Perception and practice of Kangaroo Mother Care after discharge from hospital in Kumasi, Ghana: A longitudinal study

BMC Pregnancy and Childbirth, Volume 11, Year 2011

Interpretation

Background: The practice of Kangaroo Mother Care (KMC) is life saving in babies weighing less than 2000 g. Little is known about mothers’ continued unsupervised practice after discharge from hospitals. This study aimed to evaluate its in-hospital and continued practice in the community among mothers of low birth weight (LBW) infants discharged from two hospitals in Kumasi, Ghana.Methods: A longitudinal study of 202 mothers and their inpatient LBW neonates was conducted from November 2009 to May 2010. Mothers were interviewed at recruitment to ascertain their knowledge of KMC, and then oriented on its practice. After discharge, the mothers reported at weekly intervals for four follow up visits where data about their perceptions, attitudes and practices of KMC were recorded. A repeated measure logistic regression analysis was done to assess variability in the binary responses at the various reviews visits.Results: At recruitment 23 (11.4%, 95%CI: 7.4 to 16.6%) mothers knew about KMC. At discharge 95.5% were willing to continue KMC at home with 93.1% willing to practice at night. 95.5% thought KMC was beneficial to them and 96.0% beneficial to their babies. 98.0% would recommend KMC to other mothers with 71.8% willing to practice KMC outdoors.At first follow up visit 99.5% (181) were still practicing either intermittent or continuous KMC. This proportion did not change significantly over the four weeks (OR: 1.4, 95%CI: 0.6 to 3.3, p-value: 0.333). Over the four weeks, increasingly more mothers practiced KMC at night (OR: 1.7, 95%CI: 1.2 to 2.6, p = 0.005), outside their homes (OR: 2.4, 95%CI: 1.7 to 3.3, p < 0.001) and received spousal help (OR: 1.6, 95%CI: 1.1 to 2.4, p = 0.007). Household chores and potentially negative community perceptions of KMC did not affect its practice with odds of 0.8 (95%CI: 0.5 to 1.2, p = 0.282) and 1.0 (95%CI: 0.6 to 1.7, p = 0.934) respectively. During the follow-up period the neonates gained 23.7 sg (95%CI: 22.6 g to 24.7 g) per day.Conclusion: Maternal knowledge of KMC was low at outset. Once initiated mothers continued practicing KMC in hospital and at home with their infants gaining optimal weight. Continued KMC practice was not affected by perceived community attitudes. © 2011 Nguah et al; licensee BioMed Central Ltd. This was a longitudinal study of mothers with LBW newborns who were willing to practice KMC at the Mother Baby Units of the Komfo Anokye Teaching Hospital (KATH) and the Suntreso Government Hospital (SGH) in Kumasi, Ghana. Kumasi is the capital of the most populous region in the country, the Ashanti region. With a population just under two million, Kumasi is the second largest city in Ghana and a typical African urban city. Families often live with extended family members who influence many of the decisions made in the household [13]. It is traditional among many Ghanaians even in urban areas to either move in to live with their mothers or have their mothers to move in around the time of childbirth. These grandmothers are highly influential in making decisions concerning the care of the newborns [14]. The study was conducted in two hospitals in Kumasi-KATH and SGH. KATH is a teaching hospital that provides tertiary care, while SGH is a district hospital and provides secondary care. There are three Mother-Baby Units in Kumasi and these units are at KATH, SGH and the Kumasi South Hospital (Regional Hospital). Collaboration between KATH and SGH has enabled moderately sick newborns not requiring specialised care to be transferred to the latter to continue with their treatment. SGH is about 5 km from KATH while KSH is about 15 km away from KATH. Because of the proximity of SGH to KATH, it was selected as one of the study sites. The KATH Mother-Baby Unit runs a 24 hour in-patient service and admits about 4000 infants less than three months old every year, with about a quarter of these being preterm. It receives referrals from district and private hospitals, maternity homes as well as home deliveries from the Kumasi metropolis and the northern sector of the country. The Unit has 77 cots, 4 functioning incubators, 2 overhead radiant heaters, 10 phototherapy units and 20 oxygen delivery outlets. The unit is overcrowded with 3 or 4 babies sharing one radiant heater or incubator, and at times 2 or 3 babies sharing a cot. KMC has therefore become a vital and indispensable intervention for preterm and LBW babies in the unit. Continuous KMC (placing the infant in skin to skin contact round the clock) would have been ideal but the KATH Mother-Baby Unit lacks space. The unit has three main wings-a High Dependency Unit, a preterm and intermittent KMC unit, and a Septic unit. Preterm babies are admitted for special care and intermittent KMC (placing the infant in skin to skin contact for less than 24 hours). Due to limited space in the overcrowded unit, mothers are accommodated in a separate room and are only able to practice intermittent KMC for approximately four to six hours in the day, mainly after breastfeeding. The SGH Mother-Baby Unit admits neonates transferred from KATH or referred from other district hospitals and facilities. The unit has three wards-one postnatal ward for sick neonates to room-in with their mothers, one neonatal care ward for babies in need of resuscitation, oxygen and phototherapy, and a KMC ward. The postnatal ward has 16 beds and KMC is encouraged to take place there as well. Continuous KMC is practiced at SGH as there is enough space for rooming in. The neonatal care ward has 13 beds, and the KMC ward has 4 beds. The Mother-Baby Unit runs a 24 hour service and is staffed by a paediatrician and seven nurses. As part of routine care before