Background
Today, approximately 800 women die due to the preventable causes of maternal deaths in the world, every day [1]. Preventable causes of maternal deaths are composed of direct causes (obstetric hemorrhage, hypertensive disorders, puerperal sepsis, and unsafe abortion) and indirect causes (HIV and AIDS, malaria, tuberculosis, other sexually transmitted infections, malnutrition) [2]. They can be prevented through increasing availability of and access to quality of sexual, reproductive, and maternal care. More than 60% of maternal deaths occur in Sub-Saharan Africa [3]. Nearly 75% of maternal deaths are caused by severe bleeding, infections, pre-eclampsia and eclampsia, complications from delivery, and unsafe abortion whose majority cases are either preventable or treatable [4]. To reduce a significantly greater number of maternal deaths in Sub-Saharan Africa, timely and quality antenatal care (ANC) and facility-based delivery (FBD), post-partum care (PPC), Emergency Obstetric Care, and family planning are imperative [5–7]. Poorer access to health facilities, inadequate quality of health services, and socio-economic and socio-cultural barriers are the major obstacles in increasing maternal health service utilization. It prevents reproductive-aged women from reaching life-saving services [8, 9].
Improvement of women’s access to health facilities and health workers alone does not increase the reproductive-aged women’s utilization of the aforementioned key maternal health services, for instance by increasing the number of health facilities and availability of public transports. Creation of health service demands through direct intervention on women in communities needs to be undertaken in parallel [10–12]. Health service demands can be created commonly through household visits and health education sessions conducted by facility-based and/or community-based formal health workers [13, 14]. However, demand creation initiated and implemented by formal health workers does not necessarily result in producing the expected effectiveness. This is largely because the formal health workers’ way of demand creation is not necessarily interactive and friendly enough for local women [15–17]. On the other hand, peer education is expected to play a vital role in increasing service utilization, as the demands can be created more from service users’ perspective. Peer education has been often employed as an effective approach for increasing service utilization not only in adolescent health [18], family planning [19, 20], HIV and other sexually transmitted infection control [21–25], but also in maternal health [10, 26]. Moreover, the interventions based on locally available resources (e.g. peer educators) are more likely to be sustainable by being integrated into local community systems, than facility-based interventions.
To improve reproductive and maternal health among reproductive-aged women (both adults and adolescents) in four African countries (i.e., Ghana, Kenya, Tanzania and Zambia), the Japanese Organization for International Cooperation in Family Planning (JOICFP) implemented a five-year program ‘Protecting the Lives of Pregnant Women in Africa: Community-centered sustainable health promotion program’ (the Program) during the period from January 2018 to December 2022 [27]. The Program was aimed at increasing pregnant women’s utilization of three key maternal health services (i.e., ANC, FBD, and PPC). The Program employed a community-centered approach to ensure its sustainable effectiveness beyond the program life. Both female and male peers recruited from local adults and youths through a series of consultations with the community key stakeholders, were trained as community health volunteers (CHVs) responsible for peer educations and peer consultations on reproductive and maternal health. They were responsible also for locally disseminating the information related to reproductive and maternal health and rights to their peers, and referring those in need of reproductive and maternal health care to primary health facilities. The Program also strengthened the functions and capacity of the existing community health management committees, to enable them to continuously support both CHVs and facility-based health workers. Capacity strengthening of community health management committees was conducted through a series of lectures, group works, and role plays. The Program trained health workers at primary health facilities to improve quality of facility-based health services, too.
By the end of December 2019, the JOICFP in collaboration with its local government partners of the four countries trained 1,856 CHVs composed of males and females, and adults and youths. Through the CHVs, a total of 466,549 individuals were reached in the Program sites with the promotive messages on reproductive and maternal health as of 31st March 2021. Of them, 79,662 were referred to primary health facilities.
To estimate the effectiveness of the aforementioned intervention package in reproductive and maternal health, this study was conducted in Ghana. There were three reasons for conducting the study only in Ghana. First, as the implementation of the Program was less affected by the SARS-CoV-2 (COVID-19) pandemic in Ghana than in other three countries. This study was conducted to estimate the effectiveness of the aforementioned intervention package in reproductive and maternal health in Ghana,. Second, the largest amount of funds was invested in Ghana (i.e., 45% of the total local implementation costs of all the four target countries of the Program). Third, the activities of the Program were fully implemented only in Suhum Municipality of Ghana throughout the entire five-year Program period. In Ghana, the Community-based Health Planning and Services (CHPS) initiative has been implemented since 2000 after careful piloting [28]. The initiative is aimed at ensuring availability of and access to basic maternal and child health services (antenatal care, delivery, postpartum care, child immunization, growth monitoring, and integrated management of childhood illnesses), in particular consideration to women in rural areas. Two community health officers are assigned at each CHPS compound, a primary health facility, to enable them to provide both facility-based and community-based maternal and child health. Specific objectives of the study are estimations of the degree of increases in proportions of women having utilized: (i) at least four ANC services; (ii) FBD services; and (iii) PNC services. National Health Insurance Scheme (NHIS) covers the significant part of maternal and child health service costs for those insured. Yet, not all costs are covered by NHIS and, needless to say, out-of-pocket payments made by those not insured become much larger. Thus, the poor have greater challenges in utilization of health services. The findings of the study are expected not simply to estimate the effectiveness of the Program, but also to serve as the key evidence for improving the design of the Program in the future.
Methods
A quasi-experimental study was conducted in Ghana. Of the four countries where the Program was implemented, Ghana was targeted for the study. Note that the community-based approach similar to this intervention package was previously tested in several countries by the JOICFP [29–31]. Their crude effectiveness was estimated in a cross-sectional observational study, while it has not been precisely assessed [32].
Study design
To estimate the effectiveness of the Program in reproductive and maternal health care service utilization, difference-in-differences (DID) approach was employed [33]. A cross-sectional household survey was conducted, to compare reproductive and maternal health care service utilization between intervention and control sites. In the survey, we sampled four types of groups of women who gave live births during pre-intervention (baseline) and post-intervention (follow-up) periods for both intervention and control groups: i.e., Group I1 as the intervention group at baseline, Group I2 as the intervention group at follow-up, Group C1 as the control group at baseline, and Group C2 as the control group at follow-up (Fig 1).
[Figure omitted. See PDF.]
(A) Three types of maternal health service coverages were employed: (i) ANC: at least four antenatal care visits as proxy for continuation of ANC; (ii) FBD: facility-based delivery; and (iii) PPC: at least one postpartum care visit within two days after delivery. (B) Utilizations of the three types of maternal health services were measured, based on mothers’ memories at the time of the cross-sectional survey.
Study area
Of seven municipalities/districts intervened by the Program in Eastern Region, Suhum Municipality was selected as the intervention site for this study. This is because Suhum Municipality was the only municipality/district where the Program implementation was long and deep enough (i.e., >2 years) to assess its effectiveness. Note that the Program intervention, nevertheless, was suspended during the period from March to October 2020 due to COVID-19 pandemic in all the intervention municipalities/districts of Ghana (incl. Suhum Municipality). The other six were the municipalities/districts where the interventions of the Program started later than in Suhum Municipality (i.e., Akyemansa District, Birim North District, Kwahu East District, Lower Manya Krobo Municipality, Upper Manya Krobo District, and Yilo Krobo Municipality). Atiwa West District was selected as the control site where the Program’s intervention was neither implemented nor planned at the time of the study. Atiwa West District was appropriate as the control group also because its socio-economic and socio-demographic characteristics, and maternal health service coverages at the baseline were reportedly at the similar level to those of Suhum Municipality. Another reason for selecting Atiwa West District is that no externally supported maternal and/or reproductive health project had been planned and implemented in the district. In both Suhum Municipality (intervention site) and Atiwa West District (control site), all the basic health services described earlier were made available.
Study participants
All the women who delivered between 1st January 2018 and 28th February 2019 before the Program’s launch in March 2019 were included in the baseline sampling frames for both intervention and control groups (Group I1 and Group C1 in Fig 1). Similarly, all the women who delivered between 1st August 2021 and 30th April 2022 after the 10 months had passed since the Program’s launch were included in the follow-up sampling frames for both intervention and control groups (Group I2 and Group C2 in Fig 1). Those not having continued to live in Suhum Municipality during the entire pregnancy were excluded from the follow-up sampling frame for the intervention group (Group I2 in Fig 1). By doing so, we ensured that, in the intervention group, the follow-up study participants were fully exposed to the intervention during their pregnancies, while the baseline participants were never. Those having been relocated from Suhum Municipality and other six intervention municipalities/districts to Atiwa West District during their pregnancies were excluded from the follow-up sampling frame for the control group (Group C2 in Fig 1). By doing so, we ensured that, in the control group, the follow-up study participants were never, even partially, exposed to the intervention during their pregnancies.
Interventions and outcome variables
The Program intervention package was composed of three pillars: (i) peer health education and promotion on reproductive and maternal health by locally recruited CHVs; (ii) improvement of the quality of reproductive and maternal health care by training existing health workers at primary health facilities on reproductive and maternal health; and (iii) strengthening of the local community health management committees (Fig 2).
[Figure omitted. See PDF.]
Under the first pillar, the Program trained a total of 180 adult and 150 youth CHVs (Maternal and Child Health Promoters and Peer Educators, respectively) in Suhum Municipality. As shown in Table 1, while a majority of Peer Educators completed either junior or senior high school education (81.3%), education attainments of Maternal and Child Health Promoters are more diverse.
[Figure omitted. See PDF.]
To effectively create reproductive and maternal health care demands, the trained CHVs conducted peer health education and promotion activities at the community level (i.e., individual/group health education and consultation sessions, and referrals of women in need of maternal health care services to local primary health facilities). The Program provided technical support to participatory development of communication strategies, tools and messages. They were designed so as to address the local common obstacles in accessing maternal and sexual reproductive health services from health service users’ perspective.
Under the second pillar, the Program supported the municipal/district health directorates in training facility-based health workers on client-centered care (i.e., respectful maternity care, adolescent-friendly services, and 5S-Initiative activities). 5S-Initiative is the conceptual framework composed of Sorting, Setting, Shining, Standardization, and Sustaining that helps organize and manage the workplace and workflow with the intent to improve efficiency, by eliminating waste, improving flow and reducing process unreasonableness [34].
