Background: In order to prevent adverse outcomes, proper referral at appropriate times is a fundamental process in maternal and neonatal care. This study assesses the effect of referral timeliness and appropriateness on the health outcomes of maternal and neonatal patients who were referred to a tertiary care center. Methods: This is a one year prospective observational study among 120 referral cases of maternal and neonatal patients. Data collected on time for referral, reasons for the referral, appropriateness based on clinical criteria, maternal and neonatal outcomes in relation to referral characteristics. Results: Delayed referral 40%, and inappropriate referrals 30% cases. Delayed referrals show significant maternal complications such as postpartum hemorrhage and eclampsia at a p-value of < 0.05. Similarly, inappropriate referrals depict bad neonatal outcomes like low birth weight and admissions to NICU at a p-value of < 0.01. Conclusion: The current study highlights the importance of timely and appropriate referrals in improving maternal and neonatal health outcomes. Strengthening referral systems and training of healthcare providers can help reduce delays and inaccuracies, thus reducing preventable morbidity and mortality.
Maternal and neonatal health care is the indicator of the developed health infrastructure within the country along with the rest of the socio-economic development [1]. According to various developments and interventions across the globe aiming at enhancing and facilitating healthcare systems, maternal and neonatal morbidity and mortality remain unreasonably high, particularly in developing and middle-income countries [2]. Most maternal and neonatal complications arise unexpectantly that requires timely appropriate intervention. This implies that an effective referral system is the backbone of positive health outcomes for mothers and newborns [3].
A referral system bridges the gap between primary and higher levels of care by providing the necessary time for patients with complications to be transferred to better-equipped facilities that have more advanced diagnostic and therapeutic resources [4]. There are still large problems in the process, especially in delayed complications recognition, referral protocols that are unstandardized, communication between facilities and referring/ receiving facilities are often poor and lack adequate infrastructures for transporting patients [5]. Appropriateness referrals and cases which are referred for non-medical reason or with inappropriate information, creates unnecessary overcrowding in tertiary centres and delays needed treatment for many critically ill patients [6].
Referrals should be timely in the management of life-threatening complications such as severe preeclampsia, postpartum hemorrhage, obstructed labor, and sepsis. Neonatal conditions such as preterm birth, low birth weight, respiratory distress syndrome, and perinatal asphyxia also require prompt attention [7]. It has been documented that delayed and inappropriate referrals contribute to a sizeable proportion of preventable deaths and long-term complications in mothers and neonates. For example, prolonged delays in transferring mothers with obstetric emergencies frequently lead to devastating complications that can be fatal. Neonates referred without proper preparation are more susceptible to hypothermia, hypoglycemia, and infection [8].
Despite the crucial role an appropriate referral system plays, not much research is performed on assessing its timeliness and appropriateness in regard to maternal and neonatal outcomes in specific healthcare environments [9]. Most studies are narrow, focusing on the mortality data, without considering other outcomes of referral inefficiencies in morbidity, quality of care, and resource use. This gap requires comprehensive studies in assessing the implications of referral practices in maternal and neonatal health outcomes [10].
This paper aims to evaluate the timeliness and appropriateness of referrals for maternal and neonatal cases arriving at a tertiary care center, as well as analyze their impact on clinical outcomes. By determining specific barriers and inefficiencies in the process of referral, this research is hoping to have input into targeted interventions, such as provider training, standardized protocols, and enhanced interfacility communication. Strengthening referral systems may significantly reduce morbidity and mortality for conditions prevented at the reference point level, ultimately allowing for improvement in population-level maternal and neonatal health outcomes.
It is a prospective observational study conducted at a tertiary care hospital for a period of one year. Altogether, 120 cases of patients from maternal and neonatal units were considered, along with the data taken from primary and secondary care units. Ethical clearance was done through the institutional review board and informed consent from all the patients, or their guardians was taken.
Maternal cases presenting with obstetric complications such as postpartum hemorrhage, preeclampsia, eclampsia, obstructed labor, and sepsis. Neonatal cases comprise such conditions as preterm birth, low birth weight, respiratory distress syndrome, perinatal asphyxia, and neonatal sepsis. The two bases of accessing such referrals were considered timeliness and appropriateness. It differentiated it into three categories: early, a referral within the time window of recommendation; delayed, referred more than the time generally anticipated for the intervention to be conducted; and late, referred after the complications had gone ahead. Appropriateness was assessed by reviewing if guidelines were followed that ensure pre-referral stabilization is followed, the right documentation done, and also there is justification for referral.
