|Year : 2020 | Volume
| Issue : 2 | Page : 158-163
Factors associated with maternal referral system in South India: A hospital-based cross-sectional analytical study
Tanveer Rehman1, Anish Keepanasseril2, Dilip Kumar Maurya2, Sitanshu Sekhar Kar3
1 Department of Community Medicine & School of Public Health, PGIMER, Chandigarh, India
2 Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
3 Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
|Date of Submission||04-Feb-2020|
|Date of Decision||18-Mar-2020|
|Date of Acceptance||03-Apr-2020|
|Date of Web Publication||22-Jul-2020|
Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 008
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Availability of free/low-cost treatment in higher government facilities increases maternity self-referrals circumventing the referral system. We aimed to find the sociodemographic and health-care service delivery pattern among the pregnant women referred for institutional delivery in a tertiary care center in south India and assess factors associated with maternity self-referral from the perspective of pregnant women. Materials and Methods: We conducted a cross-sectional analytical study among pregnant women attending the antenatal clinic and admitted to the obstetric and postnatal wards during the 6-month study period. Interview was conducted using a face validated structured questionnaire. Statistical Analysis: Adjusted prevalence ratio (aPR) with 95% confidence interval (CI) was calculated to assess the independent effects of the sociodemographic and health-care delivery factors on maternity self-referral. Results: Mean age of 4191 pregnant women was 24 years (3.9). Forty-one percent (1732) of them had come without any referral, i.e., self-referred. Fifty-two percent (909) of these self-referred pregnant women were primigravida, 77% (1330) belonged to joint families and had nearest health facility within half hour distance from their own house. Nuclear family (aPR: 1.56 [95% CI: 1.45–1.68]), monthly family income >Rs. 3000 (aPR: 1.38 [95% CI: 1.28-1.49], and nearest health facility more than half-hour (aPR: 1.57 [95% CI: 1.45–1.69]) were factors significantly associated with self-referral. Conclusions: The study presents the alarming maternal referral system prevailing in nation as 41% (95% CI: 39.8%–42.8%) of maternal admissions in a tertiary care institute of South India were without any documented referrals.
Keywords: Cross-sectional, emergency obstetric care, maternal health services, referral and consultation
|How to cite this article:|
Rehman T, Keepanasseril A, Maurya DK, Kar SS. Factors associated with maternal referral system in South India: A hospital-based cross-sectional analytical study. J Nat Sc Biol Med 2020;11:158-63
|How to cite this URL:|
Rehman T, Keepanasseril A, Maurya DK, Kar SS. Factors associated with maternal referral system in South India: A hospital-based cross-sectional analytical study. J Nat Sc Biol Med [serial online] 2020 [cited 2020 Aug 4];11:158-63. Available from: http://www.jnsbm.org/text.asp?2020/11/2/158/290492
| Introduction|| |
One of the sustainable development goals (SDG) is to “ensure healthy lives and promote well-being for all at all ages,” including maternal and child health. By 2030, SDG targets reduction in the global maternal mortality ratio (MMR) to <70 per 100,000 live births and neonatal mortality to at least as low as 12 per 1000 live births. However, maternal and neonatal mortality remain an unsolved health priority in developing countries, including India. Even though significant progress in reducing MMR from 551 in 1990 to 1991-130 in 2014 to 2016 was achieved by India, in states such as Assam, Uttarakhand, Uttar Pradesh, Rajasthan, and Bihar - it has remained unacceptably high. This is attributed to the inadequate access to quality of care, sociocultural factors, and the three delay models.
Concept of formalized maternal referral system is based on strategy of ensuring accurate, timely risk screening in antenatal period to prevent or treatment of the high-risk condition under specialized high-quality based on the individual condition. According to the World Health Organization, a referral can be defined as “a process in which a health worker at one level of the healthcare system, having insufficient resources (drugs, equipment, and skills) to manage a clinical condition, seeks the assistance of a better or differently resourced facility at the same or higher level to assist in, or take over the management of, the client's case.” A pyramid is often used to emphasize such a referral system with the Primary Health Centres (PHCs) forming the base and the tertiary regional centers/medical colleges forming its apex.
