Facilitators and barriers to home blood pressure monitoring among pregnant women in Ghana: a mixed-methods analysis of patient perspectives.

BACKGROUND: The benefit of home blood pressure monitoring during pregnancy and in low-resource settings is incompletely understood. The objective of this study was to explore the experiences, barriers, and facilitators of home blood pressure monitoring among pregnant women in Ghana. METHODS: This concurrent triangulation mixed-methods study was conducted at an urban tertiary hospital in Ghana. Participants were recruited from adult pregnant women presenting for routine antenatal care. Upon enrollment, participants' demographics and history were collected. At the next study visit, participants received audiovisual and hands-on training on using an automatic blood pressure monitor; they then monitored and logged their blood pressure daily at home for 2-4 weeks. At the final study visit, verbally administered surveys and semi-structured interviews assessed participant's experiences. Quantitative data were analyzed using R version 4.2.2, and frequencies and descriptive statistics were calculated. Qualitative data were imported into DeDoose 9.0.78 for thematic analysis. RESULTS: Of 235 enrolled participants, 194 completed surveys; of those, 33 completed in-depth interviews. Participants' mean age was 31.6 (SD 5.3) years, 32.1% had not previously given birth, and 31.1% had less than a senior high school education. On a 4-point Likert scale, the majority reported they "definitely" were able to remember (n = 134, 69.1%), could find the time (n = 124, 63.9%), had the energy (n = 157, 80.9%), could use the blood pressure monitor without problems (n = 155, 79.9%), and had family approval (n = 182, 96.3%) while engaging in home blood pressure monitoring. 95.88% (n = 186) believed that pregnant women in Ghana should monitor their blood pressure at home. Qualitative thematic analysis demonstrated that most participants liked home blood pressure monitoring because of increased knowledge of their health during pregnancy. While most participants found measuring their blood pressure at home doable, many faced challenges. Participants' experiences with five key factors influenced how easy or difficult their experience was: 1) Time, stress, and daily responsibilities; 2) Perceived importance of BP in pregnancy; 3) Role of family; 4) Capability of performing monitoring; 5) Convenience of monitoring. CONCLUSIONS: Among pregnant women in urban Ghana, home blood pressure monitoring was perceived as positive, important, and doable; however, challenges must be addressed.

Improving health literacy through group antenatal care: results from a cluster randomized controlled trial in Ghana.

BACKGROUND: Although the majority of Ghanaian women receive antenatal care (ANC), many exhibit low health literacy by misinterpreting and incorrectly operationalizing ANC messages, leading to poor maternal and newborn health outcomes. Prior research in low-resource settings has found group antenatal care (G-ANC) feasible for women and providers. This study aims to determine the effect of G-ANC on increasing maternal health literacy. We hypothesized that pregnant women randomized into G-ANC would exhibit a greater increase in maternal health literacy than women in routine, individual ANC. METHODS: A 5-year cluster randomized controlled trial was conducted in 14 rural and peri-urban health facilities in the Eastern Region of Ghana. Facilities were paired based on patient volume and average gestational age at ANC enrollment and then randomized into intervention (G-ANC) vs. control (routine, individual ANC); 1761 pregnant women were recruited. Data collection occurred at baseline (T0) and post-birth (T2) using the Maternal Health Literacy scale, a 12-item composite scale to assess maternal health literacy. Logistic regression compared changes in health literacy from T0 to T2. RESULTS: Overall, women in both the intervention and control groups improved their health literacy scores over time (p < 0.0001). Women in the intervention group scored significantly higher on 3 individual items and on overall composite scores (p < 0.0001) and were more likely to attend 8 or more ANC visits. CONCLUSION: While health literacy scores improved for all women attending ANC, women randomized into G-ANC exhibited greater improvement in overall health literacy post-birth compared to those receiving routine individual care. Life-saving information provided during ANC must be presented in an understandable format to prevent women and newborns from dying of preventable causes. TRIAL REGISTRY: Ethical approval for the study was obtained from the Institutional Review Boards of the University of Michigan (HUM#00161464) and the Ghana Health Service (GHS-ERC: 016/04/19).

