{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,24]],"date-time":"2026-07-24T22:34:21Z","timestamp":1784932461800,"version":"3.55.0"},"reference-count":29,"publisher":"Public Library of Science (PLoS)","issue":"2","license":[{"start":{"date-parts":[[2024,2,21]],"date-time":"2024-02-21T00:00:00Z","timestamp":1708473600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>Intrapartum continuity of care to reduce maternal morbidity and mortality relies heavily on a functional and effective referral system between tiers of care. Capacity building of providers in managing intrapartum referrals is expected to improve the efficiency of the referral system, but this does not always work in practice. This study explored the experiences and perceptions of maternity healthcare providers on emergency intrapartum referrals in Dar es Salaam, Tanzania.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods<\/jats:title>\n<jats:p>An exploratory qualitative study was conducted at Amana Regional Referral Hospital and Muhimbili National Hospital in Dar es Salaam. Maternity healthcare providers were purposively recruited based on cadre, working experience of more than three years in the maternity wards. An in-depth interview guide which involved questions and probes was used to conduct eleven interviews. Data was thematically analyzed.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>Three major themes emerged, namely: 1) causes of referrals are beyond medical indications; 2) limited maternity healthcare provider capability at referring facilities; and 3) limited communication between referring and receiving facilities. According to maternity healthcare professionals, referrals were seen as a way to minimize blame and a clinical management tool to prevent difficulties. They advocated for more understanding of the skill set among maternity healthcare providers, but some had negative perceptions towards performing their responsibilities.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>Skills gaps among maternity healthcare providers at referring hospitals influenced referral decision-making and service provision. There was hostility between referring and receiving hospitals. Capacity-strengthening strategies such as ongoing skills training and changes in attitudes toward referrals require improvements. The referring hospital should only consider referrals as a last resort after other case management has been completed.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0298103","type":"journal-article","created":{"date-parts":[[2024,2,21]],"date-time":"2024-02-21T18:30:43Z","timestamp":1708540243000},"page":"e0298103","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":8,"title":["\u201cAre all referrals necessary?\u201d Experiences and perceptions of maternity healthcare providers on emergency intrapartum referrals in Dar es Salaam, Tanzania"],"prefix":"10.1371","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8965-2827","authenticated-orcid":true,"given":"Shekha","family":"Selemani","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael O.","family":"Mwakyusa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Selemani","family":"Bashiri","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mangi J.","family":"Ezekiel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0975-4493","authenticated-orcid":true,"given":"Dorkasi L.","family":"Mwakawanga","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fadhlun M.","family":"Alwy Al-beity","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrea B.","family":"Pembe","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2024,2,21]]},"reference":[{"key":"pone.0298103.ref001","volume":"2023","author":"W. Bank","year":"2023","journal-title":"Tanzania Maternal Mortality Rate 2000\u20132023."},{"issue":"9","key":"pone.0298103.ref002","first-page":"2119","article-title":"Timing of maternal mortality and severe morbiduty during the postpartum period: a systematic review.","volume":"1 20","author":"J Dol","year":"2022","journal-title":"PMC"},{"key":"pone.0298103.ref003","first-page":"1","article-title":"Understanding barriers to implementing referral procedures in the rural and semi- urban district hospitals in Tanzania: Experiences of healthcare providers working in maternity units.","volume":"16","author":"LM Id","year":"2021","journal-title":"PLoS One."},{"key":"pone.0298103.ref004","author":"WHO","year":"2017","journal-title":"Quality, Equity, Dignity: A Network for Improving Quality of Care for Maternal, Newborn and Child Health."},{"key":"pone.0298103.ref005","first-page":"1","article-title":"Tanzania Demorgraphic and Health Survey Indicator Survey (TDHS-MIS) 2015\u20132016.","volume":"1","author":"TDHS","year":"2016","journal-title":"Dar es Salaam, Tanzania, Rockville, Maryland, USA MoHCDGEC, MoH, NBS, OCGS, ICF."},{"key":"pone.0298103.ref006","author":"World Health Organization","year":"2018","journal-title":"Intrapartum care for a positive childbirth experience"},{"key":"pone.0298103.ref007","first-page":"1","author":"WHO","year":"2016","journal-title":"Standards for improving quality of maternal and newborn care in health facilities"},{"key":"pone.0298103.ref008","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1371\/journal.pone.0159793","article-title":"Referrals between public sector health institutions for women with obstetric high risk, complications, or emergencies in India\u2014A systematic review.","volume":"11","author":"S Singh","year":"2016","journal-title":"PLoS One"},{"key":"pone.0298103.ref009","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1136\/bmjopen-2020-041746","article-title":"Perspectives of health workers on the referral of women with obstetric complications: A qualitative study in rural Sierra Leone","volume":"10","author":"R Proos","year":"2020","journal-title":"BMJ Open"},{"key":"pone.0298103.ref010","doi-asserted-by":"crossref","first-page":"1536","DOI":"10.4314\/ahs.v19i1.27","article-title":"Assessment of maternal referral systems used for a rural Zambian hospital: The development of setting specific protocols for the identification of