Abstract:
Over 10 million children under the age of five will die each year (Ghana Heath Service). Up to 42% of those deaths are of neonates (Feresu et. al.). The leading cause of neonatal death is prematurity. One million preterm infants die annually, accounting for 27% of neonatal death (Lawn et. al.). This study was conducted at the Kintampo Municipal Hospital in Kintampo, Ghana. It attempted to; implement a systemic way to evaluate newborns, collect data on neonates, and evaluate the hospital workers knowledge of prematurity. At the time the study commenced, there was no primary document dedicated to newborn screening and care at Kintampo Municipal Hospital. Therefore a Newborn Assessment Sheet was created to facilitate data collection and basic care for infants. Along with the Newborn Assessment Sheet, a Neonatal Care Survey was created to interview healthcare personnel regarding preterm birth. It was found that a lack of knowledge about prematurity fostered largely inadequate care for infants. Educational interventions were recommended to boost both awareness and knowledge of overall infant care, and care related specifically to preterm birth.
Background:
Worldwide approximately four million infants will die before one month of life. They are part of the over ten million children who die before reaching age five; accounting for 38% of childhood mortalities (Ghana Health Service). While under-five mortality rates in sub-Saharan Africa have declined by 22% since 1990, there has been little progress in addressing the mortality rates of newborns (Millennium Development Goals). These deaths primarily occur in low and medium income countries, where access to health care is difficult and data collection on newborn infants is minimal or non-existent. Other reasons for the predominance of neonatal death in low-income countries include; lack of systemic estimates for the prevalence of preterm births, lack of accurate estimation of gestational age, and lack of simple care and quality health services for mothers and newborns (Lawn et. al.).
Complications of preterm birth are the single biggest risk factor for neonatal death and increased morbidity. Prematurity accounts for up to 27% of the almost four million neonatal deaths every year, from both direct and indirect causes. The challenges a premature infant faces include, but are not limited to; respiratory distress (respiratory distress syndrome, brochopulmonary dysplasia, apnea of prematurity) in 93% of premature newborns, late onset sepsis (sepsis occurring at 3 days of life) in 36% of premature newborns, intraventricular hemorrhage (IVH) in 16% of premature newborns, and necrotizing enterocolitis (NEC) in 11% of premature newborns (Lawn et. al. and Mandy et.al.).
To begin to explore the risks associated with prematurity, it is necessary to define it. Preterm birth includes any infant born before 37 weeks of gestation and has gradations of moderate (33-36 weeks), very (28-32 weeks) and extremely (less than 28 weeks) preterm. These gradations of prematurity are important because survival rates increase with increasing gestation. A study of newborn infants in Nigeria found that for a gestational age of 31 weeks the survival rate was roughly 53.3%. By 35 weeks there was a substantial increase in survival to 96.6% (Owa et. al.). Along with gestational age, the weight of a newborn is often considered an important tool in determining prematurity. An infant is considered low birth weight when they are less than 2500g, and very low birth weight when less than 1500g. However, low birth weight is not necessary a product of prematurity. It can also be the result of processes like intra-uterine growth restriction. Therefore gestational age is a better indicator of preterm birth (Mandy et. al.).
Despite its influence on neonatal mortality, preterm birth lacks visibility and political backing in low-income countries. Issues such as lack of human resources, poor funding, and improper facilities make the care of neonates difficult (Victora et. al.). On top of lacking the resources to provide appropriate care, places with the highest risk of preterm death currently have the smallest amount of recorded information available on it. This presents a large problem for neonatal care, because the neonatal mortality rate depends on the place of delivery. It is related to the supplies available and the expertise of the staff. Thus each obstetric unit should establish their own gestational age-specific mortality rates contingent on the care they provide (Owa et. al.). This can only be done if the quantity and quality of information on neonates can be improved by seizing opportunities to add to ongoing hospital data collection (Lawn et. al.).
Kintampo Municipal Hospital is among the many rural district hospitals that lack accurate data collection and assessment of newborns. Steps need to be taken at Kintampo Municipal Hospital to raise awareness about both the prevalence and risks of prematurity. Assessing healthcare workers understanding of and clinical skills surrounding prematurity would help to make targeted interventions effective, thereby improving care.