Promoting respectful maternity care: challenges and prospects from the perspectives of midwives at a tertiary health facility in Ghana.

BACKGROUND: Evidence shows that women in Ghana experience disrespectful care (slapping, pinching, being shouted at, etc.) from midwives during childbirth. Hence, evidence-based research is needed to advance the adoption of respectful maternity care (RMC) by midwives. We therefore sought to explore and document midwives' perspectives concerning challenges faced and prospects available for promoting RMC in a tertiary health facility. METHODS: We employed an exploratory descriptive qualitative study design. In total, we conducted 12 interviews with midwives educated on RMC. All audio data were transcribed verbatim and exported to NVivo-12 for data management and analyses. We relied on the Consolidated Criteria for Reporting Qualitative Research guideline in reporting this study. RESULTS: The findings were broadly categorised into three themes: emotional support, dignified care and respectful communication which is consistent with the WHO's quality of care framework. For each theme, the current actions that were undertaken to promote RMC, the challenges and recommendations to improve RMC promotion were captured. Overall, the current actions that promoted RMC included provision of sacral massages and reassurance, ensuring confidentiality and consented care, and referring clients who cannot pay to the social welfare unit. The challenges to providing RMC were logistical constraints for ensuring privacy, free movement of clients, and alternative birthing positions. Poor attitudes from some midwives, workload and language barrier were other challenges that emerged. The midwives recommended the appointment of more midwives, as well as the provision of logistics to support alternative birthing positions and privacy. Also, they recommended the implementation of continuous training and capacity building. CONCLUSION: We conclude that in order for midwives to deliver RMC services that include emotional support, dignified care, and respectful communication, the government and hospital administration must make the required adjustments to resolve existing challenges while improving the current supporting activities.

Sustainable palm weevil farming as nutrition supplementation at maternity waiting homes in Liberia.

BACKGROUND: Food insecurity is a global health challenge exacerbated by COVID-19. In Liberia, two-thirds of pregnant women are anemic, one-third of children are stunted, and 70% of households experienced food insecurity due to COVID-19. Edible insects are a nutritious, environmentally responsible, and cost-effective dietary supplement used throughout sub-Saharan Africa. Rearing palm weevil insects at maternity waiting homes (MWHs)-residential dwellings near hospitals where pregnant women await childbirth and receive postpartum services-could serve as a nutritious supplement for expectant mothers in Liberia and provide an income generating activity for MWHs. METHODS: Following a one-day training, sixteen participants established palm weevil rearing sites at four MWHs in Liberia. Pre- and post-knowledge scores were assessed immediately prior to and following training. Pre-and post-knowledge scores were analyzed using paired t-test. Participants tracked two palm weevil rearing cycles (four months), using harvest amounts, turnover, barriers to implementation, and income generated as metrics. The number of women attending MWHs was recorded throughout the study period (July-December 2020). RESULTS: Sixteen participants from four MWHs completed the training and two rearing cycles (four months) successfully. All participants showed statistically significant increases in knowledge scores following the one-day workshop with a pre-test score of 2.31 and post-test score of 7.75 out of 10 (p < 0.001). Over the 6-month study, 217 women stayed in four MWHs. Larval production from the various rearing centers ranged from 120 to 721 larvae, with all four sites producing enough palm weevil to sustain MWH residents who desired to consume the insects. One site successfully commercialized its harvest to sell approximately 50% for a total of 2,000 LD (13 USD) in income. Three of the four sites continued edible insect production beyond the four-month study period. CONCLUSIONS: An edible insect project using palm weevil larva is one promising intervention as a nutrition supplement for expectant mothers at pre-established MWHs in rural Liberia. Edible insect rearing also has potential as an income generating activity for MWHs. Future studies should focus on addressing common barriers of remote implementation and metric tracking during the COVID-19 pandemic and reinforcing infrastructure to protect larvae rearing supplies.

