MPH, Faculty of Health Sciences, University of the Witwatersrand / Introduction: South African health system embraces the District Health System model. 1 District health system includes health stations or posts, other health care facilities such as private health practitioners, community based organisations. primary health care clinics and district hospitals. District hospitals provide first level of outpatient or inpatient care for patients who have been referred by their primary care providers. District hospitals usually provide 24 hour care and are integrated into district health system. The above set up is similar in Thaba Nchu Health sub district where Dr.J.S.Moroka Hospital (DJSMH) is a district hospital and therefore, a referral point for 11 clinics within Thaba Nchu sub district and 4 clinics from the neighbouring sub district. In addition, there are 5 general practitioners rooms within Thaba Nchu sub district. The DJSMH is overburdened with increasingly high caseload. Main Aim: To evaluate the referral system in the Thaba Nchu Health Sub-district, Free State Province in terms of the factors that influences its function. Methodology: This was a descriptive study undertaken at Dr.J.S.Moroka Hospital Outpatient and Casualty departments. The study included review of routinely collected hospital information on patients’ records and registers. No intervention was done for this study. Results : The referral system within the sub district is not fully functional. Most patients that are seen in the DJSMH are self referrals. The case load and work load of the two designated areas could be reduced if most of the patients could have started and be seen at the primary health care clinics. Although the registers were helpful in collecting information, the documentation on patients’ records by health workers is not consistent; it is poor and need to be improved. The records have shown that the personnel are doing little in strengthening the referral system within the district. Conclusion: This study was the first of its kind to be done in this DJSMH. Although there are good practices with regard to referral system within the Thaba Nchu subdistrict and Dr. J.S Moroka Hospital, much still has to be done to ensure that the primary health care clinics and hospitals are effectively functioning in rendering services relevant to each level of care. More patients seen in the DJSMH are self referrals that could be managed at the primary health care clinics. The interventions recommended in this study will assist in strengthening the delivery of district health care system and in particular improve the referral system within the sub district.

Although it is considered an everyday occurrence, childbirth is nonetheless an important and dramatic experience in the life of every woman. Childbirth, a normal physiological state in the life of a woman, can be an awe-inspiring and exciting experience, but sometimes disconcerting experiences may also occur. Women sometimes see labour as the end to a long drawn out process following pregnancy and therefore attribute great significance to all occurrences during labour. When complications occur in a usually uncomplicated process of labour, the health care provider must be able to make quick and effective management decisions and implement appropriate interventions. This may include the referral of women in labour to a level of care where complications can be dealt with more effectively, thereby ensuring the best maternal and neonatal outcomes. Patient referral is regarded as a fundamental component of the health care system therefore a well functioning system should ensure that patients are treated in the appropriate manner at the appropriate place at the lowest possible cost to the health system. The goal of this research study was to explore and describe the inter-level health service referral of women in labour by midwives, in order to design guidelines for midwives and other relevant health care providers involved in inter-level health service referral of women in labour in the South African public health care sector. The research design used for this study is a combination of qualitative and quantitative approaches. The paradigmatic perspective of this study was based on the World Health Organization’s Health for All Model. Appropriate data collection and analysis strategies were used for the different stages of the study. Data collection commenced only after permission to conduct the research had been obtained from relevant authorities and University of Port Elizabeth and the Nelson Mandela Metropolitan University structures. Informed consent was obtained from participants included in the study. In stage 1 of this research project, a profile of midwives at lower level maternity care centres was compiled and the perceptions and experiences of midwives working at lower level maternity services, who are responsible for inter-level health referrals of women in labour, were described. Stage 2 described, by means of analysis of maternity case records, aspects of the inter-level referral of women in labour including the profiles of women admitted to midwife obstetric units (MOUs) who are v referred to higher levels of care. Of significance in this study is the appropriateness of midwifery referrals and the maternity care implemented by health care providers during inter-level health service referral of women in labour. In stage 3 clinical guidelines for midwives and other relevant maternity care providers, to assist them in the inter-level health service referral of women in labour, were developed. Findings from stage 1 of this research study revealed that midwives were generally well qualified and sufficiently experienced in the management of women in labour who need referral. Disconcerting findings relating to human and material resource shortages were discovered; these included major problems with patient transportation and difficulties with communication relating to inter-level health service referral of women. These shortages adversely affected midwives’ ability to efficiently care for women during the inter-level health service referral of women in labour in the research area. Stage 2 of the study yielded results of questionable standards of care to women and infants included in the study. A further disturbing finding from the study is the poor state of record keeping. The development of the provisional guidelines in stage 3 of the study was informed by the four main themes identified from the research findings. Before embarking on guideline development, the researcher familiarized herself with theory related to the clinical guidelines. These included clarifying the concept ‘clinical guidelines’, justifying the need for developing clinical guidelines as well as giving consideration to concerns about clinical guidelines. The research findings as well as literature related to these findings informed the researcher on the development of the guidelines. Provisional guidelines were therefore developed on responsibilities of role players in inter-level health service referral of women in labour at first level of referral, namely the midwife obstetric units, transport personnel and maternity care providers at the referral hospital. Steps were taken throughout the study to adhere to ethical standards of research. The researcher will ensure that the research report is available to all health authorities involved, the participants included in the study and the health care providers who may benefit from the research findings.