The use of antenatal care in two rural districts of Upper West Region, Ghana

Key barriers to the provision and utilization of maternal health services in low-and lower-middle-income countries; a scoping review

BACKGROUND

The preservation and promotion of maternal health (MH) emerge as vital global health objectives. Despite the considerable emphasis on MH, there are still serious challenges to equitable access to MH services in many countries. This review aimed to determine key barriers to the provision and utilization of MH services in low- and lower-middle-income countries (LLMICs).

METHODS

In this scoping review, we comprehensively searched four online databases from January 2000 to September 2022. In this study, the approach proposed by Arksey and O'Malley was used to perform the review. Consequently, 117 studies were selected for final analysis. To determine eligibility, three criteria of scoping reviews (population, concept, and context) were assessed alongside the fulfillment of the STROBE and CASP checklist criteria. To synthesize and analyze the extracted data we used the qualitative content analysis method.

RESULTS

The main challenges in the utilization of MH services in LLMICs are explained under four main themes including, knowledge barriers, barriers related to beliefs, attitudes and preferences, access barriers, and barriers related to family structure and power. Furthermore, the main barriers to the provision of MH services in these countries have been categorized into three main themes including, resource, equipment, and capital constraints, human resource barriers, and process defects in the provision of services.

CONCLUSIONS

The evidence from this study suggests that many of the barriers to the provision and utilization of MH services in LLMICs are interrelated. Therefore, in the first step, it is necessary to prioritize these factors by determining their relative importance according to the specific conditions of each country. Consequently, comprehensive policies should be developed using system modeling approaches.

Pregnant women's satisfaction with the quality of antenatal care and the continued willingness to use health facility care in Lusaka district, Zambia

BACKGROUND

Antenatal healthcare (ANC) reduces maternal and neonatal deaths in low-middle-income countries. Satisfaction with ANC services and perception of quality of care are critical determinants of service utilization. The study aimed to assess pregnant women's satisfaction with ANC and identify sociodemographic factors associated with satisfaction and their continued willingness to use or recommend the facility to relatives or friends, in Lusaka district, Zambia.

METHODS

This was a cross-sectional study involving 499 pregnant women in Lusaka district. A combination of stratified, multistage, and systematic sampling procedures was used in selecting health facilities and pregnant women. This allowed the researcher to assess exposure and status simultaneously among individuals of interest in a population. Structured survey instruments and face-face-interview techniques were used in collecting data among pregnant women who were receiving ANC in selected health facilities.

RESULTS

Overall, the proportion of pregnant women who were fully satisfied with ANC was 58.9% (n = 292). Pregnant women's satisfaction score ranged from physical aspects (40.9 - 58.3%), interpersonal aspects (54.3 - 57.9%) to technical aspects of care (46.9 - 58.7%). Husbands' employment status (OR = 0.611, 95%CI = 0.413 - 0.903, p = 0.013), monthly household income level of > 3000 - ≤6000 Kwacha (OR = 0.480, 95%CI = 0.243 - 0.948, p = 0.035 were significantly associated with the interpersonal aspects and the physical aspects of care, respectively. Besides, pregnant women who were in their third trimester (above 33 weeks), significantly predicted satisfaction with the physical environment of antenatal care (OR = 3.932, 95%CI = 1.349 - 11.466, p = 0.012). In terms of the type of health facility, women who utilized ANC from Mtendere (OR = 0.236, 95% CI = 0.093 - 0.595, p = 0.002) and N'gombe (OR = 0.179, 95% CI = 0.064 - 0.504, p = 0.001) clinics were less satisfied with the physical environment of care. Place of residence and educational attainment showed significant association with 'willingness to return'. N'gombe clinic (n = 48, 77.4%) received the lowest consideration for 'future care'.

CONCLUSION

Drawing on Donabedian framework on assessing quality of healthcare, we posit that pregnant women's satisfaction with the quality of antenatal care was low due to concerns about the physical environment of health facilities, the interpersonal relationships between providers and pregnant women as well as the technical aspects of care. All these accounted for pregnant women's dissatisfaction with the quality of care, and the indication of unwillingness to return or recommend the health facilities to colleagues. Consistent with Donabedian framework, we suggest that the codes and ethics of healthcare must be upheld. We also call for policy initiatives to reshape the physical condition of ANC clinics and to reinforce healthcare providers' focus on the 'structures' and the 'processes' relevant to care in addition to the 'outcomes'.

