Study of maternal outcome in referral obstetric cases in a tertiary care centre.

INTRODUCTION: To identify the pattern of Obstetric referral to our hospital and the primary reasons for referral, so as to implement measures to reduce unnecessary referrals and to reduce maternal mortality and morbidity.
METHOD: All the referred cases for obstetrics indications above 20 weeks were analysed for cause of referral, their condition and outcome for a period of 6 months from January 2016 to June 2016.
RESULTS: According to our study out of a total of 10172 delivered patients, 1014 (9.96%) cases were referred patients. Maximum cases i.e. 713 (70. 3%) were in the age group of 21-30. Most of the cases 678 (66.86%) did not receive any treatment at referral hospital before being referred. Only 27.52% patients were referred with referral slips/chit etc., having adequate information and 40.24% of cases were delayed referrals. 183 (18.04%) patients required intensive care unit admission.
CONCLUSION: The present study showed that illiteracy and ignorance of female regarding healthcare requirements and poor infrastructure came out to be a major contributor of poor pregnancy outcome. Timely referral is crucial for a satisfactory maternal and fetal outcome. To reduce the number of unnecessary referrals and to reduce burden on tertiary care hospitals, health care workers should be trained in essential and emergency obstetric care which will help in reducing morbidity and mortality. Copyright:

Introduction

Women die every year in India[12] which contribute 20-25% of all maternal deaths in the world.[3] One estimate shows that with one maternal death, 15% pregnancies develop complication which necessitates tertiary obstetric care[3] and the vast majority of maternal deaths and injuries are avoidable when women have access to health care before, during and after childbirth Of course there is improvement in maternal and child healthcare after the millennium declaration 2000, but there are lacuna across different states, Kerala being the most outstanding and Uttar Pradesh the worst performer.[45]

Pregnancy and child birth, though physiological processes, are not free of risks. Despite continuous efforts by government and non-government organizations to cut down maternal mortality and to improve health services, maternal mortality is still high in most of the developing countries. The factors influencing good or adverse maternal outcome include the place of residence, socio-economic status, level of education especially in females, and other social and cultural factors. India has one of the highest maternal mortality in the world. According to National health survey (NFHS2/3) report about 1 to 1.2 lacs. After the implementation of ‘Janani Suraksha Yojana’, there is a three-fold rise in institutional deliveries, but unfortunately maternal mortality rate (MMR) has not declined appreciably. The possible reason could be poor referral system in the state. The referral system is an essential component of district health systems. It is particularly important in pregnancy care and child birth for providing up antenatal and delivery care in first line facilities.

The government has introduced the referral system to improve the service delivery at tertiary level, reduce workload at tertiary health care facilities, allow maximal utilization of health care facilities, strengthen peripheral infrastructure, improve teaching standard and to promote research activities. The emergency admission to tertiary healthcare includes large number of patients referred from rural areas. The present study was carried out to evaluate the maternal and fetal outcomes of such cases.

Methods

This study was done at Department of Obstetrics. and Gynaecology, Umaid Hospital, Dr. S N Medical College, Jodhpur. The study population consists of obstetrics referrals from periphery to our hospital for a duration of 6 months.

Inclusion criteria

All referred antenatal and intra-natal patients to our tertiary care institute of more than 20 weeks gestational age.

Exclusion criteria

Referred cases of less than 20 weeks booked gestation, post-partum referrals and gynaecological referrals.

Methodology

Detail history and relevant investigated were done i.e. complete physical and obstetric examination, basic investigations like complete blood counts (CBC), blood grouping, obstetric ultrasound, case specific investigations carried out as mandated by clinical condition of the patient. Management of the patients was documented, whether conservative or interventional. Mode of delivery was noted down, vaginal or operative. The method of transportation and accompanying staff was also noted. The neonatal outcome was documented as: term/preterm, live/still birth, birth weight, stay in neonatal intensive care unit (NICU).

Thorough study of previous check-up and case sheets was done if available with the patient or relative. Maternal outcome in the form of maternal morbidity and mortality were noted.

Results

This was an observational study of 1014 referred cases as per inclusion criteria during six month period from the teaching hospital attached to Dr. S.N. Medical College, Jodhpur, namely Umaid Hospital, Jodhpur. According to our study, out of a total of 10,172 delivered patients, 1,014 (9.96%) cases were referred as shown in Pie diagram 1.

Pie Diagram 1

Referral and direct admission

In this study, maximum no. 713 (70. 3%) cases of referred patients were in the age group of 21-30 years as shown in Table 1 because maximum pregnancies occurs between 21-30 years of age group in our country due to early marriages. The majority of the cases were either illiterate (34.52%) or poorly literate (47.24%) i.e. up to primary education. Only (18.24%) % cases were educated up to secondary, higher secondary or college standard [Table 2].

