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Matolengwe A, Murray D, Okafor UB. The Challenges of Implementing a Health Referral System in South Africa: A Qualitative Study. Risk Manag Healthc Policy 2024; 17:855-864. [PMID: 38623578 PMCID: PMC11017115 DOI: 10.2147/rmhp.s450998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/14/2024] [Indexed: 04/17/2024] Open
Abstract
Introduction Health system strengthening efforts also entails streamlining an existing referral system in a particular context to improve quality of health care offered to people. Conceptually, the referral system in South Africa, is seemingly sound. Nevertheless, gaps exist in its implementation. The aim of this study was to explore health care professionals' perceptions of referral system implementation in the Buffalo City Metropolitan Municipality (BCMM) in the Eastern Cape Province of South Africa. Methods This qualitative study included 12 health care professionals as participants. Each participant was interviewed using a semi-structured interview guide; with their consent, the interviews were audio recorded and transcribed verbatim. For data analysis, a thematic content analysis was used. Results The participants identified many impediments to the effective implementation of the referral system in BCCM. The main obstacles were deteriorating infrastructure, inadequate staffing, lack of transportation, and inadequate medical supplies and medications. Conclusion In mitigation, the participants proposed suggestions such as increasing the capacity of the health workforce, allocating personnel appropriately, increasing the availability of transportation, and providing essential medications to all levels of care. They also suggested involving all stakeholders in the referral process, providing education and training to health professionals on the referral system, and enhancing communication and feedback between the various levels of care. These challenges emphasised in this study highlight the need for targeted interventions to improve the referral system in this setting.
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Affiliation(s)
- Aseza Matolengwe
- Department of Public Health, University of Fort Hare, East London, South Africa
| | - Daphne Murray
- Department of Public Health, University of Fort Hare, East London, South Africa
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Kanyesigye H, Ngonzi J, Mulogo E, Fajardo Y, Kabakyenga J. Health Care Workers' Experiences, Challenges of Obstetric Referral Processes and Self-Reported Solutions in South Western Uganda: Mixed Methods Study. Risk Manag Healthc Policy 2022; 15:1869-1886. [PMID: 36225611 PMCID: PMC9550169 DOI: 10.2147/rmhp.s377304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 09/25/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction In resource limited settings, the highest burden of adverse maternal-fetal outcomes at referral hospitals is registered from emergency obstetric referrals from lower health facilities. Implementation of referral protocols has not been optimally successful possibly attributed to lack of understanding of profile of obstetric referrals and local challenges faced during implementation process. Objective This study described the profile of emergency obstetric referrals, challenges faced in implementation of obstetric referral processes and explored self-reported solutions by health workers. Methods This was a mixed methods study done at Mbarara Regional Referral Hospital (MRRH) and health centre IVs in South-Western Uganda. We consecutively recruited emergency obstetric referrals from Isingiro district for delivery at MRRH. Using a pre-tested questionnaire, we collected demographics, obstetric and referral characteristics. We described the profile of referrals using frequencies and proportions based on demographics, obstetric and referral characteristics. We conducted focus group discussions and in-depth interviews with health workers using discussion/interview guides. Using thematic analysis, we ascertained the challenges and health worker self-reported solutions. Results We recruited 161 referrals: 104(65%) were below 26 years, 16(10%) had no formal education, 11(7%) reported no income, 151(94%) had no professional-escort, 137(85%) used taxis, 151(96%) were referred by midwives. Common diagnoses were previous cesarean scar (24% [n=39]) and prolonged labour (21% [n=33]). There was no communication prior to referral and no feedback from MRRH to lower health facilities. Other challenges included inconsistencies of ambulance and anesthesia services, electric power, medical supplies, support supervision, and harassment by colleagues. Self-reported solutions included the use of phone call technology for communication, audit meetings, support supervision and increasing staffing level. Conclusion Most referrals are of poor social-economic status, use taxis, and lack professional-escort. Health workers suffer harassment, lack of communication and shortage of supplies. We need to experiment whether mobile phone technology could solve the communication gap.