In India, tertiary level facilities provide specialized obstetric care along with allied medical specialty care. Secondary care is provided by district hospitals which have obstetric specialists available for cesarean sections. The PHC provide basic obstetric care including vaginal deliveries. Although governments often designate the provision of basic obstetric and new-born care, the hard reality is few facilities fully function as such. Various programs with cash transfer/incentive to both the mother and the primary care provider, along with availability of free/low-cost treatment facilities in the tertiary centers lead to an increase in maternity self-referrals circumventing the referral system. Self-referral may be initiated by the pregnant women themselves in majority of the cases and not uncommonly by the healthcare providers in the primary centers after achieving the delivery targets.
Maternity referral systems have been under-documented, under researched, and under-theorized, and no study of the referral system in troubled contexts has been found in the literature., Hence, this study aims to find the sociodemographic and health care service delivery pattern among the pregnant women referred for institutional delivery in a tertiary care center of Puducherry and assess the factors associated with maternity self-referral from the perspective of the pregnant women.
| Materials and Methods|| |
Study design and setting
A cross-sectional analytical study was conducted in a tertiary care institute of Puducherry from October 1, 2014, to March 31, 2015. This is a teaching hospital that serves as a tertiary referral center to the surrounding districts of Puducherry and Tamil Nadu, with nearly 15,000 deliveries conducted per year. All the investigations and treatment provided are free of cost along with all the national programs such as Janani Suraksha Yojana, Janani Sishu Suraksha Karyakram, and Jansankhya Sthirata Kosh (JSK) being implemented. In Tamil Nadu and Puducherry, the primary point of maternity care is the PHC/Community Health Centre (CHC), under which the Auxiliary Nurse Midwife and the Accredited Social Health Activist health-care workers provide the basic obstetric care and follow-up; with referral to District hospitals, by the medical officers in charge of PHC, which are the first referral units. From there it can be referred to the nearby medical colleges or the present tertiary care center. Puducherry district has one CHC, nine medical colleges and each of the surrounding districts have at least one medical college each. For high-risk pregnancy, the final referral point is the present tertiary care center. On an average, 50 new and 150 follow-up patients attend the OPD daily. Emergency registration varies between 30 and 40 patients a day.
All pregnant women attending the antenatal clinic and those admitted to the obstetric and postnatal wards of the women and child hospital during the study were eligible to participate in the study.
Consecutive (sequential) sampling was done.
The sample size was calculated using OpenEpi (version 3.01 updated on 2013, Andrew G. Dean and Kevin M. Sullivan, Atlanta, GA, USA). Around 75% of the pregnant mothers visiting this institute are high risk pregnancies. Assuming both relative precision and alpha error to be 5%, the minimum sample size obtained was 4589 and considering a nonresponse rate of 5%, the sample size required was estimated to be 4818 pregnant women.
Two social workers trained with the particulars of the questionnaire collected the data in the morning from the antenatal clinic and in the afternoon from the pregnant women admitted in the wards. The participants were contacted only once for the purpose of the study.
Interview was conducted using a structured questionnaire which had three parts. First section comprised the sociodemography such as age, education, family type, income, and parity. Second part had details regarding health care delivery system proximal to the participant's house like type of nearest health facility and its travel time. The last section consisted of their referral characteristics which included if it was an outpatient department or emergency admission, were they self-referred and if so reasons for it. Since no standard questionnaire was available, so face and content validity were ensured by the authors and by an exhaustive literature review. It was pilot tested in 30 pregnant women before the data were collected. The questionnaire was originally developed in English. It was translated into the vernacular language (Tamil) and was crosschecked by back translating to English by two bi-linguistic people who were well versed in English and Tamil.
Data were entered into Microsoft Excel sheet 2010 and analyzed using STATA 14 software (manufactured by StataCorp LP, College Station, Texas, USA). Continuous variables like age, travel time were summarized as mean (standard deviation) or median (interquartile range) depending on their distribution. Categorical variables such as educational status and family type were summarized as percentages (frequency). According to JSK, a girl should marry at least on or after 19 years of age and give birth to the first child at least after 2 years of marriage; so, age is categorized based on this. Educational status of the study participants was categorized based on “International Standard Classification of Education.” However, for further analysis, primary and middle school were clubbed together as one group. To provide a comprehensive primary health care, the principle is that the first point of healthcare contact should be within 30-min travel time from any house. Hence in the present study, travel time was categorized accordingly. Self-referred denotes pregnant women without having any documented referral slip, i.e., bypassing primary healthcare facilities without their referral. To assess the independent effects of the sociodemographic and health-care delivery factors on maternity self-referral, multivariable analysis using generalized linear models (log binomial regression) was be done. Those variables with P < 0.10 in the univariate analyses were included for the multivariable analysis after checking for collinearity among the variables using variance inflation factor. Adjusted prevalence ratio (aPR) with 95% confidence interval (CI) was calculated. A P < 0.05 was considered as statistically significant.
