Background: Institutional delivery rates in India have improved in the past decade, but maternal mortality remains high. The aim of this study was to describe current referral pathways and transport services for pregnant women in the Indian public health sector to identify strategies for strengthening the referral system for emergency obstetric care. Methods: I conducted three literature reviews; a health provider’s KAP survey of staff in primary level public health facilities from two states; analyses of ‘108’ ambulance service data from six states; and telephone interviews of women who called this service in two states. Results: The reviews found no standard protocols or guidelines for referral of women with obstetric high-risk or complications in India, and over half of pregnant women attending primary level health facilities were referred. There was poor quality institution referral care and no studies on the effectiveness of transport interventions. The KAP study found staff had sub-optimal knowledge and practice for screening common high-risk conditions and complications, and low confidence and resources to manage emergency situations. Less than a quarter of pregnancies and institutional deliveries in the study populations used ‘108’ ambulances. Most women called the service for normal labour: only 4.3% had an obstetric emergency and 5.8% were inter-facility transfers. Of pregnant callers to the ‘108’ service, one third reported a high-risk condition or early complication in pregnancy. Women transported using other means were more likely to use private facilities than those transported by ‘108’. Conclusion: The quality of obstetric care at peripheral health centres is suboptimal and the high proportion of referrals could be avoided. The ‘108’ ambulance service is underused, especially in emergency situations. India’s health systems should improve the provision of obstetric care by standardising services at each level of health care. Strategies are required to increase the use of ‘108’ services for obstetric emergencies.