Effectiveness of care bundles for prevention and treatment of postpartum hemorrhage: a systematic review.

OBJECTIVE: Care bundles are a promising approach to reducing postpartum hemorrhage-related morbidity and mortality. We assessed the effectiveness and safety of care bundles for postpartum hemorrhage prevention and/or treatment. DATA SOURCES: We searched MEDLINE, Embase, Cochrane CENTRAL, Maternity and Infant Care Database, and Global Index Medicus (inception to June 9, 2023) and ClinicalTrials.gov and the International Clinical Trials Registry Platform (last 5 years) using a phased search strategy, combining terms for postpartum hemorrhage and care bundles. STUDY ELIGIBILITY CRITERIA: Peer-reviewed studies evaluating postpartum hemorrhage-related care bundles were included. Care bundles were defined as interventions comprising ≥3 components implemented collectively, concurrently, or in rapid succession. Randomized and nonrandomized controlled trials, interrupted time series, and before-after studies (controlled or uncontrolled) were eligible. METHODS: Risk of bias was assessed using RoB 2 (randomized trials) and ROBINS-I (nonrandomized studies). For controlled studies, we reported risk ratios for dichotomous outcomes and mean differences for continuous outcomes, with certainty of evidence determined using GRADE. For uncontrolled studies, we used effect direction tables and summarized results narratively. RESULTS: Twenty-two studies were included for analysis. For prevention-only bundles (2 studies), low-certainty evidence suggests possible benefits in reducing blood loss, duration of hospitalization, and intensive care unit stay, and maternal well-being. For treatment-only bundles (9 studies), high-certainty evidence shows that the E-MOTIVE intervention reduced risks of composite severe morbidity (risk ratio, 0.40; 95% confidence interval, 0.32-0.50) and blood transfusion for bleeding, postpartum hemorrhage, severe postpartum hemorrhage, and mean blood loss. One nonrandomized trial and 7 uncontrolled studies suggest that other postpartum hemorrhage treatment bundles might reduce blood loss and severe postpartum hemorrhage, but this is uncertain. For combined prevention/treatment bundles (11 studies), low-certainty evidence shows that the California Maternal Quality Care Collaborative care bundle may reduce severe maternal morbidity (risk ratio, 0.64; 95% confidence interval, 0.57-0.72). Ten uncontrolled studies variably showed possible benefits, no effects, or harms for other bundle types. Nearly all uncontrolled studies did not use suitable statistical methods for single-group pretest-posttest comparisons and should thus be interpreted with caution. CONCLUSION: The E-MOTIVE intervention improves postpartum hemorrhage-related outcomes among women delivering vaginally, and the California Maternal Quality Care Collaborative bundle may reduce severe maternal morbidity. Other bundle designs warrant further effectiveness research before implementation is contemplated.

Physiotherapy practice in women's health: awareness and attitudes of obstetricians and gynecologists in Ghana.

BACKGROUND: Physiotherapy is relatively well integrated into women's health in many high-income countries (HICs) as compared to low- and middle- countries (LMICs) like Ghana. Suboptimal integration of physiotherapy in modern obstetrics and gynecology especially in low resource settings is partly due to issues related to the awareness and attitudes of referring physicians. This study assessed the awareness and attitude levels towards physiotherapy in women's health among obstetricians/gynecologists and factors associated with its utilization in Ghana. METHODS: A cross-sectional study was conducted among obstetricians/gynecologists working at a tertiary hospital in Ghana using an "Awareness and Attitude Questionnaire" adapted from a standardized questionnaire. Chi-square test or Fisher exact test was performed and logistic regression was used to assess the association between doctors' awareness level of physiotherapy's role in women's health and years of clinical practice. RESULTS: Sixty-one (61) respondents comprising 7 consultants, 20 senior residents and 34 junior residents, with age median age of 35 years (range: 29-65 years) were recruited. There were more males than females (82% versus 18%) with a mean (SD) duration of practice of (9.41 ± 4.71) years. The participants reported a considerable awareness of physiotherapists' role in obstetrics (between 72.1% for intrapartum to 91.8% for postnatal) but wide variation in gynecology (from 19.7% in PID to 95. 1% in uterine prolapse). Consultants were more (71.4%) aware of the role of physiotherapy in antenatal care and gynecology while senior residents had more awareness in intrapartum and postnatal care. Junior residents generally showed lowest awareness levels. Duration of clinical practice (≥ 10years) was not significantly associated with doctors' awareness regarding the importance of physiotherapy in childbirth. There were mixed findings concerning doctors' attitudes toward physiotherapy: (1) 41% indicated that physiotherapists have been effective in their inter-professional relationship; (2) none of the doctors strongly agreed that physiotherapy may not contribute significantly to the complete well-being of gynecological patients. The main factors influencing utilization of physiotherapy were the perceived notion of non-availability of physiotherapists to cover various wards and physiotherapists not attending ward rounds with doctors to facilitate more education on the scope of physiotherapy practice. CONCLUSION: Although obstetricians/gynecologists showed appreciable awareness and attitudes towards physiotherapy, there remains a considerable gap in provider education to ensure optimal utilization of physiotherapy in contemporary obstetrics and gynecology. Further research is recommended to assess implementation challenges associated with regular utilization of physiotherapy services in women's health in the hospital.

