BEYOND THE NUMBERS: CONFIDENTIAL ENQUIRIES INTO MATERNAL DEATHS IN ACCRA-GHANA Researcher: Afisah Yakubu Zakariah Universite Libre de Bruxelles- School of Public Health Reproductive Health and Epidemiology of Perinatal Health Unit Brussels-Belgium Afiyakzak@yahoo.com Promoter: Professor Sophie Alexander-Karlin Universite Libre de Bruxelles- School of Public Health Reproductive Health and Epidemiology of Perinatal Health Unit Brussels-Belgium salexand@ulb.ac.be Co-Promoter: Professor Jos van Roosmalen Leiden University Medical Centre Department of Obstetrics and Gynaecology Leiden-The Netherlands J.J.M.van_Roosmalen@lumc.nl "A thesis submitted for the Degree of Doctor of Philosophy in Public Health Sciences Universite Libre de Bruxelles-School of Public Health Reproductive Health and Epidemiology of Perinatal Health Unit. November, 2008. EXECUTIVE SUMMARY Background Maternal mortality remains a severe problem in many parts of the world, despite efforts to reach MDG 5. Assessing progress towards this goal is difficult because maternal mortality is difficult to measure and the information available at country level does not generally permit the establishment of good baseline data. Countries with high maternal mortality ratios neither have adequate vital registration systems nor adequate resources to carry out surveys. Only few low-income countries have been able to establish a comprehensive reporting system and even where such vital registration systems are in place, maternal deaths are often underreported or misclassified as non-maternal even in large well developed cities. Ghana belongs to the group of low-income countries with high maternal mortality ratios (point estimate 560, lower bound 200 and upper bound 1300) per 100,000 live births and inadequate data on maternal deaths. Previous studies have demonstrated that most of these deaths could be prevented with existing effective practices. In this dissertation, we looked at the registration system of births and deaths in the Greater Accra Region of Ghana. We assessed completeness of registration of maternal deaths and data quality. We also looked at the degree of underreporting of maternal deaths, assessed causes of maternal deaths and substandard care of these cases through a confidential enquiry. This enabled us to identify problems associated with measuring of maternal mortality in Ghana and the standard of care of the cases. Through our findings we were able to make recommendations to achieve MDG 5 in the country by 2015 if implemented. Other maternal and child health (MCH) interventions were also looked as working to improve MCH is a continuum, and no aspect should be neglected. The first relates to seeking evidence based practice in presence of potentially complicated obstetrical conditions like premature rupture of membranes and the second pertains to preventive activities in MCH and concentrates on the results of tetanus immunisation of women in their reproductive age in the Northern Region of Ghana. Objectives 1. To assess the precision (quality) of civil registration of maternal deaths in Ghana 2. To identify the magnitude of maternal deaths using multiple sources and assess the degree of underreporting of these deaths 3. To identify the root causes and related factors of the identified maternal deaths as well as classify the deaths 4. To assess the level of substandard care in maternal deaths in order to identify weakness in the Ghanaian maternity care system and propose locally relevant and affordable solutions to improve maternity care in Ghana 5. To discuss the results of the research with the Decision makers and health care providers leading to an adoption of the method at national level and a reduction of maternal mortality in Ghana as a whole 6. To assess risk factors and management of premature rupture of membranes and make recommendations that will address avoidable complications 7. To assess challenges of other maternal and child health interventions like Tetanus Toxoid immunization in women of reproductive age group and formulate recommendations to increase the coverage in this group. Organization of dissertation This dissertation contains eight chapters. Chapter one is on general introduction, which gives an overview of the problems associated with the reduction of maternal mortality by literature review. Chapter two highlights the profile of Ghana and the Health system Chapter three is on maternal mortality in the Greater Accra region of Ghana for the year 2000. In this chapter, we assessed completeness of registration and data quality as well as the sensitivity and specificity of the civil registration system to capture maternal deaths in Ghana. Chapter four discusses Reproductive Age Mortality Survey (RAMOS) conducted in Accra city (Metropolis) for the year 2002. It showed how effective the method is in identifying maternal deaths using multiple sources approach. In this study, we aimed at identifying the magnitude of maternal deaths in the city and the degree of underreporting during the study period. Chapter five elaborates the main content of this thesis, which is on confidential enquiries into maternal deaths for the year 2002. This chapter deals solely with the seventy three cases of maternal deaths that were identified during the study period (1st January 2002-31st December 2002) with adequate information surrounding the deaths. We identified the root causes and related factors of the identified maternal deaths as well as their classification. We also assessed the level of substandard care in maternal deaths, identified weaknesses in the Ghanaian maternity care system and proposed locally relevant and affordable solutions to improve maternity care in Ghana. Chapter six is on controversy of management of premature rupture of membranes at term. We reviewed systematically the existing evidence on expectant management of PROM and prompt delivery after a premature rupture of membranes at term and gave an answer to this controversy. Chapter seven assessed challenges of other maternal and child health interventions like Tetanus Toxoid immunization in women of reproductive age group and formulated recommendations to increase the coverage in this group. Chapter eight gives the general discussion, conclusion and recommendations. Main results and conclusion The study on the assessment of completeness of registration and data quality of maternal deaths in the Greater Accra Region of Ghana found the process of registration of maternal deaths in the Region to be incomplete even though there is a system of registration of deaths in Ghana. We identified the major causes of under registration of maternal deaths during the study as omission of pregnancy status in the registers. Pregnancy status is not systematically noted in the registers and the death certificate forms. Other contributing factors to the under registration of maternal deaths were erroneous classification of maternal deaths as non-maternal and imprecision in the death certification and registration. The study on Reproductive Age Mortality Survey (RAMOS) in Accra city (Metropolis) for the year 2002 has almost doubled the officially reported figures, which showed that the method is effective in identifying maternal deaths using multiple sources approach. The findings of the confidential enquiries into maternal deaths for the year 2002 showed that the proportion of maternal deaths associated with substandard care factors at various levels is high in the Metropolis even though the city has the best medical services in the country. The study on the controversy of management of premature rupture of membranes at term shows that prompt delivery after the membranes are ruptured averts many complications both for the mother and the baby. It is presented as an illustration of how evidence based guidelines can be instrumental in challenging the maternal mortality problem In the study on challenges of maternal and child health interventions like Tetanus Toxoid immunization in women of reproductive age, we found out that the tetanus toxoid vaccine was perceived as an anti fertility drug by those who refused to be vaccinated. Among other reasons for refusal was complete authority over wives by their husbands and therefore not allowing them to be vaccinated. It also is an illustration of the role of good organisation of care in meeting MDGs 4 and 5. We finally conclude that, even in environments with limited resources, most maternal deaths can be prevented if appropriate measures are put in place to prevent their occurrence. Key words: Maternal mortality, registration, underreporting, RAMOS, confidential enquiries, sub-standard care, PROM.

