Department of Population, Family and Reproductive Health
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Item Institutional Approaches to Research Integrity in Ghana(Science and Engineering Ethics, 2020) Laar, A.K.; Redman, B.K.; Ferguson, K.; Caplan, A.Research misconduct (RM) remains an important problem in health research despite decades of local, national, regional, and international efforts to eliminate it. The ultimate goal of every health research project, irrespective of setting, is to produce trustworthy findings to address local as well as global health issues. To be able to lead or participate meaningfully in international research collaborations, individual and institutional capacities for research integrity (RI) are paramount. Accordingly, this paper concerns itself not only with individuals’ research skills but also with institutional and national policies and governance. Such policies and governance provide an ethical scaffold for the production of knowledge and structure incentives. This paper’s operational definition of research therefore draws from the Institute of Medicine’s articulation of health research as an inquiry that aims to produce knowledge about the structure, processes, or effects of personal health services; and from an existing health systems framework. The paper reviews the research regulatory environment and the ethics apparatus in Ghana and describes a project jointly undertaken by Ghanaian researchers in collaboration with New York University to assess the perceived adequacy of current institutional practices, opportunities, and incentives for promoting RI.Item Substance Use Disorders And Rehabilitation Among Youth In Ghana And Effects On The Family(University Of Ghana, 2022-10) Assah-Offei, V.E.INTRODUCTION Substance use disorders (SUDs) is a chronic, relapsing brain disorder that is characterized by compulsive seeking and use of addictive substances. SUDs among the youth continue to be a global public health concern. Treatment of SUDs places a heavy burden on public health systems. This study assessed the factors associated with substance use disorders and examine the effects and cost burden of SUDs and drug rehabilitation on families in Ghana. METHODS The study used an embedded concurrent mixed-method design. It was conducted among 101 participants drawn from four (4) drug rehabilitation centres in the Greater Accra and Eastern Regions of Ghana, from December 2018 to February 2019. The quantitative component relied on a matched case-control design. One hundred and one (101) cases were enrolled from the only existing rehabilitation centres in Ghana, whereas 303 controls consisted of persons living in the same community as the cases but who had never used substances. A closed-ended questionnaire and semi-structured interview guide were used for face-to-face quantitative and qualitative data collection. Quantitative data were analysed using STATA version 15, and qualitative data were analysed using a thematic approach. The cost burden of substance use rehabilitation was calculated by summing the direct and indirect costs of managing drug users. The student t-test and one-way ANOVA test were used to compare average costs. Bivariate and multivariate analyses were done to test statistical relationships between outcome and observed explanatory variables. Statistical significance was set at a p-value of 0.1%, 1% and 5%. RESULTS Multiple logistic regression analysis showed that sex, age, highest educational level, employment status, residential status, and friendship with drug users had a statistically significant association with SUDs. Male participants had 1.5 (95% CI:1.2-2.5, p=0.001) times higher odds of SUDs than female participants. Participants aged above 20 years had lower odds of substance use disorders compared to those aged below 20 years (p<0.01). The estimated average household cost of rehabilitation was GHS 4,445.60 per month. The mean monthly indirect cost incurred by urban substance users (472.1 } 196.40) was statistically significantly higher (p<0.05) than that of rural substance users (181.2 } 100.30). Of 101 family members of substance users, 57.4% experienced a high intangible burden. Overall, the mean UNODC standard rehabilitation compliance was 3.0 ( }0.0), signifying that the compliance standards at the rehabilitation facilities were inadequate. CONCLUSION Males, rural dwellers and younger age have a higher risk of SUDs. Hence public health strategies must target such vulnerable groups. To reduce the high-cost burden associated with the rehabilitation of substance users, the government and stakeholders must subsidize rehabilitation registration costs which contribute more than half of the economic burden of rehabilitation. KEYWORDS: Substance use disorder, drug abuse, rehabilitation, youth, economic cost, Ghana.Item Chronic Stress in Pregnancy: Implications on Maternal Mental Health in Lower Manya Krobo Municipality, Ghana(University of Ghana, 2020-07) Letsa, D.P.A.Background: Chronic stress causes adverse effects both physiologically and psychologically. Research indicates that