Facilitators and barriers to home blood pressure monitoring among pregnant women in Ghana: a mixed-methods analysis of patient perspectives.

BACKGROUND: The benefit of home blood pressure monitoring during pregnancy and in low-resource settings is incompletely understood. The objective of this study was to explore the experiences, barriers, and facilitators of home blood pressure monitoring among pregnant women in Ghana. METHODS: This concurrent triangulation mixed-methods study was conducted at an urban tertiary hospital in Ghana. Participants were recruited from adult pregnant women presenting for routine antenatal care. Upon enrollment, participants' demographics and history were collected. At the next study visit, participants received audiovisual and hands-on training on using an automatic blood pressure monitor; they then monitored and logged their blood pressure daily at home for 2-4 weeks. At the final study visit, verbally administered surveys and semi-structured interviews assessed participant's experiences. Quantitative data were analyzed using R version 4.2.2, and frequencies and descriptive statistics were calculated. Qualitative data were imported into DeDoose 9.0.78 for thematic analysis. RESULTS: Of 235 enrolled participants, 194 completed surveys; of those, 33 completed in-depth interviews. Participants' mean age was 31.6 (SD 5.3) years, 32.1% had not previously given birth, and 31.1% had less than a senior high school education. On a 4-point Likert scale, the majority reported they "definitely" were able to remember (n = 134, 69.1%), could find the time (n = 124, 63.9%), had the energy (n = 157, 80.9%), could use the blood pressure monitor without problems (n = 155, 79.9%), and had family approval (n = 182, 96.3%) while engaging in home blood pressure monitoring. 95.88% (n = 186) believed that pregnant women in Ghana should monitor their blood pressure at home. Qualitative thematic analysis demonstrated that most participants liked home blood pressure monitoring because of increased knowledge of their health during pregnancy. While most participants found measuring their blood pressure at home doable, many faced challenges. Participants' experiences with five key factors influenced how easy or difficult their experience was: 1) Time, stress, and daily responsibilities; 2) Perceived importance of BP in pregnancy; 3) Role of family; 4) Capability of performing monitoring; 5) Convenience of monitoring. CONCLUSIONS: Among pregnant women in urban Ghana, home blood pressure monitoring was perceived as positive, important, and doable; however, challenges must be addressed.

"If You Need a Psychiatrist, It's BAD": Stigma Associated with Seeking Mental Health Care Among Obstetric Providers in Ghana.

Purpose: Globally, the COVID-19 pandemic has brought attention to the impact of negative patient outcomes on healthcare providers. In Ghana, obstetric providers regularly face maternal and neonatal mortality, yet limited research has focused on provision of mental health support for these providers. This study sought to understand how obstetric providers viewed seeking mental health support after poor clinical outcomes, with a focus on the role of mental health stigma. Patients and Methods: Participants were 52 obstetric providers (20 obstetrician/gynecologists and 32 midwives) at two tertiary care hospitals in Ghana. Five focus groups, led by a trained facilitator and lasting approximately two hours, were conducted to explore provider experiences and perceptions of support following poor maternal and neonatal outcomes. Discussions were audiotaped and transcribed verbatim, then analyzed qualitatively using grounded theory methodology. Results: Most participants (84.3%, N=43) were finished with training, and 46.2% (N=24) had been in practice more than 10 years. Emerging themes included pervasive stigma associated with seeking mental health care after experiencing poor clinical outcomes, which was derived from two overlapping dimensions. First, societal-level stigma resulted from a cultural norm to keep emotions hidden, and the perception that psychiatry is equated with severe mental illness. Second, provider-level stigma resulted from the belief that healthcare workers should not have mental health problems, a perception that mental health care is acceptable for patients but not for providers, and a fear about lack of confidentiality. Despite many providers acknowledging negative mental health impacts following poor clinical outcomes, these additive layers of stigma limited their willingness to engage in formal mental health care. Conclusion: This study demonstrates that stigma creates significant barriers to acceptance of mental health support among obstetric providers. Interventions to support providers will need to respect provider concerns without reinforcing the stigma associated with seeking mental health care.