discharge from both Mother-Baby Units, mothers are encouraged to continue practicing KMC at home and bring their babies for weekly follow up care till they attain a weight of 3000 g. To detect an overall two sided change in the proportion of mothers practicing KMC by 10%, the proportion of mothers practicing KMC at first visit was assumed to be 80%. The sample size required for a four repeated binary outcome with 80% statistical power and a two-sided 0.05 significance level in a balanced longitudinal design was calculated to be 157. Assuming a 25% dropout or loss to follow-up rate, a final sample size of 196 was required for the study if an interclass correlation among measurements within subjects is assumed to be 0.5. Neonates admitted to either the KATH Mother-Baby Unit or the SGH Mother-Baby Unit from November 2009 through May 2010 were eligible for the study. However, only those weighing between 1000 g and 2000 g and less than a week old, whose mothers were willing to practice KMC, lived within a distance of ten kilometres from the hospital and gave consent, were included in the study. Very sick neonates with life threatening conditions, major congenital abnormalities or requiring intensive care were excluded. All neonates brought to the KATH Mother-Baby Unit and SGH Mother-Baby Unit were first admitted and stabilized. For those who fulfilled all the inclusion criteria and none of the exclusion criteria, the study was fully explained to the mother and or legal guardian. The mothers and or guardians were then taken through a brief but comprehensive training session on the practice of KMC by an experienced nurse who has been trained in teaching KMC. A verbal consent was then obtained from the mothers or legal guardians and neonates were recruited into the study at this point if their mothers or guardians were still willing to participate in the study. Verbal consent was sought because practice of KMC was routine for mothers of low birth weight babies on admission. After recruitment, clinical data was collected using a pre-tested questionnaire and included variables such as the birth weight, mode of delivery, gestational age, type of KMC and weight of infant at initiation of KMC. Mothers were supported by a nurse during their first attempts at practicing KMC to ensure the technique was right before they continued to practice without supervision. Mothers also helped each other in initiating the KMC position. Neonates admitted to both Mother-Baby Units were monitored until discharge or death. Upon discharge from either Mother-Baby Unit data was collected on the infant, including discharge weight, duration of stay in hospital and mode of feeding. The mothers were then interviewed to ascertain their perception of the usefulness, challenges and benefits of practicing KMC to themselves and their babies. They were also asked whether or not they thought their spouses would help practice KMC when they got home. Finally they were asked about how they envision the community's acceptance of the practice of KMC both within and outside their homes. They were then encouraged to practice continuous KMC at home and to come for weekly reviews for the next four weeks. Only the mothers' telephone numbers were taken at recruitment. They were assured no Mother-Baby Unit or study staff would be visiting them at home or would monitor their practice of KMC at home. This was to assure them their continued practice at home will be purely voluntary with no compulsion whatsoever. After discharge the mothers or guardians together with their babies came for follow up visits weekly for four consecutive visits. The infants' weight, length, head circumference, type of KMC practiced since last seen, and feeding practices were recorded at every visit. The mother or guardian was also asked about any challenges they faced practicing KMC since their last review or discharge. The data collected included perception of the benefits and challenges of KMC to them and their babies. Also, data were recorded on the community and spousal acceptability, support or challenges mothers encountered in their practice of KMC since their last visit or discharge from hospital. Mothers who missed their review appointment were called on telephone several times and reminded. However, those who could not be reached on phone or still did not come for their appointment were not traced to their homes. Completed case report forms were double entered using Microsoft Access® 2007, compared and cleaned for anomalous data. The clean data was then transferred to Stata/SE version 11.1 for analysis. Continuous variable such as the birth weight and gestational ages were summarised and presented as means with their 95% confidence intervals and ranges. Categorical variables were analysed and presented as proportions with their binomial exact 95% confidence intervals. Comparison between the birth and discharge weights was done using a paired t test. A repeated measure logistic regression analysis was done for the binary responses at the various reviews. Cumulative changes in the proportions of these binary outcomes over the four review visits were expressed as odds ratios with their 95% confidence intervals. These odds were then adjusted for the weight at review as it was reasonable to assume KMC practice will decrease as the infants gain weight and grew older. In reporting, a two sided p-value less than or equal to 0.05 was considered statistically significant. The Committee on Human Research, Publications and Ethics of Kwame Nkrumah University of Science and Technology, Kumasi gave ethical clearance for this study after reviewing the study protocol. All mothers or legal guardians provided verbal informed consent before any study related information was obtained. The mothers or guardians were, however, assured of strict anonymity in answering the questions.

