Assessing health system factors affecting access and delivery of IPTp-SP and ITN to pregnant women attending ANC clinics in Ghana

BMC Health Services Research, Volume 21, No. 1, Year 2021

Interpretação

Introduction: Malaria interventions including use of Sulfadoxine-Pyrimethamine as Intermittent Preventive Treatment (IPTp-SP) and distribution of Insecticide Treated Nets (ITNs) have been implemented through ante-natal clinic (ANC) services in Ghana. Yet, the high ANC attendance is not commensurate with the uptake of these interventions, with missed opportunities to deliver the interventions. This study sought to assess the health system factors affecting access and delivery of IPTp-SP and ITN as defined by the Ghana Malaria Policy Guideline to eligible pregnant women attending ANC clinic sessions. Methods: A quantitative cross-sectional study was conducted in the Volta Region of Ghana, with data collected across three levels of health care delivery facilities, including hospitals, health centres and Community-Based Health Planning Service (CHPS) compounds. Data collection included structured observation checklists to document the communication and interaction between the ANC health staff and pregnant women. Additionally, structured questionnaires were used to elicit information on cadre, trainings attended, knowledge and delivery practices of health workers on IPTp-SP and ITN. Stata 16 was used for data analysis, and a defined delivery algorithm was used to compute appropriate and inappropriate delivery practices, using the Ghana policy directive as a guide. Predictors of appropriate delivery were determined using logistic regression analysis. Results: Approximately 97% of the 680 ANC observations had complete information for analysis. Of these, 78% (511/657) were eligible for IPTp-SP after excluding women who have less than 16 weeks of gestation, G6PD deficient, malaria positive and have taken 5 doses of IPTp-SP prior to day of observation. Appropriate delivery of IPTp-SP was 76% (390/511). Despite the availability of SP, 15% (75/511) of all eligible women were not offered the medication and 37% (44/119) of inappropriate delivery was recorded during periods of stock out. ITNs were appropriately delivered to 59% (139) out of 237 eligible women. Thirty-two percent (77/237) of eligible women, mostly continuing ANC clients, were not given ITN despite stock availability. Conclusions: IPTp-SP was appropriately delivered to most of the eligible pregnant women compared to ITN. While stock out of both intervention could account for inappropriate delivery, despite stock availability, IPTp-SP and ITN were not delivered to some eligible women. This study was conducted in the Agortime-Ziope and South Tongu Districts located in the Volta Region of Ghana (Fig. 1). This research was part of a bigger study that sought to assess parasitic infections among pregnant women as well as an ethnographic study to ascertain the practices of pregnant women in preventing malaria. The study districts were therefore selected based on rural-urban characteristics of the settlements. The Agortime-Ziope district is predominantly rural, with a population of about 35,360, 49% (17,326) of whom are females [32]. Approximately, 39.4% (6843) of the females are between 15 and 49 years, and the General Fertility Rate (GFR), defined as the number of live births per 1000 women aged between 15 and 49 years in a given year was 109.2 according to the 2010 Census [32]. The district had no hospital at the time of the data collection, however, there were three health centres, four Community-Based Health Planning Services (CHPS) compound, and one private maternity home [32]. The South Tongu district is peri-urban with a population of 110,777, 52% of whom are females [33]. Approximately, 37% (21,325) of the females are aged between 15 and 49 years and the GFR (103.3) is comparable to that of Agortime-Ziope [33].. The district has a total of 29 health facilities (two hospitals, four health centres, 18 CHPS compounds and 5 private clinics) [33]. Data was collected across three levels of healthcare delivery facilities – hospitals, health centres and CHPS compound. Study Site In Ghana, health care is provided by both public and private facilities with the Ministry of Health being the overarching body of governance [34]. The public health care services are facilities under the Ghana Health Service, Teaching Hospitals and Quasi-Government Institutions such as the Police Service, Military and Public Universities [34]. The private sector is made up of Faith-Based, Private-for-Profit, Private not-for-Profit health institutions and the Traditional Health System [34]. Health services are organized in a three-tier health delivery system of primary, secondary and tertiary level, with five levels of providers; CHPS compounds, health centers and clinics, district hospitals, regional hospitals and tertiary hospitals [34]. The CHPS compounds, health centers and clinics render primary health care, with the district hospitals rendering both primary and secondary health care and serving as the main referral hospital. The regional hospitals are the referral level for secondary care and they are run by general practitioners and specialists [34]. The teaching hospitals provide tertiary care and training of doctors [34]. To reduce out of pocket payments, Ghana instituted a National Health Insurance Scheme (NHIS) in 2003, financed through the National Health Insurance Fund (NHIF) which has three main funding sources; tax revenue from Value Added Tax (2.5%), contributions of Social Security and National Insurance Trust (2.5%) and income adjusted premiums ranging between seven Ghana Cedis to 48 Cedis [34]. A free maternal health care policy was also instituted in 2008, thus all pregnant women are entitled to free enrolment on the NHIS to enable access to maternal health services [35]. This was a quantitative health facility-based cross-sectional study, with data collected over a period of 5 months; from April to June 2019 and from November to December, 2019. Seven health facilities across three levels of health care delivery system were included in this study. All the health facilities provided ANC services, however Focused ANC (FANC), which is an individualised, client centred, comprehensive care, with emphasis on disease detection rather than risk assessment [36] was limited to the hospitals and CHPS compounds. Although health centres had laboratory services, Glucose-6-phosphate dehydrogenase (G6PD) tests were conducted only in the hospital laboratories. MiP and case management guidelines were unavailable in some of the facilities, however, wall charts on IPTp-SP and ITN were visibly displayed on the walls in all the ANC units. Stock outs of SP (two health centres) and ITNs (one hospital and two health centres) were recorded during the data collection period. In the hospitals and health centres, a section outside the ANC consulting room was used for recording blood pressure, temperature, weight and height of the pregnant women. A waiting area was also designated for pregnant women to sit and wait their turn, with collective health education organized for them. Services provided to pregnant women in the ANC consulting room included history taking, physical examination (palpating the abdomen, measuring fundal height, and listening to foetal