| Results|| |
A total of 4850 pregnant women were contacted out of which 4191 were included in the study. Response rate was 86%; after excluding 659 antenatal women who either were unable to understand and respond to the complete questionnaire or refused to participate in the study.
Detailed referral characteristics of the study population are portrayed in [Table 1]. One out of every four self-referred pregnant women (25%, n = 433) attended the tertiary center as either they themselves or their family members had perceived complication regarding the pregnancy. Around one-fifth of the self-referred pregnant women (18%, n = 315) came for delivery just because they were registered in the center as per the advices of their primary care providers and were subsequently advised to continue attending the tertiary care center in spite of not having a high-risk condition. Perceived high quality of care and previous deliveries being conducted here, were the other frequent reasons.
|Table 1: Referral characteristics of pregnant women (from their perspective) referred for institutional delivery in a tertiary care center of Puducherry, 2015 (n=4191)|
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[Table 2] describes the distribution of study participants based on sociodemographic and health care delivery system pattern. The mean age of the pregnant women was 24 years (3.9). Half of the self-referred group (n = 858) belonged to the age group of 22–26 years. Most of the participants were educated till eighth standard in school (35%, n = 1457) followed by tenth standard (32%, n = 1355). One-third of the pregnant women who self-referred had studied till tenth standard (33%, n = 571). The median income per month of the participant's families was Rs. 3000 (3000–5000). Based on this, income was categorized. Majority of the participants belonged to joint families (85%, n = 3583) and were primigravida (54%, n = 2260). Nearly, all the self-referred pregnant women were from Tamil Nadu (97%, n = 1676). PHCs providing only antenatal care (ANC) were the nearest health facility for more than half (54.9%, n = 2301) of the study participants and the median travel time taken to access it was 10 (10–15) min.
|Table 2: Multivariable analysis showing the association of sociodemographic and health-care delivery system pattern (pertaining to the locality morbidity) with self-referral among pregnant women referred for institutional delivery in a tertiary care center of Puducherry, 2015 (n=4191)|
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Nearly, half of the pregnant women (41%, 95% CI: 39.8%–42.8%) who attended the tertiary institute had come without any referral, i.e., self-referred. In adjusted analysis, pregnant women from nuclear families (aPR: 1.56 [95% CI: 1.45–1.68]) and residing in places where nearest health facility is more than half-hour (aPR: 1.57 [95% CI: 1.45–1.69]) were nearly two times significantly more self-referred compared to joint families and less than half-hour time travel, respectively. Similarly, self-referral was significantly more prevalent among pregnant women whose family earned more than Rs. 3000 per month and having a PHC as nearest health facility – independent of all other factors [Table 2].
| Discussion|| |
In a tertiary care setting in south India, we found about 41% of the maternal admissions were without any documented referrals. More than half (52%) of these self-referred pregnant women were primigravida, more than three quarter (77%) belonged to joint families and had nearest health facility within half hour distance from their own house. One out of every four self-referred pregnant women attended the tertiary center as either they themselves or their family members had perceived complication regarding the pregnancy. Nuclear family (aPR: 1.56 [95% CI: 1.45–1.68]), monthly family income >Rs. 3000 (aPR: 1.38 [95% CI: 1.28–1.49], and nearest health facility more than half-hour (aPR: 1.57 [95% CI: 1.45–1.69]) were factors significantly associated with self-referral.
Nearly, all of the self-referred pregnant women were from neighboring districts of Tamil Nadu (96.8%), majority belonged to joint families (76.8%) and had nearest health facility within half hour (77%), around two-third had PHCs providing only ANC (64.2%) as the nearest health facility and half of them were aged between 22 and 26 years (49.5%) and were primigravida (52.5%). Such high number of self-referrals are prevalent in other developing nations too – Tanzania (70%), Ghana (82%), Kenya (80%). This has several implications.
