Impact of health system strengthening interventions on child survival in sub-Saharan Africa: a systematic review protocol.

BACKGROUND: Strengthening healthcare systems is a practical approach to enhance healthcare delivery and services. Although there has been a rise in the number of health systems strengthening (HSS) interventions in sub-Saharan Africa (SSA), there is limited evidence on the causal effect of these activities on child survival. Furthermore, the findings reported so far have been varied, and how they relate to each other remains unclear. This systematic review study aims to assess all available evidence to understand the impact of HSS activities on child survival in SSA. METHODS: We developed a search strategy to retrieve all relevant studies from electronic databases such as PubMed/MEDLINE, Web of Science, and African Journals Online. We will use a combination of search terms such as "under-five mortality," "child mortality," "infant mortality," "neonatal mortality," "child survival," and "health systems strengthening." The review will include studies that establish a causal relationship between HSS interventions and child survival. This will include studies with designs such as randomized controlled trials and quasi-experimental and methods like difference-in-difference. Two reviewers will independently screen all citations, abstracts, and full-text data and a third reviewer will act as a tiebreaker in case of disagreements. The primary outcome of interest is the impact of HSS activities on under-five survival. We will evaluate the quality of each study using the Bradford Hill criteria for causation. DISCUSSION: Our systematic review will identify and evaluate all relevant evidence that establishes a causal relationship between HSS activities and the survival of children under five years in SSA. The review's findings regarding the impact of HSS activities on child survival could be of significant interest to the donor community and policy actors in the region. We also anticipate that the review's conclusions could serve as a valuable guide for the development of future health system interventions and strategies in SSA. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42022333913.

Postpartum contraceptive initiation and use: Evidence from Accra, Ghana.

BACKGROUND: Postpartum contraceptive use reduces unintended pregnancies and results in better health outcomes for children and women. However, there is a dearth of knowledge on postpartum contraceptive use in Ghana, particularly among women in low-income urban settings. To shed light on strategies that might enhance access to postpartum family planning services in low-income urban settings, we examined contraceptive use among postpartum women in Accra, Ghana, at 1, 3, 6, and 12 months following the birth and the methods used. The predictors of modern contraceptive use in the 12-month postpartum period were also examined. METHODS: Data come from a cross-sectional survey conducted in 2018 among 624 women aged 16-44 years who reported giving birth in the past 13-31 months prior to the interview. We generated descriptive statistics to examine the prevalence of contraceptive use among postpartum women at 1, 3, 6, and 12 months after birth. We further estimated a binary logistic regression to examine the predictors of modern contraceptive use at 12 months postpartum. RESULTS: Forty percent of postpartum women never used any contraceptive method during 1 year after birth and of those who used a method, 40% relied on traditional methods. Moreover, 29% of women started using a method the immediate 1 month post-birth. Results further show that postpartum modern contraceptive uptake was positively associated with higher education, having more live births, and being currently in a union. CONCLUSIONS: Findings highlight that there may be opportunities to improve the quality of counseling during antenatal and postnatal care visits by clients to ensure fully informed choices regarding postpartum contraception. Community outreach by health providers/promoters or similar models should be promoted in low-income population settings to educate postpartum women on modern contraceptive use. Women who plan to use traditional methods should be provided with information on the consistent and correct use of these methods.

Covert Contraceptive Use amongst the urban poor in Accra, Ghana: experiences of health providers.

BACKGROUND: An estimated one-third of women in Ghana use contraceptives without the knowledge of their partners, a phenomenon known as Covert Contraceptive Use (CCU). Most research on CCU to date has focused on individual women to the neglect of the role of health system. This study explores CCU in urban poor communities of Accra, Ghana, from the experiences and perspectives of health providers. METHODS: Qualitative in-depth interviews were conducted with health care providers in both the public and private sectors at multiple levels, from the community clinic to the tertiary hospital, to gain insights into the strategies women use and the ways in which the health system supports the practice of CCU. RESULTS: Five major thematic areas emerged: use of easily concealed-methods, discrete-access-and-information-keeping, time-of-day, non-verbal-communication and use of relationships. The study further revealed that fear, mistrust, shyness, myths, and misperceptions regarding contraceptives explain CCU among women in the communities that the providers serve. CONCLUSION: Importantly, disclosure of methods used by providers without women's consent could potentially lead to violent outcomes for both women and the providers. Our results highlight the pivotal role that providers play in confidentially supporting women's choices regarding the use of contraceptives.

