Institutionalising maternal and newborn quality-of-care standards in Bangladesh, Ghana and Tanzania: a quasi-experimental study.

INTRODUCTION: Facility interventions to improve quality of care around childbirth are known but need to be packaged, tested and institutionalised within health systems to impact on maternal and newborn outcomes. METHODS: We conducted cross-sectional assessments at baseline (2016) and after 18 months of provider-led implementation of UNICEF/WHO's Every Mother Every Newborn Quality Improvement (EMEN-QI) standards (preceding the WHO Standards for improving quality of maternal and newborn care in health facilities). 19 hospitals and health centres (2.8M catchment population) in Bangladesh, Ghana and Tanzania were involved and 24 from adjoining districts served for 'comparison'. We interviewed 43 facility managers and 818 providers, observed 1516 client-provider interactions, reviewed 12 020 records and exit-interviewed 1826 newly delivered women. We computed a 39-criteria institutionalisation score combining clinical, patient rights and cross-cutting domains from EMEN-QI and used routine/District Health Information System V.2 data to assess the impact on perinatal and maternal mortality. RESULTS: EMEN-QI standards institutionalisation score increased from 61% to 80% during EMEN-QI implementation, exceeding 75% target. All mortality indicators showed a downward trajectory though not all reached statistical significance. Newborn case-fatality rate fell significantly by 25% in Bangladesh (RR=0·75 (95% CI=0·59 to 0·96), p=0·017) and 85% in Tanzania (RR=0.15 (95% CI=0.08 to 0.29), p<0.001), but not in Ghana. Similarly, stillbirth (RR=0.64 (95% CI=0.45 to 0.92), p<0.01) and perinatal mortality in Tanzania reduced significantly (RR=0.59 (95% CI=0.40 to 0.87), p=0.007). Institutional maternal mortality ratios generally reduced but were only significant in Ghana: 362/100 000 to 207/100 000 livebirths (RR=0.57 (95% CI=0.33 to 0.99), p=0.046). Routine mortality data from comparison facilities were limited and scarce. Systematic death audits and clinical mentorship drove these achievements but challenges still remain around human resource management and equipment maintenance systems. CONCLUSION: Institutionalisation of the UNICEF/WHO EMEN-QI standards as a package is feasible within existing health systems and may reduce mortality around childbirth. Critical gaps around sustainability must be fundamental considerations for scale-up.

Factors consistently associated with utilisation of essential maternal and child health services in Nigeria: analysis of the five Nigerian national household surveys (2003-2018).

OBJECTIVE: This study aims to identify the individual and contextual factors consistently associated with utilisation of essential maternal and child health services in Nigeria across time and household geolocation. DESIGN, SETTING AND PARTICIPANTS: Secondary data from five nationally representative household surveys conducted in Nigeria from 2003 to 2018 were used in this study. The study participants are women and children depending on essential maternal and child health (MCH) services. OUTCOME MEASURES: The outcome measures were indicators of whether participants used each of the following essential MCH services: antenatal care, facility-based delivery, modern contraceptive use, childhood immunisations (BCG, diphtheria, tetanus, pertussis/Pentavalent and measles) and treatments of childhood illnesses (fever, cough and diarrhoea). METHODS: We estimated generalised additive models with logit links and smoothing terms for households' geolocation and survey years. RESULTS: Higher maternal education and households' wealth were significantly associated with utilisation of all types of essential MCH services (p<0.05). On the other hand, households with more children under 5 years of age and in poor communities were significantly less likely to use essential MCH services (p<0.05). Except for childhood immunisations, greater access to transport was positively associated with utilisation (p<0.05). Households with longer travel times to the most accessible health facility were less likely to use all types of essential MCH services (p<0.05), except modern contraceptive use and treatment of childhood fever and/or cough. CONCLUSION: This study adds to the evidence that maternal education and household wealth status are consistently associated with utilisation of essential MCH services across time and space. To increase utilisation of essential MCH services across different geolocations, interventions targeting poor communities and households with more children under 5 years of age should be appropriately designed. Moreover, additional interventions should prioritise to reduce inequities of essential MCH service utilisation between the wealth quantiles and between education status.

Parasitic infections among pregnant women at first antenatal care visit in northern Ghana: A study of prevalence and associated factors.