Thyroid hormone profile in preeclampsia patients: a case control study.

Objective: Preeclamptic women are reported to have a higher incidence of thyroid dysfunction that correlates with the severity of preeclampsia. The aim of this study was to assess thyroid hormone profiles in in pregnant women with preeclampsia and gestational hypertension and the risk for thyroid dysfunction.Methods: In this study, age-matched pregnant females in the second trimester of pregnancy, diagnosed with preeclampsia (PE), gestational hypertension (GH), as cases, and apparently healthy normotensive (NT) pregnant woman as controls were recruited. Blood samples were drawn for the assessment of thyroid hormone (TSH, FT3 and FT4) levels and thyroid dysfunction.Results: Out of the total of 133 pregnant women recruited for this study, sub-clinical hypothyroidism was the only thyroid dysfunction common to all study groups, with a prevalence of 3.3% in both PE and NT groups, and 4.3% in the GH group. 1% of women in the PE group had sub-clinical hyperthyroidism, compared to 3.3% in the NT group. Although TSH and FT3 were elevated in normotensives, mean differences between the three groups were not statistically significant. However, mean FT4 levels in the GH group (12.99 ± 1.24) and PE group (12.33 ± 2.26), when compared to the control group (11.55 ± 1.94), were significantly higher (p < 0.05).Conclusion: Undiagnosed subclinical hypothyroidism was found in all the categories of pregnant women studied, which if uncontrolled, could increase the risk of pregnancy-related complications, especially in pregnant women with preeclampsia and gestational hypertension.

Provision and experience of care among women with hypertension in pregnancy: a multi-center qualitative study in Ghana.

BACKGROUND: Hypertensive disorders of pregnancy (HDP) remain a leading global health problem with complex clinical presentations and potentially grim birth outcomes for both mother and fetus. Improvement in the quality of maternal care provision and positive women's experiences are indispensable measures to reduce maternal and perinatal adverse outcomes. OBJECTIVE: To explore the perspectives and lived experiences of healthcare provision among women with HDP and the associated challenges. METHODS: A multi-center qualitative study using in-depth interviews (IDIs) and focus group discussions (FGDs) was conducted in five major referral hospitals in the Greater Accra Region of Ghana between June 2018 and March 2019. Women between 26 and 34 weeks' gestation with confirmed HDP who received maternity care services were eligible to participate. Thematic content analysis was performed using the inductive analytic framework approach. RESULTS: Fifty IDIs and three FGDs (with 22 participants) were conducted. Most women were between 20 and 30 years, Akans (ethnicity), married/cohabiting, self-employed and secondary school graduates. Women reported mixed (positive and negative) experiences of maternal care. Positive experiences reported include receiving optimal quality of care, satisfaction with care and good counselling and reassurance from the health professionals. Negative experiences of care comprised ineffective provider-client communication, inappropriate attitudes by the health professionals and disrespectful treatment including verbal and physical abuse. Major health system factors influencing women's experiences of care included lack of logistics, substandard professionalism, inefficient national health insurance system and unexplained delays at health facilities. Patient-related factors that influenced provision of care enumerated were financial limitations, chronic psychosocial stress and inadequate awareness about HDP. CONCLUSION: Women with HDP reported both positive and negative experiences of care stemming from the healthcare system, health providers and individual factors. Given the importance of positive women's experiences and respectful maternal care, dedicated multidisciplinary women-centered care is recommended to optimize the care for pregnant women with HDP.

High blood pressure (hypertension) in pregnancy can have severe complications for both mother and fetus including loss of life. The outcome of pregnancy for women who develop hypertension during pregnancy can be improved by ensuring optimal quality of care. In this study, we explored the opinions and experiences of women whose pregnancies were affected by hypertension concerning the care they received during their recent admission at different hospitals in Ghana and the challenges they faced. In four major referral hospitals in the Greater Accra Region of Ghana, we interviewed the women and had focus group discussions. Women who were pregnant for 26 weeks up to 34 weeks and had hypertension in pregnancy were invited for inclusion in the study.We conducted in-depth interviews with fifty women and three focus group discussions with 22 women. Most women who participated in the study were between 20 and 30 years old, Akans (ethnicity), married/cohabiting, self-employed and secondary school graduates. The women reported both positive and negative experiences of care during their admission at the hospitals. Examples of positive experiences were receiving good quality of care, satisfaction with care, and adequate counselling from the health workers. Examples of negative experiences were poor communication between the providers and affected women, inappropriate attitudes by the healthcare providers, and disrespectful treatment such as verbal and physical abuse. The major factors in the health system that influenced women's experiences of care were lack of logistics, substandard professionalism, inefficient national health insurance system and long delays at health facilities prior to receiving treatment. The individual women's factors that affected the quality of care included financial constraints, psychosocial stress and inadequate knowledge about hypertension during pregnancy.In conclusion, we determined that women with hypertension in pregnancy experience both positive and negative aspects of care and these may be due to challenges associated with the healthcare system, health providers and women themselves. There is the need to ensure optimal quality and respectful maternity care considering the nature of hypertension in pregnancy. These women require dedicated hospital staff with significant  experience to improve the quality of care provided to women with hypertension in pregnancy.

