Contextual conditions shaping the upward referral of obstetric emergencies from community health centres in the Eastern Cape: a Straussian Grounded Theory study

Introduction Maternal mortality remains a significant public health concern in South Africa, particularly in resource limited settings where timely access to higher-level care is vital. Community Health Centres are the first point of contact for women faced with obstetric emergencies, yet systemic, contextual, and operational challenges impede effective upward referral. Guided by Straussian Grounded Theory, this qualitative study explored the contextual conditions shaping the upward referral of obstetric emergencies in the OR Tambo district, Eastern Cape. Methods Data was collected through focus group discussions, in–depth interviews, document analysis, and observations, and analysed using open, axial, and selective coding. Results Findings revealed four key categories which were resource limitations, workforce and budget gaps, communication and Emergency Medical Services, geographical and socioeconomic barriers. Discussion These interrelated conditions contribute to delayed, unsafe, and fragmented referrals, placing mothers and newborns at heightened risk of further complicated conditions. Addressing these systemic challenges requires multi-sectoral interventions, including regular multidisciplinary emergency obstetric training, strengthened referral communication, investment in transport infrastructure and facility-based ambulances. Conclusion This study indicates that strengthening referral process is essential in enhancing timely and safe obstetric care, ultimately reducing preventable maternal and neonatal mortality.