Contextualising maternal morbidity through maternal health audits

Introduction: Recent efforts towards data collection on maternal health have focused on women who survived a life-threatening maternal morbidity (near miss). This has been based on the assumption that the causes of near misses are similar to those that lead to mortality. The work on near misses has shed significant light on challenges within health facilities. However, this focus overlooks critical insights that could be gained from an analysis of health systems more broadly defined to include the critical role played by major actors in communities. Methods: This research used a multi-method and grounded theory approach to obtain local explanations of the concept of life-threatening maternal complications and tested that understanding in a population survey in the Kassena-Nankana Districts of northern Ghana. A qualitative study with traditional healers and traditional birth attendants provided a comprehensive explanation of what communities might view as a life-threatening maternal complication. These explanations were used to screen pregnant women within the community to determine how well the explanations fit with women experiences of life-threatening maternal complications. Women who qualified as having survived a life-threatening maternal complication were administered a semi-structured audit tool to assess the underlying factors to maternal complications. Using focus groups and in-depth interviews, the study explored the relevance of sharing the audit results with community leaders in order to enlist their support in addressing challenges that women face during pregnancy. Results: The study findings revealed that communities have an understanding of what constitutes a life-threatening maternal condition and traditional healers play a key role in the management of these complications. They defined a "life-threatening maternal complication” as any health condition related to pregnancy that increased a woman's risk of dying. Using this definition in a population survey produced a prevalence of life-threatening maternal complications of 19.8%. An audit with women who had complications showed that not all women with life-threatening maternal complications access care at health facilities. Delays in recognising danger signs during pregnancy, delays in making the decision to seek care, delays in arriving at an appropriate place of care and delays in receiving treatment were reported by respondents. Community leaders expressed interest in pooling resources for their collective benefits but feared such an initiative would be limited by poverty, lack of trust, corruption and the reciprocity of benefits. Conclusions: The results show the feasibility of conducting a community audit on life-threatening maternal complications and the need to pursue an agenda to integrate traditional healers within the health system. A maternal morbidity audit model that integrates community engagement in the audit process is likely to get community leaders to think about interventions that need not directly address a specific cause but may nonetheless mitigate a pathway of causes

Persistent female genital mutilation despite its illegality: Narratives from women and men in northern Ghana.

BackgroundGlobally, an estimated two million women have undergone Female Genital Mutilation (FGM), and approximately four percent of women who have been circumcised live in Ghana. In the Bawku Municipality and Pusiga District, sixty one percent of women have undergone the procedure. This study therefore aimed at identifying the factors that sustain the practice of FGM despite its illegality, in the Bawku Municipality and the Pusiga District.MethodThis study used a descriptive qualitative design based on grounded theory. We used purposive sampling to identify and recruit community stakeholders, and then used the snowball sampling to identify, recruit, and interview circumcised women. We then used community stakeholders to identify two types of focus group participants: men and women of reproductive age and older men and women from the community. In-depth interviews and focus group discussions were conducted and qualitative analysis undertaken to develop a conceptual framework for understanding both the roots and the drivers of FGM.ResultsHistorical traditions and religious rites preserve FGM and ensure its continuity, and older women and peers are a source of support for the practice through the pressure they exert. The easy movement of women across borders (to where FGM is still practice) helps to perpetuate the practice, as does the belief that FGM will preserve virginity and reduce promiscuity. In addition, male dominance and lack of female autonomy ensures continuation of the practice.ConclusionFemale Genital Mutilation continues to persist despite its illegality because of social pressure on women/girls to conform to social norms, peer acceptance, fear of criticism and religious reasons. Implementing interventions targeting border towns, religious leaders and their followers, older men and women and younger men and women will help eradicate the practice

Optimising reporting of adverse events following immunisation by healthcare workers in Ghana: A qualitative study in four regions.

IntroductionDespite the emphasis on reporting of Adverse Events Following Immunisation (AEFIs) during didactic training sessions, especially prior to new vaccine introductions, it remains low in Ghana. We explored the factors underlying the under-reporting of AEFI by healthcare workers (HCWs) to provide guidance on appropriate interventions to increase reporting.MethodsWe conducted an exploratory descriptive in-depth study of the factors contributing to low reporting of AEFI among HCWs in four regions in Ghana. Key informant interviews (KII) were held with purposively selected individuals that are relevant to the AEFI reporting process at the district, regional, and national levels. We used KII guides to conduct in-depth interviews and used NVivo 10 qualitative software to analyse the data. Themes on factors influencing AEFI reporting were derived inductively from the data, and illustrative quotes from respondents were used to support the narratives.ResultsWe conducted 116 KIIs with the health managers, regulators and frontline HCWs and found that lack of information on reportable AEFIs and reporting structures, misunderstanding of reportable AEFIs, heavy workload, cost of reporting AEFIs, fear of blame by supervisors, lack of motivation, and inadequate feedback as factors responsible for underreporting of AEFIs. Respondents suggested that capacity building for frontline HCWs, effective supervision, the provision of motivation and feedback, simplification of reporting procedures, incentives for integrating AEFI reporting into routine monitoring and reporting, standardization of reporting procedures across regions, and developing appropriate interventions to address the fear of personal consequences would help improve AEFI reporting.ConclusionFrom the perspectives of a broad range of key informants at all levels of the vaccine safety system, we found multiple factors (both structural and behavioural), that may impact HCW reporting of AEFI in Ghana. Improvements in line with the suggestions are necessary for increased AEFI reporting in Ghana