Characteristics of Women Receiving Emergency Caesarean Section: A Cross-Sectional Analysis from Ghana and Dominican Republic.

BACKGROUND: Significant inequalities still exist between low- and high-income countries regarding access to optimum emergency obstetric care including life-saving emergency caesarean section. These relationships are considerably stronger between population-based caesarean section rates and socio-economic characteristics with poorest households experiencing significant unmet needs persistently. OBJECTIVE: To explore the characteristics of women receiving emergency C-section using a new, validated definition in Ghana and the Dominican Republic. MATERIALS AND METHODS: This was a cross-sectional study conducted in Ghana and the Dominican Republic. Multivariable logistic regression analysis was used to determine women's characteristics associated with emergency C-section. RESULTS: This analysis included 2166 women who had recently delivered via C-section comprising 653 and 1513 participants from Accra and Santo Domingo, DR, respectively. Multivariable analyses showed that women, both in Ghana and the DR, were more likely to have an emergency C-section if they did not have a previous C-Section (adjusted Odds Ratio (aOR): 2.45, 95% CI [1.57-3.81]; and aOR: 15.5, 95% CI [10.5-22.90], respectively) and if they were having their first childbirth, compared to women with previous childbirth (aOR: 1.77, 95%CI [1.13-2.79]; and aOR: 1.46, 95%CI [1.04-2.04], respectively). Also, preterm birth was associated with significantly decreased likelihood of emergency C-section compared with childbirth occurring at term in both Ghana and the DR (aOR: 0.31, 95%CI [0.20-0.48]; and aOR: 0.43, 95%CI [0.32-0.58], respectively). Among the Ghanaian participants, having an emergency C-section was positively associated with being referred and negatively associated with being older than 35 years of age. Characteristics such as education, religion, marital status, and residence did not differ between women's emergency versus non-emergency C-section status. CONCLUSION: Emergency C-section was found to be significantly higher in women with no prior C-section or those having their first births but lower in those with preterm birth in both Ghana and the DR. Data from additional countries are needed to confirm the relationship between emergency C-section status and socio-economic and obstetric characteristics, given that the types of interventions required to assure equitable access to potentially life-saving C-section will be determined by how and when access to care is being denied or not available.

Health workers' and hospital administrators' perspectives on mistreatment of women during facility-based childbirth: a multicenter qualitative study in Ghana.

BACKGROUND: Globally, mistreatment of women during facility-based childbirth continues to impact negatively on the quality of maternal healthcare provision and utilization. The views of health workers are vital in achieving comprehensive understanding of mistreatment of women, and to design evidence-based interventions to prevent it. We explored the perspectives of health workers and hospital administrators on mistreatment of women during childbirth to identify opportunity for improvement in the quality of maternal care in health facilities. METHODS: A qualitative study comprising in-depth interviews (IDIs) with 24 health workers and hospital administrators was conducted in two major towns (Koforidua and Nsawam) in the Eastern region of Ghana. The study was part of a formative mixed-methods project to develop an evidence-based definition, identification criteria and two tools for measuring mistreatment of women in facilities during childbirth. Data analysis was undertaken based on thematic content via the inductive analytic framework approach, using Nvivo version 12.6.0. RESULT: Health workers and hospital administrators reported mixed feelings regarding the quality of care women receive. Almost all respondents were aware of mistreatment occurring during childbirth, describing physical and verbal abuse and denial of preferred birthing positions and companionship. Rationalizations for mistreatment included limited staff capacity, high workload, perceptions of women's non-compliance and their attitudes towards staff. Health workers had mixed responses regarding the acceptability of mistreatment of women, although most argued against it. Increasing staff strength, number of health facilities, refresher training for health workers and adequate education of women about pregnancy and childbirth were suggestions to minimize such mistreatment. CONCLUSION: Health workers indicated that some women are mistreated during birth in the study sites and provided various rationalizations for why this occurred. There is urgent need to motivate, retrain or otherwise encourage health workers to prevent mistreatment of women and promote respectful maternity care. Further research on implementation of evidence-based interventions could help mitigate mistreatment of women in health facilities.

