Action and interaction strategies for enhancing upward referral of obstetric emergencies from community health centres in the eastern cape

Introduction: Effective upward referral of obstetric emergencies from community health centres to higher-level facilities is critical for reducing maternal and neonatal mortality. In resource-limited settings such as the Eastern Cape, South Africa, referral systems are frequently constrained by transport shortages, communication gaps and staffing limitations. Although referral policies exist, limited evidence describes the practical strategies frontline healthcare workers use to maintain functional referral processes under these conditions. Methods: This study analysed the action and interaction strategies used to facilitate effective upward referral of obstetric emergencies from CHCs. A qualitative approach, embedded within a broader grounded theory inquiry and guided by the Straussian method, was employed. Data were collected through focus group discussions, in-depth interviews, observations and document analysis. Results: Healthcare workers employed a range of adaptive strategies to overcome systemic referral barriers. These included improvised transportation and logistical arrangements, informal communication pathways, bedside clinical improvisation, strategic reallocation of human and material resources and deliberate adaptation of referral protocols. These practices were collaborative, context-responsive, and frequently extended beyond formal procedures to prioritise patient survival. Discussion: Despite structural constraints, frontline healthcare workers sustain obstetric referral systems through dynamic and context-responsive practices. These findings highlight the critical role of provider agency and adaptive decision-making in maintaining continuity of emergency obstetric care and strengthening maternal and neonatal outcomes in resource-limited health systems.