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      Continuum of Care in a Maternal, Newborn and Child Health Program in Ghana: Low Completion Rate and Multiple Obstacle Factors

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          Abstract

          Background

          Slow progress has been made in achieving the Millennium Development Goals 4 and 5 in Ghana. Ensuring continuum of care (at least four antenatal visits; skilled birth attendance; postnatal care within 48 hours, at two weeks, and six weeks) for mother and newborn is crucial in helping Ghana achieve these goals and beyond. This study examined the levels and factors associated with continuum of care (CoC) completion among Ghanaian women aged 15–49.

          Methods

          A retrospective cross-sectional survey was conducted among women who experienced live births between January 2011 and April 2013 in three regions of Ghana. In a two-stage random sampling method, 1,500 women with infants were selected and interviewed about maternal and newborn service usage in line with CoC. Multiple logistic regression models were used to assess factors associated with CoC completion.

          Results

          Only 8.0% had CoC completion; the greatest gap and contributor to the low CoC was detected between delivery and postnatal care within 48 hours postpartum. About 95% of women had a minimum of four antenatal visits and postnatal care at six weeks postpartum. A total of 75% had skilled assisted delivery and 25% received postnatal care within 48 hours. Factors associated with CoC completion at 95% CI were geographical location (OR = 0.35, CI 0.13–0.39), marital status (OR = 0.45; CI 0.22–0.95), education (OR = 2.71; CI 1.11–6.57), transportation (OR = 1.97; CI 1.07–3.62), and beliefs about childhood illnesses (OR = 0.34; CI0.21–0.61).

          Conclusion

          The continuum of care completion rate is low in the study site. Efforts should focus on increasing postnatal care within 48 hours and overcoming the known obstacles to increasing the continuum of care completion rate.

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          Most cited references36

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          The association of neighbourhood and individual social capital with consistent self-rated health: a longitudinal study in Brazilian pregnant and postpartum women

          Background Social conditions, social relationships and neighbourhood environment, the components of social capital, are important determinants of health. The objective of this study was to investigate the association of neighbourhood and individual social capital with consistent self-rated health in women between the first trimester of pregnancy and six months postpartum. Methods A multilevel cohort study in 34 neighbourhoods was performed on 685 Brazilian women recruited at antenatal units in two cities in the State of Rio de Janeiro, Brazil. Self-rated health (SRH) was assessed in the 1st trimester of pregnancy (baseline) and six months after childbirth (follow-up). The participants were divided into two groups: 1. Good SRH – good SRH at baseline and follow-up, and, 2. Poor SRH – poor SRH at baseline and follow-up. Exploratory variables collected at baseline included neighbourhood social capital (neighbourhood-level variable), individual social capital (social support and social networks), demographic and socioeconomic characteristics, health-related behaviours and self-reported diseases. A hierarchical binomial multilevel analysis was performed to test the association between neighbourhood and individual social capital and SRH, adjusted for covariates. Results The Good SRH group reported higher scores of social support and social networks than the Poor SRH group. Although low neighbourhood social capital was associated with poor SRH in crude analysis, the association was not significant when individual socio-demographic variables were included in the model. In the final model, women reporting poor SRH both at baseline and follow-up had lower levels of social support (positive social interaction) [OR 0.82 (95% CI: 0.73-0.90)] and a lower likelihood of friendship social networks [OR 0.61 (95% CI: 0.37-0.99)] than the Good SRH group. The characteristics that remained associated with poor SRH were low level of schooling, Black and Brown ethnicity, more children, urinary infection and water plumbing outside the house. Conclusions Low individual social capital during pregnancy, considered here as social support and social network, was independently associated with poor SRH in women whereas neighbourhood social capital did not affect women’s SRH during pregnancy and the months thereafter. From pregnancy and up to six months postpartum, the effect of individual social capital explained better the consistency of SRH over time than neighbourhood social capital.
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            Factors Affecting Antenatal Care Attendance: Results from Qualitative Studies in Ghana, Kenya and Malawi

