Sociodemographic and Behavioral Factors Associated With Hypertension and Depression in 4 Rural Communities in Northern Ghana: A Cross-Sectional Study.

OBJECTIVES: The prevalences of hypertension and depression in sub-Saharan Africa are substantial and rising, despite limited data on their sociodemographic and behavioral risk factors and their interactions. We undertook a cross-sectional study in 4 communities in the Upper East Region of Ghana to identify persons with hypertension and depression in the setting of a pilot intervention training local nurses and health volunteers to manage these conditions. METHODS: We quantified hypertension and depression prevalence across key sociodemographic factors (age, sex, occupation, education, religion, ethnicity, and community) and behavioral factors (tobacco use, alcohol use, and physical activity) and tested for association by multivariable logistic regression. RESULTS: Hypertension prevalence was higher in older persons (7.6% among 35- to 50-year-olds vs 16.4% among 51- to 70-year-olds) and among those reporting alcohol use (18.9% vs 8.5% between users and nonusers). In multivariable models, only older age (AOR 2.39 [1.02, 5.85]) and residence in the community of Wuru (AOR 7.60 [1.81, 32.96]) were independently associated with hypertension, and residence in Wuru (AOR 23.58 [7.75-78.25]) or Navio (AOR 7.41 [2.30-24.74]) was the only factor independently associated with depression. CONCLUSIONS: We report a high prevalence of both diseases overall and in select communities, a trend that requires further research to inform targeted chronic disease interventions.

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.

Community Barriers, Enablers, and Normative Embedding of Second Year of Life Vaccination in Ghana: A Qualitative Study.

INTRODUCTION: Coverage rates for second year of life (2YL) vaccination still lag behind infant vaccination in most settings. We conducted a qualitative baseline study of community barriers and enablers to acceptance of 2YL vaccines in Ghana 4 years after introducing the second dose of the measles-containing vaccine. METHODS: We conducted 26 focus group discussions in 2016 with men and women caregivers from mixed urban, peri-urban, and rural areas, as well as pastoralists, using semistructured topic guides based on the Health Belief Model theory. We conducted a thematic analysis of the discussion using NVivo software. We use Normalization Process Theory to contextualize results as a snapshot of a dynamic process of community adaptation to change to a well-established routine immunization schedule following 2YL introduction. RESULTS: Routine immunization for infants enjoys resilient demand, grounded in strong community norms despite surprisingly low levels of vaccine literacy. Despite best practices like integration with the established 18-month "weighing visit," demand for 2YL vaccination is still conditional on individual awareness and competition for limited maternal time, household resources, and other health concerns. An embedded norm that children should be fully vaccinated by 12 months originally sustained Expanded Programme for Immunization goals but now discouraged some caregivers from seeking vaccines for children perceived to be "too old" to vaccinate. Caregivers cited greater costs and inconvenience of taking older, heavier children in for vaccination and anticipated criticism from both community members and health care providers for coming "too late." CONCLUSION: Closing the 2YL vaccination coverage gap will ultimately require modifying embedded norms among caregivers and health care providers alike. Time is necessary but not sufficient to reach this goal. Progress can be accelerated by increasing the level of community and institutional engagement and adapting services where possible to minimize added costs to caregivers of vaccinating older children.

Provider implicit and explicit bias in person-centered maternity care: a cross-sectional study with maternity providers in Northern Ghana.