Residential status and household wealth disparities in modern contraceptives use among women in Ghana: a cross-sectional analysis

BACKGROUND

Modern contraceptive refers to "a product or medical procedure that interferes with reproduction from acts of sexual intercourse". The aim of this study was to assess the relationship between residential status and wealth quintile, and modern contraceptive use among women in Ghana.

METHODS

We examined residential status and wealth quintile on contraceptive use analysing the 2006, 2011 and 2018 Multiple Indicator Cluster Surveys datasets. A sample of 30,665 women in their reproductive ages (15-49 years) were enrolled in the surveys across Ghana. STATA version 13 was used to process and analyse the data. It examined socioeconomic and demographic characteristics, assessed modern contraceptive use prevalence among women, and used logistic regression models to determine predictors. The results were presented in odds ratio and adjusted odds ratio with 95% confidence intervals. All statistical tests were measured with p < 0.05.

RESULTS

In the three survey years, the highest prevalence of modern contraceptive usage was observed in 2011 (27.16%). The odds of using modern contraceptive increased by 19% in rural places (AOR = 1.19; 95% CI = 1.097-1.284) compared to urban places. The likelihood of women in second (AOR = 1.17; 95% CI = 1.065-1.289), middle (AOR = 1.24; 95% CI = 1.118-1.385), and fourth (AOR = 1.25; 95% CI = 1.113-1.403) wealth quintile using contraceptives increased compared to those of low wealth quintile. With the interactive terms, rural-second (AOR = 1.38; 95% CI = 1.042-1.830), rural-middle (AOR = 1.45; 95% CI = 1.084-1.933), rural-fourth (AOR = 1.52; 95% CI = 1.128-2.059), and rural-high (AOR = 1.42; 95% CI = 1.019-1.973) were more likely to use contraceptives compared to urban-low women. Despite lower odds, women of the age groups 20-24 (AOR = 2.33; 95% CI = 2.054-2.637), cohabitaing (AOR = 1.07; 95% CI = 0.981-1.173), secondary or higher education (AOR = 1.55; 95% CI = 1.385-1.736), Central (AOR = 1.48; 95% CI = 1.296-1.682) and Eastern (AOR = 1.48; 95% CI = 1.289-1.695) regions significantly predicted modern contraceptive use.

CONCLUSION

Modern contraceptive use in Ghana is low. Women in rural-rich categories are more likely to use modern contraceptives. Background factors such as age, marital status, educational attainment, and previous child experiences predict modern contraceptive use. It is recommended for the intensification of contraceptive awareness and utilization for all reproductive age women, regardless of education, marriage, or wealth.

Contraceptive use among female head porters: implications for health policy and programming in Ghana

Objective

Despite the growing literature on the barriers to contraceptives use among women, the perspective of female head porters has not been exhaustively researched. Using Bronfenbrenner's socio-ecological theory, we explore the factors that influence the contraceptive decision-making of migrant female head porters in the Kumasi Metropolis and the implications for health policy and planning.

Methodology

A case study of female head porters in the Kumasi Metropolis was conducted. We employed a qualitative approach in the collection and analysis of the data. A combination of cluster, purposive, and convenience sampling procedures was used to select 48 migrant female head porters to participate in semi-structured in-depth interviews. The data collected were analyzed using the thematic analytical framework.

Results

We found the main barriers to the uptake of contraception among the head porters to include high cost of contraceptives, perceived side effects associated with contraceptive use, and the disapproval of a male sexual partners.

Conclusion

The findings indicate that head porters' contraceptive decision-making is largely influenced by their social and economic circumstances. To address these, we recommend a carefully tailored approach, starting with a free National Health Insurance Scheme (NHIS) enrollment policy for all head porters in the country. There is also the need for the Ghana Health Service, and NGOs in health to work together to create effective awareness among female head porters on the benefits and misconceptions of contraception by incorporating culturally appropriate education that would facilitate the adoption of positive attitudes towards contraception. Additionally, NGOs in health in collaboration with the health facilities should initiate a process that encourages joint reproductive health decision-making among partners which recognises the added value of men's participation. We argue that men's active participation in contraception decision-making could potentially address their scepticism towards uptake.

