Introduction
In 2010, the United Nations stated that ‘we know what works’ to provide adequate healthcare to prevent maternal mortality.1 However, approximately 300 000 women, predominantly in low-income and middle-income countries (LMIC), died last year due to pregnancy-related complications.2 The lifetime risk of maternal death has fallen from 1 in 16 to 1 in 36 pregnancies in sub-Saharan Africa (SSA), but these women still face risks of death 500–1000 times higher than women in high-income countries.2 This disparity continues due to failure to implement what we know works into clinical practice.
During the Millennium Development Goal era, access to skilled birth attendance improved. Greater recognition of complicated pregnancies, however, shifts the burden of care to facilities that may be unprepared to provide the signal functions of comprehensive emergency obstetric care (CEmOC). It is estimated that at least 15% of births will require transfer of care to CEmOC facilities.3 4 The actions taken by these facilities to quickly assess and treat already compromised women are critical to improving survival. Existing reports on delay within facilities, termed ‘the third delay’ suggest that women who need CEmOC often experience long treatment delays after reaching LMIC health facilities.5–9 Yet, there are inconsistent definitions of what constitutes delay, differing study methodologies and little evidence on the effect of delay on birth outcomes.9 One review states, ‘the third delay is likely to be a source of considerable inequity in access to emergency obstetric care in developing countries’.5
Ghana has experienced significant increases in institutional deliveries over the past decade without sufficiently addressing the quality of care.10 Consequently, mortality rates in regional hospitals are significantly higher than the national average.7 11–15 Resources required to treat high-risk patients are often lacking.9 16 Regional hospitals often have lower staff-to-patient ratios and higher acuity patients.17 An increasing work load has been found to be detrimental to morale, attentiveness and outcomes.18 Obstetric triage practices are unknown and many hospitals appear to operate on a first-come, first-served basis irrespective of patient risk. International guidelines recommend that assessment begin within 10 min of patient arrival to the hospital, to stratify care based on risk and imminence of delivery.19 Developing strategies to strengthen the initial assessment process is one step towards improving healthcare quality in high-volume obstetric facilities in low-resource countries, yet there are little published data in this context. In this report, we describe the impact of an obstetric triage improvement programme (TIP) implemented at The Greater Accra Regional Hospital (GARH), a major referral hospital in Accra, Ghana.