University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA MATERNAL AND NEONATAL FACTORS ASSOCIATED WITH CEREBRAL PALSY: A CASE CONTROL STUDY AT AGONA IN THE CENTRAL REGION OF GHANA. BY ISAAC ADOMAKO (10177008) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE A WARD OF MASTER OF PUBLIC HEALTH (MPH) DEGREE. JULY, 2017. University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Isaac Adomako, hereby declare that, apart from specific references which have been duly acknowledged, this thesis is my own work produced from research under ....... ~f.P.!l DATE (Student) .......... ~1.!~!.~.,.!: ................. . Dr. Anthony Danso-Appiah DATE (Supervisor) University of Ghana http://ugspace.ug.edu.gh DEDICATION This work is dedicated to my family, especially to my Mother, Mrs Rose Dankwa Boateng; to Mr. Boateng Alfred, my Father and Teacher and to my late Grandfather, Mr Francis Kwaku Fosu, without them I wouldn't have been at where I am today and also to all the Children living with Cerebral palsy, especially those who access the Duakwa Rehabilitation centre and Polyclinic. University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I am most grateful to the Almighty God for granting me good health, wisdom and travelling mercies throughout the period of my study at the School of Public health. I am heavily indebted to Dr. Anthony Danso-Appiah for his fatherly advice, directions, constructive criticisms and cordiality in supervising and making this work a unique one. To all my Teachers, especially my advanced Biostatistics and Epidemiology lecturers, I say thank you for the new skills you have given me. I have learnt a lot from Professor Adanu, the Dean of the School of Public health, Dr. Sarfo, the Head of Department, Drs. Sackey, Kenu, Nortey ,Addo-Lartey and Dwomoh. I am sincerely grateful to the Hon. Ato Hayford, the National Coordinator, Ghana Rehabilitation services and the Administrator of the Salvation Army Rehabilitation centre, Agona Duakwa. Papa, God bless you for your continuous support for others, especially the poor and the needy. I am very thankful to Major Kodua and Major Obeng-Appau of the Salvation Army; Priscilla, Rebecca (Becky), Aunty Rose, Mr. Mensah, Sophia, Sylvia, Saviour and all the other people who have contributed to the success of this work. Finally, I am grateful to all my colleagues: the Pioneer MPH weekend epidemiology class of20 1612017, especially Henry Ofori Duah, Delphina and Benson for their support during difficult times and the confidence they had in me throughout the programme. iii University of Ghana http://ugspace.ug.edu.gh ABSTRACT Background: Cerebral palsy (CP) refers to multiple, non-progressive, heterogeneous group of syndromes of posture and motor development. It is the most common motor disability in children, with a global prevalence of2-3 per 1000 live births. The prevalence is highest in developing countries, constituting a huge social and economic burden to families and the health system. Maternal and neonatal factors account for about 90-95% of all CP cases. The Objectives: This study sought to determine maternal and neonatal factors and types, and assessed management options of children with cerebral palsy at the Duakwa Rehabilitation centre. Methods: The study used a case-control design, with cases defined as children less than 5 years, born singleton with confirmed diagnosis of CP by a Pediatrician. Controls were Children less than 5 years with a medical condition other than CP. A pretested questionnaire was administered to mothers to obtain information on socio-demographic as well as maternal and neonatal factors associated with CPo The study was conducted at the Salvation Army Rehabilitation centre, Agona Duakwa, in the Central Region. Results: After adjusting for key variables considered in this study, 9 factors were significantly associated with CPo These were: late menarche (adjusted OR=O.OI, 95% CI: 0.002 to 0.84), multiparity (OR=0.47, 95% CI: 0.23 to 0.93), good ANC attendance (OR=0.60, 95% CI: 0.06 to 0.96); constituting the maternal factors. For the neonatal factors, significant associations were found with: Birth asphyxia (OR=20.56, 95% CI: 3.50 iv University of Ghana http://ugspace.ug.edu.gh to 120.33), Neonatal jaundice (OR=16.30, 950/oCl: 1.66 to 70.88), Neonatal seizures (OR=29.00, 95% CI: 1.55 to 55.67) and Neonatal admissions with an OR of7.32 (95% CI: 1.60 to 33.41). Ethnicity and the locality of the mother were among the demographic factors associated with CP in the study. Conclusion: The study identified 3 main neonatal factors (neonatal seizures, neonatal jaundice and birth asphyxia) which were statistically significantly associated with CPo Protective maternal factors in the study included: late menarche, after 14 years, good ANC attendance and multiparity. The two demographic factors; mother's ethnicity and locality, which showed significant association with CP need further studies to confirm this association. v University of Ghana http://ugspace.ug.edu.gh T ABLE OF CONTENTS Page DECLARATION ....................................................................................................................... i DEDICATION ....................................................................................................................... . ACKNOWLEDGEMENT ....................................................................................................... iii ABSTRACT ........... ....... . .................................................................................................. iv LIST OF TABLES ................................................................................................................. xi LIST OF FIGURES ....................... . ...................................................................... xii LIST OF ABBREVIATIONS ................. . . .................................................................. xiii DEFINITION OF TERMS ............. . . ..................................................... xiv CHAPTER ONE .................... . . ....................................................... 1 1.0: INTRODUCTION .......... . . ............................ 1 I .1 : Background .................................................... . . ·· ............................................... 1 1.1.1: Epidemiology of Cerebral Palsy ................. . ···· ............................................. 1 1.1.2: Presentation (symptoms and signs) ............................................................................ 4 1.1.3: Diagnosis ofCP ......................................................................................................... 5 I .1.4: Prevention and Management of CP ............................................................................ 6 1.2: The problem statement ................................................................................................... 