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Description of inter-institutional referrals after admission for labor and delivery: a prospective population based cohort study in rural Maharashtra, India
BACKGROUND: In 2008, the Indian government introduced financial assistance to encourage health facility deliveries. Facility births have increased, but maternal and neonatal morbidity and mortality have not decreased raising questions about the quality of care provided in facilities and access to a...
Autores principales: | , , , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
BioMed Central
2017
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5437536/ https://www.ncbi.nlm.nih.gov/pubmed/28526027 http://dx.doi.org/10.1186/s12913-017-2302-4 |
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author | Patel, Archana B. Prakash, Amber Abhijeet Raynes-Greenow, Camille Pusdekar, Yamini V. Hibberd, Patricia L. |
author_facet | Patel, Archana B. Prakash, Amber Abhijeet Raynes-Greenow, Camille Pusdekar, Yamini V. Hibberd, Patricia L. |
author_sort | Patel, Archana B. |
collection | PubMed |
description | BACKGROUND: In 2008, the Indian government introduced financial assistance to encourage health facility deliveries. Facility births have increased, but maternal and neonatal morbidity and mortality have not decreased raising questions about the quality of care provided in facilities and access to a quality referral system. We evaluated the potential role of inter-institutional transfers of women admitted for labor and delivery on adverse maternal and neonatal outcomes in an ongoing prospective, population-based Maternal and Newborn Health Registry in Central India. METHODS: Pregnant women from 20 rural Primary Health Centers near Nagpur, Maharashtra were followed throughout pregnancy and to day 42 post-partum. Inter- institutional referral was defined as transfer of a woman from a first or second level facility where she was admitted for labor and delivery to facility providing higher level of care, after admission to the day of delivery. Maternal mortality, stillbirth, early and late neonatal mortality were compared in mothers who were and were not referred. Factors associated with inter-institutional referral were analyzed using multivariable models with generalized estimating equations, adjusted for clustering at the level of the Primary Health Center. RESULTS: Between June 2009 and June 2013, 3236 (9.4%) of 34,319 women had inter-institutional referral. Factors associated with referrals were maternal age (adjusted Relative Risk or aRR 1.1; 1.0–1.2); moderate or severe anemia (aRR 1.2; 1.2–1.4), gestational age <37 weeks (aRR 1.16; 1.05–1.27), multiple gestation (aRR 1.6; 1.2–2.1), absent fetal heart rate (aRR 1.7; 1.3–2.2), primigravida (aRR 1.4; 1.3, 1.6), primigravida with any pregnancy related maternal condition such as obstructed or prolonged labor; major antepartum or post-partum hemorrhage, hypertension or preeclampsia and breech, transverse or oblique lie (aRR 4.7; 3.8, 5.8), multigravida with any pregnancy related conditions (aRR 4.2; 3.4–5.2). Stillbirths, early neonatal,late neonatal and early infant deaths occurred in 7.3% referred mothers vs. 3.7% of not referred. CONCLUSIONS: Almost 10% of the women had an inter-institutional referral and still birth or neonatal deaths were doubled in referred women. Conditions associated with referral were often known before onset of labor and delivery. Improvements in maternal and neonatal outcomes will likely require pregnant women with conditions associated with referral to be directly admitted at facilities equipped to care for complicated pregnancies and at risk neonates, as well as prompt detection and transfer those who develop “at risk” conditions during labor and delivery. TRIAL REGISTRATION: ClinicalTrials.gov NCT01073475. |
format | Online Article Text |
id | pubmed-5437536 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2017 |
publisher | BioMed Central |
record_format | MEDLINE/PubMed |
