A multilevel mixed methods study of neonatal mortality in Ghana

Background: Reducing neonatal mortality rates [NMR] (deaths/1,000 live births within 28 days of delivery) is a key global health goal. Using comparable data from Ghana (West Africa) and Scotland, I investigated NMR, specific causes of death and risk factors in the two countries. By identifying the main causes of excess mortality in Ghana and where they occur, it is hoped more effective strategies can be developed. Methods: This thesis used a multilevel mixed methods study design. Data on live births were obtained from three Health and Demographic Surveillance Systems (HDSS) in the north, middle and south of Ghana respectively: Navrongo (2004-12; 17,016 live births, 320 deaths); Kintampo (2005-10; 11,207 live births, 140 deaths); Dodowa (2006-14; 21,647 live births, 135 deaths). Comparable Scottish data were obtained from the Information Services Division (1992 to 2015; 1,278,846 live births, 2,783 deaths). Each dataset was analysed by neonatal death (dead/alive), using univariate and multivariable logistic regression. The multivariable analyses adjusted for maternal demographic and obstetric characteristics. Missing data were analysed using multiple imputation techniques. Data analyses were complemented by a researcher-developed questionnaire survey of 71 maternity care providers in the three regions of Ghana followed by face-to-face in-depth interviews with 48 maternity care providers who had experience of prematurity, birth asphyxia, neonatal infection and neonatal death. Results: The NMRs in the three HDSS were: Navrongo: 18.8; Kintampo: 12.5; and Dodowa 6.2 and in Scotland it was 2.2; the NMR in both countries is reducing. More than 99% of the neonatal deaths in Scotland occurred in the first week compared to 74% in Ghana. The leading causes of neonatal deaths (NMR) in Ghana were infection (4.3), asphyxia (3.7) and prematurity (2.2). In Scotland, they were congenital malformations (0.6), asphyxia (0.4) and prematurity (0.3). Only 88 deaths (0.07) of neonatal deaths in Scotland were due to infection. Ninety-eight percent of babies born in Scotland were born in a health facility compared to 60% of babies born in Ghana (hospital: 38.1%; clinic: 21.1%). In Ghana, babies born in hospitals had a higher risk of neonatal mortality compared to those born at home (NMR-hospital: 15.6; clinic: 7.1; home: 11.8). Most of the neonatal deaths in Ghana occurred at home (54%); there were more deaths among babies who were born in a hospital but died at home (hosp/home) compared to those born at home but died in a hospital (home/hosp). Asphyxia was the leading cause of death among hosp/hosp, and infection was the leading cause of death among hosp/home, home/home and home/hosp. Neonatal mortality in Ghana was largely influenced by where mothers sought maternity service, or the type of personnel who provided maternity care service. Mothers and babies who were cared for in hospitals by doctors and midwives received relatively better care and proper management of birth complications. Those who were cared for in clinics received basic delivery services and management of uncomplicated asphyxia. Mothers and babies who were cared for at home by traditional birth attendants (TBA) received poor care and poor management of neonatal illnesses based on traditional approaches which increased the risk of death. Women’s maternity choices were influenced by wider societal factors including prominent cultural values, family hierarchical structures and the cost of maternity services, and individual/ family factors including place of residence and availability of transport and beliefs about the cause of disease. Conclusion: There is considerable opportunity for reducing NMR in Ghana, especially deaths due to asphyxia and infections. Most uncomplicated deliveries should be performed by midwives in community clinics. The number of community maternity clinics should gradually be increased to enable home deliveries by TBAs to be phased out. Facilities should be improved for delivery and postnatal care in hospitals and the proportion of sick babies managed by health care workers trained in their care should be increased. Regular postnatal checks in the community by trained staff should be standard

Who Is missing-out on school? Exploring socioeconomic inequalities in school absenteeism