chronic stress during pregnancy may be significantly associated with high levels of antenatal depression and anxiety. Many factors may cause chronic stress for a pregnant woman. Moreover, extant literature indicates that pregnancy itself can be a source of chronic stress and that there are pregnancy-specific stressors that could contribute to depression and anxiety during pregnancy. In Ghana and other parts of sub-Saharan Africa, there are limited scientific data on chronic stress exposure during pregnancy and its implications on maternal mental health outcomes of depression and anxiety. Objective: This study first catalogued the types of chronic stressors and pregnancy-specific stressors and determined the prevalence of these types of stressors. Secondly, it examined the association between chronic stress and (1) antenatal depression and (2) antenatal anxiety. Lastly, it identified factors associated with chronic stress and pregnancy-specific stress. Methods: An analytical cross-sectional study in three health facilities in the Lower Manya Krobo Municipality of Ghana was conducted. Chronic stressors were assessed using survey tools. The Perceived Stress Scale (PSS-14) was administered to determine the prevalence of chronic stress. The Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7(GAD-7) scales were used to assess for depression and anxiety respectively. Mean scores of the 3 scales were taken and categorized into levels of stress, anxiety and depression. The Fischer’s exact test was used to test the association between chronic stress, as the main exposure variable, and depression and anxiety and other characteristics. Multivariate logistic regression was used to identify independent predictors of chronic stress, pregnancy- specific stress, depression, and anxiety. Results: A total of 603 women were recruited into the study. Financial (65.9%, n=392), work- related (47.6%, n=287), and marital/relationship (25.2%, n=152) factors were the primary self- reported stressors. Fear of childbirth (61.2%, n=369), fear of giving birth to a child with a congenital anomaly (22.3%, n= 134), were primary pregnancy-specific stressors. The prevalence of stress, depression and anxiety were (49.9%, n= 301), (37%, n=223), and (17.4%, n=105) respectively. After adjustment for maternal socio-demographic and obstetric factors, the logit multivariate regression model revealed that marital status and pregnancy concerns about the ability to care for and nurture the child were predictors of chronic stress and pregnancy-specific stress. Participants who had high chronic stress had 83% increased odds of depression compared to those with lower stress (AOR: 1.83, 95% CI: 1.15-2.9). Depression increased by approximately one and a third times higher (AOR: 1.30, 95% CI: [1.02-1.67]) for each increase in the number of pregnancies a woman had had. For pregnant women who reported fear of birthing a child with a congenital anomaly as a pregnancy-specific stressor, the odds of anxiety were 64% higher (AOR: 1.64, 95% CI: [1.04-2.58]) compared to those who did not report this stressor. Conclusion: Chronic stress in pregnancy is influenced by several critical factors: marital status, education, employment and socioeconomic status. Pregnancy-specific factors like fear of childbirth and fear of a child with a congenital anomaly are key concerns of pregnant women. As hypothesized, chronic stress is a significant contributory factor to antenatal depression and anxiety and its ensuing adverse health outcomes.Item Quality of Maternal Healthcare in Four Districts in Northern Region, Ghana(University of Ghana, 2019-07) Mumuni, V.S.Background: The quality of maternal healthcare women receive during pregnancy and delivery has attracted global attention. However, tools and empirical studies on quality of maternal healthcare women receive are lacking in many low-income settings including Ghana. Available literature shows that many of the current assessment tools are provider driven, focusing mainly on clinical care aspect of quality without considering clients' perspectives. This study aimed to fill these knowledge gaps by developing and validating an assessment tool and using same tool to assess the quality of maternal healthcare in selected districts in Northern Region of Ghana. Methods: An exploratory sequential mixed methods study design was used. This design was operationalised in three phases. The first phase was a qualitative exploration of clients' and providers' perspectives on quality of maternal healthcare. It comprised 6 focus group discussion sessions with 46 postnatal women and 39 in-depth interviews with postnatal women and 7 healthcare workers. The second phase of the design built on the first. This involved the development and validation of a quality of care assessment tool. Fifty-five (55) maternal and child health experts were purposively selected to assess quality of care domains that was proposed. The aim was to determine item's clarity and relevance on a 5-point Likert scale. The final phase involved administering the maternal healthcare quality assessment tool to