Prevalence and risk factors associated with high-risk human papillomavirus infection among women living with HIV (WLWH) at a tertiary health facility in Accra, Ghana.

BACKGROUND: Women living with HIV (WLWH) have high risk of developing cervical cancer. High- risk Human papillomavirus (hrHPV) is the single most important cause of cervical cancer. Vaccination for and early detection of pre-malignant cervical changes, through cervical cancer screening contributes to prevention of cervical cancer. This study sought to determine the prevalence of HPV among WLWH, genotypes present and the risk factors associated with cervical cancer development. METHODS AND FINDINGS: An analytical cross-sectional study of 250 sexually active women aged 18 years and above, attending HIV clinic at a tertiary health facility in Accra. Demographic data collection and risk factor assessments were done using interviewer-administered questionnaire, and patient records. Cervical swabs were collected and tested for HPV using real-time PCR assays. Genotype analysis was performed on 92 samples. Descriptive statistics and logistic regression analysis were used to establish associations between hrHPV and risk factors among WLWH. Approximately 60% of study participants tested positive for HPV. The prevalence of hr-HPV among WLH was 44.4%. Factors identified to be protective of hrHPV were employment (AOR = 0.19, 95% CI = 0.06, 0.56, p = 0.003) and highly active antiretroviral therapy (HAART) Tenofovir-Lamivudine-Ritonavir-Lopinavir (TLRL) (AOR = 0.30, 95% CI = 0.09, 0.95, p = 0.04). Women with HIV diagnosis within 6 to10 years (AOR = 4.89, 95% CI = 1.05, 22.70, p = 0.043) and diagnosis >10 years (AOR = 8.25, 95% CI = 1.24, 54.84, p = 0.029) had higher odds of hrHPV. Approximately 25% of samples analysed tested positive for hr-HPV group 1 (genotypes 16, 18, 31, 33, 35, 39, 45,51, 52, 56, 58, 69) and 46.8% for multiple HPV genotypes. CONCLUSION: A high prevalence of genotypes that include high risk genotypes 16 and 18 and multiple HPV infections was found among WLWH. Almost half of the women screened had high-risk HPV and were prone to cervical cancer without their knowledge. Regular HPV screening is recommended for high-risk patient groups.

Correlates of prevalent HIV infection among adolescents, young adults, and older adult female sex workers in Ghana: Analysis of data from the Ghana biobehavioral survey.

BACKGROUND: Human immunodeficiency virus infection remains a high burden among key populations such as female sex workers in the world. We aimed to provide distribution of prevalence and correlates of Human immunodeficiency virus infection among adolescent, young, and older adult FSWs in Ghana. METHODS: This data was obtained from the biobehavioral survey of female sex workers (2020) in Ghana based on a time location sampling approach for the selection of respondents. A sampling frame was developed taking into consideration list of venues, days, and time that sex workers operate across all the regions of Ghana. These lists were derived from a sampling universe which was obtained during a mapping exercise. All sex workers aged 16 years and above and eligible on the day of visit participated. Human immunodeficiency virus testing was done based on First Response and Oraquick. To obtain estimates for sex workers, sampling weights were calculated and applied to the dataset. Inferential analyses using Bayesian regression models were applied with interaction effects. RESULTS: A total of 5,990 participants completed both the biological and behavioral aspects of the study. The HIV prevalence among female sex workers in Ghana was 4.67% (CI: 4.05%, 5.40%). About 70% of the respondents who tested positive for Human immunodeficiency virus were among the older adults (= >25 years) group. Generally, there was a high prevalence variation across the 16 regions of Ghana, from 0.00% to 8.40%. Respondents' age was a significant contributor to the prevalence of HIV. Respondents who were forced into having sex had higher odds (38%) of being positive in the combined analysis. Respondents who had comprehensive knowledge of HIV had lower odds (39%) of testing positive. CONCLUSION: The findings suggest a low prevalence of HIV among sex workers in 2020 compared to the 2011 and 2015 biobehavioral survey results but higher than the general population. Specifically, older adults have a higher prevalence of HIV. There is generally low level of comprehensive knowledge among sex workers. Interventions geared towards increasing FSW knowledge on risky behavior should be vigorously pursued.

