Cost of childbirth in Upper West Region of Ghana: a cross-sectional study.

BACKGROUND: Out-of-pocket payment (OOPP) is reported to be a major barrier to seeking maternal health care especially among the poor and can expose households to a risk of catastrophic expenditure and impoverishment.This study examined the OOPPs women made during childbirth in the Upper West region of Ghana. METHODS: We carried out a cross-sectional study and interviewed women who gave birth between January 2013 and December 2017. Data on socio-demographic characteristics, place of childbirth, as well as direct cost (medical and non-medical) were collected from respondents. The costs of childbirth were estimated from the patient perspective. Logistics regression was used to assess the factors associated with catastrophic payments cost. All analyses were done using STATA 16.0. RESULTS: Out of the 574 women interviewed, about 71% (406/574) reported OOPPs on their childbirth. The overall average direct medical and non-medical expenditure women made on childbirth was USD 7.5. Cost of drugs (USD 8.0) and informal payments (UDD 5.7) were the main cost drivers for medical and non-medical costs respectively. Women who were enrolled into the National Health Insurance Scheme (NHIS) spent a little less (USD 7.5) than the uninsured women (USD 7.9). Also, household childbirth expenditure increased from primary health facilities level (community-based health planning and services compound = USD7.2; health centre = USD 6.0) to secondary health facilities level (hospital = USD11.0); while home childbirth was USD 4.8. Overall, at a 10% threshold, 21% of the respondents incurred catastrophic health expenditure. Regression analysis showed that place of childbirth and household wealth were statistically significant factors associated with catastrophic payment. CONCLUSIONS: The costs of childbirth were considerably high with a fifth of households spending more than one-tenth of their monthly income on childbirth and therefore faced the risk of catastrophic payments and impoverishment. Given the positive effect of NHIS on cost of childbirth, there is a need to intensify efforts to improve enrolment to reduce direct medical costs as well as sensitization and monitoring to reduce informal payment. Also, the identified factors that influence cost of childbirth should be considered in strategies to reduce cost of childbirth.

Mixed effect analysis of factors influencing the use of insecticides treated bed nets among pregnant women in Ghana: evidence from the 2019 Malaria Indicator Survey.

BACKGROUND: Malaria during pregnancy is a major cause of maternal morbidity globally and leads to poor birth outcomes. The World Health Organization has recommended the use of insecticide treated bed nets (ITN) as one of the effective malaria preventive strategies among pregnant women in malaria endemic areas. This study, therefore, seeks to examine the individual and household factors associated with the use of ITNs among pregnant women in Ghana. METHODS: Data for this study was obtained from the 2019 Ghana Malaria Indicator Survey (GMIS) conducted between September 25 and November 24, 2019. The weighted sample comprised 353 pregnant women aged 15-49 years. Data was analyzed with SPSS version 22 using both descriptive and multilevel logistics regression modelling. Statistically significant level was set at p < 0.05. RESULTS: The study found that 49.2% of pregnant women in Ghana use ITN to prevent malaria. Pregnant women aged 35-49 years (AOR = 3.403, CI: 1.191-9.725), those with no formal education (AOR = 5.585, CI = 1.315-23.716), and those who had secondary education (AOR = 3.509, CI = 1.076-11.440) had higher odds of using ITN. Similarly, higher odds of ITN usage was found among who belonged to the Akan ethnic group (AOR = 7.234, CI = 1.497-34.955), dwell in male-headed households (AOR = 2.232, CI = 1.105-4.508) and those whose household heads are aged 60-69 years (AOR = 4.303, CI = 1.160-15.966). However, pregnant women who resided in urban areas (AOR = 0.355, CI = 0.216-0.582), those whose household heads aged 40-49 years (AOR = 0.175, CI = 0.066-0.467) and those who belonged to richer (AOR =0.184, CI = 0.050-0.679) and richest (AOR = 0.107, CI = 0.021-0.552) households had lower odds of using ITN for malaria prevention. CONCLUSIONS: Individual socio-demographic and household factors such as pregnant women's age, educational level, place of residence, ethnicity, sex and age of household head, and household wealth quintile are associated with the use of ITN for malaria prevention among pregnant women. These factors ought to be considered in strengthening malaria prevention campaigns and develop new interventions to help increase ITN utilization among vulnerable population living in malaria- endemic areas.

