Validating the indicator "maternal death review coverage" to improve maternal mortality data: A retrospective analysis of district, facility, and individual medical record data.

BACKGROUND: Understanding causes and contributors to maternal mortality is critical from a quality improvement perspective to inform decision making and monitor progress toward ending preventable maternal mortality. The indicator "maternal death review coverage" is defined as the percentage of maternal deaths occurring in a facility that are audited. Both the numerator and denominator of this indicator are subject to misclassification errors, underreporting, and bias. This study assessed the validity of the indicator by examining both its numerator-the number and quality of death reviews-and denominator-the number of facility-based maternal deaths and comparing estimates of the indicator obtained from facility- versus district-level data. METHODS AND FINDINGS: We collected data on the number of maternal deaths and content of death reviews from all health facilities serving as birthing sites in 12 districts in three countries: Argentina, Ghana, and India. Additional data were extracted from health management information systems on the number and dates of maternal deaths and maternal death reviews reported from health facilities to the district-level. We tabulated the percentage of facility deaths with evidence of a review, the percentage of reviews that met the World Health Organization defined standard for maternal and perinatal death surveillance and response. Results were stratified by sociodemographic characteristics of women and facility location and type. We compared these estimates to that obtained using district-level data. and looked at evidence of the review at the district/provincial level. Study teams reviewed facility records at 34 facilities in Argentina, 51 facilities in Ghana, and 282 facilities in India. In total, we found 17 deaths in Argentina, 14 deaths in Ghana, and 58 deaths in India evidenced at facilities. Overall, >80% of deaths had evidence of a review at facilities. In India, a much lower percentage of deaths occurring at secondary-level facilities (61.1%) had evidence of a review compared to deaths in tertiary-level facilities (92.1%). In all three countries, only about half of deaths in each country had complete reviews: 58.8% (n = 10) in Argentina, 57.2% (n = 8) in Ghana, and 41.1% (n = 24) in India. Dramatic reductions in indicator value were seen in several subnational geographic areas, including Gonda and Meerut in India and Sunyani in Ghana. For example, in Gonda only three of the 18 reviews conducted at facilities met the definitional standard (16.7%), which caused the value of the indicator to decrease from 81.8% to 13.6%. Stratification by women's sociodemographic factors suggested systematic differences in completeness of reviews by women's age, place of residence, and timing of death. CONCLUSIONS: Our study assessed the validity of an important indicator for ending preventable deaths: the coverage of reviews of maternal deaths occurring in facilities in three study settings. We found discrepancies in deaths recorded at facilities and those reported to districts from facilities. Further, few maternal death reviews met global quality standards for completeness. The value of the calculated indicator masked inaccuracies in counts of both deaths and reviews and gave no indication of completeness, thus undermining the ultimate utility of the measure in achieving an accurate measure of coverage.

Validating the implementation of an indicator reporting policies and laws on free public maternal health-related services in the era of universal health coverage: A multi-country cross-sectional study.

BACKGROUND: The concept of universal health coverage (UHC) encompasses both access to essential health services and freedom from financial harm. The World Health Organization's Maternal Newborn Child and Adolescent Health (MNCAH) Policy Survey collects data on policies that have the potential to reduce maternal morbidity and mortality. The indicator, "Are the following health services provided free of charge at point-of-use in the public sector for women of reproductive age?", captures the free provision of 13 key categories of maternal health-related services, to measure the success of UHC implementation with respect to maternal health. However, it is unknown whether it provides a valid measure of the provision of free care. Therefore, this study compared free maternal healthcare laws and policies against actual practice in three countries. METHODS AND FINDINGS: We conducted a cross-sectional study in four districts/provinces in Argentina, Ghana, and India. We performed desk reviews to identify free care laws and policies at the country level and compared those with reports at the global level. We conducted exit interviews with women aged 15-49 years who used a component service or their accompanying persons, as well as with facility chief financial officers or billing administrators, to determine if women had out-of-pocket expenditures associated with accessing services. For designated free services, prevalence of expenditures at the service level for women and reports by financial officers of women ever having expenditures associated with services designated as free were computed. These three sources of data (desk review, surveys of women and administrators) were triangulated, and chi-square analysis was conducted to determine if charges were levied differentially by standard equity stratifiers. Designation of services as free matched what was reported in the MNCAH Policy Survey for Argentina and Ghana. In India, insecticide-treated bed nets and testing and treatment for syphilis were only designated as free for selected populations, differing from the WHO MNCAH Policy Survey. Among 1046, 923, and 1102 women and accompanying persons who were interviewed in Argentina, Ghana, and India, respectively, the highest prevalence of associated expenditures among women who received a component service in each setting was for cesarean section in Argentina (26%, 24/92); family planning in Ghana (78.4%, 69/88); and postnatal maternal care in India (94.4%, 85/90). The highest prevalence of women ever having out of pocket expenditures associated with accessing any free service reported by financial officers was 9.1% (2/22) in Argentina, 64.1% (93/145) in Ghana, and 29.7% (47/158) in India. Across the three countries, self-reports of out of pocket expenditures were significantly associated with district/province and educational status of women. Additionally, wealth quintile in Argentina and age in India were significantly associated with women reporting out of pocket expenditures. CONCLUSIONS: Free care laws were largely accurately reported in the global MNCAH policy database. Notably, we found that women absorbed both direct and indirect costs and made both formal and informal payments for services designated as free. Therefore, the policy indicator does not provide a valid reflection of UHC in the three settings.

