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

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

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

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

"Once you get one maternal death, it's like the whole world is dropping on you": experiences of managing maternal mortality amongst obstetric care providers in Ghana.

BACKGROUND: Maternal mortality has a significant global impact, especially in low-resource settings. Little prior research has been conducted on the potential effects of poor maternal outcomes on the personal and professional well-being of healthcare providers. This study explores the in-depth experiences and perspectives of obstetric providers in Ghana who work in a setting with frequent maternal mortalities. METHODS: This is a qualitative study of semi-structured interviews conducted at the Komfo Anokye Teaching Hospital in Ghana. Participants were obstetric healthcare providers, defined as midwives, house officers currently rotating on the obstetrics/gynecology service, and obstetrician/gynecologists at any training or practice level (residents, fellows, and specialists). Interviews were audio-recorded, transcribed verbatim, and uploaded into NVivo for qualitative analysis. Using the Attride-Stirling qualitative model, an incremental and iterative process was used to code interviews with keyword phrases and develop a framework of organizing and global themes. RESULTS: Interviews were conducted with 27 participants-15 midwives and 12 physicians (three obstetrician/gynecologist residents, six obstetrician/gynecologist specialists, and three house officers), with sample size determined by data saturation. Obstetric providers' experiences in a setting with frequent maternal mortalities were dependent on their level of preparedness to manage maternal mortalities and the workplace environment. Providers' level of preparedness was dependent on both the training they had received on the medical management of obstetric emergencies, as well as a lack of training on the mental health aspects of coping with maternal mortality. The impact of the workplace environment was dependent on systems failures and limited resources, blame from colleagues and supervisors, and a lack of support in the workplace. In turn, obstetric providers' experiences managing frequent maternal mortalities impacted their clinical care performance and mental health. CONCLUSIONS: Maternal deaths have profound personal and professional impacts on the healthcare providers who manage them. A large need exists for additional institutional training and support for obstetric providers who manage maternal mortality, especially in low-resource settings like Ghana.

"There is no joy in the family anymore": a mixed-methods study on the experience and impact of maternal mortality on families in Ghana.

BACKGROUND: Maternal mortality has a multifaceted impact on families, especially in low- and middle-income countries, where rates of maternal mortality are high and resources can be lacking. The objective of this study was to explore the ways that maternal mortality influences the physical and emotional wellbeing, financial stability, and caregiving structure of families, and identifies sources of and gaps in support. METHODS: Our study used a mixed-methods design. All maternal mortalities in an 18-month period at a tertiary hospital in Ghana were identified using death certificates. Participants were 51 family members (either husbands or other heads of households) in families affected by maternal mortality. A questionnaire assessed demographic characteristics and changes in family health, income, and family structure. Two validated scales assessing psychological wellbeing were administered: the Patient Health Questionnaire-9 and the Inventory of Complicated Grief. Semi-structured interviews were conducted to assess impact on family wellbeing. RESULTS: Quantitative and qualitative results converged to highlight large, negative impacts of maternal mortality on four areas of family wellbeing: 1) mental health and emotional wellbeing; 2) physical health; 3) family structure; 4) financial stability and security. On the Patient Health Questionnaire-9, 54% (27/50) of participants reported elevated depressive symptoms, with 14% (7/50) of scores falling in the moderately severe or severe ranges. On the Inventory of Complicated Grief, 38% (19/50) exceeded the cutoff for significant impairment in functioning. Worsened family health was associated with greater complicated grief (b = 21.41, p = .004); there were no other significant predictors of depressive symptom severity or complicated grief. Effects on family health centered on concerns about the nutritional status and health of the surviving infant. Family structure was primarily affected by fracturing of the central family unit by sending children to live with relatives. Immense economic strain resulted from hospital bills, funeral expenses, and loss of income. The majority of participants received helpful support from their family (41/51, 80.4%), the community (32/51, 62.7%), and their religious institution (43/51, 84.3%); however, support often stopped soon after the death. CONCLUSIONS: Maternal mortality has profound negative impacts on families in Ghana. Impacts are experienced by husbands and heads of households, as well as surviving children. Both immediate and sustained support is needed for families following a maternal death, especially mental health and financial support.

Attitudes, experiences, and training on comprehensive abortion care: A nationwide survey of trainee physicians in Ghana.

