Implementation matters: assessing the effectiveness and sustainment of an obstetric triage program at a high-volume facility in Ghana.

BACKGROUND: Maternal mortality remains stubbornly high in Ghana. Current national efforts are focused on improving the quality of care offered in health facilities. Obstetric triage is one intervention that has been proposed to improve the timeliness and appropriateness of care, two key elements of quality. In this study, we describe and evaluate a theory-based implementation approach to introduce obstetric triage into Tema General Hospital, a high-volume maternity hospital in Greater Accra, that blends concepts from implementation science and quality improvement. This implementation project was a first attempt to scale this intervention into a new facility, following initial development in the Greater Accra Regional Hospital (formerly Ridge Hospital) in Accra. METHODS: This was a retrospective mixed-methods evaluation of two stages of implementation: active implementation and sustainment. We triangulated monitoring data captured during active implementation with clinical outcome data (timeliness of first assessment, accuracy of diagnosis, and appropriateness of care plan) from direct observation or patient obstetric triage assessment forms at baseline, at the completion of the active implementation stage, and following a 12-month "washout" period with no contact between hospital staff and the purveyor organization. Finally, we assessed embeddedness of the new triage procedures using the NoMad, a quantitative assessment of constructs from normalization process theory (NPT). RESULTS: Patient waiting time decreased substantially during the study. At baseline, the median arrival-to-assessment waiting time was 70.5 min (IQR: 30.0-443.0 min). Waiting time decreased to 6.0 min (IQR: 3.0-15.0 min) following active implementation and to 5.0 min (IQR: 2.0-10.0 min) during the sustainment period. Accuracy of diagnosis was high at the end of active implementation (75.7% correct) and improved during the sustainment period (to 77.9%). The appropriateness of care plans also improved during the sustainment period (from 66.0 to 78.9%). Per NoMad data, hospital staff generally perceive obstetric triage to be well integrated into the facility. CONCLUSIONS: This theory-based implementation approach proved to be successful in introducing a novel obstetric triage concept to a busy high-volume hospital, despite resource constraints and a short implementation window. Results proved long-lasting, suggesting this approach has high potential for engendering sustainability in other facilities as well. Our approach will be useful to other initiatives that aim to utilize program data to create and test implementation theories.

Introduction of the Ellavi uterine balloon tamponade into the Kenyan and Ghanaian maternal healthcare package for improved postpartum haemorrhage management: an implementation research study.

OBJECTIVES: Use of intrauterine balloon tamponades for refractory postpartum haemorrhage (PPH) management has triggered recent debate since effectiveness studies have yielded conflicting results. Implementation research is needed to identify factors influencing successful integration into maternal healthcare packages. The Ellavi uterine balloon tamponade (UBT) (Ellavi) is a new low-cost, preassembled device for treating refractory PPH. DESIGN: A mixed-methods, prospective, implementation research study examining the adoption, sustainability, fidelity, acceptability and feasibility of introducing a newly registered UBT. Cross-sectional surveys were administered post-training and post-use over 10 months. SETTING: Three Ghanaian (district, regional) and three Kenyan (levels 4-6) healthcare facilities. PARTICIPANTS: Obstetric staff (n=451) working within participating facilities. INTERVENTION: PPH management training courses were conducted with obstetric staff. PRIMARY AND SECONDARY OUTCOME MEASURES: Facility measures of adoption, sustainability and fidelity and individual measures of acceptability and feasibility. RESULTS: All participating hospitals adopted the device during the study period and the majority (52%-62%) of the employed obstetric staff were trained on the Ellavi; sustainability and fidelity to training content were moderate. The Ellavi was suited for this context due to high delivery and PPH burden. Dynamic training curriculums led by local UBT champions and clear instructions on the packaging yielded positive attitudes and perceptions, and high user confidence, resulting in overall high acceptability. Post-training and post-use, ≥79% of the trainees reported that the Ellavi was easy to use. Potential barriers to use included the lack of adjustable drip stands and difficulties calculating bag height according to blood pressure. Overall, the Ellavi can be feasibly integrated into PPH care and was preferred over condom catheters. CONCLUSIONS: The training package and time saving Ellavi design facilitated its adoption, acceptability and feasibility. The Ellavi is appropriate and feasible for use among obstetric staff and can be successfully integrated into the Kenyan and Ghanaian maternal healthcare package. TRIAL REGISTRATION NUMBERS: NCT04502173; NCT05340777.

Transitioning to the maternal death surveillance and response system from maternal death review in Ghana: Challenges and lessons learned.

OBJECTIVE: To assess the current system of maternal death review (MDR) in Ghana and identify the achievements, challenges, and gaps that will assist in transitioning to the maternal death surveillance and response system (MDSR). METHODS: A secondary analysis of data from a cross-sectional study on MDSR implementation was conducted between September and October 2018. The MDSR cycle served as an analytical framework to measure the country's performance in implementing MDSR. Common facilitating or hindering factors were also identified. RESULTS: The MDR system is moderately strong at regional level with timely receipt of data and regular review meetings and reports in most regions. At district level the MDR system is less well implemented, although there is evidence of good communication with regional teams in providing timely data. Communication between districts and communities about maternal deaths seemed to be poor in general. There was no MDR committee at national level and the recommendations made were poorly implemented. CONCLUSION: MDRs in Ghana were structurally sound, but recommendations were poorly implemented. Leadership at the national level needs to be developed to ensure that the current system could transition to an MDSR system.

