Ghanaian women's experience of intimate partner violence (IPV) during group antenatal care: a brief report from a cluster randomised controlled trial

Intimate partner violence (IPV) impacts women of reproductive age globally and can lead to significant negative consequences during pregnancy. This study describes an exploratory aim of a cluster randomised controlled trial designed to assess the outcomes of Group Antenatal Care (ANC) in Ghana. The purpose was to understand the effect of a healthy relationship Group ANC module on experiences of IPV and safety planning as well as to explore the relationship between self-efficacy on the experiences of IPV and safety planning. Data were collected at baseline and at 11-14 months postpartum (post). Survey measures captured reported experiences of violence, self-efficacy, and safety. The chi-square test was used to compare baseline and post scores, and a logistic regression was performed to ascertain the effects of self-efficacy on the experiences of IPV in both groups. The sample included 1,751 participants, of whom 27.9% reported IPV at baseline. Between baseline and postpartum, there was a small increase in reported emotional (6.2% vs. 4.6%) and sexual (5.4% vs. 3.2%) violence in the intervention group compared to the control group. Logistic regression demonstrated that an increasing self-efficacy score was associated with an increased likelihood of experiencing IPV. There were no changes in safety knowledge. This study found higher rates of reported sexual and emotional violence post-intervention among the intervention group. Group ANC may be just one part of a portfolio of interventions needed to address IPV at all socio-ecological levels.Paper ContextMain findings: There was no reduction in experiences of intimate partner violence or increases in safety planning among Ghanaian pregnant women participating in a Group Antenatal Care session focused on healthy relationships and safety planning.Added knowledge: Group Antenatal Care has been identified as an effective modality for providing antenatal care and facilitating conversations about sensitive topics such as intimate partner violence and safety. However, this study highlights the importance of developing multifaceted approaches to decrease the risk of intimate partner violence among women, especially during the critical times of pregnancy and postpartum.Global health impact for policy and action: Effective global health action and policy must extend beyond educational efforts, incorporating multifaceted strategies that include healthcare provider training, robust community engagement, and legislation aimed at preventing intimate partner violence, with a special focus on safeguarding the well-being of women during pregnancy and the postpartum period.

Facilitators and barriers to home blood pressure monitoring among pregnant women in Ghana: a mixed-methods analysis of patient perspectives

BACKGROUND

The benefit of home blood pressure monitoring during pregnancy and in low-resource settings is incompletely understood. The objective of this study was to explore the experiences, barriers, and facilitators of home blood pressure monitoring among pregnant women in Ghana.

METHODS

This concurrent triangulation mixed-methods study was conducted at an urban tertiary hospital in Ghana. Participants were recruited from adult pregnant women presenting for routine antenatal care. Upon enrollment, participants' demographics and history were collected. At the next study visit, participants received audiovisual and hands-on training on using an automatic blood pressure monitor; they then monitored and logged their blood pressure daily at home for 2-4 weeks. At the final study visit, verbally administered surveys and semi-structured interviews assessed participant's experiences. Quantitative data were analyzed using R version 4.2.2, and frequencies and descriptive statistics were calculated. Qualitative data were imported into DeDoose 9.0.78 for thematic analysis.

RESULTS

Of 235 enrolled participants, 194 completed surveys; of those, 33 completed in-depth interviews. Participants' mean age was 31.6 (SD 5.3) years, 32.1% had not previously given birth, and 31.1% had less than a senior high school education. On a 4-point Likert scale, the majority reported they "definitely" were able to remember (n = 134, 69.1%), could find the time (n = 124, 63.9%), had the energy (n = 157, 80.9%), could use the blood pressure monitor without problems (n = 155, 79.9%), and had family approval (n = 182, 96.3%) while engaging in home blood pressure monitoring. 95.88% (n = 186) believed that pregnant women in Ghana should monitor their blood pressure at home. Qualitative thematic analysis demonstrated that most participants liked home blood pressure monitoring because of increased knowledge of their health during pregnancy. While most participants found measuring their blood pressure at home doable, many faced challenges. Participants' experiences with five key factors influenced how easy or difficult their experience was: 1) Time, stress, and daily responsibilities; 2) Perceived importance of BP in pregnancy; 3) Role of family; 4) Capability of performing monitoring; 5) Convenience of monitoring.

CONCLUSIONS

Among pregnant women in urban Ghana, home blood pressure monitoring was perceived as positive, important, and doable; however, challenges must be addressed.

Understanding how COVID-19 affected black pregnant women early in the pandemic: A cross-sectional survey

OBJECTIVE

Previous research has shown that the COVID-19 pandemic significantly increased anxiety among pregnant women, and at the same time, COVID-19 has disproportionately affected communities of color in the United States. We sought to understand how self-identied Black pregnant women in the United States were affected in the early days of the COVID-19 pandemic.

DESIGN

Cross-sectional, online survey distributed via social media SETTING: Online PARTICIPANTS: Non-probability, convenience sample of self-identified Black pregnant women in the United States between April 3 and 24, 2020 who responded to an online inquiry seeking women who were pregnant at the outset of the COVID-19 pandemic.

MEASUREMENTS AND FINDINGS

An anonymous, self-administered, online survey of pregnant women was conducted, including both quantitative assessment of demographics, COVID-related anxiety, and pregnancy-related anxiety as well as open-ended prompts for qualitative assessment of the impact of COVID on prenatal care, birth plans, anxiety and overall experience of pregnancy. Quantitative data were analyzed using Stata 15.0, qualitative data were thematically analyzed using NVivo12.1. Results were compared using joint display methodology. Of 87 self-identified Black or African-American women who responded, the most common concerns related to fear of getting infected with COVID (89.7 %, N = 78) and concerns related to loss of job/income (67.8 %, N = 59). More than half (55.2 %, N = 48) reported either themselves or their family members working in essential services. Findings indicate that uncertainty, lack of support, perceived quality of care, and heightened anxiety worked together to define Black women's experiences of pregnancy in the early days of the COVID-19 pandemic in the U.S. While quantitative data did not explicitly capture reports of discrimination as impacting perceived quality of care, the qualitative data suggest a link between fears of discrimination, the need for self-advocacy, and heightened anxiety.

KEY CONCLUSIONS

Despite being a relatively well-educated sample of Black women from around the United States, many respondents spoke of the fears of discrimination, the need for self-advocacy, and heightened anxiety, reinforcing that discrimination and fear of discrimation for Black women in healthcare settings are pervasive, regardless of a woman's level of education or other socioeconomic status indicators.

IMPLICATIONS FOR PRACTICE

These findings suggest that in times of uncertainty, such as the early days of the COVID-19 pandemic, it is more important than ever to provide thoughtful, supportive care to pregnant women of color who are primed for negative experiences in the healthcare settting.

Racial Disparities in Diagnosis of Postpartum Mood and Anxiety Disorders Among Symptomatic Medicaid Enrollees, 2012-2015

OBJECTIVE

This study quantified the prevalence of postpartum mood and anxiety disorder (PMAD) diagnoses among symptomatic Michigan Medicaid enrollees and explored factors associated with receiving a diagnosis.

METHODS

Data sources comprised Michigan Medicaid administrative claims and Phase 7 Michigan Pregnancy Risk Assessment Monitoring System (MI-PRAMS) survey responses, linked at the individual level. Participants were continuously enrolled in Michigan Medicaid, delivered a live birth (2012-2015), responded to the survey, and screened positive for PMAD symptoms on the adapted two-item Patient Health Questionnaire. Unadjusted and adjusted weighted logistic regression analyses were used to predict the likelihood of having a PMAD diagnosis (for the overall sample and stratified by race).

RESULTS

The weighted analytic cohort represented 24,353 deliveries across the 4-year study. Only 19.8% of respondents with symptoms of PMAD had a PMAD diagnosis between delivery and 3 months afterward. Black respondents were less likely to have PMAD diagnoses (adjusted odds ratio [AOR]=0.23, 95% CI=0.11-0.49) compared with White respondents. Among White respondents, no covariates were significantly associated with having a diagnosis. However, among Black respondents, more comorbid conditions and more life stressors were statistically significantly associated with having a diagnosis (AOR=3.18, 95% CI=1.27-7.96 and AOR=3.12, 95% CI=1.10-8.88, respectively).

CONCLUSIONS

Rate of PMAD diagnosis receipt differed by race and was low overall. Black respondents were less likely than White respondents to receive a diagnosis. Patient characteristics influencing diagnosis receipt also differed by race, indicating that strategies to improve detection of these disorders require a tailored approach.

The impact of the affordable care act on perinatal mood and anxiety disorder diagnosis and treatment rates among Michigan Medicaid enrollees 2012-2018

BACKGROUND

Perinatal Mood and Anxiety Disorders (PMADs) affect one in five birthing individuals and represent a leading cause of maternal mortality. While these disorders are associated with a variety of poor outcomes and generate significant societal burden, underdiagnosis and undertreatment remain significant barriers to improved outcomes. We aimed to quantify whether the Patient Protection Affordable Care Act (ACA) improved PMAD diagnosis and treatment rates among Michigan Medicaid enrollees.

METHODS

We applied an interrupted time series framework to administrative Michigan Medicaid claims data to determine if PMAD monthly diagnosis or treatment rates changed after ACA implementation for births 2012 through 2018. We evaluated three treatment types, including psychotherapy, prescription medication, and either psychotherapy or prescription medication. Participants included the 170,690 Medicaid enrollees who had at least one live birth between 2012 and 2018, with continuous enrollment from 9 months before birth through 3 months postpartum.

