Urban flooding: Coping with Weija Dam spillage by downstream communities in Ghana.

This study adds to knowledge by specifically focusing on the dam spillage-induced floods within a fast-urbanising city with weak law enforcement in a developing country. Employing a sequential mixed-method approach, we first selected and analysed data from 120 respondents through a survey and complemented it with key informants residing in the communities affected by flooding. The findings revealed that dramatic ramifications of dam spillage-induced floods disrupt the livelihoods of many individuals in the form of disruption to income-generating activities and substantial property loss. Notwithstanding the devastating effect of the dam spillage, residents lack advance and adequate preparedness. In coping with such challenges, most flood victims rely on support from nongovernmental sources. The challenge of flooding from the dam spillage is multifaceted and deeply rooted in complex factors which includes growing urbanisation, poor urban planning and weak law enforcement. Residents' adaptive strategies remain limited, demonstrating a dearth of resilience against such shocks. Contribution: In light of these challenges, the authors advocate a close collaborative working partnerships among stakeholders to provide flood risk management interventions, strategic planned dam spillage that minimises the effect of dam spillage-induced floods on the local communities, early warning systems and planning and enforcement of building regulations.

Evaluation of a package of continuum of care interventions for improved maternal, newborn, and child health outcomes and service coverage in Ghana: A cluster-randomized trial.

BACKGROUND: In low- and middle-income countries (LMICs), the continuum of care (CoC) for maternal, newborn, and child health (MNCH) is not always complete. This study aimed to evaluate the effectiveness of an integrated package of CoC interventions on the CoC completion, morbidity, and mortality outcomes of woman-child pairs in Ghana. METHODS AND FINDINGS: This cluster-randomized controlled trial (ISRCTN: 90618993) was conducted at 3 Health and Demographic Surveillance System (HDSS) sites in Ghana. The primary outcome was CoC completion by a woman-child pair, defined as receiving antenatal care (ANC) 4 times or more, delivery assistance from a skilled birth attendant (SBA), and postnatal care (PNC) 3 times or more. Other outcomes were the morbidity and mortality of women and children. Women received a package of interventions and routine services at health facilities (October 2014 to December 2015). The package comprised providing a CoC card for women, CoC orientation for health workers, and offering women with 24-hour stay at a health facility or a home visit within 48 hours after delivery. In the control arm, women received routine services only. Eligibility criteria were as follows: women who gave birth or had a stillbirth from September 1, 2012 to September 30, 2014 (before the trial period), from October 1, 2014 to December 31, 2015 (during the trial period), or from January 1, 2016 to December 31, 2016 (after the trial period). Health service and morbidity outcomes were assessed before and during the trial periods through face-to-face interviews. Mortality was assessed using demographic surveillance data for the 3 periods above. Mixed-effects logistic regression models were used to evaluate the effectiveness as difference in differences (DiD). For health service and morbidity outcomes, 2,970 woman-child pairs were assessed: 1,480 from the baseline survey and 1,490 from the follow-up survey. Additionally, 33,819 cases were assessed for perinatal mortality, 33,322 for neonatal mortality, and 39,205 for maternal mortality. The intervention arm had higher proportions of completed CoC (410/870 [47.1%]) than the control arm (246/620 [39.7%]; adjusted odds ratio [AOR] for DiD = 1.77; 95% confidence interval [CI]: 1.08 to 2.92; p = 0.024). Maternal complications that required hospitalization during pregnancy were lower in the intervention (95/870 [10.9%]) than in the control arm (83/620 [13.4%]) (AOR for DiD = 0.49; 95% CI: 0.29 to 0.83; p = 0.008). Maternal mortality was 8/6,163 live births (intervention arm) and 4/4,068 live births during the trial period (AOR for DiD = 1.60; 95% CI: 0.40 to 6.34; p = 0.507) and 1/4,626 (intervention arm) and 9/3,937 (control arm) after the trial period (AOR for DiD = 0.11; 95% CI: 0.11 to 1.00; p = 0.050). Perinatal and neonatal mortality was not significantly reduced. As this study was conducted in a real-world setting, possible limitations included differences in the type and scale of health facilities and the size of subdistricts, contamination for intervention effectiveness due to the geographic proximity of the arms, and insufficient number of cases for the mortality assessment. CONCLUSIONS: This study found that an integrated package of CoC interventions increased CoC completion and decreased maternal complications requiring hospitalization during pregnancy and maternal mortality after the trial period. It did not find evidence of reduced perinatal and neonatal mortality. TRIAL REGISTRATION: The study protocol was registered in the International Standard Randomised Controlled Trial Number Registry (90618993).