heartbeat), Point of Care (POC) tests (HIV tests, urine dipstick for protein and sugar, and malaria RDT), administration of treatments (IPTp-SP) and immunizations (Tetanus), case management of some disease conditions (e.g. uncomplicated malaria), distribution of ITN, and health education. The study population comprised of pregnant women and ANC health staff. Specifically, all pregnant women irrespective of gestational age attending ANC clinic during the study period were eligible to participate in the study. With regards to the ANC health staff, a complete enumeration of all ANC staff who provide clinical care in the study facilities was carried out. A sample size of 680 was calculated using Cochran’s formula (n = z2p (1-p)/e2) for calculating sample sizes for cross sectional studies. Where “n” is the computed sample size, “z” the desired confidence interval at 95% (z = 1.96), “p” the estimated proportion of an attribute that is present in the population, and “e” the desired level of precision at 5% [37]. To determine the most appropriate prevalence “p” of the two interventions (IPTp-SP or ITN) to use, the most current available national estimates of IPTp-SP3 (36.7%) [38] and ITN use (43%) [39] at the time of the data collection period was used. ITN use generated the largest sample size of 377 for each study district (Table 1). The Cochrane’s finite population correction formula [37] was then used to correct the sample sizes for each district to reflect a feasible and representative number of pregnant woman that can be sampled, after which a 10% non-response or incomplete dataset rate was computed (Table (Table1).1). This percentage was informed by a Malawian study on IPTp-SP, where 8% of the data were incomplete, thus excluded from analysis [40]. The number of pregnant women who access ANC services in the various health facilities vary, therefore a proportionate to size was used to determine the percentage of pregnant women to be sampled in each facility in a particular district. This was determined by making the total number of annual ANC registrants (reference year is 2018 retrieved from the District Health Management Information system (DHIMS), in each health facility a fraction of the sum of all pregnant women registered for ANC in all the participating health facilities in each district annually. This fraction was then multiplied by the calculated sample size for each district to get the proportion of pregnant women to be sampled from each facility (Table 2). Sample Size Calculation Proportionate to Facility Size Sample Calculation Data was collected in seven health facilities purposively sampled across three levels of care. This sampling was done to help identify the health system factors peculiar to each level of care, and ascertain how that affects the delivery of IPTp-SP and ITN. In the South Tongu District, the district hospital (Sogakope District Hospital), one health centre (Dabala Health Centre) and CHPS compound (Agbakope CHPS) with the highest number of ANC clients compared to the other CHPS and health centres in that district were included. Additionally, a faith-based facility (Richard Novarti Catholic Hospital (RNCH)) comparable to the level of a district hospital was also included to provide an insight into the delivery practices peculiar to non-governmental health facilities. In the Agortime-Ziope District, there was no district hospital at the time of data collection, two health centres; one in an urban (Kpetoe Health Centre) and the other in a peri-urban settlement (Ziope Health Centre) were included, in addition one CHPS compound (Akpokope CHPS) with the highest number of ANC clients was sampled. Data collection tools used included observation checklist and questionnaires. These tools were pre-tested in the Ho Polyclinic in the Volta region, with 10 ANC observations conducted and three ANC health workers interviewed with the questionnaires. Modifications including changing the wording for some questions for easy comprehension and adding other questions were effected. Two different observation checklists were used, one was used to document the interaction between ANC health staff and pregnant women and the second to document general ANC activities on a daily basis, including stock of IPTp-SP and ITN. Four community health nurses were recruited as research assistants (RAs) and trained on the study aim, data collection methods and research ethics for 2 days, followed by 1 day field work. The field work was to ensure that the RAs understood the data collection tools and also to make them conversant with the data collection process. Prior to commencing data collection, a meeting was convened in each study facility with the health workers to inform them about the study and also seek their consent to be observed, especially the ANC staff. Data collection commenced with all the consented ANC health staff interviewed with a questionnaire. The questionnaire elicited information on cadre, trainings attended and knowledge on the Ghana Policy on IPTp-SP and ITN. Consecutive sampling, a technique in which every study population meeting the inclusion criteria is sampled until the sampled size is reached [41] was employed in the sampling of pregnant women. The RAs approached pregnant women as they awaited their turn to be attended to, introduced the study to them and obtained written consent from those willing to participate. The observation of the ANC consultation sessions was then carried out, with the actions and communications between pregnant women and health staff documented. Data collected included the cadre of health worker delivering care, gestational age of pregnant woman, number of ANC sessions attended, physical examinations and tests conducted by the ANC staff, medications and treatments administered including IPTp-SP, and delivery of ITN. Data was collected on every ANC clinic day till the required sample size was obtained. All Filled data collection tools were cross-checked on a daily basis for data accuracy and completeness by a field supervisor. Using the 2014 Ghana MiP Policy directive [42], an algorithm to assess the delivery of IPTp-SP and ITN in the ANC unit was developed. The policy directive specified that SP should be administered as a single dose of three tablets of 500 mg Sulfadoxine and 25 mg pyrimethamine, commenced from 16 weeks of gestation or at quickening, to pregnant women who are not clinically diagnosed with malaria or G6PD deficiency. The medication should also be administered under Directly Observed Therapy (DOT) with monthly intervals. While, up to seven doses of SP can be taken as specified in the policy document, delivery in all the health facilities across Ghana has been capped at five doses. The defined algorithm for appropriate delivery of IPTp-SP for this study was therefore defined based on successful completion of three steps, which were: Inappropriate delivery of IPTp-SP entailed any of the actions or inactions below by the health worker: Similarly, delivery of ITN was assessed by an algorithm. In Ghana, every pregnant woman attending ANC clinic is eligible for an ITN free of charge. Hence, eligibility for ITN was defined as any pregnant woman who has not yet been given an ITN since starting ANC. Evidence of receipt of an ITN by a pregnant woman during her current pregnancy at the ANC is indicated through