Through this communication, we wish to highlight that adisproportionate number of obstetric patients are referredfrom the first- or second-level facilities to tertiary centreson weekends, especially Saturdays [1]. Day-of-the-weeklinked referral patterns are recognised in Western litera-ture, not necessarily only in obstetrics [2]. However, doc-umentation in contemporary Indian literature is notextensive. Our research question aimed to find if ‘‘taking abreak during weekends’’ by doctors leads to increasedinter-institutional referrals.
We conducted a prospective observational study at ourtertiary-care hospital over 1 year to ascertain if differentialreferral patterns exist. All obstetric cases referred onSaturdays were compared to those referred on all otherdays, including Sundays; data regarding reasons for refer-ral, consistency between indication for referral and actualdiagnosis after admission; and maternal and perinatalmortality patterns were analysed.
Of the total 8271 confinements, referrals constituted38.12%; however on Saturdays, 46.49% cases were refer-red as compared to only 25.36% on other days, which wasstatistically significant.There was alsostatistically signif-icant differencebetween reasons for referral on Saturdaysversus other days, with referral for non-medical reasonspredominating on Saturdays (non-availability of doctorsand NICU). Noteworthy is that almost half the casesmanaged on Saturdays were referred. (Table1).
In our country, most doctors in public sector work onSaturdays, at least in the morning. To look for differencesin referrals based on time of day, 24-h time period from7 am was divided into 3-h intervals and the time of arrivalof referred cases was noted. Majority of patients werereferred between 4 pm on Saturdays and 1 am on Sundays,as compared to a more uniform distribution among all timeperiods on other days; this wasstatistically significant(pvalue=0.0347).
Major inconsistencies were observed between reason forreferral and actual diagnosis, mainly need for NICU andPIH. 25 and 19.5% of cases referred on other days of theweek for presumed need for NICU or a diagnosis of PIH,respectively, did not need NICU nor had PIH; this numberincreased to 35 and 30% on Saturdays, respectively, forNICU and PIH. This highlights unnecessary transfers onSaturdays. LSCS rate was similar, 32.2 and 28% onSaturdays and other days. Perinatal and maternal mortalityrates were comparable other days. The commonest causes of maternal mortality were complications relating topreeclampsia, systemic medical disorders in pregnancy andantepartum haemorrhage.
Ruiz analysed the rate of 30-day mortality followingemergency admission or elective surgery. It showed a‘‘Friday effect’’ [3], very similar to the ‘‘Saturday effect’’highlighted here. Falciglia showed that more inductionsfor labour take place on weekdays than on weekends [4].Clark showed a higher occurrence of LSCS duringweekdays than on weekends [5]. In our study, we foundmore patients being referred to referral centres on week-ends. It may be postulated that less numbers of patientsare provided care at primary and secondary levels duringweekends; obstetricians tendto refer away less patients onweekdays than on weekends.Perinatal mortality has also been shown to be higherduring weekends and among those who are referred [1,6].To summarise, there is a temporal inconsistency in thepattern of inter-institutional referral, with variationattributable to non-patient factors, thereby establishing a‘‘Saturday effect’’. Inter-institutional referral is invariablynecessary when problems occur; and timely referral doesimprove patient outcomes. Here we have attempted topresent the other side; an analysis of reduction in unnec-essary burden on tertiary-care centres is the need of thehour, not only in terms of patient outcomes but also from ahealth-care resource management perspective.
Conflict of interest: All the authors declare that they have no conflictof interest.
Ethical statements: All procedures followed were in accordance withthe ethical standards of the responsible committee on human exper-imentation (institutional and national) and with the Helsinki Decla-ration of 1975, as revised in 2008 (5). Since it was a review ofrecords, no informed consent was obtained from any patients forbeing included in the study. This article does not contain any studieswith animal subjects.