RESULTS

ACA implementation was associated with a statistically significant 0.76% point increase in PMAD diagnosis rates (95% CI: 0.01 to 1.52). However, there were no statistically significant changes in treatment rates among enrollees with a PMAD diagnosis.

CONCLUSION

The ACA may have improved PMAD detection and documentation in clinical settings. While a higher rate of PMAD cases were identified after ACA Implementation, Post-ACA cases were treated at similar rates as Pre-ACA cases.

"If You Need a Psychiatrist, It's BAD": Stigma Associated with Seeking Mental Health Care Among Obstetric Providers in Ghana

Purpose

Globally, the COVID-19 pandemic has brought attention to the impact of negative patient outcomes on healthcare providers. In Ghana, obstetric providers regularly face maternal and neonatal mortality, yet limited research has focused on provision of mental health support for these providers. This study sought to understand how obstetric providers viewed seeking mental health support after poor clinical outcomes, with a focus on the role of mental health stigma.

Patients and Methods

Participants were 52 obstetric providers (20 obstetrician/gynecologists and 32 midwives) at two tertiary care hospitals in Ghana. Five focus groups, led by a trained facilitator and lasting approximately two hours, were conducted to explore provider experiences and perceptions of support following poor maternal and neonatal outcomes. Discussions were audiotaped and transcribed verbatim, then analyzed qualitatively using grounded theory methodology.

Results

Most participants (84.3%, N=43) were finished with training, and 46.2% (N=24) had been in practice more than 10 years. Emerging themes included pervasive stigma associated with seeking mental health care after experiencing poor clinical outcomes, which was derived from two overlapping dimensions. First, societal-level stigma resulted from a cultural norm to keep emotions hidden, and the perception that psychiatry is equated with severe mental illness. Second, provider-level stigma resulted from the belief that healthcare workers should not have mental health problems, a perception that mental health care is acceptable for patients but not for providers, and a fear about lack of confidentiality. Despite many providers acknowledging negative mental health impacts following poor clinical outcomes, these additive layers of stigma limited their willingness to engage in formal mental health care.

Conclusion

This study demonstrates that stigma creates significant barriers to acceptance of mental health support among obstetric providers. Interventions to support providers will need to respect provider concerns without reinforcing the stigma associated with seeking mental health care.

Improving health literacy through group antenatal care: results from a cluster randomized controlled trial in Ghana

BACKGROUND

Although the majority of Ghanaian women receive antenatal care (ANC), many exhibit low health literacy by misinterpreting and incorrectly operationalizing ANC messages, leading to poor maternal and newborn health outcomes. Prior research in low-resource settings has found group antenatal care (G-ANC) feasible for women and providers. This study aims to determine the effect of G-ANC on increasing maternal health literacy. We hypothesized that pregnant women randomized into G-ANC would exhibit a greater increase in maternal health literacy than women in routine, individual ANC.

METHODS

A 5-year cluster randomized controlled trial was conducted in 14 rural and peri-urban health facilities in the Eastern Region of Ghana. Facilities were paired based on patient volume and average gestational age at ANC enrollment and then randomized into intervention (G-ANC) vs. control (routine, individual ANC); 1761 pregnant women were recruited. Data collection occurred at baseline (T0) and post-birth (T2) using the Maternal Health Literacy scale, a 12-item composite scale to assess maternal health literacy. Logistic regression compared changes in health literacy from T0 to T2.

RESULTS

Overall, women in both the intervention and control groups improved their health literacy scores over time (p < 0.0001). Women in the intervention group scored significantly higher on 3 individual items and on overall composite scores (p < 0.0001) and were more likely to attend 8 or more ANC visits.

CONCLUSION

While health literacy scores improved for all women attending ANC, women randomized into G-ANC exhibited greater improvement in overall health literacy post-birth compared to those receiving routine individual care. Life-saving information provided during ANC must be presented in an understandable format to prevent women and newborns from dying of preventable causes.

TRIAL REGISTRY

Ethical approval for the study was obtained from the Institutional Review Boards of the University of Michigan (HUM#00161464) and the Ghana Health Service (GHS-ERC: 016/04/19).

Ability and accuracy of patient-performed blood pressure monitoring among pregnant women in urban Ghana

BACKGROUND

Patient-performed blood pressure monitoring in pregnancy is rarely performed in low- and middle-income country settings, including Ghana. The clinical efficacy of home blood pressure monitoring relies on a pregnant patient being able to independently execute the correct steps to position and use a blood pressure monitor and to achieve accurate blood pressure measurements.

OBJECTIVE

This study aimed to (1) assess whether pregnant women can correctly use an automatic blood pressure monitor to check their blood pressure before and after a brief training and (2) determine whether blood pressure values measured by pregnant women using an automatic monitor are similar to values measured by a healthcare provider using a standard clinic monitor.

STUDY DESIGN

This was a cross-sectional study conducted at the Korle Bu Teaching Hospital, a tertiary hospital in Accra, Ghana. Participants were adult pregnant women presenting for their first prenatal care visit. Data collection was performed by 2 Ghanaian physicians. Information on demographics, obstetrical history, and past medical history was collected. A brief training was provided on the correct use of the blood pressure monitor, including a verbal script, annotated photographs, and a hands-on demonstration. Pre- and posttraining assessments using a 9-item checklist of correct preparation, position, and use of an automatic blood pressure monitor were performed. Following a modified British Hypertension Society protocol, a series of 4 blood pressure measurements were taken, alternating between provider performed using a clinic monitor and patient performed using an automatic monitor intended for individual use and validated in pregnancy.

RESULTS

Among 176 participants, the mean age was 31.5 years (±5.6), and 130 (73.9%) were multiparous. Regarding socioeconomic characteristics, 128 (72.7%) were married, 171 (97.2%) had public insurance, and 87 (49.7%) had completed ≤9 years of formal education. Regarding clinical blood pressure issues, 19 (10.9%) had a history of a hypertensive disorder in a previous pregnancy, and 6 (3.4%) had chronic hypertension. Before receiving any training, 21 participants (12.1%) performed all 9 steps correctly to prepare, position, and use the automatic blood pressure monitor. Comparing pretraining vs posttraining ability, statistically significant increases were seen in the correct performance of each step and the mean number of steps performed correctly (6.1±1.8 vs 9.0±0.2, respectively; P<.001) and proportion performing all 9 steps correctly (12.1% vs 96.6%, respectively; P<.001). The mean difference between doctor-performed and patient-performed blood pressure measurements was 5.6±4.8 mm Hg for systolic blood pressure values and 3.4±3.08 mm Hg for diastolic blood pressure values, with most differences within 5 mm Hg for both systolic blood pressure values (102/176 [58.0%]) and diastolic blood pressure values (141/176 [80.1%]).

CONCLUSION

After a brief training, pregnant women in Ghana demonstrated that they are able to use an automatic blood pressure monitor to check their blood pressure correctly and accurately.

A qualitative study of health workers' perspectives on malaria case identification and management among pregnant women in Savelugu Municipality, Ghana

Despite successes in malaria control interventions over the past two decades, malaria remains a major public health concern. Over 125 million women live in endemic areas and experience adverse pregnancy outcomes due to malaria. Understanding health workers' perspectives on malaria identification and management is important to informing policy changes on the control and eradication of the disease. This study explored the perspectives of health workers on malaria case identification and management among pregnant women in Savelugu Municipality, Ghana. A qualitative study with a phenomenology design was conducted among participants. Participants were purposively selected and interviewed using a semi-structured interview guide. Thematic analysis was performed and the results were presented as themes and sub-themes. Four themes and eight sub-themes regarding case identification and management of malaria in pregnancy were identified including malaria case identification training (trained and untrained), identification approach (signs/symptoms and routine laboratory test), diagnostic tools (rapid diagnostic test and microscopy) and management options. It revealed that attending malaria training programs was generally optional. Some of the participants had not undergone any refresher training for malaria identification after their formal training at health institutions. Participants identified malaria by its signs and symptoms. However, they often referred clients for routine laboratory tests for confirmation. When malaria is confirmed in pregnancy, quinine is used for first trimester treatment, while Artemisinin-based Combination Therapies are prescribed after the first trimester. Clindamycin was not used in the first trimester treatment. This study found that training programs were optional for health workers. Some participants have not received refresher training after graduating from health institutions. Treatment of confirmed cases did not include clindamycin for first trimester malaria infections. Malaria refresher training programs should be made mandatory for health workers. Every suspected case should be confirmed using Rapid Diagnostic Test or microscopy before treatment.

Factors associated with mental health treatment among Michigan medicaid enrollees with perinatal mood and anxiety disorders, 2012-2015

OBJECTIVE

Perinatal mood and anxiety disorders (PMADs) represent the most prevalent pregnancy-related comorbidity and a leading cause of maternal mortality. Effective treatments exist, but remain underutilized. We sought to identify factors associated with receipt of prenatal and postpartum mental health treatment.

METHODS

This observational, cross-sectional analysis used self-reported survey data from the Michigan Pregnancy Risk Assessment Monitoring System linked to Michigan Medicaid administrative claims for births from 2012 to 2015. We used survey-weighted multinomial logistic regression to predict prescription medication and psychotherapy utilization among respondents with PMADs.

RESULTS

Only 28.0% of respondents with prenatal PMAD and 17.9% of respondents with postpartum PMAD received both prescription medication and psychotherapy. During pregnancy, Black respondents were 0.33 (95%CI: 0.13-0.85, p = 0.022) times less likely to receive both treatments while more comorbidities were associated with receipt of both treatments (adjRR = 1.31, 95%CI: 1.02-1.70, p = 0.036). In the first three months postpartum, respondents with four or more stressors were 6.52 times more likely to receive both treatments (95%CI: 1.62-26.24, p = 0.008) and those satisfied with prenatal care were 16.25 times more likely to receive both treatments (95%CI: 3.35-78.85, p = 0.001).

