PLoS One

[This corrects the article DOI: 10.1371/journal.pone.0221789.]

Pregnancy outcomes in Ghana : Relavance of clinical decision making support tools for frontline providers of care

Ghana’s slow progress towards attaining millennium development goal 5 has been associated with gaps in quality of care, particularly quality of clinical decision making for clients. This thesis reviews the relevance and effect of clinical decision making support tools on pregnancy outcomes. Relevance of three clinical decision making support tools available to frontline providers of care in the Greater Accra region is discussed. These are routine maternal health service delivery data population based reproductive data and clinical care guidelines. First, the quality of routine health system data, determined by the completeness and accuracy of transfer of routine antenatal and delivery service data in the Greater Accra Region of Ghana is assessed and found to be good and reliable for use for decision making. Secondly, predictors of skilled attendance at delivery were identified amongst women who attend antenatal clinic at least once during their pregnancy in Ghana, using the 2008 Ghana Demographic and Health Survey (DHS) data. These predictors were wealth status class, rural or urban residency, previous delivery complication and health insurance coverage. Finally, adherence to first antenatal care guidelines was assessed. Overall, complete adherence to guidelines was low and providers were more likely to completely adhere to guidelines when caring for women 20 years or older, employed and married women. Also, public health facility resource availability in relation to provider adherence to first antenatal visit guidelines was explored.It was evident that although antenatal workload varies across different facility types in the Greater Accra region, other health facility resources that support implementation of first antenatal care guidelines are equally available in all the facilities. Thus, availability of these resources do not adequately account for the low and varying proportions of complete adherence to guidelines across facility types. Regarding effect, two clinical decision making support tools (first antenatal care guidelines and mobile health) on pregnancy outcomes were examined. Complete adherence to first antenatal care guidelines decreased risk of any neonatal complication and delivery complication. A systematic review evaluating the effectiveness of mHealth interventions targeting health care workers to improve maternal and neonatal outcomes in low- and middle-income countries (LMICs) was conducted. From this review, mHealth interventions were used as communication, data collection, or educational tool by health care providers in the provision of antenatal, delivery and postnatal care. None of the studies directly assessed effect of mHealth on maternal and neonatal mortality. We conclude that there is a gap in the knowledge of whether mHealth interventions directly affect maternal and neonatal outcomes and future research should address this gap. In conclusion I discuss the importance of reducing subjectivity of provider judgement by encouraging them to use available clinical decision making support tools. I also emphasize the need for them to be supported by the health system to be able to incorporate these tools in their daily practice to enhance the quality of care for mothers and improve pregnancy outcomes

Attitudes towards abortion and decision-making capacity of pregnant adolescents: perspectives of medicine, midwifery and law students in Accra, Ghana

Objectives: Because medical, midwifery and law students in Ghana constitute the next generation of health care and legal practitioners, this study aimed to evaluate their attitudes towards abortion and their perceptions of the decision-making capacity of pregnant adolescents. Methods: We conducted a cross-sectional survey among 340 medical, midwifery and law students. A pretested and validated questionnaire was used to collect relevant data on respondents’ sociodemographic characteristics, attitudes towards abortion and the perceived capacity and rationality of pregnant adolescents’ decisions. The χ2 test of independency and Fischer’s exact test were used where appropriate. Results: We retained 331 completed questionnaires for analysis. Respondents’ mean age was 21.0 ± 2.9 years and the majority (95.5%) were of the Christian faith. Women made up 77.9% (n = 258) of the sample. Most students (70.1%) were strongly in favour of abortion if it was for health reasons. More than three-quarters (78.0%) of the students strongly disagreed on the use of abortion for the purposes of sex selection. Most respondents (89.0%) were not in favour of legislation to make abortion available on request for pregnant adolescents, with medical students expressing a more negative attitude compared with law and midwifery students (p < 0.001). Over half of the midwifery students (52.6%) believed that adolescents should have full decision-making capacity regarding their pregnancy outcome, compared with law and medical students (p < 0.001). Conclusion: Tensions between adolescent reproductive autonomy, the accepted culture of third party involvement (parents and partners), and the current abortion law may require keen reflection if an improvement in access to safe abortion services is envisioned

Strategies to improve interpersonal communication along the continuum of maternal and newborn care: A scoping review and narrative synthesis.

