Delays in emergency obstetrics referrals in Addis Ababa hospitals, Ethiopia: a facility-based, cross-sectional study

Objectives: To assess where the delays occur in the referral chain at most
and maternal health outcomes based on the three delay model in Addis
Ababa, Ethiopia. Design: The study was a facility-based cross-sectional
study Setting:  Two public and tertiary hospitals in Addis Ababa
Participants: All pregnant women who were referred for only labor and
delivery services after 28 weeks of gestation between December 2018 and
February 2019 in Zewditu and Gandhi Memorial hospitals. Primary and
secondary outcome measures: The primary outcome was the type of delays
from the three-delay model which met operationally defined time. Maternal
health outcomes based on the three-delay model as a secondary outcome.
   Results: A total of 403 pregnant women referred for
delivery to the study hospitals were included in the study. Three-fourth
(301, 74.7%) of referred pregnant women had the third delay (delayed
receiving appropriate care); (211, 52.4%) had a first delay (delay in
making a decision to seek care). Overall 366(90.8%) pregnant women had
experienced at least one of the three delays and 71(17.6%) had all the
three delays. Twenty-nine (7.2%) referred women had severe maternal
outcomes (SMO). The most leading causes/diagnosis of SMO were blood
transfusion 17 (58.6%) followed by postpartum hemorrhage 15 (52%) then
eclampsia 9 (31%). In addition, women who experienced severe maternal
outcomes were 2.9 times more likely to have at least one of the three
delays. Conclusion & recommendation:  This study
highlights the persistence of delays at all levels and especially delay
three and its contribution to severe maternal outcomes. Strengthening
health referral systems and addressing specific health system bottlenecks
during labor and birth in order to ensure no mother will be endangered. We
also recommend a qualitative method of study (focus group discussion and
in-depth interview) and observing the tertiary hospitals set-up and
readiness to manage obstetrics emergencies.