Discrete-event simulation (DES) is an invaluable tool which organizations can use to help better understand, diagnose, and optimize their operational processes. Studies have shown that for the typical DES exercise, the greatest amount of time is spent on developing an accurate model of the process that is to be studied. Process mining, a similar field of study, focuses on using historical data stored in software databases to accurate recreate and analyze business processes. Utilizing process mining techniques to help rapidly develop DES models can drastically reduce the amount of time spent building simulation models, which ultimately will enable organizations to more quickly identify and correct shortcomings in their operations. Although there have been significant advances in process mining research, there are still several issues with current process mining methods which prevent them from seeing widespread industry adoption. One such issue, which this study examines, is the lack of cross-compatibility between process mining tools and other process analysis tools. Specifically, this study develops and characterizes a method through which mined process models can be converted into discrete-event simulation models. The developed method utilizes a plugin written for the ProM Framework, an existing collection of process mining tools, which takes a mined process model as its input and outputs an Excel workbook which provides the process data in a format more easily read by DES packages. Two event logs which mimic real-world processes were used in the development and validation of the plugin. The developed plugin successfully extracted the critical process data from the mined process model and converted it into a format more easily utilized by DES packages. There are several limitations which will limit model accuracy, but the plugin developed by this study shows that the conversion of process models to basic simulation models is possible. Future research can focus on addressing the limitations to improve model accuracy.

