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Background Slow progress has been made in achieving the Millennium Development Goals 4 and 5 in Ghana. Ensuring continuum of care (at least four antenatal visits; skilled birth attendance; postnatal care within 48 hours, at two weeks, and six weeks) for mother and newborn is crucial in helping Ghana achieve these goals and beyond. This study examined the levels and factors associated with continuum of care (CoC) completion among Ghanaian women aged 1549. Methods A retrospective cross-sectional survey was conducted among women who experienced live births between January 2011 and April 2013 in three regions of Ghana. In a two-stage random sampling method, 1,500 women with infants were selected and interviewed about maternal and newborn service usage in line with CoC. Multiple logistic regression models were used to assess factors associated with CoC completion. Results Only 8.0% had CoC completion; the greatest gap and contributor to the low CoC was detected between delivery and postnatal care within 48 hours postpartum. About 95% of women had a minimum of four antenatal visits and postnatal care at six weeks postpartum. A total of 75% had skilled assisted delivery and 25% received postnatal care within 48 hours. Factors associated with CoC completion at 95% CI were geographical location (OR = 0.35, CI 0.130.39), marital status (OR = 0.45; CI 0.220.95), education (OR = 2.71; CI 1.116.57), transportation (OR = 1.97; CI 1.073.62), and beliefs about childhood illnesses (OR = 0.34; CI0.210.61). Conclusion The continuum of care completion rate is low in the study site. Efforts should focus on increasing postnatal care within 48 hours and overcoming the known obstacles to increasing the continuum of care completion rate.
We collected data on background characteristics and MNCH services received by women and their infants from pregnancy to delivery, and up to six weeks after delivery. The total population of this survey area was 467,000 in 2012 [38,39]. This study was conducted as part of the formative research of the Ghana EMBRACE Implementation Research Project [37]. EMBRACE stands for Ensure Mothers and Babies Regular Access to Care; it exploits a package of evidence-based interventions to improve the health of mothers and children through the CoC approach. The Government of Japan launched EMBRACE in 2010 as a strategic initiative to accelerate efforts to help attain the health-related MDGs in developing countries, especially maternal and child health [40]. The Ghana EMBRACE Implementation Research Project was launched in 2012 and the details of the project has been published elsewhere [41] This study was done in Navrongo, Kintampo, and Dodowa, where the three Health Research Centres (HRCs) of the Ghana Health Service’s (GHS) are located (Fig 1). These HRCs operate a Health and Demographic Surveillance System (HDSS). The three HRCs are strategically located to represent the three geographical belts of Ghana namely; Northern Savanah (Navrongo), Middle forest (Kintampo), and Coastal (Dodowa). The Navrongo HRC is situated in the Kassena-Nankana Districts (KNDs) of the Upper East Region of Northern Ghana. The area is predominantly rural and majority of people are subsistence farmers living in small, scattered settlements. The KNDs have one district hospital that draws from 9 health centres, 2 private clinics, and over 50 CHPS Compounds offering basic health care [42,43], manned by 7 doctors, 61 midwives, and 140 community health nurses/officers (CHNs/CHOs), CHPS started in Navrongo in 1999, and has helped to improve the health of the people in the communities. Due to the impact of CHPS, Navrongo is reported to be the only HRC on track to achieve MDG 5 in Ghana [26,38,44]. The Kintampo HRC operates within the boundaries of the Kintampo North Municipality and Kintampo South District in the Brong-Ahafo Region. The inhabitants are mainly rural, constituting about 65% of the population. The road network linking most communities to the district capital is bad, inhibiting access to health facilities. Thus, many women choose to give birth at home [45,46]. There are 7 doctors, 17 midwives and 56 CHNs/CHOs providing MNCH services in 2 hospitals supported by 6 health centres, and 34 CHPS compounds. The Dodowa HRC is located within the boundaries of the Shai-Osudoku and Ningo-Prampram districts in the Greater Accra Region, about 41 kilometers from Accra. It is fairly rural and coastal with scattered communities. The main occupations are farming, fishing and petty trading. The provision of health services is hindered by a poor road network and by the long distances between settlements [39]. There are 21 static health facilities which have 8 doctors, 34 midwives and 93 CHNS/CHOs, and 150 outreach sites mainly for public health services. This study was cross-sectional, and the target population was women aged 15 to 49 years who’s most recent pregnancy and live birth was between January 2011 and April 2013. Using a two-stage random sampling method, 1,500 pairs of women and their infants (500 from each of the three HDSS sites) were selected for interview. The primary sampling unit (PSU) was the zone or sub-district, depending on the HDSS site. The sub-districts which have populations ranging from 5,000 to 35,000 are the lowest health administration units in Ghana. There are 22 PSUs in the study area, each of which had