Challenges in preterm birth research: Ghanaian perspective.

Preterm birth is highly prevalent in Ghana. It is a major public health concern because of the high burden as well as the associated immediate and long-term consequences including increased healthcare cost. Studies conducted in high-income countries may not be sufficiently generalizable in our context. Locally generated evidence-based interventions will be indispensable in improving the clinical management and prevention of preterm birth in the country. However, there are limited published literature on preterm birth and prematurity in the country. This review seeks to discuss the major challenges associated with preterm birth research in Ghana and proposes evidence-based strategies to improve biomedical and epidemiological research on preterm birth and prematurity. The limited high quality preterm birth research is partly attributable to a variety of challenges related to accurate gestational age estimation, research training, capacity and support including funding, efficient ethics committees, local and international collaboration as well as effective health management information systems. Other related challenges include unavailability of reliable internet connectivity, poor compensation for researchers and lack of conductive research environment. There is the need to expedite advocacy on implementation of practical interventions and strategies aimed at increasing high quality research in the area of preterm birth and prematurity in the country. A paradigm shift in preterm birth research with appropriate integration of concerted multidisciplinary research groups should be constituted to put basic science research to clinical practice as well as the prevention of preterm birth in the country.

Determinants and outcomes of preterm births at a tertiary hospital in Ghana.

INTRODUCTION: Preterm birth remains an important clinical challenge with significant short and long-term complications although its burden in the developing world is not adequately explored. This study determines the incidence, specific determinants and outcomes of preterm birth at a teaching hospital in Ghana. METHODS: Retrospective review of singleton births at Korle-Bu Teaching Hospital (KBTH) in Ghana between 1st January to 31st December, 2015. RESULTS: Preterm birth (PTB) occurred in 1478 (18.9%) out of 7801 single deliveries with etiological distribution of 879 (59.5%) spontaneous and 599 (40.5%) provider-initiated phenotypes. Gestational age categorization (WHO classification) of the preterm births included 68 (4.6%), 235 (15.9%) and 1175 (79.5%) below 28, between 28-31 and 32-36 weeks respectively. Adverse perinatal outcomes (low birth weight, perinatal deaths and poor Apgar scores) but not adverse maternal outcomes (cesarean and maternal deaths) were significantly higher in preterm compared to term births. Major factors associated with PTB include advanced maternal age (>35 years), poor antenatal care, hypertensive disorders and preterm premature rupture of membranes (PPROM) whiles obesity was protective. There were 156 stillbirths (105.6 per1000 births) comprising 93 macerated (62.9 per 1000 births) and 63 fresh stillbirths (42.6 per 1000 births), and perinatal mortality rate of 119.8 per 1000 births. DISCUSSION: Preterm birth is highly prevalent with significant adverse outcomes among singleton gestations at KBTH in Ghana, with disproportionately higher spontaneous etiology compared to provider-initiated phenotype. A paradigm shift in clinical management of preterm births/prematurity is urgently required with proactively dedicated multidisciplinary team and involvement of the global community.

Lifting and pregnancy outcomes: feasibility of a randomized controlled trial.

Background: The highest incidence of preterm birth (18%) occurs in Africa but the causes are largely unknown. Some studies have reported adverse effects of maternal physical exertion on birth outcomes. A randomized controlled trial (RCT) is proposed to determine the effectiveness of an intervention reducing lifting and carrying in pregnant women in reducing preterm birth and low birthweight. Aims: To test the feasibility and acceptability of the proposed lift-less intervention RCT. Methods: We recruited pregnant women and midwives from antenatal clinics within the Greater Accra Region of Ghana. The midwives were trained to administer the intervention during a 5-week trial. Four intervention trial sessions were organized at weekly intervals. Results: Seven pregnant women and six midwives participated. After piloting, we observed a reduction in participants' self-reported daily exposure to heavy lifting and carrying. The daily average frequency of lifting by a participant within the first seven days of the study was 3.5 (SD 1.7) with an estimated mean total weight of 41.1 kg (SD = 13.3 kg). This had decreased to 2.3 (SD = 1.0) and the amount to 13.4 kg (SD = 10.9) within the last seven days of the study. Conclusions: The findings provide insight into the daily physical exertion experienced by pregnant women in Ghana. The lift-less intervention trial is feasible with modifications and has the potential to reduce excessive physical exertion among pregnant women in Ghana to improve birth outcomes.

