Strategies to increase rural maternal utilization of skilled health personnel for childbirth delivery in low- and middle-income countries: a narrative review.

BACKGROUND: Skilled attendance at birth is considered key to accomplishing Sustainable Development Goal (SDG) 3.1 aimed at reducing maternal mortality. Many maternal deaths can be prevented if a woman receives care by skilled health personnel. Maternal utilization of skilled health delivery services in rural areas in low- and middle-income countries is 70% compared to 90% in urban areas. Previous studies have found community-based interventions may increase rural maternal uptake of skilled health delivery services, but evidence is lacking on which strategies are most effective. OBJECTIVE: To review the effectiveness of community-based strategies to increase rural maternal utilization of skilled health personnel for childbirth delivery in low-and middle-income countries. METHODS: We conducted a narrative review. PubMed, CINAHL, Cochrane Library, and PsycINFO databases were searched for articles from database inception through 13 November 2019. Key search terms were pre-determined. Information was extracted on studies meeting our inclusion criteria: cluster and randomized trials, rural setting, reproductive aged women, community engagement, low- and middle-income countries. Studies were considered effective if statistically significant (p < 0.05). A narrative synthesis was conducted. RESULTS: Ten cluster randomized trials out of 5,895 candidate citations met the inclusion criteria. Strategies included home-based visits, women's groups, and combined approaches. Out of the ten articles, only three studies were found to significantly increase maternal uptake of skilled health personnel for delivery, and each used a different strategy. The results are inconclusive as to which strategies are most effective. Limitations of this review include heterogeneity and generalizability of studies. CONCLUSIONS: This research suggests that different strategies may be effective at improving maternal utilization of skilled health personnel for delivery in certain rural settings while ineffective in others. More research is warranted to better understand the context in which strategies may be effective and under what conditions.

Abortion in rural Ghana: Cultural norms, knowledge and attitudes.

Using qualitative methodology, semi-structured questionnaires were administered to participants in the Barakese subdistrict of Ghana in order to understand the extent to which men and women have knowledge of family planning services and in what ways cultural norms, practices, and attitudes toward abortion affect the decision to abort. Women in the community pursue abortion using unsafe methods, despite fear of shame, bleeding, infection, or death, as the perceived cost of maintaining the pregnancy is greater. Protective factors that were reported to dissuade women from pursuing unsafe abortion include fear of social disgrace, divine retribution, and death. Women reported the inability to control the timing of their pregnancies, despite harboring knowledge of family planning. Concerned about perceived side effects of modern family planning methods, respondents chose to use fertility awareness methods or to use no contraception. There remains a gap between knowledge of the benefits of and the actual use of family planning methods, leading to unwanted pregnancy and seeking unsafe abortion. Intensified health promotion and education regarding side effects to combat misconceptions related to contraception, as well as expanding alternative contraceptive options to all regions of Ghana, are critical to improve uptake.

Forming a supplement intervention using a multi-theoretical behavior model.

OBJECTIVES: To identify behavior theory-based strategies to improve compliance with daily multiple micronutrient supplementation (MMS) among rural Ghanaian women. METHODS: Components of a multi-theoretical framework were investigated in focus groups of reproductive-aged women in 6 communities. RESULTS: Participants were generally unaware of MMS' purpose. Perceived benefits included better health and stimulated appetite, which some believe escalates food purchases and financial constraints. Cost, forgetfulness, and unsustainability were also perceived barriers. Facilitators for compliance incorporated initial visual reminders and daily announcements with reinforcement using the 'keeper' system. CONCLUSIONS: Application of a tailored health behavioral model can effectively guide the design, implementation and evaluation of community-based MMS interventions.

Development and validation of the Indian Adolescent Health Questionnaire.

The period of adolescence is a critical time of development. There is an urgent need to better assess adolescent health worldwide, particularly in India, a country with the world's largest adolescent population. Validated screening tools are needed to evaluate health-related risks and behaviors in this growing demographic. We developed, validated and administered a school-based health assessment, the Indian Adolescent Health Questionnaire, which can be used as a comprehensive health-screening tool among Indian adolescents in secondary school.

Impact of early and concurrent stunting on cognition.

