BackgroundDelay in receiving care significantly contributes to maternal morbidity and mortality. Much has been studied about reducing delays prior to arrival to referral facilities, but the delays incurred upon arrival to the hospital have not been described in many low- and middle-income countries.MethodsWe report on the obstetric referral process at Ridge Regional Hospital, Accra, Ghana, the largest referral hospital in the Ghana Health System. This study uses data from a prospectively-collected cohort of 1082 women presenting with pregnancy complications over a 10-week period. To characterize which factors lead to delays in receiving care, we analyzed wait times based on reason for referral, time and day of arrival, and concurrent volume of patients in the triage area.ResultsThe findings show that 108 facilities refer patients to Ridge Regional Hospital, and 52 facilities account for 90.5% of all transfers. The most common reason for referral was fetal-pelvic size disproportion (24.3%) followed by hypertensive disorders of pregnancy (9.8%) and prior uterine scar (9.1%). The median arrival-to-evaluation (wait) time was 40 min (IQR 15–100); 206 (22%) of women were evaluated within 10 min of arrival. Factors associated with longer wait times include presenting during the night shift, being in latent labour, and having a non-time-sensitive risk factor. The median time to be evaluated was 32 min (12–80) for women with hypertensive disorders of pregnancy and 37 min (10–66) for women with obstetric hemorrhage. In addition, the wait time for women in the second stage of labour was 30 min (12–79).ConclusionsReducing delay upon arrival is imperative to improve the care at high-volume comprehensive emergency obstetric centers. Although women with time-sensitive risk factors such as hypertension, bleeding, fever, and second stage of labour were seen more quickly than the baseline population, all groups failed to be evaluated within the international standard of 10 min. This study emphasizes the need to improve hospital systems so that space and personnel are available to access high-risk pregnancy transfers rapidly.

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Abstractobjective The objective of this study was to evaluate perinatal outcomes of pregnancies complicated by hypertensive disorders in pregnancy in an urban sub-Saharan African setting.methods A prospective cohort study of 1010 women of less than 17 weeks of gestation was conducted at two antenatal clinics in Accra, Ghana, between July 2012 and March 2014. Information about hypertensive disorders was available for analysis on 789 pregnancies. The main outcomes were pre-term birth, birthweight, Apgar scores, small for gestational age and mortality. Relative risk (RR, 95% confidence interval (CI)) for the association between hypertensive disorders of pregnancy and perinatal outcomes was assessed using logistic regression adjusting for potential confounders.results A total of 88.7% of women remained normotensive, 7.5% developed pregnancy-induced hypertension, 2.0% had chronic hypertension, and 1.7% developed (pre-)eclampsia. No adverse effects were observed in women with pregnancy-induced hypertension. Women with chronic hypertension were more likely to have a lower gestational age at delivery (38.0 AE 2.3 weeks vs. 39.0 AE 1.9 weeks, P = 0.04) and higher risk of pre-term delivery (aRR 4.63, 95% CI 1.35-15.91). Women with pre-eclampsia had emergency Caesarean section significantly more often (88.9% vs. 50%, P = 0.04), with a higher risk for low birthweight infants (aRR 7.95, 95% CI 1.41-44.80) and a higher risk of neonatal death (aRR 18.41,.conclusion Comparable to high-income countries, in Accra hypertensive disorders during pregnancy were associated with increased risk of adverse perinatal outcomes necessitating maternal and newborn care.

Maternal and newborn mortality were reduced in a low-resource setting when appropriate models for continuous quality improvement were developed and employed.

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