LINKING UNINTENDED PREGNANCY TO THE BURDEN OF PRE-ECLAMPSIA IN A TERTIARY HOSPITAL IN GHANA.

BACKGROUND: Although pre-eclampsia remains a major public health challenge associated with significant adverse maternal outcomes especially in low-income countries, there are no well-defined screening and preventive measures. However, primary prevention of unintended pregnancy represents a viable and reliable measure for reducing the high maternal morbidity and mortality attributable to pre-eclampsia. OBJECTIVE: To determine and relate the proportion of unintended pregnancies among pre-eclamptic women to the burden of pre-eclampsia in Korle-Bu Teaching Hospital (KBTH), Accra, Ghana. METHOD: A cross-sectional study involving pregnant women with pre-eclampsia conducted at the KBTH, Accra, Ghana. Structured questionnaire was employed to obtain the required data regarding pregnancy intendedness and the use of modern contraception. Data on maternal mortality were also collected to determine maternal deaths related to pre-eclampsia. The data obtained were analyzed using SPSS version 18. RESULTS: There were 269 women with hypertensive disorders in pregnancy with 177 (65.8%) having pre-eclampsia out of which 100 met the inclusion criteria and 86 gave informed consent. Most, 71(82.6%), were married and 69 (80.2%) had had at least Junior High School education with a mean age of 29.34±1.08 years. The prevalence of unintended pregnancy among the women with pre-eclampsia was 32.6% as 28 patients were affected with 12 (13.9%) women on modern contraception prior to the index pregnancy. However, 83 (96.5%) had adequate knowledge on modern contraception and 58 (67.4%) reported of a previous history of induced abortion. As many as 16 (57.1%) women of those whose pregnancies were unintended were not using any form of contraception. During the study period, 36 maternal deaths occurred and 14 (38.9%) were due to pre-eclampsia. CONCLUSION: Unintended pregnancy constitutes a significant proportion of the burden of pre-eclampsia in the Ghanaian population resulting in high maternal morbidity and mortality. Increasing contraceptive usage in general represents a viable and effective primary preventive measure in reducing maternal mortality attributable to pre-eclampsia.

Is there a safe limit of delay for emergency caesarean section in Ghana? Results of analysis of early perinatal outcome.

OBJECTIVE: To determine the limits of delaying caesarean section in a busy obstetric unit in a developing country setting that is not associated with neonatal survival. METHODS: Retrospective cohort study of emergency cesarean sections. Indications were sub-divided into imminent threat and no imminent threat to fetal wellbeing. The primary outcomes was a composite measure of adverse perinatal outcome including stillbirth, 5-minute Apgar score < 7 and neonatal intensive care unit admission. Effect of decision-to-delivery interval on perinatal outcomes was evaluated using Kaplan-Meier survival analysis. RESULTS: 495 women met inclusion criteria (142 'imminent threat' group, 353 'no imminent threat' group). The median decision-to-delivery interval was significantly shorter in the 'imminent threat' group (2.25 [95% CI 1.38 - 5.83] versus 3.42 [95% CI 1.83 - 5.85] hours, p <0.001). Only 1.7% and 12.7% sections were performed within 30 minutes and 1 hour, respectively. Risk of the composite outcome was significantly higher in the 'imminent threat group (46.5% versus 31.2%, RR=1.49 [95% CI 1.18 - 1.89], p=0.001). A 95% probability of 'live intact' survival occurred at 1 hr and 2 hrs respectively, for the imminent threat and the no imminent threat groups. CONCLUSION: Increasing decision-to-delivery interval is associated with higher risk of adverse perinatal outcomes, but a 95% live intact survival can be achieved if the delivery occurs within 2 hours.