a total of 520 randomly sampled postnatal women in a survey in four districts in the northern region (Tamale metropolis, Savelugu-Nanton municipality, Kumbungu and Sagnerigu districts) to assess quality of maternal healthcare they received during their most recent pregnancy. Thematic content analysis techniques were used to analyse qualitative data. Content Validity index (CVI), polychoric correlation co-efficient, and Item Response Theory (lRT) model were used, to assess suitability, correlation between items in each construct and reliability of the tool. Descriptive statistical analysis was done to describe important demographic and maternal health characteristics of survey respondents. To assess quality of maternal healthcare women received, mean quality of care scores were obtained for each domain by adding the mean scores for individual items and dividing the results by the number of items in each domain. Based on this mean score for each domain, the quality of care under each domain was then recategorized into three scales, where a mean score of 1.0 - 2.0 meant low quality; mean score of 2.1- 3.9 meant moderate quality; and mean score of 4-5 meant high quality. Percentage distribution tables were then constructed to show the proportion of respondents who rated the quality of care they received as either low, moderate or high. Findings: Results from the qualitative interviews identified a total of 13 domains of care and 57 indicators of maternal healthcare quality. These domains included proximity of health facilities to clients, availability of infrastructure and other amenities, availability of logistics including equipment and medicines and good environmental sanitation, quality of the human resource/workforce. non-discriminatory provision of maternal healthcare services, interpersonal relationship, privacy of clients, pain management, Safety, outcome of pregnancy and client's satisfaction with the care processes and outcomes. Results from the experts' evaluation of the appropriateness and validity of the 57- indicators identified from the qualitative research showed that all the items of the construct were rated above a content validity index (CVI) of 0.6, where 0.6 was the benchmark below which items would be rated as irrelevant/inappropriate. However, following modification and pretesting of the tool and further reliability testing of the items in the tool using item discrimination indices, only 47 indicators had acceptable item discrimination indices. These were, therefore, included in the final tool. Findings from the survey showed that overall, 72% of the respondents rated the quality of maternal healthcare they received as high, with 27% and 0.6% rating the quality of care as moderate and low respectively. The highest rated domain was the outcome domain with a mean score 4.26 ± 0.57. The proportion of women who rated the outcome domain as high was 91.15% while 8.08% and 0.77% of them rated it as moderate and low respectively. The least rated' domain was pain management, which had an average rating score of 3.14 ± 1.18, with 277(53.27%) of respondents rating it as high, 179(34.42%) rating it as moderate and 64(12.31%) rating as low. Conclusion: For any meaningful quality of maternal healthcare assessment to occur, there is need for including both women's and provider's perspectives. Although majority of women rated the overall quality of care, they received to be high, there is space for further improvement. There is the need for more attention to be paid to aspects of maternity care that were poorly rated by clients. In this regard, good inter-personal relationships with clients. better resourcing of health facilities and sustained collaboration between clients and healthcare providers is needed for enhancing the status of maternal healthcare in the region.Item Socio-Cultural Practices Influencing Intrapartum and Postpartum Continuum of Care In the Asante Akim North District Ashanti Region(University of Ghana, 2019-07) Ansong, J.Background: The growing recognition of the critical importance of providing care to mothers and new-borns and the substantial gaps in coverage that exists have prompted a paradigm shift in responding to maternal and new-born health issues. Invariably, the health care that a mother receives during pregnancy, at the time of delivery, and soon after delivery is important for the survival and well-being of both the mother and her child. However, evidence suggests that maternal and neonatal deaths are accentuated by socio-cultural practices along the intrapartum and postpartum continuum of care and several studies have documented this across the globe. However, in Ghana, studies on the role socio-cultural practices play along intrapartum and postpartum continuum of care remains unexplored. This study, therefore, seeks to identify the gaps in the knowledge and practices along the intrapartum and postpartum continuum of care in the Asante Akim North District of Ashanti Region of Ghana. Methods: This was a descriptive cross-sectional study which employed mixed sequential qualitative and quantitative strategies. An