Adolescents' satisfaction with abortion services received and factors associated with satisfaction at reproductive health centres.

AIM: This study assessed adolescents' satisfaction with services received during their most recent abortion and the factors associated with satisfaction at reproductive health centres in the Greater Accra region of Ghana. DESIGN: A facility-based cross-sectional survey was used for this study. METHODS: Overall, 254 adolescent girls aged between 15 and 19 years, who had an abortion within 1 week of the study period were recruited for the study. All the 254 respondents were recruited consecutively as they visited health facilities for abortion services from March 2019 to February 2020. Written informed consent was signed by respondents, and data were collected using the Patient Satisfaction with Nursing Care Quality Questionnaire, and the data were analysed using Stata version 15.0. Univariate, bivariate and multivariate logistic regression analyses were conducted. RESULTS: A majority of adolescents reported being satisfied with the abortion services they received. Ample waiting space and the system of 'first-come-first-served' were the highest rated elements of service satisfaction. Adolescents were least satisfied with the inadequacy of instructions and lack of information on medications received and their therapeutic or side effects. Ethnicity, having a stable intimate partner and perceived adequacy of staff were the factors associated with satisfaction with abortion services. CONCLUSION: Adolescents are unique group of people with peculiar health needs. If they are treated with respect and dignity, they are likely to be satisfied with services received from the reproductive health centres offering comprehensive abortion care. IMPACT: The study addresses adolescent satisfaction with abortion care received; if health providers treat adolescent seeking abortion care with respect, friendly and non-judgemental attitude, it will enable adolescents to seek abortion care from qualified professionals instead of unskilled service providers to reduce maternal mortality. PATIENT'S CONTRIBUTION: Patients from 11 reproductive centres responded to the questionnaire used for the data collection.

Mistreatment of women during childbirth and postpartum depression: secondary analysis of WHO community survey across four countries.

BACKGROUND: Postpartum depression (PPD) is a leading cause of disability globally with estimated prevalence of approximately 20% in low-income and middle-income countries. This study aims to determine the prevalence and factors associated with PPD following mistreatment during facility-based childbirth. METHOD: This secondary analysis used data from the community survey of postpartum women in Ghana, Guinea, Myanmar and Nigeria for the WHO study, 'How women are treated during facility-based childbirth'. PPD was defined using the Patient Health Questionnaire (PHQ-9) tool. Inferential analyses were done using the generalised ordered partial proportional odds model. RESULTS: Of the 2672 women, 39.0% (n=1041) developed PPD. 42.2% and 5.2% of mistreated women developed minimal/mild PPD and moderate/severe PPD, respectively. 43.0% and 50.6% of women who experienced verbal abuse and stigma/discrimination, respectively developed minimal/mild PPD. 46.3% of women who experienced physical abuse developed minimal/mild PPD while 7.6% of women who experienced stigma/discrimination developed moderate/severe PPD. In the adjusted model, women who were physically abused, verbally abused and stigma/discrimination compared with those who were not were more likely to experience any form of PPD ((OR: 1.57 (95% CI 1.19 to 2.06)), (OR: 1.42 (95% CI 1.18 to 1.69)) and (OR: 1.69 (95% CI 1.03 to 2.78))), respectively. Being single and having higher education were associated with reduced odds of experiencing PPD. CONCLUSION: PPD was significantly prevalent among women who experienced mistreatment during childbirth. Women who were single, and had higher education had lower odds of PPD. Countries should implement women-centred policies and programmes to reduce mistreatment of women and improve women's postnatal experiences.

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.

Comparing observed occurrence of mistreatment during childbirth with women's self-report: a validation study in Ghana, Guinea and Nigeria.

