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A study of referrals due to obstetrical complications from the Ejisu district, Ashanti region, Ghana was done to determine the institutions that receive them, their outcome and the effectiveness of the referral system. This formed part of a multidisciplinary research on the prevention of maternal mortality in the district. It covered 15 health facilities in the district. The receiving institutions identified in the study were Komfo Anokye teaching Hospital (KATH) in Kumasi, Agogo Presbyterian Hospital in the neighbouring Ashanti Akim district and the St. Michael's Hospital at Pramso in the same district. In the period under review, there were 192 referrals from the district, 139 to KATH with 87 (63%) reporting, 19 to Pramso with 14 (74%) reporting and 34 to Agogo with 17 (50%) reporting. The 3 most important complications referred were maternal haemorrhage (29%), high-risk pregnancy (24%) and delayed second stage (21%). The referring institutions had a defaulting rate varying from 8-56% with a median of 42%. This study did not specifically investigate the factors influencing the high defaulting rates in some institutions. However, focus-group discussions (FGDs) held in selected communities revealed the following factors as inhibiting the utilization of health services: * prohibitive hospital fees; * illegal fees and bribes; * irregular transport and uncooperative drivers; * poor and unmotorable roads; * lack of drugs and essential supplies and; * negative staff attitudes. Those health facilities with low defaulting rates had their own transport or were close to major trunk roads. From the study, the referral system was very weak. It is also possible that some of the referrals reported at the receiving institutions but were not classified as such. Interventions to improve the situation are currently being implemented.

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The aim of the study was to determine the clinical epidemiology of genitourinary fistulae as seen at Komfo Anokye Teaching Hospital in Kumasi, Ghana. A retrospective study was carried out from the hospital records and operative reports of all patients with genitourinary fistulae seen at Komfo Anokye Teaching Hospital between January 1977 and December 1992. Patient age, parity, type of fistula and cause of fistula were abstracted from the medical records. There were 164 cases of genitourinary fistula managed during the study period. There were 150 fistulae due to obstetric causes (91, 5%), the vast majority of which were due to prolonged obstructed labor (121 cases, 73.8% of all fistulae), with a minority related to complications of lower-segment cesarean section (14 cases, 8.5% of all fistulae). In 5 cases (3.1%) patients developed a rectovaginal fistula owing to perineal tears and prolonged obstructed labor. During this time period there were 157,449 deliveries, giving an obstetric fistula rate of 1 fistula per 1000 deliveries. Obstetric fistulae were most common at the extremes of reproductive age and parity Fourteen additional fistulae (8.5% of all cases) were due to gynecologic causes, most commonly from surgical injury occurring at the time of abdominal hysterectomy for leiomyomata uteri (12 cases, 7.3% of all fistulae). It was concluded that in Kumasi, Ghana, obstetric trauma from prolonged obstructed labor is the most common cause of genitourinary fistula formation. Such fistulae occur in older multiparous women as well in young primigravidae. Obstructed labour can, and does, occur in women who have previously undergone uneventful vaginal delivery. Birth attendants should be aware of that fact. Prompt referral for obstetric intervention should be made in obstructed labor, irrespective of the age and parity of the patient.

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A non-comparative study of the Norplant contraceptive subdermal implant system was conducted in Kumasi, Ghana. A total of 100 acceptors were enrolled in the clinical trial, which began in 1987. There were no pregnancies during the first two years of use. Only nine post-insertion medical problems were reported during the first two years of use. One woman in this study requested removal for menstrual pattern changes through two years of use. As assessed through user-satisfaction questionnaires administered at approximately six months of use, there has been an overall positive user experience with Norplant in this study. Although the sample size in this study is small, our results seem to be consistent with other studies and it appears that Norplant offers an effective, safe and acceptable method of contraception for Ghanaian women.

