ABOUT THE COUNTRY

Ghana is a West African country with 23 million inhabitants. It is English speaking, peaceful and has a stable, democratically elected government. It is famous for gold, cocoa, and historically was a major port for the slave trade. Maternal mortality in Ghana is estimated to be 560 deaths/100,000 live births, although reports vary from 220 to 750 deaths/100,000 live births.  The leading causes of maternal death are acute hemorrhage, sepsis, pre-eclampsia, obstructed labor, non-hemorrhagic anemia and unsafe abortion. Overall, 92 % of women attend at least one antenatal clinic, but only half of all deliveries are attended by a skilled health professional, such as a midwife or physician.   Neonatal mortality rates are 43/1000 live births with the majority caused by infection, asphyxia and prematurity. Despite Ghana leading many other African countries in efforts to improve maternal and child health, interventions to lower mortality have yielded slow results.

ABOUT OUR PROJECT (2004 - 2006)

In November 2004, three Kybele members visited Ghana at the invitation of Dr. Frank Boni, a consultant anesthesiologist at the University of Ghana’s teaching hospital, Korle Bu, to seek information and identify opportunities for long term collaboration. Three main referral hospitals were visited and staffing, training standards, facilities, equipment availability, and the conduct of anesthesia were observed. Seminars on maternal mortality and neonatal resuscitation were jointly conducted by a multi-disciplinary team of Ghanaian and Kybele faculty, and participants included obstetricians, anesthesia providers, pediatricians, nurses, midwifes, hospital administrators and health ministry representatives. Local, cultural and operational issues were highlighted

During the initial collaboration period (2005-2006), Kybele trips and activities in Ghana consisted of demonstrating anesthesia techniques and conducting neonatal resuscitation training programs at several hospitals. As the partnership evolved, it became clear that to improve childbirth conditions in Ghana, a more comprehensive strategic plan was required. This included: shifting from an anesthesia-focused to a multidisciplinary team, tri-annual visits with smaller teams to promote sustainability, a systems improvement approach incorporating definable, quantifiable metrics and creating “centers of excellence’, where two to three targeted hospitals would receive concentrated education and training to improve perinatal care. If successful, a model could be developed for replication throughout the health service. The Ghana Health Service supported this approach.

ABOUT OUR PROJECT (2007 - 2010)

In January 2007, Kybele entered a 5 year agreement with the Ghana Health Service to establish several obstetric centers of excellence with the goal of reducing by half the number of maternal and neonatal deaths. The program was titled “Making Obstetric Management Safer” (MOMS). The first center, Ridge Regional Hospital, is a main obstetric referral hospital in Accra with 8,000 annual births. Nearly 80% of the deliveries at Ridge are high risk referrals from other institutions, some extending beyond Greater Accra to contiguous regions. Ridge Hospital was selected based on interactions with the enthusiastic chief obstetrician in the hospital, who was motivated to create a platform for change to reduce maternal and newborn mortality.

In the first year of the agreement, Kybele analyzed Ridge Hospital’s systems and patient care processes. The year culminated when the chief obstetrician at Ridge was invited to visit three US-based institutions of key Kybele faculty.  Many ideas and recommendations for Ridge Hospital crystallized as a result of this visit.  Twelve specific areas for improvement were identified and a strategic template or “process map” was jointly constructed. This has helped all staff realize what aspects of patient care and systems management are being addressed. The template identifies the problems, recommends realistic solutions and charts progress towards defined goals.

WHAT WE ARE ACCOMPLISHING

Through utilization of the “process map”, there have been numerous quality improvements in the development of clinical guidelines and standard operating procedures, teaching and training, advocacy, research and patient centered care. A 35 % reduction in maternal mortality and 40 % reduction in institutional stillbirth have been achieved since beginning the program January 2007. This is in light of higher delivery rates and more complicated patients, particularly those with pregnancy induced hypertension and without significant staffing increases or infrastructure improvements. Simply, a framework for teamwork and efficiency has been built and key organizational changes have been made. Some of the improvements have included: fetal surveillance with ultrasound and electronic fetal monitoring, daily morning staff conference to discuss census and patient management in the obstetrics and gynecology ward, prompt triaging of patients on arrival for early detection of high risk problems, greater physician involvement in medically complicated patients, better dialogue between the obstetric and anesthetic teams in shared responsibility towards the obstetric patient, development and adherence to protocols, an increase in the delivery bed capacity from two to ten with the acquisition of convertible labor and delivery beds, earlier discharge of uncomplicated patients to the post natal ward and home vastly improving turnover. Additional topics that will receive ongoing focus are the following:

Improved customer care: A key aspect of the partnership has been to improve customer care. Initiatives have taken the form of lectures, behavioral modeling and recognition of staff who demonstrate excellent customer care practices. It bears emphasizing that working conditions remain stressful for the staff at Ridge Hospital. Many of the health workers are inundated with an excessive amount of work not plausible in more developed countries. As an example, the delivery rate exploded from under 3000 deliveries a year to over 8000 in 5 years, with minimal change in staff numbers. Despite this, many of the staff are committed to the principle of improved customer care and are making great strides to achieve this.

Computer based patient record: A computer based patient record system and database is in the trial stage of use by the nurse midwives. This program enables midwives to electronically enter patient data and automatically generate statistical reports. Currently all patient information is handwritten and recopied manually to various reports. Having a more efficient charting process will reduce the paperwork burden on the nurses and encourage more interaction with the patients.

Nurse anesthesia training program: Kybele has participated in the curriculum development for a new nurse anesthesia training program (only the third in the country) that began in October 2009 at Ridge Regional Hospital. One unique aspect of this program will be a special focus on training in the use of regional anesthesia techniques to relieve pain and improve safety for obstetric patients.

Improved critical care capacity: High risk parturients must have close surveillance in the peripartum period. Kybele faculty are working to develop critical care capacity at Ridge Hospital through the creation of a high dependency unit with enhanced nursing protocols and hemodynamic monitors.  

Process Replication: Having spent nearly five years understanding and addressing the issues that have impacted maternity care at Ridge Hospital and its referral base, Kybele has created a template for institutional assessment that recognizes problems, offers practical solutions and measures progress. In 2010, at the request of the Ghana Health Service, Kybele will expand our program to Sunyani, a city located in the Brong Ahofo region of the country.  Separate smaller teams will travel to Sunyani to observe practices and begin development of a second “Center of Excellence” based on the format at Ridge Hospital. The model that has been developed at Ridge needs to be validated and replicated in other hospital settings.  Visits are planned to Ridge and Sunyani in January, May and September 2010.

The success of the Kybele partnership to date has not been without the strong support of the Ghanaian government, both at the national and local level. Ultimately there is no single silver bullet to dramatically improve maternal and perinatal mortality in Ghana. Kybele believes that in the multitude of the smaller things that are recognized, quantified, corrected and measured, lasting differences can be achieved. None of these can be achieved without the cohesiveness of multidisciplinary teams committed to the same vision.  





References:

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Okiwelu T, Hussein J, Adjei S, Arhinful D, Armar-Klemesu M. Safe motherhood in Ghana: still on the agenda? Health Policy 2007; 84:359-67.

Lassey AT, Obed SA. Trends in concurrent maternal and perinatal deaths at a teaching hospital in Ghana: the facts and prevention strategies. J Obstet Gynaecol Can 2004; 26:799-804.

Ghana 2003: results from the Demographic and Health Survey. Stud Fam Plann 2005; 36:158-62.