Jean McFarlane Building, University of Manchester, Manchester, M139PL, UK.
Ministry of Health Headquarters, Department of Public Health and Research, Lusaka, Zambia.
BMC Pregnancy Childbirth. 2020 May 14;20(1):292. doi: 10.1186/s12884-020-02996-8.
Timely intrapartum referral between facilities is pivotal in reducing maternal/neonatal mortality and morbidity but is distressing to women, resource-intensive and likely to cause delays in care provision. We explored the complexities around referrals to gain understanding of the characteristics, experiences and outcomes of those being transferred.
We used a mixed-method parallel convergent design, in Tanzania and Zambia. Quantitative data were collected from a consecutive, retrospective case-note review (target, n = 2000); intrapartum transfers and stillbirths were the outcomes of interest. A grounded theory approach was adopted for the qualitative element; data were collected from semi-structured interviews (n = 85) with women, partners and health providers. Observations (n = 33) of transfer were also conducted. Quantitative data were analysed descriptively, followed by binary logistic regression models, with multiple imputation for missing data. Qualitative data were analysed using Strauss's constant comparative approach.
Intrapartum transfer rates were 11% (111/998; 2 unknown) in Tanzania and 37% (373/996; 1 unknown) in Zambia. Main reasons for transfer were prolonged/obstructed labour and pre-eclampsia/eclampsia. Women most likely to be transferred were from Zambia (as opposed to Tanzania), HIV positive, attended antenatal clinic < 4 times and living > 30 min away from the referral hospital. Differences were observed between countries. Of those transferred, delays in care were common and an increase in poor outcomes was observed. Qualitative findings identified three categories: social threats to successful transfer, barriers to timely intrapartum care and reparative interventions which were linked to a core category: journey of vulnerability.
Although intrapartum transfers are inevitable, modifiable factors exist with the potential to improve the experience and outcomes for women. Effective transfers rely on adequate resources, effective transport infrastructures, social support and appropriate decision-making. However, women's (and families) vulnerability can be reduced by empathic communication, timely assessment and a positive birth outcome; this can improve women's resilience and influence positive decision-making, for the index and future pregnancy.
及时在医疗机构之间转诊对于降低母婴/新生儿死亡率和发病率至关重要，但这对女性来说令人痛苦、资源密集且可能导致护理提供延迟。我们探讨了转诊的复杂性，以了解被转移者的特征、经历和结果。
我们在坦桑尼亚和赞比亚使用混合方法平行收敛设计。定量数据来自连续的回顾性病历审查（目标，n=2000）；产时转移和死产是感兴趣的结果。采用扎根理论方法进行定性部分；数据来自 85 名妇女、伴侣和卫生提供者的半结构化访谈（n=85）。还进行了 33 次（n=33）转移观察。定量数据进行描述性分析，然后进行二元逻辑回归模型分析，对于缺失数据进行多重插补。定性数据采用斯特劳斯的恒定比较方法进行分析。
坦桑尼亚的产时转移率为 11%（111/998；2 例未知），赞比亚为 37%（373/996；1 例未知）。转移的主要原因是产程延长/梗阻和子痫前期/子痫。最有可能被转移的妇女来自赞比亚（而非坦桑尼亚），艾滋病毒阳性，产前就诊次数<4 次，距离转诊医院>30 分钟。两国之间存在差异。在转移的患者中，护理延迟很常见，不良结局增加。定性研究结果确定了三个类别：成功转移的社会威胁、及时分娩护理的障碍和修复干预措施，这些类别与一个核心类别相关：脆弱之旅。
尽管产时转移是不可避免的，但存在可改变的因素，有可能改善妇女的体验和结果。有效的转移依赖于充足的资源、有效的交通基础设施、社会支持和适当的决策制定。然而，通过共情沟通、及时评估和积极的分娩结果，可以减轻妇女（和家庭）的脆弱性；这可以提高妇女的适应能力并影响积极的决策，不仅对本次妊娠，对未来妊娠也是如此。