Under the third pillar, the capacity of community health management committees was strengthened in the implementation of evidence-based planning, implementation, monitoring and evaluation as well as resource mobilization for sustaining the CHVs’ activities and health workers’ quality client-centered care. Capacity strengthening of community health management committees was conducted through a series of lectures, group works, and role plays. These three pillars are mutually complemented to synergically ensure women’s timely access to maternal-health-related information and care.
To estimate the effectiveness of the interventions of the Program, three variables related to the utilization of essential maternal health services (i.e., ANC, FBD and PPC) were set as the outcome variables (Table 2). They were selected as the outcome variables since they serve as the appropriate proxies for health-seeking behavior changes that can be expected to be achieved through the interventions of the Program. All the three outcome variables were defined as dichotomous variables (i.e,. 0 as not utilized and 1 as utilized). In addition to the outcome variables, socio-economic and socio-demographic data were collected as the independent variables, by conducting structured interviews in local languages (Akan, Ewe and Krobo).
[Figure omitted. See PDF.]
Sample size and sampling
The sample size was calculated, so as to detect a significant DID for each outcome variable, by making finite population correction adjustments [35]. This is because the target group was the specific populations in limited geographic areas: i.e., those who delivered between 1st January 2018 and 28th February 2019 (baseline) and those who delivered between 1st August 2021 and 30th April 2022 (follow-up), in Suhum Municipality (intervention site) and Atiwa West District (control site). Those having delivered during the period other than the above two periods were excluded from the sampling. Moreover, those having been relocated, absent despite three repeated visits or refused to participate in the study were excluded, too. Then, design effect of 1.3 was multiplied, as two-stage cluster sampling where mean cluster size was 25 was employed [36]. Assuming 10% non-response rate, the final sample sizes was set at 1,812 mothers (i.e., 453 for each of four groups: Group I1, Group I2, Group C1 and Group C2 in Fig 1). Systematic random sampling was used for selecting mothers having children of respective age groups, for both first and second sampling stages. Expanded Programme on Immunization (EPI) registers readily available at all the Community-based Health Planning and Services (CHPS) compounds (primary healthcare facilities in Ghana) in Suhum Municipality and Atiwa West District were used as sampling frames of mothers of children.
Data analysis
A series of data analyses were conducted in a two-step manner. First, descriptive analysis was conducted for both outcome/dependent and independent variables. As a part of descriptive analyses, the characteristics of study participants were presented. Second, to estimate the effectiveness of the interventions of the Program, both crude and adjusted DID values were estimated. For calculating adjusted DID estimates, mixed-effect logistic regression was employed, by applying sub-district as the random effect of and independent variables (i.e., group, time, maternal age, education attainment, marital status, enrollment in health insurance, household size, and household’s wealth group) as the fixed effects. To test possible multicollinearity, variance inflation factor (VIF) was assessed for each independent variable, by applying VIF value equal to or greater than 10 as the presence of multi-collinearity. Significance levels were set at the values of 0.10, 0.05, and 0.01. The reason for unusually employing 0.10 as one of the significance levels was that the service coverages of the outcome variables had been already too high to have room for an increase at the significance level of 0.05 (e.g., 93.1% of ANC in the intervention group at baseline). Moreover, note that 0.10 has been widely employed as a significance level for behavioral studies into which this study can be categorized [37, 38].
Wealth index was calculated for each household to which respective respondent women belonged, by applying the variables on households’ ownership of 11 types of utilities and assets to principal component analysis. The 11 types of utilities and assets were composed of bicycle, cart, electricity, fixed-line telephone, motorbike, radio, personal computer, refrigerator, television set, vehicle, and watch. The principal component score was calculated for each household, by applying all the dichotomous variables of ownership of 11 types of utilities and assets to principal component analysis with varimax rotation [39]. Then, all the households were categorized into three groups (i.e., wealth tertiles) according to the values of wealth index. In addition, for an additional analysis to assess the impact of interventions by wealth groups, we divided all the households into two groups (i.e., rich and poor) to produce robust estimates and avoid quite high standard errors due to small sample size in each group. All the statistical analyses were conducted, by using Stata 17 (Stata Corp LLC, College Station, TX, USA).
Ethical considerations
An informed consent to participate in the study was obtained in a written form from each mother after the explanation of the study upon household visits. For mothers under 18 years of age, both informed assent and informed consent were obtained from them and their guardians, respectively. In view of the ongoing COVID-19 pandemic, the interviewers practiced either hand washing or alcohol-based hand sanitization both before and after the interviews, and wore face masks during an interview by keeping themselves 1.5 meters away from the respondent. The authors had access to the information that could identify individual participants during and after data collection. To ensure the confidentiality of personal data of the participants, the dataset for analyses was anonymized by encoding the data with unique participant identification numbers. Another dataset composed exclusively of the identification numbers and participants’ personal data (i.e., names and phone numbers) was separately created. Both datasets were protected by using the different passwords.
The study protocol was both internationally and locally approved by: (i) the Institutional Review Board, School of Tropical Medicine Global Health, Nagasaki University, Japan (Approval no. NU_TMGH_2021_179_1); and (ii) Ethics Review Committee, Ghana Health Service, Ghana (Approval no. GHS-ERC 001/02/22). The official permissions for the implementations of the study were obtained from both Suhum Municipal Health Directorate and Atiwa West District Health Directorate. Moreover, local agreements on the implementation of the study were obtained from the leaders of all the target communities, prior to data collection.
Results
Data collection was conducted during the period from 5th to 29th May 2022. Of 1,812 mothers sampled, 1,471 participated in the study (76.1%). Those not having participated were composed of: (i) 158 having already relocated; (ii) 148 ineligible without meeting the inclusion criteria; (iii) 20 absent; (iv) 14 refusals; and (v) one withdrawal in the middle of the interview.
Characteristics of participants
Table 3 shows the socio-demographic and socio-economic characteristics of the respondent mothers, by comparing between the intervention and control groups and between baseline and follow-up. Significant differences were unexpectedly detected in the proportions and mean values of nine and seven of 12 characteristic variables between the intervention and control groups at the baseline and follow-up respectively. This indicates that a need for calculating an adjusted DID estimate for each outcome variable by controlling its confounders, in addition to estimating its crude DID. In both groups, approximately 70% or more of mothers completed secondary education or higher. More than three quarters of their households had at least one mobile phone. Approximately, 90% or more of the mothers were either protestants or other types of Christians.
[Figure omitted. See PDF.]
Overall difference-in-differences
Fig 3(A)–3(C) (show crude DID for three outcome variables, i.e., ANC, FBD and PPC, respectively. Of the three outcome variables, ANC produced a significant crude DID between the intervention and control groups while the others did not. Note that these crude DID values are likely to be less accurate because they were estimated without controlling the possible confounders despite difference in characteristics of mothers between the two groups.
[Figure omitted. See PDF.]
Crude DID is expressed in form of percentage points. * P < 0.10, ** P < 0.05, *** P < 0.01.
Therefore, adjusted DID estimates were calculated by controlling the possible confounders, using mixed-effect logistic regressions. None of independent variables produced VIF values equal to or greater than 10. Thus, no multicollinearity was assumed. Table 4 shows the results of mixed-effect logistic regressions for the three outcome variables. Similarly to crude DID, only ANC produced a significant adjusted DID estimate (aOR = 2.23; P = 0.099 < 0.10) also in the regression models. FBD and PPD did not produced significant adjusted DID estimates. Thus, significant effectiveness of the intervention package among mothers was detected exclusively for ANC.
[Figure omitted. See PDF.]
Wealth-group-specific difference-in-differences
As shown in Table 4, the household wealth group was the only independent variable that systematically produced significant odds ratio across the three models. This implies that the household wealth group was a common predictor of effectiveness of the intervention package. Moreover, it should be carefully noted that the intervention package had been originally designed to priority target women from poor households. For the above two reasons, wealth-group-specific DID was examined, through estimating crude DID by wealth group of mothers’ households (Fig 4). Again, ANC for the poor group was the only outcome variable that produced significant crude DID (11.4 percentage points; P = 0.085). For the other two outcome variables, no significant crude DID values were produced in all three economic level groups. Considering not only the importance of mothers from poor households as the Program’s priority target populations but also a need for more precisely DID estimates, adjusted DID estimates among mothers from poor households were further calculated for the three key outcome variables.
[Figure omitted. See PDF.]
Crude DID is expressed in form of percentage points. * P < 0.10, ** P < 0.05, *** P < 0.01.
Table 5 shows the results of mixed-effect logistic regressions for the three outcome variables with an interaction between DID estimates and wealth groups (i.e., poor and rich). Mothers from poor households in the intervention group exhibited an increase in the likelihood of utilizing ANC services, although it was not significant (aOR = 3.63; P = 0.231). Also, our analysis did not reveal a variation in the effectiveness of the intervention package for the other outcomes across wealth tertiles.
[Figure omitted. See PDF.]
Discussion
Of the three types of essential maternal health service utilization (ANC, FBD and PPC), the intervention package improved only ANC visit coverage. A positive impact of the intervention package on FBD and PPC was not confirmed. Moreover, an adjusted DID estimate for ANC among mothers from poor households shows the positive trend, while it was not significant (aOR = 3.63; P = 0.231).
Effectiveness in ANC coverage
Overall, the intervention package of the Program was effective only in increasing ANC coverage. The differences in DID estimates among the poor group did not produce statistically significant effect size, as indicated by the adjusted odds ratios (Table 5). These findings may suggest that a larger sample size would have uncovered a discernible trend of the impact of the intervention package across different wealth groups. Several earlier studies in low- and middle-income countries reported that health education and promotion contributed to an increase in the proportion of those having completed at least four ANC visits among rural pregnant women [13, 40, 41]. Generally, when health education and promotion activities were conducted by peers rather than by health workers [42], parents [43], or teachers [44, 45] and internet [46], its effectiveness became more conspicuous.
A study in Ethiopia indicated that peer education was one of the factors significantly associated with ANC coverage [28]. Another study in Zambia reported that a combination of ANC service availability and peer education significantly increased ANC coverage, compared with ANC service availability alone [20]. Thus, the findings of our study support the results of these earlier studies. Higher education and greater exposure to media are the facilitators for service utilization [47–52]. However, mothers from poor households are generally likely not only to be poorly educated and less literate [53, 54], but also to have limited access to media and mobile phones [55, 56]. In fact, our study found the proportion of mothers having completed secondary education or higher was significantly smaller among those from poor households than among the others (P < 0.001). Thus, peer educators likely to be friendlier to mothers from poor households should be appropriate facilitators in more effectively encouraging them to make at least four ANC visits.
