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

Effectiveness of trained religious leaders' engagement in maternal health education on improving maternal health service utilizations: Protocol of cluster randomized controlled trial in Hadiya Zone, Southern Ethiopia

BACKGROUND

Despite the many supply- and demand-side interventions aimed at increasing uptake of maternal health service utilizations, the maternal and new-born health service utilizations remains low. Religious leaders have the power to inhibit or facilitate effective adoption of maternal health service utilizations to promote maternal health. However, evidence on the roles of religious leaders in promoting maternal health in developing world is not fully known. Therefore this cluster-randomized trial is designed to evaluate the effects of trained religious leaders' engagement in maternal health education in improving maternal health service utilization and knowledge of obstetric danger signs.

METHODS

A community based cluster randomized control trial in which the study kebeles are randomly assigned into intervention and control groups will be conducted. The sample size is calculated using stata software. Three hundred six pregnant mothers will be enrolled in each group. A baseline study will be conducted before the intervention and post-intervention evaluation will be conducted after four months of intervention. Religious leaders will be selected and trained to lead participatory sessions on maternal health. Data on maternal health service utilizations, knowledge about obstetric danger signs, attitude towards skilled delivery service utilization and perception of pregnancy risk will be collected from a repeated cross sectional household survey. Effect of intervention will be assessed using multivariable logistic regression with generalized estimating equation model. Data will be analyzed using STATA software. For qualitative study, coded transcripts will be further analyzed and summarized in narratives for each theme and sub-themes.

DISCUSSION

This is one of the first trials to evaluate the effectiveness of trained religious leaders' engagement in maternal health education and will provide much needed evidence to policy makers about aspects of functionality and the religious leaders engagement required as they scale-up this programme in Ethiopia.

A scoping review of the residual barriers to skilled birth attendance in Ghana: A conceptual framework and a fish bone analysis

The achievement of the Sustainable Development Goals (SDGs) targets 3.1, 3.2 and 3.3.1 is strongly dependent on the effective utilization of skilled birth services. Despite advancements made in Skilled Birth Attendance (SBA) in Ghana, there are still instances of unassisted childbirths taking place. The aim of this study was to explore the residual barriers of SBA such as community- and health system-related factors affecting SBA in Ghana and to identify strategies for addressing them. An electronic search was done using PubMed, Popline, Science direct, BioMed Central, Scopus and Google scholar for peer reviewed articles as well as grey articles from other relevant sources, published between 200 and 2022 on community- and health system related factors influencing SBA in Ghana. Out of the 89 articles retrieved for full screening, a total of 52 peer-reviewed articles and 1 grey article were selected for the final review. The study revealed that cultural practices (community factors), low quality of service delivery due to the inappropriate behaviors, lack of competency of skilled birth attendants (SBAs) as well as the inefficient distribution of SBAs contribute to ineffective uptake of SBA (health system factors). Also, indirect costs are associated with the utilization of skilled delivery care even with the existence of 'free' delivery care policy under the national health insurance (policy factor). For Ghana to achieve the SDGs above and improve SBA, it is essential to enhance the quality of skilled delivery care by addressing the attitude and competencies of skilled birth professionals, while plans are put in place to expand and develop the Community-based Health Planning and Services (CHPS) strategy to help address the access barriers to SBA. More so, the 'free' delivery care policy should absorb all the costs associated with skilled delivery for pregnant women as it is intended for.

Reaching young people living with HIV & AIDS and young people in detention with comprehensive sexuality education (CSE): a preparatory formative study in Ghana

As an interface between health and education, comprehensive sexuality education (CSE) offers a potent tool among other interventions to accelerate healthy transition of adolescents into adulthood. With increasing interest in in-school CSE provision/delivery, young people in out-of-school contexts may be left behind. This study forms part of implementation research to understand if the activities used to train and support the facilitators are feasible, appropriate, acceptable, and effective in enabling them to engage a defined group of young people, deliver CSE to them in the out-of-school context, and assist them in obtaining relevant services. This paper presents findings of mapping of out-of-school CSE interventions in Ghana, ongoing or completed between 2015 and 2020, and then discusses a needs assessment of two purposively selected groups of vulnerable out-of-school youth: young people living with HIV and AIDS (YPLHIV) and those living in detention (YPiD). We conducted 10 interviews with YPLHIV and three focus group discussions with YPiD in November 2020. Qualitative data were analysed thematically using both deductive and inductive approaches. The mapping yielded 29 interventions (18/62% were ongoing) focused extensively on the delivery of CSE-related knowledge and information; none were aimed at building facilitators' capacity and most targeted the northern regions. Among YPLHIV, living positively after diagnosis, disclosure skills and use of HIV/AIDS health services were critical. YpID sought clarification on personal hygiene, consent in sexual relationships, medium/channel to deliver CSE, and issues around same-sex sexual intercourse. Both groups sought skills in dealing with stigmatisation and discrimination. Implications of the findings for our own and other interventions are highlighted.

Increasing health facility childbirth in Ghana: the role of network and community norms

BACKGROUND

Reducing pregnancy-related deaths in Sub-Saharan Africa through increases in health facility births may be achieved by promoting community norms and network norms favoring health facility births. However, the process of how both norms shift attitudes and actions towards facility delivery is little studied. We examined the association of network and community norms with facility birth, following a quality improvement intervention to improve facility births in Ghana.

METHODS

A 2015 mixed methods evaluation of a Maternal and Newborn Health Referral (MNHR) project in Ghana included a cross-sectional survey of women (N = 508), aged 15-49 years; in-depth interviews (IDIs) with mothers (n = 40), husbands (n = 20) and healthcare improvement collaborative leaders (n = 8); and focus group discussions (FGDs) with mothers-in-law (n = 4) and collaborative members (n = 7). Multivariable logistic regression was used to examine the association of network and community norms with facility birth. Thematic analysis of the qualitative data was conducted to explain this relationship.

RESULTS

The network norm of perceived family approval of facility delivery (AOR: 5.54, CI: 1.65-18.57) and the community norm of perceived number of women in the community that deliver in a facility (AOR: 3.00, CI: 1.66-5.43) were independently associated with facility delivery. In qualitative IDIs and FGDs both norms were also collectively perceived as influencing facility delivery. However, network norms were more influential in women's utilization of facility-based pregnancy-related care. Healthcare improvement collaboratives were important in swaying both network and community norms toward facility-based delivery by offering pregnancy-related health information, antenatal care, and support for facility delivery.

CONCLUSION

Quality improvement initiatives impact both community and network norms. To be most impactful in advancing facility-based pregnancy-related care, these initiatives should focus on highlighting the shifting trend toward facility delivery in rural communicates and promoting support for facility delivery among women's personal networks.

Trends and motivations for freebirth: A scoping review

BACKGROUND

Even when maternity care facilities are available, some women will choose to give birth unassisted by a professional (freebirth). This became more apparent during the pandemic of coronavirus disease 2019 (COVID-19), as women were increasingly concerned they would contract the virus in health care facilities. Several studies have identified the factors that influence women to seek alternative places of birth to hospitals, but research focusing specifically on freebirth is limited.

METHODS

Eight databases were searched from their respective inception dates to April 2022 for studies related to freebirth. Data from the studies were charted and a thematic analysis was subsequently conducted.

RESULTS

Four themes were identified based on findings from the 25 included studies: (1) Geographical and socio-demographic determinants influencing freebirth, (2) Reasons for choosing freebirth, (3) Factors hindering freebirth, and (4) Preparation for and varied experiences of freebirth.

DISCUSSION

More women chose to give birth unassisted in low- and middle-income countries (LMICs) compared with high-income countries (HICs). Overall, motivation for freebirth included previous negative birth experiences with health care professionals, a desire to adhere to their birth-related beliefs, and fear of contracting the COVID-19 virus. Included studies reported that study participants were often met with negative responses when they revealed that they were planning to freebirth. Most women in the included studies had positive freebirth experiences. Future research should explore the different motivators of freebirth present in LMICs or HICs to help inform effective policies that may improve birth experiences while maintaining safety.

Social networks, perceived social support, and HbA1c in individuals with type 2 diabetes mellitus in urban Ghana

OBJECTIVES

Although links between social relationships and health are well established, few studies have concurrently examined the effects of compositional, structural, and functional dimensions of social networks on glycemic (HbA1c) control in low- and middle-income countries such as Ghana. In these settings where informal social relationships are critical for access to resources, evaluating the links between social network characteristics, social support, and glycemic control may provide clarity about important relationships that facilitate the well-being of individuals with type 2 diabetes mellitus (T2DM).

DESIGN

In 2018, we conducted a hospital-based, cross-sectional survey of noninstitutionalized adults with T2DM in Ghana. Using data from 247 study participants, multivariable linear regression models were used to estimate associations between: 1) HbA1c and three social network characteristics (kin composition, household composition, and network density); 2) social support and the three social network characteristics; and 3) HbA1c and social support. We also examined gender differences in these associations and applied mediation techniques to determine if network characteristics operated through social support to affect HbA1c.

RESULTS

Findings indicated that higher kin composition and higher household composition were each significantly associated with increased social support. Neither social support nor social network characteristics were significantly related to HbA1c, and there were no gender differences in any of these associations.

