Obstetric Referral Barriers Survey Form

Obstetric Referral Barriers Survey Form
Please complete this survey to help us understand barriers to obstetric referral. Your responses are anonymous and will be used to improve referral processes.
What is your professional role?
How many years of experience do you have in maternal health?
In your opinion, how frequently do you encounter barriers to referring obstetric cases?
Which of the following do you consider significant barriers to obstetric referral? (Select all that apply)
Other
Rate the following potential barriers to obstetric referral in your setting:
Rows Not a barrier Minor barrier Moderate barrier Major barrier
Transportation availability
Referral communication
Patient willingness
Referral facility readiness
Cost to patient
How would you rate the overall effectiveness of the current obstetric referral system?
What strategies do you think could improve obstetric referrals in your area?
Have you received formal training on obstetric referral protocols?
If yes, how recently did you receive this training?
Please share any additional comments or suggestions regarding obstetric referrals:
Should be Empty:

Select theme:

Rows	Not a barrier	Minor barrier	Moderate barrier	Major barrier
Transportation availability
Referral communication
Patient willingness
Referral facility readiness
Cost to patient