Probably, improvement of the quality of services through increasing clinical staff’s skills alone has limited effectiveness in increasing ANC coverage. In rural areas where access to health facilities is often more challenging, the creation of service demands is an equally necessary intervention for increasing ANC4 coverage [11, 12, 57]. Note that the Program attempted to creating ANC service demands through peer education and promotion, while other previous projects did it through offering an incentive [11, 12, 58].
A significant increase in ANC coverage has been reported often among women from poor households [26, 59–61]. One of the possible reasons for this is that there is relatively greater room for an increase in ANC coverage among women from poor households [62], compared with those from middle-wealth or richer households. ANC coverages among middle-wealth and rich households are generally already high enough [63]. The results of our study are in the similar trend, by identifying 91.1%, 94.0%, and 97.6% of ANC coverages among those from poor households, middle-wealth households, and rich households, respectively.
Effectiveness in FBD and PPC
This study did not identify the effectiveness of the intervention package in increasing service coverages of FBD and PPC not only among mothers in general but also even specifically among those from poor households.
The effectiveness of intervention projects aimed at increasing the coverage of ANC, FBD, and PPC differs according to the type, combination, and magnitude of interventions, and is mixed. Some interventions such as mass media campaigns and health education reported to significantly increase the service coverage of ANC but not of FBD [64, 65]. The intensive quality improvement initiative jointly implemented by District Health Management Team and respective health facilities improved service coverage of both ANC and FBD in Kenya [66]. Health promoters’ intervention targeting the poorest population was successful in increasing service coverages of ANC, FBD and PPC [26, 58]. One study in Uganda found that an intervention package composed of community mobilization and capacity building of health workers increased service coverage of FBD but not of ANC [67], In Ethiopia, an intervention package composed of training of health workers and extension workers, rehabilitations of health centers, consumable supplies and community sensitization resulted in increased service coverage only of FBD [10].
It is reasonable that increasing ANC visits is less challenging and earlier realizable than increasing utilization of FBD and PPC services. This is because a majority of those having utilized FBD services must have made ANC visits while very few mothers not having made any ANC visits choose FBD. In other words, ANC attendance is one of the determinants of utilization of FBD services [68–76]. For the same logic, ANC and FBD service utilization are the primary and secondary determinants of utilization of PPC services, respectively [71, 77–79]. A systematic review of the studies in Ethiopia reported that mothers having attended one or more ANC were four times more likely to deliver at facilities and, then, receive PPC [80]. Moreover, deliveries are unpredictable events that can take place on rainy days, at night, and on weekends. Unpredictability of labor is a significant barrier to increasing FBD coverage [78].
More intensive and comprehensive intervention may increase FBD and PPC coverage. Improving quality of care is indispensable to increasing FBD coverage [74, 81, 82]. The Program provided facility-based clinical health workers with the training on client-centered care that addresses four of the eight standards of quality of maternal care: (i) effective communication; (ii) respect and preservation of dignity; (iii) emotional support; and (iv) competent and motivated human resources [83]. However, training on other maternal care standards (e.g., evidence-based routine care practices and essential physical resource availability) might be additionally necessary to increase FBD coverage [10, 67]. Client-centered care, the second pillar of the intervention package, might not have been effective enough to adequately attract pregnant women to FBD and PPC services. This is because there are several other key barriers to FBD and PPC services utilization in Ghana, as reported earlier (i.e., greater informal payments to health workers, and inadequate health infrastructures, medical equipment and essential medicine) [84].
Limitations of the study
There are four types of limitations of the study. First, there is possible sampling bias in both intervention and control groups. Since the lists of children were not readily available in the local civil registration systems, EPI registers were used as the sampling frame for both groups. This is because EPI registers were expected to cover almost all the children whose mothers were the study participants as 96.4% of children were vaccinated at least once through EPI in Eastern Region.
Second, the quality of baseline data could be less accurate because they were collected at the time of follow-up data collection, too. Though baseline data should be collected from both groups prior to the implementation of interventions generally in any DID studies, this study collected both baseline and follow-up data cross-sectionally only after the interventions was implemented. For this reason, the reliability of the baseline data particularly those derived from the respondents’ memories (e.g., the number of ANC visits) should be less accurate.
Third, the COVID-19 pandemic made health services available in an intermittent manner during its pandemic period. This extraordinary situation sometimes created the cases where pregnant women and mothers returned home without receiving ANC, FBD, and/or PPC services at health facilities in Ghana [85–87]. They were caused largely by temporary reassignments of health workers from obstetric and gynecological department to other clinical departments at health facilities [85]. Moreover, some women must have been hesitant and reluctant in utilizing maternal care services for fear of possible infections with COVID-19 at health facilities. This might have led to underestimation of the effectiveness of the intervention package of the Program. If it had not been for the COVID-19 pandemic, the effectiveness of the intervention package would have been more precisely estimated. Thus, the COVID-19 pandemic undermined the generalizability of the results of the study.
Fourth, there are little possibilities of contamination of a series of interventions from the intervention group into the control group. This is because: (i) Atiwa West District (control group) and Suhum Municipality (intervention group) are not mutually adjacent; and (ii) people’s movement was regulated and voluntarily refrained from during the COVID-19 pandemic. Yet, a certain level of the possibilities of contamination cannot be negated.
Conclusion
Of the three outcome variables set, only the proportion of women having utilized at least four ANC services significantly increased in the intervention group, compared with the control group. We recommend the intervention package be scaled up either nationwide or selectively to the areas where greater room for improvement in ANC coverage is identified. Ghana has been in transition process of shifting the minimum number ANC visits from four to eight. This indicates the additional need for an overall nationwide increase in the number of ANC visits. Thus, scaling up of the intervention package tested in this study is expected to help the transition be smoothly completed though ensuring increasing in the number of ANC visits.
Acknowledgments
The authors gratefully thank Magnus Ebo Duncan and his team for their technical supports in data collection. This work is sincerely dedicated to all the reproductive-aged women in rural areas of Ghana.
References
1. 1. World Health Organization, United Nations Children’s Fund, United Nations Population Fund, World Bank Group, United Nations Department of Economic and Social Affair/Population Division. Trends in maternal mortality 2000 to 2020. Geneva: World Health Organization; 2023.
2. 2. United States Agency International Development. Ending Preventable Maternal Mortality: USAID Maternal Health Vision for Action. 2014 Jun; Available from: https://www.usaid.gov/sites/default/files/2022-05/MCHVision.pdf
3. 3. World Health Organization, World Bank, United Nations Population Fund, United Nations Children’s Fund. Trends in maternal mortality: 1990 to 2010: WHO, UNICEF, UNFPA and The World Bank estimates. 2012 [cited 2023 Mar 25]; Available from: https://apps.who.int/iris/handle/10665/44874
4. 4. World Health Organization. Maternal mortality [Internet]. 2023 [cited 2023 Mar 25]. Available from: https://www.who.int/news-room/fact-sheets/detail/maternal-mortality
5. 5. Sexual and Reproductive Health and Research, WHO. Maternal mortality: Evidence brief [Internet]. 2019. Available from: https://www.who.int/publications/i/item/WHO-RHR-19.20
6. 6. Paxton A, Maine D, Freedman L, Fry D, Lobis S. The evidence for emergency obstetric care. Intl J Gynecology & Obste. 2005 Feb;88(2):181–93. pmid:15694106
* View Article
* PubMed/NCBI
* Google Scholar
7. 7. Levine R, Langer A, Birdsall N, Matheny G, Wright M, Bayer A. Contraception. In: Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, et al., editors. Disease Control Priorities in Developing Countries [Internet]. 2nd ed. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2006 [cited 2023 Oct 18]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK11771/
8. 8. Thaddeus S, Maine D. Too far to walk: Maternal mortality in context. Social Science & Medicine. 1994 Apr 1;38(8):1091–110. pmid:8042057
* View Article
* PubMed/NCBI
* Google Scholar
9. 9. Matsuoka S, Aiga H, Rasmey LC, Rathavy T, Okitsu A. Perceived barriers to utilization of maternal health services in rural Cambodia. Health Policy. 2010 May;95(2–3):255–63. pmid:20060193
* View Article
* PubMed/NCBI
* Google Scholar
10. 10. Wilunda C, Tanaka S, Putoto G, Tsegaye A, Kawakami K. Evaluation of a maternal health care project in South West Shoa Zone, Ethiopia: before-and-after comparison. Reprod Health. 2016 Dec;13(1):95. pmid:27543121
* View Article
* PubMed/NCBI
* Google Scholar
11. 11. Elmusharaf K, Byrne E, O’Donovan D. Strategies to increase demand for maternal health services in resource-limited settings: challenges to be addressed. BMC Public Health. 2015 Dec;15(1):870. pmid:26350731
* View Article
* PubMed/NCBI
* Google Scholar
12. 12. Hirai M, Morris J, Luoto J, Ouda R, Atieno N, Quick R. The impact of supply-side and demand-side interventions on use of antenatal and maternal services in western Kenya: a qualitative study. BMC Pregnancy Childbirth. 2020 Dec;20(1):453. pmid:32770963
* View Article
* PubMed/NCBI
* Google Scholar
13. 13. Wafula ST, Nalugya A, Kananura RM, Mugambe RK, Kyangwa M, Isunju JB, et al. Effect of community-level intervention on antenatal care attendance: a quasi-experimental study among postpartum women in Eastern Uganda. Global Health Action. 2022 Dec 31;15(1):2141312. pmid:36369730
* View Article
* PubMed/NCBI
* Google Scholar
14. 14. Lassi ZS, Bhutta ZA. Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Pregnancy and Childbirth Group, editor. Cochrane Database of Systematic Reviews [Internet]. 2015 Mar 23 [cited 2023 Mar 26];2015(3). Available from: http://doi.wiley.com/10.1002/14651858.CD007754.pub3 pmid:25803792
* View Article
* PubMed/NCBI
* Google Scholar
15. 15. Moyer CA, Adongo PB, Aborigo RA, Hodgson A, Engmann CM. ‘They treat you like you are not a human being’: Maltreatment during labour and delivery in rural northern Ghana. Midwifery. 2014 Feb;30(2):262–8. pmid:23790959
* View Article
* PubMed/NCBI
* Google Scholar
16. 16. Dapaah JM, Nachinaab JO. Sociocultural Determinants of the Utilization of Maternal Health Care Services in the Tallensi District in the Upper East Region of Ghana. Advances in Public Health. 2019 Feb 10;2019:1–11.
