April 23rd, 2019 by Galit Rudelson

Today I attended the neonatal mortality conference, and it was incredibly interesting. For starters, I should set the scene (this actually took a lot more typing than I realized, so if its boring just skip to the 5th paragraph, I don’t blame you). This conference was supposed to occur last week, starting around 10:00am. I was the first one there at 10:00am and people gradually trickled in for the next 45 minutes. Ghanians are very loose with their time, very relaxed about it. Around 11:00 it was realized that one of the main doctors was in an emergency surgery and would not be able to attend for a long while, so it was cancelled and moved to today at 7:30am.
I arrived today at 8:00am, knowing by now that 7:30 does not actually mean 7:30. I came to a room full of new nurses, starting at the hospital this month. They were doing some orientation thing. I waited outside of the door for 30 minutes, wondering if we were going to start after them. Every once in a while a doctor would rush up and ask me “weren’t we supposed to have a meeting today.” I told each one of them that I thought the same thing and was waiting to see if we were starting later. They all said “Ill make some calls” and walked away, so I never heard the result of these calls. Not that I am complaining. This is just the nature of being here. Be flexible and relaxed, adapt to the situation.
Eventually the meeting was moved until “later.” At 10:00am I was told it would start “soon, come now.” Hilariously the meeting did not start until 10:45! This is just a classic example of Ghanian time, happens all the time!
The room itself is on the second floor. All the windows are open (as barely any windows close in Ghana, there is no need, it is always hot enough to keep them open). Downstairs is the generator. The power has been off all day, so the generator has been working. It is incredibly loud. So imagine this meeting, in the heat, everyone sweating, and yelling just to be able to be heard over the generator. Ok that was a long set up.
The meeting was set up to discuss the death of 8 babies, either in utero or shortly after birth. They had a premade packet (which seemed to be used throughout all of Ghana) that asked for the details of the death. It started basic, name of mother, age, how many previous babies has the mother had, gestational age. Then it got into the details of the delivery. Was the patient referred, were baby heart tones heard and monitored. How long was labor. Was a c-section necessary. How long after decision to do a c-section did it occur. Then what were the complications of the pregnancy. What was the cause of death if intrauterine. If shortly after birth, what were the APGARs of the baby, and what interventions were done. At what age did the baby pass away.
All of this information is readily available in the US. The charts can easily be searched through on the computer, and everything can be done in a matter of minutes. Here, everything is paper charts. Things are recorded in many different locations. Some things are not recorded. Our first case took 2 hours to complete.
What was interesting to me is that this was clearly generated to do some sort of research off of it. It was made it what I would think is a very clear and straightforward method. So to me it was interesting to see where all of the confusion was coming from. It showed how difficult it would be to use this information in any sort of research, or to come up with any conclusions from it.
For example, a mother had pre-eclampsia (high blood pressure and some other side effects). A decision was made to take her to c-section. Between decision to go and the actual c-section was 4 hours. During this time the mother refused fetal monitoring (because it hurts. It is not like in the US where they just put a sticker on your belly. Here they press a baby fetoscope onto your abdomen HARD until they can hear. Not comfortable). Once the c-section occurred, the baby had passed away. So on the form there is a section of “cause of death.” There was a long debate: was it “pre-eclapsia” or “fetal distress” (and how can we say its fetal distress if nobody was monitoring the baby), or “placental insufficiency, since that happens in pre eclampsia” (“but we already said that the placenta looked normal on delivery, cant be that”). Or was it “unable to do adequate physical exam” (“no that is not it because it implies we did something wrong, but it was the mother that was refusing.”)
Point being, I can easily see that once the person collecting this data receives this information, he will simply add a tally to “pre-eclampsia” for example, and the rest of the picture is forgotten. Which makes for very inaccurate research. But what can you do?
The same type of thing happened for 5 hours. We got though 4 of the cases. 4 small data points for whoever will be reviewing all of this work. It seemed mind boggling.
I was also interested to see the outcome of this meeting. Everyone was identifying problems, and setting new goals for the maternity ward. The listed the mistakes made in each death, and thought of ways to correct it. Would be interesting to see how these go into effect long term.