The role of Savings and Internal Lending Communities (SILCs) in improving community-level household wealth, financial preparedness for birth, and utilization of reproductive health services in rural Zambia: a secondary analysis.

BACKGROUND: Savings and Internal Lending Communities (SILCs) are a type of informal microfinance mechanism widely adapted in Zambia. The benefits of SILCs paired with other interventions have been studied in many countries. However, limited studies have examined SILCs in the context of maternal health. This study examined the association between having access to SILCs and: 1) household wealth, 2) financial preparedness for birth, and 3) utilization of various reproductive health services (RHSs). METHODS: Secondary analysis was conducted on baseline and endline household survey data collected as part of a Maternity Waiting Home (MWH) intervention trial in 20 rural communities across seven districts of Zambia. Data from 4711 women who gave birth in the previous year (baseline: 2381 endline: 2330) were analyzed. The data were stratified into three community groups (CGs): CG1) communities with neither MWH nor SILC, CG2) communities with only MWH, and CG3) communities with both MWH and SILC. To capture the community level changes with the exposure to SILCs, different women were randomly selected from each of the communities for baseline and endline data, rather than same women being surveyed two times. Interaction effect of CG and timepoint on the outcome variables - household wealth, saving for birth, antenatal care visits, postnatal care visits, MWH utilization, health facility based delivery, and skilled provider assisted delivery - were examined. RESULTS: Interaction effect of CGs and timepoint were significantly associated only with MWH utilization, health facility delivery, and skilled provider delivery. Compared to women from CG3, women from CG1 had lower odds of utilizing MWHs and delivering at health facility at endline. Additionally, women from CG1 and women from CG2 had lower odds of delivering with a skilled provider compared to women from CG3. CONCLUSION: Access to SILCs was associated with increased MWH use and health facility delivery when MWHs were available. Furthermore, access to SILCs was associated with increased skilled provider delivery regardless of the availability of MWH. Future studies should explore the roles of SILCs in improving the continuity of reproductive health services. TRIAL REGISTRATION: NCT02620436.

High Prevalence of Low Birth Weight Babies Born to Pregnant Women Referred to a District Hospital in Rural Zambia.

OBJECTIVES: Low birthweight (LBW) is a significant public health problem in sub-Saharan Africa and LBW in rural Zambia is high. Our study explored the prevalence of LBW for newborns whose mothers were referred from a rural health center to a district referral hospital in Lundazi, Zambia. METHODS: A five-month retrospective record review of Ministry of Health data was performed to examine birthweight characteristics of a convenience sample of newborns from ten facilities referring to one district hospital (n = 234). RESULTS: Among all cases, 21% (n = 49) of newborns were LBW. For LBW newborns, 73% (n = 36) were preterm with mothers having a pregnancy duration of less than 37 weeks. Newborns whose mothers experienced twin pregnancies (p = .021) and prolonged labor (p = .033) were more often LBW. However, regression models demonstrated no difference among newborns with and without LBW for prolonged labor (p = .344) and twin pregnancies (p = .324) when controlling for variables that could interact with the maternal-newborn delivery outcomes. CONCLUSIONS: for Practice Healthcare providers and policy makers need to address the short and long-term effects of LBW throughout the lifecycle in rural Zambia. More maternal-newborn health research is needed to understand the underlying socioeconomic, social, and cultural determinants influencing LBW in rural Zambia.

Financial Preparedness for Birth Among Rural Zambian Women: Do Antenatal Care Contacts Make a Difference?