VAGINAL BIRTH AFTER A PREVIOUS CAESAREAN SECTION: CURRENT TRENDS AND OUTLOOK IN GHANA.

BACKGROUND: The optimal mode of subsequent delivery of women with prior caesarean birth remains a subject of intense research and debate in contemporary obstetric practice especially in low resource settings like West Africa where there are obvious systemic and management-related challenges associated with trial of scar. However, there is evidence that vaginal birth after caesarean section (VBAC) is safe in appropriately selected women in addition to adequate intrapartum monitoring and ready access to theatre when emergency CS is indicated. AIM & OBJECTIVES: The primary objective of the study was to determine the current trends and performance of VBAC in Ghana after decades of practice of trial of labour after caesarean section (TOLAC) in the mist of inherent challenges in deciding the optimal mode of childbirth for women with a previous caesarean birth. The secondary objective was to relate evidence based practice of TOLAC to obstetric practice in low resource settings like Ghana and provide recommendations for improving maternal and newborn health among women with prior caesarean birth. PATIENTS & METHODS: This was a retrospective study of the records of patients who had had a prior caesarean delivery and who then proceeded to deliver the next babies at the Korle Bu Teaching Hospital (KBTH) between Jan 2010 and Dec 2014. The data on demography, antenatal care, labour and delivery and outcomes were collected from the Labour and Recovery wards and the Biostatistics unit of the Maternity unit of the Hospital. Excluded were women with a previous CS who had multiple pregnancies and those with incomplete notes as well as those whose delivery plans were not predetermined antenatally.. The data were analyzed using SPSS version 20. RESULTS: There were 53,581 deliveries during the study period. Vaginal delivery was obtained in 31,870 (59.5%) pregnancies and 21,711(40.5%) had CS. Also, 6261 (11.7%) had had a prior CS and 2472 (39.5%) of these were selected for TOLAC while 2119 (33.8) were scheduled for planned repeat CS. There was an inverse trend between the annual caesarean sections rates and the proportion of women with one previous CS scheduled for TOLAC. There was a statistically significant difference between women who had successful or failed VBAC regarding maternal age, parity, number of ANC visits, gestational age at delivery, birth weight, Apgar score at 1 min and Apgar score at 5 min. Birth weights of less than 1.5kg, and 3.5Kg or greater were associated significantly with higher incidence failed TOLAC and emergency repeat CS. However, birth weights ranging from 2.0 to 3.49kg were associated with significantly lower incidence of failed TOLAC and emergency repeat CS. Birth weight of 2.5-2.99kg was associated with the lowest incidence of failed TOLAC and repeat CS. CONCLUSION: . There is a significantly high vaginal birth after caesarian section (VBAC) success rate among carefully selected women undergoing trial of scar in Ghana although a decreasing trend towards trial of labor after caesarian section (TOLAC) and a rising CS rate were determined. TOLAC remains a viable option for child birth in low resource settings like West Africa even though there are specific clinical and management related challenges to overcome. Adequate patient education and counselling in addition to appropriate patient selection for TOLAC remains the cornerstone to achieving high VBAC success rate with minimal adverse outcomes in such settings.

Ten -year review of vacuum assisted vaginal deliveries at a district hospital in Ghana.

