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Background Per UNICEF’s Nurturing Care Framework, early childhood development (ECD) begins during pregnancy and many lower-resource settings need data to inform their programs for optimal child development. The maternal-fetal relationship can be partly examined via a series of bonding activities called early stimulation behaviors (ESB). This study describes early stimulation behaviors and the associated correlates among pregnant women in Ghana. Methods This cross-sectional study used data from a cluster-randomized trial in two districts of Northern Ghana. A total of 374 pregnant women were enrolled at baseline and administered a pre-intervention survey. Communication-related early stimulation behaviors was the primary outcome which was evaluated using three maternal-fetal bonding activities; did the woman self-report touching and/or talking, singing, and/or talking about family to her belly. A generalized estimating equation modified Poisson model was used for the bivariate and multivariable analysis. Results About half of the participants reported performing communication-related ESB during pregnancy frequently or sometimes. Bivariate analysis revealed that negative life experiences including higher rates of emotional, physical and sexual intimate partner violence (IPV) and having moderate to severe depressive symptoms were associated with women performing early stimulation behaviors more often. In the multivariable model, physical intimate partner violence remained significantly associated with early stimulation behaviors. Conclusion Research on early stimulation behaviors is still in a nascent phase. It is unclear why our results revealed an association between intimate partner violence and early stimulation behaviors; this could reflect a coping mechanism for the expectant mother. Further research is needed to better understand this association and explore potential long-term impacts of early stimulation behaviors during pregnancy on child development. Trial registration Clinical Trials # NCT03665246, August 29, 2018.

Objective:Despite efforts to improve maternal and child nutrition, undernutrition remains a major public health challenge in Ghana. The current study explored community perceptions of undernutrition and context-specific interventions that could improve maternal and child nutrition in rural Northern Ghana.Design:This exploratory qualitative study used ten focus group discussions to gather primary data. The discussions were recorded, transcribed and coded into themes using Nvivo 12 software to aid thematic analysis.Setting:The study was conducted in rural Kassena-Nankana Districts of Northern Ghana.Study participants:Thirty-three men and fifty-one women aged 18–50 years were randomly selected from the community.Results:Most participants reported poverty, lack of irrigated agricultural land and poor harvests as the main barriers to optimal nutrition. To improve maternal and child nutrition, study participants suggested that the construction of dams at the community level would facilitate all year round farming including rearing of animals. Participants perceived that the provision of agricultural materials such as high yield seedlings, pesticides and fertiliser would help boost agricultural productivity. They also recommended community-based nutrition education by trained health volunteers, focused on types of locally produced foods and appropriate ways to prepare them to help improve maternal and child nutrition.Conclusion:Drawing on these findings and existing literature, we argue that supporting community initiated nutrition interventions such as improved irrigation for dry season farming, provision of agricultural inputs and community education could improve maternal and child nutrition.

Background CVD is the leading cause of morbidity and mortality worldwide, and its prevalence is rising in Ghana. The Community-Based Health Planning and Services (CHPS) initiative has used community-level clinics, home visits by nurses, and outreach services to decrease maternal and child mortality across Ghana. However, CHPS currently lacks capacity to screen for or treat CVD and its risk factors. Methods We conducted in-depth interviews (IDIs) with 21 nurse community health officers (CHOs) and 10 supervising sub-district leaders (SDLs) to identify factors that constrain or facilitate CHPS screening and treatment for CVD through the World Health Organization’s HEARTS protocol in the rural communities of the Kassena-Nankana East and West districts of Ghana. We transcribed audio recordings of the interviews, coded their content, and analyzed codes for key themes. Results Respondents spoke to CVD care barriers across three themes: community demand for CVD care; community access to CVD care; and provider capacity to render CVD care. CHOs and SDLs noted that community members were often unaware of CVD, despite high reported local prevalence of risk factors such as alcohol use and stress. Moreover, community members were unable to travel to or pay for treatment once diagnosed. CHOs lacked training on CVD and its risk factors, as well as medications and supplies to treat conditions such as high blood pressure. However, CHOs and SDLs recognized the importance of CVD care, expressed interest in acquiring further training, and emphasized the need to improve logistical support for primary care as a precondition for CVD care. Conclusion Nurses and supervisors associated with the CHPS program voiced multiple obstacles to CVD care, but also listed several feasible steps to address them. Initiatives such as CVD-focused training; provision of essential CVD equipment and pharmaceuticals; community education campaigns; and transportation to aid patients and providers could address these barriers. Future work will explore the feasibility and acceptability of these interventions among staff and community members, in preparation for a locally adapted pilot initiative drawing from the HEARTS initiative designed to control CVD risk factors such as hypertension, depression, and alcohol abuse.

Background: Person-centered maternity care (PCMC), which refers to care that is respectful and responsive to women’s preferences needs, and values, is core to high-quality maternal and child health. Provider report of PCMC is a potentially valid means of assessing the extent of PCMC and contributing factors. Methods: We used data from two cross-sectional surveys with 236 maternity providers from Ghana (N=150) and Kenya (N=86) to assess the psychometric properties of a provider-reported PCMC scale, and to examine factors associated with provision of PCMC. Analysis included factor analysis to assess construct validity and Cronbach’s alpha to assess internal consistency of the scale; descriptive analysis to assess extent of PCMC; and bivariate and multivariable linear regression to examine factors associated with PCMC. Findings: The 9-item provider-reported PCMC scale has high construct validity and reliability representing a unidimensional scale with a Cronbach’s alpha of 0·72. The average standardized PCMC score for the combined sample was 66·8 (SD=14·7). PCMC decreased with increasing report of stress and burnout. Compared to providers with no burnout, providers with burnout had lower average PCMC scores (β= -7·30, 95%CI:-11·19, -3·40 for low burnout and β=-10·86, 95%CI:-17·21, -4·51 for high burnout). Burnout accounted for over half of the effect of perceived stress on PCMC. Interpretation: The provider PCMC scale is a valid and reliable measure of provider self-reported PCMC and highlights inadequate provision of PCMC in Kenya and Ghana. Provider burnout is a key driver of poor PCMC that needs to be addressed to improve PCMC. Funding: NICHD and UCSF Bixby Center Declaration of Interest: We declare no competing interests. Ethical Approval: This study was approved by the UCSF Committee for Human Subjects, the Kenya Medical Research Institute Scientific and Ethics Review Unit, and the Navrongo Health Research Center Ethics Review Unit.