* View Article
* Google Scholar
17. 17. Amu H, Nyarko SH. Satisfaction with Maternal Healthcare Services in the Ketu South Municipality, Ghana: A Qualitative Case Study. BioMed Research International. 2019 Apr 10;2019:1–6.
* View Article
* Google Scholar
18. 18. Kotwal N, Khan N, Kaul S. A Review of the Effectiveness of the Interventions on Adolescent Reproductive Health in Developing Countries. 2014;4(5).
* View Article
* Google Scholar
19. 19. Beckham SW, Stockton M, Galai N, Davis W, Mwambo J, Likindikoki S, et al. Family planning use and correlates among female sex workers in a community empowerment HIV prevention intervention in Iringa, Tanzania: a case for tailored programming. BMC Public Health. 2021 Dec;21(1):1377. pmid:34247614
* View Article
* PubMed/NCBI
* Google Scholar
20. 20. Corneli A, Lemons A, Otieno-Masaba R, Ndiritu J, Packer C, Lamarre-Vincent J, et al. Contraceptive service delivery in Kenya: A qualitative study to identify barriers and preferences among female sex workers and health care providers. Contraception. 2016 Jul;94(1):34–9. pmid:26976072
* View Article
* PubMed/NCBI
* Google Scholar
21. 21. Kweyamba M, Buregyeya E, Kusiima J, Kweyamba V, Mukose AD. Loss to Follow-Up among HIV Positive Pregnant and Lactating Mothers on Lifelong Antiretroviral Therapy for PMTCT in Rural Uganda. Advances in Public Health. 2018 Jul 2;2018:1–9.
* View Article
* Google Scholar
22. 22. Obiri-Yeboah D, Amoako-Sakyi D, Baidoo I, Adu-Oppong A, Rheinländer T. The ‘Fears’ of Disclosing HIV Status to Sexual Partners: A Mixed Methods Study in a Counseling Setting in Ghana. AIDS Behav. 2016 Jan;20(1):126–36. pmid:25711298
* View Article
* PubMed/NCBI
* Google Scholar
23. 23. Mustapha M, Musiime V, Bakeera-Kitaka S, Rujumba J, Nabukeera-Barungi N. Utilization of “prevention of mother-to-child transmission” of HIV services by adolescent and young mothers in Mulago Hospital, Uganda. BMC Infect Dis. 2018 Dec;18(1):566. pmid:30428835
* View Article
* PubMed/NCBI
* Google Scholar
24. 24. Chanda MM, Ortblad KF, Mwale M, Chongo S, Kanchele C, Kamungoma N, et al. HIV self-testing among female sex workers in Zambia: A cluster randomized controlled trial. Bekker LG, editor. PLoS Med. 2017 Nov 21;14(11):e1002442. pmid:29161260
* View Article
* PubMed/NCBI
* Google Scholar
25. 25. Awungafac G, Delvaux T, Vuylsteke B. Systematic review of sex work interventions in sub-Saharan Africa: examining combination prevention approaches. Trop Med Int Health. 2017 Aug;22(8):971–93. pmid:28449198
* View Article
* PubMed/NCBI
* Google Scholar
26. 26. Jacobs C, Michelo C, Chola M, Oliphant N, Halwiindi H, Maswenyeho S, et al. Evaluation of a community-based intervention to improve maternal and neonatal health service coverage in the most rural and remote districts of Zambia. Larson BA, editor. PLoS ONE. 2018 Jan 16;13(1):e0190145. pmid:29337995
* View Article
* PubMed/NCBI
* Google Scholar
27. 27. Japanese Organization for International Cooperation in Family Planning. JOICFP Annual Report 2020; JFY 2020 April 2020- March 2021 [Internet]. 2021 [cited 2023 Mar 25]. Available from: https://www.joicfp.or.jp/eng/wp-content/uploads/2022/10/WEB_2020_English-web.pdf
28. 28. Nyonator FK, Akosa AB, Awoonor-Williams JK, Phillips JF, Jones TC. Scaling up experimental project success with the Community-based Health Planning and Services initiative in Ghana.
29. 29. United Nations Population Fund, Family Health International. Peer Education Toolkit [Internet]. 2006. Available from: https://www.unfpa.org/resources/peer-education-toolkit
30. 30. Japanese Organization for International Cooperation in Family Planning. Improving Sexual Reproductive Health for the Youth in Tanzania [Internet]. 2018. Available from: https://www.joicfp.or.jp/eng/where_we_work/tanzania/
31. 31. Japanese Organization for International Cooperation in Family Planning. Maternal, Newborn and Child Health One Stop Service Project [Internet]. 2021. Available from: https://www.joicfp.or.jp/eng/where_we_work/zambia/maternal-newborn-and-child-health-one-stop-service-project/
32. 32. Koshihara R, Funabashi A, Yaguchi M, Goto K, Emoto S, Kunimura S. Community health promotion in developing countries, adapting experience of Maternal and Child Health Promoters in Japan. 34th Annual Meeting of the Japan Association of International Health;
33. 33. Columbia University. Difference-inDifference Estimation [Internet]. Mailman School of Public Health. [cited 2023 Mar 25]. Available from: https://www.publichealth.columbia.edu/research/population-health-methods/difference-difference-estimation
34. 34. Ishijima H, Nishikido K, Teshima M, Nishikawa S, Gawad EA. Introducing the “5S-KAIZEN-TQM” approach into public hospitals in Egypt. IJHCQA. 2019 Dec 17;33(1):89–109. pmid:31940154
* View Article
* PubMed/NCBI
* Google Scholar
35. 35. The Pennsylvania State University. Estimating a Proportion for a Small, Finite Population [Internet]. STAT415; Introduction to Mathematical Statistics. [cited 2023 Mar 25]. Available from: https://online.stat.psu.edu/stat415/lesson/6/6.3
36. 36. Ghana Statistical Service. Ghana demographic and health survey 2022 [Internet]. Accra; 2024 [cited 2024 Apr 9]. Available from: https://www.dhsprogram.com/pubs/pdf/FR387/FR387.pdf
37. 37. Buxton OM, Marcelli E. Short and long sleep are positively associated with obesity, diabetes, hypertension, and cardiovascular disease among adults in the United States. Social Science & Medicine. 2010 Sep;71(5):1027–36. pmid:20621406
* View Article
* PubMed/NCBI
* Google Scholar
38. 38. Kim JH, Choi I. Choosing the Level of Significance: A Decision‐theoretic Approach. Abacus. 2021 Mar;57(1):27–71.
* View Article
* Google Scholar
39. 39. Shea O. Rutstein. Steps to constructing the new DHS Wealth Index [Internet]. Available from: https://dhsprogram.com/programming/wealth%20index/Steps_to_constructing_the_new_DHS_Wealth_Index.pdf
40. 40. Tesfaye G, Chojenta C, Smith R, Loxton D. Application of the Andersen-Newman model of health care utilization to understand antenatal care use in Kersa District, Eastern Ethiopia. East CE, editor. PLoS ONE. 2018 Dec 6;13(12):e0208729. pmid:30521640
* View Article
* PubMed/NCBI
* Google Scholar
41. 41. Namatovu HK, Semwanga AR. A Systems Dynamics Approach to Understanding the Determinants of Antenatal Care Utilization in Low-and Middle-Income Countries: A Systematic Review. In: Management Association IR, editor. Research Anthology on Advancements in Women’s Health and Reproductive Rights [Internet]. IGI Global; 2022 [cited 2023 Mar 18]. p. 836–56. Available from: https://services.igi-global.com/resolvedoi/resolve.aspx?doi=10.4018/978-1-6684-6299-7.ch044
42. 42. Kyilleh JM, Tabong PTN, Konlaan BB. Adolescents’ reproductive health knowledge, choices and factors affecting reproductive health choices: a qualitative study in the West Gonja District in Northern region, Ghana. BMC Int Health Hum Rights. 2018 Dec;18(1):6. pmid:29361947
* View Article
* PubMed/NCBI
* Google Scholar
43. 43. Owusu SA, Blankson EJ, Abane AM. Sexual and Reproductive Health Education among Dressmakers and Hairdressers in the Assin South District of Ghana.
44. 44. Pound P, Langford R, Campbell R. What do young people think about their school-based sex and relationship education? A qualitative synthesis of young people’s views and experiences. BMJ Open. 2016 Sep;6(9):e011329. pmid:27625058
* View Article
* PubMed/NCBI
* Google Scholar
45. 45. Pound P, Denford S, Shucksmith J, Tanton C, Johnson AM, Owen J, et al. What is best practice in sex and relationship education? A synthesis of evidence, including stakeholders’ views. BMJ Open. 2017 May;7(5):e014791. pmid:28669970
* View Article
* PubMed/NCBI
* Google Scholar
46. 46. Stice E, Rohde P, Shaw H, Gau JM. Clinician-led, peer-led, and internet-delivered dissonance-based eating disorder prevention programs: Acute effectiveness of these delivery modalities. Journal of Consulting and Clinical Psychology. 2017 Sep;85(9):883–95. pmid:28425735
* View Article
* PubMed/NCBI
* Google Scholar
47. 47. Bobo FT, Asante A, Woldie M, Hayen A. Poor coverage and quality for poor women: Inequalities in quality antenatal care in nine East African countries. Health Policy and Planning. 2021 Jun 3;36(5):662–72. pmid:33822943
* View Article
* PubMed/NCBI
* Google Scholar
48. 48. Kumar G, Choudhary TS, Srivastava A, Upadhyay RP, Taneja S, Bahl R, et al. Utilisation, equity and determinants of full antenatal care in India: analysis from the National Family Health Survey 4. BMC Pregnancy Childbirth. 2019 Dec;19(1):327. pmid:31488080
* View Article
* PubMed/NCBI
* Google Scholar
49. 49. Kyei-Nimakoh M, Carolan-Olah M, McCann TV. Access barriers to obstetric care at health facilities in sub-Saharan Africa—a systematic review. Syst Rev. 2017 Dec;6(1):110. pmid:28587676
* View Article
* PubMed/NCBI
* Google Scholar
50. 50. Macharia PM, Joseph NK, Nalwadda GK, Mwilike B, Banke-Thomas A, Benova L, et al. Spatial variation and inequities in antenatal care coverage in Kenya, Uganda and mainland Tanzania using model-based geostatistics: a socioeconomic and geographical accessibility lens. BMC Pregnancy Childbirth. 2022 Dec 6;22(1):908. pmid:36474193
* View Article
* PubMed/NCBI
* Google Scholar
51. 51. Obse AG, Ataguba JE. Explaining socioeconomic disparities and gaps in the use of antenatal care services in 36 countries in sub-Saharan Africa. Health Policy and Planning. 2021 Jun 3;36(5):651–61. pmid:33751100
* View Article
* PubMed/NCBI
* Google Scholar
52. 52. Zhao Q, Huang ZJ, Yang S, Pan J, Smith B, Xu B. The utilization of antenatal care among rural-to-urban migrant women in Shanghai:a hospital-based cross-sectional study. BMC Public Health. 2012 Dec;12(1):1012. pmid:23170773
* View Article
* PubMed/NCBI
* Google Scholar
53. 53. Boudet AMM, Buitrago P, Scott K, Suarez P. Gender Differences in Poverty and Household Composition through the Life‐cycle: A Global Perspective. 2018 Mar;
* View Article
* Google Scholar
54. 54. Silva-Laya M, D’Angelo N, García E, Zúñiga L, Fernández T. Urban poverty and education. A systematic literature review. Educational Research Review. 2020 Feb;29:100280.