OBJECTIVE: To find the incidence, indications, failure rate and the maternal and neonatal morbidity associated with the use of the vacuum extractor in a district hospital. METHODS: A retrospective study of vacuum assisted vaginal deliveries. SETTING: Holy Family Hospital, Nkawkaw from 1st January 2000 to 31st December 2009. RESULTS: There were a total of 22,947 deliveries at the Holy Family Hospital over the ten year period of the study. There were 180 (0.78% of the total deliveries) cases of vacuum extraction out of which 164 (91.1%) of the extractions had successful vacuum assisted vaginal deliveries. The incidence of successful vacuum assisted vaginal delivery was 0.71% of the total number of deliveries. The failure rate of vacuum extraction was 8.9%. The commonest indications for vacuum assisted vaginal delivery were delayed second stage 40.5%, and poor maternal effort 29.3%. The maternal complication rate was 3.1% while 16 (9.7%) babies were admitted to babies unit with birth asphyxia and other complications which were mainly minor injuries. CONCLUSION: The vacuum extractor is an effective and safe device for assisted vaginal delivery with high success rate even in a district hospital. Steps should be taken to encourage the safe use of vacuum assisted vaginal deliveries and it should be made more accessible.

Clinic visits and cervical cancer screening in accra.

OBJECTIVE: To determine the factors that increase the chances of a woman in Accra having a Pap smear and whether women who have recently visited clinics have higher chances of having had Pap smears. DESIGN: A cross-sectional study METHODS: A representative sample of women in Accra, Ghana was interviewed and the clinical and demographic factors influencing cervical cancer screening was assessed. RESULTS: Out of 1193 women with complete data, only 25 (2.1%) had ever had a Pap smear performed though 171 (14.3%) had their last outpatient clinic visit for either a gynaecological consultation or a regular check up. Simple logistic regression showed that a high educational level, high socioeconomic status and a history over the past month of postmenopausal or intermenstrual bleeding significantly increased the odds of ever having a pap smear. Neither monthly income nor last clinic visit for a gynaecological consultation or regular check up increased the odds of having a pap smear. Multiple logistic regression showed that a high educational level and experiencing postmenopausal or intermenstrual bleeding were the most important determinants of ever having a Pap smear. CONCLUSION: While we wait for a national program for cervical cancer screening, there is a need for clinicians to put more individual effort into ensuring that asymptomatic women are screened for cervical cancer.

Sonographic findings in women with complications after hysterectomy.

OBJECTIVE: To study the role of abdominal ultrasound in the management of complications after emergency or elective hysterectomy. METHODOLOGY: The study compared 102 women who had complications after emergency peripartum hysterectomy (study group) with 102 women who had complications after elective hysterectomy for fibroids (control group). RESULTS: The study group had a lower mean age (31.1+/-2.1 vs 40.1+/-3.4 years) but higher parity (3.0+/-1.3 vs 2.0+/-1.2) compared with the control group. The primary complication in the study group was abdominal mass or distension (55.9%) compared with chronic abdominal pain (49.0%) in the control group. The leading sonographic abnormality in the study group was pelvic abscess (9.8%) while hydrosalpinx (6.9%) was more common in the control group. There was no statistical difference in the findings between the groups. Management of complications included ovarian cystectomy and drainage of pelvic abscesses. CONCLUSION: Ultrasound facilitates accurate diagnosis of complications after hysterectomy and enhances management.

Emergency peripartum hysterectomy in the nulliparous patient.

OBJECTIVE: To find out the incidence, indications and outcomes of emergency peripartum hysterectomy in the nulliparous woman. METHOD: Retrospective study at the Korle Bu Teaching Hospital in Accra, Ghana, between January 1995 and December 2003. RESULTS: During the eight-year study period there were 92,966 deliveries out of which 36,550 (39.5%) were for the nulliparous. Peripartum hysterectomy was performed for 39 nulliparous women, thus giving an incidence of 1 per 1000 nulliparous deliveries. The indications for the hysterectomy were: atonic uterus 28 (71.8%), ruptured uterus 8 (20.5%) and placenta praevia/accreta 3 (7.7%). The perinatal losses were 8 (20.5%) and the total blood loss ranged from 1 to 4.5 l. There were no maternal deaths but there were 7 near-missed fatalities. CONCLUSION: Though rare, peripartum hysterectomy in the nulliparous patients carries high maternal morbidity and perinatal mortality.