Respectful maternity care is vital to achieving positive pregnancy and childbirth experiences for women and their families. Mistreatment of women during childbirth at facilities can negatively impact women's future health seeking behaviors and utilization of maternal care services. The experiences and perspectives of doctors, midwives and nurses working in labour wards are vital in understanding how women are treated during childbirth, and what measures can be taken to prevent it. In this study, we explored the opinions of health workers and hospital administrators on how women are treated during childbirth to determine the gaps in the quality of maternal care in health facilities in Ghana.Participants expressed mixed feelings concerning mistreatment of women during childbirth. Most were aware of the occurrence of mistreatment in health facilities including physical and verbal abuse, and denial of preferred position for childbirth and companionship. The reasons provided for mistreatment included low staff capacity, high workload, non-compliance by women and poor attitudes towards health workers. Most health workers were against mistreatment during childbirth. Participants thought mistreatment could be minimized by improving staff skills, refresher training, and childbirth preparation education for women. Our study indicates the need to motivate, retrain or encourage health professionals to provide respectful care to women during childbirth to improve their experience of care. Further research to help implement better maternity care devoid of mistreatment in health facilities in Ghana is needed.

How women are treated during facility-based childbirth in four countries: a cross-sectional study with labour observations and community-based surveys.

BACKGROUND: Women across the world are mistreated during childbirth. We aimed to develop and implement evidence-informed, validated tools to measure mistreatment during childbirth, and report results from a cross-sectional study in four low-income and middle-income countries. METHODS: We prospectively recruited women aged at least 15 years in twelve health facilities (three per country) in Ghana, Guinea, Myanmar, and Nigeria between Sept 19, 2016, and Jan 18, 2018. Continuous observations of labour and childbirth were done from admission up to 2 h post partum. Surveys were administered by interviewers in the community to women up to 8 weeks post partum. Labour observations were not done in Myanmar. Data were collected on sociodemographics, obstetric history, and experiences of mistreatment. FINDINGS: 2016 labour observations and 2672 surveys were done. 838 (41·6%) of 2016 observed women and 945 (35·4%) of 2672 surveyed women experienced physical or verbal abuse, or stigma or discrimination. Physical and verbal abuse peaked 30 min before birth until 15 min after birth (observation). Many women did not consent for episiotomy (observation: 190 [75·1%] of 253; survey: 295 [56·1%] of 526) or caesarean section (observation: 35 [13·4%] of 261; survey: 52 [10·8%] of 483), despite receiving these procedures. 133 (5·0%) of 2672 women or their babies were detained in the facility because they were unable to pay the bill (survey). Younger age (15-19 years) and lack of education were the primary determinants of mistreatment (survey). For example, younger women with no education (odds ratio [OR] 3·6, 95% CI 1·6-8·0) and younger women with some education (OR 1·6, 1·1-2·3) were more likely to experience verbal abuse, compared with older women (≥30 years), adjusting for marital status and parity. INTERPRETATION: More than a third of women experienced mistreatment and were particularly vulnerable around the time of birth. Women who were younger and less educated were most at risk, suggesting inequalities in how women are treated during childbirth. Understanding drivers and structural dimensions of mistreatment, including gender and social inequalities, is essential to ensure that interventions adequately account for the broader context. FUNDING: United States Agency for International Development and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO.

Household fuel use and adverse pregnancy outcomes in a Ghanaian cohort study.

BACKGROUND: Accruing epidemiological evidence suggests that prenatal exposure to emissions from cooking fuel is associated with increased risks of adverse maternal and perinatal outcomes including hypertensive disorders of pregnancy, low birth weight, stillbirth and infant mortality. We aimed to investigate the relationship between cooking fuel use and various pregnancy related outcomes in a cohort of urban women from the Accra region of Ghana. METHODS: Self-reported cooking fuel use was divided into "polluting" (wood, charcoal, crop residue and kerosene) and "clean" fuels (liquid petroleum gas and electricity) to examine 12 obstetric outcomes in a prospective cohort of pregnant women (N = 1010) recruited at < 17 weeks of gestation from Accra, Ghana. Logistic and multivariate linear regression analyses adjusted for BMI, maternal age, maternal education and socio-economic status asset index was conducted. RESULTS: 34% (n = 279) of 819 women with outcome data available for analysis used polluting fuel as their main cooking fuel. Using polluting cooking fuels was associated with perinatal mortality (aOR: 7.6, 95%CI: 1.67-36.0) and an adverse Apgar score (< 7) at 5 min (aOR:3.83, 95%CI: (1.44-10.11). The other outcomes (miscarriage, post-partum hemorrhage, pre-term birth, low birthweight, caesarian section, hypertensive disorders of pregnancy, small for gestational age, and Apgar score at 1 min) had non-statistically significant findings. CONCLUSIONS: We report an increased likelihood of perinatal mortality, and adverse 5-min Apgar scores in association with polluting fuel use. Further research including details on extent of household fuel use exposure is recommended to better quantify the consequences of household fuel use. STUDY REGISTRATION: Ghana Service Ethical Review Committee (GHS-ERC #: 07-9-11).

Methodological development of tools to measure how women are treated during facility-based childbirth in four countries: labor observation and community survey.