Table 1

Distribution of cases according to age

Age group In years	No. of cases	Percentage%
16-20	256	25.25
21-25	555	54.73
26-30	158	15.58
31-35	39	3.85
>35	6	0.59
Total	1014	100

Table 2

Distribution of cases according to Educational status

Educational status	No. of cases	Percentage
Illiterate	350	34.52
Primary school	479	47.24
Secondary	56	5.52
Higher Secondary	114	11.24
College and above	15	1.48
Total	1014	100

Majority of cases were referred from CHC i.e. 637 (62.84%) cases, 230 (22.68%) cases were referred from DH, 111 (10.94%) from PHC's, 27 (2.66%), from sub-centre and only a few (0.88%) cases from private hospital and clinics [Table 3].

Table 3

Distribution of cases according to referral centres

Institutions from where referred	No. of cases	Percentage%
District hospital (DH)	230	22.68
Community health centre (CHC)	637	62.84
Primary health centre (PHC)	111	10.94
Sub centre (SC)	27	2.66
Private Hospital & Clinic	9	0.88
Total	1014	100

The Table 4 shows that out of 1,014, 408 cases came late to our centre because of some reasons like delay in getting transport facility in 21.50% cases, delay in decision by relatives in 9.86% cases and in 8.88% cases the economic constraints i.e. arrangement of money was the issue.

Table 4

Reasons for delay

Reason	No. of Cases	Percentage%
Delay in decision taking-by relatives	100	9.86
Delay in transportation	218	21.50
Arrangement for money	90	8.88
No delay	606	59.76
Total	1014	100

The referral causes are listed in Table 5. In the present study, majority of patients were referred for labour pain and for better management of active labour 368 (36.29%), previous caesarean section 116 (11.44%), hypertensive disorder of pregnancy 74 (7.30%), antipartum hemorrhage (APH) 66 (6.51%) and anemia 87 (8.58%). Other common causes were obstructed labour, failed progress, mal presentation, cephalo-pelvic disproportion (CPD), premature repture of membrane (PROM), intrauterine death (IUD), post term, fetal distress, hand prolapsed, twins, pre term, intrauterine growth retardation (IUGR), respiratory distress, SLOC, human immunodeficiency virus (HIV) infection, heart disease, rupture uterus and no cause mentioned in 63 (6.21%) cases.

Table 5

Causes for referral

Referral causes	No. of Cases	Percentage%
Hypertensive disorder of pregnancy	74	7.30
Previous CS	116	11.44
APH	66	6.51
Obstructed Labour	14	1.38
Anemia	87	8.58
Failed Progress	51	5.03
Mal presentation	39	3.85
CPD	12	1.18
PROM	41	4.04
IUD	18	1.78
Post term	6	0.59
Fetal distress	29	2.86
No cause mentioned	63	6.21
Hand prolapsed	4	0.39
Twin	10	0.99
Rupture Uterus	6	0.59
Labour Pain	368	36.29
Heart Disease	1	0.10
HIV	1	0.10
SLOC	1	0.10
Respiratory Distress	1	0.10
IUGR	1	0.10
Pre Term	5	0.49
Total	1014	100

The various causes of maternal morbidities are depicted in Table 6. Most common cause of maternal morbidity was anemia in 188 cases (51.09%) followed by postpartum haemorrhage (PPH) which was seen in 67 (18.20%) and vaginal wall tear was seen in58 (15.77%) cases. There were 9 maternal mortalities as shown in Table 7. 3 maternal deaths were due to IHS + PPH + DIC (disseminated intravascular coagulation). Sec. PPH + DIC + Shock caused 2 deaths. 9 patients were referred from our hospital to other specialties like medicine for further management.

Table 6

Cause of post-partum maternal morbidity (n=368)

Causes	No. of cases	Percentage%
Anemia	188	51.09
Post partumEclampsia	12	3.27
DIC/Coagulopathy	16	4.34
Atonic PPH	67	18.20
Traumatic PPH (Vaginal wall tear)	58	15.77
UTI	7	1.90
Prolonged Catheterization	5	1.36
Infection (Wound gap, Fever, Sepsis, Distension)	15	4.07
Total	368	100

Table 7

Cause of maternal mortality (n=9)

Cause of mortality	No. of cases	Percentage%
Irreversible haemorrhagic shock (IHS)+PPH+DIC	3	33.33
CVA+HIS	1	11.11
DIC+Shock+APH	1	11.11
PPH+MODS (multi organ dysfunction)	1	11.11
Secondary PPH+DIC+Shock	2	22.22
Traumatic PPH+Shock	1	11.11
Total	9	100

The overall maternal outcome is depicted in Table 8. Majority of patients (98.34%) included in the study were discharged. There were 9 maternal mortalities and 8 patients were transferred from our department to other specialities for further management of respective complications.