CONCLUSION

Although family and household members were identified as important sources of social support for diabetes management, the ways in which they influence HbA1c control among Ghanaians require further investigation. Future studies can examine whether changes in social support over time, social support satisfaction, or other dimensions of social relationships improve T2DM outcomes in countries like Ghana.

Trends in antenatal care visits and associated factors in Ghana from 2006 to 2018

Introduction

Given that maternal mortality is a major global health concern, multiple measures including antenatal care visits have been promoted by the global community. However, most pregnant women in Ghana and other sub-Saharan African countries do not attain the recommended timelines, in addition to a slower progress towards meeting the required minimum of eight visits stipulated by the World Health Organization. Therefore, this study explored the trends in antenatal care visits and the associated factors in Ghana from 2006 to 2018 using the Multiple Indicator Cluster Surveys.

Methods

The study used women datasets (N = 7795) aged 15 to 49 years from three waves (2006, 2011, and 2017-2018) of the Ghana Multiple Indicator Cluster Surveys (GMICS). STATA version 14 was used for data analyses. Univariable analyses, bivariable analyses with chi-square test of independence, and multivariable analyses with robust multinomial logistic regression models were fitted.

Results

The study found a consistent increase in the proportion of women having adequate and optimal antenatal attendance from 2006 to 2018 across the women’s sociodemographic segments. For instance, the proportion of mothers achieving adequate antenatal care (4 to 7 antenatal care visits) increased from 49.3% in 2006 to 49.98% in 2011 to 58.61% in 2017-2018. In the multivariable model, women with upward attainment of formal education, health insurance coverage, increasing household wealth, and residing in the Upper East Region were consistently associated with a higher likelihood of adequate and/or optimal antenatal care attendance from 2006 to 2018.

Conclusion

Women who are less likely to achieve optimal antenatal care visits should be targeted by policies towards reducing maternal mortalities and other birth complications. Poverty-reduction policies, promoting maternal and girl-child education, improving general livelihood in rural settings, expanding health insurance coverage and infrastructural access, harnessing community-level structures, and innovative measures such as telehealth and telemedicine are required to increase antenatal care utilization.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04404-9.

Access barriers to maternal healthcare services in selected hard-to-reach areas of Zambia: a mixed methods design

Introduction

poor access to maternal health services is a one of the major contributing factors to maternal deaths in low-resource settings, and understanding access barriers to maternal services is an important step for targeting interventions aimed at promoting institutional delivery and improving maternal health. This study explored access barriers to maternal and antenatal services in Kaputa and Ngabwe; two of Zambia´s rural and hard-to-reach districts.

Methods

a concurrent mixed methods approach was therefore, undertaken to exploring three access dimensions, namely availability, affordability and acceptability, in the two districts. Structured interviews were conducted among 190 eligible women in both districts, while key informant interviews, in-depth interviews and focus group discussions were conducted for the qualitative component.

Results

the study found that respondents were happy with facilities´ opening and closing times in both districts. By comparison, however, women in Ngabwe spent significantly more time traveling to facilities than those in Kaputa, with bad roads and transport challenges cited as factors affecting service use. The requirement to have a traditional birth attendant (TBA) accompany a woman when going to deliver from the facility, and paying these TBAs, was a notable access barrier. Generally, services seemed to be more acceptable in Kaputa than in Ngabwe, though both districts complained about long queues, being delivered by male health workers and having delivery rooms next to male wards.

Conclusion

based on the indicators of access used in this study, maternal health services seemed to be more accessible in Kaputa compared to Ngabwe.

Understanding Women's Choices: How Women's Perceptions of Quality of Care Influences Place of Delivery in a Rural Sub-County in Kenya. A Qualitative Study

BACKGROUND

Maternal mortality is still unacceptably high in Kenya. The Kenyan Government introduced a free maternity service to overcome financial barriers to access. This policy led to a substantial increase in women's delivery options. This increase in coverage might have led to a reduction in quality of care. This study explores women's perceptions of quality of delivery services in the context of the free policy and how the perceptions lead to the choice of a place for delivery.

METHODS

Our study site was Naivasha sub-County in Kenya, a rural context, whose geography encompasses pastoralists, rural agrarian, and high population density informal settlements near flower farms. Women from this area are from the lowest wealth quintile in Kenya. We conducted a qualitative study to explore the women's perceptions of quality of care based on their experiences during maternity care. The participants were women of reproductive age (18-49 years) attending antenatal care clinics at six health facilities in the sub-county. Six focus group discussions with 55 respondents were used. For inclusion, the women needed to have delivered a baby within the six months preceding the study. Interviews were recorded with consent, translated and transcribed. The interviews were analyzed using a thematic content approach.

RESULTS

Four broad themes that determined the choice of health facility for delivery were identified: women's perceptions of clinical quality of care; the cost of delivery; distance to the health facility and management of primary health facilities. An unexpected theme was the presence of home deliveries amongst pastoralist women. These findings suggest that in this setting both process and structural dimensions of quality of care and financial and physical accessibility influence women's choices for place of delivery.

CONCLUSION

This study expands our understanding of how women make choices regarding place of delivery. Understanding women's perceptions can provide useful insights to policy makers and facility managers on providing high quality patient centered maternity care necessary to sustain the increased utilization of maternity services at health facilities under the free maternity policy and further reductions in maternal mortality.

Neonatal mortality rates, characteristics, and risk factors for neonatal deaths in Ghana: analyses of data from two health and demographic surveillance systems

Background

Reducing neonatal mortality rates (NMR) in developing countries is a key global health goal, but weak registration systems in the region stifle public health efforts.

Objective

To calculate NMRs, investigate modifiable risk factors, and explore neonatal deaths by place of birth and death, and cause of death in two administrative areas in Ghana.

Methods

Data on livebirths were extracted from the health and demographic surveillance systems in Navrongo (2004–2012) and Kintampo (2005–2010). Cause of death was determined from neonatal verbal autopsy forms. Univariable and multivariable logistic regression were used to analyse factors associated with neonatal death. Multiple imputations were used to address missing data.

Results

The overall NMR was 18.8 in Navrongo (17,016 live births, 320 deaths) and 12.5 in Kintampo (11,207 live births, 140 deaths). The annual NMR declined in both areas. 54.7% of the births occurred in health facilities. 70.9% of deaths occurred in the first week. The main causes of death were infection (NMR 4.3), asphyxia (NMR 3.7) and prematurity (NMR 2.2). The risk of death was higher among hospital births than home births: Navrongo (adjusted OR 1.14, 95% CI: 1.03–1.25, p = 0.01); Kintampo (adjusted OR 1.76, 95% CI: 1.55–2.00, p < 0.01). However, a majority of deaths occurred at home (Navrongo 61.3%; Kintampo 50.7%). Among hospital births dying in hospital, the leading cause of death was asphyxia; among hospital and home births dying at home, it was infection.

Conclusion

The NMR in these two areas of Ghana reduced over time. Preventing deaths by asphyxia and infection should be prioritised, centred respectively on improving post-delivery care in health facilities and subsequent post-natal care at home.

Reproductive health decision making among nomadic pastoralists in North Eastern Kenya: a qualitative social network analysis

BACKGROUND

To our knowledge, no studies exist on the influence of nomadic pastoralist women's networks on their reproductive and sexual health (RSH), including uptake of modern family planning (FP).

METHODS

Using name generator questions, we carried out qualitative egocentric social network analysis (SNA) to explore the networks of four women. Networks were analyzed in R, visuals created in Visone and a framework approach used for the qualitative data.

RESULTS

Women named 10-12 individuals. Husbands were key in RSH decisions and never supported modern FP use. Women were unsure who supported their use of modern FP and we found evidence for a norm against it within their networks.

CONCLUSIONS

Egocentric SNA proves valuable to exploring RSH reference groups, particularly where there exists little prior research. Pastoralist women's networks likely change as a result of migration and conflict; however, husbands make RSH decisions and mothers and female neighbors provide key support in broader RSH issues. Interventions to increase awareness of modern FP should engage with women's wider networks.

Determinants of antenatal care and skilled birth attendance services utilization among childbearing women in Guinea: evidence from the 2018 Guinea Demographic and Health Survey data

BACKGROUND

Globally, maternal health remains a major priority. Most of maternal deaths globally occur in sub-Saharan Africa, with most of these deaths linked to lack of access to antenatal care and skilled assistance during delivery. This study assessed the determinants of antenatal care and skilled birth attendance services utilization among childbearing women in Guinea.

METHODS

Data for this study were obtained from the 2018 Guinea Demographic and Health Survey (GDHS). Data of 4,917 childbearing women were considered as our analytical sample. The outcome variables for the study were utilization of antenatal care and skilled birth attendance. Analysis was carried out using chi-square tests and multivariable logistic regression.