* View Article
* Google Scholar
55. 55. Rotondi V, Kashyap R, Pesando LM, Spinelli S, Billari FC. Leveraging mobile phones to attain sustainable development. Proc Natl Acad Sci USA. 2020 Jun 16;117(24):13413–20. pmid:32482867
* View Article
* PubMed/NCBI
* Google Scholar
56. 56. Tran MC, Labrique AB, Mehra S, Ali H, Shaikh S, Mitra M, et al. Analyzing the Mobile “Digital Divide”: Changing Determinants of Household Phone Ownership Over Time in Rural Bangladesh. JMIR mHealth uHealth. 2015 Feb 25;3(1):e24. pmid:25720457
* View Article
* PubMed/NCBI
* Google Scholar
57. 57. Wilunda C, Scanagatta C, Putoto G, Montalbetti F, Segafredo G, Takahashi R, et al. Barriers to utilisation of antenatal care services in South Sudan: a qualitative study in Rumbek North County. Reprod Health. 2017 Dec;14(1):65. pmid:28532513
* View Article
* PubMed/NCBI
* Google Scholar
58. 58. Fagerli K , O’Connor K, Kim S, Kelley M, Odhiambo A, Faith S, et al. Impact of the Integration of Water Treatment, Hygiene, Nutrition, and Clean Delivery Interventions on Maternal Health Service Use. Am J Trop Med Hyg. 2017 Feb 13;16–0709. pmid:28193744
* View Article
* PubMed/NCBI
* Google Scholar
59. 59. Benova L, Dennis ML, Lange IL, Campbell OMR, Waiswa P, Haemmerli M, et al. Two decades of antenatal and delivery care in Uganda: a cross-sectional study using Demographic and Health Surveys. BMC Health Serv Res. 2018 Dec;18(1):758. pmid:30286749
* View Article
* PubMed/NCBI
* Google Scholar
60. 60. Wagstaff A, Bredenkamp C, Buisman LR. Progress on Global Health Goals: Are the Poor Being Left Behind? The World Bank Research Observer. 2014 Aug 1;29(2):137–62.
* View Article
* Google Scholar
61. 61. França GVA, Restrepo-Méndez MC, Maia MFS, Victora CG, Barros AJD. Coverage and equity in reproductive and maternal health interventions in Brazil: impressive progress following the implementation of the Unified Health System. Int J Equity Health. 2016 Dec;15(1):149. pmid:27852276
* View Article
* PubMed/NCBI
* Google Scholar
62. 62. Kawakatsu Y, Osei I, Debpuur C, Ayi A, Osei-Sarpong F, Shetye M, et al. Effects of the COVID-19 pandemic on essential health and nutrition service utilisations in Ghana: interrupted time-series analyses from 2016 to 2020. BMJ Open. 2023 Jan;13(1):e061608. pmid:36690407
* View Article
* PubMed/NCBI
* Google Scholar
63. 63. Ali N, Sultana M, Sheikh N, Akram R, Mahumud RA, Asaduzzaman M, et al. Predictors of Optimal Antenatal Care Service Utilization Among Adolescents and Adult Women in Bangladesh. Health Services Research and Managerial Epidemiology. 2018 Jan 1;5:233339281878172. pmid:30083573
* View Article
* PubMed/NCBI
* Google Scholar
64. 64. August F, Pembe AB, Mpembeni R, Axemo P, Darj E. Effectiveness of the Home Based Life Saving Skills training by community health workers on knowledge of danger signs, birth preparedness, complication readiness and facility delivery, among women in Rural Tanzania. BMC Pregnancy Childbirth. 2016 Dec;16(1):129. pmid:27251052
* View Article
* PubMed/NCBI
* Google Scholar
65. 65. Zamawe COF, Banda M, Dube AN. The impact of a community driven mass media campaign on the utilisation of maternal health care services in rural Malawi. BMC Pregnancy Childbirth. 2016 Dec;16(1):21. pmid:26819242
* View Article
* PubMed/NCBI
* Google Scholar
66. 66. Mwaniki MK, Vaid S, Chome IM, Amolo D, Tawfik Y, Kwale Improvement Coaches. Improving service uptake and quality of care of integrated maternal health services: the Kenya kwale district improvement collaborative. BMC Health Serv Res. 2014 Dec;14(1):416.
* View Article
* Google Scholar
67. 67. Ekirapa-Kiracho E, Muhumuza Kananura R, Tetui M, Namazzi G, Mutebi A, George A, et al. Effect of a participatory multisectoral maternal and newborn intervention on maternal health service utilization and newborn care practices: a quasi-experimental study in three rural Ugandan districts. Global Health Action. 2017 Aug;10(sup4):1363506. pmid:28871853
* View Article
* PubMed/NCBI
* Google Scholar
68. 68. Atusiimire LB, Waiswa P, Atuyambe L, Nankabirwa V, Okuga M. Determinants of facility based–deliveries among urban slum dwellers of Kampala, Uganda. Nelson BD, editor. PLoS ONE. 2019 Apr 18;14(4):e0214995. pmid:30998693
* View Article
* PubMed/NCBI
* Google Scholar
69. 69. Ayele GS, Melku AT, Belda SS. Utilization of skilled birth attendant at birth and associated factors among women who gave birth in the last 24 months preceding the survey in Gura Dhamole Woreda, Bale zone, southeast Ethiopia. BMC Public Health. 2019 Dec;19(1):1501.
* View Article
* Google Scholar
70. 70. Boah M, Mahama AB, Ayamga EA. They receive antenatal care in health facilities, yet do not deliver there: predictors of health facility delivery by women in rural Ghana. BMC Pregnancy Childbirth. 2018 Dec;18(1):125. pmid:29724178
* View Article
* PubMed/NCBI
* Google Scholar
71. 71. Dahiru T, Oche OM. Determinants of antenatal care, institutional delivery and postnatal care services utilization in Nigeria. Pan Afr Med J [Internet]. 2015 [cited 2023 Mar 22];21. Available from: http://www.panafrican-med-journal.com/content/article/21/321/full/ pmid:26587168
* View Article
* PubMed/NCBI
* Google Scholar
72. 72. Doctor HV, Nkhana-Salimu S, Abdulsalam-Anibilowo M. Health facility delivery in sub-Saharan Africa: successes, challenges, and implications for the 2030 development agenda. BMC Public Health. 2018 Dec;18(1):765. pmid:29921275
* View Article
* PubMed/NCBI
* Google Scholar
73. 73. Ensor T, Quigley P, Green C, Razak Badru A, Kaluba D, Siziya S. Knowledgeable antenatal care as a pathway to skilled delivery: modelling the interactions between use of services and knowledge in Zambia. Health Policy and Planning. 2014 Aug 1;29(5):580–8. pmid:23894074
* View Article
* PubMed/NCBI
* Google Scholar
74. 74. Gudu W, Addo B. Factors associated with utilization of skilled service delivery among women in rural Northern Ghana: a cross sectional study. BMC Pregnancy Childbirth. 2017 Dec;17(1):159. pmid:28566088
* View Article
* PubMed/NCBI
* Google Scholar
75. 75. Kawakatsu Y, Sugishita T, Oruenjo K, Wakhule S, Kibosia K, Were E, et al. Determinants of health facility utilization for childbirth in rural western Kenya: cross-sectional study. BMC Pregnancy Childbirth. 2014 Dec;14(1):265. pmid:25106432
* View Article
* PubMed/NCBI
* Google Scholar
76. 76. Moyer CA, Mustafa A. Drivers and deterrents of facility delivery in sub-Saharan Africa: a systematic review. Reprod Health. 2013 Dec;10(1):40. pmid:23962135
* View Article
* PubMed/NCBI
* Google Scholar
77. 77. Ndugga P, Namiyonga NK, Sebuwufu D. Determinants of early postnatal care attendance: analysis of the 2016 Uganda demographic and health survey. BMC Pregnancy Childbirth. 2020 Dec;20(1):163. pmid:32178635
* View Article
* PubMed/NCBI
* Google Scholar
78. 78. Ochieng CA, Odhiambo AS. Barriers to formal health care seeking during pregnancy, childbirth and postnatal period: a qualitative study in Siaya County in rural Kenya. BMC Pregnancy Childbirth. 2019 Dec;19(1):339. pmid:31533640
* View Article
* PubMed/NCBI
* Google Scholar
79. 79. Rwabufigiri BN, Mukamurigo J, Thomson DR, Hedt-Gautier BL, Semasaka JPS. Factors associated with postnatal care utilisation in Rwanda: A secondary analysis of 2010 Demographic and Health Survey data. BMC Pregnancy Childbirth. 2016 Dec;16(1):122. pmid:27245586
* View Article
* PubMed/NCBI
* Google Scholar
80. 80. Fekadu GA, Kassa GM, Berhe AK, Muche AA, Katiso NA. The effect of antenatal care on use of institutional delivery service and postnatal care in Ethiopia: a systematic review and meta-analysis. BMC Health Serv Res. 2018 Dec;18(1):577. pmid:30041655
* View Article
* PubMed/NCBI
* Google Scholar
81. 81. Bohren MA, Hunter EC, Munthe-Kaas HM, Souza JP, Vogel JP, Gülmezoglu AM. Facilitators and barriers to facility-based delivery in low- and middle-income countries: a qualitative evidence synthesis. Reprod Health. 2014 Dec;11(1):71. pmid:25238684
* View Article
* PubMed/NCBI
* Google Scholar
82. 82. Dahab R, Sakellariou D. Barriers to Accessing Maternal Care in Low Income Countries in Africa: A Systematic Review. IJERPH. 2020 Jun 16;17(12):4292. pmid:32560132
* View Article
* PubMed/NCBI
* Google Scholar
83. 83. World Health Organization. Standards for improving quality of maternal and newborn care in health facilities [Internet]. Geneva: World Health Organization; 2016 [cited 2023 Mar 23]. 73 p. Available from: https://apps.who.int/iris/handle/10665/249155