8 1.3.1: Conceptual framework ............................................................................................ 10 vi University of Ghana http://ugspace.ug.edu.gh 1.3.2: The Namnive of the conceptual framework .......................... ······ .............................. 11 1.4: Justification ..........................................................•......................................................... 12 1.5: The Objectives of the study ............................................................................................ 13 1.5.1: The General objective .............................................................................................. 13 1.5.2: Specific objectives ................................................................................................... 13 CHAPTER TWO ................................................................................................................... 14 2.0: LITERATURE REVIEW ................................................................................................ 14 2.1 : Maternal factors associated with CP ............................................................................... 14 22: Neonatal factors associated with CP ............................................................................... 16 2.3: Types ofCP ................................................................................................................... 18 2.4: Treatment options for CP ............................................................................................... 19 2.5: Impact of treatment on CP .................................................................... .. ................... 20 CHAPTER THREE ............................................................................................................... 22 3.0: METHODS ........................................................................................ . ... ... . ............... 22 3.1: The study design ............................................................................................................ 22 3.1.1: Case definition ......................................................................................................... 22 3.1.2: Controls ................................................................................................................... 22 3.2: The study area .............................. .. ··········· .. ···· .. ··· .. ····· .. ·· .. · ................................. 23 3.3: The Study variables ........... .. ······· ............ · .................. · ...... · ............................ 24 vii University of Ghana http://ugspace.ug.edu.gh 3.4: The study population ................................................................................................... 25 3.5: Sample siZi! detennination ............................................... · ...... ··· .. ····· .. ·· ....... . ..... 25 3.6 Sampling method ............................................................................................................ 27 3.6.1 Sampling of cases ....................................................................... . ........................ 27 3.6.2: S8lIlpling of controls ........................................................ .. ............................ 27 3.6.3: The Inclusion and exclusion criteria for cases .......................................................... 28 3.7: Data collection tools ....................................................................................................... 28 3.8: Data collection techniques .............................................................................................. 29 3.9: Quality control ............................................................................................................... 29 3.9.1: Research Assistants ................................................................................................ 29 3.9.2: Pretesting of questionnaires .................................................................................... 30 3.9.3: Data Collection Review .......................................................................................... 30 3.10: Data processing ........................................................................................................... 31 3.11: Data analysis ................................................................................................................ 31 3.12 Ethical considenttions .................................................................................................... 32 3.12.1: Ethical approving body .......................................................................................... 32 3.12.2 Study area approval ............................................................................................... 32 3.12.3: Subjects involved ................................................................................................... 32 3.12.4: Potential risklbenefits ............................................................................................ 32 viii University of Ghana http://ugspace.ug.edu.gh 3.12.5: Infonned consent. .........•.•• ~ ....................................................................................... 33 3.12.6: Privacy and confidentiality ..................................................................................... 33 3.12.7: Data storage/security and usage ............................................................................. 33 3.12.8: Voluntary withdrawal .............................................................. ·· .. · ......................... 33 3.12.9: CostiCompensation/payment .................................................................................. 34 3.12.10: Contlict of interest ............................................................................................... 34 3.12.11: Funding ............................................................................................................. 34 3.12.12: Contact Persons ................................................................................................... 34 CHAPTER FOUR ................................................................................................................... 35 4.0: RESULTS. ....................................................................................................................... 35 4. t: Introduction .................................................................................................................... 35 4.2: Descriptive statistics of the socio-demographic characteristics of the Participants ........... 35 4.3: Bivariate analysis of the factors associated with CP ........................................................ 38 4.4: Simple logistic regression analysis ................................................................................. 