The what's, where's and why's of miscarriage: evidence from the 2017 Ghana Maternal Health Survey

OBJECTIVES

Miscarriage remains a significant public health challenge in most low- and middle-income settings, including Ghana. We thus examined the sociodemographic and maternal characteristics associated with miscarriage in Ghana using the 2017 Maternal Health Survey dataset.

STUDY DESIGN

This was a cross-sectional quantitative study.

METHODS

We quantitatively analysed Ghana Maternal and Health Survey dataset. Demographic and Health Survey (DHS) collected the data using survey techniques. Approximately 25,062 women within the active reproductive ages of 15-49 years were involved in the survey. We analysed the data using binary and multivariate logistic regression models at a 95% confidence level. The findings were reported using the World Health Organisation's Conceptual Social Determinants of Health framework.

RESULTS

We found that the prevalence of miscarriage was 15.6%. Education, religion and ethnicity were the most significant structural factors associated with miscarriage. We also found that women of all ages (20-49 years), starting antenatal care (ANC) in the fifth month of gestation, residing in rural area, having history of abortion (aOR = 0.622, 95% CI = 0.570-0.679, P < 0.001), and not using mobile phone during complications (adjusted odds ratio = 0.601, 95% confidence interval = 0.556-0.651, P < 0.001) were key intermediary determinants of miscarriage. The analysis found increased odds of miscarriage among women who had no mobile phone and could not access the same during obstetric complications.

CONCLUSIONS

The study concludes that country-policy frameworks on maternal and neonatal health care do not go far enough in providing specific solutions for preventing miscarriage. To reverse this trend, we recommend targeted ANC, including enhanced twenty-four-hour primary emergency obstetric care within 5 km, advocacy, and education as a lever to increasing utilisation of ANC, and removal of indirect financial barriers to maternal health care. We further recommend a qualitative research to understand some of the findings and explore the feasibility of promoting mobile phone technology to address maternal health problems, particularly obstetric care for women in hard-to-reach rural communities.

Adequacy of antenatal care services utilisation and its effect on anaemia in pregnancy

Anaemia in pregnancy remains a critical public health concern in many countries including Ghana and it poses severe consequences in the short to long-term for women and their unborn babies. Although antenatal care (ANC) is largely provided for pregnant women, the extent its utilisation protects against anaemia in pregnancy remains largely understudied. The study assessed the adequacy of ANC services utilisation and its effect on anaemia among pregnant women in the Wa Municipality of Ghana. A facility-based cross-sectional survey was conducted. Probability proportionate to size sampling and systematic random sampling were used to select the facilities and 353 respondents. While 80⋅2 % of the pregnant women reported having received a sufficient number of ANC services provided, the prevalence of the overall ANC adequacy was only 44⋅2 %. After adjusting for potential confounders, pregnant women who could not achieve adequate ANC attendance were 2⋅3 times more likely to be anaemic in the third trimester of gestation AOR = 2⋅26 (95 % CI 1⋅05, 4⋅89), compared to their counterparts who maintained adequate ANC attendance. Adequate ANC attendance was a consistent and significant predictor of anaemia in pregnancy in the third trimester. Health and nutrition education on the need for early initiation of ANC attendance and support for the consumption of diversified diets are two possible interventions that can help contain anaemia in pregnancy.

Harmful cultural practices during perinatal period and associated factors among women of childbearing age in Southern Ethiopia: Community based cross-sectional study

INTRODUCTION

Although the maternal mortality ratio has decreased by 38% in the last decade, 810 women die from preventable causes related to pregnancy and childbirth every day, and two-thirds of maternal deaths occur in Sub-Saharan Africa alone. The lives of women and newborns before, during, and after childbirth can be saved by skilled care. The main factors that prevent women from receiving care during pregnancy and childbirth are harmful cultural practices. The aim of this study was to assess the level of harmful cultural practices during pregnancy, childbirth, and postnatal period, and associated factors among women of childbearing age in Southern Ethiopia.

