Postnatal care education in health facilities in Accra, Ghana: perspectives of mothers and providers

Early discharge in health facilities following vaginal delivery and its associated factors among mothers in four African countries: a cross-sectional study

OBJECTIVE

This study aimed to assess the prevalence of early discharge among women who gave vaginal delivery in health facilities.

DESIGN

Cross-sectional study.

SETTING

Four African countries.

PARTICIPANTS

A total weighted sample of 14 942 women who delivered vaginally in health facilities.

METHODS

In this study, data were obtained from the recent Demographic and Health Survey data from four African countries. A total weighted sample of 14 942 women who delivered vaginally in a health facility was included. A multilevel mixed effect binary logistic regression model was fitted to identify significant factors associated with early discharge following health facility vaginal delivery. Statistical significance was determined using adjusted OR (odd ratio) with a 95% CI.

RESULTS

The overall prevalence of early discharge following health facility vaginal delivery in four African countries was 30.91% (95% CI: 30.18% to 31.66%). Overall, first-born babies (AOR=0.7; 95% CI: 0.57 to 0.85), women with a high maternal body mass index (AOR=0.8; 95% CI: 0.71 to 0.89), women with multiple pregnancies (AOR=0.48; 95% CI: 0.31 to 0.74), women who reside in Burkina Faso (AOR=0.15; 95% CI: 0.12 to 0.18) and women who reside in Ghana (AOR=0.28; 95% CI: 0.24 to 0.33) had lower odds of early discharge following health facility vaginal delivery. On the other hand, women having no difficulty accessing health facilities (AOR=1.18; 95% CI: 1.05 to 1.33) and women delivering in private health facilities (AOR=1.46; 95% CI: 1.08 to 1.99) had higher odds of early discharge following health facility vaginal delivery.

CONCLUSION

Overall, in four African countries, a higher proportion of women who gave birth vaginally in health facilities were discharged home early without optimum immediate postpartum care. As a result, legislators, programmers and other stakeholders should make every effort to lessen the burden of early discharge, with a special focus on women who deliver in private health institutions.

Maternal Perspectives on and Preferences for an Enhanced Neonatal Jaundice Education Program: An Evaluation Using the Consolidated Framework for Implementation Research

Introduction

Neonatal mortality is a major contributor to under-five deaths yet the main causes of these deaths are preventable. Postnatal health education programs can improve timely detection and care seeking for newborn morbidities such as neonatal jaundice (NNJ). Being a common occurrence in low-income countries, it is surprising that women do not have sufficient knowledge about NNJ. Although the knowledge can be improved through routine education programs, healthcare providers rarely engage women in evaluating such programs, which limits their uptake and sustainability.

Methods

This was a qualitative study evaluating a postnatal neonatal jaundice health education program conducted at Jinja Regional Referral Hospital (JRRH). Narrative data on the structure, design, and delivery of the program was recorded from 12 postnatal women through unstructured interviews. The participants were those who had taken part in an enhanced NNJ education program. Qualitative content analysis, guided by the Consolidated Framework for Implementation Research (CFIR) was performed.

Results

Using the CFIR, two themes were identified; the intervention characteristics domain and the individual domains. The constructs under these domains were intervention design quality and packaging, relative advantage, and maternal knowledge needs. The augmented nature of the intervention, sorting individual needs, ability to promote continuity of care, and care-seeking were identified as key facilitators. Lack of group interaction was identified by some women as a possible barrier.

Conclusion

Overall, the education program was positively perceived by women and preferred compared to the conventional method of health education. In low-resource settings where maternal health education can contribute to a reduction in newborn mortality, the design, implementation, and evaluation of maternal education programs should be informed by women's preferences. Healthcare providers should utilize multiple sources of information and routinely practice patient-centered evaluation to meet the changing knowledge demands of postnatal women.