The COVID-19 pandemic has affected job satisfaction among healthcare workers; yet this has not been empirically examined in sub-Saharan Africa (SSA). We addressed this gap by examining job satisfaction and associated factors among healthcare workers in Ghana and Kenya during the COVID-19 pandemic. We conducted a cross-sectional study with healthcare workers (N = 1012). The two phased data collection included: (1) survey data collected in Ghana from April 17 to May 31, 2020, and (2) survey data collected in Ghana and Kenya from November 9, 2020, to March 8, 2021. We utilized a quantitative measure of job satisfaction, as well as validated psychosocial measures of perceived preparedness, stress, and burnout; and conducted descriptive, bivariable, and multivariable analysis using ordered logistic regression. We found high levels of job dissatisfaction (38.1%), low perceived preparedness (62.2%), stress (70.5%), and burnout (69.4%) among providers. High perceived preparedness was positively associated with higher job satisfaction (adjusted proportional odds ratio (APOR) = 2.83, CI [1.66,4.84]); while high stress and burnout were associated with lower job satisfaction (APOR = 0.18, CI [0.09,0.37] and APOR = 0.38, CI [0.252,0.583] for high stress and burnout respectively). Other factors positively associated with job satisfaction included prior job satisfaction, perceived appreciation from management, and perceived communication from management. Fear of infection was negatively associated with job satisfaction. The COVID-19 pandemic has negatively impacted job satisfaction among healthcare workers. Inadequate preparedness, stress, and burnout are significant contributing factors. Given the already strained healthcare system and low morale among healthcare workers in SSA, efforts are needed to increase preparedness, better manage stress and burnout, and improve job satisfaction, especially during the pandemic.

Despite didactic training on adverse events following immunization (AEFI) in Ghana, the reporting ratio of AEFI was 1.56 per 100,000 surviving infants in 2015, below the minimum reporting ratio of 10. We aimed to estimate the proportion of health care workers (HCWs) reporting AEFI and to identify barriers to reporting. We conducted a cross-sectional survey of HCWs in four regions in Ghana. A simple random sample of 176 health facilities was selected and up to two HCWs were randomly selected per facility. We used the Rao-Scott Chi-squared test to compare factors associated with reporting of AEFI in the last year. We used an open-ended question to identify reasons for low reporting. One supervisor from each facility, responsible for overall reporting and management of AEFI, was also interviewed. A total of 306 HCWs from 169 facilities were interviewed. Of these, 176 (57.5%) reported they had ever encountered an AEFI. Of the 120 who had encountered an AEFI in the last year, 66 (55.0%) indicated they had reported the AEFI, and 38 (31.7%) completed a reporting form. HCWs (n = 120) reported multiple barriers to reporting of AEFI; the most common barriers were fear of personal consequences (44.1%), lack of knowledge or training (25.2%), and not believing an AEFI was serious enough to report (22.2%). Discussion of AEFI during the last supervisory visit was significantly associated with reporting in the past year (OR 7.39; p .001). Of 172 supervisors interviewed, 65 (37.8%) mentioned their facilties had ever encountered an AEFI; over 90% of facilities had reporting forms. We identified low reporting of AEFI and multiple barriers to reporting among HCWs in the four selected regions of Ghana. Discussing AEFI during supervisory visits with HCWs might improve reporting. Additionally, strategies to address fear of personal consequences as a barrier to reporting of AEFI are needed.

Breast cancer is steadily increasing in Ghana, with the majority of Ghanaians only seeking care in the advanced stage of the disease. Furthermore, structured breast cancer control strategies are mostly non-existent. This study aimed to examine breast cancer and breast screening pathways in a tertiary healthcare facility within the Kumasi metropolis.We used a single exploratory case-study design to purposefully select one healthcare facility as a case with embedded sub-units of analysis (patients, first-degree relatives of patients, and clinicians) to address the study's aim. In-depth interview was used to generate evidence from 35 participants. Applying Miles and Huberman's thematic strategy, a cross-case analysis was conducted using Morse's analytical framework.Five (5) main themes emerged from the data: description of breast cancer, breast health education in Ghana, breast screening practices among women, the state of breast screening and barriers to breast screening uptake and lastly, the way forward. Malignancy of the breast was described as common, especially among young women who commonly present with advanced disease with poor prognostic outcomes. There were reports of limited breast cancer awareness and knowledge among women. Comparatively, urban educated women were noted to be relatively knowledgeable and more proactive about breast cancer than the less-privileged women in rural communities. Self and clinical-breast examination practices were reported as unusual habits for Ghanaian women. Several provider-related factors, lack of screening facilities, and attitude of women were highlighted as barriers to breast screening practices. Education among health professionals and interventions to promote opportunistic and organized breast screening were cited as the way forward for breast cancer control and early detection in GhanaThis is a confirmatory result of a stark burden of breast cancer in Ghana, inferring a need to address the deficiencies around breast cancer and early detection practices.

IntroductionThe COVID-19 pandemic has compounded the global crisis of stress and burnout among healthcare workers (HCWs). But few studies have empirically examined the factors driving these outcomes. We examined the association between perceived preparedness to respond to the pandemic and HCW stress and burnout and identified potential mediating factors among HCWs in Ghana.MethodsData are from HCWs in Ghana who completed a cross-sectional self-administered online survey; 414 and 409 HCWs completed stress and burnout questions, respectively. Perceived preparedness, stress, and burnout were measured using validated psychosocial measures. We assessed associations using linear regressions with robust standard errors.ResultsThe average score for preparedness was 24 (SD = 8.8), 16.3 (SD = 5.9) for stress, and 37.4 (SD = 15.5) for burnout. In multivariate analysis, HCWs who felt somewhat prepared and prepared had lower stress (β = −1.89, 95%CI:-3.49 to −0.30 and β = –2.66, 95%CI:-4.48 to −0.84) and burnout (β = –7.74, 95%CI:−11.8 to −3.64 and β = –9.25, 95%CI:-14.1 to –4.41) scores than those who did not feel prepared. Appreciation from management and family support were associated with lower stress and burnout, while fear of infection was associated with higher stress burnout. Fear of infection partially mediated the relationship between perceived preparedness and stress/burnout, accounting for about 16 to17% of the effect.ConclusionLow perceived preparedness to respond to COVID-19 increases stress and burnout, and this is partly through fear of infection. Interventions to increase HCWs’ morale and capacity to respond to the pandemic are needed.Strengths and limitations of this studyOur study is among the first to report data on COVID-19 related stress and burnout among HCWs in Africa and to identify contributing factors, including HCWs’ perceived preparedness to respond to the pandemic.We used validated psychosocial measures of stress and burnout, as well as a perceived preparedness for COVID-19 scale developed by our team, which has high validity and reliability; this scale can facilitate similar research in other settings.Our study shows that among healthcare workers in Ghana, low perceived preparedness to respond to the COVID-19 pandemic is associated with higher levels of stress and burnout and this association is partially mediated by fear of infection.Perceived appreciation from management and family support on the other hand are associated with lower stress and burnout.Findings are based on self-reported data from a cross-sectional online survey, thus, there may be social desirability bias; associations described are not causal; and the online survey may limit generalizability.

