Co-creation of a toolkit to assist risk communication and clinical decision-making in severe preeclampsia: SPOT-Impact study design.

Globally, the incidence of hypertensive disorders of pregnancy, especially preeclampsia, remains high, particularly in low- and middle-income countries. The burden of adverse maternal and perinatal outcomes is particularly high for women who develop a hypertensive disorder remote from term (<34 weeks). In parallel, many women have a suboptimal experience of care. To improve the quality of care in terms of provision and experience, there is a need to support the communication of risks and making of treatment decision in ways that promote respectful maternity care. Our study objective is to co-create a tool(kit) to support clinical decision-making, communication of risks and shared decision-making in preeclampsia with relevant stakeholders, incorporating respectful maternity care, justice, and equity principles. This qualitative study detailing the exploratory phase of co-creation takes place over 17 months (Nov 2021-March 2024) in the Greater Accra and Eastern Regions of Ghana. Informed by ethnographic observations of care interactions, in-depth interviews and focus group and group discussions, the tool(kit) will be developed with survivors and women with hypertensive disorders of pregnancy and their families, health professionals, policy makers, and researchers. The tool(kit) will consist of three components: quantitative predicted risk (based on external validated risk models or absolute risk of adverse outcomes), risk communication, and shared decision-making support. We expect to co-create a user-friendly tool(kit) to improve the quality of care for women with preeclampsia remote from term which will contribute to better maternal and perinatal health outcomes as well as better maternity care experience for women in Ghana.

Adverse maternal and perinatal outcomes is high for women who develop preeclampsia remote from term (<34 weeks). To improve the quality of provision and experience of care, there is a need to support communication of risks and treatment decisions that promotes respectful maternity care.This article describes the methodology deployed to cocreate a user-friendly tool(kit) to support risk communication and shared decision-making in the context of severe preeclampsia in a low resource setting.

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.

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.

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.

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.

Extracellular matrix metalloproteinases inducer gene polymorphism and reduced serum matrix metalloprotease-2 activity in preeclampsia patients.

Preeclampsia increases the risk of pregnancy-related complications, nevertheless a successful spiral vessel remodeling, and trophoblast invasion reduces disorders of pregnancy. Matrix metalloproteinase-2 (MMP-2) clears the path for trophoblast invasion, and activation of MMP-2 largely depends on extracellular matrix metalloproteinases inducer (EMMPRIN) protein. This study aimed to investigate EMMPRIN gene polymorphism and MMP-2 activity in preeclampsia patients. Archival whole blood and serum samples of 74 preeclampsia and 66 normotensive pregnant women age-matched were used in this case-control study. Genomic DNA was extracted from the whole blood samples and EMMPRIN gene amplified with specific primers following fragments sequence mutation analysis. Serum MMP-2 activity was determined using enzyme-linked immunosorbent assay (ELISA) and socio-demographic data of participants retrieved from the database. Age of preeclampsia patients (32.78 ± 6.39) years and body mass index (BMI) (33.09 ± 7.27) kg/m2 compared with the normotensive counterparts (32.33 ± 5.56) years and (32.33 ± 5.56) kg/m2,respectively, were not statistically significant (P > 0.05). Serum matrix metalloprotease-2 (MMP-2) activity was significantly reduced in preeclampsia group (16.34 ± 7.07) compared with the normotensives (25.63 ± 4.56) (P < 0.001), and rs424243T/G variant (55.6%) was overrepresented among the cases compared with the normotensives (16.7%). The single-nucleotide polymorphism T/G was found to be associated with preeclampsia (odds ratio [OR] = 7.63; 95% confidence interval [CI] = 3.95-14.75; P < 0.0001). Decreased activity of MMP-2 and rs424243T/G SNP of EMMPRIN gene was reported in preeclampsia. These preliminary data warrant a further investigation into the relationship between EMMPRIN gene polymorphism and MMP-2 activity in preeclampsia.