BACKGROUND: Parasitic infections remain widespread in developing countries and constitute a major public health problem in many parts of sub-Saharan Africa. It is prevalent among children under 5 years and pregnant women; however, studies among the later high risk group is limited in the northern part of Ghana. Here, we evaluated the prevalence and associated factors of parasitic infections among pregnant women at first antenatal care visit in northern Ghana. METHODS: This was a cross-sectional study conducted at the Department of Obstetrics and Gynecology, Bolgatanga Regional Hospital, Upper East Region-Ghana. A total of 334 consecutive consenting pregnant women were included. Questionnaires were administered to obtain socio-demographic data. Venous blood, stool and urine samples were collected for parasite identification using microscopy. Factors associated with parasitic infections were evaluated using regression models. Statistical analysis was performed using R. RESULTS: Parasitic infections identified were giardiasis (30.5%), P. falciparum malaria (21.6%) and schistosomiasis (0.6%). Polyparasitic infection was identified in 6.6% of the population. Increasing age [Age of 20-29 years: AOR = 0.16, 95% CI (0.06-0.38); Age of 30-39 years: AOR = 0.21, 95% CI (0.08-0.50); Age >39 years: AOR = 0.30, 95% CI (0.11-0.83)] was associated with lower odds whiles presence of domestic animals [AOR = 1.85, 95% CI (1.01-3.39)], being in the second trimester of pregnancy [AOR = 2.21, 95% CI (1.17-4.19)], having no formal education [AOR = 3.29, 95% CI (1.47-7.35)] and basic education as the highest educational level [AOR = 6.03, 95% CI (2.46-10.81)] were independent predictors of increased odds of giardiasis. Similarly, having no formal education [AOR = 2.88, 95% CI (1.21-8.79)] was independently associated with higher odds of P. falciparum malaria. The use of insecticide treated net (ITN) [AOR = 0.43, 95% CI (0.21-0.89)] and mosquito repellent [AOR = 0.09, 95% CI (0.04-0.21)] were independent predictors of lower odds of P. falciparum malaria. CONCLUSION: Giardiasis and P. falciparum malaria are common among pregnant women in northern Ghana. The major associated factors of giardiasis are lack of or low level of formal education, the presence of domestic animals and being in the second trimester of pregnancy. Increasing age confers protection against giardiasis. Likewise, lack of formal education is an associated factor for P. falciparum malaria among pregnant women in northern Ghana. The use of ITN and mosquito repellents reduce the risk of P. falciparum malaria. Given the possible role of parasitic infections in adverse pregnancy outcomes, our findings highlight the need for regular screening and treatment of infected women in the northern parts of Ghana. Public health education and improving socio-economic status could help reduce the risk of parasitic infections among pregnant women in the region.

Exploring Conscientious Objection to Abortion Among Health Providers in Ghana.

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

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

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

Hand hygiene practices and perceptions among healthcare workers in Ghana: A WASH intervention study.

INTRODUCTION: We aimed to investigate whether the provision of water, sanitation, and hand hygiene (WASH) interventions were associated with changes in hand hygiene compliance and perceptions of healthcare workers towards infection control. METHODOLOGY: The study was conducted from June 2017 through February 2018 among healthcare workers in two Northern districts of Ghana. Using a pretest-posttest design, we performed hand hygiene observations and perception surveys at baseline (before the start of WASH interventions) and post-intervention (midline and endline). We assessed adherence to hand hygiene practice using the WHO direct observation tool. The perception study was conducted using the WHO perception survey for healthcare workers. Study outcomes were compared between baseline, midline and endline assessments. RESULTS: The hand hygiene compliance significantly improved from 28.8% at baseline through 51.7% at midline (n = 726/1404; 95% CI: 49.1-54.2%) to 67.9% at endline (n = 1000/1471; 95% CI: 65.6-70.3%). The highest increase in compliance was to the WHO hand hygiene moment 5 after touching patients surrounding (relative increase, 205%; relative rate, 3.05; 95% CI: 2.23-4.04; p < 0.0001). Post-intervention, the top three policies deemed most effective at improving hand hygiene practice were: provision of water source (rated mean score, n = 6.1 ± 1.4), participation in educational activities (rated mean score 6.0 ± 1.5); and hand hygiene promotional campaign (6.0 ± 1.3). CONCLUSION: Hand hygiene compliance significantly improved post-intervention. Sustaining good hand hygiene practices in low resource settings should include education, the provision of essential supplies, and regular hand hygiene audits and feedback.

Implementing safe abortion in Ghana: "We must tell our story and tell it well".

In the first years of the new century, the Ministry of Health/Ghana Health Service determined to reduce abortion-associated morbidity and mortality by increasing access to safe care. This was accomplished by interpreting Ghana's restrictive law so that more women qualified for legal services; by framing this effort in public health terms; by bundling abortion together with contraception and postabortion care in a comprehensive package of services; and by training new cadres of health workers to provide manual vacuum aspiration and medical abortion. The Ministry of Health/Ghana Health Service convened medical and midwifery societies, nongovernmental organizations, and bilateral agencies to implement this plan, while retaining the leadership role. However, because of provider shortages, aggravated by conscientious objection, and because many still do not understand when abortion can be legally provided, some women still resort to unsafe care. Nonetheless, Ghana provides an example of the critical role of political will in redressing harms from unsafe abortion.

