Menu
Menu
Menu
Menu
Background: The burden of maternal mortality in sub-Saharan Africa is very high. In Ghana maternal mortality ratio was 380 deaths per 100,000 live births in 2013. Skilled birth attendance has been shown to reduce maternal mortality and morbidity, yet in 2010 only 68 percent of mothers in Ghana gave birth with the assistance of skilled birth attendants. In 2005, the Ghana Health Service piloted a strategy that involved using the integrated Community-based Health Planning and Services (CHPS) program and training Community Health Officers (CHOs) as midwives to address the gap in skilled attendance in rural Upper East Region (UER). The study assesses the feasibility of and extent to which the skilled delivery program has been implemented as an integrated component of the existing CHPS, and documents the benefits and challenges of the integrated program. Methods: We employed an intrinsic case study design with a qualitative methodology. We conducted 41 in-depth interviews with health professionals and community stakeholders. We used a purposive sampling technique to identify and interview our respondents. Results: The CHO-midwives provide integrated services that include skilled delivery in CHPS zones. The midwives collaborate with District Assemblies, Non-Governmental Organizations (NGOs) and communities to offer skilled delivery services in rural communities. They refer pregnant women with complications to district hospitals and health centers for care, and there has been observed improvement in the referral system. Stakeholders reported community members’ access to skilled attendants at birth, health education, antenatal attendance and postnatal care in rural communities. The CHO-midwives are provided with financial and non-financial incentives to motivate them for optimal work performance. The primary challenges that remain include inadequate numbers of CHO-midwives, insufficient transportation, and infrastructure weaknesses. Conclusions: Our study demonstrates that CHOs can successfully be trained as midwives and deployed to provide skilled delivery services at the doorsteps of rural households. The integration of the skilled delivery program with the CHPS program appears to be an effective model for improving access to skilled birth attendance in rural communities of the UER of Ghana.
The study was conducted in the Kassena-Nankana East (KNE), Kassena-Nankana West (KNW), and Bongo Districts of the UER of Ghana. These districts were the first to provide skilled delivery as part of the CHPS Program. The UER population estimate from the 2010 census was 1,046,545. The KNE district had an estimated population of 109,944[18] whereas the KNW district, newly carved out of the Kassena-Nankana District in the UER, had an estimated population of 70,667 in 2012. Bongo District’s 2010 estimated census population was 84,545[18]. We employed an intrinsic case study design with a qualitative methodology. An intrinsic case study is the study of a case (e.g., person, specific group, occupation, department, organization) where the case itself is of primary interest in the exploration. The exploration is driven by a desire to know more about the uniqueness of the case rather than to build theory or how the case represents other cases[19]. We conducted in-depth interviews with community key informants such as chiefs, traditional birth attendants (TBAs), community volunteers, women leaders and elders and health professionals such as CHO-midwives, tutors of the midwifery school and the Navrongo Community Nurses School, the CHPS Coordinator, officials of the Maternal and Child Health Unit, District Directors of Health Services for the KNE, KNW, and Bongo Districts. We also reviewed annual reports of the Districts and Regional Directorate of the Ghana Health Service, UER. We employed purposive sampling to select 41 stakeholders for in-depth interviews: 10 CHO-midwives, 6 CHO-midwives supervisors, 3 District Directors of Health Services, heads of maternity wards of the Navrongo Hospital, Bongo Health Centre, and Paga Health Centre, two tutors of the community health nurses and midwifery schools, two health professionals from the Regional Directorate of Health Services – UER, 15 community leaders and residents (a chief, an elder, a TBA, a community volunteer, and a woman leader from each of the three districts). We selected the program implementers based on their role in the CHPS Program and recruited the community stakeholders who were most knowledgeable about the CHPS Program. The questions focused on the range of health services including skilled delivery services provided by CHO-midwives, how the work of skilled birth attendance is integrated with other community health services, and the successes and challenges of the new program. Two research assistants were recruited from the UER and trained for the in-depth interviews. They translated the interview guides into the local languages of the three districts. They were also instructed to use tape recorders and to moderate the interviews, and they were introduced to the instructions developed for the data collection procedure. They were coached to ask questions, probe for more answers and prompt respondents for clarifications. The research assistants recorded interviews on audiotape, and a transcriber, who did not participate in interviewing, translated and transcribed the data in English. The interview formats focused on the extent to which the CHO-midwifery program has been integrated into the existing CHPS and successes and challenges of the program from their perspectives. We pre-tested the interview guides in communities of the three districts excluded from the study, but have similar characteristics, in order to improve the relevance and appropriateness of the questions. The pre-testing was a learning session for the research assistants to improve their interviewing skills, and we revised the guides appropriately after the pre-test. Data were collected from January 13, 2012 to March 31, 2012. The analysis of narrative data on similar topics from multiple sources allows for comparison of perspectives and triangulation of reports. Members of the team (the Principal Investigator and the two Research Assistants) began the analysis by reading all interviews multiple times and discussing broad themes that emerged across respondents and areas of inquiry (integration and benefits/challenges). The team developed a coding scheme that reflected these areas and the sub-themes within each, and proceeded to code each transcript using the qualitative data software (QSR NVIVO software version 8). We produced reports on each of the broad and specific themes, which allowed us to synthesize key findings and compare responses within and between groups (e.g., community stakeholders and health professionals). Content analysis of program documents helped provide current and historical context in which the skilled delivery program has been implemented through the CHPS program. The investigators analyzed by objective across the documents. We obtained ethical approval from the Navrongo Health Research Centre and the Boston University (BU) Institutional Review Boards (BU IRB reference number H-31245). We also obtained written informed consent from participants before they took part in the study.
N/A
