This study generated data about quality of care aspects (organization, structure, the process and outcomes) of intrapartum care specifically focusing on the duty handover period. Poorly organized, poorly-conducted and poorly supervised handover processes are a potential recipe for harm during intrapartum care. While this qualitative data may not indicate causality, it sheds light on the contextual factors of poor quality of care and associated severe maternal and perinatal morbidity. The study identified healthcare provider, health system factors and leadership and management-related factors related to handover processes which need to be improved in order to promote maternal and newborn survival and wellbeing during and after childbirth. Our objective was to describe handover as a phenomenon experienced or as perceived by mothers who sought intrapartum care. The objective was not to indicate whether poor handovers were associated with poor pregnancy or child birth outcomes, but to reveal the context and process by which adverse pregnancy outcomes may be related to poor handover practices and processes. The data may be utilized by clinicians, hospital managers, and policy makers for informing quality improvement programs for childbirth.
Poor organization and poor conduct of handovers
All the women interviewed were aware that t health workers changed duty frequently, and did not expect to be looked after by the same individuals throughout their hospitalization. They were also aware of and expected that different teams of health workers would look after them during intrapartum care. The way in which handover (from one team of healthcare providers to another) was managed was believed to be key to women’s perception of quality of care and satisfaction with childbirth. Some of the participants reported having spent more than two days in the labor ward, and therefore witnessed several teams of health workers handing over to each other. All the participants indicated that there was no structured, formal or consistent approach to how handovers actually occurred or were conducted. The handovers ranged from a very brief exchange between teams of health workers, to a prolonged ward round where each and every admitted patient was reviewed. In either case, there was minimal involvement of the mothers in labor (or their attendants) in the handover process, as exemplified by one respondent:
“I t was not done well. It was usually very brief. Often the doctors did not even look at you, let alone examine you. They only talked to themselves, often in a language you could not understand. There was no open communication. So you are left wondering what is happening, what they are talking about. Yet the doctors change all the time. They do not seem to be working as one healthcare team.”
Gaps in continuity of care during and after handovers
For some women, continuity of care was maintained because the new teams showed them more care and reassessed them with urgency after the handover process. In that respect, appearance of different people was a positive change, that positively impacted on the subsequent process of care.. The women described this as ‘signs of hope’, ‘reassuring’ or ‘relief’. Such women felt more satisfaction with the handover process. For other women, the new teams merely focused on finishing the handover round as soon as possible, without giving the mothers much attention or addressing their problems and needs. This often necessitated the on-coming teams to repeat the ward rounds, inevitably leading to inefficiencies and delays. Such women described the handover experience as being ‘abandoned’ by the previous teams after the hasty duty handovers. One woman describes this situation as very ‘frustrating’ or ‘uncertainty’: The handover process varied greatly between individuals and between different teams, thus indicating problems in the organization and strudture of care and consequemnly, the process of care during and after handovers. The handover therefore created gaps in continuity of care
“There should be a better method of transfer of care. The new teams often went through the same questions that had been asked earlier without checking your file. This was and duplication of effort. Other times they just checked your file without re-assessing your situation or taking any action. At times doctors stop reviewing patients before they reach you.”
The handover process often led to what women thought was indecision. Some women indicated that critical information is frequently not transmitted between health professionals, wrong decisions were taken or delays in receiving care were caused. Errors were related to omissions of vital content that is required for synthesis and rational judgment for assessment of the clinical condition of the patient, evaluation of results of investigations, critique of an ongoing management plan or assessment of the patient’s prognosis. This is exemplified by one aggrieved mother who developed a ruptured uterus after obstructed labor:
“Some doctors make wrong diagnoses or make wrong decisions. And when one group comes to replace the one that has been treating you, they change the treatment, without asking you any questions or examining you. One team tells that you are for an operation, another team cancels the operation or tells you that nothing was written. Nobody asks for your opinion and rarely do they answer your questions during rounds.”
Traumatic experiences and negative outcomes of care related to handovers
The participants were aware that it was necessary for health workers to change duty in order to get some rest. Where they knew that they would be unavailable, (it was expected that) health workers would ask colleagues to cover their duties. However, most participants believed that duty shift change, duty transfers and poorly coordinated or poorly communicated health worker sign-offs triggered off several problems that affected quality of care or continuity of care. Such negative outcomes of care related to poorly organized or poorly conducted handovers included problems in decision-making for emergency care (wrong decisions could be made or there could be delays in decision-making). Other errors could be related to drug prescriptions (changing the route, timing or duration of treatment), poor interpretation of results of investigations (different teams could interpret the results differently) and poor evaluation of treatment or patient management plans (errors could be made regarding subsequent women’s care during patient follow-up). Where such errors occurred, participants reported negative or even traumatic experiences.
On their interaction with healthcare providers, some women described the health worker behaviour as ‘negligence’, ‘degrading’, ‘inhumane’ and ‘horrific.’ Even when they felt satisfied with the overall care received, some participants identified the duty shift handovers as partly responsible. One woman, who waited for one week for an elective caesarean section but had to undergo an emergency caesarean section, believed poor handover processes were partly responsible, exemplifies this view:
“I’m very happy with the care I received while on the ward waiting for the operation. However, I am not happy that I had to go though labor pains as I was operated on by the night team as an emergency case, yet I was not supposed to go through labor. During the many hours of waiting, nobody explained to me what was going on.”
For many women who developed and survived severe complications of childbirth, childbirth was a difficult period described as ‘trauma’, ‘degrading’, ‘terrible’, and ‘a period of suffering.’ Their description of the experience depicted anguish and grief. Women perceived childbirth negatively if medical intervention occurred, if the mode of delivery was not by natural birth or if they perceived negatively the treatment from healthcare professionals. This is exemplified by one woman who had a ruptured uterus following obstructed labor, and had a postpartum interview 4 months later:
“I just keep thinking about it all the time. One of the hardest things ever was walking out of the hospital empty handed. I still feel the pain. They regularly checked on me, but nobody explained to me what happened.…At first the midwives said they were not aware of my case. I keep getting flashbacks all the time. I wonder how my baby looked like. I am still so upset. I can believe I will never get another child.”
Poor handovers as a feature of health system failures
Several mothers reported that health workers could not communicate to them about theirhealth status or the health status of their babies during handovers. . Neither did the healthcare providers seem concerned about the mothers’ anxiety. The mothers therefore felt left out in the decision-making at that critical time, when important decisions were being made. The participants were thus able to distinguish between human aspect healthcare and professional/technical skills. However, the consensus view was that these two aspects were essential and complementary. This is exemplified by one mother:
“When the baby was born, they took her away and I could see frantic activities to revive the baby. They put the baby on oxygen briefly before whisking her away to the intensive care unit. They briefly showed me the sex of the baby. Yet for other babies, they would put them on top of the mothers’ abdomen. They even let mothers hold them or even kiss them. For me I never got back my baby until after 5 hours, after several inquiries to a new team of midwives. This really made me frightened. Later I had problems with breast feeding, so they had to return the baby to the nursery.”
Many women needed to be communicated to about the health status of the baby, but often this was not done, particularly by new teams that took over work. This is illustrated by one mother who yearned for contact with her baby after premature childbirth:
“They took him away without telling me what they were going to do or even getting my consent. The new team seemed unaware of what happened. For a whole day I was not allowed to touch him and that was really frustrating. They could not even let me take his photograph.”