Estimating obstetric and gynecologic surgical rate: A benchmark of surgical capacity building in Ghana

OBJECTIVE

To estimate the annual rate of obstetric and gynecologic (ObGyn) operations performed in Ghana and establish a baseline for tracking the expansion of Ghana's surgical capacity.

METHODS

Data were obtained for ObGyn operations performed in Ghana between 2014 and 2015 from a nationally representative sample of hospitals and scaled up for national estimates. Operations were classified as "essential" or "other" according to The World Bank's Disease Control Priorities Project. Data were used to calculate cesarean-to-total-operation ratio (CTR) and estimate the rate of cesarean deliveries based on the number of live births in 2014.

RESULTS

A total of 90 044 (95% uncertainty interval [UI] 69 461-110 628) ObGyn operations were performed nationally over the 1-year period, yielding an annual national ObGyn operation rate of 881/100 000 females aged 12 years and over (95% UI 679-1082). Eighty-seven percent were essential procedures, 80% of which were cesarean deliveries. District hospitals performed 71% of ObGyn operations. The national rate of cesarean deliveries was 7.2% and the CTR was 0.27.

CONCLUSION

The cesarean delivery rate of 7.2% suggests inadequate access to obstetric care. The CTR of 0.27 suggests inadequate overall surgical capacity. These measures, along with estimates of distribution of procedures by hospital level, provide useful baseline data to support surgical capacity building efforts in Ghana and similar countries.

Cross-cultural perspectives on the patient-provider relationship: a qualitative study exploring reflections from Ghanaian medical students following a clinical rotation in the United States

BACKGROUND

In international health experiences, learners are exposed to different culturally-based patient care models. Little is known about student perceptions of patient-provider interactions when they travel from low-to high-resource settings. The purpose of this study was to explore these reflections among a subset of Ghanaian medical students who participated in clinical rotations at the University of Michigan Medical School (UMMS).

METHODS

In-depth, semi-structured interviews lasting 60-90 min were conducted with 15 individuals who had participated in 3-to 4-week clinical rotations at UMMS between January 2008 and December 2011. Interviews were conducted from March to August 2012 and transcribed verbatim, then independently coded by three investigators. Investigators compared open codes and reached a consensus regarding major themes.

RESULTS

Participating Ghanaian medical students reported that their perspectives of the patient-provider relationship were significantly affected by participation in a UMMS rotation. Major thematic areas included: (1) observations of patient care during the UMMS rotation, including patient comfort and privacy, physician behavior toward patients, and patient behavior; (2) reflections on the role of humanism and respect within patient care; (3) barriers to respectful care; and (4) transformation of student behaviors and attitudes. Students also reported integrating more patient-centered care into their own medical practice upon return to Ghana

DISCUSSION

Participation in a US-based clinical rotation has the potential to introduce medical students from resource-limited settings to a different paradigm of patient-provider interactions, which may impact their future behavior and perspectives regarding patient care in their home countries.

CONCLUSIONS

Students from under-resourced settings can derive tremendous value from participation in clinical electives in more affluent settings, namely through exposure to a different type of medical care.

Perceptions of Ghanaian medical students completing a clinical elective at the University of Michigan Medical School

PROBLEM

International medical electives typically represent a unidirectional flow of students from economically advantaged countries in the global "North" to resource-poor nations in the global "South." Little is known about the impact of bilateral exchanges on students from less affluent nations.

APPROACH

Since 2007, students from the University of Michigan Medical School (UMMS) and medical schools in Ghana have engaged in a bilateral clinical exchange program. A 45-item online survey was distributed to all 73 Ghanaian medical students who had rotated at UMMS from 2008 to 2010 to assess perspectives on the value and impact of their participation.

OUTCOMES

Incoming Ghanaian students outnumbered outgoing UMMS students 73 to 33 during the study period. Of eligible Ghanaian students, 70% (51/73) participated in the survey, with 40 of 51 providing valid data on at least 50% of questions. Ninety-seven percent (37/38) reported that the UMMS rotation was valuable to their medical training, 90% (35/39) reported changes in how they approach patient care, and 77% (24/31) reported feeling better equipped to serve patients in their home community. Eighty-five percent of students (28/33) felt more inclined to pursue training opportunities outside of their home country after their rotation at UMMS.

