Increasing access to care for sick newborns: evidence from the Ghana Newhints cluster-randomised controlled trial.

OBJECTIVES: To evaluate the impact of Newhints community-based surveillance volunteer (CBSV) assessments and referrals on access to care for sick newborns and on existing inequities in access. DESIGN: We evaluated a prospective cohort nested within the Newhints cluster-randomised controlled trial. SETTING: Community-based intervention involving more than 750 000, predominantly rural, population in seven contiguous districts in the Brong-Ahafo Region, Ghana. PARTICIPANTS: Participants were recently delivered women (from more than 120 000 women under surveillance) and their 16 168 liveborn babies. Qualitative in-depth interviews with referral narratives (IDIs) were conducted with 92 mothers, CBSVs and health facility front-desk and maternity/paediatrics ward staff. INTERVENTIONS: Newhints trained and effectively supervised 475 CBSVs (existing within the Ghana Health Service) in 49 of 98 supervisory zones (clusters) to assess and refer newborns with any of the 10-key-danger signs to health facilities within the first week after birth; promote independent care seeking for sick newborns and problem-solve around barriers between November 2008 and December 2009. PRIMARY OUTCOMES: The main evaluation outcomes were rates of compliance with referrals and independent care seeking for newborn illnesses. RESULTS: Of 4006 sampled, 2795 (69.8%) recently delivered women received CBSV assessment visits and 279 (10.0%) newborns were referred with danger signs. Compliance with referrals was unprecedentedly high (86.0%) with women in the poorest quintile (Q1) complying better than the least poor (Q5):87.5%(Q1) vs 69.7%(Q5); p=0.038. Three-quarters went to hospitals; 18% were admitted and 58% received outpatient treatment. Some (24%) mothers were turned away at facilities and follow-on IDIs showed that some of these untreated babies subsequently died. Independent care seeking for severe newborn illness increased from 55.4% in control to 77.3% in Newhints zones, especially among Q1 where care seeking almost doubled (95.0% vs 48.6%; RR=1.94 (1.32, 2.84); p=0.001). Rates were the highest among rural residents but urban residents complied quicker. CONCLUSIONS: Home visits are feasible and a potentially pro-poor approach to link sick newborns to facilities. Its effectiveness in improving survival hinges on matched improvement in facility quality of care. TRIAL REGISTRATION NUMBER: NCT00623337.

Determinants of postnatal depression in rural ghana: findings from the don population based cohort study.

BACKGROUND: Risk factors for postnatal depression (PND), one of the most pervasive complications of child bearing, are poorly understood in Africa. A recent systematic review of 31 studies found that the strongest predictors are social and economic disadvantage and gender-based factors; only six of these studies were community based, and almost all were in South Asia. METHODS: Cohort study nested within 4 weekly surveillance of all women of reproductive age to identify pregnancies and collect data on births and deaths in the Kintampo Health Research Centre study area of Ghana. Women were screened for depression during pregnancy and after birth using the Patient Health Questionnaire to ascertain DSM-IV major or minor depression. Information was collected on determinants relating to the mother, birth, and baby, which were examined using logistic regression; effect sizes reported as relative risks with 95% confidence intervals. RESULTS: Thirteen thousand nine hundred and twenty nine women were screened both during pregnancy and after birth, of whom 13,360 (95.9%) had complete data on potential determinants. Two hundred and fifty five (3.8%, 95% CI: 3.5%, 4.1%) had PND. Antenatal depression (AND) was the strongest determinant accounting for 34.4% of PND cases. Other determinants were season of delivery, peripartum/postpartum complications, newborn ill health, still birth, or neonatal death. Common determinants were observed for onset and persistent depression. CONCLUSIONS: Although most AND resolves in this setting, more than a third of women with PND also had AND. Adverse birth- and baby-related outcomes are the other main determinants. We recommend that programs detect and treat depression during pregnancy and provide support to women with adverse birth outcomes.

Prevalence and determinants of antenatal depression among pregnant women in a predominantly rural population in Ghana: the DON population-based study.

BACKGROUND: While depression during pregnancy is one of the strongest risk factors for postnatal depression, it has been comparatively little studied, particularly in sub-Saharan Africa. METHODS: Cohort study nested within 4-weekly surveillance of all women of reproductive age to identify pregnancies and collect data on births and deaths in the Kintampo Health Research Centre study area of Ghana. Women were screened for depression during pregnancy using the Patient Health Questionnaire to ascertain DSM-IV major or minor depression. Information on demographic factors, indicators of social and economic disadvantage, and previous obstetric history were also collected which were examined using logistic regression; effect sizes reported as relative risks with 95% confidence intervals. RESULTS: 21,135 pregnant women were screened of whom 20,920 (98.9%) had complete data on potential determinants. 2086 (9.9%, 95% CI: 9.5%-10.3%) had AND. Determinants of AND were: maternal age 30+ years (relative risk [RR], 1.16 (1.06-1.27); never married ([RR] 1.34, (1.14-1.58); lower wealth quintile ([RR], 1.30 (1.13-1.50); unplanned pregnancy ([RR], 1.55 (1.43-1.69); previous pregnancy loss ([RR], 1.30 (1.18-1.43). LIMITATIONS: We did not assess women for physical health during pregnancy, and lacked information on some potentially relevant psychosocial factors. CONCLUSION: Prevalence of antenatal depression, applying clinical criteria, is similar to that seen in high income countries. Factors related to chronic social and economic disadvantage are among the most important co-determinants. Population-level interventions that address these problems among women of reproductive age may be the most effective strategy for reducing the prevalence and impact of depression in pregnancy.