The coverage of continuum of care in maternal, newborn and child health: A cross-sectional study of woman-child pairs in Ghana

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Study Justification:
– The study addresses the importance of the continuum of care in maternal, newborn, and child health (MNCH).
– It highlights the need for effective policy frameworks to ensure timely and appropriate services for women and children.
– The study aims to assess the continuum of care achievement based on two measurements: continuous visits to health facilities and receiving key components of services.
– It explores individual-level and area-level factors associated with the continuum of care achievement and investigates how it differs across areas.
Study Highlights:
– Only 7.9% of women and children achieved the continuum of care through continuous visits to health facilities.
– 10.3% achieved the continuum of care by receiving all key components of MNCH services.
– Only 1.8% achieved the continuum of care under both measurements.
– Women and children from wealthier households were more likely to achieve the continuum of care.
– Women’s education and complications were associated with higher continuum of care services-based achievement.
– The variance of a random intercept was larger in the services-based model than the visit-based model.
Study Recommendations:
– Improve access to health facilities and encourage continuous visits for MNCH services.
– Ensure that key components of MNCH services are provided to all women and children.
– Address socioeconomic disparities to improve the continuum of care achievement.
– Focus on women’s education and addressing complications to enhance MNCH services.
– Consider the area-level factors that contribute to the variation in continuum of care achievement.
Key Role Players:
– Health policymakers and administrators
– MNCH service providers
– Community health workers
– Women and children
– NGOs and international organizations
Cost Items for Planning Recommendations:
– Infrastructure development for health facilities
– Training and capacity building for MNCH service providers
– Community outreach programs and awareness campaigns
– Health education materials and resources
– Monitoring and evaluation systems for tracking continuum of care achievement
– Research and data collection for evidence-based decision making

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a cross-sectional study design and includes a large sample size. The study collected data using a structured questionnaire and employed multilevel logistic regression analysis. However, the abstract does not provide information on the representativeness of the sample or the response rate. To improve the evidence, the authors could provide more details on the sampling method and response rate, as well as the generalizability of the findings to the population of interest.

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.

Based on the provided information, here are some potential innovations that could be used to improve access to maternal health:

1. Mobile Health (mHealth) Solutions: Develop mobile applications or SMS-based systems that provide pregnant women with information and reminders about antenatal care visits, immunizations, and postnatal care. These solutions can also enable women to schedule appointments and receive personalized health advice.

2. Telemedicine: Implement telemedicine services to connect pregnant women in remote or underserved areas with healthcare providers. This allows for virtual consultations, remote monitoring of vital signs, and timely access to medical advice.

3. Community Health Workers (CHWs): Train and deploy CHWs to provide maternal health education, conduct antenatal and postnatal visits, and facilitate referrals to healthcare facilities. CHWs can play a crucial role in reaching women in rural or marginalized communities.

4. Maternal Health Vouchers: Introduce voucher programs that provide financial assistance to pregnant women, enabling them to access essential maternal health services. These vouchers can cover costs for antenatal care, delivery, and postnatal care, reducing financial barriers to care.

5. Transport and Emergency Referral Systems: Establish efficient transportation systems, such as ambulances or community-based transport services, to ensure timely access to emergency obstetric care. This can help address the challenges of distance and transportation that often hinder women from reaching healthcare facilities in emergencies.

6. Maternity Waiting Homes: Set up maternity waiting homes near healthcare facilities to accommodate pregnant women who live far away. These homes provide a safe and comfortable place for women to stay before and after delivery, ensuring they are closer to healthcare services when needed.

7. Public-Private Partnerships: Foster collaborations between the public and private sectors to improve access to maternal health services. This can involve leveraging private healthcare providers, pharmacies, and diagnostic centers to expand service delivery and reach underserved populations.

8. Quality Improvement Initiatives: Implement quality improvement programs in healthcare facilities to enhance the overall quality of maternal health services. This includes training healthcare providers, improving infrastructure and equipment, and ensuring adherence to evidence-based guidelines.

