Table 3 Practice, problems and suggestions regarding referral during antenatal care, reported by health staff working at CHC/PHC/SHC

Components of referral practice, %

Problems faced in referring antenatal women

• Patients are uncooperative, they refuse to go to higher centres –PHC & CHC

• Transport is not available in remote villages. ‘108’ ambulances are sometimes late –PHC in HP

• No transport for antenatal elective or emergency referral –PHC in HP

• ANM supervisor conducted ANC and referred by herself –PHC in HP

• Nurse experienced and willing to provide care, but in-experienced doctor suggested referral –PHC in HP

• Not a delivery point, so all pregnant women referred to the delivery point –PHC in HP

• Not clear about when to refer. Mostly refer when doctor is not available –PHC & CHC

• Refer to District hospitals on weekend, as doctors may not be available at CHC/Sub-district hospital-PHC in HP

• Referral not accepted at higher centre –PHC in HP

• ANC referrals usually from the outpatient clinic and there was no record maintenance –PHC & CHC

• Lab technician not available to provide basic investigations –PHC & CHC in HP

• No information on any change in services and availability of blood at the higher centre –PHC

Support required from system to improve referrals for antenatal women

• Transport facility for emergency antenatal care cases –PHC & CHC

• Need access to obstetrician. In case of any high-risk or complication, the patient needs to visit an obstetrician at least once –PHC & CHC

• Call centre support to discuss difficult cases

• Training required to upgrade knowledge and skills for high-risk and complication cases

• Support from senior staff and doctor to allow ANC care and help in decision making for management of difficult cases

• Need more staff. PHCs should have two medical officers and at least 3–4 staff nurses and one lab technician –PHCs in HP

• Moral support from the system and senior staff should support our decisions

• Lab technician required at seven PHCs and 2 Sub-district hospitals; radiology services required for USG at CHC or Sub-district hospital.

• Blood bank and better testing facilities for thyroid and diabetes so that more women can be managed at CHC/Sub-district hospitals