Determinants of willingness to accept child vaccination against malaria in Ghana.

BACKGROUND: Malaria is a public health problem in Ghana with children being one of the most vulnerable. Given this, in 2019, Ghana decided to add the first malaria vaccine (RTS, S) as part of routine immunisations for children in the near future. This study, thus, examines the determinants of malaria vaccine awareness and willingness to uptake the vaccine for children in Ghana. METHOD: The study uses data from the 2019 Ghana Malaria Indicator Survey while employing the binary logistic regression as the empirical estimation technique. RESULTS: The study finds that religion, region of residence and awareness of the malaria vaccine, influence the willingness to uptake the vaccine for children. Moreover, younger mothers (15-26 years), households in the richest wealth quintile, male-headed households and the number of children aged five years and below in a household, are found to be associated with less willingness to uptake the vaccine for children. CONCLUSION: Paying attention to awareness creation, region, religion, younger mothers (15-26 years), households in the richest wealth quintile, male-headed households and households with more children aged five years and below, can ensure optimal uptake of the malaria vaccine for children in Ghana.

Supporting maternal and child nutrition: views from community members in rural Northern Ghana.

OBJECTIVE: Despite efforts to improve maternal and child nutrition, undernutrition remains a major public health challenge in Ghana. The current study explored community perceptions of undernutrition and context-specific interventions that could improve maternal and child nutrition in rural Northern Ghana. DESIGN: This exploratory qualitative study used ten focus group discussions to gather primary data. The discussions were recorded, transcribed and coded into themes using Nvivo 12 software to aid thematic analysis. SETTING: The study was conducted in rural Kassena-Nankana Districts of Northern Ghana. STUDY PARTICIPANTS: Thirty-three men and fifty-one women aged 18-50 years were randomly selected from the community. RESULTS: Most participants reported poverty, lack of irrigated agricultural land and poor harvests as the main barriers to optimal nutrition. To improve maternal and child nutrition, study participants suggested that the construction of dams at the community level would facilitate all year round farming including rearing of animals. Participants perceived that the provision of agricultural materials such as high yield seedlings, pesticides and fertiliser would help boost agricultural productivity. They also recommended community-based nutrition education by trained health volunteers, focused on types of locally produced foods and appropriate ways to prepare them to help improve maternal and child nutrition. CONCLUSION: Drawing on these findings and existing literature, we argue that supporting community initiated nutrition interventions such as improved irrigation for dry season farming, provision of agricultural inputs and community education could improve maternal and child nutrition.

Updated Emission Factors from Diffuse Combustion Sources in Sub-Saharan Africa and Their Effect on Regional Emission Estimates.

Diffuse emission sources outside of kitchen areas are poorly understood, and measurements of their emission factors (EFs) are sparse for regions of sub-Saharan Africa. Thirty-one in-field emission measurements were taken in northern Ghana from combustion sources common to rural regions worldwide. Sources sampled included commercial cooking, trash burning, kerosene lanterns, and diesel generators. EFs were calculated for carbon monoxide (CO), carbon dioxide (CO2), as well as carbonaceous particulate matter, specifically elemental carbon (EC) and organic carbon (OC). EC and OC emissions were measured from kerosene lighting events (EFEC = 25.1 g/kg-fuel SD = 25.7, EFOC = 9.5 g/kg-fuel SD = 10.0). OC emissions from trash burning events were large and highly variable (EFOC = 38.9 g/kg-fuel SD = 30.5). Combining our results with other recent in-field emission factors for rural Ghana, we explored updated emission estimates for Ghana using a region specific emissions inventory. Large differences are calculated for all updated source emissions, showing a 96% increase in OC and 78% decrease in EC compared to prior estimates for Ghana's emissions. Differences for carbon monoxide were small when averaged across all updated source types (-1%), though the household wood use and trash burning categories individually show large differences.

The role of community-based health services in influencing postnatal care visits in the Builsa and the West Mamprusi districts in rural Ghana.

