Completeness of obstetric referral letters/notes from subdistrict to district level in three rural districts in Greater Accra region of Ghana: an implementation research using mixed methods

Abstract

ObjectiveTo assess the completeness of obstetric referral letters/notes at the district level of healthcare.DesignAn implementation research within three districts in Greater Accra region using mixed methods. During baseline and intervention phases, referral processes for all obstetric referrals from lower level facilities seen at the district hospitals were documented including indications for referrals, availability and completeness of referral notes/forms. An assessment of before and after intervention availability and completeness of referral forms was carried out. Focus group discussions, non-participant observations and in-depth interviews with health workers and pregnant women were conducted for qualitative data.SettingThree (3) districts in the Greater Accra region of Ghana.ParticipantsPregnant women referred from lower levels of care to and seen at the district hospital, health workers within the three districts and pregnant women attending antenatal clinic in the district and their family members or spouses.InterventionAn enhanced interfacility referral communication system consisting of training, provision of communication tools for facilities, formation of hospital referral teams and strengthening feedback mechanisms.OutcomeCompleteness of obstetric referral letters/notes.ResultsProportion of obstetric referrals with referral notes improved from 27.2% to 44.3% from the baseline to intervention period. Mean completeness (95% CI) of all forms was 71.3% (64.1% to 78.5%) for the study period, improving from 70.7% (60.4% to 80.9%) to 71.9% (61.1% to 82.7%) from baseline to intervention periods. Health workers reported they do not always provide referral notes and that most referral notes are not completely filled due to various reasons.ConclusionsMost obstetric referrals did not have referral notes. The few notes provided were not completely filled. Interventions such as training of health workers, regular review of referral processes and use of electronic records can help improve both the provision of and completeness of the referral notes.

Effectiveness of Communication Interventions in Obstetrics—A Systematic Review

“…Eighteen studies (25.3%) used qualitative approaches to gain an in-depth understanding of participants’ experiences with the intervention and perceived learning. Four studies (5.6%) measured outcomes with recorded reviews in pre–post designs or RCTs [ 20 , 28 , 43 , 53 ].…”

Audit of documentation accompanying referred maternity cases to a referral hospital in northern Ghana: a mixed-methods study

“…These issues with referral documentation have been reported in other studies [ 28 – 30 ]. Similarly, earlier studies from Ghana have found gaps, including a lack of essential information such as the diagnosis, findings of obstetric examinations, and details concerning the care provided to manage the women’s conditions [ 8 , 31 ].…”

“…The gaps in referral documentation indicate the need for concerted efforts by the Ghanaian central government and partner organisations to ensure that providers abide by the referral recommendations and guidelines issued by the Ministry of Health [ 9 ]. Regular professional development training, supportive supervision and feedback are required for health providers at lower healthcare levels to model the accurate completion of referral forms [ 8 ].…”

“…Referrals with limited information may lead to repeated and unnecessary tests and medical errors [ 7 ]. Thus, communicating patient’s information during referral is critical as it assists receiving health facilities to provide the required healthcare interventions [ 8 ].…”

Interventions to improve obstetric emergency referral decision making, communication and feedback between health facilities in sub‐Saharan Africa: A systematic review

“…Countries where included studies were conducted comprised Ghana [22,23], Kenya [24], Mozambique [25], Nigeria [26], Rwanda [27,28], Sierra Leone [29], Tanzania [30], Uganda [31][32][33][34] and Zambia [35,36] (Figure 3). Of the 14 studies identified (Table 1), 8 were quantitative [25][26][27][28][29][32][33][34][35], including 2 RCTs [25,32], and 6 were quasiexperimental studies [22,26,28,29,[33][34][35](Table 2). Five were qualitative [22][23][24]30,31,36], with 1 mixed methods study [22] (Table 3).…”