We report results from our thematic analysis using interview excerpts. This can lead to a fragmented sense of the overall results. So, we first detail three different delivery journeys, one from each category of stakeholder (woman, clinical staff, other) that highlights a positive aspect of current practice. These narratives are important in themselves because individual tracking is one way to understand when referral is successful (Macintyre and Hotchkiss, 1999) but remains under documented (Hussein et al., 2012). Thereafter, we present our interview results by analytical theme in each of the discovery and dream phase.
Case study one is an account of a post-partum haemorrhage as told by a DRH director and highlights the importance of strong oversight and management of a critical emergency. A woman was referred from HC to DRH because of severe post-partum haemorrhage. The director was not involved in the emergency treatment of the woman but coordinated the communication and staffing to enable treatment. The woman delivered vaginally but suffered severe blood loss (attributed to tearing by an unforeseen high weight baby). The tears could not be stitched by HC midwives so they used compresses to slow the bleeding and immediately called for the DRH ambulance. The ambulance could not reach the HC as the road was flooded and damaged because of heavy rain. Because it was common for the area to be flooded in the rainy season, the DRH director telephoned the HC manager who agreed to find a boat to transport the woman to a point that the ambulance could access. In the meantime, the DRH director organised two midwives and emergency obstetric kits to travel with the ambulance so that the woman would have access to immediate, basic life-saving actions. A few family members also accompanied the woman on the ambulance and later took care of the newborn. After arriving at the DRH, healthcare staff (interviewees refer to healthcare workers in general and did not distinguish cadre) examined the woman, conducted an ultrasound scan and arranged for a blood transfusion. Because the woman came with aged relatives, they were not asked by staff to donate blood, rather blood was taken from the National Blood Transfusion Center in Phnom Penh (free of charge for the family). The director did not follow the case further though believes no further problems arose as none were reported to the DRH by the HC through ad-hoc telephone calls or regular OD meetings.
Case study two is of a normal referral as told by a pregnant woman and highlights the critical role of family. The woman expected a HC delivery and on advice of the HC midwife, prepared her bag in advance. Her contractions started around 5:30 pm. At 8 am the next day, her mother decided she should go to the HC. Her husband drove her there by motorbike, with one elder brother. At the HC, the (only) staff on duty examined her and advised her to keep walking and eating until her waters broke. By midnight, she had not delivered and her husband and family stayed overnight at HC whilst her elder sister brought meals from home for them all. The following day, the midwife examined the woman and said she was still not dilated—this caused her mother to worry and request a referral letter from HC to go to the DRH. At the DRH, health staff were on standby and took her to the delivery room, with five other staff. They examined her and advised that she was 2 cm dilated and that she should continue to walk and eat. Many relatives visited her but returned home except for her parents and husband who stayed with her overnight. Her sister cooked and her brother brought meals for them to the DRH. Her family comforted her during labour. By 4:00 am on the fourth day, she was dilated enough to enter the delivery room with her mother. She delivered at 5.30 am and stayed one further night at the DRH. Many relatives visited her there and her mother stayed close to assist her with toileting, eating and baby care. Her husband ran errands for her and took her home. Her mother, husband and sister stayed with her at home to cook, undertake chores and care for the child. Many relatives and neighbours visited her at home.
Case study three is of a local delivery at a HC as told by a VHSG. It highlights how community health volunteers are an integral part of successful referral. The delivery took place at a HC after prolonged labour. The contraction started at 5:00 pm at the family called on the volunteer to accompany them to the HC. The husband drove the woman, whilst the volunteer used her motorbike to take the mother-in-law, an aunt and the delivery bag. On the way to HC, the family stopped at the home of another HC staff to request her assistance, together with one healthcare staff on standby at the HC. The standby staff came out to welcome the family and turned on the lamp but because it was not yet time to deliver, she continued her dinner. During the wait, the volunteer entertained the woman and her family by telling jokes and acting funny to reduce the tension. At 11:00 pm, the waters broke and staff examined the woman and said the cervix was fully dilated, so the healthcare worker started to assist the delivery. Present in the delivery room were the two staff, the volunteer, the mother-in-law and aunt. One massaged the woman's tummy and guided her on pushing, another prepared to catch the baby. The mother-in-law and the aunt each held a knee of the labouring woman and the volunteer placed the woman's head on her thighs. The volunteer verbally encouraged the woman to push and not give up. The pushing stage lasted for almost two hours before the baby was born. After delivery, the woman had bleeding so one staff set up an IV drip. Sometime later, the woman could not urinate and was bloated. One staff assisted her urination and she returned to normal. She was discharged from the HC the following morning. The volunteer (who had gone home) returned to help carry the delivery bag and drive the family home.
