Prevalence and correlates of maternal early stimulation behaviors during pregnancy in northern Ghana: a cross-sectional survey.

BACKGROUND: Per UNICEF's Nurturing Care Framework, early childhood development (ECD) begins during pregnancy and many lower-resource settings need data to inform their programs for optimal child development. The maternal-fetal relationship can be partly examined via a series of bonding activities called early stimulation behaviors (ESB). This study describes early stimulation behaviors and the associated correlates among pregnant women in Ghana. METHODS: This cross-sectional study used data from a cluster-randomized trial in two districts of Northern Ghana. A total of 374 pregnant women were enrolled at baseline and administered a pre-intervention survey. Communication-related early stimulation behaviors was the primary outcome which was evaluated using three maternal-fetal bonding activities; did the woman self-report touching and/or talking, singing, and/or talking about family to her belly. A generalized estimating equation modified Poisson model was used for the bivariate and multivariable analysis. RESULTS: About half of the participants reported performing communication-related ESB during pregnancy frequently or sometimes. Bivariate analysis revealed that negative life experiences including higher rates of emotional, physical and sexual intimate partner violence (IPV) and having moderate to severe depressive symptoms were associated with women performing early stimulation behaviors more often. In the multivariable model, physical intimate partner violence remained significantly associated with early stimulation behaviors. CONCLUSION: Research on early stimulation behaviors is still in a nascent phase. It is unclear why our results revealed an association between intimate partner violence and early stimulation behaviors; this could reflect a coping mechanism for the expectant mother. Further research is needed to better understand this association and explore potential long-term impacts of early stimulation behaviors during pregnancy on child development. TRIAL REGISTRATION: Clinical Trials # NCT03665246 , August 29, 2018.

Community utilisation and satisfaction with the community-based health planning and services initiative in Ghana: a comparative study in two system learning districts of the CHPS+ project.

BACKGROUND: To strengthen the implementation of the Community-based Health Planning and Services (CHPS) programme which is Ghana's key primary health care delivery strategy, the CHPS+ Project was initiated in 2017. We examined community utilisation and satisfaction with CHPS services in two System Learning Districts (SLDs) of the project. METHODS: This community-based descriptive study was conducted in the Nkwanta South Municipality and Central Tongu District of Ghana. Data were collected from 1008 adults and analysed using frequency, percentage, chi-square, and logistic regression models. RESULTS: While the level of utilisation of CHPS services was 65.2%, satisfaction was 46.1%. Utilisation was 76.7% in Nkwanta South and 53.8% in Central Tongu. Satisfaction was also 55.2% in Nkwanta South and 37.1% in Central Tongu. Community members in Nkwanta South were more likely to utilise (AOR = 3.17, 95%CI = 3.98-9.76) and be satisfied (AOR = 2.77, 95%CI = 1.56-4.90) with CHPS services than those in Central Tongu. Females were more likely to utilise (AOR = 1.75, 95%CI = 1.27-2.39) but less likely to be satisfied [AOR = 0.47, 95%CI = 0.25-0.90] with CHPS services than males. Even though subscription to the National Health Insurance Scheme (NHIS) was just 46.3%, NHIS subscribers were more likely to utilise (AOR = 1.51, 95%CI = 1.22-2.03) and be satisfied (AOR = 1.45, 95%CI = 0.53-1.68) with CHPS services than non-subscribers. CONCLUSION: Ghana may not be able to achieve the goal of universal health coverage (UHC) by the year 2030 if current levels of utilisation and satisfaction with CHPS services persist. To accelerate progress towards the achievement of UHC with CHPS as the vehicle through which primary health care is delivered, there should be increased public education by the Ghana Health Service (GHS) on the CHPS concept to increase utilisation. Service quality should also be improved by the GHS and other stakeholders in Ghana's health industry to increase satisfaction with CHPS services. The GHS and the National Health Insurance Authority (NHIA) should also institute innovative strategies to increase subscription to the NHIS since it has implications for CHPS service utilisation and satisfaction.

Exploring Conscientious Objection to Abortion Among Health Providers in Ghana.