42 4.5: Multivariate analysis ...................................................................................................... 47 4.6: Detailed Case control analysis of some selected significant maternal and neonatal factors ......................................................... ··· .. · .......... •. ..... · .... · ............ · ......................................... 49 4.7: Pattern ofCP cases ........................................................................................................ 50 CHAPTERS. ........... . . .................................................................................................. 52 5.0: DISCUSSIONS. '"'''' .............................. ···· ................ ·. ... ·. ....................................... 52 ix University of Ghana http://ugspace.ug.edu.gh 5.1: lntroduction. ................................................................................................................... 52 5.2: Socio-demographic description of the Participants .............................................. ·· .......... 52 5.3: Socio-demographic factors associated with CP ............................................................... 53 5.4: Maternal factors associated with CP ............................................................................... 54 5.5: Neonatal factors associated with CP .............................................................................. 56 5.6: The Types, Severity and Treatment options ofCP .......................................................... 58 5.7: Strengths and Limitations of the study ............................................................................ 59 5.7.1: The major strengths of this study include ................................................................. 59 5.7.2: Some of the Limitations of this study include .......................................................... 59 CHAPTER 6 ........................................................................................................................... 60 CO!'lCLUSIONS AND RECOMMENDATIONS .................. . . ................................. 60 6.1: Conclusions ..................................................... . . ............................................ 60 6.2: Recommendations ........................................... . .. ................................................. 61 62.1: Implications for Clinical practice ............................................................................ 61 6.22: Implications for policy ............................................................................................. 61 6.2.2: Implications for research: ........................................................................................ 62 References .............................................................................................................................. 63 APPENDICES ........................................................................................................................ 67 University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 1: A table showing the characteristics of the various variables .................. 24&25 Table 2: The Socio-demographic description oft he study participants ..................... 37 Table 3A: Bivariate analysis of the socio-demographic variables ........................... .39 Table 3B: Bivariate analysis of the maternal factors ...........................................4 0 Table 3C: Bivariate analysis of the neonatal factors ............................................4 1 Table 4A: Simple logistic regression analysis of the socio-demographic factors ......... .44 Table 48: Simple logistic regression analysis of the maternal factors ..................... .45 Table 4C: Simple logistic regression analysis of the neonatal factors .......................4 6 Table 5:Multivariate analysis of the significant variables, reporting adjusted odds ratios .................................................................................................. .48 xi University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1: Conceptual framework depicting the maternal and neonatal mctors associated with cerebral palsy ....................................................................... ········· .. 10 Figure 2: The map of Agona East, showing the geographical location of the Salvation Army Polyclinic .....................................................................................2 3 Figure 3:A Pie chart showing the types of CP at the Duakwa Rehabilitation centre ..................................................................................................5 1 Figure4:A Pie chart showing the severity ofCP cases seen at the Duakwa Rehabilitation centre .................................................................................................5 1 Figure S:A Pie chart showing the treatment forms received by children with CP at the Duakwa Rehabilitation ............................................................................ 51 xii University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS CDC Centre for Disease Control CHAG Christian Health Association of Ghana CI Confidence Interval CPA Cerebral Palsy Africa CP Cerebral Palsy CRP Community Rehabilitation Project CIS Caesarean Section DM Diabetes Mellitus GDHS Ghana Demographic and Health Survey GUS Ghana Health Service OPD Out Patients Department OR Odds Ratio PIH Pregnancy-Induced Hypertension PROM Premature Rupture of Membranes xiii University of Ghana http://ugspace.ug.edu.gh DEFINITION OF TERMS Good ANC attendance-Attending clinic for antenatal care on at least 4 occasions throughout the pregnancy. Menarche- Age at first menstrual flow. Multiparity-delivered more than one (Parity of more than I) Primiparity- delivered once (Parity of one) PROM- Premature rupture of amniotic membranes after 28 weeks of gestation before the onset oflabour Preterm PROM· Premature rupture of amniotic membranes before the onset of labour, after 28 weeks but before 37 completed weeks of gestation. PIH-High Blood pressure associated with pregnancy, usually occurring after 20 weeks (second halfofthe pregnancy) xiv University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE 1.0: INTRODUCTION 1.1: Background 1.1.1: Epidemiology of Cerebral Palsy Cerebral Palsy (CP) is a neurodevelopmental disorder affecting motor and posture, resulting from abnormality ofthe brain (Holmes, 2013). CP is a symptom complex, rather than a specific disorder or disease (Reddihough & Collins, 2003). The most recent consensus definition states that, CP is an ''umbrella term covering a group of non- progressive. but often changing, motor impairment syndromes secondary to lesions or anomalies of the brain arising in the early stages ofits development" (Saadi, Sutan, Dhaher. & Alshaham, 