Background Community participation in health care delivery will ensure service availability and accessibility and guarantee community ownership of the program. Community-based strategies such as the involvement of Community Health Volunteers (CHVs) and Community Health Management Committees (CHMCs) are likely to advance primary healthcare in general, but the criteria for selecting CHVs, CHMCs and efforts to sustain these roles are not clear 20 years after implementing the Community-based Health Planning Services program. We examined the process of selecting these cadres of community health workers and their current role within Ghana’s flagship program for primary care–the Community-based Health Planning and Services program. Methods This was an exploratory study design using qualitative methods to appraise the health system and stakeholder participation in Community-based Health Planning and Services program implementation in the Upper East region of Ghana. We conducted 51 in-depth interviews and 33 focus group discussions with health professionals and community members. Results Community Health Volunteers and Community Health Management Committees are the representatives of the community in the routine implementation of the Community-based Health Planning and Services program. They are selected, appointed, or nominated by their communities. Some inherit the position through apprenticeship and others are recruited through advertisement. The selection is mostly initiated by the health providers and carried out by community members. Community Health Volunteers lead community mobilization efforts, support health providers in health promotion activities, manage minor illnesses, and encourage pregnant women to use maternal health services. Community Health Volunteers also translate health messages delivered by health providers to the people in their local languages. Community Health Management Committees mobilize resources for the development of Community-based Health Planning and Services program compounds. They play a mediatory role between health providers in the health compounds and the community members. Volunteers are sometimes given non-financial incentives but there are suggestions to include financial incentives. Conclusion Community Health Volunteers and Community Health Management Committees play a critical role in primary health care. The criteria for selecting Community Health Volunteers and Community Health Management Committees vary but need to be standardized to ensure that only self-motivated individuals are selected. Thus, CHVs and CHMCs should contest for their positions and be endorsed by their community members and assigned roles by health professionals in the CHPS zones. Efforts to sustain them within the health system should include the provision of financial incentives.

Background: Cardiovascular disease (CVD) is a growing burden in low- and middle-income countries. Ghana seeks to address this problem by task-shifting CVD diagnosis and management to nurses. The Community-Based Health Planning and Services (CHPS) initiative offers maternal and pediatric health care throughout Ghana but faces barriers to providing CVD care. We employed in-depth interviews to identify solutions to constraints in CVD care to develop a nurse-led CVD intervention in two districts of Ghana’s Upper East Region. Objective: This study sought to identify non–physician-led interventions for the screening and treatment of cardiovascular disease to incorporate into Ghana’s current primary health care structure. Methods: Using a qualitative descriptive design, we conducted 31 semistructured interviews of community health officers (CHOs) and supervising subdistrict officers (SDOs) at CHPS community facilities. Summative content analysis revealed the most common intervention ideas and endorsements by the participants. Findings: Providers endorsed three interventions: increasing community CVD knowledge and engagement, increasing nonphysician prescribing abilities, and ensuring provider access to medical and transportation equipment. Providers suggested community leaders and volunteers should convey CVD knowledge, marshaling established gathering practices to educate communities and formulate action plans. Providers requested lectures paired with experiential learning to improve their prescribing confidence. Providers recommended revising reimbursement and equipment procurement processes for expediting access to necessary supplies. Conclusions: Frontline CHPS primary care providers believe CVD care is feasible. They recommended a three-pronged intervention that combines community outreach, provider training, and logistical support, thereby expanding task-shifting beyond hypertension to include other CVD risk factors. This model could be replicable elsewhere.

Ghana has made progress in expanding providers in abortion care but access to the service is still a challenge. We explored stakeholder perspectives on task-sharing in abortion care and the opportunities that exist to optimize this strategy in Ghana. We purposively sampled 12 representatives of agencies that played a key role in expanding abortion care to include midwives for key informant interviews. All interviews were audio recorded, transcribed verbatim, and then coded for thematic analysis. Stakeholders indicated that Ghana was motivated to practice task-sharing in abortion care because unsafe abortion was contributing significantly to maternal mortality. They noted that the Ghana Health Service utilized the high maternal mortality in the country at the time, advancements in medicine, and the lack of clarity in the definition of the term "health practitioner" to work with partner nongovernmental organizations to successfully task-share abortion care to include midwives. Access, however, is still poor and provider stigma continues to contribute significantly to conscientious objection. This calls for further task-sharing in abortion care to include medical or physician assistants, community health officers, and pharmacists to ensure that more women have access to abortion care.

Background Utilization of antenatal care services in Ghana has substantially increased over the years, but the rates of mother-to-child transmission of HIV is still high. The high burden of HIV among pregnant women has serious implications for mother-to-child transmission. The main objective of this study was to assess the compliance of HIV testing and counseling provided at antenatal care clinics in two rural districts in northern Ghana by comparing reported practices to the national guidelines. Methods This study was a descriptive qualitative study conducted in the Kassena-Nankana Districts of northern Ghana. In-depth interviews were conducted with 10 midwives, 10 mothers, and 2 public health nurses who were recruited through purposive and snowball sampling. All interviews were audio recorded, transcribed into English, and imported into NVivo 12.0 software for open, axial, and selective coding. Results The findings indicate that not all pregnant women were informed prior to testing nor informed of their test results. Many mothers indicated that pre-test counseling is limited although the midwives claimed to provide it. Post-test counseling is primarily given to those who test positive, and several midwives agreed that there is no need to counsel HIV-negative women. Perceptions of the lack of confidentiality and privacy were pervasive among mothers despite the emphasis placed on its importance by the midwives. There were conflicting reports on whether HIV testing during antenatal care is voluntary or compulsory. The challenges with HIV testing and counseling that were mentioned by midwives include lack of adequate infrastructure, language barriers, and insufficient training. Conclusions HIV testing and counseling provided at antenatal care is not uniform across all health facilities and does not strictly adhere to national guidelines. Future interventions that focus on standardization, monitoring, privacy, and capacity building are likely to prove valuable in ensuring quality services are provided.

BackgroundCaregiver mental health is linked to early childhood development, yet more robust evidence of community-based interventions to prevent maternal depression and optimize socio-emotional development of young children is needed. Objectives of this cluster-randomized controlled trial (cRCT), based in Northern Ghana, are to assess the impact of the lay counselor-delivered, group-based Integrated Mothers and Babies Course and Early Childhood Development (iMBC/ECD) program on (1) the mental health of mothers of children under age 2; and (2) the socio-emotional development of their children.MethodsThis cRCT randomized 32 women's groups – 16 received iMBC/ECD content (intervention) and 16 received general health education content (control). Surveys were administered at baseline, immediate post-intervention, and 8-month post-intervention. The primary outcome was maternal depression [Patient Health Questionnaire (PHQ-9)], and the secondary outcome was child's socio-emotional development [Ages and Stages Questionnaire: Social Emotional (ASQ:SE-2)]. Qualitative interviews with 33 stakeholders were also conducted.ResultsIn total, 374 participants were enrolled at baseline while pregnant with the index child, 19% endorsing moderate/severe depression. Of these, 266 (71.1%) completed the 8-month post-intervention survey (~19 months post-baseline). There were no significant effects of iMBC/ECD on PHQ-9 and ASQ:SE-2 scores. However, results favored the intervention arm in most cases. iMBC participants were highly satisfied with the program but qualitative feedback from stakeholders indicated some implementation challenges.ConclusionsThis real-world evaluation had null findings; however, post-intervention depression levels were very low in both arms (3%). Future research should examine the potential impact of women's groups on postpartum mental health more broadly with varying content.