initial explorative study using focus group discussions and in-depth interviews was done to explore community leaders. health managers and mothers' perceptions and experiences in relation to the influence of socio-cultural practices along the intrapartum and post postpartum continuum of care. NVivo II was used to analyze the qualitative data and the themes and sub-theme converted into a survey questionnaire. A multistage sampling technique was used to sample 439 mothers with infants (0-6 months) from four subdistricts, based on proportion to population. Quantitative data was analyzed using STATA 14. Multivariable logistic regression to determine associations between independent and dependent variables was done. Results: The study found that 65.1 % of women had adequate ANC 4+, 49. JO/o had skilled delivery, and 65.4% had received postnatal care at six weeks with only 28.5% having achieved complete continuum of care. Women who practiced confinement were 2.42 times (95% C\=0.4450-0.7789) more likely to discontinue care at ANC, 1.98 times (95%CI=O. I 891.0.4000) the relative risk of discontinuing at postnatal than those who did not practice confinement. Women who believed in bewitchment during pregnancy and postnatal period had relative risk of 2.22 (95% CI=0.3634-0.9234) discontinuing at ANC, 1.67 (95% CI=0.4712-0.9178) at delivery and 2.89 (95% CI=0.4381-0.8172) during postnatal. Again, women who did not receive home visits by health care workers during pregnancy had higher relative risk of discontinuing at ANC (RR-1.89, 95% Cl=O.2190-0.9182), delivery (RR-2.71, 95% CI=0.8791) and PNC (RR=1.78, 95% C\=0.6981-0.8132). Receiving education on ANC also reduced a woman' s relative risk of interruptions along the continuum. Out of 439 participants, only 208 (47.4%) were advised to deliver in the health facilities. Women who were not advised to have skilled delivery had higher relative risk of discontinuing at delivery (RR=2.91, 95% CI=0.4001-0.7211) and PNC (RR=2.88, 95% CI=0.4412· 0.7219). Women who also reported having experienced bad attitudes from health workers were more likely to discontinue at ANC, delivery and PNC. Local practices such as use of enema and use of squatting position were reasons attributed to accessing unskilled delivery. With respect to maternal illness, 241 (55.2%) and 196 (44.8%) sought health care from biomedical and non-biomedical facilities respectively. After delivery, 88 (20.0%) sought health services from traditional healers, a factor affecting neonatal health. The study further found that 281 (65.1%) neonates experienced ill health during the neonatal period. Difficulty in breathing, 98 (34.3) and fever, 78 (27.3%) were the two most reported condition during the neonatal period. Of the 286 who fell sick during neonatal period, 201 (70.3%) sought health care whilst 85 (29.7%) did not seek health care. Among those who sought health care, 125 (62.2%) used biomedical health facilities. Conclusion: The study concludes that socio-cultural practices are common in the study area and transcends the perinatal period. These socio-cultural practices are viewed as indispensable and closely related to people's worldview that illnesses during pregnancy, childbirth, neonatal and postnatal period have social and supernatural causes. This belief system favoured accessing health care from traditional healers. The good interpersonal relationship of TBAs, local beliefs and poor services at biomedical facilities pushed expectant mothers towards traditional care. Both neonatal and postnatal illnesses were believed to have both biomedical and social causes but with social causes given more prominence. Hence, health seeking behaviour was directed toward non-orthodox service outlets; thus affecting the continuum of care.Item Predictors of Intrapartum Stillbirths in Singletons in Six Public Hospitals in the Greater Accra Region, Ghana(University of Ghana, 2019-07) Vanotoo, L.A.Introduction . Globally. 2.6 million stillbirths are recorded annually: 50% occur during labour (intrapartum). Ghana records 11,000 stillbirths annually and 40% occur during. labour. The Greater Accra Region records 2000 stillbirths annually: 40 % of them occur intrapartum. An understanding of the contributory factors will facilitate the development of preventive strategies to reduce the huge numbers of intrapartum stillbirths. Objectives The objectives of this study were to identify contributors to intrapartum stillbirths; explore perceptions about stillbirth from women with experience of intrapartum stillbirth, document views of health professionals about causes and prevention of intrapartum stillbirths and develop a model to predict intrapartum stillbirths. Method This was a retrospective 2: I unmatched case-control study with a qualitative component. The study sample was all deliveries between 1st January to 31st December 2016 in six public hospitals in the Greater Accra Region. Cases were selected through census while controls were selected from the live births using systematic random sampling. Relevant information was retrieved from clinical records for