Referrals for obstetrical complications from Ejisu district, Ghana.

A study of referrals due to obstetrical complications from the Ejisu district, Ashanti region, Ghana was done to determine the institutions that receive them, their outcome and the effectiveness of the referral system. This formed part of a multidisciplinary research on the prevention of maternal mortality in the district. It covered 15 health facilities in the district. The receiving institutions identified in the study were Komfo Anokye teaching Hospital (KATH) in Kumasi, Agogo Presbyterian Hospital in the neighbouring Ashanti Akim district and the St. Michael's Hospital at Pramso in the same district. In the period under review, there were 192 referrals from the district, 139 to KATH with 87 (63%) reporting, 19 to Pramso with 14 (74%) reporting and 34 to Agogo with 17 (50%) reporting. The 3 most important complications referred were maternal haemorrhage (29%), high-risk pregnancy (24%) and delayed second stage (21%). The referring institutions had a defaulting rate varying from 8-56% with a median of 42%. This study did not specifically investigate the factors influencing the high defaulting rates in some institutions. However, focus-group discussions (FGDs) held in selected communities revealed the following factors as inhibiting the utilization of health services: * prohibitive hospital fees; * illegal fees and bribes; * irregular transport and uncooperative drivers; * poor and unmotorable roads; * lack of drugs and essential supplies and; * negative staff attitudes. Those health facilities with low defaulting rates had their own transport or were close to major trunk roads. From the study, the referral system was very weak. It is also possible that some of the referrals reported at the receiving institutions but were not classified as such. Interventions to improve the situation are currently being implemented.

Upgrading obstetric care at the health center level, Juaben, Ghana. The Kumasi PMM Team.

PRELIMINARY STUDIES: Inventory and observations at Juaben Teaching Health Center (JTHC) revealed an inability to treat obstetric complications. Women with complications needed to be referred to other institutions, resulting in delays. INTERVENTIONS: During 1993 and 1994, an operating theater and blood bank were established and equipped, the maternity refurbished, and a revolving drug fund created. A physician was posted and trained in obstetrics, and midwives were trained in life-saving skills. A running water supply was established. Subsequent community interventions focused on improving access and reducing the delay in seeking care. RESULTS: The number of women with complications coming for care increased almost three-fold, from 26 in 1993 to 73 in 1995 and the proportion of these who were referred for treatment dropped from 42 to 14%. Surgical obstetric procedures performed at JTHC increased from 23 in 1993 to 90 in 1995. Midwives performed 32% of manual removals, 58% of vacuum extractions and 98% of episiotomy repairs. No deaths occurred among the women treated. COSTS: The cost of improvements was approximately US $30,000, mostly for equipment and supplies. Forty percent came from project funds, 36% from non-governmental organizations (NGOs), 15% from government and 9% from community members. The salary of the new physician cost an additional $4700 annually. CONCLUSIONS: Modest improvements can increase the provision and utilization of emergency obstetric care. Collaboration with NGOs, government and the community can be beneficial.

Improving recordkeeping for maternal mortality programs, Kumasi, Ghana. The Kumasi PMM Team.

PRELIMINARY STUDIES: Data on obstetric complications are the basis of monitoring maternal mortality interventions in the PMM Network. A review of recordkeeping procedures at 10 facilities in the study area revealed that information on obstetric complications was often inconsistent or missing. Some hospital records were not designed to collect such information at all. INTERVENTIONS: In 1992, registers at facilities were revised to collect information on complications and time of treatment. Doctors, nurses, midwives and clerks were trained to record, compile and analyze data. Monitoring and supervisory mechanisms were also set up. RESULTS: Recordkeeping has improved. Data collection and analysis have been regular and timely. Doctors have begun using the data for morning meetings. Nurses and midwives compile monthly summaries of data showing complications by type. Two other districts outside the research area have adopted the reporting system and it is possible that facilities in the whole region will follow suit. COSTS: The cost of improving recordkeeping at the 10 healthcare facilities was approximately US $2543, with 85% coming from project funds. CONCLUSIONS: Existing recordkeeping systems can be modified to collect data necessary to monitor maternal mortality interventions. Staff training and monitoring visits are important to success.

Community education to improve utilization of emergency obstetric services in Ghana. The Kumasi PMM Team.

PRELIMINARY STUDIES: Focus group studies in the Ashanti region showed that people avoided utilizing health facilities because of lack of confidence in the services and concern about the availability of drugs and supplies, among other reasons. INTERVENTIONS: After services at the health center were upgraded, community education activities began in early 1994. These activities were carried out through existing mechanisms--e.g. Ministry of Health (MOH) outreach workers and village health workers, public health nurses and midwives, and village health committees. They addressed a variety of audiences, including women's and church groups, emphasizing early recognition and treatment of obstetric complications, and the improved availability of services. RESULTS: The number of women with obstetric complications admitted to the health center rose from 26 in 1993 to 73 in 1995. It was the impression of the health center staff that women were also coming for treatment more promptly. COSTS: The cost of this intervention was US$1950. This was mostly project funds, with the government and community together contributing approximately one-fifth. CONCLUSIONS: Once services are available, community education and information activities can enhance utilization. The cost of such activities can be reduced, and sustainability promoted, by involving MOH personnel and community groups.

