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Background  South African maternal and neonatal mortality rates remain unnecessarily high, which are considered avoidable through timeous identification, treatment and referral. An efficient referral process of high-risk pregnant women is dependent on the midwives’ ability to respond with relevance to the maternal and neonatal healthcare needs. The attainment of improved maternal and neonatal outcomes commences at the primary healthcare level, with the midwife, recognised as the first person responsible and accountable for pregnant women’s healthcare.    Aim  To explore midwives’ perceptions of their role in the referral of high-risk pregnant women from primary health care clinics to expert-centred sites.    Methods  A qualitative, exploratory, descriptive in nature approach, underpinned by a social constructivism paradigm, guided the methodology. Purposive sampling was used to select both the primary health care clinics in the feeder zone and the registered midwives working in these clinics. Data were collected through four focus group discussions and analysed using content analysis. The principles of trustworthiness were observed.    Setting  Department of Health primary health care clinics in the eThekwini district, South Africa.    Results  The midwives understood their role in the up referral of high-risk pregnant women but experienced many interruptions in its execution. Four categories emerged from the data, namely, enhanced by team support in the clinics, restrictions in transfer to expert-centred sites, impeding social determinants and midwifery competence facilitates referral process.    Conclusion  Global initiatives cannot guarantee maternal and neonatal health because of the challenges experienced by the midwives in the execution of their roles as they interface with the healthcare team.

Midwives’ perceived role in up referral of high-risk pregnancies in primary healthcare settings, eThekwini district, South Africa