Effectiveness of a culturally tailored text messaging program for promoting cervical cancer screening in accra, Ghana: a quasi-experimental trial.

INTRODUCTION: Despite breakthroughs in cervical cancer detection, resource-constrained countries continue to have a disproportionately high incidence and death rate. Mhealth has been identified as an important tool for increasing cervical cancer screening rates in Sub-Saharan Africa. We determined whether sending Ghanaian women culturally tailored one-way mobile phone SMS text messages about cervical cancer would encourage the uptake of the human papillomavirus (HPV) test. METHODS: From August to November 2016, 88 women aged 18 to 39 living or working in an urban community (Accra, Ghana) participated in a quasi-experimental study. For 8 weeks, 32 SMS messages regarding cervical cancer were developed and sent to the personal phones of intervention arm participants (n = 42). Women in the control group (n = 46) received SMS texts with general health and lifestyle advice. Fischer's exact tests were performed to assess cervical cancer screening uptake and associated reasons for non-uptake between the intervention and control groups (p < 0.05). RESULTS: At the baseline, women differed in terms of ethnicity and wealth. After the intervention, participants' self-reported risk factors for cervical cancer, such as early menarche, usual source of medical treatment, family history of cancer, smoking, and alcohol history, changed. None of the women in the intervention group sought cervical cancer screening after the intervention, but only one (2.2%) of the control arm participants did. Almost all the women (> 95%) agreed that an HPV test was essential and that regular healthcare check-ups could help prevent cervical cancer. Some women believed that avoiding particular foods could help prevent cervical cancer (23.8% intervention vs. 58.7% control, p < 0.001). Time constraints and out-of-pocket expenses were significant barriers to cervical cancer screening. CONCLUSION: A one-way SMS delivered to urban women did not increase cervical cancer screening attendance. The time spent in screening facilities and the lack of coverage by the National Health Insurance Scheme limited screening uptake. We urge for the establishment of screening centers in all healthcare facilities, as well as the inclusion of cervical cancer screening in healthcare programs through cost-sharing.

Validation of a measure to assess decision-making autonomy in family planning services in three low- and middle-income countries: The Family Planning Autonomous Decision-Making scale (FP-ADM).

BACKGROUND: Integrating measures of respectful care is an important priority in family planning programs, aligned with maternal health efforts. Ensuring women can make autonomous reproductive health decisions is an important indicator of respectful care. While scales have been developed and validated in family planning for dimensions of person-centered care, none focus specifically on decision-making autonomy. The Mothers Autonomy in Decision-Making (MADM) scale measures autonomy in decision-making during maternity care. We adapted the MADM scale to measure autonomy surrounding a woman's decision to use a contraceptive method within the context of contraceptive counselling. This study presents a psychometric validation of the Family Planning Autonomous Decision-Making (FP-ADM) scale using data from Argentina, Ghana, and India. METHODS AND FINDINGS: We used cross-sectional data from women in four subnational areas in Argentina (n = 890), Ghana (n = 1,114), and India (n = 1,130). In each area, 20 primary sampling units (PSUs) were randomly selected based on probability proportional to size. Households were randomly selected in Ghana and India. In Argentina, all facilities providing reproductive and maternal health services within selected PSUs were included and women were randomly selected upon exiting the facility. Interviews were conducted with a sample of 360 women per district. In total, 890 women completed the FP-ADM in Argentina, 1,114 in Ghana and 1,130 in India. To measure autonomous decision-making within FP service delivery, we adapted the items of the MADM scale to focus on family planning. To assess the scale's psychometric properties, we first examined the eigenvalues and conducted a parallel analysis to determine the number of factors. We then conducted exploratory factor analysis to determine which items to retain. The resulting factors were then identified based on the corresponding items. Internal consistency reliability was assessed with Cronbach's alpha. We assessed both convergent and divergent construct validity by examining associations with expected outcomes related to the underlying construct. The Eigenvalues and parallel analysis suggested a two-factor solution. The two underlying dimensions of the construct were identified as "Bidirectional Exchange of Information" (Factor 1) and "Empowered Choice" (Factor 2). Cronbach's alpha was calculated for the full scale and each subscale. Results suggested good internal consistency of the scale. There was a strong, significant positive association between whether a woman expressed satisfaction with quality of care received from the healthcare provider and her FP-ADM score in all three countries and a significant negative association between a woman's FP-ADM score and her stated desire to switch contraceptive methods in the future. CONCLUSIONS: Our results suggest the FP-ADM is a valid instrument to assess decision-making autonomy in contraceptive counseling and service delivery in diverse low- and middle-income countries. The scale evidenced strong construct, convergent, and divergent validity and high internal consistency reliability. Use of the FP-ADM scale could contribute to improved measurement of person-centered family planning services.