Flowchart depicting Ghana national guidelines on PMTCT.

Flowchart depicting Ghana national guidelines on PMTCT.</p

Demographic characteristics of respondents.

Demographic characteristics of respondents.</p

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S1 File -

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Infant nutrition in the first seven days of life in rural northern Ghana

BACKGROUND: Good nutrition is essential for increasing survival rates of infants. This study explored infant feeding practices in a resource-poor setting and assessed implications for future interventions focused on improving newborn health. METHODS: The study took place in the Kassena-Nankana District of the Upper East Region of northern Ghana. In-depth interviews were conducted with 35 women with newborn infants, 8 traditional birth attendants and local healers, and 16 community leaders. An additional 18 focus group discussions were conducted with household heads, compound heads and grandmothers. All interviews and discussions were audio taped, transcribed verbatim and analyzed using NVivo 9.0. RESULTS: Community members are knowledgeable about the importance of breastfeeding, and most women with newborn infants do attempt to breastfeed. However, data suggest that traditional practices related to breastfeeding and infant nutrition continue, despite knowledge of clinical guidelines. Such traditional practices include feeding newborn infants water, gripe water, local herbs, or traditionally meaningful foods such as water mixed with the flour of guinea corn (yara’na). In this region in Ghana, there are significant cultural traditions associated with breastfeeding. For example, colostrum from first-time mothers is often tested for bitterness by putting ants in it – a process that leads to a delay in initiating breastfeeding. Our data also indicate that grandmothers – typically the mother-in-laws – wield enormous power in these communities, and their desires significantly influence breastfeeding initiation, exclusivity, and maintenance. CONCLUSION: Prelacteal feeding is still common in rural Ghana despite demonstrating high knowledge of appropriate feeding practices. Future interventions that focus on grandmothers and religious leaders are likely to prove valuable in changing community attitudes, beliefs, and practices with regard to infant nutrition

Why are babies dying in the first month after birth? A 7-year study of neonatal mortality in northern Ghana

OBJECTIVES: To determine the neonatal mortality rate in the Kassena-Nankana District (KND) of northern Ghana, and to identify the leading causes and timing of neonatal deaths. METHODS: The KND falls within the Navrongo Health Research Centre's Health and Demographic Surveillance System (HDSS), which uses trained field workers to gather and update health and demographic information from community members every four months. We utilized HDSS data from 2003-2009 to examine patterns of neonatal mortality. RESULTS: A total of 17,751 live births between January 2003 and December 2009 were recorded, including 424 neonatal deaths 64.8%(275) of neonatal deaths occurred in the first week of life. The overall neonatal mortality rate was 24 per 1000 live births (95%CI 22 to 26) and early neonatal mortality rate was 16 per 1000 live births (95% CI 14 to 17). Neonatal mortality rates decreased over the period from 26 per 1000 live births in 2003 to 19 per 1000 live births in 2009. In all, 32%(137) of the neonatal deaths were from infections, 21%(88) from birth injury and asphyxia and 18%(76) from prematurity, making these three the leading causes of neonatal deaths in the area. Birth injury and asphyxia (31%) and prematurity (26%) were the leading causes of early neonatal deaths, while infection accounted for 59% of late neonatal deaths. Nearly 46% of all neonatal deaths occurred during the first three postnatal days. In multivariate analysis, multiple births, gestational age <32 weeks and first pregnancies conferred the highest odds of neonatal deaths. CONCLUSIONS: Neonatal mortality rates are declining in rural northern Ghana, with majority of deaths occurring within the first week of life. This has major policy, programmatic and research implications. Further research is needed to better understand the social, cultural, and logistical factors that drive high mortality in the early days following delivery

AEFI reporting in Ghana (adapted from the Ghana FDA) [17].

AEFI reporting in Ghana (adapted from the Ghana FDA) [17].</p