INTRODUCTION: Financial constraints are one of the biggest barriers for women of low-income countries to receive necessary reproductive health services. Educating women about the importance of saving money has been incorporated as a component of antenatal care (ANC) contacts, but little is known whether ANC contacts influence women's saving. METHODS: A secondary analysis was conducted on data from a cross-sectional household survey study of 1109 women who recently gave birth in two rural districts of Zambia. RESULTS: Receiving ANC contacts early and often and discussing saving money during ANC were associated with saving money for the mother's birth, but not with saving enough money for the most recent birth. DISCUSSION: Continued effort is needed to encourage women to attend ANC contacts earlier and more frequently. Additionally, the importance of saving money for birth should be discussed during ANC contacts. Future studies need to explore why women's action in saving does not necessarily lead to saving enough for childbirth.

Midwives' experiences of implementing respectful maternity care knowledge in daily maternity care practices after participating in a four-day RMC training.

BACKGROUND: In Ghana, studies documenting the effectiveness of evidence-based specialized training programs to promote respectful maternity care (RMC) practices in healthcare facilities are few. Thus, we designed a four-day RMC training workshop and piloted it with selected midwives of a tertiary healthcare facility in Kumasi, Ghana. The present paper evaluated the impact of the training by exploring midwives' experiences of implementing RMC knowledge in their daily maternity care practices 4 months after the training workshop. METHODS: Through a descriptive qualitative research design, we followed-up and conducted 14 in-depth interviews with participants of the RMC training, exploring their experiences of applying the acquired RMC knowledge in their daily maternity care practices. Data were managed and analysed using NVivo 12. Codes were collapsed into subthemes and assigned to three major predetermined themes. RESULTS: The findings have been broadly categorized into three themes: experiences of practising RMC in daily maternity care, health facility barriers to practising RMC, and recommendations for improving RMC practices. The midwives mentioned that applying the newly acquired RMC knowledge has positively improved their relationship with childbearing women, assisted them to effectively communicate with the women, and position them to recognize the autonomy of childbearing women. Despite the positive influence of the training on clinical practice, the midwives said the policy and the built environment in the hospital does not support the exploration of alternative birthing positions. Also, the hospital lacked the required logistics to ensure privacy for multiple childbearing women in the open labour ward. The midwives recommended that logistics for alternative birthing positions and privacy in the ward should be provided. Also, all midwives and staff of the hospital should be taken through the RMC training program to encourage good practice. CONCLUSION: Despite the report of some RMC implementation challenges, the midwives noted that the 4-day RMC training has had a positive impact on their maternity caregiving practice in the hospital. Policies and programs aimed at addressing the issue of disrespect and abusive practices during maternity care should advocate and include the building of facilities that support alternative birthing positions and privacy of childbearing women during childbirth.

Maternal knowledge of essential newborn care in rural Zambia.

Maternity waiting homes (MWHs) may offer an intervention to improve newborn outcomes in rural Zambia. This study compared maternal knowledge of newborn care for women referred from facilities with and without MWHs. Topics assessed included: (1) umbilical cord care; (2) thermal and skin care; (3) nutrition, and; (4) prevention of diarrhea, and; (5) newborn danger signs prompting care-seeking. A two-group comparison design with a convenience sample was employed using a face-to-face interviews at one district hospital. Descriptive, inferential, and multivariate analyses were employed to compare knowledge. Overall, mothers demonstrated newborn care knowledge in accordance with World Health Organization (WHO) guidelines for newborn health and there were no significant differences in maternal knowledge of newborn care practices among MWH and non-MWH users. Younger mothers more often did not know about umbilical cord care, newborn skin care, and newborn danger signs. MWH users went more often for antenatal care than non-MWH users. In both groups, we found as the number of ANC visits increases, odds of answering "Don't know" decreases. This study is the first to assess maternal newborn care knowledge and MWH use in rural Zambia. Both MWH users and non-users in the rural district were knowledgeable about essential newborn care.

"I wouldn't have hit you, but you would have killed your baby:" exploring midwives' perspectives on disrespect and abusive Care in Ghana.