EMBRACE intervention to improve the continuum of care in maternal and newborn health in Ghana: The RE-AIM framework-based evaluation.

BACKGROUND: Improving maternal and newborn health remains one of the most critical public health challenges, particularly in low- and lower-middle-income countries. To overcome this challenge, interventions to improve the continuum of care based on real-world settings need to be provided. The Ghana Ensure Mothers and Babies Regular Access to Care (EMBRACE) Implementation Research Team conducted a unique intervention program involving over 21 000 women to improve the continuum of care, thereby demonstrating an intervention program's effectiveness in a real-world setting. This study evaluates the implementation process of the EMBRACE intervention program based on the RE-AIM framework. METHODS: A cluster-randomized controlled trial was conducted in 32 sub-district-based clusters in Ghana. Interventions comprised of four components, and to evaluate the implementation process, we conducted baseline and endline questionnaire surveys for women who gave birth and lived in the study site. The key informant interviews of health workers and intervention monitoring were conducted at the health facilities in the intervention area. The data were analyzed using 34 components of the RE-AIM framework and classified under five general criteria (Reach, Effectiveness, Adoption, Implementation, and Maintenance). RESULTS: In total, 1480 and 1490 women participated in the baseline and endline questionnaire survey, respectively. In the intervention area, 83.8% of women participated (reach). The completion rate of the continuum of care increased from 7.5% to 47.1%. Newborns who had danger signs immediately after birth decreased after the intervention (relative risk = 0.82, 95% confidence interval = 0.68-0.99) (effectiveness). In the intervention area, 94% of all health facilities participated. Mothers willing to use their continuum of care cards in future pregnancies reached 87% (adoption). Supervision and manual use resolved the logistical and human resource challenges identified initially (implementation). The government included the continuum of care measures in their routine program and developed a new Maternal and Child Health Record Book, which was successfully disseminated nationwide (maintenance). CONCLUSIONS: Following the RE-AIM framework evaluation, the EMBRACE intervention program was considered effective and as having great potential for scaling across in real-world settings, especially where the continuum of care needs to be improved. TRIAL REGISTRATION: ISRCTN 90618993.

High uptake of Intermittent Preventive Treatment of malaria in pregnancy is associated with improved birth weight among pregnant women in Ghana.

Despite the clinically proven advantages of intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP), utilisation has been low in many African countries. To increase uptake and achieve the desired effect, the World Health Organization revised the policy to a monthly administration. Assessing the coverage and impact of the revised policy on pregnancy and neonatal outcomes is, therefore, a necessity. A 2-parallel cross-sectional hospital-based study was carried out among pregnant women attending first antenatal care (ANC) and delivery. Maternal and cord blood samples were assayed for malaria parasites by quantitative PCR targeting both the 18S rDNA and the acidic terminal segment of Plasmodium falciparum var genes, and plasma SP levels were measured by liquid chromatography coupled to tandem mass spectrometry. Parasite prevalence was similar between the two study sites but decreased significantly between the first ANC (9% or 43%) and delivery (4% or 11%) based on the qPCR target. At delivery, 64.5% of women received ≥3 IPTp-SP dose, 15.5% received 2 doses and 6% had 1 dose. Taking ≥3 IPTp-SP doses was associated with an average birth weight increase of more than 0.165 kg. IPTp-SP uptake was associated with plasma SP level at delivery (OR = 32.3, p ≤ 0.005, 95% CI (13.3;78.4) for those that reported ≥3 IPTp-SP doses) while the same trend of improved birth weight was observed with high plasma SP levels. The new IPTp policy is well implemented and well utilised by women in the sites considered in this study and translates to the improved birth weight observed. This study confirms the interest and the clinical benefit expected from this policy change.

Effect of continuum-of-care intervention package on improving contacts and quality of maternal and newborn healthcare in Ghana: a cluster randomised controlled trial.