Epidemiology of Maternal Nutritional Status and Risk of Adverse Birth Outcomes in Undernourished Mothers with Sickle Cell Disease: A Systematic Review and Meta-Analysis Protocol.

In pregnancies complicated by sickle cell disease (SCD), the maternal-fetal dyad is at high risk for mortality and morbidity. In healthy pregnancies, maternal nutritional status is a critical factor for the healthy growth and development of the fetus. However, there are no reviews of the current research on the nutritional status of pregnant women with SCD and pregnancy outcomes. First, we aim to assess the burden of malnutrition in pregnant women with SCD. Next, we aim to systematically evaluate if pregnant women with SCD who have poor nutritional status are at increased risk for adverse birth outcomes compared to pregnant women with sickle cell disease and normal nutritional status. We will systematically search multiple electronic databases. Our exposure is pregnant women with SCD and poor nutritional status. The primary outcomes of interest include low birth weight (categorical) and birth weight z-scores (continuous). We will also evaluate maternal and perinatal outcomes as secondary outcomes. We will evaluate the risk of bias and overall certainty of evidence with Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I), and the overall evidence will be assessed using Grading of Recommendation Assessment, Development, and Evaluation (GRADE) criteria. We will pool findings with a meta-analysis if sufficient homogeneity exists among studies. Findings will be published in a peer-reviewed journal and disseminated to SCD advocacy groups. PROSPERO registration number: 429412.

Impact of antenatal care on severe maternal and neonatal outcomes in pregnancies complicated by preeclampsia and eclampsia in Ghana.

OBJECTIVES: To explore how specific measures of antenatal care utilization are associated with outcomes in pregnancies complicated by preeclampsia and eclampsia in Ghana. STUDY DESIGN: Participants were adult pregnant women with preeclampsia or eclampsia at a tertiary hospital in Ghana. Antenatal care utilization measures included timing of first visit, total visits, facility and provider type, and referral status. Antenatal visits were characterized by former and current World Health Organization recommendations, and by gestational age-based adequacy. MAIN OUTCOME MEASURES: Composites of maternal complications and poor neonatal outcomes. Multivariate logistic regressions identified associations with antenatal care factors. RESULTS: Among 1176 participants, median number of antenatal visits was 5.0 (IQR 3.0-7.0), with 72.9% attending ≥4 visits, 19.4% attending ≥8 visits, and 54.9% attending adequate visits adjusted for gestational age. Care was most frequently provided in a government polyclinic (n = 522, 47.2%) and by a midwife (n = 704, 65.1%). Odds of the composite maternal complications were lower in women receiving antenatal care at a tertiary hospital (aOR 0.47, p = 0.01). Odds of poor neonatal outcomes were lower in women receiving antenatal care at a tertiary hospital (aOR 0.56, p < 0.001), by a specialist Obstetrician/Gynecologist (aOR 0.58, p < 0.001), and who attended ≥8 visits (aOR 0.67, p = 0.04). Referred women had twice the odds of a maternal complication (aOR 2.12, p = 0.007) and poor neonatal outcome (aOR 1.68, p = 0.002). CONCLUSIONS: Fewer complications are seen after receiving antenatal care at tertiary facilities. Attending ≥8 visits reduced poor neonatal outcomes, but didn't impact maternal complications. Quality, not just quantity, of antenatal care is essential.

Ability and accuracy of patient-performed blood pressure monitoring among pregnant women in urban Ghana.