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Affiliation(s)
- Hamson Kanyesigye
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda,Correspondence: Hamson Kanyesigye, Tel +256752806921, Email
| | - Joseph Ngonzi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Edgar Mulogo
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Yarine Fajardo
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jerome Kabakyenga
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
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Bain LE, Aboagye RG, Malunga G, Amu H, Dowou RK, Saah FI, Kongnyuy EJ. Individual and contextual factors associated with maternal healthcare utilisation in Mali: a cross-sectional study using Demographic and Health Survey data. BMJ Open 2022; 12:e057681. [PMID: 35193922 PMCID: PMC8867328 DOI: 10.1136/bmjopen-2021-057681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE We examined the national prevalence as well as the individual and contextual factors associated with maternal healthcare utilisation in Mali. SETTING The study was conducted in Mali. PARTICIPANTS We analysed data on 6335 women aged 15-49 years from Mali's 2018 Demographic and Health Survey. OUTCOME VARIABLE Maternal healthcare utilisation comprising antenatal care (ANC) attendant, skilled birth attendant (SBA), and postnatal care (PNC) attendant, was our outcome variable. RESULTS Prevalence of maternal healthcare utilisation was 45.6% for ANC4+, 74.7% for SBA and 25.5% for PNC. At the individual level, ANC4 + and SBA utilisation increased with increasing maternal age, level of formal education and wealth status. Higher odds of ANC4 + was found among women who are cohabiting (adjusted OR (aOR)=2.25, 95% CI 1.16 to 4.37) and delivered by caesarean section (aOR=2.53, 95% CI 1.72 to 3.73), while women who considered getting money for treatment (aOR=0.72, 95% CI 0.60 to 0.88) and distance to health facility (aOR=0.73, 95% CI 0.59 to 0.90) as a big problem had lower odds. Odds to use PNC was higher for those who were working (aOR=1.22, 95% CI 1.01 to 1.48) and those covered by health insurance (aOR=1.87, 95% CI 1.36 to 2.57). Lower odds of SBA use were associated with having two (aOR=0.48, 95% CI 0.33 to 0.71), three (aOR=0.37, 95% CI 0.24 to 0.58), and four or more (aOR=0.38, 95% CI 0.24 to 0.59) children, and residing in a rural area (aOR=0.35, 95% CI 0.17 to 1.69). Listening to the radio and watching TV were associated with increased maternal healthcare utilisation. CONCLUSION The government should increase availability, affordability and accessibility to healthcare facilities by investing in health infrastructure and workforce to achieve Sustainable Development Goal 3.4 of reducing maternal morality to less than 70 deaths per 100 000 live births by 2030. It is important to ascertain empirically why PNC levels are astonishingly lower relative to ANC and SBA.
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Affiliation(s)
- Luchuo Engelbert Bain
- Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, Lincolnshire, UK
- Global South Health Research and Services, Amsterdam, The Netherlands
| | - Richard Gyan Aboagye
- Epidemiology and Biostatistics, School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
| | | | - Hubert Amu
- Population and Behavioural Sciences, School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
| | - Robert Kokou Dowou
- Epidemiology and Biostatistics, School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
| | - Farrukh Ishaque Saah
- Global South Health Research and Services, Amsterdam, The Netherlands
- Epidemiology and Biostatistics, School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
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Malhotra SK, White H, Dela Cruz NAO, Saran A, Eyers J, John D, Beveridge E, Blöndal N. Studies of the effectiveness of transport sector interventions in low- and middle-income countries: An evidence and gap map. CAMPBELL SYSTEMATIC REVIEWS 2021; 17:e1203. [PMID: 36951810 PMCID: PMC8724647 DOI: 10.1002/cl2.1203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
BACKGROUND There are great disparities in the quantity and quality of infrastructure. European countries such as Denmark, Germany, Switzerland, and the UK have close to 200 km of road per 100 km2, and the Netherlands over 300 km per 100 km2. By contrast, Kenya and Indonesia have <30, Laos and Morocco <20, Tanzania and Bolivia <10, and Mauritania only 1 km per 100 km2. As these figures show, there is a significant backlog of transport infrastructure investment in both rural and urban areas, especially in sub-Saharan Africa. This situation is often exacerbated by weak governance and an inadequate regulatory framework with poor enforcement which lead to high costs and defective construction.The wellbeing of many poor people is constrained by lack of transport, which is called "transport poverty". Lucas et al. suggest that up to 90% of the world's population are transport poor when defined as meeting at least one of the following criteria: (1) lack of available suitable transport, (2) lack of transport to necessary destinations, (3) cost of necessary transport puts household below the income poverty line, (4) excessive travel time, or (5) unsafe or unhealthy travel conditions. OBJECTIVES The aim of this evidence and