IMPROVING ACCESS TO EMERGENCY OBSTETRIC AND PERINATAL CARE IN GHANA

IMPROVING ACCESS TO EMERGENCY OBSTETRIC AND PERINATAL CARE IN GHANA E. Y Kwawukume Professor and Chair, K.K. Bentsi-Enchill Chair, University of Ghana Medical School, College of Health Sciences, Dept of Obst and Gynae, Korle Bu

INTRODUCTION • The main indices of quality obstetric and perinatal care in a given geographical location are maternal and perinatal mortality. • WHO estimates that at least 1,600 women die every day associated with pregnancy and child birth. • 90% of these deaths occur in sub-Saharan Africa and Asia. • Annual del KBTH is between 10,000 to 12,000 women. • About 36% of the pregnant women with complications reach the hospital in a moribund state

Introduction • 40% or more of pregnant women may experience acute obstetric problems during pregnancy, child birth and puerperium. • Of this number an estimated15% of the pregnant women develop life-threatening complications. • Significant percentage of the maternal deaths is therefore due to emergency complications of pregnancy.

METHODStudy Population • This is a descriptive study. • Data was collected from published articles including studies from 1984 to 1994 and 1995 to 2002, • records were retrieved from the depart of Obs/Gynae and Child Health, KBTH • Ghana Statistical Service, Ministry of Health Human resource Division • University of Ghana Medical School.

RESULTSTable 1: Deliveries at Maternity block KBTH 2002-2008 • Year Total deliveries Live births Still Births SB/Live births% • 2002 11,798 11,122 676 5.7 • 2003 10,528 9,901 627 6.3 • 2004 11,099 10, 392 707 6.8 • 2005 11,175 10, 443 732 7.0 • 2006 7,229 7,624 395 5.2 • 2007 7,378 6,993 385 5.5 • 2008 10,310 9,785 525 5.4

Table 2: Maternal Mortality at KBTH Year Live births Maternal deaths MMR • 2005 10,443 95 909 • 2006 7,624 62 813 • 2007 6,993 72 1,029 • 2008 9,785 77 786 • 2005-2008 - - 884 • MMR/100,000 Most of the cases are referrals from the district

Table3: MM per 100,000 live births • Year Rate • 1984-1994 734.4 • 1995-2002 777.2 • 2003-2008 884.2

Table 4: Causes of MM at KBTH 1984- 2008 Causes 1984-1994. 2005-2008 • Hemorrhage 17.7% 30.0% • Hypertensive disorders 17.5% 25.8% • Abortions 13.5% 10.7% • Genital infections 9.5% 3.5% • Obstructed labour 5.5% 0.3% • Others 36.3% 29.4% Causes of MM remain the same but there is significant increase in the major causes, iehypert and haemorrage

Table 5: Perinatal mortality rates per 1,000 births for weights greater than 1,000 grams Year Rates . • 1991 99.1 • 1992 99.8 • 2008 80.7 • The perinatal mortality rate showed 18.4% decrease as compared to the year 1991.

Table 6: Neonatal deaths: Intensive care unit KBTH Causes Number • Prematurity 145 • Birth Asphyxia 121 • Bacteria Sepsis 6

Table 7: Causes of perinatal mortality Causes year 1990 1992 1991/1902 2008 • Prematurity 52.1% 55.3% 58.8% 53.3% • Birth asphyxia 26.7% 19.1% 23% 44.4% • Bacteria sepsis 11.6% 14.6% 13% 2.2%

Table 8: The literacy rate in Ghana. 15yrs and above . Languages Women Men • English/other languages 45.7% 62.9% • English/one Ghanaian language 27.2% 41.6% More than half of the population in Ghana is illiterate. The literacy rate of women is lower than that of men.

Table 9: The population of Ghana projected by sex for 2009 from 2000 census. Sex Number • Women 11,816,192 • Men 11,600,326 • Total 23,416,518 The population of women and men is almost equal with the women having a slight edge over the men

Table 10: Medical staff projected for 2006 and relationship to population of women • Staff Number % Population Ratio . • Nurses 14,297 0.1 1 to 1,000 women • Doctors 2,334 0.02 1 to 5,000 women • There is a geographical there are regional variation from the North to the South

Table 11: Training of medical students from the UGMS Year enrolled No Year graduated No graduated • 1999 83 2005 77 • 2000 89 2006 87 • 2001 90 2007 83 • 2002 89 2008 88 • 2003 111 2009 105 • An average of 88 doctors is produced annually since 1999.

