Background Reducing maternal and neonatal deaths in low- and middle-income countries requires a comprehensive understanding of the challenges within the healthcare system. Effective upward referral systems play a crucial role in ensuring timely emergency care for obstetric complications in the healthcare system. The aim of this study is to understand the factors (antecedents) and defining characteristics (attributes) that influence upward referrals of obstetric emergencies. from Community Health Centres to higher-level hospitals in the OR Tambo district, Eastern Cape, South Africa. Methods Data were collected through document analysis, observations, focus group discussions and in-depth interviews, consisting of 59 participants, using a qualitative grounded theory approach. Results The study reveals a complex web of interrelated antecedents and attributes that influence the effectiveness of upward referrals in obstetric emergencies. While formal protocols exist, referral decisions are often undermined by systemic barriers. The findings suggest that the lack of coordination between referring and receiving facilities, coupled with fragmented feedback systems, hampers continuity of care. Despite these challenges, instances of effective referral were observed in settings where interprofessional collaboration, timely information sharing, and adequate preparation of patients were prioritised. Conclusion Effective upward referral of obstetric emergencies depends on timely decision-making, adequate patient preparation, clear communication, and inter-facility collaboration. This highlights the need for an integrated approach that strengthens health system functions, which are essential to reducing preventable maternal and neonatal morbidity and mortality in resource-constrained settings like South Africa.
Juqu et al. (2026) studied this question.