OBJECTIVE: To evaluate the effect of a continuum-of-care intervention package on adequate contacts of women and newborn with healthcare providers and their reception of high-quality care. DESIGN: Cluster randomised controlled trial. SETTING: 32 subdistricts in 3 rural sites in Ghana. PARTICIPANTS: The baseline survey involved 1480 women who delivered before the trial, and the follow-up survey involved 1490 women who received maternal and newborn care during the trial. INTERVENTIONS: The intervention package included training healthcare providers, using an educational and recording tool named 'continuum-of-care card', providing the first postnatal care (PNC) by retaining women and newborns at healthcare facility or home visit by healthcare providers. OUTCOME MEASURES: Adequate contacts were defined as at least four contacts during pregnancy, delivery with assistance of skilled healthcare providers at a healthcare facility and three timely contacts within 6 weeks postpartum. High-quality care was defined as receiving 6 care items for antenatal care (ANC), 3 for peripartum care (PPC) and 14 for PNC. RESULTS: The difference-in-difference method was used to assess the effects of the intervention on the study outcome. The percentage of adequate contacts with high-quality care in the intervention group in the follow-up survey and the adjusted difference-in-difference estimators were 12.6% and 2.2 (p=0.61) at ANC, 31.5% and 1.9 (p=0.73) at PPC and 33.7% and 12.3 (p=0.13) at PNC in the intention-to-treat design, whereas 13.0% and 2.8 (p=0.54) at ANC, 34.2% and 2.7 (p=0.66) at PPC and 38.1% and 18.1 (p=0.02) at PNC in the per-protocol design that assigned the study sample by possession of the continuum-of-care card. CONCLUSIONS: The interventions improved contacts with healthcare providers and quality of care during PNC. However, having adequate contact did not guarantee high-quality care. Maternal and newborn care in Ghana needs to improve its continuity and quality. TRIAL REGISTRATION NUMBER: ISRCTN90618993. .

Women's overall satisfaction with health facility delivery services in Ghana: a mixed-methods study.

BACKGROUND: Skilled birth delivery has increased up to nearly 74% in Ghana, but its quality has been questioned over the years. As understanding women's satisfaction could be important to improving service quality, this study aimed to determine what factors were associated with women's overall satisfaction with delivery services quantitatively and qualitatively in rural Ghanaian health facilities. RESULTS: This cross-sectional, mixed methods study used an explanatory sequential design across three Ghana Health Service research areas in 2013. Participants were women who had delivered in the preceding 2 years. Two-stage random sampling was used to recruit women for the quantitative survey. Relationships between women's socio-demographic characteristics and their overall satisfaction with health facility delivery services were examined using univariate and multiple logistic regression analyses. For qualitative analyses, women who completed the quantitative survey were purposively selected to participate in focus group discussions. Data from the focus group discussions were analyzed based on predefined and emerging themes. Overall, 1130 women were included in the quantitative analyses and 136 women participated in 15 focus group discussions. Women's mean age was 29 years. Nearly all women (94%) were satisfied with the overall services received during delivery. Women with middle level/junior high school education [adjusted odds ratio (AOR) = 0.50, 95% confidence interval (CI) = (0.26-0.98)] were less likely to be satisfied with overall delivery services compared to women with no education. Qualitatively, women were not satisfied with the unconventional demands, negative attitude, and unavailability of healthcare workers, as well as the long wait time. CONCLUSIONS: Although most women were satisfied with the overall service they received during delivery, they were not satisfied with specific aspects of the health services; therefore, higher quality service delivery is necessary to improve women's satisfaction. Additional sensitivity training and a reduction in work hours may also improve the experience of clients.

The coverage of continuum of care in maternal, newborn and child health: a cross-sectional study of woman-child pairs in Ghana.

INTRODUCTION: The continuum of care has recently received attention in maternal, newborn and child health. It can be an effective policy framework to ensure that every woman and child receives timely and appropriate services throughout the continuum. However, a commonly used measurement does not evaluate if a pair of woman and child complies with the continuum of care. This study assessed the continuum of care based on two measurements: continuous visits to health facilities (measurement 1) and receiving key components of services (measurement 2). It also explored individual-level and area-level factors associated with the continuum of care achievement and then investigated how the continuum of care differed across areas. METHODS: In this cross-sectional study in Ghana in 2013, the continuum of care achievement and other characteristics of 1401 pairs of randomly selected women and children were collected. Multilevel logistic regression was used to estimate the factors associated with the continuum of care and its divergence across 22 areas. RESULTS: Throughout the pregnancy, delivery and post-delivery stages, 7.9% of women and children achieved the continuum of care through continuous visits to health facilities (measurement 1). Meanwhile, 10.3% achieved the continuum of care by receiving all key components of maternal, newborn and child health services (measurement 2). Only 1.8% of them achieved it under both measurements. Women and children from wealthier households were more likely to achieve the continuum of care under both measurements. Women's education and complications were associated with higher continuum of care services-based achievement. Variance of a random intercept was larger in the continuum of care services-based model than the visit-based model. CONCLUSIONS: Most women and children failed to achieve the continuum of care in maternal, newborn and child health. Those who consistently visited health facilities did not necessarily receive key components of services.