BACKGROUND: Person-centered maternity care (PCMC) has become a priority in the global health discourse on quality of care due to the high prevalence of disrespectful and lack of responsive care during facility-based childbirth. Although PCMC is generally sub-optimal, there are significant disparities. On average, women of low socioeconomic status (SES) tend to receive poorer PCMC than women of higher SES. Yet few studies have explored factors underlying these inequities. In this study, we examined provider implicit and explicit biases that could lead to inequitable PCMC based on SES. METHODS: Data are from a cross-sectional survey with 150 providers recruited from 19 health facilities in the Upper East region of Ghana from October 2020 to January 2021. Explicit SES bias was assessed using situationally-specific vignettes (low SES and high SES characteristics) on providers' perceptions of women's expectations, attitudes, and behaviors. Implicit SES bias was assessed using an Implicit Association Test (IAT) that measures associations between women's SES characteristics and providers' perceptions of women as 'difficult' or 'good'. Analysis included descriptive statistics, mixed-model ANOVA, and bivariate and multivariate linear regression. RESULTS: The average explicit bias score was 18.1 out of 28 (SD = 3.60) for the low SES woman vignette and 16.9 out of 28 (SD = 3.15) for the high SES woman vignette (p < 0.001), suggesting stronger negative explicit bias towards the lower SES woman. These biases manifested in higher agreement to statements such as the low SES woman in the vignette is not likely to expect providers to introduce themselves and is not likely to understand explanations. The average IAT score was 0.71 (SD = 0.43), indicating a significant bias in associating positive characteristics with high SES women and negative characteristics with low SES women. Providers with higher education had significantly lower explicit bias scores on the low SES vignette than those with less education. Providers in private facilities had higher IAT scores than those in government hospitals. CONCLUSIONS: The findings provide evidence of both implicit and explicit SES bias among maternity providers. These biases need to be addressed in interventions to achieve equity in PCMC and to improve PCMC for all women.

Individual and situational predictors of psychological and physiological stress and burnout among maternity providers in Northern Ghana.

BACKGROUND: Maternity providers, including nurses, midwives, physicians, are at significant risk for stress and burnout due to the nature of care provision in maternal and child health settings. Yet, the empirical evidence on stress and burnout among maternity providers in sub-Saharan Africa is scarce. Therefore, the purpose of our study was to (1) assess levels of stress and burnout among maternity providers and support staff in Ghana, and (2) identify individual and situational factors associated with maternity provider stress, burnout, and physiology. METHOD: Using a purposive sampling technique, we recruited 150 maternity providers from 19 high delivery health facilities within the 15 districts of the Upper East region (UER) of Ghana into a cross-sectional study. Participants completed Cohen's Perceived Stress Scale, the Shirom-Melamed Burnout scale, and sociodemographic, health-, and work-related items. Participants' heart rate variability (HRV) and hair cortisol levels were assessed for stress-related physiologic responses. We computed bivariate and multivariate linear regression models to examine factors associated with stress and burnout. RESULT: Most participants were experiencing moderate to high stress (58.0%) and burnout (65.8%). Each unit increase in overcommitment to work was associated with 0.62 higher perceived stress scores (ß = 0.62, 95% CI: 0.22, 1.02) and 0.15 higher burnout scores. On average, those who had experienced disrespect from colleagues in the last year had higher perceived stress scores compared to those who had not experienced disrespect (ß = 1.77, 95% CI: 0.50, 3.04); and those who had experienced disrespect from patients in the last year had higher cortisol levels than those who had not (ß = 0.52, 95% CI: 0.11, 0.93). Those who work for more than 5 days also had higher cortisol levels, on average, compared to those who worked fewer days a week. CONCLUSION: We found high levels of stress and burnout among maternity providers in Northern Ghana, underscoring the need for interventions to manage the effects of stress and burnout on maternity providers' wellbeing, quality of care, and patient outcomes. Healthcare management teams should assist providers in reducing their overcommitment by hiring more staff, given its strong link to stress and burnout. Additionally, facilitating a respectful workplace culture could also help reduce stress and burnout among maternity providers.

'Poverty can break a home': Exploring mechanisms linking cash plus programming and intimate partner violence in Ghana.