its documentation in the MHRB of the woman. Pregnant women with no documentation of ‘ITN given’ in their MHRB was interpreted as ITN not yet received. Appropriate delivery of ITN was therefore defined as: Inappropriate delivery was defined as: Data were entered and cleaned using Statistical Package for Social Sciences (SPSS) (SPSS Inc., Chicago, IL) version 22, after which the data was imported into STATA 16 SE software (Stata Corp LP) for analysis. Continuous variables in the observation checklist such as gestational age of pregnancy and number of ANC sessions attended were reclassified into ranges. Prior to computing IPTp-SP delivery, ineligible pregnant women (< 16 weeks, G6PD deficient, malaria positive and those who have already taken 5 doses of IPTp-SP) were filtered from the overall sample of pregnant women observed (Fig. 2). This gave rise to a sub-sample of pregnant women, which was then used to assess the delivery of IPTp-SP (Fig. 3). Similarly, ineligible pregnant women (have already received ITN during that pregnancy) were filtered out before the delivery of ITN was computed (Fig. 4). To ensure accurate assessment of the factors influencing the delivery of both IPTp-SP and ITN, inappropriate delivery that occurred during periods of stock out was filtered out, in order not to confound estimation of other predictive variables. Pearson Chi-Square (X2) and Fishers Exact Test analysis were used to determine the association between selected explanatory variables and delivery of IPTp-SP and ITN. Statistical significance was set at a p-value of less than 0.05 (p < 0.05). To ascertain the strength of association between appropriate delivery of the interventions and significant explanatory variables from the X2 analysis, a bivariable logistic regression analysis was performed by estimating Odds Ratios (ORs) with 95% confidence intervals (CIs). All explanatory variables with p < 0.05 were fitted into an investigator led backward-stepwise multivariable logistic regression model to further ascertain the strength of association with the outcome variable by estimating the adjusted Odds Ratios (aORs). P-value of < 0.05 was deemed significant. The results of the study are presented in figures and tables. Determining Eligibility of Pregnant Women for IPTp-SP IPTp-SP Delivery Algorithm Determining Eligibility of Pregnant Women for ITN Six hundred and eighty observations of the ANC clinic sessions between pregnant women and ANC staff were conducted. Some of the observations had pertinent missing data such as current gestational age, and this was mainly due to unfilled sections in the MHRB. Incomplete records were omitted from the analysis. After data cleaning, 657 (96.6%) of the observed cases had complete datasets tools adequate for analysis. Ineligible women as specified in the Ghana MiP policy document were excluded from the analysis, with the derived sub-sample of pregnant women eligible for IPTp-SP being 511. (Fig. (Fig.22). Using the study’s defined delivery assessment algorithm, appropriate and inappropriate delivery of IPTp-SP was computed. Figure 3, shows that out of the 511 pregnant women eligible for IPTp-SP, 76.7% (392) were offered the medication by the ANC staff, of which 390 were administered under DOT, with all of them being told their next ANC visit date. IPTp-SP was appropriately administered to 76.3% of the pregnant women. On the other hand, 23.3% (119) of eligible pregnant women were not offered the medication, 37% (44) of which occurred during a period of stock out. Despite the availability of SP in health facilities during the data collection period, almost 15% (75) of all eligible women were not offered the medication. Years of experience of the ANC staff was found to be significantly associated (p < 0.007) with appropriate delivery of IPTp-SP in the Pearson Chi–Square analysis. Health workers who had 1-5 years experience delivered IPTp-SP appropriately to 88.9% (152) of pregnant women. Type of pregnant woman (first time or continuing ANC client) was also found to be a significant factor (p < 0.0001) affecting delivery of IPTp-SP, with 86.1% (360) of the continuing pregnant women having IPTp-SP delivered to them appropriately. The number of ANC sessions attended by pregnant women (p < 0.0001) and gestational age of pregnancy (p < 0.0001) were also significantly associated with the delivery of IPTp-SP (Table 3). Factors Influencing Delivery of IPT-SP Factors found to be significantly associated with appropriate delivery of IPTp-SP in the crude analysis were type of health facility, years of experience as an ANC staff, type of pregnant woman, number of ANC clinic sessions attended and gestational age of pregnant woman (Table 4). In the multivariable logistic regression analysis, type of facility, years of experience as an ANC staff and gestational age of pregnant woman were the predictors that remained significant with appropriate delivery of IPTp-SP. Regarding the type of facility, the faith-based hospital (aOR 0.68, 95%CI = 0.275–1.707), the health centres (aOR0.60, 95%CI = 0.236–1.545) and CHPS compounds (aOR 0.12, 95%CI = 0.039–0.375) had reduced odds of appropriate delivery compared to the district hospital. Higher odds of appropriate delivery were found among ANC health workers with one to 5 years’ experience (aOR 3.57, 95%CI = 1.564–8.145) and more than 5 years’ experience (aOR 3.08, 95%CI = 1.181–8.028). The odds of appropriate delivery of IPTp-SP increased with increasing gestational age, where pregnant women with gestational ages between 21 to 25 weeks had more than twice (aOR = 2.33, 95%CI = 1.621–5.343) the odds of appropriate delivery, and those between 26 and 30 weeks had more than four times (aOR 4.64, 95%CI = 1.807–11.918) the odds of appropriate delivery compared to those between 16 to 20 weeks (Table (Table44). Determinants of Appropriate Delivery Out of the 657 ANC sessions observed, 19.3% (127) of the pregnant women were first time ANC attendees with the remaining being continuing clients. Seventy-nine percent (420) of the continuing clients had “ITN given” documented in their MHRB, with the remaining 21% (110), having no record of ITN given in their MHRB. Defining eligibility for ITN in this study as all pregnant women who have not yet received an ITN, the number of pregnant women eligible for the intervention was 237 as shown in Fig. Fig.44. Insecticide treated net was appropriately delivered to 58.65% (139) of the 237 pregnant women who had not yet received an ITN prior to day of observation (Fig. 5). Appropriate delivery was highest amongst first time ANC clients (114) than the continuing clients [25] (Table 5). While 21% [21] of inappropriate delivery occurred during periods of stock out, the remaining 32% (77) of eligible women were not given ITN despite stock availability. ITN Delivery Factors Influencing ITN Delivery The type of health worker (p = 0.018), type of pregnant woman (p < 0.0001), number of ANC clinic sessions attended (p < 0.0001), and gestational age of the pregnancy (p < 0.0001) were significantly associated with delivery of ITN in the Pearson Chi-Square analysis (Table (Table5).5). Appropriate delivery of ITN was highest among first time ANC clients (97.44%), compared to continuing clients who have not yet received one (25.25%). Similarly, delivery of ITN decreased with increasing number of ANC attendances.

