Improving screening and management of infectious diseases during pregnancy in Ghana
Summary
How PATH, the Ghana Health Service, and local health workers have improved screening and management of maternal infections in Bono East, Ghana.
When asked what a typical workday entails, Joana Yinpaab Duubon describes what sounds like several different jobs rolled into one. Yet she tackles them all with impressive efficiency.
As the Ghana Health Service’s (GHS) Training/Project Coordinator for the Bono East Region, Joana’s role is multifaceted. She coordinates health care provider trainings, mentors, manages staff, and offers technical guidance for health personnel. She also advises on patient screening procedures, coordinates establishment of “pregnancy schools”, facilitates meetings, and much more.
By leveraging her diverse skills, Joana has played a central role in the Integrated Antenatal Care (ANC) project, a collaboration between PATH and the GHS that is improving how maternal infections are diagnosed and managed during pregnancy.
In Ghana each year, an estimated 2,700 women die of pregnancy and childbirth-related causes and more than 20,000 babies die in the first month of life.
To address the critical challenges of infant and maternal mortality, the GHS and PATH have expanded infectious disease screening and treatment among pregnant women during antenatal visits. While HIV and syphilis screening were already being conducted, the expanded regimen includes testing for conditions like hepatitis B, urinary tract infections, group B streptococcus, and sexually transmitted infections.
Between November 2022 to March 2024, the GHS and PATH worked across five districts in Ghana’s Bono East Region to build the capacities of community-based and first-level health care providers in screening, diagnosis, and management of maternal infections; improving availability of services through ANC; and strengthening connections between primary and referral facilities. The interventions focused on three main areas: (a) including point-of-care and laboratory diagnostics for infections; (b) streamlining linkages and referral systems between primary and regional facilities by identifying point persons to coordinate referrals at higher-level facilities; and (c) leading social and behavioral change communication activities with health care providers, patients, and communities. Through this three-pronged approach, the project addressed supply- and demand-side barriers in an integrated manner to improve infection prevention and management.
“Treat the mother, and it helps the baby”
“[Maternal and child health is] an area I have so much interest and passion in,” Joana says. “Any health issue that destabilizes pregnant women and their children is of concern to me. The integrated ANC approach prevents infections for better outcomes and helps to prevent premature deliveries and stillbirths.”
Joana works closely with her supervisor, Dr. Paulina Clara Appiah, GHS Deputy Director of Public Health for the Bono East Region. Dr. Appiah monitors and evaluates program implementation across health areas, including noncommunicable diseases and maternal and child health and nutrition. Along with the PATH team, Dr. Appiah and Joana have ensured the smooth operation of integrated ANC services at nearly 70 facilities in Bono East.
“Treat the mother, and it helps the baby,” Dr. Appiah says, recalling a previous project aimed at helping newborns unable to breathe or cry at birth. She knew many infant health issues like this could be prevented altogether through early screening and treatment of mothers during pregnancy.
To that end, the Integrated ANC project has made it easier for health workers to test pregnant women for infections during ANC visits, streamlined how clients get referred to other facilities, and provided health care workers, pregnant women, and communities with information on maternal infections.
The project has trained nearly 700 providers on improved screening and management of maternal infections and screened more than 24,000 pregnant women during their first ANC visit. Across all ANC visits, 51,000 women were screened.
New tools, better outcomes
The Integrated ANC project builds on a partnership between PATH and GHS that goes back at least two decades. Dr. George Amofah, now a technical advisor with PATH, has worked with GHS throughout his career.
“It was easy to introduce new ideas with the Bono East Region staff,” Dr. Amofah says. Not only were staff enthusiastic about the integrated ANC approach, they also played a critical role in improving an ANC data collection mobile app, through what Dr. Amofah calls, “a process of ongoing co-creation.” Designed for providers and the regional team, the app provides real-time monitoring of coverage, screening, and management as providers enter clients’ data in the system. This enables the team to track progress across facilities, identify missed opportunities for screening, and address issues more quickly.