Biochemical and hematological changes among anemic and non-anemic pregnant women attending antenatal clinic at the Bolgatanga regional hospital, Ghana.

BACKGROUND: Anemia in pregnancy may not only be associated with maternal morbidity and mortality but can also be detrimental to the fetus. A definitive diagnosis of anemia is a pre-requisite to unravelling possible cause(s), to allow appropriate treatment intervention. It is hypothesised that measured hemoglobin (HGB), complemented by biochemical and other hematological parameters would enhance anemia diagnosis. METHODS: This was a cross-sectional study among 400 pregnant women comprising 253 anemic and 147 non-anemic pregnant women, attending an antenatal clinic at Bolgatanga Regional Hospital, Ghana. Venous blood was collected and hemoglobin genotype, complete blood count and biochemical parameters [ferritin, iron, total iron binding capacity (TIBC), transferrin saturation (TfS), C-reactive protein (CRP) and bilirubin] were determined. Thick blood films were prepared for malaria parasitemia, while early morning stool and midstream urine samples were examined for enteric and urogenital parasites, respectively. RESULTS: There were significantly reduced levels of HGB (p < 0.0001), HCT (p < 0.0001), MCV (p < 0.0001), iron (0.0273), ferritin (p = 0.018) and transferrin saturation (0.0391) and increased WBC (p = 0.006), RDW (p = 0.0480), TIBC (p = 0.0438) and positivity of CRP in anemic, compared to non-anemic pregnant women. Anemic women were associated with increased proportion of hemoglobinopathies (AS, SS and SC), Plasmodium falciparum, Schistosoma hematobium and intestinal parasite infections. CONCLUSION: Anemic pregnant women are associated with a significant derangement in hematological and iron indices that implicate iron deficiency. This was influenced by hemoglobinopathies and parasitic infections.

Prevalence of conscientious objection to legal abortion among clinicians in northern Ghana.

OBJECTIVE: To assess the prevalence of conscientious objection (CO), motivations, knowledge of Ghana's abortion law, attitudes, and behaviors toward abortion provision among medical providers in northern Ghana, and measures to regulate CO. METHODS: Between June and November 2015, the present cross-sectional survey-based descriptive study measured prevalence, knowledge, and attitudes about CO among 213 eligible health practitioners who were trained in abortion provision and working in hospital facilities in northern Ghana. Results were stratified by facility ownership and provider type. RESULTS: Approximately half (94/213, 44.1%) of trained providers reported that they were currently providing abortions. The overall prevalence of self-identified and hypothetical objection was 37.9% and 33.8%, respectively. Among 87 physicians, 37 (42.5%) and 39 (44.8%) were categorized as self-identified and hypothetical objectors, respectively. Among 126 midwives, nurses, and physician assistants, 43 (34.7%) and 33 (26.2%) were coded as self-identified and hypothetical objectors, respectively. A high proportion of providers reported familiarity with Ghana's abortion law and supported regulation of CO. CONCLUSION: CO based on moral and religious grounds is prevalent in northern Ghana. Providers indicated an acceptance of policies and guidelines that would regulate its application to reduce the burden that CO poses for women seeking abortion services.

Development of a Conceptual Model and Survey Instrument to Measure Conscientious Objection to Abortion Provision.

BACKGROUND AND OBJECTIVE: Conscientious objection to abortion, clinicians' refusal to perform legal abortions because of their religious or moral beliefs, has been the subject of increasing debate among bioethicists, policymakers, and public health advocates in recent years. Conscientious objection policies are intended to balance reproductive rights and clinicians' beliefs. However, in practice, clinician objection can act as a barrier to abortion access-impinging on reproductive rights, and increasing unsafe abortion and related morbidity and mortality. There is little information about conscientious objection from a medical or public health perspective. A quantitative instrument is needed to assess prevalence of conscientious objection and to provide insight on its practice. This paper describes the development of a survey instrument to measure conscientious objection to abortion provision. METHODS: A literature review, and in-depth formative interviews with stakeholders in Colombia were used to develop a conceptual model of conscientious objection. This model led to the development of a survey, which was piloted, and then administered, in Ghana. RESULTS: The model posits three domains of conscientious objection that form the basis for the survey instrument: 1) beliefs about abortion and conscientious objection; 2) actions related to conscientious objection and abortion; and 3) self-identification as a conscientious objector. CONCLUSIONS: The instrument is intended to be used to assess prevalence among clinicians trained to provide abortions, and to gain insight on how conscientious objection is practiced in a variety of settings. Its results can inform more effective and appropriate strategies to regulate conscientious objection.