BACKGROUND: Patient-performed blood pressure monitoring in pregnancy is rarely performed in low- and middle-income country settings, including Ghana. The clinical efficacy of home blood pressure monitoring relies on a pregnant patient being able to independently execute the correct steps to position and use a blood pressure monitor and to achieve accurate blood pressure measurements. OBJECTIVE: This study aimed to (1) assess whether pregnant women can correctly use an automatic blood pressure monitor to check their blood pressure before and after a brief training and (2) determine whether blood pressure values measured by pregnant women using an automatic monitor are similar to values measured by a healthcare provider using a standard clinic monitor. STUDY DESIGN: This was a cross-sectional study conducted at the Korle Bu Teaching Hospital, a tertiary hospital in Accra, Ghana. Participants were adult pregnant women presenting for their first prenatal care visit. Data collection was performed by 2 Ghanaian physicians. Information on demographics, obstetrical history, and past medical history was collected. A brief training was provided on the correct use of the blood pressure monitor, including a verbal script, annotated photographs, and a hands-on demonstration. Pre- and posttraining assessments using a 9-item checklist of correct preparation, position, and use of an automatic blood pressure monitor were performed. Following a modified British Hypertension Society protocol, a series of 4 blood pressure measurements were taken, alternating between provider performed using a clinic monitor and patient performed using an automatic monitor intended for individual use and validated in pregnancy. RESULTS: Among 176 participants, the mean age was 31.5 years (±5.6), and 130 (73.9%) were multiparous. Regarding socioeconomic characteristics, 128 (72.7%) were married, 171 (97.2%) had public insurance, and 87 (49.7%) had completed ≤9 years of formal education. Regarding clinical blood pressure issues, 19 (10.9%) had a history of a hypertensive disorder in a previous pregnancy, and 6 (3.4%) had chronic hypertension. Before receiving any training, 21 participants (12.1%) performed all 9 steps correctly to prepare, position, and use the automatic blood pressure monitor. Comparing pretraining vs posttraining ability, statistically significant increases were seen in the correct performance of each step and the mean number of steps performed correctly (6.1±1.8 vs 9.0±0.2, respectively; P<.001) and proportion performing all 9 steps correctly (12.1% vs 96.6%, respectively; P<.001). The mean difference between doctor-performed and patient-performed blood pressure measurements was 5.6±4.8 mm Hg for systolic blood pressure values and 3.4±3.08 mm Hg for diastolic blood pressure values, with most differences within 5 mm Hg for both systolic blood pressure values (102/176 [58.0%]) and diastolic blood pressure values (141/176 [80.1%]). CONCLUSION: After a brief training, pregnant women in Ghana demonstrated that they are able to use an automatic blood pressure monitor to check their blood pressure correctly and accurately.

Corrigendum: Perinatal autopsy in Ghana: healthcare workers knowledge and attitude.

[This corrects the article DOI: 10.3389/fgwh.2022.1021474.].

Challenges to diagnosing and managing preeclampsia in a low-resource setting: A qualitative study of obstetric provider perspectives from Ghana.

Preeclampsia is a leading cause of global maternal morbidity and mortality. The greatest burden of disease is in low- and middle-income countries where healthcare providers face significant, understudied, challenges to diagnosing and managing preeclampsia. This qualitative study used semi-structured interviews to explore the challenges of diagnosing and managing preeclampsia from the perspectives of obstetric doctors. Participants were doctors who provide obstetric care at the Korle Bu Teaching Hospital, an urban tertiary hospital in Ghana. Purposive sampling identified doctors with meaningful experience in managing patients with preeclampsia. Thematic saturation of data was used to determine sample size. Interviews were audio recorded, transcribed verbatim, coded using an iteratively-developed codebook, and thematically analyzed. Interviews were conducted with 22 participants, consisting of 4 house officers, 6 junior obstetrics/gynecology residents, 8 senior obstetrics/gynecology residents, and 4 obstetrics/gynecology consultants. Doctors identified critical challenges faced at the patient, provider, and systems levels in detecting and managing preeclampsia, each of which mediates the health outcomes of a pregnancy complicated by preeclampsia. Challenges centered around three overarching global themes: (1) low education levels and health literacy among women, (2) insufficient number of healthcare providers highly trained in obstetric care, and (3) inadequate health infrastructure to support critically ill patients with preeclampsia. Recognizing and addressing root challenges to preeclampsia care has great potential to improve outcomes in pregnancies complicated by preeclampsia in low-resource settings.