approximately 1,200 eligible women on average for this study. Women were randomly selected from each zone or sub-district using probability proportional to size. To calculate the sample size we assumed that the coverage of key MNCH services from pregnancy to delivery and six weeks postpartum was 15% (significance level = 0.05; power = 0.8). Data from women who had live births and children who were under six weeks old at the time of the survey were excluded. Data from women with missing information on key variables such as transportation were also excluded from the regression analyses. A total of 42 individuals with missing data on some variables (transport to delivery place, and women’s beliefs) were excluded in the final regression analysis CoC is the outcome variable in this study. The EMBRACE indicators for CoC include: These indicators follow the Ghana Safe Motherhood Protocol guidelines (adopted from WHO guidelines) [46,47] and the literature [9,48–50]. These CoC indicators were used to construct a binary CoC variable as follows: 1 for women who completed CoC (ANC4+, SBA, and PNC within 48 hours, at two weeks, and at six weeks), and 0 otherwise. A woman was considered to have discontinued CoC at three levels: pregnancy, delivery, and postpartum. Thus, non-achievement of ANC4+, regardless of achieving SBA and the three PNCs, was discontinuation CoC at pregnancy; non-achievement of SBA, with achievement of ANC4+ and regardless of achieving the three PNCs, was discontinuation at delivery; and a lack of any of the PNCs with achievement of ANC4+ and SBA was discontinuation at postpartum. They were age, education, partner’s education, marital status, socio-economic status (SES), religion, location, parity, timing of pregnancy, transportation to delivery place, family support for woman (e.g. Support taking care of baby), and woman’s beliefs about childhood illnesses. Location in this study refers to geographical location, that is, the place where the three HRCs are located in Ghana as explained under study setting (Fig 1). Socio-economic status (SES) was measured using a household assets index [51]. The assets index was calculated as the first component obtained in a principal component analysis (PCA) about information on house ownership, land ownership, water source, electricity source, toilet type, and household assets including telephones, television, video decks, fridges, sewing machines, car, motorbikes, bicycles, tractors, cattle, and other livestock [52]. To measure woman’s belief about childhood illnesses, respondents were also asked whether they believe all childhood illnesses can be treated or not. In rural Ghana, some causes of new-born illnesses such as severe malaria, fontanel and “asram” (symptoms include green/black veins, a big head and newborn growing lean) are mostly believed to be spiritual and cannot be treated at the health facility [36,53,54]. Also, in rural Northern Ghana, children born with abnormalities such as hydrocephaly are sometimes believed to be spirit children (sent from the bush to destroy the family) [55], thus care is not sought for them at the health facility. Through a structured questionnaire, this study collected data on CoC and most of independent variables. It also used HDSS data from three HRCs for data on ethnicity, religion, and SES. The questionnaire was developed by the Ghana EMBRACE Implementation Research Project Team in English, but the interviewers conducted interviews in local languages that the respondents spoke. The questionnaire was developed based on data collection tools used in previous studies in the same setting, including Demographic and Health Survey, Ghana Maternal Health Survey [30,56,57]. The questionnaire was pre-tested in each of the HRCs, and finalized in July 2013. Data collection using face-to-face interviews with women was undertaken from August to September 2013 with a 100% response rate. Descriptive analysis was performed to show the background characteristics of participants. Multivariable logistic models were performed to examine the factors associated with the CoC. The models were built using the backward selection. The final model assessed the effect of the independent variables on CoC. By using the log-likelihood test, the parsimony of the final model was checked using age “apriori” and it was not significant (LRR2 = 1.76, P = 0.6236). A multinomial logistic model was used to assess the factors associated with discontinuity in CoC. For the multinomial logistic regression, the dependent variable was the level of continuity in care and had four values. The base value was to receive care at ANC, delivery, and PNC. The other three values were 1) discontinued at ANC (not received ANC4+), 2) discontinued at delivery (received ANC4+ but delivered without SBA), and 3) discontinued at PNC (received ANC4+ and delivered assisted by SBA, but not received PNC three times). Stata 12 was used for analysis, and a two-sided p-value of 0.05 was considered statistically significant. This research obtained ethical approval from the Research Ethics Committee of the Graduate School of Medicine, the University of Tokyo; Ethics Review Committee of the Ghana Health Service; and the Institutional Review Boards of Navrongo, Kintampo, and Dodowa HRCs. Written informed consent was obtained from all participants and their confidentiality was assured.
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