Predictors of caesarean section in Northern Ghana: a case-control study

Introduction: Caesarean section rates have become a global public health. This study investigated obstetric and socio-demographic factors associated with caesarean section in northern Ghana. Methods: This was a case-control study comparing 150 women who had caesarean section (cases) and 300 women who had vaginal delivery (controls). Data were collected retrospectively from delivery registers, postpartum and postnatal registers in the Bolgatanga Regional Hospital. Univariate and multivariate analysis of data were done using SPSS 22. Results: The study revealed that women who had higher odds of having a caesarean section were women who; attended Antenatal care (ANC) ≥ 4 times (Adjusted OR= 2.99, 95% CI1.762-5.065), were referred from other health facilities (Adjusted OR = 1.19, 95% CI 1.108-1.337) and had a foetal weight of ≥ 4000 grams (Adjusted OR = 1.21, 95% CI 1.064-1.657). There was a slight increase in odds of having a caesarean section among women who had a gestational age > 40 weeks (Adjusted OR = 1.09, 95% CI 1.029-1.281). Women who had secondary/higher education (Adjusted OR = 0.55, 95% CI 0.320-0.941), gestational age < 37 weeks (Adjusted OR = 0.20, 95% CI: 0.100-0.412) and women who had a foetal weight of 1500 grams to 2499 grams (Adjusted OR = 0.17, 95% CI 0.086-0.339) were associated with a lower odds of having a caesarean section. Conclusion: There was an increase in odds of having a caesarean section among pregnant women who had a foetal weight of ≥ 4000 grams and women who attended ANC ≥ 4 times. Pregnant women who were referred also had increase odds of having a caesarean section

Does the operations of the National Health Insurance Scheme (NHIS) in Ghana align with the goals of primary health care? Perspectives of key stakeholders in northern Ghana

In 2005, the World Health Assembly (WHA) of the World Health Organization (WHO) urged member states to aim at achieving affordable universal coverage and access to key promotive, preventive, curative, rehabilitative and palliative health interventions for all their citizens on the basis of equity and solidarity. Since then, some African countries, including Ghana, have taken steps to introduce national health insurance reforms as one of the key strategies towards achieving universal health coverage (UHC). The aim of this study was to get a better understanding of how Ghana's health insurance institutions interact with stakeholders and other health sector programmes in promoting primary health care (PHC). Specifically, the study identified the key areas of misalignment between the operations of the NHIS and that of PHC.; Using qualitative and survey methods, this study involved interviews with various stakeholders in six selected districts in the Upper East region of Ghana. The key stakeholders included the National Health Insurance Authority (NHIA), district coordinators of the National Health Insurance Schemes (NHIS), the Ghana Health Service (GHS) and District Health Management Teams (DHMTs) who supervise the district hospitals, health centers/clinics and the Community-based Health and Planning Services (CHPS) compounds as well as other public and private PHC providers. A stakeholders' workshop was organized to validate the preliminary results which provided a platform for stakeholders to deliberate on the key areas of misalignment especially, and to elicit additional information, ideas and responses, comments and recommendations from respondents for the achievement of the goals of UHC and PHC.; The key areas of misalignments identified during this pilot study included: delays in reimbursements of claims for services provided by health care providers, which serves as a disincentive for service providers to support the NHIS; inadequate coordination among stakeholders in PHC delivery; and inadequate funding for PHC, particularly on preventive and promotive services. Other areas are: the bypassing of PHC facilities due to lack of basic services at the PHC level such as laboratory services, as well as proximity to the district hospitals; and finally the lack of clear understanding of the national policy on PHC.; This study suggests that despite the progress that has been made since the establishment of the NHIS in Ghana, there are still huge gaps that need urgent attention to ensure that the goals of UHC and PHC are met. The key areas of misalignment identified in this study, particularly on the delays in reimbursements need to be taken seriously. It is also important for more dialogue between the NHIA and service providers to address key concerns in the implementation of the NHIS which is key to achieving UHC

The Ghana Community-based Health Planning and Services Initiative: Fostering evidence-based organizational change and development in a resource-constrained setting