IntroductionHealthcare workers’ (HCWs) preparedness to respond to pandemics is critical to containing disease spread. Low-resource countries, however, experience barriers to preparedness due to limited resources. In Ghana, a country with a constrained healthcare system and high COVID-19 cases, we examined HCWs’ perceived preparedness to respond to COVID-19 and associated factors.Methods472 HCWs completed questions in a cross-sectional self-administered online survey. Perceived preparedness was assessed using a 15-question scale (Cronbach alpha=0.91) and summative scores were created (range=0-45). Higher scores meant greater perceived preparedness. We used linear regression with robust standard errors to examine associations between perceived preparedness and potential predictors.ResultsThe average preparedness score was 24 (SD=8.9); 27.8% of HCWs felt prepared. In multivariate analysis, factors associated with higher perceived preparedness were: training (β=3.35, 95%CI: to 4.69); having adequate PPE (β=2.27, 95%CI: 0.26 to 4.29), an isolation ward (β=2.74, 95%CI: 1.15 to 4.33), and protocols for screening (β=2.76, 95%CI: 0.95 to 4.58); and good perceived communication from management (β=5.37, 95%CI: 4.03 to 7.90). When added to the model, perceived knowledge decreased the effect of training by 28.0%, although training remained significant, suggesting a partial mediating role. Perceived knowledge was associated with a 6-point increase in perceived preparedness score (β=6.04, 95%CI: 4.19 to 7.90).ConclusionHCWs reported low perceived preparedness to respond to COVID-19. Training, clear protocols, PPE availability, isolation wards, and communication play an important role in increasing preparedness. Government stakeholders must institute necessary interventions to increase HCWs’ preparedness to respond to the ongoing pandemic and prepare for future pandemics.Strengths and limitations of this studyThis is one of the few studies globally to empirically examine Healthcare workers’ (HCWs) perceived preparedness to respond to COVID-19, and the first study to do so among HCWs in Ghana and in Africa.We developed a perceived preparedness for COVID-19 scale and conducted psychometric analysis to confirm its validity and reliability; this scale can facilitate similar research in other settings.We show that providers have low perceived preparedness to respond to the COVID-19 pandemic, and that this is associated with a lack of training on COVID-19, PPE, clear protocols, and isolation wards, as well as poor communication from management.The use of an online survey with recruitment via social media may have accounted for a relatively young sample.Findings are based on self-reported data from a cross-sectional survey, thus, there may be social desirability bias and associations described are not causal.

Women in many sub-Saharan African countries are at elevated risk of depression during pregnancy. However, there are still gaps in the estimates of antenatal depression and associated risk factors in very low-resource settings such as Northern Ghana. This study describes the prevalence of depression among rural pregnant women, participating in a maternal and child health program, in Ghana, and examines associated risk factors for depression. Pregnant women who were registered for group-based maternal and child health community programs were recruited for study participation from 32 communities in two rural districts in Northern Ghana (n = 374). Baseline surveys were conducted and depression was assessed using the Patient Health Questionnaire (PHQ-9). Bivariate and multivariable analyses used a modified Poisson and generalized estimating equations (GEE) model. Of the women in our study population, 19.7% reported symptoms indicative of moderate to severe depression (PHQ-9 score ≥ 10), with 14.1% endorsing suicidal ideation in the last 2 weeks. Bivariate analyses revealed that lower hopefulness, moderate and severe hunger, experiences of emotional, physical, and/or sexual intimate partner violence (IPV), and insufficient social support from female relatives were associated with symptoms indicating moderate to severe depression. In the multivariable analyses, low hopefulness, household hunger, emotional IPV, physical and/or sexual IPV, and insufficient female relative support remained significantly associated with depression. Antenatal depression is associated with unmet basic needs and safety. Perinatal mental health programming must take an ecological perspective and address personal, familial, and community-level factors.

A growing body of research in West Africa and globally shows that cash transfers can decrease intimate partner violence (IPV). The purpose of this study was to explore how the government of Ghana's Livelihood Empowerment Against Poverty (LEAP) 1000 program, an unconditional cash transfer plus health insurance premium waiver targeted at pregnant women and women with young children, influenced IPV experiences. Existing program theory hypothesizes three pathways through which cash transfers influence IPV, including: 1) increased economic security and emotional wellbeing; 2) reduced intra-household conflict; and 3) increased women's empowerment. Informed by this theory, we conducted qualitative in-depth interviews with women in northern Ghana (n = 30) who were or had been beneficiaries of LEAP 1000 and had reported declines in IPV in an earlier impact evaluation. We used narrative and thematic analytic techniques to examine these pathways in the context of gender norms and household dynamics, as well as a fourth potential pathway focused on interactions with healthcare providers. Overall, the most prominent narrative was that poverty is the main determinant of physical IPV and that by reducing poverty, LEAP 1000 reduced conflict and violence in households and communities and improved emotional wellbeing. Participant narratives also supported pathways of reduced intra-household conflict and increased empowerment, as well as interplay between these three pathways. However, participants also reflected that cash transfers did not fundamentally change gender norms or reduce gender-role strain in a context of ongoing economic insecurity, which could limit the gender transformative potential and sustainability of IPV reductions. Finally, while health insurance increased access to healthcare, local norms, shame, fear, and minimal provider screening deterred IPV disclosure to healthcare providers. Additional research is needed to explore interplay between pathways of impact across programs with different design features and implementation contexts to continue informing effective programming to maximize impact.

Neonatal morbidity and mortality remain a significant challenge in Ghana. Given the relationship between care-seeking and understanding of illness, this study aimed to explore mothers' perceptions of the cause of illness and/or death in Northern Ghana. All neonatal deaths and near-misses (babies who survived a life-threatening complication) in 2015 and 2016 were identified through a community - and facility-based surveillance system. Mothers of the deceased or ill infants participated in open narrative qualitative interviews. Narratives that included discussion of whether the mother understood what caused the baby's illness or death were analysed. Interviews with 155 mothers included discussion of their perception of the cause of newborn illness or death. Of the 155 interviews, 108 interviews involved mothers whose babies died, and 47 interviews involved mothers whose newborns survived a life-threatening illness, a neonatal 'near-miss'. Very few expressed a clear understanding of the cause of death or illness. Those mothers who did not understand were either not told or did not understand the cause of illness or death. Newborn health outcomes may be improved by increased maternal awareness and understanding of neonatal illnesses. Future interventions need to address communication issues that impair mothers' understanding, facilitate recognition of danger signs, and prompt timely care-seeking.

