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Cycle 9 (2020 Deadline)
Community and hospital-based obstetrics WhatsApp triage, referral, and transfer (WAT-RT) system
PI: Veronica Millicent Dzomeku (vmdzomeku@gmail.com), Kwame Nkrumah University of Science and Technology (KNUST), and co-PI Dr. Bernice Dahn, University of Liberia
U.S. Partner: Jody Lori, University of Michigan
Project Dates: May 2021 - July 2023
Project Overview:
The overarching project goal was to increase continuity and access to quality maternal care, reducing preventable obstetric-related deaths through (1) a WhatsApp Triage, Referral and Transfer (WAT-RT) System connecting community health workers (CHWs), midwives at rural health facilities, and healthcare personnel at referral hospitals; and (2) an obstetric (OB) triage system implemented at referral hospitals to decrease facility delays. The WAT-RT system allows two-way communication to assist in early problem identification and prompt referral to the next level of care. It will allow the facility to prepare for incoming increased workload, thus preventing delays upon arrival. Phase I of the project employed a participatory action research design to identify health system challenges from the perspective of patients, providers, community leaders, and government. The team conducted a learning needs assessment of the familiarity of CHWs and healthcare providers with the WhatsApp platform and a review of the risk factors for OB emergencies warranting referral from the community to the facility. Next, with stakeholders, the team designed the protocol for the WAT-RT system. Using a train-the-trainer model to implement the system at 40 rural clinics and two referral hospitals, the team trained clinic staff who will then become facilitators, training CHWs from their respective catchment communities. Phase II training took place at the referral hospitals. Following an assessment of current OB triage protocols, including observations of admission and labor ward activities, structured intake assessments, waiting times, and focus group discussions, the project team used an iterative approach to design and deliver an interactive triage training course for all emergency department and labor and delivery hospital personnel.
The project should have a population-level effect by engaging multiple partners, working in collaboration, to achieve a significant impact on maternal health in Ghana and Liberia. In both countries, a fundamental gap exists with preventable deaths disproportionately affecting poor women living far from healthcare centers. Evidence generated from this research will be presented to the ministries of health in both countries, as well as stakeholders from other sub-Saharan African countries, with the ability to replicate and scale up the WAT-RT system in their settings. The anticipated outcomes of the project include (1) timely care-seeking along the referral pathway for pregnant women between first-line CHWs, rural health facility nurses/midwives, and district hospital staff; (2) optimization of patient care through a triage protocol for high-risk OB patients; (3) reduced wait time and delay upon arrival at the health facility; and (4) improvement of the quality and experience of care.
Final Summary of Project Activities
After baseline data collection and protocol design were complete, the project applied a carefully coordinated train-the-trainers model for introducing their WhatsApp based system to healthcare providers. In November 2021, the project team trained Ghanaian midwives and community health workers on triaging, referral, and transfer of obstetric emergencies using the WAT-RT system. Specifically, 29 rural health workers from 16 rural health facilities and 3 midwives from the Kwame Danso hospital were trained on identifying risk factors for OB emergencies warranting referral from the rural health facility to the referral hospital. As part of their training, all 32 participants representing the total of 17 health facilities from the Sene West and Sene East Districts, were split into groups of 6 to develop and present on a birth preparedness plan they will develop with each pregnant woman they encounter. Again, they all received a step-by-step training on using WhatsApp for communicating as part of the WAT-RT System. During the same period, the project team in Liberia also held a train-the-trainers workshop for 20 rural health facility midwives in Bong County to guide the on the establishment and operation of the WhatsApp platform on smart phones/tablets and recognition of danger signs during pregnancy. The objective of the training was to ensure that the midwives in turn, will train community health assistants in their catchment community use the WhatsApp platform for referral and for feedback communication loop.
As the system rolled out in both countries, the project teams remained in regular contact with the implementers, including making site visits to the facilities where they were based, to make sure the system was working well and make any necessary adjustments or provide retraining. As the project culminated, the researchers convened a dissemination meeting on May 24, 2023, at the KD District Hospital in Ghana to share their findings with stakeholders and agree on next steps with regards to sustainability. The district directors, midwives, and the in-charges of the participating health facilities participated in the meeting, along with Ghana Health Service Deputy Director Dr. Anthony Ofosu, U.S. partner Dr. Jody Lori, and a maternal and child health specialist from USAID. The project team recommended that extending the intervention to other rural communities and districts within Ghana would ensure that obstetric emergencies are handled appropriately.
A strong collaboration has been developed with the Ghana Health Service from national, regional and district levels for the implementation of the project. Dr. Anthony Ofosu has served as an advisor to the project, and the team has also been regular contact with relevant Liberian healthcare authorities. Regular meetings were held with the Bong County Health team that supervises the implementation level of the project. KNUST has also formed a stronger collaboration with the University of Liberia through sharing of experiences and learning on the project.
The main output from the project is the user-friendly, online-based triage and referral system that was developed and piloted at 16 rural health facilities. After they experienced the effectiveness of the system with regards to improving communication between health facilities at different levels of care and preparing the receiving facility for incoming referrals to avoid delays in emergencies, the health facilities have adopted the system, as well as the associated triage form that was also developed under the project. Another key result was that midwives received training on OB emergencies, triaging, and effective communication with clients and colleagues. During the two years that the project was implemented with PEER support, a total of 306 referrals were made using the system. Midwives and patients attested that the system was effective and contributed to improving health outcomes. Going forward now that the PEER project has ended, the PI and her team will create a network of all midwives who received training in the use of the referral system to ensure frequent communication and sustained implementation of the system. The district health directors and directors of the implementing facilities will also be engaged to ensure that resources are available to support the system. Researchers from the project team will continue to provide technical support to the implementing facilities, and Dr. Ofosu will lead the team for national engagement and dissemination of the developed system. Other funding support will be explored to extend the project beyond the district to the regional level.
Publication
Veronica Millicent Dzomeku, Adwoa Bemah Boamah Mensah, Emmanuel Kweku Nakua, Pascal Agbadi, Joshua Okyere, Alex Kumah, Jacob Munukpa, Anthony Adofo Ofosu, Nancy Lockhart, and Jody R. Lori. 2023. Feasibility of the use of WhatsApp messaging technology to facilitate obstetric referrals in rural Ghana. BMC Digital Health 1: 11 https://doi.org/10.1186/s44247-023-00012-5
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