A growing body of research in West Africa and globally shows that cash transfers can decrease intimate partner violence (IPV). The purpose of this study was to explore how the government of Ghana's Livelihood Empowerment Against Poverty (LEAP) 1000 program, an unconditional cash transfer plus health insurance premium waiver targeted at pregnant women and women with young children, influenced IPV experiences. Existing program theory hypothesizes three pathways through which cash transfers influence IPV, including: 1) increased economic security and emotional wellbeing; 2) reduced intra-household conflict; and 3) increased women's empowerment. Informed by this theory, we conducted qualitative in-depth interviews with women in northern Ghana (n = 30) who were or had been beneficiaries of LEAP 1000 and had reported declines in IPV in an earlier impact evaluation. We used narrative and thematic analytic techniques to examine these pathways in the context of gender norms and household dynamics, as well as a fourth potential pathway focused on interactions with healthcare providers. Overall, the most prominent narrative was that poverty is the main determinant of physical IPV and that by reducing poverty, LEAP 1000 reduced conflict and violence in households and communities and improved emotional wellbeing. Participant narratives also supported pathways of reduced intra-household conflict and increased empowerment, as well as interplay between these three pathways. However, participants also reflected that cash transfers did not fundamentally change gender norms or reduce gender-role strain in a context of ongoing economic insecurity, which could limit the gender transformative potential and sustainability of IPV reductions. Finally, while health insurance increased access to healthcare, local norms, shame, fear, and minimal provider screening deterred IPV disclosure to healthcare providers. Additional research is needed to explore interplay between pathways of impact across programs with different design features and implementation contexts to continue informing effective programming to maximize impact.

Self-reported provision of person-centred maternity care among providers in Kenya and Ghana: scale validation and examination of associated factors.

INTRODUCTION: Person-centred maternity care (PCMC), which refers to care that is respectful and responsive to women's preferences needs, and values, is core to high-quality maternal and child health. Provider-reported PCMC provision is a potentially valid means of assessing the extent of PCMC and contributing factors. Our objectives are to assess the psychometric properties of a provider-reported PCMC scale, and to examine levels and factors associated with PCMC provision. METHODS: We used data from two cross-sectional surveys with 236 maternity care providers from Ghana (n=150) and Kenya (n=86). Analysis included factor analysis to assess construct validity and Cronbach's alpha to assess internal consistency of the scale; descriptive analysis to assess extent of PCMC and bivariate and multivariable linear regression to examine factors associated with PCMC. FINDINGS: The 9-item provider-reported PCMC scale has high construct validity and reliability representing a unidimensional scale with a Cronbach's alpha of 0.72. The average standardised PCMC score for the combined sample was 66.8 (SD: 14.7). PCMC decreased with increasing report of stress and burnout. Compared with providers with no burnout, providers with burnout had lower average PCMC scores (ß: -7.30, 95% CI:-11.19 to -3.40 for low burnout and ß: -10.86, 95% CI: -17.21 to -4.51 for high burnout). Burnout accounted for over half of the effect of perceived stress on PCMC. CONCLUSION: The provider PCMC scale is a valid and reliable measure of provider self-reported PCMC and highlights inadequate provision of PCMC in Kenya and Ghana. Provider burnout is a key driver of poor PCMC that needs to be addressed to improve PCMC.

Inadequate preparedness for response to COVID-19 is associated with stress and burnout among healthcare workers in Ghana.

INTRODUCTION: The COVID-19 pandemic has compounded the global crisis of stress and burnout among healthcare workers. But few studies have empirically examined the factors driving these outcomes in Africa. Our study examined associations between perceived preparedness to respond to the COVID-19 pandemic and healthcare worker stress and burnout and identified potential mediating factors among healthcare workers in Ghana. METHODS: Healthcare workers in Ghana completed a cross-sectional self-administered online survey from April to May 2020; 414 and 409 completed stress and burnout questions, respectively. Perceived preparedness, stress, and burnout were measured using validated psychosocial scales. We assessed associations using linear regressions with robust standard errors. RESULTS: The average score for preparedness was 24 (SD = 8.8), 16.3 (SD = 5.9) for stress, and 37.4 (SD = 15.5) for burnout. In multivariate analysis, healthcare workers who felt somewhat prepared and prepared had lower stress (ß = -1.89, 95% CI: -3.49 to -0.30 and ß = -2.66, 95% CI: -4.48 to -0.84) and burnout (ß = -7.74, 95% CI: -11.8 to -3.64 and ß = -9.25, 95% CI: -14.1 to -4.41) scores than those who did not feel prepared. Appreciation from management and family support were associated with lower stress and burnout, while fear of infection was associated with higher stress and burnout. Fear of infection partially mediated the relationship between perceived preparedness and stress/burnout, accounting for about 16 to 17% of the effect. CONCLUSIONS: Low perceived preparedness to respond to COVID-19 increases stress and burnout, and this is partly through fear of infection. Interventions, incentives, and health systemic changes to increase healthcare workers' morale and capacity to respond to the pandemic are needed.