Hepatitis B and human immunodeficiency virus infections within correctional facilities in Ghana.

Previous studies have suggested high Immunodeficiency Virus (HIV) and hepatitis B virus (HBV) prevalence in prisons in Ghana. However, this study was part of a nationally representative bio-behavioural survey and determined the prevalence of HIV and HBV among prison inmates and identified factors associated with these infections. Both biomedical and behavioural data were collected from a total of 2,443 prison inmates from 19 prison stations during 2013 in Ghana; 12 male prisons and 7 female prisons selected across the country. The national HIV screening algorithm was used for HIV testing while two rapid detection tests were used to confirm HBV infections. HIV and HBV prevalence among prisoners in Ghana were approximately 2.34% and 12.38% respectively. Only 5 inmates, had co-infection with both viruses. The prevalence of HIV was significantly lower among male inmates (1.5%) compared to the female inmates (11.8%). Age, sex, and marital status, were significantly associated with both HIV and HBV infections. However, BMI category, IDU, and time spent in prison were associated with HIV infections. The educational level was significantly associated with HBV infections. After binary logistic regression, being female (AOR: 0.18, 95% CI: 0.07-0.45, p<0.001) and having a stay of 5 years or more (AOR: 0.07, 95% CI: 0.01-0.60, p = 0.016), increased the risk of having HIV infection. While, those with no formal education (AOR: 0.65, 95% CI: 0.45-0.95, p = 0.024) and are underweight (AOR: 0.51, 95% CI: 0.27-0.99, p = 0.046), were more likely to have HBV infection. Forced penetrative sex may be a problem in the prisons. The need to have and strengthen an integrated screening, treatment and vaccination plan for the prison is emphasized. The prison does not serve as an exceptionally high risk to the general population. The findings support a critical look at the issue of forced penetrative sex in the prisons.

Validating indicators for monitoring availability and geographic distribution of emergency obstetric and newborn care (EmoNC) facilities: A study triangulating health system, facility, and geospatial data.

Availability of emergency obstetric and newborn care (EmONC) is a strong supply side measure of essential health system capacity that is closely and causally linked to maternal mortality reduction and fundamentally to achieving universal health coverage. The World Health Organization's indicator "Availability of EmONC facilities" was prioritized as a core indicator to prevent maternal death. The indicator focuses on whether there are sufficient emergency care facilities to meet the population need, but not all facilities designated as providing EmONC function as such. This study seeks to validate "Availability of EmONC" by comparing the value of the indicator after accounting for key aspects of facility functionality and an alternative measure of geographic distribution. This study takes place in four subnational geographic areas in Argentina, Ghana, and India using a census of all birthing facilities. Performance of EmONC in the 90 days prior to data collection was assessed by examining facility records. Data were collected on facility operating hours, staffing, and availability of essential medications. Population estimates were generated using ArcGIS software using WorldPop to estimate the total population, and the number of women of reproductive age (WRA), pregnancies and births in the study areas. In addition, we estimated the population within two-hours travel time of an EmONC facility by incorporating data on terrain from Open Street Map. Using these data sources, we calculated and compared the value of the indicator after incorporating data on facility performance and functionality while varying the reference population used. Further, we compared its value to the proportion of the population within two-hours travel time of an EmONC facility. Included in our study were 34 birthing facilities in Argentina, 51 in Ghana, and 282 in India. Facility performance of basic EmONC (BEmONC) and comprehensive EmONC (CEmONC) signal functions varied considerably. One facility (4.8%) in Ghana and no facility in India designated as BEmONC had performed all seven BEmONC signal functions. In Argentina, three (8.8%) CEmONC-designated facilities performed all nine CEmONC signal functions, all located in Buenos Aires Region V. Four CEmONC-designated facilities in Ghana (57.1%) and the three CEmONC-designated facilities in India (23.1%) evidenced full CEmONC performance. No sub-national study area in Argentina or India reached the target of 5 BEmONC-level facilities per 20,000 births after incorporating facility functionality yet 100% did in Argentina and 50% did in India when considering only facility designation. Demographic differences also accounted for important variation in the indicator's value. In Ghana, the total population in Tolon within 2 hours travel time of a designated EmONC facility was estimated at 99.6%; however, only 91.1% of women of reproductive age were within 2 hours travel time. Comparing the value of the indicator when calculated using different definitions reveals important inconsistencies, resulting in conflicting information about whether the threshold for sufficient coverage is met. This raises important questions related to the indicator's validity. To provide a valid measure of effective coverage of EmONC, the construct for measurement should extend beyond the most narrow definition of availability and account for functionality and geographic accessibility.