Scorecards and social accountability for improved maternal and newborn health services: A pilot in the Ashanti and Volta regions of Ghana.

BACKGROUND: With the limited availability of quality emergency obstetric and newborn care (EmONC) in Ghana, and a lack of dialogue on the issue at district level, the Evidence for Action (E4A) program (2011-2015) initiated a pilot intervention using a social accountability approach in two regions of Ghana. OBJECTIVE: Using scorecards to assess and improve maternal and newborn health services, the intervention study evaluated the effectiveness of engaging multiple, health and non-health sector stakeholders at district level to improve the enabling environment for quality EmONC. METHODS: The quantitative study component comprised two rounds of assessments in 37 health facilities. The qualitative component is based on an independent prospective policy study. RESULTS: Results show a marked growth in a culture of accountability, with heightened levels of community participation, transparency, and improved clarity of lines of accountability among decision-makers. The breadth and type of quality of care improvements were dependent on the strength of community and government engagement in the process, especially in regard to more complex systemic changes. CONCLUSION: Engaging a broad network of stakeholders to support MNH services has great potential if implemented in ways that are context-appropriate and that build around full collaboration with government and civil society stakeholders.

SYMPTEK homemade foam models for client education and emergency obstetric care skills training in low-resource settings.

Clinical training for health care workers using anatomical models and simulation has become an established norm. A major requirement for this approach is the availability of lifelike training models or simulators for skills practice. Manufactured sophisticated human models such as the resuscitation neonatal dolls, the Zoë gynaecologic simulator, and other pelvic models are very expensive, and are beyond the budgets of many training programs or activities in low-resource countries. Clinical training programs in many low-resource countries suffer greatly because of this cost limitation. Yet it is also in these same poor countries that the need for skilled human resources in reproductive health is greatest. The SYMPTEK homemade models were developed in response to the need for cheaper, more readily available humanistic models for training in emergency obstetric skills and also for client education. With minimal training, a variety of cheap SYMPTEK models can easily be made, by both trainees and facilitators, from high-density latex foam material commonly used for furnishings. The models are reusable, durable, portable, and easily maintained. The uses, advantages, disadvantages, and development of the SYMPTEK foam models are described in this article.

Cervical cancer prevention: safety, acceptability, and feasibility of a single-visit approach in Accra, Ghana.

OBJECTIVE: The purpose of this study was to assess the safety and acceptability of a single-visit approach to cervical cancer prevention combining visual inspection of the cervix with acetic acid wash (VIA) and cryotherapy. STUDY DESIGN: The study was observational. Nine clinicians were trained in VIA and cryotherapy. Over 18 months 3665 women were VIA-tested. If positive and eligible, cryotherapy was offered immediately. Treated women were followed-up at 3 months and 1 year. RESULTS: The test-positive rate was 13.2%. Of those eligible, 70.2% and 21% received immediate or delayed treatment, respectively. No major complications were recorded, and 5.6% presented for a perceived problem post-cryotherapy. Among those treated over 90% expressed satisfaction with their experience, and 96% had an indentifiable squamo-columnar junction. Only 2.6% (6/232) were test positive, 1-year posttreatment. CONCLUSION: A single-visit approach using VIA and cryotherapy proved to be safe, acceptable, and feasible in an urban African setting.

Revealing the burden of maternal mortality: a probabilistic model for determining pregnancy-related causes of death from verbal autopsies.

BACKGROUND: Substantial reductions in maternal mortality are called for in Millennium Development Goal 5 (MDG-5), thus assuming that maternal mortality is measurable. A key difficulty is attributing causes of death for the many women who die unaided in developing countries. Verbal autopsy (VA) can elicit circumstances of death, but data need to be interpreted reliably and consistently to serve as global indicators. Recent developments in probabilistic modelling of VA interpretation are adapted and assessed here for the specific circumstances of pregnancy-related death. METHODS: A preliminary version of the InterVA-M probabilistic VA interpretation model was developed and refined with adult female VA data from several sources, and then assessed against 258 additional VA interviews from Burkina Faso. Likely causes of death produced by the model were compared with causes previously determined by local physicians. Distinction was made between free-text and closed-question data in the VA interviews, to assess the added value of free-text material on the model's output. RESULTS: Following rationalisation between the model and physician interpretations, cause-specific mortality fractions were broadly similar. Case-by-case agreement between the model and any of the reviewing physicians reached approximately 60%, rising to approximately 80% when cases with a discrepancy were reviewed by an additional physician. Cardiovascular disease and malaria showed the largest differences between the methods, and the attribution of infections related to pregnancy also varied. The model estimated 30% of deaths to be pregnancy-related, of which half were due to direct causes. Data derived from free-text made no appreciable difference. CONCLUSION: InterVA-M represents a potentially valuable new tool for measuring maternal mortality in an efficient, consistent and standardised way. Further development, refinement and validation are planned. It could become a routine tool in research and service settings where levels and changes in pregnancy-related deaths need to be measured, for example in assessing progress towards MDG-5.