Objective: To identify the number and causes of obstetrical referrals from district level hospitals to tertiary care and factors influencing the referrals. Methodology: This descriptive study took place in 2 district hospitals of Khyber Pukhtunkhwa (KP) namely, District Headquarter Hospital, Nowshera and Government Maternity Hospital, Peshawar. It was a 06 months study starting from January 2014 to June 2014. A referral register was kept to record the number of patients, and reasons for referral, to tertiary care during antenatal, intrapartum and postpartum period. Data was collected prospectively, by involved doctors or nurse on duty, responsible for transfer of patient. Number and reasons for transfer of patients were studied. Results: Total number of OPD patients was 12718, in both hospitals. Among these total number obstetrical or booked patients were 7757(61%). Mean age of patient was found to be 27 (+5 yrs). About 347 (4.47%) patients were referred to tertiary care. Of these referrals antenatal referrals comprised 216 (2.78%), intrapartum or during labor pains 108 (1.39%) and postpartum 23 (0.29%). Antenatal reasons for transfer of patient were found to be hypertensive disorders 55 (0.7%), anemia 42 (0.54%), medical disorders 29 (0.37%), trial of labor 27 (0.34%), preterm labor 24 (0.31%), self referrals 15 (0.19%), higher order pregnancy 13 (0.16%) and bad obstetrical history 11 (0.14%). Intrapartum reasons included antepartum hemorrhage 38 (0.49%), non – progressive labor 17 (0.22%), malpresentation 16 (0.20%), reduced fetal movements 16 (0.20%), fetal distress 13 (0.16%) and self referrals 08 (0.10%). Postpartum referrals comprised stabilization with blood transfusions i.e. 18 patients (0.23%), septicemia 03 (0.038%), and postpartum hemorrhage 02(0.025%). Conclusion: A proper referral system is needed from district to tertiary care level hospitals. The value of a team work is demonstrated in inter -hospital transfer process.