Sociodemographic and Obstetric Characteristics of Anaemic Pregnant Women Attending Antenatal Clinic in Bolgatanga Regional Hospital.

The study determined the sociodemographic and obstetric characteristics of pregnant women which contribute to the risk of developing anaemia. A cross-sectional study was conducted among 400 pregnant women attending their first antenatal visit at the Bolgatanga Regional Hospital Antenatal Clinic. Anaemia was significantly associated (p < 0.05) with younger maternal age, parity, gravidity, trimester of pregnancy, and source of drinking water. Multivariate logistic regression identified the following factors with adjusted odds ratios (aOR) and 95% confidence intervals (CI): unemployment (aOR = 4.76 (CI: 2.26-11.33); p < 0.0001), rural dwelling (aOR = 3.10 (CI: 2.16-4.91); p = 0.0071), primigravida (aOR = 2.13 (CI: 1.34-3.18); p = 0.0201), nulliparity (aOR = 1.92 (CI: 1.23-2.86); p = 0.0231), first antenatal visit at second trimester (aOR = 1.71 (CI: 1.33-3.12); p = 0.0149) and first antenatal visit at third trimester (aOR = 2.73 (CI: 1.24-4.35); p = 0.0017), drinking from well and boreholes (aOR = 2.78 (CI: 2.27-5.21); p < 0.0001), and the presence of domestic livestock (aOR = 2.15 (CI: 1.33-3.68); p = 0.0019). This study has shown the various sociodemographic and obstetric factors which significantly contribute to anaemia in pregnancy.

District-level hospital trauma care audit filters: Delphi technique for defining context-appropriate indicators for quality improvement initiative evaluation in developing countries.

INTRODUCTION: Prospective clinical audit of trauma care improves outcomes for the injured in high-income countries (HICs). However, equivalent, context-appropriate audit filters for use in low- and middle-income country (LMIC) district-level hospitals have not been well established. We aimed to develop context-appropriate trauma care audit filters for district-level hospitals in Ghana, was well as other LMICs more broadly. METHODS: Consensus on trauma care audit filters was built between twenty panellists using a Delphi technique with four anonymous, iterative surveys designed to elicit: (i) trauma care processes to be measured; (ii) important features of audit filters for the district-level hospital setting; and (iii) potentially useful filters. Filters were ranked on a scale from 0 to 10 (10 being very useful). Consensus was measured with average percent majority opinion (APMO) cut-off rate. Target consensus was defined a priori as: a median rank of ≥9 for each filter and an APMO cut-off rate of ≥0.8. RESULTS: Panellists agreed on trauma care processes to target (e.g. triage, phases of trauma assessment, early referral if needed) and specific features of filters for district-level hospital use (e.g. simplicity, unassuming of resource capacity). APMO cut-off rate increased successively: Round 1--0.58; Round 2--0.66; Round 3--0.76; and Round 4--0.82. After Round 4, target consensus on 22 trauma care and referral-specific filters was reached. Example filters include: triage--vital signs are recorded within 15 min of arrival (must include breathing assessment, heart rate, blood pressure, oxygen saturation if available); circulation--a large bore IV was placed within 15 min of patient arrival; referral--if referral is activated, the referring clinician and receiving facility communicate by phone or radio prior to transfer. CONCLUSION: This study proposes trauma care audit filters appropriate for LMIC district-level hospitals. Given the successes of similar filters in HICs and obstetric care filters in LMICs, the collection and reporting of prospective trauma care audit filters may be an important step towards improving care for the injured at district-level hospitals in LMICs.

Conducting an audit to improve the facilitation of emergency maternal and newborn referral in northern Ghana.

Ghana Health Service conducted an audit to strengthen the referral system for pregnant or recently pregnant women and newborns in northern Ghana. The audit took place in 16 facilities with two 3-month cycles of data collection in 2011. Midwife-led teams tracked 446 referred women until they received definitive treatment. Between the two audit cycles, teams identified and implemented interventions to address gaps in referral services. During this time period, we observed important increases in facilitating referral mechanisms, including a decrease in the dependence on taxis in favour of national or facility ambulances/vehicles; an increase in health workers escorting referrals to the appropriate receiving facility; greater use of referral slips and calling ahead to alert receiving facilities and higher feedback rates. As referral systems require attention from multiple levels of engagement, on the provider end we found that regional managers increasingly resolved staffing shortages; district management addressed the costliness and lack of transport and increased midwives' ability to communicate with pregnant women and drivers; and that facility staff increasingly adhered to guidelines and facilitating mechanisms. By conducting an audit of maternal and newborn referrals, the Ghana Health Service identified areas for improvement that service providers and management at multiple levels addressed, demonstrating a platform for problem solving that could be a model elsewhere.