Geographical access to point-of-care testing for hypertensive disorders of pregnancy as an integral part of maternal healthcare in Ghana

  • BMC Pregnancy and Childbirth, Volume 20, No. 1, Year 2020

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Study Justification:
– Hypertensive disorders of pregnancy (HDP) are a major cause of maternal mortality in Ghana and globally.
– There is evidence of poor availability of pregnancy-related point-of-care (POC) tests in Ghana’s primary healthcare clinics.
– This study aims to assess the geographical distribution and physical accessibility of HDP POC testing services in the Upper East Region (UER) of Ghana.
Study Highlights:
– Data was collected from 100 out of 365 primary healthcare clinics and public hospitals providing HDP testing in the UER.
– Geographic information systems (GIS) and spatial analysis tools were used to measure distance and travel time to the nearest facility offering HDP POC testing.
– Results showed that only 19% of the participating clinics had HDP POC testing available, with some clinics located more than 10 km away from the nearest facility.
– The spatial distribution of health facilities providing HDP POC testing was found to be random.
– The study estimated that if 19% of all PHC clinics offered HDP POC testing, the coverage ratio would be 1:3,869 (health facility-to-women in fertility age ratio) in the UER.
Recommendations for Lay Reader and Policy Maker:
– Improve the availability of HDP POC diagnostic tests in Ghana’s rural clinics.
– Increase the number of primary healthcare clinics offering HDP POC testing to improve accessibility for pregnant women.
– Consider the geographical distribution and proximity to existing health facilities when planning the placement of HDP POC testing services.
– Address the issue of long travel distances (> 10 km) for pregnant women seeking HDP POC testing by ensuring closer access to testing facilities.
Key Role Players:
– Ministry of Health: Responsible for policy-making and implementation of healthcare services.
– Regional Health Directorate: Oversees healthcare services in the Upper East Region.
– Primary Healthcare Clinic Staff: Provide healthcare services and can play a role in implementing HDP POC testing.
– Public Hospitals: Provide referral points for HDP POC testing services.
Cost Items for Planning Recommendations:
– Procurement of HDP POC diagnostic tests: Budget for acquiring the necessary tests for primary healthcare clinics.
– Training and Capacity Building: Allocate funds for training healthcare staff on conducting HDP POC testing.
– Infrastructure and Equipment: Budget for necessary infrastructure and equipment in primary healthcare clinics to support HDP POC testing.
– Transportation: Consider costs associated with transportation of tests, equipment, and staff to remote clinics.
– Monitoring and Evaluation: Allocate funds for monitoring and evaluating the implementation and impact of HDP POC testing services.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study employed geographic information systems to estimate the geographical distribution and physical accessibility to HDP POC testing services in the Upper East Region of Ghana. Data was collected from 100 out of 365 PHC clinics and public hospitals providing HDP testing. The study used ArcGIS to measure distance and travel time, and Stata for statistical analysis. The findings indicate poor physical accessibility to HDP POC testing services, with some clinics located more than 10 km away from the nearest facility. To improve the strength of the evidence, the study could have included a larger sample size and conducted a more comprehensive analysis of the spatial distribution of health facilities providing HDP POC testing services. Additionally, the study could have explored the reasons for the poor availability of POC tests in Ghana’s primary healthcare clinics and suggested specific interventions to improve accessibility.