This cross-sectional study assessed attitudes and experiences with abortion care among physician trainees in Ghana. Participants were 27 Obstetrics/Gynecology (OBGYN) residents and 138 house officers. An electronic survey evaluated attitudes, training, clinical experience, and technical skills with abortion care. The majority of participants believe that women should have access to safe abortion. However, only 51.6% of OBGYN residents and 40.9% of house officers want to currently perform abortions as a trainee, primarily due to religious or ethical beliefs. Among house officers, increased likelihood of performing abortions in their future practice is associated with greater exposure to abortion training, (OR 1.40, p=0.032), fewer years practicing medicine (OR 0.26, p=0.010), and believing abortion laws should be liberalized (OR 3.62, p=0.03). Overall, we demonstrate that only two-thirds of physician trainees in Ghana are likely to perform abortion care after completing training, and greater exposure to abortion training is associated with an increased likelihood of performing abortions.

Preeclampsia knowledge among postpartum women treated for preeclampsia and eclampsia at Korle Bu Teaching Hospital in Accra, Ghana.

BACKGROUND: Preeclampsia/eclampsia is a major cause of maternal morbidity and mortality worldwide, yet patients' perspectives about their diagnosis are not well understood. Our study examines patient knowledge among women with preeclampsia/eclampsia in a large urban hospital in Ghana. METHODS: Postpartum women diagnosed with preeclampsia or eclampsia were asked to complete a survey 2-5 days after delivery that assessed demographic information, key obstetric factors, and questions regarding provider counseling. Provider counseling on diagnosis, causes, complications, and future health effects of preeclampsia/eclampsia was quantified on a 4-point scale ('Counseling Composite Score'). Participants also completed an objective knowledge assessment regarding preeclampsia/eclampsia, scored from 0 to 22 points ('Preeclampsia/Eclampsia Knowledge Score' (PEKS)). Linear regression was used to identify predictors of knowledge score. RESULTS: A total of 150 participants were recruited, 88.7% (133) with preeclampsia and 11.3% (17) with eclampsia. Participants had a median age of 32 years, median parity of 2, and mean number of 5.4 antenatal visits. Approximately half of participants reported primary education as their highest level of education. While 74% of women reported having a complication during pregnancy, only 32% of participants with preeclampsia were able to correctly identify their diagnosis, and no participants diagnosed with eclampsia could correctly identify their diagnosis. Thirty-one percent of participants reported receiving no counseling from providers, and only 11% received counseling in all four categories. Even when counseled, 40-50% of participants reported incomplete understanding. Out of 22 possible points on a cumulative knowledge assessment scale, participants had a mean score of 12.9 ± 0.38. Adjusting for age, parity, and the number of antenatal visits, higher scores on the knowledge assessment are associated with more provider counseling (ß 1.4, SE 0.3, p < 0.001) and higher level of education (ß 1.3, SE 0.48, p = 0.008). CONCLUSIONS: Counseling by healthcare providers is associated with higher performance on a knowledge assessment about preeclampsia/eclampsia. Patient knowledge about preeclampsia/eclampsia is important for efforts to encourage informed healthcare decisions, promote early antenatal care, and improve self-recognition of warning signs-ultimately improving morbidity and reducing mortality.

Embedding international medical student electives within a 30-year partnership: the Ghana-Michigan collaboration.

BACKGROUND: Global health experiences are an increasingly popular component of medical student curricula. There is little research on the impact of international medical electives embedded within long-standing, sustainable partnerships. Our research explores the University of Michigan medical student elective experience in Ghana within the context of the Ghana-Michigan collaborative. METHODS: Study participants are University of Michigan medical students who completed an international elective in Ghana between March 2006 and June 2017. Post-elective reports were completed by students, including a description of the experience, highlights, disappointments, and the impact of the experience on interest in future international work and future practice of medicine. A retrospective thematic analysis of reports was carried out using NVivo 12 (QSR International, Melbourne, Australia). RESULTS: A total of 57 reports were analyzed. Benefits of the elective experience included building cross-cultural relationships, exposure to different healthcare environments, hands-on clinical and surgical experience, and exposure to different patient populations. Ninety-five percent of students planned to engage in additional international work in the future. Students felt that the long-standing bidirectional exchange allowed them to build cross-cultural relationships and be incorporated as a trusted part of the local clinical team. The partnership modeled collaboration, and many students found inspiration for the direction of their own careers. CONCLUSIONS: Embedding clinical rotations within a well-established, sustained partnerships provides valuable experiences for trainees by modeling reciprocity, program management by local physicians, and cultural humility-all of which can help prepare learners to ethically engage in balanced, long-term partnerships in the future.

