Factors associated with maternal referral system in South India: A hospital-based cross-sectional analytical study

Background: Availability of free/low-cost treatment in higher government facilities increases maternity self-referrals circumventing the referral system. We aimed to find the sociodemographic and health-care service delivery pattern among the pregnant women referred for institutional delivery in a tertiary care center in south India and assess factors associated with maternity self-referral from the perspective of pregnant women. Materials and Methods: We conducted a cross-sectional analytical study among pregnant women attending the antenatal clinic and admitted to the obstetric and postnatal wards during the 6-month study period. Interview was conducted using a face validated structured questionnaire. Statistical Analysis: Adjusted prevalence ratio (aPR) with 95% confidence interval (CI) was calculated to assess the independent effects of the sociodemographic and health-care delivery factors on maternity self-referral. Results: Mean age of 4191 pregnant women was 24 years (3.9). Forty-one percent (1732) of them had come without any referral, i.e., self-referred. Fifty-two percent (909) of these self-referred pregnant women were primigravida, 77% (1330) belonged to joint families and had nearest health facility within half hour distance from their own house. Nuclear family (aPR: 1.56 [95% CI: 1.45–1.68]), monthly family income >Rs. 3000 (aPR: 1.38 [95% CI: 1.28-1.49], and nearest health facility more than half-hour (aPR: 1.57 [95% CI: 1.45–1.69]) were factors significantly associated with self-referral. Conclusions: The study presents the alarming maternal referral system prevailing in nation as 41% (95% CI: 39.8%–42.8%) of maternal admissions in a tertiary care institute of South India were without any documented referrals.