Can community health officer-midwives effectively integrate skilled birth attendance in the community-based health planning and services program in rural Ghana?

Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence

BACKGROUND

Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses.

OBJECTIVES

To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified.

SELECTION CRITERIA

We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification.

DATA COLLECTION AND ANALYSIS

For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population.

MAIN RESULTS

The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations.

AUTHORS' CONCLUSIONS

This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.

Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence

BACKGROUND

Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses.

OBJECTIVES

To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified.

SELECTION CRITERIA

We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification.

DATA COLLECTION AND ANALYSIS

For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population.

MAIN RESULTS

The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations.

AUTHORS' CONCLUSIONS

This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.

Effects of computerized decision support on maternal and neonatal health-worker performance in the context of combined implementation with performance-based incentivisation in Upper East Region, Ghana: a qualitative study of professional perspectives

BACKGROUND

Computerized decision support systems (CDSS) and performance-based incentives (PBIs) can improve health-worker performance. However, there is minimal evidence on the combined effects of these interventions or perceived effects among maternal and child healthcare providers in low-resource settings. We thus aimed to explore the perceptions of maternal and child healthcare providers of CDSS support in the context of a combined CDSS-PBI intervention on performance in twelve primary care facilities in Ghana's Upper East Region.

METHODS

We conducted a qualitative study drawing on semi-structured key informant interviews with 24 nurses and midwives, 12 health facility managers, and 6 district-level staff familiar with the intervention. We analysed data thematically using deductive and inductive coding in NVivo 10 software.

RESULTS

Interviewees suggested the combined CDSS-PBI intervention improved their performance, through enhancing knowledge of maternal health issues, facilitating diagnoses and prescribing, prompting actions for complications, and improving management. Some interviewees reported improved morbidity and mortality. However, challenges described in patient care included CDSS software inflexibility (e.g. requiring administration of only one intermittent preventive malaria treatment to pregnant women), faulty electronic partograph leading to unnecessary referrals, increased workload for nurses and midwives who still had to complete facility forms, and power fluctuations affecting software.

CONCLUSION

Combining CDSS and PBI interventions has potential to improve maternal and child healthcare provision in low-income settings. However, user perspectives and context must be considered, along with allowance for revisions, when designing and implementing CDSS and PBIs interventions.

What improves access to primary healthcare services in rural communities? A systematic review

BACKGROUND

To compile key strategies from the international experiences to improve access to primary healthcare (PHC) services in rural communities. Different innovative approaches have been practiced in different parts of the world to improve access to essential healthcare services in rural communities. Systematically collecting and combining best experiences all over the world is important to suggest effective strategies to improve access to healthcare in developing countries. Accordingly, this systematic review of literature was undertaken to identify key approaches from international experiences to enhance access to PHC services in rural communities.

METHODS

All published and unpublished qualitative and/or mixed method studies conducted to improvement access to PHC services were searched from MEDLINE, Scopus, Web of Science, WHO Global Health Library, and Google Scholar. Articles published other than English language, citations with no abstracts and/or full texts, and duplicate studies were excluded. We included all articles available in different electronic databases regardless of their publication years. We assessed the methodological quality of the included studies using mixed methods appraisal tool (MMAT) version 2018 to minimize the risk of bias. Data were extracted using JBI mixed methods data extraction form. Data were qualitatively analyzed using emergent thematic analysis approach to identify key concepts and coded them into related non-mutually exclusive themes.

RESULTS

Our analysis of 110 full-text articles resulted in ten key strategies to improve access to PHC services. Community health programs or community-directed interventions, school-based healthcare services, student-led healthcare services, outreach services or mobile clinics, family health program, empanelment, community health funding schemes, telemedicine, working with traditional healers, working with non-profit private sectors and non-governmental organizations including faith-based organizations are the key strategies identified from international experiences.

