Interventions to improve obstetric emergency referral decision making, communication and feedback between health facilities in sub‐Saharan Africa: A systematic review

OBJECTIVE: The objective of the study was to review the evidence on interventions to improve obstetric emergency referral decision making, communication and feedback between health facilities in sub‐Saharan Africa (SSA). METHODS: A systematic search of PubMed, Embase, Cochrane Register and CINAHL Plus was conducted to identify studies on obstetric emergency referral in SSA. Studies were included based on pre‐defined eligibility criteria. Details of reported referral interventions were extracted and categorised. The Joanna Biggs Institute Critical Appraisal checklists were used for quality assessment of included studies. A formal narrative synthesis approach was used to summarise findings guided by the WHO's referral system flow. RESULTS: A total of 14 studies were included, with seven deemed high quality. Overall, 7 studies reported referral decision‐making interventions including training programmes for health facility and community health workers, use of a triage checklist and focused obstetric ultrasound, which resulted in improved knowledge and practice of recognising danger signs for referral. 9 studies reported on referral communication using mobile phones and referral letters/notes, resulting in increased communication between facilities despite telecommunication network failures. Referral decision making and communication interventions achieved a perceived reduction in maternal mortality. 2 studies focused on referral feedback, which improved collaboration between health facilities. CONCLUSION: There is limited evidence on how well referral interventions work in sub‐Saharan Africa, and limited consensus regarding the framework underpinning the expected change. This review has led to the proposition of a logic model that can serve as the base for future evaluations which robustly expose the (in)efficiency of referral interventions.