RESULTS

The results showed that women aged 15-24 (AOR=1.29, CI=1.03-1.62), women who had secondary/higher level of education (AOR=1.70, CI=1.33-2.19), and those whose partners had secondary/higher level of education (AOR=1.46, CI=1.22-1.75), women in the richest wealth quintile (AOR=5.09, CI=3.70-7.00), those with planned pregnancies (AOR=1.50, CI=1.23-1.81), Muslim women (AOR=1.65, CI=1.38-2.12), those who take healthcare decisions alone (AOR=1.53, CI=1.24-1.89), and those who listened to radio less than once a week (AOR= 1.30, CI=1.10-1.53) had higher odds of antenatal care uptake. Also, women with secondary/higher level of education (AOR=1.83, CI=1.25-2.68), those whose partners had secondary/higher level of education (AOR=1.40, CI=1.11-1.76), those in the richest wealth quintile (AOR=10.79, CI=6.64-17.51), those with planned pregnancies (AOR=1.25, CI=1.03-1.52), Christian women (AOR=4.13, CI=3.17-5.39), those living in urban areas (AOR=3.00, CI=2.29-3.94), women with one birth (AOR= 1.58, CI=1.20-2.06), those who take healthcare decisions alone (AOR=1.87, CI=1.46-2.39), those who read newspaper at least once a week (AOR= 1.19, CI=1.01-1.40), those who watched television at least once week (AOR=1.69, CI=1.30-2.19), and those in female-headed households (AOR=1.52, CI=1.20-1.92) were more likely to utilize the services of skilled birth attendants.

CONCLUSION

The study proved that various socio-economic and contextual factors influence antenatal care and skilled birth attendance in Guinea. These findings suggest the need to design community-based interventions (e.g., miniature local ANC clinics, early screening services) that prioritize women's education and vocational training, media accessibility, especially among the poor, and those residing in rural settings. Such interventions should not ignore the influence of other socio-cultural norms that hinder the utilization of antenatal care and skilled birth attendance services in Guinea.

Why some women who attend focused antenatal care fail to deliver in health facilities: a qualitative study of women's perspectives from slums of Addis Ababa, Ethiopia

OBJECTIVE

The purpose of this study was to explore why some women who attend focused antenatal care (FANC) fail to deliver in health facilities from slums of Addis Ababa, Ethiopia.

SETTING

Public health facilities (three health centres and one district hospital).

STUDY DESIGN

A qualitative exploratory and descriptive research design was used.

STUDY PARTICIPANTS

Study participants comprised women of reproductive age (18-49 years) living in slum areas of Addis Ababa, Ethiopia. We used 20 in-depth audio-recorded interviews. Data were analysed concurrently with data collection. Thematic analysis was done for the study. A multilevel life-course framework of facility-based delivery in low-income and middle-income countries developed by Bohren et al was used to frame the current study and link the findings of the study to the body of knowledge.

RESULTS

From the analysis of in-depth interview data, four themes emerged, namely, perceived benefits of home delivery, knowledge deficit about health facility-based delivery, poor access to healthcare facilities and inadequate (demand side) resources. These themes were identified as rich and detailed accounts of the perspectives of facility-based and home delivery among attendees of FANC in Addis Ababa, Ethiopia.

CONCLUSION

The findings of this qualitative study revealed that perceived benefits of home delivery, knowledge deficit about health facility-based delivery, poor access to healthcare facilities and inadequate (demand side) resources were related to low uptake of facility-based delivery services. Use of ANC visits to advise women about birth preparedness and complication readiness, the use of facility deliveries to reduce risks of home delivery to the mother and the newborn should be stressed.

Eliciting women's preferences for place of child birth at a peri-urban setting in Nairobi, Kenya: A discrete choice experiment

Objective

Maternal and newborn mortality rates are high in peri-urban areas in cities in Kenya, yet little is known about what drives women’s decisions on where to deliver. This study aimed at understanding women’s preferences on place of childbirth and how sociodemographic factors shape these preferences.

Methods

This study used a Discrete Choice Experiment (DCE) to quantify the relative importance of attributes on women’s choice of place of childbirth within a peri-urban setting in Nairobi, Kenya. Participants were women aged 18–49 years, who had delivered at six health facilities. The DCE consisted of six attributes: cleanliness, availability of medical equipment and drug supplies, attitude of healthcare worker, cost of delivery services, the quality of clinical services, distance and an opt-out alternative. Each woman received eight questions. A conditional logit model established the relative strength of preferences. A mixed logit model was used to assess how women’s preferences for selected attributes changed based on their sociodemographic characteristics.

Results

411 women participated in the Discrete Choice Experiment, a response rate of 97.6% and completed 20,080 choice tasks. Health facility cleanliness was found to have the strongest association with choice of health facility (β = 1.488 p<0.001) followed respectively by medical equipment and supplies availability (β = 1.435 p<0.001). The opt-out alternative (β = 1.424 p<0.001) came third. The attitude of the health care workers (β = 1.347, p<0.001), quality of clinical services (β = 0.385, p<0.001), distance (β = 0.339, p<0.001) and cost (β = 0.0002 p<0.001) were ranked 4^th to 7^th respectively. Women who were younger and were the main income earners having a stronger preference for clean health facilities. Older married women had stronger preference for availability of medical equipment and kind healthcare workers.

Conclusions

Women preferred both technical and process indicators of quality of care. DCE’s can lead to the development of person-centered strategies that take into account the preferences of women to improve maternal and newborn health outcomes.

Understanding what women want: eliciting preference for delivery health facility in a rural subcounty in Kenya, a discrete choice experiment

OBJECTIVE

To identify what women want in a delivery health facility and how they rank the attributes that influence the choice of a place of delivery.

DESIGN

A discrete choice experiment (DCE) was conducted to elicit rural women's preferences for choice of delivery health facility. Data were analysed using a conditional logit model to evaluate the relative importance of the selected attributes. A mixed multinomial model evaluated how interactions with sociodemographic variables influence the choice of the selected attributes.

SETTING

Six health facilities in a rural subcounty.

PARTICIPANTS

Women aged 18-49 years who had delivered within 6 weeks.

PRIMARY OUTCOME

The DCE required women to select from hypothetical health facility A or B or opt-out alternative.

RESULTS

A total of 474 participants were sampled, 466 participants completed the survey (response rate 98%). The attribute with the strongest association with health facility preference was having a kind and supportive healthcare worker (β=1.184, p<0.001), second availability of medical equipment and drug supplies (β=1.073, p<0.001) and third quality of clinical services (β=0.826, p<0.001). Distance, availability of referral services and costs were ranked fourth, fifth and sixth, respectively (β=0.457, p<0.001; β=0.266, p<0.001; and β=0.000018, p<0.001). The opt-out alternative ranked last suggesting a disutility for home delivery (β=-0.849, p<0.001).

CONCLUSION

The most highly valued attribute was a process indicator of quality of care followed by technical indicators. Policymakers need to consider women's preferences to inform strategies that are person centred and lead to improvements in quality of care during delivery.

Sociocultural Practices Affecting the Care of Preterm Infants in the Ghanaian Community

Introduction

Although culture is an integral part of health, there is scarcity of evidence on the influence of culture on caregiving experiences of parents of preterm infants. The aim of this study was to explore the influence of sociocultural practices on caring for preterm infants in the Ghanaian community.

Method

Narrative inquiry was utilized to explore the influence of sociocultural practices on the care of preterm infants from 21 mothers, 9 fathers, and 12 household members. Data were collected through face-to-face semistructured interviews and observations at participants’ homes.

Results

Analysis of data resulted in three threads/themes—respect for the elderly, use of herbal medicines, and communal living.

Discussion

Community and extended family members have great influence on the care of preterm infants. Traditional herbal medicines are considered effective in treating traditional illnesses among preterm infants. Understanding the influence of culture on the care of vulnerable preterm infants in the community is essential in developing interventions for infant survival.

Women's Lived Experiences of Giving Birth in Ghana: A Metasynthesis of the Literature

BACKGROUND

The purpose of this metasynthesis is to analyze women's lived experiences of giving birth in Ghana during and after the Millennium Development Goals (MDGs), when health policy in Ghana was changed to urge women to birth in health services with skilled attendants.

METHOD

An interpretive phenomenological framework guided the review of the literature. Three electronic databases were searched as well as reference lists and author searches. Articles that met the screening criteria for inclusion were coded and thematically analyzed, then drawn together to construct the essence of women's experiences of giving birth in Ghana.

RESULTS

Seven themes were constructed from the data and these were poor quality health services, maltreatment by midwives, mixed emotions about pregnancy and childbirth, supernatural fears, women wanting safe births with skilled birth attendants, uncertainty about reaching a health facility, and decision-making hierarchy. There were three counter themes and these were women wanting a home birth with a traditional midwife, defiance against dominant decision-makers by some women, and a belief that “not all nurses are bad.”

CONCLUSION

Ghanaian women have heeded the MDGs and health policy messages to birth with skilled attendants, but in reality, they are not always accessible, available, appropriate, or of high quality. Maternal health services still need much improvement including more resources such as staff, essential services, medicines, and quality assurance standards.

