Objective: To describe our experience of using ultrasonography to locate and remove impalpable implants in a low-resource environment. Methodology: We report a series of non-palpable subdermal contraceptive implants with unsuccessful removal attempts at other facilities, who were referred to the Reproductive Health Unit, KorleBu Teaching Hospital, between 2015-2018. A high-resolution linear-array probe ultrasound was done to localize the implants. Removal was performed under local anaesthesia, involving a longitudinal incision within the ultrasound-guided skin markings and blunt dissection to locate and retrieve the implant. Results: Fifteen patients with non-palpable subdermal contraceptive implants were referred after failed attempts by midwives or gynaecologists over the period. Implants included Implanon (9) and Jadelle (6), with durations of use ranging from 8 months to 5 years. Most implants were successfully located using high-resolution linear-array ultrasound probe, and removed under local anaesthesia. Implants were abnormally positioned in 5 cases, with depths ranging between 5 mm and 7 mm. In 14 cases, removal was successful through skin marker guidance or direct ultrasound guidance. One case required general anaesthesia and plastic surgeon’s assistance. No significant complications were reported. Conclusion: In Ghana, the increasing incidence of impalpable contraceptive implants necessitates the use of interventional radiological methods for removal. Our case series demonstrates that ultrasound-guided removal of non-palpable implants is effective and can be performed with minimal complications in low-resource settings. We recommend training providers, including midwives, in ultrasound-guided implant removal techniques and advocating for early referral to specialized centers.

Pre-eclampsia is a leading cause of maternal and neonatal mortality, affecting nearly 5

Africa has a high burden of congenital anomalies due in part to limited preconception care, infections, and environmental exposures. However, the true prevalence of congenital anomalies is unclear because of insufficient access to prenatal diagnostic services. We aimed to determine the rate of congenital anomalies, and characterize the anomalies detected prenatally at a referral hospital in Ghana. We performed a four-year retrospective review of all fetal anomaly ultrasounds performed and congenital anomalies detected from January 1st, 2020, to December 31st, 2023, at Korle Bu Teaching Hospital, Accra, Ghana. Data were extracted from the electronic database on maternal age, gestational age at time of ultrasound, and occupation. Detected congenital anomalies were identified, and each anomaly was categorized by ICD-10 code and EUROCAT classification. Descriptive statistics were performed. The mean maternal age and median gestational age at the time of ultrasound were 31.1 (SD 6.3) years and 26.9 (IQR 22.5–31.0) weeks, respectively. 3,981 anatomy ultrasounds were performed during the study period, and 7.0

Avoidable cesarean deliveries (CDs) have associated morbidity and mortality. External cephalic version (ECV) is a low-risk, cost-effective procedure to reduce avoidable CDs. In low- and middle-income countries, ECVs are not commonly performed. Our aim is to determine the acceptability and feasibility of external cephalic version among Ghanaian patients and clinicians. We are conducting a prospective cohort study of patients presenting with malpresentation and their respective clinicians at an urban, teaching hospital in Accra, Ghana, from July 2024. Patients were followed up from 36 weeks of gestation to delivery. After delivery, patients and clinicians completed a semistructured interview regarding their malpresentation experience and management, respectively. We are analyzing data via sequential explanatory mixed methods. About 14 (58%) eligible patients were offered ECV, and 3 (21%) patients declined. The success rate of ECV is 36%. For patients who had an ECV whether successful or not, they appreciated the ability to try to avoid a CD. For patients declining ECV, this was influenced by their partner. All patients not offered ECV expressed that if given the opportunity, they would try an ECV to avoid a CD. All clinicians understood the importance of offering ECV to reduce avoidable CDs, and those who did not offer ECV took a conservative approach to the patient’s potential ECV success. Patients and clinicians understand the importance of reducing avoidable CDs and accept the role of ECV in achieving that goal. Including patients’ partners in counseling and further clinician training for ECV can help to increase the feasibility of ECV.

