Challenges in preterm birth research: Ghanaian perspective.

Preterm birth is highly prevalent in Ghana. It is a major public health concern because of the high burden as well as the associated immediate and long-term consequences including increased healthcare cost. Studies conducted in high-income countries may not be sufficiently generalizable in our context. Locally generated evidence-based interventions will be indispensable in improving the clinical management and prevention of preterm birth in the country. However, there are limited published literature on preterm birth and prematurity in the country. This review seeks to discuss the major challenges associated with preterm birth research in Ghana and proposes evidence-based strategies to improve biomedical and epidemiological research on preterm birth and prematurity. The limited high quality preterm birth research is partly attributable to a variety of challenges related to accurate gestational age estimation, research training, capacity and support including funding, efficient ethics committees, local and international collaboration as well as effective health management information systems. Other related challenges include unavailability of reliable internet connectivity, poor compensation for researchers and lack of conductive research environment. There is the need to expedite advocacy on implementation of practical interventions and strategies aimed at increasing high quality research in the area of preterm birth and prematurity in the country. A paradigm shift in preterm birth research with appropriate integration of concerted multidisciplinary research groups should be constituted to put basic science research to clinical practice as well as the prevention of preterm birth in the country.

Determinants and outcomes of preterm births at a tertiary hospital in Ghana.

INTRODUCTION: Preterm birth remains an important clinical challenge with significant short and long-term complications although its burden in the developing world is not adequately explored. This study determines the incidence, specific determinants and outcomes of preterm birth at a teaching hospital in Ghana. METHODS: Retrospective review of singleton births at Korle-Bu Teaching Hospital (KBTH) in Ghana between 1st January to 31st December, 2015. RESULTS: Preterm birth (PTB) occurred in 1478 (18.9%) out of 7801 single deliveries with etiological distribution of 879 (59.5%) spontaneous and 599 (40.5%) provider-initiated phenotypes. Gestational age categorization (WHO classification) of the preterm births included 68 (4.6%), 235 (15.9%) and 1175 (79.5%) below 28, between 28-31 and 32-36 weeks respectively. Adverse perinatal outcomes (low birth weight, perinatal deaths and poor Apgar scores) but not adverse maternal outcomes (cesarean and maternal deaths) were significantly higher in preterm compared to term births. Major factors associated with PTB include advanced maternal age (>35 years), poor antenatal care, hypertensive disorders and preterm premature rupture of membranes (PPROM) whiles obesity was protective. There were 156 stillbirths (105.6 per1000 births) comprising 93 macerated (62.9 per 1000 births) and 63 fresh stillbirths (42.6 per 1000 births), and perinatal mortality rate of 119.8 per 1000 births. DISCUSSION: Preterm birth is highly prevalent with significant adverse outcomes among singleton gestations at KBTH in Ghana, with disproportionately higher spontaneous etiology compared to provider-initiated phenotype. A paradigm shift in clinical management of preterm births/prematurity is urgently required with proactively dedicated multidisciplinary team and involvement of the global community.

Lifting and pregnancy outcomes: feasibility of a randomized controlled trial.

Background: The highest incidence of preterm birth (18%) occurs in Africa but the causes are largely unknown. Some studies have reported adverse effects of maternal physical exertion on birth outcomes. A randomized controlled trial (RCT) is proposed to determine the effectiveness of an intervention reducing lifting and carrying in pregnant women in reducing preterm birth and low birthweight. Aims: To test the feasibility and acceptability of the proposed lift-less intervention RCT. Methods: We recruited pregnant women and midwives from antenatal clinics within the Greater Accra Region of Ghana. The midwives were trained to administer the intervention during a 5-week trial. Four intervention trial sessions were organized at weekly intervals. Results: Seven pregnant women and six midwives participated. After piloting, we observed a reduction in participants' self-reported daily exposure to heavy lifting and carrying. The daily average frequency of lifting by a participant within the first seven days of the study was 3.5 (SD 1.7) with an estimated mean total weight of 41.1 kg (SD = 13.3 kg). This had decreased to 2.3 (SD = 1.0) and the amount to 13.4 kg (SD = 10.9) within the last seven days of the study. Conclusions: The findings provide insight into the daily physical exertion experienced by pregnant women in Ghana. The lift-less intervention trial is feasible with modifications and has the potential to reduce excessive physical exertion among pregnant women in Ghana to improve birth outcomes.

LINKING UNINTENDED PREGNANCY TO THE BURDEN OF PRE-ECLAMPSIA IN A TERTIARY HOSPITAL IN GHANA.

