Obstetric referrals to a tertiary care maternity: a descriptive study

Introduction An effective referral system is considered as a key to saving mothers' and children's lives. The aims of this study were to determine the frequency and the indications of obstetric referrals in a Tunisian tertiary care maternity and to assess the conformity of referral mechanisms with the National Perinatality Programme (NPP) guidelines. Methods A descriptive study was undertaken among women referred to Farhat Hached University Hospital in Sousse, Tunisia with antenatal complications requiring urgent delivery and those referred while in labour or with immediate post partum complications. The ICD-10 was used to code recorded indications and diagnoses for referrals. Results Referrals represents 15.23% of the obstetric activity in this facility. There were 32 reasons for referrals with the most common being premature rupture of membranes (14.1%) and fetal distress (13.5%). A fifth of the referrals were unclassifiable according to ICD-10. Most of the indications for referrals (95.8%) did not conform to the list of referral indications of the NPP. Twenty eight diagnoses were retained after referrals: the most common of which were prolonged pregnancy (29.5%) and premature rupture of membranes (19.3%). In 41% of women, reasons for referral did not match with diagnoses established at the time of the patients' admission to hospital. Conclusion The current referral system in the region of Sousse still faces several challenges that need to be addressed in order to make it more effective.


Introduction
For decades, improving maternal health has been a worldwide priority component of global health and development community [1]. In  85% of direct obstetric deaths were classified as preventable or conditionally preventable [1] and were to a great extent, related to health care system factors such as the shortage of material (drugs, blood...) or human resources and the inadequacy of the existing referral system. In fact, access to all levels of care system is considered as a key dimension in saving mothers' live [3]. "Referral" means "any upwards movement of health care seeking individuals in the health system" [4]. There are many ways to do this with respect to pathway, timing and urgency. So, it will be designed-"Evacuation" when it is urgent [4,5]. A formalised maternity referral system lie within strategy of risk screening in the antenatal period, in which frontline health workers would attempt to identify those women at high risk of obstetric complications and refer them on for specialized antenatal and delivery care at a higher level [3].
According to the WHO maternal health and safe motherhood program estimates, obstetric references account for more than 20% of pregnancy-related morbidity [6] and according to previous African studies, obstetric evacuations from peripheral health structures represent 3 to 66% of the activities of the receiving hospitals and are associated with a high maternal and fetal morbi-mortality [7]. In Tunisia, inadequate obstetric transfer was responsible for almost half of maternal deaths (48.38%) between 1998 and 2007 in a third level maternity in Tunis (Tunisia) [8]. Rapid screening and transfer in good conditions of pregnant women at risk would theoretically reduce maternal mortality rate by half [8]. For a more effective planning of medical and community-based actions for both mother and child, we have to assess this system of referral. Thus, we conducted this study aiming to determine the frequency and the epidemiological profile of obstetric referrals in a Tunisian tertiary care maternity, and identifying the major indications for such transfer during labour and delivery periods and to assess the conformity of referral mechanisms with the guidelines of the National Perinatality Programme.

Methods
Design and Setting: a cross sectional descriptive study was conducted in a tertiary care maternity in Sousse (Tunisia) over a period of two months from 1 st September to 30 th November 2014.
This institution is a public medical care center and one of the most important maternal care facilities in Tunisia. It receives referrals mainly from the lower level facilities (peripheral maternities) within the Sousse Health region, but also within the surrounding areas. This maternity is part of the Department of Obstetrics and Gynecology of Farhat Hached (FH) University Hospital [9]. In most of these peripheral maternities, the pregnant women are cared for almost solely by midwives [10]. The annual number of deliveries in the region of Sousse was about 12 261 in 2013, of which 10 169 (82.9%) occurred in FH maternity [11].  related health problems were used to code recorded indications and diagnoses for referral. Descriptive data analysis was performed using SPSS. Quantitative variables were presented as means with standard deviation when they were normally distributed. Qualitative variables were described as frequencies and percentages.
Ethical considerations: a verbal consent was obtained from all participants and all information was treated in confidentiality.