both cases and controls. Thirteen (10%) women from the cases and 14 health workers were purposively selected for in-depth interviews. Bivariate and multi variable data analyses were used to determine association between the variables and intrapartum stillbirth. Qualitative data were analysed by themes using NVIVO II. The Area Under the Receiver Operating Characteristics Curve (AUROq and the Brier Score (BS) were used to identify factors to include in the model to predict intrapartum stillbirths. Approval for the study was obtained from the Ghana Health Service Ethics Review Committee. Results During the study period. there were 36,168 deliveries with 918 stillbirths; 362 (39%) occurred intrapartum. Through the census, 125 cases were identified, in addition, 250 controls and 27 participants were included in the study. Mean age of cases and controls were 28.8= 5.54 and 28.9 ± 6.05 years respectively. Mean gestational age was 36.5 ± 3.95 weeks for cases and 38.8 ± 2.69 weeks for controls; median birth weight was 2. 7kg.± 0.92 for cases and 3.1kg ± 0.65 for controls. The following maternal factors were associated with intrapartum stillbirths: pregnancy-induced hypertension (PIH) (aOR 3.70); antepartum haemorrhage (APH) (aOR, 3.28) and premature rupture of membranes (PROM) (aOR 3.36). The major fetal contributory factor was low gestational age (aOR. 0.86). Service delivery factors included lack of trained health staff, inadequate number of beds, theatre space. Non use of partograph to monitor women in labour and non-auditing of perinatal deaths. Fetal autopsy was not performed on stillbirths. The best model to predict intrapartum stillbirth was the model with combination of maternal (PHI. APH and PROM); fetal (low gestational age) and service delivery (mode of delivery and health provider who conducted the delivery) factors. Conclusions and recommendations Improved management of PIH, APH, PROM and preterm delivery will reduce intrapartum stillbirth. Hospitals should improve on monitoring of women during labour. Auditing of intrapartum stillbirths should be mandatory for all hospitals and Ghana Health Service (GHS) should include fetal autopsy in stillbirth auditing to identify other causes of fetal deaths. The best model to predict intrapartum stillbirth is a combination of maternal, fetal and health service delivery factors. Thus, interventions to reduce intrapartum stillbirth must combine maternal, fetal and service delivery factors to make them effective.Item Negative Early Reproductive Health Decisions and Associated Outcomes Among Women in the Northern Region of Ghana(University of Ghana, 2019-03) Iddrisu, M.R.Background: A growing body of demographic and sociological literature indicates that early life decisions and choices individuals make have important health consequences in later life Within reproductive health in particular, a number of studies suggest that early reproductive health decisions that women make have an impact on their reproductive health outcomes in later life. Despite this growing evidence, little understanding exists in Ghana about the relationship between negative early reproductive health decisions of women and later life reproductive health outcomes. Based on a life course perspective, this study aimed to examine the early reproductive health decisions of women and their associated reproductive health outcomes in the northern region of Ghana. Methods: A concurrent mixed methods retrospective study design was conducted to elicit information from married women within the ages of 15-49 years as well as other key informants. Systematic sampling was used to sample a total of 390 married women to take part in the survey. A combination of purposive and snowball sampling was used to select 40 key informants and a total of 130 women between ages 15- 49 with a minimum marriage experience of five years to take part in qualitative focus group discussions, in-depth interviews and key informant interviews. Quantitative data were collected through a face-face interview using structured questionnaires. Qualitative data were collected through focus group discussions, in-depth interviews and key informant interviews using unstructured topic/discussion guides. Descriptive statistical methods were used to describe important characteristics of survey respondents. Bivariate and multivariate logistic regression analyses were performed to examine association between early reproductive health decisions and reproductive health outcomes in later life. Confidence level and statistical significance were set at 95% and a p-value<0.05 respectively. Stata 13 version software was used in the analysis of the quantitative data. Qualitative interviews were audio-recorded, transcribed verbatim and analysed thematically with Nvivo 10 software. Results: Prevalence of early sex (first intercourse before age 16) was 58%, early marriage (union contracted before the age 18) was 30.0% and 80% of respondents did not consent to their marriage partner. About 42% of women have engaged in spousal communication on contraceptives. Also 24% experienced gender-based