Background: Hypertensive disorders of pregnancy (HDP) are associated with high maternal mortality in Ghana and globally. Evidence shows that there is poor availability of pregnancy-related point-of-care (POC) tests in Ghana’s primary healthcare (PHC) clinics (health centre or community-based health planning services facilities). Therefore, we employed geographic information systems to estimate the geographical distribution of and physical accessibility to HDP POC testing services in the Upper East Region (UER), Ghana. Methods: We collected data on 100 out of 365 PHC clinics, public hospitals providing HDP testing, PHC clinic type, ownership, and availability of urine dipsticks and blood pressure (BP) devices. We also obtained the geo-located data of the PHC clinics and hospitals using the global positioning system. We employed ArcGIS 10.4 to measure the distance and travel time from the location of each PHC clinic without HDP POC testing services as well as from all locations of each district to the nearest hospital/clinic where the service is available. The travel time was estimated using an assumed motorised tricycle speed of 20 km/hour. We further calculated the spatial distribution of the hospitals/clinics providing HDP POC testing services using the spatial autocorrelation tool in ArcMap, and Stata version 14 for descriptive statistical analysis. Results: Of the 100 participating PHC clinics, POC testing for HDP was available in 19% (14% health centres and 5% community-based health planning services compounds) in addition to the 10 hospitals use as referral points for the service. The findings indicated that the spatial pattern of the distribution of the health facilities providing HDP POC testing was random (z-score = -0.61; p = 0.54). About 17% of the PHC clinics without HDP POC testing service were located > 10 km to the nearest facility offering the service. The mean distance and travel time from PHC clinics without HDP POC testing to a health facility providing the service were 11.4 ± 9.9 km and 31.1 ± 29.2 min respectively. The results suggest that if every 19% of the 365 PHC clinics are offering HDP POC testing in addition to these 10 hospitals identified, then the estimated coverage (health facility-to-women in fertility age ratio) in the UER is 1: 3,869. Conclusions: There is poor physical accessibility to HDP POC testing services from PHC clinics without HDP POC testing in the UER. Mothers who obtain maternal healthcare in about 17% of the PHC clinics travel long distances (> 10 km) to access the service when needed. Hence, there is a need to improve the availability of HDP POC diagnostic tests in Ghana’s rural clinics.

We employed geographic information systems to estimate the geographical distribution of and physical accessibility to HDP POC testing services as an integral part of ANC in the UER of Ghana based on the findings of a previous cross-sectional survey [18]. The cross-sectional study before the current study found poor availability of pregnancy-related POC diagnostic tests in the UER [18]. A detailed description of the study setting has been described and published elsewhere [17–19]. The study was conducted from February to March 2018 in all 13 districts using a random sample of 100 out of a total 365 public PHC clinic providing maternal healthcare services from all the districts. A multistage sampling strategy involving stratified, probability proportionate to size, and simple random sampling techniques. A detailed description of this study’s sampling strategy is published elsewhere [18]. We obtained the geographic information (geo-located data) of the PHC clinics and their referral health facilities from the Upper East Regional Health Directorate, and the use of a global positioning system. We then applied the world geodetic system Zone 30 north coordinate system to all spatial data to allow for the results of spatial processes in a chosen unit of meters. Topographic data included roads, rivers, and the digital elevation model. The collectors interviewed the midwives/nurses in-charge of the antenatal clinics or the heads of the clinics for information about the clinic type, ownership, availability of urine dipsticks, BP monitoring devices, and name of the nearest hospital (referral facility) and geographical location (Town/village) using a questionnaire (published elsewhere) [18]. We also cross-checked the information about the referral health facilities to be sure of the availability of urine dipsticks for proteinuria testing and BP monitoring device. To ensure data quality, the principal investigator closely supervised the data collection and data entry activities for consistency and completeness of information throughout the study period. The availability of urine dipsticks for proteinuria testing and BP monitoring devices, or laboratory services. Proximity to the nearest health facility where a POC testing service for HDP is available. Estimated time likely to be spent by an expectant mother traveling from a PHC clinic or her settlement location to the entrance of a health facility providing HDP diagnostic services. We used PHC clinics that lacked urine dipsticks and BP monitoring devices from all 13 districts, as inputs to measure proximity to the nearest health facilities providing HDP testing services. We computed the Euclidean distance from the PHC clinic to the nearest HDP diagnostic services using the near function of analysis tools in ArcGIS 10.4 software. Data on the health facilities, area, and the geographic coordinates of the PHC clinics and their referral health facilities were linked to ArcGIS 10.5 software and a base map. Travel time was estimated using a motorised tricycle transport system (“motor king”) since it is the most used public transport in the UER. The model and procedure used to estimate the travel time for this study have been published elsewhere [19]. We employed ArcMap 10.5. to calculate the spatial autocorrelation or Moran’s Index (MI) of the health facilities providing HDP diagnostic services and, the z-score and p-value reported. MI value of 0, or very close to 0, was considered as random distribution, MI value less than zero was interpreted as dispersed distribution, and MI value greater than zero was considered as a clustered distribution. Data on the distance and travel time to the nearest health facility providing HDP diagnostic services from the clinics were exported to Stata version 14.0 and the mean distance and travel time calculated for each district. We considered PHC clinics located > 10 km from the nearest health facility providing HDP POC testing services as areas with poor physical accessibility. Research has shown that physical access to healthcare beyond 10 km is significantly associated with higher risks of poor health outcomes [22].