METHODS

A community-based cross-sectional study design was conducted in the Gurage zone, among representative sample of 422 women of reproductive age who had at least one history of childbirth. A simple random sampling technique was used to recruit participants. Data were collected by six experienced and trained data collectors using a pretested structured questionnaire with face to face interviews. Harmful cultural practices are assessed using 11 questions and those who participate in any one of them are considered as harmful cultural practices. Descriptive statistics were performed and the findings were presented in text and tables. Binary logistic regression was used to assess the association between each independent variable and outcome variable.

RESULTS

Harmful cultural practices were found to be 71.4% [95%CI, 66.6-76.0]. The mean age of study participants was 27.6 (SD ± 5.4 years). Women with no formal education [AOR 3.79; 95%CI, 1.97-7.28], being a rural resident [AOR 4.41, 95%CI, 2.63-7.39], having had no antenatal care in the last pregnancy [AOR 2.62, 95%CI, 1.54-4.48], and pregnancy being attended by untrained attendants [AOR 2.67, 95%CI, 1.58-4.51] were significantly associated with harmful cultural practice during the perinatal period.

CONCLUSION

In this study we found that low maternal education, rural residence, lack of antenatal care and lack of trained birth attendant were independent risk factors associated with women employing harmful cultural practices during the perinatal period. Thus, strong multi-sectoral collaboration targeted at improving women's educational status and primary health care workers should take up the active role of women's health education on the importance of ANC visits to tackle harmful cultural practices.

Climate change, women's workload in smallholder agriculture, and embodied political ecologies of undernutrition in northern Ghana

The burden of child undernutrition across Africa remains extraordinarily high. Among children under age five, chronic and acute undernutrition is responsible for more ill-health than any other cause. While climate change exacerbates the multiple burdens of undernutrition, we know very little about the embodied effects on women's workload in agriculture and implications for feeding practices, especially for infants whose nutrition depends on mothers' time. In this article, political ecologies of health, with its nested, place-based analysis, is used as a framework to address this knowledge gap. The study took place in Ghana's Upper West Region, a semi-arid and resource-poor setting with higher undernutrition rates. In-depth interviews were conducted with smallholder farmers (n = 33) whose infants have sub-optimal growth, and key informants (n = 7) with expertise in nutrition and health. Findings from the study demonstrate how climate change puts pressure on women's productive time, leading to poor child feeding practices and undernutrition. Ultimately, the article argues that there are hidden impacts of climate change on undernutrition. Global undernutrition interventions should therefore move beyond biomedical solutions to address these hidden impacts, some of which are social, gendered, and structural in nature.

'They Forget I'm Deaf': Exploring the Experience and Perception of Deaf Pregnant Women Attending Antenatal Clinics/Care

Background:

Antenatal care (ANC) services provide access to integrated health management for several pregnancy related conditions. Unfortunately, deaf pregnant women remain vulnerable during pregnancy due to lack of access as well as communication barriers at antenatal clinics in Nigeria.

Objective:

The primary aim of this study was to explore the experiences and satisfaction of pregnant deaf women with antenatal care in Nigeria.

Methods:

This was a qualitative study, conducted among nine deaf pregnant women from two local government areas, attending both private and public health facilities for antenatal care in Ibadan, Oyo State, Nigeria. Data were collected using semi-structured, video recorded one-on-one interviews, with sign language as the medium of communication. The interviews were conducted until saturation of the themes was reached. The recorded interviews were precisely transcribed and thematic analyses were conducted on the data obtained.

Findings:

The mean age of the participants was 29.5 years. Participants indicated that they had registered/booked for antenatal care in their second trimester. Registration at this stage was regarded as late registration of the pregnancies. Communication difficulties during their ANC (antenatal care) visits, distance and location of the clinics, knowledge and perception of what ANC entailed, finance/cost, and health care professionals’ attitudes towards the participants were the major themes identified for late ANC bookings. Participants who attended privately owned health care facilities for ANC had more satisfaction with ANC care than those attending publicly owned health facilities.

Conclusions:

Deaf pregnant women were knowledgeable about ANC but registered late for the service, largely due to communication difficulties, distance to the clinic, cost, and the perceived attitudes of the health care workers. There existed a variance in the level of satisfaction of deaf pregnant women who attended private or public health facilities.