Clinical evaluation of Norplant in Kumasi, Ghana.

A non-comparative study of the Norplant contraceptive subdermal implant system was conducted in Kumasi, Ghana. A total of 100 acceptors were enrolled in the clinical trial, which began in 1987. There were no pregnancies during the first two years of use. Only nine post-insertion medical problems were reported during the first two years of use. One woman in this study requested removal for menstrual pattern changes through two years of use. As assessed through user-satisfaction questionnaires administered at approximately six months of use, there has been an overall positive user experience with Norplant in this study. Although the sample size in this study is small, our results seem to be consistent with other studies and it appears that Norplant offers an effective, safe and acceptable method of contraception for Ghanaian women.

PIP: A two-year pre-introductory study of 100 Norplant acceptors from Kumasi, Ghana, indicated that the contraceptive implants are safe, effective, and acceptable to this population. The mean age of study participants was 31.2 years; they had completed an average of 8.3 years of schooling and had a mean of 4.4 live births. Although 35% did not want any more children, 64% had used no contraceptive method in the month prior to study admission. No pregnancies were reported during interviews at 1, 3, 6, 12, 18, and 24 months post-insertion. The continuation rate was 86.6/100 women at two years, for a total of 2119 woman-months of use. 75 women elected to continue Norplant use, while 12 opted for removal and 13 were lost to follow-up. Reasons for discontinuation included desire for pregnancy (3), husband's insistence (5), travel (2), menstrual problems (1), and tuberculosis (1). Only nine acceptors reported any adverse effects; most frequent were itchiness and infection at the implant site. The incidence of amenorrhea decreased from 27% at the end of the first year of use to 2% by the end of the second year. When asked to identify the most attractive feature of the Norplant system, half the respondents cited its five-year duration of action; most disliked was Norplant's effect on the menstrual cycle. 83.7% indicated they would recommend Norplant to a friend, and 55% expressed an interest in having a second set of implants inserted after the full five years.

Utilization of maternal health services in Ejisu District, Ghana.

A study on the utilization of maternal health services in Ejisu district of Ghana was carried out in January and February 1990. 1200 women aged between 15 and 49 were interviewed in 80 communities. The findings of the study indicated that over 50% of respondents married under 20 years, 70% of them attended antenatal clinic at least 4 times in their last pregnancy, over 80% had their last delivery in a health facility and over 80% knew about at least one modern method of family planning. Only 5.5% were currently using a modern family planning method. 90% of them were willing to stay in a maternity waiting home if advised to do so. Most would be prepared to stay for a month or 2. 20% of the respondents knew about local herbal preparations used for first aid in bleeding in pregnancy, although they would seek definitive treatment at a health facility. From the study, some women were not using the services. These would have to be reached through improving the quality of care in health facilities and increasing community awareness on maternal health in order to improve accessibility and utilization further.

PIP: This operations research project on the use of maternal health care services in Ejisu district in Ghana was performed during January and February 1990. The sample was comprised of 1200 women from 80 communities (population 131,199 persons in 1984) in the district, which has 19 health facilities (a Catholic mission hospital, 8 government health centers, 5 mission clinics, and 3 private maternity homes serving a population in 160 communities). Retrospective data was collected on health service use during January 1985-December 1989. Characteristics of the sample population included 59% 20-34 years old, 11% younger than 20, and 33% with no formal education. 37.9% were farmers, 26.7% were housewives, and 25% were traders. 74% were married. 50.3% married before the age of 20. 70.9% made at least 4 visits for prenatal care before their last pregnancy. 17.3% did not receive any prenatal care. 33.3% delivered at a health center. 28% used a Government Maternity Home, 22% used a hospital, and 13% relied on traditional birth attendants at home. 29% (349 women) reported complaints during their last pregnancy. 85.5% knew at least 1 method of contraception. 5.5% were current users of modern contraception, of which the pill was the most popular (45.4% of users). Treatment for bleeding during pregnancy was reported by 16.7% of the sample to involve eating a ripe banana or a banana in combination with cassava products. External use of plantain leaves or sanitary pads was also mentioned. These treatments were considered as first aid and not definitive treatment. 90% indicated a willingness to stay in a maternity waiting home if advised to do so. 58% would be able to stay 1 month, 21% would stay 2 months, and 21% would stay 3 or more months. Effective community education and social mobilization is still needed in order to attract those not using services.