BACKGROUND: Efforts to improve maternal health are increasingly focused on improving the quality of care provided to women at health facilities, including the promotion of respectful care and eliminating mistreatment of women during childbirth. A WHO-led multi-country research project aims to develop and validate two tools (labor observation and community survey) to measure how women are treated during facility-based childbirth. This paper describes the development process for these measurement tools, and how they were implemented in a multi-country study (Ghana, Guinea, Myanmar and Nigeria). METHODS: An iterative mixed-methods approach was used to develop two measurement tools. Methodological development was conducted in four steps: (1) initial tool development; (2) validity testing, item adjustment and piloting of paper-based tools; (3) conversion to digital, tablet-based tools; and (4) data collection and analysis. These steps included systematic reviews, primary qualitative research, mapping of existing tools, item consolidation, peer review by key stakeholders and piloting. RESULTS: The development, structure, administration format, and implementation of the labor observation and community survey tools are described. For the labor observations, a total of 2016 women participated: 408 in Nigeria, 682 in Guinea, and 926 in Ghana. For the community survey, a total of 2672 women participated: 561 in Nigeria, 644 in Guinea, 836 in Ghana, and 631 in Myanmar. Of the 2016 women who participated in the labor observations, 1536 women (76.2%) also participated in the community survey and have linked data: 779 in Ghana, 425 in Guinea, and 332 in Nigeria. CONCLUSIONS: An important step to improve the quality of maternity care is to understand the magnitude and burden of mistreatment across contexts. Researchers and healthcare providers in maternal health are encouraged to use and implement these tools, to inform the development of more women-centered, respectful maternity healthcare services. By measuring the prevalence of mistreatment of women during childbirth, we will be able to design and implement programs and policies to transform maternity services.

Women's perspectives of mistreatment during childbirth at health facilities in Ghana: findings from a qualitative study.

Mistreatment of women during childbirth at health facilities violates their human rights and autonomy and may be associated with preventable maternal and newborn mortality and morbidity. In this paper, we explore women's perspectives on mistreatment during facility-based childbirth as part of a bigger World Health Organization (WHO) multi-country study for developing consensus definitions, and validating indicators and tools for measuring the burden of the phenomenon. Focus group discussions (FGDs) and in-depth interviews (IDIs) were used to explore experiences of mistreatment from women who have ever given birth in a health facility in Koforidua and Nsawam, Ghana. Interviews were audio-recorded, transcribed and thematic analysis conducted. A total of 39 IDIs and 10 FGDs involving 110 women in total were conducted. The major types of mistreatment identified were: verbal abuse (shouting, insults, and derogatory remarks), physical abuse (pinching, slapping) and abandonment and lack of support. Mistreatment was commonly experienced during the second stage of labour, especially amongst adolescents. Inability to push well during the second stage, disobedience to instructions from birth attendants, and not bringing prescribed items for childbirth (mama kit) often preceded mistreatment. Most women indicated that slapping and pinching were acceptable means to "correct" disobedient behaviours and encourage pushing. Women may avoid giving birth in health facilities in the future because of their own experiences of mistreatment, or hearing about another woman's experience of mistreatment. Consensus definitions, validated indicators and tools for measuring mistreatment are needed to measure prevalence and identify drivers and potential entry points to minimise the phenomenon and improve respectful care during childbirth.

Endothelial dysfunction in the pathogenesis of pre-eclampsia in Ghanaian women.

BACKGROUND: Pre-eclampsia (PE) remains a disease of theories despite extensive research into its etiology. Alteration in the production of vascular endothelial growth factor (VEGF), a biomarker of endothelial dysfunction, is associated with pre-eclampsia although conflicting reports have been reported. The aim of the study was to determine and compare maternal serum levels of VEGF among pre-eclamptics, normotensive non pregnant and pregnant women. This was a cross-sectional study involving 100 women with pre-eclampsia, 102 women with normotensive pregnancy and 75 normotensives who were not pregnant. The study was carried out at Korle Bu Teaching Hospital (KBTH) from April to June in 2011. Basic socio-demographic and obstetric data were obtained by means of structured questionnaire. Following venesection, about 5mls of blood was sampled from the participants for the various tests. Enzyme Linked Immunosorbent Assay was used to determine the maternal serum levels of free VEGF. Data analysis was performed using SPSS version 20. RESULTS: Significant reduction in median serum levels of free VEGF was seen in both, normal pregnant [84.06 pg/ml (IQR: 78.90-99.67)] and pre-eclamptic women [4.71 pg/ml, (IQR: 3.41-7.93)] compared to the non-pregnant (395.85 pg/ml, IQR 234.93-625) with p < 0.001; the reduction was far greater in the pre-eclamptic group compared to that of normotensive pregnant group (p < 0.001). Early-onset pre-eclampsia had significantly more severe reduction in free VEGF levels (3.89, IQR: 2.60-5.67 pg/ml) compared to that of late onset PE (5.23, IQR: 3.78-16.97 pg/ml) with p<0.001 indicating a severer endothelial damage in former. CONCLUSIONS: Endothelial dysfunction contributes significantly to the pathogenesis of pre-eclampsia as demonstrated by profound decrease in maternal serum VEGF levels in PE compared to normotensive pregnancy and non-pregnancy state. The pathophysiology of early-onset pre-eclampsia may be partly explained by marked reduction in free serum VEGF levels with resultant severe endothelial dysfunction.