Diversity of cervicovaginal human papillomavirus (HPV) genotypes and naturally occurring E6/E7 DNA polymorphisms of HPV-16 in Ghana.

Human papillomavirus (HPV) E6 and E7 oncogene expression is essential for cervical carcinogenesis. Evidence exists that E6/E7 variants may have different transforming activities while the risk of HPV-16 variants (A/D) differs by race/ethnicity. We determined the type-specific diversity of HPV infection in women with high grade cervical disease or cervical cancer in Ghana and investigated naturally occurring E6/E7 DNA variants in this population. HPV genotyping was carried out on 207 cervical swab samples collected from women referred to a gynaecology clinic at two teaching hospitals in Ghana. HPV-16, HPV-18 and HPV-45 were detected in 41.9%, 23.3% and 16.3% of cases respectively. HPV-16 E6/E7 DNA sequencing was performed in 36 samples. Thirty samples contained E6/E7 variants of the HPV-16-B/C lineage. 21/36 samples were of the HPV-16C1 sublineage variant and all contained the E7 A647G(N29S) single nucleotide polymorphism (SNP). This study reveals the diversity of E6/E7 DNA and the dominance of HPV16 B/C variants in cervicovaginal HPV infection in Ghana. Type-specific HPV diversity analysis indicates that most Ghanaian cervical disease cases are vaccine preventable. The study provides an important baseline from which for the impact of vaccine and antivirals on clinically relevant HPV infection and associated disease can be measured.

Benefits and barriers of home blood pressure monitoring in pregnancy: perspectives of obstetric doctors from a Ghanaian tertiary hospital.

BACKGROUND: Delayed diagnosis of preeclampsia contributes to maternal morbidity and mortality. Patient-performed home blood pressure monitoring facilitates more frequent monitoring and earlier diagnosis. However, challenges may exist to implementation in low- and middle income-countries. METHODS: This cross-sectional mixed methods study evaluated obstetric doctors' perspectives on the benefits of and barriers to the implementation of home blood pressure monitoring among pregnant women in Ghana. Participants were doctors providing obstetric care at Korle Bu Teaching Hospital. Electronic surveys were completed by 75 participants (response rate 49.3%), consisting of demographics and questions on attitudes and perceived benefits and challenges of home BP monitoring. Semi-structured interviews were completed by 22 participants to expand on their perspectives. RESULTS: Quantitative and qualitative results converged to highlight that the current state of blood pressure monitoring among pregnant women in Ghana is inadequate. The majority agreed that delayed diagnosis of preeclampsia leads to poor health outcomes in their patients (90.6%, n = 68) and earlier detection would improve outcomes (98.7%, n = 74). Key qualitative benefits to the adoption of home blood pressure monitoring were patient empowerment and trust of diagnosis, more quantity and quality of blood pressure data, and improvement in systems-level efficiency. The most significant barriers were the cost of monitors, lack of a communication system to convey abnormal values, and low health literacy. Overall, doctors felt that most barriers could be overcome with patient education and counseling, and that benefits far outweighed barriers. The majority of doctors (81.3%, n = 61), would use home BP data to inform their clinical decisions and 89% (n = 67) would take immediate action based on elevated home BP values. 91% (n = 68) would recommend home BP monitoring to their pregnant patients. CONCLUSION: Obstetric doctors in Ghana strongly support the implementation of home blood pressure monitoring, would use values to inform their clinical management, and believe it would improve patient outcomes. Addressing the most significant barriers, including cost of blood pressure monitors, lack of a communication system to convey abnormal values, and need for patient education, is essential for successful implementation.

Effect of intimate partner violence in pregnancy on maternal and perinatal outcomes at the Korle Bu teaching hospital, Ghana: An observational cross sectional study.

