Background: Indian women of a child bearing age (15–45 years) constitutes 22% of the population. They are a vulnerable special group. The risk is due to pregnancy and childbearing. To decrease this risk and improvement of the maternal and perinatal outcome, a referral system has been introduced which decreases the risk by improving service delivery at the tertiary center level, by reducing the workload, by strengthening the infrastructure in the peripheries and by the effective utilization of this by the patients. Major causes of referral to a tertiary center includes preterm labor, preeclampsia, eclampsia, previous CS, Rh negative blood group, antepartum hemorrhage, postpartum hemorrhage and sometimes due to lack of manual resources. Liking the different levels of care was an essential element of primary health care from the very beginning. Objectives: To identify the primary reasons and pattern of obstetric case referral to our hospital and to study the maternal and perinatal outcome in those cases. Materials and methods: One hundred and fifty consecutive obstetric referred cases of more than 28 weeks gestation admitted to Sri Adichunchanagiri Hospital and Research Centre were analyzed for the maternal and perinatal outcome. Results: In this study of the total studied patient's majority were in the group 21–25 years constituting about 60.6%. Nearly 38.7% of the referral was from THQ covering the areas like Nagamangala, Kunigal, Turuvekere and Channarayapattana. 28.7% were from PHC, 12% were from CHC, 6.7% from district hospital and 14% of the referral were from private hospital. Analyzing at the quality of referral according to the predefined criteria only 48% of the cases had adequate referral whereas about 28% of the cases had poor referral most of which were from the PHCs. About 58.8% of the patients delivered vaginally, with about 41.2% of the patient delivered by cesarean section. In the vaginally delivered cases 8.7% was instrumental delivery, 1.4% was breech delivery and 10.7% patient delivered after induction. In the present study major indication of the cesarean section include dystocia 29.1%, fetal distress with or without meconium aspiration 20.9%, hypertensive disorders of pregnancy 17.7%, repeat section 11.3%, malpresentation 8.1% and others 12.9%. About 86.1% of the referral has been made with an obstetric indication.12.6% of the referral had a medical indication for referral. Only 1.3% of the cases had a lack of manual resource as an indication for referral. Preterm labor and PROM accounted for about 20% of the referral. Hypertensive disorders were the next commonest cause of referral of about 13.3% of the cases. In the present study, there were a total of 126 live births, 5 stillbirths and 7 early neonatal deaths making the perinatal mortality rate (PNMR) of 95.23 per 1000 live births. Perinatal outcome was best for patients with age group of 21–25 years and was worst for the age group for more than 30 years. Interpretation and conclusion: Although better than the national data, there is indeed no doubt that rural health care infrastructure is falling short of the existing requirement. However, educating the population about the existing health care delivery system and sensitizing the public toward improving maternal and child health would go a long way in optimally utilizing the existing infrastructure and improving the maternal and perinatal outcome.