Neonatal mortality in rural northern Ghana and the three delays model: are we focusing on the right delays?

OBJECTIVE: The Three Delays Model outlines, three common delays that lead to poor newborn outcomes: (i) recognising symptoms and deciding to seek care; (ii) getting to care and; (iii) receiving timely, high-quality care. We gathered data for all newborn deaths within four districts in Ghana to explore how well the Three Delays Model explains outcomes. METHODS: In this cross-sectional, observational study, trained field workers conducted verbal and social autopsies with the closest surviving relative (typically mothers) of all neonatal deaths across four districts in northern Ghana from September 2015 until April 2017. Data were collected using Survey CTO and analysed using StataSE 15.0. Frequencies and descriptive statistics were calculated for key variables. RESULTS: 247 newborn deaths were identified. Nearly 77% (190) of newborns who died were born at a health facility, and 48.9% (93) of those who died before discharge. Of the 149 newborns who were discharged or born at home, 71.8% (107) sought care at a facility for illness, and 72.9% (N = 78) of those did so within the same day of illness recognition. Of the 83 respondents who arranged for transportation, 82% (68) did so within 1 h. Newborns received prompt care but insufficient interventions - 25% or fewer received IV fluids, oral medications, antibiotics or oxygen. CONCLUSIONS: These data suggest that women are following recommendations for safe delivery and prompt care-seeking. In rural northern Ghana, behaviour change interventions focused on mothers and families may not be as pressing as interventions focused on the Third Delay - obtaining timely, high-quality care.

Job satisfaction among healthcare workers in Ghana and Kenya during the COVID-19 pandemic: Role of perceived preparedness, stress, and burnout.

The COVID-19 pandemic has affected job satisfaction among healthcare workers; yet this has not been empirically examined in sub-Saharan Africa (SSA). We addressed this gap by examining job satisfaction and associated factors among healthcare workers in Ghana and Kenya during the COVID-19 pandemic. We conducted a cross-sectional study with healthcare workers (N = 1012). The two phased data collection included: (1) survey data collected in Ghana from April 17 to May 31, 2020, and (2) survey data collected in Ghana and Kenya from November 9, 2020, to March 8, 2021. We utilized a quantitative measure of job satisfaction, as well as validated psychosocial measures of perceived preparedness, stress, and burnout; and conducted descriptive, bivariable, and multivariable analysis using ordered logistic regression. We found high levels of job dissatisfaction (38.1%), low perceived preparedness (62.2%), stress (70.5%), and burnout (69.4%) among providers. High perceived preparedness was positively associated with higher job satisfaction (adjusted proportional odds ratio (APOR) = 2.83, CI [1.66,4.84]); while high stress and burnout were associated with lower job satisfaction (APOR = 0.18, CI [0.09,0.37] and APOR = 0.38, CI [0.252,0.583] for high stress and burnout respectively). Other factors positively associated with job satisfaction included prior job satisfaction, perceived appreciation from management, and perceived communication from management. Fear of infection was negatively associated with job satisfaction. The COVID-19 pandemic has negatively impacted job satisfaction among healthcare workers. Inadequate preparedness, stress, and burnout are significant contributing factors. Given the already strained healthcare system and low morale among healthcare workers in SSA, efforts are needed to increase preparedness, better manage stress and burnout, and improve job satisfaction, especially during the pandemic.

Providing respectful maternity care in northern Ghana: A mixed-methods study with maternity care providers.

