The third delay: understanding waiting time for obstetric referrals at a large regional hospital in Ghana
Open accessAbstract
BACKGROUND: Delay in receiving care significantly contributes to maternal morbidity and mortality. Much has been studied about reducing delays prior to arrival to referral facilities, but the delays incurred upon arrival to the hospital have not been described in many low- and middle-income countries. METHODS: We report on the obstetric referral process at Ridge Regional Hospital, Accra, Ghana, the largest referral hospital in the Ghana Health System. This study uses data from a prospectively-collected cohort of 1082 women presenting with pregnancy complications over a 10-week period. To characterize which factors lead to delays in receiving care, we analyzed wait times based on reason for referral, time and day of arrival, and concurrent volume of patients in the triage area. RESULTS: The findings show that 108 facilities refer patients to Ridge Regional Hospital, and 52 facilities account for 90.5% of all transfers. The most common reason for referral was fetal-pelvic size disproportion (24.3%) followed by hypertensive disorders of pregnancy (9.8%) and prior uterine scar (9.1%). The median arrival-to-evaluation (wait) time was 40 min (IQR 15-100); 206 (22%) of women were evaluated within 10 min of arrival. Factors associated with longer wait times include presenting during the night shift, being in latent labour, and having a non-time-sensitive risk factor. The median time to be evaluated was 32 min (12-80) for women with hypertensive disorders of pregnancy and 37 min (10-66) for women with obstetric hemorrhage. In addition, the wait time for women in the second stage of labour was 30 min (12-79). CONCLUSIONS: Reducing delay upon arrival is imperative to improve the care at high-volume comprehensive emergency obstetric centers. Although women with time-sensitive risk factors such as hypertension, bleeding, fever, and second stage of labour were seen more quickly than the baseline population, all groups failed to be evaluated within the international standard of 10 min. This study emphasizes the need to improve hospital systems so that space and personnel are available to access high-risk pregnancy transfers rapidly.
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Lack of a well coordinated and functional national referral system coupled with inadequate and expensive ambulance services is a health service delivery challenge that deprives some expectant women from accessing basic or comprehensive emergency obstetric care during emergencies.
“Some studies mentioned the lack of a well coordinated and functional national referral system coupled with inadequate and expensive ambulance services in the country, as a health service delivery challenge that deprives some expectant women from accessing basic emergency obstetric care (BEmOC) or CEmOC services during emergency situations [18–20].”
From A scoping review of the residual barriers to skilled birth attendance in Ghana: A conceptual framework and a fish bone analysis (2024) · cites this paper as [20]
Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredUnacceptable attitudes of skilled birth attendants are widely reported barriers to skilled delivery.
“Besides the problem of incompetence, unacceptable attitudes of SBAs are also widely reported barriers to skilled delivery.”
From A scoping review of the residual barriers to skilled birth attendance in Ghana: A conceptual framework and a fish bone analysis (2024) · cites this paper as [20]
The Background discusses encouraging skilled and institutional delivery, while the Results and Discussion examine delays after obstetric referral; none identifies attendants’ attitudes as a barrier to skilled delivery. Searches for attitudes, disrespectful care, and barriers to skilled delivery found no passage addressing that claim. (LLM, conf=0.76)
Experimental — accuracy not yet measuredUnofficial demands from pregnant women, for example soap and other disinfectants after delivery, are among unacceptable attitudes of skilled birth attendants.
“Some of which are: unofficial demands from pregnant women, for example soap and other disinfectants after delivery [7,15,16,19,20,22,23,31–36] and abusive behaviors [7,23,37].”
From A scoping review of the residual barriers to skilled birth attendance in Ghana: A conceptual framework and a fish bone analysis (2024) · cites this paper as [20]
The Background and Results discuss obstetric referrals and delays in care, but do not address unofficial demands for soap or disinfectants after delivery. Searches for that example and for demands or abusive behavior by skilled birth attendants found no relevant passage in our copy; page numbers were not available. (LLM, conf=0.73)
Experimental — accuracy not yet measuredLack of adequate supply of drugs on the National Health Insurance drug list in health facilities has a detrimental effect on quality-of-service delivery, including skilled delivery care.
“Lack of adequate supply of drugs on the National Health Insurance drug list in health facilities, have a detrimental effect on the quality-of-service delivery, including skilled delivery care [20,41].”
From A scoping review of the residual barriers to skilled birth attendance in Ghana: A conceptual framework and a fish bone analysis (2024) · cites this paper as [20]
The Background and Discussion address delays in obstetric referral, triage and staffing, but do not link drug supplies to quality of care. Searches for the National Health Insurance drug list and for medicine availability found no passage addressing the claimed effect on skilled delivery care. (LLM, conf=0.76)
Experimental — accuracy not yet measuredMany studies highlight the cost associated with skilled delivery despite the 'free' delivery care policy under the national health insurance, such as the cost involved in buying delivery items (layette), as the main determinant to accessing skilled attendant at birth considering the low household income status of families.
“Further, many studies highlight the cost associated with skilled delivery despite the ‘free’ delivery care policy under the national health insurance, such as the cost involved in buying delivery items (layette), as the main determinant to accessing skilled attendant at birth considering the low household income status of families [7,10,20,33,49].”
From A scoping review of the residual barriers to skilled birth attendance in Ghana: A conceptual framework and a fish bone analysis (2024) · cites this paper as [20]
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- Authors
- Goodman, D. M., Srofenyoh, E. K., Olufolabi, A. J., Kim, S. M., & Owen, M. D.
- Affiliations
- Duke University (US)
- Duke Medical Center (US)
- Wake Forest University (US)
- Atrium Health Wake Forest Baptist (US)
- Corresponding author
- Owen, Medge D.
- Venue
- BMC Pregnancy and Childbirth
- Published
- 2017-07-11
- Volume
- 17
- Issue
- 1
- Pages
- 216-216
- ISSN
- 1471-2393 (ISSN-L)
- PMC
- PMC5504760
- OpenAlex
- W2736080277
- Cited by
- 62
- References
- 11
- Citations by year
- 2026: 3 · 2025: 10 · 2024: 8 · 2023: 2 · 2022: 8 · 2021: 7 · 2020: 12 · 2019: 6 · 2018: 5 · 2017: 1
- FWCI
- 7.17
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- BMC Pregnancy and Childbirth (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- Lacy Foundation
- Society of Obstetric Anesthesiology and Perinatology
- Obstetric Anaesthetists' Association (GB)
- Topics
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Global Maternal and Child Health
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Maternal and fetal healthcare
- Health Sciences › Medicine › Obstetrics and Gynecology › Maternal and Perinatal Health Interventions
- Keywords
- obstetric referral, waiting time, maternal mortality, maternal morbidity, emergency obstetric care, fetal-pelvic disproportion, hypertensive disorders of pregnancy, uterine scar, obstetric hemorrhage, second stage of labor, night shift work, triage, Ghana
- MeSH terms
- Female, Ghana, Hospitals, Humans, Maternal Health Services, Pregnancy, Prospective Studies, Referral and Consultation, Time Factors, Triage, Delivery, Obstetric, Time-to-Treatment
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Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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