BACKGROUND: There has been substantial progress in developing approaches to measure mistreatment of women during childbirth. However, less is known about the differences in measurement approaches. In this study, we compare measures of mistreatment obtained from the same women using labour observations and community-based surveys in Ghana, Guinea and Nigeria. METHODS: Experiences of mistreatment during childbirth are person-centred quality measures. As such, we assessed individual-level and population-level accuracy of labour observation relative to women's self-report for different types of mistreatment. We calculated sensitivity, specificity, percent agreement and population-level inflation factor (IF), assessing prevalence of mistreatment in labour observation divided by 'true' prevalence in women's self-report. We report the IF degree of bias as: low (0.75

Determinants of sexual dysfunction in pregnancy in a large tertiary hospital in Ghana.

OBJECTIVE: To determine the factors associated with sexual dysfunction in pregnancy. METHODS: A cross-sectional facility-based study using quantitative methods was carried out among pregnant women attending antenatal clinic of the Greater Accra Regional Hospital from 14th May to 25th June 2018. Four hundred and twenty-seven married or cohabiting women who were at least eight weeks pregnant and have been living together with their partners for at least four weeks prior to the survey were consecutively recruited. The Female Sexual Function Index (FSFI) tool was used to assess their sexual function. Pearson's Chi Square, Fischer's exact, Mann Whitney and Student's t-tests were used for bivariate analysis where appropriate between sexual dysfunction (dependent variable) and demographic, obstetrics and gynecologic factors (independent variables). Multiple logistic regression was done. Statistical significance was set at p-value of less than 0.05 at bivariate and multivariable analyses. RESULTS: The mean age of the respondents was 30.8 ± 4.8 years. Their mean gestational age was 32.3 ± 7.1 weeks. Marital status and duration of stay in marriage or cohabitation were significantly associated with sexual dysfunction with adjusted odds ratios of 1.88 (p-value < 0.05) and 1.08 (p-value < 0.05) respectively. CONCLUSION: Cohabiting and increasing length of stay with spouse are significantly associated with sexual dysfunction in pregnancy.

Contraceptive counseling in 2 urban cities in Ghana and the extent of shared decision-making.

BACKGROUND: Increased use of contraception is associated with reduced maternal mortality worldwide; however, an unmet need remains high in many places, including Ghana. The quality of care provided by family planning practitioners influences contraceptive use; one way to improve the quality of care is to adopt a client-centered approach to counseling, including engaging in shared decision-making. In Ghana, little is currently known about the extent of shared decision-making between clients and providers in contraceptive counseling encounters. OBJECTIVE: The purpose of this study was to explore the extent of shared decision-making during contraceptive counseling in 2 cities in Ghana. STUDY DESIGN: This was a cross-sectional study across 6 urban family planning clinics in Accra and Kumasi, Ghana. We recorded, transcribed, and analyzed 20 family planning patient-provider interactions using the "Observing PatienT InvOlvemeNt" (OPTION) scale. This scale has 12 domains, which are scored on a 5-point scale, from 0 ("the behavior is not observed") to 4 ("the behavior is observed and executed at a high standard"); the scores of each domain are summed up for a total score ranging from 0 to 48. RESULTS: In these encounters, the mean total scores for each interaction ranged from a low of 9.25/48 to a high of 21.5/48. Although providers were thorough in sharing medical information with clients, they did not actively involve clients in the decision-making process and did not generally elicit client preferences. Across the 12 domains, the mean total score was 34.7%, which is below the 50% that would correspond with a "baseline skill level," suggesting there are very low levels of shared decision-making currently occurring. CONCLUSIONS: In these 20 patient-provider encounters, counseling was mainly a sharing of medical information from the provider with the client, without the provider eliciting information from the client about her preferences for method characteristics, side effects, or method preference. Family planning counseling in these settings would benefit from increased shared decision-making to engage patients in their contraceptive choice.

Malaria and typhoid fever among patients presenting with febrile illnesses in Ga West Municipality, Ghana.

