Publications by authors named "Edward Antwi"

14 Publications

  • Page 1 of 1

Systematic review of prediction models for gestational hypertension and preeclampsia.

PLoS One 2020 21;15(4):e0230955. Epub 2020 Apr 21.

Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.

Introduction: Prediction models for gestational hypertension and preeclampsia have been developed with data and assumptions from developed countries. Their suitability and application for low resource settings have not been tested. This review aimed to identify and assess the methodological quality of prediction models for gestational hypertension and pre-eclampsia with reference to their application in low resource settings.

Methods: Using combinations of keywords for gestational hypertension, preeclampsia and prediction models seven databases were searched to identify prediction models developed with maternal data obtained before 20 weeks of pregnancy and including at least three predictors (Prospero registration CRD 42017078786). Prediction model characteristics and performance measures were extracted using the CHARMS, STROBE and TRIPOD checklists. The National Institute of Health quality assessment tools for observational cohort and cross-sectional studies were used for study quality appraisal.

Results: We retrieved 8,309 articles out of which 40 articles were eligible for review. Seventy-seven percent of all the prediction models combined biomarkers with maternal clinical characteristics. Biomarkers used as predictors in most models were pregnancy associated plasma protein-A (PAPP-A) and placental growth factor (PlGF). Only five studies were conducted in a low-and middle income country.

Conclusions: Most of the studies evaluated did not completely follow the CHARMS, TRIPOD and STROBE guidelines in prediction model development and reporting. Adherence to these guidelines will improve prediction modelling studies and subsequent application of prediction models in clinical practice. Prediction models using maternal characteristics, with good discrimination and calibration, should be externally validated for use in low and middle income countries where biomarker assays are not routinely available.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0230955PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7173928PMC
July 2020

Equity in maternal health outcomes in a middle-income urban setting: a cohort study.

Reprod Health 2019 Jun 18;16(1):84. Epub 2019 Jun 18.

Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.

Background: Low socioeconomic status (SES) is associated with more adverse perinatal health outcomes, risk factors and lower access to and use of maternal health care services. However, evidence for the association between SES and maternal health outcomes is limited, particularly for middle-income countries like sub-Saharan Ghana. We assessed the association between parental SES and adverse maternal and perinatal outcomes of Ghanaian women during pregnancy, delivery and the postpartum period.

Methods: A prospective cohort study of 1010 women of two public hospitals in Accra, Ghana (2012-2014). SES was proxied by maternal and paternal education, wealth and employment status. The association of SES with maternal and perinatal outcomes was analyzed with multivariable logistic and linear regression.

Results: The analysis included 790 women with information on pregnancy outcomes. Average age was 28.2 years (standard deviation, SD 5.0). Over a third (n = 292, 37.0%) had low SES, 176 (22.3%) were classified to have high SES using the assets index. Nearly half (n = 374, 47.3%) of women had lower secondary school or vocational training as highest education level. Compared to women with middle assets SES, women with low assets SES were at higher risk for miscarriage (odds ratio, OR 1.61, 95% CI 1.06 to 2.45) and instrumental delivery (OR 1.74, 95% CI 1.03 to 2.94), but this association was not observed for the other SES proxies. For any of the maternal or perinatal outcomes and SES proxies, no other statistically significant differences were found.

Conclusion: Women attending public maternal health care services in urban Ghana had overall equitable maternal and perinatal health outcomes, with the exception of a higher risk of miscarriage and instrumental delivery associated with low assets SES. This suggests known associations between SES, risk factors and outcomes could be mitigated with universal and accessible maternal health services.
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http://dx.doi.org/10.1186/s12978-019-0736-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6580627PMC
June 2019

Anaerobic digestion and the effect of hydrothermal pretreatment on the biogas yield of cocoa pods residues.

Waste Manag 2019 Apr 22;88:131-140. Epub 2019 Mar 22.

Universität Rostock, Professorship of Waste and Resource Management, Justus-von-Liebig-Weg 6, 18059 Rostock, Germany.