gap map (EGM) is to identify, map, and describe existing evidence from studies reporting the quantitative effects of transport sector interventions related to all means of transport (roads, rail, trams and monorail, ports, shipping, and inland waterways, and air transport). METHODS The intervention framework of this EGM reframes Berg et al's three categories (infrastructure, prices, and regulations) broadly as infrastructure, incentives, and institutions as subcategories for each intervention category which are each mode of transport (road, rail trams and monorail, ports, shipping, and inlands waterways, and air transport). This EGM identifies the area where intervention studies have been conducted as well as the current gaps in the evidence base.This EGM includes ongoing and completed impact evaluations and systematic reviews (SRs) of the effectiveness of transport sector interventions. This is a map of effectiveness studies (impact evaluations). The impact evaluations include experimental designs, nonexperimental designs, and regression designs. We have not included the before versus after studies and qualitative studies in this map. The search strategies included both academic and grey literature search on organisational websites, bibliographic searches and hand search of journals.An EGM is a table or matrix which provides a visual presentation of the evidence in a particular sector or a subsector. The map is presented as a matrix in which rows are intervention categories (e.g., roads) and subcategories (e.g., infrastructure) and the column outcome domains (e.g., environment) and subcategories as (e.g., air quality). Each cell contains studies of the corresponding intervention for the relevant outcome, with links to the available studies. Included studies were coded according to the intervention and outcomes assessed and additional filters as region, population, and study design. Critical appraisal of included SR was done using A Measurement Tool to Assess Systematic Reviews (AMSTAR -2) rating scale. SELECTION CRITERIA The search included both academic and grey literature available online. We included impact evaluations and SRs that assessed the effectiveness of transport sector interventions in low- and middle-income countries. RESULTS This EGM on the transport sector includes 466 studies from low- and middle-income countries, of which 34 are SRs and 432 impact evaluations. There are many studies of the effects of roads intervention in all three subcategories-infrastructure, incentives, and institutions, with the most studies in the infrastructure subcategories. There are no or fewer studies on the interventions category ports, shipping, and waterways and for civil aviation (Air Transport).In the outcomes, the evidence is most concentrated on transport infrastructure, services, and use, with the greatest concentration of evidence on transport time and cost (193 studies) and transport modality (160 studies). There is also a concentration of evidence on economic development and health and education outcomes. There are 139 studies on economic development, 90 studies on household income and poverty, and 101 studies on health outcomes.The major gaps in evidence are from all sectors except roads in the intervention. And there is a lack of evidence on outcome categories such as cultural heritage and cultural diversity and very little evidence on displacement (three studies), noise pollution (four studies), and transport equity (2). There is a moderate amount of evidence on infrastructure quantity (32 studies), location, land use and prices (49 studies), market access (29 studies), access to education facilities (23 studies), air quality (50 studies), and cost analysis including ex post CBA (21 studies).The evidence is mostly from East Asia and the Pacific Region (223 studies (40%), then the evidence is from the sub-Saharan Africa (108 studies), South Asia (96 studies), Latin America & Caribbean (79 studies). The least evidence is from Middle East & North Africa (30 studies) and Europe & Central Asia (20 studies). The most used study design is other regression design in all regions, with largest number from East Asia and Pacific (274). There is total 33 completed SRs identified and one ongoing, around 85% of the SR are rated low confidence, and 12% rated as medium confidence. Only one review was rated as high confidence. This EGM contains the available evidence in English. CONCLUSION This map shows the available evidence and gaps on the effectiveness of transport sector intervention in low- and middle-income countries. The evidence is highly concentrated on the outcome of transport infrastructure (especially roads), service, and use (351 studies). It is also concentrated in a specific region-East Asia and Pacific (223 studies)-and more urban populations (261 studies). Sectors with great development potential, such as waterways, are under-examined reflecting also under-investment.The available evidence can guide the policymakers, and government-related to transport sector intervention and its effects on many outcomes across sectors. There is a need to conduct experimental studies and quality SRs in this area. Environment, gender equity, culture, and education in low- and middle-income countries are under-researched areas in the transport sector.