When asked to highlight the most important elements of the project, Dr. Appiah, Joana, and Dr. Amofah all agree: improved point-of-care diagnostics have made a major impact on infection diagnosis and treatment. Bundling rapid tests and regimens for 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. These tests help minimize wait times, loss to follow-up, and delays in needed treatment—ultimately enhancing patients’ quality of care and a positive patient experience.
While in the past, sending out samples and obtaining laboratory results took several days, investments in improved point-of-care testing and laboratory capacities have enabled screening and treatment during ANC visits, saving women time and money and minimizing loss to follow-up. Availability of point-of-care tests has improved, particularly at lower-level facilities, with an increase of nearly 25% in the number of women screened.
While some of these new diagnostics are more expensive for the health system, Dr. Appiah maintains, “the benefits outweigh the costs,” and the GHS has expressed a commitment to continuing their use.
The team has also strengthened linkages between primary care facilities and district and regional hospitals to improve patient management and referral systems. And the project’s training program to build capacities of community-based and first-level health care providers has been critical to improving maternal infection diagnosis and management.
In addition, the ANC data collection app has enabled providers and facility managers to assess missed opportunities within their own facilities, while data across districts has allowed the team to assess fidelity to the intervention.
Community engagement key to impact
Providing enhanced health services is essential, but successful implementation hinges on community engagement. The project team led outreach including “pregnancy schools”—health education sessions for pregnant women and their families—this concept developed by the GHS provides an interactive forum for counseling and health education. Currently limited to a few settings in Ghana, the project prioritized this activity, including investments in human resources and logistics to rapidly scale up the reach in intervention districts. Other outreach activities included community forums, radio campaigns, and development of resources such as behavior change materials to educate communities on maternal infections.
These activities have reached more than 2,000 community leaders and nearly 790,000 community members. Joana highlights the importance of involving stakeholders at all levels: “You can’t handle ANC issues and outcomes alone at the health facility. You need to collaborate with local stakeholders and leaders right from the ground.”
Dr. Amofah also emphasized the importance of local outreach, particularly through pregnancy schools, where participants learn about infection prevention and how to have a healthy pregnancy. Many clients are joined by family members, including partners, mothers, or in-laws—those who support women during their pregnancy and beyond.
“While the idea is not novel, it’s about implementation” Dr. Amofah explains. These schools are not a new concept in Ghana, but only a few existed before the project. Now through the leadership, planning, and coordination efforts of Joana and the GHS/PATH team, there are nearly 40 pregnancy schools across Bono East, where 365 health education sessions have been conducted, reaching more than 8,000 pregnant women and 2,000 family members.
Looking ahead
As the project concludes, PATH and the GHS are working to ensure sustained impact through these ANC interventions—not only to prevent maternal and neonatal deaths in Ghana but also to provide a replicable model for other countries looking to improve ANC.
The GHS plans to continue the integrated ANC approach on a long-term basis in Bono East, as many of the interventions are now fully integrated in the services offered to pregnant women. The Ministry of Health has also discussed national scale-up of services based on their demonstrated feasibility and acceptability through the project. PATH and the GHS are currently developing a roadmap to scale across Ghana.
Health worker training materials have also been adapted into eLearning modules that will be offered on the GHS eLearning platform. This will serve as an important project legacy to help ensure that the capacity-building efforts will continue.
Sadaf Khan, MBBS, MPH, DrPH is a Program Advisor with PATH’s Maternal, Newborn Child Health and Nutrition team, where she focuses on research and programming around innovations for maternal and perinatal infections, postpartum hemorrhage, and family planning.
Beth Balderston is a Senior Communications Officer on PATH’s Sexual and Reproductive Health team. Her specialties include developing communication and training materials that connect with diverse audiences. Beth holds a MS in Human Centered Design and Engineering from the University of Washington.