Strategies to improve interpersonal communication along the continuum of maternal and newborn care: A scoping review and narrative synthesis.

Effective interpersonal communication is essential to provide respectful and quality maternal and newborn care (MNC). This scoping review mapped, categorized, and analysed strategies implemented to improve interpersonal communication within MNC up to 42 days after birth. Twelve bibliographic databases were searched for quantitative and qualitative studies that evaluated interventions to improve interpersonal communication between health workers and women, their partners or newborns' families. Eligible studies were published in English between January 1st 2000 and July 1st 2020. In addition, communication studies in reproduction related domains in sexual and reproductive health and rights were included. Data extracted included study design, study population, and details of the communication intervention. Communication strategies were analysed and categorized based on existing conceptualizations of communication goals and interpersonal communication processes. A total of 138 articles were included. These reported on 128 strategies to improve interpersonal communication and were conducted in Europe and North America (n = 85), Sub-Saharan Africa (n = 12), Australia and New Zealand (n = 10), Central and Southern Asia (n = 9), Latin America and the Caribbean (n = 6), Northern Africa and Western Asia (n = 4) and Eastern and South-Eastern Asia (n = 2). Strategies addressed three communication goals: facilitating exchange of information (n = 97), creating a good interpersonal relationship (n = 57), and/or enabling the inclusion of women and partners in the decision making (n = 41). Two main approaches to strengthen interpersonal communication were identified: training health workers (n = 74) and using tools (n = 63). Narrative analysis of these interventions led to an update of an existing communication framework. The categorization of different forms of interpersonal communication strategy can inform the design, implementation and evaluation of communication improvement strategies. While most interventions focused on information provision, incorporating other communication goals (building a relationship, inclusion of women and partners in decision making) could further improve the experience of care for women, their partners and the families of newborns.

Mistreatment of women during childbirth and postpartum depression: secondary analysis of WHO community survey across four countries.

BACKGROUND: Postpartum depression (PPD) is a leading cause of disability globally with estimated prevalence of approximately 20% in low-income and middle-income countries. This study aims to determine the prevalence and factors associated with PPD following mistreatment during facility-based childbirth. METHOD: This secondary analysis used data from the community survey of postpartum women in Ghana, Guinea, Myanmar and Nigeria for the WHO study, 'How women are treated during facility-based childbirth'. PPD was defined using the Patient Health Questionnaire (PHQ-9) tool. Inferential analyses were done using the generalised ordered partial proportional odds model. RESULTS: Of the 2672 women, 39.0% (n=1041) developed PPD. 42.2% and 5.2% of mistreated women developed minimal/mild PPD and moderate/severe PPD, respectively. 43.0% and 50.6% of women who experienced verbal abuse and stigma/discrimination, respectively developed minimal/mild PPD. 46.3% of women who experienced physical abuse developed minimal/mild PPD while 7.6% of women who experienced stigma/discrimination developed moderate/severe PPD. In the adjusted model, women who were physically abused, verbally abused and stigma/discrimination compared with those who were not were more likely to experience any form of PPD ((OR: 1.57 (95% CI 1.19 to 2.06)), (OR: 1.42 (95% CI 1.18 to 1.69)) and (OR: 1.69 (95% CI 1.03 to 2.78))), respectively. Being single and having higher education were associated with reduced odds of experiencing PPD. CONCLUSION: PPD was significantly prevalent among women who experienced mistreatment during childbirth. Women who were single, and had higher education had lower odds of PPD. Countries should implement women-centred policies and programmes to reduce mistreatment of women and improve women's postnatal experiences.

Comparing observed occurrence of mistreatment during childbirth with women's self-report: a validation study in Ghana, Guinea and Nigeria.