BACKGROUND: Quality maternal health reduces maternal and neonatal mortality and morbidity. Healthcare professionals, including midwives, are significant agents for the promotion of quality maternal health. Frequents reports of disrespect and abuse of childbearing women by midwives during intrapartum care are becoming common, suggesting that many of these agents are engaging in care practices that compromise quality maternal health. Thus, understanding midwives' descriptions and experiences of the phenomenon is critical to addressing the threat. This paper, therefore, explored the understanding of midwives on D&AC and their occurrence in professional practice in a tertiary health facility in Kumasi, Ghana. METHODS: An exploratory descriptive qualitative research design using an interpretative approach was employed in the study. Data were generated through individual in-depth interviews. Data saturation was reached with fifteen interviews. The interviews were audio-recorded and transcribed verbatim. Open Code 4.03 was used to manage and analyse the data. RESULTS: The midwives understood D&AC. They also confirmed meting out or witnessing colleagues engage in D&AC in their professional practice. The midwives described D&AC as the provision of inadequate care and the overlooking of patient-centred care, and verbal, physical, and psychological abuse. The themes revealed that socio-economic inequalities, provider perception and victim-blaming, and health system-related factors facilitate D&AC. It emerged that the following marginalized groups were at high risk for D&AC: the non-compliant, mentally ill, HIV/AIDs+, teenagers, poor, and childbearing women on admission at the general labour ward. CONCLUSION: The midwives understood D&AC and revealed that it frequently occurred in their professional practice. Frequent in-service training on respectful maternity care and monitoring of care provision in healthcare facilities are needed to eliminate the incidence of D&AC.

Acceptability and feasibility of insect consumption among pregnant women in Liberia.

Maternity waiting homes (MWHs) in Liberia promote facility-based delivery to reduce maternal mortality. However, women often must bring their own food and supplies to MWHs, which makes food insecurity a barrier to the utilisation of MWHs. Consumption of edible indigenous insects is a common practice and has notable nutritional benefits but has not been studied in Liberia as a potential solution to food insecurity at MWHs. The purpose of this study is to (a) examine the acceptability of insect consumption in the context of Liberian beliefs, (b) identify species commonly consumed by pregnant women in Liberia, and (c) examine the feasibility of harvesting insects as food and income generation for women staying at MWHs. Focus groups were conducted at 18 healthcare facilities in Liberia. Participants included chiefs, community leaders, women of reproductive age, traditional birth attendants, women staying at MWHs, and male partners. Focus group participants identified many different species of insects consumed by pregnant women in the community as well as the perceived health impacts of insect consumption. They also described their own experiences with insect hunting and consumption and the perceived marketability of insects, particularly palm weevil larvae. The results of these discussions demonstrate that insect consumption is an acceptable practice for pregnant women in rural Liberia. These findings suggest that it is feasible to further explore the use of palm weevil larvae as dietary supplementation and income generation for women staying at MWHs in Liberia.

Maternity waiting homes as part of a comprehensive approach to maternal and newborn care: a cross-sectional survey.

BACKGROUND: Increased encounters with the healthcare system at multiple levels have the potential to improve maternal and newborn outcomes. The literature is replete with evidence on the impact of antenatal care and postnatal care to improve outcomes. Additionally, maternity waiting homes (MWHs) have been identified as a critical link in the continuum of care for maternal and newborn health yet there is scant data on the associations among MWH use and antenatal/postnatal attendance, family planning and immunization rates of newborns. METHODS: A cross-sectional household survey was conducted to collect data from women who delivered a child in the past 13 months from catchment areas associated with 40 healthcare facilities in seven rural Saving Mothers Giving Life districts in Zambia. Multi-stage random sampling procedures were employed with a final sample of n = 2381. Logistic regression models with adjusted odds ratios and 95% confidence intervals were used to analyze the data. RESULTS: The use of a MWH was associated with increased odds of attending four or more antenatal care visits (OR = 1.45, 95% CI = 1.26, 1.68), attending all postnatal care check-ups (OR = 2.00, 95% CI = 1.29, 3.12) and taking measures to avoid pregnancy (OR = 1.31, 95% CI = 1.10, 1.55) when compared to participants who did not use a MWH. CONCLUSIONS: This is the first study to quantitatively examine the relationship between the use of MWHs and antenatal and postnatal uptake. Developing a comprehensive package of services for maternal and newborn care has the potential to improve acceptability, accessibility, and availability of healthcare services for maternal and newborn health. Maternity waiting homes have the potential to be used as part of a multi-pronged approach to improve maternal and newborn outcomes. TRIAL REGISTRATION: National Institutes of Health Trial Registration NCT02620436, Impact Evaluation of Maternity Homes Access in Zambia, Date of Registration - December 3, 2015.