84. 84. Sumankuuro J, Crockett J, Wang S. Perceived barriers to maternal and newborn health services delivery: a qualitative study of health workers and community members in low and middle-income settings. BMJ Open. 2018 Nov;8(11):e021223. pmid:30413495
* View Article
* PubMed/NCBI
* Google Scholar
85. 85. Agbozo F, Jahn A. COVID-19 in Ghana: challenges and countermeasures for maternal health service delivery in public health facilities. Reprod Health. 2021 Dec;18(1):151. pmid:34281582
* View Article
* PubMed/NCBI
* Google Scholar
86. 86. Moyer CA, Sakyi KS, Sacks E, Compton SD, Lori JR, Williams JEO. COVID‐19 is increasing Ghanaian pregnant women’s anxiety and reducing healthcare seeking. Int J Gynecol Obstet. 2021 Mar;152(3):444–5. pmid:33222215
* View Article
* PubMed/NCBI
* Google Scholar
87. 87. Asuming PO, Gaisie DA, Agula C, Bawah AA. Impact of Covid‐19 on Maternal Health Seeking in Ghana. J of Intl Development. 2022 May;34(4):919–30. pmid:35465457
* View Article
* PubMed/NCBI
* Google Scholar
Citation: Aiga H, Kawakatsu Y, Kadoi N, Obeng E, Addai FT, Ofosu F, et al. (2024) Effectiveness of a community-based intervention package in maternal health service utilization: A cross-sectional quasi-experimental study in rural Ghana. PLoS ONE 19(11): e0311966. https://doi.org/10.1371/journal.pone.0311966
About the Authors:
Hirotsugu Aiga
Roles: Conceptualization, Data curation, Formal analysis, Methodology, Supervision, Writing – original draft, Writing – review & editing
E-mail: [email protected], [email protected], [email protected]
Affiliations: School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan, Human Development Department, Japan International Cooperation Agency (JICA), Tokyo, Japan
ORICD: https://orcid.org/0000-0001-5910-3379
Yoshito Kawakatsu
Roles: Conceptualization, Formal analysis, Methodology
Affiliation: Department of Nursing, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
Nobuhiro Kadoi
Roles: Conceptualization, Data curation, Writing – review & editing
Affiliation: Human Development Department, Japan International Cooperation Agency (JICA), Tokyo, Japan
Emmanuel Obeng
Roles: Data curation, Writing – review & editing
Affiliation: Ghana Country Office, The Japanese Organization for International Cooperation in Family Planning (JOICFP), Suhum, Eastern Region, Ghana
Frank Tabi Addai
Roles: Data curation, Writing – review & editing
Affiliation: Ghana Country Office, The Japanese Organization for International Cooperation in Family Planning (JOICFP), Suhum, Eastern Region, Ghana
ORICD: https://orcid.org/0009-0003-6162-4116
Frederick Ofosu
Roles: Data curation, Writing – review & editing
Affiliation: Suhum Municipal Health Directorate, Ghana Health Service (GHS), Suhum, Eastern Region, Ghana
Kazuki Fujishima
Roles: Conceptualization, Funding acquisition, Writing – review & editing
Affiliation: International Program, The Japanese Organization for International Cooperation in Family Planning (JOICFP), Tokyo, Japan
Mayumi Omachi
Roles: Validation, Writing – original draft, Writing – review & editing
Affiliation: Interfaculty Initiative in Planetary Health, Nagasaki University, Nagasaki, Japan
Etsuko Yamaguchi
Roles: Conceptualization, Data curation, Methodology, Project administration, Resources, Supervision, Writing – review & editing
Affiliation: International Program, The Japanese Organization for International Cooperation in Family Planning (JOICFP), Tokyo, Japan
[/RAW_REF_TEXT]
[/RAW_REF_TEXT]
[/RAW_REF_TEXT]
[/RAW_REF_TEXT]
[/RAW_REF_TEXT]
[/RAW_REF_TEXT]
[/RAW_REF_TEXT]
[/RAW_REF_TEXT]
[/RAW_REF_TEXT]
[/RAW_REF_TEXT]
[/RAW_REF_TEXT]
[/RAW_REF_TEXT]
[/RAW_REF_TEXT]
[/RAW_REF_TEXT]
[/RAW_REF_TEXT]
[/RAW_REF_TEXT]
[/RAW_REF_TEXT]
[/RAW_REF_TEXT]
[/RAW_REF_TEXT]
1. World Health Organization, United Nations Children’s Fund, United Nations Population Fund, World Bank Group, United Nations Department of Economic and Social Affair/Population Division. Trends in maternal mortality 2000 to 2020. Geneva: World Health Organization; 2023.
2. United States Agency International Development. Ending Preventable Maternal Mortality: USAID Maternal Health Vision for Action. 2014 Jun; Available from: https://www.usaid.gov/sites/default/files/2022-05/MCHVision.pdf
3. World Health Organization, World Bank, United Nations Population Fund, United Nations Children’s Fund. Trends in maternal mortality: 1990 to 2010: WHO, UNICEF, UNFPA and The World Bank estimates. 2012 [cited 2023 Mar 25]; Available from: https://apps.who.int/iris/handle/10665/44874
4. World Health Organization. Maternal mortality [Internet]. 2023 [cited 2023 Mar 25]. Available from: https://www.who.int/news-room/fact-sheets/detail/maternal-mortality
5. Sexual and Reproductive Health and Research, WHO. Maternal mortality: Evidence brief [Internet]. 2019. Available from: https://www.who.int/publications/i/item/WHO-RHR-19.20
6. Paxton A, Maine D, Freedman L, Fry D, Lobis S. The evidence for emergency obstetric care. Intl J Gynecology & Obste. 2005 Feb;88(2):181–93. pmid:15694106
7. Levine R, Langer A, Birdsall N, Matheny G, Wright M, Bayer A. Contraception. In: Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, et al., editors. Disease Control Priorities in Developing Countries [Internet]. 2nd ed. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2006 [cited 2023 Oct 18]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK11771/
8. Thaddeus S, Maine D. Too far to walk: Maternal mortality in context. Social Science & Medicine. 1994 Apr 1;38(8):1091–110. pmid:8042057
9. Matsuoka S, Aiga H, Rasmey LC, Rathavy T, Okitsu A. Perceived barriers to utilization of maternal health services in rural Cambodia. Health Policy. 2010 May;95(2–3):255–63. pmid:20060193
10. Wilunda C, Tanaka S, Putoto G, Tsegaye A, Kawakami K. Evaluation of a maternal health care project in South West Shoa Zone, Ethiopia: before-and-after comparison. Reprod Health. 2016 Dec;13(1):95. pmid:27543121
11. Elmusharaf K, Byrne E, O’Donovan D. Strategies to increase demand for maternal health services in resource-limited settings: challenges to be addressed. BMC Public Health. 2015 Dec;15(1):870. pmid:26350731
12. Hirai M, Morris J, Luoto J, Ouda R, Atieno N, Quick R. The impact of supply-side and demand-side interventions on use of antenatal and maternal services in western Kenya: a qualitative study. BMC Pregnancy Childbirth. 2020 Dec;20(1):453. pmid:32770963
13. Wafula ST, Nalugya A, Kananura RM, Mugambe RK, Kyangwa M, Isunju JB, et al. Effect of community-level intervention on antenatal care attendance: a quasi-experimental study among postpartum women in Eastern Uganda. Global Health Action. 2022 Dec 31;15(1):2141312. pmid:36369730
14. Lassi ZS, Bhutta ZA. Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Pregnancy and Childbirth Group, editor. Cochrane Database of Systematic Reviews [Internet]. 2015 Mar 23 [cited 2023 Mar 26];2015(3). Available from: http://doi.wiley.com/10.1002/14651858.CD007754.pub3 pmid:25803792
15. Moyer CA, Adongo PB, Aborigo RA, Hodgson A, Engmann CM. ‘They treat you like you are not a human being’: Maltreatment during labour and delivery in rural northern Ghana. Midwifery. 2014 Feb;30(2):262–8. pmid:23790959
16. Dapaah JM, Nachinaab JO. Sociocultural Determinants of the Utilization of Maternal Health Care Services in the Tallensi District in the Upper East Region of Ghana. Advances in Public Health. 2019 Feb 10;2019:1–11.
17. Amu H, Nyarko SH. Satisfaction with Maternal Healthcare Services in the Ketu South Municipality, Ghana: A Qualitative Case Study. BioMed Research International. 2019 Apr 10;2019:1–6.
18. Kotwal N, Khan N, Kaul S. A Review of the Effectiveness of the Interventions on Adolescent Reproductive Health in Developing Countries. 2014;4(5).
19. Beckham SW, Stockton M, Galai N, Davis W, Mwambo J, Likindikoki S, et al. Family planning use and correlates among female sex workers in a community empowerment HIV prevention intervention in Iringa, Tanzania: a case for tailored programming. BMC Public Health. 2021 Dec;21(1):1377. pmid:34247614
20. Corneli A, Lemons A, Otieno-Masaba R, Ndiritu J, Packer C, Lamarre-Vincent J, et al. Contraceptive service delivery in Kenya: A qualitative study to identify barriers and preferences among female sex workers and health care providers. Contraception. 2016 Jul;94(1):34–9. pmid:26976072
21. Kweyamba M, Buregyeya E, Kusiima J, Kweyamba V, Mukose AD. Loss to Follow-Up among HIV Positive Pregnant and Lactating Mothers on Lifelong Antiretroviral Therapy for PMTCT in Rural Uganda. Advances in Public Health. 2018 Jul 2;2018:1–9.