PIP: A two-year pre-introductory study of 100 Norplant acceptors from Kumasi, Ghana, indicated that the contraceptive implants are safe, effective, and acceptable to this population. The mean age of study participants was 31.2 years; they had completed an average of 8.3 years of schooling and had a mean of 4.4 live births. Although 35% did not want any more children, 64% had used no contraceptive method in the month prior to study admission. No pregnancies were reported during interviews at 1, 3, 6, 12, 18, and 24 months post-insertion. The continuation rate was 86.6/100 women at two years, for a total of 2119 woman-months of use. 75 women elected to continue Norplant use, while 12 opted for removal and 13 were lost to follow-up. Reasons for discontinuation included desire for pregnancy (3), husband's insistence (5), travel (2), menstrual problems (1), and tuberculosis (1). Only nine acceptors reported any adverse effects; most frequent were itchiness and infection at the implant site. The incidence of amenorrhea decreased from 27% at the end of the first year of use to 2% by the end of the second year. When asked to identify the most attractive feature of the Norplant system, half the respondents cited its five-year duration of action; most disliked was Norplant's effect on the menstrual cycle. 83.7% indicated they would recommend Norplant to a friend, and 55% expressed an interest in having a second set of implants inserted after the full five years.

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OBJECTIVE: To describe a unique international effort to develop a training program in West Africa that would be of similar quality to any other in the world (but with sensitivity to cross-cultural needs) and would retain physicians in West Africa to improve women's health in that part of the world. METHODS: Step-by-step formulation of a program included initial trainee recruitment, the inclusion of foreign guest faculty, and the establishment of institutional libraries. This was followed by a phase of curriculum development, recruitment of West African faculty, and organization of an innovative, community-based fourth year. RESULTS: Between ten and 12 postgraduates will have completed the program by January 1996, and will be placed in Ghana. More than 60% of Ghanaian postgraduates have passed the relevant regional examinations, compared with less than 25% of candidates from other countries. Nine Ghanaian specialists have returned to Ghana to become faculty members in the program. Over 20 published peer-reviewed articles have resulted from this program since 1989. The number of residents being trained has increased from three to 28. Seven new residents joined the program in 1994. An early reduction in maternal mortality from 9.9 deaths per 1000 births in 1991 to 4.2 deaths per 1000 births in 1992 was noted when senior postgraduates took over labor and delivery at the teaching hospital in Accra, Ghana, where approximately 10,000 deliveries occur per year. CONCLUSION: Specialty training in obstetrics and gynecology that is specifically aimed at meeting the needs of West Africa has been initiated successfully. Long-range success will require support from regional governments and continued long-term commitments from the international community of obstetricians and gynecologists.

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A study on the utilization of maternal health services in Ejisu district of Ghana was carried out in January and February 1990. 1200 women aged between 15 and 49 were interviewed in 80 communities. The findings of the study indicated that over 50% of respondents married under 20 years, 70% of them attended antenatal clinic at least 4 times in their last pregnancy, over 80% had their last delivery in a health facility and over 80% knew about at least one modern method of family planning. Only 5.5% were currently using a modern family planning method. 90% of them were willing to stay in a maternity waiting home if advised to do so. Most would be prepared to stay for a month or 2. 20% of the respondents knew about local herbal preparations used for first aid in bleeding in pregnancy, although they would seek definitive treatment at a health facility. From the study, some women were not using the services. These would have to be reached through improving the quality of care in health facilities and increasing community awareness on maternal health in order to improve accessibility and utilization further.

