Birthweight data completeness and quality in population-based surveys: EN-INDEPTH study.

BACKGROUND: Low birthweight (< 2500 g) is an important marker of maternal health and is associated with neonatal mortality, long-term development and chronic diseases. Household surveys remain an important source of population-based birthweight information, notably Demographic and Health Surveys (DHS) and UNICEF's Multiple Indicator Cluster Surveys (MICS); however, data quality concerns remain. Few studies have addressed how to close these gaps in surveys. METHODS: The EN-INDEPTH population-based survey of 69,176 women was undertaken in five Health and Demographic Surveillance System sites (Matlab-Bangladesh, Dabat-Ethiopia, Kintampo-Ghana, Bandim-Guinea-Bissau, IgangaMayuge-Uganda). Responses to existing DHS/MICS birthweight questions on 14,411 livebirths were analysed and estimated adjusted odds ratios (aORs) associated with reporting weighing, birthweight and heaping reported. Twenty-eight focus group discussions with women and interviewers explored barriers and enablers to reporting birthweight. RESULTS: Almost all women provided responses to birthweight survey questions, taking on average 0.2 min to answer. Of all babies, 62.4% were weighed at birth, 53.8% reported birthweight and 21.1% provided health cards with recorded birthweight. High levels of heterogeneity were observed between sites. Home births and neonatal deaths were less likely to be weighed at birth (home births aOR 0.03(95%CI 0.02-0.03), neonatal deaths (aOR 0.19(95%CI 0.16-0.24)), and when weighed, actual birthweight was less likely to be known (aOR 0.44(95%CI 0.33-0.58), aOR 0.30(95%CI 0.22-0.41)) compared to facility births and post-neonatal survivors. Increased levels of maternal education were associated with increases in reporting weighing and knowing birthweight. Half of recorded birthweights were heaped on multiples of 500 g. Heaping was more common in IgangaMayuge (aOR 14.91(95%CI 11.37-19.55) and Dabat (aOR 14.25(95%CI 10.13-20.3) compared to Bandim. Recalled birthweights were more heaped than those recorded by card (aOR 2.59(95%CI 2.11-3.19)). A gap analysis showed large missed opportunity between facility birth and known birthweight, especially for neonatal deaths. Qualitative data suggested that knowing their baby's weight was perceived as valuable by women in all sites, but lack of measurement and poor communication, alongside social perceptions and spiritual beliefs surrounding birthweight, impacted women's ability to report birthweight. CONCLUSIONS: Substantial data gaps remain for birthweight data in household surveys, even amongst facility births. Improving the accuracy and recording of birthweights, and better communication with women, for example using health cards, could improve survey birthweight data availability and quality.

Gestational age data completeness, quality and validity in population-based surveys: EN-INDEPTH study.

BACKGROUND: Preterm birth (gestational age (GA) <37 weeks) is the leading cause of child mortality worldwide. However, GA is rarely assessed in population-based surveys, the major data source in low/middle-income countries. We examined the performance of new questions to measure GA in household surveys, a subset of which had linked early pregnancy ultrasound GA data. METHODS: The EN-INDEPTH population-based survey of 69,176 women was undertaken (2017-2018) in five Health and Demographic Surveillance System sites in Bangladesh, Ethiopia, Ghana, Guinea-Bissau and Uganda. We included questions regarding GA in months (GAm) for all women and GA in weeks (GAw) for a subset; we also asked if the baby was 'born before expected' to estimate preterm birth rates. Survey data were linked to surveillance data in two sites, and to ultrasound pregnancy dating at <24 weeks in one site. We assessed completeness and quality of reported GA. We examined the validity of estimated preterm birth rates by sensitivity and specificity, over/under-reporting of GAw in survey compared to ultrasound by multinomial logistic regression, and explored perceptions about GA and barriers and enablers to its reporting using focus group discussions (n = 29). RESULTS: GAm questions were almost universally answered, but heaping on 9 months resulted in underestimation of preterm birth rates. Preference for reporting GAw in even numbers was evident, resulting in heaping at 36 weeks; hence, over-estimating preterm birth rates, except in Matlab where the peak was at 38 weeks. Questions regarding 'born before expected' were answered but gave implausibly low preterm birth rates in most sites. Applying ultrasound as the gold standard in Matlab site, sensitivity of survey-GAw for detecting preterm birth (GAw <37) was 60% and specificity was 93%. Focus group findings suggest that women perceive GA to be important, but usually counted in months. Antenatal care attendance, women's education and health cards may improve reporting. CONCLUSIONS: This is the first published study assessing GA reporting in surveys, compared with the gold standard of ultrasound. Reporting GAw within 5 years' recall is feasible with high completeness, but accuracy is affected by heaping. Compared to ultrasound-GAw, results are reasonably specific, but sensitivity needs to be improved. We propose revised questions based on the study findings for further testing and validation in settings where pregnancy ultrasound data and/or last menstrual period dates/GA recorded in pregnancy are available. Specific training of interviewers is recommended.