Objective This study explored providers’ perspectives and behavior regarding respectful maternity care, including knowledge, attitudes, and practices. Design Mixed-methods cross-sectional study combining quantitative survey data, qualitative interviews, and observations of labor and delivery across four health facilities Setting Government health facilities in rural northern Ghana Participants 43 front-line maternity care providers completed a survey of practice patterns before a quality of care training. We then used purposive and convenience sampling to recruit a sub-sample for in-depth interviews (N=17), and convenience sampling and self-selection to observe approximately half (N=8) providing clinical care. Measurements and findings We calculated descriptive statistics from quantitative data and used the framework approach for qualitative analysis. Observational data were examined using the CHANGE Project's Assessment Tools for Caring Providers. We utilized split frame methodology to make comparisons across data sources. Quantitative survey results (N=43) indicate most providers report explaining procedures to women (89.5%), involving women and families in care decisions (84.1%), and covering or screening women for privacy (81.5%). At the same time, 38.9% reported they have shouted at, scolded, insulted, threatened, or talked rudely to a woman, and 26.4% said they have treated a woman differently because of her personal attributes. Qualitative interview data (N=17) suggested that providers can articulate a vision of respectful care, aspire to offer respectful care, and recognize they do not always meet those aspirations. Among those (N=8) volunteering to be observed, introductions and explanations for procedures were rare, privacy screening was infrequent, and participants were observed slapping, scolding, and restraining women in labor, often associated with patient non-compliance to provider instructions. Key conclusions Even among providers knowledgeable about respectful maternity care and who agreed to be observed providing delivery care, disrespect and abuse were present. Implications for practice Further research and programmatic efforts are needed to address the gap between knowledge and behavior.

Background: Person-centred maternity care (PCMC) is maternity care that is responsive to and respectful of women's needs and values. It is a key dimension of quality, capturing the experience of interpersonal dimensions of care. Poor PCMC contributes to high maternal mortality not only directly but also indirectly through decreased demand for services. Although there is growing recognition of the importance of PCMC to maternal and child health outcomes, there is a paucity of data on interventions that aim to integrate a person-centred approach to maternity care. In this study, we aimed to evaluate the effect of an integrated simulation training on provision of PCMC. Methods: The pilot PCMC training project was launched in a rural district in Northern Ghana in April, 2017. To improve quality of care, including PCMC, we integrated specific components of such care, emphasising dignity and respect, communication and autonomy, and supportive care, into a simulation training to improve identification and management of obstetric and neonatal emergencies. 43 providers in the district participated in two 2-day trainings led by PRONTO international trainers. Six providers were then trained as simulation facilitators, and they led refresher sessions every month for 4 months at the five highest-volume delivery facilities in the district. We conducted surveys at baseline and endline with women who had recently given birth to assess their experiences of care using a 24-item version of the 30-item PCMC scale. Findings: We included data from 215 baseline surveys, conducted in March and April, 2017, and 318 surveys at endline in November, 2017. Women at endline reported higher PCMC scores than did women at baseline. The average PCMC score increased from 35·9 (SD 6·3) at baseline to 51·5 (12·9) at endline, a change of 43% (p

Introduction Little is known about the effect of integrating respectful maternity care into clinical training programs. We sought to examine the effectiveness of an integrated simulation training on emergency obstetric and neonatal care and respectful maternity care on providers’ knowledge and self-efficacy, and to asess providers’ perceptions of the integrated training. Methods The project was piloted in East Mamprusi district in Northern Ghana. Forty-three maternity providers were trained, with six participants trained as Simulation Facilitators. Data are from self-administered evaluation forms (with structured and open-ended questions) from all 43 providers and in-depth interviews with 17 providers. We conducted descriptive quantitative analysis and framework qualitative analysis. Results Provider knowledge increased from an average of 61.6% at pre-test to 74.5% at post-test. Self-efficacy also increased from an average of 5.8/10 at pretest to 9.2/10 at post-test. Process evaluation data showed that providers valued the training. Over 95% of participants agreed that the training was useful to them and that they will use the tools learned in the training in their practice. Overall, providers had positive perceptions of the training. They noted improvements in their knowledge and confidence to manage obstetric and neonatal emergencies, as well as in patient-provider communication and teamwork. Many listed respectful maternity care elements as what was most impactful to them from the training. Conclusions Simulation and team-training on emergency obstetric and neonatal care, combined with respectful maternity care content, can enable health care providers to improve both their clinical and interpersonal knowledge and skills in a training setting that reflects their complex and stressful work environments. Our findings suggest this type of training is feasible, acceptable, and effective in limited-resource settings. Uptake of such trainings could drive efforts towards providing high quality safe, responsive, and respectful obstetric and neonatal care.

Summary: Background: Several qualitative studies have described disrespectful, abusive, and neglectful treatment of women during facility-based childbirth, but few studies document the extent of person-centred maternity care (PCMC)—ie, responsive and respectful maternity care—in low-income and middle-income countries. In this Article, we present descriptive statistics on PCMC in four settings across three low-income and middle-income countries, and we examine key factors associated with PCMC in each setting. Methods: We examined data from four cross-sectional surveys with 3625 women aged 15–49 years who had recently given birth in Kenya, Ghana, and India (surveys were done from August, 2016, to October, 2017). The Kenya data were collected from a rural county (n=877) and from seven health facilities in two urban counties (n=530); the Ghana data were from five rural health facilities in the northern region (n=200); and the India data were from 40 health facilities in Uttar Pradesh (n=2018). The PCMC measure used was a previously validated scale with subscales for dignity and respect, communication and autonomy, and supportive care. We analysed the data using descriptive statistics and bivariate and multivariate regressions to examine predictors of PCMC. Findings: The highest mean PCMC score was found in urban Kenya (60·2 [SD 12·3] out of 90), and the lowest in rural Ghana (46·5 [6·9]). Across sites, the lowest scores were in communication and autonomy (from 8·3 [3.3] out of 27 in Ghana to 15·1 [5·9] in urban Kenya). 3280 (90%) of the total 3625 women across all countries reported that providers never introduced themselves, and 2076 (57%) women (1475 [73%] of 1980 in India) reported providers never asked permission before performing medical procedures. 120 (60%) of 200 women in Ghana and 1393 (69%) of 1980 women in India reported that providers did not explain the purpose of examinations or procedures, and 116 (58%) women in Ghana and 1162 (58%) in India reported they did not receive explanations on medications they were given; additionally, 104 (52%) women in Ghana did not feel able to ask questions. Overall, 576 (16%) women across all countries reported verbal abuse, and 108 (3%) reported physical abuse. PCMC varied by socioeconomic status and type of facility in three settings (ie, rural and urban Kenya, and India). Interpretation: Regardless of the setting, women are not getting adequate PCMC. Efforts are needed to improve the quality of facility-based maternity care. Funding: Bill & Melinda Gates Foundation, Marc and Lynne Benioff, and USAID Systems for Health.