Assessment of Neonatal Mortality and Associated Hospital-Related Factors in Healthcare Facilities Within Sunyani and Sunyani West Municipal Assemblies in Bono Region, Ghana

Objectives

Ghana's quest to reduce neonatal mortality, in hospital facilities and communities, continues to be a nightmare. The pursuit of achieving healthy lives and well-being for neonates as enshrined in Sustainable Development Goal three lingered in challenging hospital facilities and communities. Notwithstanding that, there have been increasing efforts in that direction. This study examines the contributing factors that hinder the fight against neonatal mortality in all hospital facilities in the Sunyani and Sunyani West Municipal Assemblies in Bono Region, Ghana.

Methods

The study utilized neonatal mortality data consisting of neonatal deaths, structural facility related variables, medical human resources, types of hospital facilities and natal care. The data was collected longitudinally from 2014 to 2019. These variables were analysed using the negative binomial hurdle regression (NBH) model to determine factors that contribute to this menace at the facility level. Cause-specific deaths were obtained to determine the leading causes of neonatal deaths within health facilities in the two municipal assemblies.

Results

The study established that the leading causes of neonatal mortality in these districts are birth asphyxia (46%), premature birth (33%), neonatal sepsis (11%) and neonatal jaundice (7%). The NBH showed that neonatal mortality in hospital facilities depend on the number of incubators, monitoring equipment, hand washing facilities, CPAPb machines, radiant warmers, physiotherapy machines, midwives, paediatric doctors and paediatric nurses in the hospital facility.

Conclusions

Early management of neonatal sepsis, birth asphyxia, premature birth and neonatal infections is required to reduce neonatal deaths. The government and all stakeholders in the health sector should provide all hospital facilities with the essential equipment and the medical human resources necessary to eradicate the menace. This will make the realization of Sustainable Development Goal three, which calls for healthy lives and well-being for all, a reality.

Effect of post-discharge postnatal educational intervention on postnatal practices among low-income primiparas in Nairobi informal settlements, Kenya: a post-test quasi-experiment

Introduction

informal settlements exhibit disproportionately worse maternal and newborn outcomes. Postnatal care (PNC) is a high-impact intervention for populations contributing to higher mortalities. Postnatal education is crucial to adopting evidence-based postnatal practices (PNPs) thus its post-discharge reinforcement is vital for low-income primiparas. This study aimed to determine the effect of post-discharge follow-up postnatal education intervention (PNE) on the adoption of recommended PNPs among low-income primiparas.

Methods

quasi-experimental study in Nairobi informal settlements with 118 primiparas discharged early after normal delivery on each arm. Facility and demographic data collected using an interviewer-administered questionnaire. Study arm received the intervention for 6 weeks in addition to routine PNC while control received routine PNC only. An interviewer-administered exit questionnaire was applied after 6 weeks. Focus group discussions were conducted for qualitative data then analyzed thematically. SPSS used to analyze quantitative data then descriptive statistics, t-tests, Chi-square, Mann-Whitney, and multiple linear or logistic regressions derived. PNPs composed of health-seeking for maternal and newborn danger signs, self and baby care practices, and utilization of PNC contacts.

Results

the intervention was a positive predictor of adoption of composite PNPs (β=0.26, p=0.00), self-care practices (β=0.39, p=0.00) and mothers' two weeks PNC contact (OR=4.64, p=0.00, 95% CI=1.9-11.2). Neither a significant predictor of health-seeking for maternal (β=-0.11, p=0.31) nor newborns danger signs (β=-0.04, p=0.73) though inversely related. No influence on baby care practices, two weeks of newborn contact and six weeks contact for the dyad. Multi-pronged approaches are appreciated.

Conclusion

follow-up post-discharge PNE intervention enhances adoption of PNPs among low-income primiparas thus a worthwhile supplement to routine PNC.

Knowledge about unintended pregnancy shortly after childbirth: An issue of ineffective counseling or adherence?

BACKGROUND

Being aware of the possibility of becoming pregnant shortly after childbirth before the resumption of the menstrual period is often overlooked but remains a significant contributor to unintended pregnancies and may lead to maternal and neonatal comorbidities. Exploring the extent of awareness and associated factors could help tailor more interventions toward reducing the rates of short-interval unplanned pregnancies.