CONCLUSION

This review identified key strategies from international experiences to improve access to PHC services in rural communities. These strategies can play roles in achieving universal health coverage and reducing disparities in health outcomes among rural communities and enabling them to get healthcare when and where they want.

Effects of combined decision-support and performance-based incentives on reported client satisfaction with maternal health services in primary facilities: A quasi-experimental study in the Upper East Region of Ghana

BACKGROUND

Computerized decision-support systems (CDSS) and performance-based incentives (PBIs) have potential to contribute to client satisfaction with health services. However, rigorous evidence is lacking on the effectiveness of these strategies in lower-income countries such as Ghana. This study aimed to determine the effect of a combined CDSS-PBI intervention on client satisfaction with maternal health services in primary facilities in the Upper East Region of Ghana.

METHODS

We employed a quasi-experimental controlled baseline and endline design to assess the effect of the combined interventions on client satisfaction with maternal health services, measured by quantitative pre/post-test client satisfaction survey. Our analysis used difference-in-difference logistic regression, controlling for potential covariates, to compare variables across intervention and comparison facilities at baseline and endline.

RESULTS

The combined CDSS-PBI intervention was associated with increased or unchanged client satisfaction with all maternal health services compared at endline. Antenatal client difference-in-difference of mean satisfaction scores were significant at endline for intervention (n = 378) and comparison (n = 362) healthcare facilities for overall satisfaction (DiD 0.058, p = 0.014), perception of providers' technical performance (DiD = 0.142; p = 0.006), client-provider interaction (DiD = 0.152; p = 0.001), and provider availability (DiD = 0.173; p = 0.001). Delivery client difference-in-difference of satisfaction scores were significant at endline for intervention (n = 318) and comparison (n = 240) healthcare facilities for overall satisfaction with delivery services (DiD = 0.072; p = 0.02) and client-provider interaction (DiD = 0.146; p = 0.02). However, mean overall satisfaction actually reduced slightly in intervention facilities, while DiD for technical performance and provider availability were not significant.

CONCLUSION

This combined CDSS-PBI intervention was associated with greater antenatal and delivery client satisfaction with some aspects of maternity services within two years of implementation. It could be expanded elsewhere if funds allow, though further research is still required to assess cost-effectiveness and long-term effects on client satisfaction and maternal health outcomes.

An examination of the moral habitability of resource-constrained obstetrical settings

BACKGROUND

While there have been studies exploring moral habitability and its impact on the work environments of nurses in Western countries, little is known about the moral habitability of the work environments of nurses and midwives in resource-constrained settings.

RESEARCH OBJECTIVE

The purpose of this research was to examine the moral habitability of the work environment of nurses and midwives in Ghana and its influence on their moral agency using the philosophical works of Margaret Urban Walker.

RESEARCH DESIGN AND PARTICIPANTS

A critical moral ethnography was conducted through the analysis of interviews with 30 nurses and midwives, along with observation, and documentary materials.

ETHICAL CONSIDERATIONS

After receiving ethics approval, signed informed consent was obtained from participants before data collection.

RESULTS

Five themes were identified: (1) holding onto the values, identities, and responsibilities of being a midwife/nurse; (2) scarcity of resources as limiting capacity to meet caring responsibilities; (3) gender and socio-economic inequities shaping the moral-social context of practice; (4) working with incoherent moral understandings and damaged identities in the context of inter- and intra-professional relationships; and (5) surviving through adversity with renewed commitment and courage.

DISCUSSION

The nurses and midwives were found to work in an environment that was morally uninhabitable and dominated by the scarcity of resources, overwhelming and incoherent moral responsibilities, oppressive conditions, and workplace violence. These situations constrained their moral agency and provoked suffering and distress. The nurses and midwives negotiated their practice and navigated through morally uninhabitable work environment by holding onto their moral values and commitments to childbearing women.

CONCLUSION

Creating morally habitable workplaces through the provision of adequate resources and instituting interprofessional practice guidelines and workplace violence prevention policies may promote safe and ethical nursing and midwifery practice.