violence, 25% respondents' ever experienced unintended pregnancy and 44% experienced high fertility. The results from the qualitative study showed that persons who influence negative early Reproductive Health (RI-l) decisions of early sex, early marriage and consent of marriage partner were future partner, fathers of respondents and arranged marriages. Women who married before age 18 (early marriage) were also 3.27 times more likely to experience poor spousal communication relative to those who married between the age bracket of 26 - 36. Also women who had early sex and married early were significantly more likely to experience Gender Based Violence (GBV). The study further established a significant association between respondents experiencing early sex and GBV (p= 0.001). The odds of experiencing GBV were 2.65 times higher among women who first had sex before age 16 years (early sex) compared to those who first had sex between the ages of 16-25. Also of the respondents who had experienced unintended pregnancy, 72.5% (n=71) engaged in early sex (first intercourse before age 16). The odds of experiencing unintended pregnancy was 3.10 times higher among women who had sex before age 16 (early sex) compared to those who had sex between the ages of 16 to 25. Again, 39.8% (n=39) of the respondents who had unintended pregnancy married early. Also 81.6% (n=80) of the respondents who experienced unintended pregnancy did not consent to their marriage partner. Conclusion: The study found evidence linking negative early RH decisions of women to RH outcomes in the adult lives, suggesting that early RH choices affect later life reproductive health outcomes of respondents. These findings suggest that understanding women's current RH outcomes in the northern region requires looking closely at early life decisions which are likely to affect women later in life. Interventions in this direction can considerably improve women's health in the Northern region.Item A Study of Community Perceptions and Strategies to Improve Women’s Dietary Quality in Savelugu-Nanton District, Ghana(University Of Ghana, 2018-07) Sawudatu, Z.Background: The diets of women in reproductive age (WRA) are an important determinant of their health outcomes and quality of life especially in northern Ghana, where women’s diets remain persistently suboptimal. However, socio-cultural barriers, one of the multiple influences on WRA’s diets, are rarely addressed in existing interventions. This study identified the socio-cultural barriers to WRA achieving optimal diets, which, herein, represent beliefs, attitudes and actions that are derived from the existing native and emergent culture of the community and tested the feasibility of a community-based pilot intervention developed in consultation with the community to address these barriers. Methods: Socio-cultural barriers to women’s diets were identified and characterized through a qualitative study involving the exploration of the local food system, dietary knowledge, attitudes and practices at Yilkpene and Kpachilo. Data was collected through key informant interviews, focus group discussions, qualitative 24-hour dietary recalls with in-depth interviews and observations at the household and community levels. A 17-week attitudinal and behaviour change intervention was designed and implemented at Yilkpene in consultation with key community stakeholders. The first component, nutrition education, emphasized the importance of women’s diets and their reproductive health. The second component, advocacy, concerned empowering women to have more control over household food resources and modifying food taboos affecting women. Messages were delivered in the local language through participatory activities including community durbars, small group meetings, home-visits and food demonstration sessions. In the post-evaluation of the intervention, data was collected from 182 participants using the same tools used at baseline. The two sets of data were compared to assess the impact of the intervention at Yilkpene. Results: Study participants, all aged at least 15 years, were mostly WRA (73%), married Muslims (87.4%) without formal education whose source of livelihood was farming (84.1%) and had households with sizes ranging between 6 and 40. At baseline, gender and socio-cultural factors significantly influenced all aspects of the food system, limiting women’s access to quality foods. Animal-source food taboos, which are mostly gender-based and affect the quality of women’s diets, were identified. At endline, these practices did not change but members of Yilkpene community were sensitized about them. Prior to the intervention, the dietary knowledge and attitudes among members of both communities were sub-optimal; but, at endline, improved knowledge and attitudes were observed in both communities even though the scope of improvements was more in the intervention community. There were also less reported beliefs about plant-source food restrictions at Yilkpene compared to Kpachilo. At baseline, close to half (45%) of women in either community could not meet their