Increasing postpartum family planning uptake through group antenatal care: a longitudinal prospective cohort design.

BACKGROUND: Despite significant improvements, postpartum family planning uptake remains low for women in sub-Saharan Africa. Transmitting family planning education in a comprehensible way during antenatal care (ANC) has the potential for long-term positive impact on contraceptive use. We followed women for one-year postpartum to examine the uptake and continuation of family planning following enrollment in group versus individual ANC. METHODS: A longitudinal, prospective cohort design was used. Two hundred forty women were assigned to group ANC (n = 120) or standard, individual care (n = 120) at their first ANC visit. Principal outcome measures included intent to use family planning immediately postpartum and use of a modern family planning method at one-year postpartum. Additionally, data were collected on intended and actual length of exclusive breastfeeding at one-year postpartum. Pearson chi-square tests were used to test for statistically significant differences between group and individual ANC groups. Odds ratios and adjusted odds ratios were calculated using logistic regression. RESULTS: Women who participated in group ANC were more likely to use modern and non-modern contraception than those in individual care (59.1% vs. 19%, p < .001). This relationship improved when controlled for intention, age, religion, gravida, and education (AOR = 6.690, 95% CI: 2.724, 16,420). Women who participated in group ANC had higher odds of using a modern family planning method than those in individual care (AOR = 8.063, p < .001). Those who participated in group ANC were more likely to exclusively breastfeed for more than 6 months than those in individual care (75.5% vs. 50%, p < .001). This relationship remained statistically significant when adjusted for age, religion, gravida, and education (AOR = 3.796, 95% CI: 1.558, 9.247). CONCLUSIONS: Group ANC has the potential to be an effective model for improving the uptake and continuation of post-partum family planning up to one-year. Antenatal care presents a unique opportunity to influence the adoption of postpartum family planning. This is the first study to examine the impact of group ANC on family planning intent and use in a low-resource setting. Group ANC holds the potential to increase postpartum family planning uptake and long-term continuation. TRIAL REGISTRATION: Not applicable. No health related outcomes reported.

Improving health literacy through group antenatal care: a prospective cohort study.

BACKGROUND: To examine whether exposure to group antenatal care increased women's health literacy by improving their ability to interpret and utilize health messages compared to women who received standard, individual antenatal care in Ghana. METHODS: We used a prospective cohort design. The setting was a busy urban district hospital in Kumasi, the second most populous city in Ghana. Pregnant women (N = 240) presenting for their first antenatal visit between 11 and 14 weeks gestation were offered participation in the study. A 27% drop-out rate was experienced due to miscarriage, transfer or failure to return for follow-up visits, leaving 184 women in the final sample. Data were collected using an individual structured survey and medical record review. Summary statistics as well as two sample t-tests or chi-square were performed to evaluate the group effect. RESULTS: Significant group differences were found. Women participating in group care demonstrated improved health literacy by exhibiting a greater understanding of how to operationalize health education messages. There was a significant difference between women enrolled in group antenatal care verses individual antenatal care for preventing problems before delivery, understanding when to access care, birth preparedness and complication readiness, intent to use a modern method of family planning postpartum, greater understanding of the components of breastfeeding and lactational amenorrhea for birth spacing, and intent for postpartum follow-up. CONCLUSION: Group antenatal care as compared to individual care offers an opportunity to increase quality of care and improve maternal and newborn outcomes. Group antenatal care holds the potential to increase healthy behaviors, promote respectful maternity care, and generate demand for services. Group ANC improves women's health literacy on how to prevent and recognize problems, prepare for delivery, and care for their newborn.