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.

Impact of free maternal health care policy on maternal health care utilization and perinatal mortality in Ghana: protocol design for historical cohort study

Background

Ghana introduced what has come to be known as the 'Free’ Maternal Health Care Policy (FMHCP) in 2008 via the free registration of pregnant women to the National Health Insurance Scheme to access healthcare free of charge. The policy targeted every pregnant woman in Ghana with a full benefits package covering comprehensive maternal healthcare.

Purpose

This study seeks to measure the contribution of the FMHCP to maternal healthcare utilization; antenatal care uptake, and facility delivery and determine the utilization impact on stillbirth, perinatal, and neonatal deaths using quasi-experimental methods. The study will also contextualize the findings against funding constraints and operational bottlenecks surrounding the policy operations in the Upper East Region of Ghana.

Methods

This study adopts a mixed-method design to estimate the treatment effect using variables generated from historical data of Ghana and Kenya Demographic and Health Survey data sets of 2008/2014, as treatment and comparison groups respectively. As DHS uses complex design, weighting will be applied to the data sets to cater for clustering and stratification at all stages of the analysis by setting the data in STATA and prefix Stata commands with ‘svy’. Thus, the policy impact will be determined using quasi-experimental designs; propensity score matching, and difference-in-differences methods. Prevalence, mean difference, and test of association between outcome and exposure variables will be achieved using the Rao Scot Chi-square. Confounding variables will be adjusted for using Poisson and multiple logistics regression models. Statistical results will be reported in proportions, regression coefficient, and risk ratios. This study then employs intrinsic-case study technique to explore the current operations of the ‘free’ policy in Ghana, using qualitative methods to obtain primary data from the Upper East Region of Ghana for an in-depth analysis.

Discussion

The study discussions will show the contributions of the ‘free’ policy towards maternal healthcare utilization and its performance towards stillbirth, perinatal and neonatal healthcare outcomes. The discussions will also centre on policy designs and implementation in resource constraints settings showing how SDG3 can be achievement or otherwise. Effectiveness of policy proxy and gains in the context of social health insurance within a broader concept of population health and economic burden will also be conferred.

Protocol approval

This study protocol is registered for implementation by the Ghana Health Service Ethical Review Committee, number: GHS-ERC 002/04/19.

The effectiveness of training in emergency obstetric care: a systematic literature review

Providing quality emergency obstetric care (EmOC) reduces the risk of maternal and newborn mortality and morbidity. There is evidence that over 50% of maternal health programmes that result in improving access to EmOC and reduce maternal mortality have an EmOC training component. The objective was to review the evidence for the effectiveness of training in EmOC. Eleven databases and websites were searched for publications describing EmOC training evaluations between 1997 and 2017. Effectiveness was assessed at four levels: (1) participant reaction, (2) knowledge and skills, (3) change in behaviour and clinical practice and (4) availability of EmOC and health outcomes. Weighted means for change in knowledge and skills obtained, narrative synthesis of results for other levels. One hundred and one studies including before-after studies (n = 44) and randomized controlled trials (RCTs) (n = 15). Level 1 and/or 2 was assessed in 68 studies; Level 3 in 51, Level 4 in 21 studies. Only three studies assessed effectiveness at all four levels. Weighted mean scores pre-training, and change after training were 67.0% and 10.6% for knowledge (7750 participants) and 53.1% and 29.8% for skills (6054 participants; 13 studies). There is strong evidence for improved clinical practice (adherence to protocols, resuscitation technique, communication and team work) and improved neonatal outcomes (reduced trauma after shoulder dystocia, reduced number of babies with hypothermia and hypoxia). Evidence for a reduction in the number of cases of post-partum haemorrhage, case fatality rates, stillbirths and institutional maternal mortality is less strong. Short competency-based training in EmOC results in significant improvements in healthcare provider knowledge/skills and change in clinical practice. There is emerging evidence that this results in improved health outcomes.

