Characterizing the referral care continuum among complex obstetric patients in the Blantyre District of Malawi: A mixed methods study.

Despite high rates of facility delivery and skilled attendance at birth in Malawi, maternal mortality remains high underscoring the need to improve quality of care. With most deaths occurring at secondary and tertiary levels of care, our midwifery-led team aimed to understand the characteristics of pre-referral care driving poor maternal outcomes. We leveraged a convergent, parallel mixed methods approach to characterize obstetric care and outcomes across the referral care continuum and explore facilitators and barriers to the referral process between March 2019 and March 2020. Complex obstetric patient charts from seven Blantyre District primary health centers referred to the only local tertiary hospital were extracted and analyzed for associations between individual- and facility-level characteristics and referral care and outcomes. Transcripts from three focus group discussions and 18 in-depth interviews with clinical providers and referred mothers were analyzed using qualitative inference. Among 398 birthing women, 54% were between 18 and 24 years-old and 32% were referred from a facility more than 10km from the Hospital. Compared to survivors, mothers who died (n = 10) were significantly more likely to have been referred from a facility >10 km away, to have arrived in critical condition, and 100% experienced complications during their stay ranging from postpartum hemorrhage to cardiac arrest. Three primary themes emerged as barriers to quality pre-referral care in the district: systemic and structural challenges, inconsistent inter- and intra-facility communication, and community and provider influences on maternal expectations and beliefs. Triangulation of these findings suggests that strengthening referral infrastructure, bolstering communication and documentation, and reducing total referral time are key to improving care quality and outcomes for complex obstetric cases. Additionally, providers across the care continuum need additional training and support to ensure timely interventions and comprehensive, continuous referral care.