title: High proportions of obstetric referrals in Addis Ababa: the case of term premature rupture of membranes.
abstract: BACKGROUND
  The Public Health Centers (HCs) provide basic obstetric and neonatal care to about 80% of the eligible population in Addis Ababa. Hospitals provide comprehensive services and are referral centers for complications that cannot be managed at the HCs. This study assessed the proportion of obstetric referrals in general and referrals due to premature rupture of membranes (PROM) at term in particular, from the HCs in Addis Ababa and explored its appropriateness and management in hospitals.
  
  
  METHODS
  The study used a sequential explanatory mixed methods design. Routine retrospective data were collected from ten randomly selected HCs in 2012. Key informant interviews were conducted using a guide developed following a preliminary analysis of the quantitative data. Ten head midwives, one from each health center participated in the interviews.
  
  
  RESULTS
  Of the 9340 mothers who sought skilled birth care in the ten HCs in 2012, 2820 (30.3%) were diagnosed with obstetric complications and referred to hospital. Term PROM accounted for 557 (19.7%) of the referrals and it was widely varied across the HCs. Fifteen (7.8%) mothers who were referred for PROM, had intact membranes upon hospital examinations. Forty-two (77.8%) of the referred mothers who had spontaneous labour and delivery could have been misclassified as not having labour upon referral. In the interviews, variations in diagnosing and managing term PROM were identified as themes. Three HCs relayed solely on mothers' self reports of amniotic fluid leakage to diagnose, two HCs did complementary speculum/vaginal examination, three HCs monitored sign of labour on top of confirming the leakage. Regarding management, two HCs practiced expectant management, three referred mothers after 30 min of observation while others issued referral right away. All providers reported the lack of clinical guidelines for most common obstetric problems in their HC.
  
  
  CONCLUSIONS
  The study reported large proportion of obstetric referrals in general and PROM referrals in particular as well as variations in diagnosing and managing term PROM. These could largely be attributed to lack of clinical guidelines for most common obstetric complications at the HCs and competency gap among providers. Addressing the identified gaps and strengthening the primary care settings could contribute to improved quality of obstetric care and outcomes.
authors.affiliation: Center for International Health, University of Bergen, Årstadv 21, Overlegedanielsenshus, 5020, Bergen, Norway. alemmirkuzie@yahoo.com.
authors.forename: Alemnesh H
authors.initials: AH
authors.lastname: Mirkuzie
authors.affiliation: School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia. mitikemolla@gmail.com.
authors.forename: Mitike Molla
authors.initials: MM
authors.lastname: Sisay
authors.affiliation: WAHA International, University of Gondar, Post Box 41822, Gondar, Ethiopia. M.muleta@yahoo.com.
authors.forename: Mulu Muleta
authors.initials: MM
authors.lastname: Bedane
mesh_terms: D000293:Adolescent; D000328:Adult; D002983:Clinical Competence; D036861:Delivery, Obstetric / Q000706:statistics & numerical data*; D005002:Ethiopia; D005260:Female; D005322:Premature Rupture of Fetal Membranes / Q000175:diagnosis* / Q000473:pathology; D006801:Humans; D007743:Labor, Obstetric; D008880:Midwifery / Q000941:ethics; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011634:Public Health / Q000706:statistics & numerical data*; D058996:Quality Improvement; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D000078329:Workforce
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