No / Improving cognition is service users' top research priority for life after stroke, and future research should include outcomes that they deem important. Patient perspectives on outcomes are collected using patient-reported outcome measures (PROMs). There is currently no patient-centred PROM specific for cognitive rehabilitation trials. Objective Inform PROM development by exploring stroke survivor perspectives on the important, measurable impacts of persisting post-stroke cognitive problems. Design Qualitative semi-structured interviews in participants' homes. Participants Purposive sample of 16 cognitively impaired stroke survivors at least six months post-stroke. Methods Interviews used a schedule and communication aids developed through patient consultation. Interviews were transcribed verbatim with non-verbal communication recorded using field notes. Data were analysed using a framework approach to find commonalities to shape the focus and content of an outcome measure. Results Participants identified important impacts of their ‘invisible’ cognitive problems, outside of other stroke-related impairments. Cognitive problems exacerbated emotional issues and vice versa. Changes in self-identity and social participation were prominent. Impact was not spoken about in terms of frequency but rather in terms of the negative affect associated with problems; terms like ‘bothered’ and ‘frustration’ were often used. Conclusions The results support the development of a PROM specifically designed to address the impact of cognitive problems. It should: include items addressing a comprehensive range of cognitive skills; ask questions about mood, self-identity and social participation; use accessible wording that respondents understand and endorse; measure impact rather than frequency; and explore perceived impact on carers.

Cognitive difficulties can persist for months and years after stroke and adversely impact confidence, mood and functional recovery. Stroke survivors, carers and healthcare professionals collectively agree that improving cognition is the number one research priority for life after stroke. Future research should include measurements of outcome that service users deem important. Patient reported outcome measures (PROMs) are a means of gaining patient perspectives that can be standardised for use in a trial. PROMs should be developed with service users to incorporate their priorities but people with cognitive difficulties are often systematically excluded from the development and use of PROMs. Study 1 used qualitative interviews (N=16) to explore stroke survivor perspectives on the important and measureable impacts of persisting cognitive problems. The results of this study generated requirements for a PROM that related to conceptual underpinning and face validity of a measurement tool. Study 2 was a systematic review of existing PROMs related to cognition. 20 Identified PROMs were critically appraised against the requirements generated in the qualitative study. No existing PROMs were identified that met all of the qualitative study review criteria. The next stage described in chapter 3, was to develop a new PROM that: utilised the strengths of existing tools; met qualitative study requirements; and was refined through consultation with different stakeholders, prioritising feedback of stroke survivors with cognitive difficulties. The result of this work was the Patient Reported Evaluation of Cognitive State (PRECiS) scale. Study 3 was a psychometric study with stroke survivors (N=164) to test PRECiS in a large sample. Quantitative and qualitative data were collected on acceptability, feasibility and other psychometric properties of validity and reliability. PRECiS demonstrated good acceptability to stroke survivors and performed well psychometrically. Future validation work required for PRECiS is described in discussion chapter 4. Subject to further validation work, PRECiS may be particularly useful for pragmatic trials of cognitive rehabilitation after stroke.

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This thesis aim was to find the answer the following research question: What do queer gamers think of the game Monster Prom. The material gathered for this thesis was through a participant observation with four people from the LGBTQIA+ community playing the game Monster Prom and a subsequent focus group interview with these people. The material was analysed using Queer Game Studies research. In this paper I came to the conclusion that representation does matter to queer gamers. According to my interviewees, there is a need for representation in games and that it needs to be diverse and made undramatic. The interviewees brought forward how and why this design of an avatar system gives the player freedom, queer possibilities, and being positively received by queer players. The interviewees also brought forward how and when one should/shouldn't write a story surrounding the representation of queer oppression from a queer player´s point of view.

