Toward a New Definition of Unmet Need for Contraception.

The current definition of unmet need for contraception assumes that all women who are using a method have a met need. We argue that without taking into account the level of satisfaction with a method, many women are classified as having a met need, when in fact they have an unmet need. They are using a method that does not meet their preferences, either because it causes side effects they find untenable or has other characteristics they do not like. Given the large number of contraceptive episodes that end in discontinuation, reportedly often due to the experience of side effects, we argue that the current definition of unmet need undercounts the number of women with a true unmet need for contraception as it misses the many women who are using a method that does not meet their preferences. We suggest the addition of satisfaction questions in national surveys such as the Demographic and Health Surveys to more fully assess the level of true met need for contraception.

The Relationship between Facility-Based Delivery and Infant Immunization in sub-Saharan Africa.

This study explored the relationship between facility-based delivery and infant immunizations in sub-Saharan Africa, controlling for economic development indicators. Publically available data were collected and imported into Stata 11.0 for descriptive, correlation, and regression analyses. Facility delivery was significantly associated with full vaccination and BCG immunization in children aged 12-23 months. Facility delivery was associated with full vaccination (p<.019), even after controlling for antenatal care usage, Gross National Income per capita, percent of the country's population residing in an urban setting, and percent of the population with at least a secondary education (ß: 0.45 (95% CI: 0.08 - 0.81)). The relationship between facility delivery and immunization is significant, and robust enough to remain after controlling for economic and social indicators linked to both. These results suggest the benefits of facility delivery transcend the immediate survival benefit for mothers and their babies, and may serve as a gateway to further interactions with the healthcare system.

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.

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.

Abortion care in Ghana: a critical review of the literature.

The Government of Ghana has taken important steps to mitigate the impact of unsafe abortion. However, the expected decline in maternal deaths is yet to be realized. This literature review aims to present findings from empirical research directly related to abortion provision in Ghana and identify gaps for future research. A total of four (4) databases were searched with the keywords "Ghana and abortion" and hand review of reference lists was conducted. All abstracts were reviewed. The final include sample was 39 articles. Abortion-related complications represent a large component of admissions to gynecological wards in hospitals in Ghana as well as a large contributor to maternal mortality. Almost half of the included studies were hospital-based, mainly chart reviews. This review has identified gaps in the literature including: interviewing women who have sought unsafe abortions and with healthcare providers who may act as gatekeepers to women wishing to access safe abortion services.

Rural origin and exposure drives Ghanaian midwives reported future practice.

A primary cause of Ghana's higher than global average maternal mortality rate is limited access to maternal care in rural areas. To date, few studies have examined how rural background/training of midwives impacts their future willingness to work in remote areas. The purpose of this paper is to describe the relationship between Ghanaian student midwife place of origin and rural training on their willingness to choose a future rural practice location. A cross-sectional computer-based survey was completed by 238 final year Ghanaian midwifery students from two public midwifery training schools located in urban Ghana between October and December 2009. The relationship between rural exposure and willingness to work in rural Ghana was analyzed using independent t-test, chi-square, and bivariate logistic regression. Participants who experienced a rural rotation (OR: 1.51, 95% CI: 0.71, 3.22) and those born in a rural area (OR: 2.24, 95% CI: 0.74, 6.75) resulted in greater odds ratio to choose rural practice following graduation. This study indicates an association between midwifery students' place of origin and training and their willingness to practice in a rural area after graduation.

Factors that influence midwifery students in Ghana when deciding where to practice: a discrete choice experiment.

BACKGROUND: Mal-distribution of the health workforce with a strong bias for urban living is a major constraint to expanding midwifery services in Ghana. According to the UN Millennium Development Goals (MDG) report, the high risk of dying in pregnancy or childbirth continues in Africa. Maternal death is currently estimated at 350 per 100,000, partially a reflection of the low rates of professional support during birth. Many women in rural areas of Ghana give birth alone or with a non-skilled attendant. Midwives are key healthcare providers in achieving the MDGs, specifically in reducing maternal mortality by three-quarters and reducing by two-thirds the under 5 child mortality rate by 2015. METHODS: This quantitative research study used a computerized structured survey containing a discrete choice experiment (DCE) to quantify the importance of different incentives and policies to encourage service to deprived, rural and remote areas by upper-year midwifery students following graduation. Using a hierarchical Bayes procedure we estimated individual and mean utility parameters for two hundred and ninety eight third year midwifery students from two of the largest midwifery training schools in Ghana. RESULTS: Midwifery students in our sample identified: 1) study leave after two years of rural service; 2) an advanced work environment with reliable electricity, appropriate technology and a constant drug supply; and 3) superior housing (2 bedroom, 1 bathroom, kitchen, living room, not shared) as the top three motivating factors to accept a rural posting. CONCLUSION: Addressing the motivating factors for rural postings among midwifery students who are about to graduate and enter the workforce could significantly contribute to the current mal-distribution of the health workforce.