The strong relationship between family background and school performance among secondary pupils is a well-established finding in the cross-national comparative literature (Van de Werfhorst and Mijs 2010) and for Scotland (Sosu and Ellis 2014). “Closing the attainment gap” between children from lower and higher socioeconomic backgrounds is the main priority of the Scottish government’s education policy (Scottish Government 2016). A potential mechanism that may help to account for the association between family background and school performance is school absenteeism. Being absent from school may result from legitimate (e.g. sickness) or illegitimate reasons (e.g. truancy), as well as exclusion from school. In the school year 2014/2015, the total rate of absence for secondary schools in Scotland was 8.1% with significant differences between low (12%) and high-income (5.5%) neighbourhoods (Scottish Government, 2015). Several studies have found that school absenteeism is linked to lower educational achievement (Aucejo and Romano 2016; Buscha and Conte 2014; Gottfried 2011; London, Sanchez and Castrechini 2016; Steward et al. 2008). This is because absent students miss out on teacher-led lessons, peer interactions or activities that may stimulate their learning and ultimately their performance in exams. In addition, they might feel less integrated into their class and struggle to participate in classroom activities and interactions with peers and teachers which, in turn, is detrimental to their learning. Importantly, school absenteeism may be particularly harmful for children from lower socio-economic backgrounds as their parents have neither the time nor resources to compensate for school absence by supporting their children in engaging with the content of the missed school lessons. The relationship between family background and school absenteeism may operate through health-related behaviour (e.g. Moonie et al. 2006), environmental hazards (e.g. Currie et al. 2009), residential and school mobility (Nolan et al. 2013), family structure and environment (Evans 2004), and parental employment characteristics (Han 2005). Although a few studies show that students from the lower socio-economic background are more often absent from school (Attwood and Croll 2006; Nolan et al. 2013; Theriot, Craun and Dupper 2010), they do not address if and and to what extent parental resources are associated with absenteeism. Additionally, it is not clear if students from lower socioeconomic backgrounds or specific family structures are more likely to experience particular forms of absenteeism- such as exclusion- possibly due to the tendency for teacher bias towards students from low-income households (Campbell, 2015). Finally, it is not clear if boys and girls from different socioeconomic backgrounds experience absenteeism in the same way. This study attempts to fill the existing knowledge gaps in trying to answer the following questions: 1. To what extent do different socioeconomic factors (parental education, parental class or neighbourhood deprivation) and family structures (Eg. single parent, number of siblings) determine school absenteeism? 2. Do students from lower socioeconomic backgrounds or specific family structures differ in their experience of particular forms of school absenteeism (legitimate absence, truancy and exclusion)? 3. Drawing on the theory of intersectionality, does the relationship between socioeconomic backgrounds and school absenteeism differ between boys and girls

School absenteeism and academic achievement : Is missing-out on school more detrimental to students from lower socioeconomic backgrounds?

Significant social inequalities in academic achievement are well established. Evidence suggests that students from lower socioeconomic backgrounds are more frequently absent from school. Whereas school absenteeism is a potential mechanism for explaining the social inequality in academic achievement, empirical evidence on the link between absenteeism and achievement is sparse. Additionally, it is not clear if different forms of absenteeism have the same detrimental effect on achievement. Absent students miss out on teacher-led lessons, peer interactions or activities that may stimulate their learning and ultimately their performance in exams. In addition, they might feel less integrated into their class and struggle to participate in classroom activities and interactions with peers and teachers which, in turn, is harmful to their learning. Importantly, school absenteeism may be particularly detrimental to children from lower socio-economic backgrounds as their parents have neither the time nor resources to compensate for school absence by supporting their children in engaging with the content of the missed school lessons. In this paper, we first examine the association between different types of school absenteeism (legitimate absence, truancy and exclusion) and academic achievement in secondary school. Besides, we consider whether the association between absenteeism and academic achievement varies between different socioeconomic groups and family structures. We analysed a sample (N=5,000) from the Scottish Longitudinal Study (SLS) by linking census, school administrative and achievement, and administrative health data. The unique SLS data provided us with a rich set of confounders from the Census and health data in estimating the adjusted association between school absenteeism and academic achievement using regression-based approaches. We will discuss the data linkage process as well as the policy and practice implications of our findings

School Absenteeism and Academic Achievement:Does the Reason for Absence Matter?