OBJECTIVE: This study explored providers' perspectives and behavior regarding respectful maternity care, including knowledge, attitudes, and practices. DESIGN: Mixed-methods cross-sectional study combining quantitative survey data, qualitative interviews, and observations of labor and delivery across four health facilities SETTING: Government health facilities in rural northern Ghana PARTICIPANTS: 43 front-line maternity care providers completed a survey of practice patterns before a quality of care training. We then used purposive and convenience sampling to recruit a sub-sample for in-depth interviews (N=17), and convenience sampling and self-selection to observe approximately half (N=8) providing clinical care. MEASUREMENTS AND FINDINGS: We calculated descriptive statistics from quantitative data and used the framework approach for qualitative analysis. Observational data were examined using the CHANGE Project's Assessment Tools for Caring Providers. We utilized split frame methodology to make comparisons across data sources. Quantitative survey results (N=43) indicate most providers report explaining procedures to women (89.5%), involving women and families in care decisions (84.1%), and covering or screening women for privacy (81.5%). At the same time, 38.9% reported they have shouted at, scolded, insulted, threatened, or talked rudely to a woman, and 26.4% said they have treated a woman differently because of her personal attributes. Qualitative interview data (N=17) suggested that providers can articulate a vision of respectful care, aspire to offer respectful care, and recognize they do not always meet those aspirations. Among those (N=8) volunteering to be observed, introductions and explanations for procedures were rare, privacy screening was infrequent, and participants were observed slapping, scolding, and restraining women in labor, often associated with patient non-compliance to provider instructions. KEY CONCLUSIONS: Even among providers knowledgeable about respectful maternity care and who agreed to be observed providing delivery care, disrespect and abuse were present. IMPLICATIONS FOR PRACTICE: Further research and programmatic efforts are needed to address the gap between knowledge and behavior.

Optimizing task-sharing in abortion care in Ghana: Stakeholder perspectives.

Ghana has made progress in expanding providers in abortion care but access to the service is still a challenge. We explored stakeholder perspectives on task-sharing in abortion care and the opportunities that exist to optimize this strategy in Ghana. We purposively sampled 12 representatives of agencies that played a key role in expanding abortion care to include midwives for key informant interviews. All interviews were audio recorded, transcribed verbatim, and then coded for thematic analysis. Stakeholders indicated that Ghana was motivated to practice task-sharing in abortion care because unsafe abortion was contributing significantly to maternal mortality. They noted that the Ghana Health Service utilized the high maternal mortality in the country at the time, advancements in medicine, and the lack of clarity in the definition of the term "health practitioner" to work with partner nongovernmental organizations to successfully task-share abortion care to include midwives. Access, however, is still poor and provider stigma continues to contribute significantly to conscientious objection. This calls for further task-sharing in abortion care to include medical or physician assistants, community health officers, and pharmacists to ensure that more women have access to abortion care.

Provider knowledge and perceptions following an integrated simulation training on emergency obstetric and neonatal care and respectful maternity care: A mixed-methods study in Ghana.

INTRODUCTION: Little is known about the effect of integrating respectful maternity care into clinical training programs. We sought to examine the effectiveness of an integrated simulation training on emergency obstetric and neonatal care and respectful maternity care on providers' knowledge and self-efficacy, and to asess providers' perceptions of the integrated training. METHODS: The project was piloted in East Mamprusi district in Northern Ghana. Forty-three maternity providers were trained, with six participants trained as Simulation Facilitators. Data are from self-administered evaluation forms (with structured and open-ended questions) from all 43 providers and in-depth interviews with 17 providers. We conducted descriptive quantitative analysis and framework qualitative analysis. RESULTS: Provider knowledge increased from an average of 61.6% at pre-test to 74.5% at post-test. Self-efficacy also increased from an average of 5.8/10 at pretest to 9.2/10 at post-test. Process evaluation data showed that providers valued the training. Over 95% of participants agreed that the training was useful to them and that they will use the tools learned in the training in their practice. Overall, providers had positive perceptions of the training. They noted improvements in their knowledge and confidence to manage obstetric and neonatal emergencies, as well as in patient-provider communication and teamwork. Many listed respectful maternity care elements as what was most impactful to them from the training. CONCLUSIONS: Simulation and team-training on emergency obstetric and neonatal care, combined with respectful maternity care content, can enable health care providers to improve both their clinical and interpersonal knowledge and skills in a training setting that reflects their complex and stressful work environments. Our findings suggest this type of training is feasible, acceptable, and effective in limited-resource settings. Uptake of such trainings could drive efforts towards providing high quality safe, responsive, and respectful obstetric and neonatal care.