Analysis of nursing education in Ghana: Priorities for scaling-up the nursing workforce.

In this cross-sectional study, the strengths, challenges and current status of baccalaureate nursing education in Ghana were described using a descriptive design. The World Health Organization Global Standards for the Initial Education of Nurses and Midwives were used as the organizing framework, with baseline data on the status of nursing education from two state-funded universities in Ghana presented. A serious shortage of qualified faculty was identified, along with the need for significant upgrading to the existing infrastructure. Additionally, the number of qualified applicants far exceeds the available training slots. Faculty and infrastructure shortages are common issues in nursing education and workforce expansion; however, in low-resource countries, such as Ghana, these issues are compounded by high rates of preventable disease and injury. An understanding of the strengths and challenges of nursing education in Ghana can inform the development of strategies for nursing workforce expansion for other low-resource countries.

Clean delivery practices in rural northern Ghana: a qualitative study of community and provider knowledge, attitudes, and beliefs.

BACKGROUND: Knowledge, attitudes and practices of community members and healthcare providers in rural northern Ghana regarding clean delivery are not well understood. This study explores hand washing/use of gloves during delivery, delivering on a clean surface, sterile cord cutting, appropriate cord tying, proper cord care following delivery, and infant bathing and cleanliness. METHODS: In-depth interviews and focus group discussions were audiotaped, transcribed, and analyzed using NVivo 9.0. RESULTS: 253 respondents participated, including women with newborn infants, grandmothers, household and compound heads, community leaders, traditional birth attendants, and formally trained health care providers. There is widespread understanding of the need for clean delivery to reduce the risk of infection to both mothers and their babies during and shortly after delivery. Despite this understanding, the use of gloves during delivery and hand washing during and after delivery were mentioned infrequently. The need for a clean delivery surface was raised repeatedly, including explicit discussion of avoiding delivering in the dirt. Many activities to do with cord care involved non-sterile materials and practices: 1) Cord cutting was done with a variety of tools, and the most commonly used were razor blades or scissors; 2) Cord tying utilized a variety of materials, including string, rope, thread, twigs, and clamps; and 3) Cord care often involved applying traditional salves to the cord - including shea butter, ground shea nuts, local herbs, local oil, or "red earth sand." Keeping babies and their surroundings clean was mentioned repeatedly as an important way to keep babies from falling ill. CONCLUSIONS: This study suggests a widespread understanding in rural northern Ghana of the need for clean delivery. Nonetheless, many recommended clean delivery practices are ignored. Overarching themes emerging from this study included the increasing use of facility-based delivery, the disconnect between healthcare providers and the community, and the critical role grandmothers play in ensuring clean delivery practices. Future interventions to address clean delivery and prevention of neonatal infections include educating healthcare providers about harmful traditional practices so they are specifically addressed, strengthening facilities, and incorporating influential community members such as grandmothers to ensure success.

Infant nutrition in the first seven days of life in rural northern Ghana.

BACKGROUND: Good nutrition is essential for increasing survival rates of infants. This study explored infant feeding practices in a resource-poor setting and assessed implications for future interventions focused on improving newborn health. METHODS: The study took place in the Kassena-Nankana District of the Upper East Region of northern Ghana. In-depth interviews were conducted with 35 women with newborn infants, 8 traditional birth attendants and local healers, and 16 community leaders. An additional 18 focus group discussions were conducted with household heads, compound heads and grandmothers. All interviews and discussions were audio taped, transcribed verbatim and analyzed using NVivo 9.0. RESULTS: Community members are knowledgeable about the importance of breastfeeding, and most women with newborn infants do attempt to breastfeed. However, data suggest that traditional practices related to breastfeeding and infant nutrition continue, despite knowledge of clinical guidelines. Such traditional practices include feeding newborn infants water, gripe water, local herbs, or traditionally meaningful foods such as water mixed with the flour of guinea corn (yara'na). In this region in Ghana, there are significant cultural traditions associated with breastfeeding. For example, colostrum from first-time mothers is often tested for bitterness by putting ants in it - a process that leads to a delay in initiating breastfeeding. Our data also indicate that grandmothers - typically the mother-in-laws - wield enormous power in these communities, and their desires significantly influence breastfeeding initiation, exclusivity, and maintenance. CONCLUSION: Prelacteal feeding is still common in rural Ghana despite demonstrating high knowledge of appropriate feeding practices. Future interventions that focus on grandmothers and religious leaders are likely to prove valuable in changing community attitudes, beliefs, and practices with regard to infant nutrition.