AI Digest

Study Justification:

– The study aimed to assess the health system factors affecting access and delivery of IPTp-SP and ITN to pregnant women attending ANC clinics in Ghana.
– The high attendance at ANC clinics in Ghana is not matched by the uptake of malaria interventions, indicating missed opportunities for delivery.
– Understanding the factors that affect access and delivery of these interventions is crucial for improving maternal and child health outcomes.

Study Highlights:

– The study was conducted in the Volta Region of Ghana, specifically in the Agortime-Ziope and South Tongu Districts.
– Data was collected from hospitals, health centers, and Community-Based Health Planning Service (CHPS) compounds.
– The study used structured observation checklists and questionnaires to collect data on communication and interaction between ANC health staff and pregnant women, as well as health worker knowledge and delivery practices.
– The analysis showed that IPTp-SP was appropriately delivered to most eligible pregnant women, while ITN delivery was lower.
– Stockouts of both interventions were identified as a contributing factor to inappropriate delivery.
– Factors such as years of experience, type of health facility, gestational age, and number of ANC sessions attended were found to influence the appropriate delivery of IPTp-SP and ITN.

Recommendations:

– Improve training and knowledge of ANC health staff on the Ghana Malaria Policy Guideline for IPTp-SP and ITN delivery.
– Address stockouts of IPTp-SP and ITN to ensure consistent availability.
– Strengthen monitoring and supervision of ANC clinics to ensure adherence to delivery guidelines.
– Target interventions towards pregnant women attending ANC for the first time to improve ITN delivery.

Key Role Players:

– Ministry of Health, Ghana
– Ghana Health Service
– Teaching Hospitals
– Quasi-Government Institutions (Police Service, Military, Public Universities)
– Faith-Based Health Institutions
– Private-for-Profit Health Institutions
– Private not-for-Profit Health Institutions
– Traditional Health System

Cost Items for Planning Recommendations:

– Training programs for ANC health staff on malaria interventions (IPTp-SP and ITN)
– Procurement and supply of IPTp-SP and ITN to health facilities
– Monitoring and supervision activities to ensure adherence to delivery guidelines
– Information and education campaigns for pregnant women on the importance of IPTp-SP and ITN

Força da prova

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a quantitative cross-sectional study conducted in the Volta Region of Ghana. The study collected data from multiple levels of health care delivery facilities and used structured observation checklists and questionnaires to assess health system factors affecting access and delivery of IPTp-SP and ITN to pregnant women attending ANC clinics. The study found that IPTp-SP was appropriately delivered to 76% of eligible pregnant women, while ITNs were appropriately delivered to 59% of eligible women. The study identified factors such as type of health facility, years of experience of ANC staff, type of pregnant woman, number of ANC sessions attended, and gestational age of pregnancy that influenced the delivery of IPTp-SP and ITN. However, the study did not provide information on the representativeness of the sample or the generalizability of the findings. To improve the strength of the evidence, future studies could consider using a larger and more diverse sample, including multiple regions in Ghana, and employing a longitudinal design to assess the long-term impact of health system factors on the delivery of IPTp-SP and ITN.