NEXT STEPS

More studies are needed to determine the feasibility of bidirectional exchanges as well as the short-term and long-term impact of rotations on students from underresourced settings and their hosts in more resource-rich environments.

International family planning fellowship program: advanced training in family planning to reduce unsafe abortion

Maternal mortality remains a huge problem in the developing world, especially in Sub-Saharan Africa.1 According to the World Health Organization, efforts intended to decrease maternal deaths need to recognize and address unsafe abortions as a significant contributor to the high rates of maternal mortality found in developing countries.2,3 In Africa, where abortions are highly restricted, 680 women die per 100,000 abortions, compared with 0.2-1.2 women per 100,000 in developed countries, where most abortions are legal.4.

eNOSI4 and EPHX1 polymorphisms affect maternal susceptibility to preeclampsia: analysis of five polymorphisms predisposing to cardiovascular disease in 279 Caucasian and 241 African women

PURPOSE

The aim of this study was to evaluate possible associations of genetic polymorphisms predisposing to cardiovascular disease with the development and/or the severity of preeclampsia.

METHODS

A two hospital-based prospective case-control study was performed in Germany and Ghana. 470 blood samples of 250 Caucasian and 220 black African have been genotyped by pyrosequencing and fragment length analysis. We evaluated the distribution of the epoxide hydrolase 1 (EPHX1) polymorphism on exon 3, the endothelial nitric oxide synthase (eNOS) polymorphisms on exon 7 and on intron 4, the angiotensinogen polymorphism on exon 2 and the estrogen receptor 1 polymorphism in intron 1.

RESULTS

74 Caucasian and 84 African were classified as preeclampsia with 27 Caucasian developing a hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome and 17 African women experiencing eclampsia. Multivariate logistic regression analysis adjusting for ethnicity, age and parity revealed for carriers of eNOSI4 VNTR4a a 1.7-fold increased (95% CI 1.10-2.711, p = 0.016) risk to develop preeclampsia and a 3.6-fold increase for carriers of the EPHX1 113Tyr (95% CI 1.366-8.750, p = 0.009) to develop severest preeclampsia.

CONCLUSION

Our finding of eNOSI4 polymorphism predisposing to preeclampsia independently of ethnicity, age and parity supports the concept of NO being involved in the endothelial disorder preeclampsia. Since EPHX1 is highly expressed in the liver, can interact with various signaling pathways and is involved in central nervous system disorders, the association of EPHX1 polymorphism with the HELLP syndrome and eclampsia may hint to EPHX being a further key player in the pathogenesis of preeclampsia.

Group versus individual family planning counseling in Ghana: a randomized, noninferiority trial

BACKGROUND

Group, rather than individual, family planning counseling has the potential to increase family planning knowledge and use through more efficient use of limited human resources.

STUDY DESIGN

A randomized, noninferiority study design was utilized to identify whether group family planning counseling is as effective as individual family planning counseling in Ghana. Female gynecology patients were enrolled from two teaching hospitals in Ghana in June and July 2008. Patients were randomized to receive either group or individual family planning counseling. The primary outcome in this study was change in modern contraceptive method knowledge. Changes in family planning use intention before and after the intervention and intended method type were also explored.

RESULTS

Comparisons between the two study arms suggest that randomization was successful. The difference in change in modern contraceptive methods known from baseline to follow-up between the two study arms (group-individual), adjusted for study site, was -0.21, (95% confidence interval: -0.53 to 0.12) suggesting no difference between the two arms.

CONCLUSIONS

Group family planning counseling was as effective as individual family planning counseling in increasing modern contraceptive knowledge among female gynecology patients in Ghana.

Pathways to unsafe abortion in Ghana: the role of male partners, women and health care providers

BACKGROUND

Despite abortion being legal, complications from induced abortion are the second leading cause of maternal mortality in Ghana. The objective of this study was to understand the decision-making process associated with induced abortion in Ghana.

STUDY DESIGN

Data were collected from female postabortion patients, male partners, family planning nurses and obstetricians/gynecologists at two teaching hospitals in Ghana using in-depth interviews and focus group discussions.