The rate of Emergency Department (ED) visits due to mental health and drug abuse among children and youth has been increasing for more than a decade and is projected to become the leading cause of ED visits. Identifying high-risk patients well before an ED visit will enable mental health care providers to better predict ED resource utilization, improve their service, and ultimately reduce the risk of a future ED visit. Many studies in the literature utilized medical history to predict future hospitalization. However, in mental health care, the medical history of new patients is not always available from the first visit and it is crucial to identify high risk patients from the beginning as the rate of drop-out is very high in mental health treatment. In this study, a new approach of creating a text representation of questionnaire data for deep learning analysis is proposed. Employing this new text representation has enabled us to use transfer learning and develop a deep Natural Language Processing (NLP) model that estimates the possibility of 6-month ED visit among children and youth using mental health patient reported outcome measures (PROM). The proposed method achieved an Area Under Receiver Operating Characteristic Curve of 0.75 for classification of 6-month ED visit. In addition, a novel method was proposed to identify the words that carry the highest amount of information related to the outcome of the deep NLP models. This measurement of word information using Entropy Gain increases the explainability of the model by providing insight to the model attention. Finally, the results of this method were analyzed to explain how the deep NLP model achieved a high classification performance. / Dissertation / Master of Applied Science (MASc) / In this document, an Artificial Intelligence (AI) approach for predicting 6-month Emergency Department (ED) visits is proposed. In this approach, the questionnaires gathered from children and youth admitted to an outpatient or inpatient clinic are converted to a text representation called Textionnaire. Next, AI is utilized to analyze the Textionnaire and predict the possibility of a future ED visit. This method was successful in about 75% of the time. In addition to the AI solution, an explainability component is introduced to explain how the natural language processing algorithm identifies the high risk patients.

Maternal mortality remains a severe problem in many parts of the world, despite efforts to reach MDG 5. Assessing progress towards this goal is difficult because maternal mortality is difficult to measure and the information available at country level does not generally permit the establishment of good baseline data. Countries with high maternal mortality ratios neither have adequate vital registration systems nor adequate resources to carry out surveys. Only few low-income countries have been able to establish a comprehensive reporting system and even where such vital registration systems are in place, maternal deaths are often underreported or misclassified as non-maternal even in large well developed cities. <p>Ghana belongs to the group of low-income countries with high maternal mortality ratios (point estimate 560, lower bound 200 and upper bound 1300) per 100,000 live births and inadequate data on maternal deaths. Previous studies have demonstrated that most of these deaths could be prevented with existing effective practices.<p><p>In this dissertation, we looked at the registration system of births and deaths in the Greater Accra Region of Ghana. We assessed completeness of registration of maternal deaths and data quality. We also looked at the degree of underreporting of maternal deaths, assessed causes of maternal deaths and substandard care of these cases through a confidential enquiry. This enabled us to identify problems associated with measuring of maternal mortality in Ghana and the standard of care of the cases. Through our findings we were able to make recommendations to achieve MDG 5 in the country by 2015 if implemented. Other maternal and child health (MCH) interventions were also looked as working to improve MCH is a continuum, and no aspect should be neglected. The first relates to seeking evidence based practice in presence of potentially complicated obstetrical conditions like premature rupture of membranes and the second pertains to preventive activities in MCH and concentrates on the results of tetanus immunisation of women in their reproductive age in the Northern Region of Ghana.<p><p>Objectives<p>1.\ / Doctorat en Sciences de la santé publique / info:eu-repo/semantics/nonPublished

The topic of this thesis is the completion of compulsory education at elementary school. The goal of the theoretical part of this thesis is detailed description of specifics which relate to 9th grade. It can be useful to teachers who are, at the moment, teaching this grade and could help them to realize all the factors that influence their work. They might also find some new options how to improve their work. The practical part of this thesis is focused on a case study of project that is realised at Elementary School Josefa Kajetána Tyla, Písek. It is the 9th grade student's prom. The main focus is on what are the students learning, whether and how it influences their teaching and what does organizing this kind of event entitles.

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