Factors influencing referral of pregnant women seeking care at level three and four facilities in Nairobi County, Kenya

Background/Aims Midwives play a critical role in preparation and response during maternal and newborn emergencies. However, many public health facilities have demonstrated poor service delivery marked by delays in care and referral of pregnant women, often resulting in poor maternal and neonatal outcomes. This study's aim was to explore the factors influencing referral of pregnant women seeking care in Nairobi County. Methods This cross-sectional mixed methods study was carried out in Nairobi County's level three and four public health facilities with maternity units and county referral facilities that included the Nairobi County emergency response unit. Data were collected from 67 randomly sampled midwives at the facilities via questionnaires, from 23 purposively sampled key informants (13 members of the emergency response teams and 10 facility in-charges) via interviews, and from 45 purposively sampled mothers using focus group discussions. Quantitative data were analysed using descriptive and inferential statistics, while qualitative data were analysed thematically. Results Understaffing was a major issue that affected referral procedures. The participants' median knowledge score for their skills and competence was 41 out of 50. Approximately half (53.7%) of the midwives had a score equal to or above the median score, indicating the need for capacity building. It was reported that ambulance services faced frequent emergencies on weekends, increasing demand for emergency services. A number of health facilities were located in areas with poor infrastructure, making access to ambulance services a challenge. Conclusions The referral process for pregnant women is influenced by multiple factors that include understaffing, inefficient ambulance services and the average capacity of midwives for referral procedures. There is a need for better systems and resources for effective and efficient referrals. Implications for practice Referring midwives must ensure that the receiving facility has the resources and services that the patient requires at the expected level or condition. Additionally, decentralisation of referral and ambulance services may improve care, as well as training for midwives on the referral process.