RESULTS

While experiences differ for married and single women, men are involved in abortion decision making directly, through "orders" to abort, or indirectly, through denying responsibility for the pregnancy. Health care providers can be barriers to seeking safe abortions in this setting.

CONCLUSIONS

Women who choose to terminate a pregnancy without their male partners' knowledge should have the means (both financial and social) to do so safely. Interventions with health care providers should discourage judgemental attitudes and emphasize individually focused patient care.

Reproductive experiences of teenagers in the Ejisu-Juabeng district of Ghana

OBJECTIVE

To determine the proportions of male and female teenagers aged 15-19 years who have ever been involved in pregnancy, and to examine factors associated with involvement in teenage pregnancy in the Ejisu-Juabeng district of Ghana.

METHODS

In a household-based cross-sectional survey, 481 randomly selected male and female teenagers were enrolled between August 3 and September 17, 2009. Study variables included demographics; sexual exposure; contraceptive use; and involvement in pregnancy, childbirth, and induced abortion. Multivariable multinomial logistic regression analyses were used to examine the association between involvement in pregnancy, and the background and reproductive profiles of the respondents via SPSS version 16.0.

RESULTS

Both the mean and median ages of the respondents were 17.2 years. One-third of respondents lived with both parents, and one-third lived with single mothers. The median age of sexual debut was 16.0 years. Approximately 58% of sexually experienced females had been pregnant, and 37% had had an induced abortion. Age at sexual debut, gender, and being out of school were significantly associated with involvement in teenage pregnancy, whereas residential status, relationship with first partner, and contraceptive use were not.

CONCLUSION

Keeping adolescents enrolled in school might reduce their risk of involvement in pregnancy in the Ejisu-Juabeng district of Ghana.

Radiotracer investigation in gold leaching tanks

Measurement and analysis of residence time distribution (RTD) is a classical method to investigate performance of chemical reactors. In the present investigation, the radioactive tracer technique was used to measure the RTD of aqueous phase in a series of gold leaching tanks at the Damang gold processing plant in Ghana. The objective of the investigation was to measure the effective volume of each tank and validate the design data after recent process intensification or revamping of the plant. I-131 was used as a radioactive tracer and was instantaneously injected into the feed stream of the first tank and monitored at the outlet of different tanks. Both sampling and online measurement methods were used to monitor the tracer concentration. The results of measurements indicated that both the methods provided identical RTD curves. The mean residence time (MRT) and effective volume of each tank was estimated. The tanks-in-series model with exchange between active and stagnant volume was used and found suitable to describe the flow structure of aqueous phase in the tanks. The estimated effective volume of the tanks and high degree of mixing in tanks could validate the design data and confirmed the expectation of the plant engineer after intensification of the process.

A comparison of women with induced abortion, spontaneous abortion and ectopic pregnancy in Ghana

BACKGROUND

Despite having one of the most liberal abortion laws in sub-Saharan Africa, complications from induced abortion are the second leading cause of maternal mortality in Ghana.

STUDY DESIGN

The sample is composed of patients with pregnancy termination complications in Ghana between June and July 2008. The majority of patients report having had a spontaneous abortion (75%; n=439), while 17% (n=100) and 8% (n=46) report having had an induced abortion or an ectopic pregnancy, respectively. Factors associated with women in each of the three groups were explored using multinomial logistic regression.

RESULTS

When compared to women with spontaneous abortions, women with induced abortions were younger, poorer, more likely to report no religious affiliation, less likely to be married, more likely to report making the household decisions and more likely to fail to disclose this pregnancy to their partners. Within the induced abortion subsample, failure to disclose the most recent pregnancy was associated with already having children and autonomous household decision making.

CONCLUSION

Identifying the individual and relationship characteristics of induced abortion patients is the first step toward targeted policies and programs aimed at reducing unsafe abortion in Ghana.

Attitude of women with abortion-related complications toward provision of safe abortion services in Ghana

OBJECTIVES

To determine the attitude and perception of women with abortion-related complications toward the provision of safe abortion services, their sociodemographic characteristics, and their awareness of the law permitting abortion under certain circumstances in Ghana.

METHODS

A cross-sectional study using a standardized questionnaire was conducted over a 2-month period among patients admitted with abortion-related complications at Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana.