Perceived barriers and motivating factors influencing student midwives' acceptance of rural postings in Ghana.

BACKGROUND: Research on the mal-distribution of health care workers has focused mainly on physicians and nurses. To meet the Millennium Development Goal Five and the reproductive needs of all women, it is predicted that an additional 334,000 midwives are needed. Despite the on-going efforts to increase this cadre of health workers there are still glaring gaps and inequities in distribution. The objectives of this study are to determine the perceived barriers and motivators influencing final year midwifery students' acceptance of rural postings in Ghana, West Africa. METHODS: An exploratory qualitative study using focus group interviews as the data collection strategy was conducted in two of the largest midwifery training schools in Ghana. All final year midwifery students from the two training schools were invited to participate in the focus groups. A purposive sample of 49 final year midwifery students participated in 6 focus groups. All students were women. Average age was 23.2 years. Glaser's constant comparative method of analysis was used to identify patterns or themes from the data. RESULTS: Three themes were identified through a broad inductive process: 1) social amenities; 2) professional life; and 3) further education/career advancement. Together they create the overarching theme, quality of life, we use to describe the influences on midwifery students' decision to accept a rural posting following graduation. CONCLUSIONS: In countries where there are too few health workers, deployment of midwives to rural postings is a continuing challenge. Until more midwives are attracted to work in rural, remote areas health inequities will exist and the targeted reduction for maternal mortality will remain elusive.

A low-cost method for performing a curriculum gap-analysis in developing countries: medical school competencies in Ghana.

BACKGROUND: In this study, we undertook a comparison of the international, national, and local curricula of Ghanaian medical schools in order to identify any gaps. PURPOSE: To identify gaps in the Ghanaian medical school curriculum. METHODS: The Ministry of Health and the two major sites for medical education in Ghana (UGMS, KNUST) participated using the only internationally accepted and validated set of outcome standards for medical education, the Global Minimum Essential Requirements. The competencies were reviewed by two U.S. consultants (DS, SR) and then edited, revised, and validated by individuals who are deeply involved in medical education in Ghana. RESULTS: The KNUST team validated 6 gaps in their curriculum, and the team from UGMS identified 5. The standards were found by the U.S.-based consultants and validated by the Ghanaian team to have 6 gaps, many of which overlapped with those found in the Ghanaian medical school curricula. CONCLUSIONS: This analysis is a first step to determining physician training competency and an inexpensive method for identifying agreed-upon gaps in the current national requirements and local curriculum.

The prevalence of self-reported medical comorbidities in patients with vulvar lichen sclerosus: A single-center retrospective study.

OBJECTIVE: To compare the demographics and self-reported medical comorbidities of patients with vulvar lichen sclerosus (VLS) with those of women with other vulvar conditions. METHODS: Intake questionnaires for patients presenting to the University of Michigan Center for Vulvar Diseases between 1996 and 2019 were entered into a de-identified database (n = 1983). Responses to questions about thyroid disease, urinary symptoms and signs, gastrointestinal conditions, and pain conditions were collected. RESULTS: A total of 1983 women, including 865 patients with VLS and 1118 patients without VLS were enrolled. Pearson's χ2 analysis showed that age, hypertension, anorectal fissures, peptic ulcer disease/gastroesophageal reflux disease, urinary incontinence, fibromyalgia, thyroid disease, kidney problems, liver problems, and cancer were significantly associated with VLS when compared between the VLS and non-VLS groups (P < 0.01). However, multiple regression analysis demonstrated that only age, thyroid disease, and anorectal fissures were strongly associated with VLS (P < 0.01). CONCLUSION: Increasing age, thyroid disease, and anorectal fissures were significantly associated with VLS. The association between anorectal fissures and VLS likely represents a sequela of the disease rather than a true comorbidity.

Predictors of burnout: the role of agency among obstetric providers in Kumasi, Ghana.