DISCUSSION

Race, comorbidities, and stress are critical factors in PMAD treatment. Satisfaction with perinatal healthcare may facilitate access to care.

Challenges to diagnosing and managing preeclampsia in a low-resource setting: A qualitative study of obstetric provider perspectives from Ghana

Preeclampsia is a leading cause of global maternal morbidity and mortality. The greatest burden of disease is in low- and middle-income countries where healthcare providers face significant, understudied, challenges to diagnosing and managing preeclampsia. This qualitative study used semi-structured interviews to explore the challenges of diagnosing and managing preeclampsia from the perspectives of obstetric doctors. Participants were doctors who provide obstetric care at the Korle Bu Teaching Hospital, an urban tertiary hospital in Ghana. Purposive sampling identified doctors with meaningful experience in managing patients with preeclampsia. Thematic saturation of data was used to determine sample size. Interviews were audio recorded, transcribed verbatim, coded using an iteratively-developed codebook, and thematically analyzed. Interviews were conducted with 22 participants, consisting of 4 house officers, 6 junior obstetrics/gynecology residents, 8 senior obstetrics/gynecology residents, and 4 obstetrics/gynecology consultants. Doctors identified critical challenges faced at the patient, provider, and systems levels in detecting and managing preeclampsia, each of which mediates the health outcomes of a pregnancy complicated by preeclampsia. Challenges centered around three overarching global themes: (1) low education levels and health literacy among women, (2) insufficient number of healthcare providers highly trained in obstetric care, and (3) inadequate health infrastructure to support critically ill patients with preeclampsia. Recognizing and addressing root challenges to preeclampsia care has great potential to improve outcomes in pregnancies complicated by preeclampsia in low-resource settings.

Benefits and barriers of home blood pressure monitoring in pregnancy: perspectives of obstetric doctors from a Ghanaian tertiary hospital

BACKGROUND

Delayed diagnosis of preeclampsia contributes to maternal morbidity and mortality. Patient-performed home blood pressure monitoring facilitates more frequent monitoring and earlier diagnosis. However, challenges may exist to implementation in low- and middle income-countries.

METHODS

This cross-sectional mixed methods study evaluated obstetric doctors' perspectives on the benefits of and barriers to the implementation of home blood pressure monitoring among pregnant women in Ghana. Participants were doctors providing obstetric care at Korle Bu Teaching Hospital. Electronic surveys were completed by 75 participants (response rate 49.3%), consisting of demographics and questions on attitudes and perceived benefits and challenges of home BP monitoring. Semi-structured interviews were completed by 22 participants to expand on their perspectives.

RESULTS

Quantitative and qualitative results converged to highlight that the current state of blood pressure monitoring among pregnant women in Ghana is inadequate. The majority agreed that delayed diagnosis of preeclampsia leads to poor health outcomes in their patients (90.6%, n = 68) and earlier detection would improve outcomes (98.7%, n = 74). Key qualitative benefits to the adoption of home blood pressure monitoring were patient empowerment and trust of diagnosis, more quantity and quality of blood pressure data, and improvement in systems-level efficiency. The most significant barriers were the cost of monitors, lack of a communication system to convey abnormal values, and low health literacy. Overall, doctors felt that most barriers could be overcome with patient education and counseling, and that benefits far outweighed barriers. The majority of doctors (81.3%, n = 61), would use home BP data to inform their clinical decisions and 89% (n = 67) would take immediate action based on elevated home BP values. 91% (n = 68) would recommend home BP monitoring to their pregnant patients.

CONCLUSION

Obstetric doctors in Ghana strongly support the implementation of home blood pressure monitoring, would use values to inform their clinical management, and believe it would improve patient outcomes. Addressing the most significant barriers, including cost of blood pressure monitors, lack of a communication system to convey abnormal values, and need for patient education, is essential for successful implementation.

Comparing quantitative and qualitative verbal and social autopsy tools: does a qualitative supplement improve understanding of the social determinants of under-five deaths in the slums of Kampala, Uganda?

Background

Understanding biological causes of death and sociocultural factors influencing outcomes is critical to reducing mortality in low-resource settings. Verbal and Social Autopsy instruments (VASAs) query family members about events leading to an individual’s death, resulting in quantitative, categorical data. This study sought to determine the value of a supplemental in-depth qualitative interview (VASA-QUAL).

Methods

This cross-sectional study was conducted in two slum neighborhoods in Kampala, Uganda, among families who lost a child under five within the preceding six months. A trained, local researcher conducted the quantitative VASA and then administered the VASA-QUAL to family members. Quantitative data were analyzed using Stata V16.0; qualitative data were transcribed into English and analyzed using NVivo V12.0. The biomedical cause of death was determined using a panel of physicians to code verbal autopsy items. Quantitative VASA variables were compared with qualitative variables from the VASA-QUAL using a rubric of indicators derived from the Pathways to Survival framework. Kappa statistics and percent agreement were calculated to compare quantitative and qualitative data. Three coders independently rated whether qualitative data provided additional information that improved understanding of the cause of death.

Results

48 VASAs were conducted (child age range: 1 month to 52 months). Agreement on key indicators ranged from 81.2% (place of death) to 93.8% (recognition of illness), with Kappa coefficients ranging from -0.038 to 0.368. The qualitative component added or clarified information about pediatric illness and care-seeking across all indicators, including recognition of illness (94.0%), care-seeking decisions (79.0%), whether home care was provided (73.0%), and choice of outside care (85.0%). Qualitative interviews frequently included symptoms missing or denied in the quantitative VASA and clarified the chronological order of symptoms. Many qualitative interviews described complicated mechanisms of decision-making not captured in the quantitative survey. Both agreement across data types and whether meaningful information was added by the qualitative data varied by cause of death, although our sample size limited our ability to conduct statistical analysis in this regard.

Conclusions

Supplementing quantitative VASA tools with an in-depth VASA-QUAL interview provided important additional information, but not consistently across indicators or causes of death. Despite challenges associated with feasibility, supplemental qualitative interviews may be an important tool for understanding the complexity of events leading up to childhood deaths.

Group Antenatal Care in Ghana: Protocol for a Cluster Randomized Controlled Trial

Background

While group antenatal care (ANC) has been delivered and studied in high-income countries for over a decade, it has only recently been introduced as an alternative to individual care in sub-Saharan Africa. Although the experimental design of the studies from high-resource countries have been scientifically rigorous, findings cannot be generalized to low-resource countries with low literacy rates and high rates of maternal and newborn morbidity and mortality. The Group Antenatal Care Delivery Project (GRAND) is a collaboration between the University of Michigan in the United States and the Dodowa Health Research Centre in Ghana. GRAND is a 5-year, cluster randomized controlled trial (RCT). Our intervention—group ANC—consists of grouping women by similar gestational ages of pregnancy into small groups at the first ANC visit. They then meet with the same group and the same midwife at the recommended intervals for care.

Objective

This study aims to improve health literacy, increase birth preparedness and complication readiness, and optimize maternal and newborn outcomes among women attending ANC at seven rural health facilities in the Eastern Region of Ghana.

Methods

Quantitative data will be collected at four time points using a secure web application for data collection and a database management tool. Data will be analyzed on an intention-to-treat basis to test the differences between the two arms: women randomized to group-based ANC and women randomized to routine individual ANC. We will conduct a process evaluation concurrently to identify and document patient, provider, and system barriers and facilitators to program implementation.

Results

The study was funded in September 2018. Recruitment and enrollment of participants and data collection started in July 2019. In November 2021, we completed participant enrollment in the study (n=1761), and we completed data collection at the third trimester in May 2022 (n=1284). Data collection at the additional three time points is ongoing: 6 weeks postpartum, 6 months postpartum, and 1 year postpartum.

Conclusions

This study is significant and timely because it is among the first RCTs to be conducted to examine the effects of group ANC among low-literacy and nonliterate participants. Our findings have the potential to impact how clinical care is delivered to low-literacy populations, both globally and domestically, to improve maternal and newborn outcomes.

Trial Registration

ClinicalTrials.gov NCT04033003; https://clinicaltrials.gov/ct2/show/NCT04033003

International Registered Report Identifier (IRRID)

DERR1-10.2196/40828

"There is no joy in the family anymore": a mixed-methods study on the experience and impact of maternal mortality on families in Ghana

Background

Maternal mortality has a multifaceted impact on families, especially in low- and middle-income countries, where rates of maternal mortality are high and resources can be lacking. The objective of this study was to explore the ways that maternal mortality influences the physical and emotional wellbeing, financial stability, and caregiving structure of families, and identifies sources of and gaps in support.

Methods

Our study used a mixed-methods design. All maternal mortalities in an 18-month period at a tertiary hospital in Ghana were identified using death certificates. Participants were 51 family members (either husbands or other heads of households) in families affected by maternal mortality. A questionnaire assessed demographic characteristics and changes in family health, income, and family structure. Two validated scales assessing psychological wellbeing were administered: the Patient Health Questionnaire-9 and the Inventory of Complicated Grief. Semi-structured interviews were conducted to assess impact on family wellbeing.