BACKGROUND: Clinicians in areas where malaria and typhoid fever are co-endemic often treat infected patients irrationally, which may lead to the emergence of drug resistance and extra cost to patients. This study determined the proportion of febrile conditions attributable to either malaria and/or typhoid fever and the susceptibility patterns of Salmonella spp. isolates to commonly used antimicrobial agents in Ghana. METHODS: One hundred and fifty-seven (157) febrile patients attending the Ga West Municipal Hospital, Ghana, from February to May 2017 were sampled. Blood samples were collected for cultivation of pathogenic bacteria and the susceptibility of the Salmonella isolates to antimicrobial agents was performed using the Kirby-Bauer disk diffusion method with antibiotic discs on Müller Hinton agar plates. For each sample, conventional Widal test for the detection of Salmonella spp was done as well as blood film preparation for detection of Plasmodium spp. Data on the socio-demographic and clinical characteristics of the study participants were collected using an android technology software kobo-collect by interview. RESULTS: Of the total number of patients aged 2-37 years (median age = 6 years, IQR 3-11), 82 (52.2%) were females. The proportion of febrile patients with falciparum malaria was 57/157 (36.3%), while Salmonella typhi O and H antigens were detected in 23/157 (14.6%) of the samples. The detection rate of Salmonella spp in febrile patients was 10/157 (6.4%). Malaria and typhoid fever coinfection using Widal test and blood culture was 9 (5.7%) and 3 (1.9%), respectively. The isolates were highly susceptible to cefotaxime, ceftriaxone, ciprofloxacin, and amikacin but resistant to ampicillin, tetracycline, co-trimoxazole, gentamicin, cefuroxime, chloramphenicol, and meropenem. CONCLUSION: Plasmodium falciparum and Salmonella spp coinfections were only up to 1.9%, while malaria and typhoid fever, individually, were responsible for 36.3% and 6.4%, respectively. Treatment of febrile conditions must be based on laboratory findings in order not to expose patients to unnecessary side effects of antibiotics and reduce the emergence and spread of drug resistance against antibiotics.

Are respectful maternity care (RMC) interventions effective in reducing intrapartum mistreatment against adolescents? A systematic review.

Intrapartum mistreatment of women by health professionals is a widespread global public health challenge. It leads to a decreased quality of maternity care and is evinced to precipitate detrimental maternal and neonatal outcomes, especially among adolescents. Relatedly, research indicates that Respectful Maternity Care (RMC) interventions are especially effective in mitigating intrapartum mistreatment and improving birth outcomes. However, evidence on the success of RMC, specifically for adolescents, is insufficient and unaggregated. Accordingly, this review specifically aims to synthesize existing evidence on RMC care provision to adolescent parturients. This review searched for relevant literature from published and gray sources including PubMed, ScienceDirect, Cochrane, CINAHL, PsycINFO, Scopus, as well as Population Council, WHO and White Ribbon Alliance data sources published between January 1990 and December 2021. Based on eligibility, studies were selected and quality appraised after which thematic analysis and narrative synthesis was conducted. Twenty-nine studies were included in the systematic review. Due to paucity and heterogeneity of quantitative studies, the review was limited to a thematic analysis. Adolescent and health provider perspectives alike underscored the burden and outcomes of mistreatment. Need for RMC interventions to improve quality of maternity care was recommended by majority of studies. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42020183440.

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.

Give women what they want: contraceptive discontinuation and method preference in urban Ghana.

