Referrals for obstetrical complications from Ejisu district, Ghana.

A study of referrals due to obstetrical complications from the Ejisu district, Ashanti region, Ghana was done to determine the institutions that receive them, their outcome and the effectiveness of the referral system. This formed part of a multidisciplinary research on the prevention of maternal mortality in the district. It covered 15 health facilities in the district. The receiving institutions identified in the study were Komfo Anokye teaching Hospital (KATH) in Kumasi, Agogo Presbyterian Hospital in the neighbouring Ashanti Akim district and the St. Michael's Hospital at Pramso in the same district. In the period under review, there were 192 referrals from the district, 139 to KATH with 87 (63%) reporting, 19 to Pramso with 14 (74%) reporting and 34 to Agogo with 17 (50%) reporting. The 3 most important complications referred were maternal haemorrhage (29%), high-risk pregnancy (24%) and delayed second stage (21%). The referring institutions had a defaulting rate varying from 8-56% with a median of 42%. This study did not specifically investigate the factors influencing the high defaulting rates in some institutions. However, focus-group discussions (FGDs) held in selected communities revealed the following factors as inhibiting the utilization of health services: * prohibitive hospital fees; * illegal fees and bribes; * irregular transport and uncooperative drivers; * poor and unmotorable roads; * lack of drugs and essential supplies and; * negative staff attitudes. Those health facilities with low defaulting rates had their own transport or were close to major trunk roads. From the study, the referral system was very weak. It is also possible that some of the referrals reported at the receiving institutions but were not classified as such. Interventions to improve the situation are currently being implemented.

Perceptions of caretakers of pre-school children on acute respiratory infection (ARI) in a rural district in Ghana.

Focus group discussions, key informant interviews and structured community interviews were used to describe the perceptions of caretakers of pre-school children in a predominantly rural district in Ghana. Over 75% considered ARI important in the community and there are a variety of local terms of describe various ARI illness entities. The perception of signs of severe ARI in children above two months of age was reasonably high; over 88% could mention at least one of two cardinal signs for severe ARI (difficulty in breathing, rapid breathing). The same cannot be said of their perception of signs for children less than two months of age. There was also a favourable perception of cause; a few misconceptions were however identified. There was no significant difference in perception between locality, age groups and educational levels. A high correlation between perception of cause and prevention of ARI was found. Health education programmes should re-enforce positive perceptions and address misconceptions. The difference in presentation of signs of severe ARI between older children and younger ones should also be stressed.

Improving recordkeeping for maternal mortality programs, Kumasi, Ghana. The Kumasi PMM Team.

PRELIMINARY STUDIES: Data on obstetric complications are the basis of monitoring maternal mortality interventions in the PMM Network. A review of recordkeeping procedures at 10 facilities in the study area revealed that information on obstetric complications was often inconsistent or missing. Some hospital records were not designed to collect such information at all. INTERVENTIONS: In 1992, registers at facilities were revised to collect information on complications and time of treatment. Doctors, nurses, midwives and clerks were trained to record, compile and analyze data. Monitoring and supervisory mechanisms were also set up. RESULTS: Recordkeeping has improved. Data collection and analysis have been regular and timely. Doctors have begun using the data for morning meetings. Nurses and midwives compile monthly summaries of data showing complications by type. Two other districts outside the research area have adopted the reporting system and it is possible that facilities in the whole region will follow suit. COSTS: The cost of improving recordkeeping at the 10 healthcare facilities was approximately US $2543, with 85% coming from project funds. CONCLUSIONS: Existing recordkeeping systems can be modified to collect data necessary to monitor maternal mortality interventions. Staff training and monitoring visits are important to success.

Community education to improve utilization of emergency obstetric services in Ghana. The Kumasi PMM Team.

PRELIMINARY STUDIES: Focus group studies in the Ashanti region showed that people avoided utilizing health facilities because of lack of confidence in the services and concern about the availability of drugs and supplies, among other reasons. INTERVENTIONS: After services at the health center were upgraded, community education activities began in early 1994. These activities were carried out through existing mechanisms--e.g. Ministry of Health (MOH) outreach workers and village health workers, public health nurses and midwives, and village health committees. They addressed a variety of audiences, including women's and church groups, emphasizing early recognition and treatment of obstetric complications, and the improved availability of services. RESULTS: The number of women with obstetric complications admitted to the health center rose from 26 in 1993 to 73 in 1995. It was the impression of the health center staff that women were also coming for treatment more promptly. COSTS: The cost of this intervention was US$1950. This was mostly project funds, with the government and community together contributing approximately one-fifth. CONCLUSIONS: Once services are available, community education and information activities can enhance utilization. The cost of such activities can be reduced, and sustainability promoted, by involving MOH personnel and community groups.