BACKGROUND: Globally, maternal mortality is still a challenge. In Ghana, maternal morbidity and mortality rates remain high, particularly in rural areas. Postnatal Care (PNC) is one of the key strategies for improving maternal health. This study examined determinants of at least three PNC visits in rural Ghana. METHODS: We conducted a cross-sectional study at the Community-Based Health Planning and Services (CHPS) Zones in the Builsa and West Mamprusi Districts between April and June 2016. We selected 650 women who delivered within 5 years preceding the survey (325 from each of the two sites) using the two-stage random sampling technique. RESULTS: Of the 650 respondents, 62% reported attending postnatal care at least three times. In the Builsa district, the percentage of women who made at least three PNC visits were 90% compared with 35% in the West Mamprusi district. Older women and those who attended antenatal clinics at least four times (AOR: 5.23; 95% CI: 2.49-11.0) and women who had partners with some secondary education (AOR: 3.31; 95% CI: 1.17-9.39) were associated with at least three PNC visits. CONCLUSIONS: Men engagement in maternal health services and the introduction of home-based PNC services in rural communities could help health workers reach out to many mothers and children promptly and improve PNC visits in those communities.

Prices, peers, and perceptions (P3): study protocol for improved biomass cookstove project in northern Ghana.

BACKGROUND: Despite their potential health and social benefits, adoption and use of improved cookstoves has been low throughout much of the world. Explanations for low adoption rates of these technologies include prices that are not affordable for the target populations, limited opportunities for households to learn about cookstoves through peers, and perceptions that these technologies are not appropriate for local cooking needs. The P3 project employs a novel experimental design to explore each of these factors and their interactive effects on cookstove demand, adoption, use and exposure outcomes. METHODS: The P3 study is being conducted in the Kassena-Nankana Districts of Northern Ghana. Leveraging an earlier improved cookstove study that was conducted in this area, the central design of the P3 biomass stove experiment involves offering stoves at randomly varying prices to peers and non-peers of households that had previously received stoves for free. Using household surveys, electronic stove use monitors, and low-cost, portable monitoring equipment, we measure how prices and peers' experience affect perceptions of stove quality, the decision to purchase a stove, use of improved and traditional stoves over time, and personal exposure to air pollutants from the stoves. DISCUSSION: The challenges that public health and development communities have faced in spreading adoption of potentially welfare-enhancing technologies, like improved cookstoves, have highlighted the need for interdisciplinary, multisectoral approaches. The design of the P3 project draws on economic theory, public health practice, engineering, and environmental sciences, to more fully grasp the drivers and barriers to expanding access to and uptake of cleaner stoves. Our partnership between academic institutions, in the US and Ghana, and a local environmental non-governmental organization creates unique opportunities to disseminate and scale up lessons learned. TRIAL REGISTRATION: ClinicalTrials.gov NCT03617952 7/31/18 (Retrospectively Registered).

Cost of delivering health care services at primary health facilities in Ghana.

BACKGROUND: There is limited knowledge on the cost of delivering health services at primary health care facilities in Ghana which is posing a challenge in resource allocations. This study therefore estimated the cost of providing health care in primary health care facilities such as Health Centres (HCs) and Community-based Health Planning and Services (CHPS) in Ghana. METHODS: The study was cross-sectional and quantitative data was collected from the health provider perspective. Data was collected between July and August, 2016 at nine primary health facilities (six CHPS and three HCs) from the Upper West region of Ghana. All health related costs for the year 2015 and revenue generated for the period were collected. Data were captured and analysed using Microsoft excel. Costs of delivery health services were estimated. In addition, unit costs such as cost per Outpatient Department (OPD) attendance were estimated. RESULTS: The average annual cost of delivering health services through CHPS and HCs was US$10,923 and US$44,638 respectively. Personnel cost accounted for the largest proportion of cost (61% for CHPS and 59% for HC). The cost per OPD attendance was higher at CHPS (US$8.79) than at HCs (US$5.16). The average Internally Generated Funds (IGF) recorded for the period at CHPS and HCs were US$2327 and US$ 15,795 respectively. At all the facilities, IGFs were greatly lower than costs of running the health facilities. Also, at both the CHPS and HCs, the National Health Insurance Scheme (NHIS) reimbursement was the main source of revenue accounting for over 90% total IGF. CONCLUSIONS: The average annual cost of delivering primary health services through CHPS and HCs is US$10,923 and US$44,638 respectively and personnel cost accounts for the major cost. The government should be guided by these findings in their financial planning, decision making and resource allocation in order to improve primary health care in the country. However, more similar studies involving large numbers of primary health facilities in different parts of the country are needed to assess the cost of providing primary health care.