Hypertension and associated factors among patients attending HIV clinic at Korle-Bu Teaching Hospital.

Objectives: This study determined the prevalence of hypertension and its associated factors among patients attending the HIV clinic at the Korle-Bu Teaching Hospital (KBTH). Design: A hospital-based cross-sectional study was conducted at KBTH. The prevalence of hypertension was estimated among study participants, and socio-demographic, lifestyle, anthropometric, metabolic and HIV/ART-related factors associated with hypertension were determined by logistic regression modelling. Setting: Study participants were recruited from the HIV clinic at the KBTH. Participants: A total of 311 Persons Living with HIV were recruited as study participants. Interventions: Simple random sampling technique was used to recruit study participants. A questionnaire adapted from the WHO STEPwise approach to chronic disease risk-factor surveillance was used to collect study participants' data. Results: The prevalence of hypertension was 36.7%, and the factors associated with hypertension were increasing age, positive family history of hypertension, minimal exercising, current BMI ≥25.0 kg/m2, total cholesterol level ≥5.17 mmol/L, exposure to anti-retroviral therapy (ART) and increasing duration of ART exposure. Conclusions: This study shows a high prevalence of hypertension among patients attending the HIV clinic at KBTH, associated with exposure to ART and increasing duration of this exposure. Blood pressure monitoring should move from routine to a more purposeful screening of patients for hypertension. Patients with the identified risk factors should be encouraged to have regular blood pressure measurements at home and not only when they visit the HIV clinic. Funding: Office of Research, Innovation and Development (ORID) of the University of Ghana. The funding agency was not involved in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Male characteristics and contraception in four districts of the central region, Ghana.

BACKGROUND: A lack of male involvement in contraception can negatively affect its practice. To promote male participation in family planning, there is a dire need to understand male attributes that play a role in contraception. This study focuses on the male characteristics that influence the practice of traditional and modern methods of contraception. METHODS: This study is a secondary analysis of quantitative data obtained from the baseline assessment of the Ghana Community-Based Action Teams Study that aimed to prevent violence against women in the Central Region of Ghana in 2016. The analysis included 1742 partnered males aged 18-60 years. Chi-square test, t-test and logistic regression analyses were used to assess the association between male characteristics and the practice of contraception (significance level = 0.05). RESULTS: The prevalence of contraception was 24.4% (95% CI = 20.8-28.5). Significant male characteristics that were positively associated with the practice of contraception in adjusted models were: post-primary education (AOR = 1.96, 95% CI = 1.27-3.04), perpetration of Intimate Partner Violence (AOR = 1.83, 95% CI = 1.49-2.26), and the number of main sexual partners (AOR = 1.78, 95% CI = 1.15-2.75). However, wanting the first child (AOR = 0.71, 95% CI = 0.54-0.94) and male controlling behaviour (AOR = 0.7, 95% CI = 0.49-0.99) statistically significantly associated with reduced odds of practicing contraception. CONCLUSION: Male partner characteristics influence the practice of contraception. Family planning sensitization and education programs should target males who are less likely to practice contraception.

The influence of depressive symptoms and school-going status on risky behaviors: a pooled analysis among adolescents in six sub-Saharan African countries.

