Reduction of maternal and perinatal mortality depends on provision of quality obstetric services, such as obstetric surgery and blood replacement, which can only be provided in a hospital setting ( WHO 1991). An important aim of screening in antenatal care is to identify pregnancies likely to develop complications. These have then to be referred early to a level of care with the necessary expertise and equipment to prevent or minimize the anticipated adverse pregnancy outcome. A link between facilities providing first-level antenatal and delivery care and the referral hospital providing back-up obstetric care is essential for the management of high-risk pregnancies as well as obstetric emergencies. This link is a serious bottleneck ( Rooney 1992; Dujardin et al. 1995 ; Juncker & Vanneste 1995; McDonagh 1996).
Our study was triggered by the observed coexistence ofan almost complete coverage (> 95%) of antenatal care ( Tanzania Bureau of Statistics 1992), the use of an action-orientated antenatal card with clear referral criteria ( Table 1) and persistently high maternal mortality (572–960/100 000 live births) ( Urassa et al. 1995 ; WHO 1996a; Macleod & Rohde 1998) and perinatal mortality (71/1000 live births) ( World Bank 1993). We set out to investigate the extent to which health services in southern Tanzania succeed in providing obstetric care to high-risk pregnancies and deliveries as stipulated by national guidelines ( Table 1). As antenatal screening and monitoring of deliveries should result in a highly risk-selected clientele at referral level, we compared the prevalence of risk factors in users of referral-level obstetric care to the prevalence in pregnant women in general.
Our specific objectives were to determine the coverage of obstetric referral level care for high-risk pregnancies; to determine the potential of specific risk factors to trigger referral; and to identify determinants for use of referral level care other than risk status.