Obstetric referral practices and health system factors in public health centres of Addis Ababa, Ethiopia: A mixed-methods study

Objective To determine the magnitude of obstetric referral and to explore contextual factors influencing referral practices in public health centres of Addis Ababa, Ethiopia. Design Explanatory sequential mixed-methods study. Setting and period Fifty public health centres in Addis Ababa City Administration, January–April 2021. Methods Delivery and referral registers from 50 health centres were reviewed retrospectively for 12 months (8 July 2019–7 June 2020). Facility observations and interviews with maternity unit heads were conducted in all selected centres. In-depth interviews were conducted with 20 midwives and 13 health-centre managers. Quantitative data were analysed descriptively, and qualitative data were analysed thematically using Colaizzi’s method. Results Eighty percent of health centres had a functional referral system. The overall obstetric referral rate was 32%, with substantially higher referral rates in facilities without caesarean section (CS) services compared with those providing CS (39% vs 21%). Qualitative findings indicated that high referral rates were associated with limitations in the predictive capacity of the partograph, variability in providers’ clinical skills, and risk-averse practices driven by accountability concerns related to maternal and perinatal outcomes. Conclusion Although referral systems were largely functional, obstetric referral rates were high, suggesting potential over-referral. Updating labour monitoring tools, strengthening provider competencies, and clarifying accountability mechanisms may reduce unnecessary referrals.