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Addressing the third delay: implementing a novel obstetric triage system in Ghana
  1. David M Goodman1,
  2. Emmanuel K Srofenyoh2,
  3. Rohit Ramaswamy3,
  4. Fiona Bryce4,
  5. Liz Floyd4,
  6. Adeyemi Olufolabi5,
  7. Cecilia Tetteh2,
  8. Medge D Owen6
  1. 1 Department of Obstetrics and Gynecology, Hubert-Yeargan Center for Global Health, Duke University Medical Center, Durham, North Carolina, USA
  2. 2 Department of Obstetrics and Gynecology, Greater Accra Regional Hospital, Ghana Health Service, Accra, Ghana
  3. 3 Gillings School of Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
  4. 4 Department of Obstetrics and Gynaecology, South Tees National Health Service Trust, Richmond, UK
  5. 5 Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
  6. 6 Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
  1. Correspondence to Dr Medge D Owen; mowen{at}


Institutional delivery has been proposed as a method for reducing maternal morbidity and mortality, but little is known about how referral hospitals in low-resource settings can best manage the expected influx of patients. In this study, we assess the impact of an obstetric triage improvement programme on reducing hospital-based delay in a referral hospital in Accra, Ghana. An Active Implementation Framework is used to describe a 5-year intervention to introduce and monitor obstetric triage capabilities. Baseline data, collected from September to November 2012, revealed significant delays in patient assessment on arrival. A triage training course and monitoring of quality improvement tools occurred in 2013 and 2014. Implementation barriers led to the construction of a free-standing obstetric triage pavilion, opened January 2015, with dedicated midwives. Data were collected at three time intervals following the triage pavilion opening and compared with baseline including: referral indications, patient and labour characteristics, waiting time from arrival to assessment and the documentation of a care plan. An obstetric triage improvement programme reduced the median (IQR) patient waiting time from facility arrival to first assessment by a midwife from 40 min (15–100) to 5 min (2–6) (p<0.001) over the 5-year intervention. The triage pavilion enhanced performance resulting in the elimination of previous delays associated with the time of admission and disease acuity. Care plan documentation increased from 51% to 96%. Obstetric triage, when properly implemented, reduced delay in a busy, low-resource hospital. The implementation process was sustained under local leadership during transition to a new hospital.

  • maternal health
  • obstetrics
  • cohort study

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  • Handling editor Seye Abimbola

  • Contributors DMG made significant contribution to data analysis and interpretation and wrote the initial manuscript draft. EKS made significant contribution to study conception and design and acquisition of data, envisioned and sourced the triage pavilion and led the triage implementation. RR oversaw the quality improvement aspects of the project and contributed to manuscript writing. FB conducted observations of clinical care, developed and taught the triage training course and provided clinical coaching. LF conducted observations of clinical care, developed and taught the triage training course and provided clinical coaching. AO maintained an electronic patient database, facilitated the training and provided edits to the manuscript draft. CT was a clinical champion leading the triage implementation and conducted data collection for Phase 3. MDO made significant contributions to study conception, design, acquisition and interpretation of data and was heavily involved in manuscript writing and revision. All authors agreed to be accountable for the accuracy and integrity of the work. All authors have read and approved the final version of this manuscript.

  • Funding This work was part of the ‘Making Every Baby Count Initiative’ awarded to PATH by the Children’s Investment Fund Foundation. Kybele received a subaward (CIF.1838-01-705622-SUB) to improve maternal and newborn care capacity in regional hospitals in Ghana. Funding for Phase 4 and Phase 5 data collection was provided by a USAID Systems for Health Innovation Grant (Subagreement No. FY16-CR05-6017). Activities within the awards underwent review; however, the funders played no role in conducting the research, analysing the results or writing the manuscript.

  • Competing interests All authors report grants from PATH, during the conduct of the study and non-financial support from Kybele, outside the submitted work. MDO is the founder and president of Kybele.

  • Patient consent Not required.

  • Ethics approval The study was granted Institutional Review Board’s approval by Wake Forest University Health Sciences, Winston-Salem, North Carolina, USA, on 24 September 2012 (IRB#00021947) and the Ghana Health Service, Accra, Ghana, on 30 November 2012 (IRB#GHS/DGS/G-27). The study qualified for expedited review and met the criteria to waive informed consent.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Original data are available upon request to the corresponding author.

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