All but two of the delivery journeys resulted in a living mother and child, and all 30 respondents were satisfied with their selected delivery journey for various reasons. Thematic analysis identified 80 aspects that were provided to explain why the 30 selected delivery journey were satisfactory/considered positive to respondents (see Box 1). Some aspects retained significance throughout a journey. ‘Care and assistance from family and community’ was highlighted at all stages except at PRH/NH; ‘successful delivery and emergency treatment’ dominated HC and DRH stages whilst ‘quick referral action’ was only noted at the home/HC stage. ‘Caring and hard-working attitudes of health staff’ were highly appreciated at all hospitals and a ‘well-equipped health facility’ was raised for all health facilities. Responses were received across interviewee categories. For instance, on ‘prompt care and assistance from family and community’,
‘… [the mother] came to HC when seeing bleeding. The mother knew that there was something wrong with her daughter.’ (HC midwife)
‘…the presence of my husband… (it) is more comfortable than asking mother or sister … I want my husband to comfort me verbally …(in) such a difficult situation.’ (Woman)
‘…helping each other. Helping the people is like helping the country… the community does not give me any money, but I help all.’ (VHSG)
Interviewees chose to recount stories in which delivery was difficult but the mother survived—they were proud, and relieved, at the outcome:
‘…happy that she could deliver… “crossing the four-faces river” means delivering the baby… when we reach the end of the river, we are happy.’ (Aunt)
‘…happy because post-partum hemorrhage is very common and most dangerous…the patient could die within two hours, if we don't pay attention.’ (DRH midwife)
‘…the woman was having seizures when she arrived here, but we could save both the mother and the baby.’ (PRH midwife)
Families valued the attitude and behaviour of staff, especially polite, friendly attention along with amusing stories to relieve tension:
‘…[Staff] spoke politely to us … I could not walk because I had C-section, so they told me to try to walk and move my body. They told jokes to entertain a child of the patient nearby, and we all laughed.’ (Woman)
‘…when they say something friendly… female staff told us not to worry because we already arrived at her place and just try to eat a lot. So, I did not [worry].’ (Woman)
Instances of systematic and shared communication between the initiating and receiving facility and within clinical teams to learn lesson from their own experience was valued by clinical staff.
‘…happy about communication from HC. If all HC managers could do so, I can fulfil my responsibilities, and be successful… If [PRH] can get prior notice, we can prepare all arrangements… birth delivery patients can die very quickly. So, the emergency treatment needs to be quick.’ (PRH midwife)
‘good because we could disseminate during the OD meeting. We raised [the case] for discussion on how HC can refer the women quickly. We talked about the reasons… (and) change our practice as a result of the discussion on this case.’ (DRH doctor)
Cooperation extended to the woman's family.
‘What I like the most is the good cooperation from her family. They did not use harsh language to us… they cooperated with us very well. For example, we told them to do something, they followed us. For everything, we need cooperation from the women and their families to succeed. We can't do it alone.’ (DRH midwife)
‘two family members who came to report back the result to me also felt happy. They were not angry with us or felt that we are weak and could not do anything. They did not think like that.’ (HC manager)
The main delivery-associated costs were transportation, food and medical fees. To reduce food costs, relatives brought meals from home though one woman took food and cooker to cook at the hospital. A DRH midwife considered the total cost of onward referral when treating.