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Shibre G, Zegeye B, Ahinkorah BO, Seidu AA, Ameyaw EK, Keetile M, Yaya S. Trends in socio-economic, sex and geographic disparities in childhood underweight in Mauritania: evidence from Multiple Indicator Cluster Surveys (2007-2015). Int Health 2021; 14:271-279. [PMID: 34185850 PMCID: PMC9070513 DOI: 10.1093/inthealth/ihab040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/12/2021] [Accepted: 06/11/2021] [Indexed: 12/14/2022] Open
Abstract
Background Underweight is one of the largest contributors to child morbidity and mortality and is considered to be the largest contributor to the global burden of diseases in low-and middle-income countries. In Mauritania, where one-fifth of children are underweight, there is a dearth of evidence on socio-economic, sex and geographic disparities in childhood underweight. As a result, this study aimed at investigating the socio-economic, sex and geographic disparities in childhood underweight in Mauritania. Methods Using the World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) software, data from the Mauritania Multiple Indicator Cluster Surveys (MICSs) conducted between 2007 and 2015 were analysed. Childhood underweight was disaggregated by five equity stratifiers: education, wealth, residence, region and sex. In addition, absolute and relative inequality measures, namely difference (D), population attributable risk (PAR), ratio (R) and population attributable fraction (PAF) were calculated to understand inequalities from wider perspectives. Corresponding 95% confidence intervals (CIs) were computed to measure statistical significance. Results Substantial absolute and relative socio-economic, sex and geographic disparities in underweight were observed from 2007 to 2015. Children from the poorest households (PAR=−12.66 [95% CI −14.15 to −11.16]), those whose mothers were uneducated (PAF=−9.11 [95% CI −13.41 to −4.81]), those whose mothers were rural residents (R=1.52 [95% CI 1.37 to 1.68]), residents of HodhCharghy (PAF=−66.51 [95% CI −79.25 to −53.76]) and males (D=4.30 [95% CI 2.09 to 6.52]) experienced a higher burden of underweight. Education-related disparities decreased from 2007 to 2015. The urban–rural gap in underweight similarly decreased over time with the different measures showing slightly different reductions. Wealth-driven disparities decreased marginally from 2011 to 2015. The sex-based and regional disparities increased, at least on average, over the 8-y intersurvey period. Conclusions The burden of underweight was significantly higher among children from disadvantaged subpopulations, those with uneducated and poorest/poor mothers, those living in rural areas and those living in HodhCharghy. Special nutrition intervention and efforts focused on these deprived subpopulations are required to reduce childhood morbidity and mortality associated with underweight and help achieve the Sustainable Development Goals.
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Affiliation(s)
- Gebretsadik Shibre
- Department of Reproductive, Family and Population Health, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Bright Opoku Ahinkorah
- School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Abdul-Aziz Seidu
- Department of Population and Health, University of Cape Coast, Cape Coast, Ghana.,College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD, Australia
| | - Edward Kwabena Ameyaw
- School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Mpho Keetile
- Department of Population Studies and Demography, University of Botswana, Gaborone, Botswana
| | - Sanni Yaya
- University of Parakou, Faculty of Medicine, Parakou, Benin
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Ameyaw EK, Amoah RM, Njue C, Tran NT, Dawson A. Women's experiences and satisfaction with maternal referral service in Northern Ghana: A qualitative inquiry. Midwifery 2021; 101:103065. [PMID: 34161917 DOI: 10.1016/j.midw.2021.103065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 05/28/2021] [Accepted: 06/02/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To gain insights and improve existing referral structures with maternity care in Northern region of Ghana, this study explored the referral experiences and satisfaction of women. RESEARCH DESIGN Twenty women referred to the Tamale Teaching Hospital for maternal health conditions were interviewed along with three husdands of these women between January and April 2020. An interview guide was used in individual face-to-face semi-structured interviews. The transcripts were inductively coded using content analysis. The study was guided by the three delays model and the availability, accessibility, acceptability and quality framework. FINDINGS The study revealed seven key themes. These are women's involvement in referral decision; available health workers and care at the first facility; inadequate transportation; communication between facilities; quality of care at the receiving hospital; worth the time and money; and women's companions during referral. While several women acknowledged and appreciated the care and emotional support they received in the hospitals they first presented to, some women reported poor attitudes of healthcare providers. Most women acknowledged that there was no communication between the facilities for the referral. A woman's socioeconomic status appeared to determine the respect and support she received from healthcare providers. KEY CONCLUSIONS To ensure a responsive and efficient referral service, the central government of Ghana should commit to ensuring that each district hospital has at least one ambulance for effective emergency transportation. Career progression opportunities need to be explored for health workers in northern Ghana to attract and retain more professionals. To prevent abuse and ensure empathetic and supportive care, testimonial videos may help health providers to assess the services they provide to women. During referral, inter-facility communication can be strengthened through effective supervision and dedicated mobile phones for communication between health facilities.
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Affiliation(s)
- Edward Kwabena Ameyaw
- School of Public Health, Faculty of Health, University of Technology Sydney, Australia.
| | - Roberta Mensima Amoah
- Department of Public Health, School of Allied Sciences, University for Development Studies, Tamale, Northern Region, Ghana.
| | - Carolyne Njue
- School of Public Health, Faculty of Health, University of Technology Sydney, Australia.
| | - Nguyen Toan Tran
- School of Public Health, Faculty of Health, University of Technology Sydney, Australia.
| | - Angela Dawson
- School of Public Health, Faculty of Health, University of Technology Sydney, Australia.