2012). The condition is one of the most common motor disabilities in children (Mohammed, 2009). with a global prevalence ranging between 1.5 and 50 per 1000 live births (CDC, 2013). Averagely, I in 323 children have been identified with cerebral palsy and this is highest in developing countries, especially in Sub-Saharan Africa (SSA) (CDC ADDM, 2014). Data on CP prevalence in developing countries, especially SSA is limited (Badoe, Sciences, & Turan, 2015). In Ghana, there is paucity of data on the prevalence, types, age at diagnosis and severity ofCP, even treatment and management options. Children with CP often become dependent on others for survival in the greater part of their lives. CP has a lot of myths and misconceptions, often leading to failure or delay in seeking University of Ghana http://ugspace.ug.edu.gh treatment (Badu, 2012). Evidence suggests that CP is associated with preterm delivery and low birth weight at delivery ( Reddihough & Collins, 2003). The incidence rate ofCP can be as high as 50 per 1,000 live births among preterm deliveries (CDC, 2013). Factors in the prenatal (before birth), perinatal (during birth) and postnatal (after birth) periods are responsible for CP (Reddihough & Collins, 2003). Prenatal metors account for 70-80% of all the causes ofCP (Holmes., 2013). Reported risk mctors in the preterm inmnt include congenital heart diseases like patent ductus arteriosus, Atrioventricular septal defeets(A VSD); hypotension, blood transfusion, prolonged ventilation, pneumothorax, sepsis, hyponatremia, hypocalcaemia, total parenteral nutrition, seizures, among others. Neonatal seizures, in particular, are strongly associated with the risk of cerebral palsy (Badoe et aI., 2015; Saadi et aI., 2012). For most children who have cerebral palsy, there appears to be no single factor responsible for the motor damage (Reddihough & Collins, 2003). This has led to the concept of "causal pathways" - a sequence of complex and interdependent sequalae that lead to the disease (Stanley et al 2000, Reddihough & Collins, 2003). Some identified prenatal causes ofCP include congenital brain malformations (Reddihough & Collins, 2003). Other known prenatal causes of cerebral palsy are vascular abnormalities as demonstrated by brain imaging (for example, middle cerebral artery occlusion), as well as maternal infections during the first and second trimesters of pregnancy (including rubella, cytomegalovirus, toxoplasmosis). Less common causes of cerebral palsy include metabolic disorders, University of Ghana http://ugspace.ug.edu.gh maternal ingestion oft oxins., drugs and rare genetic syndromes, including Down syndrome (Reddihough & Collins., 2003). Perinatal filctors are the problems that arise during labour and delivery. Obstetric emergencies such as: obstructed labour, cord prolapse as well as antepartum haemorrhage may compromise the fetal circulation, leading to birth asphyxia (Donald et aI., 2014). Postnatal causes can be early neonatal (the first week of life) or post-neonatal (after one month of life). Severe hypoglycemia, untreated jaundice and severe neonatal infections such as meningitis., encephalitis, and cerebral malaria are the main neonatal factors associated with cerebral palsy (Reddihough & Collins., 2003). During the post-neonatal period, infections and injuries are responsible for most cases of acquired cerebral palsy in developed countries (Hasegawa, Toyokawa, Ikenoue, Asano, & Satoh, 2016). Accidental injuries resulting from vehicular accidents, as well as non- vehicular accidental injuries such as heavy falls and near drowning episodes may result in CP (Reddihough & Collins., 2003). Maternal factors such as delayed onset of menstruation (late menarche), irregular menstruation and long intermenstrual intervals are associated with an increased risk ofCP. An unusually short or long interval between pregnancies has also been described as an antecedent factor of cerebral palsy. Two studies have found that, low socioeconomic status is associated with cerebral palsy in children with normal birth weights (Dolk et al 200 I, Dowding and Barry 1990). 3 University of Ghana http://ugspace.ug.edu.gh Parity of three or more, multiple pregnancies, as well as elderly primigravida have been found to have a strong association with CP (Torfs et al 1990). Increased maternal age at first pregnancy (elderly primigravida) increases the risk of developing chromosomal abnormalities such as trisomy (e.g. Down syndrome-trisomy 21 ),translocations etc., leading to neurodevelopmental problems (Reddihough & Collins, 2003). 1.1.2: Presentation (symptoms and signs) The symptoms of cerebral palsy (CP) in children are often wide ranged (Jang et aI., 2013). This may include spasticity (rigidity of muscles), impaired motor functioning, delayed sitting, standing, locomotion and other daily living skills (Jang et aI., 2013). children with CP may have behavioral, cognitive, as well as sensory problems; learning difficulties and most commonly seizures (Terra et aI., 2011). Mental disability is usually characterized by underdevelopment of intelligence that results in an inability to react appropriately and timely to the immediate environment and may be worsened by the occurrence of seizures (Terra et aI., 20 II). Symptoms of cerebral palsy usually start with delayed developmental milestones, especially gross motor function. Child not able to walk after 2 years with speech impairment is one of the first symptoms that strike a parent, usually the mother to seek medical attention. Others include: frequent seizures with spasticity (rigidity), abnormal posturing and speech impairment. Lack of head control after six (6) months of life. The clinical presentation of cerebral palsy depends on the part of the brain affected which also defines the type of cerebral palsy. Clinically, 4 main types of cerebral palsy exist- 4 University of Ghana http://ugspace.ug.edu.gh spastic, ataxic. choreo-athetoid and mixed. Spastic tetraplegia. defined as spasticity of all four limbs with involvement of the arms more than or equal to the legs; spastic diplegia. defined as spasticity of the lower extremities with a variable but a lesser degree of involvement ofthe upper limbs; spastic hemiplegia characterized by spasticity of the arm and leg on one side; hypotonic, defined by a reduction in the tone of all or most of the limbs; the choreo-athetoid type, characterized by abnormal involuntary muscle movements and the mixed type, which encompasses a combination of the previous types, as well as ataxic and dystonic episodes. 