Objective Rates of maternal and neonatal death remain high in the Global South, especially in Sub-Saharan Africa. In addition, indicators vary significantly by geography. This study aimed to understand what communities in northern Ghana with frequent maternal and newborn deaths or near deaths (near-misses) perceive to be the causes. As part of a larger study, four communities in Ghana's Northern Region were identified as areas with high concentrations of deaths and near-misses of mothers and babies. Design Stakeholders were interviewed using in-depth interviews (IDIs) and focus-group discussions (FGDs). Field workers conducted 12 FGDs and 12 IDIs across a total of 126 participants. Setting This exploratory descriptive study was conducted in the East Mamprusi District in the Northern Region of Ghana, in the communities of Jawani, Nagboo, Gbangu and Wundua. Participants FGDs were led by trained field workers and attended by traditional chiefs and their elders, members of women's groups, and traditional birth attendants in each of the four study communities. IDIs, or one-on-one interviews, were conducted with traditional healers who manage maternal and neonatal cases, community health nurses, and midwives. Measurements and findings Qualitative data were audio-recorded, transcribed, and thematically analyzed using the Attride-Sterling analytical framework. Discussions focused on where blame should be attributed for the negative outcomes of mothers and babies – with blame either being directed at the actions or inactions of the mothers (behavioral), or at the larger factors associated with poverty (situational) that necessitate mothers’ behavior. For example, some respondents blamed women for their poor diets, while others blamed the lack of money or household support to buy nutritious foods. Blame was rarely attributed to the fathers despite local gender norms of males being the household decision-makers with regard to spending and care-seeking. Key conclusions These findings contribute to a small but growing body of literature on the blaming of mothers for their own deaths and those of their newborns – a phenomenon also described in high-income countries – and is supported by blame attribution theories that explain the self-protective nature of victim-blaming. Implications for practice These results carry important implications for education and intervention design related to maternal and neonatal mortality, including more focused efforts at incorporating men and the larger community. More research is warranted on blame attribution for these adverse outcomes and its effects on the victims.

Background Few evidence-based interventions exist on how to improve respectful maternity care (RMC) in low-resource settings. We sought to evaluate the effect of an integrated simulation-based training on provision of RMC. Methods The pilot project was in East Mamprusi District in northern Ghana. We integrated specific components of RMC, emphasizing dignity and respect, communication and autonomy, and supportive care, into a simulation training to improve identification and management of obstetric and neonatal emergencies. Forty-three providers were trained. For evaluation, we conducted surveys at baseline (N = 215) and endline (N = 318) 6 months later, with recently delivered women to assess their experiences of care using the person-centered maternity care scale. Higher scores on the scale represent more respectful care. Results Compared to the baseline, women in the endline reported more respectful care. The average person-centered maternity care score increased from 50 at baseline to 72 at endline, a relative increase of 43%. Scores on the subscales also increased between baseline and endline: 15% increase for dignity and respect, 87% increase for communication and autonomy, and 55% increase for supportive care. These differences remained significant in multivariate analysis controlling for several potential confounders. Conclusions The findings suggest that integrated provider trainings that give providers the opportunity to learn, practice, and reflect on their provision of RMC in the context of stressful emergency obstetric simulations have the potential to improve women's childbirth experiences in low-resource settings. Incorporating such trainings into preservice and in-service training of providers will help advance global efforts to promote RMC.

Background Globally, three million girls are at risk of female genital mutilation (FGM) and an estimated 200 million girls and women in the world have undergone FGM. While the overall prevalence of FGM in Ghana is 4%, studies have shown that the overall prevalence in the Upper East Region is 38%, with Bawku municipality recording the highest at 82%. Methods This study used a cross-sectional design with a quantitative approach: a survey with women of reproductive age (15–49). Results Among all respondents, 830 women who participated in the study, 61% reported having undergone FGM. Of those circumcised, 66% indicated their mothers influenced it. Three quarters of the women think FGM could be stopped through health education. Women who live in the Pusiga district (AOR: 1.66; 95% CI: 1.16–2.38), are aged 35–49 (AOR: 4.24; 95% CI: 2.62–6.85), and have no formal education (AOR: 2.78; 95% CI: 1.43–5.43) or primary education (AOR: 2.10; 95% CI: 1.03–4.31) were more likely to be circumcised relative to those who reside in Bawku Municipal, are aged 15–24, and had tertiary education. Likewise, married women (AOR: 3.82; 95% CI: 2.53–5.76) were more likely to have been circumcised compared with unmarried women. At a site-specific level, factors associated with FGM included age and marital status in Bawku, and age, marital status, and women’s education in Pusiga. Conclusion Female Genital Mutilation is still being practiced in the Bawku Municipality and the Pusiga District of northern Ghana, particularly among women with low socio-economic status. Implementing interventions that would provide health education to communities and promote girl-child education beyond the primary level could help end the practice.

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.

Objective To develop a shortened, valid and reliable scale applicable across multiple settings for routine monitoring of person-centered maternity care (PCMC). Methods Exploratory analysis was used to generate parsimonious versions of a 30-item PCMC scale in four datasets from cross-sectional surveys conducted between August 2016 and October 2017, involving women aged 15-49 years in Kenya, Ghana and India who had recently given birth. Analysis was informed by expert opinion via a separate online survey of global maternal and child health experts. Items retained in each dataset were compared, and those unique to a single setting removed. The remaining items were pooled and assessed for construct and criterion validity and reliability in each setting. Results Thirteen items were retained for a potential multi-setting short PCMC scale, incorporating the domains of dignity and respect, communication and autonomy, and supportive care. Cronbach's alpha for the scale was >0.7 in each setting. Scores on the 13-item scale were correlated with the 30-item scale scores, and with global measures of care satisfaction in Kenya and India. Conclusion Analysis yielded a 47% shorter PCMC scale, that showed promise for routine assessment of women's experience of care during childbirth across multiple settings. However, further validation is needed.

OBJECTIVE To explore basic and comprehensive emergency obstetric service provision across four districts in rural northern Ghana, and whether women were more likely to deliver at facilities with more skilled care. METHODS Field workers geo-coded all health facilities in East Mamprusi, Sissala East, Kassena Nankana Municipal, and Kassena Nankana West districts, and administered surveys to assess providers and emergency obstetric care available. Data were also prospectively collected on delivery locations of women and neonates who died, or nearly died (near misses), between September 1, 2015 and April 30, 2017. RESULTS There were 14 physicians for a population of nearly 360 000 women. Six (6%) facilities could provide basic emergency care, and 3 (3%) could provide comprehensive care. Services were distributed unequally, with 6 (67%) of the emergency facilities located in the least populated district. Among the sample of women and neonates who died or nearly died, 175 (39%) delivered at locations unable to provide basic emergency services. CONCLUSION Access to emergency obstetric and neonatal care was distributed inequitably across these districts, suggesting the need to revisit geographic placement of facilities relative to population. The study also raised the question of how to ensure facilities are equipped to respond to emergencies.