Burnout rates among sub-Saharan African healthcare providers are high. In particular, obstetric providers experience unique stressors surrounding poor neonatal and maternal outcomes. This study explores predictors of burnout among obstetric providers at the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana. A survey was electronically distributed to midwives, house officers, and Obstetrician Gynecologists (OBGYNs) at KATH in Ghana. Demographic and clinical practice information was collected. Burnout was assessed using a 4-point Likert scale. To evaluate perceived agency caring for critically ill obstetric patients, participants responded to three statements and responses were summed to create an Agency Scale. Logistic regression was used to evaluate predictors of burnout. Marginal effects were calculated for factors significantly associated with burnout. Participants were 48 physicians and 222 midwives. Mean age was 32.4 years, mean years in practice was 6.5 years, and 83% had completed their medical training. Nearly half (49.6%) have personal experience with maternal mortality and 28.3% manage more than 5 maternal mortalities annually. The majority of participants (n = 152, 62%) reported feeling burned out from their work. After adjusting for role, number of annual maternal mortalities managed, and personal experience with maternal mortality, participants with more years in practice were 15.8% more likely to report being burned out (marginal effect = 0.158). Even after adjusting for years in practice, participants who scored higher on the Agency Scale had a significantly lower likelihood of reporting burnout (OR 0.76, 95% CI 0.66-0.88, p < 0.001). For each step up the Agency Scale, participants were 6.4% less likely to report they felt burned out. Rates of burnout are high among obstetric providers, particularly among providers who have practiced longer. Supporting provider agency to manage critically ill patients may reduce burnout rates.

Adapting a Sexual Violence Primary Prevention Program to Ghana Utilizing the ADAPT-ITT Framework.

Prevention of sexual violence among young people has become a priority area in Ghana, although few initiatives have focused on this topic. The ADAPT-ITT (Assessment, Decisions, Administration, Production, Topical experts, Integration, Training staff, and Testing) framework was used to systematically adapt an evidence-based sexual violence prevention program developed in the United States to a university in Ghana. Results from cognitive interviews, focus groups, beta testing, and topical experts indicate the adapted primary prevention program is promising for use in Ghanaian universities. To our knowledge, this is the first study that has used the ADAPT-ITT framework for a sexual violence program.

Maternity waiting homes in Liberia: Results of a countrywide multi-sector scale-up.

OBJECTIVE: Descriptions of maternity waiting homes (MWHs) as an intervention to increase facility delivery for women living in remote geographic areas dates back to the 1950s, yet there is limited information on the scale-up and sustainability of MWHs. The objective of this study was to describe the evolutionary scale-up of MWHs as a component of health system strengthening efforts and document the successes, challenges, and barriers to sustainability in Liberia. METHODS: Data were collected from a national sample of 119 MWHs in Liberia established between 2010-2018. The study used a mixed method design that included focus group discussions, individual interviews, logbook reviews, and geographic information systems. Qualitative data were grouped into themes using Glaser's constant comparative method. Quantitative data were analyzed using negative binomial regression to measure the differences in the counts of monthly stays at facilities with different funding sources and presence of advisory committee. Additionally, each MWH was geo-located for purposes of geo-visualization. RESULTS: In the years since the original construction of five MWHs, an additional 114 MWHs were constructed in 14 of the 15 counties in Liberia. Monthly stays at facilities funded by community were 2·5 times those funded by NGOs (IRR, 2·46, 95% CI 1·33-4·54). Attributes of sustainability included strong local leadership/active community engagement and community ownership and governance. CONCLUSION: Success factors for scale-up and sustainability included strong government support through development of public policy, local and county leadership, early and sustained engagement with communities, and self-governance. A multi-pronged approach with strong community engagement is key to the scale-up and sustainability of MWHs as an intervention to increase facility delivery for women living the farthest from a healthcare facility.

Is abortion justified to save the life or health of a woman? Evidence of public opinion from Accra, Ghana.

OBJECTIVE: In this study, we sought to determine to what extent the abortion law in Ghana is reflective of public opinion. METHODS: In a cross-sectional, community-based survey, individuals in two fishing communities in Accra were interviewed about their beliefs on abortion between May and July 2016, and sociodemographic, attitudinal, and experience data were collected. Factors associated with the outcome variable (abortion is justified to save the life/health of the woman: Yes/No) were entered into a multivariate logistic regression. RESULTS: A total of 508 participants completed the survey. Thirty-nine percent (n=198) of the sample agreed that abortion was justified to save the life/health of the woman, with no significant differences in this finding when controlling for understanding of the law, gender, marital status, or personal experience of abortion in multivariate analysis. Higher education (odds ratio [OR] 1.64 [P<0.001]) and older age (OR 1.28 [P<0.001]) are positively associated with abortion being justified to save life/health, while those who have had an experience of unwanted sex are less likely to believe that (OR 0.60 [P=0.029]). CONCLUSION: The participants held conservative views about the justification of abortion to save a woman's life and/or health. Improving access to safe abortion services will require acknowledgment of the broader social and cultural context that may make accessing such services difficult.

