Edward Antwi

Care Decision Making of Frontline Providers of Maternal and Newborn Health Services in the Greater Accra Region of Ghana

Objectives To explore the “how” and “why” of care decision making by frontline providers of maternal and newborn services in the Greater Accra region of Ghana and determine appropriate interventions needed to support its quality and related maternal and neonatal outcomes. Methods A cross sectional and descriptive mixed method study involving a desk review of maternal and newborn care protocols and guidelines availability, focus group discussions and administration of a structured questionnaire and observational checklist to frontline providers of maternal and newborn care. Results Tacit knowledge or ‘mind lines’ was an important primary approach to care decision making. When available, protocols and guidelines were used as decision making aids, especially when they were simple handy tools and in situations where providers were not sure what their next step in management had to be. Expert opinion and peer consultation were also used through face to face discussions, phone calls, text messages, and occasional emails depending on the urgency and communication medium access. Health system constraints such as availability of staff, essential medicines, supplies and equipment; management issues (including leadership and interpersonal relations among staff), and barriers to referral were important influences in decision making. Frontline health providers welcomed the idea of interventions to support clinical decision making and made several proposals towards the development of such an intervention. They felt such an intervention ought to be multi-faceted to impact the multiple influences simultaneously. Effective interventions would also need to address immediate challenges as well as more long-term challenges influencing decision-making. Conclusion Supporting frontline worker clinical decision making for maternal and newborn services is an important but neglected aspect of improved quality of care towards attainment of MDG 4 & 5. A multi-faceted intervention is probably the best way to make a difference given the multiple inter-related issues.

Advancing the application of systems thinking in health: provider payment and service supply behaviour and incentives in the Ghana National Health Insurance Scheme – a systems approach

BackgroundAssuring equitable universal access to essential health services without exposure to undue financial hardship requires adequate resource mobilization, efficient use of resources, and attention to quality and responsiveness of services. The way providers are paid is a critical part of this process because it can create incentives and patterns of behaviour related to supply. The objective of this work was to describe provider behaviour related to supply of health services to insured clients in Ghana and the influence of provider payment methods on incentives and behaviour.MethodsA mixed methods study involving grey and published literature reviews, as well as health management information system and primary data collection and analysis was used. Primary data collection involved in-depth interviews, observations of time spent obtaining service, prescription analysis, and exit interviews with clients. Qualitative data was analysed manually to draw out themes, commonalities, and contrasts. Quantitative data was analysed in Excel and Stata. Causal loop and cause tree diagrams were used to develop a qualitative explanatory model of provider supply incentives and behaviour related to payment method in context.ResultsThere are multiple provider payment methods in the Ghanaian health system. National Health Insurance provider payment methods are the most recent additions. At the time of the study, the methods used nationwide were the Ghana Diagnostic Related Groupings payment for services and an itemized and standardized fee schedule for medicines. The influence of provider payment method on supply behaviour was sometimes intuitive and sometimes counter intuitive. It appeared to be related to context and the interaction of the methods with context and each other rather than linearly to any given method.ConclusionsAs countries work towards Universal Health Coverage, there is a need to holistically design, implement, and manage provider payment methods reforms from systems rather than linear perspectives, since the latter fail to recognize the effects of context and the between-methods and context interactions in producing net effects.

Maternal body mass index and adverse pregnancy outcomes: A ghanaian cohort study

To examine the association between maternal weight at <17 weeks gestation and maternal and infant outcomes of pregnancy, delivery, and the postpartum period in pregnant Ghanaian women.

Perinatal outcomes after hypertensive disorders in pregnancy in a low resource setting

The objective of this study was to evaluate perinatal outcomes of pregnancies complicated by hypertensive disorders in pregnancy in an urban sub‐Saharan African setting.

Development and validation of a prediction model for gestational hypertension in a Ghanaian cohort

Objective To develop and validate a prediction model for identifying women at increased risk of developing gestational hypertension (GH) in Ghana. Design A prospective study. We used frequencies for descriptive analysis, χ2 test for associations and logistic regression to derive the prediction model. Discrimination was estimated by the c-statistic. Calibration was assessed by calibration plot of actual versus predicted probability. Setting Primary care antenatal clinics in Ghana. Participants 2529 pregnant women in the development cohort and 647 pregnant women in the validation cohort. Inclusion criterion was women without chronic hypertension. Primary outcome Gestational hypertension. Results Predictors of GH were diastolic blood pressure, family history of hypertension in parents, history of GH in a previous pregnancy, parity, height and weight. The c-statistic of the original model was 0.70 (95% CI 0.67–0.74) and 0.68 (0.60 to 0.77) in the validation cohort. Calibration was good in both cohorts. The negative predictive value of women in the development cohort at high risk of GH was 92.0% compared to 94.0% in the validation cohort. Conclusions The prediction model showed adequate performance after validation in an independent cohort and can be used to classify women into high, moderate or low risk of developing GH. It contributes to efforts to provide clinical decision-making support to improve maternal health and birth outcomes.