PROFILE: Indigenous Institutions and Environmental Assessment: The Caseof Ghana

/ The search for sustainable development provides the impetus forexamining the role of indigenous institutions and their ecological knowledgein environmental assessment and local sustainability. This paper attempts totrace the evolution of environmental assessment in Ghana. Focusing on theAshanti Region, the paper further discusses the nature and operations ofindigenous institutions, their ecological knowledge, beliefs, practices, andsocial norms that are relevant to environmental assessment process in thecountry. Some of the challenges that emerge from the discussions arehighlighted. There is a need to establish environmental assessment andcooperative management boards that would include representatives ofindigenous institutions. In addition, the introduction of technicaldictionaries and training manuals based on indigenous ecological knowledgeand their humane environmental practices will further improve theenvironmental assessment process in Ghana.KEY WORDS: Environmental assessment; Indigenous institutions; Indigenousecological knowledge; Sustainable development; Environmental assessmentboards

Intended response of caretakers of pre-school children to acute respiratory infection in a rural district in Ghana.

Caretakers of pre-school children were interviewed in Afigya Sekyere district, Ghana. Over 46% (n = 400) will buy drugs and 33% will use various herbs for mild ARI at home. Food is withheld during ARI episodes and few will attempt to treat perceived severe ARI at home. No association was found between knowledge of signs or causation of ARI and intended practice for mild and severe ARI. Finance and poor attitude of health workers were major concerns expressed by caretakers in seeking help from the orthodox health system.

Utilization of maternal health services in Ejisu District, Ghana.

A study on the utilization of maternal health services in Ejisu district of Ghana was carried out in January and February 1990. 1200 women aged between 15 and 49 were interviewed in 80 communities. The findings of the study indicated that over 50% of respondents married under 20 years, 70% of them attended antenatal clinic at least 4 times in their last pregnancy, over 80% had their last delivery in a health facility and over 80% knew about at least one modern method of family planning. Only 5.5% were currently using a modern family planning method. 90% of them were willing to stay in a maternity waiting home if advised to do so. Most would be prepared to stay for a month or 2. 20% of the respondents knew about local herbal preparations used for first aid in bleeding in pregnancy, although they would seek definitive treatment at a health facility. From the study, some women were not using the services. These would have to be reached through improving the quality of care in health facilities and increasing community awareness on maternal health in order to improve accessibility and utilization further.

PIP: This operations research project on the use of maternal health care services in Ejisu district in Ghana was performed during January and February 1990. The sample was comprised of 1200 women from 80 communities (population 131,199 persons in 1984) in the district, which has 19 health facilities (a Catholic mission hospital, 8 government health centers, 5 mission clinics, and 3 private maternity homes serving a population in 160 communities). Retrospective data was collected on health service use during January 1985-December 1989. Characteristics of the sample population included 59% 20-34 years old, 11% younger than 20, and 33% with no formal education. 37.9% were farmers, 26.7% were housewives, and 25% were traders. 74% were married. 50.3% married before the age of 20. 70.9% made at least 4 visits for prenatal care before their last pregnancy. 17.3% did not receive any prenatal care. 33.3% delivered at a health center. 28% used a Government Maternity Home, 22% used a hospital, and 13% relied on traditional birth attendants at home. 29% (349 women) reported complaints during their last pregnancy. 85.5% knew at least 1 method of contraception. 5.5% were current users of modern contraception, of which the pill was the most popular (45.4% of users). Treatment for bleeding during pregnancy was reported by 16.7% of the sample to involve eating a ripe banana or a banana in combination with cassava products. External use of plantain leaves or sanitary pads was also mentioned. These treatments were considered as first aid and not definitive treatment. 90% indicated a willingness to stay in a maternity waiting home if advised to do so. 58% would be able to stay 1 month, 21% would stay 2 months, and 21% would stay 3 or more months. Effective community education and social mobilization is still needed in order to attract those not using services.

Maternal mortality and related factors in Ejisu District, Ghana.

