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).

Pharmacokinetic profile of amodiaquine and its active metabolite desethylamodiaquine in Ghanaian patients with uncomplicated falciparum malaria.

BACKGROUND: Accurate measurement of anti-malarial drug concentrations in therapeutic efficacy studies is essential to distinguish between inadequate drug exposure and anti-malarial drug resistance, and to inform optimal anti-malarial dosing in key target population groups. METHODS: A sensitive and selective LC-MS/MS method was developed and validated for the simultaneous determination of amodiaquine and its active metabolite, desethylamodiaquine, and used to describe their pharmacokinetic parameters in Ghanaian patients with uncomplicated falciparum malaria treated with the fixed-dose combination, artesunate-amodiaquine. RESULTS: The day-28 genotype-adjusted adequate clinical and parasitological response rate in 308 patients studied was > 97% by both intention-to-treat and per-protocol analysis. After excluding 64 patients with quantifiable amodiaquine concentrations pre-treatment and 17 with too few quantifiable concentrations, the pharmacokinetic analysis included 227 patients (9 infants, 127 aged 1-4 years, 91 aged ≥ 5 years). Increased median day-3 amodiaquine concentrations were associated with a lower risk of treatment failure [HR 0.87 (95% CI 0.78-0.98), p = 0.021]. Amodiaquine exposure (median AUC0-∞) was significantly higher in infants (4201 ng h/mL) and children aged 1-5 years (1994 ng h/mL) compared to older children and adults (875 ng h/mL, p = 0.001), even though infants received a lower mg/kg amodiaquine dose (median 25.3 versus 33.8 mg/kg in older patients). Desethylamodiaquine AUC0-∞ was not significantly associated with age. No significant safety concerns were identified. CONCLUSIONS: Efficacy of artesunate-amodiaquine at currently recommended dosage regimens was high across all age groups. Reassuringly, amodiaquine and desethylamodiaquine exposure was not reduced in underweight-for-age young children or those with high parasitaemia, two of the most vulnerable target populations. A larger pharmacokinetic study with close monitoring of safety, including full blood counts and liver function tests, is needed to confirm the higher amodiaquine exposure in infants, understand any safety implications and assess whether dose optimization in this vulnerable, understudied population is needed.

Risk factors for acquisition of meningococcal carriage in the African meningitis belt.

OBJECTIVE: To investigate potential risk factors for acquisition in seven countries of the meningitis belt. METHODS: Households were followed up every 2 weeks for 2 months, then monthly for a further 4 months. Pharyngeal swabs were collected from all available household members at each visit and questionnaires completed. Risks of acquisition over the whole study period and for each visit were analysed by a series of logistic regressions. RESULTS: Over the course of the study, acquisition was higher in: (i) 5-to 14-year olds, as compared with those 30 years or older (OR 3.6, 95% CI 1.4-9.9); (ii) smokers (OR 3.6, 95% CI 0.98-13); and (iii) those exposed to wood smoke at home (OR 2.6 95% CI 1.3-5.6). The risk of acquisition from one visit to the next was higher in those reporting a sore throat during the dry season (OR 3.7, 95% CI 2.0-6.7) and lower in those reporting antibiotic use (OR 0.17, 95% CI 0.03-0.56). CONCLUSIONS: Acquisition of meningococcal carriage peaked in school age children. Recent symptoms of sore throat during the dry season, but not during the rainy season, were associated with a higher risk of acquisition. Upper respiratory tract infections may be an important driver of epidemics in the meningitis belt.