Neonatal mortality in the central districts of Ghana: analysis of community and composition factors.

BACKGROUND: Communities and their composition have an impact on neonatal mortality. However, considering the smallest health administrative units as communities and investigating the impact of these communities and their composition on neonatal mortality in Ghana have not been studied. Therefore, this study aimed to investigate the effect of community-, household- and individual-level factors on the risk of neonatal mortality in two districts in Ghana. METHODS: This was a longitudinal study that used the Kintampo Health and Demographic Surveillance System as a platform to select 30,132 neonatal singletons with 634 deaths. Multilevel cox frailty model was used to examine the effect of community-, household- and individual-level factors on the risk of neonatal mortality. RESULTS: Regarding individual-level factors, neonates born to mothers with previous adverse pregnancy (aHR = 1.38, 95% CI: 1.05-1.83), neonates whose mothers did not receive tetanus toxoid vaccine (aHR = 1.32, 95% CI: 1.08-1.60) and neonates of mothers with Middle, Junior High School or Junior Secondary School education (aHR = 1.30, 95% CI: 1.02-1.65) compared to mothers without formal education, had a higher risk of neonatal mortality. However, female neonates (aHR = 0.61, 95% CI: 0.51-0.73) and neonates whose mother had secondary education or higher (aHR = 0.37, 95% CI: 0.18-0.75) compared to those with no formal education had a lower risk of mortality. Neonates with longer gestation period (aHR = 0.95, 95% CI: 0.94-0.97) and those who were delivered at home (aHR = 0.56, 95% CI: 0.45-0.70), private maternity home (aHR = 0.45, 95% CI: 0.30-0.68) or health centre/clinic (aHR = 0.40, 95% CI: 0.26-0.60) compared to hospital delivery had lower risk of mortality. Regarding the household-level, neonates belonging to third quintile of the household wealth (aHR = 0.70, 95% CI: 0.52-0.94) and neonates belonging to households with crowded sleeping rooms (aHR = 0.91, 95% CI: 0.85-0.97) had lower risk of mortality. CONCLUSION: The findings of the study suggest the risk of neonatal mortality at the individual- and household-levels in the Kintampo Districts. Interventions and strategies should be tailored towards the high-risk groups identified in the study.

Intermittent preventive treatment of pregnant women in Kintampo area of Ghana with sulphadoxine-pyrimethamine (SP): trends spanning 2011 and 2015.

OBJECTIVE: In Ghana, intermittent preventive treatment during pregnancy with sulphadoxine-pyrimethamine (IPTp-SP) is recommended for the prevention of malaria-related adverse outcomes. This study demonstrates the coverage of IPTp-SP use among pregnant women over a period (2011-2015) and the impact of various sociodemographic groups on the uptake of IPTp-SP. DESIGN: Retrospective analysis using data from all pregnant women in the Kintampo Health and Demographic Surveillance System area on the uptake of IPTp-SP. SETTING: Kintampo North Municipality and Kintampo South District of Ghana. PARTICIPANTS: All pregnant women in the Kintampo Health and Demographic Surveillance System area. PRIMARY AND SECONDARY OUTCOME MEASURES: The number of doses of IPTp-SP taken by pregnant women were examined. Logistic regression was used to assess the determinant of uptake of IPTp-SP while adjusting for within-subject correlation from women with multiple pregnancies. RESULTS: Data from 2011 to 2015 with a total of 17 484 pregnant women were used. The coverage of the recommended three or more doses of IPTp-SP among all pregnant women was 40.6%, 44.0%, 45.9%, 20.9% and 32.4% in 2011, 2012, 2013, 2014 and 2015, respectively. In the adjusted analysis, age, household size, education, religion, number of antenatal care visits, ethnicity, marital status, wealth index and place of residence were significantly associated with the uptake of three or more doses of IPTp-SP. Having middle school education or higher, aged 20 years and above, visiting antenatal care five times or more (OR 2.83, 95% CI 2.64 to 3.03), being married (OR 1.10, 95% CI 1.02 to 1.19) and those in higher wealth quintiles were significantly more likely to take three or more doses of IPTp-SP. CONCLUSION: The uptake of the recommended three or more doses of IPTp-SP is low in the study area. We recommend a community-based approach to identify women during early pregnancy and to administer IPTp-SP.