OBJECTIVE: To determine the association between intimate partner violence and pregnancy outcomes. METHODS: This was a descriptive study of sociodemographic characteristics of participants, their partners and intimate partner violence. Participants' delivery records were reviewed for additional medical and obstetric information and abused women and their neonates followed until discharge. χ2 and Student t test were used to assess associations, followed by logistic regression with odds ratio (OR) and 95% confidence intervals (CI). A value of P less than 0.05 was considered statistically significant. RESULTS: The study included 270 participants of whom 84 (31.1%) reported experiencing domestic violence during pregnancy. One hundred and fourteen (42%) had experienced domestic violence pre-pregnancy and 69 (60.5%) of these women experienced further domestic violence during pregnancy. Emotional violence was commonest 80/270 (29.6%) and no sexual violence was reported. Domestic violence declined from 42% (pre-pregnancy) to 31.1% (in-pregnancy) (P = 0.009). Risk factors during pregnancy were young age (15-24 years; OR 5.8, 95% CI1.65-20.38), nulliparity (OR 3.75, 95% CI 1.90-7.41), and partner's alcohol consumption (OR 5.04, 95% CI 2.50-10.13). Associated outcomes included late prenatal booking, gestational hypertension, and cephalopelvic disproportion. CONCLUSION: We found high prevalence of domestic violence during pregnancy, preponderance of emotional abuse, and decline of physical abuse. Nulliparity, younger age, and partner's alcohol consumption predicted abuse. Late-booking, gestational hypertension, cephalopelvic disproportion, and fetal distress were associated.

Acute pain episodes, acute chest syndrome, and pulmonary thromboembolism in pregnancy.

Pregnancy in women with sickle cell disease (SCD) is a life-threatening condition. In both high- and low-income countries, there is an 11-fold increased risk of maternal death and a 4-fold increased risk of perinatal death. We highlight the epidemiology of SCD-specific and obstetric complications commonly seen during pregnancy in SCD and propose definitions for acute pain and acute chest syndrome (ACS) episodes during pregnancy. We conducted a systematic review of the recent obstetric and hematology literature using full research articles published within the last 5 years that reported outcomes in pregnant women with SCD. The prevalence of acute pain episodes during pregnancy ranged between 4% and 75%. The prevalence of ACS episodes during pregnancy ranged between 4% and 13%. The estimated prevalence of pulmonary thromboembolism in women with SCD during pregnancy is approximately 0.5 to 1%. ACS is the most common cause of death and is often preceded by acute pain episodes. The most crucial time to develop these complications in pregnancy is during the third trimester and postpartum period. In a pooled analysis from studies in low- and middle-income settings, maternal death in women with SCD is approximately 2393 and 4300 deaths per 100 000 live births with and without multidisciplinary care, respectively. In comparison, in the US and northern Europe, the general maternal mortality rate is approximately 23.8 and 8 deaths per 100 000 live births, respectively. A multidisciplinary SCD obstetrics care approach reduces maternal and perinatal morbidity and mortality in low- and middle-income countries.

Clinical presentation and predictors of eclampsia among women with hypertensive disorders of pregnancy in Ghana.

OBJECTIVES: Eclampsia is a leading contributor to global maternal morbidity and mortality. Past studies demonstrate varying relationships between demographic and antenatal factors and subsequent development of eclampsia. This study sought to identify predictors of eclampsia in a tertiary hospital in Ghana. STUDY DESIGN: Participants were women admitted to Korle Bu Teaching Hospital in Ghana with a diagnosis of preeclampsia with severe features or eclampsia. Medical and obstetric history were extracted from medical records. Clinical information, including vital signs and maternal complications, was prospectively collected. MAIN OUTCOME MEASURES: Bivariate analysis compared demographic, antenatal, obstetric history, and clinical characteristics between patients presenting with eclampsia and preeclampsia. Multivariable logistic regression identified independent predictors of eclampsia. RESULTS: Among 1,176 participants, 116 (9.9 %) had a diagnosis of eclampsia. The majority of women with eclampsia experienced their first seizure antepartum (68.7 %), in a location outside a health facility (56.5 %), and witnessed by a family member (55.9 %). Women with eclampsia had a median of 1.0 seizure (IQR 1.0, 2.0). Only 15 (12.9 %) had a prior diagnosis of preeclampsia. There was a nearly threefold increased odds of eclampsia in women aged <20 (aOR 2.75, 95 % CI 1.10-6.89, p = 0.03) and those with twin pregnancy (aOR 2.59, 95 % CI 1.26-5.32, p = 0.01). Decreased odds of eclampsia was observed with age ≥35 (aOR 0.32, 95 % CI 0.15-0.67, p = 0.002), obesity (aOR 0.44, 95 % CI 0.25-0.77, p = 0.004), and chronic hypertension (aOR 0.38, 95 % CI 0.17-0.86, p = 0.02). CONCLUSIONS: Understanding predictors of eclampsia is important to identify high-risk patients and make informed decisions about antenatal care.

