Referral is critical in the chain of managing women receiving post-abortion care (PAC). We assessed factors influencing referral among women receiving PAC at two tertiary hospitals in Northern Uganda. An embedded, mixed-methods study design was conducted from July to December 2023. Quantitative data were collected from 152 women of reproductive age (15-49 years) using structured questionnaires, while qualitative data were gathered through 20 in-depth interviews with women and healthcare providers. Logistic regression was applied for quantitative analysis, and thematic content analysis was used for qualitative data. Median age of all participants was 26 years (IQR: 21-32). Referrals accounted for 46 (30.3%). The odds of being referred was significantly higher among rural residence (adjusted Odds Ratio (aOR): 15.5; 95% Confidence Interval (CI) 4.44-53.83; p < 0.001) and those under 20 years of age (aOR: 2.8; 95% CI 1.02-7.56; p = 0.046). Qualitatively, limited PAC services at lower-level facilities, financial barriers to private care, and transport challenges were key drivers for referral. Therefore, strengthening PAC services at lower-level facilities could reduce referrals and improve care access. Major economic reforms are essential to achieving universal health coverage, including PAC services in northern Uganda.
Globally, about one in every 3 of the 227 million pregnancies each year, ends up in spontaneous abortions, induced abortions or stillbirth . The incidence of abortions remains high globally with over 48.3 million induced abortions especially in developing countries , contributing to global and regional maternal mortality of 7.9% and 9.6% respectively . Over 75% of the maternal deaths due to abortion and its complications occur in sub-Saharan Africa, where there are laws that may restrict women from receiving comprehensive abortion care .
Referral is a vital strategy in the chain of managing patients with abortion related complications which supports patients to receive early and appropriate healthcare, reducing morbidity and mortality . Patients are either self-referred or referred by qualified healthcare workers from lower to higher level capable health facilities based on clinical judgement . Incomplete abortion is the commonest complications of first trimester abortions, and despite antibiotics therapy, 1.4% of the affected women develop post-abortion sepsis, and some experience hemorrhage with significant hemodynamic instability requiring blood transfusion . Uterine perforation can occur during uterine evacuation or induced abortion, often necessitating hospital interventions. Some women also develop anesthesia-related complications . Mitigating these impacts requires appropriate intervention including referral. Referral is one of the modalities in promoting definitive management of patients in health facilities and are necessary because healthcare facilities operate at different levels of care offered . In Uganda, these levels include health center I, II, III, IV, General hospitals, Regional Referral Hospital and National Referral Hospital each providing healthcare services at certain level as per set standard, hence promoting inter-facility referral systems . Level I facilities consist of community-based services mainly delivered by the village health teams (VHTs) serving population of about 1,000 people. Level II facilities provide primary health care limited to outpatient care by nurses servicing approximately 5000 people. Level III facilities provide outpatient services with some inpatient services and is headed by a clinical officer serving about 20,000 people. Level IV facilities provide comprehensive healthcare including outpatient care, inpatient care, surgical intervention including C/section and is headed by a medical officer within a catchment population of 100,000 people. Hospitals (General Hospitals, Regional Referral Hospitals and National Referral Hospitals) are referral centers for lower level facilities providing increasingly complex specialist services at district, regional and national levels .
Despite the availability of facilities, many women still die or suffer complications due to delays or failure of referral to healthcare facilities capable of offering post-abortion care (PAC). In Northern Uganda, previous study has shown that about 21.1% of women utilized one or more PAC services . The factors associated with referrals included lack of transport means, failure to make decision and lack of money . Despite the crucial need for a comprehensive PAC, data on factors influencing referral among women attending PAC services are scarce in our low-resource settings. Therefore, we assessed factors influencing referral among women attending post abortion care at two tertiary hospitals in Northern Uganda.
