Background: This study was undertaken to investigate women's accounts of interactions with health care providers during labour and delivery and to assess the implications for acceptability and utilisation of maternity services in Ghana.

Malaria and pneumonia are leading causes of childhood mortality. Home Management of fever as Malaria (HMM) enables presumptive treatment with antimalarial drugs but excludes pneumonia. We aimed to evaluate the impact of adding an antibiotic, amoxicillin (AMX) to an antimalarial, artesunate amodiaquine (AAQ+AMX) for treating fever among children 2–59 months of age within the HMM strategy on all-cause mortality. In a stepped-wedge cluster-randomized, open trial, children 2–59 months of age with fever treated with AAQ or AAQ+AMX within HMM were compared with standard care. Mortality reduced significantly by 30% (rate ratio [RR] = 0.70, 95% confidence interval [CI] = 0.53– 0.92, P = 0.011) in AAQ clusters and by 44% (RR = 0.56, 95% CI = 0.41–0.76, P = 0.011) in AAQ+AMX clusters compared with control clusters. The 21% mortality reduction between AAQ and AAQ+AMX (RR = 0.79, 95% CI = 0.56 –1.12, P = 0.195) was however not statistically significant. Community fever management with antimalarials significantly reduces under-five mortality. Given the lower mortality trend, adding an antibiotic is more beneficial.

The relatively moderate rate of attrition could be attributed to the high level of community involvement in the selection process as well as other aspects of the intervention leading to high community approval and support. Attention for these aspects could help improve CHW retention in community-based health interventions in Ghana, and the lessons could be applied to countries within similar settings.

Increasing the proportion of deliveries with skilled attendance is widely regarded as key to reducing maternal mortality and morbidity in developing countries. The percentage of deliveries with a health professional is commonly used to assess skilled attendance, but measures only the presence of an attendant, not the skills used or the enabling environment. To supplement currently available information on the presence of an attendant at delivery, a method to measure the extent of skilled attendance at delivery through use of clinical records was devised. Data were collected from 416 delivery records in hospitals, government health centres and private non-hospital maternity facilities servicing Kintampo District, Ghana, using a case extraction form. Based on the defined criteria, summary measures of skilled attendance were calculated. Between 32.6% and 93.0% of the criteria for skilled attendance were met in the sample, with a mean of 65.5%. No delivery met all the criteria. A Skilled Attendance Index (SAI) was developed as a composite measure of delivery care. The SAI revealed that 26.9% of delivery records met at least three-quarters of the criteria for skilled attendance. Documentation of haemoglobin, current pregnancy complications, post-partum vital signs and completed partographs were amongst the criteria most poorly recorded. The purpose of applying these measures should be seen not as an end in itself but to advance improvements in delivery care. A 2004 Reproductive Health Matters. All rights reserved.Keywords: safe motherhood, skilled attendance at birth, delivery care, Ghana I NCREASING the proportion of deliveries with skilled attendance is now being promoted as an important approach to reducing maternal mortality and morbidity in developing countries. This is reflected in the published literature, 1,2 international initiatives 3 and safe motherhood programmes. 4 Current knowledge on the link between skilled attendance and maternal mortality is documented, as well as the limitations of the evidence.5 Skilled attendance is defined as ''the process by which a woman is provided with adequate care during labour, delivery and the early post-partum period' ' . 6 This requires a skilled person to attend the delivery and an enabling environment, including adequate supplies, equipment, transport and drugs. The indicator most commonly used to measure skilled attendance is the percentage of deliveries with a health professional, the information usually being obtained from community-based surveys by asking women to identify the attendant at each of their deliveries over the past three to five years. Much importance is placed on this indicator, and it is currently being used to measure achievement of the international Millennium Development Goal on maternal health. 7Data for this indicator are widely regarded as simple to collect, but the indicator is only a proxy measure of skilled attendance for several reasons. Firstly, only the presence of the health professional is measured, not their skills, and i...

Abstractobjective To assess the cost-effectiveness of two strategies of home management of under-five fevers in Ghana -treatment using antimalarials only (artesunate-amodiaquine -AAQ) and combined treatment using antimalarials and antibiotics (artesunate-amodiaquine plus amoxicillin -AAQ + AMX).methods We assessed the costs and cost-effectiveness of AAQ and AAQ + AMX compared with a control receiving standard care. Data were collected as part of a cluster randomised controlled trial with a step-wedged design. Approximately, 12 000 children aged 2-59 months in Dangme West District in southern Ghana were covered. Community health workers delivered the interventions. Costs were analysed from societal perspective, using anaemia cases averted, under-five deaths averted and disabilityadjusted life years (DALYs) averted as effectiveness measures.