Traditional medical systems in low income countries remain the first line service of choice, particularly for rural communities. Although the role of traditional birth attendants (TBAs) is recognised in many primary health care systems in low income countries, other types of traditional practitioners have had less traction. We explored the role played by traditional healers in northern Ghana in managing pregnancy-related complications and examined their relevance to current initiatives to reduce maternal morbidity and mortality. A grounded theory qualitative approach was employed. Twenty focus group discussions were conducted with TBAs and 19 in-depth interviews with traditional healers with expertise in managing obstetric complications. Traditional healers are extensively consulted to manage obstetric complications within their communities. Their clientele includes families who for either reasons of access or traditional beliefs, will not use modern health care providers, or those who shop across multiple health systems. The traditional practitioners claim expertise in a range of complications that are related to witchcraft and other culturally defined syndromes; conditions for which modern health care providers are believed to lack expertise. Most healers expressed a willingness to work with the formal health services because they had unique knowledge, skills and the trust of the community. However this would require a stronger acknowledgement and integration within safe motherhood programs.

Background Community interventions are often created by researchers, non-profit organisations, or other community outsiders and launched in communities with minimal input from the community members themselves. In addition, these are often blanket interventions, or generic programming offered across varied communities that do not take into account the unique needs of each community. The PREventing Maternal And Neonatal Death (PREMAND) project in rural northern Ghana hypothesised that the root causes of maternal and neonatal deaths and near-misses would vary based on each community's unique geographic, social, and cultural factors, and that interventions to address these issues should be driven by the community members and tailored to their specific needs. Methods PREMAND is a three-phase project beginning with sociocultural audits of near-misses and verbal and social autopsies of deaths of mothers and babies in four districts in Ghana. Semi-structured qualitative interviews about each event are also conducted and transcribed. Data are then mapped to demonstrate where clusters of events are located and to determine which five communities are experiencing the highest numbers of deaths and near-deaths. Lastly, data and maps generated by PREMAND are presented to community leaders and elders through large community meetings. Communities are provided with small seed grants (US$2000) to generate their own solutions based on the data presented and their own experiences as experts on their own communities. Findings The community intervention stage is still underway, but preliminary results indicate that all five identified communities have planned unique interventions, and two of the communities have completed their interventions. One community plumbed water to a local health facility where deliveries occur, and another purchased and retrofitted a motor ambulance for emergency transport. All of the communities have committed to putting forth their own funds so that they can undertake bigger projects than seed money will allow. Interpretation Preliminary results from the community intervention phase demonstrate that, when provided with basic information about the problem and a small amount of resources to develop their own solutions, community members are motivated to enact change, develop unique solutions specific to their own needs, and even contribute their own time and funds to improve their communities. Funding USAID Ghana.

Previous research suggests that care-seeking in rural northern Ghana is often governed by a woman's husband or compound head. This study was designed to explore the role grandmothers (typically a woman's mother-in-law) play in influencing maternal and newborn healthcare decisions. In-depth interviews were conducted with 35 mothers of newborns, 8 traditional birth attendants and local healers, 16 community leaders and 13 healthcare practitioners. An additional 18 focus groups were conducted with stakeholders such as household heads, compound leaders and grandmothers. In this region, grandmothers play many roles. They may act as primary support providers to pregnant mothers, care for newborns following delivery, preserve cultural traditions and serve as repositories of knowledge on local medicine. Grandmothers may also serve as gatekeepers for health-seeking behaviour, especially with regard to their daughters and daughters-in-law. This research also sheds light on the potential gap between health education campaigns that target mothers as autonomous decision-makers, and the reality of a more collectivist community structure in which mothers rarely make such decisions without the support of other community members.

Objective: to explore community and health-care provider attitudes towards maltreatment during delivery in rural northern Ghana, and compare findings against The White Ribbon Alliance's seven fundamental rights of childbearing women. Design: a cross-sectional qualitative study using in-depth interviews and focus groups. Setting: the Kassena-Nankana District of rural northern Ghana between July and October 2010. Participants: 128 community members, including mothers with newborn infants, grandmothers, household heads, compound heads, traditional healers, traditional birth attendants, and community leaders, as well as 13 formally trained health-care providers. Measurements and findings: 7 focus groups and 43 individual interviews were conducted with community members, and 13 individual interviews were conducted with health-care providers. All interviews were transcribed verbatim and entered into NVivo 9.0 for analysis. Despite the majority of respondents reporting positive experiences, unprompted, maltreatment was brought up in 6 of 7 community focus groups, 14 of 43 community interviews, and 8 of 13 interviews with health-care providers. Respondents reported physical abuse, verbal abuse, neglect, and discrimination. One additional category of maltreatment identified was denial of traditional practices. Key conclusions: maltreatment was spontaneously described by all types of interview respondents in this community, suggesting that the problem is not uncommon and may dissuade some women from seeking facility delivery. Implications for practice: provider outreach in rural northern Ghana is necessary to address and correct the problem, ensuring that all women who arrive at a facility receive timely, professional, nonjudgmental, high-quality delivery care.

Background: Social, cultural, and behavioral factors are often potent upstream contributors to maternal, neonatal, and child mortality, especially in low- and middle-income countries (LMICs). Social autopsy is one method of identifying the impact of such factors, yet it is unclear how social autopsy methods are being used in LMICs. Objective: This study aimed to identify the most common social autopsy instruments, describe overarching findings across populations and geography, and identify gaps in the existing social autopsy literature. Methods: A systematic search of the peer-reviewed literature from 2005 to 2016 was conducted. Studies were included if they were conducted in an LMIC, focused on maternal/neonatal/infant/child health, reported on the results of original research, and explicitly mentioned the use of a social autopsy tool. Results: Sixteen articles out of 1950 citations were included, representing research conducted in 11 countries. Five different tools were described, with two primary conceptual frameworks used to guide analysis: Pathway to Survival and Three Delays models. Studies varied in methods for identifying deaths, and recall periods for respondents ranged from 6 weeks to 5+ years. Across studies, recognition of danger signs appeared to be high, while subsequent care-seeking was inconsistent. Cost, distance to facility, and transportation issues were frequently cited barriers to care-seeking, however, additional barriers were reported that varied by location. Gaps in the social autopsy literature include the lack of: harmonized tools and analytical methods that allow for cross-study comparisons, discussion of complexity of decision making for care seeking, qualitative narratives that address inconsistencies in responses, and the explicit inclusion of perspectives from husbands and fathers. Conclusion: Despite the nascence of the field, research across 11 countries has included social autopsy methods, using a variety of tools, sampling methods, and analytical frameworks to determine how social factors impact maternal, neonatal, and child health outcomes.

