European Journal of Cardiovascular Medicine

Maternal and neonatal health outcomes are pivotal indicators of the quality and effectiveness of a healthcare system. Particularly in tertiary healthcare centers, which often serve as the final referral points for high-risk pregnancies and neonatal complications, understanding the nuances of patient outcomes is crucial for improving clinical practices and patient care strategies. The complexity of cases treated at these centers, including patients referred from primary and secondary healthcare facilities, underscores the importance of examining maternal and neonatal outcomes within this context.

The referral of patients to tertiary healthcare centers is a process critical for the management of complicated pregnancies and neonatal issues that cannot be adequately addressed at lower levels of care. These referrals are essential for accessing specialized care, including advanced maternal-fetal medicine, neonatal intensive care units (NICUs), and specialized surgical interventions. Studies have shown that the outcomes of referred patients can serve as a barometer for the accessibility, efficiency, and quality of the healthcare system, particularly in regions where healthcare resources are limited (1,2).

A significant proportion of maternal and neonatal morbidity and mortality is preventable, with the right care provided at the right time (3). The World Health Organization emphasizes the importance of timely and efficient referral systems in improving maternal and neonatal outcomes (4). This perspective is supported by research indicating that delays in referral and in receiving appropriate care at tertiary centers are associated with poorer outcomes (5,6). Therefore, understanding the outcomes of referred patients, including the factors influencing these outcomes, is paramount in addressing the gaps in healthcare delivery.

The methodology adopted for this study was a prospective observational approach, conducted at PES Institute of Medical Sciences and Research (PESIMSR), Kuppam. The study spanned 18 months, from January 2020 to June 2021, focusing on all referred pregnant women in labor who were admitted to the hospital during this period. The sampling method was purposive, ensuring that the study participants met the inclusion criteria of being either primigravida or multigravida referred in labor. The study explicitly excluded any primigravida and multigravida women who were less than 28 weeks into their pregnancy and those referred post-partum. This was a time-bound study aiming to include a minimum of 60 subjects to ensure the robustness of the findings.

For the collection of data, after obtaining informed consent from each participant, a separate proforma was used for every study subject. This proforma was meticulously designed to gather comprehensive data on each referred case, including the patient's arrival time, detailed clinical history, place and time of referral, and the type of transportation used to reach the tertiary care center. Additionally, the reasons for referral were recorded to analyze the patterns and timeliness of the referral process. Every participant underwent a complete physical and obstetric examination, alongside basic and case-specific investigations, as required by the clinical condition of each patient. The study subjects were followed up until discharge, collecting details on pregnancy outcomes, modes of delivery, and any maternal complications that arose. The fetal outcomes were also closely monitored until discharge, with specific attention to the causes of NICU admissions, instances of birth asphyxia, neonatal sepsis, stillbirths, and neonatal mortality rates.

To ensure the ethical integrity of the study, clearance was obtained from the Institutional Ethics Committee (IHEC) of PESIMSR before commencing the study. This step was critical in safeguarding the rights and wellbeing of the study participants.

In the comprehensive prospective observational study conducted over 18 months at a tertiary care hospital, a total of 4972 deliveries were analyzed, among which 275 cases (5.5%) were identified as referrals from nearby health facilities. This subset of referred cases constituted the focus of the investigation to assess the maternal and neonatal outcomes within this specific population.

Demographically, the age distribution of the study participants revealed a predominance of younger women, with 171 of the 275 referred cases (62.2%) aged between 21 and 30 years. Those under 20 years accounted for 86 cases (31.3%), while the group aged over 30 years represented the smallest segment, with 18 cases (6.5%). In terms of socioeconomic status, the majority of the participants fell into the lower socioeconomic classes, with 142 cases (51.6%) classified as Class IV and 50 cases (18.1%) as Class V. Classes I, II, and III were notably less represented, indicating a higher prevalence of referrals among the economically disadvantaged sectors of the population.

Clinical characteristics and referral patterns provided further insights into the study cohort. A significant portion of the participants, 238 cases (86.6%), had been booked outside the present tertiary care hospital, highlighting an extensive network of prenatal care extending beyond the immediate healthcare facility. The analysis of parity showed that primiparas constituted the majority, with 161 cases (58.5%), compared to 114 multiparas (41.5%). The gestational age at the time of referral was predominantly between 37 and 40 weeks, accounting for 138 cases (50.2%), followed by those over 40 weeks (79 cases, 28.7%), and 28 to 36 weeks (58 cases, 21.1%). The presence of a referral slip was noted in 233 cases (84.7%), underscoring the formal nature of most referrals.