A comparative analysis of neonatal outcomes in pregnancies complicated by preeclampsia and eclampsia in Ghana.

BACKGROUND: Worldwide, hypertensive disorders of pregnancy are a serious complication of pregnancy, and contribute to poor maternal and neonatal outcomes. The most significant consequences of hypertensive disorders of pregnancy are observed in sub-Saharan Africa, where neonatal outcomes have not been fully described. Understanding relationships between maternal disease severity and neonatal outcomes can guide patient counseling and allow the targeting of limited resources to the most at-risk neonates. OBJECTIVE: To describe and compare neonatal outcomes in pregnancies complicated by preeclampsia with severe features and eclampsia. STUDY DESIGN: This study is a secondary analysis of data collected as part of a randomized controlled trial at the Korle-Bu Teaching Hospital in Ghana. Participants were adult pregnant women with preeclampsia with severe features or eclampsia and their neonates. Data include prospectively collected medical and obstetrical history, intrapartum events, and neonatal outcomes. The main outcome of this secondary analysis was a composite of poor neonatal outcomes, defined as 1 or more of the following: stillbirth, very low birthweight (<1500 g), 5-minute Apgar score <7, neonatal intensive care unit admission, or a live birth with a subsequent death before discharge. RESULTS: Median gestational age at delivery was 36.6 weeks (interquartile range, 33.3-38.9). Median birthweight was 2.3 kg (interquartile range, 1.6-3.0), with 227 (19.0%) birthweights <1500 g. There were 162 neonates (15.5%) with an Apgar score <7 at 5 minutes and 144 (11.9%) were stillbirths. Of live births, half (n=524, 50.3%) were admitted to the neonatal intensive care unit and 7.9% (n=91) died before discharge. A composite of poor neonatal outcomes was experienced by 58.2% (n=707) of neonates and was twice as likely with a maternal diagnosis of eclampsia (odds ratio, 1.91; P=.04). For each additional week of gestational age, the probability of a poor neonatal outcome was reduced by 39% (odds ratio, 0.61; P<.0001). CONCLUSION: Poor neonatal outcomes were experienced by more than half of pregnancies complicated by preeclampsia with severe features or eclampsia. Even after controlling for gestational age, pregnancies complicated by eclampsia were twice as likely to have poor neonatal outcomes.

Factors Associated with Ruptured Ectopic Pregnancy: A 10-Year Review at a District Hospital in Ghana.

Background: Approximately 1-2% of all pregnancies are ectopic. Despite a decline in ectopic pregnancy-related mortality, there is still a paucity of information on the factors associated with clinical presentation and outcomes in Sub-Saharan Africa which is essential in determining the most appropriate treatment modalities. Methods: We performed a ten-year retrospective chart review of cases of ectopic pregnancies managed at the Lekma hospital and assessed them for peculiar risk factors, clinical presentation, and outcomes. Associations between patients' sociodemographic characteristics, clinical presentation, and treatment outcome were evaluated using multiple logistic regression and reported as adjusted odds ratios (AOR). The confidence interval (CI) was set at 95%, and a p value <0.05 were considered significant. Results: Over the ten-year period, there were 115 ectopic pregnancies and 14,450 deliveries (7.9/1,000). The mean age ± standard deviation of the 115 patients was 27.61 ± 5.56. More than half of the patients were single (59/115, 51.3%). The majority (71.3%) of the patients presented with a ruptured ectopic pregnancy. After adjusting for covariates, the odds of an ectopic pregnancy presenting as ruptured among single patients was 2.63 times higher than that of married patients (AOR = 3.63, 95% CI: 1.33-9.93, p=0.01). Ectopic pregnancies located in the isthmic region of the tube had a 77% lower odds of presenting as ruptured than those located in the ampullary region (AOR = 0.23, 95% CI: 0.07-0.74, p=0.01). The odds of rupturing were 1.69 times increased for every additional week after the missed period (AOR = 2.69, 95% CI: 1.56-4.64, p < 0.01). No mortalities were reported as a result of an ectopic pregnancy. Conclusion: Most of the cases of ectopic pregnancy presented ruptured. Marital status and period of amenorrhoea were significantly associated with rupture.

