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Afari, Henrietta

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Afari

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Afari, Henrietta

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2014 - 20152

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    Quality improvement in emergency obstetric referrals: qualitative study of provider perspectives in Assin North district, Ghana
    (BMJ Publishing Group, 2014) Afari, Henrietta; Hirschhorn, Lisa; Michaelis, Annie; Barker, Pierre; Sodzi-Tettey, Sodzi
    Objective: To describe healthcare worker (HCW)-identified system-based bottlenecks and the value of local engagement in designing strategies to improve referral processes related to emergency obstetric care in rural Ghana. Design: Qualitative study using semistructured interviews of participants to obtain provider narratives. Setting: Referral systems in obstetrics in Assin North Municipal Assembly, a rural district in Ghana. This included one district hospital, six health centres and four local health posts. This work was embedded in an ongoing quality improvement project in the district addressing barriers to existing referral protocols to lessen delays. Participants: 18 HCWs (8 midwives, 4 community health officers, 3 medical assistants, 2 emergency room nurses, 1 doctor) at different facility levels within the district. Results: We identified important gaps in referral processes in Assin North, with the most commonly noted including recognising danger signs, alerting receiving units, accompanying critically ill patients, documenting referral cases and giving and obtaining feedback on referred cases. Main root causes identified by providers were in four domains: (1) transportation, (2) communication, (3) clinical skills and management and (4) standards of care and monitoring, and suggested interventions that target these barriers. Mapping these challenges allowed for better understanding of next steps for developing comprehensive, evidence-based solutions to identified referral gaps within the district. Conclusions: Providers are an important source of information on local referral delays and in the development of approaches to improvement responsive to these gaps. Better engagement of HCWs can help to identify and evaluate high-impact holistic interventions to address faulty referral systems which result in poor maternal outcomes in resource-poor settings. These perspectives need to be integrated with patient and community perspectives.
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    Improving Emergency Obstetric Referrals: A Mixed Methods Study of Barriers and Solutions in Assin North, Ghana
    (2015-05-13) Afari, Henrietta
    Background: Women in developing countries often face serious health risks during pregnancy and delivery due to poor access to early and appropriate referrals. Despite studies that show clear linkages between timely referrals and improved maternal outcomes, challenges still remain in the referral process, particularly in rural communities. Objectives: To investigate baseline referral systems in obstetrics in rural Ghana with a focus on describing barriers, solutions and the value of healthcare workers (HCW) in identifying system based bottlenecks. Design: A mixed methods approach: for the quantitative component, we reviewed health facility registers; for the qualitative section, we used semi-structured interviews to obtain provider narratives. Setting: Referral systems in obstetrics in Assin North Municipal Assembly, a rural district in Ghana. This included 1 district hospital, 6 health centers, and 4 local health posts. This work was embedded in an ongoing quality improvement project in the district addressing barriers to existing referral protocols to lessen delays. Eighteen HCWs (8 midwives, 4 community health officers, 3 medical assistants, 2 ER nurses, 1 doctor) at different facility levels within the district were interviewed for the qualitative section. Results: Between January – June 2012, the leading causes for obstetric referrals to the district hospital were prolonged labor, retained placenta, postpartum hemorrhage, malpresentation of baby, and premature rupture of membranes. From the district hospital to tertiary care hospitals, the leading cause of referrals was severe eclampsia. Delay indicators were not able to be obtained due to poor documentation. From the qualitative study, we identified important gaps in referral processes in Assin North, with the most commonly noted including recognizing danger signs, alerting receiving units, accompanying critically-ill patients, documenting referral cases, and giving and obtaining feedback on referred cases. Main root causes identified by providers were in five domains: 1) individual and socio-cultural factors 2) transportation, 3) communication, 4) clinical skills and management, and 5) standards of care and monitoring, and suggested interventions that target these barriers. Mapping these challenges allowed for better understanding of next steps for developing comprehensive, evidence-based solutions to identified referral gaps within the district. Conclusions: Addressing referral processes may hold better promise for reducing maternal mortality if frameworks for designing solutions target multiple referral challenges concurrently. Providers are an important source of information on local referral delays and should be better engaged in identifying the challenges and in the development of approaches to improvement responsive to these gaps. Similar work is needed to integrate their perspectives with those of patients and their communities.