Determinants of attending antenatal care at least four times in rural Ghana: analysis of a cross-sectional survey.

BACKGROUND: Improving maternal health is a global challenge. In Ghana, maternal morbidity and mortality rates remain high, particularly in rural areas. Antenatal care (ANC) attendance is known to improve maternal health. However, few studies have updated current knowledge regarding determinants of ANC attendance. OBJECTIVE: This study examined factors associated with ANC attendance in predominantly rural Ghana. METHODS: We conducted a cross-sectional study at three sites (i.e. Navrongo, Kintampo, and Dodowa) in Ghana between August and September 2013. We selected 1500 women who had delivered within the two years preceding the survey (500 from each site) using two-stage random sampling. Data concerning 1497 women's sociodemographic characteristics and antenatal care attendance were collected and analyzed, and factors associated with attending ANC at least four times were identified using logistic regression analysis. RESULTS: Of the 1497 participants, 86% reported attending ANC at least four times, which was positively associated with possession of national health insurance (AOR 1.64, 95% CI: 1.14-2.38) and having a partner with a high educational level (AOR 1.64, 95% CI: 1.02-2.64) and negatively associated with being single (AOR 0.39, 95% CI: 0.22-0.69) and cohabiting (AOR 0.57, 95% CI: 0.34-0.97). In site-specific analyses, factors associated with ANC attendance included marital status in Navrongo; marital status, possession of national health insurance, partners' educational level, and wealth in Kintampo; and preferred pregnancy timing in Dodowa. In the youngest, least educated, and poorest women and women whose partners were uneducated, those with health insurance were more likely to report at least four ANC attendances relative to those who did not have insurance. CONCLUSIONS: Ghanaian women with low socioeconomic status were less likely to report at least four ANC attendances during pregnancy if they did not possess health insurance. The national health insurance scheme should include a higher number of deprived women in predominantly rural communities.

Factors Influencing Health Facility Delivery in Predominantly Rural Communities across the Three Ecological Zones in Ghana: A Cross-Sectional Study.

BACKGROUND: Maternal and neonatal mortality indicators remain high in Ghana and other sub-Saharan African countries. Both maternal and neonatal health outcomes improve when skilled personnel provide delivery services within health facilities. Determinants of delivery location are crucial to promoting health facility deliveries, but little research has been done on this issue in Ghana. This study explored factors influencing delivery location in predominantly rural communities in Ghana. METHODS: Data were collected from 1,500 women aged 15-49 years with live or stillbirths that occurred between January 2011 and April 2013. This was done within the three sites operating Health and Demographic Surveillance Systems, i.e., the Dodowa (Greater Accra Region), Kintampo (Brong Ahafo Region), and Navrongo (Upper-East Region) Health Research Centers in Ghana. Multivariable logistic regression was used to identify the determinants of delivery location, controlling for covariates that were statistically significant in univariable regression models. RESULTS: Of 1,497 women included in the analysis, 75.6% of them selected health facilities as their delivery location. After adjusting for confounders, the following factors were associated with health facility delivery across all three sites: healthcare provider's influence on deciding health facility delivery, (AOR = 13.47; 95% CI 5.96-30.48), place of residence (AOR = 4.49; 95% CI 1.14-17.68), possession of a valid health insurance card (AOR = 1.90; 95% CI 1.29-2.81), and socio-economic status measured by wealth quintiles (AOR = 2.83; 95% CI 1.43-5.60). CONCLUSION: In addition to known factors such as place of residence, socio-economic status, and possession of valid health insurance, this study identified one more factor associated with health facility delivery: healthcare provider's influence. Ensuring care provider's counseling of clients could improve the uptake of health facility delivery in rural communities in Ghana.