Results

Quantitative and qualitative results converged to highlight large, negative impacts of maternal mortality on four areas of family wellbeing: 1) mental health and emotional wellbeing; 2) physical health; 3) family structure; 4) financial stability and security. On the Patient Health Questionnaire-9, 54% (27/50) of participants reported elevated depressive symptoms, with 14% (7/50) of scores falling in the moderately severe or severe ranges. On the Inventory of Complicated Grief, 38% (19/50) exceeded the cutoff for significant impairment in functioning. Worsened family health was associated with greater complicated grief (b = 21.41, p = .004); there were no other significant predictors of depressive symptom severity or complicated grief. Effects on family health centered on concerns about the nutritional status and health of the surviving infant. Family structure was primarily affected by fracturing of the central family unit by sending children to live with relatives. Immense economic strain resulted from hospital bills, funeral expenses, and loss of income. The majority of participants received helpful support from their family (41/51, 80.4%), the community (32/51, 62.7%), and their religious institution (43/51, 84.3%); however, support often stopped soon after the death.

Conclusions

Maternal mortality has profound negative impacts on families in Ghana. Impacts are experienced by husbands and heads of households, as well as surviving children. Both immediate and sustained support is needed for families following a maternal death, especially mental health and financial support.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05006-1.

Rural-Urban Migration, Childbearing Decision-Making, Fertility and Contraceptive Perspectives of Street Adolescents and Youth in Kampala, Uganda

Introduction

This paper aims to describe and assess social demographic factors associated with childbearing decision-making, fertility and contraceptive intentions among street adolescents and youth in Kampala, Uganda while considering rural-urban migration as an explanatory factor.

Materials and Methods

A cross-sectional survey of 513 adolescents and youth aged 12–24 years self-identifying as street adolescents and youth were interviewed with a structured questionnaire in 2019. Street adolescents and youth who migrated from other rural districts to Kampala were compared with those from the city. Logistic regression was performed to assess associations between the independent factors and personal childbearing decision-making, fertility and contraceptive intentions.

Results

Overall, 80.31% of the street adolescents and youth had a rural-urban migration experience. Fifty six percent (56.32%) of the street adolescents and youth made personal childbearing decisions, 94.15% expressed intentions to have children in the future and 42.88% expressed intentions to use contraceptives in the future. Intentions to use contraceptives were significantly higher among males (58.75%) than females (20.00%), and higher among migrants (65.91%) compared to non-migrants (34.09%). Contraceptive intentions were positively associated with self-perceived permanent residential status (aOR = 10.26, 2.70–39.08), intra-urban mobility (aOR = 4.99, 95%CI 1.50–6.59) and intentions to migrate to other towns within the country (aOR = 5.33, 95%CI 1.59–17.80). Being married (aOR = 0.13, 95%CI 0.02–0.85), a large shelter population size (aOR = 0.13, 95%CI 0.03–0.63) and having repeat migrations between the city and home district (aOR = 0.23, 95%CI 0.05–0.94), including migration-associated challenges reduced the odds of street youth's personal childbearing decision-making, while belonging to a social support group increased the odds of childbearing decision-making. We found no significant association between social demographic characteristics and fertility intentions.

Discussion

Factors that influenced personal childbearing decision-making and contraceptive intentions among street adolescents and youth in Kampala operate mainly at the interpersonal and community levels, with marital status, shelter population size, rural-urban migration and its associated challenges associated with childbearing decision-making. Interventions to promote childbearing decision-making and contraceptive use among street adolescents and youth should take into consideration their migration and intra-urban mobility patterns.

Migration, personal physical safety and economic survival: drivers of risky sexual behaviour among rural–urban migrant street youth in Kampala, Uganda

Background

Despite the vulnerabilities associated with the youth migration process, knowledge on the drivers of risky sexual behaviour among migrant street youth is limited. This study sought to explore the pathways driving risky sexual behaviour among rural–urban migrant street youth in Kampala, Uganda.

Methods

We conducted 11 focus-group discussions composed of 8–10 participants each, and 15 in-depth interviews with urban street adolescents and youth aged 12–24 years. We purposively recruited street youth who had migrated from other districts to Kampala, Uganda, and who identified themselves as street youth. Data were analysed thematically using an inductive approach facilitated by Dedoose software.

Results

The migration journey acted as a catalyst for risky sexual behaviour among the adolescents and youth moving from rural districts to Kampala. Three primary pathways were found to drive risky sexual behaviour of street youth: 1) rural–urban migration itself, through sexual exploitation of and violence toward street youth especially young girls during movement, 2) economic survival through engaging in casual jobs and sex work upon arrival in the city, and 3) personal physical safety through friendships and networks, which consequently lead to having multiple sexual partners and unprotected sex. Engagement in risky sexual behaviour, especially sex work, was found to be an adaptation to the challenging and complex street life within the city.

Conclusions

This study highlights the migration process, personal physical safety and economic survival as major pathways driving risky sexual behaviour among rural–urban street youth in Kampala. Interventions to improve sexual health, physical safety and protection of street youth during the migration process and within the city spaces should be prioritised.

A Comparative Analysis of Neonatal Outcomes in Pregnancies Complicated by Preeclampsia and Eclampsia in Ghana

BACKGROUND

Worldwide, hypertensive disorders of pregnancy are a serious complication of pregnancy, and contribute to poor maternal and neonatal outcomes. The most significant consequences of hypertensive disorders of pregnancy are observed in sub-Saharan Africa, where neonatal outcomes have not been fully described. Understanding relationships between maternal disease severity and neonatal outcomes can guide patient counseling and allow the targeting of limited resources to the most at-risk neonates.

OBJECTIVE

To describe and compare neonatal outcomes in pregnancies complicated by preeclampsia with severe features and eclampsia.

STUDY DESIGN

This study is a secondary analysis of data collected as part of a randomized controlled trial at the Korle-Bu Teaching Hospital in Ghana. Participants were adult pregnant women with preeclampsia with severe features or eclampsia and their neonates. Data include prospectively collected medical and obstetrical history, intrapartum events, and neonatal outcomes. The main outcome of this secondary analysis was a composite of poor neonatal outcomes, defined as 1 or more of the following: stillbirth, very low birthweight (<1500 g), 5-minute Apgar score <7, neonatal intensive care unit admission, or a live birth with a subsequent death before discharge.

RESULTS

Median gestational age at delivery was 36.6 weeks (interquartile range, 33.3–38.9). Median birthweight was 2.3 kg (interquartile range, 1.6–3.0), with 227 (19.0%) birthweights <1500 g. There were 162 neonates (15.5%) with an Apgar score <7 at 5 minutes and 144 (11.9%) were stillbirths. Of live births, half (n=524, 50.3%) were admitted to the neonatal intensive care unit and 7.9% (n=91) died before discharge. A composite of poor neonatal outcomes was experienced by 58.2% (n=707) of neonates and was twice as likely with a maternal diagnosis of eclampsia (odds ratio, 1.91; P=.04). For each additional week of gestational age, the probability of a poor neonatal outcome was reduced by 39% (odds ratio, 0.61; P<.0001).

CONCLUSION

Poor neonatal outcomes were experienced by more than half of pregnancies complicated by preeclampsia with severe features or eclampsia. Even after controlling for gestational age, pregnancies complicated by eclampsia were twice as likely to have poor neonatal outcomes.

Using the Ghana malaria indicator survey to understand the difference between female and male-headed households and their prevention and testing for malaria among children under 5

Background

Globally, 94% of malaria deaths occur in sub-Saharan Africa, and children under age 5 account for 70% of malaria-related mortality in the region. This study sought to examine differences between female-headed households (FHHs) and male-headed households (MHHs) with regard to malaria prevention and testing among children under age 5 (U5) in Ghana.

Methods

This cross-sectional study used publicly available data from the 2019 Ghana Malaria Indicator Survey (GMIS). Frequencies and descriptive statistics were calculated for all key variables. Bivariate analyses comparing FHHs and MHHs were conducted using t tests and Chi-square analysis. A P value of 0.05 was taken for statistical significance.

Results

Five thousand one hundred and eighty one household were identified, of which 1938 (37.4%) were female-headed and 3243 (62.6%) were male-headed. 51.7% of FHHs included a child U5, whereas 67.8% of MHHs included a child U5. MHHs were significantly more likely to own an ITN than FHHs (83.1% vs. 78.3%, P < 0.001), whereas FHHs were more likely to report taking malaria prevention steps such as spraying the house with insecticide, filling in stagnant puddles, and keeping surroundings clear (all significant at P < 0.001). U5 children in MHHs were more likely to sleep under a bed net the night preceding the survey (51.0%) than U5 children in FHHs (44.8%), although the finding was not statistically significant. The rates of fevers in the previous two weeks among children U5 were similar across MHH and FHH (24.2% vs. 22.3%), and the rates of testing for malaria among those who experienced a febrile episode were also similar across MHHs and FHHs (39.0% vs. 41.3%). Of those tested, the percentage of U5 children who tested positive for malaria was also similar across MHHs and FHHs (63.9% vs. 63.0%).

Conclusions

Both FHHs and MHHs in Ghana make a concerted effort to prevent and test for malaria among children U5 in their households. Despite differences in malaria prevention strategies, there were no significant difference in febrile episodes, malaria testing, and rates of positivity, suggesting that malaria prevention is challenging for all households in Ghana. In the face of a newly-developed malaria vaccine, future research is warranted to ensure adequate uptake across all households.

"Once you get one maternal death, it's like the whole world is dropping on you": experiences of managing maternal mortality amongst obstetric care providers in Ghana

Background

Maternal mortality has a significant global impact, especially in low-resource settings. Little prior research has been conducted on the potential effects of poor maternal outcomes on the personal and professional well-being of healthcare providers. This study explores the in-depth experiences and perspectives of obstetric providers in Ghana who work in a setting with frequent maternal mortalities.