With improvements in health care, most females with sickle cell disease (SCD) are surviving into adolescence and adulthood. Delayed onset menarche, increased risk of acute vaso-occlusive pain associated with menstruation and dysmenorrhea, and increased odds of pregnancy-related complications are prevalent in females with SCD. Significant knowledge gaps exist in the management of reproductive health issues in adolescent females with SCD. This article highlights the pediatric clinicians' approach to essential reproductive health issues such as menarche, acute vaso-occlusive pain temporarily associated with menstruation and dysmenorrhea, and pregnancy in adolescent females with SCD.

OBJECTIVES:(1) To explore pregnant Ghanaian women's perspectives on family involvement in their home blood pressure monitoring (HBPM); (2) to define forms of family involvement in pregnant women's HBPM; and (3) to understand how family involvement influences HBPM for pregnant women in this setting. STUDY DESIGN:This phenomenological qualitative study was conducted at a tertiary hospital in urban Ghana. Participants were adult pregnant women participating in HBPM. Enrolled participants received audiovisual and hands-on HBPM training and completed daily BP monitoring for 2-4 weeks. MAIN OUTCOME MEASURES:Semi-structured interviews assessed participant perspectives on family involvement with their HBPM. Interviews were audio-recorded, translated, transcribed, coded, and thematically analyzed. RESULTS:Thirty-three participants completed in-depth interviews. Participants had a mean age of 31.2 ± 5.2 years, 30.3 % had not previously given birth, and 39.4 % had less than a senior high school education. Overall, participants felt their family's involvement made HBPM easier and a more positive experience. There were three forms of family involvement: 1) approval, 2) assistance, and 3) participation. All family members approved of HBPM. Assistance and participation were associated with the most positive perceptions. Participants referenced family togetherness, enjoyment of HBPM, and decreased stress as outcomes. Negative aspects of family involvement were disruptions from children and participants' preference to monitor alone, were experienced rarely, and were able to be overcome. CONCLUSIONS:Among pregnant women in urban Ghana, family involvement in HBPM was perceived as helpful and enjoyable, resulted in psychosocial benefits, and may help overcome barriers to HBPM in low- and middle-income countries. ABBREVIATIONS:BP, blood pressure; HBPM, home blood pressure monitoring; HDP, hypertensive disorders of pregnancy; LMID, low- and middle-income countries; KBTH, Korle Bu Teaching Hospital; OBGYN, Obstetrics and Gynaecology; ANC, antenatal care.

Background: Sickle cell disease (SCD) has evolved from a condition predominantly fatal in childhood to a chronic illness impacting many adults, including women of reproductive age. For females with SCD, pregnancy represents one of the greatest health threats, exacerbating existing health challenges and introducing new risks. Despite advancements in healthcare, routine screening for existing complications like pulmonary hypertension (PH) remains inconsistent, particularly in low- and middle-income countries (LMICs), where the prevalence of SCD is highest. Objective: This study aimed to assess the feasibility of screening for PH in pregnant women with SCD in LMICs, with the goal of enhancing maternal health outcomes in this vulnerable population. Study Design: A prospective multi-center feasibility study was conducted from September 2022 to February 2023 at teaching hospitals in Ghana and Nigeria. The study included pregnant women with SCD between 28 and 34 weeks of gestation. Screening for PH utilized a tricuspid regurgitation velocity (TRV) criterion (>2.5 m/s), with adherence to American Society of Echocardiography guidelines. Statistical analysis included descriptive statistics and proportions. Results: Among 3091 pregnant women attending antenatal care, 88 had SCD (2.8%), and 55 were eligible for the study. We recruited 44 participants (mean age 28.9 years, SD 4.8), with 48% (21/44) SS genotype and 52% (23/44) SC genotype. Most participants (95.3%) had normal TRV (<2.5 m/s), with only one showing elevated TRV, successfully referred. Protocol adherence was 100%. Antenatal outcomes showed 95% echo uptake and 95.7% retention to term whilst postnatal echo follow-up was 43.5%. Notably, 27.1% (10/37) of deliveries required neonatal intensive care unit admission, and 18.2% were preterm. The sole participant with PH required intensive care unit care and experienced a preterm delivery with neonatal death on day 5. Conclusion: Screening and referral for PH in pregnant women with SCD in LMICs are feasible but face challenges in early diagnosis, healthcare personnel availability, and postnatal follow-up. Strategic planning is crucial to address these challenges and improve outcomes in this high-risk population