1.1.3: Diagnosis ofCP The Diagnosis of cerebral palsy is purely clinical. A parent, usually a mother presents a child of 2-4 years with delayed motor milestones such as lack of head control after 6 months, inability to sit without support after 9 months, inability to walk after 18 months and or frequent seizures with spasticity of the whole body. Detailed antenatal, delivery, and early neonatal history often identifies one or more factors that may have predisposed the child to CPo Laboratory investigations as well as imaging are usually not necessary in diagnosing CPo They may be needed in difficult situations to rule out other causes or to detect complications and other comorbidities. Diagnosis is often delayed at the primary and even secondary levels, because of failure in recognizing the condition by clinicians. delay in seeking medical care by the caregivers due to the myths, misconceptions and superstitions associated with CP as well as lack of appropriate centres 5 University of Ghana http://ugspace.ug.edu.gh and skilled personnel for managing children with disabilities at the primary and even the secondary levels. Accurate diagnosis is often made after several episodes of seizures, which are often referred to the neuro-paediatricians. Diagnosis is usually confirmed by a Paediatrician from the history and the physical findings, with emphasis on the developmental history and assessment. A thorough and a good history of the developmental milestones often lead to the correct diagnosis. 1.1.4: Prevention and Management ofCP In preventing cerebral palsy, it is important to apply all the four levels of prevention, that is: primordial, primary, secondary and the tertiary levels of prevention. Tertiary level is currently what is widely being applied in the management of CP, partly due to the late diagnosis and the non-involvement of Public health professionals in the management of the condition. Secondary prevention requires screening and early diagnosis of the condition. This is currently lacking in Ghana. Health care providers, especially midwives must have a basic knowledge about the risk factors associated with CP and how to recognize both the risk factors and the condition as early as possible. Physician assistants, Medical Officers and Nurses at the primary and secondary facilities must actively look for CP through comprehensive history, especially developmental history during the neonatal period. Prompt referral to Physicians and Pediatricians for early diagnosis is key in managing CPo 6 University of Ghana http://ugspace.ug.edu.gh Primary and primordial prevention involves: knowledge about the risk factors; measures to prevent them from occurring; interventions to prevent exposure of the fetus, the mother or the neonate to the risk factors, when they occur. Some of these interventions involve preconception care: genetic counseling to prevent couples with ABO and Rhesus incompatibilities from marrying, discouraging too early and too late pregnancies, women empowerment. community involvement of all health interventions, policy, grassroot as well as media advocacies for the prevention, and management ofCP. Health education to increase community knowledge about CP and to reduce the stigma, misconceptions, myths and superstitions attached to CPo Management of cerebral palsy requires a multidisciplinary approach. Professionals from various disciplines are involved right after diagnosis. Physiotherapist, Occupational therapist, Orthopedic Surgeons, Pediatricians, especially Pediatric Neurologist, Speech therapist, Psychologist, among a host of others are usually involved. Care is usually rehabilitative (tertiary prevention). Current interventions for CP include: Physical therapy to prevent the weakening or deterioration of muscles and for motor development; braces or orthotic devices to stretch spastic muscles, which can disrupt balance and normal motor development; occupational therapy to help develop daily living skills, such as feeding, dressing or using the bathroom; speech therapy to help develop communication and language skills; behavioral therapy to promote socially-appropriate behaviors; and surgery to treat severe cases of contractures (Chen et aI., 2013). 7 University of Ghana http://ugspace.ug.edu.gh Children with CP have increased risk of acquiring infections. They often experience episodes of severe malaria, aspiration pneumoniae, which are all risks factors for febrile convulsions. Distinguishing a seizure due to the CP and that of a febrile seizure can be difficult for clinicians, especially at the primary level. Therefore children with CP and their parents often find themselves in and out oftertiary health facilities for one reason or the other. Rehabilitation which includes physiotherapy, speech therapy and use of devices are employed throughout the child's life. A child with CP becomes dependent on others for most motor functions for the greater part of their lives. The purpose of rehabilitation is to decrease their dependence on others and to be able to perform daily living activities. 1.2: The problem statement Cerebral palsy is one of the most common motor disabilities in children (Donald et al.. 2014) with about I in 323 children having the condition (CDC, 2013). Children with CP for the greater part of their lives depend one way or the other on others for survival. This is a burden to both family members and the entire society, especially in societies where there are a lot of myths and misconceptions associated with the condition. In Ghana, CP has a lot of myths and misconceptions attached to it. making its diagnosis and therefore access to treatment difficult. In most societies in Ghana, a child with CP is seen as a curse, born out of infidelity on the part of the mother. Others see them as "spirits" delivered as a result of punishment by the gods for parental or family offences. Such 8 University of Ghana http://ugspace.ug.edu.gh children are often abandoned with most of them denied access to basic education. Most of these children are therefore kept in homes, camps etc., without accessing health filcilities and Rehabilitation centres. These factors result in delays in diagnosing CP ,under- estimation of incidence and prevalence and high mortality and morbidity associated with the condition in developing countries. In Ghana, the prevalence among high risk groups is about 33 per 1000 live births (CPA, 2014). This prevalence continues to increase due to the chronicity of the condition, emergence of new cases and high survival rates of children with CP. Lack of adequate studies on CP in Ghana, especially on filctors associated with it has resulted in lack of policies on support towards children with CP and their families. This study will be one of the few that will provide a blueprint for prevention, managing and rehabilitating children with CP at the National as well as the local level. Findings from this study will bridge the knowledge gap of the causes ofCP among health workers and the general public. 