Optimizing antenatal care: Integrating screening and management of maternal infections in Ghana

Neonatal and maternal mortality: An ongoing challenge

In recent decades, investments in health care infrastructure and improvement in practices have helped reduce the numbers of babies who die in the first 28 days of life, known as the neonatal period. However, approximately 2.4 million neonatal babies still die annually, most from easily preventable or manageable conditions. Most of these deaths occur in low- and middle-income countries.

Maternal mortality is also a significant challenge. Each year, 295,000 mothers die around the world with maternal mortality being the health indicator with greatest disparity between high and low- to middle-income countries.

In Ghana each year, 2,700 women die of pregnancy and childbirth-related causes—a statistic that has remained nearly unchanged over the last two decades. And more than 20,000 babies die in the first month of life; more than half of all under-five deaths in Ghana.

Bundling solutions for prevention

These are, for the most part, preventable deaths. Compelling evidence indicates that improved early screening, diagnosis, and management of sexually transmitted infections and other maternal infections, as well as improved linkages to care during pregnancy, results in improved maternal and neonatal health outcomes.

Bundling simplified, inexpensive, and rapid tests and regimens for antenatal care (ANC) visits can be efficient and cost-effective ways to prevent mother-to-child transmission of infections. Tests to prevent transmission of HIV, syphilis, and bacterial infections such as reproductive and urinary tract infections can be included as a consolidated kit at the point of care.

Ghana Health Service and PATH's enduring partnership

Over the past two decades, the Ghana Health Service (GHS) and PATH and have built a strong partnership to improve maternal and newborn health. Since November 2022, GHS and PATH have been working to improve diagnosis and management of maternal infections during the antenatal period through the Integrated ANC project. Over a 24-month period, the team is integrating screening and treatment for infectious diseases including hepatitis B, urinary tract infections, group B Streptococcus, and sexually transmitted infections into routine ANC in five districts of Ghana’s Bono East Region.

Working mainly at the primary health care level in nearly 70 facilities, the project is expanding the capacities of community-based and first-level health care providers in diagnosis and management of maternal infections; improving availability of services through ANC; and strengthening connections between primary and referral facilities. Interventions include point-of-care and laboratory diagnostics for infections; streamlining linkages and referral systems between primary and regional facilities; and social and behavioral change communication activities with health care providers, patients, and communities.

Integrated Antenatal Care project activities

GHS and PATH are collaborating on the following activities through the project:

• Leading regional trainings to upgrade provider ANC skills and expand screening and diagnostics to optimize maternal and neonatal infection prevention and control at the primary health care level. Trainings are augmented by on-the-job supportive supervision to build and maintain provider capacity and confidence in infection screening and management.
• Strengthening linkages between primary care facilities and district and regional hospitals to improve patient management and referral systems.
• Conducting social and behavioral change activities to engage communities and increase demand for services by improving knowledge of maternal infections, risks to newborns, and prevention strategies.
• Mobilizing human and financial resources through advocacy activities.
• Developing a smartphone application to streamline data on infection screening management and referral of ANC clients.

Several elements have contributed to the project’s success. Strong regional, district, and facility leadership and commitment has contributed to rapid ramp-up and ownership of project activities. ANC providers are also keen to learn and put new skills into practice, seeing value in the intervention’s impact on improving maternal and newborn health outcomes. The intervention has also been positively received by women, demonstrated by an increase in follow-up ANC visits. Local community leaders have also shown a high level of engagement, serving as project champions and building awareness in the community.

The team has also encountered a few implementation challenges. For example, the long distances required for sending follow-up samples (e.g., cultures) to adequately equipped labs has proved difficult. Upgrades to municipal labs could help reduce time for sample transport. These and other challenges are being discussed in order to identify long-term solutions that are sustainable beyond the life of the project.

As the project nears completion, PATH and GHS are developing a roadmap for sustained impact through long-term integration and scale-up of these ANC interventions—not only to prevent maternal and neonatal deaths in Ghana, but to provide a replicable model for other low- and middle-income country settings around the globe.

Since the project launch*, the team has achieved the following:

• 19,897 pregnant women screened.
• 689 ANC providers trained on improved screening and management of maternal infections.
• 67 health facilities across the hierarchy of care provided with improved logistics for screening of maternal infections.
• App-based system implemented for recording data on pregnant women, including testing and referrals.
• Screening for urinary tract infections, group B Streptococcus, and additional sexually transmitted infections introduced at facilities.
• A compendium of technical and social and behavior change materials developed for education of providers and communities.
• 1,743 community leaders engaged in health education on maternal infections.
• 271 health education sessions conducted through pregnancy schools reaching 2,237 pregnant women.
• 743,898 community members reached through FM radio community information center media campaigns on maternal infections.

*The project launched in November 2022; data shown as of December 2023.

Project resources

• Integrated ANC project brief and community impact stories
• Integrated ANC social and behavior change communication materials

References

1. UNICEF Data website. Maternal Mortality page. https://data.unicef.org/topic/maternal-health/maternal-mortality/
2. World Health Organization (WHO), UNICEF, United Nations Population Fund (UNFPA), World Bank Group, and United Nations Population Division. Trends in maternal mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: WHO; 2019. https://www.unfpa.org/featured-publication/trends-maternal-mortality-2000-2017
3. The World Bank Data. Neonatal Deaths page. https://data.worldbank.org/indicator/SH.DTH.NMRT?locations=GH.
4. Mashamba-Thompson TP, Sartorius B, and Drain PK. Point-of-care diagnostics for improving maternal health in South Africa. Diagnostics (Basel). 2016;6(3):31. https://doi.org/10.3390/diagnostics6030031