Perceived barriers to maternal and newborn health services delivery: a qualitative study of health workers and community members in low and middle-income settings

OBJECTIVES

In considering explanations for poor maternal and newborn health outcomes, many investigations have focused on the decision-making patterns and actions of expectant mothers and families, as opposed to exploring the 'supply side' (health service provider) barriers. Thus, we examined the health system factors impacting on access to and delivery of quality maternal and newborn healthcare in rural settings.

DESIGN

A semistructured qualitative study using face-to-face in-depth interviews with health professionals, and focus group sessions with community members, in eight project sites in two districts of Upper West Region, Ghana, was employed. Participants were purposively selected to generate relevant data to help address the study objective. The survey was guided by WHO standard procedures and Ghana Health Ministry's operational work plan for maternal and newborn care.

SETTING

Nadowli-Kaleo and Daffiama-Bussie-Issa districts in Upper West Region, Ghana.

PARTICIPANTS

Two hundred and fifty-three participants were engaged in the study through convenient and purposive sampling: healthcare professionals (pharmacist, medical doctor, two district directors of health services, midwives, community health and enrolled nurses) (n=13) and community members comprising opinion leaders, youth leaders and adult non-pregnant women (n=240 in 24 units of focus groups).

RESULTS

Results show significant barriers affecting the quality and appropriateness of maternal and neonatal health services in the rural communities and the Nadowli District Hospital. The obstacles were inadequate medical equipment and essential medicines, infrastructural challenges, shortage of skilled staff, high informal costs of essential medicines and general limited capacities to provide care.

CONCLUSION

Implementation of the birth preparedness and complication readiness strategy is in its infancy at the health facility level in the study areas. Increasing the resources at the health provider level is essential to achieving international targets for maternal and neonatal health outcomes and for bridging inequities in access to essential maternal and newborn healthcare.

The role of community-based health services in influencing postnatal care visits in the Builsa and the West Mamprusi districts in rural Ghana

Background

Globally, maternal mortality is still a challenge. In Ghana, maternal morbidity and mortality rates remain high, particularly in rural areas. Postnatal Care (PNC) is one of the key strategies for improving maternal health. This study examined determinants of at least three PNC visits in rural Ghana.

Methods

We conducted a cross-sectional study at the Community-Based Health Planning and Services (CHPS) Zones in the Builsa and West Mamprusi Districts between April and June 2016. We selected 650 women who delivered within 5 years preceding the survey (325 from each of the two sites) using the two-stage random sampling technique.

Results

Of the 650 respondents, 62% reported attending postnatal care at least three times. In the Builsa district, the percentage of women who made at least three PNC visits were 90% compared with 35% in the West Mamprusi district. Older women and those who attended antenatal clinics at least four times (AOR: 5.23; 95% CI: 2.49–11.0) and women who had partners with some secondary education (AOR: 3.31; 95% CI: 1.17–9.39) were associated with at least three PNC visits.

Conclusions

Men engagement in maternal health services and the introduction of home-based PNC services in rural communities could help health workers reach out to many mothers and children promptly and improve PNC visits in those communities.

Maternal Death in Rural Ghana: A Case Study in the Upper East Region of Ghana

Maternal mortality remains a challenge in providing quality maternal and other reproductive healthcare services in Ghana. This is a case investigation of a maternal death in rural Ghana that seeks to unravel the circumstances that lead to her death. We conducted three in-depth interviews with healthcare staff as well as a focused group discussion comprising of six relatives of the deceased, including her husband. The investigation revealed that lack of logistics, medical, and laboratory equipment, inadequate knowledge about the benefits of antenatal care services as well as non-adherence of healthcare workers to treatment protocols and standard operating procedures were found as major setbacks to the provision of effective and quality maternal healthcare services in Ghana. It is, therefore, imperative for the Government of Ghana and other Non-Governmental Organizations to invest in strengthening the healthcare delivery system especially in rural Ghana by making available basic logistics, medical, and laboratory equipment, as well as improving upon maternal health education, and consistently organizing capacity building training programs for healthcare workers.