Measures of physical growth, such as weight and height have long been the predominant outcomes for monitoring child health and evaluating interventional outcomes in public health studies, including those that may impact neurodevelopment. While physical growth generally reflects overall health and nutritional status, it lacks sensitivity and specificity to brain growth and developing cognitive skills and abilities. Psychometric tools, e.g., the Bayley Scales of Infant and Toddler Development, may afford more direct assessment of cognitive development but they require language translation, cultural adaptation, and population norming. Further, they are not always reliable predictors of future outcomes when assessed within the first 12-18 months of a child's life. Neuroimaging may provide more objective, sensitive, and predictive measures of neurodevelopment but tools such as magnetic resonance (MR) imaging are not readily available in many low and middle-income countries (LMICs). MRI systems that operate at lower magnetic fields (< 100mT) may offer increased accessibility, but their use for global health studies remains nascent. The UNITY project is envisaged as a global partnership to advance neuroimaging in global health studies. Here we describe the UNITY project, its goals, methods, operating procedures, and expected outcomes in characterizing neurodevelopment in sub-Saharan Africa and South Asia.

Elderly primigravidae refers to women who become pregnant for the first time from age 35 years and above. Advanced maternal age is a known risk factor for numerous maternal and perinatal complications. This study sought to determine pregnancy outcomes of elderly primigravidae at the Korle-Bu Teaching Hospital (KBTH). A retrospective cohort study was conducted. Women who had their first delivery at KBTH from January 1, 2015 to December 31, 2017 had their demographic and obstetrics and gynecology history and maternal and fetal outcomes retrieved from the department's electronic database. Women aged 35 years or more who had their first delivery within the study period constituted the exposed, whereas those between 20 and 34 were considered unexposed. Modified Poisson regression with robust error variance estimation and the log link function between the sociodemographic and obstetric factors and maternal and fetal outcomes to estimate adjusted risk ratios (aRRs) and 95% CI were used. Of 29,243 total deliveries, elderly primigravidae constituted 1.81% (530/29,243). Maternal outcomes associated with elderly primigravidae were increased incidence of Caesarean section or instrument delivery (aRR [95% CI] = 1.73 [1.56-1.92]) and prolonged length of stay in hospital (aRR [95% CI] = 1.14 [1.06-1.23]). Fetal outcome associated with the elderly primigravidae was stillbirth (aRR [95% CI] = 1.91 [1.25-2.91]). Elderly primigravidae therefore require more intensive monitoring, even in the absence of any obvious maternal complications. These findings will help in counseling and in the shared decision-making for delivery of elderly primigravidae.

Objectives: E6 and E7 DNA sequence profile of HPV-18 and HPV-45 lineage/sublineage variants in Ghana.Design: A cross-sectional study.Setting: Obstetrics/Gynaecology Directorate, Komfo Anokye Teaching Hospital, Kumasi and Department of Radio-therapy/Nuclear Medicine and the Family Planning Unit, Korle-Bu Teaching Hospital, Accra.Participants: 207 individuals referred with clinical suspicion of cervical cancer (CxCa) or confirmed CxCa/precancer cases.Methods: Cervical swabs were collected (from October 2018 to November 2020) from individuals, with L1 DNA positivity for HPV-18(40 samples) and/or HPV-45(28 samples), out of 207 samples tested for 24-HPV-genotypes. DNA was extracted from a convenience sample and HPV-E6/E7-PCR (33/40-HPV-18-+ve- or 20/28-HPV-45-+ve samples), sequencing, and BLAST analysis was carried out.Results: After PCR amplification, the E6/E7 gene regions of 26 out of 33(HPV-18+ve) samples and ten (10) out of 20 (HPV-45+ve) samples were eligible for sequencing. For HPV-18 variants, 24 out of 26 samples (92.31%) were of lineage-B/C, including samples of lineage-C and 22 samples of lineage-B (out of which ten (10) samples were with E7-SNP-C665T). Nine out of ten HPV-45 variants were sublineage-A1, of which two (2) samples harboured both E6-SNPs-C134T and C4I7T including one sample with E6-SNPs-C134T, G415C, C4I7T detected together.Conclusions: Our study confirms a dominance of HPV-45-sublineage-A1 and HPV-18-lineage-B (with rare occurrence of Africa-specific HPV-18-lineage-C) variants in Ghana. Our study provides preliminary data on E6/E7 SNPs of HPV-18 and HPV-45 lineages and sublineages among CxCa cases in Ghana. We hope our data will inform future studies on pattern and distribution of HPV type-specific nucleotide changes that can be useful for therapeutic intervention.