Background: Evidence from sub-Saharan Africa (SSA) regarding risky behaviors among adolescents remains scarce, despite the large population (approximately 249 million out of 1.2 billion globally in 2019) of adolescents in the region. We aimed to examine the potential influence of depressive symptoms and school-going status on risky behaviors among adolescents in six SSA countries. Methods: We used individual cross-sectional data from adolescents aged 10-19 based in eight communities across six SSA countries, participating in the ARISE Network Adolescent Health Study (N = 7,661). Outcomes of interest were cigarette or tobacco use, alcohol use, other substance use, getting into a physical fight, no condom use during last sexual intercourse, and suicidal behavior. We examined the proportion of adolescents reporting these behaviors, and examined potential effects of depressive symptoms [tertiles of 6-item Kutcher Adolescent Depression Scale (KADS-6) score] and school-going status on these behaviors using mixed-effects Poisson regression models. We also assessed effect modification of associations by sex, age, and school-going status. Results: The proportion of adolescents reporting risky behaviors was varied, from 2.2% for suicidal behaviors to 26.2% for getting into a physical fight. Being in the higher tertiles of KADS-6 score was associated with increased risk of almost all risky behaviors [adjusted risk ratio (RR) for highest KADS-6 tertile for alcohol use: 1.70, 95% confidence interval (95% CI): 1.48-1.95, p < 0.001; for physical fight: 1.52, 95% CI: 1.36-1.70, p < 0.001; for suicidal behavior: 7.07, 95% CI: 2.69-18.57, p < 0.001]. Being in school was associated with reduced risk of substance use (RR for alcohol use: 0.73, 95% CI: 0.53-1.00, p = 0.047), and not using a condom (RR: 0.81, 95% CI: 0.66-0.99, p = 0.040). There was evidence of modification of the effect of school-going status on risky behaviors by age and sex. Conclusion: Our findings reinforce the need for a greater focus on risky behaviors among adolescents in SSA. Addressing depressive symptoms among adolescents, facilitating school attendance and using schools as platforms to improve health may help reduce risky behaviors in this population. Further research is also required to better assess the potential bidirectionality of associations.

Health-seeking experiences of women with obstetric fistula: a qualitative study at two fistula centres in Ghana.

OBJECTIVES: The study explored the health-seeking experiences of women with obstetric fistula from the onset of the condition until surgical treatment was obtained. It also describes their interactions with health staff and traditional healers. DESIGN: Exploratory, descriptive qualitative study. SETTING: Two secondary-level health facilities in the northern and central regions of Ghana; data collection took place in 2018-2019. PARTICIPANTS: A purposive sample of 37 women who had experienced fistula resulting from childbirth and were awaiting fistula repair at the two fistula centres in Ghana was obtained. DATA ANALYSIS: Thematic analysis was used to analyse the data. RESULTS: Health-seeking experiences and behaviours of women with obstetric fistula were identified. Six major themes were generated: attribution and perceptions of fistula; competing alternatives/multiple sources of care; limited awareness and access to care; financial barriers; psychosocial challenges, and abuse by healers. The results indicate that the health-seeking experiences of women with obstetric fistula were characterised by long delays in care-seeking. The major themes and subthemes are presented with quotes from participants. CONCLUSION: The women experienced winding pathways of treatment-seeking due to lack of awareness and incorrect attribution. The major barriers to health-seeking included poverty, challenges with transportation and inadequate repair centres. Increased awareness of obstetric fistula and access to repair centres could shorten the suffering women go through while awaiting fistula treatment. Improved awareness of obstetric fistula and establishment of more fistula centres would be beneficial.

Validating midwifery professionals' scope of practice and competency: A multi-country study comparing national data to international standards.

BACKGROUND: There is a global shortage of midwives, whose services are essential to meet the healthcare needs of pregnant women and newborns. Evidence suggests that if enough midwives, trained and regulated to global standards, were deployed worldwide, maternal, and perinatal mortality would decline significantly. Health workforce planning estimates the number of midwives needed to achieve population coverage of midwifery interventions. However, to provide a valid measure of midwifery care coverage, an indicator must consider not only the raw number of midwives, but also their scope and competency. The tasks midwives are authorized to deliver and their competency to perform essential skills and behaviors provide crucial information for understanding the availability of safe, high-quality midwifery services. Without reliable estimates for an adequate midwifery workforce, progress toward ending preventable maternal and perinatal mortality will continue to be uneven. The International Labor Organization (ILO) and the International Confederation of Midwives (ICM) suggest standards for midwifery scope of practice and competencies. This paper compares national midwifery regulations, scope, and competencies in three countries to the ILO and ICM standards to validate measures of midwife density. We also assess midwives' self-reported skills/behaviors from the ICM competencies and their acquisition. METHODS AND FINDINGS: We compared midwives' scope of practice in Argentina, Ghana, and India to the ILO Tasks and ICM Essential Competencies for Midwifery Practice. We compared midwives self-reported skills/behaviors with the ICM Competencies. Univariate and bivariate analysis was conducted to describe the association between midwives' skills and selected characteristics. National scopes of practice matched two ILO tasks in Argentina, four in India, and all in Ghana. National standards partially reflected ICM skills in Categories 2, 3, and 4 (pre-pregnancy and antenatal care; care during labor and birth; and ongoing care of women and newborns, respectively) in Argentina (range 11% to 67%), mostly in India (range 74% to 100%) and completely in Ghana (100% match). 1,266 midwives surveyed reported considerable variation in competency for skills and behaviors across ICM Category 2, 3, and 4. Most midwives reported matching skills and behaviors around labor and childbirth (Category 2). Higher proportions of midwives reported gaining basic skills through in-service training and on-job-experience than in pre-service training. CONCLUSION: Estimating the density of midwives needed for an adequate midwifery workforce capable of providing effective population coverage is predicated on a valid numerator. A reliable and valid count of midwives to meet population needs assumes that each midwife counted has the authority to exercise the same behaviors and reflects the ability to perform them with comparable competency. Our results demonstrate variation in midwifery scopes of practice and self-reported competencies in comparison to global standards that pose a threat to the reliability and validity of the numerator in measures of midwife density, and suggest the potential for expanded authorization and improved education and training to meet global reference standards for midwifery practice has not been fully realized. Although the universally recognized standard, this study demonstrates that the complex, composite descriptions of skills and behaviors in the ICM competencies make them difficult to use as benchmark measures with any precision, as they are not defined or structured to serve as valid measures for assessing workforce competency. A simplified, content-validated measurement system is needed to facilitate evaluation of the competency of the midwifery workforce.

