BACKGROUND:
Timely referral from lower- to higher-level hospitals is vital for saving pregnant women’s lives. Yet the importance of quality referrals in improving maternal health outcomes has been neglected, leaving limited data on referral patterns. In Ghana, research on maternal referral processes and factors influencing compliance remains insufficient. This study therefore explored the personal and health system factors affecting pregnant women’s compliance with referrals to higher-level facilities.

METHODS:
A phenomenological qualitative study used purposive sampling to recruit 16 respondents (8 postpartum mothers, 8 health workers). In-person interviews (45–60 minutes) followed separate open-ended guides, were audio-recorded, transcribed, thematically analyzed, and ethically approved by the Ghana Health Service.

RESULTS:
Twelve main themes and thirty sub-themes emerged from the data. The study reported referral process issues, absence of documented maternal referral protocol, problems with receiving facility, challenges with the referral preparation and referral communication mishaps. Also, foetal, obstetric and maternal factors accounted for most referrals. Compliance with maternal referrals was found to be impacted by cost of care, the attitude of healthcare professionals, and the availability of medical equipment. Additionally, new mothers cited facility preferences, financial constraints, and dread of a Caesarean section as determining factors for compliance. Other determinants included “big” hospital myths and cultural beliefs. Health professionals reported two solutions to address the many obstacles: the use of digital platforms like WhatsApp and birth preparation activities like attending pregnancy school.

CONCLUSIONS:
The study found no documented maternal referral protocol. Personal and health system factors hinder postpartum mothers’ compliance with referrals. It recommends developing a structured protocol to guide maternal referrals across all health facility levels for improved outcomes.