A community-based survey on maternal mortality was carried out in the Ejisu health district of Ghana in January and February 1990 to identify all women who died in pregnancy, delivery or the puerperium from January 1985 to December 1989, determine their characteristics, the presumptive causes of death and related factors. Forty-four women who died in pregnancy, delivery or the puerperium were identified over the stated period. 59% were aged between 20 and 34 years. Eighty-two percent were married and sixty-six percent had at least primary education. Based on an average crude birth rate of 40 per 1000 population for the district over the period, the lowest maternal mortality rate occurred in 1988, 120 per 100,000 total births and the highest occurred a year later, 235 per 100,000 total births. The main presumptive causes of maternal mortality in the district were postpartum haemorrhage 45.5%, jaundice in pregnancy 22.7%, obstructed labour 6.8%, eclampsia 6.8% and fever 4.6%. 59% of them died in a hospital, 2% died at a Government Maternity Home and 7% died during referral from health facilities in the district. Thirty-four percent of the women who died did not attend any antenatal clinic. The actual number of deaths may be underestimated due to the sampling method used and the difficulties encountered in linking survey data with hospital records. Based on the survey findings and other related PMM research, plans have been developed to reduce maternal mortality in the district as outline in the conclusion.

PIP: A community-based survey was conducted among 1200 reproductive age women living in 80 out of 160 communities in Ejisu health district in Ghana during January-February 1990. Retrospective data was collected for the period January 1985-December 1989. Data was analyzed in order to determine maternal mortality, causes of death, and the characteristics of the mothers who died. The sample community was comprised of 223,632 persons in 1990. 44 women were identified as having died in pregnancy, delivery, or postpartum. 59% were 20-34 years old, and 41% were in high-risk age groups. 65.9% had at least some primary education, and 81.8% were married at the time of death. 27.3% were childless at the time of death. Maternal deaths were distributed by year as follows: 9 deaths in 1985, 10 in 1986, 7 in 1987, 6 in 1988, and 12 in 1989. The estimated maternal mortality was 211 per 100,000 live births in 1986 and 235 per 100,000 in 1989. The 4-year average was 181 per 100,000. 34% of deaths were to women who had not received any prenatal care in the last pregnancy. Almost 75% died during delivery. 59% died in a hospital, 7% during a referral to a hospital, and 2% at a Government Maternity Home. Over 66% died after reaching a health facility. 27% died at home. 2% died while under the care of a local traditional birth attendant. Causes of maternal death were postpartum hemorrhage (45.5%), jaundice in pregnancy (22.7%), obstructed labor (6.8%), eclampsia (6.8%), and fever (4.6%). 2.3% of deaths were attributed to antepartum hemorrhage, ectopic pregnancy, and septic abortion. Prenatal care alone is not sufficient to prevent some deaths. The high mortality rate during delivery is a justification to improve the quality of care during delivery at all levels of the district health system. Listed are 9 potential interventions to reduce maternal mortality, including: establishing operating facilities at local health centers and maintaining a resident doctor for obstetric emergencies.

Maternal mortality due to hemorrhage in Ghana.

OBJECTIVE: This hospital-based review of maternal mortality due to hemorrhage in Kumasi, Ghana was undertaken to determine the factors related to and influencing cases of fatal maternal hemorrhage. METHOD: The review was based on inpatient case notes, labor ward delivery notes, and operative records at the Maternity Block of the Komfo Anokye Teaching Hospital, Kumasi. The diagnoses were based on International Classification of Diseases (ICD) 9th and 10th editions. It covered the period 1981 to 1989. RESULT: It was observed that maternal hemorrhage accounted for over 40% of all obstetric complications admitted and also 27% of all maternal deaths in the period under review. However, the case fatality rate for maternal hemorrhage decreased from 1.34% in 1981 to 0.7% in 1989. The cesarean section rate increased from 6.7% in 1981 to 9.1% in 1989. The maternal mortality rate over the period was 1140 per 100,000 births. CONCLUSION: Based on this review and other related research, the following interventions have been planned for implementation in order to improve the situation: improving staff-patient relationship through training in interpersonal skills; ensuring 24-h availability of drugs, supplies and blood; establishment of a resuscitation unit at the casualty department so that first aid can be provided to patients with obstetric emergencies before transfer to the wards; establishment of a maternity care monitoring system to continually improve the quality of care; introduction of confidential enquiry into all maternal deaths in order to reduce their incidence. A monitoring and evaluation plan has been developed to assess regularly progress on implementation. Although, maternal deaths are due to multifactorial causes, it is hoped that these interventions, if successfully implemented, will contribute significantly towards the reduction of maternal deaths due to institutional factors, especially direct obstetric causes like maternal hemorrhage.