Secular trends in menarcheal age among Ghanaian women in Accra.

The Women's Health Study of Accra is a population-based cross-sectional survey that was conducted between March and September 2003 to assess the burden of disease in women in Accra. In addition to data relating to general health and living conditions, data on age at first menstruation was collected during the survey. A retrospective cohort analysis of the reported age at menarche was conducted using data from 2,644 women aged between 18 and 100 years. The median age of first menstruation of the entire cohort was 15.5 years and the median age of first menstruation among those aged <20 was 14.5 years. There was a statistically significant difference in median age at menstruation among the different age and socioeconomic groups. Multiple linear regression showed a significant decline of 0.2 years per decade in the mean age at menarche among Ghanaian women.

Re-laparotomy after Cesarean section.

OBJECTIVE: The objective of the study was to find out the indications for management and the outcomes of reopening the abdomen during the puerperium after Cesarean section. PATIENTS AND METHODS: This was a retrospective descriptive survey at the Korle Bu Teaching Hospital in Accra, Ghana. RESULTS: There were 6120 Cesarean sections (17%) out of a total of 36,010 deliveries. Re-laparotomy was done in 44 patients (0.7%) of the Cesarean sections. The indications were: hemorrhage from uterine atony, hemorrhage from placental bed after operation for placenta previa, uterine sepsis with hemorrhage, hemorrhage after Cesarean section, myomectomy and hemorrhage from anterior abdominal wound dehiscence. The main surgeries performed were: hysterectomy, ligation of ascending branches of uterine arteries, ligation of hypogastric arteries, debridement and re-suturing of the uterine incision and secondary suturing of anterior abdominal wall. There were 6 near missed fatalities. There were 4 mortalities caused by excessive hemorrhage and severe sepsis. CONCLUSION: The case fatality rate for re-laparotomy after Cesarean section is high (9%). Near missed-fatalities are common. To reduce the unfavorable outcomes, instituting more intensive education on the use of the partograph should prevent prolonged labor. Centers carrying out Cesarean section should have efficient blood transfusion service in place.

Caesarean section and birth weight at Korle Bu Teaching Hospital--preliminary report.

OBJECTIVE: This preliminary retrospective survey was done to find out whether the indications for Caesarean Section had any bearing on the birth weight. METHOD: The foetal outcome for 673 parturients who delivered at the Korle Bu Teaching Hospital between September 1, 1998 and December 31, 1998 was analysed. RESULT: Caesarean section done for cephalopelvic disproportion and for 2 or more previous sections yielded the highest mean birth weight (3.43 kg +/- 0.02 kg) and the best foetal outcome. Hypertensive disorders yielded the lowest mean birth weight (1.8 kg +/- 0.3 kg) and poorest foetal outcome. The mean parity and age of the parturients were similarly distributed. CONCLUSION: The birth weights appeared to vary with the indications for Caesarean section. Confounding factors such as the gestational age, parity and age of the parturients need to be controlled in a prospective study in future. Good antenatal supervision could improve on the birth weights.

Antenatal ultrasonography for breech delivery.

OBJECTIVE: We studied the role of sonography in the management of 370 breech presentations > or = 34 weeks maturity. METHOD: 185 cases had sonographic confirmation of breech presentation prior to the delivery at the Korle Bu Teaching Hospital. A control group of 185 cases did not have prior scanning. RESULTS: Significantly more elective cesarean sections were done in the study group, while the control group had more emergency sections (P = 0.008), and had more traumatic delivery. Birth asphyxia and perinatal mortality were significantly more common in the control group (P < 0.05). CONCLUSION: Sonography done before delivery improved neonatal outcome in breech presentation > or = 34 weeks maturity.