Table 12: Diploma Training; Ghana College Year No. Obstetricians No. Pediatricians • 2006 3 6 • 2007 - 1 • 2008 2 1

Table 13: Membership training from the Ghana college • Year Obst Pedia Anes Family Med • 2007 - - - 7 • 2008 9 5 7 7

DISCUSSION • MMR of 884.2 per 100,000 live births and the perinatal mortality rate of 80.7 per1,000 births are high compared to that obtained in the developed countries. • The causes of maternal and perinatal mortality have remained the same • the major causes of maternal mortality, hemorrhage and hypertensive disorders of pregnancy, showed a significant percentage increase. • These causes are emergency obstetric and perinatal conditions.

Factors that impede access to emergency health care delivery. • More than half of the population of Ghana are illiterate . • The illiterate population is less likely to lead a healthy life style. • They are also less likely to make use of available health services. • Clinical features of complications of pregnancy may not be recognized and as such may be misinterpreted and report late for treatment.

Factors that impede access to emergency health care delivery. • Poverty is a high risk factor • It is associated with illiteracy and impedes access to health care. • The global economic situation is not in favor of the developing countries. • This situation has been worsened by bad governance; bad developmental policies and corruption • The majority of the population is therefore poor. • When complications arise there may be no money to finance transportation and medical bills. • The patient may not be taken to a health care facility.

Delays in reaching a health care facility • Due to physical distance, • Poor road networks, • Inadequate ambulance services.

Factors that impede access to health care at the level of health care facility, • lack of medical supplies and equipment, • non functioning theaters • shortage of medical staff. • From the study the ratio of a nurse to the women population is 1:1000 • doctor to the women population 1:5000. • This is woefully inadequate leading to MM/PNM.

Access to Health Care • Measures presently taken to address the situation are also woefully inadequate. • On the average 88 doctors are trained annually from KBTH • Much more worse is the number of Specialist doctors

Reasons for increase in MMR at KBTH • inadequate number of midwives, • lack of functioning theatres • frequent shortages of blood and blood products as against a high annual delivery rate.

How can access be improved • To increase the literacy rate at all the levels of education including informal education. • To reach out to the populace on health issues both in English and the local languages. • The transportation network should be improved. • The National Ambulance Service should be resourced and expanded to reach a large number of communities. • Helicopter services should be established to airlift emergency cases to health facilities.

How can access be improved • mobile phone services to compliment the services in the transport sector • Governments to tackle the problems of corruption, show good governance and formulate policies when dealing with multinational coorperationsin order to get better deals for their countries • National Health Insurance Scheme to be encouraged. • The challenges in the NHIS affecting the finances of the health providers should be quickly addressed. • Health personnel should have continuous heath education including ethics. This is currently being done - Continuous Professional Development Programs for doctors.

Problems of delivery in Teaching Hospitals • Efforts must be made to decongest the hospitals • Polyclinics should be fully functional

Good News • La polyclinic now a hospital. • The burden on KBTH has reduced. Delivery from 12,000 to 9,931 babies annually. • Many standard Private hospitals are springing up • Private organizations are helping government facilities egMTN refurbishing KBTH labourward and thaetres. • Private institutions should train more health personnel • They should be encouraged to grow to effectively supplement the efforts of government

Neonatal death • Major causes are Prematurity and asphyxia • Supervised delivery should be encouraged • Adequate ambu-bags in labour wards and NICU • Availabilty of Maternal and neonatal ventilators • Oxygen cylinders to be at all delivery units • Management protocols should be established.

CONCLUSION • Maternal mortality is a Human Rights issue and should be recognized as such

Conclusion • Doctors and nurses- Are we doing enough! • What about Hospital Administrators! • What about Parliamentarians!-do you know the needs of pregnant women in your constituency? • And our Ministers- are we visiting health institutions including maternity homes! • What about ourselves who are hearing this presentation

Imagine that the first woman had died from Pregnancy or delivery, what would have become of the world

Ladies and Gentlemen let us be more proactive towards the needs of those who deliver the most important human beings on earth “our makers on earth!”

Thank you

IMPROVING ACCESS TO EMERGENCY OBSTETRIC AND PERINATAL CARE IN GHANA