Research projects demonstrating ways to improve health services often fail to have an impact on what national health programs actually do. An approach to evidence-based policy development has been launched in Ghana that bridges the gap between research and program implementation. The Community-based Health Planning and Services (CHPS) initiative employs strategies tested in the successful Navrongo experiment to guide national health reforms that mobilize volunteers, resources, and cultural institutions to support community-based primary health care. Over the 1999 to 2002 period, 100 out of the 110 districts in Ghana adopted a CHPS initiative. This paper reviews features of the initiative that explain its success and constrain future progress

The Application of Geographic Information Systems (GIS) to Improving Health Systems in the Upper East Region of Ghana

Despite the increased use of Geographic Information System (GIS) for health research, the technology is least used in settings where evidence based decision-making is needed most: High mortality settings of Africa where resource constraints impede the provision of essential care. This paper reports on a case study of GIS application in the Upper East Region (UER), one of the poorest regions in Ghana. Methods: Ghana Health Service (GHS) workers were trained to use GPS handheld devices to gather waypoints (coordinates) of all health care facilities and amenities throughout the UER. The waypoints data were then exported to Excel spreadsheets and cleaned of all inconsistencies. The final data was imported into ArcMap 10.2.2 software for data manipulation, display, and analysis. Results: Preventive health issues portrayed by GIS visualization included a substandard access to potable water in one community and health facility deficiencies in the Binduri district. As examples of GIS morbidity surveillance, we map the temporal incidence of cholera in two districts, and evidence of a pattern in the seasonal outbreaks of cerebral spinal meningitis (CSM). Conclusion: Results attest to the feasibility of using GIS to clarify health issues in a severely health service deprived setting, enabling public health authorities to optimize system responses where mostly needed. GIS technology has enabled health officials in the region to visualize the geographic pattern of disease outbreaks in ways that permit the imposition of efficient containment strategies

Socio-economic and demographic disparities in ownership and use of insecticide-treated bed nets for preventing malaria among rural reproductive-aged women in northern Ghana

Background Malaria continues to be a leading cause of morbidity and mortality in most countries in Sub-Saharan Africa. Insecticide-treated bed nets (ITNs) is one of the cost-effective interventions for preventing malaria in endemic settings. Ghana has made tremendous efforts to ensure widespread ownership and use of ITNs. However, national coverage statistics can mask important inequities that demand targeted attention. This study assesses the disparities in ownership and utilization of ITNs among reproductive-aged women in a rural impoverished setting of Ghana. Methods Population-based cross-sectional data of 3,993 women between the age of 15 and 49 years were collected in seven districts of the Upper East region of Ghana using a two-stage cluster sampling approach. Bivariate and multivariate regression models were used to assess the social, economic and demographic disparities in ownership and utilization of ITN and to compare utilization rates among women in households owning at least one ITN. Results As high as 79% of respondents were found to own ITN while 62% of ITN owners used them the night preceding the survey. We identified disparities in both ownership and utilization of ITNs in wealth index, occupational status, religion, and district of residence. Respondents in the relative richest wealth quintile were 74% more likely to own ITNs compared to those in the poorest quintile (p-value< 0.001, CI = 1.29–2.34) however, they were 33% less likely to use ITNs compared to the poorest (p-value = 0.01, CI = 0.50–0.91). Conclusion Interventions aimed at preventing and controlling malaria through the use of bed nets in rural Ghana and other similar settings should give more attention to disadvantage populations such as the poor and unemployed. Tailored massages and educational campaigns are required to ensure consistent use of treated bed nets

Cost of implementing a community-based primary health care strengthening program: The case of the Ghana Essential Health Interventions Program in northern Ghana

Background The absence of implementation cost data constrains deliberations on consigning resources to community-based health programs. This paper analyses the cost of implementing strategies for accelerating the expansion of a community-based primary health care program in northern Ghana. Known as the Ghana Essential Health Intervention Program (GEHIP), the project was an embedded implementation science program implemented to provide practical guidance for accelerating the expansion of community-based primary health care and introducing improvements in the range of services community workers can provide. Methods Cost data were systematically collected from intervention and non-intervention districts throughout the implementation period (2012–2014) from a provider perspective. The step-down allocation approach to costing was used while WHO health system blocks were adopted as cost centers. We computed cost without annualizing capital cost to represent financial cost and cost with annualizing capital cost to represent economic cost. Results The per capita financial cost and economic cost of implementing GEHIP over a three-year period was $1.79, and$1.07 respectively. GEHIP comprised only 3.1% of total primary health care cost. Health service delivery comprised the largest component of cost (37.6%), human resources was 28.6%, medicines was 13.6%, leadership/governance was 12.8%, while health information comprised 7.5% of the economic cost of implementing GEHIP. Conclusion The per capita cost of implementing the GEHIP program was low. GEHIP project investments had a catalytic effect that improved community-based health planning and services (CHPS) coverage and enhanced the efficient use of routine health system resources rather than expanding overall primary health care costs