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

Summary Objectives To compare (i) side effects associated with the simultaneous adminstration of praziquantel, albendazole and ivermectin with side affects associated with albendazole and ivermectin only and (ii) coverage by volunteers distributing three or two drugs. Methods Two-arm comparative study in northern Ghana integrated praziquantel distribution into an existing lymphatic filariasis and onchocerciasis control programme using Community Directed Distributors. The control arm continued to distribute only ivermectin and albendazole. Dosages of ivermectin and praziquantel were based on height. Treatment was directly observed, and all two/three drugs were co-administered. Adverse effects were recorded based on passive surveillance. Parasitological, anthropometric and haematological data were collected at baseline. Results Prevalence of Schistosoma haematobium infection among 1001 (boys: 47.9% girls: 52.1%) school-age children (6–15 years) [intervention: 30.0% (CI: 23.1–34.2); control: 23.0% (CI: 18.9–27.0)], mean haemoglobin, weight and age were similar among the intervention and control groups. While 1676 (99.1%) compounds in the control area were visited and 15 020 (96.58%) people were treated, only 1375 (88.5%) compounds in the intervention area were visited and 8454 (80.97%) people treated (P

ObjectiveThis paper investigated the cost-effectiveness of a computer-assisted Clinical Decision Support System (CDSS) in the identification of maternal complications in Ghana.MethodsA cost-effectiveness analysis was performed in a before- and after-intervention study. Analysis was conducted from the provider's perspective. The intervention area was the Kassena- Nankana district where computer-assisted CDSS was used by midwives in maternal care in six selected health centres. Six selected health centers in the Builsa district served as the non-intervention group, where the normal Ghana Health Service activities were being carried out.ResultsComputer-assisted CDSS increased the detection of pregnancy complications during antenatal care (ANC) in the intervention health centres (before-intervention = 9 /1,000 ANC attendance; after-intervention = 12/1,000 ANC attendance; P-value = 0.010). In the intervention health centres, there was a decrease in the number of complications during labour by 1.1%, though the difference was not statistically significant (before-intervention =107/1,000 labour clients; after-intervention = 96/1,000 labour clients; P-value = 0.305). Also, at the intervention health centres, the average cost per pregnancy complication detected during ANC (cost -effectiveness ratio) decreased from US$17,017.58 (before-intervention) to US$15,207.5 (after-intervention). Incremental cost -effectiveness ratio (ICER) was estimated at US$1,142. Considering only additional costs (cost of computer-assisted CDSS), cost per pregnancy complication detected was US$285.ConclusionsComputer -assisted CDSS has the potential to identify complications during pregnancy and marginal reduction in labour complications. Implementing computer-assisted CDSS is more costly but more effective in the detection of pregnancy complications compared to routine maternal care, hence making the decision to implement CDSS very complex. Policy makers should however be guided by whether the additional benefit is worth the additional cost.

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

Introduction : The Government of Ghana introduced the National Health Insurance Scheme (NHIS) in 2003 to replace out-of-pocket (OOP) payment for health services with the inherent aim of reducing the direct cost of treating illness to households. Objective : To assess the effects of the NHIS in reducing cost of treating malaria to households in the Kassena-Nankana districts of northern Ghana. Methods : We conducted a cross-sectional survey between October 2009 and October 2011 in the Kassena-Nankana districts. A sample of 4,226 households was randomly drawn from the Navrongo Health and Demographic Surveillance System household database and administered a structured interview. The costs of malaria treatment were collected from the patient perspective. Results : Of the 4,226 households visited, a total of 1,324 (31%) household members reported fever and 51% (675) reported treatment for malaria and provided information on where they sought care. Most respondents sought malaria treatment from formal health facilities 63% (424), with the remainder either self-medicating with drugs from chemical shops 32% (217) or with leftover drugs or herbs 5% (34). Most of those who sought care from formal health facilities were insured 79% (334). The average direct medical cost of treating malaria was GH¢3.2 (US$2.1) per case with the insured spending less (GH¢2.6/US$1.7) per case than the uninsured (GH¢3.2/US$2.1). The overall average cost (direct and indirect) incurred by households per malaria treatment was GH¢20.9 (US$13.9). Though the insured accounted for a larger proportion of admissions at health facilities 76% (31) than the uninsured 24% (10), the average amount households spent on the insured was less (GH¢4/US$2.7) than their uninsured counterparts (GH¢6.4/US$4.3). The difference was not statistically significant ( p =0.2330). Conclusion : Even though some insured individuals made OOP payments for direct medical care, there is evidence that the NHIS has a protective effect on cost (outpatient and in-patient) of malaria treatment. Keywords : national health insurance; treatment seeking; malaria; cost; Kassena-Nankana district; Ghana ( Published: 13 May 2014) Citation : Glob Health Action 2014, 7 : 23848 - http://dx.doi.org/10.3402/gha.v7.23848

Objective To investigate factors associated with self-reported pregnancy termination in Ghana and thereby appreciate the correlates of abortion-seeking in order to understand safe abortion care provision. Methods In a retrospective study, data from the Ghana 2008 Demographic and Health Survey were used to investigate factors associated with self-reported pregnancy termination. Variables on an individual and household level were examined by both bivariate analyses and multivariate logistic regression. A five-point autonomy scale was created to explore the role of female autonomy in reported abortion-seeking behavior. Results Among 4916 women included in the survey, 791 (16.1%) reported having an abortion. Factors associated with abortion-seeking included being older, having attended school, and living in an urban versus a rural area. When entered into a logistic regression model with demographic control variables, every step up the autonomy scale (i.e. increasing autonomy) was associated with a 14.0% increased likelihood of reporting the termination of a pregnancy (P Conclusion Although health system barriers might play a role in preventing women from seeking safe abortion services, autonomy on an individual level is also important and needs to be addressed if women are to be empowered to seek safe abortion services.

Background: Due to a paucity of statistics from vital registration systems in developing countries, the verbal autopsy (VA) approach has been used to obtain cause-specific mortality data by interviewing lay respondents on the signs and symptoms experienced by the deceased prior to death. In societies where the culture of mourning is adhered to, the use of VA could clash with traditional norms, thus warranting ethical consideration by researchers. Objective: The study was designed to explore the ethics and cultural context of collecting VA information through a demographic and health surveillance system in the Kassena-Nankana District (KND) of Ghana. Study Design: Data were collected through qualitative in-depth interviews (IDIs) with four field staff involved in the routine conduct of VAs, four physicians who code VAs, 20 selected respondents to the VA tool, and eight opinion leaders in the KND. The interviews were supplemented with observation by the researchers and with the field notes of field workers. Interviews were audio-recorded, and local language versions transcribed into English. Thematic analysis was performed using QSR NVivo 8 software. Results: The data indicate that cultural sensitivities in VA procedures at both the individual and family levels need greater consideration not only for ethical reasons but also to ensure the quality of the data. Discussions of some deaths are culturally prohibited and therefore lead to refusal of interviews. Families were also concerned about the confidentiality of information because of the potential of blame for the death. VA teams do not necessarily engage in culturally appropriate bereavement practices such as the presentation of tokens. The desire by families for feedback on the cause of death, which is currently not provided by researchers, was frequently expressed. Finally, no standard exists on the culturally acceptable time interval between death and VA interviews. Conclusion: Ethical issues need to be given greater consideration in the collection of cause of death data, and this can be achieved through the establishment of processes that allow active engagement with communities, authorities of civil registrations, and Institutional Review Boards to take greater account of local contexts. Keywords: verbal autopsy; research ethics; bereavement practices; demographic and health surveillance; maternal mortality; institutional review boards; feedback; confidentiality; Ghana (Published: 19 September 2013) Citation: Glob Health Action 2013, 6 : 18570 - http://dx.doi.org/10.3402/gha.v6i0.18570

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