The research, led by Final Zimkhitha Juqu of the University of KwaZulu-Natal together with Zamadonda Xulu-Kasaba and Olivia B. Baloyi, employed Straussian Grounded Theory to move beyond simply cataloguing referral barriers. The team wanted to explain how contextual conditions interact to shape the upward referral of obstetric emergencies from community health centres, which serve as the first point of contact for women experiencing complications during pregnancy and childbirth. The stakes could hardly be higher. Globally, an estimated 260,000 women die from maternal causes each year, with excessive bleeding, infections, pre-eclampsia and eclampsia, delivery complications, and unsafe abortion accounting for 75 percent of all maternal deaths. Most of these deaths are preventable or treatable when timely access to higher-level care exists.

South Africa’s maternal mortality ratio stands at 111.7 deaths per 100,000 live births, a figure that remains stubbornly high despite national policies designed to ensure functional referral pathways. The Eastern Cape is particularly burdened. According to the Health Systems Trust’s District Health Barometer, the province recorded the highest institutional maternal mortality ratio in the country in 2024, at 136.2 per 100,000 live births. OR Tambo district ranks among the top five districts with the highest maternal mortality within healthcare facilities in South Africa, and the municipality studied bears a maternal mortality ratio of 378.5 deaths per 100,000 live births, more than three times the national average.

To understand why, the researchers spent nearly a year collecting data between August 2024 and May 2025. They conducted thirteen focus group discussions with midwives, eight in-depth interviews with medical officers, and three with Emergency Medical Services paramedics, alongside document analysis and field observations. Data collection continued until theoretical saturation was achieved, the point at which no new categories emerged from the interviews. All discussions were conducted in English and isiXhosa, transcribed verbatim, and translated with careful verification of meaning. Analysis proceeded through the three coding stages of the Straussian approach: open coding to break data into concepts, axial coding to specify relationships between categories, and selective coding to integrate the findings into a coherent explanatory account.

The analysis revealed four interrelated categories of contextual conditions that shape upward referral: resource limitations, workforce and budget gaps, communication and Emergency Medical Services challenges, and geographical and socioeconomic factors. Each category contains subcategories that illustrate how systemic weaknesses compound one another across the referral pathway. What emerged was not a picture of isolated failures but of a chain of dependence in which community health centres depend on functional equipment, medicines, and communication to initiate safe referral; Emergency Medical Services depend on timely activation, road access, and patient stabilisation; and hospitals depend on prior notification and adequate handover to prepare for emergency care. When one part of this chain fails, the next part is weakened in turn.

Resource limitations emerged as pervasive. Midwives described labour wards with only three beds, cramped postnatal areas, and shortages of consulting rooms that delayed proper examination and decision-making. Equipment failures were equally consequential. Broken laryngoscopes, unreliable suction machines, and non-functional cardiotocographs made it difficult to stabilise patients before transfer or assess foetal distress accurately. One midwife described a centre with only one working phone for the entire facility, making it a struggle to contact ambulances or hospitals to arrange emergency referrals. Medication restrictions compounded these problems. Midwives reported being unable to administer Fentanyl intravenously due to scope-of-practice limitations, lacking blood supplies for women with haemorrhage, and facing unreliable pharmaceutical depots that left essential medications out of stock. Women were sometimes transferred before optimal stabilisation could be achieved, increasing dependence on EMS personnel and receiving facilities to continue urgent management during transit.

Workforce and budget gaps placed additional strain on the referral system. Community health centres functioned with very limited personnel, sometimes only two nurses per day for emergencies, with no advanced midwives available. Specialists avoided rural posts, leaving junior and acting staff who hesitated to make critical referral decisions while patients deteriorated. Training gaps weakened referral quality further. Midwives who lacked skills to interpret cardiotocograph scans produced incomplete referral notes, while inadequately trained EMS staff delayed or mishandled patient transfers. One midwife described waiting seven hours for an ambulance only to find the paramedics were untrained in obstetrics and functioned merely as drivers, requiring another seven-hour wait for a trained crew. Budget limitations operated indirectly but powerfully. Employment moratoria left hospitals understaffed, unpaid phone bills resulted in disconnected landlines at receiving facilities, and management responses to every shortage were that the department was aware but had no money.

Communication and Emergency Medical Services challenges emerged as persistent barriers to effective referral. Power outages and weak signal reception disrupted coordination between community health centres, EMS, and referral hospitals, resulting in unanticipated arrivals and inadequate preparation at receiving facilities. One paramedic explained that in some rural areas, radio signals were so weak that referring facilities could not notify hospitals beforehand, meaning obstetric emergency patients arrived without warning at facilities frequently ill-equipped to handle them quickly. Ambulance shortages were equally severe. One ambulance covered a vast area because vehicles were few and some did not work, meaning women sometimes waited until the next day for transport while their conditions worsened. Road construction lasting over a year and frequent community protests further delayed emergency access.

Geographical and socioeconomic factors compounded every systemic weakness. Long distances, rough roads, muddy routes, and flooded bridges converted obstetric referral into a prolonged and risky process. One-hour journeys extended to two or three hours because of road conditions. In extreme cases, women were transported in wheelbarrows across flooded bridges, arriving in already obstructed labour that could have been managed in time. When ambulances were unavailable, families faced impossible choices. One midwife described families charged R700 for night-time taxi fares to reach hospitals, with women experiencing eclampsia arriving at facilities having seizures in the back of old vans. Another described a woman who developed umbilical cord prolapse during a delay caused by an unavailable ambulance and a family unable to afford private transport.

The study’s central contribution lies in reframing these barriers not as background constraints but as active referral mechanisms that shape the timing of clinical decisions, the safety of stabilisation, and the preparedness of receiving hospitals. The researchers argue that delays in obstetric referral are emergent outcomes of a wider system of interdependent contextual conditions rather than transport or facility problems in isolation. Their recommendations call for regular multidisciplinary emergency obstetric training, strengthened referral communication with contingency mechanisms for power outages, upgraded road networks prioritising healthcare access routes, and dedicated facility-based ambulances at every community health centre. Addressing these bottlenecks, the authors conclude, is essential to enhancing timely and safe obstetric care and ultimately reducing preventable maternal and neonatal mortality in one of the world’s most challenging settings for maternal health.

Subject of Research: Obstetric emergency referral from community health centres in South Africa's Eastern Cape

Article Title: Contextual conditions shaping the upward referral of obstetric emergencies from community health centres in the Eastern Cape: a Straussian Grounded Theory study

Article References: Juqu, F. Z., Xulu-Kasaba, Z., & Baloyi, O. B. (2026). Contextual conditions shaping the upward referral of obstetric emergencies from community health centres in the Eastern Cape: a Straussian Grounded Theory study. Frontiers in Global Women's Health, 7, Article 1924667. https://doi.org/10.3389/fgwh.2026.1924667

Image Credits: AI Generated

DOI: 10.3389/fgwh.2026.1924667

Keywords: maternal mortality, obstetric emergencies, referral systems, community health centres, South Africa, Eastern Cape, grounded theory, Emergency Medical Services, rural health, qualitative research, health systems, neonatal outcomes