Inter-facility referrals for childbirth care in Lubumbashi city, DRC: results from a healthcare facility census in 2023

<title>Abstract</title> <p> <bold>Background</bold> Ensuring continuity of care around the time of childbirth is essential to maternal and perinatal survival and wellbeing. In many health systems, health facilities (HFs) are mandated to refer women needing more advanced care within a designated structure. However, inter-facility referral practices remain under-documented, especially in complex urban settings with diverse and fragmented care provision. This study describes the characteristics, capacity, and spatial relations of inter-facility referrals for childbirth care in Lubumbashi, Democratic Republic of the Congo. <bold>Methods</bold> A facility census was conducted in November 2023, recording geographic coordinates for all HFs. Representatives of HFs without childbirth care capacity cited the HFs to which they refer women needing childbirth care; representatives of HFs providing childbirth care cited destination HFs to which they referred women needing higher-level care. Sending-destination HF pairs were characterized by sector (public vs. private) and childbirth care capacity (none, non-caesarean section (CS), or CS-offering). We assessed the extent to which HFs referred to their designated hospital under national referral policies (lower-level HF should send patients to the referral hospital within the same health zone) and calculated straight-line distances to it. <bold>Results</bold> We enumerated 1,254 primary and secondary HFs in Lubumbashi. Overall, 20% cited no destination HF (14% of 296 facilities without childbirth care capacity, 15% of 658 non-CS facilities, and 38% of 300 CS-offering facilities). The two public tertiary hospitals were the most frequently cited destinations regardless of sending facility capacity and location. Although 80% of HFs cited at least one destination HF, 58% cited a public CS-offering facility. Overall, 43% cited their designated referral hospital and 11% cited the equivalent hospital in a different health zone. Among facilities citing their designated hospital, the median distance to it was 2.6km; among facilities citing an alternative, the median distance to their own designated hospital was 3.3km. <bold>Conclusion</bold> Referral patterns in Lubumbashi deviate somewhat from the designated structure, at times bypassing designated hospitals in favour of facilities closer by and public tertiary facilities. Strategies to strengthen inter-facility referral policies and practices should account for the importance of proximity, to improve the efficiency, continuity, and timeliness of childbirth care. </p>