Barriers to Accessing Maternal Care in Low Income Countries in Africa: A Systematic Review

The new Sustainable Development Goals (SDGs) to 2030 aim to reduce maternal mortality and provide equitable access to maternal healthcare. Compromised access to maternal health facilities in low-income countries, and specifically in Africa, contribute to the increased prevalence of maternal mortality. We conducted a systematic review to investigate access barriers to maternal health in low-income countries in Africa since 2015, from the perspective of both community members and health providers. The findings show that the most important barriers to maternal health are transportation barriers to health facilities, economic factors, and cultural beliefs, in addition to lack of family support and poor quality of care. Further research is required to guide policymakers towards firm multi-sectoral action to ensure appropriate and equitable access to maternal health in line with the SDGs to 2030.

Religious, socio-cultural norms and gender stereotypes influence uptake and utilization of maternal health services among the Digo community in Kwale, Kenya: a qualitative study

Background

Maternal health outcomes in resource-limited settings are typically influenced by supply-side factors affecting the provision of quality health services. The extent to which demand-side factors contribute to this influence is unclear. We aimed to explore how individual and community-wide factors influenced uptake and utilization of maternal health services among the Digo community residing in Kwale County of coastal Kenya.

Methods

Between March and December 2015, we conducted 5 focus group discussions (FGDs) and 15 in-depth interviews (IDIs) with members of the Digo community predominant in Kwale county, Kenya. Respondents were sampled purposively and included female (pregnant and postpartum) as well as male adult community members. A thematic content analytic approach was used.

Results

There were a total of 47 FGD respondents, including 15 (32%) females with a median (interquartile, IQR) age of 38 (27–55) years and 6 (3–8) children. Majority (40%) reported attaining secondary-level education. All IDI respondents were female with a median (IQR) age of 27 (24–35) years and 4 (2–5) children. Majority (80%) had attained primary-level education. We found that religious and socio-cultural norms as well as gender stereotypes were important influences on the uptake and utilization of maternal health services, including facility-based delivery and contraception. Key amongst this was the unspoken deference to the counsel of a prominent matriarchal figure in the decision-making process.

Conclusions

Among the Digo community of coastal Kenya, a unique social-cultural context comprising of a religious and gendered value belief system influences women’s reproductive health and rights. These findings highlight the important role of demand-side factors in influencing maternal health outcomes. In addition to addressing supply-side factors, programs in such settings should aim to address factors that leverage inherent social capital to drive demand for maternal health services ensuring that they are not only effective, but also responsive to the local context.

Maternal health services utilisation among primigravidas in Uganda: what did the MDGs deliver?

BACKGROUND

Achieving maternal health outcomes in the SDGs requires the implementation of more targeted policies and strategies. While the MDGs may have deepened our understanding in this regard, we know little about the trends in maternal health services utilisation among primigravidas, and how age and geographical regions could have influenced these trends. In this study, we examined utilisation of antenatal and skilled delivery services among primigravidas in Uganda, a country with one of the highest maternal mortality ratios, and where early childbearing and its attendant challenges are common.

METHODS

Guided by Andersen's Behavioural Model, we fitted multivariate regression models to a pooled dataset of the 2006, 2011 and 2016 Ugandan Demographic and Health Survey (n = 3477) to understand the dynamics in Antenatal Care (ANC) and Skilled Birth Attendance (SBAs) utilisation among primigravidas. Post-estimation margins were employed to further highlight the effect of age and geographical regions.

RESULTS

The analyses show an improvement in access to maternal health services among primigravidas from 2006 to 2016. Compared to 2006, primigravidas in 2016 were 48%, 24% and 2.98 times more likely to have early ANC, four or more ANC visits, and SBAs, respectively. Altogether, a primigravida in 2016 relative to 2006 was 42% more likely to meet all three maternal health service indicators. Post-estimation margins analyses on age and geographical disparities revealed that younger primigravidas have lower probability, while primigravidas in Eastern Region, one of the most deprived in the country, have the lowest probability of accessing maternal health services. Also, the study found education, wealth, women's household decision-making power, place of residence as important determinants of ANC visits and SBAs.