"Nobody gave me information": Hospital experiences of Ghanaian families after maternal mortalities.

Background: Rates of maternal mortality are highest in low-resource settings. Family members are often involved in the critical periods surrounding a maternal death, including transportation to health centers and financial and emotional support during hospital admissions. Maternal death has devastating impacts on surviving family members, which are often overlooked and understudied. Objective: Our study aimed to explore the hospital experiences of family members surrounding a maternal death, and to define their access to and need for institutional and psychosocial support. Study Design: This mixed methods cross-sectional study was conducted at an urban tertiary hospital in Ghana. Maternal mortalities from June 2019 to December 2020 were identified using death certificates. Participants, defined as husbands or other heads of households in families affected by maternal mortality, were purposively recruited. An interview guide was developed using grounded theory. In-person semi-structured interviews were conducted in English or Twi to explore impacts of maternal mortality on family members, with a focus on hospital experiences. Surveys were administered on types of and needs for institutional support. Interviews were audio recorded, translated, transcribed, coded with an iteratively-developed codebook, and thematically analyzed. Survey data was descriptively analyzed. Results: Fifty-one participants included 26 husbands of the deceased woman, 5 parents, 12 siblings, and 8 second-degree relatives. Interviews revealed an overall negative hospital experience for surviving family members, who expressed substantial dissatisfaction and distress. Four themes regarding the hospital experience emerged from the interviews: 1) poor communication from healthcare workers and hospital personnel, which contributed to 2) limited understanding of the patient's clinical status, hospital course, and cause of death; 3) maternal death perceived as avoidable; and 4) maternal death perceived as unexpected and shocking. Survey data revealed that only 10% of participants were provided psychosocial support following the maternal death event, yet 93.3% of those who did not receive support desired this resource. Conclusion: The hospital experience was overall negative for family members and a lack of effective communication emerged as the root cause of this negative perception. Strategies to improve communication between healthcare providers and families are essential. In addition, there is an unmet need for formal mental health resources for families who experience a maternal death.

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

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

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

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

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

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

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

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

Maternal Mortality in Low and Middle-Income Countries.

Despite a 38% decrease in global maternal mortality during the last decade, rates remain unacceptably high with greater than 800 maternal deaths occurring each day. There exists significant regional variation among rates and causes of maternal mortality, and the vast majority occurs in low-income and middle-income countries. The leading causes of direct maternal mortality are hemorrhage, hypertensive disorders of pregnancy, sepsis, complications of abortion, and thromboembolism. Eliminating preventable maternal mortality hinges on improving clinical management of these life-threatening obstetric conditions, as well as addressing the complex social and economic barriers that pregnant women face to access quality care.

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

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

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

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

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

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

The burden of COVID-19 infection on medical doctors in the first year of the pandemic in Ghana.

Objective: To quantify and describe the burden of COVID-19 infection amongst doctors in Ghana. Design: A quantitative and qualitative analysis of cross-sectional data was performed. Setting: All 16 regions in Ghana. Participants: Participants were medical doctors diagnosed with COVID-19 between March 2020 and March 2021. Main outcome measures: Data sources were Ghana Medical Association and Ministry of Health records. Demographics and workplace data included age, gender, the rank of the doctor, and location and type of current facility. Characteristics of the COVID-19 infection included the likely source, clinical and recovery status, and place of management. Doctors reported their desire for a general checkup and psychological support and described the challenges encountered. Results: The prevalence of COVID-19 infection was 88.9 cases per 1000 doctor-population. Of 544 infected doctors, 59.2% were stable but symptomatic, and 1.7% were in critical condition, with a case fatality rate of 1.7%. Overall, 31.6% had recovered from their COVID-19 infection, and the majority (82.4%) were managed at home in self-isolation. Compared to medical officers, house officers (OR 1.36, p=0.03), senior house officers (OR 7.60, p<0.001), and consultants (OR 2.94, p=0.001) were more likely to have a COVID-19 infection. Desire for support was varied, with 13.0% desiring someone to check on them and 9.7% desiring psychological support. The majority (75.3%) reported facing a challenge, including difficulty obtaining needed vitamins and medications, and accessing daily necessities like groceries. Conclusions: In Ghana, COVID-19 infections greatly burden medical doctors. Funding: None declared.

'I don't really understand this BP': Women's knowledge, attitudes, and experiences with preeclampsia in Ghana.

Preeclampsia and eclampsia are common and serious complications of pregnancies, often presenting as obstetric emergencies. In low- and middle-income countries, limited numbers of healthcare providers and a high volume of critically ill patients can negatively impact provider communication and counseling. Lack of knowledge or awareness of preeclampsia and eclampsia among pregnant women can lead to delays in health seeking behavior. Our study uses grounded theory to explore patients' experience of preeclampsia and eclampsia in a low-resource setting. Participants were postpartum women diagnosed with preeclampsia or eclampsia at Korle Bu Teaching Hospital in Ghana. Interviews consisted of semi-structured, open-ended questions regarding participant understanding of their diagnosis of preeclampsia and eclampsia; counseling from their healthcare providers; and experiences with their delivery, monitoring, and treatment. Qualitative thematic analysis was performed according to the Attride-Sterling analytical framework, using NVivo 12. A total of 45 women were interviewed, 88.9% with preeclampsia and 11.1% with eclampsia. Major themes identified include participants' low general knowledge of their diagnosis, inadequate counseling from healthcare providers, and resulting emotional distress. Women desire more information regarding their diagnosis and associate their health-seeking behaviors with counseling they receive from healthcare providers. Women also acknowledge the systemic barriers that make patient care and counseling challenging for providers, especially in low- and middle-income countries. These findings highlight the need for improved models of counseling and health education for women with pregnancies complicated by preeclampsia and eclampsia.

Barriers to adequate pain control among women with cervical cancer: exploring unmet pain control needs in Ghana.

BACKGROUND: Pain because of cervical cancer is a significant health issue globally, especially in women with advanced disease. However, little is known about unmet needs for pain control in low-resource settings where the burden of cervical cancer is the greatest. OBJECTIVE: This study aimed to quantify the level of pain that women with cervical cancer in Ghana experience, explore attitudes toward pain and pain medications, and determine the barriers to adequate pain control. STUDY DESIGN: A cross-sectional survey was conducted on 100 adult women with a histopathologic diagnosis of cervical cancer presenting for care at Komfo Anokye Teaching Hospital in Ghana. In addition, a descriptive analysis was conducted among all participants and the subgroup of women who reported pain but did not report pain medication use. RESULTS: Among 100 participants with cervical cancer, the mean age was 59.5 years, and the median parity was 6.0 (interquartile range, 5.0-6.0); moreover, most participants presented with inoperable stage II or greater cervical cancer (99 of 100 [99%]). Of 100 participants, 80 (80%) had pain caused by their cervical cancer, with more than half (51 of 100 [51%]) rating their pain as a 3, 4, or 5 on a 5-point scale. Most participants reported pain significant enough to impact their sleep (58 of 99 [58.6%]) and their ability to carry out daily activities (54 of 100 [54%]). Furthermore, 55 of 100 participants (55%) took pain medications in the last week; however, only 5 of 54 participants (9.3%) reported complete improvement in their pain, and most participants (30 of 54 [55.6%]) felt they needed a stronger pain medication. Barriers to adequate pain control included the healthcare provider's focus on pain, with 14.1% of women reporting that their healthcare providers never asked about their pain (14 of 99 [14.1%]). In addition, participants' attitudes toward pain control demonstrated that 34 of 95 participants (35.8%) believed that they should be able to tolerate their cervical cancer pain without medication. Among participants who ever took pain medication, 16 of 58 (27.6%) were bothered that they took pain medication, and 19 of 58 (32.7%) were concerned that they used too much medication. Most participants were able to afford (51 of 58 [88%]) and access (56 of 58 [96.6%]) pain medications and did not worry their supply would run out (56 of 58 [96.6%]). CONCLUSION: Most patients had significant pain because of cervical cancer, and many of them endorsed needing more pain medications than what they were prescribed. The etiologies of the unmet need for pain control included missed opportunities to discuss pain control at clinic visits and patients' attitudes toward pain management. Financial and access barriers to obtaining pain medications were minimal.