            Background Antenatal care (ANC) is a key strategy to improve maternal and infant health. However, survey data from sub-Saharan Africa indicate that women often only initiate ANC after the first trimester and do not achieve the recommended number of ANC visits. Drawing on qualitative data, this article comparatively explores the factors that influence ANC attendance across four sub-Saharan African sites in three countries (Ghana, Kenya and Malawi) with varying levels of ANC attendance. Methods Data were collected as part of a programme of qualitative research investigating the social and cultural context of malaria in pregnancy. A range of methods was employed interviews, focus groups with diverse respondents and observations in local communities and health facilities. Results Across the sites, women attended ANC at least once. However, their descriptions of ANC were often vague. General ideas about pregnancy care – checking the foetus’ position or monitoring its progress – motivated women to attend ANC; as did, especially in Kenya, obtaining the ANC card to avoid reprimands from health workers. Women’s timing of ANC initiation was influenced by reproductive concerns and pregnancy uncertainties, particularly during the first trimester, and how ANC services responded to this uncertainty; age, parity and the associated implications for pregnancy disclosure; interactions with healthcare workers, particularly messages about timing of ANC; and the cost of ANC, including charges levied for ANC procedures – in spite of policies of free ANC – combined with ideas about the compulsory nature of follow-up appointments. Conclusion In these socially and culturally diverse sites, the findings suggest that ‘supply’ side factors have an important influence on ANC attendance: the design of ANC and particularly how ANC deals with the needs and concerns of women during the first trimester has implications for timing of initiation.
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              Factors affecting home delivery in rural Tanzania.

              Studies of factors affecting place of delivery have rarely considered the influence of gender roles and relations within the household. This study combines an understanding of gender issues relating to health and help-seeking behaviour with epidemiological knowledge concerning place of delivery. In-depth interviews, focus group discussions and participant observation were used to explore determinants of home delivery in southern Tanzania. Quantitative data were collected in a cross-sectional survey of 21,600 randomly chosen households. Issues of risk and vulnerability, such as lack of money, lack of transport, sudden onset of labour, short labour, staff attitudes, lack of privacy, tradition and cultures and the pattern of decision-making power within the household were perceived as key determinants of the place of delivery. More than 9000 women were interviewed about their most recent delivery in the quantitative survey. There were substantial variations between ethnic groups with respect to place of delivery (P<0.0001). Women who lived in male-headed households were less likely to deliver in a health facility than women in female-headed households (RR 0.86, 95% CI 0.80-0.91). Mothers with primary and higher education were more likely to deliver at a health facility (RR 1.30, 95% CI 1.23-1.38). Younger mothers and the least poor women were also more likely to deliver in a health facility compared with the older and the poorest women, respectively. To address neonatal mortality, special attention should be paid to neonatal health in both maternal and child health programmes. The findings emphasize the need for a systematic approach to overcome health-system constraints, community based programmes and scale-up effective low-cost interventions which are already available.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                9 December 2015
                2015
                : 10
                : 12
                : e0142849
                Affiliations
                [1 ]Navrongo Health Research Centre, P.O. Box 114, Navrongo, Upper-East, Ghana
                [2 ]Department of Community and Global Health, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113–0033, Japan
                [3 ]Kintampo Health Research Centre, P.O. Box 200, Kintampo, Brong-Ahafo, Ghana
                [4 ]Dodowa Health Research Centre, P.O. Box DD1, Dodowa, Greater Accra, Ghana
                [5 ]Research and Development Division, Ghana Health Service, Accra MB 190, Ghana
                [6 ]Ghana Health Service Headquarters, Accra MB 190, Ghana
                Vanderbilt University, UNITED STATES
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: FY AS MJ AH. Performed the experiments: FY AS AO CD KK SOA MG SO EA GQA KN JW SA CT JY YE ES PW MJ AH. Analyzed the data: FY AS MJ SO PW. Wrote the paper: FY. Reviewed and finalized the manuscript: FY AS AO CD KK SOA MG SO EA GQA KN JW SA CT JY YE ES PW MJ AH.

                ¶ Membership of the Ghana EMBRACE Implementation Research Project Team is provided in the Acknowledgments.

                Article
                PONE-D-15-25827
                10.1371/journal.pone.0142849
                4674150
                26650388
                0e529433-84b8-4ce5-8012-5d279311ab5f
                © 2015 Yeji et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

                History
                : 12 June 2015
                : 26 October 2015
                Page count
                Figures: 2, Tables: 4, Pages: 23
                Funding
                This paper was funded by the Japan International Cooperation Agency (JICA) Human Development Department, and JICA Research Institute ( http://www.jica.go.jp/english/index.html). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Custom metadata
                The dataset used in this study is available upon request for ethical reasons. To request the data, contact Professor Masamine Jimba, Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo ( mjimba@ 123456m.u-tokyo.ac.jp ).

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