Background The benefit of home blood pressure monitoring during pregnancy and in low-resource settings is incompletely understood. The objective of this study was to explore the experiences, barriers, and facilitators of home blood pressure monitoring among pregnant women in Ghana. Methods This concurrent triangulation mixed-methods study was conducted at an urban tertiary hospital in Ghana. Participants were recruited from adult pregnant women presenting for routine antenatal care. Upon enrollment, participants’ demographics and history were collected. At the next study visit, participants received audiovisual and hands-on training on using an automatic blood pressure monitor; they then monitored and logged their blood pressure daily at home for 2–4 weeks. At the final study visit, verbally administered surveys and semi-structured interviews assessed participant’s experiences. Quantitative data were analyzed using R version 4.2.2, and frequencies and descriptive statistics were calculated. Qualitative data were imported into DeDoose 9.0.78 for thematic analysis. Results Of 235 enrolled participants, 194 completed surveys; of those, 33 completed in-depth interviews. Participants’ mean age was 31.6 (SD 5.3) years, 32.1% had not previously given birth, and 31.1% had less than a senior high school education. On a 4-point Likert scale, the majority reported they “definitely” were able to remember ( n = 134, 69.1%), could find the time ( n = 124, 63.9%), had the energy ( n = 157, 80.9%), could use the blood pressure monitor without problems ( n = 155, 79.9%), and had family approval ( n = 182, 96.3%) while engaging in home blood pressure monitoring. 95.88% ( n = 186) believed that pregnant women in Ghana should monitor their blood pressure at home. Qualitative thematic analysis demonstrated that most participants liked home blood pressure monitoring because of increased knowledge of their health during pregnancy. While most participants found measuring their blood pressure at home doable, many faced challenges. Participants’ experiences with five key factors influenced how easy or difficult their experience was: 1) Time, stress, and daily responsibilities; 2) Perceived importance of BP in pregnancy; 3) Role of family; 4) Capability of performing monitoring; 5) Convenience of monitoring. Conclusions Among pregnant women in urban Ghana, home blood pressure monitoring was perceived as positive, important, and doable; however, challenges must be addressed.

Purpose:Globally, the COVID-19 pandemic has brought attention to the impact of negative patient outcomes on healthcare providers. In Ghana, obstetric providers regularly face maternal and neonatal mortality, yet limited research has focused on provision of mental health support for these providers. This study sought to understand how obstetric providers viewed seeking mental health support after poor clinical outcomes, with a focus on the role of mental health stigma. Patients and Methods:Participants were 52 obstetric providers (20 obstetrician/gynecologists and 32 midwives) at two tertiary care hospitals in Ghana. Five focus groups, led by a trained facilitator and lasting approximately two hours, were conducted to explore provider experiences and perceptions of support following poor maternal and neonatal outcomes. Discussions were audiotaped and transcribed verbatim, then analyzed qualitatively using grounded theory methodology. Results:Most participants (84.3%, N=43) were finished with training, and 46.2% (N=24) had been in practice more than 10 years. Emerging themes included pervasive stigma associated with seeking mental health care after experiencing poor clinical outcomes, which was derived from two overlapping dimensions. First, societal-level stigma resulted from a cultural norm to keep emotions hidden, and the perception that psychiatry is equated with severe mental illness. Second, provider-level stigma resulted from the belief that healthcare workers should not have mental health problems, a perception that mental health care is acceptable for patients but not for providers, and a fear about lack of confidentiality. Despite many providers acknowledging negative mental health impacts following poor clinical outcomes, these additive layers of stigma limited their willingness to engage in formal mental health care. Conclusion:This study demonstrates that stigma creates significant barriers to acceptance of mental health support among obstetric providers. Interventions to support providers will need to respect provider concerns without reinforcing the stigma associated with seeking mental health care.