Sometimes women use contraceptives without the knowledge of their sexual partners. That is to say, they hide their contraceptive use. Many studies have explored why women hide their contraceptive use. Reasons include the desire of men to have absolute control of their women's bodies including their sexuality and fertility regulation. This occurs in cultures where women do not have as much power as men. In Ghana, as much as one-in-three women hide their contraceptive use from their partners. This study explores the ways in which health facilities assist women to hide their contraceptives use by talking to leaders of units responsible for providing contraceptives in the hospitals. First, people prefer contraceptives like injectables that are not visible on the bodies of those using them. Second, some hospitals have modified their space to provide ample privacy and security for women. Third, some women visit the facilities at odd hours, such as very early in the morning, very late at night and at other favorable times. Sometimes nurses arrange to meet women outside the facility. Lastly, nurses create avenues through various personal relationships. For example, leaving their contacts in market spaces and arranging meeting places with market queens.

Partner support and women's contraceptive use: insight from urban poor communities in Accra, Ghana.

BACKGROUND: Despite the benefits associated with contraceptive use, there is a low prevalence of contraceptive use in sub-Saharan Africa and Ghana. Previous studies have partly and consistently attributed the low prevalence of contraceptive use to partner opposition. However, little is known about the influence of men in contraceptive related choices of their partners, particularly within the context of urban poverty. This study examines the influences of partners on women's contraceptive choices. METHODS: The study utilized a cross-sectional household survey data of 1578 currently married women and women in a union of reproductive ages 16-44 years. Women who were pregnant and those trying to be pregnant were excluded from the analysis. The dependent variables for the study were current use of any contraceptive method, types of contraceptive methods and types of modern contraceptive methods. The independent variable for the study was a woman's report of partner support in contraceptive related choices. A binary logistic regression model was used to examine the associations between partner support in contraceptive related choices and contraceptive use of women. RESULTS: The results of the study show that partner support of contraceptive related choices has a significant influence on contraceptive use of women. Women who indicated support from their partners were more likely to be current users of any contraceptive method, yet were less likely to use modern contraceptive methods. CONCLUSION: The study highlights the need to involve men in family planning programs and research, as well as educating them on the various contraceptive modern methods and the side effects.

Impact of Covid-19 on Maternal Health Seeking in Ghana.

The Covid-19 pandemic is widely speculated to have disrupted the delivery of primary health care in low-income countries. Yet, there is little rigorous empirical research identifying this effect. This paper estimates the impact of Covid-19 on facility and skilled delivery and utilisation of antenatal care (ANC) services by comparing these outcomes for women who were pregnant/delivered before and during the Covid-19 period. The results show that Covid-19 led to 23% and 25% reductions, respectively, in the likelihood of facility delivery and four or more ANC visits during pregnancy. These findings highlight the need to build more resilient health systems in low-income settings.

Methods women use for induced abortion and sources of services: insights from poor urban settlements of Accra, Ghana.

