title: Measuring the impact of a quality improvement collaboration to decrease maternal mortality in a Ghanaian regional hospital.
abstract: OBJECTIVE
  To evaluate the performance of a continuous quality improvement collaboration at Ridge Regional Hospital, Accra, Ghana, that aimed to halve maternal and neonatal deaths.
  
  
  METHODS
  In a quasi-experimental, pre- and post-intervention analysis, system deficiencies were analyzed and 97 improvement activities were implemented from January 2007 to December 2011. Data were collected on outcomes and implementation rates of improvement activities. Severity-adjustment models were used to calculate counterfactual mortality ratios. Regression analysis was used to determine the association between improvement activities, staffing, and maternal mortality.
  
  
  RESULTS
  Maternal mortality decreased by 22.4% between 2007 and 2011, from 496 to 385 per 100000 deliveries, despite a 50% increase in deliveries and five- and three-fold increases in the proportion of pregnancies complicated by obstetric hemorrhage and hypertensive disorders of pregnancy, respectively. Case fatality rates for obstetric hemorrhage and hypertensive disorders of pregnancy decreased from 14.8% to 1.6% and 3.1% to 1.1%, respectively. The mean implementation score was 68% for the 97 improvement processes. Overall, 43 maternal deaths were prevented by the intervention; however, risk severity-adjustment models indicated that an even greater number of deaths was averted. Mortality reduction was correlated with 26 continuous quality improvement activities, and with the number of anesthesia nurses and labor midwives.
  
  
  CONCLUSIONS
  The implementation of quality improvement activities was closely correlated with improved maternal mortality.
authors.affiliation: Ridge Regional Hospital, Ghana Health Service, Accra, Ghana. Electronic address: emmanuelsrofenyoh@gmail.com.
authors.forename: Emmanuel K
authors.initials: EK
authors.lastname: Srofenyoh
authors.affiliation: Department of Anesthesiology and Pain Medicine, and the Institute for Health Metrics and Evaluation, Seattle Children's Hospital, University of Washington, Seattle, WA, USA.
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Kassebaum
authors.affiliation: Department of Obstetrics and Gynecology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
authors.forename: David M
authors.initials: DM
authors.lastname: Goodman
authors.affiliation: Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA.
authors.forename: Adeyemi J
authors.initials: AJ
authors.lastname: Olufolabi
authors.affiliation: Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
authors.forename: Medge D
authors.initials: MD
authors.lastname: Owen
mesh_terms: D036861:Delivery, Obstetric / Q000706:statistics & numerical data* / Q000639:trends; D003710:Demography; D005260:Female; D005869:Ghana; D006801:Humans; D008427:Maternal Health Services; D008428:Maternal Mortality / Q000639:trends*; D011247:Pregnancy; D011248:Pregnancy Complications / Q000401:mortality*; D058996:Quality Improvement / Q000706:statistics & numerical data* / Q000639:trends; D012017:Referral and Consultation; D012044:Regression Analysis; D020379:Risk Adjustment; D000078329:Workforce
keywords: Case fatality rates; Maternal mortality; Quality improvement; Risk adjustment; Sub-Saharan Africa