Methods

This is a qualitative study of semi-structured interviews conducted at the Komfo Anokye Teaching Hospital in Ghana. Participants were obstetric healthcare providers, defined as midwives, house officers currently rotating on the obstetrics/gynecology service, and obstetrician/gynecologists at any training or practice level (residents, fellows, and specialists). Interviews were audio-recorded, transcribed verbatim, and uploaded into NVivo for qualitative analysis. Using the Attride-Stirling qualitative model, an incremental and iterative process was used to code interviews with keyword phrases and develop a framework of organizing and global themes.

Results

Interviews were conducted with 27 participants—15 midwives and 12 physicians (three obstetrician/gynecologist residents, six obstetrician/gynecologist specialists, and three house officers), with sample size determined by data saturation. Obstetric providers’ experiences in a setting with frequent maternal mortalities were dependent on their level of preparedness to manage maternal mortalities and the workplace environment. Providers’ level of preparedness was dependent on both the training they had received on the medical management of obstetric emergencies, as well as a lack of training on the mental health aspects of coping with maternal mortality. The impact of the workplace environment was dependent on systems failures and limited resources, blame from colleagues and supervisors, and a lack of support in the workplace. In turn, obstetric providers’ experiences managing frequent maternal mortalities impacted their clinical care performance and mental health.

Conclusions

Maternal deaths have profound personal and professional impacts on the healthcare providers who manage them. A large need exists for additional institutional training and support for obstetric providers who manage maternal mortality, especially in low-resource settings like Ghana.

Perspectives on Resuscitation Decisions at the Margin of Viability among Specialist Newborn Care Providers in Ghana and Ethiopia: A Qualitative Analysis

Background

In high income countries, guidelines exist recommending gestational age thresholds for offering and obligating neonatal resuscitation for extremely preterm infants. In low- and middle- income countries, this approach may be impractical due to limited/inconsistent resource availability and challenges in gestational dating. Scant literature exists on how clinicians in these settings conceptualize viability or make resuscitation decisions for premature infants.

Methods

Qualitative interviews of interprofessional neonatal clinicians were conducted in Kumasi, Ghana, at Komfo Anokye Teaching Hospital and Suntreso Government Hospital, and in Addis Ababa, Ethiopia, at St. Paul’s Hospital Millennium Medical College. Transcribed interviews were coded through the constant comparative method.

Results

Three discrete major themes were identified. The principal theme was a respect for all life, regardless of the likelihood for survival. This sense of duty arose from a duty to God, a duty to the patient, and a duty intrinsic to one’s role as a medical provider. The duty to resuscitate was balanced by the second major theme, an acceptance of futility for many premature infants. Lack of resources, inappropriate staffing, and historically high local neonatal mortality rates were often described. The third theme was a desire to meet global standards of newborn care, including having resources to adopt the 22–25-week thresholds used in high income countries and being able to consistently provide life-saving measures to premature infants.

Conclusions

Neonatal clinicians in Ghana and Ethiopia described respect for all life and desire to meet global standards of newborn care, balanced with an awareness of futility based on local resource limitations. In both countries, clinicians highlighted how wide variations in regional survival outcomes limited their ability to rely on structured resuscitation guidelines based on gestational age and/or birthweight.

'I don't really understand this BP': Women's knowledge, attitudes, and experiences with preeclampsia in Ghana

Preeclampsia and eclampsia are common and serious complications of pregnancies, often presenting as obstetric emergencies. In low- and middle-income countries, limited numbers of healthcare providers and a high volume of critically ill patients can negatively impact provider communication and counseling. Lack of knowledge or awareness of preeclampsia and eclampsia among pregnant women can lead to delays in health seeking behavior. Our study uses grounded theory to explore patients' experience of preeclampsia and eclampsia in a low-resource setting. Participants were postpartum women diagnosed with preeclampsia or eclampsia at Korle Bu Teaching Hospital in Ghana. Interviews consisted of semi-structured, open-ended questions regarding participant understanding of their diagnosis of preeclampsia and eclampsia; counseling from their healthcare providers; and experiences with their delivery, monitoring, and treatment. Qualitative thematic analysis was performed according to the Attride-Sterling analytical framework, using NVivo 12. A total of 45 women were interviewed, 88.9% with preeclampsia and 11.1% with eclampsia. Major themes identified include participants' low general knowledge of their diagnosis, inadequate counseling from healthcare providers, and resulting emotional distress. Women desire more information regarding their diagnosis and associate their health-seeking behaviors with counseling they receive from healthcare providers. Women also acknowledge the systemic barriers that make patient care and counseling challenging for providers, especially in low- and middle-income countries. These findings highlight the need for improved models of counseling and health education for women with pregnancies complicated by preeclampsia and eclampsia.

The Association Between Maternity Waiting Home Use and Maternal-Newborn Knowledge: Latent Class Analysis

BACKGROUND AND PURPOSE

An exploratory latent class analysis (LCA) was performed assessing the association between maternity waiting home (MWH) use and maternal-newborn care knowledge.

METHODS

A two-group comparison design using a face-to-face interview (n = 250) was conducted to understand if MWH use was associated with greater maternal knowledge of newborn care.

RESULTS

High levels of maternal knowledge of newborn care were associated with MWH use. Mothers with low levels of knowledge were less likely to use an MWH prior to delivery and more likely to have fewer pregnancies, attend less than four antenatal care (ANC) visits, and receive no education about newborn health problems during ANC.

CONCLUSIONS

Nurses need to target younger, primigravida mothers attending fewer ANC visits with educational opportunities while advocating for expansion of health education at MWHs to potentiate long-term benefits for improved maternal-newborn health and delivery outcomes.

High Prevalence of Low Birth Weight Babies Born to Pregnant Women Referred to a District Hospital in Rural Zambia

OBJECTIVES

Low birthweight (LBW) is a significant public health problem in sub-Saharan Africa and LBW in rural Zambia is high. Our study explored the prevalence of LBW for newborns whose mothers were referred from a rural health center to a district referral hospital in Lundazi, Zambia.

METHODS

A five-month retrospective record review of Ministry of Health data was performed to examine birthweight characteristics of a convenience sample of newborns from ten facilities referring to one district hospital (n = 234).

RESULTS

Among all cases, 21% (n = 49) of newborns were LBW. For LBW newborns, 73% (n = 36) were preterm with mothers having a pregnancy duration of less than 37 weeks. Newborns whose mothers experienced twin pregnancies (p = .021) and prolonged labor (p = .033) were more often LBW. However, regression models demonstrated no difference among newborns with and without LBW for prolonged labor (p = .344) and twin pregnancies (p = .324) when controlling for variables that could interact with the maternal-newborn delivery outcomes.

CONCLUSIONS

for Practice Healthcare providers and policy makers need to address the short and long-term effects of LBW throughout the lifecycle in rural Zambia. More maternal-newborn health research is needed to understand the underlying socioeconomic, social, and cultural determinants influencing LBW in rural Zambia.

Provider perspectives on Asram in Ghana

Neonatal mortality is one of the leading causes of under-five mortality globally, with the majority of these deaths occurring in low- and middle-income countries. In Ghana, there is a belief in an array of newborn conditions, called Asram, that are thought to have a spiritual, rather than physical, cause. These conditions are predominantly managed by traditional healers as they are considered unable to be treated by allopathic medical providers. Through a series of semi-structured qualitative interviews of medical providers in Kumasi, Ghana, conducted in July-August 2018, this study sought to elucidate perspectives of allopathic medical providers about Asram, including the perceived implications of traditional newborn care patterns on newborn health and higher-level neonatal care. Twenty health care providers participated and represented a tertiary care hospital and a district hospital. Medical providers were universally aware of Asram but varied on the latitude they gave this belief system within the arena of newborn care. Some providers rationalized the existence of Asram in the backdrop of high neonatal mortality rates and long-standing belief systems. Others highlighted their frustration with Asram, citing delays in care and complications due to traditional medical treatments. Providers utilized varying approaches to bridge culture gaps with families in their care and emphasized the importance of open communication with the shared goal of improved newborn health and survival. This study describes the importance of providers being aware of socio-cultural constructs within which pregnant women operate and suggests a focus on the shared goal of timely and effective newborn care in Ghana.

Stigma Associated With Sickle Cell Disease in Kumasi, Ghana

INTRODUCTION

People with sickle cell disease (SCD) often face stigmatization in Ghana and elsewhere in Africa. Research is needed to understand whether it is necessary to design an SCD stigma reduction program in the Ghanaian setting. The aim of this study was to explore the perception of stigmatization for adults with SCD in Kumasi, Ghana.

METHODOLOGY

Using in-depth qualitative interviews, researchers conducted a phenomenological study to investigate the perception of stigmatization for people with SCD in Kumasi, Ghana. Snowball and purposive sampling was used to identify the participants.

RESULTS

Participants (n = 12) were mostly female, Akan, and Christian. Researchers categorized three main themes: (a) Feelings of social isolation, (b) Fear of disclosure, and (c) Bullying about physical appearance.

DISCUSSION

The findings highlight the need to develop effective strategies to counteract stigma. Transcultural health care providers can implement stigma reduction interventions that might be applicable throughout Africa where findings are likely to resonate with patients with SCD.

Self-reported medicinal plant use by Ghanaian women during pregnancy is associated with poor neonatal health

BACKGROUND

More than a third of pregnant women in Africa use medicinal plants (hereafter, 'herbs') during pregnancy, yet little is known about herb use among urban African women, or about the potential impact on newborns.

