Back-Referral of Convalescing Neonates: Challenges and Strategies in India.

Objectives: To investigate the barriers and facilitators involved in the back-referral process of newborns from a tertiary care centre to district Special Newborn Care Units (SNCUs) for step-down care.

Methods: The study employed mixed methods, including feedback questionnaires for parents of back-referred neonates, in-depth interviews with doctors and nurses from six SNCUs, and focused group discussions with medical staff at a tertiary-level institute. The study was conducted over a period of seven and a half months in a north Indian tertiary care centre.

Results: The back-referral process received positive acceptance from parents and healthcare personnel. Notable barriers included the lack of Retinopathy of Prematurity (ROP) screening services in some SNCUs, inadequate free transport facilities for back-referral, and deficiencies in two-way communication. Parents provided valuable feedback for improvement, suggesting back-referral to the SNCU nearest to their home, daytime back-referral with adequate prior notice, and the availability of post-partum obstetric care at SNCUs for the mother. Inadequate environmental hygiene and limited availability of ROP services were identified as concerns. Facilitators included effective communication, proximity-based back-referral, and ongoing mentoring of SNCUs by tertiary centres.

Conclusions: Establishing efficient two-way communication between tertiary centres and district SNCUs, provision of essential facilities at SNCUs, and ensuring a seamless continuum of care are pivotal for successful back-referral of convalescent neonates. Addressing these factors can contribute to improving the back-referral process, level 3 bed availability at the tertiary centres and neonatal health outcomes.