I am apolitical. I leave that world to my father and my boyfriend who relish in unsolvable philosophical talking points. But today I found out that Osama Bin Laden was killed. At first I was frightened…because I thought Osama was Obama. Can you imagine? I can, which frightens me. Maybe I shouldn’t keep reading Malcolm X’s autobiography before bed. When I realized it was an s not a b, I was skeptical. Was he really killed? How could they do DNA tests in the first place…who had his DNA? Why did they bury him in the ocean? Who saw his body? I remain skeptical…but optimistic?
I found it amazing that the American political scene had reached Ghana. Not only that, but people here cared to talk about it. I started talking to another American at the Beach Hotel about Osama…save for he spends 75% of his time in Ghana and only 25% of his time in the United States,so maybe he’s more Ghanaian than American. He spoke fondly of the US. Many things I’ve heard others criticize about America, he saw as its strengths. In particular he lauded over our sense of individualism and constant desire for change. He likened our thirst for more and better to increased self-esteem and creativity.
Ghana is more traditional. People hold onto old technology and old beliefs. There is an adrinkra called Sankofa…in western terms it means that you learn from the mistakes of your past…but for Ghanaians it also means that you should not abandon stalwart tradition. So Ghanaians believe in voodoo, herbal medications, spirits…these things are real to them. These beliefs keep them rooted to an ancient practice and past, but at the same time stop them from evolving. They are caught between a vibrant flame of cultural identity, and a tank of gasoline gearing them up to drive to the future…it's a society that could explode at any minute.
Why doesn’t Ghana blow up like so many African nations around it? I’m not sure. There are some hints that it might…for instance if you steal, even if its a loaf of bread, an angry mobs will hunt you down and kill you with their bare hands…justice or violence? Again, I’m not sure. That is the allure of Africa. It's muted tensions, its struggle to define itself, the ebb and flow of life...it's so...human.
I mentioned that we made friends with Christian missionaries yesterday. Because we hit it off, at dinner last night we were approached to look at the eye of one of the young girls in the group. It was swollen shut, with purulent discharge fusing together her eyelashes, and dripping down her face. When she pried it open for us the eye was an angry red, and a white opacity clouded her iris…we couldn’t even see her pupil, and she couldn’t see.
Even though she was using antibacterial eye-drops, it appeared as though she had a raging infection. We agreed to take her to the hospital in the morning. We found each other at breakfast, and another scholar and I took the Christian’s white van to the hospital. It was a ghost town. The usual groups of brightly clad patients sitting outside offices were nowhere to be found. Instead empty benches and a wandering goat greeted us. We woke Dr. Tengan from sleep, and he consulted with her.
The eye was still swollen shut. It looked like it hadn’t gotten any better overnight. The doctor confirmed my worst fear – that this was a periorbital cellulitis. While it can be life threatening if the infection spreads to the skill, the biggest complication is a loss of vision. I can’t imagine being 17 years old and blind in one eye.
So he prescribed IV (intra-venous) antibiotics, to be given every 8 hours. We walked her from the out patient offices to the woman’s ward to get an IV inserted in her arm. What followed was a comedy of errors. The nursing student fumbled with the needle, dropping it on the floor several times. She sprayed antibiotics on herself and in my face. When it was clear that she was incompetent, a senior nurse took over. The senior nurse could not insert an IV. She tried two times before she was able to get one that was working. Then she pushed medication outside of the vein into the poor girls skin – infiltrating her with antibiotics that could cause skin necrosis. So a third IV had to be put in the opposite arm.
It’s hard to understand if you’re not in the medical profession how dangerous it is to push large doses of medication into someone’s veins…and then watch that medication leak out into their skin…all while observing un-sterile practices. I think in the states we can be too cautious about patient care (after all, it’s only a matter of time before you get sued)…but I think what I saw today could be classified as negligence. In the states we would have hung her medication to be delivered over several hours, given her a CT scan to see the scope of her infection, and made her stay in the hospital overnight…
What the healthcare system in Ghana needs…more than supplies, more than money, more than improved facilities…is education and training. It would make a world of difference if the staff could see what quality care was.