Authorization of midwives to perform basic emergency obstetric and newborn care signal functions in Argentina, Ghana, and India: A multi-country validation study of a key global maternal and newborn health indicator.

BACKGROUND: Midwives' authorization to deliver the seven basic emergency obstetric and newborn care (BEmONC) functions is a core policy indicator in global monitoring frameworks, yet little evidence supports whether such data are captured accurately, or whether authorization demonstrates convergence with midwives' skills and actual provision of services. In this study, we aimed to validate the data reported in global monitoring frameworks (criterion validity) and to determine whether a measure of authorization is a valid indicator for BEmONC availability (construct validity). METHODS: We conducted a validation study in Argentina, Ghana, and India. To assess accuracy of the reported data on midwives' authorization to provide BEmONC services, we reviewed national regulatory documents and compared with reported country-specific data in Countdown to 2030 and the World Health Organization Maternal, Newborn, Child and Adolescent Health Policy Survey. To assess whether authorization demonstrates convergent validity with midwives' skills, training, and performance of BEmONC signal functions, we surveyed 1257 midwives/midwifery professionals and assessed variance. RESULTS: We detected discrepancies between data reported in the global monitoring frameworks and the national regulatory framework in all three countries. We found wide variations between midwives' authorization to perform signal functions and their self-reported skills and actual performance within the past 90 days. The percentage of midwives who reported performing all signal functions for which they were authorized per country-specific regulations was 17% in Argentina, 23% in Ghana, and 31% in India. Additionally, midwives in all three countries reported performing some signal functions that the national regulations did not authorize. CONCLUSION: Our findings suggest limitations in criterion and construct validity for this indicator in Argentina, Ghana, and India. Some signal functions such as assisted vaginal delivery may be obsolete based on current practice patterns. Findings suggest the need to re-examine the emergency interventions that should be included as BEmONC signal functions.

Measuring adequacy of the midwifery workforce using standards of competency and scope of work: Exploring the density and distribution of midwives in three low- and middle-income countries using cross-sectional and geospatial data.

BACKGROUND: A global midwifery shortage hampers the goal of ending preventable maternal/newborn mortality and stillbirths. Whether current measures of midwifery workforce adequacy are valid is unknown. We compare two measures of density and distribution of midwifery professionals to assess their consistency, and explore how incorporating midwifery scope, competency, and the adjusting reference population impacts this critical metric. METHODS AND FINDINGS: We collected a census of midwives employed in eligible facilities in our study settings, (422 in Ghana; 909 in India), assessed the number practicing within the scope of work for midwifery professionals defined in the International Labor Organization International Standard Classification of Occupations, and whether they reported possessing the ICM essential competencies for basic midwifery practice. We altered the numerator, iteratively narrowing it from a simple count to include data on scope of practice and competency and reported changes in value. We altered the denominator by calculating the number of midwives per 10,000 total population, women of reproductive age, pregnancies, and births and explored variation in the indicator. Across four districts in Ghana, density of midwives decreased from 8.59/10,000 total population when counting midwives from facility staffing rosters to 1.30/10,000 total population when including only fully competent midwives by the ICM standard. In India, no midwives met the standard, thus the midwifery density of 1.37/10,000 total population from staffing rosters reduced to 0.00 considering competency. Changing the denominator to births vastly altered subnational measures, ranging from ~1700% change in Tolon to ~8700% in Thiruvallur. CONCLUSION: Our study shows that varying underlying parameters significantly affects the value of the estimate. Factoring in competency greatly impacts the effective coverage of midwifery professionals. Disproportionate differences were noted when need was estimated based on total population versus births. Future research should compare various estimates of midwifery density to health system process and outcome measures.

Determinants of induced abortion among women of reproductive age: evidence from the 2013 and 2019 Sierra Leone Demographic and Health Survey.

