Mary Amoakoh-Coleman

Assessing the Effect of mHealth Interventions in Improving Maternal and Neonatal Care in Low- and Middle-Income Countries: A Systematic Review.

Introduction Maternal and neonatal mortality remains high in many low- and middle-income countries (LMIC). Availability and use of mobile phones is increasing rapidly with 90% of persons in developing countries having a mobile-cellular subscription. Mobile health (mHealth) interventions have been proposed as effective solutions to improve maternal and neonatal health. This systematic review assessed the effect of mHealth interventions that support pregnant women during the antenatal, birth and postnatal period in LMIC. Methods The review was registered with Prospero (CRD42014010292). Six databases were searched from June 2014–April 2015, accompanied by grey literature search using pre-defined search terms linked to pregnant women in LMIC and mHealth. Quality of articles was assessed with an adapted Cochrane Risk of Bias Tool. Because of heterogeneity in outcomes, settings and study designs a narrative synthesis of quantitative results of intervention studies on maternal outcomes, neonatal outcomes, service utilization, and healthy pregnancy education was conducted. Qualitative and quantitative results were synthesized with a strengths, weaknesses, opportunities, and threats analysis. Results In total, 3777 articles were found, of which 27 studies were included: twelve intervention studies and fifteen descriptive studies. mHealth interventions targeted at pregnant women increased maternal and neonatal service utilization shown through increased antenatal care attendance, facility-service utilization, skilled attendance at birth, and vaccination rates. Few articles assessed the effect on maternal or neonatal health outcomes, with inconsistent results. Conclusion mHealth interventions may be effective solutions to improve maternal and neonatal service utilization. Further studies assessing mHealth’s impact on maternal and neonatal outcomes are recommended. The emerging trend of strong experimental research designs with randomized controlled trials, combined with feasibility research, government involvement and integration of mHealth interventions into the healthcare system is encouraging and can pave the way to improved decision making on best practice implementation of mHealth interventions.

Individual and community determinants of neonatal mortality in Ghana: a multilevel analysis

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.

Contextual risk factors for low birth weight: A multilevel analysis

Background Low birth weight (LBW) remains to be a leading cause of neonatal death and a major contributor to infant and under-five mortality. Its prevalence has not declined in the last decade in sub-Saharan Africa (SSA) and Asia. Some individual level factors have been identified as risk factors for LBW but knowledge is limited on contextual risk factors for LBW especially in SSA. Methods Contextual risk factors for LBW in Ghana were identified by performing multivariable multilevel logistic regression analysis of 6,900 mothers dwelling in 412 communities that participated in the 2003 and 2008 Demographic and Health Surveys in Ghana. Results Contextual-level factors were significantly associated with LBW: Being a rural dweller increased the likelihood of having a LBW infant by 43% (OR 1.43; 95% CI 1.01–2.01; P-value <0.05) while living in poverty-concentrated communities increased the risk of having a LBW infant twofold (OR 2.16; 95% CI 1.29–3.61; P-value <0.01). In neighbourhoods with a high coverage of safe water supply the odds of having a LBW infant reduced by 28% (OR 0.74; 95% CI 0.57–0.96; P-value <0.05). Conclusion This study showed contextual risk factors to have independent effects on the prevalence of LBW infants. Being a rural dweller, living in a community with a high concentration of poverty and a low coverage of safe water supply were found to increase the prevalence of LBW infants. Implementing appropriate community-based intervention programmes will likely reduce the occurrence of LBW infants.

Predictors of skilled attendance at delivery among antenatal clinic attendants in Ghana: a cross-sectional study of population data.