Resumo

This study was conducted in the Agortime-Ziope and South Tongu Districts located in the Volta Region of Ghana (Fig. 1). This research was part of a bigger study that sought to assess parasitic infections among pregnant women as well as an ethnographic study to ascertain the practices of pregnant women in preventing malaria. The study districts were therefore selected based on rural-urban characteristics of the settlements. The Agortime-Ziope district is predominantly rural, with a population of about 35,360, 49% (17,326) of whom are females [32]. Approximately, 39.4% (6843) of the females are between 15 and 49 years, and the General Fertility Rate (GFR), defined as the number of live births per 1000 women aged between 15 and 49 years in a given year was 109.2 according to the 2010 Census [32]. The district had no hospital at the time of the data collection, however, there were three health centres, four Community-Based Health Planning Services (CHPS) compound, and one private maternity home [32]. The South Tongu district is peri-urban with a population of 110,777, 52% of whom are females [33]. Approximately, 37% (21,325) of the females are aged between 15 and 49 years and the GFR (103.3) is comparable to that of Agortime-Ziope [33].. The district has a total of 29 health facilities (two hospitals, four health centres, 18 CHPS compounds and 5 private clinics) [33]. Data was collected across three levels of healthcare delivery facilities – hospitals, health centres and CHPS compound. Study Site In Ghana, health care is provided by both public and private facilities with the Ministry of Health being the overarching body of governance [34]. The public health care services are facilities under the Ghana Health Service, Teaching Hospitals and Quasi-Government Institutions such as the Police Service, Military and Public Universities [34]. The private sector is made up of Faith-Based, Private-for-Profit, Private not-for-Profit health institutions and the Traditional Health System [34]. Health services are organized in a three-tier health delivery system of primary, secondary and tertiary level, with five levels of providers; CHPS compounds, health centers and clinics, district hospitals, regional hospitals and tertiary hospitals [34]. The CHPS compounds, health centers and clinics render primary health care, with the district hospitals rendering both primary and secondary health care and serving as the main referral hospital. The regional hospitals are the referral level for secondary care and they are run by general practitioners and specialists [34]. The teaching hospitals provide tertiary care and training of doctors [34]. To reduce out of pocket payments, Ghana instituted a National Health Insurance Scheme (NHIS) in 2003, financed through the National Health Insurance Fund (NHIF) which has three main funding sources; tax revenue from Value Added Tax (2.5%), contributions of Social Security and National Insurance Trust (2.5%) and income adjusted premiums ranging between seven Ghana Cedis to 48 Cedis [34]. A free maternal health care policy was also instituted in 2008, thus all pregnant women are entitled to free enrolment on the NHIS to enable access to maternal health services [35]. This was a quantitative health facility-based cross-sectional study, with data collected over a period of 5 months; from April to June 2019 and from November to December, 2019. Seven health facilities across three levels of health care delivery system were included in this study. All the health facilities provided ANC services, however Focused ANC (FANC), which is an individualised, client centred, comprehensive care, with emphasis on disease detection rather than risk assessment [36] was limited to the hospitals and CHPS compounds. Although health centres had laboratory services, Glucose-6-phosphate dehydrogenase (G6PD) tests were conducted only in the hospital laboratories. MiP and case management guidelines were unavailable in some of the facilities, however, wall charts on IPTp-SP and ITN were visibly displayed on the walls in all the ANC units. Stock outs of SP (two health centres) and ITNs (one hospital and two health centres) were recorded during the data collection period. In the hospitals and health centres, a section outside the ANC consulting room was used for recording blood pressure, temperature, weight and height of the pregnant women. A waiting area was also designated for pregnant women to sit and wait their turn, with collective health education organized for them. Services provided to pregnant women in the ANC consulting room included history taking, physical examination (palpating the abdomen, measuring fundal height, and listening to foetal heartbeat), Point of Care (POC) tests (HIV tests, urine dipstick for protein and sugar, and malaria RDT), administration of treatments (IPTp-SP) and immunizations (Tetanus), case management of some disease conditions (e.g. uncomplicated malaria), distribution of ITN, and health education. The study population comprised of pregnant women and ANC health staff. Specifically, all pregnant women irrespective of gestational age attending ANC clinic during the study period were eligible to participate in the study. With regards to the ANC health staff, a complete enumeration of all ANC staff who provide clinical care in the study facilities was carried out. A sample size of 680 was calculated using Cochran’s formula (n = z2p (1-p)/e2) for calculating sample sizes for cross sectional studies. Where “n” is the computed sample size, “z” the desired confidence interval at 95% (z = 1.96), “p” the estimated proportion of an attribute that is present in the population, and “e” the desired level of precision at 5% [37]. To determine the most appropriate prevalence “p” of the two interventions (IPTp-SP or ITN) to use, the most current available national estimates of IPTp-SP3 (36.7%) [38] and ITN use (43%) [39] at the time of the data collection period was used. ITN use generated the largest sample size of 377 for each study district (Table 1). The Cochrane’s finite population correction formula [37] was then used to correct the sample sizes for each district to reflect a feasible and representative number of pregnant woman that can be sampled, after which a 10% non-response or incomplete dataset rate was computed (Table (Table1).1). This percentage was informed by a Malawian study on IPTp-SP, where 8% of the data were incomplete, thus excluded from analysis [40]. The