AI Digest

Study Justification:

– The practice of Kangaroo Mother Care (KMC) is life-saving for babies weighing less than 2000 g.
– Little is known about mothers’ continued unsupervised practice of KMC after discharge from hospitals.
– This study aimed to evaluate the in-hospital and continued practice of KMC in the community among mothers of low birth weight infants in Kumasi, Ghana.

Highlights:

– At recruitment, only 11.4% of mothers knew about KMC.
– After discharge, 95.5% of mothers were willing to continue practicing KMC at home.
– Over the four-week follow-up period, 99.5% of mothers were still practicing either intermittent or continuous KMC.
– The neonates gained an average of 23.7 grams per day during the follow-up period.
– Continued KMC practice was not affected by perceived community attitudes.

Recommendations:

– Increase awareness and knowledge of KMC among mothers, especially during antenatal care visits.
– Provide ongoing support and education to mothers after discharge to ensure continued practice of KMC.
– Encourage fathers and other family members to support and participate in KMC.
– Improve access to resources and facilities for practicing continuous KMC, especially in overcrowded hospitals.

Key Role Players:

– Healthcare providers (doctors, nurses, midwives) to provide education and support to mothers.
– Community health workers to promote awareness and provide follow-up care.
– Policy makers to develop guidelines and policies supporting the implementation of KMC.
– Non-governmental organizations (NGOs) to provide resources and funding for KMC programs.

Cost Items for Planning Recommendations:

– Training and education materials for healthcare providers and community health workers.
– Awareness campaigns and promotional materials.
– Equipment and supplies for practicing KMC (e.g., kangaroo care wraps, breastfeeding support).
– Monitoring and evaluation of KMC programs.
– Staffing and personnel costs for implementing and managing KMC programs.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is strong, but there are some areas for improvement. The study design is longitudinal, which allows for the collection of data over time and provides more robust evidence. The sample size is appropriate for the study objectives. The study includes a diverse population, which increases the generalizability of the findings. The study measures various factors related to the perception and practice of Kangaroo Mother Care (KMC) among mothers of low birth weight infants. The findings indicate that maternal knowledge of KMC was low at the beginning, but once initiated, mothers continued practicing KMC in the hospital and at home, resulting in optimal weight gain for the infants. However, the abstract does not provide information on the statistical significance of the findings, which would strengthen the evidence. Additionally, the abstract does not mention any limitations of the study, which should be included to provide a balanced view of the evidence. To improve the evidence, the abstract should include the statistical significance of the findings and a brief discussion of the limitations of the study.