Studies consistently show associations between school absences and academic achievement. However, questions remain about whether this link depends on the reason for children's absence. Using a sample of the Scottish Longitudinal Study (n = 4,419), we investigated whether the association between school absenteeism and achievement in high-stakes exams at the end of compulsory and post-compulsory schooling varies with the reason for absence. In line with previous research, our findings show that overall absences are negatively associated with academic achievement at both school stages. Likewise, all forms of absences (truancy, sickness absence, exceptional domestic circumstances, family holidays) are negatively associated with achievement at the end of compulsory and post-compulsory schooling. First difference regressions confirm these negative associations, except for family holidays. These results suggest that, in addition to lost instruction, other mechanisms such as behavioral, health-related, and psychosocial pathways may account for the association between absenteeism and achievement. The findings have implications for designing tailored absenteeism interventions to improve pupils' academic achievement

Socioeconomic Inequalities in School Attendance in Scotland : Research Brief

School absenteeism is a pervasive problem in education worldwide and Scotland. Persistent absenteeism has a significant impact at both a societal and individual level. Frequently missing school is associated with poorer academic performance, a higher likelihood of school dropout, and a lower probability of going on to further or higher education. At a societal level, we can see a knock-on effect of associations between absenteeism and lower rates of employment; higher likelihood of delinquency; and increased contact with the criminal justice system, and imprisonment

Socioeconomic status and school absenteeism:A systematic review and narrative synthesis

School absenteeism is detrimental to life course outcomes and is known to be socioeconomically stratified. However, the link between socioeconomic status (SES) and school absence is complex given the multidimensional nature of both family SES (e.g., income, education, occupational status) and absenteeism (e.g., truancy, sickness, suspension). Despite the vast literature on socioeconomic inequalities in school attendance, no systematic review on SES and school absenteeism exists. This study systematically reviewed and provides a narrative synthesis of journal articles (n = 55) published between 1998 to 2019 on the association between SES dimensions and forms of absenteeism. The majority of studies from high-income contexts found an association between SES and absenteeism in the expected direction, albeit on average with small effect sizes. Studies largely confirmed these findings among populations at risk of school absence and those from low- and middle-income countries. There was greater evidence for an association between absenteeism and SES measured at the family than the school level. Studies using SES measures of financial resources (e.g., free or reduced-price lunch) provided more evidence for this association than studies measuring sociocultural resources (e.g., parental education). There is limited evidence that socioeconomic achievement gaps in absenteeism vary by the reasons for absence. Research on the mediating pathways between SES and absenteeism is sparse. A key implication is that attempts to address inequalities in educational outcomes must include tackling SES gaps in school attendance

Rural-urban variation in insecticide-treated net utilization among pregnant women:evidence from 2018 Nigeria Demographic and Health Survey

Background: In 2018, Nigeria accounted for the highest prevalence of malaria worldwide. Pregnant women and children under five years bear the highest risk of malaria. Geographical factors affect utilization of insecticide-treated nets (ITN), yet existing literature have paid little attention to the rural-urban dimension of ITN utilization in Nigeria. This study aimed at investigating the rural-urban variation in ITN utilization among pregnant women in Nigeria using data from the 2018 Demographic and Health Survey.Methods: A total of 2909 pregnant women were included in the study. The prevalence of ITN utilization for rural and urban pregnant women of Nigeria were presented with descriptive statistics. Chi-square test was employed to assess the association between residence, socio-demographic characteristics and ITN utilization at 95% level of significance. Subsequently, binary logistic regression was used to assess the influence of residence on ITN utilization.Results: Eight out of ten of the rural residents utilized ITN (86.1%) compared with 74.1% among urban residents. Relative to urban pregnant women, those in rural Nigeria had higher odds of utilizing ITNs both in the crude [cOR = 2.17, CI = 1.66-2.84] and adjusted models [aOR = 1.18, CI = 1.05-1.24]. Pregnant women aged 40-44 had lower odds of ITN utilization compared to those aged 15-19 [aOR = 0.63, CI = 0.44-0.92]. Poorer pregnant women had higher odds of ITN utilization compared with poorest pregnant women [aOR = 1.09, CI = 1.04-1.32]. Across regions, those in the south [aOR = 0.26, CI = 0.14-0.49] and south-west [aOR = 0.29, CI = 0.16-0.54] had lower odds of ITN use compared to their counterparts in the north-west region.Conclusion: The high use of ITNs among pregnant women in Nigeria may be due to the prioritization of rural communities by previous interventions. This is a dimension worth considering to enhance the attainment of the national anti-malarial initiatives. Since possession of ITN is not a guarantee for utilization, women in urban locations need constant reminder of ITN use through messages delivered at ANC and radio advertisements. Moreover, subsequent mass ITN campaigns ought to take cognizance of variations ITN use across regions and pragmatic steps be taken to increase the availability of ITN in households since there is a moderately high use in households with at least one ITN in Nigeria.</p