A novel 12-hour versus 24-hour magnesium sulfate regimen in the management of eclampsia and preeclampsia in Ghana (MOPEP Study): A randomized controlled trial.

OBJECTIVE: We compared the efficacy of a 12-h versus 24-h regimen of intramuscular magnesium sulfate in the management of eclampsia and preeclampsia. METHODS: This is an open-labeled parallel randomized controlled trial conducted in Accra, Ghana from November 2018 to November 2020. Participants were adult pregnant women admitted to the Korle Bu Teaching Hospital (KBTH) with a diagnosis of antepartum, intrapartum, or postpartum eclampsia or preeclampsia with severe features, having received no more than a loading dose of magnesium sulfate prior to admission at KBTH. Participants in the standard 24-h group received a loading dose of magnesium sulfate 4 g intravenous and 10 g intramuscular (5 g in each buttock) followed by six, 5 g intramuscular maintenance doses over 24 h. Participants in the 12-h intervention group received the same loading dose followed by three, 5 g intramuscular maintenance doses over 12 h. The primary outcome was occurrence of seizure after completion of the assigned magnesium sulfate regimen. Secondary outcomes were magnesium sulfate toxicity, magnesium sulfate side effects, maternal outcomes (mode of delivery, duration of inpatient admission, duration of urethral catheterization), maternal complications (pulmonary edema, acute kidney injury, intensive care unit admission, death), and neonatal outcomes. RESULTS: Among 1176 total participants, we found no difference in occurrence of seizure after completion of the assigned regimen in the 24-h group (n = 5, 0.9%) versus the 12-h group (n = 2, 0.3%), P = 0.29; RR 0.40, 95% CI 0.08, 2.04), or in occurrence of seizure any time after enrollment (n = 9, 1.5% vs. n = 5, 0.9%, P = 0.28, RR 0.55, 95% CI 0.19-1.64). Participants in the 12-h group had a shorter duration of inpatient admission (9.4 ± 8.8 vs. 7.7 ± 6.5 days, P = 0.0009) and urethral catheterization (2.1 ± 1.0 vs. 1.9 ± 1.3 days, P < 0.0001). Rates of side effects from magnesium sulfate were lower in the 12-h group: pain at the injection site (94.8% (n = 548) vs. 91.5% (n = 540), P = 0.03), inflammation (62.2% (n = 358) vs. 40.0% (n = 237), P < 0.0001), and bleeding or bruising at the injection site (25.1% (n = 144) vs. 14.4% (n = 85), P < 0.0001). CONCLUSIONS: Compared with 24 h, 12 h of intramuscular magnesium sulfate showed similar rates of seizures, with fewer side effects and shorter inpatient admission. TRIAL REGISTRATION: Prospective registration was with Pan African Clinical Trial Registry (PACTR201811515303983): https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=4690.

Perinatal autopsy in Ghana: Healthcare workers knowledge and attitude.