The current research investigated the possibility of valorizing cocoa pods residues through anaerobic digestion and the possibility of increasing the biogas yield by hydrothermal pretreatment. Using a central composite surface response methodology, the effect of temperature and reaction time on the hydrothermal pretreatment process was studied. Temperature and reaction time was varied between 150-220 °C and 5-15 min respectively. The result show that untreated cocoa pods residues has a biogas potential of 357 l(N)/kgVS and a methane content of 55%. The effect of hydrothermal pretreatment on the biogas yield was diverse. Severities below 3.0 resulted in increased biogas yield. However, higher severity resulted in lower biogas yield. The optimum biogas yield (526.38 l(N)/kgVS) was obtained at 150 °C and 15 min, which represents a severity of 2.65.
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http://dx.doi.org/10.1016/j.wasman.2019.03.034DOI Listing
April 2019

Does body mass index early in pregnancy influence the risk of maternal anaemia? An observational study in Indonesian and Ghanaian women.

BMC Public Health 2018 07 13;18(1):873. Epub 2018 Jul 13.

Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.

Background: Anaemia is common among pregnant women, especially in low- and middle-income countries (LMICs). While body mass index (BMI) relates to many risk factors for anaemia in pregnancy, little is known about the direct relation with anaemia itself. This is particularly relevant in Southeast Asia and Sub-Saharan Africa where the prevalence of anaemia in pregnancy and the associated adverse outcomes is among the highest worldwide. This study aimed to assess the association between early pregnancy BMI and anaemia at first antenatal care visit in Indonesian and Ghanaian women. In addition, the associations between early pregnancy anaemia and adverse birth outcomes was assessed.

Methods: Prospective cohort studies of women in early pregnancy were conducted in Jakarta, Indonesia (n = 433) and in Accra, Ghana (n = 946), between 2012 and 2014. Linear regression analysis was used to assess relations between early pregnancy BMI and pregnancy haemoglobin levels at booking. Logistic regression analyses were used to assess associations between early pregnancy anaemia as defined by the World Health Organization (WHO) criteria and a composite of adverse birth outcomes including stillbirth, low birth weight and preterm birth.

Results: Indonesian women had lower BMI than Ghanaian women (23.0 vs 25.4 kg/m, p < 0.001) and higher mean haemoglobin levels (12.4 vs 11.1 g/dL, p < 0.001), corresponding to anaemia prevalence of 10 and 44%, respectively. Higher early pregnancy BMI was associated with higher haemoglobin levels in Indonesian (0.054 g/dL/kg/m, 95% CI 0.03 to 0.08, p < 0.001) and Ghanaian women (0.044 g/dL/kg/m, 0.02 to 0.07, p < 0.001). Accordingly, risk for anaemia decreased with higher early pregnancy BMI for Indonesians (adjusted OR 0.88, 0.81 to 0.97, p = 0.01) and Ghanaians (adjusted OR 0.95, 0.92 to 0.98, p < 0.001). No association between anaemia and the composite of adverse birth outcomes was observed.

Conclusion: Higher BMI in early pregnancy is associated with higher haemoglobin levels at antenatal booking and with a reduced risk of anaemia in Indonesian and Ghanaian women.
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http://dx.doi.org/10.1186/s12889-018-5704-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6045841PMC
July 2018

Improved prediction of gestational hypertension by inclusion of placental growth factor and pregnancy associated plasma protein-a in a sample of Ghanaian women.

Reprod Health 2018 Mar 27;15(1):56. Epub 2018 Mar 27.

Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.

Background: We assessed whether adding the biomarkers Pregnancy Associated Plasma Protein-A (PAPP-A) and Placental Growth Factor (PlGF) to maternal clinical characteristics improved the prediction of a previously developed model for gestational hypertension in a cohort of Ghanaian pregnant women.