BACKGROUND: Worldwide, pregnancy termination due to unintended pregnancy is crucial in maternal health, particularly in settings where abortion laws are restrictive. Presently, there is a paucity of literature on determinants of induced abortion among women of reproductive age in Sierra Leone. The study findings could be used to improve the country's maternal mortality indices and inform health programs and reproductive health policies geared toward tackling induced abortion. METHODS: We analyzed secondary data from the 2013 and 2019 Sierra Leone Demographic and Health Surveys. The surveys were nationally representative, with weighted samples comprising 16,658 (2013) and 15,574 (2019) women of reproductive age. Descriptive statistics, including frequencies and percentages, were computed, while Chi-square and Binomial Logistics Regression were employed to identify correlates of induced abortion. RESULTS: The results showed that a minority (9%) of the participants had induced abortion in both surveys. Abortion was significantly associated with age, marital status, employment status, education, parity, and frequency of listening to the radio and watching television (p < 0.05). For instance, women aged 45-49 years (AOR = 7.91; 95% CI: 5.76-10.87), married women (AOR = 2.52; 95% CI: 1.95-3.26), and working women (AOR = 1.65; 95% CI: 1.45-1.87) had a higher likelihood of induced abortion compared to their counterparts. Moreover, women with primary education (AOR = 1.27; 95% CI:1.11-1.46) and those who watch television once a week (AOR = 1.29; 95% CI: 1.11-1.49) were more likely to terminate a pregnancy. Women with six or more children (AOR = 0.40; 95% CI: 0.31-0.52) were less likely to terminate a pregnancy compared to those with no child. CONCLUSION: The study revealed that a minority of the women had induced abortions. The prevalence of induced abortion did not change over time. Induced abortion was influenced by age, marital status, employment status, education, parity, and exposure to mass media. Therefore, policies and programs to reduce unwanted pregnancies should focus on increasing access to modern contraceptives among women of lower socio-economic status.

Improving measures of access to legal abortion: A validation study triangulating multiple data sources to assess a global indicator.

BACKGROUND: Global mechanisms have been established to monitor and facilitate state accountability regarding the legal status of abortion. However, there is little evidence describing whether these mechanisms capture accurate data. Moreover, it is uncertain whether the "legal status of abortion" is a valid proxy measure for access to safe abortion, pursuant to the global goals of reducing preventable maternal mortality and advancing reproductive rights. Therefore, this study sought to assess the accuracy of reported monitoring data, and to determine whether evidence supports the consistent application of domestic law by health care professionals such that legality of abortion functions as a valid indicator of access. METHODS AND FINDINGS: We conducted a validation study using three countries as illustrative case examples: Argentina, Ghana, and India. We compared data reported by two global monitoring mechanisms (Countdown to 2030 and the Global Abortion Policies Database) against domestic source documents collected through in-depth policy review. We then surveyed health care professionals authorized to perform abortions about their knowledge of abortion law in their countries and their personal attitudes and practices regarding provision of legal abortion. We compared professionals' responses to the domestic legal frameworks described in the source documents to establish whether professionals consistently applied the law as written. This analysis revealed weaknesses in the criterion validity and construct validity of the "legal status of abortion" indicator. We detected discrepancies between data reported by the global monitoring and accountability mechanisms and the domestic policy reviews, even though all referenced the same source documents. Further, provider surveys unearthed important context-specific barriers to legal abortion not captured by the indicator, including conscientious objection and imposition of restrictions at the provider's discretion. CONCLUSIONS: Taken together, these findings denote weaknesses in the indicator "legal status of abortion" as a proxy for access to safe abortion, as well as inaccuracies in data reported to global monitoring mechanisms. This information provides important groundwork for strengthening indicators for monitoring access to abortion and for renewed advocacy to assure abortion rights worldwide.

Modeling clinical and non-clinical determinants of intrapartum stillbirths in singletons in six public hospitals in the Greater Accra Region of Ghana: a case-control study.

The Greater Accra Region (GAR) of Ghana records 2000 stillbirths annually and 40% of them occur intrapartum. An understanding of the contributing factors will facilitate the development of preventive strategies to reduce the huge numbers of intrapartum stillbirths. This study identified determinants of intrapartum stillbirths in GAR. A retrospective 1:2 unmatched case-control study was conducted in six public hospitals in the Greater Accra Region of Ghana. A multivariable binary logistic regression model was used to quantify the effect of exposures on intrapartum stillbirth. The area under the receiver operating characteristics curve and the Brier scores were used to screen potential risk factors and assess the predictive performance of the regression models. The following maternal factors increased the odds of intrapartum stillbirths: pregnancy-induced hypertension (PIH) [adjusted Odds Ratio; aOR = 3.72, 95% CI:1.71-8.10, p < 0.001]; antepartum haemorrhage (APH) [aOR = 3.28, 95% CI: 1.33-8.10, p < 0.05] and premature rupture of membranes (PROM) [aOR = 3.36, 95% CI: 1.20-9.40, p < 0.05]. Improved management of PIH, APH, PROM, and preterm delivery will reduce intrapartum stillbirth. Hospitals should improve on the quality of monitoring women during labor. Auditing of intrapartum stillbirths should be mandatory for all hospitals and Ghana Health Service should include fetal autopsy in stillbirth auditing to identify other causes of fetal deaths. Interventions to reduce intrapartum stillbirth must combine maternal, fetal and service delivery factors to make them effective.