METHODS

This cross-sectional study of 504 women giving birth at an urban government hospital in Kumasi, Ghana (May-July 2018) collected data via chart reviews and maternal interviews. Data were analyzed using conditional logistic regression.

RESULTS

Of 380 singleton births with complete data, 102 mothers (26.84%) reported using herbs during pregnancy and/or delivery. Herb users and non-users did not differ significantly across a range of sociodemographic variables. Controlling for age, education, neonatal birthweight and household running water (socioeconomic status (SES) indicator), herb-using women were twice as likely to have their newborn admitted to the hospital (odds ratio (OR) = 2.05; confidence interval (CI) 95% 1.17, 3.60) and four times as likely to bear a child with a low Apgar score (OR = 4.09; CI 95% 1.66, 10.07) compared with non-users.

CONCLUSION

Urban-dwelling Ghanaian women from diverse backgrounds use herbs during pregnancy. Maternal herb use was associated with poor neonatal outcomes, regardless of the baby's birthweight and mother's age, education or SES, suggesting the importance of educating all women about the possible negative impacts of herb use during pregnancy and delivery.

"Even when people live just across the road…they won't go": Community health worker perspectives on incentivized delays to under-five care-seeking in urban slums of Kampala, Uganda

Background

Although under-five (U5) mortality in Uganda has dropped over the past two decades, rates in urban slum neighborhoods remain high. As part of a broader verbal and social autopsy study of U5 deaths, this study explored the perspectives of volunteer community health workers, called Village Health Teams (VHTs), on why children under five in Kampala’s informal settlements are still dying despite living in close proximity to nearby health facilities.

Methods

This exploratory, qualitative study took place between January and March 2020 in the Rubaga division of Kampala, Uganda. VHTs from the slums of Kawaala and Nankulabye parishes, both located near a large government health center, were interviewed by a trained local interviewer to determine their perceptions of barriers to care-seeking and attribution for U5 childhood deaths. All interviews were audiotaped, transcribed into English, imported into NVivo V 12.0 and thematically analyzed using the Attride-Stirling framework.

Results

20 VHTs were interviewed, yielding two global themes, the first focusing on VHTs perceptions of their role in the community to promote positive health outcomes, and the second focusing on VHTs’ perceptions of how prompt care-seeking is disincentivized. Within the latter theme, three inter-related sub-themes emerged: disincentives for care-seeking at the health system level, which can drive negative beliefs held by families about the health system, and in turn, drive incentives for alternative health behaviors, which manifest as “incentivized delays” to care-seeking.

Discussion

This study illustrates VHT perspectives on the complex interactions between health system disincentives and the attitudes and behaviors of families with a sick child, as well as the reinforcing nature of these factors. Findings suggest a need for multi-pronged approaches that sensitize community members, engage community and health system leadership, and hold providers accountable for providing high-quality care. VHTs have enormous potential to foster improvement if given adequate resources, training, and support.

Neonatal mortality in rural northern Ghana and the three delays model: are we focusing on the right delays?

OBJECTIVE

The Three Delays Model outlines, three common delays that lead to poor newborn outcomes: (i) recognising symptoms and deciding to seek care; (ii) getting to care and; (iii) receiving timely, high-quality care. We gathered data for all newborn deaths within four districts in Ghana to explore how well the Three Delays Model explains outcomes.

METHODS

In this cross-sectional, observational study, trained field workers conducted verbal and social autopsies with the closest surviving relative (typically mothers) of all neonatal deaths across four districts in northern Ghana from September 2015 until April 2017. Data were collected using Survey CTO and analysed using StataSE 15.0. Frequencies and descriptive statistics were calculated for key variables.

RESULTS

247 newborn deaths were identified. Nearly 77% (190) of newborns who died were born at a health facility, and 48.9% (93) of those who died before discharge. Of the 149 newborns who were discharged or born at home, 71.8% (107) sought care at a facility for illness, and 72.9% (N = 78) of those did so within the same day of illness recognition. Of the 83 respondents who arranged for transportation, 82% (68) did so within 1 h. Newborns received prompt care but insufficient interventions - 25% or fewer received IV fluids, oral medications, antibiotics or oxygen.

CONCLUSIONS

These data suggest that women are following recommendations for safe delivery and prompt care-seeking. In rural northern Ghana, behaviour change interventions focused on mothers and families may not be as pressing as interventions focused on the Third Delay - obtaining timely, high-quality care.

Utilisation of sexual and reproductive health services among street children and young adults in Kampala, Uganda: does migration matter?

BACKGROUND

While the nexus of migration and health outcomes is well acknowledged, the effect of rural-urban migration on the use of sexual and reproductive health (SRH) services has received less attention. We assessed the effect of rural-urban migration on the use of SRH services, while controlling for confounding, and whether there is a difference in the use of SRH services among migrant and non-migrant street children and young adults.

METHODS

Data were collected from 513 street children and young adults aged 12-24 years, using venue-based time-space sampling (VBTS). We performed multivariate logistic regression analysis using Stata 16.0 to identify factors associated with SRH services use, with rural-urban migration status as the main predictor. Participants were further classified as new migrants (≤ 2 years of stay in city), established migrants (> 2 years of stay in city) or non-migrants (lifelong native street children) with no rural-urban migration history.

RESULTS

Overall, 18.13% of the street children and young adults had used contraception/family planning, 58.67% had tested for human immunodeficiency virus (HIV) and knew their status and 34.70% had been screened for sexually transmitted infections (STIs). Non-migrants were 2.70 times more likely to use SRH services (HIV testing, STI screening and family planning) compared to the migrants (aOR = 2.70, 95% CI 1.23-5.97). Other factors associated with SRH services use among street children and young adults include age (aOR = 4.70, 95% CI 2.87-7.68), schooling status (aOR = 0.33, 95% CI 0.15-0.76), knowledge of place of care (aOR = 2.71, 95% CI 1.64-4.46) and access to SRH information (aOR = 3.23, 95% CI 2.00-5.24).

CONCLUSIONS

SRH services utilisation among migrant street children and young adults is low compared to their non-migrant counterparts and is independently associated with migration status, age, schooling status, knowledge of place of care and access to SRH information. Our findings call for the need to design and implement multi-dimensional interventions to increase the use of SRH services among street children and young adults, while taking into consideration their migration patterns.

Demographic and behavioural drivers of intra-urban mobility of migrant street children and youth in Kampala, Uganda

While research on the nexus of migration and wellbeing of individuals has gained recognition in recent years, far less attention has been devoted to intra-urban mobility especially among the urban poor young populations. We assess the drivers of intra-urban mobility using a random sample of 412 migrant street children and youth in Kampala city, Uganda. This paper draws from a larger cross-sectional survey of circular migration and sexual and reproductive health choices among street children in Kampala, Uganda. We define 'migrants' as street children and youth with a rural-urban migration experience and 'intra-urban mobility' as the number of places stayed in or moved since migrating to the city, measured on a continuous scale. More than half (54.37%) of the migrant street children and youth had lived in two or more places since migrating to the city. Multivariate negative binomial regression analysis reveals migrant street children and youth's intra-urban mobility to be associated with gender (aIRR = 0.71, 95%CI 0.53-0.96), sex work (aIRR = 1.38, 95%CI 1.01-1.88), a daily income of one USD or more (aIRR = 1.57, 95%CI 1.16-2.13) and duration of stay in the city (aIRR = 1.54, 95%CI 1.17-2.01). Other drivers of intra-urban mobility included availability of causal work, personal safety and affordability of rental costs. Our findings suggest the need for urban housing and health policies to take into account street children and youth's intra-urban mobility and its drivers. Future research on all drivers of street children and youth's intra-urban mobility and its linkage with their health outcomes is recommended.

Optimizing task-sharing in abortion care in Ghana: Stakeholder perspectives

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.

Midwives are providing abortion care in Ghana through task‐sharing; access is still limited, therefore further expansion to include physician assistants and community health nurses is needed.

Preparedness to deal with maternal mortality among obstetric providers at an urban tertiary hospital in Ghana

OBJECTIVE

This study explores the impacts of managing frequent maternal mortalities on obstetric healthcare providers in Ghana.

METHODS

Two hundred and seventy obstetric providers at the Komfo Anokye Teaching Hospital in Ghana completed an electronic survey. Questions included coping strategies, sources and adequacy of support, training, and emotional impact. Logistic regression assessed predictors of perceived preparedness to manage maternal mortalities.

RESULTS

Over half of participants (55.1%) did not report adequate support to deal with maternal death and only 35.9% received training. The vast majority (96.4%) agreed that managing maternal deaths takes a large emotional toll-27.6% considered giving up their obstetric practice, half experienced guilt or shame, and half worried about legal or disciplinary action. After adjusting for age, gender, years in practice, and annual maternal mortalities managed, perceived adequacy of support (odds ratio [OR] 6.6, 95% confidence interval [CI] 3.0-14.7, P < 0.001) and receiving training (OR 9.5, 95% CI 3.5-25.8, P < 0.001) were significantly associated with preparedness to deal with maternal mortality.

CONCLUSION

Managing maternal mortalities has significant emotional impact on obstetric healthcare providers. Preparedness to deal with maternal death is significantly improved when providers receive adequate support and training.

Self-reported challenges to border screening of travelers for Ebola by district health workers in northern Ghana: An observational study

BACKGROUND

The 2013-2016 Ebola Virus Disease (EVD) outbreak remains the largest on record, resulting in the highest mortality and widest geographic spread experienced in Africa. Ghana, like many other African nations, began screening travelers at all entry points into the country to enhance disease surveillance and response. This study aimed to assess the challenges of screening travelers for EVD at border entry in northern Ghana.