OBJECTIVES:To explore how specific measures of antenatal care utilization are associated with outcomes in pregnancies complicated by preeclampsia and eclampsia in Ghana. STUDY DESIGN:Participants were adult pregnant women with preeclampsia or eclampsia at a tertiary hospital in Ghana. Antenatal care utilization measures included timing of first visit, total visits, facility and provider type, and referral status. Antenatal visits were characterized by former and current World Health Organization recommendations, and by gestational age-based adequacy. MAIN OUTCOME MEASURES:Composites of maternal complications and poor neonatal outcomes. Multivariate logistic regressions identified associations with antenatal care factors. RESULTS:Among 1176 participants, median number of antenatal visits was 5.0 (IQR 3.0-7.0), with 72.9% attending ≥4 visits, 19.4% attending ≥8 visits, and 54.9% attending adequate visits adjusted for gestational age. Care was most frequently provided in a government polyclinic (n = 522, 47.2%) and by a midwife (n = 704, 65.1%). Odds of the composite maternal complications were lower in women receiving antenatal care at a tertiary hospital (aOR 0.47, p = 0.01). Odds of poor neonatal outcomes were lower in women receiving antenatal care at a tertiary hospital (aOR 0.56, p < 0.001), by a specialist Obstetrician/Gynecologist (aOR 0.58, p < 0.001), and who attended ≥8 visits (aOR 0.67, p = 0.04). Referred women had twice the odds of a maternal complication (aOR 2.12, p = 0.007) and poor neonatal outcome (aOR 1.68, p = 0.002). CONCLUSIONS:Fewer complications are seen after receiving antenatal care at tertiary facilities. Attending ≥8 visits reduced poor neonatal outcomes, but didn't impact maternal complications. Quality, not just quantity, of antenatal care is essential.

In pregnancies complicated by sickle cell disease (SCD), the maternal-fetal dyad is at high risk for mortality and morbidity. In healthy pregnancies, maternal nutritional status is a critical factor for the healthy growth and development of the fetus. However, there are no reviews of the current research on the nutritional status of pregnant women with SCD and pregnancy outcomes. First, we aim to assess the burden of malnutrition in pregnant women with SCD. Next, we aim to systematically evaluate if pregnant women with SCD who have poor nutritional status are at increased risk for adverse birth outcomes compared to pregnant women with sickle cell disease and normal nutritional status. We will systematically search multiple electronic databases. Our exposure is pregnant women with SCD and poor nutritional status. The primary outcomes of interest include low birth weight (categorical) and birth weight z-scores (continuous). We will also evaluate maternal and perinatal outcomes as secondary outcomes. We will evaluate the risk of bias and overall certainty of evidence with Risk of Bias in Non-randomized Studies—of Interventions (ROBINS-I), and the overall evidence will be assessed using Grading of Recommendation Assessment, Development, and Evaluation (GRADE) criteria. We will pool findings with a meta-analysis if sufficient homogeneity exists among studies. Findings will be published in a peer-reviewed journal and disseminated to SCD advocacy groups. PROSPERO registration number: CRD42023429412.

Preeclampsia is a leading cause of global maternal morbidity and mortality. The greatest burden of disease is in low- and middle-income countries where healthcare providers face significant, understudied, challenges to diagnosing and managing preeclampsia. This qualitative study used semi-structured interviews to explore the challenges of diagnosing and managing preeclampsia from the perspectives of obstetric doctors. Participants were doctors who provide obstetric care at the Korle Bu Teaching Hospital, an urban tertiary hospital in Ghana. Purposive sampling identified doctors with meaningful experience in managing patients with preeclampsia. Thematic saturation of data was used to determine sample size. Interviews were audio recorded, transcribed verbatim, coded using an iteratively-developed codebook, and thematically analyzed. Interviews were conducted with 22 participants, consisting of 4 house officers, 6 junior obstetrics/gynecology residents, 8 senior obstetrics/gynecology residents, and 4 obstetrics/gynecology consultants. Doctors identified critical challenges faced at the patient, provider, and systems levels in detecting and managing preeclampsia, each of which mediates the health outcomes of a pregnancy complicated by preeclampsia. Challenges centered around three overarching global themes: (1) low education levels and health literacy among women, (2) insufficient number of healthcare providers highly trained in obstetric care, and (3) inadequate health infrastructure to support critically ill patients with preeclampsia. Recognizing and addressing root challenges to preeclampsia care has great potential to improve outcomes in pregnancies complicated by preeclampsia in low-resource settings.