minimum dietary diversity but diversity deficit declined at endline (25% at Yilkpene and 10% at Kpachilo). Conclusion: Attitudinal and behavioural change communication interventions on entrenched socio-cultural issues pertaining to women’s diets need more prolonged and sustained durations to enhance their scopes of feasibility. Ghana Health Service and individuals should organize similar interventions.Item Contraceptive Discontinuation and Switching among Women in the Shai-Osudoku and Ningo Prampram Districts, Ghana(University Of Ghana, 2018-07) Modey, E.J.INTRODUCTION: The intended and continued use of contraceptives is critical for attaining individual reproductive health goals and the prevention of unintended births that may be subject to induced abortions. Women who eventually overcome barriers and adopt a contraceptive method, encounter challenges that result in discontinuation, switching, or method failure. The occurrence of discontinuation for reasons other than the desire to conceive or switching to less effective methods, places women at an increased risk of unintended pregnancies. Identifying the period within which any form of discontinuation or switching is likely to occur and the reasons influencing these, will facilitate the identification of opportunities for providing a more accurate guide to users and encourage the delivery of context–appropriate support to users of family planning services. OBJECTIVE: This study sought to identify the occurrence of contraceptive discontinuation and switching among women in the Shai-Osudoku and Ningo Prampram districts, Ghana. METHODS: Individual in-depth interviews with 20 women reporting for reproductive and child health care services at the district Hospital were undertaken. This was complimented by a retrospective survey of 1,114 women using a structured questionnaire that incorporated the contraceptive calendar to collect reproductive histories. Cox regression and life table analysis was used to estimate discontinuation or switching. RESULTS: All method discontinuation for any reason at 12, 24 and 36 months after starting use were 4%, 18% and 38% respectively. This study identifies increasing age, number of children, use of contraceptives between births, after childbearing and receiving counselling on methods were associated with the reduced risk of contraceptive discontinuation at all times of follow up. A change in marital status and was associated with increased contraceptive discontinuation. At 12 months of use 10% of women discontinued because they are afraid of side effects of contraceptives, this increases to 37% at 24 months of use. Women who expressed fear of side effects of contraceptives had a 60% increase in the hazard of discontinuation at all times of follow up [HR=1.60 95% CI (1.17, 2.20)] whilst women who experienced side effects had a 50% increase in the hazard of discontinuation [HR=1.34; 95% CI (1.04, 1.75)] compared to women who discontinued for any other reason implying dissatisfaction with the method. A reduced need for contraceptives was associated with a 57% increase in the hazard of discontinuation at all times of follow up [HR=1.57; 95% CI (1.22, 2.01)]. Discontinuation of the pill was significantly increased compared to users of the male condom [HR=2.35, 95% CI (1.40, 3.97)] and compared to all other methods [HR=1.68; 95% CI (1.26, 2.25)]. Approximately 39% of switching occurred within the next month of use. Increasing number of children and counselling on methods were associated with a reduction in the hazard of discontinuation. The choice of switching to modern method was associated with an increased hazard at all times of follow up and the male condom was the preferred method for 20% of all switchers. Overall, 3.4% of pregnancies were identified as unintended, with the emergency contraceptive identified as the method with the most failures recorded. CONCLUSION: A reduced need for contraceptives, fear of side effects and the experience of side effects carry an increased risk of discontinuation compared to all other reasons. The strength of the influence that fears of side effects play in method selection, discontinuation and choice of method switched to where switching occurs, is a critical but amenable element if allocated the necessary attention.Item Continuity and Fragmentation of Antenatal and Delivery Care in the Volta Region of Ghana(University Of Ghana, 2017-03) Dery, S.K.K.Maternal mortality has over the years remained a global health issue with most of the deaths occurring in sub-Saharan Africa. With skilled antenatal care (ANC), many of these deaths can be prevented and as such skilled ANC attendance and skilled delivery have become key global indicators for measuring maternal health programmes across the world. The World Health Organization, until recently (2016) had recommended a minimum of 4 antenatal visits for pregnant women without any medical condition and whose pregnancies were progressing smoothly. This has since been updated to a minimum of 8 ANC contacts for a positive pregnancy experience. Ghana, over the years has been improving on the