BACKGROUND: There has been substantial progress in developing approaches to measure mistreatment of women during childbirth. However, less is known about the differences in measurement approaches. In this study, we compare measures of mistreatment obtained from the same women using labour observations and community-based surveys in Ghana, Guinea and Nigeria. METHODS: Experiences of mistreatment during childbirth are person-centred quality measures. As such, we assessed individual-level and population-level accuracy of labour observation relative to women's self-report for different types of mistreatment. We calculated sensitivity, specificity, percent agreement and population-level inflation factor (IF), assessing prevalence of mistreatment in labour observation divided by 'true' prevalence in women's self-report. We report the IF degree of bias as: low (0.75

Effect of magnesium sulfate treatment on mediators of endothelial dysfunction and electrolytes in mild and severe preeclampsia: A case-control study.

Background and Aims: Magnesium sulfate (MgSO4) treatment is widely used for the prevention of eclamptic seizures. However, its effect on mediators of endothelial dysfunction (ED) and electrolytes remains unclear. We evaluated the effects of MgSO4 treatment on mediators of ED and electrolytes. Methods: We recruited 100 women comprising 50 severe, 50 mild preeclampsia (PE) as cases and 50 normotensive pregnant women as controls from the Sampa Government Hospital, Ghana. We estimated for adrenomedullin (AM), calcitonin gene-related peptide (CGRP), soluble forms of intercellular adhesion molecule-1 (sICAM-1), Na+, K+, and Mg2+ before MgSO4 treatment, 24 h after MgSO4 treatment, and 48 h after delivery. p < 0.05 were considered significant for statistical analyses. Results: Levels of AM, sICAM-1, and Na+ decreased significantly at 24 h after MgSO4 treatment and 48 h after delivery among PE women compared to the AM levels before treatment (p < 0.0001). The levels of CGRP and Mg2+ increased significantly after 24 h of MgSO4 treatment and 48 h after delivery among PE compared to the AM levels before treatment (p < 0.0001). The changes in AM, sICAM-1, CGRP, and Mg2+ at 24 h after treatment and 48 h after delivery were significantly higher in severe compared to mild PE (p < 0.0001). AM levels reduced significantly by 14.7% in mild and 42.7% in severe PE after MgSO4 treatment (p < 0.05). sICAM-1 levels reduced significantly by 20.9% in mild and 25% in severe PE after MgSO4 treatment. After MgSO4 treatment, there was significant increase of 42.1% and >100% in CGRP levels in mild and severe PE, respectively (p < 0.05). After MgSO4 treatment, Mg²âº levels increased significantly by 67.0% and 63.8% in mild and severe PE, respectively (p < 0.05). Conclusion: MgSO4 treatment reduces AM, sICAM-1, and sodium levels but improves magnesium and CGRP in severe than mild PE thus have more beneficial role in severe PE.

Prevention and Screening for Cardiometabolic Disease Following Hypertensive Disorders in Pregnancy in Low-Resource Settings: A Systematic Review and Delphi Study.

Hypertensive disorders in pregnancy (HDP) and cardiometabolic and kidney diseases are rising in low- and middle-income countries (LMICs). While HDP are risk factors for cardiometabolic and kidney diseases, cost-effective, scalable strategies for screening and prevention in women with a history of HDP are lacking. Existing guidelines and recommendations require adaptation to LMIC settings. This article aims to generate consensus-based recommendations for the prevention and screening of cardiometabolic and kidney diseases tailored for implementation in LMICs. We conducted a systematic review of guidelines and recommendations for prevention and screening strategies for cardiometabolic and chronic kidney diseases following HDP. We searched PubMed/Medline, Embase and Cochrane Library for relevant articles and guidelines published from 2010 to 2021 from both high-income countries (HICs) and LMICs. No other filters were applied. References of included articles were also assessed for eligibility. Findings were synthesized narratively. The summary of guiding recommendations was subjected to two rounds of Delphi consensus surveys with experts experienced in LMIC settings. Fifty-four articles and 9 guidelines were identified, of which 25 were included. Thirty-five clinical recommendations were synthesized from these and classified into six domains: identification of women with HDP (4 recommendations), timing of first counseling and provision of health education (2 recommendations), structure and care setting (12 recommendations), information and communication needs (5 recommendations), cardiometabolic biomarkers (8 recommendations) and biomarkers thresholds (4 recommendations). The Delphi panel reached consensus on 33 final recommendations. These recommendations for health workers in LMICs provide practical and scalable approaches for effective screening and prevention of cardiometabolic disease following HDP. Monitoring and evaluation of implementation of these recommendations provide opportunities for reducing the escalating burden of noncommunicable diseases in LMICs.

