Multidisciplinary sickle cell disease obstetrics care program in Ghana: Non-academic vs.Academic Hospital (Pilot Study)

With increasing life expectancy in Africa, pregnancy has become an emerging life-threatening complication in SCD women. In low and middle-income countries, the odds ratio of maternal death associated with SCD is 22.81, 95% CI 14.67–35.46.1 From 2012-2014, the Obstetrics Department, Korle-Bu Teaching Hospital (KBTH), Accra, Ghana, established an obstetrician-led SCD Obstetrics (OB) clinic. The Institutional maternal mortality for SCD over these three years (2012-2014) was approximately 12%. In January 2015, a multidisciplinary SCD OB team was established. The team conducted a combined retrospective/ prospective case series of all maternal deaths in women with SCD at KBTH over seven years (2010-2016).2 This retrospective data collection highlighted failures and challenges to delivering improved care. Acute chest syndrome, preceded by acute pain episodes, was the leading cause of death in nearly 87% of women.2 In May 2015, the team implemented a joint obstetrics/ hematology clinic, instituted close maternal and fetal monitoring, and implemented clinical guidelines/ protocols. In addition, the SCD OB team established a weekly communication system to adjudicate the management of challenging cases. These interventions resulted in an 89.1% risk reduction in maternal mortality (from 10,791 to 1,176 deaths per 100,000 live births; p=0.007) over 13 months.3 Since initiating our multidisciplinary SCD OB program, we have consistently decreased maternal mortality in this cohort by approximately 90% compared to before the team was established.4,5 This physician-mentored application aims to conduct an Effectiveness-Implementation Feasibility Study to extend our results of decreasing maternal mortality from an academic hospital to a non- academic hospital setting in Accra, Ghana with a current maternal mortality rate of 5,940 deaths/ 100,000 live births in SCD women. Over five years, the applicant will acquire the skills to use the Consolidated Framework for Implementation Research (CFIR)6 and the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance)7 to inform the stages of the study. The applicant will test the hypothesis that " In a before and after study design, the applicant will test the hypothesis that multi- disciplinary care and task-shifting in a non-academic hospital for pregnant women with SCD will have an 80% relative risk reduction in death compared to the mortality rate in the same hospital before the multi-disciplinary medical care." The specific aims for this mentored award are: 1) Identify contextual determinants (barriers/ facilitators) that influence the adaptability of the evidence-based practice for establishing a multidisciplinary SCD OB team as an intervention in the non-academic hospital, including the implementation process (Years 1-2); 2) Build capacity for a multidisciplinary SCD OB program in a non- academic hospital (Years 3-5), and 3) Conduct a Hybrid type 1 feasibility study comparing the effectiveness of a task-shifted multidisciplinary SCD OB program in a non-academic site (Years 3-5).