OBJECTIF: Investiguer les facteurs de risque potentiels d'acquisition dans sept pays de la ceinture de la méningite. MÉTHODES: Des ménages ont été suivis toutes les deux semaines pendant deux mois, puis tous les mois pendant quatre mois. Des prélèvements pharyngés sur écouvillons ont été collectés auprès de tous les membres disponibles du ménage à chaque visite et des questionnaires ont été remplis. Les risques d'acquisition sur l'ensemble de la période d'étude et pour chaque visite ont été analysés par une série de régressions logistiques. RÉSULTATS: Au cours de l'étude, l'acquisition a été plus élevée chez: (i) les 5-14 ans, par rapport à ceux âgés de 30 ans ou plus (OR = 3,6; IC95%: 1,4-9,9); (ii) les fumeurs (OR = 3,6; IC95%: 0,98-13); et (iii) les personnes exposées à la fumée de bois à la maison (OR = 2,6; IC95%: 1,3-5,6). Le risque d'acquisition d'une visite à l'autre était plus élevé chez les personnes signalant un mal de gorge pendant la saison sèche (OR = 3,7; IC95%: 2,0-6,7) et plus faible chez celles signalant une utilisation d'antibiotique (OR = 0,17; IC95%: 0,03-0,56). CONCLUSIONS: L'acquisition du portage du méningocoque a culminé chez les enfants d'âge scolaire. Les symptômes récents de maux de gorge pendant la saison sèche, mais pas pendant la saison des pluies, étaient associés à un risque d'acquisition plus élevé. Les infections des voies respiratoires supérieures pourraient être un facteur important d'épidémies dans la ceinture de la méningite.

Non-falciparum malaria infections in pregnant women in West Africa.

BACKGROUND: Non-Plasmodium falciparum malaria infections are found in many parts of sub-Saharan Africa but little is known about their importance in pregnancy. METHODS: Blood samples were collected at first antenatal clinic attendance from 2526 women enrolled in a trial of intermittent screening and treatment of malaria in pregnancy (ISTp) versus intermittent preventive treatment (IPTp) conducted in Burkina Faso, The Gambia, Ghana and Mali. DNA was extracted from blood spots and tested for P. falciparum, Plasmodium vivax, Plasmodium malariae and Plasmodium ovale using a nested PCR test. Risk factors for a non-falciparum malaria infection were investigated and the influence of these infections on the outcome of pregnancy was determined. RESULTS: P. falciparum infection was detected frequently (overall prevalence by PCR: 38.8 %, [95 % CI 37.0, 40.8]), with a prevalence ranging from 10.8 % in The Gambia to 56.1 % in Ghana. Non-falciparum malaria infections were found only rarely (overall prevalence 1.39 % [95 % CI 1.00, 1.92]), ranging from 0.17 % in the Gambia to 3.81 % in Mali. Ten non-falciparum mono-infections and 25 mixed falciparum and non-falciparum infections were found. P. malariae was the most frequent non-falciparum infection identified; P. vivax was detected only in Mali. Only four of the non-falciparum mono-infections were detected by microscopy or rapid diagnostic test. Recruitment during the late rainy season and low socio-economic status were associated with an increased risk of non-falciparum malaria as well as falciparum malaria. The outcome of pregnancy did not differ between women with a non-falciparum malaria infection and those who were not infected with malaria at first ANC attendance. CONCLUSIONS: Non-falciparum infections were infrequent in the populations studied, rarely detected when present as a mono-infection and unlikely to have had an important impact on the outcome of pregnancy in the communities studied due to the small number of women infected with non-falciparum parasites.

Should consent forms used in clinical trials be translated into the local dialects? A survey among past participants in rural Ghana.

BACKGROUND: Obtaining informed consent is part of the expression of the principle of participant autonomy during clinical trials. It is critical that participants understand the content of informed consent forms and remain in a position to seek independent advice on its content. We conducted a survey among past participants of a clinical trial in the Kassena-Nankana Districts of rural northern Ghana about the usefulness of informed consent forms that are written in the local dialects. The written forms of local dialects are largely undeveloped. METHOD: We contacted a randomly selected sample of caregivers whose children were enrolled in a completed clinical trial and interviewed them using a structured questionnaire. Analysis sought to determine participants' preference and whether or not they were likely to find confidants who will be able to read, understand and give advice on the content of the informed consent form to them when they take the informed consent forms home. RESULTS: We interviewed 394 caregivers, 88.6% of whom were women. About half (54%) of the respondents wanted the informed consent forms to be in the English language. Caregivers with higher than primary level education were more likely to prefer the informed consent form to be in English than those with no formal education (74% versus 26%, p = 0.04). The majority (85%) indicated that they would be able to find close confidants who would be able to read and explain it to them if it is in English. In contrast, only 8% thought they would be able to do the same if the informed consent form was written in the local language. Respondents were more likely to find close confidants to read and explain the informed consent form if it were written in English than if it were written in the local language (94% versus 19%, p value < 0.01). CONCLUSION: The practice of translating informed consent forms into undeveloped local dialects and giving such copies to trial participants to send home needs to be re-evaluated. In populations where the written forms of local dialects are undeveloped and literacy is low, the use of local dialect versions of informed consent forms could ironically enhance the vulnerability of trial participants.