RESULTS

Abortion-related complications accounted for 42.7% of admissions to the gynecological ward. The median age of the women was 26 years. Of the 296 patients interviewed, 28% reported induced abortion in the index pregnancy, 29% were not married, 30% had no formal education, and 92% were not aware of the current legal status of abortion in Ghana. They thought there was the need to provide safe abortion services in the country, and almost all of them were willing to patronize such services.

CONCLUSIONS

Awareness of the current legal status of abortion was lacking among women with abortion-related complications attending a tertiary center in Kumasi. However, the provision of safe abortion services was much needed in this population.

Chlamydia trachomatis infection as a risk factor for infertility among women in Ghana, West Africa

In developing countries, data about the prevalence of genital Chlamydia trachomatis infections and their sequelae, especially tubal infertility, is scarce. A prospective case-control study was performed enrolling 439 Ghanaian women. The case group included 191 patients with primary or secondary infertility. The control group consisted of 248 healthy pregnant women. First-void urine samples were investigated by PCR, and serum specimens were tested for C. trachomatis-specific IgG and IgA antibodies. Demographic and behavioral information were gathered for statistical analysis. The PCR prevalence of C. trachomatis was relatively low and did not differ significantly among both groups (2.4 versus 1.6%). In contrast, significantly higher prevalences of specific IgG (39% versus 19%) and IgA (14% versus 3%) antibodies were found among infertile women. The adjusted odds ratios were 2.1 and 2.8, respectively. Our data suggest that previous C. trachomatis infections may contribute to infertility in Ghanaian women.

Attitudes of doctors toward establishing safe abortion units in Ghana

OBJECTIVES

To assess physician knowledge of the current legal status of abortion in Ghana and determine the proportion physicians in favor of establishing units where safe abortion would be provided, and the proportion of those willing to offer such services.

METHODS

A survey conducted at Komfo Anokye Teaching Hospital, Ghana, in August 2003. Using a self-administered questionnaire, 74 randomly selected physicians expressed their views on whether abortion units should be established within national health facilities in Ghana, and what role they would play in them.

RESULTS

Of the 59 physicians (80%) who favored the establishment of safe abortion units within national health facilities, 27 (36%) indicated a willingness to take part in counseling only, 33 (45%) were prepared to carry out abortions, and 14 (19%) said they would play no role in these units.

CONCLUSION

Most physicians participating in this study conducted in Ghana were willing to play some role in the provision of safe abortion services.

Asymptomatic bacteriuria in pregnant women attending antenatal clinic at komfo anokye teaching hospital, kumasi, ghana

SUMMARY OBJECTIVE

Symptomatic bacteriuria is common in pregnant women and if untreated could lead to serious complications. Although asymptomatic bacteriuria could also lead to such complications, this fact is not so well known. This study was to determine the prevalence of asymptomatic bacteriuria in pregnant women attending antenatal clinic at the Komfo Anokye Teaching Hospital (KATH) Kumasi.

DESIGN

A prospective study to screen antenatal attendants for asymptomatic bacteriuria.

SETTING

The study was undertaken at KATH.

PARTICIPANTS

All pregnant women attending antenatal clinic at KATH, Kumasi between February and April 2003 and who agreed to enter the study were clinically evaluated to exclude signs and symptoms of urinary tract infection (UTI).

METHODS

Samples of 10-15ml urine were examined for pus cells, bacteria and parasitic ova. The samples were further cultured on cysteine lactose electrolyte deficient agar and colony counts yielding bacterial growth of 10(5)/ml or more of pure isolates were deemed significant.

RESULTS

Of the 220 pregnant women, 16 had significant bacteriuria giving a prevalence rate of 7.3%. The highest age-specific prevalence was found in the 35-39 year-olds (13%) and the lowest in the 15-19 year-olds (0.0%). There was no significant difference in prevalence with increasing parity. The dominant bacteria isolates were E. coli (37%) and Staph aureus (31%).

CONCLUSION

The prevalence of asymptomatic bacteriuria in pregnant women at KATH is 7.3%. The predominant organisms are E.coli and Staph aureus, and most isolates are sensitive to nitrofurantoin, cefuroxime and gentamicin.

