When Simple Things Save Lives
The National Rollout of Kybele’s OTIP
Consider two scenarios.
In the first, three vehicles pull up–almost simultaneously–to a regional hospital in Ghana. Each carries a woman in labor. Like many hospitals in Ghana, this facility is busy, and there are already many women waiting. Two women are showing signs of preeclampsia, a serious but treatable condition in pregnancy, but no one is the wiser because they are told to get in line behind the last woman who arrived.
There they sit, sometimes on a bench, sometimes on the floor, in a hallway for hours, in some cases a day or more, before they are assessed by a medical professional. For some of these women or their babies, those hours of waiting could mean developing complications that lead to suffering and, far too often, death.
It doesn’t have to be this way.
Consider a second scenario, one that actually happened at the Eastern Regional Hospital, Koforidua (ERHK) in Ghana. Three ambulances pull up, almost simultaneously. Each carries a woman in labor.
ERHK is another busy facility, however, in this scenario, three midwives arm themselves with triage assessment forms and climb, one each, into the ambulances. Having been trained recently in obstetric triage, the midwives do a complete assessment of all three women in the ambulances, discovering that two of them are exhibiting signs of preeclampsia, giving them higher priority.
One midwife, however, notes that, based on her chart, one of the women with preeclampsia is exhibiting a dangerous respiratory rate–a key indicator of risk.
“Sincerely, I think that the assessment tool is one of the things that saved the client’s life,” Dr. Francis Wuobar says. As the head of the Department of Obstetrics and Gynecology at EHRK, he witnessed the second scenario firsthand. It occurred at EHRK after he helped implement a new standard of obstetric triage.
In this very real scenario, the woman was flagged with respiratory issues and identified as a high-risk delivery. She was moved to the intensive care unit where her baby was delivered and her life saved. If these three women arrived prior to the new triage standards, such as in the first scenario, Wuobar is confident that at least one or more of the women would not have made it.
Scenarios like these are the reason that Kybele, a nonprofit dedicated to improving childbirth for mothers and their babies, developed the Obstetric Triage Implementation Package (OTIP) in the first place, because–all too commonly–in countries all over the world, a situation like the one above doesn’t have a happy ending. OTIP provided the assessment tools Wuobar’s teams now use, and its scenario-based training methodology is the reason the triage program is fully operational at EHRK.
This new medical standard isn’t just at one hospital. Across the country of Ghana, obstetric triage training is happening, bringing life-saving procedures and tools to pregnant women and their babies, thanks to a national rollout begun in 2023 as a partnership between the Ghana Health Service (GHS) and Kybele.
What Is the Obstetric Triage Implementation Package?
In many places the world over, waiting in line during labor is a dangerous place for a woman to be. The wait times can be hours or longer, and, during that time, a woman’s condition can go unnoticed, often leading to preventable complications that are the cause of the majority of maternal deaths.
“There’s just not the mindset or the tools to know how to rank conditions or vital signs and symptoms based on what is most life-threatening and urgent,” Erin Pfeiffer says. Pfeiffer is the Grants Manager for Kybele, a role in which she helps find the funding that brings Kybele’s innovative solutions to the people who need it.
Kybele is an organization that addresses the preventable deaths of mothers and babies that happen during pregnancy and childbirth every day across the globe. Kybele’s mission began when founder, Dr. Medge Owen, observed medical practices in low-resource areas that were 30-40 years behind the current medical standards. Her desire to close that gap became Kybele in 2001.
Dr. Owen witnessed first-hand the significant delay between patients’ arrival at a hospital and their assessment in the country of Ghana, alongside her colleague, Dr. Fiona Bryce. They wanted to understand the causes of the problem, and through research determined that if they could systematically introduce the fundamentals of obstetric triage—which prioritizes the care of pregnant women due to their risk factors—many of the women who die on the waiting bench could be saved.
“Fiona, Medge, and some others figured out a way to bring triage to these places in a really simple, affordable way, creating a system that uses colored wristbands and assessment forms to quickly take the most important information needed from a patient,” Pfeiffer says.
Kybele found that when triage is consistently implemented, the results are outstanding—like the woman at EHRK whose complications were quickly identified through the triage process. Kybele developed the Obstetric Triage Implementation Package, which includes a set of forms that help frontline medical professionals–usually midwives–to assess the risks facing each woman quickly and categorize their risk levels with color-coded bands.
But the linchpin of the whole OTIP system is triage training, where medical professionals learn obstetric triage in a hands-on and practical way that they can adopt immediately. With a combination of medical education and a simulation game that allows trainees to work through real-life scenarios, midwives and other medical professionals master triage principles that prioritize care for the women and babies who arrive at their facilities.
But could something this straightforward, this simple, really make a difference? The answer came from putting the program to the test in a place with the greatest need.
The Proof in the Pilot
Once OTIP was developed, Kybele piloted the triage training in a busy referral hospital in Accra, Ghana with over 8,000 annual births. Referral hospitals in Ghana see the most complicated cases, with many patients in potentially life-threatening circumstances.