Introduction:Sickle Cell Disease (SCD) is a rare genetic disease in high-income countries where most of the cited literature used to guide clinical management emanate from. One of the most serious and potentially fatal complications of SCD is acute chest syndrome (ACS) which requires immediate medical attention. Approximately 50% of individuals with SCD will eventually develop ACS ( Blood 84, 643-649 (1994)). Despite the high frequency of ACS and its associated risk of death, no consensus diagnosis has been established that applies to children and adults living in low-middle income countries, where 95% of the children born with SCD are found. To create a uniform definition of ACS in both low, middle, and high-income countries, we propose using a new ACS definition that does not require a chest X-ray. Additionally, the new ACS definition should have a quantifiable and reproducible physical examination and clinical findings to allow for the reproducibility of the definition in all settings. This definition was developed over several years at Korle Bu Teaching Hospital, Accra Ghana, in pregnant women with SCD. Before we started the multidisciplinary team care in pregnant women with SCD, ACS was the most common cause of maternal death. Subsequently, based on the new ACS definition that did not require a chest X-ray, we developed strategies to prevent, aid early diagnosis, and treat ACS resulting in an 89% relative risk reduction of death. We refer to this new definition as the Korle Bu Teaching Hospital (KBTH)-ACS definition. In this study, we compare the ACS definition in the top 20 cited ACS articles as of July 2023 with our proposed KBTH-ACS definition. Methods:Using Google Scholar, we identified the top 20 cited articles with ACS in children or adults with SCD as primary or secondary outcomes. Each article was reviewed for the presence of the following criteria: chest x-ray, vitals, hemoglobin oxygen saturation, and lung physical exam findings. We compared the definition of ACS in the top 20 cited ACS articles to the KBTH-ACS definition that included the following features: “abnormal findings on lung auscultation and the presence of at least 2 of the following criteria: 1) temperature ≥ 38.0°C, 2) increased respiratory rate greater than the 90th percentile for age, positive chest pain or pulmonary auscultatory findings, 3) hemoglobin oxygen saturation decrease by ≥3% from a documented steady-state value on room air, and 4) a new radiodensity on chest roentgenogram. A diagnosis of pneumonia was considered an ACS episode.”. Results:The 20 most cited ACS articles required radiographical criteria to diagnose ACS. Fourteen of twenty articles included fever in their ACS definition. However, only 4 articles specified any temperature and all specified ≥ 38.5 ºC. A total of 17 articles mentioned the presence of lung or respiratory findings, but only 12 articles specifically identified the pulmonary findings. Among the 12 articles that specified lung findings, 5 included increased respiratory rate (tachypnea) without a specific definition, 2 included abnormal auscultatory findings, and 3 included hypoxemia/hypoxia in their definition. However. One study defined hypoxemia/hypoxia as “transcutaneous oxygen saturation <85% despite supplemental oxygen.”. Another article included “SpO2 of ≥ 3% compared to baseline steady-state values.”. In addition, among the twelve studies that specified respiratory findings, the following were present or absent features: chest pain (n=12), wheezing (n=3), coughing(n=3), and respiratory distress without a formal definition (n=3). No article included pneumonia in the ACS definition nor defined a threshold for tachypnea that was age-adjusted. None of the articles would allow for a direct comparison with the KBTH-ACS definition. Conclusion: All the 20 most cited ACS articles required a chest X-ray with various clinical and physical examination findings. Many of the ACS definitions in these studies were based on clinical impressions that were not quantifiable or reproducible. We propose using the KBTH-ACS definition in future ACS studies to improve generalizability, reproducibility, and genotype and phenotype studies designed to elucidate the genetic variation of lung disease in children and adults with SCD.