22. Obiri-Yeboah D, Amoako-Sakyi D, Baidoo I, Adu-Oppong A, Rheinländer T. The ‘Fears’ of Disclosing HIV Status to Sexual Partners: A Mixed Methods Study in a Counseling Setting in Ghana. AIDS Behav. 2016 Jan;20(1):126–36. pmid:25711298
23. Mustapha M, Musiime V, Bakeera-Kitaka S, Rujumba J, Nabukeera-Barungi N. Utilization of “prevention of mother-to-child transmission” of HIV services by adolescent and young mothers in Mulago Hospital, Uganda. BMC Infect Dis. 2018 Dec;18(1):566. pmid:30428835
24. Chanda MM, Ortblad KF, Mwale M, Chongo S, Kanchele C, Kamungoma N, et al. HIV self-testing among female sex workers in Zambia: A cluster randomized controlled trial. Bekker LG, editor. PLoS Med. 2017 Nov 21;14(11):e1002442. pmid:29161260
25. Awungafac G, Delvaux T, Vuylsteke B. Systematic review of sex work interventions in sub-Saharan Africa: examining combination prevention approaches. Trop Med Int Health. 2017 Aug;22(8):971–93. pmid:28449198
26. Jacobs C, Michelo C, Chola M, Oliphant N, Halwiindi H, Maswenyeho S, et al. Evaluation of a community-based intervention to improve maternal and neonatal health service coverage in the most rural and remote districts of Zambia. Larson BA, editor. PLoS ONE. 2018 Jan 16;13(1):e0190145. pmid:29337995
27. Japanese Organization for International Cooperation in Family Planning. JOICFP Annual Report 2020; JFY 2020 April 2020- March 2021 [Internet]. 2021 [cited 2023 Mar 25]. Available from: https://www.joicfp.or.jp/eng/wp-content/uploads/2022/10/WEB_2020_English-web.pdf
28. Nyonator FK, Akosa AB, Awoonor-Williams JK, Phillips JF, Jones TC. Scaling up experimental project success with the Community-based Health Planning and Services initiative in Ghana.
29. United Nations Population Fund, Family Health International. Peer Education Toolkit [Internet]. 2006. Available from: https://www.unfpa.org/resources/peer-education-toolkit
30. Japanese Organization for International Cooperation in Family Planning. Improving Sexual Reproductive Health for the Youth in Tanzania [Internet]. 2018. Available from: https://www.joicfp.or.jp/eng/where_we_work/tanzania/
31. Japanese Organization for International Cooperation in Family Planning. Maternal, Newborn and Child Health One Stop Service Project [Internet]. 2021. Available from: https://www.joicfp.or.jp/eng/where_we_work/zambia/maternal-newborn-and-child-health-one-stop-service-project/
32. Koshihara R, Funabashi A, Yaguchi M, Goto K, Emoto S, Kunimura S. Community health promotion in developing countries, adapting experience of Maternal and Child Health Promoters in Japan. 34th Annual Meeting of the Japan Association of International Health;
33. Columbia University. Difference-inDifference Estimation [Internet]. Mailman School of Public Health. [cited 2023 Mar 25]. Available from: https://www.publichealth.columbia.edu/research/population-health-methods/difference-difference-estimation
34. Ishijima H, Nishikido K, Teshima M, Nishikawa S, Gawad EA. Introducing the “5S-KAIZEN-TQM” approach into public hospitals in Egypt. IJHCQA. 2019 Dec 17;33(1):89–109. pmid:31940154
35. The Pennsylvania State University. Estimating a Proportion for a Small, Finite Population [Internet]. STAT415; Introduction to Mathematical Statistics. [cited 2023 Mar 25]. Available from: https://online.stat.psu.edu/stat415/lesson/6/6.3
36. Ghana Statistical Service. Ghana demographic and health survey 2022 [Internet]. Accra; 2024 [cited 2024 Apr 9]. Available from: https://www.dhsprogram.com/pubs/pdf/FR387/FR387.pdf
37. Buxton OM, Marcelli E. Short and long sleep are positively associated with obesity, diabetes, hypertension, and cardiovascular disease among adults in the United States. Social Science & Medicine. 2010 Sep;71(5):1027–36. pmid:20621406
38. Kim JH, Choi I. Choosing the Level of Significance: A Decision‐theoretic Approach. Abacus. 2021 Mar;57(1):27–71.
39. Shea O. Rutstein. Steps to constructing the new DHS Wealth Index [Internet]. Available from: https://dhsprogram.com/programming/wealth%20index/Steps_to_constructing_the_new_DHS_Wealth_Index.pdf
40. Tesfaye G, Chojenta C, Smith R, Loxton D. Application of the Andersen-Newman model of health care utilization to understand antenatal care use in Kersa District, Eastern Ethiopia. East CE, editor. PLoS ONE. 2018 Dec 6;13(12):e0208729. pmid:30521640
41. Namatovu HK, Semwanga AR. A Systems Dynamics Approach to Understanding the Determinants of Antenatal Care Utilization in Low-and Middle-Income Countries: A Systematic Review. In: Management Association IR, editor. Research Anthology on Advancements in Women’s Health and Reproductive Rights [Internet]. IGI Global; 2022 [cited 2023 Mar 18]. p. 836–56. Available from: https://services.igi-global.com/resolvedoi/resolve.aspx?doi=10.4018/978-1-6684-6299-7.ch044
42. Kyilleh JM, Tabong PTN, Konlaan BB. Adolescents’ reproductive health knowledge, choices and factors affecting reproductive health choices: a qualitative study in the West Gonja District in Northern region, Ghana. BMC Int Health Hum Rights. 2018 Dec;18(1):6. pmid:29361947
43. Owusu SA, Blankson EJ, Abane AM. Sexual and Reproductive Health Education among Dressmakers and Hairdressers in the Assin South District of Ghana.
44. Pound P, Langford R, Campbell R. What do young people think about their school-based sex and relationship education? A qualitative synthesis of young people’s views and experiences. BMJ Open. 2016 Sep;6(9):e011329. pmid:27625058
45. Pound P, Denford S, Shucksmith J, Tanton C, Johnson AM, Owen J, et al. What is best practice in sex and relationship education? A synthesis of evidence, including stakeholders’ views. BMJ Open. 2017 May;7(5):e014791. pmid:28669970
46. Stice E, Rohde P, Shaw H, Gau JM. Clinician-led, peer-led, and internet-delivered dissonance-based eating disorder prevention programs: Acute effectiveness of these delivery modalities. Journal of Consulting and Clinical Psychology. 2017 Sep;85(9):883–95. pmid:28425735
47. Bobo FT, Asante A, Woldie M, Hayen A. Poor coverage and quality for poor women: Inequalities in quality antenatal care in nine East African countries. Health Policy and Planning. 2021 Jun 3;36(5):662–72. pmid:33822943
48. Kumar G, Choudhary TS, Srivastava A, Upadhyay RP, Taneja S, Bahl R, et al. Utilisation, equity and determinants of full antenatal care in India: analysis from the National Family Health Survey 4. BMC Pregnancy Childbirth. 2019 Dec;19(1):327. pmid:31488080
49. Kyei-Nimakoh M, Carolan-Olah M, McCann TV. Access barriers to obstetric care at health facilities in sub-Saharan Africa—a systematic review. Syst Rev. 2017 Dec;6(1):110. pmid:28587676
50. Macharia PM, Joseph NK, Nalwadda GK, Mwilike B, Banke-Thomas A, Benova L, et al. Spatial variation and inequities in antenatal care coverage in Kenya, Uganda and mainland Tanzania using model-based geostatistics: a socioeconomic and geographical accessibility lens. BMC Pregnancy Childbirth. 2022 Dec 6;22(1):908. pmid:36474193
51. Obse AG, Ataguba JE. Explaining socioeconomic disparities and gaps in the use of antenatal care services in 36 countries in sub-Saharan Africa. Health Policy and Planning. 2021 Jun 3;36(5):651–61. pmid:33751100
52. Zhao Q, Huang ZJ, Yang S, Pan J, Smith B, Xu B. The utilization of antenatal care among rural-to-urban migrant women in Shanghai:a hospital-based cross-sectional study. BMC Public Health. 2012 Dec;12(1):1012. pmid:23170773
53. Boudet AMM, Buitrago P, Scott K, Suarez P. Gender Differences in Poverty and Household Composition through the Life‐cycle: A Global Perspective. 2018 Mar;
54. Silva-Laya M, D’Angelo N, García E, Zúñiga L, Fernández T. Urban poverty and education. A systematic literature review. Educational Research Review. 2020 Feb;29:100280.
55. Rotondi V, Kashyap R, Pesando LM, Spinelli S, Billari FC. Leveraging mobile phones to attain sustainable development. Proc Natl Acad Sci USA. 2020 Jun 16;117(24):13413–20. pmid:32482867
56. Tran MC, Labrique AB, Mehra S, Ali H, Shaikh S, Mitra M, et al. Analyzing the Mobile “Digital Divide”: Changing Determinants of Household Phone Ownership Over Time in Rural Bangladesh. JMIR mHealth uHealth. 2015 Feb 25;3(1):e24. pmid:25720457
57. Wilunda C, Scanagatta C, Putoto G, Montalbetti F, Segafredo G, Takahashi R, et al. Barriers to utilisation of antenatal care services in South Sudan: a qualitative study in Rumbek North County. Reprod Health. 2017 Dec;14(1):65. pmid:28532513
58. Fagerli K , O’Connor K, Kim S, Kelley M, Odhiambo A, Faith S, et al. Impact of the Integration of Water Treatment, Hygiene, Nutrition, and Clean Delivery Interventions on Maternal Health Service Use. Am J Trop Med Hyg. 2017 Feb 13;16–0709. pmid:28193744
59. Benova L, Dennis ML, Lange IL, Campbell OMR, Waiswa P, Haemmerli M, et al. Two decades of antenatal and delivery care in Uganda: a cross-sectional study using Demographic and Health Surveys. BMC Health Serv Res. 2018 Dec;18(1):758. pmid:30286749
60. Wagstaff A, Bredenkamp C, Buisman LR. Progress on Global Health Goals: Are the Poor Being Left Behind? The World Bank Research Observer. 2014 Aug 1;29(2):137–62.