Perspectives and practices of healthcare providers and caregivers on healthcare-associated infections in the neonatal intensive care units of two hospitals in Ghana

Healthcare-associated infections (HAIs) remain a serious threat to patient safety worldwide, particularly in low- and middle-income countries. Reducing the burden of HAIs through the observation and enforcement of infection prevention and control (IPC) practices remains a priority. Despite growing emphasis on HAI prevention in low- and middle-income countries, limited evidence is available to improve IPC practices to reduce HAIs. This study examined the perspectives of healthcare providers (HPs) and mothers in the neonatal intensive care unit on HAIs and determined the major barriers and facilitators to promoting standard IPC practices. This study draws on data from an ethnographic study using 38 in-depth interviews, four focus group discussions and participant observation conducted among HPs and mothers in neonatal intensive care units of a secondary- and tertiary-level hospital in Ghana. The qualitative data were analysed using a grounded theory approach, and NVivo 12 to facilitate coding. HPs and mothers demonstrated a modest level of understanding about HAIs. Personal, interpersonal, community, organizational and policy-level factors interacted in complex ways to influence IPC practices. HPs sometimes considered HAI concerns to be secondary in the face of a heavy clinical workload, a lack of structured systems and the quest to protect professional authority. The positive attitudes of some HPs, and peer interactions promoted standard IPC practices. Mothers expressed interest in participation in IPC activities. It however requires systematic efforts by HPs to partner with mothers in IPC. Training and capacity building of HPs, provision of adequate resources and improving communication between HPs and mothers were recommended to improve standard IPC practices. We conclude that there is a need for institutionalizing IPC policies and strengthening strategies that acknowledge and value mothers' roles as caregivers and partners in IPC. To ensure this, HPs should be better equipped to prioritize communication and collaboration with mothers to reduce the burden of HAIs.

Trends and correlates of maternal, newborn and child health services utilization in primary healthcare facilities: an explorative ecological study using DHIMSII data from one district in the Volta region of Ghana

Background

Sustainable Development Goal 3 aims at reducing global neonatal mortality to at least 12 per 1000 livebirths, under-five mortality to at least 25 per 1000 livebirths and maternal mortality ratio to less than 70 per 100,000 livebirths by 2030. Considering the achievement so far, many countries in sub-Saharan Africa, including Ghana are not likely to achieve these targets. Low utilization of maternal, newborn and child health (MNCH) services partly account for this predicament. This study explored the trend and correlates of MNCH services utilization in one administrative district in the Volta Region of Ghana.

Methods

This is an explorative ecological study employing trend analysis of 2015–2017 data from Ghana Health Service District Health Information Management System II. Univariate Poisson regression models were used to determine the factors associated with MNCH services utilization at 95% confidence level.

Results

Cumulative record of 17,052 antenatal care (ANC) attendance and 2162 facility-based spontaneous vaginal deliveries (SVDs) was discovered. Compelling evidence of potential unskilled deliveries was observed in 23% of the 26 facilities reported in the DHIMSII data. High cumulative number of midwives in health facilities associated positively with high records of ANC visits (IRR = 1.30, [95% CI:1.29, 1.32]; p = 0.0001), facility-based SVDs (IRR = 1.30 [95% CI:1.25, 1.35]; p = 0.0001) and BCG immunizations (IRR = 1.32 [95% CI:1.29, 1.34]; p = 0.0001). Likewise, high records of ANC visits correlated positively with high facility-based SVDs and child immunizations records (p < 0.0001).

Conclusion

Targeted health system and community level interventions alongside progressive frontline health staff motivation and retention strategies could further enhance enrollment and retention of mothers in pre-natal and postnatal care services throughout the continuum of care to guarantee better MNCH health outcomes. Investments in universal coverage for quality ANC services has the potential to enhance utilization of supervised deliveries and post-natal care services such as immunizations.

Social norms as possible causes of stillbirths

OBJECTIVE

High stillborn rates are a concern in developing countries. Hence, this article aims to describe the sociocultural norms contributing to the high number of stillbirths as perceived by mothers, significant others, midwives and records of the Pregnancy Problem Identification Programme (PPIP).

DESIGN & SETTING

A multimethod qualitative descriptive study was conducted in a district in the Free State, South Africa. Each of the five sub-districts has a district hospital where most pregnant women give birth. Eighty per cent of the community is black of which about a quarter live in poor conditions below the poverty line.

PARTICIPANTS

The first author conducted unstructured in-depth interviews with 36 mothers and their significant other who gave birth to a stillborn. She also extracted relevant data from the PPIP record of each mother. A skilled moderator conducted three focus group interviews with a convenience sample of midwives. The data were inductively analysed to identify subthemes under the central theme of social norms.

KEY CONCLUSIONS

The authors concluded that traditional practices, traditional role players (traditional healer, mother-in-law, partner), abuse, and prescriptive social norms might contribute to stillbirths. Pregnant women are oppressed as they adhere to traditional social norms and are unable to make independent, informed healthcare decisions. The midwives, who are mostly female, may find it difficult to empower pregnant women because they are under the same social oppression as their clients.

IMPLICATIONS FOR PRACTICE

It is imperative that healthcare providers consider social determinants of health, including social norms, when providing healthcare, especially to pregnant women as some social practices may have detrimental outcomes for the mother and/or baby.

Women's decision-making autonomy in the household and the use of maternal health services: An Indonesian case study

OBJECTIVES

The study aimed to examine the influence of Indonesian women's decision-making within the household regarding the use of maternal health services. It explored whether women who had high involvement in household decision-making experienced a higher likelihood of using antenatal care services, delivery services assisted by skilled birth attendance, and facility-based delivery compared to those with limited autonomy.

METHODS

The study used the individual subset data on women from the 2017 Indonesia Demographic and Health Survey, which included 3435 women of reproductive age (15-49 years) who had given birth within one year preceding the survey. The study also used the Women's Participation Index to measure women's decision-making autonomy in the household. Descriptive statistics and multiple logistic regression analyses were conducted to identify the association of women's autonomy with the use of three key maternal health services.

RESULTS

The Women's Participation Index had a significant positive relationship to adequate antenatal care service use, but no effect on the use of skilled birth attendance and facility-based delivery, after adjusting for maternal and sociodemographic variables. Women with more autonomy experienced 1.7 (95% confidence interval: 1.17-2.45) times higher odds of using adequate antenatal care services. In addition, the likelihood of the utilization of adequate antenatal care services, skilled birth attendance, and facility-based delivery was higher among women who were age ≥35 years at birth, attained a higher education level, and were in the richest quintile compared to their respective counterparts.

CONCLUSION

Women's decision-making autonomy had a significant effect on the use of adequate antenatal care services only. Initiatives that are more gender-sensitive to promote husband involvement should be conducted to increase men's awareness of the importance of maternal health services.

Community-level factors associated with the use of facility-based delivery assistance in Uganda: a multilevel analysis

BACKGROUND

In low- and middle-income countries, the proportion of pregnant women who use health facilities for delivery remains low. Although delivering in a health facility with skilled health providers can make the critical difference between survival and death for both mother and child, in 2016, more than 25% of pregnant women did not deliver in a health facility in Uganda. This study examines the association of contextual factors measured at the community-level with use of facility-based delivery in Uganda, after controlling for household and individual-level factors.

METHODS

Pooled household level data of 3310 observations of women who gave birth in the last five years is linked to community level data from the Uganda National Panel Survey (UNPS). A multilevel model that adequately accounted for the clustered nature of the data and the binary outcome of whether or not the woman delivered in a health facility was estimated.

RESULTS

The study findings show a positive association at the county level between place of delivery, education and access to health services, and a negative association between place of delivery and poverty. Individuals living in communities with a high level of education amongst the household heads were 1.67 times (95% Confidence Interval: 1.07-2.61) more likely to have had a facility-based delivery compared to women living in communities where household heads did not have high levels of education. Women who lived in counties with a short travel time (less than 33 min) were 1.66 times (95% CI: 1.11-2.48) more likely to have had a facility-based delivery compared to women who lived in counties with longer travel time to any health facility. Women living in poor counties were only 0.64 times (95% CI: 0.42-0.97) as likely to have delivered in a health facility compared to pregnant women from communities with more affluent individuals.

CONCLUSIONS

The findings on household head's education, community economic status and travel time to a health facility are useful for defining the attributes for targeting and developing relevant nation-wide community-level health promotion campaigns. However, limited evidence was found in broad support of the role of community level factors.

Cultural beliefs and health-seeking practices: Rural Zambians' views on maternal-newborn care

•

Mothers caring for newborns have a maternal dualism between cultural and health system obligations.

•

Traditional newborn protective rituals were identified to help nurses provide health education.

•

Family and community expressed a strong need to protect the newborn using traditional belief systems.

Background

- Far too many newborns die or face serious morbidity in Zambia, as in many other sub-Saharan African countries. New knowledge is needed to enhance our understanding of newborn care and the cultural factors influencing the ways mothers seek newborn care. This study adds to the literature about rural Zambians’ cultural beliefs and practices related to newborn care and health-seeking practices that influence maternal-newborn health.

Objective

- The goal of this study was to describe the factors associated with newborn care in rural Zambia.

Design

- Sixty focus groups were conducted. Each group contained a minimum of 8 and maximum of 12 participants. Recruitment was conducted orally by word of mouth through the nurse in charge at the health facilities and village chiefs.