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Based on the information provided, here are some potential innovations that could improve access to maternal health in Ghana:

1. Mobile Point-of-Care Testing: Develop and implement mobile clinics equipped with point-of-care testing devices for hypertensive disorders of pregnancy. These clinics can travel to remote areas, bringing essential diagnostic services closer to pregnant women in need.

2. Telemedicine: Establish telemedicine programs that allow healthcare providers to remotely monitor and diagnose pregnant women with hypertensive disorders. This would enable women in rural areas to receive timely medical advice and reduce the need for long-distance travel.

3. Training and Capacity Building: Provide training and capacity building programs for healthcare workers in primary healthcare clinics. This would ensure that they have the necessary skills and knowledge to perform point-of-care testing for hypertensive disorders of pregnancy, improving access to these services at the local level.

4. Public-Private Partnerships: Foster collaborations between public healthcare facilities and private sector organizations to improve access to maternal health services. This could involve leveraging private sector resources and expertise to expand the availability of point-of-care testing devices and services in underserved areas.

5. Community Health Workers: Strengthen the role of community health workers in maternal healthcare by providing them with the necessary training and resources to perform point-of-care testing for hypertensive disorders of pregnancy. This would bring healthcare services closer to communities and improve access for pregnant women.

6. Health Information Systems: Implement robust health information systems that can track the availability and distribution of point-of-care testing services for hypertensive disorders of pregnancy. This would enable policymakers to identify gaps in access and allocate resources more effectively.

7. Infrastructure Development: Invest in improving transportation infrastructure, particularly in rural areas, to reduce travel time and distance for pregnant women seeking maternal healthcare services. This could involve building new roads or improving existing ones to facilitate easier access to healthcare facilities.

These innovations aim to address the poor physical accessibility to hypertensive disorders of pregnancy point-of-care testing services in Ghana’s rural clinics, ultimately improving access to maternal health services for pregnant women.
AI Innovations Description
Based on the description provided, the recommendation to improve access to maternal health in Ghana is to enhance the availability and accessibility of point-of-care (POC) testing for hypertensive disorders of pregnancy (HDP) in primary healthcare (PHC) clinics. This can be achieved through the following steps:

1. Increase the availability of POC testing: Ensure that all PHC clinics have the necessary resources, such as urine dipsticks and blood pressure devices, to conduct HDP POC testing. This will enable early detection and management of HDP, reducing the risk of maternal mortality.

2. Improve geographic distribution: Use geographic information systems (GIS) to identify areas with limited access to HDP POC testing services. Establish new clinics or expand existing ones in these underserved areas to ensure equitable access to maternal healthcare.

3. Enhance physical accessibility: Reduce travel distances and time for pregnant women by strategically locating PHC clinics that offer HDP POC testing services. Consider factors such as population density, transportation infrastructure, and the distribution of existing healthcare facilities to optimize accessibility.

4. Strengthen referral systems: Establish clear referral pathways between PHC clinics and hospitals that provide specialized care for HDP. This will ensure that pregnant women who require further evaluation or treatment can access appropriate healthcare services in a timely manner.