Community-based surveillance of maternal deaths in rural Ghana.

OBJECTIVE: To examine the feasibility and effectiveness of community-based maternal mortality surveillance in rural Ghana, where most information on maternal deaths usually comes from retrospective surveys and hospital records. METHODS: In 2013, community-based surveillance volunteers used a modified reproductive age mortality survey (RAMOS 4+2) to interview family members of women of reproductive age (13-49 years) who died in Bosomtwe district in the previous five years. The survey comprised four yes-no questions and two supplementary questions. Verbal autopsies were done if there was a positive answer to at least one yes-no question. A mortality review committee established the cause of death. FINDINGS: Survey results were available for 357 women of reproductive age who died in the district. A positive response to at least one yes-no question was recorded for respondents reporting on the deaths of 132 women. These women had either a maternal death or died within one year of termination of pregnancy. Review of 108 available verbal autopsies found that 64 women had a maternal or late maternal death and 36 died of causes unrelated to childbearing. The most common causes of death were haemorrhage (15) and abortion (14). The resulting maternal mortality ratio was 357 per 100 000 live births, compared with 128 per 100 000 live births derived from hospital records. CONCLUSION: The community-based mortality survey was effective for ascertaining maternal deaths and identified many deaths not included in hospital records. National surveys could provide the information needed to end preventable maternal mortality by 2030.

Measuring regional and district variations in the incidence of pregnancy-induced hypertension in Ghana: challenges, opportunities and implications for maternal and newborn health policy and programmes.

OBJECTIVES: The objectives were to assess the quality of health management information system (HMIS) data needed for assessment of local area variation in pregnancy-induced hypertension (PIH) incidence and to describe district and regional variations in PIH incidence. METHODS: A retrospective review of antenatal and delivery records of 2682 pregnant women in 10 district hospitals in the Greater Accra and Upper West regions of Ghana was conducted in 2013. Quality of HMIS data was assessed by completeness of reporting. The incidence of PIH was estimated for each district. RESULTS: Key variables for routine assessment of PIH such as blood pressure (BP) at antenatal visits, weight and height were 95-100% complete. Fundal height, gestational age and BP at delivery were not consistently reported. The incidence of PIH differed significantly between Greater Accra region (6.1%) and Upper West region (3.2%). Prevalence of obesity among pregnant women in Greater Accra region (13.9%) was significantly higher than that of women in Upper West region (2.2%). CONCLUSIONS: More attention needs to be given to understanding local area variations in PIH and possible relationships with urbanisation and lifestyle changes that promote obesity, to inform maternal and newborn health policy. This can be done with good quality routine HMIS data.

Continuum of Care in a Maternal, Newborn and Child Health Program in Ghana: Low Completion Rate and Multiple Obstacle Factors.

BACKGROUND: Slow progress has been made in achieving the Millennium Development Goals 4 and 5 in Ghana. Ensuring continuum of care (at least four antenatal visits; skilled birth attendance; postnatal care within 48 hours, at two weeks, and six weeks) for mother and newborn is crucial in helping Ghana achieve these goals and beyond. This study examined the levels and factors associated with continuum of care (CoC) completion among Ghanaian women aged 15-49. METHODS: A retrospective cross-sectional survey was conducted among women who experienced live births between January 2011 and April 2013 in three regions of Ghana. In a two-stage random sampling method, 1,500 women with infants were selected and interviewed about maternal and newborn service usage in line with CoC. Multiple logistic regression models were used to assess factors associated with CoC completion. RESULTS: Only 8.0% had CoC completion; the greatest gap and contributor to the low CoC was detected between delivery and postnatal care within 48 hours postpartum. About 95% of women had a minimum of four antenatal visits and postnatal care at six weeks postpartum. A total of 75% had skilled assisted delivery and 25% received postnatal care within 48 hours. Factors associated with CoC completion at 95% CI were geographical location (OR = 0.35, CI 0.13-0.39), marital status (OR = 0.45; CI 0.22-0.95), education (OR = 2.71; CI 1.11-6.57), transportation (OR = 1.97; CI 1.07-3.62), and beliefs about childhood illnesses (OR = 0.34; CI0.21-0.61). CONCLUSION: The continuum of care completion rate is low in the study site. Efforts should focus on increasing postnatal care within 48 hours and overcoming the known obstacles to increasing the continuum of care completion rate.