Setting

– Data were collected between June and August 2016 in 20 communities located in Zambia's rural Lundazi (Eastern province), Mansa, and Chembe (Luapula province) Districts.

Participants

- The study included community members (n = 208), health workers (n = 225), and mothers with infants younger than 1-year-old (n = 213).

Findings

- The following themes emerged. From mothers with infants, the dominant theme concerned traditional and protective newborn rituals. From community members, the dominant theme was a strong sense of family and community to protect the newborn, and from health workers, the major theme was an avoidance of shame. A fourth theme, essential newborn care, was common among all groups.

Key conclusions

– Together the themes pointed toward a maternal dualism for mothers in rural Zambia. Mothers with infants in rural Zambia likely experience a dualistic sense of responsibility to satisfy both cultural and health system expectations when caring for their newborns. Mothers are pulled to engage in traditional protective newborn care rituals while at the same time being pushed to attend ANC and deliver at the health facility. These findings can be used to understand how mothers care for their newborns to develop interventions aimed at improving maternal-child health outcomes.

Implications for practice

- There were findings about the culture-specific prevention of cough, care of the umbilical cord, and early introduction of traditional porridge that carry implications for nursing practice. There is an obvious need to reinforce the importance of partner testing for STIs during routine ANC even though there is a desire to preserve dignity.

"I couldn't buy the items so I didn't go to deliver at the health facility" Home delivery among rural women in northern Ghana: A mixed-method analysis

Background

Maternal mortality remains a major challenge to health systems in low and middle-incoming countries. Some pregnant women develop potentially life-threatening complications during childbirth. Therefore, home delivery is a precursor for maternal mortality. In this study, we aimed at not only estimating the percentage of deliveries occurring at home and examining the factors associated with home delivery, but we also explored the reasons for home delivery among women in rural Ghana.

Methods

The study was conducted among mothers with delivery experience in selected communities in the Builsa South district located in the Upper East Region of Ghana. Both quantitative and qualitative data were collected using semi-structured questionnaires and Focus Group Discussion (FGD) guide respectively. A total of 456 mothers participated in this study. Regression models were used in the quantitative analysis whereas a thematic analysis approach was used to analyze the qualitative data.

Results

Of the 423 mothers in the quantitative research, 38.1% (95% CI: 33.5–42.8) delivered their index child at home. In adjusted analysis, women who were not exposed to information (AOR = 13.64, p<0.001) and women with 2 (AOR = 4.64, p = 0.014), 3 (AOR = 4.96, p = 0.025) or at least 4 living children (AOR = 9.59, p = 0.001) had higher odds of delivering at home. From the qualitative analysis, the poor attitude of nurses (midwives), lack of, and cost of transportation, cost of delivery kits, and traditional beliefs and practices were cited as reasons for home delivery.

Conclusion

Despite the government’s efforts to provide free maternal care services to women in Ghana, a significant proportion of rural women still deliver at home due to other ‘hidden costs’. Addressing poor staff attitude, transportation challenges, and negative traditional beliefs and practices through awareness creation may contribute to improving health facility delivery by rural pregnant women in Ghana.

A qualitative study of community elders' perceptions about the underutilization of formal maternal care and maternal death in rural Nigeria

BACKGROUND

Underutilization of formal maternal care services and accredited health attendants is a major contributor to the high maternal mortality rates in rural communities in Nigeria. Perceptions of a poor quality of care and inaccessible services in health facilities strongly influence the low use of formal maternal care services. There is therefore a need to understand local perceptions about maternal health services utilization and maternal death. This study thereby aims to explore perceptions and beliefs about the underutilization of formal care and causes of maternal death, as well as to identify potential solutions to improve use and reduce maternal mortality in rural Nigeria.

METHODS

Data were collected through 9 community conversations, which were conducted with 158 community elders in 9 rural communities in Edo State, Nigeria. Data from transcripts were analyzed through inductive thematic analysis using NVivo 12 software.

RESULTS

Perceived reasons for the underutilization of formal maternal care included poor qualities of care, physical inaccessibility, financial inaccessibility, and lack of community knowledge. Perceived reasons for maternal death were related to medical causes, maternal healthcare services deficiencies, uptake of native maternal care, and poor community awareness and negligence. Elders identified increased access to adequate maternal care, health promotion and education, community support, and supernatural assistance from a deity as solutions for increasing use of formal maternal care and reducing maternal mortality rates.

CONCLUSION

Study results revealed that multifaceted approaches that consider community contexts, challenges, and needs are required to develop acceptable, effective and long-lasting positive changes. Interventions aiming to increase use of formal care services and curb maternal mortality rates must target improvements to the technical and interpersonal qualities of care, ease of access, community awareness and knowledge, and allow community members to actively engage in implementation phases.

Preferences for formal and traditional sources of childbirth and postnatal care among women in rural Africa: A systematic review

Background

The underutilization of formal, evidence-based maternal health services continues to contribute to poor maternal outcomes among women living in rural Africa. Women’s choice of the type of maternal care they receive strongly influences their utilization of maternal health services. There is therefore a need to understand rural women’s preferred choices to help set priorities for initiatives attempting to make formal maternal care more responsive to women’s needs. The aim of this review was to explore and identify women’s preferences for different sources of childbirth and postnatal care and the factors that contribute to these preferences.

Methods

A systematic literature search was conducted using the Ovid Medline, Embase, CINAHL, and Global Health databases. Thirty-seven studies that elicited women’s preferences for childbirth and postnatal care using qualitative methods were included in the review. A narrative synthesis was conducted to collate study findings and to report on patterns identified across findings.

Results

During the intrapartum period, preferences varied across communities, with some studies reporting preferences for traditional childbirth with traditional care-takers, and others reporting preferences for a formal facility-based childbirth with health professionals. During the postpartum period, the majority of relevant studies reported a preference for traditional postnatal services involving traditional rituals and customs. The factors that influenced the reported preferences were related to the perceived need for formal or traditional care providers, accessibility to maternal care, and cultural and religious norms.

Conclusion

Review findings identified a variety of preferences for sources of maternal care from intrapartum to postpartum. Future interventions aiming to improve access and utilization of evidence-based maternal healthcare services across rural Africa should first identify major challenges and priority needs of target populations and communities through formative research. Evidence-based services that meet rural women’s specific needs and expectations will increase the utilization of formal care and ultimately improve maternal outcomes across rural Africa.

Barriers to formal health care seeking during pregnancy, childbirth and postnatal period: a qualitative study in Siaya County in rural Kenya

Background

There is broad agreement that antenatal care (ANC) interventions, skilled attendance at birth and management of complications arising after delivery are key strategies that can tackle the high burden of maternal mortality in sub-Saharan Africa. In Kenya, utilisation rate of these services has remained low despite a government policy on free maternal care. The present study sought to understand what factors are leading to the low healthcare seeking during pregnancy, child birth and postnatal period in Siaya County in Kenya.

Methods

Six Focus Group Discussions were conducted with 50 women attending ANC in 6 public primary healthcare facilities. Participants were drawn from a sample of 200 women who were eligible participants in a Conditional Cash Transfer project aimed at increasing utilization of healthcare services during pregnancy and postnatal period. Interviews were conducted at the health facilities, recorded, transcribed and analysed using thematic analysis.

Results

Multiple factors beyond the commonly reported distance to health facility and lack of transportation and finances explained the low utilization of services. Emergent themes included a lack of understanding of the role of ANC beyond the treatment of regular ailments. Women with no complicated pregnancies therefore missed or went in late for the visits. A missed health visit contributed to future missed visits, not just for ANC but also for facility delivery and postnatal care. The underlying cause of this relationship was a fear of reprimand from the health staff and denial of care. The negative attitude of the health workers explained the pervasive fear expressed by the participants, as well as being on its own a reason for not making the visits. The effect was not just on the woman with the negative experience, but spiraled and affected the decision of other women and their social networks.

Conclusions

The complexity of the barriers to healthcare visits implies that narrow focused solutions are unlikely to succeed. Instead, there should broad-based solutions that focus on the entire continuum of maternal care with a special focus on ANC. There is an urgent need to shift the negative attitude of healthcare workers towards their clients.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2485-2) contains supplementary material, which is available to authorized users.

Key Decision Makers and Actors in Selected Newborn Care Practices: A Community-Based Survey in Northern Uganda

Knowledge of key decision makers and actors in newborn care is necessary to ensure that health interventions are targeted at the right people. This was a cross-sectional study carried out in Lira district, Northern Uganda. Multivariable logistic regression was used to determine factors associated with mothers being the key decision maker regarding where to give birth from and when to initiate breastfeeding. Fathers were the key decision makers on the place of birth (54.3%, n = 505) and on whether to seek care for a sick newborn child (47.7%, n = 92). Grandmothers most commonly bathed the baby immediately after birth (55.5%, n = 516), whereas mothers and health workers were common decision makers regarding breastfeeding initiation. Predictors for a mother being the key decision maker on the place of birth included: Mother having a secondary education (AOR 1.9: 95% C.I (1.0–3.6)) and mother being formally employed (AOR 2.0: 95% (1.5–2.9)). Mothers, fathers, grandmothers, health-workers, and traditional birth attendants were the most influential in the selected newborn care practices. Programs that aim to promote newborn care need to involve husbands, grandmothers, and health workers in addition to mothers.