Maternal mortality and related factors in Ejisu District, Ghana.

A community-based survey on maternal mortality was carried out in the Ejisu health district of Ghana in January and February 1990 to identify all women who died in pregnancy, delivery or the puerperium from January 1985 to December 1989, determine their characteristics, the presumptive causes of death and related factors. Forty-four women who died in pregnancy, delivery or the puerperium were identified over the stated period. 59% were aged between 20 and 34 years. Eighty-two percent were married and sixty-six percent had at least primary education. Based on an average crude birth rate of 40 per 1000 population for the district over the period, the lowest maternal mortality rate occurred in 1988, 120 per 100,000 total births and the highest occurred a year later, 235 per 100,000 total births. The main presumptive causes of maternal mortality in the district were postpartum haemorrhage 45.5%, jaundice in pregnancy 22.7%, obstructed labour 6.8%, eclampsia 6.8% and fever 4.6%. 59% of them died in a hospital, 2% died at a Government Maternity Home and 7% died during referral from health facilities in the district. Thirty-four percent of the women who died did not attend any antenatal clinic. The actual number of deaths may be underestimated due to the sampling method used and the difficulties encountered in linking survey data with hospital records. Based on the survey findings and other related PMM research, plans have been developed to reduce maternal mortality in the district as outline in the conclusion.

PIP: A community-based survey was conducted among 1200 reproductive age women living in 80 out of 160 communities in Ejisu health district in Ghana during January-February 1990. Retrospective data was collected for the period January 1985-December 1989. Data was analyzed in order to determine maternal mortality, causes of death, and the characteristics of the mothers who died. The sample community was comprised of 223,632 persons in 1990. 44 women were identified as having died in pregnancy, delivery, or postpartum. 59% were 20-34 years old, and 41% were in high-risk age groups. 65.9% had at least some primary education, and 81.8% were married at the time of death. 27.3% were childless at the time of death. Maternal deaths were distributed by year as follows: 9 deaths in 1985, 10 in 1986, 7 in 1987, 6 in 1988, and 12 in 1989. The estimated maternal mortality was 211 per 100,000 live births in 1986 and 235 per 100,000 in 1989. The 4-year average was 181 per 100,000. 34% of deaths were to women who had not received any prenatal care in the last pregnancy. Almost 75% died during delivery. 59% died in a hospital, 7% during a referral to a hospital, and 2% at a Government Maternity Home. Over 66% died after reaching a health facility. 27% died at home. 2% died while under the care of a local traditional birth attendant. Causes of maternal death were postpartum hemorrhage (45.5%), jaundice in pregnancy (22.7%), obstructed labor (6.8%), eclampsia (6.8%), and fever (4.6%). 2.3% of deaths were attributed to antepartum hemorrhage, ectopic pregnancy, and septic abortion. Prenatal care alone is not sufficient to prevent some deaths. The high mortality rate during delivery is a justification to improve the quality of care during delivery at all levels of the district health system. Listed are 9 potential interventions to reduce maternal mortality, including: establishing operating facilities at local health centers and maintaining a resident doctor for obstetric emergencies.

Maternal mortality due to hemorrhage in Ghana.

OBJECTIVE: This hospital-based review of maternal mortality due to hemorrhage in Kumasi, Ghana was undertaken to determine the factors related to and influencing cases of fatal maternal hemorrhage. METHOD: The review was based on inpatient case notes, labor ward delivery notes, and operative records at the Maternity Block of the Komfo Anokye Teaching Hospital, Kumasi. The diagnoses were based on International Classification of Diseases (ICD) 9th and 10th editions. It covered the period 1981 to 1989. RESULT: It was observed that maternal hemorrhage accounted for over 40% of all obstetric complications admitted and also 27% of all maternal deaths in the period under review. However, the case fatality rate for maternal hemorrhage decreased from 1.34% in 1981 to 0.7% in 1989. The cesarean section rate increased from 6.7% in 1981 to 9.1% in 1989. The maternal mortality rate over the period was 1140 per 100,000 births. CONCLUSION: Based on this review and other related research, the following interventions have been planned for implementation in order to improve the situation: improving staff-patient relationship through training in interpersonal skills; ensuring 24-h availability of drugs, supplies and blood; establishment of a resuscitation unit at the casualty department so that first aid can be provided to patients with obstetric emergencies before transfer to the wards; establishment of a maternity care monitoring system to continually improve the quality of care; introduction of confidential enquiry into all maternal deaths in order to reduce their incidence. A monitoring and evaluation plan has been developed to assess regularly progress on implementation. Although, maternal deaths are due to multifactorial causes, it is hoped that these interventions, if successfully implemented, will contribute significantly towards the reduction of maternal deaths due to institutional factors, especially direct obstetric causes like maternal hemorrhage.