OBJECTIVE

This study explores the extent to which Ghanaian women are aware of the possibility of becoming pregnant shortly after childbirth before the resumption of the menstrual period and its associated factors.

DESIGN

A cross-sectional study was conducted using the 2017 Ghana Maternal Health Survey. The women participants were sampled using a two-stage cluster sampling design.

METHODS

We analyzed the 2017 Ghana Maternal Health Survey data of 8815 women who had given birth and received both antenatal care and postnatal checks after delivery in health facilities (private and public) and responded to questions on being aware of short interpregnancy intervals. A multivariable survey logistic regression was used for the analysis.

RESULTS

Of the 8815 women, approximately 62% of women who received both antenatal care and postnatal examinations before discharge reported being aware of short interpregnancy intervals. Postnatal examination before discharge but not antenatal care was associated with a higher awareness of short interpregnancy intervals. Women who received a postnatal examination were more aware of short interpregnancy intervals than their counterparts (adjusted odds ratio = 1.29, 95% confidence interval: 1.03-1.61). Also, awareness of short interpregnancy intervals increased with age, education, knowledge of the fertile period, contraceptive use, and delivery via cesarean section.

CONCLUSION

Over a decade following the initiation of Ghana's free maternal health policy, there remains a significant gap in the awareness of short interpregnancy intervals, even among women who received both antenatal pregnancy care and postnatal examinations before discharge. The unawareness of the short interpregnancy interval observed in approximately 38% of women raises concerns about the effectiveness of counseling or education provided during antenatal care and immediate post-partum care regarding birth spacing, contraceptive use, the timing of resumption of sexual activity, and the extent to which women adhere to such guidance.

Health-system drivers influencing the continuum of care linkages for low-birth-weight infants at the different care levels in Ghana

BACKGROUND

Low birth weight (LBW) is associated with short and long-term consequences including neonatal mortality and disability. Effective linkages in the continuum of care (CoC) for newborns at the health facility, community (primary care) and home care levels have a high tendency of minimizing adverse events associated with LBW. But it is unclear how these linkages work and what factors influence the CoC process in Ghana as literature is scarce on the views of health professionals and families of LBW infants regarding the CoC. Therefore, this study elicited the drivers influencing the CoC for LBW infants in Ghana and how linkages in the CoC could be strengthened to optimize quality of care.

METHODS

A constructivist grounded theory study design was used. Data was collected between September 2020 to February 2021. A total of 25 interviews were conducted with 11 family members of LBW infants born in a secondary referral hospital in Ghana, 9 healthcare professionals and 7 healthcare managers. Audio recordings were transcribed verbatim, analyzed using initial and focused coding. Constant comparative techniques, theoretical memos, and diagramming were employed until theoretical saturation was determined.

RESULTS

Emerging from the analysis was a theoretical model describing ten major themes along the care continuum for LBW infants, broadly categorized into health systems and family-systems drivers. In this paper, we focused on the former. Discharge, review, and referral systems were neither well-structured nor properly coordinated. Efficient dissemination and implementation of guidelines and supportive supervision contributed to higher staff motivation while insufficient investments and coordination of care activities limited training opportunities and human resource. A smooth transition between care levels is hampered by procedural, administrative, logistics, infrastructural and socio-economic barriers.

CONCLUSION

A coordinated care process established on effective communication across different care levels, referral planning, staff supervision, decreased staff shuffling, routine in-service training, staff motivation and institutional commitment are necessary to achieve an effective care continuum for LBW infants and their families.

Postpartum care needs assessment: women's understanding of postpartum care, practices, barriers, and educational needs

BACKGROUND

Complications in the postpartum period pose substantial risks to women and can result in significant maternal morbidity and mortality. However, there is much less attention on postpartum care compared to pregnancy and childbirth. The goal of this study was to gather information on women's knowledge of postpartum care and complications, recovery practices after childbirth, perceived barriers to receiving care during the postpartum period, and educational needs in four health centers. The findings can inform the development of appropriate curriculum and interventions for postnatal care education in similar settings.