61. França GVA, Restrepo-Méndez MC, Maia MFS, Victora CG, Barros AJD. Coverage and equity in reproductive and maternal health interventions in Brazil: impressive progress following the implementation of the Unified Health System. Int J Equity Health. 2016 Dec;15(1):149. pmid:27852276
62. Kawakatsu Y, Osei I, Debpuur C, Ayi A, Osei-Sarpong F, Shetye M, et al. Effects of the COVID-19 pandemic on essential health and nutrition service utilisations in Ghana: interrupted time-series analyses from 2016 to 2020. BMJ Open. 2023 Jan;13(1):e061608. pmid:36690407
63. Ali N, Sultana M, Sheikh N, Akram R, Mahumud RA, Asaduzzaman M, et al. Predictors of Optimal Antenatal Care Service Utilization Among Adolescents and Adult Women in Bangladesh. Health Services Research and Managerial Epidemiology. 2018 Jan 1;5:233339281878172. pmid:30083573
64. August F, Pembe AB, Mpembeni R, Axemo P, Darj E. Effectiveness of the Home Based Life Saving Skills training by community health workers on knowledge of danger signs, birth preparedness, complication readiness and facility delivery, among women in Rural Tanzania. BMC Pregnancy Childbirth. 2016 Dec;16(1):129. pmid:27251052
65. Zamawe COF, Banda M, Dube AN. The impact of a community driven mass media campaign on the utilisation of maternal health care services in rural Malawi. BMC Pregnancy Childbirth. 2016 Dec;16(1):21. pmid:26819242
66. Mwaniki MK, Vaid S, Chome IM, Amolo D, Tawfik Y, Kwale Improvement Coaches. Improving service uptake and quality of care of integrated maternal health services: the Kenya kwale district improvement collaborative. BMC Health Serv Res. 2014 Dec;14(1):416.
67. Ekirapa-Kiracho E, Muhumuza Kananura R, Tetui M, Namazzi G, Mutebi A, George A, et al. Effect of a participatory multisectoral maternal and newborn intervention on maternal health service utilization and newborn care practices: a quasi-experimental study in three rural Ugandan districts. Global Health Action. 2017 Aug;10(sup4):1363506. pmid:28871853
68. Atusiimire LB, Waiswa P, Atuyambe L, Nankabirwa V, Okuga M. Determinants of facility based–deliveries among urban slum dwellers of Kampala, Uganda. Nelson BD, editor. PLoS ONE. 2019 Apr 18;14(4):e0214995. pmid:30998693
69. Ayele GS, Melku AT, Belda SS. Utilization of skilled birth attendant at birth and associated factors among women who gave birth in the last 24 months preceding the survey in Gura Dhamole Woreda, Bale zone, southeast Ethiopia. BMC Public Health. 2019 Dec;19(1):1501.
70. Boah M, Mahama AB, Ayamga EA. They receive antenatal care in health facilities, yet do not deliver there: predictors of health facility delivery by women in rural Ghana. BMC Pregnancy Childbirth. 2018 Dec;18(1):125. pmid:29724178
71. Dahiru T, Oche OM. Determinants of antenatal care, institutional delivery and postnatal care services utilization in Nigeria. Pan Afr Med J [Internet]. 2015 [cited 2023 Mar 22];21. Available from: http://www.panafrican-med-journal.com/content/article/21/321/full/ pmid:26587168
72. Doctor HV, Nkhana-Salimu S, Abdulsalam-Anibilowo M. Health facility delivery in sub-Saharan Africa: successes, challenges, and implications for the 2030 development agenda. BMC Public Health. 2018 Dec;18(1):765. pmid:29921275
73. Ensor T, Quigley P, Green C, Razak Badru A, Kaluba D, Siziya S. Knowledgeable antenatal care as a pathway to skilled delivery: modelling the interactions between use of services and knowledge in Zambia. Health Policy and Planning. 2014 Aug 1;29(5):580–8. pmid:23894074
74. Gudu W, Addo B. Factors associated with utilization of skilled service delivery among women in rural Northern Ghana: a cross sectional study. BMC Pregnancy Childbirth. 2017 Dec;17(1):159. pmid:28566088
75. Kawakatsu Y, Sugishita T, Oruenjo K, Wakhule S, Kibosia K, Were E, et al. Determinants of health facility utilization for childbirth in rural western Kenya: cross-sectional study. BMC Pregnancy Childbirth. 2014 Dec;14(1):265. pmid:25106432
76. Moyer CA, Mustafa A. Drivers and deterrents of facility delivery in sub-Saharan Africa: a systematic review. Reprod Health. 2013 Dec;10(1):40. pmid:23962135
77. Ndugga P, Namiyonga NK, Sebuwufu D. Determinants of early postnatal care attendance: analysis of the 2016 Uganda demographic and health survey. BMC Pregnancy Childbirth. 2020 Dec;20(1):163. pmid:32178635
78. Ochieng CA, Odhiambo AS. Barriers to formal health care seeking during pregnancy, childbirth and postnatal period: a qualitative study in Siaya County in rural Kenya. BMC Pregnancy Childbirth. 2019 Dec;19(1):339. pmid:31533640
79. Rwabufigiri BN, Mukamurigo J, Thomson DR, Hedt-Gautier BL, Semasaka JPS. Factors associated with postnatal care utilisation in Rwanda: A secondary analysis of 2010 Demographic and Health Survey data. BMC Pregnancy Childbirth. 2016 Dec;16(1):122. pmid:27245586
80. Fekadu GA, Kassa GM, Berhe AK, Muche AA, Katiso NA. The effect of antenatal care on use of institutional delivery service and postnatal care in Ethiopia: a systematic review and meta-analysis. BMC Health Serv Res. 2018 Dec;18(1):577. pmid:30041655
81. Bohren MA, Hunter EC, Munthe-Kaas HM, Souza JP, Vogel JP, Gülmezoglu AM. Facilitators and barriers to facility-based delivery in low- and middle-income countries: a qualitative evidence synthesis. Reprod Health. 2014 Dec;11(1):71. pmid:25238684
82. Dahab R, Sakellariou D. Barriers to Accessing Maternal Care in Low Income Countries in Africa: A Systematic Review. IJERPH. 2020 Jun 16;17(12):4292. pmid:32560132
83. World Health Organization. Standards for improving quality of maternal and newborn care in health facilities [Internet]. Geneva: World Health Organization; 2016 [cited 2023 Mar 23]. 73 p. Available from: https://apps.who.int/iris/handle/10665/249155
84. Sumankuuro J, Crockett J, Wang S. Perceived barriers to maternal and newborn health services delivery: a qualitative study of health workers and community members in low and middle-income settings. BMJ Open. 2018 Nov;8(11):e021223. pmid:30413495
85. Agbozo F, Jahn A. COVID-19 in Ghana: challenges and countermeasures for maternal health service delivery in public health facilities. Reprod Health. 2021 Dec;18(1):151. pmid:34281582
86. Moyer CA, Sakyi KS, Sacks E, Compton SD, Lori JR, Williams JEO. COVID‐19 is increasing Ghanaian pregnant women’s anxiety and reducing healthcare seeking. Int J Gynecol Obstet. 2021 Mar;152(3):444–5. pmid:33222215
87. Asuming PO, Gaisie DA, Agula C, Bawah AA. Impact of Covid‐19 on Maternal Health Seeking in Ghana. J of Intl Development. 2022 May;34(4):919–30. pmid:35465457
You have requested "on-the-fly" machine translation of selected content from our databases. This functionality is provided solely for your convenience and is in no way intended to replace human translation. Show full disclaimer
Neither ProQuest nor its licensors make any representations or warranties with respect to the translations. The translations are automatically generated "AS IS" and "AS AVAILABLE" and are not retained in our systems. PROQUEST AND ITS LICENSORS SPECIFICALLY DISCLAIM ANY AND ALL EXPRESS OR IMPLIED WARRANTIES, INCLUDING WITHOUT LIMITATION, ANY WARRANTIES FOR AVAILABILITY, ACCURACY, TIMELINESS, COMPLETENESS, NON-INFRINGMENT, MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. Your use of the translations is subject to all use restrictions contained in your Electronic Products License Agreement and by using the translation functionality you agree to forgo any and all claims against ProQuest or its licensors for your use of the translation functionality and any output derived there from. Hide full disclaimer
© 2024 Aiga et al. This is an open access article distributed under the terms of the Creative Commons Attribution License: http://creativecommons.org/licenses/by/4.0/ (the “License”), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.
Abstract
Background
We examined the effectiveness of a community-based intervention package that targeted pregnant women for increasing utilization of maternal health services. The intervention package was implemented in Suhum Municipality, Ghana, from March 2019 to April 2022. The package consisted of: (i) maternal health education by female and male peers; (ii) training existing health workers on maternal health; and (iii) strengthening the local community health management committees.
Methods
A cross-sectional household survey was conducted in May 2022. We sampled four groups of women: (i) intervention at baseline; (ii) intervention at follow-up; (iii) control at baseline; and (iv) control at follow-up. Three outcome variables were set, i.e., the proportions of women having utilized: (i) at least four antenatal care (ANC) services; (ii) facility-based delivery (FBD) services; and (iii) post-partum care (PPC) services. To estimate the effectiveness of the intervention package in increasing the service coverages, both crude and adjusted difference-in-differences (DID) estimates were calculated. Significance levels were set at the values of 0.10, 0.05, and 0.01, since the aforementioned service coverages had already been too high to have room for an increase at the significance level of 0.05.
Results
The proportion of women completing at least four ANC services displayed significant DID in both crude and adjusted analyses. The proportions of women utilizing facility-based delivery services and post-partum care services did not display significant DID.
Conclusions
Of the three outcome variables set, only the proportion of women having utilized at least four ANC services significantly increased in the intervention group, compared with the control group. Ghana has been in the transition process of shifting the minimum number of ANC visits from four to eight. Thus, nationwide scaling up of the intervention package is expected to help the transition be smooth by increasing the number of ANC visits.
You have requested "on-the-fly" machine translation of selected content from our databases. This functionality is provided solely for your convenience and is in no way intended to replace human translation. Show full disclaimer
Neither ProQuest nor its licensors make any representations or warranties with respect to the translations. The translations are automatically generated "AS IS" and "AS AVAILABLE" and are not retained in our systems. PROQUEST AND ITS LICENSORS SPECIFICALLY DISCLAIM ANY AND ALL EXPRESS OR IMPLIED WARRANTIES, INCLUDING WITHOUT LIMITATION, ANY WARRANTIES FOR AVAILABILITY, ACCURACY, TIMELINESS, COMPLETENESS, NON-INFRINGMENT, MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. Your use of the translations is subject to all use restrictions contained in your Electronic Products License Agreement and by using the translation functionality you agree to forgo any and all claims against ProQuest or its licensors for your use of the translation functionality and any output derived there from. Hide full disclaimer
Details
; Kawakatsu, Yoshito; Kadoi, Nobuhiro; Obeng, Emmanuel; Frank Tabi Addai
; Ofosu, Frederick; Fujishima, Kazuki; Omachi, Mayumi; Yamaguchi, Etsuko