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Healthcare providers’ perception of the referral system in maternal care facilities in Aceh, Indonesia: a cross-sectional study
  1. Farah Diba1,
  2. Ichsan Ichsan1,
  3. Muhsin Muhsin1,
  4. Marthoenis Marthoenis1,
  5. Hizir Sofyan1,
  6. Mohammad Andalas1,
  7. Ida Monfared2,
  8. Katharina Richert3,4,
  9. Lennart Kaplan5,
  10. Lisa Rogge6,
  11. Siobhan Doria2,
  12. Samadi Samadi1,
  13. Sebastian Vollmer2
  1. 1 Universitas Syiah Kuala, Banda Aceh, Aceh, Indonesia
  2. 2 Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany
  3. 3 Centre for Evaluation and Development, Mannheim, Germany
  4. 4 Department of Economics, University of Mannheim, Mannheim, Baden-Württemberg, Germany
  5. 5 Deutsches Institut für Entwicklungspolitik, Bonn, Nordrhein-Westfalen, Germany
  6. 6 Leibniz University Hanover, Hannover, Niedersachsen, Germany
  1. Correspondence to Dr Ida Monfared; ida.gohardoustmonfared{at}


Objectives Our study investigates the barriers perceived by staff in the referral systems in maternal healthcare facilities across Aceh province in Indonesia.

Design With a cross-sectional approach, two sets of surveys were administered during September to October 2016 in 32 sampling units of our study. We also collected referral data in the form of the frequency of ingoing and outgoing referral cases per facility.

Setting In three districts, Aceh Besar, Banda Aceh and Bireuen, a total of 32 facilities including hospitals, community health centres, and private midwife clinics that met the criteria of providing at least basic emergency obstetric and neonatal care (BEonC) were covered.

Participants Across the 32 healthcare centres, 149 members of staff (mainly midwives) agreed to participate in our surveys.

Primary and secondary outcome measures The first survey consisted of 65 items focusing on organisational measures as well as case numbers for example, patient counts, mortality rate and complications. The second survey with 68 items asked healthcare providers about a range of factors including attitudes towards the referral process in their facility and potential barriers to a well-functioning system in their district.

Results Overall, mothers’/families’ consent as well as the complex administration process were found to be the main barriers (36% and 12%, respectively). Healthcare providers noted that information about other facilities has the biggest room for improvement (37%) rather than transport, timely referral of mothers and babies, or the availability of referral facilities.

Conclusions The largest barrier perceived by healthcare providers in our study was noted to be family consent and administrative burden. Moreover, lack of information about the referral system itself and other facilities seemed to be affecting healthcare providers and mothers/families alike and improvements perhaps through a shared information system is needed.

  • referral system
  • neonatal health
  • maternal health
  • Aceh
  • Indonesia

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • Contributors SV, KR, LK and SS: conceptualised the study. FD, MA, II, MM, MM, SD, KR, LK and LR: contributed to the data collection. KR and LK: analysed the data and wrote the first draft of the manuscript. HS: contributed to the statistical analysis. IM: contributed to the conceptual writing and analysis of the study. All authors revised the manuscript for important intellectual content and approved the final version.

  • Funding The study was supported by funding from the Volkswagen Stiftung, the European Commission’s Experts4Asia scholarship program as well as the German Research Foundation (DFG).

  • Map disclaimer The depiction of boundaries on this map does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. This map is provided without any warranty of any kind, either express or implied.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval (I) Ethical Review Board of the University of Göttingen (Ethikkommission der Universität Göttingen), 27/06/2016; (II) Ethical Clearance Committee of the Medical Faculty of Syiah Kuala University, 24/06/2016 ref: No: 08/KE/FK/2016.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request and when the dissemination of the project full results is completed.

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