Objective To identify demographic, maternal and community predictors of skilled attendance at delivery among women who attend antenatal clinic at least once during their pregnancy in Ghana. Design A cross-sectional study using the 2008 Ghana Demographic and Health Survey (DHS) data. We used frequencies for descriptive analysis, χ2 test for associations and logistic regression to identify significant predictors. Predictive models were built with estimation of area under the receiver operating characteristic curves (AUC). Setting Ghana. Participants A total of 2041 women who had a live birth in the 5 years preceding the survey, and attended an antenatal clinic having a skilled provider, at least once, during the pregnancy. Outcome Skilled attendance at delivery. Results Overall, 60.5% (1235/2041) of women in our study sample reported skilled attendance at delivery. Significant positive associations existed between skilled attendance at delivery and the variables such as maternal educational level, wealth status class, ever use of contraception, previous pregnancy complications and health insurance coverage (p<0.001). Significant predictors of skilled attendance were wealth status class, residency, previous delivery complication, health insurance coverage and religion in a model with AUC (95% CI) of 0.85 (0.83 to 0.88). Conclusions Women less likely to have skilled attendance at delivery can be identified during antenatal care by using data on wealth status class, health insurance coverage, residence, history of previous birth complications and religion, and targeted with interventions to improve skilled attendance at delivery.

Effectiveness of mHealth Interventions Targeting Health Care Workers to Improve Pregnancy Outcomes in Low- and Middle-Income Countries: A Systematic Review

Background Low- 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. Objective We conducted a systematic review evaluating the effectiveness of mHealth interventions targeting health care workers to improve maternal and neonatal outcomes in LMIC. Methods The 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. Results A 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. Conclusions mHealth 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.

Completeness and accuracy of data transfer of routine maternal health services data in the greater Accra region

BackgroundHigh quality routine health system data is essential for tracking progress towards attainment of the Millennium Development Goals 4 & 5. This study aimed to determine the completeness and accuracy of transfer of routine maternal health service data at health facility, district and regional levels of the Greater Accra Region of Ghana.MethodsA cross sectional study was conducted using secondary data comprised of routine health information data collected at facility level for the first quarter of 2012. Twelve health facilities were selected using a multistage sampling method. Data relating to antenatal care and delivery were assessed for completeness and accuracy of data transfer. Primary source data from health facility level (registers and record notebooks where health information data are initially entered) , used as the reference data, were counted, collated, and compared with aggregate data on aggregate forms compiled from these sources by health facility staff. The primary source data was also compared with data in the district health information management system (DHIMS–II), a web-based data collation and reporting system. Percentage completeness and percentage error in data transfer were estimated.ResultsData for all 5,537 antenatal registrants and 3, 466 deliveries recorded into the primary source for the first quarter of 2012 were assessed. Completeness was best for age data, followed by data on parity and hemoglobin at registration. Mean completeness of the facility level aggregate data for the data sampled, was 94.3% (95% CI = 90.6% – 98.0%) and 100.0% respectively for the aggregate form and DHIMS-II database. Mean error in data transfer was 1.0% (95% CI = 0.8% - 1.2%). Percentage error comparing aggregate form data and DHIMS-II data respectively to the primary source data ranged from 0.0% to 4.9% respectively, while percentage error comparing the DHIMS-II data to aggregate form data, was generally very low or 0.0%.ConclusionRoutine maternal health services data in the Greater Accra region, available at the district level through the DHIMS-II system is complete when compared to facility level primary source data and reliable for use.

Quantifying the Validity of Routine Neonatal Healthcare Data in the Greater Accra Region, Ghana

Objectives The District Health Information Management System–2 (DHIMS–2) is the database for storing health service data in Ghana, and similar to other low and middle income countries, paper-based data collection is being used by the Ghana Health Service. As the DHIMS-2 database has not been validated before this study aimed to evaluate its validity. Methods Seven out of ten districts in the Greater Accra Region were randomly sampled; the district hospital and a polyclinic in each district were recruited for validation. Seven pre-specified neonatal health indicators were considered for validation: antenatal registrants, deliveries, total births, live birth, stillbirth, low birthweight, and neonatal death. Data were extracted on these health indicators from the primary data (hospital paper-registers) recorded from January to March 2012. We examined all the data captured during this period as these data have been uploaded to the DHIMS-2 database. The differences between the values of the health indicators obtained from the primary data and that of the facility and DHIMS–2 database were used to assess the accuracy of the database while its completeness was estimated by the percentage of missing data in the primary data. Results About 41,000 data were assessed and in almost all the districts, the error rates of the DHIMS-2 data were less than 2.1% while the percentages of missing data were below 2%. At the regional level, almost all the health indicators had an error rate below 1% while the overall error rate of the DHIMS-2 database was 0.68% (95% C I = 0.61–0.75) and the percentage of missing data was 3.1% (95% C I = 2.96–3.24). Conclusion This study demonstrated that the percentage of missing data in the DHIMS-2 database was negligible while its accuracy was close to the acceptable range for high quality data.