Abstract

This was a longitudinal study of mothers with LBW newborns who were willing to practice KMC at the Mother Baby Units of the Komfo Anokye Teaching Hospital (KATH) and the Suntreso Government Hospital (SGH) in Kumasi, Ghana. Kumasi is the capital of the most populous region in the country, the Ashanti region. With a population just under two million, Kumasi is the second largest city in Ghana and a typical African urban city. Families often live with extended family members who influence many of the decisions made in the household [13]. It is traditional among many Ghanaians even in urban areas to either move in to live with their mothers or have their mothers to move in around the time of childbirth. These grandmothers are highly influential in making decisions concerning the care of the newborns [14]. The study was conducted in two hospitals in Kumasi-KATH and SGH. KATH is a teaching hospital that provides tertiary care, while SGH is a district hospital and provides secondary care. There are three Mother-Baby Units in Kumasi and these units are at KATH, SGH and the Kumasi South Hospital (Regional Hospital). Collaboration between KATH and SGH has enabled moderately sick newborns not requiring specialised care to be transferred to the latter to continue with their treatment. SGH is about 5 km from KATH while KSH is about 15 km away from KATH. Because of the proximity of SGH to KATH, it was selected as one of the study sites. The KATH Mother-Baby Unit runs a 24 hour in-patient service and admits about 4000 infants less than three months old every year, with about a quarter of these being preterm. It receives referrals from district and private hospitals, maternity homes as well as home deliveries from the Kumasi metropolis and the northern sector of the country. The Unit has 77 cots, 4 functioning incubators, 2 overhead radiant heaters, 10 phototherapy units and 20 oxygen delivery outlets. The unit is overcrowded with 3 or 4 babies sharing one radiant heater or incubator, and at times 2 or 3 babies sharing a cot. KMC has therefore become a vital and indispensable intervention for preterm and LBW babies in the unit. Continuous KMC (placing the infant in skin to skin contact round the clock) would have been ideal but the KATH Mother-Baby Unit lacks space. The unit has three main wings-a High Dependency Unit, a preterm and intermittent KMC unit, and a Septic unit. Preterm babies are admitted for special care and intermittent KMC (placing the infant in skin to skin contact for less than 24 hours). Due to limited space in the overcrowded unit, mothers are accommodated in a separate room and are only able to practice intermittent KMC for approximately four to six hours in the day, mainly after breastfeeding. The SGH Mother-Baby Unit admits neonates transferred from KATH or referred from other district hospitals and facilities. The unit has three wards-one postnatal ward for sick neonates to room-in with their mothers, one neonatal care ward for babies in need of resuscitation, oxygen and phototherapy, and a KMC ward. The postnatal ward has 16 beds and KMC is encouraged to take place there as well. Continuous KMC is practiced at SGH as there is enough space for rooming in. The neonatal care ward has 13 beds, and the KMC ward has 4 beds. The Mother-Baby Unit runs a 24 hour service and is staffed by a paediatrician and seven nurses. As part of routine care before discharge from both Mother-Baby Units, mothers are encouraged to continue practicing KMC at home and bring their babies for weekly follow up care till they attain a weight of 3000 g. To detect an overall two sided change in the proportion of mothers practicing KMC by 10%, the proportion of mothers practicing KMC at first visit was assumed to be 80%. The sample size required for a four repeated binary outcome with 80% statistical power and a two-sided 0.05 significance level in a balanced longitudinal design was calculated to be 157. Assuming a 25% dropout or loss to follow-up rate, a final sample size of 196 was required for the study if an interclass correlation among measurements within subjects is assumed to be 0.5. Neonates admitted to either the KATH Mother-Baby Unit or the SGH Mother-Baby Unit from November 2009 through May 2010 were eligible for the study. However, only those weighing between 1000 g and 2000 g and less than a week old, whose mothers were willing to practice KMC, lived within a distance of ten kilometres from the hospital and gave consent, were included in the study. Very sick neonates with life threatening conditions, major congenital abnormalities or requiring intensive care were excluded. All neonates brought to the KATH Mother-Baby Unit and SGH Mother-Baby Unit were first admitted and stabilized. For those who fulfilled all the inclusion criteria and none of the exclusion criteria, the study was fully explained to the mother and or legal guardian. The mothers and or guardians were then taken through a brief but comprehensive training session on the practice of KMC by an experienced nurse who has been trained in teaching KMC. A verbal consent was then obtained from the mothers or legal guardians and neonates were recruited into the study at this point if their mothers or guardians were still willing to participate in the study. Verbal consent was sought because practice of KMC was routine for mothers of low birth weight babies on admission. After recruitment, clinical data was collected using a pre-tested questionnaire and included variables such as the birth weight, mode of delivery, gestational age, type of KMC and weight of infant at initiation of KMC. Mothers were supported by a nurse during their first attempts at practicing KMC to ensure the technique was right before they continued to practice without supervision. Mothers also helped each other in initiating the KMC position. Neonates admitted to both Mother-Baby Units were monitored until discharge or death. Upon discharge from either Mother-Baby Unit data was collected on the infant, including discharge weight, duration of stay in hospital and mode of feeding. The mothers were then interviewed to ascertain their perception of the usefulness, challenges and benefits of practicing KMC to themselves and their babies. They were also asked whether or not they thought their spouses would help practice KMC when they got home. Finally they were asked about how they envision the community's acceptance of the practice of KMC both within and outside their homes. They were then encouraged to practice continuous KMC at home and to come for weekly reviews for the next four weeks. Only the mothers' telephone numbers were taken at recruitment. They were assured no Mother-Baby Unit or study staff would be visiting them at home or would monitor their practice of KMC at home. This was to assure them their continued practice at home will be purely voluntary with no compulsion whatsoever. After discharge the mothers or guardians together with their babies came for follow up visits weekly for four consecutive visits. The infants' weight, length, head circumference, type of KMC practiced since last seen, and feeding practices were recorded at every visit. The mother or guardian was also asked about any challenges they faced practicing KMC since their last review or discharge. The data collected included perception of the benefits and challenges of KMC to them and their babies. Also, data were recorded on the community and spousal acceptability, support or challenges mothers encountered in their practice of KMC since their last visit or discharge from hospital. Mothers who missed their review appointment were called on telephone several times and reminded. However, those who could not be reached on phone or still did not come for their appointment were not traced to their homes. Completed case report forms were double entered using Microsoft Access® 2007, compared and cleaned for anomalous data. The clean data was then transferred to Stata/SE version 11.1 for analysis. Continuous variable such as the birth weight and gestational ages were summarised and presented as means with their 95% confidence intervals and ranges. Categorical variables were analysed and presented as proportions with their binomial exact 95% confidence intervals. Comparison between the birth and discharge weights was done using a paired t test. A repeated measure logistic regression analysis was done for the binary responses at the various reviews. Cumulative changes in the proportions of these binary outcomes over the four review visits were expressed as odds ratios with their 95% confidence intervals. These odds were then adjusted for the weight at review as it was reasonable to assume KMC practice will decrease as the infants gain weight and grew older. In reporting, a two sided p-value less than or equal to 0.05 was considered statistically significant. The Committee on Human Research, Publications and Ethics of Kwame Nkrumah University of Science and Technology, Kumasi gave ethical clearance for this study after reviewing the study protocol. All mothers or legal guardians provided verbal informed consent before any study related information was obtained. The mothers or guardians were, however, assured of strict anonymity in answering the questions.