BACKGROUND: Unmet need for contraception remains high in Ghana. Reducing the number of women who discontinue their contraceptive use is one way to decrease the number of women with an unmet need. In this study, we investigated factors associated with discontinuation among a cohort of Ghanaian women. METHODS: Women who were beginning a new method of contraception at one of six urban clinics in Accra and Kumasi, Ghana were invited to participate in our study. Participants were interviewed before and after their counseling session, and at 3-, 6-, 9-, and 12-months post-enrollment to determine continuation. During follow-up, participants who were no longer using their method were asked why, if they were using any method of contraception, and if so, which method. Logistic regression analysis was performed to identify factors associated with discontinuation for reason other than pregnancy or desired pregnancy. RESULTS: Of the 472 women who reported leaving their counseling session with a method, 440 (93.2%) had at least one follow-up contact. Of the 440 women, 110 (25%) discontinued their method at some point over the 12-month period, and 94 (85.5%) did so for reasons other than pregnancy or desired pregnancy. In the multivariate regression analysis, women who reported they were given their method of choice were 12.0% less likely to discontinue due to a non-pregnancy reason (p=0.005); those who used a long-acting reversible contraceptive (LARC) method were 11.1% less likely (p=.001); and those who reported they would choose to use that method again, one measure of satisfaction, were 23.4% less likely (p<.001). CONCLUSIONS: To our knowledge, the current study is the first to explore method preference and its relation to continuation. Women in our study who reported they were given the contraceptive method of their choice were less likely to discontinue using that method for non-pregnancy-related reasons. Further, those who adopted a LARC method and those who reported they would make the same method choice again were less likely to discontinue. Women should be supported in selecting a contraceptive method of their choice. Providers should work with their clients to find a method which meets their preferences.

Health workers' and hospital administrators' perspectives on mistreatment of women during facility-based childbirth: a multicenter qualitative study in Ghana.

BACKGROUND: Globally, mistreatment of women during facility-based childbirth continues to impact negatively on the quality of maternal healthcare provision and utilization. The views of health workers are vital in achieving comprehensive understanding of mistreatment of women, and to design evidence-based interventions to prevent it. We explored the perspectives of health workers and hospital administrators on mistreatment of women during childbirth to identify opportunity for improvement in the quality of maternal care in health facilities. METHODS: A qualitative study comprising in-depth interviews (IDIs) with 24 health workers and hospital administrators was conducted in two major towns (Koforidua and Nsawam) in the Eastern region of Ghana. The study was part of a formative mixed-methods project to develop an evidence-based definition, identification criteria and two tools for measuring mistreatment of women in facilities during childbirth. Data analysis was undertaken based on thematic content via the inductive analytic framework approach, using Nvivo version 12.6.0. RESULT: Health workers and hospital administrators reported mixed feelings regarding the quality of care women receive. Almost all respondents were aware of mistreatment occurring during childbirth, describing physical and verbal abuse and denial of preferred birthing positions and companionship. Rationalizations for mistreatment included limited staff capacity, high workload, perceptions of women's non-compliance and their attitudes towards staff. Health workers had mixed responses regarding the acceptability of mistreatment of women, although most argued against it. Increasing staff strength, number of health facilities, refresher training for health workers and adequate education of women about pregnancy and childbirth were suggestions to minimize such mistreatment. CONCLUSION: Health workers indicated that some women are mistreated during birth in the study sites and provided various rationalizations for why this occurred. There is urgent need to motivate, retrain or otherwise encourage health workers to prevent mistreatment of women and promote respectful maternity care. Further research on implementation of evidence-based interventions could help mitigate mistreatment of women in health facilities.

Respectful maternity care is vital to achieving positive pregnancy and childbirth experiences for women and their families. Mistreatment of women during childbirth at facilities can negatively impact women's future health seeking behaviors and utilization of maternal care services. The experiences and perspectives of doctors, midwives and nurses working in labour wards are vital in understanding how women are treated during childbirth, and what measures can be taken to prevent it. In this study, we explored the opinions of health workers and hospital administrators on how women are treated during childbirth to determine the gaps in the quality of maternal care in health facilities in Ghana.Participants expressed mixed feelings concerning mistreatment of women during childbirth. Most were aware of the occurrence of mistreatment in health facilities including physical and verbal abuse, and denial of preferred position for childbirth and companionship. The reasons provided for mistreatment included low staff capacity, high workload, non-compliance by women and poor attitudes towards health workers. Most health workers were against mistreatment during childbirth. Participants thought mistreatment could be minimized by improving staff skills, refresher training, and childbirth preparation education for women. Our study indicates the need to motivate, retrain or encourage health professionals to provide respectful care to women during childbirth to improve their experience of care. Further research to help implement better maternity care devoid of mistreatment in health facilities in Ghana is needed.