Motivation and incentive preferences of community health officers in Ghana: an economic behavioral experiment approach.

BACKGROUND: Health worker shortage in rural areas is one of the biggest problems of the health sector in Ghana and many developing countries. This may be due to fewer incentives and support systems available to attract and retain health workers at the rural level. This study explored the willingness of community health officers (CHOs) to accept and hold rural and community job postings in Ghana. METHODS: A discrete choice experiment was used to estimate the motivation and incentive preferences of CHOs in Ghana. All CHOs working in three Health and Demographic Surveillance System sites in Ghana, 200 in total, were interviewed between December 2012 and January 2013. Respondents were asked to choose from choice sets of job preferences. Four mixed logit models were used for the estimation. The first model considered (a) only the main effect. The other models included interaction terms for (b) gender, (c) number of children under 5 in the household, and (d) years worked at the same community. Moreover, a choice probability simulation was performed. RESULTS: Mixed logit analyses of the data project a shorter time frame before study leave as the most important motivation for most CHOs (ß 2.03; 95 % CI 1.69 to 2.36). This is also confirmed by the largest simulated choice probability (29.1 %). The interaction effect of the number of children was significant for education allowance for children (ß 0.58; 95 % CI 0.24 to 0.93), salary increase (ß 0.35; 95 % CI 0.03 to 0.67), and housing provision (ß 0.16; 95 % CI -0.02 to 0.60). Male CHOs had a high affinity for early opportunity to go on study leave (ß 0.78; 95 % CI -0.06 to 1.62). CHOs who had worked at the same place for a long time greatly valued salary increase (ß 0.28; 95 % CI 0.09 to 0.47). CONCLUSIONS: To reduce health worker shortage in rural settings, policymakers could provide "needs-specific" motivational packages. They should include career development opportunities such as shorter period of work before study leave and financial policy in the form of salary increase to recruit and retain them.

Community Perspectives Associated With the African PsA-TT (MenAfriVac) Vaccine Trials.

BACKGROUND: The Meningitis Vaccine Project (MVP) was established to address epidemic meningitis as a public health problem in sub-Saharan Africa and, to that end, worked to develop a group A meningococcal conjugate vaccine, PsA-TT. METHODS: Experiences in 4 clinical trial sites are described. Culturally sensitive collaborative strategies were adopted to manage acceptable communication methods, peculiarities with the consent process, participant medical issues, community care, and death. RESULTS: The clinical trials were completed successfully through community acceptance and active community collaboration. The trials also strengthened the capacities in the participating communities, and actively worked to resolve community problems. CONCLUSIONS: The understanding and integration of sociocultural realities of communities were major assets in the conduct and acceptance of these trials. MVP succeeded in these sites and provided a sound example for future clinical studies in Africa. CLINICAL TRIALS REGISTRATION: ISRTCN78147026 (PsA-TT 002); ISRCTN87739946 (PsA-TT 003); ISRCTN82484612 (PsA-TT 004); PACTR ATMR2010030001913177 (PsA-TT 006); and PACTR201110000328305 (PsA-TT 007).

Immunogenicity of Yellow Fever Vaccine Coadministered With MenAfriVac in Healthy Infants in Ghana and Mali.