5. Capacity building and training: Provide comprehensive training to healthcare providers in PHC clinics on the proper use of POC testing for HDP. This will enhance their skills and knowledge in diagnosing and managing HDP, leading to improved maternal health outcomes.

6. Collaborate with stakeholders: Engage with relevant stakeholders, including government agencies, non-governmental organizations, and community leaders, to garner support and resources for implementing and sustaining the recommended improvements in maternal healthcare access.

By implementing these recommendations, Ghana can improve access to maternal health by ensuring that pregnant women have timely and convenient access to HDP POC testing services, leading to early detection and appropriate management of hypertensive disorders of pregnancy.
AI Innovations Methodology
Based on the provided description, here are some potential recommendations to improve access to maternal health:

1. Increase availability of point-of-care (POC) testing for hypertensive disorders of pregnancy (HDP) in primary healthcare (PHC) clinics: This can be achieved by ensuring that all PHC clinics have the necessary equipment, such as urine dipsticks and blood pressure devices, to perform HDP POC testing.

2. Improve distribution of health facilities providing HDP POC testing: The spatial distribution of these facilities should be optimized to ensure that they are easily accessible to pregnant women in rural areas. This may involve establishing new clinics or upgrading existing ones to provide HDP POC testing services.

3. Strengthen referral systems: Enhance coordination between PHC clinics and hospitals to ensure that pregnant women can easily access HDP POC testing services when needed. This may involve establishing clear referral pathways and improving communication between healthcare providers.

4. Enhance transportation infrastructure: Improve road networks and transportation options, particularly in rural areas, to reduce travel time and distance for pregnant women seeking HDP POC testing services. This may include providing transportation subsidies or incentives for pregnant women to encourage them to seek care.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the study area: Determine the specific geographic region or districts where the simulation will be conducted, such as the Upper East Region (UER) in Ghana.

2. Collect data: Gather relevant data on the current availability and distribution of HDP POC testing services, including the location of PHC clinics, hospitals, and their respective equipment. This data can be obtained from health authorities, surveys, or existing databases.

3. Use geographic information systems (GIS): Utilize GIS software, such as ArcGIS, to analyze the data and estimate the geographical distribution and physical accessibility of HDP POC testing services. This can involve measuring distances and travel times from PHC clinics without HDP POC testing services to the nearest facilities offering the service.

4. Calculate coverage ratios: Determine the estimated coverage of HDP POC testing services by calculating the ratio of health facilities providing the service to the population of women in the fertility age group. This can help assess the adequacy of the current healthcare infrastructure in meeting the needs of pregnant women.

5. Simulate the impact of recommendations: Apply the proposed recommendations, such as increasing availability of POC testing in PHC clinics or improving distribution of health facilities, to the GIS model. This can involve adjusting the location and accessibility of HDP POC testing services based on the recommendations.

6. Measure the simulated impact: Assess the changes in geographical distribution, physical accessibility, and coverage of HDP POC testing services resulting from the simulated recommendations. This can be done by comparing the pre- and post-simulation data and analyzing the differences.

7. Evaluate the effectiveness of the recommendations: Analyze the simulated impact to determine the effectiveness of the proposed recommendations in improving access to maternal health. This evaluation can help identify any further adjustments or additional interventions that may be needed.

It is important to note that the methodology described above is a general framework and may need to be adapted based on the specific context and available data. Additionally, involving relevant stakeholders, such as healthcare providers and policymakers, in the simulation process can help ensure the feasibility and relevance of the recommendations.

Statistics:
Citations: 1
Authors: 6
Identifiers:
DOI: 10.1186/s12884-020-03441-6
Research Areas:
Community Interventions, Disparities, Health System and Policy, Maternal Access, Maternal and Child Health, Noncommunicable Diseases, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce
Study Countries:
Ghana
Study Design:
Cross Sectional Study, Grounded Theory
Study Approach:
Quantitative
Participants Gender:
Female
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