BACKGROUND: Increasing access to safe abortion methods is crucial for improving women's health. Understanding patterns of service use is important for identifying areas for improvement. Limited evidence is available in Ghana on factors associated with the type of method used to induce abortion. This paper examined the methods and sources of services used for abortion by women living in poor urban settings of Accra. METHODS: Data are from a survey that was conducted in 2018 among 1233 women aged 16-44 years who reported ever having had an induced abortion. We estimated a multinomial logistic regression model to examine factors associated with the type of abortion methods women used. We further generated descriptive statistics for the source of abortion services. RESULTS: About 50% women used surgical procedures for their last abortion, 28% used medication abortion (MA), 12% used other pills, 3% used injection, and 7% used non-medical methods. However, nearly half (46%) of the women who terminated a pregnancy within the year preceding the survey used medication abortion (MA), 32% used surgical procedures, while 5% used non-medical methods. Women who terminated a pregnancy within three years preceding the survey had a 60% lower chance of using surgical procedures if they did not use MA compared to those who terminated a pregnancy more than 3 years before the survey (Relative Risk Ratio [RRR] 0.4; 95% CI 0.3-0.5). The vast majority (74%) of women who used MA obtained services from pharmacies. CONCLUSIONS: The use of MA pills to terminate pregnancies has increased in recent years in Ghana and these pills are mostly accessed from pharmacies. This suggests a need for a review of the national guidelines to include pharmacists and chemists in the provision of MA services.

Dynamics of Emergency Contraceptive Use in Accra, Ghana.

Recent data suggest increasing rates of emergency contraception (EC) use in Ghana, particularly in urban areas. In 2018, we collected survey data from 3,703 sexually experienced women aged 16-44 years living in low-income settlements of Accra. We estimated the prevalence of lifetime and current EC use. Multivariate logistic regression was used to assess factors associated with current use of EC. Retrospective monthly calendar data on contraceptive use were analyzed to identify patterns of EC use, including repeat and continuous use, and uptake of other contraceptive methods in the months following EC use. Nearly 15 percent of women had ever used EC. About half of recent EC users (52 percent) used EC for at least four months cumulatively within a 12-month window. There was no evidence of adoption of other modern methods in the months after using EC. Our results suggest that EC is a common method for pregnancy prevention in Accra, particularly among young, unmarried, highly educated women. Counseling on effective EC use and strategies that promote equitable access should be prioritized.

Contraceptive method use, discontinuation and failure rates among women aged 15-49 years: evidence from selected low income settings in Kumasi, Ghana.

BACKGROUND: This paper provides estimates of contraceptive discontinuation and failure rates in a poor urban setting in Ghana. Contraceptive use is for the purposes of preventing unintended or mistimed pregnancies. Unfortunately, evidence abounds in many parts of the world where there is considerable levels of contraceptive failure and high levels of discontinuation resulting in unintended pregnancies. METHODS: We estimated discontinuation rates during a 12-month period since starting use by applying single and multiple decrement life table methods to the contraceptive calendar data collected in a survey of women in reproductive age of 15-49 years. RESULTS: Modern contraceptive method use was estimated to be 13.7% at the time of the survey. The results show that contraceptive method discontinuation vary markedly by type of contraceptive method but are high for almost all methods, except for implants (23.7%). Discontinuation rate for emergency contraception was estimated at 88.5%, withdrawal 87.6%, and male condom use 80.9%. However, discontinuation rates were moderately high for rhythm (63.6%), pills (65.6%) and injectables (56%). In terms of failure rates, overall contraceptive failure for all methods was estimated at 7.9%. The factors significantly associated with method failure include being within age bracket 40-44 years (OR = 0.3, p < 0.05), having secondary/higher education (OR = 0.4, p < 0.01), belonging to the richest household wealth scale (OR = 3.3, p < 0.01), currently in union with a partner (OR = 2.2, p < 0.01), and using contraceptive methods such as rhythm (OR = 5.6, p < 0.01) and withdrawal (OR = 3.7, p < 0.01). On the flip side, the odds for method discontinuation were significantly higher for women in their 20s and mid 30s, formerly in union (OR = 1.9, p < 0.05) and use of withdrawal method (OR = 1.4, p < 0.05) and lower for women formerly in union (OR = 0.4, p < 0.01) and use of implants (OR = 0.2, p < 0.01) and injectables (OR = 0.6, p < 0.01). CONCLUSION: While contraceptives use is low, both discontinuation and failure rates are high and variable among different methods. Failure and discontinuation rates are lowest for long-acting methods such as implants while higher failure rates are more prevalent among women who rely on withdrawal and the rhythm methods.