BACKGROUND: Yellow fever (YF) is still a major public health problem in endemic regions of Africa and South America. In Africa, one of the main control strategies is routine vaccination within the Expanded Programme on Immunization (EPI). A new meningococcal A conjugate vaccine (PsA-TT) is about to be introduced in the EPI of countries in the African meningitis belt, and this study reports on the immunogenicity of the YF-17D vaccines in infants when administered concomitantly with measles vaccine and PsA-TT. METHODS: Two clinical studies were conducted in Ghana and in Mali among infants who received PsA-TT concomitantly with measles and YF vaccines at 9 months of age. YF neutralizing antibody titers were measured using a microneutralization assay. RESULTS: In both studies, the PsA-TT did not adversely affect the immune response to the concomitantly administered YF vaccine at the age of 9 months. The magnitude of the immune response was different between the 2 studies, with higher seroconversion and seroprotection rates found in Mali vs Ghana. CONCLUSIONS: Immunogenicity to YF vaccine is unaffected when coadministered with PsA-TT at 9 months of age. Further studies are warranted to better understand the determinants of the immune response to YF vaccine in infancy. CLINICAL TRIALS REGISTRATION: ISRCTN82484612 (PsA-TT-004); PACTR201110000328305 (PsA-TT-007).

Ethical Challenges and Lessons Learned During the Clinical Development of a Group A Meningococcal Conjugate Vaccine.

BACKGROUND: The group A meningococcal vaccine (PsA-TT) clinical development plan included clinical trials in India and in the West African region between 2005 and 2013. During this period, the Meningitis Vaccine Project (MVP) accumulated substantial experience in the ethical conduct of research to the highest standards. METHODS: Because of the public-private nature of the sponsorship of these trials and the extensive international collaboration with partners from a diverse setting of countries, the ethical review process was complex and required strategic, timely, and attentive communication to ensure the smooth review and approval for the clinical studies. Investigators and their site teams fostered strong community relationships prior to, during, and after the studies to ensure the involvement and the ownership of the research by the participating populations. As the clinical work proceeded, investigators and sponsors responded to specific questions of informed consent, pregnancy testing, healthcare, disease prevention, and posttrial access. RESULTS: Key factors that led to success included (1) constant dialogue between partners to explore and answer all ethical questions; (2) alertness and preparedness for emerging ethical questions during the research and in the context of evolving international ethics standards; and (3) care to assure that approaches were acceptable in the diverse community contexts. CONCLUSIONS: Many of the ethical issues encountered during the PsA-TT clinical development are familiar to groups conducting field trials in different cultural settings. The successful approaches used by the MVP clinical team offer useful examples of how these problems were resolved. CLINICAL TRIALS REGISTRATION: ISRCTN17662153 (PsA-TT-001); ISRTCN78147026 (PsA-TT-002); ISRCTN87739946 (PsA-TT-003); ISRCTN46335400 (PsA-TT-003a); ISRCTN82484612 (PsA-TT-004); CTRI/2009/091/000368 (PsA-TT-005); PACTR ATMR2010030001913177 (PsA-TT-006); PACTR201110000328305 (PsA-TT-007).

Research on Emissions, Air quality, Climate, and Cooking Technologies in Northern Ghana (REACCTING): study rationale and protocol.

BACKGROUND: Cooking over open fires using solid fuels is both common practice throughout much of the world and widely recognized to contribute to human health, environmental, and social problems. The public health burden of household air pollution includes an estimated four million premature deaths each year. To be effective and generate useful insight into potential solutions, cookstove intervention studies must select cooking technologies that are appropriate for local socioeconomic conditions and cooking culture, and include interdisciplinary measurement strategies along a continuum of outcomes. METHODS/DESIGN: REACCTING (Research on Emissions, Air quality, Climate, and Cooking Technologies in Northern Ghana) is an ongoing interdisciplinary randomized cookstove intervention study in the Kassena-Nankana District of Northern Ghana. The study tests two types of biomass burning stoves that have the potential to meet local cooking needs and represent different "rungs" in the cookstove technology ladder: a locally-made low-tech rocket stove and the imported, highly efficient Philips gasifier stove. Intervention households were randomized into four different groups, three of which received different combinations of two improved stoves, while the fourth group serves as a control for the duration of the study. Diverse measurements assess different points along the causal chain linking the intervention to final outcomes of interest. We assess stove use and cooking behavior, cooking emissions, household air pollution and personal exposure, health burden, and local to regional air quality. Integrated analysis and modeling will tackle a range of interdisciplinary science questions, including examining ambient exposures among the regional population, assessing how those exposures might change with different technologies and behaviors, and estimating the comparative impact of local behavior and technological changes versus regional climate variability and change on local air quality and health outcomes. DISCUSSION: REACCTING is well-poised to generate useful data on the impact of a cookstove intervention on a wide range of outcomes. By comparing different technologies side by side and employing an interdisciplinary approach to study this issue from multiple perspectives, this study may help to inform future efforts to improve health and quality of life for populations currently relying on open fires for their cooking needs.