Review of emergency obstetric care interventions in health facilities in the Upper East Region of Ghana: a questionnaire survey

Background

Maternal morbidity and mortality is most prevalent in resource-poor settings such as sub-Saharan Africa and southern Asia. In sub-Saharan Africa, Ghana is one of the countries still facing particular challenges in reducing its maternal morbidity and mortality. Access to emergency obstetric care (EmOC) interventions has been identified as a means of improving maternal health outcomes. Assessing the range of interventions provided in health facilities is, therefore, important in determining capacity to treat obstetric emergencies. The aim of this study was to examine the availability of emergency obstetric care interventions in the Upper East Region of Ghana.

Methods

A cross-sectional survey of 120 health facilities was undertaken. Status of emergency obstetric care was assessed through an interviewer administered questionnaire to directors/in-charge officers of maternity care units in selected facilities. Data were analysed using descriptive statistics.

Results

Eighty per cent of health facilities did not meet the criteria for provision of emergency obstetric care. Comparatively, private health facilities generally provided EmOC interventions less frequently than public health facilities. Other challenges identified include inadequate skill mix of maternity health personnel, poor referral processes, a lack of reliable communication systems and poor emergency transport systems.

Conclusion

Multiple factors combine to limit women’s access to a range of essential maternal health services. The availability of EmOC interventions was found to be low across the region; however, EmOC facilities could be increased by nearly one-third through modest investments in some existing facilities. Also, the key challenges identified in this study can be improved by enhancing pre-existing health system structures such as Community-based Health Planning and Services (CHPS), training more midwifery personnel, strengthening in-service training and implementation of referral audits as part of health service monitoring. Gaps in availability of EmOC interventions, skilled personnel and referral processes must be tackled in order to improve obstetric outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2980-6) contains supplementary material, which is available to authorized users.

Ghana's community-based primary health care: Why women and children are 'disadvantaged' by its implementation

Policy analysis on why women and children in low- and middle-income settings are still disadvantaged by access to appropriate care despite Primary Health Care (PHC) programmes implementation is limited. Drawing on the street-level bureaucracy theory, we explored how and why frontline providers (FLP) actions on their own and in interaction with health system factors shape Ghana's community-based PHC implementation to the disadvantage of women and children accessing and using health services. This was a qualitative study conducted in 4 communities drawn from rural and urban districts of the Upper West region. Data were collected from 8 focus group discussions with community informants, 73 in-depth interviews with clients, 13 in-depth interviews with district health managers and FLP, and observations. Data were recorded, transcribed and coded deductively and inductively for themes with the aid of Nvivo 11 software. Findings showed that apart from FLP frequent lateness to, and absenteeism from work, that affected care seeking for children, their exercise of discretionary power in determining children who deserve care over others had ripple effects: families experienced financial hardships in seeking alternative care for children, and avoided that by managing symptoms with care provided in non-traditional spaces. FLP adverse behaviours were driven by weak implementation structures embedded in the district health systems. Basic obstetric facilities such as labour room, infusion stand, and beds for deliveries, detention and palpation were lacking prompting FLP to cope by conducting deliveries using a patchwork of improvised delivery methods which worked out to encourage unassisted home deliveries. Perceived poor conditions of service weakened FLP commitment to quality maternal and child care delivery. Findings suggest the need for strategies to induce behaviour change in FLP, strengthen district administrative structures, and improve on the supply chain and logistics system to address gaps in CHPS maternal and child care delivery.