CONCLUSIONS

Based on our findings, it is important to address the vulnerabilities of primigravidas, particularly younger individuals, in accessing early ANC. Uganda should scale-up decentralisation and integration of maternal health delivery in local communities as a strategy of addressing lingering geographical disparities, and ultimately improve maternal health outcomes in the SDGs period.

Effect of pregnancy induced hypertension on adverse perinatal outcomes in Tigray regional state, Ethiopia: a prospective cohort study

Background

The prevalence of pregnancy-induced hypertension in Ethiopia ranges from 2.2 to 18.3%. However, so far little is known about the adverse perinatal outcomes of pregnancy-induced hypertension in Tigray regional state, Ethiopia. Therefore, the objective of this study was to assess the effect of pregnancy-induced hypertension on adverse perinatal outcomes in Tigray Regional State, Ethiopia.

Methods

a prospective cohort study was conducted on a total sample of 782 pregnant women attending antenatal care in hospitals of Tigray regional state, Ethiopia. Pregnant mothers diagnosed with PIH during the data collection period in the selected hospitals were included as exposed group and normotensive women were also enrolled as a control group. This study addresses women diagnosed with preeclampsia, eclampsia and gestational hypertension between 28 and 35 weeks of gestation. Data were collected using an interviewer-administered questionnaire and review of their medical records from February 2018, to February 2019. The adverse perinatal outcome event includes low birth weight, birth asphyxia, small for gestational age, preterm delivery, admission to neonatal intensive care unit and perinatal death. A modified Poisson regression model with robust standard errors was used to analyze relative risk.

Results

In this study, the overall incidence of adverse perinatal outcome was higher among women with pregnancy-induced hypertension than normotensive women (66.4% vs 22.2%). After adjusted for confounders women with pregnancy-induced hypertension were born babies with a higher risk of low birth weight (adjusted RR (95%CI) = 5.1(3.4,7.8)), birth asphyxia (aRR = 2.6(1.9,3.8)), small for gestational age (aRR = 3.3(2.3,4.6)), preterm delivery (aRR = 5.2(3.4,7.9)), stillbirth (aRR = 3.46(1.40,8.54)), admission to neonatal intensive care unit (aRR = 5.1(3.1,8.4)) and perinatal death (aRR = 3.6(1.8,7.4)) compared to normotensive pregnant women.

Conclusions

Higher incidences of adverse perinatal outcomes occurred among women pregnancy-induced hypertension in Tigray regional state, Ethiopia. Hence, health care providers should strengthen prevention, early diagnosis and prompt management of pregnancy-induced hypertension to reduce adverse perinatal outcomes of pregnancy-induced hypertension.

Factors Associated with Uptake of Intermittent Preventive Treatment of Malaria in Pregnancy: A Cross-Sectional Study in Private Health Facilities in Tema Metropolis, Ghana

Introduction

Intermittent preventive treatment of malaria in pregnancy with sulfadoxine pyrimethamine (IPTp-SP) is effective in preventing the adverse consequences of malaria on birth outcomes.

Methods

A cross-sectional survey was carried out among antenatal and postnatal women and midwives at private health facilities in Tema using the mixed method to investigate factors associated with uptake of IPTp-SP. Antenatal and postnatal women were consecutively enrolled and data on their sociodemographic characteristics and antenatal service utilization collected using a questionnaire and review of antenatal care (ANC) records. In-depth interviews involving attending midwives were conducted and data on ANC service delivery collected. The interviews were manually analyzed. Bivariate and multiple logistic regression analyses were done to determine factors associated with uptake of SP.

Results

Of the 382 respondents, 178 (46.6%) took ≥ 3 doses of SP. Uptake was similar for those who had delivered and those yet to deliver (χ² =2.94, p > 0.05). Ninety-seven of the 176 (55.1%) women who initiated antenatal visit during the first trimester received ≥ 3 doses of SP whilst 42.0% (76/181) of those who started during the second trimester received ≥ 3 doses (χ² = 5.64, p = 0.02). Those who initiated ANC during the second trimester received more doses compared to those who started during the third trimester (χ² = 4.43, p = 0.04). Respondents who attended ANC > 5 times increased their uptake by 83% compared to those who attended < 5 times (OR 0.2, 95% C.I 0.12-0.31). There was poor adherence to directly observed treatment and low knowledge of midwives on IPTp-SP protocol.