Maternal hypertensive mother's knowledge, attitudes and misconceptions on hypertension in pregnancy: A multi-center qualitative study in Ghana.

Hypertension in pregnancy is one of the commonest complications of pregnancy and a leading cause of maternal and perinatal morbidity and mortality globally, with the highest burden in low and middle income countries. Pregnant women's knowledge about hypertension in pregnancy facilitates early health seeking behavior, which can result in early diagnosis and treatment. This study therefore explored the knowledge, misconceptions and attitudes of Ghanaian women who were affected by hypertension in pregnancy. A qualitative study was carried out across five referral hospitals in the Greater Accra Region of Ghana. In-depth interviews (IDIs) and focus group discussions (FGDs) were used to explore the women's knowledge on hypertensive disorders of pregnancy (HDP), and particularly preeclampsia. Women of at least 16 years, admitted with a HDP to the maternity ward with gestational ages from 26-34 weeks were eligible for participation. The inductive approach was used to develop a code book and the dataset was coded using Nvivo version 12 software. A total of 72 women participated in the study. Fifty IDIs and 3 FGDs involving 22 women were conducted. Although most of the women had regular antenatal visits, several had never heard of "pre-eclampsia". More common terminology used by women (i.e. "Bp") referred to any of the hypertensive disorders (e.g. pre-eclampsia, gestational hypertension and chronic hypertension). Women also perceived that pre-eclampsia may be inherited or caused by "thinking too much". The study revealed that the knowledge about hypertension in pregnancy is limited among the affected women despite regular antenatal attendance with some form of health education. There should be more education programs on hypertensive disorders of pregnancy including pre-eclampsia with revised strategies.

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.

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.

Prevalence of gestational diabetes mellitus and associated factors among women receiving antenatal care at a tertiary hospital in South-Western Uganda.

INTRODUCTION: gestational diabetes mellitus is one of the major causes of morbidity and mortality among pregnant women worldwide. We aimed to determine the prevalence and factors associated with gestational diabetes mellitus among women attending the antenatal care clinic at a tertiary care hospital in South-Western Uganda. METHODS: this was a hospital-based cross-sectional study conducted among women at ≥24 weeks of amenorrhea attending the antenatal care clinic at Mbarara Regional Referral Hospital between December 2020 and March 2021. We screened all women for gestational diabetes mellitus using the World Health Organization 2013 diagnostic criteria. We obtained socio-demographic, medical, and obstetric data. Multivariable logistic regression was used to determine the factors independently associated with gestational diabetes mellitus. RESULTS: we enrolled 343 pregnant women with a mean age of 27.3 (SD ±12.3) years. Of the 343 participants, 35 (10.2%) had gestational diabetes mellitus (GDM) (95% C.I: 7.4%-13.9%) and 7 (2%) had diabetes in pregnancy. The factors significantly associated with gestational diabetes mellitus were; previous history of foetal macrosomia in any of the previous pregnancies (aOR: 5.53, 95% C.I: 1.29-23.65) and family history of diabetes mellitus in the first-degree relatives (aOR: 4.45, 95% C.I:1.48-13.34). CONCLUSION: one in every ten pregnant women attending the antenatal care clinic at Mbarara Regional Referral Hospital is likely to have gestational diabetes mellitus in pregnancy. There is a need to strengthen routine testing for gestational diabetes mellitus among women attending the antenatal care clinic, especially pregnant women with a prior history of foetal macrosomia and a family history of diabetes mellitus in first-degree relatives.