Perinatal outcomes of hypertensive disorders in pregnancy at a tertiary hospital in Ghana.

BACKGROUND: Hypertensive disorders in pregnancy remain a major global health issue not only because of the associated high adverse maternal outcomes but there is a close accompaniment of significant perinatal morbidity and mortality especially in Sub-Saharan Africa (SSA). However, the perinatal burden of HDP in Ghana has not been explored. We conducted this study to determine the perinatal outcomes of HDP at a tertiary hospital in Ghana. METHODS: A cross-sectional study conducted between January to February 2013 at Korle Bu Teaching Hospital (KBTH) in Accra, Ghana. Data collection involved baseline review of all the obstetric population who had just delivered to identify those with HDP. An informed consent was obtained after which a structured questionnaire was adminstered to the hypertensive mothers. The medical records of the mothers and their babies were also reviewed to determine the perinatal outcome indicators of relevance to the study. Data obtained were analyzed using SPSS version 20. RESULTS: We included 368 women with HDP and singleton births with a mean gestational age at delivery of 37.4 ± 3.3 weeks. Adverse perinatal outcomes determined include the following: 91 (24.7%) neonates were admitted to the Neonatal Intensive Care Unit, 56 (15.2%) had neonatal respiratory distress/asphyxia with 14 (3.8%) requiring ventilatory support and 80 (21.7%) were delivered preterm. Also, stillbirth, early neonatal death, intrauterine growth restriction and low birth weight occurred in 25 (6.8%), 14 (3.8%), 23 (6.1%) and 91 (24.7%) respectively with a perinatal mortality rate of 106 per 1000 births. One and 5 minute APGAR scores <7 occurred in 125 (34.0%) and 55 (14.7%) neonates respectively. Most of the adverse perinatal outcomes were significantly more common in those with preeclampsia compared to the other hypertensive disorders. CONCLUSION: There is a significant burden of perinatal morbidity and mortality associated with HDP in the Ghanaian obstetric population and these adverse outcomes were more prevalent in preeclampsia compared to the other hypertensive disorders. Regular goal-oriented clinical audit into perinatal morbidity and mortality associated with HDP and an active multidisciplinary approach to the management of these disorders in the hospital might improve the clinical outcomes of women with maternal hypertension.

Evaluating Facility-Based Decision-Making in Women with a Prior Cesarean Delivery and Association with Maternal and Perinatal Outcomes.

Objective To describe facility-based decision-making for women with one prior cesarean delivery (CD) in a resource-limited setting and to characterize maternal and perinatal outcomes in these groups. Methods One year retrospective study of women with one prior CD delivering at Korle-Bu Teaching Hospital (KBTH), Ghana. Women were categorized into three groups based on initial plan of management on admission [trial of labor after cesarean (TOLAC), emergency repeat CD (EMCD) or non-emergent repeat CD (RCD)]. Characteristics and outcomes across these groups were then compared. Results During the study period, 1247 women with one prior CD delivered at KBTH, of which 377 (30.2%) were triaged to RCD, 439 (35.2%) to EMCD and 431 (34.6%) to TOLAC. Twelve uterine ruptures and no maternal deaths occurred. Perinatal mortality was 4.2% (n = 52). Compared to the RCD group, the TOLAC group had a lower risk for maternal adverse events (aOR 0.3, 95% CI 0.1-1.0; p = 0.04) and non-significant higher risk of perinatal adverse events (aOR 1.6, 95% CI 0.7-3.3; p = 0.25). Compared to women triaged to RCD, the EMCD group had a non-significant increase in risk of maternal adverse events (aOR 1.6, 95% CI 0.8-3.5; p = 0.2) and a significantly higher rate of perinatal adverse events (aOR 2.4, 95% CI 1.2-4.9; p = 0.01). Conclusions for Practice Women triaged to EMCD at admission are different when compared to women allowed a TOLAC or offered a non-emergent RCD. These women bear increased rates of adverse outcomes and should be considered as a separate group for analysis in future studies conducted in similar settings.

How women are treated during facility-based childbirth: development and validation of measurement tools in four countries - phase 1 formative research study protocol.