Methods: This study was nested in a prospective cohort of 1010 pregnant women attending antenatal clinics in two public hospitals in Accra, Ghana. Pregnant women who were normotensive, at a gestational age at recruitment of between 8 and 13 weeks and provided a blood sample for biomarker analysis were eligible for inclusion. From serum, biomarkers PAPP-A and PlGF concentrations were measured by the AutoDELFIA immunoassay method and multiple of the median (MoM) values corrected for gestational age (PAPP-A and PlGF) and maternal weight (PAPP-A) were calculated. To obtain prediction models, these biomarkers were included with clinical predictors maternal weight, height, diastolic blood pressure, a previous history of gestational hypertension, history of hypertension in parents and parity in a logistic regression to obtain prediction models. The Area Under the Receiver Operating Characteristic Curve (AUC) was used to assess the predictive ability of the models.

Results: Three hundred and seventy three women participated in this study. The area under the curve (AUC) of the model with only maternal clinical characteristics was 0.75 (0.64-0.86) and 0.89(0.73-1.00) for multiparous and primigravid women respectively. The AUCs after inclusion of both PAPP-A and PlGF were 0.82 (0.74-0.89) and 0.95 (0.87-1.00) for multiparous and primigravid women respectively.

Conclusion: Adding the biomarkers PAPP-A and PlGF to maternal characteristics to a prediction model for gestational hypertension in a cohort of Ghanaian pregnant women improved predictive ability. Further research using larger sample sizes in similar settings to validate these findings is recommended.
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http://dx.doi.org/10.1186/s12978-018-0492-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5870183PMC
March 2018

Development and validation of a prediction model for gestational hypertension in a Ghanaian cohort.

BMJ Open 2017 01 16;7(1):e012670. Epub 2017 Jan 16.

Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.

Objective: To develop and validate a prediction model for identifying women at increased risk of developing gestational hypertension (GH) in Ghana.

Design: A prospective study. We used frequencies for descriptive analysis, χ test for associations and logistic regression to derive the prediction model. Discrimination was estimated by the c-statistic. Calibration was assessed by calibration plot of actual versus predicted probability.

Setting: Primary care antenatal clinics in Ghana.

Participants: 2529 pregnant women in the development cohort and 647 pregnant women in the validation cohort. Inclusion criterion was women without chronic hypertension.

Primary Outcome: Gestational hypertension.

Results: Predictors of GH were diastolic blood pressure, family history of hypertension in parents, history of GH in a previous pregnancy, parity, height and weight. The c-statistic of the original model was 0.70 (95% CI 0.67-0.74) and 0.68 (0.60 to 0.77) in the validation cohort. Calibration was good in both cohorts. The negative predictive value of women in the development cohort at high risk of GH was 92.0% compared to 94.0% in the validation cohort.

Conclusions: The prediction model showed adequate performance after validation in an independent cohort and can be used to classify women into high, moderate or low risk of developing GH. It contributes to efforts to provide clinical decision-making support to improve maternal health and birth outcomes.
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http://dx.doi.org/10.1136/bmjopen-2016-012670DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5253568PMC
January 2017

Pregnancy Associated Plasma Protein-A and Placental Growth Factor in a Sub-Saharan African Population: A Nested Cross-Sectional Study.

PLoS One 2016 17;11(8):e0159592. Epub 2016 Aug 17.

Center for Infectious Diseases Research, Diagnostics and Screening (IDS), National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands.

Background: Baseline distributions of pregnancy disorders' biomarkers PlGF and PAPP-A levels are primarily based on Western European populations of Caucasian ethnicity. Differences in PAPP-A and PlGF concentrations by ethnicity have been observed, with increased levels in Afro-Caribbean, East Asian, and South Asian women. Baseline concentrations of sub-Saharan African women have not been evaluated.

Objectives: To investigate PlGF and PAPP-A in a sub-Saharan African population and assess the performance of existing reference values of PAPP-A and PlGF.

Methods: A nested cross-sectional study was conducted in two public hospitals in Accra, Ghana. Out of the original 1010 women enrolled in the cohort, 398 participants were eligible for inclusion with a normotensive singleton gestation and serum samples taken between 56-97 days of pregnancy. PAPP-A and PlGF concentrations were measured with an automated immunoassay. Multiple of the median (MoM) values corrected for gestation and maternal weight for PAPP-A and PlGF were calculated using reference values of a Dutch perinatal screening laboratory based on over 10.000 samples, and PlGF manufacturer reference values, respectively.