Antenatal Doppler screening for fetuses at risk of adverse outcomes: a multicountry cohort study of the prevalence of abnormal resistance index in low-risk pregnant women.

INTRODUCTION: Few interventions exist to address the high burden of stillbirths in apparently healthy pregnant women in low- and middle-income countries (LMICs). To establish whether a trial on the impact of routine Doppler screening in a low-risk obstetric population is warranted, we determined the prevalence of abnormal fetal umbilical artery resistance indices among low-risk pregnant women using a low-cost Doppler device in five LMICs. METHODS: We conducted a multicentre, prospective cohort study in Ghana, India, Kenya, Rwanda and South Africa. Trained nurses or midwives performed a single, continuous-wave Doppler screening using the Umbiflow device for low-risk pregnant women (according to local guidelines) between 28 and 34 weeks' gestation. We assessed the prevalence of abnormal (raised) resistance index (RI), including absent end diastolic flow (AEDF), and compared pregnancy and health service utilisation outcomes between women with abnormal RI versus those with normal RI. RESULTS: Of 7151 women screened, 495 (6.9%) had an abnormal RI, including 14 (0.2%) with AEDF. Caesarean section (40.8% vs 28.1%), labour induction (20.5% vs 9.0%) and low birth weight (<2500 g) (15.0% vs 6.8%) were significantly more frequent among women with abnormal RI compared with women with normal RI. Abnormal RI was associated with lower birth weights across all weight centiles. Stillbirth and perinatal mortality rates were similar between women with normal and abnormal RI. CONCLUSION: A single Doppler screening of low-risk pregnant women in LMICs using the Umbiflow device can detect a large number of fetuses at risk of growth restriction and consequent adverse perinatal outcomes. Many perinatal deaths could potentially be averted with appropriate intervention strategies. TRIAL REGISTRATION NUMBER: CTRI/2018/07/01486.

Fragmentation of care during pregnancy in the Volta Region of Ghana: A social network analysis approach.

To determine the extent of care fragmentation during pregnancy and delivery in the Volta Region of Ghana. The National Health Insurance Claims Data for the Volta Region for the period January -December 2013 was used. Pregnant women who delivered at a health facility and made at least 3 visits were included in the study. Social network analysis (SNA) approach was used to determine care fragmentation. Fragmentation of care during delivery was defined to be any delivery at a facility different from the woman's most frequently visited antenatal care (ANC) facility. Network metrics (weighted in-degree and weighted out-degree) were used to determine extent of care fragmentation and also the key facilities contributing to the fragmentation. Overall, 14,474 pregnant women were included in the study with 15% (2,185) having cesarean section (CS). A total of 6,025 (42%) of all the pregnant women visited more than one facility during ANC and delivery, out of which 960 (16%) had CS. About 26% (3,769) of all deliveries and 32% (696) of all CS deliveries were fragmented. Fragmentation among those that had CS was significantly higher compared to those that had vaginal delivery (VD) (32% versus 25%, x²=45.88, p<0.001). Among those who visited multiple facilities, 63% (73% CS and 61% VD, x²=49.22, p<0.001) were fragmented. In addition, 15% of all deliveries (36% among those who visited multiple facilities) and 20% of all CS deliveries (45% among those who visited multiple facilities) were performed at facilities that the pregnant women never received ANC services from. There is high level of care fragmentation during the critical period of delivery among pregnant women who visited more than one facility. This fragmentation is particularly higher among those that had CS compared to vaginal delivery. This calls for policy to ensure coordination and continuity of care during pregnancy.

Physician Experiences and Perceived Barriers to Providing Quality Infertility Care in the Greater Accra Region of Ghana.

