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Introduction The 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. Methods In 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. results Throughout 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. Conclusions Most 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.
Under a cross-sectional design, this study measured MNCH service-seeking behaviours of women and their children at the pregnancy, delivery and post-delivery stages in Ghana. It also measured their background characteristics and complications using face-to-face interviews with women in health demographic surveillance sites under three Health Research Centres (HRC) in Ghana, namely Dodowa,39 Kintampo40 and Navrongo.41 The total population of this survey area was 456 492 in 2012 and the estimated number of live births per year was 13 695, assuming that the crude birth rate was 30 out of 1000 people. This study was conducted as part of the formative research of the Ghana EMBRACE (Ensure Mothers and Babies Regular Access to Care) Implementation Research.42 This research is aimed at evaluating the impact and implementation process of a set of MNCH interventions that enhance CoC under the EMBRACE Model, as proposed by the Government of Japan.43 44 It was funded by the Japan International Cooperation Agency (JICA) and the JICA Research Institute. The targeted women in this study were aged between 15 and 49 years who experienced their latest pregnancy as a live birth or stillbirth between January 2011 and April 2013. Inclusion criteria were women who lived in study site on the date of the data collection. If the women delivered twice or more during the above period, the latest pregnancy data were used. A total of 1500 women were selected based on the two-stage random sampling method. The primary sampling unit involved communities under a zone or subdistrict (area), depending on HRC. The study site has 22 areas in three HRCs. Women were randomly selected under probability proportional to the sample size. The sample size was calculated based on the assumption that the expected coverage of key MNCH services throughout pregnancy, delivery and post-delivery was 15%. A sample size of 1275 provided an estimate with 2% confidence limits at a 0.05 significance level. Assuming 15% of women with incomplete information, a total of 1500 women was proposed. Two outcome variables were used to assess CoC achievement in MNCH. The first measurement is the proportion of women and children who received MNCH services at the pregnancy, delivery and post-delivery stages. Under this measurement, a pair (woman and child) achieved the CoC when the woman received ANC four times or more, delivered at a health facility and received both maternal and child PNC within 48 hours and around 2 and 6 weeks post-delivery. According to our observations in the study site, women and children visited health facilities and received such MNCH services while few received them at the community level. Thus, coverage under the first measurement is referred to as ‘visit-based CoC’. The second measurement is the proportion of women and children who received the key components of MNCH services during ANC and PNC, and during and post-delivery based on women’s self-reports. Coverage under the second measurement is referred to as ‘services-based CoC’. The components of MNCH services were measured in this study as follows. As services received during ANC, three components of the services were measured: received immunisation for tetanus toxoid, received intermittent preventive treatment, and received an HIV test. For delivery, two components of the services were measured: exercised skin-to-skin care immediately after delivery and initiated breast feeding within an hour of delivery. For PNC, three components of the services were measured: learnt about post-delivery complications among women and children, learnt about nutrition, anaemia and breast feeding, and received immunisation. These components of services were selected based on the guidelines and policy documents for ANC, delivery care and PNC,3 45–47 related literature48–54 and comments from health administrators at the study site. The services measured as listed above were limited to those that could be determined through women’s self-reports. This study collected the socioeconomic characteristics of women and their households that were likely to affect their MNCH service-seeking behaviour based on previous research.55–58 These characteristics included the women’s ages, educational attainment, marital status, religion, number of pregnancies, age and educational attainment of their partners and number of children aged under 5 years in the household. Socioeconomic status was also estimated using factor analysis based on the following variables: availability of electric power, availability of a clean toilet, type of roof material of the house, ownership of refrigerator, availability of clean water, ownership of TV, ownership of radio, ownership of mobile phone and ownership of transportation (car and motorbike). Factors during the latest pregnancy of women were also measured. These factors included intended pregnancy, birth preparedness, health insurance, support from household members and complications and danger signs. This study collected data using a structured questionnaire that was written in English. Interviewers who could speak at least one local language in a survey area were hired and received training in July 2013 on the objectives, design and ethical consideration of this study, as well as the contents of the questionnaire. Pretesting was undertaken in each HRC in July 2013, and the contents of the questionnaire were confirmed. Face-to-face interviews with women were undertaken from July to September 2013 in local languages that women could listen to and speak. The data items used to construct the socioeconomic status were extracted from the health demographic surveillance database at each HRC. First of all, women whose information was partly missing or they were found not to meet the inclusion criteria were excluded from analysis. Then, descriptive analysis was performed to present the background characteristics of women and children in the sample and the coverage of CoC. Paired t-test was performed to compare the coverage in MNCH services using the definitions of visit-based CoC and services-based CoC. A multilevel logistic regression with a random intercept at the area level was performed to identify the factors associated with the achievement of CoC and the variance of the achievement across areas. In the regression, both of visit-based CoC and services-based CoC were dichotomised so that this study could evaluate factors associated with making all necessary visits to health facilities (visit-based CoC) and received all necessary components of MNCH services (services-based CoC) as defined in the ’Measurements’ section. As explanatory variables, socioeconomic characteristics (the women’s ages, educational attainment, marital status, religion, number of pregnancies, age and educational attainment of their partners and number of children aged under 5 years in the household) and factors during the latest pregnancy of women (intended pregnancy, birth preparedness, health insurance, support from household members and complications and danger signs) were included in the model. Variance inflation factor was used to check the multicollinearity, although no variable exceeded 4 as a threshold. To evaluate to what extent differences in the level of CoC were caused by specific factors at the area level, this study used different sets of explanatory variables in the regression model. In addition to the full model (socioeconomic characteristics and factors relating to the latest pregnancy as explanatory variables), the null model (excluding all explanatory variables) and the model excluding factors relating to the latest pregnancy were tested. Then, intraclass correlation coefficient (ICC) was used to compare the proportion of variance caused by the random intercept at the area level among different models. All respondents voluntarily participated and were given details of the study before the survey. Written informed consent was obtained, and confidentiality was assured for all participants.
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