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Alobo G, Ochola E, Bayo P, Muhereza A, Nahurira V, Byamugisha J. Why women die after reaching the hospital: a qualitative critical incident analysis of the 'third delay' in postconflict northern Uganda. BMJ Open 2021; 11:e042909. [PMID: 33753439 PMCID: PMC7986759 DOI: 10.1136/bmjopen-2020-042909] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 02/18/2021] [Accepted: 02/25/2021] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To critically explore and describe the pathways that women who require emergency obstetrics and newborn care (EmONC) go through and to understand the delays in accessing EmONC after reaching a health facility in a conflict-affected setting. DESIGN This was a qualitative study with two units of analysis: (1) critical incident technique (CIT) and (2) key informant interviews with health workers, patients and attendants. SETTING Thirteen primary healthcare centres, one general private-not-for-profit hospital, one regional referral hospital and one teaching hospital in northern Uganda. PARTICIPANTS Forty-nine purposively selected health workers, patients and attendants participated in key informant interviews. CIT mapped the pathways for maternal deaths and near-misses selected based on critical case purposive sampling. RESULTS After reaching the health facility, a pregnant woman goes through a complex pathway that leads to delays in receiving EmONC. Five reasons were identified for these delays: shortage of medicines and supplies, lack of blood and functionality of operating theatres, gaps in staff coverage, gaps in staff skills, and delays in the interfacility referral system. Shortage of medicines and supplies was central in most of the pathways, characterised by three patterns: delay to treat, back-and-forth movements to buy medicines or supplies, and multiple referrals across facilities. Some women also bypassed facilities they deemed to be non-functional. CONCLUSION Our findings show that the pathway to EmONC is precarious and takes too long even after making early contact with the health facility. Improvement of skills, better management of the meagre human resource and availing essential medical supplies in health facilities may help to reduce the gaps in a facility's emergency readiness and thus improve maternal and neonatal outcomes.
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Affiliation(s)
- Gasthony Alobo
- Obstetrics and Gynecology, Lira University, Lira, Uganda
- Obstetrics and Gynecology, St Mary's Hospital Lacor, Gulu, Uganda
| | - Emmanuel Ochola
- Public Health, St Mary's Hospital Lacor, Gulu, Uganda
- Public Health, Gulu University Faculty of Medicine, Gulu, Uganda
| | - Pontius Bayo
- Obstetrics and Gynecology, Torit State Hospital, Torit, South Sudan
| | - Alex Muhereza
- Maternal and Newborn Care, RHITES - North Acholi, Gulu, Uganda
| | | | - Josaphat Byamugisha
- Department of Obstetrics and Gynecology, Makerere University, Kampala, Uganda
- Obstetrics and Gynecology, Mulago National Referral Hospital, Kampala, Uganda
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Quality and women's satisfaction with maternal referral practices in sub-Saharan African low and lower-middle income countries: a systematic review. BMC Pregnancy Childbirth 2020; 20:682. [PMID: 33176732 PMCID: PMC7656726 DOI: 10.1186/s12884-020-03339-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 10/15/2020] [Indexed: 01/23/2023] Open
Abstract
Background sub-Saharan African Low and Lower-Middle Income Countries (sSA LLMICs) have the highest burden of maternal and perinatal morbidity and mortality in the world. Timely and appropriate maternal referral to a suitable health facility is an indicator of effective health systems. In this systematic review we aimed to identify which referral practices are delivered according to accepted standards for pregnant women and newborns in sSA LLMICs by competent healthcare providers in line with the needs of pregnant women. Methods Six electronic databases were systematically searched for primary data studies (2009–2018) in English reporting on maternal referral practices and their effectiveness. We conducted a content analysis guided by a framework for assessing the quality of maternal referral. Quality referral was defined as: timely identification of signal functions, established guidelines or standards, adequate documentation, staff accompaniment and prompt care by competent healthcare providers in the receiving facility. Results Seventeen articles were included in the study. Most studies were quantitative (n = 11). Two studies reported that women were dissatisfied due to delays in referral processes that affected their health. Most articles (10) reported that women were not accompanied to higher levels of care, delays in referral processes, transport challenges and poor referral documentation. Some healthcare providers administered essential drugs such as misoprostol prior to referral. Conclusions Efforts to improve maternal health in LLMICs should aim to enhance maternity care providers’ ability to identify conditions that demand referral. Low cost transport is needed to mitigate barriers of referral. To ensure quality maternal referral, district level health managers should be trained and equipped with the skills needed to monitor and evaluate referral documentation, including quality and efficiency of maternal referrals. Trial registration Systematic review registration: PROSPERO registration CRD42018114261. Supplementary information Supplementary information accompanies this paper at 10.1186/s12884-020-03339-3.