Health professionals' perspectives on clinical challenges in managing hypertensive disorders of pregnancy and recommendations for improving care: A multi-center qualitative study.

Background: Hypertensive disorders of pregnancy (HDP) are a leading cause of maternal mortality and morbidity globally despite the intensive international effort to improving maternal care. Substandard clinical care has emerged as a major contributing factor to the high maternal deaths associated with maternal hypertension globally and the impact is severer in low- and middle-income countries (LMICs). Context specific challenges impact negatively on the quality of maternity care and health providers play a crucial role in achieving positive pregnancy experiences for women. This study explored the perspectives of health professionals on the clinical challenges associated with the management of HDP in Ghana and recommendations for improving care. Methods: A multi-center qualitative study using in-depth interviews (IDIs) was conducted in five major hospitals in the Greater Accra Region of Ghana between June 2018 and March 2019. Health professionals (midwives/nurses and medical doctors) who have worked at the study sites for at least three months were included. Data were analysed based on thematic content using Nvivo software. Results: We included 62 health professionals comprising 40 midwives/nurses (64.5%) with a median age of 32.5 years (range 26 to 59) and 22 medical doctors (34.5%) with a median age of 34 years (range 25 to 55). Health providers highlighted major challenges associated with clinical management of hypertension in pregnancy: (1) patient-related factors (inadequate understanding and misconceptions about hypertension in pregnancy, women's non-compliance with clinical advice, financial constraints); (2) health system-related challenges (frequent unavailability of logistics, medications and laboratory support, delays in provision of care and limitations in the health insurance coverage); (3) health provider associated factors (inadequate number of health professionals and poor attitudes). Context-specific recommendations suggested for improving the quality of care in managing maternal hypertension include restructuring of the health system to reduce delays in providing care, improving financial coverage of medical insurance, encouraging social/family support, enhancing education on HDP and strengthening the health workers' numbers and working conditions. Conclusion: Major challenges in the clinical management of HDP relate to the health system, health professionals and pregnant women themselves. Context-specific interventions are required to improve the quality of care for hypertensive mothers including regular health education, re-structuring of the health systems, refresher courses for health providers, improvement in health insurance coverage and government subsidy for hypertensive women.

Preferred mode of childbirth among women attending antenatal clinic at a tertiary hospital in Ghana: a cross-sectional study.

Background: The preference for mode of childbirth by women is emerging as a global subject of interest to many researchers, especially with the steady increase in caesarean section (CS) rates with some countries exceeding the world health organization (WHO) recommended rate. This study explored the preferences of mode of childbirth and associated factors among pregnant women in Ghana. Methods: A cross-sectional study was conducted among pregnant women at tertiary hospital in Ghana. Descriptive analysis and multivariate logistic regression were performed. Results: Among the 415 pregnant women included, 357(86.0%) and 58(14.0%) preferred vaginal delivery and CS respectively. Majority (26%) attributed their preference for vaginal delivery to its being the natural way of childbirth. The most common reason why women preferred to deliver by CS was mainly influenced by medical indication such as doctors' remarks. Significant determinants influencing preference for CS were previous childbirth [aOR:0.21, 95%CI (0.05, 0.91)], previous caesarean [aOR:20.08, 95%CI (7.73, 52.19)] and urban settlement [aOR:2.51, 95%CI (1.01, 6.29)]. Conclusion: There was a clear preference for vaginal birth by pregnant women although a significant proportion preferred caesarean birth. Integration of women's preferred mode of childbirth into the clinical decision with appropriate counselling is recommended to improve women's pregnancy and childbirth experiences.

Antenatal and Postnatal Care.