Materials

N/A

Innovations

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

1. Mobile Health (mHealth) Solutions: Develop mobile applications or SMS-based systems to provide information and support to mothers regarding Kangaroo Mother Care (KMC) practices. This could include reminders for KMC sessions, educational resources, and access to healthcare professionals for guidance.

2. Community Outreach Programs: Implement community-based programs to raise awareness about the benefits of KMC and provide training to mothers and families on how to practice KMC effectively. This could involve partnerships with local healthcare providers, community leaders, and organizations to ensure widespread education and support.

3. Telemedicine Services: Establish telemedicine services to provide remote consultations and support for mothers practicing KMC. This would enable healthcare professionals to monitor progress, address concerns, and provide guidance without the need for in-person visits, particularly for mothers living in remote or underserved areas.

4. Peer Support Networks: Create peer support networks or online communities where mothers practicing KMC can connect with and learn from each other. This would provide a platform for sharing experiences, tips, and emotional support, which can be crucial for sustaining KMC practices.

5. Training and Capacity Building: Invest in training programs for healthcare professionals to enhance their knowledge and skills in promoting and supporting KMC practices. This would ensure that healthcare providers are equipped to educate and guide mothers effectively.

6. Policy and Advocacy: Advocate for policy changes and increased funding to prioritize maternal health, including KMC practices. This could involve working with government agencies, NGOs, and international organizations to raise awareness and allocate resources towards improving access to maternal health services.