Background: Perinatal mortality refers to stillbirths and early neonatal deaths. Stillbirth, the death of a foetus from 28 weeks or with a birth weight below 1,000 g, and early neonatal deaths, the death of a new-born within 24 h of delivery, are among the most distressing global health problems, with approximately 2 million stillbirths occurring annually. Although a post-mortem examination of the stillborn baby is essential for understanding and learning the cause of stillbirth, many couples decline the procedure. Sub-Saharan Africa has one of the highest stillbirth rates in the world, yet there is a dearth of studies on post-mortem uptake from the region. Aim: To explore healthcare professionals' views and perceptions of perinatal autopsy in Ghana. Methods: Mixed-method approach consisted of semi-structured interviews and an electronic cross-sectional survey to evaluate the views and perceptions of healthcare professionals at Korle-Bu Teaching Hospital on autopsy for stillbirths and early neonatal deaths. Descriptive quantitative data were summarised in frequencies and percentages, and statistical results and descriptions were tabulated and coded in terms of types of barriers. For the qualitative aspect, the audio-taped interviews were transcribed, themes generated, and direct quotes and descriptions were coded for all knowledge, beliefs, attitudes and practices concerning the barriers and facilitators for post-mortem. Results: Ninety-nine healthcare professionals participated. No participant had formal training regarding counselling for perinatal autopsy and 40% had " no idea " who is responsible for counselling and obtaining consent for a perinatal autopsy. Forty-four percent (44%) of the participants knew of only the "Conventional/ Full" autopsy and <4% were aware of less invasive methods of performing an autopsy. Qualitative data showed healthcare worker influence, religious and financial considerations impede the implementation of perinatal autopsies. Despite the low uptake of perinatal autopsies, interviews from healthcare workers suggest acceptance rates would improve if parents knew about different options, especially less invasive procedures. Conclusion: At Ghana's largest referral centre, perinatal autopsy counselling and uptake are at extremely low levels. Most healthcare professionals have little knowledge, skills, and capacity to advise parents regarding perinatal autopsies. Training is needed to update the workforce on recommended perinatal autopsy practices.

Causes, survival rates, and short-term outcomes of preterm births in a tertiary hospital in a low resource setting: An observational cohort study.

Background: Prematurity is the most important cause of death among children under the age of five years. Globally, most preterm births occur in Sub-Saharan Africa. Subsequent prematurity leads to significant neonatal morbidity, mortality and long-term disabilities. This study aimed to determine the causes, survival rates and outcomes of preterm births up to six weeks of corrected age in Ghana. Materials and methods: An observational prospective cohort study of infants born preterm was conducted in a tertiary hospital in Accra, Ghana from August 2019 to March 2020. Inclusion was performed within 48 h after birth of surviving infants; multiple pregnancies and stillbirths were excluded. Causes of preterm birth were categorized as spontaneous (including preterm pre-labour rupture of membranes) or provider-initiated (medically indicated birth based on maternal or fetal indications). Survival rates and adverse outcomes were assessed at six weeks of corrected age. Recruitment and follow-up were suspended due to the COVID-19 outbreak. Descriptive statistics and differences between determinants were calculated using Chi-squared tests or Kruskal-Wallis test. Results: Of the 758 preterm deliveries, 654 (86.3%) infants were born alive. 179 were enrolled in the cohort and were analyzed. Nine (5%) were extremely preterm [gestational age (GA) < 28 weeks], 40 (22%) very preterm (GA 28-31 weeks), and 130 (73%) moderate to late preterm (GA 32-37 weeks) births. Most deliveries (n = 116, 65%) were provider-initiated, often due to hypertensive disorders in pregnancy (n = 79, 44.1%). Sixty-two infants were followed-up out of which fifty-two survived, presenting a survival rate of 84% (n = 52/62) at six weeks corrected age in this group. Most infants (90%, n = 47/52) experienced complications, predominantly consisted of NICU admission (92%) and interval illnesses (21%) including jaundice and sepsis. Conclusions: The incidence of adverse outcomes associated with preterm birth in a tertiary facility with NICU capacity is high. Larger longitudinal studies are needed for an in-depth understanding of the causes and longer-term outcomes of preterm birth, and to identify effective strategies to improve outcomes in resource constrained settings.