9. Maternal Health Awareness Campaigns: Conduct targeted awareness campaigns to educate communities about the importance of maternal health and the available services. These campaigns can address cultural and social barriers, promote early antenatal care, and encourage women to seek care from skilled healthcare providers.

10. Task-Shifting and Task-Sharing: Explore opportunities to delegate certain maternal health tasks to lower-level healthcare providers, such as nurses and midwives, to alleviate the burden on doctors and increase service availability.

It is important to note that the specific context and needs of the target population should be considered when implementing these innovations.
AI Innovations Description
Based on the information provided, the study conducted in Ghana aimed to assess the continuum of care (CoC) in maternal, newborn, and child health (MNCH) and identify factors associated with its achievement. The study used two measurements to evaluate CoC: continuous visits to health facilities and receiving key components of services. The results showed that only a small percentage of women and children achieved CoC under both measurements. Factors such as household wealth, women’s education, and complications were associated with higher CoC achievement. The study also found that the variance of CoC achievement was larger in the services-based model compared to the visit-based model.

Based on these findings, a recommendation to improve access to maternal health could be to focus on strengthening the delivery of key components of MNCH services during antenatal care (ANC), delivery, and postnatal care (PNC). This could involve ensuring that health facilities are equipped to provide the necessary services, training healthcare providers to deliver quality care, and promoting awareness among women about the importance of receiving these services. Additionally, efforts should be made to address socioeconomic disparities in CoC achievement, such as by implementing targeted interventions for women from disadvantaged backgrounds. By improving the availability and quality of MNCH services and addressing barriers to access, the goal of achieving CoC in maternal health can be better realized, leading to improved health outcomes for women and children.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthen community-based healthcare services: Implementing community-based healthcare services can help improve access to maternal health by bringing healthcare services closer to women and children in remote areas. This can include mobile clinics, community health workers, and outreach programs.

2. Enhance transportation infrastructure: Improving transportation infrastructure, such as roads and transportation systems, can help overcome geographical barriers and ensure that women can reach healthcare facilities in a timely manner during pregnancy, delivery, and post-delivery stages.

3. Increase awareness and education: Conducting awareness campaigns and providing education on the importance of maternal health can help increase knowledge and understanding among women and their families. This can lead to increased utilization of maternal health services and better overall health outcomes.

4. Strengthen health systems: Investing in healthcare infrastructure, equipment, and trained healthcare professionals can help ensure that healthcare facilities are adequately equipped to provide quality maternal health services. This includes improving the availability of essential medicines and supplies.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify specific indicators that can measure the impact of the recommendations on access to maternal health. This could include indicators such as the number of women accessing antenatal care, the percentage of women delivering in healthcare facilities, and the availability of skilled birth attendants.

2. Collect baseline data: Gather data on the current status of access to maternal health services in the target area. This can include data on healthcare facilities, transportation infrastructure, awareness levels, and utilization of maternal health services.

3. Develop a simulation model: Create a simulation model that incorporates the recommendations and their potential impact on access to maternal health. This model should consider factors such as population demographics, geographical distribution, and resource availability.

4. Run simulations: Use the simulation model to run different scenarios based on the recommendations. This can involve adjusting variables such as the number of community-based healthcare services, transportation infrastructure improvements, and the effectiveness of awareness campaigns.

5. Analyze results: Evaluate the results of the simulations to determine the potential impact of the recommendations on access to maternal health. This can include analyzing changes in the indicators defined in step 1 and comparing them to the baseline data.

6. Refine and iterate: Based on the analysis of the simulation results, refine the recommendations and simulation model as needed. Repeat the simulation process to further optimize the impact on access to maternal health.

By following this methodology, policymakers and stakeholders can gain insights into the potential impact of different recommendations on improving access to maternal health and make informed decisions on which interventions to prioritize.

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