Effective interpersonal communication is essential to provide respectful and quality maternal and newborn care (MNC). This scoping review mapped, categorized, and analysed strategies implemented to improve interpersonal communication within MNC up to 42 days after birth. Twelve bibliographic databases were searched for quantitative and qualitative studies that evaluated interventions to improve interpersonal communication between health workers and women, their partners or newborns' families. Eligible studies were published in English between January 1st 2000 and July 1st 2020. In addition, communication studies in reproduction related domains in sexual and reproductive health and rights were included. Data extracted included study design, study population, and details of the communication intervention. Communication strategies were analysed and categorized based on existing conceptualizations of communication goals and interpersonal communication processes. A total of 138 articles were included. These reported on 128 strategies to improve interpersonal communication and were conducted in Europe and North America (n = 85), Sub-Saharan Africa (n = 12), Australia and New Zealand (n = 10), Central and Southern Asia (n = 9), Latin America and the Caribbean (n = 6), Northern Africa and Western Asia (n = 4) and Eastern and South-Eastern Asia (n = 2). Strategies addressed three communication goals: facilitating exchange of information (n = 97), creating a good interpersonal relationship (n = 57), and/or enabling the inclusion of women and partners in the decision making (n = 41). Two main approaches to strengthen interpersonal communication were identified: training health workers (n = 74) and using tools (n = 63). Narrative analysis of these interventions led to an update of an existing communication framework. The categorization of different forms of interpersonal communication strategy can inform the design, implementation and evaluation of communication improvement strategies. While most interventions focused on information provision, incorporating other communication goals (building a relationship, inclusion of women and partners in decision making) could further improve the experience of care for women, their partners and the families of newborns

Blood pressure patterns and body mass index status in pregnancy: An assessment among women reporting for antenatal care at the Korle-Bu Teaching hospital, Ghana

<div><p>Background</p><p>Maternal obesity in pregnancy has been linked with increased risk of pregnancy induced hypertension (PIH). In some tertiary referral hospitals in Ghana, PIH is the leading cause of institutional maternal mortality.</p><p>Objective</p><p>To evaluate blood pressure changes during pregnancy amongst different body mass index (BMI) groups and how this relates to the risk of developing PIH.</p><p>Methods</p><p>Women who had a dating ultrasound before 20 weeks gestation and registering for antenatal care at the Korle-Bu Teaching Hospital in Accra, between February and December 2013 and met the inclusion criteria were recruited into a cohort study. BMI was assessed at baseline. Blood pressure measurements were taken at (±2) 24, 28 and 36 weeks. Primary outcome measure of interest during follow-up was a diagnosis of PIH at these points. BP changes during follow up at the three points were measured. Descriptive analysis of baseline factors was carried out and compared for the BMI groups. Relative risk (RR) of PIH was estimated at 95% confidence interval.</p><p>Results</p><p>Mean (SD) age for the 361 women was 30.9 (4.8) years. Incidence of PIH amongst the cohort was 10.5% (95% CI: 7.45% - 14.45%) and 40.4% and 33.0% of them were overweight and obese respectively at baseline. Pregnant women who were obese at baseline had a three-fold increased risk of PIH compared to those with normal BMI [RR = 3.01 (1.06–8.52), p = 0.04].</p><p>Conclusion</p><p>Obese women have a significantly increased risk of PIH. Women should be screened at booking for obesity status. Antenatal protocols should have interventions for prevention or early detection of obesity and management of obesity to improve outcomes.</p></div

To keep or not to keep? Decision making in adolescent pregnancies in Jamestown, Ghana

Background Jamestown, an urban coastal slum in Accra, Ghana, has one of the highest adolescent pregnancy rates in the country. We sought to understand the decision (to keep or terminate) factors and experiences surrounding adolescent pregnancies. Methods Thirty semi-structured indepth interviews were carried out among adolescents (aged 13–19 years) who had been pregnant at least once. Half of these were adolescent mothers and the other half had at least one past experience of induced abortion. A pretested and validated questionnaire to assess the awareness and use of contraception in adolescent participants was also administered. To aid social contextualization, semi-structured in depth interviews were carried out among 23 purposively selected stakeholders. Results The main role players in decision making included family, friends, school teachers and the partner, with pregnant adolescents playing the most prominent role. Adolescents showed a high degree of certainty in deciding to either abort or carry pregnancies to term. Interestingly, religious considerations were rarely taken into account. Although almost all adolescents (96.1%) were aware of contraception, none was using any prior to getting pregnant. Of the 15 adolescents who had had abortion experiences, 13 (87.0%) were carried out under unsafe circumstances. The main barriers to accessing safe abortion services included poor awareness of the fairly liberal nature of the Ghanaian abortion law, stigma, high cost and non-harmonization of safe abortion service fees, negative abortion experiences (death and bleeding), and distrust in the health care providers. Adolescents who chose to continue their pregnancies to term were motivated by personal and sociocultural factors. Conclusion Decision-making in adolescent pregnancies is influenced by multiple external factors, many of which are modifiable. Despite legal access to services, options for the safe termination of pregnancy or its prevention are not predominantly taken, resulting in a high number of negative experiences and outcomes. Including safe abortion care within the sexual and reproductive health package, could diminish barriers to safe abortion services. Given the vulnerability of the Jamestown setting, a comprehensive sexual education package that addresses the main decision factors is recommended. Interventions aiming to reduce adolescent pregnancy rates should also recognize that adolescent pregnancies are culturally acceptable in some settings, and under certain circumstances, are desired by the adolescents themselves

Association of baseline characteristics with diagnosis of PIH among cohort.

<p>Association of baseline characteristics with diagnosis of PIH among cohort.</p