BACKGROUND: Every woman has the right to dignified, respectful care during childbirth. Recent evidence has demonstrated that globally many women experience mistreatment during labour and childbirth in health facilities, which can pose a significant barrier to women attending facilities for delivery and can contribute to poor birth experiences and adverse outcomes for women and newborns. However there is no clear consensus on how mistreatment of women during childbirth in facilities is defined and measured. We propose using a two-phased, mixed-methods study design in four countries to address these research gaps. This protocol describes the Phase 1 qualitative research activities. METHODS/DESIGN: We will employ qualitative research methodologies among women, healthcare providers and administrators in the facility catchment areas of two health facilities in each country: Ghana, Guinea, Myanmar and Nigeria. In-depth interviews (IDIs) and focus group discussions (FGDs) will be conducted among women of reproductive age (15-49 years) to explore their perceptions and experiences of facility-based childbirth care, focused on how they were treated by healthcare workers and perceived factors affecting how they were treated. IDIs will also be conducted with healthcare providers of different cadres (e.g.: nurses, midwives, medical officers, specialist obstetricians) and facility administrators working in the selected facilities to explore healthcare providers' perceptions and experiences of facility-based childbirth care and how staff are treated, colleagues and supervisors. Audio recordings will be transcribed and translated to English. Textual data will be analysed using a thematic framework approach and will consist of two levels of analysis: (1) conduct of local analysis workshops with the research assistants in each country; and (2) line-by-line coding to develop a thematic framework and coding scheme. DISCUSSION: This study serves several roles. It will provide an in-depth understanding of how women are treated during childbirth in four countries and perceived factors associated with this mistreatment. It will also provide data on where and how an intervention could be developed to reduce mistreatment and promote respectful care. The findings from this study will contribute to the development of tools to measure the prevalence of mistreatment of women during facility-based childbirth.

Understanding the continuum of maternal morbidity in Accra, Ghana.

The objective was to determine the levels of maternal morbidity from no complications to near miss and describe factors associated with different levels of morbidity. We conducted an observational study of all women delivering at a tertiary hospital in Accra, Ghana between October 2010 and March 2011. We examined the factors associated with the continuum of maternal outcomes in terms of severity using multinomial logistic regression. Data were extracted from women's maternal care files with the main outcome measures of no complications, non-life threatening complications, potentially life-threatening conditions (PLTC), and near miss as defined by World Health Organization. Our study includes 1,586 women with no complications, 1,205 women with non-life threatening complications, 516 women with PLTC, and 94 near-miss cases. All of the factors associated with PLTC and near-miss cases were similar. None of the socio-demographic variables remained significant in the multivariate analysis comparing different levels of severe morbidity with no complications. Women with no complications shared similar characteristics with women who experienced non-life threatening complications. As compared to women who had no complications, women who had severe morbidity were significantly more likely to have had no antenatal care. Our results underline the concept that morbidity is a continuum and indicate that if the underlying causes of poor maternal health outcomes are addressed, it is likely that changes such as better access to antenatal care will improve health outcomes across the continuum of morbidity. However, by only monitoring near-miss cases and mortality, we underestimate the impact on women who will live with non-life threatening, yet serious maternal morbidities.

Family planning needs of women experiencing severe maternal morbidity in Accra, Ghana: another missed opportunity?

Women with severe maternal morbidity represent an important group to target for increasing contraceptive uptake. Our objective was to explore the future fertility intentions, use of family planning including methods and reasons for not wanting to use contraception among a group of women who had traumatic delivery experience at a tertiary teaching hospital in Accra, Ghana. Our results show that despite higher educational attainment, longer hospital stays and intention to limit or stop childbearing among women, there is a missed opportunity for family planning among women with severe maternal morbidity in this urban African hospital setting. Integrating postpartum family planning consultations by linking available services such as reproductive health clinics at the facilities rather than including additional tasks for the midwives and the doctors in the wards could be a sustainable solution in such urban, high-volume settings.

Maternal serum angiopoietins levels in pre-eclampsia and pregnancy outcomes.

Background and Aims: Although the understanding of pre-eclampsia (PE) has improved, there is still insufficient knowledge on the exact etiology and pathophysiological mechanisms. Dysregulation of angiogenic factors has emerged as a significant contributing factor. Among these factors, angiopoietins (Ang-1 and Ang-2) have gained considerable attention due to their crucial role in regulating vascular development and endothelial function. This study explored the maternal serum levels of angiopoietins and perinatal outcomes in PE. Methods: A case-control study involving women with PE (cases) and normotensive pregnancies (controls) was conducted at the Maternity unit of the Korle-Bu Teaching Hospital. Descriptive analysis was performed and the Mann-Whitney U test (two-sided) was used to compare maternal serum levels of angiopoietins between the cases and controls. Results: We included 188 participants comprising 94 cases (women with PE) and 94 controls (normotensive pregnancies) with an average maternal age of 29.76 ± 5.56 and 28.43 ± 5.57 years, respectively. Maternal serum levels of Ang-2 were significantly lower among the PE cases compared to the normotensive controls (1.25 [0.90, 2.15] vs. 2.14 [1.18, 5.73] ng/mL, p = 0.001) but no significant difference in Ang-1 levels (92.61 [80.92, 114.92] vs. 99.26 [81.76, 113.12] ng/mL, p = 0.429) was observed between the groups. The Ang-1/Ang-2 ratio was significantly elevated among women with PE compared to normotensive controls (74.47 [37.69, 110.59] vs. 45.98 [16.11, 88.22] ng/mL, p = 0.014). Also, women who delivered vaginally had significantly high maternal serum levels of Ang-1 compared to women who had cesarean section delivery (107.98 ± 27.79 vs. 89.02 ± 32.62 ng/mL). Conclusion: Maternal serum levels of Ang-2 but not Ang-1 were significantly depressed in women with PE compared to the pregnant normotensive controls. No significant associations were observed between Ang-1, Ang-2 levels, or the Ang-1/Ang-2 ratio and pregnancy outcomes such as preterm birth, birth weight, and severity of hypertension.