DESIGN AND METHODS

This was an observational study using epidemiological weekly reports (Oct 2014-Mar 2015) of travelers entering Ghana in the Upper East Region (UER) and qualitative interviews with 12 key informants (7 port health officers and 5 district directors of health) in the UER. We recorded the number of travelers screened, their country of origin, and the number of suspected EVD cases from paper-based weekly epidemiological reports at the border entry. We collected qualitative data using an interview guide with a particular focus on the core and support functions (e.g. detection, reporting, feedback, etc.) of the World Health Organization's Integrated Disease Surveillance and Response system. Quantitative data was analyzed based on travelers screened and disaggregated by the three most affected countries. We used inductive approach to analyze the qualitative data and produced themes on knowledge and challenges of EVD screening.

RESULTS

A total of 41,633 travelers were screened, and only 1 was detained as a suspected case of EVD. This potential case was eventually ruled out via blood test. All but 52 of the screened travelers were from Ghana and its contiguous neighbors, Burkina Faso and Togo. The remaining 52 were from the four countries most affected by EVD (Guinea, Liberia, Sierra Leone, and Mali). Challenges to effective border screening included: inadequate personal protective equipment and supplies, insufficient space or isolation rooms and delays at the border crossings, and too few trained staff. Respondents also cited lack of capacity to confirm cases locally, lack of cooperation by some travelers, language barriers, and multiple entry points along porous borders. Nonetheless, no potential Ebola case identified through border screening was confirmed in Ghana.

CONCLUSION

Screening for Ebola remains sub-optimal at the entry points in northern Ghana due to several systemic and structural factors. Given the likelihood of future infectious disease outbreaks, additional attention and support are required if Ghana is to minimize the risk of travel-related spread of illness.

Feasibility of establishing a network of community health workers to support care of people with sickle cell disease in Kumasi, Ghana

Globally, sickle cell disease (SCD) is a common, yet often neglected, non-communicable disease. Community health worker (CHW) interventions have been shown to improve outcomes for chronic diseases but have not been evaluated with SCD. This study assessed the interest in and feasibility of establishing a network of CHWs to support care of people with SCD in Kumasi, Ghana. Using in-depth interviews with key stakeholders (N = 15) identified through purposive and snowball sampling from January to March 2020, we gathered focused information about interest in and feasibility of establishing a network of CHWs. Respondents were chosen for their knowledge and oversight of health services for people with SCD. Latent content analysis was used to examine the data. Participants expressed interest in establishing a network of CHWs to better support care for people with SCD. Three primary themes emerged from the data: (1) support by CHWs could be beneficial for people with SCD; (2) using existing CHW networks for SCD services would be best; and (3) funding of expanded CHW network might be a problem. We advocate for the mobilization of resources to expand the current network of CHWs to include a focus on SCD in Kumasi, Ghana. Participants believe that it is feasible to use CHWs to improve care outcomes of people with SCD. There is potential for findings from this exploratory project to be adapted and implemented in other settings throughout sub-Saharan Africa, as well as areas of higher income countries where there are higher proportions of people living with sickle cell.

Women's Empowerment and Child Vaccination in Kenya: The Modifying Role of Wealth

INTRODUCTION

Although vaccination coverage is high in Kenya relative to other African nations, undervaccinated children remain, making it important to identify characteristics of these children and their caregivers. Potentially relevant but understudied factors are women's empowerment and early marriage. Women who marry older and have more autonomous decision-making authority may be better able to ensure their children receive health services, including immunizations. This analysis examines the relationship between early marriage and multiple dimensions of women's empowerment and child vaccination status in Kenya and explores whether these relationships are modified by wealth.

METHODS

Data were from the 2014 Kenya Demographic and Health Survey. The analysis was completed in 2020 using updated data made available to researchers in 2019. Logistic regressions assessed relationships among early marriage, 3 dimensions of women's empowerment (enabling conditions, intrinsic agency, and instrumental agency), and child vaccination. Analyses were stratified by wealth to explore potential effect modification.

RESULTS

For women in the middle wealth tertile, the odds of having a fully vaccinated child were 3.45 (95% CI=1.51, 7.91) times higher for those with higher versus lower empowerment. Further, among the wealthiest women, those with middle empowerment were 5.99 (95% CI=2.06, 17.40) times more likely to have a fully vaccinated child than women with lower empowerment.

CONCLUSIONS

Results suggest a threshold effect of wealth's role in the relationship between empowerment and vaccination. Enabling conditions may not influence immunization among the poorest women but exert a stronger positive influence on childhood vaccination among wealthier women.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Global Vaccination Equity, which is sponsored by the Global Institute for Vaccine Equity at the University of Michigan School of Public Health.

Caregiver Perception of Sickle Cell Disease Stigma in Ghana: An Ecological Approach

INTRODUCTION

Sickle cell disease (SCD) stigma is a major community health issue. The challenges of caring for someone with SCD can be overwhelming. We explored stigma and related factors for caregivers of pediatric patients with SCD in Kumasi, Ghana.

METHOD

Guided by the Ecological Systems Theory, we used in-depth interviews with a semistructured guide to learn about the perception of stigmatization for Ghanaian caregivers of patients with SCD.

RESULTS

Overall, participants were knowledgeable about SCD. We identified three themes, including (1) blame for SCD, (2) public misconception about SCD, and (3) shame for the financial burden of SCD.

DISCUSSION

Findings demonstrate the need to design an SCD stigma reduction program for caregivers, families, and the community. Providers need to consider SCD stigma and interaction with multiple ecological levels, including the family, community, health care system, culture, and health policy in Ghana. Findings can be used as a catalyst to explore the reduction of stigmatization in other sub-Saharan countries.

Preeclampsia knowledge among postpartum women treated for preeclampsia and eclampsia at Korle Bu Teaching Hospital in Accra, Ghana

BACKGROUND

Preeclampsia/eclampsia is a major cause of maternal morbidity and mortality worldwide, yet patients' perspectives about their diagnosis are not well understood. Our study examines patient knowledge among women with preeclampsia/eclampsia in a large urban hospital in Ghana.

METHODS

Postpartum women diagnosed with preeclampsia or eclampsia were asked to complete a survey 2-5 days after delivery that assessed demographic information, key obstetric factors, and questions regarding provider counseling. Provider counseling on diagnosis, causes, complications, and future health effects of preeclampsia/eclampsia was quantified on a 4-point scale ('Counseling Composite Score'). Participants also completed an objective knowledge assessment regarding preeclampsia/eclampsia, scored from 0 to 22 points ('Preeclampsia/Eclampsia Knowledge Score' (PEKS)). Linear regression was used to identify predictors of knowledge score.

RESULTS

A total of 150 participants were recruited, 88.7% (133) with preeclampsia and 11.3% (17) with eclampsia. Participants had a median age of 32 years, median parity of 2, and mean number of 5.4 antenatal visits. Approximately half of participants reported primary education as their highest level of education. While 74% of women reported having a complication during pregnancy, only 32% of participants with preeclampsia were able to correctly identify their diagnosis, and no participants diagnosed with eclampsia could correctly identify their diagnosis. Thirty-one percent of participants reported receiving no counseling from providers, and only 11% received counseling in all four categories. Even when counseled, 40-50% of participants reported incomplete understanding. Out of 22 possible points on a cumulative knowledge assessment scale, participants had a mean score of 12.9 ± 0.38. Adjusting for age, parity, and the number of antenatal visits, higher scores on the knowledge assessment are associated with more provider counseling (β 1.4, SE 0.3, p < 0.001) and higher level of education (β 1.3, SE 0.48, p = 0.008).

CONCLUSIONS

Counseling by healthcare providers is associated with higher performance on a knowledge assessment about preeclampsia/eclampsia. Patient knowledge about preeclampsia/eclampsia is important for efforts to encourage informed healthcare decisions, promote early antenatal care, and improve self-recognition of warning signs-ultimately improving morbidity and reducing mortality.

Maternal knowledge of essential newborn care in rural Zambia

Maternity waiting homes (MWHs) may offer an intervention to improve newborn outcomes in rural Zambia. This study compared maternal knowledge of newborn care for women referred from facilities with and without MWHs. Topics assessed included: (1) umbilical cord care; (2) thermal and skin care; (3) nutrition, and; (4) prevention of diarrhea, and; (5) newborn danger signs prompting care-seeking. A two-group comparison design with a convenience sample was employed using a face-to-face interviews at one district hospital. Descriptive, inferential, and multivariate analyses were employed to compare knowledge. Overall, mothers demonstrated newborn care knowledge in accordance with World Health Organization (WHO) guidelines for newborn health and there were no significant differences in maternal knowledge of newborn care practices among MWH and non-MWH users. Younger mothers more often did not know about umbilical cord care, newborn skin care, and newborn danger signs. MWH users went more often for antenatal care than non-MWH users. In both groups, we found as the number of ANC visits increases, odds of answering "Don't know" decreases. This study is the first to assess maternal newborn care knowledge and MWH use in rural Zambia. Both MWH users and non-users in the rural district were knowledgeable about essential newborn care.

Maternity waiting homes in Liberia: Results of a countrywide multi-sector scale-up

Objective

Descriptions of maternity waiting homes (MWHs) as an intervention to increase facility delivery for women living in remote geographic areas dates back to the 1950s, yet there is limited information on the scale-up and sustainability of MWHs. The objective of this study was to describe the evolutionary scale-up of MWHs as a component of health system strengthening efforts and document the successes, challenges, and barriers to sustainability in Liberia.

