Does the Referral System for Emergency Obstetric Care in India Require a Major Overhaul?

Public Health System for Obstetric Care in India

The structure of obstetric care in India is depicted in Figure 1. The processes involved in the reduction of maternal mortality are put in place from the prenatal to postpartum stages.⁴ One of the steps is to identify women with high-risk pregnancies, and take measures to mitigate the risk in the antepartum period, and plan delivery at an appropriate facility. Timely referral after basic treatment is one of the key competencies expected from skilled birth attendants (SBAs) who usually serve independently in the subcenters, and assist the medical officer (MO) in the primary health center (PHC).⁵

Understanding Our Referral Systems

A systematic review by Singh et al. in 2016 showed that emergency referrals from a nurse run sub-center or PHC to a first referral unit or community health center (CHC) or tertiary center ranged from 14.3 to 36.3%. Compared to this, referral percentages from Doctor-Run Centers were 2–7.5%. The review also revealed that auxiliary nurse midwives lacked the instruments and skills to diagnose and refer high-risk cases appropriately. Compliance to referral in both urban and rural settings was only around 70%, with the cost and absence of transport facilities being among the most common reasons for noncompliance. The other reason was the absence of a perceived urgency among the patient and family members. The review also found that a lot of cases from the PHCs were being referred directly to the district level, bypassing the CHCs. This was attributed to a lack of information about facilities at the CHC, distrust and lack of confidence in the CHCs. This resulted in overcrowding at the Tertiary Center and underutilization of resources at the level of the CHC.⁴

A strong referral system will help ensure early identification of complications, timely referral to the appropriate center, efficient use of facilities at every level and mitigation of unnecessary delays. Levels of delays have been classified as listed in Table 1.⁵

Each of these delays requires a detailed analysis and specific interventions to overcome hurdles at various levels. The first step is to gather information. The study by Marwah et al. attempted to gather information regarding referred cases requiring admission to the intensive care unit of their tertiary hospital. The study highlights, once again the challenges faced at every level when a pregnant patient has to be referred for emergency obstetric care.⁶

The study by Marwah et al.⁶ showed that nearly half of the women visited 2 or more centers prior to arrival, contributing to delay 2, which may seriously affect maternal and fetal outcomes.^7,8 This is a scathing indictment of the inefficiency of the whole process of referral. The study also found that there was no consistent referral advice, referral notes and no formal communication between referral centers. Most patients did not have a referral letter upon arrival.⁶ As demonstrated previously, this can result in delay 2 and delay 3.^4,8 In a small but noteworthy study from Uganda, Kanyesigye et al. demonstrated that a phone call between the primary center and the referral center resulted in a significant reduction in adverse maternal-fetal outcomes (adjusted OR = 0.22; 95% CI: 0.09–0.44, p = 0.001) by reducing delay 3 in the intervention group.⁹ This highlights the need to establish clear communication channels between primary health center, community health center and the tertiary centers, so the personnel have a better idea regarding where to refer and how to connect with the referral center. It will also allow clear communication of the issue and better preparedness to handle the problem.

The absence of proper transport between centers is another issue identified by the study. More than 67% of women arrived via private modes of transport and without medical personnel accompanying them.⁶ This was also seen in a study by Dikid et al. who showed that auto rickshaws, tractors and private cars were the most common modes of transport to transfer pregnant women being referred for emergency obstetric care.⁷ States like Madhya Pradesh have implemented the Janani Express Yojana (JEY) which provides ambulance services for transporting pregnant patients. A study in 2014 showed that only 35% of the referred patients arrived using this facility at JEY. The JEY usage was highest in rural areas and among women from schedule tribes. The median time from the decision to seek healthcare services to reaching the center was almost 120 minutes when the JEY was used as, compared to 60 minutes with an own vehicle and 75 minutes with a hired vehicle. The time taken by women using JEY was comparable to that taken by those using public transportation. The delay was noted in waiting for the arrival of JEY to pick up the pregnant woman.¹⁰ In 2021, the Atal Bihari Vajpayee Institute of Good Governance and Policy Analysis (AIGGPA), Bhopal, released a report analyzing the performance of JEY and 108 services in Madhya Pradesh. They reported that the time from calling the JEY ambulance to arrival at the scene was 28 minutes in rural areas and an additional 50 minutes from the scene to the hospital. The report stressed on the minimization of this time and ensuring the availability of well-trained staff in the ambulances.¹¹ While the 108 service is available in several districts across the country, this study stresses the need to ensure assistance to transport pregnant women in need of emergency obstetric care. The Pan-India presence of such a support system would improve health care access for the women, especially in remote areas.