'I am still confused as to what caused the problem': Perceptions of mothers on communication regarding newborn illness and death in Northern Ghana.

Neonatal morbidity and mortality remain a significant challenge in Ghana. Given the relationship between care-seeking and understanding of illness, this study aimed to explore mothers' perceptions of the cause of illness and/or death in Northern Ghana. All neonatal deaths and near-misses (babies who survived a life-threatening complication) in 2015 and 2016 were identified through a community - and facility-based surveillance system. Mothers of the deceased or ill infants participated in open narrative qualitative interviews. Narratives that included discussion of whether the mother understood what caused the baby's illness or death were analysed. Interviews with 155 mothers included discussion of their perception of the cause of newborn illness or death. Of the 155 interviews, 108 interviews involved mothers whose babies died, and 47 interviews involved mothers whose newborns survived a life-threatening illness, a neonatal 'near-miss'. Very few expressed a clear understanding of the cause of death or illness. Those mothers who did not understand were either not told or did not understand the cause of illness or death. Newborn health outcomes may be improved by increased maternal awareness and understanding of neonatal illnesses. Future interventions need to address communication issues that impair mothers' understanding, facilitate recognition of danger signs, and prompt timely care-seeking.

Understanding the gap in emergency obstetric and neonatal care in Ghana through the PREventing Maternal And Neonatal Deaths (PREMAND) study.

OBJECTIVE: To explore basic and comprehensive emergency obstetric service provision across four districts in rural northern Ghana, and whether women were more likely to deliver at facilities with more skilled care. METHODS: Field workers geo-coded all health facilities in East Mamprusi, Sissala East, Kassena Nankana Municipal, and Kassena Nankana West districts, and administered surveys to assess providers and emergency obstetric care available. Data were also prospectively collected on delivery locations of women and neonates who died, or nearly died (near misses), between September 1, 2015 and April 30, 2017. RESULTS: There were 14 physicians for a population of nearly 360 000 women. Six (6%) facilities could provide basic emergency care, and 3 (3%) could provide comprehensive care. Services were distributed unequally, with 6 (67%) of the emergency facilities located in the least populated district. Among the sample of women and neonates who died or nearly died, 175 (39%) delivered at locations unable to provide basic emergency services. CONCLUSION: Access to emergency obstetric and neonatal care was distributed inequitably across these districts, suggesting the need to revisit geographic placement of facilities relative to population. The study also raised the question of how to ensure facilities are equipped to respond to emergencies.

Can an integrated obstetric emergency simulation training improve respectful maternity care? Results from a pilot study in Ghana.

BACKGROUND: Few evidence-based interventions exist on how to improve respectful maternity care (RMC) in low-resource settings. We sought to evaluate the effect of an integrated simulation-based training on provision of RMC. METHODS: The pilot project was in East Mamprusi District in northern Ghana. We integrated specific components of RMC, emphasizing dignity and respect, communication and autonomy, and supportive care, into a simulation training to improve identification and management of obstetric and neonatal emergencies. Forty-three providers were trained. For evaluation, we conducted surveys at baseline (N = 215) and endline (N = 318) 6 months later, with recently delivered women to assess their experiences of care using the person-centered maternity care scale. Higher scores on the scale represent more respectful care. RESULTS: Compared to the baseline, women in the endline reported more respectful care. The average person-centered maternity care score increased from 50 at baseline to 72 at endline, a relative increase of 43%. Scores on the subscales also increased between baseline and endline: 15% increase for dignity and respect, 87% increase for communication and autonomy, and 55% increase for supportive care. These differences remained significant in multivariate analysis controlling for several potential confounders. CONCLUSIONS: The findings suggest that integrated provider trainings that give providers the opportunity to learn, practice, and reflect on their provision of RMC in the context of stressful emergency obstetric simulations have the potential to improve women's childbirth experiences in low-resource settings. Incorporating such trainings into preservice and in-service training of providers will help advance global efforts to promote RMC.

Person-centred maternity care in low-income and middle-income countries: analysis of data from Kenya, Ghana, and India.