‘my elder daughter went home to bring meals for us. She went back and forth to bring meals that my aunt cooked at home.’ (Woman)
‘If the woman was referred further, she would spend a lot of money for everything. For all the referral cases, I want to help successfully at the DRH, so that HC would not feel discouraged that they referred to us.’ (DRH Midwife)
‘If the women do not have ID poor card, I will pay. We do everything to make sure that the women can go and are alive. Whether they pay back or not depends on their heart. …we had fundraising boxes placed at pagodas… to help share the [financial] burden on the HC.’ (HC Manager)
Box 1: Referral at its Best
• Women used ANC and prepared in advance for delivery at a healthcare facility
• Prompt care and assistance from family and community throughout a delivery journey
• Natural delivery/successful care and treatment at a facility
• Skills, caring work and attitudes of staff at DRH/PRH
• Quick referral actions
• Systematic cooperation and communication between HC-DRH-PRH staff
• Well-equipped DRH/NRH and sufficient medicines at HC
• Reduction in delivery associated delivery costs
• Collective post birth care and assistance from family, community, HC and DRH
• Family confidence in HC and DRH staff
• ID poor card
The Dream envisioned by interviewees was not broken down by journey stage. In this, interviewees attempted to solve problems that had been backgrounded in questioning thus far (such as danger in childbirth, delays in getting to a facility, rude and unsupportive clinical staff at healthcare facilities). The most common response was for a safe, easy and natural delivery near their home, from eighteen (18) interviewees:
‘the mother is safe, and the baby is also safe…Not to go further to province [PRH] or district [DRH]… end just at HC…not to go too far.’ (Mother)
‘skilled midwives should stand by at HC and for the women to go to deliver at HC, not at home.’ (Village Leader)
‘The women feel confident that they can deliver by themselves…for example, [sometimes when they have] terrible pain, they said that could not bear the pain any longer and they asked to have c-section. [I] don't want them to feel like that. [I want them] to believe that based on what the midwife examined—small baby, good position, and good cervix dilation—they trust [that they could deliver on their own].’ (PRH Midwife)
Respondents provided a number of explanations on how their dream could be enabled. Thirteen (13) interviewees thought that care from family and community was critical for successful referral. This could take many forms, such as physical and emotional support from husbands, mothers and the VHSG. Interviewees also wanted many relatives and neighbors to visit the women at HC or at home after delivery.
Eleven (11) research participants thought that women possessing good antenatal and postnatal knowledge through consultation with health staff and having regular ANC was important. Care also includes having healthy diet, taking iron supplements and relevant vaccinations as well as returning to facilities for post-natal care.
Available transportation that is safe, fast and convenient was essential to 7 interviewees. Some dreamed that women had their own motorbike or tuktuk [motor tricycle] to bring the women to the HC. Husbands should check the vehicle before use and drive carefully. Interviewees also dreamed of HCs with an ambulance and a driver and roads in good condition.
Friendly polite staff, who are more skilled and caring, was important for 9 interviewees. For respondents, this meant not only carrying out the required technical tasks but also being friendly, amusing and kind, speaking politely to all labouring and birthing women. One DRH midwife had a comprehensive philosophy of care, arguing that staff needed to take care of five aspects of birth—the physical, emotional, religious, social and political, whilst remaining ethical by not breaking confidential information on women. To enable friendly, polite and skilled care, respondents thought that the community could influence staff behaviour by themselves being polite and kind towards healthcare staff. VHSG could report complaints from women and their families directly to staff though one respondent went further and suggested anyone in the community, any staff in a HC or DRH or any other stakeholders should report staff misbehaviour at monthly OD meetings. Hospital directors could remind staff on their attitudes and behaviour during daily meetings. MOH and NGOs could provide additional training on women centred communication skills as well as technical obstetric skills. Ongoing mentoring from senior and experienced midwives for junior midwives would also enable skilled care. Last, management can take responsibility by providing more performance incentives to staff, send staff for additional training, undertake cross-department learning rotation and create check-and-balance system for the payment of user fees.
Seven interviewees touched on health facilities—that facilities charge lower user fees so that services are accessible to the poor; more skilled midwives on stand-by as well as enough equipment, especially for emergency treatment. The building should be of patient-centred design, with separate rooms for different types of patient, private rooms for the couple, delivery rooms close to operation rooms as well as waiting rooms.