BACKGROUND: Although pre-eclampsia remains a major public health challenge associated with significant adverse maternal outcomes especially in low-income countries, there are no well-defined screening and preventive measures. However, primary prevention of unintended pregnancy represents a viable and reliable measure for reducing the high maternal morbidity and mortality attributable to pre-eclampsia. OBJECTIVE: To determine and relate the proportion of unintended pregnancies among pre-eclamptic women to the burden of pre-eclampsia in Korle-Bu Teaching Hospital (KBTH), Accra, Ghana. METHOD: A cross-sectional study involving pregnant women with pre-eclampsia conducted at the KBTH, Accra, Ghana. Structured questionnaire was employed to obtain the required data regarding pregnancy intendedness and the use of modern contraception. Data on maternal mortality were also collected to determine maternal deaths related to pre-eclampsia. The data obtained were analyzed using SPSS version 18. RESULTS: There were 269 women with hypertensive disorders in pregnancy with 177 (65.8%) having pre-eclampsia out of which 100 met the inclusion criteria and 86 gave informed consent. Most, 71(82.6%), were married and 69 (80.2%) had had at least Junior High School education with a mean age of 29.34±1.08 years. The prevalence of unintended pregnancy among the women with pre-eclampsia was 32.6% as 28 patients were affected with 12 (13.9%) women on modern contraception prior to the index pregnancy. However, 83 (96.5%) had adequate knowledge on modern contraception and 58 (67.4%) reported of a previous history of induced abortion. As many as 16 (57.1%) women of those whose pregnancies were unintended were not using any form of contraception. During the study period, 36 maternal deaths occurred and 14 (38.9%) were due to pre-eclampsia. CONCLUSION: Unintended pregnancy constitutes a significant proportion of the burden of pre-eclampsia in the Ghanaian population resulting in high maternal morbidity and mortality. Increasing contraceptive usage in general represents a viable and effective primary preventive measure in reducing maternal mortality attributable to pre-eclampsia.

Is there a safe limit of delay for emergency caesarean section in Ghana? Results of analysis of early perinatal outcome.

OBJECTIVE: To determine the limits of delaying caesarean section in a busy obstetric unit in a developing country setting that is not associated with neonatal survival. METHODS: Retrospective cohort study of emergency cesarean sections. Indications were sub-divided into imminent threat and no imminent threat to fetal wellbeing. The primary outcomes was a composite measure of adverse perinatal outcome including stillbirth, 5-minute Apgar score < 7 and neonatal intensive care unit admission. Effect of decision-to-delivery interval on perinatal outcomes was evaluated using Kaplan-Meier survival analysis. RESULTS: 495 women met inclusion criteria (142 'imminent threat' group, 353 'no imminent threat' group). The median decision-to-delivery interval was significantly shorter in the 'imminent threat' group (2.25 [95% CI 1.38 - 5.83] versus 3.42 [95% CI 1.83 - 5.85] hours, p <0.001). Only 1.7% and 12.7% sections were performed within 30 minutes and 1 hour, respectively. Risk of the composite outcome was significantly higher in the 'imminent threat group (46.5% versus 31.2%, RR=1.49 [95% CI 1.18 - 1.89], p=0.001). A 95% probability of 'live intact' survival occurred at 1 hr and 2 hrs respectively, for the imminent threat and the no imminent threat groups. CONCLUSION: Increasing decision-to-delivery interval is associated with higher risk of adverse perinatal outcomes, but a 95% live intact survival can be achieved if the delivery occurs within 2 hours.

VAGINAL BIRTH AFTER A PREVIOUS CAESAREAN SECTION: CURRENT TRENDS AND OUTLOOK IN GHANA.