9 University of Ghana http://ugspace.ug.edu.gh 1.3.1: Conceptual framework MATERNAL FACTORS MAlERNAL MQ!lli.QE Mother's age at: £LLNESSES: DELIVERY: CIS, Parity, menarche and during Vaginal delivery educational lewl qPIH, the index pregnancy or assisted vaginal marital status, OM, febrile deli wry socio- illnesses economic status, menstrual cycle, Menarche. CONDITION Age at birth OF CHILD AT (pretenn or BIRTH: Low ANTENATAL Tenn APOARS, ATTENDANCE L....----_:> Birth : Good or Bad Defonnities, infections, trauma, seizures Figure 1: Tbe conceptual framework depicting major maternal and neonatal factors a5!Iodated with CPo 10 University of Ghana http://ugspace.ug.edu.gh 1.3.2: The Narrative ofthe conceptual framework The Diagram above depicts how the maternal and neonatal factors affect cerebral palsy. The main dependent variable here is a child with cerebral palsy while the independent variables are the various maternal and neonatal factors associated with CPo Maternal factors such as parity, marital status, occupation, highest educational levels and socio-economic status are key factors that determine antenatal attendance. The economic status of people influence their health-seeking behaviors (Kumar, 2014). Antenatal attendance influences both the pregnancy and delivery outcomes. High risk pregnancies are usually identified early during ANC and action taken to avoid complications. Gestational age at delivery is usually determined by the maternal and fetal conditions. Maternal conditions such as pre-eclampsia, eclampsia, Gestational Diabetes, preterm PROM also lead to spontaneous or iatrogenic preterm deliveries. Prematurity is a high risk factor for birth asphyxia and respiratory distress, due to premature lungs and low surfactant levels in the alveoli. Untreated or poorly treated birth asphyxia eventually leads to cerebral palsy. Prematurity can lead to early neonatal problems such as neonatal jaundice, neonatal sepsis etc. which can result in CPo Linked directly to CP is the mother's age. Increasing age at first pregnancy (elderly primigravida) is a single most important risk factor in most congenital and acquired fetal neuro-developmental problems. This often leads to Down syndrome, Autism, CP, among others. Late menarche has also been reportedly associated with CPo 11 University of Ghana http://ugspace.ug.edu.gh Neonatal filctors such as jaundice, sepsis, trauma, brain infections like cerebral malaria, meningitis, encephalitis are directly associated with CPo 1.4: Justification In Ghana, not much research has been done, in terms of the factors, types and treatment options. Few of such studies include an unpublished study by Badu (2012), who looked at the attitude and perception of people in Agona East District towards children with CPo There is the need to create more awareness of cerebral palsy in Ghana and beyond, especially factors leading to its development and the need to seek early treatment as soon as it is recognized. This study will add to the literature to increase the knowledge of the factors affecting cerebral palsy in Ghana, since the study is sited at a rehabilitation centre that sees cases of cerebral palsy across the country. Directly, the outcome of the study will provide the basis for the need to create awareness about CP, especially during antenatal visits by pregnant women, thorough screening of mothers during the antenatal period, looking out for risk factors in children, especially during delivery, and in the early neonatal period. The Salvation Army as an organization as well as other organizations dealing with rehabilitation ofep children will be encouraged after this study, based on the evidence to inculcate creation of a\\-areness in the society and even among health workers about CP as well as the emphasis on primary prevention in their programmes. 12 University of Ghana http://ugspace.ug.edu.gh 1.5: The Objectives of the study 1.5.1: Tbe General objective To determine maternal and neonatal factors and types, and assess treatment and management options of children with cerebral palsy at the Duakwa Rehabilitation centre. I.S.2: Specific objectives • To identify maternal factors that influence the risk of having a child with cerebral palsy. • To assess neonatal filctors associated with cerebral palsy. • To determine types of cerebral palsy at the Duakwa Rehabilitation centre including the age at diagnosis and severity of symptoms. To assess treatment and management options available to children with CPo 13 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO 2.0: LITERATURE REVIEW 2.1: Maternal factors associated with CP Several studies have come out with some maternal factors strongly associated with CPo Most of these studies were retrospective. The fact that CP is rare and also associated with mUltiple exposures make retrospective study the most appropriate. Some Maternal factors that have been found to have a strong association with CP include: Pre-eclampsia (pregnancy-induced hypertension), Gestational Diabetes, Maternal infections, increasing maternal age, irregular menstruation as well as trauma. Other factors not strongly associated with CP may include parity. menarche and number of fetuses (Hasegawa et aI., 2016; Jang et al.. 2013; Saadi et aI., 2012). In one large population-based cohort study. it was found that, out of the 6,145,357 deliveries examined during the study, 8946 cases ofCP were identified (prevalence of 1.45 per 1000 live births). In both term and preterm CP groups, there were significantly increased risks ofCP related to advanced maternal age (>40 years) and increasing parity; Pregnancy risk factors (e.g. chronic hypertension and preeclampsia). Gestational (but not pre gestational) diabetes increased the risk in term babies by 19% as against controls. Maternal infection was seen more frequently in term cases ofCP. 14 University of Ghana http://ugspace.ug.edu.gh Intrapartum adverse events likely to be associated with CP (all of which have been documented in past studies) were: (19.7% in all CP cases, vs. 7.7% in controls, P < 0.0001); birth trauma (7.8%, vs. 4.8% in controls, P < 0.000 I); placental abruption (5.7%, vs. 0.9% in controls, P < 0.000 I) (Saadi et aI., 2012). According to the theory put forth by Adinolfi, maternal infections during pregnancy might lead to neurologic impairment and the development of CP via cytokines. His theory suggested that, cytokines contribute not only to neurologic impairment, but to preterm birth as well. This prenatal hypothesis has now come to be known as the inflammatory/cytokine hypothesis (Hasegawa et aI., 2016; Saadi et at, 2012,Leviton, 1993). Infections might appear in the form of intrauterine infection (chorioamnionitis) as well as extra-uterine infections such as pyelonephritis, cystitis, pneumonia, severe malaria etc. There was a strong correlation between chorioamnionitis and cerebral palsy in a Meta- analysis study. Twelve of the 15 studies had data on the association between clinical chorioamnionitis and cerebral palsy with an OR that ranged from 0.9 to 5.8 (Keough, and