APOL1 genotype associated risk for preeclampsia in African populations: Rationale and protocol design for studies in women of African ancestry in resource limited settings.

BACKGROUND: Women of African ancestry are highly predisposed to preeclampsia which continues to be a major cause of maternal death in Africa. Common variants in the APOL1 gene are potent risk factor for a spectrum of kidney disease. Recent studies have shown that APOL1 risk variants contribute to the risk of preeclampsia. The aim of the study is to understand the contribution of APOL1 risk variants to the development of preeclampsia in pregnant women in Ghana. METHODS: The study is a case-control design which started recruitment in 2019 at the Korle Bu Teaching Hospital in Ghana. The study will recruit pregnant women with a target recruitment of 700 cases of preeclampsia and 700 normotensives. Clinical and demographic data of mother- baby dyad, with biospecimens including cord blood and placenta will be collected to assess clinical, biochemical and genetic markers of preeclampsia. The study protocol was approved by Korle Bu Teaching Hospital Institutional Review Board (Reference number: KBTH-IRB/000108/2018) on October 11, 2018. PRELIMINARY RESULTS: As of December 2021, a total of 773 mother-baby pairs had been recruited and majority of them had complete entry of data for analysis. The participants are made up of 384 preeclampsia cases and 389 normotensive mother-baby dyad. The mean age of participants is 30.69 ± 0.32 years for cases and 29.95 ± 0.32 for controls. Majority (85%) of the participants are between 20-30years. At booking, majority of cases had normal blood pressure compared to the time of diagnosis where 85% had a systolic BP greater than 140mmHg and a corresponding 82% had diastolic pressure greater than 90mmHg. CONCLUSION: Our study will ultimately provide clinical, biochemical and genotypic data for risk stratification of preeclampsia and careful monitoring during pregnancy to improve clinical management and outcomes.

Incidence and determinants of maternal sepsis in Ghana in the midst of a pandemic.

BACKGROUND: Despite being preventable, maternal sepsis continues to be a significant cause of death and morbidity, killing one in every four pregnant women globally. In Ghana, clinicians have observed that maternal sepsis is increasingly becoming a major contributor to maternal mortality. The lack of a consensus definition for maternal sepsis before 2017 created a gap in determining global and country-specific burden of maternal sepsis and its risk factors. This study determined the incidence and risk factors of clinically proven maternal sepsis in Ghana. METHODS: We conducted a prospective cohort study among 1476 randomly selected pregnant women in six health facilities in Ghana, from January to September 2020. Data were collected using primary data collection tools and reviewing the client's charts. We estimated the incidence rate of maternal sepsis per 1,000 pregnant women per person-week. Poisson regression model and the cox-proportional hazard regression model estimators were used to assess risk factors associated with the incidence of maternal sepsis at a 5% significance level. RESULTS: The overall incidence rate of maternal sepsis was 1.52 [95% CI: 1.20-1.96] per 1000 person-weeks. The majority of the participants entered the study at 10-13 weeks of gestation. The study participants' median body mass index score was 26.4 kgm-2 [22.9-30.1 kgm-2]. The risk of maternal sepsis was 4 times higher among women who developed urinary tract infection after delivery compared to those who did not (aHR: 4.38, 95% CI: 1.58-12.18, p < 0.05). Among those who developed caesarean section wound infection after delivery, the risk of maternal sepsis was 3 times higher compared to their counterparts (aHR: 3.77, 95% CI: 0.92-15.54, p < 0.05). Among pregnant women who showed any symptoms 14 days prior to exit from the study, the risk was significantly higher among pregnant women with a single symptom (aHR: 6.1, 95% CI: 2.42-15.21, p < 0.001) and those with two or more symptoms (aHR: 17.0, 95% CI: 4.19-69.00, p < 0.001). CONCLUSIONS: Our findings show a low incidence of maternal sepsis in Ghana compared to most Low and Middle-Income Countries. Nonetheless, Maternal sepsis remains an important contributor to the overall maternal mortality burden. It is essential clinicians pay more attention to ensure early and prompt diagnosis. Factors significantly predicting maternal sepsis in Ghana were additional maternal morbidity, urinary tract infections, dysuria, and multiple symptoms. We recommend that Ghana Health Service should institute a surveillance system for maternal sepsis as a monthly reportable disease.