BACKGROUND: The optimal mode of subsequent delivery of women with prior caesarean birth remains a subject of intense research and debate in contemporary obstetric practice especially in low resource settings like West Africa where there are obvious systemic and management-related challenges associated with trial of scar. However, there is evidence that vaginal birth after caesarean section (VBAC) is safe in appropriately selected women in addition to adequate intrapartum monitoring and ready access to theatre when emergency CS is indicated. AIM & OBJECTIVES: The primary objective of the study was to determine the current trends and performance of VBAC in Ghana after decades of practice of trial of labour after caesarean section (TOLAC) in the mist of inherent challenges in deciding the optimal mode of childbirth for women with a previous caesarean birth. The secondary objective was to relate evidence based practice of TOLAC to obstetric practice in low resource settings like Ghana and provide recommendations for improving maternal and newborn health among women with prior caesarean birth. PATIENTS & METHODS: This was a retrospective study of the records of patients who had had a prior caesarean delivery and who then proceeded to deliver the next babies at the Korle Bu Teaching Hospital (KBTH) between Jan 2010 and Dec 2014. The data on demography, antenatal care, labour and delivery and outcomes were collected from the Labour and Recovery wards and the Biostatistics unit of the Maternity unit of the Hospital. Excluded were women with a previous CS who had multiple pregnancies and those with incomplete notes as well as those whose delivery plans were not predetermined antenatally.. The data were analyzed using SPSS version 20. RESULTS: There were 53,581 deliveries during the study period. Vaginal delivery was obtained in 31,870 (59.5%) pregnancies and 21,711(40.5%) had CS. Also, 6261 (11.7%) had had a prior CS and 2472 (39.5%) of these were selected for TOLAC while 2119 (33.8) were scheduled for planned repeat CS. There was an inverse trend between the annual caesarean sections rates and the proportion of women with one previous CS scheduled for TOLAC. There was a statistically significant difference between women who had successful or failed VBAC regarding maternal age, parity, number of ANC visits, gestational age at delivery, birth weight, Apgar score at 1 min and Apgar score at 5 min. Birth weights of less than 1.5kg, and 3.5Kg or greater were associated significantly with higher incidence failed TOLAC and emergency repeat CS. However, birth weights ranging from 2.0 to 3.49kg were associated with significantly lower incidence of failed TOLAC and emergency repeat CS. Birth weight of 2.5-2.99kg was associated with the lowest incidence of failed TOLAC and repeat CS. CONCLUSION: . There is a significantly high vaginal birth after caesarian section (VBAC) success rate among carefully selected women undergoing trial of scar in Ghana although a decreasing trend towards trial of labor after caesarian section (TOLAC) and a rising CS rate were determined. TOLAC remains a viable option for child birth in low resource settings like West Africa even though there are specific clinical and management related challenges to overcome. Adequate patient education and counselling in addition to appropriate patient selection for TOLAC remains the cornerstone to achieving high VBAC success rate with minimal adverse outcomes in such settings.

Thoracic endometriosis syndrome.

BACKGROUND: Thoracic endometriosis syndrome is a rare constellation of different pathological entities arising from intrathoracic endometriosis. Reports from centers in Africa are scanty. Varying theories have been proposed but none satisfactorily explains the varying clinical manifestations. OBJECTIVE: To describe the demographics, pathological spectrum, and outcome of treatment of patients seen at a single centre in West Africa with intrathoracic endometriosis. METHODS: Twelve women who were seen at Ghana's National Cardiotharacic Centre with intrathoracic endometriosis from 2004-2012 were retrospectively reviewed. RESULTS: The age range was from 24 - 39 years with a mean of 32 ± 5 years. Pelvic endometriosis was confirmed in 8 (66.7%) of the patients, 2 (16.7%) had ectopic endometrial tissue at the umbilicus and one (16.7%) had ectopic endometrial tissue at the mons pubis. Seven (58.3%) of the patients had undergone prior uterine surgery before the clinical onset of thoracic endometriosis. The right hemithorax was involved in all 12 (100%) patients studied. Pneumothorax was present in six (50%) women, hemothorax in five (41.7%) and hemopneumothorax in one (8.3%). Three of the four patients who benefited from video assisted thoracoscopy had abrasive pleurodesis followed by hormonal therapy. The rest of the patients had chemical pleurodesis with or without hormonal therapy. CONCLUSION: Thoracic endometriosis may be more prevalent in West Africa than previously believed. Outcome of treatment is satisfactory using a multidisciplinary approach.

Sexual and reproductive health in Accra, Ghana.

OBJECTIVE: To describe sexual and reproductive health among women in Accra and explore the burden of sexual and reproductive ill health among this urban population. DESIGN: Cross-sectional study. METHODS: We analysed data from the WHSA-II (n=2814), a cross-sectional household survey on women's health, and supplemental data from an in-depth survey (n=400), focus groups discussions (n=22) and in-depth interviews (n=20) conducted among a sub-sample of women which focused specifically on reproductive health issues. RESULTS: Modern contraceptive use was uncommon. More than one third of women reported ever using abstinence; condoms, injectables and the pill were the most commonly reported modern methods ever used. The total fertility rate among this sample of women was just 2.5 births. We found a considerable burden of sexual and reproductive ill health; one in ten women reported menstrual irregularities and almost one quarter of women reported symptoms of a Sexually Transmitted Infection (STI) or Reproductive Tract Infection (RTI) in the past 6 months. Focus group results and in-depth interviews reveal misperceptions about contraception side-effects and a lack of information. CONCLUSION: In urban Ghana, modern contraceptive use is low and a significant proportion of women experience reproductive ill health (defined here as menstrual irregularity or RTI, UTI, STI symptoms). Increased access to information, products and services about for preventive care and contraception could improve reproductive health. More research on healthy sexuality and the impact of reproductive ill health on sexual experience is needed.