The results were eye-opening. Kybele’s research revealed that women could wait as long as a day or more to be assessed, despite the fact that the international recommendation for arrival to assessment is 10 minutes. Through the OTIP pilot, the waiting times were slashed, going from 22% of women being assessed within 10 minutes of arrival to 65%.
With some additional funding, Kybele was able to scale up the OTIP program to six more referral hospitals in Ghana, including ERHK where Dr. Wuobar works. During this phase, waiting time across all hospitals was reduced even more dramatically, going from 5% of women being assessed within 10 minutes of arrival to 85%.
“I was selected to be part of the team to implement the pilot in my hospital,” Wuobar says. “I was excited to know what obstetric triage was about, and I loved the impact that training had for myself and also for my clients.”
At this point, the Ghana Health Service (GHS) took notice.
“For almost 20 years, we’ve worked in close collaboration with the GHS in Ghana,” Pfeiffer says. “When the GHS saw that the OTIP pilot was reducing patient wait times and making clinical staff practices more efficient, which ultimately saves lives and money, it was a pretty easy decision.”
That “easy decision” was about implementing OTIP in many more hospitals across the country. In 2023, Kybele and the GHS initiated the national rollout of OTIP in 76 district and referral hospitals, which ultimately covers 64% of Ghana’s institutional births.
With a national effort, more manpower was needed. Kybele hired Robert Asambobillah to be the in-country Program Manager for the OTIP rollout.
“I have worked in other organizations where we have implemented health programs that spent millions of dollars buying very big and heavy equipment, and you really do not get the impact and the results as clear as with OTIP,” Asambobillah says. “OTIP is such a simple innovation that has high impact, but is less expensive.”
Asambobillah is a key part of the OTIP rollout. He also embodies one of Kybele’s core values: finding local leaders who will spearhead the charge to implement–and sustain–the changes to medical techniques.
Owning the Change
The results of OTIP’s pilot program were compelling, but to create long-term change, the training component of the program needed to be self-sustaining.
Before the rollout, Kybele trained a select group of Ghanaian medical professionals in obstetric triage and the OTIP program as a whole, a group called the national champions. They’re called champions because they champion the cause of triage in their country.
“One of the things also that we feel very passionate about is the concept of sustainability,” Dr. Wuobar, who is one of the national trainers, says. “Training should not be a one-off event. We expect this process to be sustainable. There has to be some ownership of the program from the local level.”
There are about 16 of these national trainers, and, when it’s time to get OTIP up and running in a new facility, two of these trainers are sent out to the hospital for a five-day program. During this time, they train a hand-picked group of ten medical professionals at each facility, who become clinical champions within their facilities.
“The idea is to ensure that in each facility there are enough people to implement and continue the program,” Asambobillah says.
As part of their training, clinical champions train a group of other obstetric staff under the supervision of the national champions, which is usually around 30 people.
“By the end of the fifth day, they have received the knowledge and the skills, and so by the next Monday, they actually start triaging,” Asambobillah says.
By tasking local medical professionals with the training of their peers, the program places ownership of triage in the hands of those who are using it day in and day out—the professionals who will be most invested in sustaining it.
Rolling Out the Benefits
To date, 63 of the 76 referral hospitals have undergone OTIP training and have set up an obstetric triage area. The last 13 hospitals should be completed by early 2025. More than 2,400 medical professionals on the frontlines of caring for mothers and babies are now trained in life-saving triage techniques.
“I participate in most of the trainings, and I wish I could share the testimonies after the training, how the participants have expressed excitement about their gained knowledge and the passion with which they are working,” Asambobillah says.
Testing done before and after training objectively shows an uptick in skills learned, but that’s not the only way that the difference can be felt.
When medical professionals on the frontlines gain knowledge and skills, that translates into better treatment for mothers and babies in their care. Trainees recognize problems more quickly, allowing for swifter treatment, which also stops complications before they start. Not only does that save lives, but it also reduces suffering for both women and children.
OTIP training also empowers medical professionals by improving communication between intake and those who treat the patients downstream.
“If a midwife has a case and cannot handle it, triage training teaches her to call a medical doctor and gives them the communication skills they need,” Asambobillah says. “They get the doctor’s attention much faster than normal in a way that the one receiving the information understands clearly.”
Making Triage the Norm
The success of the OTIP rollout is turning heads. In 2024, Kybele received a national GHS Excellence Award in recognition of the nonprofit’s achievements in the healthcare sector by using collaboration to improve healthcare services.
However, Ghana is not the only place where obstetric triage is needed. There are high-volume hospitals in low-resource contexts around the world where the simultaneous arrival of three laboring women would have ended with one or more tragedies.
“The ultimate of everything we are doing is to reduce maternal mortality,” Asambobillah says.
You can help Kybele continue to reduce lives lost of both women and babies by participating in our mission to make obstetric triage the norm, not the exception. Help us make modern medical techniques available to mothers and babies everywhere.
