Table 2.

Suggested recommendations for the improvement of the emergency obstetric referral system

Sub-theme	Quote
Multidisciplinary and inter-intra facility Communication & Coordination	Q1	“there needs to be a coordination of the emergency care...the whole district or sub-region has to have a meeting to iron out systematically patient flow and communication...and see how best they can improve on the present …” A1 Doctor
	Q2	“… we can do the WhatsApp platform for the referral sources, that would be the beginning of some better approach...” A1 Doctor
	Q3	“… Encourage Korle Bu to join the Kybele (WhatsApp Platform) or Korle Bu should create a similar medium to facilitate the delivery of prompt service … A8 Midwife
	Q4	“… we need to audit current referral forms and get them in a state that would help with communication …” A2 Doctor
	Q5	Take advantage of technology like activating the Kybele (WhatsApp Platform) at the district level … A7 Doctor
	Q6	Make communication gadgets available to facilitate smooth communicate among centres before referral … A9 Midwife
	Q7	“… there needs to be a better coordination between the referral sources and experts within the Ghana health service as well as outside so cases are not just pushed unnecessarily as an emergency to clog up clinics and clog up the wards that are required by genuine emergencies …” A1 Doctor
	Q8	“… getting the referral forms in such a way that referral facility eventually after the care has been given can also write back to the referring centres … because patients are stable …” A2 Doctor
	Q9	“… certain consumables … and the health insurance system should be reviewed and well-coordinated to help patient get the best care at the shortest time … A1Doctor
Strengthening Transport System	Q10	“… If ambulance service would overlook where they have to confirm from the receiving end before attending to the emergency will help to minimize the delay process. The money issue too if it can be looked at again because not all client can afford to pay for their service …” A8 Midwife
	Q11	“… I think we should go back to the old days where every health facility has their own ambulance it will really help and also if Korle Bu cannot be on Kybele, the facility can have it own form of Kybele it makes it easier …” A7 Doctor
	Q12	“… Review the current Ambulance service charges … A8 Midwife
	Q13	“… ambulance availability should be ensured …” A9 Midwife
Policy/ Guidelines	Q14	“… I think we should really pay attention to our referral system by putting a strategy and getting people to understand it. We should look at it as nation and not by individual facilities …” A6 Doctor
	Q15	“… there has to be an outline of what cases needs to be referred and until it is flagged that yes you can send this case, too many cases are being dumbed …” A1 Doctor
	Q16	“… we need good notices, we should type out what the processes are supposed to be; what the standard operating procedures are for everybody patients, drivers, ambulance, and even the care givers so they can follow the procedures to improve the lives of the people …” A2 Doctor
Leadership /Accountability	Q17	“… so, if that is in place [sanctions for not taking responsibility], people would play by the policies that are on the ground. …” A1 Doctor
	Q18	“… Until we really have some transparency in the apportion of blame accordingly if there is substandard care. It is not going to be a system that would correct itself …” A1 Doctor
Resources (Human Equipment, Medicines and Infrastructure)	Q19	“… Redesigning the entrance … once a vehicle lands there should be someone that people can approach … and do resuscitation along the line …” A2 Doctor
	Q20	“… the facility [DPC] must get its own delivery ward, get an attached obstetrician if not permanent one we can easily call to assist when we have problem … and the emergency bed management should improve at the higher facilities …” A6 Doctor
	Q21	“… it will go a long way to help if at least if the major once gets their own obstetricians... The person will not be able to work 24/7 but will lessen the number of referrals …” A7 Doctor
	Q22	“… most drugs for pre-referral treatment be made readily available if not free and also make available logistics to work with …” A9 Midwife