Gestational diabetes mellitus among women attending prenatal care at Korle‐Bu Teaching Hospital, Accra, Ghana

To determine the burden of gestational diabetes mellitus (GDM) among pregnant women in Accra, Ghana.

Client Factors Affect Provider Adherence to Clinical Guidelines during First Antenatal Care

Background The first antenatal clinic (ANC) visit helps to distinguish pregnant women who require standard care, from those with specific problems and so require special attention. There are protocols to guide care providers to provide optimal care to women during ANC. Our objectives were to determine the level of provider adherence to first antenatal visit guidelines in the Safe Motherhood Protocol (SMP), and assess patient factors that determine complete provider adherence. Methods This cross-sectional study is part of a cohort study that recruited women who delivered in eleven health facilities and who had utilized antenatal care services during their pregnancy in the Greater Accra region of Ghana. A record review of the first antenatal visit of participants was carried out to assess the level of adherence to the SMP, using a thirteen-point checklist. Information on their socio-demographic characteristics and previous pregnancy history was collected using a questionnaire. Percentages of adherence levels and baseline characteristics were estimated and cluster-adjusted odds ratios (OR) calculated to identify determinants. Results A total of 948 women who had delivered in eleven public facilities were recruited with a mean age (SD) of 28.2 (5.4) years. Overall, complete adherence to guidelines pertained to only 48.1% of pregnant women. Providers were significantly more likely to completely adhere to guidelines when caring for multiparous women [OR = 5.43 (1.69–17.44), p<0.01] but less likely to do so when attending to women with history of previous pregnancy complications [OR = 0.50 (0.33–0.75), p<0.01]. Conclusion Complete provider adherence to first antenatal visit guidelines is low across different facility types in the Greater Accra region of Ghana and is determined by parity and history of previous pregnancy complication. Providers should be trained and supported to adhere to the guidelines during provision of care to all pregnant women.

Variation in neonatal mortality and its relation to country characteristics in sub-Saharan Africa: an ecological study

Background A substantial reduction in neonatal mortality is the main priority to reduce under-five mortality. A clear understanding of the variation in neonatal mortality and the underlying causes is important for targeted intervention. We aimed to explore variation in neonatal mortality and identify underlying causes of variation in neonatal mortality in sub-Saharan Africa (SSA). Methods This ecological study used 2012 publicly available data from WHO, the US Agency for International Development and the World Bank. Variation in neonatal mortality across 49 SSA countries was examined using control chart and explanatory spatial data analysis. Associations between country-level characteristics and neonatal mortality were examined using linear regression analysis. Results The control chart showed that 28 (57%) SSA countries exhibited special-cause variation, 14 countries were below and 14 above the 99.8% control-limits. The remaining 21 (43%) SSA countries showed common-cause variation. No spatial clustering was observed for neonatal mortality (Global Moran’s I statistic −0.10; p=0.74). Linear regression analysis showed HIV/AIDS prevalence among the population of reproductive age to be positively associated with neonatal mortality (β=0.463; 95% CI 0.135 to 0.790; p<0.01). Declining socioeconomic deprivation (β=−0.234; 95% CI −0.424 to −0.044; p<0.05) and high quality of healthcare governance (β=−1.327, 95% CI −2.073 to −0.580; p<0.01) were inversely associated with neonatal mortality. Conclusion This study shows a wide variation in neonatal mortality in SSA. A substantial part of this variation can be explained by differences in the quality of healthcare governance, prevalence of HIV and socioeconomic deprivation. Future studies should validate our findings using more rigorous epidemiological study designs.