Cost-effectiveness of an electronic clinical decision support system for improving quality of antenatal and childbirth care in rural Tanzania: an intervention study.

BACKGROUND: QUALMAT project aimed at improving quality of maternal and newborn care in selected health care facilities in three African countries. An electronic clinical decision support system was implemented to support providers comply with established standards in antenatal and childbirth care. Given that health care resources are limited and interventions differ in their potential impact on health and costs (efficiency), this study aimed at assessing cost-effectiveness of the system in Tanzania. METHODS: This was a quantitative pre- and post- intervention study involving 6 health centres in rural Tanzania. Cost information was collected from health provider's perspective. Outcome information was collected through observation of the process of maternal care. Incremental cost-effectiveness ratios for antenatal and childbirth care were calculated with testing of four models where the system was compared to the conventional paper-based approach to care. One-way sensitivity analysis was conducted to determine whether changes in process quality score and cost would impact on cost-effectiveness ratios. RESULTS: Economic cost of implementation was 167,318 USD, equivalent to 27,886 USD per health center and 43 USD per contact. The system improved antenatal process quality by 4.5% and childbirth care process quality by 23.3% however these improvements were not statistically significant. Base-case incremental cost-effectiveness ratios of the system were 2469 USD and 338 USD per 1% change in process quality for antenatal and childbirth care respectively. Cost-effectiveness of the system was sensitive to assumptions made on costs and outcomes. CONCLUSIONS: Although the system managed to marginally improve individual process quality variables, it did not have significant improvement effect on the overall process quality of care in the short-term. A longer duration of usage of the electronic clinical decision support system and retention of staff are critical to the efficiency of the system and can reduce the invested resources. Realization of gains from the system requires effective implementation and an enabling healthcare system. TRIAL REGISTRATION: Registered clinical trial at www.clinicaltrials.gov ( NCT01409824 ). Registered May 2009.

A qualitative analysis of the effect of a community-based primary health care programme on reproductive preferences and contraceptive use among the Kassena-Nankana of northern Ghana.

BACKGROUND: In 2000, Ghana launched the Community-based Health Planning and Services (CHPS) initiative to improve access to health and family planning services. This initiative was based in part on research, known as the Navrongo Project, conducted in the Kassena-Nankana district (KND) between 1994 to 2003 which demonstrated significant impact on fertility and child mortality. This paper examines current contraceptive perceptions in communities that were exposed to the Project's service models over the 1994 to 2003 period, and the post-experimental policies of the CHPS era. METHODS: Qualitative study was conducted in the KND of Ghana from June to September, 2012, by convening 8 male and 8 female FGD panels as well as 8 in-depth interviews of community leaders. Data collection was stratified by original experimental cell of the Navrongo Project to permit appraisal of social effects of contrasting experimental conditions. Inductive content analysis was performed with QSR Nvivo 10 to identify predominant themes. RESULTS: While findings show that exposure to community-based services was associated with enhanced approval of birth spacing and limitation, this view is grounded in perceptions that childhood survival has improved. Nonetheless, concerns were expressed about contraceptive side effects, prominently permanent sterility. Strategies for male outreach and community engagement originally introduced during the Navrongo Project have not been sustained with CHPS scale-up. The apparent atrophy of attention to the needs of men may explain the resistance of some males to the notion of female reproductive autonomy and the practice of some women to adopt contraception in secret. Despite this apparent programmatic dearth of male engagement, there is evidence to suggest that social impact of the original male engagement strategy persists in communities where male mobilization was combined with doorstep provision of family planning care during the Navrongo Project. CONCLUSION: Community-based services fostered attitudinal change towards family planning in a traditional sub-Saharan African setting. Sustained exposure to primary health care that have improved the survival of children has made the use of contraception more acceptable. Efforts should be embedded in primary health care programmes that address concerns about child survival while also consigning sustained priority to the information needs of men.