number of pregnant women who access ANC services in the various health facilities vary, therefore a proportionate to size was used to determine the percentage of pregnant women to be sampled in each facility in a particular district. This was determined by making the total number of annual ANC registrants (reference year is 2018 retrieved from the District Health Management Information system (DHIMS), in each health facility a fraction of the sum of all pregnant women registered for ANC in all the participating health facilities in each district annually. This fraction was then multiplied by the calculated sample size for each district to get the proportion of pregnant women to be sampled from each facility (Table 2). Sample Size Calculation Proportionate to Facility Size Sample Calculation Data was collected in seven health facilities purposively sampled across three levels of care. This sampling was done to help identify the health system factors peculiar to each level of care, and ascertain how that affects the delivery of IPTp-SP and ITN. In the South Tongu District, the district hospital (Sogakope District Hospital), one health centre (Dabala Health Centre) and CHPS compound (Agbakope CHPS) with the highest number of ANC clients compared to the other CHPS and health centres in that district were included. Additionally, a faith-based facility (Richard Novarti Catholic Hospital (RNCH)) comparable to the level of a district hospital was also included to provide an insight into the delivery practices peculiar to non-governmental health facilities. In the Agortime-Ziope District, there was no district hospital at the time of data collection, two health centres; one in an urban (Kpetoe Health Centre) and the other in a peri-urban settlement (Ziope Health Centre) were included, in addition one CHPS compound (Akpokope CHPS) with the highest number of ANC clients was sampled. Data collection tools used included observation checklist and questionnaires. These tools were pre-tested in the Ho Polyclinic in the Volta region, with 10 ANC observations conducted and three ANC health workers interviewed with the questionnaires. Modifications including changing the wording for some questions for easy comprehension and adding other questions were effected. Two different observation checklists were used, one was used to document the interaction between ANC health staff and pregnant women and the second to document general ANC activities on a daily basis, including stock of IPTp-SP and ITN. Four community health nurses were recruited as research assistants (RAs) and trained on the study aim, data collection methods and research ethics for 2 days, followed by 1 day field work. The field work was to ensure that the RAs understood the data collection tools and also to make them conversant with the data collection process. Prior to commencing data collection, a meeting was convened in each study facility with the health workers to inform them about the study and also seek their consent to be observed, especially the ANC staff. Data collection commenced with all the consented ANC health staff interviewed with a questionnaire. The questionnaire elicited information on cadre, trainings attended and knowledge on the Ghana Policy on IPTp-SP and ITN. Consecutive sampling, a technique in which every study population meeting the inclusion criteria is sampled until the sampled size is reached [41] was employed in the sampling of pregnant women. The RAs approached pregnant women as they awaited their turn to be attended to, introduced the study to them and obtained written consent from those willing to participate. The observation of the ANC consultation sessions was then carried out, with the actions and communications between pregnant women and health staff documented. Data collected included the cadre of health worker delivering care, gestational age of pregnant woman, number of ANC sessions attended, physical examinations and tests conducted by the ANC staff, medications and treatments administered including IPTp-SP, and delivery of ITN. Data was collected on every ANC clinic day till the required sample size was obtained. All Filled data collection tools were cross-checked on a daily basis for data accuracy and completeness by a field supervisor. Using the 2014 Ghana MiP Policy directive [42], an algorithm to assess the delivery of IPTp-SP and ITN in the ANC unit was developed. The policy directive specified that SP should be administered as a single dose of three tablets of 500 mg Sulfadoxine and 25 mg pyrimethamine, commenced from 16 weeks of gestation or at quickening, to pregnant women who are not clinically diagnosed with malaria or G6PD deficiency. The medication should also be administered under Directly Observed Therapy (DOT) with monthly intervals. While, up to seven doses of SP can be taken as specified in the policy document, delivery in all the health facilities across Ghana has been capped at five doses. The defined algorithm for appropriate delivery of IPTp-SP for this study was therefore defined based on successful completion of three steps, which were: Inappropriate delivery of IPTp-SP entailed any of the actions or inactions below by the health worker: Similarly, delivery of ITN was assessed by an algorithm. In Ghana, every pregnant woman attending ANC clinic is eligible for an ITN free of charge. Hence, eligibility for ITN was defined as any pregnant woman who has not yet been given an ITN since starting ANC. Evidence of receipt of an ITN by a pregnant woman during her current pregnancy at the ANC is indicated through its documentation in the MHRB of the woman. Pregnant women with no documentation of ‘ITN given’ in their MHRB was interpreted as ITN not yet received. Appropriate delivery of ITN was therefore defined as: Inappropriate delivery was defined as: Data were entered and cleaned using Statistical Package for Social Sciences (SPSS) (SPSS Inc., Chicago, IL) version 22, after which the data was imported into STATA 16 SE software (Stata Corp LP) for analysis. Continuous variables in the observation checklist such as gestational age of pregnancy and number of ANC sessions attended were reclassified into ranges. Prior to computing IPTp-SP delivery, ineligible pregnant women (< 16 weeks, G6PD deficient, malaria positive and those who have already taken 5 doses of IPTp-SP) were filtered from the overall sample of pregnant women observed (Fig. 2). This gave rise to a sub-sample of pregnant