Referral of patients from primary to higher levels of care is considered as a vital part of the health system throughout the world. Self-referral to tertiary centers bypassing the primary centers will overburden the higher centers, inverting the pyramid of referral system leading to compromise in quality of care. Bypassing the PHCs as first choice renders it to be under-utilized to provide basic delivery care. So nearly, all the admissions in the present study are from antenatal clinic as they are not visiting the primary health-care facilities routinely. This underutilization clearly indicates the perceived poor quality of maternity care at government facilities, particularly at the subcenter and PHC level in the rural areas.,,, Nearly one-fifth of the self-referred women (18%), who were registered as per the instruction of the primary care providers, were forced to continue follow-up in the tertiary center in spite of not having any high risk condition.
The common reasons for approaching the tertiary care center were perceived complications by pregnant mother or her family and high-quality care. By high quality one assumes it to be having more competent health workers, required drugs and equipment, access to more sophisticated services and better outcome indices such as perinatal outcome., Some women and their families are willing to incur substantial expenses for transportation and accommodation incurred to visit these tertiary institutions even though some of these services are available in medical colleges or other government facilities free of cost. This also can lead to diversion of the available limited resources and specialist services in the referral facilities, especially in low- and middle-income countries, which are essential for the management of high-risk/complicated cases.
This study shows that whatever be the age, education, income, or parity of the mother, if she belongs to nuclear family then she will be having nearly two times higher chance of being in the self-referred group when compared to a mother from joint family. Same is the chance for pregnant women from whose house the nearest health facility is more than half hour. In contrast to other studies, the present study finds decreased literacy as well as nulliparity to be more associated with self-referral., This indicates the anxiety of pregnant women and their families resulting in following up in tertiary care centers. This may be also due to the lack of counseling by the primary care provider in local health facilities regarding pregnancy and its associated changes. To prevent this, the primary health system needs to be re-developed. Health and Wellness Centres will be helpful in this. The facilities in already existing subcenters and PHCs need to be refined and health workers have to be trained regarding health communication and providing basic obstetric care to pregnant women and to identify the high-risk mothers among them. The ambulance services need to made aware to the people.
This was a first of a kind study conducted in India to demonstrate the helpless plight of the health system in the top of the pyramid by maternal referral. Being a tertiary care referral center, the sample size was adequate enough to reflect the views of the pregnant women and no other similar Indian study was done. To take care of interviewer bias, the participants were assured of confidentiality and no change in treatment outcome. A prospective study could have added more information by comparing the outcomes in the self-referred and other participants.
The study gives us an overview of the present alarming maternal referral system prevailing throughout the nation. Tamil Nadu though having 99% institutional deliveries, most of the mothers attending our center were from nearby districts of Tamil Nadu such as Cuddalore, Villupuram, and Thiruvannamalai. For any maternity care program to give fruitful results, a sound functional referral system is needed. In addition our results demonstrate the importance of prioritizing the reorganization of referral systems. Creating protocols and standard guidelines that reflect a facility's capacity and resources and strict monitoring of these referrals is the need of the hour. Some interventions can be made at the community level concerning educational activities to raise awareness and encourage nuclear families to use primary care obstetric services. In addition, to make referral more effective and efficient, user-fee policy except for poor can be initiated. It will narrow down the incessant unnecessary referrals and can be a key to reduce bypassing.
| Conclusions|| |
Two out of five pregnant women who attended a tertiary institute had come without any referral, i.e., were self-referred. The most common reason for self-referral was perceived pregnancy complication and the mothers were largely from nuclear families with the nearest health facility more than half-hour away from their homes.
The study was approved by the Institute Ethical Committee (IEC) (Human Studies) of the institute
We extend our thanks to the study participants for support and the help provided by Mr. Ramaswamy and Mr. Karunakaran (Medical Social Workers Attached to HRRC) for their contribution in conducting this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Transforming Our World: The 2030 Agenda for Sustainable Development. New York: Sustainable Development Knowledge Platform, Division for Sustainable Development, Department of Economic and Social Affairs – United Nations; 2015.
Nabyonga-Orem J. Monitoring sustainable development goal 3: How ready are the health information systems in low-income and middle-income countries? BMJ Glob Health 2017;2:e000433.