Eclampsia/severe preeclampsia has been consistently demonstrated as one of the leading reasons for referral, as was seen in this study too.^6–8 In 2013, Chaturvedi et al. studied the availability and use of MgSO₄ for treatment of severe preeclampsia and eclampsia in the Public Health Centers of Maharashtra. They found that 61% of the centers did not have stock of MgSO₄ since a period ranging from 3 months to 3 years. They also found that while there was awareness of the use of MgSO₄ for eclampsia, awareness regarding its use in severe preeclampsia was unclear. There was a hesitation among the public health care providers to use MgSO₄ for eclampsia as they feared its complications. Most of the patients interviewed sought treatment at private centers after inadequate responses from the public centers. They found that eclamptic patients were directly referred to Tertiary Centers or Higher Centers without stabilization or MgSO₄. This stresses a need to ensure adequate supplies of essential drugs at all centers along with ongoing training and upskilling of healthcare personnel in Public Health Care Centers. Concerns, fears and misconceptions need to be addressed.¹²

Absence of infrastructure, skilled manpower for cesarean section, blood bank services, obstetric critical care and adequate neonatal care services are among the other common reasons for referral that have been observed in this study. This is supported by previous reviews and audits.^4,7,8 It emphasizes the need to ensure adequate staffing and maintenance of infrastructure at the level of the community health centers.

We Need to Do Better

The high maternal mortality among the pregnant women (10.4%) being admitted to the critical care unit in this study is an alarming sign. A root-cause analysis of each death must be undertaken. To gain a better understanding of how these can be prevented, audits are required at the level of every Primary and Community Health Center. Circumstances around the need and timing of referrals must be studied. Solutions need to be tailored to each district, based on the lacunae identified by these audits. Creation of a standard operating procedure (SOP) that is specific to a particular Primary Health Center or a district is needed rather than a one-size-fits-all solution. The SOP should detail steps to be undertaken when faced with various anticipated complications. This will go a long way in ensuring adequate care even when faced with attrition of manpower or a change in personnel. Models like the hub and spoke model have resulted in efficient utilization of resources in the aviation industry.¹³ Such models have been used in India by private healthcare companies, and are also being implemented as part of the Ayushman Bharat scheme.^13,14 The idea is that a resource rich central hub can support the peripheral spoke centers by offering training and technical expertise. Srivastava et al. studied the implementation of such a model to improve the quality of healthcare delivery. While there was a significant improvement noted, it was observed that the engagement of state/district level administration was deficient, resulting in an impact on the sustenance of the positive impact. It was noted that strong political backing and administrative support over the long-term would be imperative for the success of such a mode.¹⁴ Such models may offer solutions to strengthen the referral system and improve the quality of care.

Look to the Future

Every study has revealed the same deficiencies, year after year. The struggle to ensure the presence of skilled manpower, availability of infrastructure and maintenance of existing infrastructure is ongoing and faced with budgetary and governance issues. Despite this, there may be some simple solutions, for example, the phone call referenced earlier, which may have a profound impact on outcomes.

As technology advances, we must look at how it can be used to train health care personnel and connect healthcare professionals at different levels of the public health system. Some of the solutions may include the use of virtual training modules, and use of telemedicine facilities in remote areas. Efforts can also be made to create a virtual, active database of healthcare resources to be accessed when a referral is needed. This would allow the peripheral center to reduce delays by identifying the closest, most appropriate center to send the patient. This would ensure proper use of resources and prevent overburdening of the tertiary center.

While a lot has been done to reduce maternal mortality over the last few decades, we are still a long way off from achieving the best use of available resources. Even a single maternal death can have devastating consequences for the family and community. Apart from preventing mortality, focus must also be given to reducing maternal morbidity, and improving the whole pregnancy and childbirth experience for women at every level of society, and providing appropriate support in the postnatal period.

To paraphrase Robert Frost, “We have promises to keep, and miles to go before we sleep, and miles to go before we sleep”.