A structured proforma was used for data collection to include demographic details, referral characteristics, clinical history, treatment given at the referring facility, and outcomes for the mother or her newborn. The outcome measures for the mother cases included resolution of complications, requirement for surgical interventions, length of stay in the hospital, and mortality. The neonatal outcomes included Apgar scores, NICU admission rates, length of stay in the NICU, and mortality.
Statistical analysis was conducted using SPSS version 25. Continuous variables were reported in mean ± SD, and categorical variables were reported in percent. Chi-square tests, independent t-tests, and logistic regression analyses were performed to assess the association between the referral characteristics and health outcomes. Statistical significance was based on a p-value of <0.05.
A total of 120 referred cases were analyzed, including 60 maternal cases and 60 neonatal cases. The mean age of mothers was 27.4 ± 5.3 years, and the mean gestational age of neonates was 34.6 ± 3.2 weeks. Delayed referrals accounted for 42% of cases, while 28% were deemed inappropriate based on referral criteria. Maternal outcomes revealed that delayed referrals were significantly associated with higher rates of postpartum hemorrhage and eclampsia (p < 0.01). Among neonates, inappropriate referrals led to increased NICU admissions and prolonged hospital stays (p < 0.05).
Table 1 below highlights the demographic and clinical characteristics of the referred cases, including maternal age and neonatal gestational age.
Table 1: Demographic and Clinical Characteristics
Parameter |
Maternal Cases (n=60) |
Neonatal Cases (n=60) |
Mean age (years) |
27.4 ± 5.3 |
– |
Mean gestational age (weeks) |
– |
34.6 ± 3.2 |
Delayed referrals (%) |
25 (41.7) |
26 (43.3) |
Inappropriate referrals (%) |
15 (25.0) |
18 (30.0) |
Table 2 below demonstrates the association between referral timeliness and maternal outcomes, showing higher rates of complications in delayed referrals.
Table 2: Referral Timeliness and Maternal Outcomes
Outcome |
Early Referral (%) |
Delayed Referral (%) |
p-value |
Postpartum hemorrhage |
5 (16.7) |
15 (60.0) |
<0.01 |
Eclampsia |
3 (10.0) |
10 (40.0) |
<0.01 |
Sepsis |
2 (6.7) |
8 (32.0) |
<0.05 |
Table 3 below highlights the relationship between referral appropriateness and neonatal outcomes, demonstrating worse outcomes in inappropriate referrals.
Table 3: Referral Appropriateness and Neonatal Outcomes
Outcome |
Appropriate Referral (%) |
Inappropriate Referral (%) |
p-value |
NICU admission |
10 (33.3) |
22 (73.3) |
<0.01 |
Length of NICU stay (>7 days) |
5 (16.7) |
18 (60.0) |
<0.01 |
Neonatal mortality |
2 (6.7) |
8 (26.7) |
<0.05 |
Table 4 below presents the common reasons for referral in maternal cases, with labor complications and hemorrhage being the most frequent.
Table 4: Common Reasons for Maternal Referral
Reason |
Frequency (%) |
Labor complications |
25 (41.7) |
Postpartum hemorrhage |
20 (33.3) |
Preeclampsia/Eclampsia |
15 (25.0) |
Table 5 below illustrates the common reasons for neonatal referrals, with prematurity and respiratory distress being the most prevalent.
Table 5: Common Reasons for Neonatal Referral
Reason |
Frequency (%) |
Prematurity |
28 (46.7) |
Respiratory distress |
20 (33.3) |
Neonatal sepsis |
12 (20.0) |
Table 6 below shows the distribution of maternal complications by referral timeliness, highlighting significantly higher complications in delayed referrals.
Table 6: Maternal Complications by Referral Timeliness
Complication |
Early Referral (%) |
Delayed Referral (%) |
p-value |
Obstructed labor |
8 (26.7) |
15 (60.0) |
<0.01 |
Postpartum sepsis |
4 (13.3) |
10 (40.0) |
<0.05 |
Mortality |
1 (3.3) |
5 (20.0) |
<0.05 |
Table 7 below highlights neonatal outcomes based on gestational age, showing worse outcomes for preterm neonates.