PIP: This operations research project on the use of maternal health care services in Ejisu district in Ghana was performed during January and February 1990. The sample was comprised of 1200 women from 80 communities (population 131,199 persons in 1984) in the district, which has 19 health facilities (a Catholic mission hospital, 8 government health centers, 5 mission clinics, and 3 private maternity homes serving a population in 160 communities). Retrospective data was collected on health service use during January 1985-December 1989. Characteristics of the sample population included 59% 20-34 years old, 11% younger than 20, and 33% with no formal education. 37.9% were farmers, 26.7% were housewives, and 25% were traders. 74% were married. 50.3% married before the age of 20. 70.9% made at least 4 visits for prenatal care before their last pregnancy. 17.3% did not receive any prenatal care. 33.3% delivered at a health center. 28% used a Government Maternity Home, 22% used a hospital, and 13% relied on traditional birth attendants at home. 29% (349 women) reported complaints during their last pregnancy. 85.5% knew at least 1 method of contraception. 5.5% were current users of modern contraception, of which the pill was the most popular (45.4% of users). Treatment for bleeding during pregnancy was reported by 16.7% of the sample to involve eating a ripe banana or a banana in combination with cassava products. External use of plantain leaves or sanitary pads was also mentioned. These treatments were considered as first aid and not definitive treatment. 90% indicated a willingness to stay in a maternity waiting home if advised to do so. 58% would be able to stay 1 month, 21% would stay 2 months, and 21% would stay 3 or more months. Effective community education and social mobilization is still needed in order to attract those not using services.

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A community-based survey on maternal mortality was carried out in the Ejisu health district of Ghana in January and February 1990 to identify all women who died in pregnancy, delivery or the puerperium from January 1985 to December 1989, determine their characteristics, the presumptive causes of death and related factors. Forty-four women who died in pregnancy, delivery or the puerperium were identified over the stated period. 59% were aged between 20 and 34 years. Eighty-two percent were married and sixty-six percent had at least primary education. Based on an average crude birth rate of 40 per 1000 population for the district over the period, the lowest maternal mortality rate occurred in 1988, 120 per 100,000 total births and the highest occurred a year later, 235 per 100,000 total births. The main presumptive causes of maternal mortality in the district were postpartum haemorrhage 45.5%, jaundice in pregnancy 22.7%, obstructed labour 6.8%, eclampsia 6.8% and fever 4.6%. 59% of them died in a hospital, 2% died at a Government Maternity Home and 7% died during referral from health facilities in the district. Thirty-four percent of the women who died did not attend any antenatal clinic. The actual number of deaths may be underestimated due to the sampling method used and the difficulties encountered in linking survey data with hospital records. Based on the survey findings and other related PMM research, plans have been developed to reduce maternal mortality in the district as outline in the conclusion.

PIP: A community-based survey was conducted among 1200 reproductive age women living in 80 out of 160 communities in Ejisu health district in Ghana during January-February 1990. Retrospective data was collected for the period January 1985-December 1989. Data was analyzed in order to determine maternal mortality, causes of death, and the characteristics of the mothers who died. The sample community was comprised of 223,632 persons in 1990. 44 women were identified as having died in pregnancy, delivery, or postpartum. 59% were 20-34 years old, and 41% were in high-risk age groups. 65.9% had at least some primary education, and 81.8% were married at the time of death. 27.3% were childless at the time of death. Maternal deaths were distributed by year as follows: 9 deaths in 1985, 10 in 1986, 7 in 1987, 6 in 1988, and 12 in 1989. The estimated maternal mortality was 211 per 100,000 live births in 1986 and 235 per 100,000 in 1989. The 4-year average was 181 per 100,000. 34% of deaths were to women who had not received any prenatal care in the last pregnancy. Almost 75% died during delivery. 59% died in a hospital, 7% during a referral to a hospital, and 2% at a Government Maternity Home. Over 66% died after reaching a health facility. 27% died at home. 2% died while under the care of a local traditional birth attendant. Causes of maternal death were postpartum hemorrhage (45.5%), jaundice in pregnancy (22.7%), obstructed labor (6.8%), eclampsia (6.8%), and fever (4.6%). 2.3% of deaths were attributed to antepartum hemorrhage, ectopic pregnancy, and septic abortion. Prenatal care alone is not sufficient to prevent some deaths. The high mortality rate during delivery is a justification to improve the quality of care during delivery at all levels of the district health system. Listed are 9 potential interventions to reduce maternal mortality, including: establishing operating facilities at local health centers and maintaining a resident doctor for obstetric emergencies.