CONTEXT: Few studies have explored clinicians' roles in the abortion experience in Ghana. Examining how clinicians understand conscientious objection to abortion-the right to refuse to provide legal abortion on the basis of moral or personal beliefs-may provide insight that could help manage the practice. METHODS: Eight in-depth interviews and four focus group discussions were conducted with 14 doctors and 20 midwives in health facilities in Ghana's Eastern and Volta Regions in May 2018. The semi-structured interview guides covered such topics as clinicians' understanding of conscientious objection, how it is practiced and the consequences of conscientious objection for providers and clients. The data were analyzed using thematic analysis. RESULTS: Most clinicians did not understand the term "conscientious objection," and midwives had more knowledge on the subject than doctors. The main reasons for conscientious objection were antiabortion religious and cultural beliefs. Clinicians who objected referred clients to willing providers, counseled them to continue the pregnancies or inadvertently encouraged unsafe abortions. The negative consequences of conscientious objection to abortion for clients were complications and death from unsafe abortions; the consequences for providers included high patient volume and stigma for nonobjectors, leading some to claim objection to avoid these. CONCLUSIONS: The findings highlight the need for further research on the consequences of conscientious objection, including stigma leading to refusals. Such research may ultimately help to restrict clinicians' misuse of the right to object and improve women's reproductive health care in Ghana.

RESUMEN Contexto: Pocos estudios han explorado los roles del personal clínico en la experiencia del aborto en Ghana. Examinar la forma en que el personal clínico comprende la objeción de conciencia al aborto ­el derecho de rehusarse a proveer servicios de aborto legal sobre la base de la moral o creencias personales­ podría aportar conocimientos que ayuden a gestionar la práctica del procedimiento. Métodos: Se realizaron ocho entrevistas en profundidad y cuatro discusiones de grupos focales con la participación de 14 médicos y 20 parteras en instituciones de salud en las regiones de Ghana oriental y del Volta en mayo de 2018. Las guías de entrevistas semiestructuradas cubrieron temas como la comprensión del personal clínico acerca de la objeción de conciencia, la forma en que se practica y las consecuencias de la objeción de conciencia para proveedores de servicios y clientes. Los datos se analizaron mediante análisis temático. Resultados: La mayor parte del personal clínico no comprendió el término "objeción de conciencia" y las parteras tuvieron más conocimiento del tema que los médicos. Las principales razones para la objeción de conciencia fueron las creencias religiosas y culturales contrarias al aborto. El personal clínico que practicó la objeción refirió a sus clientes a proveedores dispuestos a dar el servicio, les aconsejó continuarcon los embarazos o inadvertidamente les motivó para tener abortos inseguros. Las consecuencias negativas de la objeción de conciencia al aborto para las clientas fueron complicaciones y muerte debidas a abortos inseguros; las consecuencias para los proveedores incluyeron un alto volumen de pacientes y el estigma para los no objetores, lo que condujo a que algunos se identificaran como objetores para evitar dichas consecuencias. Conclusiones: Los hallazgos destacan la necesidad de mayor investigación sobre las consecuencias de la objeción de conciencia, incluido el estigma que conduce a negar los servicios. Esa investigación podría ayudar, en última instancia, a restringir el uso indebido del derecho a objetar por parte del personal clínico y a mejorar los servicios de salud reproductiva para las mujeres en Ghana.

RÉSUMÉ Contexte: Rares sont les études qui examinent le rôle des cliniciens dans l'expérience de l'avortement au Ghana. Il peut être utile d'examiner comment les cliniciens comprennent l'objection de conscience à l'avortement ­ c.-à-d. le droit de refuser la prestation d'un avortement légal sur la base de croyances morales ou personnelles ­, afin de mieux gérer la pratique. Méthodes: Huit entretiens en profondeur et quatre discussions de groupe ont été menés avec 14 médecins et 20 sages-femmes de structures sanitaires des régions Orientale et de la Volta au Ghana, en mai 2018. Les guides de ces entretiens semistructurés couvraient des questions telles que la compréhension du concept d'objection de conscience par les cliniciens, sa pratique et ses conséquences pour les prestataires et les patientes. Les données ont été analysées par analyse thématique. Résultats: La plupart des cliniciens ne comprenaient pas l'expression « objection de conscience ¼; les sages-femmes étaient mieux informées sur la question que les médecins. Les principales raisons de l'objection de conscience étaient les croyances religieuses et culturelles opposées à l'avortement. Les cliniciens objecteurs aiguillaient les patientes vers les prestataires qui ne l'étaient pas, leur conseillaient de poursuivre leur grossesse ou les encourageaient par inadvertance à recourir à l'avortement non médicalisé. Les conséquences négatives de l'objection de conscience à l'avortement étaient, pour les patientes, les complications, parfois mortelles, de l'avortement non médicalisé; pour les prestataires, ces conséquences se révélaient dans le grand nombre de patientes et la stigmatisation des non-objecteurs, en conduisant certains à invoquer eux aussi l'objection pour les éviter. Conclusions: Les constats de l'étude mettent en lumière la nécessité d'une recherche approfondie sur les conséquences de l'objection de conscience, y compris la stigmatisation menant au refus d'assurer le service. Cette recherche aidera peutêtre, en fin de compte, à limiter l'abus du droit d'objection des cliniciens et à améliorer les soins de santé reproductive des femmes au Ghana.