Factors influencing the use of supervised delivery services in Garu-Tempane District, Ghana

Background

There is evidence that supervised delivery has the potential to improve birth outcomes for both women and newborns. However, not all women especially in low-income settings like Ghana use supervised delivery services during childbirth. The purpose of this study was to estimate the prevalence of supervised delivery and determine factors that influence use of supervised delivery services in a local district of Ghana.

Methods

A retrospective cross-sectional survey of 322 randomly sampled postpartum women who delivered between January and December 2016 in the Garu-Tempane District was conducted. Structured questionnaires were used to collect data. Descriptive, binary and multivariate logistic regression analysis techniques were used to analyse data.

Results

Although antenatal care attendance among respondents was very high 291(90.4%), prevalence of supervised birth was only 219(68%). More than a quarter 103(32%) of the postpartum women delivered their babies at home without skilled birth attendants. After controlling for possible confounders in multivariable logistic regression analyses, factors that strongly independently predicted supervised delivery were religion (p < 0.01), distance to health facility (p < 0.05), making at least 4 antenatal care visits (p < 0.01), national health insurance scheme registration (p < 0.01), satisfaction with services received during antenatal care (p < 0.01), need partner’s approval before delivering in health facility (p < 0.01), woman’s thoughts that her religious beliefs prohibited health facility delivery(p < 0.01), and woman’s belief that there are norms in her community that did not support health facility delivery (p < 0.01).

Conclusion

There is need for targeted interventions, including community mobilization and health education, and male partner involvement to help generate local demand for, and uptake of, supervised delivery services. Improvement in the quality of services in health facilities, including ensuring respect and dignity for service users, would also be essential.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2295-6) contains supplementary material, which is available to authorized users.

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.

The Effect of the Removal of User Fees for Delivery at Public Health Facilities on Institutional Delivery in Urban Kenya

Objectives In 2013, Kenya removed delivery fees at public health facilities in an effort to promote equity in access to health services and address high maternal mortality. This study determines the effect of the policy to remove user fees on institutional delivery in a population-based sample of women from urban Kenya. Methods Longitudinal data were collected from a representative sample of 8500 women from five cities in Kenya in 2010 with a follow-up interview in 2014 (response rate 58.9%). Respondents were asked about their most recent birth since 2008 at baseline and 2012 at endline, including the delivery location. Multinomial logistic regression is used, controlling for the temporal time trend and background characteristics, to determine if births which occurred after the national policy change were more likely to occur at a public facility than at home or a private facility. Results Multivariate findings show that women were significantly more likely to deliver at a public facility as compared to a private facility after the policy. Among the poor, the results show that poor women were significantly more likely to deliver in a public facility compared to home or a private facility after policy change. Conclusions for Practice These findings show Kenya’s progress towards achieving universal access to delivery services and meeting its national development targets. The removal of delivery fees in the public sector is leading to increased use of facilities for delivery among the urban poor; this is an important first step in reducing maternal death.

Utilization and quality: How the quality of care influences demand for obstetric care in Nigeria

This paper examines the association between health facility quality, subjective perceptions, and utilization of obstetric care. We draw on unique survey data from Nigeria describing the quality of care at rural primary health care facilities and the utilization of obstetric care by households in the service areas of these facilities. Constructing a quality index using the detailed survey data, we show that facility quality is positively related to perceptions of quality and utilization. Disaggregating quality into structural, process and outcome dimensions, we find a consistently strong relationship only between utilization and structural measures of quality. The results suggest that efforts to improve quality may involve a trade-off between investing in dimensions that are more easily observed by households, which will influence utilization, and investing in dimensions that are more closely related to outcomes.

Does knowledge on socio-cultural factors associated with maternal mortality affect maternal health decisions? A cross-sectional study of the Greater Accra region of Ghana

Background

The concern of all maternal health stakeholders is to improve maternal health and reduce maternal deaths to the barest minimum. This remains elusive in low and middle-income countries as the majority of factors that drive maternal deaths stem from the socio-cultural environment especially in rural settings. This study was aimed at finding out if knowledge on socio-cultural factors related to maternal mortality affects maternal health decisions in rural Ghana.

Methods

Community-based cross-sectional in design, the study involved 233 participants from 3 rural districts in the Greater Accra Region. Mixed-method of data collection was employed after informed consent. Quantitative data were analyzed using simple statistics, Fisher’s Exact Test of independence and crude odds ratio were used to interpret the results, whilst the FGDs were recorded, transcribed and analyzed based on themes.

Results

Statistically, significant relationship exists between all the socio-cultural factors studied (Traditional Birth Attendants (TBAs), religious beliefs and practices, herbal concoctions, and pregnancy and childbirth-related taboos) and maternal health decisions (p = 0.001 for all the variables) with very strong associations between maternal health decisions and knowledge on pregnancy and childbirth related taboos, TBA patronage, and religious beliefs and practices (OR = 21.06; 13; 7.28 respectively). However, misconceptions on factors associated with maternal mortality deeply rooted in rural communities partly explain why maternal morbidity and mortality are persistent in Ghana.

Conclusion

Meaningful and successful interventions on maternal mortality can only be achieved if misconceptions on causes of maternal mortality especially in rural areas of the country are tackled through mass education of communities. This should be done consistently over a long period of time for sustained behavioral change.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2197-7) contains supplementary material, which is available to authorized users.

Exploring mistreatment of women during childbirth in a peri-urban setting in Kenya: experiences and perceptions of women and healthcare providers

Background

In Kenya, indirectly caused maternal deaths form a significant portion of all maternal deaths within the health system. Many of these deaths are avoidable and occur during delivery and labor. Poor quality health service has been a recurring concern among women in Kenya, with women reporting interactions with healthcare workers that are often demeaning and abusive. This paper explores the experiences and perceptions of both female patients and healthcare workers regarding mistreatment during childbirth. This study aims to provide recommendations on how dignified care can be made the norm, specifically focusing on a peri-urban setting in Kenya.

Methods

The research was accomplished using qualitative research methods with focus group discussions and in depth interviews with women and healthcare workers. The aim was to gain a deeper understanding of the manifestations of mistreatment within the context of a peri-urban setting in Kenya.

Results

Female patients reported different forms of mistreatment, such as verbal abuse, physical abuse, neglect, discrimination, abandonment, poor rapport and failure of the health system to uphold professional standards. The healthcare workers described a health system that was weak and fragmented with poor policy support particularly for the new free maternity services policy leading to the mistreatment of women.

Conclusion

Newly formed County Governments need to provide resources for a functioning health system to ensure an enabling environment for the provision of high quality maternal health services. This process can include feedback loops with maternity clients to ensure woman-centered services. Policy makers need to strengthen oversight for the implementation of the free maternity services Community health volunteers can be trained to provide this information. Professional associations that govern the standards of quality care for healthcare workers need to address the mistreatment through retraining and norms transformation.

Electronic supplementary material

The online version of this article (10.1186/s12978-018-0643-z) contains supplementary material, which is available to authorized users.

A qualitative study of women's network social support and facility delivery in rural Ghana

Similar to many sub-Saharan African countries, maternal mortality in Ghana ranks among the highest (39th) globally. Prior research has demonstrated the impact of social network characteristics on health facility delivery in sub-Saharan Africa. However, in-depth examination of the function of all members in a woman's network, in providing various types of support for the woman's pregnancy and related care, is limited. We qualitatively explore how women's network social support influences facility delivery. Qualitative data came from a mixed methods evaluation of a Maternal and Newborn Health Referral project in Ghana. In 2015 we conducted in-depth interviews with mothers (n = 40) and husbands (n = 20), and 4 focus group interviews with mothers-in-law. Data were analyzed using narrative summaries and thematic coding procedures to first examine women's network composition during their pregnancy and childbirth experiences. We then compared those who had homebirths versus facility births on how network social support influenced their place of childbirth. Various network members were involved in providing women with social support. We found differences in how informational and instrumental support impacted women's place of childbirth. Network members of women who had facility delivery mobilized resources to support women's facility delivery. Among women who had homebirth but their network members advocated for them to have facility delivery, members delayed making arrangements for the women's facility delivery. Women who had homebirth, and their network members advocated homebirth, received support to give birth at home. Network support for women's pregnancy-related care affects their place of childbirth. Hence, maternal health interventions must develop strategies to prioritize informational and instrumental support for facility-based pregnancy and delivery care.

"Who'll do all these if I'm not around?": Bonding social capital and health and well-being of inpatients

Purpose: Although social capital influences health-related decisions and behavioural patterns in many developing countries, minimal attention has been paid to the nuances of its effect on healthcare. This paper examines how bonding social capital affects healthcare delivery for inpatients in Ghana.

Methods: Semi-structured in-depth interviews were used and thematic analysis method employed to analyse the data. Interviews were conducted with health professionals and relatives and close friends of inpatients in three public health facilities in Ashanti region.