Table 8

Distribution of cases according to maternal outcome

Maternal outcome	No. of cases	Percentage%
Discharge	997	98.34
Shift to other specialty	8	0.78
Expired	9	0.88
Total	1014	100

Discussion

The study includes 1,014 cases of obstetric referral during a duration of six month. There were 10,172 total deliveries during this period.

The percentage of referred cases (pie diagram), in our study is 9.96, which is lower than other studies like study done by Gupta et al.,[6] in 2016 showed 15.37% of obstetric referrals. Similarly, study by Sable and Patankar[7] in 2015, Pandya and Patel[8] in PHC's of Gujarat and Sharma[9] at Indore (2007) reported referral rate of 17.83%, 15.2% and 14.02%.

Referred cases in various age groups

In the present study, most of the patients were in the age groups of 21-30 years, similar to study by Devneni and Sodumu,[10] where 73% of patients were in this age group. Study by Pandya and Patel[8] (2015) reported that 64% referred cases belonged to age group of 21-30 years, which is also comparable to our study. Gupta et al.[6] (2016) reported that 86.98% of referred cases were in this age group, much higher than our study, because maximum pregnancy occurs between 21-30 years of age group in our country, due to trend of early marriages, we get maximum referral cases in this group.

Educational status

Education is the key for the success of health programs. In our study majority of the cases were either poorly literate (47.24%) or illiterate (34.52%). Only 18.24% cases were educated up to secondary, higher secondary or college standard. These data are comparable to the study of Devneni and Sodumu,[10] which showed 40% of referred cases were illiterate. Thaker and Jadav,[11] showed 34.7% of cases illiterate in unregistered group in their study and Sharma[9] (2007), who reported that 77% of referred cases were illiterate and only 6% were educated to secondary education or more. This results in ignorance of utilization of medical facilities. The educational and socio-economic status of women is significant for the utilization of maternal health services as education plays an important role in health seeking behaviour.

It shows that in our country even after more than 70 years of independence we are not that much successful to provide education to females as is the requirement of the time. Ultimately, female education in a community also reflects health status and economic condition of the family, so female education is a great empowerment for reducing early marriages, high birth order and repeated pregnancies, and increasing the utilization of health care services for antenatal check-up, institutional deliveries and postpartum care with family planning.

Referring centres

Majority of cases were referred from CHCs (51.7%), next from District hospitals (22.68%), PHCs (10.94%), Sub centres 27 (2.66%) and only 9 cases (0.88%) were referred from private hospitals and clinics. Study by Sable and Patankar[7] showed that 15.79% were referred from PHCs, 42.37% from DHs, 34.74% from referral hospitals and 2.63% from ESI (employee's state insurance) hospital. Study by Panchal and Patel[12] et al., (2015) showed 61% referred from PHCs and CHCs, and 33% from private hospitals.

The reason for referral includes non-availability of obstetrician, anaesthetist, paediatrician, and lack of facilities to do caesarean section, lack of blood bank services, trained staff and equipments to manage obstetric emergencies.

Thus, it increases the referral and burden on tertiary centres and lowers their quality of health services. So proper equipment and manpower strengthening of existing first referral units (FRUs) is necessary to provide better services.

Causes of delayed referral

Our study reported that out of 1014, 408 (40.24%) cases came late to our centre because of some reasons like delay in getting transport facility in 21.50% cases, delay in decision by relatives in 9.86% cases and in 8.88% cases arrangement of money was the issue. The percentage of cases with delayed referral in our study was quite high as compare to the study of Gupta[4] et al., who reported that 76% of cases reached within 8 hours of reference and only 5.58% were delayed referrals (more than 12 hours). Time interval of reference and reporting depends not only on availability of transport system and distance between the referral and tertiary health care centre but also on patients and her relative's attitude, awareness and socio-economic status and that affects directly feto-maternal outcome.

Referral causes

In the present study, majority of patients were referred for labour pain and for better management of active labour, 368 (36.29%), previous caesarean section 116 (11.44%), hypertensive disorders of pregnancy 74 (7.30%), APH 66 (6.51%) and anemia (8.58%). Other common causes were obstructed labour, mal-presentations, CPD, PPH, PROM, fetal distress and preterm labour pain which shows negligence or inability of the health care providers at referring health centres in proper evaluation of patients. Gupta et al.[6] reported that majority of cases were referred for anemia (18.05%), hypertensive disorders of pregnancy (22.27%) and mal-presentations (15.19%).

Panchal and Patel[12] reported that the common causes of referral were anemia (15%) and hypertensive disorders of pregnancy (15%). Other causes were pregnancy with previous caesarean section (12%), APH (6%), mal-presentations (4%) and obstructed labour (4%).