Evidence-based training and mentorship combined with enhanced outcomes surveillance to address the leading causes of neonatal mortality at the district hospital level in Ghana.

OBJECTIVE: To evaluate the impact of a district hospital intervention focused on enhancing healthcare provider capacity to address leading causes of neonatal death: birth asphyxia, infection and prematurity. METHODS: The neonatal quality improvement initiative was launched at two intervention referral district hospitals in Ghana. Local Health and Demographic Surveillance Systems were enlisted to enhance recording of neonatal and infant deaths in the community and at the facility. After baseline site assessments, a team of local paediatric experts conducted three clinical trainings on-site at each intervention hospital. Assessments were conducted to evaluate participant knowledge before and after participation in training modules. Monthly mentorship visits provided additional training to support the adoption of essential early neonatal care practices. RESULTS: In the first year of implementation, the initiative provided focused clinical training to 278 participants. A comparison of pre- and post-training test results demonstrates significant improvement in provider knowledge (73% vs. 89% correct, P < 0.001), with even greater improvement among trainees receiving recurrent refresher training (86% vs. 94% correct, P < 0.001). Participant feedback following training revealed enthusiasm about the programme and improved confidence. CONCLUSIONS: Locally led initiatives that invest directly in healthcare provider education and health systems strengthening represent a promising avenue for reducing neonatal morbidity and mortality. The NQI initiative demonstrates the positive impact of a district hospital intervention that combines on-site training, mentorship and enhanced demographic surveillance.

The acceptability of intermittent screening and treatment versus intermittent preventive treatment during pregnancy: results from a qualitative study in Northern Ghana.

BACKGROUND: Affecting mother and child, malaria during pregnancy (MiP) provokes a double morbidity and mortality burden. Within a package of interventions to prevent MiP in endemic areas, the WHO currently recommends intermittent preventive treatment (IPTp). Concerns about anti-malarial resistance have however prompted interest in intermittent screening and treating (IST) as an alternative approach to IPTp. IST involves screening for malaria infection at scheduled antenatal care (ANC) clinic visits and treating malaria cases. In light of the need to comprehensively evaluate new interventions prior to roll out, this article explores the acceptability of IST with artemether-lumefantrine (AL) compared to IPTp with sulphadoxine-pyrimethamine (SP) and in Upper East Region, northern Ghana. METHODS: Data were collected alongside an open-label, randomized, controlled trial of IST-AL and IPTp-SP in Kassena-Nankana District. Thirty pregnant women enrolled in the clinical trial participated in six focus group discussions. Ten in-depth interviews were carried out with clinical trial staff. Observations were also made at the health facilities where the clinical trial took place. RESULTS: Trial participants were generally willing to endure the discomfort of the finger prick necessary for a rapid diagnostic test for malaria and this reflected a wider demand for diagnostic techniques. Reports of side effects were however linked to both trial anti-malarials. Direct complaints about SP were particularly severe with regard to women's experience of vomiting. Although the follow-up treatment doses of AL for IST were not supervised, based on blister inspection and questioning trial, staff were confident about participants' adherence to the treatment course. One case of partial adherence to the AL treatment course was reported. CONCLUSION: Despite the discomfort of the finger prick required to perform the intermittent malaria screening, trial participants generally expressed more positive sentiments towards IST-AL than IPTp-SP. Nonetheless, questions remain about adherence to a multiple dose anti-malarial regimen during pregnancy, particularly in endemic areas where MiP is often non-symptomatic. Any implementation of IST must be accompanied by appropriate health messages on adherence and the necessary training for health staff regarding case management.

"It's up to the woman's people": how social factors influence facility-based delivery in Rural Northern Ghana.