An exploration of moral hazard behaviors under the national health insurance scheme in Northern Ghana: a qualitative study.

BACKGROUND: The government of Ghana introduced the National Health Insurance Scheme (NHIS) in 2003 through an Act of Parliament (Act 650) as a strategy to improve financial access to quality basic health care services. Although attendance at health facilities has increased since the introduction of the NHIS, there have been media reports of widespread abuse of the NHIS by scheme operators, service providers and insured persons. The aim of the study was to document behaviors and practices of service providers and clients of the NHIS in the Kassena-Nankana District (KND) of Ghana that constitute moral hazards (abuse of the scheme) and identify strategies to minimize such behaviors. METHODS: Qualitative methods through 14 Focused Group Discussions (FGDs) and 5 individual in-depth interviews were conducted between December 2009 and January 2010. Thematic analysis was performed with the aid of QSR NVivo 8 software. RESULTS: Analysis of FGDs and in-depth interviews showed that community members, health providers and NHIS officers are aware of various behaviors and practices that constitute abuse of the scheme. Behaviors such as frequent and 'frivolous' visits to health facilities, impersonation, feigning sickness to collect drugs for non-insured persons, over charging for services provided to clients, charging clients for services not provided and over prescription were identified. Suggestions on how to minimize abuse of the NHIS offered by respondents included: reduction of premiums and registration fees, premium payments by installment, improvement in the picture quality of the membership cards, critical examination and verification of membership cards at health facilities, some ceiling on the number of times one can seek health care within a specified time period, and general education to change behaviors that abuse the scheme. CONCLUSION: Attention should be focused on addressing the identified moral hazard behaviors and pursue cost containment strategies to ensure the smooth operation of the scheme and enhance its sustainability.

Cost to households in treating maternal complications in northern Ghana: a cross sectional study.

BACKGROUND: The cost of treating maternal complications has serious economic consequences to households and can hinder the utilization of maternal health care services at the health facilities. This study estimated the cost of maternal complications to women and their households in the Kassena-Nankana district of northern Ghana. METHODS: We carried out a cross-sectional study between February and April 2014 in the Kassena-Nankana district. Out of a total of 296 women who were referred to the hospital for maternal complications from the health centre level, sixty of them were involved in the study. Socio-demographic data of respondents as well as direct and indirect costs involved in the management of the complications at the hospital were collected from the patient's perspective. Analysis was performed using STATA 11. RESULTS: Out of the 60 respondents, 60% (36) of them suffered complications due to prolonged labour, 17% (10) due to severe abdominal pain, 10% (6) due to anaemia/malaria and 7% (4) due to pre-eclampsia. Most of the women who had complications were primiparous and were between 21-25 years old. Transportation cost accounted for the largest cost, representing 32% of total cost of treatment. The median direct medical cost was US$8.68 per treatment, representing 44% of the total cost of treatment. Indirect costs accounted for the largest proportion of total cost (79%). Overall, the median expenditure by households on both direct and indirect costs per complication was US$32.03. Disaggregating costs by type of complication, costs ranged from a median of US$58.33 for pre-eclampsia to US$6.84 for haemorrrhage. The median number of days spent in the hospital was 2 days - five days for pre-eclampsia. About 33% (6) of households spent more than 5% of annual household expenditure and therefore faced catastrophic payments. CONCLUSION: Although maternal health services are free in Ghana, women still incur substantial costs when complications occur and face the risk of incurring catastrophic health expenditure.

Cost of installing and operating an electronic clinical decision support system for maternal health care: case of Tanzania rural primary health centres.