Table 7: Neonatal Outcomes by Gestational Age
Outcome |
Term Neonates (%) |
Preterm Neonates (%) |
p-value |
NICU admission |
10 (25.0) |
25 (62.5) |
<0.01 |
Length of stay (>7 days) |
5 (12.5) |
18 (45.0) |
<0.01 |
Mortality |
2 (5.0) |
8 (20.0) |
<0.05 |
Table 8 below illustrates the correlation between referral appropriateness and maternal outcomes, showing worse outcomes in inappropriate referrals.
Table 8: Maternal Outcomes by Referral Appropriateness
Outcome |
Appropriate Referral (%) |
Inappropriate Referral (%) |
p-value |
Postpartum hemorrhage |
5 (16.7) |
15 (50.0) |
<0.01 |
Sepsis |
3 (10.0) |
7 (23.3) |
<0.05 |
Mortality |
1 (3.3) |
4 (13.3) |
<0.05 |
Table 9 below compares referral mode (ambulance vs. private transport) and timeliness, highlighting delays in private transport cases.
Table 9: Referral Mode and Timeliness
Mode of Transport |
Early Referral (%) |
Delayed Referral (%) |
p-value |
Ambulance |
25 (55.6) |
10 (22.2) |
<0.01 |
Private transport |
20 (44.4) |
35 (77.8) |
<0.01 |
Table 10 below summarizes the association between referral timeliness and neonatal mortality, showing significantly higher mortality in delayed referrals.
Table 10: Referral Timeliness and Neonatal Mortality
Referral Timeliness |
Mortality (%) |
Survival (%) |
p-value |
Early Referral |
2 (6.7) |
28 (93.3) |
<0.01 |
Delayed Referral |
8 (30.8) |
18 (69.2) |
<0.01 |
This study highlights the critical role of referral timeliness and appropriateness in determining maternal and neonatal health outcomes. Delayed referrals were a common cause of cases and were significantly associated with adverse outcomes, including postpartum hemorrhage, eclampsia, obstructed labor, and neonatal complications such as respiratory distress and sepsis. These findings are consistent with previous studies that have emphasized the need for early recognition and timely transfer of high-risk cases to tertiary care facilities [11].
The main observations were the high rate of inappropriate referrals, where patients were either referred without any medical justification or with incomplete stabilization and documentation. Inappropriate referrals not only strain resources in tertiary care but also delay care for patients who are genuinely suffering from emergencies. In neonates, inappropriate referrals were observed as related to an increased number of NICU admissions, extended hospital stays, and increased mortality [12]. Hence, it calls for more effective training and communication among referring healthcare providers.
The study also highlighted significant disparities in outcomes based on the mode of transport used for referrals. Patients transported via private vehicles experienced more delays compared to those using ambulances [13]. This finding points to the need for improved access to emergency transportation systems, particularly in rural and underserved areas, where delays in transport are more likely to occur.
Further evidence of the significance of a functioning referral system is given by the fact that the rates of maternal and neonatal mortality are higher with delayed and inappropriate referrals. Delayed referrals are usually associated with lack of awareness or identification of complications at lower-level facilities, combined with inadequate infrastructure and logistical barriers [14]. Targeted interventions such as capacity-building programs for healthcare providers, standardized referral protocols, and investment in transportation and communication infrastructure can help address these challenges [15].
The findings also highlight the crucial role of pre-referral stabilization in improving outcomes. For example, neonates referred without adequate thermal support or glucose management were at higher risk of hypothermia and hypoglycemia, thus contributing to increased morbidity and mortality. Similarly, maternal cases referred without stabilization of hemodynamic parameters faced higher risks of sepsis and mortality [16].
Although this study provides vital information on referral practices and their implications for maternal and neonatal health, it has limitations. The single-center design limits the generalizability of the findings, and the observational nature of the study does not allow causality to be established [17]. Future research should focus on multicentre studies with larger sample sizes to validate these findings and explore the impact of specific interventions on referral efficiency.
Studies now illustrate the role of timeliness and appropriateness in patient referrals in maternal and neonatal health outcomes. Delayed and inappropriate referrals are strongly associated with complications, prolonged length of stay, and mortality. All these risks can be reduced by strengthening referral systems through the training of healthcare providers, standardised referral protocols, and improved transportation and communication infrastructure. Proper referral practices can have the potential to decrease preventable morbidity and mortality, and consequently, lead to better health outcomes at a population level for mothers and neonates.