Alteration in maternal serum uric acid levels in pre-eclampsia and associated perinatal outcomes: a cross-sectional study in Ghana.

Introduction: pre-eclampsia (PE) is a multisystemic pregnancy-specific hypertensive disorder associated with significant adverse maternal and perinatal outcomes. Maternal serum uric acid level is hypothesized as a reliable marker for predicting the severity and adverse outcomes of pre-eclampsia and facilitating clinical decisions. This study explored the association between maternal serum uric acid and adverse pregnancy outcomes in pre-eclampsia. Methods: a cross-sectional study involving women diagnosed with pre-eclampsia was conducted at Korle-Bu Teaching Hospital (KBTH), a tertiary hospital in Ghana. Descriptive analyses were performed and multivariable logistic regression model was used to explore the association between maternal serum uric acid levels and pregnancy outcomes using R software. Results: we included 100 women with pre-eclampsia comprising 79% and 21% preterm and term pre-eclampsia respectively and with mean gestational age (GA) at diagnosis of 32.35±2.66 weeks and 35.96±1.94 weeks respectively. The mean maternal age of preterm and term pre-eclampsia groups was 29.81±5.29 years and 29.46±5.78 years respectively. Hyperuricemia (serum uric acid >375 µmol/L) occurred in 61% of the pre-eclamptic women. The mean gestational age (in weeks) at diagnosis was significantly lower in the pre-eclamptic women with hyperuricemia compared with those with normal levels of uric acid (33.51±3.03 versus 34.80±2.71). There was a significant negative association (moderate correlation) between maternal serum uric acid levels and birth weight (R= -0.34, p < 0.001) in pre-eclampsia; the statistical significance was limited to preterm only (Pearson R= -0.39, p-value <0.001) but not term pre-eclampsia. Hyperuricemia was significantly associated with low birth weight [aOR: 3.222 (95% CI: 1.098, 10.393)], caesarean section [aOR: 2.281 (95% CI: 1.084, 7.568)] and severe diastolic pressure at birth [aOR: 3.517 (95% CI: 1.123, 11.939)]. Conclusion: hyperuricemia in pre-eclampsia was significantly associated with both maternal (caesarean section and severe hypertension) and neonatal (low birth weight) adverse outcomes. Hyperuricemia seems clinically useful in predicting pregnancy outcomes, especially in preterm pre-eclampsia. Further longitudinal study is recommended in exploring the clinical significance of maternal uric acid levels and pregnancy outcomes in pre-eclampsia.

Lived experiences of women during induction of labour at a tertiary hospital in Ghana: A qualitative study.

Induction of labour (IOL) has become a major and vital maternal health intervention to facilitate childbirth and minimize the rising caesarean section rates globally. However, there is limited information to facilitate appropriate client counselling, birth preparedness and informed decision making although the procedure has inherent tendency for adverse maternal/perinatal outcomes. Given the need for optimal client education and shared decision making in maternal health, this study explored women's knowledge and their lived experiences of IOL. This qualitative study used in-depth interviews, conducted at the largest teaching hospital in Ghana. Purposive sampling was used to recruit the study participants. Data analysis was performed based on thematic content using inductive framework synthesis. We included 17 women who had undergone IOL, delivered and discharged. Most participants(52.9%) were ≥30 years old, married(88.2%), and 41.1% had no previous childbirth experience. The main indications of IOL were postdate(47%), pre-eclampsia(29%) and gestational diabetes mellitus(11.8%). Data synthesis resulted in three broad themes: women's knowledge on IOL, women's experiences of care and women's difficult experiences including coping mechanisms. We determined mixed responses concerning the themes explored: adequate versus inadequate knowledge; positive versus negative experiences of care and satisfaction. Nearly all women mentioned vaginal examination as their most difficult experience due to severe pain, extreme discomfort, and being psychologically traumatic. The main coping strategy the women developed to navigate the traumatic vaginal examination was by "psyching" themselves. Our study indicates women encounter significant negative and positive experiences during IOL and childbirth in Ghana with vaginal examination cited as the most painful experience. Appropriate antenatal counselling, women empowerment and pre-labour education on childbirth processes and expectations are recommended to enhance birth preparedness and complication awareness. Health system improvement and regular refreshers courses for health workers are urgently required to promote positive women's experiences of care during labour induction and childbirth.