Results: The PAPP-A median MoM was 2.34 (interquartile range (IQR) 1.24-3.97). Median PlGF MoM was 1.25 (IQR 0.95-1.80). Median MoM values for PAPP-A and PlGF tended to be slightly different for various Ghanaian ethnic subgroups.

Conclusions: PAPP-A and PlGF MoM values appear to be substantially higher in a sub-Saharan African population compared to the Caucasian or Afro-Caribbean MoM values previously reported. The difference suggests the need for a specific correction factor for this population to avoid underestimation of risk for fetal aneuploidies or placental disorders when using PAPP-A and PlGF MoM for screening purposes.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0159592PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4988712PMC
August 2017

Human Health Risk Assessment of Artisanal Miners Exposed to Toxic Chemicals in Water and Sediments in the Prestea Huni Valley District of Ghana.

Int J Environ Res Public Health 2016 Jan 18;13(1). Epub 2016 Jan 18.

Department of Immunology, Noguchi Memorial Institute for Medical Research, College of Health and Allied Sciences, University of Ghana, Legon, Ghana.

A human health risk assessment of artisanal miners exposed to toxic metals in water bodies and sediments in the PresteaHuni Valley District of Ghana was carried out in this study, in line with US EPA risk assessment guidelines. A total of 70 water and 30 sediment samples were collected from surface water bodies in areas impacted by the operations of artisanal small-scale gold mines in the study area and analyzed for physico-chemical parameters such as pH, TDS, conductivity, turbidity as well as metals and metalloids such as As, Cd, Hg and Pb at CSIR-Water Research Institute using standard methods for the examination of wastewater as outlined by American Water Works Association (AWWA). The mean concentrations of As, Cd, Hg and Pb in water samples ranged from 15 μg/L to 325 μg/L (As), 0.17 μg/L to 340 μg/L (Cd), 0.17 μg/L to 122 μg/L (Pb) and 132 μg/L to 866 μg/L (Hg), respectively. These measured concentrations of arsenic (As), mercury (Hg), cadmium (Cd) and lead (Pb) were used as input parameters to calculate the cancer and non-cancer health risks from exposure to these metals in surface water bodies and sediments based on an occupational exposure scenario using central tendency exposure (CTE) and reasonable maximum exposure (RME) parameters. The results of the non-cancer human health risk assessment for small-scale miners working around river Anikoko expressed in terms of hazard quotients based on CTE parameters are as follows: 0.04 (Cd), 1.45 (Pb), 4.60 (Hg) and 1.98 (As); while cancer health risk faced by ASGM miners in Dumase exposed to As in River Mansi via oral ingestion of water is 3.1 × 10(-3). The hazard quotient results obtained from this study in most cases were above the HQ guidance value of 1.0, furthermore the cancer health risk results were found to be higher than the USEPA guidance value of 1 × 10(-4) to 1 × 10(-6). These findings call for case-control epidemiological studies to establish the relationship between exposure to the aforementioned toxic chemicals and diseases associated with them as identified in other studies conducted in different countries as basis for developing policy interventions to address the issue of ASGM mine workers safety in Ghana.
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http://dx.doi.org/10.3390/ijerph13010139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4730530PMC
January 2016

Maternal body mass index and adverse pregnancy outcomes: A ghanaian cohort study.

Obesity (Silver Spring) 2016 Jan 17;24(1):215-22. Epub 2015 Nov 17.

Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands.

Objective: To examine the association between maternal weight at <17 weeks gestation and maternal and infant outcomes of pregnancy, delivery, and the postpartum period in pregnant Ghanaian women.

Methods: A prospective cohort study of 1,000 women in Accra, Ghana (2012-2014), was conducted. Women were classified as having overweight (BMI 25-30) and obesity (BMI ≥ 30), and their obstetric and infant outcomes were analyzed using multivariate logistic regression.

