ObjectivesTo explore the “how” and “why” of care decision making by frontline providers of maternal and newborn services in the Greater Accra region of Ghana and determine appropriate interventions needed to support its quality and related maternal and neonatal outcomes.MethodsA cross sectional and descriptive mixed method study involving a desk review of maternal and newborn care protocols and guidelines availability, focus group discussions and administration of a structured questionnaire and observational checklist to frontline providers of maternal and newborn care.ResultsTacit knowledge or ‘mind lines’ was an important primary approach to care decision making. When available, protocols and guidelines were used as decision making aids, especially when they were simple handy tools and in situations where providers were not sure what their next step in management had to be. Expert opinion and peer consultation were also used through face to face discussions, phone calls, text messages, and occasional emails depending on the urgency and communication medium access. Health system constraints such as availability of staff, essential medicines, supplies and equipment; management issues (including leadership and interpersonal relations among staff), and barriers to referral were important influences in decision making. Frontline health providers welcomed the idea of interventions to support clinical decision making and made several proposals towards the development of such an intervention. They felt such an intervention ought to be multi-faceted to impact the multiple influences simultaneously. Effective interventions would also need to address immediate challenges as well as more long-term challenges influencing decision-making.ConclusionSupporting frontline worker clinical decision making for maternal and newborn services is an important but neglected aspect of improved quality of care towards attainment of MDG 4 & 5. A multi-faceted intervention is probably the best way to make a difference given the multiple inter-related issues.

BackgroundAntibiotic resistance due to the presence of extended-spectrum beta-lactamases (ESBLs) among Enterobacteriaceae is a worldwide problem. Data from Ghana regarding this resistance mechanism is limited. This study was designed to investigate the presence of TEM-type ESBL genes, their locations and their conjugabilities in clinical isolates of enterobacteria collected from the Korle-Bu Teaching Hospital in Ghana.MethodsStudy isolates were characterized with respect to ESBL phenotype, TEM-type ESBL gene detection, location of the ESBL gene(s) and conjugability of the ESBL phenotype using nalidixic acid-resistant Escherichia coli K-12 as recipient. Phenotyping was by Kirby Bauer disk diffusion using cefpodoxime, ceftazidime, cefotaxime and their combinations with clavulanate. Gene detections were by PCR using blaTEM primers.ResultsOverall, 37.96 % of 137 clinical isolates showed ESBL phenotype. The ESBLs occurred mostly in Klebsiella spp. (42.3 %) and then Escherichia coli (34.6 %). The TEM gene was detected in 48.1 % of ESBL-positive isolates and was determined to be plasmid-borne in 24 of 25 blaTEM detections. Overall, 62.7 % of TEM-producing isolates transferred the ESBL phenotype by conjugation.ConclusionsThe results highlight the presence of TEM-type ESBLs in the Korle-Bu Teaching Hospital and show considerable risk of environmental contamination through the urine of infected persons. An inhibition zone chart was generated which indicates the possible presence of complex beta-lactamase types. The data points to the fact that the ESBL-producing bacteria may disseminate this resistance mechanism via conjugation.

Background Developing and maintaining resilient health systems in low-resource settings like Ghana requires innovative approaches that adapt technology to context to improve health outcomes. One such innovation was a mobile health (mHealth) clinical decision-making support system (mCDMSS) that utilized text messaging (short message service, SMS) of standard emergency maternal and neonatal protocols via an unstructured supplementary service data (USSD) on request of the health care providers. This mCDMSS was implemented in a cluster randomized controlled trial (CRCT) in the Eastern Region of Ghana. Objective This study aimed to analyze the pattern of requests made to the USSD by health workers (HWs). We assessed the relationship between requests made to the USSD and types of maternal and neonatal morbidities reported in health facilities (HFs). Methods For clusters in the intervention arm of the CRCT, all requests to the USSD during the 18-month intervention period were extracted from a remote server, and maternal and neonatal health outcomes of interest were obtained from the District Health Information System of Ghana. Chi-square and Fisher exact tests were used to compare the proportion and type of requests made to the USSD by cluster, facility type, and location; whether phones accessing the intervention were shared facility phones or individual-use phones ( type-of-phone ); or whether protocols were accessed during the day or at night ( time-of-day ). Trends in requests made were analyzed over 3 6-month periods. The relationship between requests made and the number of cases reported in HFs was assessed using Spearman correlation. Results In total, 5329 requests from 72 (97%) participating HFs were made to the intervention. The average number of requests made per cluster was 667. Requests declined from the first to the third 6-month period (44.96% [2396/5329], 39.82% [2122/5329], and 15.22% [811/5329], respectively). Maternal conditions accounted for the majority of requests made (66.35% [3536/5329]). The most frequently accessed maternal conditions were postpartum hemorrhage (25.23% [892/3536]), other conditions (17.82% [630/3536]), and hypertension (16.49% [583/3536]), whereas the most frequently accessed neonatal conditions were prematurity (20.08% [360/1793]), sepsis (15.45% [277/1793]), and resuscitation (13.78% [247/1793]). Requests made to the mCDMSS varied significantly by cluster, type of request (maternal or neonatal), facility type and its location, type-of-phone , and time-of-day at 6-month interval ( P <.001 for each variable). Trends in maternal and neonatal requests showed varying significance over each 6-month interval. Only asphyxia and sepsis cases showed significant correlations with the number of requests made ( r ...

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Background Referral and clinical decision-making support are important for reducing delays in reaching and receiving appropriate and quality care. This paper presents analysis of the use of a pilot referral and decision making support call center for mothers and newborns in the Greater Accra region of Ghana, and challenges encountered in implementing such an intervention. Methods We analyzed longitudinal time series data from routine records of the call center over the first 33 months of its operation in Excel. Results During the first seventeen months of operation, the Information Communication Technology (ICT) platform was provided by the private telecommunication network MTN. The focus of the referral system was on maternal and newborn care. In this first phase, a total of 372 calls were handled by the center. 93% of the calls were requests for referral assistance (87% obstetric and 6% neonatal). The most frequent clinical reasons for maternal referral were prolonged labor (25%), hypertensive diseases in pregnancy (17%) and post-partum hemorrhage (7%). Birth asphyxia (58%) was the most common reason for neonatal referral. Inadequate bed space in referral facilities resulted in only 81% of referrals securing beds. The national ambulance service was able to handle only 61% of the requests for assistance with transportation because of its resource challenges. Resources could only be mobilized for the recurrent cost of running the center for 12 h (8.00 pm – 8.00 am) daily. During the second phase of the intervention we switched the use of the ICT platform to a free government platform operated by the National Security. In the next sixteen-month period when the focus was expanded to include all clinical cases, 390 calls were received with 51% being for medical emergency referrals and 30% for obstetrics and gynaecology emergencies. Request for bed space was honoured in 69% of cases. Conclusions The call center is a potentially useful and viable M-Health intervention to support referral and clinical decision making in the LMIC context of this study. However, health systems challenges such inadequacy of human resources, unavailability of referral beds, poor health infrastructure, lack of recurrent financing and emergency transportation need to be addressed for optimal functioning.