Conclusion

Early initiation and regular visit to antenatal care centres promoted uptake of optimal doses of SP.

Narratives on why pregnant women delay seeking maternal health care during delivery and obstetric complications in rural Ghana

BACKGROUND

Despite the many maternal healthcare policy programmes in Ghana such as free the antenatal care (ANC) and the fee-exemption policy under the National Health Insurance Scheme, among others, the country has yet to make substantial improvements in addressing low skilled care utilisation in pregnancy and delivery. From previous studies, maternal mortality has been linked to women's healthcare decision-making power at the household level in many low and middle-income countries. Thus, a pregnant women's ability to choose a healthcare provider, act on her preferences, and to be sufficiently financially empowered to take the lead in deciding on reproductive and pregnancy care has significant effects on service utilisation outcomes. Therefore, we explored rural community-level barriers to seeking care related to obstetric complications and delivery from the perspectives of mothers, youth, opinion leaders and healthcare providers in Nadowli-Kaleo and Daffiama-Bussie-Issa districts in the Upper West Region of Ghana.

METHODS

This exploratory qualitative study was based on the narratives of women, health providers and community stakeholders regarding the expectant women's autonomy to decide and utilise maternal care. To achieve maximal diversity of responses, purposive sampling procedures were followed in selecting 16 health professionals, three traditional birth attendants and 240 community members (opinion leaders, youth and non-pregnant women) who participated in individual depth interviews and focus group discussions.

RESULTS

Women's lack of autonomy to seek care without prior permission, perceived quality care of traditional birth attendants, stigmatisation of unplanned pregnancies and cultural beliefs associated with late disclosure of childbirth labour all delayed mothers timely use of skilled care in the study communities. These barriers compounded problems arising from communities that are geographically isolated from hospital care.

CONCLUSIONS

Decisions about seeking maternal care were usually made by the expectant woman's husband and family without providing adequate support to pregnant women during the latter stages of pregnancy and delivery. We conclude that this is primarily a cultural issue. The study recommends a change in the approach to community-level health education campaigns for maximum impacts through the increased involvement of men and families in health service delivery and utilisation.

Improving Access and Utilization of Maternal Healthcare Services through Focused Antenatal Care in Rural Ghana: A Qualitative Study

Improved access to and utilization of various maternal healthcare services have been seen as the panacea to poor maternal and child health outcomes characterizing many developing countries. Focused Antenatal Care (FANC) replaced the regular antenatal care model about a decade and a half ago. This study sought to document empirical outcomes of how the FANC approach translates access and utilization of maternal health services into positive maternal health outcomes. We utilized a descriptive qualitative design and analysis. We applied key informant interviewing to collect data from 206 respondents consisting of 140 women in their fertility age and 66 health workers across 14 communities in the study district. We found that FANC has been widely implemented across the district with most of the required services integrated into the existing healthcare delivery system. Overall, there has been successful implementation of FANC in the district, resulting in several benefits including the increased utilization of maternal healthcare services, acceptance of family planning, increased skilled delivery, and utilization of postnatal care (PNC) services. This notwithstanding, a number of issues need to be addressed to improve FANC services. These include provision of adequate infrastructure, essential supplies, communication and transportation systems, and manpower and adoption of positive sociocultural practices. No effort should be spared in providing these to sustain the successes and ensure sustainability of FANC.

Viability of diagnostic decision support for antenatal care in rural settings: findings from the Bliss4Midwives Intervention in Northern Ghana

Background

Antenatal screening is useful for early identification and management of high-risk pregnancies. In low-resource settings, provision of the full complement of tests is limited and diagnostic referrals incure additional costs for pregnant women. We assessed the viability of Bliss4Midwives (B4M) - a point-of-care diagnostic decision support device for decentralized screening of pre-eclampsia, gestational diabetes and anaemia during antenatal care (ANC).

Methods

The device was piloted in seven health facilities across two districts in Northern Ghana over a ten-month period. Health workers were expected to screen women at each ANC visit till delivery. All screening records from the device were automatically archived digitally and later downloaded. After removing duplicates or invalid entries, descriptive quantitative analysis was carried out with IBM SPSS Statistics (version 23). B4M usage behavior, diagnostic and referral outcome were analyzed.