Undernutrition is associated with poor cognitive development, late entry into school, decreased years of schooling, reduced productivity and smaller adult stature. We use longitudinal data from 1674 Peruvian children participating in the Young Lives study to assess the relative impact of early stunting (stunted at 6-18 months of age) and concurrent stunting (stunted at 4.5-6 years of age) on cognitive ability. Anthropometric data were longitudinally collected for children at 6-18 months of age and 4.5-6 years of age at which time verbal and quantitative ability were also assessed. We estimate that an increase in concurrent height-for-age z-scores (HAZ) by one standard deviation was associated with an increase in a child's score on the Peabody Picture Vocabulary Test (PPVT) by 2.35 points [confidence interval (CI): 1.55-3.15] and a 0.16 point increase on the cognitive development assessment (CDA) (CI: 0.05-0.27). Furthermore, we report that the estimate for concurrent HAZ and PPVT is significantly higher than the estimate for early stunting and PPVT. We found no significant difference between early and concurrent estimates for HAZ and CDA. Children from older mothers, children whose mothers had higher education levels, children living in urban areas, children who attended pre-school, children with fewer siblings and children from wealthier backgrounds scored higher on both assessments. Cognitive skills of children entering school were associated with early stunting but the strongest association was found with concurrent stunting suggesting that interventions preventing linear growth faltering should not only focus on the under 2s but include children up to 5 years of age.

Children who recover from early stunting and children who are not stunted demonstrate similar levels of cognition.

Stunting is associated with adverse cognitive development in childhood and adolescence, fewer years of schooling, decreased productivity, and reduced adult stature. Recovery from early stunting is possible; however, few studies explore whether those who demonstrate linear catch-up growth experience long-term cognitive deficits. Using longitudinal data on 1674 Peruvian children from the Young Lives study, we identified factors associated with catch-up growth and assessed whether children who displayed catch-up growth have significantly lower cognition than children who were not stunted during infancy and childhood. Based on anthropometric data for children 6-18 mo of age and again for the same children when they were 4.5-6 y of age, we categorized participants as not stunted, stunted in infancy but not childhood (catch-up), stunted in childhood, and stunted in infancy and childhood. Children who had grandparents in the home, had less severe stunting in infancy, and had taller mothers were more likely to demonstrate catch-up growth by round 2. Children who experienced catch-up growth had verbal vocabulary and quantitative test scores that did not differ from children who were not stunted (P = 0.6 and P = 0.7, respectively). Those stunted in childhood as well as those stunted in infancy and childhood scored significantly lower on both assessments than children who were not stunted. Based on findings from this study, policy makers and program planners should consider redoubling efforts to prevent stunting and promote catch-up growth over the first few years of life as a way of improving children's physical and intellectual development.

Exploring the relationship between chronic undernutrition and asymptomatic malaria in Ghanaian children.

BACKGROUND: A moderate association has been found between asymptomatic parasitaemia and undernutrition. However, additional investigation using the gold standard for asymptomatic parasitaemia confirmation, polymerase chain reaction (PCR), is needed to validate this association. Anthropometric measurements and blood samples from children less than five years of age in a rural Ghanaian community were used to determine if an association exists between chronic undernutrition and PCR-confirmed cases of asymptomatic malaria. METHODS: This was a descriptive cross-sectional study of 214 children less than five years of age from a community near Kumasi, Ghana. Blood samples and anthropometric measurements from these children were collected during physical examinations conducted in January 2007 by partners of the Barekuma Collaborative Community Development Programme. RESULTS: Findings from the logistic model predicting the odds of asymptomatic malaria indicate that children who experienced mild, moderate or severe stunting were not more likely to have asymptomatic malaria than children who were not stunted. Children experiencing anaemia had an increased likelihood (OR = 4.15; 95% CI: 1.92, 8.98) of asymptomatic malaria. Similarly, increased spleen size, which was measured by ultrasound, was also associated with asymptomatic malaria (OR = 2.17; 95% CI: 1.44, 3.28). Fast breathing, sex of the child, and age of the child were not significantly associated with the asymptomatic malaria. CONCLUSIONS: No significant association between chronic undernutrition and presence of asymptomatic malaria was found. Children who experience anaemia and children who have splenomegaly are more likely to present asymptomatic malaria. Programmes aimed at addressing malaria should continue to include nutritional components, especially components that address anaemia.