Contraception before and after induced abortion: Trajectories of women in selected urban-poor settlements of Accra, Ghana.

This paper examined women's pre- and post-induced abortion contraceptive use and predictors of post-abortion modern contraceptive uptake in selected poor settlements of Accra, Ghana. Data from a cross-sectional study of 251 women aged 16-44 years were used. Patterns of contraceptive use were analysed descriptively while the predictors of modern contraceptive use in the month following induced abortion were examined using a binary logistic regression model. Majority of women (60%) were not using any method of contraception when they became pregnant before their abortion. Just over 30% of these women switched to using any method in the month immediately after abortion (22% modern and 9% traditional). Women who had became pregnant while using a modern method before their abortion had higher odds of using a modern method post-abortion than women who had not been using any method of contraception when they became pregnant. Following induced abortion, many women remained at potential risk of future unintended pregnancy. Our findings suggest the need for improved contraceptive counselling for women who seek abortion services, both during post-abortion care for facility-based abortions or at the time of obtaining medication abortion pills for those who are self-managing their abortion.

The impact of a personalized, community-based counselling and referral programme on modern contraceptive use in urban Ghana: a retrospective evaluation.

Community-based demand-generation family planning programmes have been associated with increased contraceptive use in rural areas of Ghana. However, rigorous evaluations of such programmes in urban contexts are lacking. We used a retrospective, cross-sectional with comparison group design to estimate the immediate and sustained impact of the Willows intervention on modern contraceptive use in Kumasi, Ghana. The Willows intervention is a home-based counselling and referral programme for women in low-income urban settlements. We analysed data from a cross-sectional representative survey of 1205 women of reproductive age in the intervention area and 1108 women in a matched comparison site. The main outcome was women's reported contraceptive use at: (1) baseline (January 2013); (2) programme close (December 2016); and (3) follow-up (August to October 2018). We estimated the programme effect at the community level and for women who reported receiving a family planning counselling visit. We used coarsened exact matching to assess the impact of the intervention relative to outcomes for matched comparison women. Comparing those who reported a family planning visit in the intervention area with matched comparison area women who reported no visit, we estimated a 10.5 percentage point increase in use of modern contraceptives from baseline to close (95%CI : 6.2, 14.8; P < 0.001) and a 7.6 percentage point increase from baseline to follow-up (95%CI : 3.3, 11.9; P < 0.001). However, only 20.2% of women in the Willows intervention area reported a visit. The Willows intervention, therefore, did not achieve its aim to reach all reproductive-aged women in the community. At the community level, we found no significant effect of the intervention at either programme close or 2 years later. We recommend that similar community-based interventions strive for greater outreach and simultaneously launch robust prospective impact evaluations.

Correlates and spatial distribution of the co-occurrence of childhood anaemia and stunting in Ghana.

Childhood anaemia and stunting are major public health concerns in Ghana. Using the 2014 Ghana Demographic and Health Survey, we evaluated whether childhood anaemia (Haemoglobin concentration < 110 g/L) and stunting (height-for-age z score < -2) co-occur beyond what is expected in Ghana, and employed spatial analysis techniques to determine if their co-occurrence is spatially correlated. There was no statistically significant difference between the observed and expected frequency of co-occurrence. Among 24-35 month and 36-59-month-old children, belonging to a high wealth household compared to low wealth household was associated with lower odds of the co-occurrence of childhood anaemia and stunting (OR, 95% CI: 0.3[0.1, 0.8] and 0.2[0.1, 0.5], respectively). Children aged 6-23 months with caregivers who had formerly been in union compared to their counterparts with caregivers who have never been in union had higher odds of co-occurrence of anaemia and stunting (5.1, [1.1, 24.3]). Overall, households with high wealth and having a mother with secondary or more education were associated with lower odds of the co-occurrence of childhood anaemia and stunting (OR, 95% CI: 0.4[0.2, 0.8] and 0.5[0.3, 0.9], respectively). There was substantial spatial clustering of co-occurrence, particularly in the northern region of the country. Interventions purposed to improve linear growth and anaemia must identify the specific factors or context which contribute to childhood anaemia and stunting.