Management of complications

In this study, out of all 1,014 cases, there were 183 (5.3%) ICU admissions. Out of 183 ICU admissions, there were 38 (20.77%) cases of ante-partum ecclampsia (APE), 67 (36.61%) cases of PPH, 19 (10.39%) cases of APH, 46 (25.13%) cases of S. PreEclampsia, 2 case for respiratory distress and 11 cases of exploratory laparotomy was done in our hospital for atonic PPH and rupture of uterus and 6 patients underwent hysterectomy and 8 patients were transferred from our department to other specialities for further management of complications.

In our study, the important causes of maternal morbidity were anaemia (51.09%), post-partum ecclampsia (3.27%), PPH (18.20%) and infection (4.07%) i.e. wound infection, sepsis and lower respiratory infections; and APE (20.77%) whereas study by Goswami and Makhija[13] showed that 12.34% of referred patients required a ICU admissions with an average stay of 4.26 days. Charu et al.[14] in their study reported ICU care in 8% cases, which is much higher than our study. However, the ICU admission rate in our study was higher than that of Sailaja[15] Pollock[16] and Harde.[17] These differences could be ascribed to differences in demographics in different regions.[5]

All critically ill obstetric patients require a multidisciplinary team approach with good intensive care monitoring and facilities for further interventions if required, so they were referred here for further better management. The morbidity was higher in referred patients because most of these patients were admitted late in labour, after prolonged duration of ruptured membranes, anaemic, infected, exhausted, dehydrated and either handled or delivered by untrained personnel in the periphery. These morbidities are avoidable by providing adequate and proper antenatal and intra-natal care and providing adequate trained health personnel in the rural areas who can promptly identify or foresee complications and timely refer them for tertiary level intervention.

Causes of maternal mortalities

In this study, there were 9 maternal deaths – which is quite lower than other studies and were due to IHS + PPH + DIC in 3 cases (33.33%), secondary PPH + DIC + Shock in 2 cases (22.22%), cerebrovascular accident (CVA) +IHS, DIC+ Shock+ APH, PPS+ MODS, Traumatic PPH+ Shock in 1 case (5.88%) each, respectively. The most important cause was haemorrhagic shock due to PPH. In these cases, the associated factors were septicaemia, DIC and severe anaemia.

Gupta et al.[6] reported 40 (2.72%) of mortalities in their study and common causes of mortality were hypertensive disorder (35%), severe anaemia (20%), haemorrhage (20%) sepsis (10%) and medical disorders like malaria and hepatitis. In the study by Sharma,[7] the most common causes of maternal deaths were ecclampsia, hemorrhagic shock and congestive cardiac failure (CCF) due to severe anaemia.

So the TBA (trained birth attendant) and volunteer health workers should be aware about the importance of haemoglobin status of a woman in pregnancy. Iron tablets must be given to all women during the pregnancy and even after delivery in lactating period, to make her a blood bank for herself, so that she could bear the blood loss of delivery and we could reduce the maternal mortalities due to PPH.

Conclusion

Referral is a coordinated movement of healthcare seekers through the health system to reach a high level of care in a small and often fatal window of time. It involves factors like, decision to seek the healthcare and the perception of risk by the women herself and her family members, ease in reaching health facility, financial stability, identification of high risk factors by health personnel and timely decision about intervention and referral.

In our study, majority of referral were from rural areas (83.93%) and illiterate or poorly literate (81.76%) and most of them have a poor knowledge of existing antenatal services in the rural areas. Illiteracy and ignorance of female regarding healthcare requirements and unavailability of proper healthcare facilities in the reason came out to be a major contributor of poor pregnancy outcome.

In order to decrease the number of unnecessary referrals and to reduce burden on tertiary care hospitals, healthcare workers should be trained in essential and emergency obstetric care which will help in reducing morbidity and mortality.

In the present study, 40% cases had delayed referral. Timely referral is crucial for a satisfactory maternal and fetal outcome. All peripheral health sectors should be well equipped with vehicles on road transport facility.

Lack of blood bank facility is another hurdle in ensuring a satisfactory maternal outcome. We must give emphasis on correction of anaemia in ANC care, so that the woman can bear the loss during delivery. This can be achieved by measures like iron supplementation to adolescent girls, early ANC registration of pregnant women, deworming and educating women about contraception and birth spacing.

For women empowerment and their better status, we need to change the mind-set of society. Economic independence will increase her decision making power and enhance her position in household. This will also help her to interact with the outside world and be aware of services available to them.

Improving female education, health education and awareness at community level by mass media and non-government organizations can improve the health and social status of women in rural areas.

Every woman has right to get good quality healthcare and now it is high time to update our practice of maternal and child health (MCH) care services, because there was a challenge of Millennium development by 2015, which still remains a challenge.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.