spelling | pubmed-54375362017-05-19 Description of inter-institutional referrals after admission for labor and delivery: a prospective population based cohort study in rural Maharashtra, India Patel, Archana B. Prakash, Amber Abhijeet Raynes-Greenow, Camille Pusdekar, Yamini V. Hibberd, Patricia L. BMC Health Serv Res Research Article BACKGROUND: In 2008, the Indian government introduced financial assistance to encourage health facility deliveries. Facility births have increased, but maternal and neonatal morbidity and mortality have not decreased raising questions about the quality of care provided in facilities and access to a quality referral system. We evaluated the potential role of inter-institutional transfers of women admitted for labor and delivery on adverse maternal and neonatal outcomes in an ongoing prospective, population-based Maternal and Newborn Health Registry in Central India. METHODS: Pregnant women from 20 rural Primary Health Centers near Nagpur, Maharashtra were followed throughout pregnancy and to day 42 post-partum. Inter- institutional referral was defined as transfer of a woman from a first or second level facility where she was admitted for labor and delivery to facility providing higher level of care, after admission to the day of delivery. Maternal mortality, stillbirth, early and late neonatal mortality were compared in mothers who were and were not referred. Factors associated with inter-institutional referral were analyzed using multivariable models with generalized estimating equations, adjusted for clustering at the level of the Primary Health Center. RESULTS: Between June 2009 and June 2013, 3236 (9.4%) of 34,319 women had inter-institutional referral. Factors associated with referrals were maternal age (adjusted Relative Risk or aRR 1.1; 1.0–1.2); moderate or severe anemia (aRR 1.2; 1.2–1.4), gestational age <37 weeks (aRR 1.16; 1.05–1.27), multiple gestation (aRR 1.6; 1.2–2.1), absent fetal heart rate (aRR 1.7; 1.3–2.2), primigravida (aRR 1.4; 1.3, 1.6), primigravida with any pregnancy related maternal condition such as obstructed or prolonged labor; major antepartum or post-partum hemorrhage, hypertension or preeclampsia and breech, transverse or oblique lie (aRR 4.7; 3.8, 5.8), multigravida with any pregnancy related conditions (aRR 4.2; 3.4–5.2). Stillbirths, early neonatal,late neonatal and early infant deaths occurred in 7.3% referred mothers vs. 3.7% of not referred. CONCLUSIONS: Almost 10% of the women had an inter-institutional referral and still birth or neonatal deaths were doubled in referred women. Conditions associated with referral were often known before onset of labor and delivery. Improvements in maternal and neonatal outcomes will likely require pregnant women with conditions associated with referral to be directly admitted at facilities equipped to care for complicated pregnancies and at risk neonates, as well as prompt detection and transfer those who develop “at risk” conditions during labor and delivery. TRIAL REGISTRATION: ClinicalTrials.gov NCT01073475. BioMed Central 2017-05-19 /pmc/articles/PMC5437536/ /pubmed/28526027 http://dx.doi.org/10.1186/s12913-017-2302-4 Text en © The Author(s). 2017 Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. |
spellingShingle | Research Article Patel, Archana B. Prakash, Amber Abhijeet Raynes-Greenow, Camille Pusdekar, Yamini V. Hibberd, Patricia L. Description of inter-institutional referrals after admission for labor and delivery: a prospective population based cohort study in rural Maharashtra, India |
title | Description of inter-institutional referrals after admission for labor and delivery: a prospective population based cohort study in rural Maharashtra, India |
title_full | Description of inter-institutional referrals after admission for labor and delivery: a prospective population based cohort study in rural Maharashtra, India |
title_fullStr | Description of inter-institutional referrals after admission for labor and delivery: a prospective population based cohort study in rural Maharashtra, India |
title_full_unstemmed | Description of inter-institutional referrals after admission for labor and delivery: a prospective population based cohort study in rural Maharashtra, India |
title_short | Description of inter-institutional referrals after admission for labor and delivery: a prospective population based cohort study in rural Maharashtra, India |
title_sort | description of inter-institutional referrals after admission for labor and delivery: a prospective population based cohort study in rural maharashtra, india |
topic | Research Article |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5437536/ https://www.ncbi.nlm.nih.gov/pubmed/28526027 http://dx.doi.org/10.1186/s12913-017-2302-4 |
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