To explore the impact of social factors on place of delivery in northern Ghana. We conducted 72 in-depth interviews and 18 focus group discussions in the Upper East Region of northern Ghana among women with newborns, grandmothers, household heads, compound heads, community leaders, traditional birth attendants, traditional healers, and formally trained healthcare providers. We audiotaped, transcribed, and analyzed interactions using NVivo 9.0. Social norms appear to be shifting in favor of facility delivery, and several respondents indicated that facility delivery confers prestige. Community members disagreed about whether women needed permission from their husbands, mother-in-laws, or compound heads to deliver in a facility, but all agreed that women rely upon their social networks for the economic and logistical support to get to a facility. Socioeconomic status also plays an important role alone and as a mediator of other social factors. Several "meta themes" permeate the data: (1) This region of Ghana is undergoing a pronounced transition from traditional to contemporary birth-related practices; (2) Power hierarchies within the community are extremely important factors in women's delivery experiences ("someone must give the order"); and (3) This community shares a widespread sense of responsibility for healthy birth outcomes for both mothers and their babies. Social factors influence women's delivery experiences in rural northern Ghana, and future research and programmatic efforts need to include community members such as husbands, mother-in-laws, compound heads, soothsayers, and traditional healers if they are to be maximally effective in improving women's birth outcomes.

"I don't know anything about their culture": the disconnect between allopathic and traditional maternity care providers in rural northern Ghana.

The provision of maternal and neonatal health care in rural northern Ghana is pluralistic, consisting of traditional and allopathic providers. Although women often use these providers interchangeably, important differences exist. This study explored the differences in approaches to maternal and neonatal care provision by these two different types of providers. This research was part of the Stillbirth and Neonatal Death Study (SANDS), conducted in northern Ghana in 2010. Trained field staff of the Navrongo Health Research Centre conducted in-depth interviews with 13 allopathic and 8 traditional providers. Interviews were audio-recorded, transcribed, and analyzed using in vivo coding and discussion amongst the research team. Three overarching themes resulted: 1) many allopathic providers were isolated from the culture of the communities in which they practiced, while traditional providers were much more aware of the local cultural beliefs and practices. 2) Allopathic and traditional healthcare providers have different frameworks for understanding health and disease, with allopathic providers relying heavily on their biomedical knowledge, and traditional providers drawing on their knowledge of natural remedies. 3) All providers agreed that education directed at pregnant women, providers (both allopathic and traditional), and the community at large is needed to improve maternal and neonatal outcomes. Our findings suggest that, among other things, programmatic efforts need to be placed on the cultural education of allopathic providers.

Obstetric danger signs and factors affecting health seeking behaviour among the Kassena-Nankani of Northern Ghana: a qualitative study.

Improving community members' knowledge of obstetric danger signs is one strategy for increasing the use of skilled care during pregnancy and the puerperium. This study explored knowledge of obstetric danger signs among a range of community members, examined the sources of their information, and the perceived factors that affect health seeking behaviour in rural northern Ghana. We conducted 72 in-depth interviews and 18 focus groups with community members. All interactions were audio taped, transcribed verbatim and analysed using NVivo 9.0. Community members demonstrated knowledge of a wide range of obstetric danger signs, including excessive bleeding, stomach aches, waist pains, vomiting and fever. Pregnant women learn about danger signs from a range of providers, and regular contact with formal providers typically coincided with increased knowledge of danger signs. Traditional remedies for problems in obstetrics are plentiful and cultural beliefs often restrict the use of allopathic medicine. Increasing knowledge of obstetric danger signs is necessary but not sufficient to overcome cultural preferences for traditional treatments for pregnancy danger signs.

Local illness concepts and their relevance for the prevention and control of malaria during pregnancy in Ghana, Kenya and Malawi: findings from a comparative qualitative study.