METHODS

A descriptive qualitative study design was employed. Eight focus group discussions were conducted among 54 postpartum women who delivered in four health centers in Sagnarigu District in Tamale, Ghana. Audio recordings of focus group data were transcribed and translated, and thematic analysis was conducted.

RESULTS

There were six main themes that emerged from the focus group discussions: 1) baby focused postpartum care; 2) postpartum practices; 3) inadequate knowledge ofpostpartum danger signs; 4) barriers to accessing postpartum care 5) experiences of poor mental health; and 6) need for postpartum education.

CONCLUSIONS

Postpartum care for women in this study was primarily perceived as care of the baby post-delivery and missing key information on physical and mental health care for the mother. This can result in poor adjustment postpartum and critically, a lack of knowledge on danger signs for common causes of morbidity and mortality in the postpartum period. Future research needs to understand how to communicate important information on postpartum mental and physical health to better protect mothers in the region.

Knowledge of Postbirth Warning Signs and Postpartum Education Among Women in Ghana

OBJECTIVE

To assess the relationship between postpartum education and knowledge of postbirth warning signs among women in Ghana.

DESIGN

Cross-sectional survey.

SETTING

Tamale West Hospital in Tamale Metropolitan Area, Ghana.

PARTICIPANTS

Women (N = 151) who gave birth to healthy newborns and were admitted to the postnatal ward.

METHODS

We collected data from surveys distributed in the hospital. The survey included items for sociodemographic characteristics, obstetric history, postpartum education provided, and knowledge of nine common postbirth warning signs. We used descriptive statistics and multivariate logistic regression models to analyze the data.

RESULTS

Participants reported knowing an average of 5.2 of 9 (SD = 2.84) postbirth warning signs. Severe bleeding (94.70%, n = 143), fever (82.12%, n = 124), and severe headache (72.19%, n = 109) were the postbirth warning signs most frequently identified by participants. Swelling in the leg (37.09%, n = 56) and thoughts of hurting oneself (33.11%, n = 50) were the postbirth warning signs least frequently identified by participants. Knowledge about postbirth warning signs was positively associated with reports of receiving educational handouts on the postnatal ward (adjusted OR = 4.64, 95% confidence interval [1.27, 17.04]) and reports that four or more postpartum complications were taught before hospital discharge (adjusted OR = 27.97, 95% confidence interval [7.55, 103.57]) compared to zero to three postpartum complications.

CONCLUSION

All women need comprehensive discharge education on the warning signs of complications after birth. Promoting knowledge of postbirth warning signs can decrease delays in seeking care and contribute to the reduction of maternal mortality in Ghana.

Hot fomentation of newborn fontanelles as an indigenous practice in Ghana: implications for policy and integrated community-based health care in Covid-19 pandemic and beyond

OBJECTIVE

African newborns undergo numerous traditional and religious practices ranging from fontanelle fomentation to total head shaving, scalp molding, skin scarification and ano-genital irrigation which can negatively impact the health of neonates. Hot fomentation of fontanelles has been a predominant indigenous home-based postnatal practice in Ghana and among Africans in the diaspora. Mobility restrictions during the Covid-19 pandemic has impacted direct access to facility-based care as well as home care. The flourishing of newborn traditional practices among African populations during this Covid-19 pandemic offers opportunities to rethink the provision of family healthcare support for newborns during the ongoing pandemic and beyond. Hence, the aim of this critical review was to examine and describe a common indigenous practice-hot fontanelle fomentation to inform home birth support, discharge planning, and the delivery of optimal home-based care support.

STUDY DESIGN

This study is a review of literature on hot fomentation of newborn fontanelles.

METHODS

Literature search in CINAHL, PubMed, African Index Medicus and Scopus, was conducted and evidence synthesised from articles ranging from 1983-2022. Sixty articles were reviewed; however, 10 manuscripts were excluded prior to screening. The other 19 were exempted because they were either below 1983 or were not the best fit for the study purpose. In all, 31 studies were included in the study. The study was guided by Madeleine Leininger's Culture Care Diversity and Universality care theory.

