TITLE:
Improving Obstetric Referral and Counter-Referral Mechanisms in Northern Benin: Findings from a Single-Center Cross-Sectional Study Advocating a System-Level Approach
AUTHORS:
Sidi Imorou Rachidi, Vodouhe Vinadou Mahoublo, Atadé Raoul Sèdjro, Obossou Achille Awade Aafoukou, Klikpézo Roger, Hounkponou Ahouignan Fanny, Salifou Kabibou, Dénakpo Justin Lewis
KEYWORDS:
Quality of Care Assessment, Referral System, Maternal Health, Obstetric Emergencies
JOURNAL NAME:
Open Journal of Obstetrics and Gynecology,
Vol.16 No.9,
September
22,
2026
ABSTRACT: Background: An effective obstetric referral and counter-referral system is essential for ensuring timely access to comprehensive emergency obstetric care. In northern Benin, geographical barriers, transportation constraints and weaknesses in communication between health facilities may compromise the continuity and quality of care. Objective: This study sought to assess the quality of the obstetric referral and counter-referral system and identify factors associated with referral and counter-referral dysfunction among women referred to a referral hospital in northern Benin in 2022. Methods: We conducted a hospital-based cross-sectional study with prospective data collection from 1 January to 30 June 2022 at the obstetrics and gynecology emergency department of Borgou/Alibori University and Departmental Hospital Center (CHUD-B/A). All women referred or transferred from another health facility during the study period were consecutively included. Data were collected through patient or relative interviews and review of medical records, referral documents and hospital registers. Referral and counter-referral quality were assessed using predefined criteria based on national standards, with a 70% compliance threshold used to define dysfunction. Associations were assessed using bivariate and multivariable analyses, with adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs). Results: Of 1735 women admitted during the study period, 919 (52.9%) were referred; 913 were included in the final analysis. The mean age was 26.8 ± 6.6 years. Although 91.8% had consented to referral and 81.7% had a referral form, only 17.6% of receiving facilities had been notified before transfer. Medicalized transport was used in 11.0% of cases and only 1.4% of women were accompanied by a health professional. Arrangements for reception were documented in 15.4% of cases, while 41.0% waited at least 10 minutes before initial management. Counter-referral was particularly weak: feedback to referring facilities was documented in 35.4% of cases and recommendations for continued care in only 4.2%. Referral dysfunction was associated with younger age, referral from a private facility, greater distance, rural origin and delayed initial management. Rural origin and greater distance were also associated with counter-referral dysfunction. Conclusion: Important weaknesses remain in the obstetric referral and counter-referral system in northern Benin, particularly regarding communication, transportation, reception and continuity of care. Strengthening coordination between facilities and improving referral and counter-referral procedures should be prioritized.