BACKGROUND: In sub-Saharan Africa, the burden of morbidity and mortality linked to malaria during pregnancy (MiP) is significant and compounded by its unclear symptoms and links with other health problems during pregnancy. Mindful of the biomedical and social complexity of MiP, this article explores and compares local understandings of MiP and their links with other pregnancy-related health problems. METHODS: A comparative qualitative study was undertaken at four sites in three countries: Ghana, Malawi and Kenya. Individual and group interviews were conducted with pregnant women, their relatives, opinion leaders, other community members and health providers. MiP-related behaviours were also observed at health facilities and in local communities. RESULTS: Across the four sites, local malaria concepts overlapped with biomedically defined malaria. In terms of symptoms, at-risk groups, outcomes and aetiology of malaria during pregnancy, this overlap was however both site-specific and partial. Moreover, the local malaria concepts were not monolithic and their descriptions varied amongst respondents. The symptoms of pregnancy and malaria also overlapped but, for respondents, symptom severity was the distinguishing factor. Malaria was generally, though not universally, perceived as serious for pregnant women. Miscarriage was the most widely known outcome, and links with anaemia, low birth weight and congenital malaria were mentioned. Nonetheless, amongst many potential causes of miscarriage, malaria was not recognized as the most important, but rather interacted with other pregnancy-related problems. CONCLUSIONS: Given the overlap of common pregnancy problems with the symptoms of malaria, and the limited association of malaria with its main outcomes, a comprehensive antenatal care programme is the most appropriate strategy for the provision of health education, prevention and treatment for MiP. Variations in locally shared understandings of MiP must however be taken into account when designing and promoting MiP intervention strategies.

Prevention and management of malaria during pregnancy: findings from a comparative qualitative study in Ghana, Kenya and Malawi.

BACKGROUND: In endemic regions of sub-Saharan Africa, malaria during pregnancy (MiP) is a major preventable cause of maternal and infant morbidity and mortality. Current recommended MiP prevention and control includes intermittent preventive treatment (IPTp), distribution of insecticide-treated bed nets (ITNs) and appropriate case management. This article explores the social and cultural context to the uptake of these interventions at four sites across Africa. METHODS: A comparative qualitative study was conducted at four sites in three countries: Ghana, Malawi and Kenya. Individual and group interviews were conducted with pregnant women, their relatives, opinion leaders, other community members and health providers. Observations, which focused on behaviours linked to MiP prevention and treatment, were also undertaken at health facilities and in local communities. RESULTS: ITNs were generally recognized as important for malaria prevention. However, their availability and use differed across the sites. In Malawi and Kenya, ITNs were sought-after items, but there were complaints about availability. In central Ghana, women saved ITNs until the birth of the child and they were used seasonally in northern Ghana. In Kenya and central Ghana, pregnant women did not associate IPTp with malaria, whereas, in Malawi and northern Ghana, IPTp was linked to malaria, but not always with prevention. Although IPTp adherence was common at all sites, whether delivered with directly observed treatment or not, a few women did not comply with IPTp often citing previous side effects. Although generally viewed as positive, experiences of malaria testing varied across the four sites: treatment was sometimes administered in spite of a negative diagnosis in Ghana (observed) and Malawi (reported). Despite generally following the advice of healthcare staff, particularly in Kenya, personal experience, and the availability and accessibility of medication--including anti-malarials--influenced MiP treatment. CONCLUSION: Although ITNs were valued as malaria prevention, health messages could address issues that reduce their use during pregnancy in particular contexts. The impact of previous side effects on adherence to IPTp and anti-malarial treatment regimens during pregnancy also requires attention. Overtreatment of MiP highlights the need to monitor the implementation of MiP case management guidelines.

Stillbirths and early neonatal mortality in rural Northern Ghana.

OBJECTIVE: To calculate perinatal mortality (stillbirth and early neonatal death: END) rates in the Upper East region of Ghana and characterize community-based stillbirths and END in terms of timing, cause of death, and maternal and infant risk factors. METHODS: Birth outcomes were obtained from the Navrongo Health and Demographic Surveillance System over a 7-year period. RESULTS: Twenty thousand four hundred and ninty seven pregnant women were registered in the study. The perinatal mortality rate was 39 deaths/1000 deliveries, stillbirth rate 23/1000 deliveries and END rates 16/1000 live births. Most stillbirths were 31 weeks gestation or less. Prematurity, first-time delivery and multiple gestation all significantly increased the odds of perinatal death. Approximately 70% of END occurred during the first 3 postnatal days, and the most common causes of death were birth asphyxia and injury, infections and prematurity. CONCLUSION: Stillbirths and END remain a significant problem in Navrongo. The main causes of END occur during the first 3 days and may be modifiable with simple targeted perinatal policies.