BACKGROUND: Poor quality of care is among the causes of high maternal and newborn disease burden in Tanzania. Potential reason for poor quality of care is the existence of a "know-do gap" where by health workers do not perform to the best of their knowledge. An electronic clinical decision support system (CDSS) for maternal health care was piloted in six rural primary health centers of Tanzania to improve performance of health workers by facilitating adherence to World Health Organization (WHO) guidelines and ultimately improve quality of maternal health care. This study aimed at assessing the cost of installing and operating the system in the health centers. METHODS: This retrospective study was conducted in Lindi, Tanzania. Costs incurred by the project were analyzed using Ingredients approach. These costs broadly included vehicle, computers, furniture, facility, CDSS software, transport, personnel, training, supplies and communication. These were grouped into installation and operation cost; recurrent and capital cost; and fixed and variable cost. We assessed the CDSS in terms of its financial and economic cost implications. We also conducted a sensitivity analysis on the estimations. RESULTS: Total financial cost of CDSS intervention amounted to 185,927.78 USD. 77% of these costs were incurred in the installation phase and included all the activities in preparation for the actual operation of the system for client care. Generally, training made the largest share of costs (33% of total cost and more than half of the recurrent cost) followed by CDSS software- 32% of total cost. There was a difference of 31.4% between the economic and financial costs. 92.5% of economic costs were fixed costs consisting of inputs whose costs do not vary with the volume of activity within a given range. Economic cost per CDSS contact was 52.7 USD but sensitive to discount rate, asset useful life and input cost variations. CONCLUSIONS: Our study presents financial and economic cost estimates of installing and operating an electronic CDSS for maternal health care in six rural health centres. From these findings one can understand exactly what goes into a similar investment and thus determine sorts of input modification needed to fit their context.

Efficiency of antenatal care and childbirth services in selected primary health care facilities in rural Tanzania: a cross-sectional study.

BACKGROUND: Cost studies are paramount for demonstrating how resources have been spent and identifying opportunities for more efficient use of resources. The main objective of this study was to assess the actual dimension and distribution of the costs of providing antenatal care (ANC) and childbirth services in selected rural primary health care facilities in Tanzania. In addition, the study analyzed determining factors of service provision efficiency in order to inform health policy and planning. METHODS: This was a retrospective quantitative cross-sectional study conducted in 11 health centers and dispensaries in Lindi and Mtwara rural districts. Cost analysis was carried out using step down cost accounting technique. Unit costs reflected efficiency of service provision. Multivariate regression analysis on the drivers of observed relative efficiency in service provision between the study facilities was conducted. Reported personnel workload was also described. RESULTS: The health facilities spent on average 7 USD per capita in 2009. As expected, fewer resources were spent for service provision at dispensaries than at health centers. Personnel costs contributed a high approximate 44% to total costs. ANC and childbirth consumed approximately 11% and 12% of total costs; and 8% and 10% of reported service provision time respectively. On average, unit costs were rather high, 16 USD per ANC visit and 79.4 USD per childbirth. The unit costs showed variation in relative efficiency in providing the services between the health facilities. The results showed that efficiency in ANC depended on the number of staff, structural quality of care, process quality of care and perceived quality of care. Population-staff ratio and structural quality of basic emergency obstetric care services highly influenced childbirth efficiency. CONCLUSIONS: Differences in the efficiency of service provision present an opportunity for efficiency improvement. Taking into consideration client heterogeneity, quality improvements are possible and necessary. This will stimulate utilization of ANC and childbirth services in resource-constrained health facilities. Efficiency analyses through simple techniques such as measurement of unit costs should be made standard in health care provision, health managers can then use the performance results to gauge progress and reward efficiency through performance based incentives.

Predictors of sexual and reproductive health knowledge and utilization of services among adolescents in Ghana's Adaklu district.

Objective: To explore factors associated with adolescents' sexual and reproductive health (SRH) knowledge and their engagement with educational and clinical services. Design: Regression analysis of secondary data collected during a community survey. Setting: Adaklu district, Volta Region, Ghana. Participants: 221 adolescent caregiver pairs. Main outcome measures: The study employed three main outcome measures: (1) adolescents' level of SRH knowledge (assessed via questionnaire), (2) membership in district-sponsored adolescent health clubs (AHCs), and (3) ever-utilization of clinical SRH services. Results: Greater SRH knowledge was significantly associated with older age, AHC membership, and relying primarily on teachers or friends for SRH information. Increased odds of AHC membership were observed among females (AOR = 2.38, 95% CI 1.14-4.95); those who had communicated with one parent about sexual issues (OR 2.70, 95% CI 1.17-6.21); and those with a history of transactional sex (OR 5.53, 95% CI 1.04-29.37). Decreased odds were observed among adolescents whose caregivers were educated to the primary level (AOR = 0.24, 95% CI = 0.07-0.79). Overall, utilization of clinical SRH services was low, but higher odds were detected among individuals reporting a history of forced sex (AOR = 117.07, 95% CI 3.82-3588.52) and those who had discussed sexual issues with both of their parents (AOR = 13.11, 95% CI 1.85-92.93). Conclusions: Awareness of the predictors of knowledge, AHC involvement, and clinical service utilization can empower adolescent SRH initiatives-both present and future-to enhance their teaching, develop targeted outreach to underserved groups, and promote engagement with key clinical resources. Funding: This work has been supported by grants from the International Development Research Centre [108936] (IDRC), Canada.