Results: The analysis included 824 women, average 28 years (SD 5.1); 313 (31.3%) had overweight and 169 (16.9%) obesity. Women with obesity had a two-fold increased risk for cesarean sections (RR 2.20, 95% CI 1.21-4.02) and more than a six-fold higher risk for pregnancy-induced hypertension (RR 6.17, 95% CI 2.90-13.13) and chronic hypertension (RR 6.00, 95% CI 1.40-25.76). Infants of women with overweight or obesity were more likely to be macrosomic (RR 2.37, 95% CI 1.13-4.97).

Conclusions: The global obesity epidemic has reached women in low- and middle-income countries (LMIC) with important adverse consequences for maternal and infant health. Antenatal care in LMIC will need to anticipate this potential expansion of complications, including the development of guidelines for optimal maternity care for pregnant women with overweight and obesity.
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http://dx.doi.org/10.1002/oby.21210DOI Listing
January 2016

Measuring regional and district variations in the incidence of pregnancy-induced hypertension in Ghana: challenges, opportunities and implications for maternal and newborn health policy and programmes.

Trop Med Int Health 2016 Jan 16;21(1):93-100. Epub 2015 Nov 16.

Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands.

Objectives: The objectives were to assess the quality of health management information system (HMIS) data needed for assessment of local area variation in pregnancy-induced hypertension (PIH) incidence and to describe district and regional variations in PIH incidence.

Methods: A retrospective review of antenatal and delivery records of 2682 pregnant women in 10 district hospitals in the Greater Accra and Upper West regions of Ghana was conducted in 2013. Quality of HMIS data was assessed by completeness of reporting. The incidence of PIH was estimated for each district.

Results: Key variables for routine assessment of PIH such as blood pressure (BP) at antenatal visits, weight and height were 95-100% complete. Fundal height, gestational age and BP at delivery were not consistently reported. The incidence of PIH differed significantly between Greater Accra region (6.1%) and Upper West region (3.2%). Prevalence of obesity among pregnant women in Greater Accra region (13.9%) was significantly higher than that of women in Upper West region (2.2%).

Conclusions: More attention needs to be given to understanding local area variations in PIH and possible relationships with urbanisation and lifestyle changes that promote obesity, to inform maternal and newborn health policy. This can be done with good quality routine HMIS data.
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http://dx.doi.org/10.1111/tmi.12626DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4737319PMC
January 2016

Integrated Assessment of Artisanal and Small-Scale Gold Mining in Ghana-Part 2: Natural Sciences Review.

Int J Environ Res Public Health 2015 Jul 31;12(8):8971-9011. Epub 2015 Jul 31.

Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, MI 48109, USA.

This paper is one of three synthesis documents produced via an integrated assessment (IA) that aims to increase understanding of artisanal and small-scale gold mining (ASGM) in Ghana. Given the complexities surrounding ASGM, an integrated assessment (IA) framework was utilized to analyze socio-economic, health, and environmental data, and co-develop evidence-based responses with stakeholders. This paper focuses on the causes, status, trends, and consequences of ecological issues related to ASGM activity in Ghana. It reviews dozens of studies and thousands of samples to document evidence of heavy metals contamination in ecological media across Ghana. Soil and water mercury concentrations were generally lower than guideline values, but sediment mercury concentrations surpassed guideline values in 64% of samples. Arsenic, cadmium, and lead exceeded guideline values in 67%, 17%, and 24% of water samples, respectively. Other water quality parameters near ASGM sites show impairment, with some samples exceeding guidelines for acidity, turbidity, and nitrates. Additional ASGM-related stressors on environmental quality and ecosystem services include deforestation, land degradation, biodiversity loss, legacy contamination, and potential linkages to climate change. Though more research is needed to further elucidate the long-term impacts of ASGM on the environment, the plausible consequences of ecological damages should guide policies and actions to address the unique challenges posed by ASGM.
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http://dx.doi.org/10.3390/ijerph120808971DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4555259PMC
July 2015

Advancing the application of systems thinking in health: provider payment and service supply behaviour and incentives in the Ghana National Health Insurance Scheme--a systems approach.