High-quality, patient-centered care is essential to achieving equity and dignity for individuals with infertility, yet few studies have explored quality of infertility care in sub-Saharan Africa. We interviewed 13 non-specialist physicians and 2 medical school faculty to explore experiences in and perceptions of providing infertility care in Greater Accra, Ghana. We used a patient-centered infertility care model to inform our analysis and results. Individualized care and taking time to counsel and emotionally support patients were perceived as the most important things a physician can do to provide quality infertility care. Financial costs and lack of infertility services within a single facility were the most common barriers reported to providing quality infertility care. To the best of our knowledge, our study is the first to explore quality of infertility care provided by physicians in public sector facilities in Ghana, shedding light on existing barriers and identifying strategies for improvement.

Vaginal examinations and mistreatment of women during facility-based childbirth in health facilities: secondary analysis of labour observations in Ghana, Guinea and Nigeria.

BACKGROUND: Previous research on mistreatment of women during childbirth has focused on physical and verbal abuse, neglect and stigmatisation. However, other manifestations of mistreatment, such as during vaginal examinations, are relatively underexplored. This study explores four types of mistreatment of women during vaginal examinations: (1) non-consented care, (2) sharing of private information, (3) exposure of genitalia and (4) exposure of breasts. METHODS: A secondary analysis of data from the WHO multicountry study 'How Women Are Treated During Childbirth' was conducted. The study used direct, continuous labour observations of women giving birth in facilities in Ghana, Guinea and Nigeria. Descriptive and multivariable logistic regression analyses were used to describe the different types of mistreatment of women during vaginal examinations and associated privacy measures (ie, availability of curtains). RESULTS: Of the 2016 women observed, 1430 (70.9%) underwent any vaginal examination. Across all vaginal examinations, 842/1430 (58.9%) women were observed to receive non-consented care; 233/1430 (16.4%) women had their private information shared; 397/1430 (27.8%) women had their genitalia exposed; and 356/1430 (24.9%) had their breasts exposed. The observed prevalence of mistreatment during vaginal examinations varied across countries. There were country-level differences in the association between absence of privacy measures and mistreatment. Absence of privacy measures was associated with sharing of private information (Ghana: adjusted OR (AOR) 3.8, 95% CI 1.6 to 8.9; Nigeria: AOR 4.9, 95% CI 1.9 to 12.7), genitalia exposure (Ghana: AOR 6.7, 95% CI 2.9 to 14.9; Nigeria: AOR 6.5, 95% CI 2.9 to 14.5), breast exposure (Ghana: AOR 5.9, 95% CI 2.8 to 12.9; Nigeria: AOR 2.7, 95% CI 1.3 to 5.9) and non-consented vaginal examination (Ghana: AOR 2.5, 95% CI 1.4 to 4.7; Guinea: AOR 0.21, 95% CI 0.12 to 0.38). CONCLUSION: Our results highlight the need to ensure better communication and consent processes for vaginal examination during childbirth. In some settings, measures such as availability of curtains were helpful to reduce women's exposure and sharing of private information, but context-specific interventions will be required to achieve respectful maternity care globally.

Evidence on respectful maternity care for adolescents: a systematic review protocol.

BACKGROUND: Intrapartum mistreatment of women is an ubiquitous public health and human rights challenge. The issue reportedly has severe maternal and neonatal outcomes including mortality, and generally leads to a decreased satisfaction with maternity care. Intrapartum mistreatment, despite being ubiquitous, indicates higher incidence amongst adolescent parturients who are simultaneously at a higher risk of maternal morbidity and mortality. Studies have suggested that Respectful Maternity Care interventions reduce intrapartum mistreatment and improve clinical outcomes for women and neonates in general. However, evidence on the effect of RMC on adolescents is unclear. Hence, the specific aim of this study is to synthesise the available evidence relating to the provision of RMC for adolescents during childbirth. METHODS: The methodology of the proposed systematic review follows the procedural guideline depicted in the preferred reporting items for systematic review protocol. The review will include published studies and gray literature from January 1, 1990, to June 30, 2021. Electronic databases including MEDLINE, PubMed, ScienceDirect, Cochrane, CINAHL, PsycINFO, Scopus, Google Scholar and Web of Science will be searched to retrieve available studies using the appropriate search strings. Studies included in the review will be appraised for quality using tools tailored to each study design. If appropriate, we will conduct random effects meta-analysis of data to summarise the pooled estimates of respectful maternity care prevalence and outcomes. The selection of relevant studies, data extraction and quality assessment of individual studies will be carried out by two independent authors. RESULTS: Summaries of the findings will be compiled and synthesised in a narrative summary. In addition to the narrative synthesis, where sufficient data are available, a random-effects meta-analysis will be conducted to obtain a pooled estimate value for respectful maternity care prevalence and outcomes. DISCUSSION: Respectful Maternity Care for adolescents holds great promise for improved maternal and neonatal care. However, there is a gap in knowledge on the interventions that work and the extent of their effectiveness. Findings from this study will be beneficial in improving Adolescents Sexual and Reproductive Health and Rights and reducing maternal mortality, especially for adolescents. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020183440.