complications","volume":"19","author":"AE Benson","year":"2019","journal-title":"Afr Health Sci"},{"key":"pone.0298103.ref011","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2019-031484","article-title":"Healthcare providers\u2019 perception of the referral system in maternal care facilities in Aceh, Indonesia: A cross-sectional study","volume":"9","author":"F Diba","year":"2019","journal-title":"BMJ Open"},{"issue":"5","key":"pone.0298103.ref012","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2014-005052","article-title":"Quality improvement in emergency obstetric referrals: Qualitative study of provider perspectives in Assin North district, Ghana.","volume":"4","author":"H Afari","year":"2014","journal-title":"BMJ Open"},{"key":"pone.0298103.ref013","first-page":"120","article-title":"Qualitative study on maternal referrals in rural Tanzania: decision making and acceptance of referral advice.","volume":"12","author":"AB Pembe","year":"2008","journal-title":"Afr J Reprod Health"},{"key":"pone.0298103.ref014","first-page":"934","article-title":"Women \u2018 s perceptions of the quality of emergency obstetric care in a referral hospital in rural Tanzania.","volume":"20","author":"KB Stal","year":"2015"},{"key":"pone.0298103.ref015","doi-asserted-by":"crossref","DOI":"10.1186\/1472-6963-10-326","article-title":"Effectiveness of maternal referral system in a rural setting: A case study from Rufiji district, Tanzania.","volume":"10","author":"AB Pembe","year":"2010","journal-title":"BMC Health Serv Res."},{"key":"pone.0298103.ref016","first-page":"1","article-title":"Attitudes and behaviours of maternal health care providers in interactions with clients: A systematic review.","volume":"11","author":"P Mannava","year":"2015","journal-title":"Global Health."},{"key":"pone.0298103.ref017","article-title":"Sensa ya Watu na Makazi ya Mwaka 2022: Matokeo ya Mwanzo.","author":"NBST","year":"2022","journal-title":"Dodoma"},{"key":"pone.0298103.ref018","author":"T. MOHSW","year":"2017","journal-title":"Policy\u2014National Health Policy"},{"key":"pone.0298103.ref019","first-page":"120","article-title":"Teaching thematic analysis: Overcoming challenges and developing strategies for effective learning Associate Professor in Sexuality Studies Department of Psychology Faculty of Health and Life Sciences University of the West of England Coldharbour Lane Br.","volume":"26","author":"V Clarke","year":"2013","journal-title":"Univ West Engl"},{"key":"pone.0298103.ref020","doi-asserted-by":"crossref","first-page":"105","DOI":"10.1016\/j.nedt.2003.10.001","article-title":"Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness.","volume":"24","author":"UH Graneheim","year":"2004","journal-title":"Nurse Educ Today"},{"key":"pone.0298103.ref021","author":"AK Shenton","year":"2016","journal-title":"Strategies for Ensuring Trustworthiness in Qualitative Research Projects Strategies for ensuring trustworthiness in qualitative research projects"},{"issue":"1","key":"pone.0298103.ref022","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s12913-020-4886-3","article-title":"Improving emergency obstetric referral systems in low and middle income countries: A qualitative study in a tertiary health facility in Ghana.","volume":"20","author":"AA Daniels","year":"2020","journal-title":"BMC Health Serv Res."},{"key":"pone.0298103.ref023","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s12884-015-0493-4","article-title":"Barriers to providing quality emergency obstetric care in Addis Ababa, Ethiopia: Healthcare providers\u2019 perspectives on training, referrals and supervision, a mixed methods study.","volume":"15","author":"A Austin","year":"2015","journal-title":"BMC Pregnancy Childbirth"},{"issue":"702","key":"pone.0298103.ref024","first-page":"1","article-title":"Strengthening referral systems in community health programs: a qualitative study in two rural districts of Maputo Province, Mozambique.","author":"C Give","year":"2019"},{"key":"pone.0298103.ref025","first-page":"104","article-title":"Service providers\u2019 perception of the quality of emergency obsteric care provided and factors indentified which affect the provision of quality care.","volume":"22","author":"E Chodzaza","year":"2010","journal-title":"Malawi Med J"},{"key":"pone.0298103.ref026","doi-asserted-by":"crossref","DOI":"10.1016\/j.midw.2019.08.010","article-title":"Referral linkage among public health facilities in Ethiopia: A qualitative explanatory study of facilitators and barriers for emergency obstetric referral in Addis Ababa city administration.","volume":"79","author":"C Yasin","year":"2019","journal-title":"Midwifery"},{"issue":"4","key":"pone.0298103.ref027","doi-asserted-by":"crossref","first-page":"123","DOI":"10.3126\/ajms.v13i4.43375","article-title":"Spectrum of obstetric referral and their outcome at a Tertiary Care Center of Eastern Uttar Pradesh: An insight.","volume":"13","author":"Ankita Kumari","year":"2022","journal-title":"Asian J Med Sci"},{"key":"pone.0298103.ref028","first-page":"1","article-title":"Effectiveness of Maternal Referral System in Tanzania: A Mixed Method Study.","author":"MA Bugomola","year":"2022"},{"issue":"1","key":"pone.0298103.ref029","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s12884-020-03339-3","article-title":"Quality and women\u2019s satisfaction with maternal referral practices in sub-Saharan African low and lower-middle income countries: a systematic review.","volume":"20","author":"EK Ameyaw","year":"2020","journal-title":"BMC Pregnancy Childbirth"}],"container-title":["PLOS ONE"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0298103","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,2,21]],"date-time":"2024-02-21T18:31:19Z","timestamp":1708540279000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0298103"}},"subtitle":[],"editor":[{"given":"Hannah","family":"Tappis","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2024,2,21]]},"references-count":29,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2024,2,21]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0298103","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,2,21]]}}}