Newborn Outcomes and Maternity Waiting Homes in Low and Middle-Income Countries: A Scoping Review.

Objectives Decreasing neonatal morbidity and mortality remains a challenge in low resource settings. Maternity waiting homes (MWHs) may offer a way to better provide perinatal obstetric care and improve newborn outcomes. The purpose of this scoping review is to examine the impact of MWHs on newborn outcomes and to inform the development of targeted interventions and services to decrease neonatal mortality. Methods A literature search of four databases in the fields of nursing, medicine and global health was conducted yielding a total of 11 articles included for the review. Results Results indicate studies with extremely limited qualitative or quantitative measures of the impact of MWHs on neonatal health. Conclusions An exceptionally wide gap in knowledge on the outcomes of neonates born at MWHs was identified through this scoping review of the scientific literature. The review illustrates the need for more research to understand the effectiveness of MWHs on newborn morbidity and mortality. An increased focus on the study of MWHs for improving newborn outcomes in low resource settings merits immediate attention.

A case series study on the effect of Ebola on facility-based deliveries in rural Liberia.

BACKGROUND: As communities' fears of Ebola virus disease (EVD) in West Africa exacerbate and their trust in healthcare providers diminishes, EVD has the potential to reverse the recent progress made in promoting facility-based delivery. Using retrospective data from a study focused on maternal and newborn health, this analysis examined the influence of EVD on the use of facility-based maternity care in Bong Country, Liberia, which shares a boarder with Sierra Leone - near the epicenter of the outbreak. METHODS: Using a case series design, retrospective data from logbooks were collected at 12 study sites in one county. These data were then analyzed to determine women's use of facility-based maternity care between January 2012 and October 2014. The primary outcome was the number of facility-based deliveries over time. The first suspected case of EVD in Bong County was reported on June 30, 2014. Heat maps were generated and the number of deliveries was normalized to the average number of deliveries during the full 12 months before the EVD outbreak (March 2013 - February 2014). RESULTS: Prior to the EVD outbreak, facility-based deliveries steadily increased in Bong County reaching an all-time high of over 500 per month at study sites in the first half of 2014 - indicating Liberia was making inroads in normalizing institutional maternal healthcare. However, as reports of EVD escalated, facility-based deliveries decreased to a low of 113 in August 2014. CONCLUSION: Ebola virus disease has negatively impacted the use of facility-based maternity services, placing childbearing women at increased risk for morbidity and death.

Texting From the Bush: Data Collection Using SMS Text Messaging in Areas of Low Network Coverage From Low-Literacy Providers.

Mobile health technology, specifically Short Message Service (SMS), provides a low-cost medium to transmit data in real time. SMS has been used for data collection by highly literate and educated health care workers in low-resource countries; however, no previous studies have evaluated implementation of an SMS intervention by low-literacy providers. The Liberian Ministry of Health and Social Welfare identified a lack of accurate data on the number of pregnancies from rural areas. To capture these data from 11 rural communities in Liberia, 66 low-literate traditional midwives and 15 high-literate certified midwives were trained to report data via SMS. Data were reported via a 9-digit code sent from Java-based mobile phones. Study aims included determining the following components of SMS transmission: success rate, accuracy, predictors of successful transmission, and acceptance. Success rate of SMS transmission was significantly higher for certified midwives than for traditional midwives. The error rate was significantly higher for traditional midwives than for certified midwives. Years of education was the only predictor of successful SMS transmission. Traditional midwives and certified midwives accepted the intervention, although certified midwives found it easier to use. Certified midwives performed significantly better than did traditional midwives. SMS texting interventions should be targeted to health care workers with higher rates of literacy.