Results: Relatives and close friends of inpatients were a critical source of instrumental support such as provision of meals, laundry services, running errands and financial assistance as well as emotional support. These functions—that were both ‘expected’ and ‘encouraged’— reduced the burden on the health facilities, which apparently had limited resources to offer adequate care. However, the relatives of inpatients sometimes inadvertently obstructed efficient healthcare delivery through actions such as extending ‘unapproved’ alternative care to patients. Moreover, the process of contributing towards health and well-being of the sick exposed the relatives to health risks due to poor living conditions.

Conclusion: A well-defined and befitting role must be devised for at least an immediate social relation of inpatients to improve the positive effects of bonding social capital on healthcare delivery.

Structural and functional network characteristics and facility delivery among women in rural Ghana

Background

Health facility births contribute to the prevention of maternal deaths. Although theoretical and empirical evidence suggest that social network characteristics influence facility delivery, examination of this relationship in sub-Saharan Africa is limited. We determined whether network structural and functional characteristics were associated with, or had an interactive effect on health facility delivery in rural Ghana.

Methods

Data on mothers (n = 783) aged 15–49 years came from a Maternal and Newborn Health Referral (MNHR) project in Ghana, and included egocentric network data on women’s social network characteristics. Using multivariate logistic regression we examined the relationship between facility delivery and women’s network structure and functions, as well as the interaction between network characteristics and facility delivery.

Results

Higher levels of instrumental support (e.g. help with daily chores or seeking health care [OR: 1.60, CI: 1.10–2.34]) and informational support (OR: 1.66, CI: 1.08–2.54) were significantly associated with higher odds of facility delivery. Social norms, such as knowing more women who had received pregnancy-related care in a facility, were significantly associated with higher odds of facility delivery (OR: 2.20, CI: 1.21–4.00). The number of network members that respondents lived nearby moderated the positive relationship between informational support and facility delivery. Additionally, informational support moderated the positive relationship between facility delivery and the number of women the respondents knew who had utilized a facility for pregnancy-related care.

Conclusions

Social support from network members was critical to facilitating health facility delivery, and support was further enhanced by women’s network structure and norms favoring facility delivery. Maternal health interventions to increase facility delivery uptake should target women’s social networks.

WOMEN'S EDUCATION AND UTILIZATION OF MATERNAL HEALTH SERVICES IN AFRICA: A MULTI-COUNTRY AND SOCIOECONOMIC STATUS ANALYSIS

There is an abundant literature on the relationship between women's education and maternal and child outcomes, including antenatal and postnatal care, onset of antenatal care and skilled birth attendance. However, few studies have adopted the 'equity' lens, despite increasing evidence that inequities between rich and poor are increasing although maternal and child mortality is declining. This study examined the differential effects of women's education within different socioeconomic strata in Africa. The most recent Demographic and Health Surveys (DHS) conducted in the Democratic Republic of the Congo, Egypt, Ghana, Nigeria and Zimbabwe were used. In each country, the original sample was stratified into three socioeconomic groups: poor, middle and rich. For each maternal health service utilization variable, the gross and net effects of women's education, controlling for age, parity, religion, marital status, health insurance, access to health facilities, partner's education and current place of residence, were estimated using logistic regression, taking into account the complex sampling design of the DHS. The findings revealed country-specific variations in maternal health service utilization, and for most indicators there was a clear gradient among socioeconomic strata: women living in better-off households exhibited greater access to, and utilization of, maternal health services. Multivariate analyses revealed that women's education had a positive association with type of antenatal care provider, timing and frequency of antenatal care visits, place of delivery and presence of a skilled birth attendant at delivery. Many other factors were found to be significantly associated with maternal health service utilization. For instance, parity had a negative and significant association with timing of first antenatal care visit. Likewise, partner's education was positively and statistically associated with timing of first antenatal care visit. It is argued that an over-generalization of the association between women's education and maternal health service utilization can be misleading. Efforts to improve maternal health service utilization in Africa must adopt an 'equity' approach, taking into account the specific needs of sub-populations.

Effect of a package of integrated demand- and supply-side interventions on facility delivery rates in rural Bangladesh: Implications for large-scale programs

Background

According to the Bangladesh Demographic and Health Survey 2014, only approximately 37 percent of women deliver in a health facility. Among the eight administrative divisions of Bangladesh, the facility delivery rate is lowest in the Sylhet division (22.6 percent) where we assessed the effect of integrated supply- and demand-side interventions on the facility-based delivery rate.

Methods

Population-based cohort data of pregnant women from an ongoing maternal and newborn health improvement study being conducted in a population of ~120,000 in Sylhet district were used. The study required collection and processing of biological samples immediately after delivery. Therefore, the project assembled various strategies to increase institutional delivery rates. The supply-side intervention included capacity expansion of the health facilities through service provider refresher training, 24/7 service coverage, additions of drugs and supplies, and incentives to the providers. The demand-side component involved financial incentives to cover expenses, a provision of emergency transport, and referral support to a tertiary-level hospital. We conducted a before-and-after observational study to assess the impact of the intervention in a total of 1,861 deliveries between December 2014 and November 2016.

Results

Overall, implementation of the intervention package was associated with 52.6 percentage point increase in the proportions of facility-based deliveries from a baseline rate of 25.0 percent to 77.6 percent in 24 months. We observed lower rates of institutional deliveries when only supply-side interventions were implemented. The proportion rose to 47.1 percent and continued increasing when the project emphasized addressing the financial barriers to accessing obstetric care in a health facility.

Conclusions

An integrated supply- and demand-side intervention was associated with a substantial increase in institutional delivery. The package can be tailored to identify which combination of interventions may produce the optimum result and be scaled. Rigorous implementation research studies are needed to draw confident conclusions and to provide information about the costs, feasibility for scale-up and sustainability.

Developing competencies among health professions students related to the care of people with disabilities: a pilot study

This is a two-phase study, the first was a literature review that aimed to identify a set of competencies for professional practice that would be relevant for the health care of People with disabilities (PwD). These competencies were then used to plan a thirty-hour multidisciplinary course for undergraduate health care students. The educational intervention led to improvements in the students’ learning experiences, including the development of empathy and knowledge related to the care of PwD, improved knowledge around accessibility, and an awareness of the need to humanize the care of PwD. Students reported enhanced learning experiences and an increase in knowledge related to the care of PwD, and also highlighted the need to humanize the care.

Access barriers to obstetric care at health facilities in sub-Saharan Africa-a systematic review

BACKGROUND

Since 2000, the United Nations' Millennium Development Goals, which included a goal to improve maternal health by the end of 2015, has facilitated significant reductions in maternal morbidity and mortality worldwide. However, despite more focused efforts made especially by low- and middle-income countries, targets were largely unmet in sub-Saharan Africa, where women are plagued by many challenges in seeking obstetric care. The aim of this review was to synthesise literature on barriers to obstetric care at health institutions in sub-Saharan Africa.

METHODS

This review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus databases were electronically searched to identify studies on barriers to health facility-based obstetric care in sub-Saharan Africa, in English, and dated between 2000 and 2015. Combinations of search terms 'obstetric care', 'access', 'barriers', 'developing countries' and 'sub-Saharan Africa' were used to locate articles. Quantitative, qualitative and mixed-methods studies were considered. A narrative synthesis approach was employed to synthesise the evidence and explore relationships between included studies.

RESULTS

One hundred and sixty articles met the inclusion criteria. Currently, obstetric care access is hindered by several demand- and supply-side barriers. The principal demand-side barriers identified were limited household resources/income, non-availability of means of transportation, indirect transport costs, a lack of information on health care services/providers, issues related to stigma and women's self-esteem/assertiveness, a lack of birth preparation, cultural beliefs/practices and ignorance about required obstetric health services. On the supply-side, the most significant barriers were cost of services, physical distance between health facilities and service users' residence, long waiting times at health facilities, poor staff knowledge and skills, poor referral practices and poor staff interpersonal relationships.

CONCLUSION

Despite similarities in obstetric care barriers across sub-Saharan Africa, country-specific strategies are required to tackle the challenges mentioned. Governments need to develop strategies to improve healthcare systems and overall socioeconomic status of women, in order to tackle supply- and demand-side access barriers to obstetric care. It is also important that strategies adopted are supported by research evidence appropriate for local conditions. Finally, more research is needed, particularly, with regard to supply-side interventions that may improve the obstetric care experience of pregnant women.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2014 CRD42014015549.

Stakeholders' views on maternity care shortcomings in rural Ghana: An ethnographic study among women, providers, public, and quasiprivate policy sector actors

Access to skilled provider and emergency obstetric care is not universal across all districts in Ghana. The lived experiences of 3 stakeholder groups on maternity care shortcomings in 3 rural Ghanaian districts are examined in this study. We applied an ethnographic study approach where field data were collected between March to May 2015 in 3 rural districts of northern Ghana. Data were collected among women with recent births experiences (n = 90), health care providers (n = 16), and policy actors (n = 6). Transcripts were read through to identify similar and divergent stakeholders' views. Significant expressions and experiences of stakeholders on maternity care shortcomings were extracted and evaluated to define key themes. Four themes emerged: social/community factors, payments for health care, facility level factors, and policy level factors. The results show that traditional women's roles divest time for maternity care. Poor transport arrangements, insufficient health workforce, health funding gaps, insurance reimbursements delays, and catastrophic health expenditures on travel and drugs are attested as major barriers across all stakeholder groups in all districts studied. The discussion of the study findings suggests it is important to ascertain the scale of informal payments and their impacts on health access. Investments in health workforce and reliable ambulatory service systems could help address poor referral difficulties in rural areas of the country. Social support for community initiatives that pool funds could provide extra resources and relieve cost access-related challenges for using maternity care in rural settings in Ghana.