A cluster randomized controlled trial to assess the impact of the 'Caring for Providers to Improve Patient Experience' intervention on person-centered maternity care in Kenya and Ghana: Study Protocol.

Background: Poor person-centered maternal care (PCMC) contributes to high maternal mortality and morbidity, directly and indirectly, through lack of, delayed, inadequate, unnecessary, or harmful care. While evidence on poor PCMC prevalence, as well as inequities, expanded in the last decade, there is still a significant gap in evidence-based interventions to address PCMC. We describe the protocol for a trial to test the effectiveness of the "Caring for Providers to Improve Patient Experience" (CPIPE) intervention, which includes five strategies for provider behavior change, targeting provider stress and bias as intermediate factors to improve PCMC and to address inequities. Methods: The trial will assess the effect of CPIPE on PCMC, as well as on intermediate and distal outcomes, using a two-arm cluster randomized controlled trial in 40 health facilities in Migori and Homa Bay Counties in Kenya and Upper East and Northeast Regions in Ghana. Twenty facilities in each country will be randomized to 10 intervention and 10 control sites. The primary intervention targets are all healthcare workers who provide maternal health services. The intervention impact will also be assessed first among providers, and then among women who give birth in health facilities. The primary outcome is PCMC measured with the PCMC scale, via multiple cross-sectional surveys of mothers who gave birth in the preceding 12 weeks in study facilities at baseline (prior to the intervention), midline (6 months after intervention start), and endline (12 months post-baseline) (N = 2000 across both countries at each time point). Additionally, 400 providers in the study facilities across both countries will be followed longitudinally at baseline, midline, and endline, to assess intermediate outcomes. The trial incorporates a mixed-methods design; survey data alongside in-depth interviews (IDIs) with healthcare facility leaders, providers, and mothers to qualitatively explore factors influencing the outcomes. Finally, we will collect process and cost data to assess intervention fidelity and cost-effectiveness. Discussion: This trial will be the first to rigorously assess an intervention to improve PCMC that addresses both provider stress and bias and will advance the evidence base for interventions to improve PCMC and contribute to equity in maternal and neonatal health.

Exploring infant and young child-feeding practices among mothers of well-nourished children in northern Ghana: An INPreP substudy.

This study investigated infant and young child-feeding (IYCF) practices among mothers of well-nourished children in northern Ghana. This was a qualitative study where in-depth individual interviews were conducted with participants. The interviews were audio recorded, transcribed, and QSR Nvivo software version 11 was used to organize the data before thematic analysis. It was observed that mothers of well-nourished children were likely to adhere to breastfeeding guidelines and also practice appropriate complementary feeding. Furthermore, these mothers mostly had some form of support from their husbands and mother-in-laws in feeding their infants. While adoption and adherence to appropriate IYCF practices contribute to improved nutrition outcomes in children, social support systems are needed to sustain the practice.

Cost of maternal health services in selected primary care centres in Ghana: a step down allocation approach.