Supplementary polio immunization activities and prior use of routine immunization services in non-polio-endemic sub-Saharan Africa

OBJECTIVE: To determine participation in polio supplementary immunization activities (SIAs) in sub-Saharan Africa among users and non-users of routine immunization services and among users who were compliant or non-compliant with the routine oral poliovirus vaccine (OPV) immunization schedule. METHODS: Data were obtained from household-based surveys in non-polio-endemic sub-Saharan African countries. Routine immunization service users were children (aged < 5 years) who had ever had a health card containing their vaccination history; non-users were children who had never had a health card. Users were considered compliant with the OPV routine immunization schedule if, by the SIA date, their health card reflected receipt of required OPV doses. Logistic regression measured associations between SIA participation and use of both routine immunization services and compliance with routine OPV among users. FINDINGS: Data from 21 SIAs conducted between 1999 and 2010 in 15 different countries met inclusion criteria. Overall SIA participation ranged from 70.2% to 96.1%. It was consistently lower among infants than among children aged 1–4 years. In adjusted analyses, participation among routine immunization services users was > 85% in 12 SIAs but non-user participation was > 85% in only 5 SIAs. In 18 SIAs, participation was greater among users (P < 0.01 in 16, 0.05 in 1 and < 0.10 in 1) than non-users. In 14 SIAs, adjusted analyses revealed lower participation among non-compliant users than among compliant users (P < 0.01 in 10, < 0.05 in 2 and < 0.10 in 2). CONCLUSION: Large percentages of children participated in SIAs. Prior use of routine immunization services and compliance with the routine OPV schedule showed a strong positive association with SIA participation

The child survival impact of the Ghana Essential Health Interventions Program: A health systems strengthening plausibility trial in Northern Ghana

Background: The Ghana Health Service in collaboration with partner institutions implemented a five-year primary health systems strengthening program known as the Ghana Essential Health Intervention Program (GEHIP). GEHIP was a plausibility trial implemented in an impoverished region of northern Ghana around the World Health Organizations (WHO) six pillars combined with community engagement, leadership development and grassroots political support, the program organized a program of training and action focused on strategies for saving newborn lives and community-engaged emergency referral services. This paper analyzes the effect of the GEHIP program on child survival. Methods: Birth history data assembled from baseline and endline surveys are used to assess the hazard of child mortality in GEHIP treatment and comparison areas prior to and after the start of treatment. Difference-in-differences (DiD) methods are used to compare mortality change over time among children exposed to GEHIP relative to children in the comparison area over the same time period. Models test the hypothesis that a package of systems strengthening activities improved childhood survival. Models adjusted for the potentially confounding effects of baseline differentials, secular mortality trends, household characteristics such as relative wealth and parental educational attainment, and geographic accessibility of clinical care. Results: The GEHIP combination of health systems strengthening activities reduced neonatal mortality by approximately one half (HR = 0.52, 95% CI = 0.28,0.98, p = 0.045). There was a null incremental effect of GEHIP on mortality of post-neonate infants (from 1 to 12 months old) (HR = 0.72; 95% CI = 0.30,1.79; p = 0.480) and post-infants (from 1 year to 5 years old) -(HR = 1.02; 95% CI = 0.55–1.90; p = 0.940). Age-specific analyses show that impact was concentrated among neonates. However, effect ratios for post-infancy were inefficiently assessed owing to extensive survival history censoring for the later months of childhood. Children were observed only rarely for periods over 40 months of age. Conclusion: GEHIP results show that a comprehensive approach to newborn care is feasible, if care is augmented by community-based nurses. It supports the assertion that if appropriate mechanisms are put in place to enable the various pillars of the health system as espoused by WHO in rural impoverished settings where childhood mortality is high, it could lead to accelerated reductions in mortality thereby increasing survival of children. Policy implications of the pronounced neonatal effect of GEHIP merit national review for possible scale-up