Sustainable Development Goals and the Ongoing Process of Reducing Maternal Mortality

Innovative programs introduced in response to the Millennium Development Goals show promise to reduce the global rate of maternal mortality. The Sustainable Development Goals, introduced in 2015, were designed to build on this progress. In this article, we describe the global factors that contribute to maternal mortality rates, outcomes of the implementation of the Millennium Development Goals, and the new, related Sustainable Development Goals. Implications for clinical practice, health care systems, research, and health policy are provided.

The Meaning of Giving Birth: Voices of Hmong Women Living in Vietnam

Increasing knowledge about the sociocultural context of birth is essential to promote culturally sensitive nursing care. This qualitative study provides an ethnographic view of the perspectives on birthing of Hmong mothers living in the highlands of Vietnam. Unique cultural beliefs exist in Hmong culture about the spiritual and physical world as well as ritual practices associated with childbearing. This includes variations of ancestor worship, reincarnation, and healing practices by shamans. Traditionally, Hmong families take an active role in childbirth with birth frequently occurring in the home. Situated within a large collaborative anthropology project, a convenience sample of 8 Hmong women, who had recently given birth, were interviewed regarding the perinatal experience. In addition, ethnic traditional birth attendants (midwives) and other village women contributed perspectives providing richly descriptive data. This ethnographic study was conducted during 6 weeks of immersed participant observation with primary data collection carried out through fieldwork. Data were analyzed to derive cultural themes from interviews and observations. Significant themes included (1) valuing motherhood, (2) laboring and giving birth silently, (3) giving birth within the comfort of home and family, (4) feeling capable of birthing well, (5) feeling anxiety to provide for another child, and (6) embracing cultural traditions. Listening to the voices of Hmong women enhances understanding of the meaning of childbirth. Gaining greater understanding of Hmong cultural beliefs and practices can ensure childbearing women receive respectful, safe, and quality care.

Barriers to Institutional Childbirth in Rumbek North County, South Sudan: A Qualitative Study

Background

South Sudan has one of the world’s poorest health indicators due to a fragile health system and a combination of socio-cultural, economic and political factors. This study was conducted to identify barriers to utilisation of institutional childbirth services in Rumbek North County.

Methods

Data were collected through 14 focus group discussions with 169 women and 45 men, and 18 key informant interviews with community leaders, staff working in health facilities, traditional birth attendants, and the staff of the County Health Department. Data were analysed using inductive content analysis.

Results

The barriers to institutional childbirth were categorised under four main themes: 1) Issues related to access and lack of resources: long distance to health facilities, lack of transportation means, referral problems, flooding and poor roads, and payments in health facilities; 2) Issues related to the socio-cultural context and conflict: insecurity, influence of the husband, lack of birth preparedness, domestic chores of women, influence of culture; 3) Perceptions about pregnancy and childbirth: perceived benefit of institutional childbirth, low childbirth risk perception, and medicalisation of childbirth including birth being perceived to be natural, undesirable birth practices, privacy concerns, and fear of caesarean section; and 4) Perceptions about the quality of care: inadequate health facility infrastructure and perceived neglect during admission.

Conclusions

Multiple factors hinder institutional childbirth in Rumbek North. Some of the factors such as insecurity and poor roads are outside the scope of the health sector and will require a multi-sectoral approach if childbirth services are to be made accessible to women. Detailed recommendations to increase utilisation of childbirth services in the county have been suggested.

Male Involvement and Accommodation During Obstetric Emergencies in Rural Ghana: A Qualitative Analysis

CONTEXT

Although men potentially play an important role in emergency obstetric care in Sub-Saharan Africa, few studies have examined the ways in which men are involved in such emergencies, the consequences of their involvement or the degree to which health facilities accommodate men.

METHODS

Qualitative interviews were conducted with 39 mothers and fathers in two districts in Northern and Central Ghana who had experienced obstetric emergencies, such as severe birth complications, to obtain narratives about those experiences. In addition, interviews with six health facility workers and eight focus group discussions with community members were conducted. Transcripts were analyzed using an inductive analytic approach.

RESULTS

Although some men had not been involved at all during their partner's obstetric emergency, two-thirds had provided some combination of financial, emotional and instrumental support. On the other hand, several men had acted as gatekeepers, and their control of resources and decisions had resulted in care-seeking delays. Although many respondents reported that health facilities accommodated male partners (e.g., by providing an appropriate space for men during delivery), others found that facilities were not accommodating, in some cases ignoring or disrespecting men. A few respondents had encountered improper staff expectations, notably that men would accompany their partner to the facility, a requirement that limits women's autonomy and delays care.

CONCLUSIONS

Policies and programs should promote supportive behavior by men during obstetric emergencies while empowering women. Health facility policies regarding accommodation of men during obstetric emergencies need to consider women's and men's preferences. Research should examine whether particular forms of support improve maternal and newborn health outcomes.

Eating soup with nails of pig: thematic synthesis of the qualitative literature on cultural practices and beliefs influencing perinatal nutrition in low and middle income countries

BACKGROUND

The perinatal period, i.e. pregnancy, childbirth and early infancy, is a significant transition period where the biological and the social strongly intersect. In low and middle-income countries the disease burden arising from the perinatal period, is still substantial. The perinatal period is also a crucial window of opportunity for reducing undernutrition and its long term adverse effects.

METHODS

We explored qualitative research conducted in low resource settings around the perinatal continuum over the past two decades, with a particular focus on the 'cultural' realm, to identify common themes influencing maternal and infant nutrition. We systematically searched electronic databases from 1990 to 2014, including MEDLINE, EMBASE, PsycINFO, Scopus and Cumulative Index to Nursing and Allied Health Literature, using relevant search terms including traditional beliefs, practices, pregnancy, childbirth, developing countries etc. Adapted Consolidated Criteria for Reporting Qualitative Health Research and Critical Appraisal Skills Programme criteria were used to determine quality of studies. We synthesised the literature thematically, enabled by NVivo 10 software.

RESULTS

Most studies showed cultural support for breastfeeding, although most traditional societies delayed breastfeeding due to colostrum being considered 'dirty'. A range of restrictive practices through pregnancy and the post- partum period were revealed in Asia, Latin America and Africa. There was a strong cultural understanding of the healing power of everyday foods. A wide range of good foods and bad foods continued to have currency through the perinatal continuum, with little consensus between groups of what was beneficial versus harmful. Cross-cutting themes that emerged were 1) the role of the woman/mother/wife as strong and good; 2) poverty restricting women's nutrition choices; 3) change being constant, but the direction of change unpredictable.

CONCLUSIONS

A rich and diverse repertoire of cultural practices and beliefs influenced perinatal nutrition. Results from this synthesis should influence public health policymakers and practitioners, to tailor contextually specific, culturally responsive perinatal nutrition interventions to optimise health and wellbeing of mother-infant dyads. Ideally these interventions should build on culturally sanctioned life affirming behaviours such as breastfeeding, promoting post-partum rest and recovery, while modifying the potentially harmful aspects of other cultural practices in the perinatal period.

Addressing the continuum of maternal and newborn care in Ghana: implications for policy and practice

Although the past decade has brought global reductions in maternal, infant and child mortality, many low-resource settings have failed to make significant gains relative to their high-income counterparts. In Ghana, nearly 50% of under-five mortality in 2014 could be attributed to deaths during the first 28 days after birth. This article analyses the data across a mixed-methods study of the factors impacting maternal and neonatal care in northern Ghana. The stillbirth and neonatal death study (SANDS) was conducted in 2010 and included both quantitative (N = 20 497) and qualitative data collection (N = 253) to explore the issues associated with the continuum of reproductive health care. Findings were compared against an adaptation of the WHO/UNICEF framework for integrated maternal and newborn care and used to generate concrete recommendations for clinicians, policymakers and programmers across the continuum of care, from pregnancy through delivery and postnatal care. SANDS elucidated epidemiological trends: 40% of neonatal deaths occurred on the first day after birth, and the leading causes of early neonatal mortality were birth asphyxia/injury, infection and complications of prematurity. Qualitative data reflect findings along two axes-community to facility-based care, and pre-pregnancy through the postnatal period. Resulting recommendations include the need to improving clinicians' understanding of and sensitization to local traditional practices, the need for policies to better address quality of care and coordination of training efforts, and the need for comprehensive, integrated programmes that ensure continuity of care from pre-pregnancy through the post-partum period. SANDS illustrates complex medical-social-cultural knowledge, attitudes and practices that span the reproductive period in rural northern Ghana. Data illustrate that not only are the first few days of life critical in infant survival but also there are significant social and cultural barriers to ensuring that mothers and their newborns are cared for in a timely, evidence-based manner.