Results

Health workers conducted 1323 partial or full antenatal screening on 940 women, resulting in decision support for 835 (88.8%) B4M beneficiaries. Diagnostic referral was eliminated for 708 (84.7%) beneficiaries, with 335 (40.1%) of these from facilities without on-site diagnostic alternatives. Of visits with complete data, 92/559 (16.4%) women were screened in their first trimester, 28/940 (2.9%) had 4+ B4M visits and 107/835 (12.8%) women were recommended for urgent referral to a higher-level facility on the first visit. Follow-up screenings flagged an additional 17 women for urgent referral with 10 cases of repeated alerts in five women. Wide variations between high (9 months use) and low adopting (1.5 months use) facilities were observed, with some similarities in usage trend.

Conclusions

B4M helped decentralize ANC screening and decrease unnecessary referrals. Project outcomes were influenced by implementation strategy, technical features and behavioural dispositions of users and beneficiaries.

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.

Sociocultural barriers to maternity services delivery: a qualitative meta-synthesis of the literature

OBJECTIVES

Maternal and neonatal healthcare outcomes in Sub-Saharan Africa (SSA) remain poor despite decades of different health service delivery interventions and stakeholder investments. Qualitative studies have attributed these results, at least in part, to sociocultural beliefs and practices. Thus there is a need to understand, from an overarching perspective, how these sociocultural beliefs affect maternal and neonatal health (MNH) outcomes.

STUDY DESIGN

A qualitative meta-synthesis of primary studies on cultural beliefs and practices associated with maternal and neonatal health care was carried out, incorporating research conducted in any country within SSA, using data from men, women and health professionals gathered through focus group discussions, structured and semistructured interviews.

METHODS

A systematic search was carried out on seven electronic databases, Scopus, Ovid Medline, PubMed, CINAHL Plus, Humanities and Social Sciences (Informit), EMBASE and Web of Science, and on Google Scholar, using both manual and electronic methods, between 1st January 1990 and 1st January 2017. The terms 'cultural beliefs'; 'cultural beliefs AND maternal health'; 'cultural beliefs OR maternal health'; 'traditional practices' and 'maternal health' were used in the search.

RESULTS

Key components of cultural beliefs and practices associated with adverse health outcomes on pregnancy, labour and the postnatal period were identified in five overarching factors: (a) pregnancy secrecy; (b) labour complications attributed to infidelity; (c) mothers' autonomy and reproductive services; (d) marital status, trust in traditional medicines and traditional birth attendants; and (e) intergenerational beliefs attached to the 'ordeal' of giving birth.

CONCLUSION

Cultural beliefs and practices related to maternal and neonatal health care are intergenerational. Therefore, intensive community-specific education strategies to facilitate behaviour changes are required for improved MNH outcomes. Adopting practical approaches such as involving husbands/partners and communities in antenatal care services in a health facility and community settings can enhance improved MNH outcomes.

A Mixed-Methods Evaluation of a Community-Based Behavior Change Program to Improve Maternal Health Outcomes in the Upper West Region of Ghana

BACKGROUND

The Community Benefits Health (CBH) program introduced a community-based behavior change intervention to address social norms and cultural practices influencing maternal health and breastfeeding behaviors in rural Ghana. The purpose of this study was to determine if CBH influenced maternal health outcomes by stimulating community-level support in woman's social networks.

METHODS

A mixed-methods study was conducted to evaluate changes in six antenatal/postpartum care, birth attendance, and breastfeeding behaviors in response to the CBH intervention and to assess how the program was implemented and to what extent conditions during implementation influenced the results.

RESULTS

We found increases in five of the six outcomes in both the intervention and control areas. Qualitative findings indicated that this may have resulted from program spillover. We considered the dose of exposure to program activities and found that women were significantly more likely to practice maternal health behaviors with increased exposure to program activities while controlling for study area and time.

CONCLUSIONS

Overall, we determined that exposure to the CBH program significantly improved uptake of three of the six study outcomes, indicating that efforts aimed at increasing communication across women and their social networks may lead to improved health outcomes.