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Schrumpf LA, Stephens MJ, Nsarko NE, Akosah E, Baumgartner JN, Ohemeng-Dapaah S, Watt MH. Side effect concerns and their impact on women's uptake of modern family planning methods in rural Ghana: a mixed methods study. BMC Womens Health 2020; 20:57. [PMID: 32192473 PMCID: PMC7082910 DOI: 10.1186/s12905-020-0885-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 01/15/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Despite availability of modern contraceptive methods and documented unmet need for family planning in Ghana, many women still report forgoing modern contraceptive use due to anticipated side effects. The goal of this study was to examine the use of modern family planning, in particular hormonal methods, in one district in rural Ghana, and to understand the role that side effects play in women's decisions to start or continue use. METHODS This exploratory mixed-methods study included 281 surveys and 33 in-depth interviews of women 18-49 years old in the Amansie West District of Ghana between May and July 2018. The survey assessed contraceptive use and potential predictors of use. In-depth interviews examined the context around uptake and continuation of contraceptive use, with a particular focus on the role of perceived and experienced side effects. RESULTS The prevalence of unmet need for modern family planning among sexually active women who wanted to avoid pregnancy (n = 135) was 68.9%. No factors were found to be significantly different in comparing those with a met need and unmet for modern family planning. Qualitative interviews revealed significant concerns about side effects stemming from previous method experiences and/or rumors regarding short-term impacts and perceived long-term consequences of family planning use. Side effects mentioned include menstrual changes (heavier bleeding, amenorrhea or oligomenorrhea), infertility and childbirth complications. CONCLUSION As programs have improved women's ability to access modern family planning, it is paramount to address patient-level barriers to uptake, in particular information about side effects and misconceptions about long-term use. Unintended pregnancies can be reduced through comprehensive counseling about contraceptive options including accurate information about side effects, and the development of new contraceptive technologies that meet women's needs in low-income countries.
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Affiliation(s)
- Leah A Schrumpf
- Duke Global Health Institute, Duke University, Box 90519, Durham, NC, 27708, USA.
| | - Maya J Stephens
- Duke Global Health Institute, Duke University, Box 90519, Durham, NC, 27708, USA
| | | | - Eric Akosah
- Millennium Promise Ghana, 14 Bathur St, East Legon, Accra, Ghana
| | - Joy Noel Baumgartner
- Duke Global Health Institute, Duke University, Box 90519, Durham, NC, 27708, USA
| | | | - Melissa H Watt
- Duke Global Health Institute, Duke University, Box 90519, Durham, NC, 27708, USA
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Bailey PE, Awoonor-Williams JK, Lebrun V, Keyes E, Chen M, Aboagye P, Singh K. Referral patterns through the lens of health facility readiness to manage obstetric complications: national facility-based results from Ghana. Reprod Health 2019; 16:19. [PMID: 30777082 PMCID: PMC6379927 DOI: 10.1186/s12978-019-0684-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 02/11/2019] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Countries with high maternal and newborn mortality can benefit from national facility level data that describe intra-facility emergency referral patterns for major obstetric complications. This paper assesses the relationship between referral and facilities' readiness to treat complications at each level of the health system in Ghana. We also investigate other facility characteristics associated with referral. METHODS The National Emergency Obstetric and Newborn Care Assessment 2010 provided aggregated information from 977 health facilities. Readiness was defined in a 2-step process: availability of a health worker who could provide life-saving interventions and a minimum package of drugs, supplies, and equipment to perform the interventions. The second step mapped interventions to major obstetric complications. We used descriptive statistics and simple linear regression. RESULTS Lower level facilities were likely to refer nearly all women with complications. District hospitals resolved almost two-thirds of all complicated cases, referring 9%. The most prevalent indications for referral were prolonged/obstructed labor and antepartum hemorrhage. Readiness to treat a complication was correlated with a reduction in referral for all complications except uterine rupture. Facility readiness was low: roughly 40% of hospitals and 10% of lower level facilities met the readiness threshold. Facilities referred fewer women when they had higher caseloads, more midwives, better infrastructure, and systems of communication and transport. DISCUSSION Understanding how deliveries and obstetric complications are distributed across the health system helps policy makers contextualize decisions about the pathways to providing maternity services. Improving conditions for referral (by increasing access to communication and transport systems) and the management of obstetric complications (increasing readiness) will enhance quality of care and make referral more effective and efficient.