It is important to note that these recommendations are based on the information provided and may need to be tailored to the specific context and resources available in Kumasi, Ghana.

AI Innovations Description

The recommendation that can be used to develop an innovation to improve access to maternal health based on the study is to implement and promote Kangaroo Mother Care (KMC) as a standard practice in hospitals and communities. KMC is a life-saving technique for low birth weight (LBW) infants, and this study found that mothers were willing to continue practicing KMC at home after discharge from hospitals.

To improve access to maternal health, the following steps can be taken:

1. Increase awareness and knowledge about KMC among pregnant women and their families through educational campaigns and antenatal care programs. This can be done through the distribution of informational materials, workshops, and counseling sessions.

2. Provide training and support to healthcare providers on the implementation and promotion of KMC. This includes training on the benefits of KMC, proper techniques, and how to address common challenges.

3. Ensure that hospitals and healthcare facilities have the necessary resources and infrastructure to support KMC, such as adequate space for mothers and infants to practice KMC, access to breastfeeding support, and appropriate monitoring and follow-up care.

4. Establish community support networks for mothers practicing KMC, where they can receive guidance, share experiences, and receive assistance if needed. This can be done through the involvement of community health workers, peer support groups, and partnerships with local organizations.

5. Conduct regular monitoring and evaluation of KMC programs to assess their effectiveness and identify areas for improvement. This includes tracking the number of mothers practicing KMC, monitoring infant weight gain, and gathering feedback from mothers and healthcare providers.

By implementing these recommendations, access to maternal health can be improved by ensuring that more mothers have the knowledge, skills, and support to practice KMC both in hospitals and at home. This can lead to better health outcomes for LBW infants and reduce the risk of complications.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Increase awareness and education: Develop and implement educational programs to increase knowledge and awareness of maternal health issues, including the benefits of practices like Kangaroo Mother Care (KMC). This can be done through community outreach programs, workshops, and the use of multimedia platforms.

2. Strengthen healthcare infrastructure: Improve the capacity and resources of healthcare facilities, particularly in areas with high maternal health needs. This includes ensuring the availability of trained healthcare professionals, necessary equipment, and adequate space for practicing KMC.

3. Enhance community support: Engage and involve community members, including grandmothers and other influential family members, in promoting and supporting maternal health practices like KMC. This can be done through community meetings, support groups, and the dissemination of educational materials.

4. Provide post-discharge support: Establish post-discharge follow-up programs to provide ongoing support and guidance to mothers practicing KMC at home. This can include regular check-ups, counseling sessions, and access to a helpline for any questions or concerns.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify specific indicators that can measure the impact of the recommendations, such as the percentage increase in knowledge about KMC, the number of healthcare facilities with improved infrastructure, or the percentage of mothers receiving post-discharge support.

2. Collect baseline data: Gather data on the current status of maternal health access, including the level of knowledge about KMC, the availability of healthcare resources, and the support received by mothers after discharge.

3. Implement the recommendations: Roll out the recommended interventions, such as educational programs, infrastructure improvements, community engagement initiatives, and post-discharge support programs.

4. Monitor and evaluate: Continuously collect data on the indicators identified in step 1 to assess the impact of the recommendations. This can be done through surveys, interviews, and data analysis.

5. Analyze the data: Use statistical analysis techniques to analyze the collected data and determine the extent to which the recommendations have improved access to maternal health. This can involve comparing baseline data with post-intervention data and calculating statistical significance.

6. Adjust and refine: Based on the findings from the analysis, make any necessary adjustments or refinements to the recommendations and interventions to further improve access to maternal health.

7. Communicate the results: Share the findings of the impact assessment with relevant stakeholders, including healthcare providers, policymakers, and the community, to raise awareness and support for continued efforts to improve access to maternal health.

By following this methodology, it will be possible to simulate the impact of the recommendations on improving access to maternal health and make evidence-based decisions for further interventions.

Author

Dima Health

Statistics:

Citations: 44

Identifiers:

DOI: 10.1186/1471-2393-11-99

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Social Determinants, Technology and Innovations

Study Countries:

Ghana

Study Design:

Cohort Study, Cross Sectional Study, randomised-control-trial

Study Approach:

Quantitative