BackgroundSlow 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.MethodsA 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.ResultsOnly 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).ConclusionThe 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.

This paper describes factors affecting health worker motivation and satisfaction in the public sector in Ghana. The data are from a survey of public sector health care providers carried out in January 2002 and repeated in August 2003 using an interviewer administered structured questionnaire. It is part of a continuous quality improvement (CQI) effort in the health sector in the Greater Accra region of Ghana. Workplace obstacles identified that caused dissatisfaction and de-motivated staff in order of the most frequently mentioned were low salaries such that obtaining basic necessities of daily living becomes a problem; lack of essential equipment, tools and supplies to work with; delayed promotions; difficulties and inconveniences with transportation to work; staff shortages; housing, additional duty allowances and in-service (continuous) training. Others included children's education, vehicles to work with such as ambulances and pickups, staff transfer procedures, staff pre-service education inadequate for job requirements, and the effect of the job on family and other social factors. There were some differences in the percentages of staff selecting a given workplace obstacle between the purely rural districts, the highly urbanized Accra metropolis and the districts that were a mixture of urbanized and rural. It is unlikely that the Ghana Health Service can provide high quality of care to its end users (external customers) if workplace obstacles that de-motivate staff (internal customers) and negatively influence their performance are not properly recognized and addressed as a complex of inter-related problems producing a common result--dissatisfied poorly motivated staff and resulting poor quality services.

Objective To test in West Africa the impact of rapid diagnostic tests on the prescription of antimalarials and antibiotics both where microscopy is used for the diagnosis of malaria and in clinical (peripheral) settings that rely on clinical diagnosis. Design Randomised, controlled, open label clinical trial. Setting Four clinics in the rural Dangme West district of southern Ghana, one in which microscopy is used for diagnosis of malaria ("microscopy setting") and three where microscopy is not available and diagnosis of malaria is made on the basis of clinical symptoms ("clinical setting"). Participants Patients with suspected malaria. Interventions Patients were randomly assigned to either a rapid diagnostic test or the current diagnostic method at the clinic (microscopy or clinical diagnosis). A blood sample for a research microscopy slide was taken for all patients. Main outcome measures The primary outcome was the prescription of antimalarials to patients of any age whose double read research slide was negative for malaria. The major secondary outcomes were the correct prescription of antimalarials, the impact of test results on antibiotic prescription, and the correct prescription of antimalarials in children under 5 years. Results Of the 9236 patients screened, 3452 were randomised in the clinical setting and 3811 in the microscopy setting. Follow-up to 28 days was 97.6% (7088/7263). In the microscopy setting, 722 (51.6%) of the 1400 patients with negative research slides in the rapid diagnostic test arm were treated for malaria compared with 764 (55.0%) of the 1389 patients in the microscopy arm (adjusted odds ratio 0.87, 95% CI 0.71 to 1.1; P=0.16). In the clinical setting, 578 (53.9%) of the 1072 patients in the rapid diagnostic test arm with negative research slides were treated for malaria compared with 982 (90.1%) of the 1090 patients with negative slides in the clinical diagnosis arm (odds ratio 0.12, 95% CI 0.04 to 0.38; P=0.001). The use of rapid diagnostic tests led to better targeting of antimalarials and antibiotics in the clinical but not the microscopy setting, in both children and adults. There were no deaths in children under 5 years at 28 days follow-up in either arm. Conclusion Where microscopy already exists, introducing rapid diagnostic tests had limited impact on prescriber behaviour. In settings where microscopy was not available, however, using rapid diagnostic tests led to a significant reduction in the overprescription of antimalarials, without any evidence of clinical harm, and to better targeting of antibiotics. Trial registration ClinicalTrials.gov NCT00493922.

BackgroundLow- and middle-income countries (LMICs) face the highest burden of maternal and neonatal deaths. Concurrently, they have the lowest number of physicians. Innovative methods such as the exchange of health-related information using mobile devices (mHealth) may support health care workers in the provision of antenatal, delivery, and postnatal care to improve maternal and neonatal outcomes in LMICs.ObjectiveWe conducted a systematic review evaluating the effectiveness of mHealth interventions targeting health care workers to improve maternal and neonatal outcomes in LMIC.MethodsThe Cochrane Library, PubMed, EMBASE, Global Health Library, and Popline were searched using predetermined search and indexing terms. Quality assessment was performed using an adapted Cochrane Risk of Bias Tool. A strength, weakness, opportunity, and threat analysis was performed for each included paper.ResultsA total of 19 studies were included for this systematic review, 10 intervention and 9 descriptive studies. mHealth interventions were used as communication, data collection, or educational tool by health care providers primarily at the community level in the provision of antenatal, delivery, and postnatal care. Interventions were used to track pregnant women to improve antenatal and delivery care, as well as facilitate referrals. None of the studies directly assessed the effect of mHealth on maternal and neonatal mortality. Challenges of mHealth interventions to assist health care workers consisted mainly of technical problems, such as mobile network coverage, internet access, electricity access, and maintenance of mobile phones.ConclusionsmHealth interventions targeting health care workers have the potential to improve maternal and neonatal health services in LMICs. However, there is a gap in the knowledge whether mHealth interventions directly affect maternal and neonatal outcomes and future research should employ experimental designs with relevant outcome measures to address this gap.

Objective To examine the impact of providing rapid diagnostic tests for malaria on fever management in private drug retail shops where most poor rural people with fever present, with the aim of reducing current massive overdiagnosis and overtreatment of malaria.Design Cluster randomized trial of 24 clusters of shops.