Rudge MV, Maestá I, Moura PM, Rudge CV, Morceli G, Costa RA, et al
. The safe motherhood referral system to reduce cesarean sections and perinatal mortality – A cross-sectional study [1995-2006]. Reprod Health 2011;8:34.
Sample Registration System. Special Bulletin on Maternal Mortality in India 2014-16. Office of Registrar General, India. May, 2018.
Thaddeus S, Maine D. Too far to walk: Maternal mortality in context. Soc Sci Med 1994;38:1091-110.
Jahn A, De Brouwere V. Referral in Pregnancy and Childbirth: Concepts and Strategies. In: De Brouwere V, Van Lerberghe W, editors. Safe Motherhood Strategies: a Review of the Evidence. Antwerp: ITG Press; 2001. p. 225-42.
Low A, de Coeyere D, Shivute N, Brandt LJ. Patient referral patterns in Namibia: Identification of potential to improve the efficiency of the health care system. Int J Health Plann Manage 2001;16:243-57.
Bailey PE, Awoonor-Williams JK, Lebrun V, Keyes E, Chen M, Aboagye P, et al
. Referral patterns through the lens of health facility readiness to manage obstetric complications: National facility-based results from Ghana. Reprod Health 2019;16:19.
Simkhada B, Teijlingen ER, Porter M, Simkhada P. Factors affecting the utilization of antenatal care in developing countries: Systematic review of the literature. J Adv Nurs 2008;61:244-60.
Murray SF, Pearson SC. Maternity referral systems in developing countries: Current knowledge and future research needs. Soc Sci Med 2006;62:2205-15.
National Health Profile 2018. Central Bureau of Health Intelligence. Director General of Health Services. Ministry of Health & Family Welfare, Government of India; 2018.
Stata Corp. Intercooled Stata. 14th
ed. Houston, TX: Stata Corp; 2014.
Jansankhya Sthirata Kosh. National Population Stabilization Fund - India District Level Health Facility GIS Maps and Indices. Available from: http://www.jsk.gov.in/district_health.asp
. [Last accessed on 2019 29.
UNESCO Institute for Statistics. International Standard Classification of Education: ISCED 2011. Montreal. Quebec: UNESCO Institute for Statistics; 2012.
Bhawan N. Report of the Task force on Primary Health Care in India. New Delhi: Ministry of Health and Family Welfare, Government of India; 2017.
Iyengar K, Iyengar SD. Emergency obstetric care and referral: Experience of two midwife-led health centres in rural Rajasthan, India. Reprod Health Matters 2009;17:9-20.
Bhatia JC, Cleland J. Determinants of maternal care in a region of South India. Health Transit Rev.1995;5:127-42.
Singh S, Doyle P, Campbell OM, Mathew M, Murthy GV. Referrals between Public sector health institutions for women with obstetric high risk, complications, or emergencies in India – A systematic review. PLoS One 2016;11:e0159793.
Patel AB, Prakash AA, Raynes-Greenow C, Pusdekar YV, Hibberd PL. Description of inter-institutional referrals after admission for labor and delivery: A prospective population based cohort study in rural Maharashtra, India. BMC Health Serv Res 2017;17:360.
Bhatia JC, Cleland J. Obstetric morbidity in south India: Results from a community survey. Soc Sci Med 1996;43:1507-16.
Nuamah GB, Agyei-Baffour P, Akohene KM, Boateng D, Dobin D, Addai-Donkor K. Incentives to yield to obstetric referrals in deprived areas of Amansie West district in the Ashanti Region, Ghana. Int J Equity Health 2016;15:117.
Gabrysch S, Campbell OM. Still too far to walk: Literature review of the determinants of delivery service use. BMC Pregnancy Childbirth 2009;9:34.
Bakshi H, Sharma R, Kumar P. Ayushman Bharat initiative (2018): What we stand to gain or lose! Indian J Community Med 2018;43:63-6.
Accorsi S, Somigliana E, Solomon H, Ademe T, Woldegebriel J, Almaz B, et al
. Cost-effectiveness of an ambulance-based referral system for emergency obstetrical and neonatal care in rural Ethiopia. BMC Pregnancy Childbirth 2017;17:220.
International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-4), India, 2015-16: Tamil Nadu. Mumbai: IIPS; 2017.
[Table 1], [Table 2]