"Making the Mentally Ill Count", lessons from a Health and Demographic Surveillance System for people with mental and neurological disorders in the Kintampo districts of Ghana.

BACKGROUND: Persons with mental and neurological disorders (PMNDs) are among the most marginalised groups in developing countries, as they are socially excluded and overlooked in most developmental efforts. Due to high levels of stigma and other operational difficulties, PMNDs are often marginalised in routine enumeration exercises. Health and Demographic Surveillance System is an important public health research platform especially in countries that lacks reliable data systems, as it registers and monitor basic demographic and health events such as births, deaths and migration in a geographically defined population. This information is essential for policy development and resource distribution and service delivery. We aim to document the reasons for not counting PMNDs in our communities and demonstrate the usefulness of the Kintampo Health and Demographic Surveillance Systems (KHDSS) platform in counting PMNDs over time. We also documented strategies in providing vital information that helps in establishing the rights of PMNDs. METHODS: As a longitudinal study, psychiatric case register was established. Both quantitative and qualitative data collection techniques were used to solicit responses from stakeholders regarding the non-consideration of PMNDs as part of household membership in the study area. PMNDs were identified using the KHDSS and followed every 6 months. The "targeted" (actively searching for PMNDs) and "service provision" (providing medical treatment for PMNDs) approaches were adopted to enhance the identification of PMNDs. RESULTS: Stigma was the main reason cited for the non-counting of PMNDs in the area. Following a "targeted" and "service provision" approach, the number of PMNDs enrolled into the psychiatric case register went up to 68% in 2010; as against the previous levels of 49 and 54% in 2005 and 2008 respectively. The study highlights the intrinsic value of such an approach for social inclusion of PMNDs. CONCLUSIONS: Stigma against PMNDs was report in this study. We provided evidence that the KHDSS platform is useful for identification of PMNDs for service provision. The paper highlights evidence for policy formulation and implementation.

Demographic patterns and trends in Central Ghana: baseline indicators from the Kintampo Health and Demographic Surveillance System.

BACKGROUND: The dearth of health and demographic data in sub-Saharan Africa from vital registration systems and its impact on effective planning for health and socio-economic development is widely documented. Health and Demographic Surveillance Systems have the capacity to address the dearth of quality data for policy making in resource-poor settings. OBJECTIVE: This article demonstrates the utility of the Kintampo Health and Demographic Surveillance System (KHDSS) by showing the patterns and trends of population change from 2005 to 2009 in the Kintampo North Municipality and Kintampo South districts of Ghana through data obtained from the KHDSS biannual update rounds. DESIGN: Basic demographic rates for fertility, mortality, and migration were computed by year. School enrolment was computed as a percentage in school by age and sex for 6-18 year-olds. Socio-economic status was derived by use of Principal Components Analysis on household assets. RESULTS: Over the period, an earlier fertility decline was reversed in 2009; mortality declined slightly for all age-groups, and a significant share of working-age population was lost through out-migration. Large minorities of children of school-going age are not in school. Socio-economic factors are shown to be important determinants of fertility and mortality. CONCLUSION: Strengthening the capacity of HDSSs could offer added value to evidence-driven policymaking at local level.

Clustering of childhood mortality in the Kintampo Health and Demographic Surveillance System in Ghana.

BACKGROUND: Childhood mortality in Ghana has generally declined in the last four decades. However, estimates tend to conceal substantial variability among regions and districts. The lack of population-based data in Ghana, as in other less developed countries, has hindered the development of effective programmes targeted specifically at clusters where mortality levels are significantly higher. OBJECTIVE: This paper seeks to test for the existence of statistically significant clusters of childhood mortality within the Kintampo Health and Demographic Surveillance System (KHDSS) between 2005 and 2007. DESIGN: In this study, mortality rates were generated using mortality data extracted from the health and demographic surveillance database of the KHDSS and exported into STATA. The spatial and spatio-temporal scan statistic by Kulldorff was used to identify significant clusters of childhood mortality within the KHDSS. RESULTS: A significant cluster of villages with high under-five mortality in the south-eastern part of the KHDSS in 2006 was identified. This is a remote location where poverty levels are relatively higher, health facilities are more sparse and these are compounded by poor transport services in case of emergencies. CONCLUSION: This study highlights the potential of the surveillance platform to demonstrate the spatial dimensions of childhood mortality clustering. It is apparent, though, that further studies need to be carried out in order to explore the underlying risk factors for potential mortality clusters that could emerge later.