Clinical handover communication at maternity shift changes and women's safety in Banjul, the Gambia: a mixed-methods study.

BACKGROUND: Clinical handover is a vital communication process for patient safety; transferring patient responsibility between healthcare professionals (HCPs). Exploring handover processes in maternity care is fundamental for service quality, addressing continuity of care and maternal mortality. METHODS: This mixed-methods study was conducted in all three maternity hospitals in Banjul, The Gambia. Shift-to-shift maternity handovers were observed and compared against a standard investigating content and environment. Semi-structured interviews and focus group discussions with doctors, midwives and nurses explored handover experience. RESULTS: One hundred ten nurse/midwife shift-to-shift handovers were observed across all shift times and maternity wards; only 666 of 845 women (79%) were handed over. Doctors had no scheduled handover. Shift-leads alone gave/received handover, delayed [median 35 min, IQR 24-45] 82% of the time; 96% of handovers were not confidential and 29% were disrupted. Standardised guidelines and training were lacking. A median 6 of 28 topics [IQR 5-9] were communicated per woman. Information varied significantly by time, high-risk classification and location. For women in labour, 10 [IQR 8-14] items were handed-over, 8 [IQR 5-11] for women classed 'high-risk', 5 [IQR 4-7] for ante/postnatal women (p < 0.001); > 50% had no care management plan communicated. Twenty-one interviews and two focus groups were conducted. Facilitators and barriers to effective handover surrounding three health service factors emerged; health systems (e.g. absence of formalised handover training), organisation culture (e.g. absence of multidisciplinary team handover) and individual clinician factors (e.g. practical barriers such as transportation difficulties in getting to work). CONCLUSION: Maternity handover was inconsistent, hindered by contextual barriers including lack of team communication and guidelines, delays, with some women omitted entirely. Findings alongside HCPs views demonstrate feasible opportunities for enhancing handover, thereby improving women's safety.

The content and completeness of women-held maternity documents before admission for labour: A mixed methods study in Banjul, The Gambia.

BACKGROUND: Women-held maternity documents are well established for enabling continuity of maternity care worldwide, with the World Health Organisation (WHO) recommending their use in effective decision-making. We aimed to assess the presence, content and completeness of women-held maternity documents at admission to hospitals in The Gambia, and investigate barriers and facilitators to their completion. METHODS: We interviewed 250 women on maternity wards of all 3 Banjul hospitals and conducted content analysis of documentation brought by women on admission for their completeness against WHO referrals criteria. Logistic regression models were used to estimate the odds of the minimum criteria being met. Two focus groups and 21 semi-structured interviews (8 doctors, 8 midwives and 5 nurses) were conducted with healthcare practitioners to explore barriers and facilitators to documented clinical information availability on admission. FINDINGS: Of the women admitted, all but 10/250 (4%) brought either a maternity card or a structured referral sheet. Of all forms of documentation, women most frequently brought the government-issued maternity card (235/250, 94%); 16% of cards had all 9 minimum criteria completed. Of the 79 referred women, 60% carried standardised referral forms. Only 30% of 97 high-risk women had risk-status recorded. Women were less likely to have documents complete if they were illiterate, had not attended three maternity appointments, or lived more than one hour from hospital. During qualitative interviews, three themes were identified: women as agents for transporting information and documents (e.g. remembering to bring maternity cards); role of individual healthcare professionals' actions (e.g. legibility of handwriting); system and organisational culture (e.g. standardised referral guidelines). CONCLUSION: Women rarely forgot their maternity card, but documents brought at admission were frequently incomplete. This is a missed opportunity to enhance handover and quality of care, especially for high-risk women. National guidelines were recognised by providers as needed for good document keeping and would enhance the women-held maternity documents' contribution to improving both safety and continuity of care.