Enhancing healthy ecosystems in northern Ghana through eco-friendly farm-based practices: insights from irrigation scheme-types.

BACKGROUND: Farming practices vary from farmer to farmer and from place to place depending on a number of factors including the agroclimatic condition, infrastructure (e.g. irrigation facilities) and management mechanisms (private versus state management). These together affect the functioning and sustainability of the ecosystems. For the sustainability of ecosystems, farmers need to employ ecosystem-based farm practices. This paper examines the ecosystem-based farm management practices (EBFMPs) in private and state-managed irrigation schemes. It also analyses the drivers of farmers' willingness to pay for EBFMPs sustainability. The study employed mixed methods design, using both qualitative and quantitative techniques of data collection through key informant interviews, focus group discussions and semi-structured questionnaires administered to 300 households. The various EBFMPs adopted by farmers were examined and descriptively presented. The Chi-square automatic interaction detector (CHAID) and multiple linear regression were used to assess the predictors of farmers' willingness to pay for EBFMPs to enhance the health of agroecosystems. Compost application, conservative tilling, conservation of vegetation, mulching, crop rotation, intercropping with legumes, efficient drainage systems and bunding were the EBFMPs captured in this paper. RESULTS: Farmers in privately-managed irrigation schemes (PIS) more often apply EBFMPs compared with those in state-managed irrigation schemes (SIS). The paper also found that farmers' willingness to pay to sustain EBFMPs for healthy ecosystems is significantly determined by the type of irrigation scheme they cultivate in (that is, PIS or SIS), their level of education, marital status and perception of soil fertility. CONCLUSIONS: Policy makers, implementers, and other stakeholders need to consider the capacity building of irrigation farmers, especially those in SIS in northern Ghana by educating them on agricultural production and ecosystem nexus to enhance the level of usage and willingness to pay for EBFMPs sustainability.

Out-of-pocket payment for primary healthcare in the era of national health insurance: Evidence from northern Ghana.

BACKGROUND: Ghana introduced a national health insurance program in 2005 with the goal of removing user fees, popularly called "cash and carry", along with their associated catastrophic and impoverishment effects on the population and ensuring access to equitable health care. However, after a decade of implementation, the impact of this program on user fees and out-of-pocket payment (OOP) is not properly documented. This paper contributes to understanding the impact of Ghana's health insurance program on out-of-pocket healthcare payments and the factors associated with the level of out-of-pocket payments for primary healthcare in a predominantly rural region of Ghana. METHODS: Using a five-year panel data of revenues accruing to public primary health facilities in seven districts, We employed mean comparison tests (t-test) to examine the trend in revenues accruing from out-of-pocket payments vis-à-vis health insurance claims for health services, medication, and obstetric care. Furthermore, generalized estimation equation regression models were used to assess the relationship between explanatory variables and the level of out-of-pocket payments and health insurance claims. RESULTS: Out-of-pocket payment for health services and medications declined by 63% and 62% respectively between 2010 and 2014. Insurance claims however increased by 16% within the same period. There was statistically a significant mean reduction in out-of-pocket payment over the period. Factors significantly associated with out-of-pocket payments in a given district are the number of community health facilities, availability of a district hospital and the year of observation. CONCLUSION: The study provides evidence that Ghana's national health insurance program is significantly contributing to a reduction in out-of-pocket payment for primary healthcare in public health facilities. Efforts should therefore be put in place to ensure the sustainability of this policy as a major pathway for achieving universal health coverage in Ghana.