BACKGROUND: Several qualitative studies have described disrespectful, abusive, and neglectful treatment of women during facility-based childbirth, but few studies document the extent of person-centred maternity care (PCMC)-ie, responsive and respectful maternity care-in low-income and middle-income countries. In this Article, we present descriptive statistics on PCMC in four settings across three low-income and middle-income countries, and we examine key factors associated with PCMC in each setting. METHODS: We examined data from four cross-sectional surveys with 3625 women aged 15-49 years who had recently given birth in Kenya, Ghana, and India (surveys were done from August, 2016, to October, 2017). The Kenya data were collected from a rural county (n=877) and from seven health facilities in two urban counties (n=530); the Ghana data were from five rural health facilities in the northern region (n=200); and the India data were from 40 health facilities in Uttar Pradesh (n=2018). The PCMC measure used was a previously validated scale with subscales for dignity and respect, communication and autonomy, and supportive care. We analysed the data using descriptive statistics and bivariate and multivariate regressions to examine predictors of PCMC. FINDINGS: The highest mean PCMC score was found in urban Kenya (60·2 [SD 12·3] out of 90), and the lowest in rural Ghana (46·5 [6·9]). Across sites, the lowest scores were in communication and autonomy (from 8·3 [3.3] out of 27 in Ghana to 15·1 [5·9] in urban Kenya). 3280 (90%) of the total 3625 women across all countries reported that providers never introduced themselves, and 2076 (57%) women (1475 [73%] of 1980 in India) reported providers never asked permission before performing medical procedures. 120 (60%) of 200 women in Ghana and 1393 (69%) of 1980 women in India reported that providers did not explain the purpose of examinations or procedures, and 116 (58%) women in Ghana and 1162 (58%) in India reported they did not receive explanations on medications they were given; additionally, 104 (52%) women in Ghana did not feel able to ask questions. Overall, 576 (16%) women across all countries reported verbal abuse, and 108 (3%) reported physical abuse. PCMC varied by socioeconomic status and type of facility in three settings (ie, rural and urban Kenya, and India). INTERPRETATION: Regardless of the setting, women are not getting adequate PCMC. Efforts are needed to improve the quality of facility-based maternity care. FUNDING: Bill & Melinda Gates Foundation, Marc and Lynne Benioff, and USAID Systems for Health.

Male involvement in maternal health: perspectives of opinion leaders.

BACKGROUND: Twenty years after acknowledging the importance of joint responsibilities and male participation in maternal health programs, most health care systems in low income countries continue to face challenges in involving men. We explored the reasons for men's resistance to the adoption of a more proactive role in pregnancy care and their enduring influence in the decision making process during emergencies. METHODS: Ten focus group discussions were held with opinion leaders (chiefs, elders, assemblymen, leaders of women groups) and 16 in-depth interviews were conducted with healthcare workers (District Directors of Health, Medical Assistants in-charge of health centres, and district Public Health Nurses and Midwives). The interviews and discussions were audio recorded, transcribed into English and imported into NVivo 10 for content analysis. RESULTS: As heads of the family, men control resources, consult soothsayers to determine the health seeking or treatment for pregnant women, and serve as the final authority on where and when pregnant women should seek medical care. Beyond that, they have no expectation of any further role during antenatal care and therefore find it unnecessary to attend clinics with their partners. There were conflicting views about whether men needed to provide any extra support to their pregnant partners within the home. Health workers generally agreed that men provided little or no support to their partners. Although health workers had facilitated the formation of father support groups, there was little evidence of any impact on antenatal support. CONCLUSIONS: In patriarchal settings, the role of men can be complex and social and cultural traditions may conflict with public health recommendations. Initiatives to promote male involvement should focus on young men and use chiefs and opinion leaders as advocates to re-orient men towards more proactive involvement in ensuring the health of their partners.

PREventing Maternal And Neonatal Deaths (PREMAND): a study protocol for examining social and cultural factors contributing to infant and maternal deaths and near-misses in rural northern Ghana.