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Affiliation(s)
| | | | - Victoria Lebrun
- FHI 360, 359 Blackwell Street, Suite 200, Durham, NC, 27701, USA
| | - Emily Keyes
- FHI 360, 359 Blackwell Street, Suite 200, Durham, NC, 27701, USA
| | - Mario Chen
- FHI 360, 359 Blackwell Street, Suite 200, Durham, NC, 27701, USA
| | | | - Kavita Singh
- Maternal Child Health, MEASURE Evaluation/ Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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11
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Nuamah GB, Agyei-Baffour P, Mensah KA, Boateng D, Quansah DY, Dobin D, Addai-Donkor K. Access and utilization of maternal healthcare in a rural district in the forest belt of Ghana. BMC Pregnancy Childbirth 2019; 19:6. [PMID: 30612557 PMCID: PMC6322319 DOI: 10.1186/s12884-018-2159-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 12/19/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Poor maternal health delivery in developing countries results in more than half a million maternal deaths during pregnancy, childbirth or within a few weeks of delivery. This is partly due to unavailability and low utilization of maternal healthcare services in limited-resource settings. The aim of this study was to investigate the access and utilization of maternal healthcare in Amansie-West district in the Ashanti Region of Ghana. METHODS An analytical cross-sectional study, involving 720 pregnant women systematically sampled from antenatal clinics in five sub-districts was conducted from February to May 2015 in the Amansie-West district. Data on participants' socio-economic characteristics, knowledge level and access and utilization of maternal health care services were collected with a structured questionnaire. Odds ratios were estimated to describe the association between explanatory variables and maternal healthcare using generalized estimating equations (GEE). RESULTS 68.5, 83.6 and 33.6% of the women had > 3 antenatal care visits, utilized skilled delivery and postnatal care services respectively. The mothers' knowledge level of pregnancy emergencies and newborn danger signs was low. Socio-economic characteristics and healthcare access influenced the utilization of maternal healthcare. Compared to the lowest wealth quintile, being in the highest wealth quintile was associated with higher odds of receiving postnatal care (adjusted odds ratio [aOR]; 95%CI: 2.84; 1.63, 4.94). Use of health facility as a main source of healthcare was also associated with higher odds of antenatal care and skilled delivery. CONCLUSION This study demonstrates suboptimal access and utilization of maternal healthcare in rural districts of Ghana, which are influenced by socio-economic characteristics of pregnant mothers. This suggests the need for tailored intervention to improve maternal healthcare utilization for mothers in this and other similar settings.
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Affiliation(s)
- Gladys Buruwaa Nuamah
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Peter Agyei-Baffour
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Kofi Akohene Mensah
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Daniel Boateng
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Dan Yedu Quansah
- Department of Biomedical Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Dominic Dobin
- Amansie West District Health Directorate, Ghana Health Service, Manso Nkwanta, Ghana
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12
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Harahap NC, Handayani PW, Hidayanto AN. Barriers and technologies of maternal and neonatal referral system in developing countries: A narrative review. INFORMATICS IN MEDICINE UNLOCKED 2019. [DOI: 10.1016/j.imu.2019.100184] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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13
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Mambulu-Chikankheni FN, Eyles J, Ditlopo P. Exploring the roles and factors influencing community health workers' performance in managing and referring severe acute malnutrition cases in two subdistricts in South Africa. HEALTH & SOCIAL CARE IN THE COMMUNITY 2018; 26:839-848. [PMID: 30047600 DOI: 10.1111/hsc.12595] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 04/09/2018] [Accepted: 05/21/2018] [Indexed: 06/08/2023]
Abstract
As primary providers of preventive and curative community case management services in low- and middle-income countries (LMICs), community health workers (CHWs) have emerged as a formalised part of the health system (HS). However, discourses on their practices as formalised cadres of the HS are limited. Therefore, we examined their role in care, referral (to clinics) and rehabilitation of severe acute malnutrition (SAM) cases. Focusing on SAM was essential since it is a global public health problem associated with 30% of all South Africa's (SA's) child deaths in 2015. Guided by a policy analysis framework, a qualitative case study was conducted in two rural subdistricts of North West province. From April to August 2016, data collected from CHW's training manuals and guideline reviews, 20 patient record reviews and 15 in-depth interviews with four CHW leaders and 11 CHWs. Using thematic content analysis which was guided by the Walt and Gilson policy triangle, data was manually analysed to derive emerging themes on case management and administrative structures. The study found that although CHWs were responsible for identifying, referring, and rehabilitating SAM cases, they neglected curative roles of stabilisation before referral and treatment of uncomplicated cases. Such limitations resulted from restrictive CHW policies, inadequate training, lack of supportive supervision and essential resources. Concurrently, the CHW program was based on weak operational and administrative structures which challenged CHWs practices. Poor curative components and weak operational structures in this context compromised the use of CHWs in LMICs to strengthen primary healthcare. If CHWs are to contribute to Sustainable Development Goal (SDG) 3 by reducing SAM mortality, strategies on community management of acute malnutrition coupled with thorough training, supportive supervision, firm operational structures, adequate resources and providers' motivation should be adopted by governments.
