{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T18:19:08Z","timestamp":1787681948387,"version":"build-2784847793"},"reference-count":18,"publisher":"Public Library of Science (PLoS)","issue":"8","license":[{"start":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T00:00:00Z","timestamp":1787616000000},"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":"\n Objective<\/jats:title>\n To determine the rate of obstetric referral and explore contextual factors influencing referral practices in public health centres of Addis Ababa, Ethiopia.<\/jats:p>\n <\/jats:sec>\n \n Design<\/jats:title>\n Explanatory sequential mixed-methods study.<\/jats:p>\n <\/jats:sec>\n \n Setting and period<\/jats:title>\n Fifty public health centres in the Addis Ababa City Administration, January\u2013April 2021.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n Delivery and referral registers from 50 health centres were reviewed retrospectively for 12 months (8 July 2019\u20137 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\u2019s method.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n Only 13 (26%) of the 50 health centres have met all eight standards assessed for functionality of the referral system. The main gaps of the referral system were a lack of ambulance (12%), absence of formal agreement with referral centers, and lack of timely case-by-case feedback from referral centers(64%). The overall obstetric referral rate was 32%, with substantially higher referral rates in health centers 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\u2019 clinical skills, and risk-averse practices driven by accountability concerns related to maternal and perinatal outcomes.<\/jats:p>\n <\/jats:sec>\n \n Conclusion<\/jats:title>\n Improving functionality of referrals and reducing unnecessarily high referrals requires adopting and training providers on the new WHO labour guide and partograph, improving referral feedback, and clarifying accountability mechanisms.<\/jats:p>\n <\/jats:sec>","DOI":"10.1371\/journal.pone.0342872","type":"journal-article","created":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T17:27:25Z","timestamp":1787678845000},"page":"e0342872","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Obstetric referral practices and health system factors in public health centres of Addis Ababa, Ethiopia: A mixed-methods study"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1858-090X","authenticated-orcid":true,"given":"Amaha Haile","family":"Abebe","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rose","family":"Mmusi-Phetoe","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,8,25]]},"reference":[{"key":"pone.0342872.ref001","volume-title":"Managing complications in pregnancy and childbirth: a guide for midwives and doctors","author":"WHO","year":"2017","edition":"2"},{"issue":"7","key":"pone.0342872.ref002","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1001264","article-title":"The effectiveness of emergency obstetric referral interventions in developing country settings: a systematic review","volume":"9","author":"J Hussein","year":"2012","journal-title":"PLoS Med"},{"issue":"57","key":"pone.0342872.ref003","first-page":"1","article-title":"What is the optimal rate of caesarean section at the population level? A systematic review of ecologic studies","volume":"12","author":"A Betran","year":"2015","journal-title":"Reprod Health"},{"issue":"11","key":"pone.0342872.ref004","article-title":"Quality of basic maternal care functions in health facilities of five African countries: an analysis of national health system surveys","volume":"4","author":"ME Kruk","year":"2016","journal-title":"Lancet Glob Health"},{"key":"pone.0342872.ref005","volume-title":"Standards for improving the quality of maternal and newborn care in health facilities","author":"World Health Organization","year":"2016"},{"issue":"1","key":"pone.0342872.ref006","first-page":"977","article-title":"Systematic review of the referral system of obstetric complications in low-resource countries","volume":"28","author":"Z Ijaiya","year":"2025","journal-title":"Afr J Biomed Res"},{"key":"pone.0342872.ref007","doi-asserted-by":"crossref","first-page":"42","DOI":"10.1186\/s12884-015-0471-x","article-title":"Variation in referrals to secondary obstetrician-led care among primary midwifery care practices in the Netherlands: a nationwide cohort study","volume":"15","author":"PM Offerhaus","year":"2015","journal-title":"BMC Pregnancy Childbirth"},{"key":"pone.0342872.ref008","doi-asserted-by":"crossref","first-page":"326","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.0342872.ref009","doi-asserted-by":"crossref","first-page":"40","DOI":"10.1186\/s13104-016-1852-6","article-title":"High proportions of obstetric referrals in Addis Ababa: the case of term premature rupture of membranes","volume":"9","author":"AH Mirkuzie","year":"2016","journal-title":"BMC Res Notes"},{"key":"pone.0342872.ref010","volume-title":"Ethiopian Emergency Obstetric and Newborn Care (EmONC) Assessment 2016","author":"EPHI, FMoH, AMMD","year":"2018"},{"key":"pone.0342872.ref011","doi-asserted-by":"crossref","first-page":"1473191","DOI":"10.3389\/fgwh.2025.1473191","article-title":"Appropriateness of maternal referral system and its associated factors in Eastern Ethiopia: a facility-based cross-sectional study","volume":"6","author":"BM Sharew","year":"2025","journal-title":"Front Glob Womens Health"},{"key":"pone.0342872.ref012","first-page":"1","article-title":"Factors affecting the provision of referral services at the primary level of health care in Zomba District in Malawi","author":"B Chitsa","year":"2019","journal-title":"Texila Int J Public Health"},{"issue":"12","key":"pone.0342872.ref013","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":"4","key":"pone.0342872.ref014","doi-asserted-by":"crossref","first-page":"282","DOI":"10.1080\/20786190.2015.1055670","article-title":"A blank page: feedback from first referral hospitals to primary health care clinics","volume":"57","author":"T Legodi","year":"2015","journal-title":"South Afr Fam Practi"},{"key":"pone.0342872.ref015","doi-asserted-by":"crossref","first-page":"1168277","DOI":"10.3389\/frhs.2023.1168277","article-title":"Emergency obstetric referrals in public health facilities: a descriptive study from urban Maharashtra, India","volume":"3","author":"S Das","year":"2023","journal-title":"Front Health Serv"},{"issue":"8","key":"pone.0342872.ref016","first-page":"643","article-title":"Colaizzi\u2019s descriptive phenomenological method","volume":"28","author":"R Morrow","year":"2015","journal-title":"The Psychologist"},{"key":"pone.0342872.ref017","volume-title":"WHO recommendations: Intrapartum care for a positive childbirth experience","author":"World Health Organization","year":"2018"},{"key":"pone.0342872.ref018","volume-title":"WHO Labour Care Guide: User\u2019s Manual","author":"World Health Organization","year":"2020"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0342872","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T17:27:32Z","timestamp":1787678852000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0342872"}},"subtitle":[],"editor":[{"given":"Sabita","family":"Tuladhar","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,8,25]]},"references-count":18,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,8,25]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0342872","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,25]]}}}