BACKGROUND: There is a paucity of knowledge on the cost of health care services in Ghana. This poses a challenge in the economic evaluation of programmes and inhibits policy makers in making decisions about allocation of resources to improve health care. This study analysed the overall cost of providing health services in selected primary health centres and how much of the cost is attributed to the provision of antenatal and delivery services. METHODS: The study has a cross-sectional design and quantitative data was collected between July and December 2010. Twelve government run primary health centres in the Kassena-Nankana and Builsa districts of Ghana were randomly selected for the study. All health-care related costs for the year 2010 were collected from a public service provider's perspective. The step-down allocation approach recommended by World Health Organization was used for the analysis. RESULTS: The average annual cost of operating a health centre was $136,014 US. The mean costs attributable to ANC and delivery services were $23,063 US and $11,543 US respectively. Personnel accounted for the largest proportion of cost (45%). Overall, ANC (17%) and delivery (8%) were responsible for less than a quarter of the total cost of operating the health centres. By disaggregating the costs, the average recurrent cost was estimated at $127,475 US, representing 93.7% of the total cost. Even though maternal health services are free, utilization of these services at the health centres were low, particularly for delivery (49%), leading to high unit costs. The mean unit costs were $18 US for an ANC visit and $63 US for spontaneous delivery. CONCLUSION: The high unit costs reflect underutilization of the existing capacities of health centres and indicate the need to encourage patients to use health centres .The study provides useful information that could be used for cost effectiveness analyses of maternal and neonatal care interventions, as well as for policy makers to make appropriate decisions regarding the allocation and sustainability of health care resources.

Situation Analysis of a New Effort of Community-Based Health Planning and Services (CHPS) for Maternal Health in Upper West Region in Rural Ghana.

A free maternal health policy started in Ghana in 2008, however, health facility utilization is still low, and out-of-pocket payments (OOPPs) are putting households at risk of catastrophic expenditure. To improve this situation, some rural communities have assigned a midwife to a health post called community-based health planning and services (CHPS), where only assistant nurses are allocated. This study explored the effectiveness of the new approach in Upper West Region, Ghana. We conducted a cross-sectional study and interviewed women who gave birth in the last year. We systematically selected communities matched into four criteria: communities near CHPS (functional CHPS), communities near CHPS with a midwife (advanced CHPS), communities near a health centre, and communities without a health facility in their neighbourhood. In total, 534 women were interviewed: functional CHPS 104, advanced CHPS 131, near health centre 173, and no facility 126. About 78% of the women were 20 to 34 years old. About half of the women incurred OOPP, however, catastrophic payment (household spending > 5% of annual income) was significantly lower in advanced CHPS communities for normal delivery compared with the other three communities. The new local approach of assigning a midwife to CHPS functioned well, improving access to healthcare facilities for childbirth.

An Ethnographic Study of Multiple Factors Influencing Perceptions, Attitudes, and Observance of COVID-19 Preventive Measures among Rural and Urban Slum Dwellers in Ghana.

Background: The COVID-19 pandemic and government-led interventions to tackle it have had life-changing effects on vulnerable populations, especially rural and urban slum dwellers in developing countries. This ethnographic study explored how the Ghanaian government's management of COVID-19, socio-cultural factors, infrastructural challenges, and poverty influenced community perceptions, attitudes, and observance of COVID-19 prevention measures in Ghana. Methods: The study employed focused ethnography using in-depth interviews (IDIs), focus group discussions (FGDs), and nonparticipant observations to collect data from an urban slum and a rural community as well as from government officials, from October 2020 to January 2021. The data were triangulated and analyzed thematically with the support of qualitative software NVivo 12. All ethical procedures were followed. Results: The Ghanaian government's strategy of communicating COVID-19-related information to the public, health-related factors such as health facilities failing to follow standard procedures in testing and tracing persons who came into contact with COVID-19-positive cases, poverty, and lack of social amenities contributed to the poor observance of COVID-19 preventive measures. In addition, the government's relaxation of COVID-19 restrictions, community and family values, beliefs, and misconceptions contributed to the poor observance of COVID-19 preventive measures. Nevertheless, some aspects of the government's intervention measures and support to communities with COVID-19 prevention items, support from nongovernmental organizations (NGOs), and high knowledge of COVID-19 and its devastating effects contributed to positive attitudes and observance of COVID-19 preventive measures. Conclusion: There is a need for the government to use the existing community structures to engage vulnerable communities so that their concerns are factored into interventions to ensure that appropriate interventions are designed to suit the context. Moreover, the government needs to invest in social amenities in deprived communities. Finally, the government has to be consistent with the information it shares with the public to enhance trust relations.