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OBJECTIVE: This hospital-based review of maternal mortality due to hemorrhage in Kumasi, Ghana was undertaken to determine the factors related to and influencing cases of fatal maternal hemorrhage. METHOD: The review was based on inpatient case notes, labor ward delivery notes, and operative records at the Maternity Block of the Komfo Anokye Teaching Hospital, Kumasi. The diagnoses were based on International Classification of Diseases (ICD) 9th and 10th editions. It covered the period 1981 to 1989. RESULT: It was observed that maternal hemorrhage accounted for over 40% of all obstetric complications admitted and also 27% of all maternal deaths in the period under review. However, the case fatality rate for maternal hemorrhage decreased from 1.34% in 1981 to 0.7% in 1989. The cesarean section rate increased from 6.7% in 1981 to 9.1% in 1989. The maternal mortality rate over the period was 1140 per 100,000 births. CONCLUSION: Based on this review and other related research, the following interventions have been planned for implementation in order to improve the situation: improving staff-patient relationship through training in interpersonal skills; ensuring 24-h availability of drugs, supplies and blood; establishment of a resuscitation unit at the casualty department so that first aid can be provided to patients with obstetric emergencies before transfer to the wards; establishment of a maternity care monitoring system to continually improve the quality of care; introduction of confidential enquiry into all maternal deaths in order to reduce their incidence. A monitoring and evaluation plan has been developed to assess regularly progress on implementation. Although, maternal deaths are due to multifactorial causes, it is hoped that these interventions, if successfully implemented, will contribute significantly towards the reduction of maternal deaths due to institutional factors, especially direct obstetric causes like maternal hemorrhage.

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The incidence of urogenital chlamydia infections among selected patients in Kumasi, Ghana was evaluated using an immunofluorescent monoclonal antibody technique. Chlamydia trachomatis was identified in 4 of 110 patients presenting for prenatal care, 2 of 55 female patients with infertility and 6 of 15 males with acute urethritis. The findings demonstrate that C. trachomatis is a frequently identified pathogen among male patients presenting with symptoms of acute urethritis; however, the incidence of chlamydia infections among asymptomatic patients is relatively low.

PIP: The incidence of urogenital chlamydia infections among selected patients in Kumasi, Ghana was evaluated using an immuno-florescent monoclonal antibody technique. Chlamydia trachomatis was identified in 4 of 110 patients presenting for prenatal care, 2 of 55 female patients with infertility and 6 of 15 males with acute urethritis. The findings demonstrate that C. trachomatis is a frequently identified pathogen among male patients presenting with symptoms of acute urethritis; however, the incidence of chlamydia infections among asymptomatic patients is relatively low. Sites for the study were the University of Science and Technology and the Komfo Anokye Teaching Hospital in Kumasi. These findings suggest that C. trachomatis is an important pathogen in sexually transmitted infection in Kumasi, Ghana; isolation rates from this area are consistent with those reported from western countries. An asymptomatic carriage rate of 3.6% is similar to that reported from nearby Accra. The present study did not demonstrate an increased incidence of C. trachomatis infections among patients with infertility, as has been noted in other studies. However, the etiology of infertility in these patients was not fully evaluated and prior chlamydial infections might have occurred.

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Vesicovaginal fistulas remain common and serious problems for women in West Africa. Thirty-six surgical repairs done during visiting professorships by American gynecologists between the years 1978-1987 are documented. The overall success rate was 70%. The management of large (greater than 4 cm) obstetric fistulas was especially difficult until the Latzko technique was abandoned for the technique of wide mobilization of vaginal flaps over the fistula site. This technique reduced the failure rate from 75% through 1986 to approximately 25% in 1987. Ongoing controversies and basic principles of surgical techniques in fistula repair are reviewed.

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