Effective Linkages of Continuum of Care for Improving Neonatal, Perinatal, and Maternal Mortality: A Systematic Review and Meta-Analysis.

BACKGROUND: Continuum of care has the potential to improve maternal, newborn, and child health (MNCH) by ensuring care for mothers and children. Continuum of care in MNCH is widely accepted as comprising sequential time (from pre-pregnancy to motherhood and childhood) and space dimensions (from community-family care to clinical care). However, it is unclear which linkages of care could have a greater effect on MNCH outcomes. The objective of the present study is to assess the effectiveness of different continuum of care linkages for reducing neonatal, perinatal, and maternal mortality in low- and middle-income countries. METHODS: We searched for randomized and quasi-randomized controlled trials that addressed two or more linkages of continuum of care and attempted to increase mothers' uptake of antenatal care, skilled birth attendance, and postnatal care. The outcome variables were neonatal, perinatal, and maternal mortality. RESULTS: Out of the 7,142 retrieved articles, we selected 19 as eligible for the final analysis. Of these studies, 13 used packages of intervention that linked antenatal care, skilled birth attendance, and postnatal care. One study each used packages that linked antenatal care and skilled birth attendance or skilled birth attendance and postnatal care. Four studies used an intervention package that linked antenatal care and postnatal care. Among the packages that linked antenatal care, skilled birth attendance, and postnatal care, a significant reduction was observed in combined neonatal, perinatal, and maternal mortality risks (RR 0.83; 95% CI 0.77 to 0.89, I2 79%). Furthermore, this linkage reduced combined neonatal, perinatal, and maternal mortality when integrating the continuum of care space dimension (RR 0.85; 95% CI 0.77 to 0.93, I2 81%). CONCLUSIONS: Our review suggests that continuous uptake of antenatal care, skilled birth attendance, and postnatal care is necessary to improve MNCH outcomes in low- and middle-income countries. The review was conclusive for the reduction of neonatal and perinatal deaths. Although maternal deaths were not significantly reduced, composite measures of all mortality were. Thus, the evidence is sufficient to scale up this intervention package for the improvement of MNCH outcomes.

High Incidence of Neonatal Danger Signs and Its Implications for Postnatal Care in Ghana: A Cross-Sectional Study.

BACKGROUND: Reducing neonatal mortality is a major public health priority in sub-Saharan Africa. Numerous studies have examined the determinants of neonatal mortality, but few have explored neonatal danger signs which potentially cause morbidity. This study assessed danger signs observed in neonates at birth, determined the correlations of multiple danger signs and complications between neonates and their mothers, and identified factors associated with neonatal danger signs. METHODS: A cross-sectional study was conducted in three sites across Ghana between July and September in 2013. Using two-stage random sampling, we recruited 1,500 pairs of neonates and their mothers who had given birth within the preceding two years. We collected data on their socio-demographic characteristics, utilization of maternal and neonatal health services, and experiences with neonatal danger signs and maternal complications. We calculated the correlations of multiple danger signs and complications between neonates and their mothers, and performed multiple logistic regression analysis to identify factors associated with neonatal danger signs. RESULTS: More than 25% of the neonates were born with danger signs. At-birth danger signs in neonates were correlated with maternal delivery complications (r = 0.20, p < 0.001), and neonatal complications within the first six weeks of life (r = 0.19, p < 0.001). However, only 29.1% of neonates with danger signs received postnatal care in the first two days, and 52.4% at two weeks of life. In addition to maternal complications during delivery, maternal age less than 20 years, maternal education level lower than secondary school, and fewer than four antenatal care visits significantly predicted neonatal danger signs. CONCLUSIONS: Over a quarter of neonates are born with danger signs. Maternal factors can be used to predict neonatal health condition at birth. Management of maternal health and close medical attention to high-risk neonates are crucial to reduce neonatal morbidity in Ghana.

Ghana's Ensure Mothers and Babies Regular Access to Care (EMBRACE) program: study protocol for a cluster randomized controlled trial.