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Affiliation(s)
- Faith N Mambulu-Chikankheni
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - John Eyles
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- School of Geography and Earth Sciences, McMaster University, Hamilton, Canada
| | - Prudence Ditlopo
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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14
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Predictors of Neonatal Deaths in Ashanti Region of Ghana: A Cross-Sectional Study. ADVANCES IN PUBLIC HEALTH 2018. [DOI: 10.1155/2018/9020914] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background. Neonatal mortality continues to be a public health problem, especially in sub-Saharan Africa. This study was conducted to assess the maternal, neonatal, and health system related factors that influence neonatal deaths in the Ashanti Region, Ghana. Methods. 222 mothers and their babies who were within the first 28 days of life on admission at Mother and Baby unit (MBU) at the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ashanti Region of Ghana, were recruited through systematic random sampling. Data was collected by face to face interviewing using open and closed ended questions. A logistic regression analysis was conducted to determine the influence of proximal and facility related factors on the odds of neonatal death. Results. Out of the 222 mothers, there were 115 (51.8%) whose babies did not survive. Majority, 53.9%, of babies died within 1–4 days, 31.3% within 5–14 days, and 14.8% within 15–28 days. The cause of death included asphyxia, low birth weight, congenital anomalies, infections, and respiratory distress syndrome. Neonatal deaths were influenced by proximal factors (parity, duration of pregnancy, and disease of the mother such as HIV/AIDS), neonatal factors (birth weight, gestational period, sex of baby, and Apgar score), and health related factors (health staff attitude, supervision of delivery, and hours spent at labour ward). Conclusion. This study shows a high level of neonatal deaths in the Ashanti Region of Ghana. This finding suggests the need for health education programmes to improve on awareness of the dangers that can militate against neonatal survival as well as strengthening the health system to support mothers and their babies through pregnancy and delivery and postpartum to help improve child survival.
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Akuoko CP, Armah E, Sarpong T, Quansah DY, Amankwaa I, Boateng D. Barriers to early presentation and diagnosis of breast cancer among African women living in sub-Saharan Africa. PLoS One 2017; 12:e0171024. [PMID: 28192444 PMCID: PMC5305236 DOI: 10.1371/journal.pone.0171024] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 01/13/2017] [Indexed: 11/20/2022] Open
Abstract
Background Breast cancer (BC) has been described as the leading cause of cancer deaths among women especially in the developing world including sub Saharan Africa (SSA). Delayed presentation and late diagnosis at health facilities are parts of the contributing factors of high BC mortality in Africa. This review aimed to appraise the contributing factors to delayed breast cancer presentation and diagnosis among SSA women. Methods Five databases encompassing medical and social sciences were systematically searched using predefined search terms linked with breast cancer presentation and diagnosis and sub Saharan Africa. Reference lists of relevant papers were also hand searched. Quality of quantitative and qualitative articles were assessed using the National Institute of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies and the Critical Appraisal Skills Programme (CASP) quality appraisal checklist. Thematic analysis was used to synthesize the qualitative studies to integrate findings. Results Fourteen (14) quantitative studies, two (2) qualitative studies and one (1) mixed method study merited inclusion for analysis. This review identified low knowledge of breast cancer among SSA women. This review also found lack of awareness of early detection treatment, poor perception of BC, socio-cultural factors such as belief, traditions and fear as factors impacting African women’s health seeking behavior in relation to breast cancer. Conclusion Improving African women’s knowledge and understanding will improve behaviors related to breast cancer and facilitate early presentation and detection and enhance proper management and treatment of breast cancer.
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Affiliation(s)
| | | | | | - Dan Yedu Quansah
- Graduate School of Public health, Seoul National University, Seoul, South Korea
| | | | - Daniel Boateng
- Julius Global Health, University Medical Center, Utrecht University, the Netherlands
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- * E-mail:
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