Pregnancy Associated Plasma Protein-A and Placental Growth Factor in a Sub-Saharan African Population: A Nested Cross-Sectional Study.

Background Baseline distributions of pregnancy disorders’ biomarkers PlGF and PAPP-A levels are primarily based on Western European populations of Caucasian ethnicity. Differences in PAPP-A and PlGF concentrations by ethnicity have been observed, with increased levels in Afro-Caribbean, East Asian, and South Asian women. Baseline concentrations of sub-Saharan African women have not been evaluated. Objectives To investigate PlGF and PAPP-A in a sub-Saharan African population and assess the performance of existing reference values of PAPP-A and PlGF. Methods A nested cross-sectional study was conducted in two public hospitals in Accra, Ghana. Out of the original 1010 women enrolled in the cohort, 398 participants were eligible for inclusion with a normotensive singleton gestation and serum samples taken between 56–97 days of pregnancy. PAPP-A and PlGF concentrations were measured with an automated immunoassay. Multiple of the median (MoM) values corrected for gestation and maternal weight for PAPP-A and PlGF were calculated using reference values of a Dutch perinatal screening laboratory based on over 10.000 samples, and PlGF manufacturer reference values, respectively. Results The PAPP-A median MoM was 2.34 (interquartile range (IQR) 1.24–3.97). Median PlGF MoM was 1.25 (IQR 0.95–1.80). Median MoM values for PAPP-A and PlGF tended to be slightly different for various Ghanaian ethnic subgroups. Conclusions PAPP-A and PlGF MoM values appear to be substantially higher in a sub-Saharan African population compared to the Caucasian or Afro-Caribbean MoM values previously reported. The difference suggests the need for a specific correction factor for this population to avoid underestimation of risk for fetal aneuploidies or placental disorders when using PAPP-A and PlGF MoM for screening purposes.

Measuring regional and district variations in the incidence of pregnancy‐induced hypertension in Ghana: challenges, opportunities and implications for maternal and newborn health policy and programmes

The objectives were to assess the quality of health management information system (HMIS) data needed for assessment of local area variation in pregnancy‐induced hypertension (PIH) incidence and to describe district and regional variations in PIH incidence.

PP081. Predictors of pregnancy induced hypertension in an urban low resource setting

INTRODUCTION Hypertensive disorders in pregnancy, including Pregnancy Induced Hypertension (PIH), are important causes of morbidity and mortality in pregnancy. Identifying women at high risk will allow for early management to reduce complications of PIH. OBJECTIVES The objectives were to determine the incidence of PIH among pregnant women and develop risk prediction models for early detection of women at increased risk of PIH. METHODS A longitudinal cohort study involving 2539 pregnant women attending antenatal clinic in the Greater Accra region of Ghana was conducted between February and May 2010. The outcome, PIH, was defined as systolic or diastolic blood pressure BP of 140mmHg or 90mmHg respectively. Logistic regression was used to derive the prediction models and bootstrapping technique was used to internally validate them. A score chart was used to classify pregnant women into low, moderate and high risk of developing PIH. RESULTS The incidence of PIH was 8.0% (95% C.I: 7.98-8.02%) and 10.9% (95% C.I:10.89-10.91%) in nulliparous and multiparous women respectively. Systolic blood pressure, diastolic blood pressure, history of hypertension in parents, family history of diabetes, proteinuria, body mass index (BMI) were among independent predictors in early pregnancy of subsequent PIH. The prognostic performance, estimated by the area under the Receiver Operating Characteristic (ROC) curve, ranged between 0.64 and 0.84 for the models for nulliparous and multiparous. CONCLUSION Using a limited set of maternal characteristics, pregnant women at increased risk of developing PIH can be identified. Categorizing women by risk of PIH and providing tailored antenatal care will minimize complications of PIH.