BACKGROUND: The United Nations' Millennium Development Goals call for improving maternal and child health status. Their progress, however, has been minimal and uneven across countries. The continuum of care is a key to strengthening maternal, newborn, and child health. In this context, the Japanese government launched the Ghana Ensure Mothers and Babies Regular Access to Care (EMBRACE) Implementation Research Project in collaboration with the Ghanaian government. This study aims to evaluate the implementation process and effects of an intervention to increase the continuum of care for maternal, newborn, and child health status in Ghana. METHODS/DESIGN: We will conduct a cluster randomized controlled trial using an effectiveness-implementation hybrid design in Dodowa, Kintampo, and Navrongo, Ghana. We will provide an intervention package to women living in randomly allocated intervention clusters. The study population is women of reproductive age between the ages of 15 and 49 years. The package includes: 1) use of a new continuum of care card, 2) continuum of care orientation for health workers, 3) 24-hour health facility retention of mothers and newborns after delivery, and 4) postnatal care by home visits. We will measure maternal, newborn, and child health outcomes for both intervention and implementation impacts. The intervention outcomes are continuum of care completion rate, rate of postnatal care within 48 hours, complication rate requiring mothers' and newborns' hospitalizations, and perinatal and neonatal mortality. The implementation outcomes are intervention coverage of the target population, intervention adoption and fidelity, implementation cost, and sustainability. DISCUSSION: In this trial, we will investigate how successful continuum of care can contribute to improving maternal, newborn, and child health outcomes. If successful, this model will then be implemented further in Ghana and other neighboring countries. TRIAL REGISTRATION: Current Controlled Trials ISRCTN90618993 . Registered on 3 September 2014.

Parent-child communication about sexual and reproductive health: evidence from the Brong Ahafo region, Ghana.

BACKGROUND: Young people aged 10-24 years represent one-third of the Ghanaian population. Many are sexually active and are at considerable risk of negative health outcomes due to inadequate sexual and reproductive health knowledge. Although growing international evidence suggests that parent-child sexual communication has positive influence on young people's sexual behaviours, this subject has been poorly studied among Ghanaian families. This study explored the extent and patterns of parent-child sexual communication, and the topics commonly discussed by parents. METHODS: A cross-sectional design was used to sample 790 parent-child dyads through a two-stage cluster sampling technique with probability proportional to size. Interviewer-administered questionnaire method was used to gather quantitative data on parent-child communication about sex. Twenty sexual topics were investigated to describe the patterns and frequency of communication. The Pearson's chi-square and z-test for two-sample proportions were used to assess sexual communication differences between parents and young people. Qualitative data were used to flesh-out relevant issues which standard questionnaire could not cover satisfactorily. RESULTS: About 82.3% of parents had at some point in time discussed sexual and reproductive health issues with their children; nonetheless, the discussions centered on a few topics. Whereas child-report indicated that 78.8% of mothers had discussed sexual communication with their children, 53.5% of fathers had done so. Parental discussions on the 20 sexual topics ranged from 5.2%-73.6%. Conversely, young people's report indicates that mother-discussed topics ranged between 1.9%-69.5%, while father-discussed topics ranged from 0.4% to 46.0%. Sexual abstinence was the most frequently discussed topic (73.6%), followed by menstruation 63.3% and HIV/AIDS 61.5%; while condom (5.2%) and other contraceptive use (9.3%) were hardly discussed. The most common trigger of communication cited by parent-child dyads was parent's own initiation (59.1% vs. 62.6% p=0.22). CONCLUSIONS: Parents in the Brong Ahafo region of Ghana do talk to children about sex, but their conversations cover limited topics. While abstinence is the most widely discussed sexual topic, condoms and contraception were rarely discussed. Sex educational programmes ought to encourage parents to expand sexual communication to cover more topics.

Integrating family planning messages into immunization services: a cluster-randomized trial in Ghana and Zambia.

OBJECTIVE: To determine whether integrating family planning (FP) messages and referrals into facility-based, child immunization services increase contraceptive uptake in the 9- to 12-month post-partum period. METHODS: A cluster-randomized trial was used to test an intervention where vaccinators were trained to provide individualized FP messages and referrals to women presenting their child for immunization services. In each of 2 countries, Ghana and Zambia, 10 public sector health facilities were randomized to control or intervention groups. Shortly after the introduction of the intervention, exit interviews were conducted with women 9-12 months postpartum to assess contraceptive use and related factors before and after the introduction of the intervention. In total, there were 8892 participants (Control Group Ghana, 1634; Intervention Group Ghana, 1129; Control Group Zambia, 3751; Intervention Group Zambia, 2468). Intervention effects were evaluated using logistic mixed models that accounted for clustering in data. In addition, in-depth interviews were conducted with vaccinators, and a process assessment was completed mid-way through the implementation of the intervention. RESULTS: In both countries, there was no significant effect on non-condom FP method use (Zambia, P = 0.56 and Ghana, P = 0.86). Reported referrals to FP services did not improve nor did women's knowledge of factors related to return of fecundity. Some providers reported having made modifications to the intervention; they generally provided FP information in group talks and not individually as they had been trained to do. CONCLUSION: Rigorous evidence of the success of integrated immunization services in resource poor settings remains weak.