BACKGROUND: While Ghana is a leader in some health indicators among West African nations, it still struggles with high maternal and neonatal morbidity and mortality rates, especially in the northern areas. The clinical causes of mortality and morbidity are relatively well understood in Ghana, but little is known about the impact of social and cultural factors on maternal and neonatal outcomes. Less still is understood about how such factors may vary by geographic location, and how such variability may inform locally-tailored solutions. METHODS/DESIGN: Preventing Maternal And Neonatal Deaths (PREMAND) is a three-year, three-phase project that takes place in four districts in the Upper East, Upper West, and Northern Regions of Ghana. PREMAND will prospectively identify all maternal and neonatal deaths and 'near-misses', or those mothers and babies who survive a life threatening complication, in the project districts. Each event will be followed by either a social autopsy (in the case of deaths) or a sociocultural audit (in the case of near-misses). Geospatial technology will be used to visualize the variability in outcomes as well as the social, cultural, and clinical predictors of those outcomes. Data from PREMAND will be used to generate maps for local leaders, community members and Government of Ghana to identify priority areas for intervention. PREMAND is an effort of the Navrongo Health Research Centre and the University of Michigan Medical School. DISCUSSION: PREMAND uses an innovative, multifaceted approach to better understand and address neonatal and maternal morbidity and mortality in northern Ghana. It will provide unprecedented access to information on the social and cultural factors that contribute to deaths and near-misses in the project regions, and will allow such causal factors to be situated geographically. PREMAND will create the opportunity for local, regional, and national stakeholders to see how these events cluster, and place them relative to traditional healer compounds, health facilities, and other important geographic markers. Finally, PREMAND will enable local communities to generate their own solutions to maternal and neonatal morbidity and mortality, an effort that has great potential for long-term impact.

Socio-demographic and environmental determinants of infectious disease morbidity in children under 5 years in Ghana.

BACKGROUND: Globally, diarrhoea and acute respiratory infections (ARIs) have been identified as major threats to child survival. In Ghana, the two conditions are among the top three causes of morbidity and mortality among children under 5 years. An in-depth analysis of the factors associated with these two diseases is warranted, because of their high degree of fatality and also it provides a basis for intervention planning. OBJECTIVES: To investigate socio-demographic and environmental factors associated with infectious disease morbidity in children under 5 years old in Ghana. DESIGN: Population-based cross-sectional survey. The study sample comprised 2,790 children aged 0-59 months, drawn from the Ghana Demographic and Health Surveys. The mothers reported whether their children under age 5 had been ill with a cough accompanied by short, rapid breathing (ARI), or diarrhoea with the presence of blood or mucus in the stool, in the 2 weeks preceding the survey. RESULTS: Children in the 6-11, 12-23, and 24-59 months age groups had, respectively, 3.48 (95% CI=2.23, 5.44), 4.57 (95% CI=3.03, 6.90), and 1.93 (95% CI=1.30, 2.87) increased odds of getting diarrhoea infection compared to those in the youngest age category (0-5). Similarly, children in the 6-11, 12-23, and 24-59 months age brackets were, respectively, 2.64 (95% CI=1.76, 3.97), 2.63 (95% CI=1.81, 3.83), and 1.83 (95% CI=1.29, 2.59) times more likely to have cough compared to children in 0-5 months age brackets. Children who were not breastfeeding had higher odds of childhood diarrhoea (OR=1.33, 95% CI=1.03, 1.73) compared to those who were breastfeeding. Compared to children who were living in households without co-wives, children who were living in households with co-wives had 1.74 increased odds of diarrhoea (95% CI=1.33, 2.27). A unit increase in maternal opinion regarding wife beating was associated with 14% reduced odds of diarrhoea (OR=0.86, 95% CI=0.80, 0.91), while a unit change in the women's attitude towards sex index was associated with 14% reduced odds of childhood cough (OR=0.86, 95% CI=0.77, 0.97). CONCLUSIONS: Our results show that breastfeeding, polygamous marriage, and maternal decision-making autonomy are significant predictors of child morbidity. Therefore, implementing effective educational programmes that aim at promoting breastfeeding, empowering women, and discouraging polygamous marriages could help save many children from infectious disease morbidity in Ghana.