women, which was then used to assess the delivery of IPTp-SP (Fig. 3). Similarly, ineligible pregnant women (have already received ITN during that pregnancy) were filtered out before the delivery of ITN was computed (Fig. 4). To ensure accurate assessment of the factors influencing the delivery of both IPTp-SP and ITN, inappropriate delivery that occurred during periods of stock out was filtered out, in order not to confound estimation of other predictive variables. Pearson Chi-Square (X2) and Fishers Exact Test analysis were used to determine the association between selected explanatory variables and delivery of IPTp-SP and ITN. Statistical significance was set at a p-value of less than 0.05 (p < 0.05). To ascertain the strength of association between appropriate delivery of the interventions and significant explanatory variables from the X2 analysis, a bivariable logistic regression analysis was performed by estimating Odds Ratios (ORs) with 95% confidence intervals (CIs). All explanatory variables with p < 0.05 were fitted into an investigator led backward-stepwise multivariable logistic regression model to further ascertain the strength of association with the outcome variable by estimating the adjusted Odds Ratios (aORs). P-value of < 0.05 was deemed significant. The results of the study are presented in figures and tables. Determining Eligibility of Pregnant Women for IPTp-SP IPTp-SP Delivery Algorithm Determining Eligibility of Pregnant Women for ITN Six hundred and eighty observations of the ANC clinic sessions between pregnant women and ANC staff were conducted. Some of the observations had pertinent missing data such as current gestational age, and this was mainly due to unfilled sections in the MHRB. Incomplete records were omitted from the analysis. After data cleaning, 657 (96.6%) of the observed cases had complete datasets tools adequate for analysis. Ineligible women as specified in the Ghana MiP policy document were excluded from the analysis, with the derived sub-sample of pregnant women eligible for IPTp-SP being 511. (Fig. (Fig.22). Using the study’s defined delivery assessment algorithm, appropriate and inappropriate delivery of IPTp-SP was computed. Figure 3, shows that out of the 511 pregnant women eligible for IPTp-SP, 76.7% (392) were offered the medication by the ANC staff, of which 390 were administered under DOT, with all of them being told their next ANC visit date. IPTp-SP was appropriately administered to 76.3% of the pregnant women. On the other hand, 23.3% (119) of eligible pregnant women were not offered the medication, 37% (44) of which occurred during a period of stock out. Despite the availability of SP in health facilities during the data collection period, almost 15% (75) of all eligible women were not offered the medication. Years of experience of the ANC staff was found to be significantly associated (p < 0.007) with appropriate delivery of IPTp-SP in the Pearson Chi–Square analysis. Health workers who had 1-5 years experience delivered IPTp-SP appropriately to 88.9% (152) of pregnant women. Type of pregnant woman (first time or continuing ANC client) was also found to be a significant factor (p < 0.0001) affecting delivery of IPTp-SP, with 86.1% (360) of the continuing pregnant women having IPTp-SP delivered to them appropriately. The number of ANC sessions attended by pregnant women (p < 0.0001) and gestational age of pregnancy (p < 0.0001) were also significantly associated with the delivery of IPTp-SP (Table 3). Factors Influencing Delivery of IPT-SP Factors found to be significantly associated with appropriate delivery of IPTp-SP in the crude analysis were type of health facility, years of experience as an ANC staff, type of pregnant woman, number of ANC clinic sessions attended and gestational age of pregnant woman (Table 4). In the multivariable logistic regression analysis, type of facility, years of experience as an ANC staff and gestational age of pregnant woman were the predictors that remained significant with appropriate delivery of IPTp-SP. Regarding the type of facility, the faith-based hospital (aOR 0.68, 95%CI = 0.275–1.707), the health centres (aOR0.60, 95%CI = 0.236–1.545) and CHPS compounds (aOR 0.12, 95%CI = 0.039–0.375) had reduced odds of appropriate delivery compared to the district hospital. Higher odds of appropriate delivery were found among ANC health workers with one to 5 years’ experience (aOR 3.57, 95%CI = 1.564–8.145) and more than 5 years’ experience (aOR 3.08, 95%CI = 1.181–8.028). The odds of appropriate delivery of IPTp-SP increased with increasing gestational age, where pregnant women with gestational ages between 21 to 25 weeks had more than twice (aOR = 2.33, 95%CI = 1.621–5.343) the odds of appropriate delivery, and those between 26 and 30 weeks had more than four times (aOR 4.64, 95%CI = 1.807–11.918) the odds of appropriate delivery compared to those between 16 to 20 weeks (Table (Table44). Determinants of Appropriate Delivery Out of the 657 ANC sessions observed, 19.3% (127) of the pregnant women were first time ANC attendees with the remaining being continuing clients. Seventy-nine percent (420) of the continuing clients had “ITN given” documented in their MHRB, with the remaining 21% (110), having no record of ITN given in their MHRB. Defining eligibility for ITN in this study as all pregnant women who have not yet received an ITN, the number of pregnant women eligible for the intervention was 237 as shown in Fig. Fig.44. Insecticide treated net was appropriately delivered to 58.65% (139) of the 237 pregnant women who had not yet received an ITN prior to day of observation (Fig. 5). Appropriate delivery was highest amongst first time ANC clients (114) than the continuing clients [25] (Table 5). While 21% [21] of inappropriate delivery occurred during periods of stock out, the remaining 32% (77) of eligible women were not given ITN despite stock availability. ITN Delivery Factors Influencing ITN Delivery The type of health worker (p = 0.018), type of pregnant woman (p < 0.0001), number of ANC clinic sessions attended (p < 0.0001), and gestational age of the pregnancy (p < 0.0001) were significantly associated with delivery of ITN in the Pearson Chi-Square analysis (Table (Table5).5). Appropriate delivery of ITN was highest among first time ANC clients (97.44%), compared to continuing clients who have not yet received one (25.25%). Similarly, delivery of ITN decreased with increasing number of ANC attendances.