Optimal care during the antenatal and postnatal phases of the life cycle is a potentially positive determinant of health elsewhere in the continuum. A successful transition from the antenatal to the postnatal period requires early detection, optimal management, and prevention of disease; health promotion; birth preparedness; and complication readiness. Women, their babies, and families need appropriate evidence-based care based on their dignity and human rights before, during, and after birth. In this review, we present an overview of the components of antenatal and postnatal care needed to provide women a culturally sensitive and positive pregnancy and postnatal experience. The challenge of antenatal and postnatal care is determining their core components and underpinning them with evidence without overmedicalizing their practice.

Maternal near-miss and mortality associated with hypertensive disorders of pregnancy remote from term: a multicenter observational study in Ghana.

BACKGROUND: Maternal death rates remain high in many low- and middle-income countries. Hypertensive disorders of pregnancy account for 18% of maternal mortality in Ghana. The maternal near-miss approach was designed to evaluate severe (acute) complications in pregnancy, which is useful to detect potential areas for clinical care improvement. OBJECTIVE: This study aimed (1) to determine the incidence of severe maternal complications, maternal near-miss cases, and mortality cases associated with hypertensive disorders of pregnancy remote from term and (2) to assess the health system's performance indicators for the management of hypertensive disorders of pregnancy remote from term in middle-income country referral hospitals. STUDY DESIGN: This study was nested in the ongoing Severe Preeclampsia adverse Outcome Triage study, a multicenter observational cohort study, and included women recruited from December 1, 2017, to May 31, 2020, from 5 referral hospitals in Ghana. Women aged >16 years, admitted to the hospital with hypertensive disorders of pregnancy, with gestational age between 26 and 34 weeks were eligible. Near miss was defined according to the World Health Organization and sub-Saharan African near-miss criteria. Descriptive statistics of pregnancy and maternal and perinatal outcomes up to 6 weeks after delivery of women with severe maternal outcomes were presented for maternal deaths and maternal near-miss casigurees and compared with that of women without severe maternal outcomes. The health system's maternal and perinatal performance indicators were calculated. RESULTS: Overall, 447 women with hypertensive disorders of pregnancy were included in the analyses with a mean maternal age of 32 (±5.8) years and mean gestational age at recruitment of 30.5 (±2.4) weeks. Of these patients, 46 (10%) had gestational hypertension, 338 (76%) had preeclampsia, and 63 (14%) had eclampsia. There were 148 near-miss cases (33.1%) and 12 maternal deaths (2.7%). Severe maternal outcomes constituted complications from severe preeclampsia (80/160 [50%]) and eclampsia (63/160 [39.4%]). Concerning organ dysfunction, hematologic and respiratory dysfunctions constituted 59/160 [38.6%] and 23/160 [14.8%] respectively. Nearly all women had a cesarean delivery (347/447 [84%] and 140/160 [93%] in the severe maternal outcome group) and delivered prematurely (83%, with 178/379 [93%] at <32 weeks of gestation). Stillbirth and neonatal deaths occurred in 63 of 455 women (14%) and 81 of 392 women (19%), respectively, constituting a stillbirth ratio of 161 per 1000 live births and neonatal mortality rate of 207 per 1000 live births as there were 392 live births in this cohort. Overall, the intensive care unit admission rate was 12.7% (n=52/409); moreover, 45 of 52 women (86.5%) admitted to the intensive care unit had severe maternal outcomes. The maternal death ratio was 3100 per 100,000 live births, the maternal near-miss-to-mortality ratio was 12.3, and the mortality index was 8%. CONCLUSION: Maternal near miss and maternal and perinatal mortalities were common in women with hypertensive disorders of pregnancy remote from term in referral hospitals in Ghana. Providing appropriate patient-centered and multidisciplinary quality care for these women is crucial in improving pregnancy outcomes. Context-tailored interventions should be considered in the clinical management of complications associated with hypertensive disorders of pregnancy in resource-limited settings. Further research on interventions to improve timely referral and reduce in-hospital delays in care provision is recommended to facilitate emergency care services for women with hypertensive emergencies.