Penelitian ini bertujuan mengidentifikasi faktor penyebab “rujuk lepas” dalam kasus kegawatdaruratan maternal di wilayah kerja RS Dinda Tangerang, suatu kondisi di mana pelimpahan pasien tidak disertai tata laksana dan tanggung jawab yang memadai. Masalah ini berdampak signifikan pada mortalitas ibu, terutama pada kondisi seperti perdarahan, eklampsia, dan sepsis. Penelitian menggunakan pendekatan kualitatif dengan teori Model Donabedian untuk menganalisis faktor input (sumber daya), proses (sistem rujukan), dan output (hasil pelayanan). Hasil menunjukkan beberapa faktor penyebab utama: keterbatasan kompetensi bidan di fasilitas kesehatan tingkat pertama, kendala transportasi dan komunikasi antar fasilitas, serta ketidaksiapan rumah sakit rujukan menangani pasien secara optimal. Penelitian ini merekomendasikan peningkatan kompetensi tenaga kesehatan melalui pelatihan, optimalisasi sistem komunikasi antar fasilitas, dan penambahan sumber daya di rumah sakit rujukan. Hasil penelitian diharapkan menjadi landasan bagi pengembangan sistem rujukan kegawatdaruratan maternal yang lebih baik untuk menurunkan angka kematian ibu.

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This study aims to identify the factors causing “improper patient transfer” in maternal emergencies at the RS Dinda Tangerang service area, a condition where patient transfer is conducted without adequate treatment and responsibility. This issue significantly impacts maternal mortality, particularly in cases such as hemorrhage, eclampsia, and sepsis. A qualitative approach was employed using the Donabedian Model to analyze input (resources), process (referral system), and output (service outcomes) factors. The results identified several key contributing factors: limited competence of midwives at primary healthcare facilities, transportation and communication barriers between facilities, and the unpreparedness of referral hospitals to handle patients effectively. This study recommends improving healthcare professionals' competence through training, optimizing communication systems between facilities, and increasing resources at referral hospitals. The findings are expected to serve as a foundation for developing a better maternal emergency transfer system to reduce maternal mortality rates.