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

OBJECTIVE: To assess the completeness of obstetric referral letters/notes at the district level of healthcare. DESIGN: An 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. SETTING: Three (3) districts in the Greater Accra region of Ghana. PARTICIPANTS: Pregnant 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. INTERVENTION: An enhanced interfacility referral communication system consisting of training, provision of communication tools for facilities, formation of hospital referral teams and strengthening feedback mechanisms. OUTCOME: Completeness of obstetric referral letters/notes. RESULTS: Proportion 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. CONCLUSIONS: Most 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.