Results
During the period of study, there were 513 referrals, out of 3367 obstetric admissions which represent 15.23% of the obstetric activity in this facility. Only 500 cases of referrals were considered for this study. The mean age of the referred women was 29.5±5.6 years.
More than a half of them (57.8%) were from rural areas and about 86% of them did not study beyond secondary level of education. The median of parity was 2, with a parity distribution as follows:

Discussion
According to the 2013 regional statistics, 1539 pregnant women, out of 2092 obstetric admissions in peripheral maternities in the region of Sousse, were referred to FH maternity, which represent 73.5% [11].
In this study, obstetric admissions represent 15.23% of the obstetric activity in this facility. The maternal referral rates from peripheral maternities to central maternities reported in the literature vary widely and may reflect differences in health facilities [12][13][14][15] For example, in the Netherlands, New Zealand and the United Kingdom, transfers were justified by prolonged labor, failure to progress during labor or fetal distress [13,[19][20][21]. Whereas in Australia [12] and France [22], the most frequent reasons were premature rupture of the membranes and preterm labor or delivery.
The transfer patterns noted in Tunisia may be attributed to the substantial improvement made in prenatal care. In fact, prenatal care, mainly in terms of the number of antenatal visits is adequate (at least 4 visits) for about 90% of cases in Tunisia [23]. In our study it was estimated at 81.6%, but it should not be forgotten that, a good quality of health care also depends on the temporal distribution and the content of such antenatal visits. We reported that in 95.8% of cases, reasons for referral did not conform to the National Perinatality they should refer a woman to higher level of care [25]. Such referral guidelines need to reflect local epidemiological conditions, organisational capacity, and community preferences [3]. Compared to poorly resourced systems, referral transportation in this study can be considered less disturbing. In fact, 64.9% of women referred to our center were brought in by ambulance and 64.7% were accompanied by a staff member from the referring facility. But travelling a distance of 49km (range 4-179km) when the referral is unnecessary can be unsafe for the both the mother and the foetus especially if any means of transportation other than an ambulance is utilized. The time data reported in this study were mainly obtained from women interviewed; rare were cases when these informations The main means of communication was the referral letter (80%).
According to the review of Murray and Pearson, referral communications have to relay increasingly on sophisticated technologies such as the use of telemedicine to make referrals more appropriate [3]. Moreover, more than 70% of the women referred during the labour period came with partograph which had been a valuable tool for tracking the progress of labour, making decisions as regards the well being of the mother and the foetus. However, although it has been successfully integrated into routine practice, the link between "use", decision making, and successful referral action However, seeking more diagnostic precision before referring can lead to delayed transfers [7,28]. Besides these unnecessary referrals, pathologic cases of women may go unnoticed. In fact, in this study, cases of post partum haemorrhage, retro-placental hematoma, 15% of PMR and 78% of prolonged pregnancy had not been diagnosed before referral. The median time to delivery was 4.25 hours. In an Australian study, this time was estimated to 24.4h. Forty three percent of women were delivered within 24 hours of admission and 29% were either delivered after 7 days or delivered elsewhere [12].
This variability can depend on the reason for transfer.
Finally, no maternal deaths were reported among referred women during the period of study and only 1.8% babies were still born. This fact highlights the effectiveness of the health care system in terms of outcomes (maternal and neonatal mortality indicators). However, there are still a few challenges that need to be addressed to improve the quality of care delivered to pregnant women. This study is among the rare Tunisian studies to document obstetric referrals to a Tunisian tertiary level maternity and to assess the conformity of referral mechanisms with the Tunisian National Perinatality Programme guidelines. In this context, the adequacy of the transfer must be considered among the process' indicators which must be regularly estimated in the same way as outcome indicators such as maternal mortality rate. Also, in this study data was obtained from a large cohort of women referred to a single tertiary care maternity and were collected prospectively from various sources: medical records, referral letters, and interviews with referred women and the receiving midwife. This fact can limit bias resulting from the missing data in medical records, but there were limitations when we had to extract reasons for referral or diagnoses for admission from medical records.
No standard classification was used in records. Coding these reasons and diagnoses according to The International Statistical Classification of Diseases (ICD-10) and related health problems was time consuming and was beyond the scope of this observational study.

Conclusion
To improve the existing referral system in the region of Sousse, serious steps should be taken to address the current challenges. In fact, having an adequate referral center and an accepted referral transportation are not sufficient for an effective referral system. This will later require a communication and feedback system, a consensus on specific protocols for the identification of complications, trained personnel in their use, teamwork between referral levels, a unified records system and mechanisms to ensure that patients do not bypass a level of the referral system.