Methods

Data were collected from a national sample of 119 MWHs in Liberia established between 2010–2018. The study used a mixed method design that included focus group discussions, individual interviews, logbook reviews, and geographic information systems. Qualitative data were grouped into themes using Glaser’s constant comparative method. Quantitative data were analyzed using negative binomial regression to measure the differences in the counts of monthly stays at facilities with different funding sources and presence of advisory committee. Additionally, each MWH was geo-located for purposes of geo-visualization.

Results

In the years since the original construction of five MWHs, an additional 114 MWHs were constructed in 14 of the 15 counties in Liberia. Monthly stays at facilities funded by community were 2·5 times those funded by NGOs (IRR, 2·46, 95% CI 1·33–4·54). Attributes of sustainability included strong local leadership/active community engagement and community ownership and governance.

Conclusion

Success factors for scale-up and sustainability included strong government support through development of public policy, local and county leadership, early and sustained engagement with communities, and self-governance. A multi-pronged approach with strong community engagement is key to the scale-up and sustainability of MWHs as an intervention to increase facility delivery for women living the farthest from a healthcare facility.

Operationalization of the Ecological Systems Theory to Guide the Study of Cultural Practices and Beliefs of Newborn Care in Rural Zambia

Introduction: A wide gap in knowledge exists about the factors associated with newborn care in rural Zambia. In this year of the nurse and midwife, the purpose of this article is to provide transcultural researchers with an example of how Bronfenbrenner's Ecological Systems Theory (EST) can be used to guide an exploration of the cultural practices, knowledge, and beliefs of newborn care and health-seeking behaviors in rural Zambia. Methodology: Based on the EST, maternal knowledge represents the microsystem while family and community members embody the mesosystem. Health care organization denotes the exosystem with culture representing the macrosystem and health policy the chronosystem. Results: Numerous implications for transcultural nursing practice emerged from this adaptation of the ecological systems approach. Findings reveal a maternal dualism faced by Zambian mothers as they navigate the complex interplay between cultural newborn care practices and evidence-based newborn care promoted by the health care system. Discussion: Based on our proposed operationalization of the EST for a transcultural nursing study, the EST can be applied globally, further validating the theory.

Cultural beliefs and health-seeking practices: Rural Zambians' views on maternal-newborn care

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Mothers caring for newborns have a maternal dualism between cultural and health system obligations.

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Traditional newborn protective rituals were identified to help nurses provide health education.

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Family and community expressed a strong need to protect the newborn using traditional belief systems.

Background

- Far too many newborns die or face serious morbidity in Zambia, as in many other sub-Saharan African countries. New knowledge is needed to enhance our understanding of newborn care and the cultural factors influencing the ways mothers seek newborn care. This study adds to the literature about rural Zambians’ cultural beliefs and practices related to newborn care and health-seeking practices that influence maternal-newborn health.

Objective

- The goal of this study was to describe the factors associated with newborn care in rural Zambia.

Design

- Sixty focus groups were conducted. Each group contained a minimum of 8 and maximum of 12 participants. Recruitment was conducted orally by word of mouth through the nurse in charge at the health facilities and village chiefs.

Setting

– Data were collected between June and August 2016 in 20 communities located in Zambia's rural Lundazi (Eastern province), Mansa, and Chembe (Luapula province) Districts.

Participants

- The study included community members (n = 208), health workers (n = 225), and mothers with infants younger than 1-year-old (n = 213).

Findings

- The following themes emerged. From mothers with infants, the dominant theme concerned traditional and protective newborn rituals. From community members, the dominant theme was a strong sense of family and community to protect the newborn, and from health workers, the major theme was an avoidance of shame. A fourth theme, essential newborn care, was common among all groups.

Key conclusions

– Together the themes pointed toward a maternal dualism for mothers in rural Zambia. Mothers with infants in rural Zambia likely experience a dualistic sense of responsibility to satisfy both cultural and health system expectations when caring for their newborns. Mothers are pulled to engage in traditional protective newborn care rituals while at the same time being pushed to attend ANC and deliver at the health facility. These findings can be used to understand how mothers care for their newborns to develop interventions aimed at improving maternal-child health outcomes.

Implications for practice

- There were findings about the culture-specific prevention of cough, care of the umbilical cord, and early introduction of traditional porridge that carry implications for nursing practice. There is an obvious need to reinforce the importance of partner testing for STIs during routine ANC even though there is a desire to preserve dignity.

'This sickness is not hospital sickness': a qualitative study of the evil eye as a source of neonatal illness in Ghana

Previous research has described the evil eye as a source of illness for pregnant women and their newborns. This study sought to explore the perceptions of the evil eye among mothers whose newborns had experienced a life-threatening complication across three regions of Ghana. As part of a larger, quantitative study, trained research assistants identified pregnant and newly delivered women (and their newborns) who had survived a life-threatening complication at three tertiary care hospitals in southern Ghana to participate in open-ended, qualitative interviews about their experiences in March-August 2015. All interviews were audio-recorded and transcribed verbatim into English and analysis using the constant comparative method of theme generation. A total of 37 mothers were interviewed, 20 about neonatal illnesses and 17 about maternal illnesses. Six of the 20 mothers interviewed about their newborn's illnesses spoke at length about the evil eye being a potential cause of newborn illness. The evil eye was described in a variety of terms, but commonalities included a person looking at a pregnant woman, her newborn baby, the baby's clothes and even the mother's food, causing harm, even unintentionally. Prevention required mothers covering themselves while pregnant and keeping the baby away from others until it was old enough to ward off the evil eye. Treatment required traditional medicine, yet some indicated that allopathic medicine could help. The evil eye appears to serve a social control mechanism, encouraging pregnant women to dress modestly, stay indoors as much as possible and behave appropriately. The evil eye is a pervasive, universally understood phenomenon across three regions of Ghana, even amongst a hospitalized population receiving allopathic health care for life-threatening complications of childbirth. Understanding the role of the evil eye in newborn illness attribution is important for clinicians, researchers and programmatic staff to effectively address barriers to care seeking.

Acceptability and feasibility of insect consumption among pregnant women in Liberia

Maternity waiting homes (MWHs) in Liberia promote facility‐based delivery to reduce maternal mortality. However, women often must bring their own food and supplies to MWHs, which makes food insecurity a barrier to the utilisation of MWHs. Consumption of edible indigenous insects is a common practice and has notable nutritional benefits but has not been studied in Liberia as a potential solution to food insecurity at MWHs. The purpose of this study is to (a) examine the acceptability of insect consumption in the context of Liberian beliefs, (b) identify species commonly consumed by pregnant women in Liberia, and (c) examine the feasibility of harvesting insects as food and income generation for women staying at MWHs. Focus groups were conducted at 18 healthcare facilities in Liberia. Participants included chiefs, community leaders, women of reproductive age, traditional birth attendants, women staying at MWHs, and male partners. Focus group participants identified many different species of insects consumed by pregnant women in the community as well as the perceived health impacts of insect consumption. They also described their own experiences with insect hunting and consumption and the perceived marketability of insects, particularly palm weevil larvae. The results of these discussions demonstrate that insect consumption is an acceptable practice for pregnant women in rural Liberia. These findings suggest that it is feasible to further explore the use of palm weevil larvae as dietary supplementation and income generation for women staying at MWHs in Liberia.

Neonatal near-misses in Ghana: a prospective, observational, multi-center study

Background

For every newborn who dies within the first month, as many as eight more suffer life-threatening complications but survive (termed ‘neonatal near-misses’ (NNM)). However, there is no universally agreed-upon definition or assessment tool for NNM. This study sought to describe the development of the Neonatal Near-Miss Assessment Tool (NNMAT) for low-resource settings, as well as findings when implemented in Ghana.

Methods

This prospective, observational study was conducted at two tertiary care hospitals in southern Ghana from April – July 2015. Newborns with evidence of complications and those admitted to the NICUs were screened for inclusion using the NNMAT. Incidence of suspected NNM at enrollment and confirmed near-miss (surviving to 28 days) was determined and compared against institutional neonatal mortality rates. Suspected NNM cases were compared with newborns not classified as a suspected near-miss, and all were followed to 28 days to determine odds of survival. Confirmed near-misses were those identified as suspected near-misses at enrollment who survived to 28 days. The main outcome measures were incidence of NNM, NNM:mortality ratio, and factors associated with NNM classification.

Results

Out of 394 newborns with complications, 341 (86.5%) were initially classified as suspected near-misses at enrollment using the NNMAT, with 53 (13.4%) being classified as a non-near-miss. At 28-day follow-up, 68 (17%) had died, 52 (13%) were classified as a non-near-miss, and 274 were considered confirmed near-misses. Those newborns with complications who were classified as suspected near-misses using the NNMAT at enrollment had 12 times the odds of dying before 28 days than those classified as non-near-misses. While most confirmed near-misses qualified as NNM via intervention-based criteria, nearly two-thirds qualified based on two or more of the four NNMAT categories. When disaggregated, the most predictive elements of the NNMAT were gestational age < 33 weeks, neurologic dysfunction, respiratory dysfunction, and hemoglobin < 10 gd/dl. The ratio of near-misses to deaths was 0.55: 1, yet this varied across the study sites.

Conclusions

This research suggests that the NNMAT is an effective tool for assessing neonatal near-misses in low-resource settings. We believe this approach has significant systems-level, continuous quality improvement, clinical and policy-level implications.