Factors that influence the provision of intrapartum and postnatal care by skilled birth attendants in low- and middle-income countries: a qualitative evidence synthesis

BACKGROUND

In many low- and middle-income countries women are encouraged to give birth in clinics and hospitals so that they can receive care from skilled birth attendants. A skilled birth attendant (SBA) is a health worker such as a midwife, doctor, or nurse who is trained to manage normal pregnancy and childbirth. (S)he is also trained to identify, manage, and refer any health problems that arise for mother and baby. The skills, attitudes and behaviour of SBAs, and the extent to which they work in an enabling working environment, impact on the quality of care provided. If any of these factors are missing, mothers and babies are likely to receive suboptimal care.

OBJECTIVES

To explore the views, experiences, and behaviours of skilled birth attendants and those who support them; to identify factors that influence the delivery of intrapartum and postnatal care in low- and middle-income countries; and to explore the extent to which these factors were reflected in intervention studies.

SEARCH METHODS

Our search strategies specified key and free text terms related to the perinatal period, and the health provider, and included methodological filters for qualitative evidence syntheses and for low- and middle-income countries. We searched MEDLINE, OvidSP (searched 21 November 2016), Embase, OvidSP (searched 28 November 2016), PsycINFO, OvidSP (searched 30 November 2016), POPLINE, K4Health (searched 30 November 2016), CINAHL, EBSCOhost (searched 30 November 2016), ProQuest Dissertations and Theses (searched 15 August 2013), Web of Science (searched 1 December 2016), World Health Organization Reproductive Health Library (searched 16 August 2013), and World Health Organization Global Health Library for WHO databases (searched 1 December 2016).

SELECTION CRITERIA

We included qualitative studies that focused on the views, experiences, and behaviours of SBAs and those who work with them as part of the team. We included studies from all levels of health care in low- and middle-income countries.

DATA COLLECTION AND ANALYSIS

One review author extracted data and assessed study quality, and another review author checked the data. We synthesised data using the best fit framework synthesis approach and assessed confidence in the evidence using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. We used a matrix approach to explore whether the factors identified by health workers in our synthesis as important for providing maternity care were reflected in the interventions evaluated in the studies in a related intervention review.

MAIN RESULTS

We included 31 studies that explored the views and experiences of different types of SBAs, including doctors, midwives, nurses, auxiliary nurses and their managers. The included studies took place in Africa, Asia, and Latin America.Our synthesis pointed to a number of factors affecting SBAs' provision of quality care. The following factors were based on evidence assessed as of moderate to high confidence. Skilled birth attendants reported that they were not always given sufficient training during their education or after they had begun clinical work. Also, inadequate staffing of facilities could increase the workloads of skilled birth attendants, make it difficult to provide supervision and result in mothers being offered poorer care. In addition, SBAs did not always believe that their salaries and benefits reflected their tasks and responsibilities and the personal risks they undertook. Together with poor living and working conditions, these issues were seen to increase stress and to negatively affect family life. Some SBAs also felt that managers lacked capacity and skills, and felt unsupported when their workplace concerns were not addressed.Possible causes of staff shortages in facilities included problems with hiring and assigning health workers to facilities where they were needed; lack of funding; poor management and bureaucratic systems; and low salaries. Skilled birth attendants and their managers suggested factors that could help recruit, keep, and motivate health workers, and improve the quality of care; these included good-quality housing, allowances for extra work, paid vacations, continuing education, appropriate assessments of their work, and rewards.Skilled birth attendants' ability to provide quality care was also limited by a lack of equipment, supplies, and drugs; blood and the infrastructure to manage blood transfusions; electricity and water supplies; and adequate space and amenities on maternity wards. These factors were seen to reduce SBAs' morale, increase their workload and infection risk, and make them less efficient in their work. A lack of transport sometimes made it difficult for SBAs to refer women on to higher levels of care. In addition, women's negative perceptions of the health system could make them reluctant to accept referral.We identified some other factors that also may have affected the quality of care, which were based on findings assessed as of low or very low confidence. Poor teamwork and lack of trust and collaboration between health workers appeared to negatively influence care. In contrast, good collaboration and teamwork appeared to increase skilled birth attendants' motivation, their decision-making abilities, and the quality of care. Skilled birth attendants' workloads and staff shortages influenced their interactions with mothers. In addition, poor communication undermined trust between skilled birth attendants and mothers.

