(I-P 1, 3 and 5). “Hospitalandclinicsconsumablesarenotavailable”(I-P 6, 7 and 8). “Somuchworkloadwithpoorsalary”(I-P 7 and 8).“Patientsmostlycomplainoflackoffunds(I-P 1 and 3).“Meansoftransportationhasactedasabarrier”(I-P 7).“Lackofsupportfromgovernmentanduncertaintyofcareavailableatthenextlevel(I-P 5, 6 and 8).“SometimesImaynotbeverysoundatdetectingsomecomplexobstetriccomplicationsbecauseIhavebeenworkingintheclinicandIhadnotgoneforanytraininginthearea.”(I-P 8).“Hospitalandclinicsconsumablesarenotavailable”(I-P 6, 7 and 8). The implication of this finding is that the more health-care providers enlighten patients on the status of their obstetrics emergency the more they request for a referral or counter-referral and vice versa.The finding of this study credited the finding of Rahmanet al.[33]in 2017, which revealed that the strength of referral services was orientation for preparation about pregnancy, prevention of mortality and morbidity, and comprehensive services. The finding of this study also supports the findings of Saglam-Aydinatayet al.[34]in 2018, Eskandariet al.[12]in 2013, Sapruet al.[35]in 2014, and Senitanet al.[28]in 2017, which revealed that the most common facilitators to referral and counter-referral compliance were increased awareness about the disease condition, whereas the most common barriers to referral compliance were misconceptions about the problem and work responsibilities, facilities being far from the ideal referral system, lack of adequate governmental referral system, lack of connection among different levels of the referral system, self-referential and bypassing the referral system, insufficient knowledge about the referral system, and poor clinical information transfer among health-care levels in all networks analyzed. The obstacles to care coordination were related to the organization of both the health system and the health-care networks. The finding also tallies with the finding of Daniels and Abuosi[7]in 2020, which identified lack of transportation and communication infrastructure, overcrowding at the referral hospital, insufficient preservice and in-service training, and absence of supportive supervision, as key barriers to the provision of quality EmOC. The study by Rahmanet al.[33]in 2017 and Sapruet al.[35]in 2014, therefore, suggested that the following needed to be addressed: lack of awareness among clients, socioeconomic barriers, lack of resources, and organizational barrier.

The overall implication of this finding is that the barriers that linked to the main root causes of counter-referral were grouped into four domains: (1) transportation, (2) communication, (3) clinical skills and management, and (4) standards of care and monitoring. Therefore, providing important sources of information on local referral delays, and development of approaches to improve responsiveness to these gaps, and better engagement of health care can help identify and evaluate high-impact holistic interventions to address faulty referral systems, which result in poor maternal outcomes in poor resource settings.

CONCLUSIONS

Our study concluded that the availability of referral and counter-referral resources in the health-care facilities studied was not adequate. The level of referral and counter-referral practices among the health-care providers was inadequate due to inadequate resources, lack of standard protocols, poor staffing, and poor communication network among others between the various levels of health-care in the Plateau state of Nigeria. Based on the above, the following recommendations were made:

· Adequate obstetric emergency preparedness through appropriate training/retraining of care providers as empowerment strategies to ensure competency in managing obstetric emergencies among staff care providers

· Increased budgetary allocation to the health sector for the procurement of all the necessary referral resources and hiring of competent personnel and proper remuneration for effective obstetric emergency health-care delivery in Plateau state

· Implementation of single electronic record and communication systems. This will promote data portability and sharing across the different health institutions for easy referral/counter-referral practices.

Financial support and sponsorship

Research was completely self-sponsored.

Conflicts of interest

There are no conflicts of interest.