Materiais

N/A

Inovações

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

1. Mobile Health (mHealth) Solutions: Develop mobile applications or text messaging services to provide pregnant women with information and reminders about ANC visits, IPTp-SP and ITN usage, and other important maternal health practices.

2. Telemedicine: Implement telemedicine services to allow pregnant women in remote areas to consult with healthcare providers and receive guidance on maternal health issues without having to travel long distances.

3. Community Health Workers: Train and deploy community health workers to provide education and support to pregnant women in their communities. These workers can conduct home visits, distribute ITNs, and ensure that pregnant women are aware of and able to access ANC services.

4. Supply Chain Management: Improve the supply chain management system to ensure consistent availability of IPTp-SP and ITNs in healthcare facilities. This can include implementing electronic inventory management systems and establishing effective distribution networks.

5. Quality Improvement Initiatives: Implement quality improvement initiatives to address gaps in the delivery of IPTp-SP and ITNs. This can involve training healthcare providers on the correct administration of IPTp-SP, improving documentation practices, and conducting regular audits to monitor compliance.

6. Health Financing: Explore innovative financing mechanisms, such as social health insurance or community-based health financing schemes, to reduce financial barriers and ensure that pregnant women can access maternal health services without incurring high out-of-pocket expenses.

7. Public-Private Partnerships: Foster partnerships between the public and private sectors to leverage resources and expertise in improving access to maternal health. This can involve collaborations with private healthcare providers, pharmaceutical companies, and technology companies to develop and implement innovative solutions.

8. Behavior Change Communication: Develop targeted behavior change communication campaigns to raise awareness about the importance of ANC visits, IPTp-SP, and ITN usage among pregnant women and their families. These campaigns can utilize various channels, such as radio, television, social media, and community outreach programs.

9. Data Monitoring and Evaluation: Strengthen data monitoring and evaluation systems to track the delivery of IPTp-SP and ITNs, identify bottlenecks, and measure the impact of interventions. This can help inform evidence-based decision-making and ensure accountability in the delivery of maternal health services.

10. Policy and Advocacy: Advocate for policy changes and increased investment in maternal health to prioritize access to ANC services, IPTp-SP, and ITNs. This can involve engaging with policymakers, civil society organizations, and international partners to promote maternal health as a key development priority.

AI Innovations Description

Based on the study conducted in Ghana, the following recommendations can be developed into an innovation to improve access to maternal health:

1. Strengthen Health System: Address the health system factors that affect the delivery of interventions such as IPTp-SP and ITNs. This includes ensuring availability of medications and supplies, improving training and knowledge of health workers, and implementing effective communication and interaction between ANC health staff and pregnant women.

2. Improve ANC Services: Enhance the quality of ANC services by implementing individualized, client-centered care, with emphasis on disease detection. This can be achieved through the adoption of Focused ANC (FANC) approach, which includes comprehensive assessments and appropriate interventions based on the specific needs of pregnant women.

3. Address Stockouts: Take measures to prevent stockouts of essential medications and supplies, such as IPTp-SP and ITNs. This can be done through effective supply chain management, regular monitoring of stock levels, and timely procurement and distribution of these interventions.

4. Training and Capacity Building: Provide regular training and capacity building programs for ANC health staff to improve their knowledge and delivery practices of IPTp-SP and ITNs. This can include training on the Ghana Malaria Policy Guideline, as well as updates on best practices and new developments in maternal health.

5. Community Engagement: Engage the community in promoting and supporting maternal health interventions. This can be done through community education and awareness campaigns, involving community leaders and stakeholders, and encouraging community participation in ANC services.

6. Strengthen Monitoring and Evaluation: Establish a robust monitoring and evaluation system to track the delivery of IPTp-SP and ITNs, as well as other maternal health interventions. This can help identify gaps and challenges, and inform evidence-based decision making for improvement.

By implementing these recommendations, access to maternal health can be improved, leading to better outcomes for pregnant women and their babies.

AI Innovations Methodology

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

1. Strengthen Health Worker Training: Provide comprehensive training programs for ANC health staff on the delivery of interventions such as IPTp-SP and ITNs. This should include updated information on the Ghana Malaria Policy Guideline and best practices for delivering these interventions.

2. Improve Supply Chain Management: Address stockouts of IPTp-SP and ITNs by implementing effective supply chain management systems. This could involve regular monitoring of stock levels, timely procurement, and distribution of these interventions to ensure availability at all health facilities.

3. Enhance Communication and Education: Develop communication strategies to educate pregnant women about the importance of IPTp-SP and ITNs in preventing malaria during pregnancy. This could include community outreach programs, health education sessions at ANC clinics, and the use of informational materials such as posters and brochures.

4. Strengthen ANC Services: Ensure that ANC clinics have the necessary resources and infrastructure to provide quality care. This includes having adequate staffing levels, functional equipment for conducting tests and examinations, and a supportive environment for pregnant women to receive ANC services.

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

1. Define Key Indicators: Identify key indicators that measure access to maternal health, such as the percentage of eligible pregnant women receiving IPTp-SP and ITNs, the percentage of ANC clinics with stockouts, and the percentage of ANC health staff trained on delivering these interventions.

2. Collect Baseline Data: Gather baseline data on the identified indicators before implementing the recommendations. This could involve conducting surveys, interviews, and observations at ANC clinics to assess the current situation.

3. Implement Recommendations: Implement the recommended interventions, such as training programs for health workers, supply chain management improvements, communication strategies, and strengthening ANC services.

4. Monitor and Evaluate: Continuously monitor the implementation of the recommendations and collect data on the identified indicators. This could involve regular data collection through surveys, interviews, and observations at ANC clinics.

5. Analyze Data: Analyze the collected data to assess the impact of the recommendations on improving access to maternal health. This could involve comparing the baseline data with the post-implementation data to identify any changes or improvements.

6. Adjust and Refine: Based on the analysis of the data, make any necessary adjustments or refinements to the recommendations. This could involve identifying areas that require further improvement or identifying new strategies to address any remaining gaps in access to maternal health.

7. Repeat the Process: Continuously repeat the monitoring, evaluation, and adjustment process to ensure ongoing improvement in access to maternal health. This could involve regular data collection and analysis, as well as periodic reviews of the implemented interventions to ensure their effectiveness.

By following this methodology, it would be possible to simulate the impact of the recommendations on improving access to maternal health and make informed decisions on how to further enhance access to these important interventions.

Autor

Dima Health

Statistics:

Citations: 3

Identifiers:

DOI: 10.1186/s12913-021-07055-2

Research Areas:

Community Interventions, Disparities, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Noncommunicable Diseases, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce

Study Countries:

Ghana

Study Design:

Cross Sectional Study, Ethnographic Study, Grounded Theory, randomised-control-trial

Study Approach:

Mixed-methods, Qualitative, Quantitative

Participants Gender:

Female

Partilhar isto: