RESUMO
BACKGROUND: Weak referral systems remain a major concern influencing timely access to the appropriate level of care during obstetric emergencies, particularly for Low-and Middle-Income Countries, including Ghana. It is a serious factor threatening the achievement of the maternal health Sustainable Development Goal. The objective of this study is to establish process details of emergency obstetric referral systems across different levels of public healthcare facilities to deepen understanding of systemic barriers and preliminary solutions in an urban district, using Ablekuma in Accra, Ghana as a case study. METHODS: The study is an analytical cross-sectional study. Nine [1] targeted interviews were carried out for a three-week period in June and July 2019 after informed written consent with two [2] Obstetrics & Gynaecology consultants, two [2] Residents, one family physician, and four [3] Midwives managing emergency obstetric referral across different levels of facilities. Purposeful sampling technique was used to collect data that included a narration of the referral process, and challenges experienced with each step. Qualitative data was transcribed, coded by topics and thematically analysed. Transcribed narratives were used to draft a process map and analyze the defects within the emergency obstetric referral system. RESULTS: Out of the 34 main activities in the referral process within the facilities, the study identified that 24 (70%) had a range of barriers in relation to communication, transport system, resources (space, equipment and physical structures), staffing (numbers and attitude), Healthcare providers (HCP) knowledge and compliance to referral policy and guideline, and financing for referral. These findings have implication on delay in accessing care. HCP suggested that strengthening communication and coordination, reviewing referral policy, training of all stakeholders and provision of essential resources would be beneficial. CONCLUSION: Our findings clearly establish that the emergency obstetric referral system between a typical teaching hospital in an urban district of Accra-Ghana and peripheral referral facilities, is functioning far below optimum levels. This suggests that the formulation and implementation of policies should be focused around structural and process improvement interventions, strengthening collaborations, communication and transport along the referral pathway. These suggestions are likely to ensure that women receive timely and quality care.
Assuntos
Emergências , Encaminhamento e Consulta , Continuidade da Assistência ao Paciente , Estudos Transversais , Atenção à Saúde , Feminino , Gana , Acessibilidade aos Serviços de Saúde , Humanos , GravidezRESUMO
Maternal death is a major global health issue with the highest impact in low-income countries. Despite some modest decline in the maternal mortality rates in Ghana since the 1990's, this has been below expectation. The aim of this study was to describe the trends and contributory factors to maternal mortality at the Korle Bu Teaching Hospital (KBTH), Accra, Ghana. We performed a retrospective chart review of all maternal deaths at KBTH from 2015 to 2019. Data were analyzed using SPSS version 23. A p-value of <0.05 was considered statistically significant. Over the period, there were 45,676 live births, 276 maternal deaths and a maternal mortality ratio of 604/100,000 live births (95% CI: 590/100,000 - 739/100,000). The leading causes of maternal death were hypertensive disorders (37.3%), hemorrhage (20.6%), Sickle cell disease (8.3%), sepsis (8.3%), and pulmonary embolism (8.0%). Significant factors associated with maternal mortalities at the KBTH were: women with no formal education [AOR 3.23 (CI: 1.73- 7.61)], women who had less than four antenatal visits [AOR 1.93(CI: 1.23-3.03)], and emergency cesarean section [AOR 3.87(CI: 2.51-5.98)]. Hypertensive disorders remain the commonest cause of the high maternal mortality at KBTH. Formal education and improvement in antenatal visits may help prevent these deaths.
Assuntos
Hospitais de Ensino/estatística & dados numéricos , Morte Materna/estatística & dados numéricos , Mortalidade Materna , Complicações na Gravidez/mortalidade , Adolescente , Adulto , Causas de Morte , Feminino , Gana/epidemiologia , Humanos , Hipertensão Induzida pela Gravidez/mortalidade , Morte Materna/etnologia , Paridade , Gravidez , Estudos Retrospectivos , Adulto JovemRESUMO
In Africa, the maternal mortality rate in sickle cell disease (SCD) is ~10%. Our team previously demonstrated an 89% decrease in mortality rate in a before-and-after feasibility study among women with SCD living in low-resource setting in Ghana. In the same cohort including additional participants with and without SCD, we used a prospective cohort design to test the hypothesis that implementing a multidisciplinary care team for pregnant women with SCD in low-resource setting will result in similar maternal and perinatal mortality rates compared to women without SCD. We prospectively enrolled pregnant women with and without SCD or trait and followed them up for 6-week postpartum. We tested the newborns of mothers with SCD for SCD. We recruited age and parity matched pregnant women without SCD or trait as the comparison group. Maternal and perinatal mortality rates were the primary outcomes. A total of 149 pregnant women with SCD (HbSS, 54; HbSC, 95) and 117 pregnant women without SCD or trait were included in the analysis. Post-intervention, maternal mortality rates were 1.3% and 0.9% in women with and without SCD, respectively (P = 1.00); the perinatal mortality rates were 7.4% and 3.4% for women with and without SCD, respectively (P = 0.164). Among the mothers with SCD, ~15% of newborns had SCD. Multidisciplinary care of pregnant women with SCD may reduce maternal and perinatal mortality rates to similar levels in pregnant women without SCD in low-resource settings. Newborns of mothers with SCD have a high rate of SCD.
Assuntos
Anemia Falciforme/mortalidade , Recursos em Saúde , Complicações Hematológicas na Gravidez/mortalidade , Resultado da Gravidez , Adulto , África , Estudos de Casos e Controles , Feminino , Humanos , Recém-Nascido , Mortalidade Materna , Mortalidade Perinatal , Gravidez , Estudos ProspectivosRESUMO
Sickle cell disease (SCD) is associated with adverse pregnancy outcome. In women with SCD living in low-resource settings, pregnancy is associated with significantly increased maternal and perinatal mortality rates. We tested the hypothesis that implementing a multidisciplinary obstetric and hematology care team in a low-resource setting would significantly reduce maternal and perinatal mortality rates. We conducted a before-and-after study, at the Korle-Bu Teaching Hospital in Accra, Ghana, to evaluate the effect of a multidisciplinary obstetric-hematology care team for women with SCD in a combined SCD-Obstetric Clinic. The pre-intervention period was assessed through a retrospective chart review to identify every death and the post-intervention period was assessed prospectively. Interventions consisted of joint obstetrician and hematologist outpatient and acute inpatient reviews, close maternal and fetal surveillance, and simple protocols for management of acute chest syndrome and acute pain episodes. Primary outcomes included maternal and perinatal mortality rates before and after the study period. A total of 158 and 90 pregnant women with SCD were evaluated in the pre- and post- intervention periods, respectively. The maternal mortality rate decreased from 10 791 per 100 000 live births at pre-intervention to 1176 per 100 000 at post-intervention, representing a risk reduction of 89.1% (P = 0.007). Perinatal mortality decreased from 60.8 per 1000 total births at pre-intervention to 23.0 per 1000 at post-intervention, representing a risk reduction of 62.2% (P = 0.20). A multidisciplinary obstetric and hematology team approach can dramatically reduce maternal and perinatal mortality in a low-resource setting.
Assuntos
Síndrome Torácica Aguda/mortalidade , Síndrome Torácica Aguda/terapia , Complicações Hematológicas na Gravidez/mortalidade , Complicações Hematológicas na Gravidez/terapia , Adolescente , Adulto , Feminino , Humanos , Recém-Nascido , Mortalidade Materna , Mortalidade Perinatal , Gravidez , Estudos Prospectivos , Estudos RetrospectivosAssuntos
Síndrome Torácica Aguda/epidemiologia , Anemia Falciforme/epidemiologia , Período Pós-Parto , Complicações Hematológicas na Gravidez/epidemiologia , Terceiro Trimestre da Gravidez , Transtornos Puerperais/epidemiologia , Síndrome Torácica Aguda/etiologia , Adulto , Anemia Falciforme/complicações , Feminino , Seguimentos , Doença da Hemoglobina C/complicações , Doença da Hemoglobina C/epidemiologia , Hospitalização/estatística & dados numéricos , Humanos , Incidência , Gravidez , Estudos Prospectivos , Traço Falciforme/complicações , Traço Falciforme/epidemiologia , Análise de Sobrevida , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/etiologia , Adulto JovemRESUMO
OBJECTIVE: Adolescent pregnancy is a major social and public health problem that burdens affected families, the communities and societies globally. It has been associated with a higher prevalence of adverse pregnancy outcomes compared to pregnancy in adults. To compare adverse pregnancy outcomes in adolescents (13-19 years) and those in adults (20 to 35 years) at the Korle-Bu Teaching Hospital in Accra, Ghana and investigate the associated factors among adolescents. METHODS: This comparative study involved 110 adolescents (13-19 years) and 220 adults (20 to 35 years) who delivered at the Maternity Unit of the Korle-Bu Teaching Hospital between November 2016 and February 2017. Participants were recruited using the convenience sampling method. After study protocol was explained to the parturient, informed voluntary consent and assent were obtained. Participants who met the inclusion criteria were recruited in the study. Sociodemographic characteristics, antenatal and delivery records; and maternal and perinatal outcomes were collected using an interviewer administered questionnaire and the participants' records. Data analysis was done using SPSS version 16.0. RESULTS: The prevalence of adolescent pregnancies during the study period was 5.1%. Compared to adults, adolescents were about 3 times more likely to have eclampsia although preeclampsia occurred more in adults. Adolescents that resided in sub-urban dwellings were more likely to have an adverse perinatal outcome compared to their adult counterparts. CONCLUSION: Our study found that, in addition to their socioeconomic and biophysical disadvantages, adolescents were likely to have exceptionally high risk of eclampsia.
Assuntos
Resultado da Gravidez , Gravidez na Adolescência , Humanos , Feminino , Gravidez , Adolescente , Adulto , Adulto Jovem , Resultado da Gravidez/epidemiologia , Gravidez na Adolescência/estatística & dados numéricos , Recém-Nascido , Gana/epidemiologia , África Subsaariana/epidemiologia , Mães/estatística & dados numéricos , Pré-Eclâmpsia/epidemiologia , Complicações na Gravidez/epidemiologia , Prevalência , Eclampsia/epidemiologiaRESUMO
Wilms tumor (WT) occurring in adults is rare and even much more rarely found to coexist with pregnancy. Clinical outcome in adults is worse overall compared with pediatric patients with WT and is often misdiagnosed with no standardized protocols for care guided by high-evidence clinical trials. We present a case of a 23-year-old woman diagnosed with WT who was found to be pregnant immediately following nephrectomy. Workup findings showed that she had disseminated disease but was successfully managed in a multidisciplinary team setting with modified intrapartum chemotherapy followed by postpartum chemotherapy. In low-resource settings, management protocols for adult patients with WT can be individualized by multidisciplinary teams to leverage available resources for best outcomes.
Assuntos
Neoplasias Renais , Tumor de Wilms , Feminino , Humanos , Gravidez , Adulto Jovem , Neoplasias Renais/terapia , Neoplasias Renais/tratamento farmacológico , Nefrectomia , Tumor de Wilms/diagnóstico , Tumor de Wilms/terapia , Tumor de Wilms/patologiaAssuntos
Anemia Falciforme/mortalidade , Causas de Morte , Síndrome Torácica Aguda/mortalidade , Adulto , África Subsaariana/epidemiologia , Anemia Falciforme/complicações , Anemia Falciforme/epidemiologia , Feminino , Hospitalização , Humanos , Fenótipo , Gravidez , Complicações Hematológicas na Gravidez/mortalidade , Tromboembolia/mortalidade , Adulto JovemRESUMO
Pregnancy in women with sickle cell disease (SCD) is a life-threatening condition. In both high- and low-income countries, there is an 11-fold increased risk of maternal death and a 4-fold increased risk of perinatal death. We highlight the epidemiology of SCD-specific and obstetric complications commonly seen during pregnancy in SCD and propose definitions for acute pain and acute chest syndrome (ACS) episodes during pregnancy. We conducted a systematic review of the recent obstetric and hematology literature using full research articles published within the last 5 years that reported outcomes in pregnant women with SCD. The prevalence of acute pain episodes during pregnancy ranged between 4% and 75%. The prevalence of ACS episodes during pregnancy ranged between 4% and 13%. The estimated prevalence of pulmonary thromboembolism in women with SCD during pregnancy is approximately 0.5 to 1%. ACS is the most common cause of death and is often preceded by acute pain episodes. The most crucial time to develop these complications in pregnancy is during the third trimester and postpartum period. In a pooled analysis from studies in low- and middle-income settings, maternal death in women with SCD is approximately 2393 and 4300 deaths per 100 000 live births with and without multidisciplinary care, respectively. In comparison, in the US and northern Europe, the general maternal mortality rate is approximately 23.8 and 8 deaths per 100 000 live births, respectively. A multidisciplinary SCD obstetrics care approach reduces maternal and perinatal morbidity and mortality in low- and middle-income countries.