Badawi,2006). Several studies have shown a strong association between multiple gestation and CP, compared to singleton pregnancy. Multiple gestations encompass several antenatal complications including preterm labor, death of a co-twin, growth restriction, and birth defects of one or more fetuses, pre-eclampsia, preterm PROM. All of these events or occurrences can be associated with CPo lS University of Ghana http://ugspace.ug.edu.gh In one study using the Western Australia CP Register from 1980 to 1989 to investigate the rates of CP in twins and triplets, twins were at higher risk for developing CP than singletons, with the risk of a child having CP being 0.20/0, 1.3%, and 7.6% for singleton, twin, and triplet pregnancies, respectively (Petterson, B., Nelson, K.B., Watson, L., et aI, 1993). Antepartum haemorrhage is associated with cerebral palsy and white matter damage in preterm infimts but if cases are compared with controls born at the same gestation, antepartum haemorrhage is found to increase the risk of cerebral palsy associated with preterm birth, but not to add any further risk. According to Badoe et aI, (2015), a study among CP cases in Korle-Bu revealed a significant association between CP and irregular menstrual cycle (OR 4.58, PO .021). 2.2: Neonatal factors associated with CP The neonatal period, especially the early neonatal period is the most important period in the child's life so far as prevention ofCP is concerned. Problems in this period that may predispose a child to CP include: birth asphyxia, neonatal jaundice, neonatal sepsis, meningitis, cerebral malaria, trauma, among others. Birth asphyxia was for a long time hypothesized as the main cause ofCP, until recent studies began to show other neonatal factors very strongly associated with CP (Saadi et aI., 2012). Current researches suggests that. perinatal asphyxia accounts for 6-8% of the causes ofCP whereas 70-80% are from prenatal factors (Reddihough, Collins, 2003). Among the high risk such as extreme preterm, the prevalence can be as high as 50 per 1000 live births. The CDC (2015), reported a prevalence as high as 35 to 79 per 1000 live births among such groups in Europe and 16 University of Ghana http://ugspace.ug.edu.gh Australia. CP was .W:·~ ~.>.:-: 'In !.:l"·.0~[; roys than among girls, more common among black children th811 '-/'I ~ . .' ,' :. j-~:-... it; and White children were about equally J.ikely to have CP ( CDC,21J : . : In a systematic rev1;!w cf ; 5}:!ubliClJ,tions from 7 African couRtries, including t.wo from Gh~.la. DO:lalri.et ~J.(lS :~;;ro..·lld",!\'l .. the :nost commonly reported etiologies identified in Affican cohorts '.'Vere "bk~;, tU:.r"I;'.i(~. kernicterus, and neonatal infections. with prematurity and tov>, rirt:l wl!ights :~~ntified as a major etiology in only few studies(2 of the publications). Other stuC:i~s in ~,l!rope reported high risk of CP associated with low birth weight and prematurity (Donald et al.. 2014). At a delegates conference in Africa, involving 22 African nations, it was reported that a large proportion of children seem to be affected through postnatal insults, such as meningitis or cerebral malaria (Burton, 2015). A study in metropolitan Atlanta found that the prevalence of CP was 6.2 per 1.000 livebirths among children born weighing j ,500 to 2,499 grams (3Y3 to 5Y3 pounds) and 59.5 per 1,000 Iivebirths among children born weighing less than 1,500 grams, compared with 1.1 per 1,000 for children born we!ghing 2,500 grams or more (CDC,20 15). In a data from Europe and Australia, the prev8.J..!nc~ cf(:p ranged from 35.0 to 79.5 per 1,000 live births for ch i1dren born lit 2 g to 3 I \\'~eb' Er.:.,."t~ivn, compared to l.t to 1.7 per 1,000 live births for children born at 3"1 C{ mOie 'veek~; fJ'.~·.:t~k," (CDC., '"J('.:,). P. study conducted j:J Ghana", detc:.'·"UI<: r.e cJassi fi::ation and factors associated with CP came out with the following fi:t1ines: ;. r;~ors associated with an increased risk for CP were ~evere neonatal h:;perbilimbinemL (C:. ""3.94, PO .0001), neonatal seizures (OR 32.81. 1.7 University of Ghana http://ugspace.ug.edu.gh P 0.001), birth asphyxia (OR 6.69, PO.027) ,:prmnaturity (OR 3.45, PO.OOS), and neonatal sepsis (0R2.83, PO.020) (Badoe et aI., 20 15).,Fram the study, hyperbilirubinemia, causing neonatal jaundice with a fatal outcome of kernicterus had a very strong association with CP, with an odds ratio of more than 40. This is a preventable risk and early recognition and prompt treatment is needed to prevent CPo In Botswana, recent studies found perinatal hypoxia (28%), prematurity (21%), postnatal' infections (15%), and prenatal TORCH [toxoplasmosis, rubella, cytomegalovirus, and herpes] infections (10%) to be the most common etiologies of CP (Burton, 2015). 2.3: Types of CP For both clinical and research purposes, cerebral palsy has often been classified according to the nature of the movement disorders as spasticity, hypotonic, dystonia, and athetosis and the anatomic distribution ofthe motor abnormalities, such· as bilateral spastic, spastic tetraplegic etc. (Surman et aI., 2009). In a prospective cohort study by Mohammed et al (2009), out of72 cerebral palsy children who were followed up for 3 years, 27 (37.5%) had spastic tetraplegia,12 (17%) hemiplegia,9 (12.5%) dipiegia,I4 (19.4%) hypotonic and 10 (14%) mixed. In the same study, the mean age at diagnosis was 8.8 +_4.3 years with 35.6% of them younger than 48 months and 64.4% older than 48 months. In a recently published study in Ghana, Badoe and Turan, 20 IS, found the following"pattern ofCP in Accra, bilateral spastic (60.6%) and dyskinetic CP (20.4%) were the most common 18 University of Ghana http://ugspace.ug.edu.gh clinical subtypes, followed by unilateral spastic CP (10.6%), which was entirely different from clinical subtypes using the Surveillance of Cerebral Palsy in Europe classification system, which had a high prevalence of dyskinetic CP. 2.4: Treatment options for CP "Children with CP require multidisciplinary care for optimal management of their medical needs as well as support to maximize their developmental and educational potential" (Donald et aI., 2014). Modern interventions for CP involve: physical therapy to prevent the weakening or deterioration of muscles and for motor development; braces or orthotic devices to stretch spastic muscles, which can disrupt balance and motor development; occupational therapy to help develop daily living skills, such as feeding, dressing or using the bathroom; speech therapy to help develop communication and language skills; behavioral therapy to promote socially appropriate behaviors; and surgery to treat severe cases of contractures of muscles that cause movement problems, or to place a feeding tube in severe cases of swallowing problems and malnutrition (Hernandez-reif, Field, Largie, Manigat, & Seoanes, 2005). Several Guidelines