skilled ANC and delivery indicators with the 2014 Ghana Demographic and Health Survey (GDHS) showing that 87% of the pregnant women received the minimum 4 ANC visits, an increase from the 69% in 2003 while skilled delivery increased from 46% in 2003 to 74% in 2014. However, what remained unanswered is whether these ANC visits were made to several health facilities or to a single facility. In addition, it is unclear whether some pregnant women change their ANC facilities during delivery considering that labour and delivery constitute a critical point in the fight against maternal mortality, since complications during labour and delivery account for most of the maternal deaths in Ghana. In addition, though evidence from other studies show that some pregnant women receive care from multiple facilities, the extent of continuity and fragmentation of care during pregnancy and childbirth have not been quantified in Ghana. This study therefore sought to measure the level of longitudinal continuity and fragmentation of care during pregnancy and childbirth in the Volta Region of Ghana. iv Using National Health Insurance claims data for 2013 in the Volta Region, all the ANC and obstetrics data from all the facilities for the various months were merged into one file, deliveries were identified and classified as cesarean section or vaginal delivery. Visits of all the women that delivered were extracted from the data. Five continuity of care (CoC) indices (MFPC, MMCI, CoC, SECON and PDC) were calculated for each pregnant woman. Extent of repeat visits to each facility (provider continuity) and repeat visits to facilities in a district (district continuity) were calculated to represent the average of the proportion of visits that a facility/district got for all the women who visited the facility/district compared to other facilities/districts that those same women visited. Client-sharing between facilities and districts were identified. Two facilities shared a pregnant woman during ANC if the woman moves from facility of previous visit to the other facility of subsequent visit. A woman is said to have fragmented her care during delivery if she delivers at a facility different from where she sought most of her antenatal care. Five different types of network graphs were constructed using Gephi to help visualize the fragmentation of care among facilities and districts during ANC and delivery. A total of 14,474 pregnant women with a total of 92,095 visits (average of 5 visits per woman) were included in the study with 15.1% delivering by cesarean section (CS). The median maternal age was 27 and those that had CS were slightly older with a median age of 29. Although hospitals constituted 13% of the facilities in the study, they accounted for 73% of all visits and 83% of all deliveries. About 58% of all the pregnant women had perfect CoC: maintaining only one facility throughout ANC and delivery. There were medium to high levels of CoC among the various CoC indices (MFPC: 0.82 ±0.25; MMCI: 0.86 ±0.20; COC: 0.76 ±0.30; SECON: 0.80 ±0.28; PDC: 0.68 ±0.41). In addition, 32% of all the women and v 78% of those that visited multiple facilities made less than three quarters of their visits to the most frequently visited facility. The average provider (facility) continuity and district continuity in the region were 67% and 81% respectively and varies by districts and type of provider. About 19% of all subsequent visits, 26% of all deliveries, 32% of all CS deliveries, 63% of all deliveries by women with multiple facilities, 73% of all CS deliveries by women with multiple facilities were fragmented among facilities. In addition, 15% of all deliveries (36% among those with multiple facilities) and 20% of all CS deliveries (45% among those with multiple facilities) were performed at facilities that the pregnant women did not receive any ANC services from. Nine percent (8.9) of all subsequent visits, 13% of all deliveries, 20% of all CS deliveries and 30.5% of all deliveries by women with multiple facilities were fragmented across districts. In addition, 51.6% of all deliveries performed at facilities that the pregnant women never received ANC services from were fragmented across districts. Despite the high levels of CoC among the pregnant women, there is high fragmentation during the critical period of labour and delivery among those who visited multiple facilities. This situation seems to be exacerbated by the fact that there is high preference for hospital delivery, resulting in high levels of fragmentation of care during delivery among the various care facilities and across districts in the region, and is even more profound in districts that do not have hospitals, with higher proportions of the women moving from these districts to other districts with hospitals for delivery services. There is therefore the need for concerted effort to guarantee continuity and coordination of care throughout the ANC and delivery period by requiring every pregnant woman to have a primary care provider who will be responsible and accountable for coordinating the care that she receives.