‘‘When I was referred, I wasn't happy’’: A qualitative study exploring pregnant women’s compliance with maternal referrals in urban Ghana

Background Timely referral from lower-level health facilities to higher ones is crucial to saving the lives of pregnant women. Despite the role of quality referrals in improving maternal health outcomes, there is limited data on referral patterns. In Ghana, there is insufficient research on the maternal referral process and the factors affecting pregnant women's compliance with referrals. This study aimed to explore newborn mothers and healthcare workers’ perspectives on the factors affecting compliance with maternal referrals in urban Ghana. Methods Phenomenological qualitative research was conducted between October 2024 and November 2024. Purposive sampling was used to sample 15 newborn mothers and 16 health workers from Adabraka polyclinic and Greater Accra Regional Hospital. In-person interviews were conducted, usually lasting 45 to 60 minutes, and were facilitated by an open-ended separate interview guide for each participating group. The interviews were audio recorded, transcribed, coded and analysed thematically. Findings: Findings revealed that the maternal referral process is complicated by several issues including absence of documented maternal referral protocols, challenges with referral preparation and documentation, and poor referral communication. Factors promoting compliance included desire to ensure safe delivery, proximity to referral facility, social support, and perceived availability of medical equipment / resources at the receiving health facility. Barriers to compliance included religious beliefs, myths about big hospitals, fear of caesarean section, financial constraints, and poor communication between healthcare providers and patients. Conclusion A combination of personal, socio-cultural and health system factors affect compliance with material referrals from lower-level health facilities to higher-level facilities in urban Accra. There is urgent need for the development of a well-structured maternal referral protocol to serve as a guide for all maternal referrals across all levels of the health system in Ghana.