Effects of Chronic Hepatitis B Infection on Pregnancy and Birth Outcomes in Ghana

Ghana is a known endemic area for hepatitis B virus (HBV) infections, yet the consequences of HBV infection on pregnancy outcomes are unknown. This prospective cohort study was thus conducted among 512 pregnant women attending antenatal clinic in the Cape Coast Teaching Hospital, Ghana, between January, 2011 and December, 2013 to determine the effects of hepatitis B during pregnancy on birth outcomes in Ghana. The HBsAg status of all pregnant women was determined by the latex agglutination test while a researcher administered semi-structured checklist was used to collect demographic/obstetric/medical data of respondents. We obtained 262 HBsAg positive and 250 HBsAg negative women most of whom were aged 20-29 (40%), classified themselves as low income earners (50%), and had attained primary education (42%). Logistic regression analysis showed that pregnant women who had chronic hepatitis B were more likely to develop PROM (p=0.008) and foul smelling liquor (p=0.024) at delivery. Moreover, neonatal consequences for chronic hepatitis B were; preterm babies (p=0.002), underweight (p\u3c0.001), Apgar score lower than 7 (p\u3c0.001), asphyxia at birth (p=0.006) and still birth (p=0.04). We conclude that babies born to mothers with positive HBsAg status have a higher risk for vertical transmission as well as adverse neonatal consequences

Neonatal mortality rates, characteristics, and risk factors for neonatal deaths in Ghana:analyses of data from two health and demographic surveillance systems

BACKGROUND: Reducing neonatal mortality rates (NMR) in developing countries is a key global health goal, but weak registration systems in the region stifle public health efforts. OBJECTIVE: To calculate NMRs, investigate modifiable risk factors, and explore neonatal deaths by place of birth and death, and cause of death in two administrative areas in Ghana. METHODS: Data on livebirths were extracted from the health and demographic surveillance systems in Navrongo (2004-2012) and Kintampo (2005-2010). Cause of death was determined from neonatal verbal autopsy forms. Univariable and multivariable logistic regression were used to analyse factors associated with neonatal death. Multiple imputations were used to address missing data. RESULTS: The overall NMR was 18.8 in Navrongo (17,016 live births, 320 deaths) and 12.5 in Kintampo (11,207 live births, 140 deaths). The annual NMR declined in both areas. 54.7% of the births occurred in health facilities. 70.9% of deaths occurred in the first week. The main causes of death were infection (NMR 4.3), asphyxia (NMR 3.7) and prematurity (NMR 2.2). The risk of death was higher among hospital births than home births: Navrongo (adjusted OR 1.14, 95% CI: 1.03-1.25, p = 0.01); Kintampo (adjusted OR 1.76, 95% CI: 1.55-2.00, p < 0.01). However, a majority of deaths occurred at home (Navrongo 61.3%; Kintampo 50.7%). Among hospital births dying in hospital, the leading cause of death was asphyxia; among hospital and home births dying at home, it was infection. CONCLUSION: The NMR in these two areas of Ghana reduced over time. Preventing deaths by asphyxia and infection should be prioritised, centred respectively on improving post-delivery care in health facilities and subsequent post-natal care at home