Volunteer responsibilities, motivations and challenges in implementation of the community-based health planning and services (CHPS) initiative in Ghana: qualitative evidence from two systems learning districts of the CHPS+ project.

BACKGROUND: Community volunteerism is essential in the implementation of the Community-based Health Planning and Services (CHPS) in Ghana. We explored the responsibilities, motivations and challenges of community health management committees (CHMCs) in two CHPS+ Project districts in Ghana. METHODS: We used a qualitative approach to collect data through 4 focus group discussions among a purposive sample of community health volunteers in December 2018 and analysed them thematically. RESULTS: Community health management committees (CHMCs) were found to provide support in running the CHPS programme through resource mobilisation, monitoring of logistics, assisting the Community Health Officers (CHO) in the planning of CHPS activities, and the resolution of conflicts between CHOs and community members. The value, understanding and protective functions were the key motivations for serving on CHMCs. Financial, logistical and telecommunication challenges, lack of recognition and cooperation from community members, lack of motivation and lack of regular skill development training programmes for CHMC members who serve as traditional birth attendants (TBAs) were major challenges in CHMC volunteerism. CONCLUSION: Community health volunteerism needs to be prioritised by the Ghana Health Service and other health sector stakeholders to make it attractive for members to give off their best in the discharge of their responsibilities.

Cost of implementing a community-based primary health care strengthening program: The case of the Ghana Essential Health Interventions Program in northern Ghana.

BACKGROUND: The absence of implementation cost data constrains deliberations on consigning resources to community-based health programs. This paper analyses the cost of implementing strategies for accelerating the expansion of a community-based primary health care program in northern Ghana. Known as the Ghana Essential Health Intervention Program (GEHIP), the project was an embedded implementation science program implemented to provide practical guidance for accelerating the expansion of community-based primary health care and introducing improvements in the range of services community workers can provide. METHODS: Cost data were systematically collected from intervention and non-intervention districts throughout the implementation period (2012-2014) from a provider perspective. The step-down allocation approach to costing was used while WHO health system blocks were adopted as cost centers. We computed cost without annualizing capital cost to represent financial cost and cost with annualizing capital cost to represent economic cost. RESULTS: The per capita financial cost and economic cost of implementing GEHIP over a three-year period was $1.79, and $1.07 respectively. GEHIP comprised only 3.1% of total primary health care cost. Health service delivery comprised the largest component of cost (37.6%), human resources was 28.6%, medicines was 13.6%, leadership/governance was 12.8%, while health information comprised 7.5% of the economic cost of implementing GEHIP. CONCLUSION: The per capita cost of implementing the GEHIP program was low. GEHIP project investments had a catalytic effect that improved community-based health planning and services (CHPS) coverage and enhanced the efficient use of routine health system resources rather than expanding overall primary health care costs.

Improving Skilled Birth Attendance in Ghana: An Evidence-Based Policy Brief.

This commentary has the objective of improving skilled birth attendance in Ghana to reduce maternal and neonatal mortality and morbidity. We have provided evidence of causes of low-skilled birth attendance in Ghana. Physical accessibility of health care, sociocultural factors, economic factors and health care system delivery problems were found as the main underlying causes of low levels of skilled birth attendance in Ghana. The paper provides potential strategies in addressing maternal and child health issues in Ghana.