Factors influencing the intention of women in rural Ghana to adopt postpartum family planning.

BACKGROUND: Uptake of postpartum family planning (PPFP) remains low in sub-Saharan Africa and very little is known about how pregnant women arrive at their decisions to adopt PPFP. This information is needed to guide the development of interventions to promote PPFP. METHODS: We conducted a survey among pregnant women attending antenatal clinics in a rural district in Ghana. We used univariate and multivariate logistic regression analysis to explore how knowledge of various family planning (FP) methods, past experience with their use and the acceptability of PPFP to male partners and close relations influenced the intention of pregnant women to adopt PPFP. RESULTS: We interviewed 1914 pregnant women in four health facilities. About 84% considered PPFP acceptable, and 70% intended to adopt a method. The most preferred methods were injectables (31.5%), exclusive breastfeeding (16.7%), and oral contraceptive pills (14.8%). Women whose first choice of PPFP method were injectables were more likely to be women who had had past experience with its use (O.R = 2.07, 95% C.I. 1.50-2.87). Acceptability of PPFP by the pregnant woman (O.R. = 3.21, 1.64-6.26), perception of partner acceptability (O.R. = 3.20, 1.94-5.48), having had prior experience with the use of injectables (O.R. = 3.72, 2.61-5.30) were the strongest predictors of the intention to adopt PPFP. Conversely women who knew about the diaphragm (O.R. = 0.59, 0.38-0.93) and those who had past experience with IUD use (O.R. = 0.13, 0.05-0.38) were less likely to want to adopt PPFP. CONCLUSIONS: Acceptability of PPFP to the pregnant woman, male partner approval, and past experience with the use of injectables are important factors in the PPFP decisions of women in this population. Antenatal and early postnatal care need to be adapted to take these factors into consideration.

Does free pregnancy testing reduce service denial in family planning clinics? A cluster-randomized experiment in Zambia and Ghana.

BACKGROUND: In many countries, pregnancy tests are not freely available in family planning clinics. As a result, providers sometimes deny services to non-menstruating clients due to uncertainty about pregnancy. Few clients are actually pregnant, yet denied clients run the risk of becoming pregnant, and those sent to pharmacies pay inflated prices for inexpensive tests. To assess the programmatic effect of free pregnancy testing, we conducted cluster-randomized trials in Ghana and Zambia, assessing clients' uptake of contraception in family planning clinics. METHODS: In each country, 5 clinics were randomized to intervention status and 5 to control. Service data from 2,028 new, non-menstruating clients in Zambia and 1,556 in Ghana were collected. Intervention clinics received supplies of pregnancy tests, and staff were instructed to use tests as needed to help exclude pregnancy. Control clinics received no intervention. The primary outcome was the proportion of non-menstruating clients denied an effective contraceptive method. Cost-effectiveness was also evaluated. RESULTS: In Zambia, clients in intervention and control clinics faced a similar risk of service denial at baseline, 15% and 17%, respectively. At follow-up, denial remained unchanged at 17% in control clinics, but decreased significantly to 4% in intervention sites. Clients in Zambia were 4.4 (95% confidence interval [CI] = 1.3-14.4) times more likely to be denied a method in control sites versus intervention sites (P<.01). Results from Ghana were inconclusive. Cost of a "denial averted" in Zambia was estimated to be US$0.59. INTERPRETATION: Zambia results suggest that availability of free pregnancy testing significantly reduced contraceptive service denial, although results from Ghana preclude an unqualified recommendation. Authors conclude that free pregnancy testing in family planning clinics may make strong public health sense in those developing countries where denial to non-menstruating clients remains a problem. Although pregnancy can usually be excluded with a client history, pregnancy tests are often necessary.