Regarding the mode of transport to the tertiary center, ambulances were used in 192 cases (69.8%), while private vehicles accounted for 83 cases (30.2%). The distance travelled highlighted that a significant number of referrals, 128 cases (46.5%), were from within a 10 km radius, suggesting that even nearby facilities relied on the tertiary hospital for certain deliveries. The majority of referrals arrived at the hospital within 1 hour of departure (175 cases, 63.6%), with the remainder arriving within 1 to 2 hours (92 cases, 33.5%) or more than 2 hours (8 cases, 2.9%). The fact that only 10 cases (3.6%) had prior intimation of their arrival at the tertiary center indicated a potential area for improvement in communication and coordination.

The reasons for referral covered a wide range of complications, with premature rupture of membranes (PROM) being the most common cause, leading to 56 referrals (20.4%). Gestational hypertension prompted 48 referrals (17.5%), and anaemia was the cause for 32 cases (11.6%). Other combined reasons accounted for 139 referrals (50.5%), which included conditions like cephalopelvic disproportion, hydramnios, and non-progression of labour, among others.

Outcomes of the deliveries varied, with the majority resulting in normal vaginal deliveries (147 cases, 53.5%) and caesarean sections (122 cases, 44.3%). There were 5 cases (1.8%) of assisted breech deliveries and 1 case (0.4%) of vaginal birth after caesarean (VBAC). The postnatal period was largely uncomplicated, with 265 cases (96.4%) reporting no complications. However, there were instances of postpartum haemorrhages, congestive cardiac failure, prolonged catheterization, and puerperal pyrexia, cumulatively amounting to 10 cases (3.6%).

The neonatal outcomes highlighted those 199 newborns (72.4%) had a normal post-delivery course, while 65 (23.6%) required NICU admission for reasons such as respiratory distress, low birth weight, pre-term care, and birth asphyxia. There were 6 stillbirths (2.2%) and 5 neonatal deaths (1.8%), underlining the critical need for targeted interventions to enhance both maternal and neonatal health outcomes in the context of referred cases in tertiary care settings.

The analysis of maternal and neonatal outcomes among referred patients in a tertiary healthcare center over an 18-month period has yielded significant insights, echoing findings from previous studies while also uncovering unique patterns that contribute to the broader discourse on maternal and neonatal healthcare. This study found that 5.5% of the deliveries during the study period were referrals, with a majority being younger women (62.2% aged between 21-30 years) and primarily from lower socioeconomic classes. The referral reasons, modes of delivery, and outcomes have varied implications for healthcare practice and policy.

Referral Reasons and Outcomes

The high incidence of referrals due to premature rupture of membranes (PROM) and gestational hypertension in this study aligns with findings by Jones et al. (11), who reported that complications such as PROM and hypertensive disorders are among the leading causes for referral to tertiary centres. The significant proportion of referrals for conditions like anaemia and non-progression of labor also mirrors trends observed in other regions (12, 13). However, the relatively high percentage of referrals for anaemia (11.6%) in this study contrasts with lower figures reported in some studies (14), suggesting regional disparities in antenatal care and nutritional status.

The study conducted at a tertiary healthcare center over 18 months, focusing on 275 referred cases out of 4972 deliveries, has provided critical insights into the maternal and neonatal outcomes within this specific demographic. A substantial portion of these referrals were from younger women, predominantly aged between 21 to 30 years, and from lower socioeconomic statuses, highlighting the intersection of age, economic factors, and the need for specialized maternal care.

The reasons for referrals were varied, with premature rupture of membranes (PROM) and gestational hypertension being the most common, underscoring the complexity of cases handled by tertiary centers. The delivery outcomes revealed a balanced distribution between normal vaginal deliveries (53.5%) and caesarean sections (44.3%), reflecting the center's adaptability to the referred cases' diverse needs. However, the neonatal outcomes, including a 23.6% NICU admission rate, indicate the critical nature of the referred cases and the persistent challenges in managing high-risk pregnancies and their impacts on neonatal health.

This study underscores the crucial role of tertiary healthcare centers in managing high-risk referrals, the impact of socioeconomic factors on maternal health, and the outcomes of referred cases. It calls for enhanced prenatal care, especially for economically disadvantaged groups, and improved referral systems to ensure timely and efficient care, aiming to improve maternal and neonatal outcomes.

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