AUTHORS' CONCLUSIONS

Many factors influence the care that SBAs are able to provide to mothers during childbirth. These include access to training and supervision; staff numbers and workloads; salaries and living conditions; and access to well-equipped, well-organised healthcare facilities with water, electricity, and transport. Other factors that may play a role include the existence of teamwork and of trust, collaboration, and communication between health workers and with mothers. Skilled birth attendants reported many problems tied to all of these factors.

Factors associated with utilization of skilled service delivery among women in rural Northern Ghana: a cross sectional study

BACKGROUND

Ghana's current Maternal Mortality Ratio (MMR) of 319 per 100,000 live births makes achievement of the Sustainable Development Goal of 70 maternal deaths per 100,000 live births or less by 2030 appear to be illusory. Skilled assistance during childbirth is a critical strategy to reducing maternal mortality, yet the proportion of deliveries taking place within health facilities where such assistance is provided is very low in Ghana, with huge disparity between urban and rural women. To address the gap in skilled attendance in rural Upper East Region, the Ghana Health Service (GHS) in 2005 piloted a program that involved training of Community Health Officers (CHOs) as midwives. This study explored factors associated with skilled delivery services utilization in a predominantly rural district in Ghana.

METHODS

A cross-sectional study, data was collected from a sample of 400 women between the ages of 15 and 49 years who had given birth a year prior to the study. We used frequencies and percentages for descriptive analysis and chi-square (χ 2 ) test for relationship between independents factors and utilization of skilled delivery services.

RESULTS

Of the 400 women included in the analysis, 93.3% of them delivered in a health facility. Almost all of the mothers (97.3%) attended or received antenatal care at their last pregnancy with 75.0% of them having four or more ANC visits. The proportion of women who received ANC and utilized skilled delivery services was high (91.5%). Mother's educational attainment, ANC attendance, frequency of ANC visits, satisfaction with ANC services and possession of valid NHIS card significantly associated with utilisation of skilled delivery services.

CONCLUSION

For a predominantly rural district, the percentage of women who deliver within health facilities where skilled assistance is available is very encouraging and a significant stride towards reducing Ghana's overall MMR. Having four or more ANC visits and improving on the quality of care provided has a great potential of improving uptake of skilled delivery services.

Can performance-based incentives improve motivation of nurses and midwives in primary facilities in northern Ghana? A quasi-experimental study

Background

Lack of an adequate and well-performing health workforce has emerged as the biggest barrier to scaling up health services provision in sub-Saharan Africa. As the global community commits to the Sustainable Development Goals and universal health coverage, health workforce challenges are critical. In northern Ghana, performance-based incentives (PBIs) were introduced to improve health worker motivation and service quality.

Objective

The goal of this study was to determine the impact of PBIs on maternal health worker motivation in two districts in northern Ghana.

Design

A quasi-experimental study design with pre- and post-intervention measurement was used. PBIs were implemented for 2 years in six health facilities in Kassena-Nankana District with six health facilities in Builsa District serving as comparison sites. Fifty pre- and post-intervention structured interviews and 66 post-intervention in-depth interviews were conducted with health workers. Motivation was assessed using constructs for job satisfaction, pride, intrinsic motivation, timelines/attendance, and organisational commitment. Quantitative data were analysed to determine changes in motivation between intervention and comparison facilities pre- and post-intervention using STATA™ version 13. Qualitative data were analysed thematically using NVivo 10 to explore possible reasons for quantitative findings.

