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OFFICIAL JOURNAL OF THE FEDERATION OF OBSTETRIC AND GYNAECOLOGICAL SOCIETIES OF INDIA - www.jogi.co.in

VOLUME 68NUMBER 2MARCH - APRIL 2018


CASE REPORT GYNECOLOGY

The ‘‘Saturday Effect’’ in Obstetrics: A Comparison Between Referral Patterns on Saturday and Other Days of the Week

Anahita R. Chauhan • Sumit Chamariya • Madhva Prasad

Anahita R. Chauhan is a Professor and HOU in Department of Obstetrics and Gynecology at Seth GS Medical College and KEM Hospital, Mumbai. Sumit Chamariya is a Registrar in Department of Obstetrics and Gynecology at Seth GS Medical College and KEM Hospital, Mumbai. Madhva Prasad is a Assistant Professor in Department of Obstetrics and Gynecology at Seth GS Medical College and KEM Hospital, Mumbai.

Madhva Prasad
madhva@gmail.com
Department of Obstetrics and Gynecology, Seth GS Medical College and KEM Hospital, Acharya Donde Marg, Parel, Mumbai, Maharashtra 400012, India

Respected Editor,
Through this communication, we wish to highlight that a disproportionate number of obstetric patients are referred from the first- or second-level facilities to tertiary centres on weekends, especially Saturdays [1]. Day-of-the-week linked referral patterns are recognised in Western literature, not necessarily only in obstetrics [2]. However, documentation in contemporary Indian literature is not extensive. Our research question aimed to find if ‘‘taking a break during weekends’’ by doctors leads to increased inter-institutional referrals. We conducted a prospective observational study at our tertiary-care hospital over 1 year to ascertain if differential referral patterns exist. All obstetric cases referred on Saturdays were compared to those referred on all other days, including Sundays; data regarding reasons for referral, consistency between indication for referral and actual diagnosis after admission; and maternal and perinatal mortality patterns were analysed. Of the total 8271 confinements, referrals constituted 38.12%; however on Saturdays, 46.49% cases were referred as compared to only 25.36% on other days, which was statistically significant. There was also statistically significant difference between reasons for referral on Saturdays versus other days, with referral for non-medical reasons predominating on Saturdays (non-availability of doctors and NICU). Noteworthy is that almost half the cases managed on Saturdays were referred. (Table 1). In our country, most doctors in public sector work on Saturdays, at least in the morning. To look for differences in referrals based on time of day, 24-h time period from 7 am was divided into 3-h intervals and the time of arrival of referred cases was noted. Majority of patients were referred between 4 pm on Saturdays and 1 am on Sundays, as compared to a more uniform distribution among all time periods on other days; this was statistically significant (p value = 0.0347). Major inconsistencies were observed between reason for referral and actual diagnosis, mainly need for NICU and PIH. 25 and 19.5% of cases referred on other days of the week for presumed need for NICU or a diagnosis of PIH, respectively, did not need NICU nor had PIH; this number increased to 35 and 30% on Saturdays, respectively, for NICU and PIH. This highlights unnecessary transfers on Saturdays. LSCS rate was similar, 32.2 and 28% on Saturdays and other days. Perinatal and maternal mortality rates were comparable other days. The commonest causes

of maternal mortality were complications relating to preeclampsia, systemic medical disorders in pregnancy and antepartum haemorrhage. Ruiz analysed the rate of 30-day mortality following emergency admission or elective surgery. It showed a ‘‘Friday effect’’ [3], very similar to the ‘‘Saturday effect’’ highlighted here. Falciglia showed that more inductions for labour take place on weekdays than on weekends [4]. Clark showed a higher occurrence of LSCS during weekdays than on weekends [5]. In our study, we found more patients being referred to referral centres on weekends. It may be postulated that less numbers of patients are provided care at primary and secondary levels during weekends; obstetricians tend to refer away less patients on weekdays than on weekends. Perinatal mortality has also been shown to be higher during weekends and among those who are referred [1, 6]. To summarise, there is a temporal inconsistency in the pattern of inter-institutional referral, with variation attributable to non-patient factors, thereby establishing a ‘‘Saturday effect’’. Inter-institutional referral is invariably necessary when problems occur; and timely referral does improve patient outcomes. Here we have attempted to present the other side; an analysis of reduction in unnecessary burden on tertiary-care centres is the need of the hour, not only in terms of patient outcomes but also from a health-care resource management perspective.

Compliance with Ethical Standards
Conflict of interest All the authors declare that they have no conflict of interest.
Ethical statements All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5). Since it was a review of records, no informed consent was obtained from any patients for being included in the study. This article does not contain any studies with animal subjects.

References

1. Patel AB, Prakash AA, Raynes-Greenow C, Pusdekar YV et al. Description of inter-institutional referrals after admission for labor and delivery: a prospective population based cohort study in rural Maharashtra, India. BMC Health Serv Res [Internet]. 2017 May 19 [cited 2017 Nov 16];17(1):360. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28526027.
2. Arulkumaran N, Harrison DA, Brett SJ. Association between day and time of admission to critical care and acute hospital outcome for unplanned admissions to adult general critical care units: cohort study exploring the ‘‘weekend effect’’. Br J Anaesth. 2017;118(1):112–22.
3. Ruiz M, Bottle A, Aylin PP. The global comparators project: international comparison of 30-day in-hospital mortality by day of the week. BMJ Qual Saf. 2015;24(8):492–504.
4. Falciglia GH, Grobman WA, Murthy K. Variation in labor induction over the days of the week. Am J Perinatol. 2015;32(1):107–12.
5. Clark SL, Perlin JB, Fraker S, et al. Association of obstetric intervention with temporal patterns of childbirth. Obstet Gynecol. 2014;124(5):873–80.
6. Palmer WL, Bottle A, Aylin P. Association between day of delivery and obstetric outcomes: observational study. BMJ [Internet]. 2015 Nov [cited 2017 Nov 14];351:h5774. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26602245.