Comparison of latex agglutination, wet preparation, and culture for the detection of Trichomonas vaginalis

OBJECTIVES

To compare the performance of three diagnostic methods for Trichomonas vaginalis infection-latex agglutination, saline wet mount, and culture.

METHODS

Vaginal swabs from 3807 women attending antenatal clinics were tested for the presence of T vaginalis by latex agglutination. All positives and the following two negatives were tested by wet preparation and culture.

RESULTS

The prevalence of infection by latex agglutination was 5.4%. Using an expanded gold standard based on the wet mount and culture results, the sensitivity of the latex agglutination test was 98.8% (95% CI 95.9 to 99.9) and specificity was 92.1 (89.2 to 94.5). The kappa index for test agreement was 0.93 for latex and culture and 0.88 for latex and wet preparation.

CONCLUSION

The latex agglutination test is a highly sensitive test for detecting T vaginalis infection. It is a simple rapid test and has the potential for use in screening and diagnostic settings.

Ghana postgraduate obstetrics/gynecology collaborative residency training program: success story and model for Africa

OBJECTIVE

We describe a residency program in Ghana that was developed to train obstetrics/gynecologist specialists for Ghana and the subregion to promote and manage the reproductive health of women and to reduce a high maternal mortality rate.

STUDY DESIGN

The Carnegie-supported program, begun in 1989, is a 5-year residency in the two medical schools in Ghana, but with one central coordinating office. It has features that equip the graduate resident to practice in his/her environment. The fourth year of the program is unique: the resident attends a hospital management course for 3 months, goes for a clinical rotation in the United States or United Kingdom for 3 months, and moves to live and work in a rural district hospital for 6 months.

RESULTS

The success rate of the Ghanaian residents in the examination of the West African College of Surgeons has been three to four times higher than the overall pass rate. As of October 2002, the program had produced 26 specialists, all of whom are practicing in Ghana. In contrast, of 30 specialists who were trained abroad between 1960 and 1980, only 3 specialist had returned home by the end of the 1980s. The current chairpersons of the two medical schools are graduates of the program. Carnegie financial support for the program came to an end in January 2000, but the Ghana Ministry of Health has increased its support enthusiastically. The program is being sustained. Maternal mortality and morbidity rates are falling slowly in the two teaching hospitals; case fatality rates have been reduced markedly. New residents are entering the program and are progressing to completion.

CONCLUSION

The program has been an unqualified success and merits replication.

The epidemiology of genitourinary fistulae in Kumasi, Ghana, 1977-1992

The aim of the study was to determine the clinical epidemiology of genitourinary fistulae as seen at Komfo Anokye Teaching Hospital in Kumasi, Ghana. A retrospective study was carried out from the hospital records and operative reports of all patients with genitourinary fistulae seen at Komfo Anokye Teaching Hospital between January 1977 and December 1992. Patient age, parity, type of fistula and cause of fistula were abstracted from the medical records. There were 164 cases of genitourinary fistula managed during the study period. There were 150 fistulae due to obstetric causes (91, 5%), the vast majority of which were due to prolonged obstructed labor (121 cases, 73.8% of all fistulae), with a minority related to complications of lower-segment cesarean section (14 cases, 8.5% of all fistulae). In 5 cases (3.1%) patients developed a rectovaginal fistula owing to perineal tears and prolonged obstructed labor. During this time period there were 157,449 deliveries, giving an obstetric fistula rate of 1 fistula per 1000 deliveries. Obstetric fistulae were most common at the extremes of reproductive age and parity Fourteen additional fistulae (8.5% of all cases) were due to gynecologic causes, most commonly from surgical injury occurring at the time of abdominal hysterectomy for leiomyomata uteri (12 cases, 7.3% of all fistulae). It was concluded that in Kumasi, Ghana, obstetric trauma from prolonged obstructed labor is the most common cause of genitourinary fistula formation. Such fistulae occur in older multiparous women as well in young primigravidae. Obstructed labour can, and does, occur in women who have previously undergone uneventful vaginal delivery. Birth attendants should be aware of that fact. Prompt referral for obstetric intervention should be made in obstructed labor, irrespective of the age and parity of the patient.