Results

PBIs were associated with slightly improved maternal health worker motivation. Mean values for overall motivation between intervention and comparison health workers were 0.6 versus 0.7 at baseline and 0.8 versus 0.7 at end line, respectively. Differences at baseline and end line were 0.1 (p=0.40 and p=0.50 respectively), with an overall 0.01 difference in difference (p=0.90). Qualitative interviews indicated that PBIs encouraged health workers to work harder and be more punctual, increasing reported pride and job satisfaction.

Conclusions

The results contribute evidence on the effects of PBIs on motivational constructs among maternal health workers in primary care facilities in northern Ghana. PBIs appeared to improve motivation, but not dramatically, and the long-term and unintended effects of their introduction require additional study.

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

BACKGROUND

Health worker shortage in rural areas is one of the biggest problems of the health sector in Ghana and many developing countries. This may be due to fewer incentives and support systems available to attract and retain health workers at the rural level. This study explored the willingness of community health officers (CHOs) to accept and hold rural and community job postings in Ghana.

METHODS

A discrete choice experiment was used to estimate the motivation and incentive preferences of CHOs in Ghana. All CHOs working in three Health and Demographic Surveillance System sites in Ghana, 200 in total, were interviewed between December 2012 and January 2013. Respondents were asked to choose from choice sets of job preferences. Four mixed logit models were used for the estimation. The first model considered (a) only the main effect. The other models included interaction terms for (b) gender, (c) number of children under 5 in the household, and (d) years worked at the same community. Moreover, a choice probability simulation was performed.

RESULTS

Mixed logit analyses of the data project a shorter time frame before study leave as the most important motivation for most CHOs (β 2.03; 95 % CI 1.69 to 2.36). This is also confirmed by the largest simulated choice probability (29.1 %). The interaction effect of the number of children was significant for education allowance for children (β 0.58; 95 % CI 0.24 to 0.93), salary increase (β 0.35; 95 % CI 0.03 to 0.67), and housing provision (β 0.16; 95 % CI -0.02 to 0.60). Male CHOs had a high affinity for early opportunity to go on study leave (β 0.78; 95 % CI -0.06 to 1.62). CHOs who had worked at the same place for a long time greatly valued salary increase (β 0.28; 95 % CI 0.09 to 0.47).

CONCLUSIONS

To reduce health worker shortage in rural settings, policymakers could provide "needs-specific" motivational packages. They should include career development opportunities such as shorter period of work before study leave and financial policy in the form of salary increase to recruit and retain them.

Social Factors Influencing Child Health in Ghana

Objectives

Social factors have profound effects on health. Children are especially vulnerable to social influences, particularly in their early years. Adverse social exposures in childhood can lead to chronic disorders later in life. Here, we sought to identify and evaluate the impact of social factors on child health in Ghana. As Ghana is unlikely to achieve the Millennium Development Goals’ target of reducing child mortality by two-thirds between 1990 and 2015, we deemed it necessary to identify social determinants that might have contributed to the non-realisation of this goal.

Methods

ScienceDirect, PubMed, MEDLINE via EBSCO and Google Scholar were searched for published articles reporting on the influence of social factors on child health in Ghana. After screening the 98 articles identified, 34 of them that met our inclusion criteria were selected for qualitative review.

Results

Major social factors influencing child health in the country include maternal education, rural-urban disparities (place of residence), family income (wealth/poverty) and high dependency (multiparousity). These factors are associated with child mortality, nutritional status of children, completion of immunisation programmes, health-seeking behaviour and hygiene practices.

Conclusions

Several social factors influence child health outcomes in Ghana. Developing more effective responses to these social determinants would require sustainable efforts from all stakeholders including the Government, healthcare providers and families. We recommend the development of interventions that would support families through direct social support initiatives aimed at alleviating poverty and inequality, and indirect approaches targeted at eliminating the dependence of poor health outcomes on social factors. Importantly, the expansion of quality free education interventions to improve would-be-mother’s health knowledge is emphasised.