Measuring the impact of a quality improvement collaboration to decrease maternal mortality in a Ghanaian regional hospital

Abstract

Objective: To evaluate the performance of a continuous quality improvement collaboration at Ridge Regional Hospital, Accra, Ghana, that aimed to halve maternal and neonatal deaths. Methods: In a quasi-experimental, pre-and post-intervention analysis, system deficiencies were analyzed and 97 improvement activities were implemented from January 2007 to December 2011. Data were collected on outcomes and implementation rates of improvement activities. Severity-adjustment models were used to calculate counterfactual mortality ratios. Regression analysis was used to determine the association between improvement activities, staffing, and maternal mortality. Results: Maternal mortality decreased by 22.4% between 2007 and 2011, from 496 to 385 per 100 000 deliveries, despite a 50% increase in deliveries and five-and three-fold increases in the proportion of pregnancies complicated by obstetric hemorrhage and hypertensive disorders of pregnancy, respectively. Case fatality rates for obstetric hemorrhage and hypertensive disorders of pregnancy decreased from 14.8% to 1.6% and 3.1% to 1.1%, respectively. The mean implementation score was 68% for the 97 improvement processes. Overall, 43 maternal deaths were prevented by the intervention; however, risk severity-adjustment models indicated that an even greater number of deaths was averted. Mortality reduction was correlated with 26 continuous quality improvement activities, and with the number of anesthesia nurses and labor midwives. Conclusion: The implementation of quality improvement activities was closely correlated with improved maternal mortality.

The third delay: understanding waiting time for obstetric referrals at a large regional hospital in Ghana

“…Moving women out of the triage area took significantly longer on high-volume days (>30 patients) when the median triage time was 83 min ( P  = 0.0285), possibly the result of occupied labor beds. The three most common causes of maternal death at RRH have been shown to be OH, HDoP, and sepsis [10]; thus, we identified women presenting with vaginal bleeding ( n  = 39), hypertension ( n  = 139), fever ( n  = 1), or prolonged rupture of membranes ( n  = 54) as having a time-sensitive risk factor. Women with these risk factors were seen more quickly, 35 min (12–80 min) compared to 45 min (15–110 min) ( P  = 0.009) for women without these risk factors (Table 3, Fig.…”

The cost effectiveness of a quality improvement program to reduce maternal and fetal mortality in a regional referral hospital in Accra, Ghana

“…This 95% increase in patient volume over the course of the collaboration was a result of demand-side incentives in Ghana, changes in the referral patterns in Accra, and recognition of improving quality by the community. [25, 27]…”

“…The plan specified 97 improvement activities categorized into three bundles based on personnel, systems management, and quality communication. [27] The hypothesis was that long-term investment would lead to a strengthened system that would display stepwise improvement leading to a reduction in maternal and fetal mortality (Fig 1). Institutional review board approval was granted by Wake Forest University and the GHS for the conduct of the work.…”

“…[27] The Kybele-GHS partnership is unique in that it did not focus primarily on providing materials commonly associated with healthcare costs, such as medications and supplies. The partnership instead worked primarily to identify gaps and create processes that enabled the staff to use their resources more effectively.…”

“…[25, 26] As discussed elsewhere, the program proved highly effective at reducing maternal and fetal mortality rates. [14, 27] Still, it is important to recognize that not every change is an improvement[28]), and not every improvement is cost-effective. In order to be accountable to the GHS and other donors, we therefore present a CEA of the intervention which should help direct future efforts to build on this program, as well as the work of other similar organizations.…”