Health Res Policy Syst 2014 Aug 5;12:35. Epub 2014 Aug 5.

Department of Health Policy Planning and Management (HPPM), University of Ghana School of Public Health, P,O, Box LG 13, Legon, Accra, Ghana.

Background: Assuring equitable universal access to essential health services without exposure to undue financial hardship requires adequate resource mobilization, efficient use of resources, and attention to quality and responsiveness of services. The way providers are paid is a critical part of this process because it can create incentives and patterns of behaviour related to supply. The objective of this work was to describe provider behaviour related to supply of health services to insured clients in Ghana and the influence of provider payment methods on incentives and behaviour.

Methods: A mixed methods study involving grey and published literature reviews, as well as health management information system and primary data collection and analysis was used. Primary data collection involved in-depth interviews, observations of time spent obtaining service, prescription analysis, and exit interviews with clients. Qualitative data was analysed manually to draw out themes, commonalities, and contrasts. Quantitative data was analysed in Excel and Stata. Causal loop and cause tree diagrams were used to develop a qualitative explanatory model of provider supply incentives and behaviour related to payment method in context.

Results: There are multiple provider payment methods in the Ghanaian health system. National Health Insurance provider payment methods are the most recent additions. At the time of the study, the methods used nationwide were the Ghana Diagnostic Related Groupings payment for services and an itemized and standardized fee schedule for medicines. The influence of provider payment method on supply behaviour was sometimes intuitive and sometimes counter intuitive. It appeared to be related to context and the interaction of the methods with context and each other rather than linearly to any given method.

Conclusions: As countries work towards Universal Health Coverage, there is a need to holistically design, implement, and manage provider payment methods reforms from systems rather than linear perspectives, since the latter fail to recognize the effects of context and the between-methods and context interactions in producing net effects.
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http://dx.doi.org/10.1186/1478-4505-12-35DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4142471PMC
August 2014

PP081. Predictors of pregnancy induced hypertension in an urban low resource setting.

Pregnancy Hypertens 2013 Apr 6;3(2):97. Epub 2013 Jun 6.

Introduction: Hypertensive disorders in pregnancy, including Pregnancy Induced Hypertension (PIH), are important causes of morbidity and mortality in pregnancy. Identifying women at high risk will allow for early management to reduce complications of PIH.

Objectives: The objectives were to determine the incidence of PIH among pregnant women and develop risk prediction models for early detection of women at increased risk of PIH.

Methods: A longitudinal cohort study involving 2539 pregnant women attending antenatal clinic in the Greater Accra region of Ghana was conducted between February and May 2010. The outcome, PIH, was defined as systolic or diastolic blood pressure BP of 140mmHg or 90mmHg respectively. Logistic regression was used to derive the prediction models and bootstrapping technique was used to internally validate them. A score chart was used to classify pregnant women into low, moderate and high risk of developing PIH.

Results: The incidence of PIH was 8.0% (95% C.I: 7.98-8.02%) and 10.9% (95% C.I:10.89-10.91%) in nulliparous and multiparous women respectively. Systolic blood pressure, diastolic blood pressure, history of hypertension in parents, family history of diabetes, proteinuria, body mass index (BMI) were among independent predictors in early pregnancy of subsequent PIH. The prognostic performance, estimated by the area under the Receiver Operating Characteristic (ROC) curve, ranged between 0.64 and 0.84 for the models for nulliparous and multiparous.

Conclusion: Using a limited set of maternal characteristics, pregnant women at increased risk of developing PIH can be identified. Categorizing women by risk of PIH and providing tailored antenatal care will minimize complications of PIH.
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http://dx.doi.org/10.1016/j.preghy.2013.04.106DOI Listing
April 2013

Care decision making of frontline providers of maternal and newborn health services in the greater Accra region of Ghana.

PLoS One 2013 13;8(2):e55610. Epub 2013 Feb 13.

Ridge Regional Hospital OPD, Adabraka, Accra, Ghana.

Objectives: To 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.

Methods: A 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.

Results: Tacit 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.

Conclusion: Supporting 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.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0055610PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3572062PMC
August 2013