Achieving universal coverage: Understanding barriers to rural placement for final year midwifery students.

OBJECTIVE: the objective of this study is to understand the barriers final year midwifery students face when deciding to practice in a rural, deprived area. DESIGN: a cross-sectional study design using a computer based structured survey. SETTING: 15 of the 16 publicly funded midwifery colleges across all ten regions in Ghana. PARTICIPANTS: a national sample of final-year midwifery students from publically funded midwifery colleges in Ghana. MEASUREMENTS: basic frequencies and percentages were calculated for the variables cited as the top three factors motivating participants to study midwifery stratified by student type (post-basic verses diploma) and program location (urban, peri-urban, and rural). Odds ratios were calculated using separate logistic regression models to analyze the relationship between students' experience with rural communities and how it affected their willingness to work in a rural area following graduation. FINDINGS: eight hundred and fifty-six midwifery students (N = 856) completed a computerised survey for a response rate of 91.8%. The top motivation to study midwifery was a 'desire to help others'. Over half (55%) of participants reported they will 'definitely work' (11%) or 'were likely to work' (44%) in a deprived area. When examined by student type and location of school, the top reason cited by participants was 'to serve humanity'. Those born in a rural area, currently living in a rural area, or under obligation to return to a rural or peri-urban area had greater odds of being willing to work in a deprived area after graduation. KEY CONCLUSIONS: findings from our study are unique in that they examine the distinct motivational factors from a national sample of midwifery students about to join the workforce. Regardless of the type of student or the location of the school, midwifery students in Ghana were highly motivated by altruistic values. Strategies to address the rural shortage of midwifery providers in Ghana is presented. IMPLICATION FOR PRACTICE: understanding the factors that motivate midwifery students to work in rural, deprived areas will help develop effective policy interventions affecting practice.

Quality of family planning counseling among women attending prenatal care at a hospital in Addis Ababa, Ethiopia.

OBJECTIVE: To assess the quality of family planning counseling among women attending a prenatal clinic in Addis Ababa, Ethiopia. METHODS: In a descriptive cross-sectional study conducted between February and April, 2015, at the prenatal care clinic of Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia, pregnant women in their third trimester were interviewed about their experience of family planning counseling. Data were collected via a questionnaire. Logistic regression was used to assess predictors of satisfaction with the counseling service. RESULTS: During the study period, 400 women were interviewed. Only 139 women (34.8%) were counseled about family planning. Among those counseled, 126 (90.6%) decided to use a contraceptive method after delivery and 46 (36.7%) decided to use an injectable contraceptive. Women were more likely to report high satisfaction when their provider asked about their partner's attitude toward contraceptive methods (adjusted odds ratio 6.6; P<0.001), and when asked about their concerns and worries regarding family planning methods (adjusted odds ratio 5.1; P<0.001). CONCLUSION: Very few women were counseled about contraception during prenatal care. Asking about a partner's attitude toward contraceptives and discussing women's fears or worries about contraceptives should be considered during family planning counseling to improve satisfaction and quality of care.

"My friend who bought it for me, she has had an abortion before." The influence of Ghanaian women's social networks in determining the pathway to induced abortion.

BACKGROUND: Even given the liberal abortion law in Ghana, abortion complications are a large contributor to maternal morbidity and mortality. This study sought to understand why young women seeking an abortion in a legally enabling environment chose to do this outside the formal healthcare system. METHODS: Women being treated for complications arising from a self-induced abortion as well as for elective abortions at three hospitals in Ghana were interviewed. Community-based focus groups were held with women as well as men, separately. Interviews and focus group discussions were conducted until saturation was reached. RESULTS: A total of 18 women seeking care for complications from a self-induced abortion and 11 seeking care for an elective abortion interviewed. The women ranged in age from 13 to 35 years. There were eight focus groups; two with men and six with women. The reasons women self-induce are: (1) abortion is illegal; (2) attitudes of the healthcare workers; (3) keeping the pregnancy a secret; and (4) social network influence. The meta-theme of normalisation of self-inducing' an abortion was identified. DISCUSSION: When women are faced with an unplanned and unwanted pregnancy, they consult individuals in their social network whom they know have dealt with a similar situation. Misoprostol is widely available in Ghanaian cities and is successful at inducing an abortion for many women. In this way, self-inducing abortions using medication procured from pharmacists and chemical sellers has become normalised for women in Kumasi, Ghana.