RESULTS

The current study identifies hot fomentation of newborn fontanelles practices in Ghana, the description of hot fomentation practices and the dangers associated with it. The findings and suggested ways to help overcome this challenge.

CONCLUSION

There are several neonatal indigenous practices including fontanelle fomentation which pose threat to the health of the neonate as discussed in this study. Future research needs to investigate innovative ways of fontanelle fomentation where necessary instead of the use of hot water by mothers, especially in this Covid-19 pandemic where health and mobility restrictions impact physical access to timely health care. This research will help educate mothers about the dangers of fontanel fomentation and reduce the practice, especially in rural areas of developing countries. This could help reduce neonatal mortality and unnecessary healthcare costs.

Discharge Readiness and Associated Factors Among Postpartum Women in Tamale, Ghana

Ghana experiences a relatively high maternal mortality ratio, with the majority of maternal deaths occurring in the postpartum period. Discharge readiness is a reliable indicator of maternal health outcomes and involves a postpartum woman's perception of preparedness to leave the hospital following delivery. We measured the discharge readiness of postpartum women in Ghana through an institutional-based cross-sectional study involving 151 participants. Participants completed an interviewer-administered survey, and data analyses included linear regression models. The study sample demonstrated relatively high discharge readiness, with a mean score of 177.57 on a scale from 0.00 to 220.00. Higher gravidity was positively associated with discharge readiness score, while longer length of hospital stay and receiving educational handouts were negatively associated with discharge readiness score. Clinical interventions addressing the factors found to be associated with discharge readiness have significant potential to improve postpartum care and maternal outcomes in Ghana.

Effectiveness of adjunct telephone-based postnatal care on maternal and infant illness in the Greater Accra Region, Ghana: a randomized controlled trial

Introduction

Globally, postnatal care (PNC) is fraught with challenges. Despite high PNC coverages in Ghana’s Greater Accra Region (GAR), maternal and newborn health outcomes are of great concern. In 2017, neonatal and post-neonatal mortality rates in GAR were 19 and 13 per 1000 live births respectively despite PNC coverages of 93% for at least one PNC and 87.5% for PNC within 48 hours post-delivery. Telephone follow-up has been used to improve health outcomes in some settings, however, its usefulness in improving maternal and infant health during the postnatal period is not well known in Ghana. We assessed effectiveness of telephone-based PNC on infant and maternal illness in selected hospitals in GAR.

Methods

An open-label, assessor-blinded, parallel-group, two-arm superiority randomized controlled trial with 1:1 allocation ratio was conducted from September 2020 to March 2021. Mother-baby pairs in intervention arm, in addition to usual PNC, received midwife-led telephone counselling within 48 hours post-discharge plus telephone access to midwife during postnatal period. In control arm, only usual PNC was provided. Descriptive and inferential data analyses were conducted to generate frequencies, relative frequencies, risk ratios and 95% confidence intervals. Primary analysis was by intention-to-treat (ITT), complemented by per-protocol (PP) analysis.

Results

Of 608 mother-baby pairs assessed for eligibility, 400 (65.8%) were enrolled. During 3 months follow-up, proportion of infants who fell ill was 62.5% in intervention arm and 77.5% in control arm (p = 0.001). Maternal illness occurred in 27.5% of intervention and 38.5% of control participants (p = 0.02). Risk of infant illness was 20% less in intervention than control arm in both ITT analysis [RR = 0.8 (95%CI = 0.71–0.92] and PP analysis [RR = 0.8 (95%CI = 0.67–0.89)]. Compared to controls, risk of maternal illness in intervention arm was 30% lower in both ITT [RR = 0.7 (95%CI = 0.54–95.00)] and PP analysis [RR = 0.7 (95%CI = 0.51–0.94)].

Conclusion

Telephone-based PNC significantly reduced risk of maternal and infant illness within first 3 months after delivery. This intervention merits consideration as a tool for adoption and scale up to improve infant and maternal health.

Trial registration

This trial was retrospectively registered with the International Standard Randomized Controlled Trial Number (ISRCTN) Registry with number ISRCTN46905855 on 09/04/2021.