Obstetric Risk Assessment and Referral Cascade as Predictors of Perinatal Morbidity and Mortality

Abstract

Background: Using an evidence-based guideline for obstetric risk assessment in the primary and secondary healthcare settings in Nigeria has been shown to aid appropriate referral cascade of patients to tertiary centres. Aim: To assess the impact of inappropriate obstetric risk assessment and late referral to tertiary care facilities in Rivers State on perinatal morbidity and mortality. Material and methods: The study was of prospective cross-sectional design involving 475 patients who were referred from primary and secondary healthcare facilities to the labour ward of Rivers State University Teaching Hospital in Nigeria. The appropriateness of their obstetric risk assessment and referral cascade to a tertiary centre was assessed, using a preformed evidence-based guideline and the results were associated with the perinatal morbidity and mortality. Data were analysed using Epi Info 2020. Results: The perinatal outcome in women that needed to be referred in the first trimester to tertiary centres was worse than that in those women who were appropriately referred and the differences were statistically significant in terms of birthweight less than 2500 grams [170(54.66%) versus 8(24.24%), X2 = 9872 p<0.002]; birth asphyxia [78(19.02%) versus 0(0%), X2 =7.926 p<0.0003]; admission to SCBU [85(20.73%) v 0(0)%); X2=8.916 p<0.0001] and foetal death [77 (18.78%) v 0(0%); X2=7.787 p<0.0003r]. The differences were also worse in terms of the number of patients who had preterm birth at 28-37 weeks, FGR and large for date (LFD) babies but the differences were not statistically significant. Furthermore, the perinatal outcome in women that needed to be referred in the first trimester to tertiary centres was also worse than that in those who needed an earlier referral to tertiary centres and the differences were statistically significant in terms of birth asphyxia (X2=2.341, p<9.045); admission to SCBU (X2=2.699, p<0.055) and foetal death (X2=2.291, p<0.047). The differences were also worse in terms of the number of patients who had preterm births, neonatal birth weight, LFD babies and FGR but not statistically significant. Conclusion: Perinatal morbidity and mortality were worse in patients who needed to be referred to a tertiary centre from a primary and secondary healthcare facilities than in those who were appropriately referred and those that needed an earlier referral. There is therefore an urgent need for adoption of evidence-based guideline for obstetric risk assessment and referral cascade in Nigeria.