Forced migration: health and human rights issues among refugee populations.

Undocumented migration is a global phenomenon that is manifest in diverse contexts. In this article, we examine the situations that precipitate the movement of large numbers of people across several African countries, producing a unique type of undocumented migrant--the refugee. These refugee movements impact already fragile African health care systems and often involve human rights violations that are of particular concern, such as gender-based violence and child soldiers. We use examples from several countries in sub-Saharan Africa, including the Democratic Republic of the Congo, Rwanda, Liberia, Sierra Leone, and Mozambique. Drawing on key documents from the United Nations High Commissioner for Refugees, current research, and our personal international experiences, we provide an overview of forced migration and discuss implications and opportunities for nurses to impact research, practice, and policy related to refugee health.

A case series study of perinatal deaths at one referral center in rural post-conflict Liberia.

The overall objective of this study was to further our understanding of the factors contributing to the high perinatal mortality rates at a busy rural, referral hospital in Liberia. The specific aims were to: (1) analyze the records of women who experienced a perinatal loss for both medical and nonmedical contributing factors; (2) describe the timing and causes of all documented stillbirths and early neonatal deaths; and (3) understand the factors surrounding stillbirth and early neonatal death in this context. This case series study was conducted through a retrospective hospital-based record review of all perinatal deaths occurring at the largest rural referral hospital in north-central Liberia during the 2010 calendar year. A record review of 1,656 deliveries identified 196 perinatal deaths; 143 classified as stillbirth and 53 were classified as early neonatal death. The majority of stillbirths (56.6 %) presented as antenatal stillbirths with no fetal heart tones documented upon admission. Thirty-one percent of cases had no maternal or obstetrical diagnosis recorded in the chart when a stillbirth occurred. Of the 53 early neonatal deaths, 47.2 % occurred on day one of the infant's life with birth asphyxia/poor Apgar scores being the diagnosis listed most frequently. Clear and concise documentation is key to understanding the high perinatal death rates in low resource countries. Standardized, detailed documentation is needed to inform changes to clinical practice and develop feasible solutions to reduce the number of perinatal deaths worldwide.

Examining antenatal health literacy in Ghana.

PURPOSE: To explore Ghanaian pregnant women's understanding and recognition of danger signs in pregnancy, birth preparedness and complication readiness, and their understanding of newborn care. DESIGN: An exploratory, qualitative study design was used. METHODS: Data were gathered through six focus group discussions with 68 pregnant women attending antenatal care at a busy urban hospital in Ghana. Qualitative and descriptive data were analyzed using SPSS version 21. Health literacy was used as the guiding framework to analyze the qualitative data. Data were analyzed in the content domains of (a) understanding and recognition of danger signs in pregnancy, (b) preparedness for childbirth, (c) understanding and recognition of danger signs in the newborn, and (d) appropriate and timely referral. FINDINGS: Women in this study identified danger signs of pregnancy and in the newborn, but had difficulty interpreting and operationalizing information they received during antenatal care visits, indicating that health education did not translate to appropriate health behaviors. Cultural beliefs in alternative medicine, lack of understanding, and prior negative encounters with healthcare professionals may have led to underutilization of professional midwives for delivery and health services. CONCLUSIONS: Women in this study exhibited low health literacy by incorrectly interpreting and operationalizing health education received during antenatal care. With limited health literacy, pregnant women cannot fully comprehend the scope of services that a health system can provide for them and their families. CLINICAL RELEVANCE: Achieving the greatest impact with limited time in antenatal care is a challenge. Since antenatal care is widely available to pregnant women in Ghana, it is vital to reexamine the way antenatal education is delivered. Pregnant women must receive health information that is accurate and easy to understand in order to make informed health choices that will improve maternal and child health.