Women's report of mistreatment during facility-based childbirth: validity and reliability of community survey measures.

BACKGROUND: Accountability for mistreatment during facility-based childbirth requires valid tools to measure and compare birth experiences. We analyse the WHO 'How women are treated during facility-based childbirth' community survey to test whether items mapping the typology of mistreatment function as scales and to create brief item sets to capture mistreatment by domain. METHODS: The cross-sectional community survey was conducted at up to 8 weeks post partum among women giving birth at hospitals in Ghana, Guinea, Myanmar and Nigeria. The survey contained items assessing physical abuse, verbal abuse, stigma, failure to meet professional standards, poor rapport with healthcare workers, and health system conditions and constraints. For all domains except stigma, we applied item-response theory to assess item fit and correlation within domain. We tested shortened sets of survey items for sensitivity in detecting mistreatment by domain. Where items show concordance and scale reliability ≥0.60, we assessed convergent validity with dissatisfaction with care and agreement of scale scores between brief and full versions. RESULTS: 2672 women answered over 70 items on mistreatment during childbirth. Reliability exceeded 0.60 in all countries for items on poor rapport with healthcare workers and in three countries for items on failure to meet professional standards; brief scales generally showed high agreement with longer versions and correlation with dissatisfaction. Brief item sets were ≥85% sensitive in detecting mistreatment in each country, over 90% for domains of physical abuse and health system conditions and constraints. CONCLUSION: Brief scales to measure two domains of mistreatment are largely comparable with longer versions and can be informative for these four distinct settings. Brief item sets efficiently captured prevalence of mistreatment in the five domains analysed; stigma items can be used and adapted in full. Item sets are suitable for confirmation by context and implementation to increase accountability and inform efforts to eliminate mistreatment during childbirth.

Pilot monitoring and evaluation of the WHO postpartum family planning compendium mobile application: An in-depth, qualitative study.

OBJECTIVE: To assess the feasibility, functionality and acceptability of a mobile application (app), the World Health Organization (WHO) Postpartum Family Planning (PPFP) Compendium, in clinical care. METHOD: This prospective qualitative study was conducted among family planning providers routinely delivering PPFP care in Accra, Ghana. We conducted in-depth interviews at baseline and 3 months after app introduction. We elicited expected technological, psychological and environmental barriers to use, actual use in clinical settings, and feedback for app improvement. With inter-coder reliability, we analyzed the content of interview transcripts. RESULTS: Twenty providers participated in baseline interviews, and 19 participated in follow-up interviews. At baseline, providers did not have significant technological barriers to its use and felt the app was acceptable, but were concerned about the appropriateness of using an app during clinical care. At 3-month follow-up, 18 out of 19 participants reported using the app weekly, and found the app acceptable for use in clinical care. Providers recommended expanding clinical content and including similar guidance relevant to times outside the postpartum period. CONCLUSION: Use of a PPFP counseling app to aid family planning providers in clinical care delivery is feasible and acceptable. Providers recommended inclusion of similar guidance relevant to times outside the postpartum period.