IntroductionThe continuum of care has recently received attention in maternal, newborn and child health. It can be an effective policy framework to ensure that every woman and child receives timely and appropriate services throughout the continuum. However, a commonly used measurement does not evaluate if a pair of woman and child complies with the continuum of care. This study assessed the continuum of care based on two measurements: continuous visits to health facilities (measurement 1) and receiving key components of services (measurement 2). It also explored individual-level and area-level factors associated with the continuum of care achievement and then investigated how the continuum of care differed across areas.MethodsIn this cross-sectional study in Ghana in 2013, the continuum of care achievement and other characteristics of 1401 pairs of randomly selected women and children were collected. Multilevel logistic regression was used to estimate the factors associated with the continuum of care and its divergence across 22 areas.ResultsThroughout the pregnancy, delivery and post-delivery stages, 7.9% of women and children achieved the continuum of care through continuous visits to health facilities (measurement 1). Meanwhile, 10.3% achieved the continuum of care by receiving all key components of maternal, newborn and child health services (measurement 2). Only 1.8% of them achieved it under both measurements. Women and children from wealthier households were more likely to achieve the continuum of care under both measurements. Women’s education and complications were associated with higher continuum of care services-based achievement. Variance of a random intercept was larger in the continuum of care services-based model than the visit-based model.ConclusionsMost women and children failed to achieve the continuum of care in maternal, newborn and child health. Those who consistently visited health facilities did not necessarily receive key components of services.

BackgroundNeonatal mortality is a global challenge; identification of individual and community determinants associated with it are important for targeted interventions. However in most low and middle income countries (LMICs) including Ghana this problem has not been adequately investigated as the impact of contextual factors remains undetermined despite their significant influence on under-five mortality and morbidity.MethodsBased on a modified conceptual framework for child survival, hierarchical modelling was deployed to examine about 6,900 women, aged 15 – 49 years (level 1), nested within 412 communities (level 2) in Ghana by analysing combined data of the 2003 and 2008 Ghana Demographic and Health Survey. The aim was to identify individual (maternal, paternal, neonatal, antenatal, delivery and postnatal) and community (socioeconomic disadvantage communities) determinants associated with neonatal mortality.ResultsThe results showed both individual and community characteristics to be associated with neonatal mortality. Infants of multiple-gestation [OR 5.30; P-value < 0.001; 95% CI 2.81 – 10.00], neonates with inadequate birth spacing [OR 3.47; P-value < 0.01; 95% CI 1.60 – 7.57] and low birth weight [OR 2.01; P-value < 0.01; 95% CI 1.23 – 3.30] had a lower chance of surviving the neonatal period. Similarly, infants of grand multiparous mothers [OR 2.59; P-value < 0.05; 95% CI 1.03 – 6.49] and non-breastfed infants [OR 142.31; P-value < 0.001; 95% CI 80.19 – 252.54] were more likely to die during neonatal life, whereas adequate utilization of antenatal, delivery and postnatal health services [OR 0.25; P-value < 0.001; 95% CI 0.13 – 0.46] reduced the likelihood of neonatal mortality. Dwelling in a neighbourhood with high socioeconomic deprivation was associated with increased neonatal mortality [OR 3.38; P-value < 0.01; 95% CI 1.42 – 8.04].ConclusionBoth individual and community characteristics show a marked impact on neonatal survival. Implementation of community-based interventions addressing basic education, poverty alleviation, women empowerment and infrastructural development and an increased focus on the continuum-of-care approach in healthcare service will improve neonatal survival.

BackgroundContinuum of care has the potential to improve maternal, newborn, and child health (MNCH) by ensuring care for mothers and children. Continuum of care in MNCH is widely accepted as comprising sequential time (from pre-pregnancy to motherhood and childhood) and space dimensions (from community-family care to clinical care). However, it is unclear which linkages of care could have a greater effect on MNCH outcomes. The objective of the present study is to assess the effectiveness of different continuum of care linkages for reducing neonatal, perinatal, and maternal mortality in low- and middle-income countries.MethodsWe searched for randomized and quasi-randomized controlled trials that addressed two or more linkages of continuum of care and attempted to increase mothers’ uptake of antenatal care, skilled birth attendance, and postnatal care. The outcome variables were neonatal, perinatal, and maternal mortality.ResultsOut of the 7,142 retrieved articles, we selected 19 as eligible for the final analysis. Of these studies, 13 used packages of intervention that linked antenatal care, skilled birth attendance, and postnatal care. One study each used packages that linked antenatal care and skilled birth attendance or skilled birth attendance and postnatal care. Four studies used an intervention package that linked antenatal care and postnatal care. Among the packages that linked antenatal care, skilled birth attendance, and postnatal care, a significant reduction was observed in combined neonatal, perinatal, and maternal mortality risks (RR 0.83; 95% CI 0.77 to 0.89, I2 79%). Furthermore, this linkage reduced combined neonatal, perinatal, and maternal mortality when integrating the continuum of care space dimension (RR 0.85; 95% CI 0.77 to 0.93, I2 81%).ConclusionsOur review suggests that continuous uptake of antenatal care, skilled birth attendance, and postnatal care is necessary to improve MNCH outcomes in low- and middle-income countries. The review was conclusive for the reduction of neonatal and perinatal deaths. Although maternal deaths were not significantly reduced, composite measures of all mortality were. Thus, the evidence is sufficient to scale up this intervention package for the improvement of MNCH outcomes.