Open Access Research article

Effectiveness of maternal referral system in a rural setting: a case study from Rufiji district, Tanzania

Andrea B Pembe12*, Anders Carlstedt23, David P Urassa4, Gunilla Lindmark2, Lennarth Nyström5 and Elisabeth Darj2

Author Affiliations

1 Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania

2 Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, Sweden

3 Department of Surgery, Central Hospital, Karlstad, Sweden

4 Department of Community Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania

5 Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden

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BMC Health Services Research 2010, 10:326  doi:10.1186/1472-6963-10-326

Published: 3 December 2010



The functional referral system is important in backing-up antenatal, labour and delivery, and postnatal services in the primary level of care facilities. The aim of this study was to evaluate the effectiveness of the maternal referral system through determining proportion of women reaching the hospitals after referral advice, appropriateness of the referral indications, reasons for non-compliance and to find out if compliance to referrals makes a difference in the perinatal outcome.


A follow-up study was conducted in Rufiji rural district in Tanzania. A total of 1538 women referred from 18 primary level of care facilities during a 13 months period were registered and then identified at hospitals. Those not reaching the hospitals were traced and interviewed.


Out of 1538 women referred 70% were referred for demographic risks, 12% for obstetric historical risks, 12% for prenatal complications and 5.5% for natal and immediate postnatal complications. Five or more pregnancies as well as age <20 years were the most common referral indications. The compliance rate was 37% for women referred due to demographic risks and more than 50% among women referred in the other groups. Among women who did not comply with referral advice, almost half of them mentioned financial constraints as the major factor. Lack of compliance with the referral did not significantly increase the risk for a perinatal death.


Majority of the maternal referrals were due to demographic risks, where few women complied. To improve compliance to maternal referrals there is need to review the referral indications and strengthen counseling on birth preparedness and complication readiness.