exists for the recommended investigation and management of specific aspects ofep through pediatric organizations such as the American Academy of Pediatrics and Cerebral palsy Africa. However, little is known about either the availability of guidelines or the recommendations in practice across resource-poor countries in Africa. In the first instance, several studies identified barriers toward optimal care for children with 19 University of Ghana http://ugspace.ug.edu.gh CP in Africa. Limited access to health care facilities and specialists, as well as a lack of adaptive equipment such as wheelchairs and other ambulation aids, contributes to the treatment gap for children with CPo In addition to high levels of social stigma, myths and misconceptions towards children with neurologic disorders were reported as reasons for families failing to seek treatment even when it was available. Further contributing to difficulties in accessing health care facilities for children with CP is a lack of support such as accessible transport. This represents a particular challenge for families with older paralytic children with CPo A multisite country study conducted by the African Child Policy Forum on the lives of children with disabilities in Africa noted that, poverty contributed immensely towards a family's decision to seek medical care (Donald et aI., 2014). A systematic review of literature conducted by Joshi et ai, came out that, there have been changes and improvements in the management and treatment ofCP patients with respect to respiratory conditions or issues, feeding and nutrition and overall functioning, survival however does not seem to decrease significantly as we was expected (Joshi et aI., 2013). 2.5: Impact of treatment on CP A study by Maria, Tiffany and Shay, (2005), 27 children with average age 32 months, receiving interventional programmes, it was realized that, 30 minutes of massage therapy and weekly writings for 2 weeks improved symptoms tremendously. Massage therapy has been effective for several of the problems related to CP and in other conditions. For 20 University of Ghana http://ugspace.ug.edu.gh example. fine motor functioning, dressing and arm and leg muscle tones improve following massage therapy in preschool children with Down syndrome (Hernandez-Reif et aI., 2005). Sti ffness was reduced in joints of children with chronic juvenile rheumatoid arthritis. Massage therapy might also be expected to reduce spasticity, to improve muscle tone and to improve the range of motion or enhance motor functioning in children with CPo The current study evaluated massage therapy versus reading as an attention control group for children with moderate to severe CP for (I) reducing spasticity, (2) improving range of motion, (3) facilitating motor functioning and (4) enhancing social interactions and development .Improvements in symptoms were observed for those receiving frequent massage therapy, compared to the controls (Hernandez et aI2005). 21 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE 3.0: METHODS 3.t: The study design The study was carried out using a case control design. Cases and controls were children less than 5 years and of singleton gestation. Case-control study, an analytical, observational type ofe pidemiological design was most suitable for this study because, cerebral palsy, the main motor disorder in children, is a very rare condition with a prevalence of2-3 per 1,000 live births (far less than 10%). Additionally, this study design allows for multiple exposures to be measured within the shortest possible time, and at a minimum cost. Cases and controls were in the ratio of I :3. 3.1.1: Case definition A case ofCP was defined as a child with cerebral palsy aged 0-5 years diagnosed by a Pediatrician or any experienced Medical officer from January 2015 to the time of the study and who accesses the Duakwa Rehabilitation centre. 3.1.2: Controls Controls were children less than 5 years from the same source popUlation of the CP cases and who did not have CP and attended the health facility for other conditions. A semi-structured questionnaire were used to interview mothers of the participating children to retrospectively identifY exposures related to cerebral palsy in the prenatal, perinatal and neonatal periods. Review of Antenatal and child health records was 22 University of Ghana http://ugspace.ug.edu.gh conducted to obtain additional data and validate the information obtained from the interviews. The data collection and analysis were completed in 2 months. 3.2: The study area The study was conducted at the Salvation Army polyclinic and Rehabilitation centres, Agona Duakwa. This Health facility is located at the south-eastern part of Duakwa, on the main Winneba- Oda road. Agona Duakwa, a suburb of Agona Swedru, belongs to the Agona East District, whose capital is Agona Nsaba, to the east of Agona Duakwa. The main occupation of the people of Duakwa is farming .Others engage in trading etc. It is one of the most deprived Districts of the central region and it represents a typical District in Ghana, in terms of its demographic and Health characteristics. Duakwa and Salvation Army are well-known for their excellence in cerebral palsy management, with the presence ofa Rehabilitation centre, specialized in cerebral palsy and other motor disorders, since 1990. Figure 2: Tbe District map of Agona East, showing the location of the Salvation Army and surrounding communities 23 University of Ghana http://ugspace.ug.edu.gh 3.3: The Study variables The dependent variable is "a child with cerebral palsy" The main independent variables are: The various maternal and neonatal factors associated with cerebral palsy. Table 1: Cbaracteristics of tbe dependent and some independent variables in tbe study. Name of variable Operational Type ofvariable Measurement definition seale Child with cerebral palsy Child Categorical Nominal diagnosed with cerebral palsy aged 0-5 years Sevmty of symptoms Mild, Categorical Ordinal moderate and severe Age at diagnosis(age Uesa than categories) month 2.1-6 months Categorical Ordinal 3.7months-1 year 4.1-2 years 5.3-5 years Gestational age at deli very prctenn(28- 37weeks) Categorical Ordinal Term(37 completed weeks or more) 24 University of Ghana http://ugspace.ug.edu.gh Table I eont'd Defmition Type ofvariable Measurement seale Name ofvariable Mode of delivery l.vaginal delivery Categorical Nominal 2.Caesarean section Antenalal illnesses PIH OM Febrile Categorical Nominal conditions APH Primiparous Mother's parity Categorical Nominal Multiparous Male Sex of the child Categorical Nominal Female 3.4: The study population The study involved 60 confinned cases ofCP accessing the Duakwa Rehabilitation centre and 182 hospital controls, similar to cases except having CP. 3.5: Sample size determination For a case-control study, sample size (n) is given by the fonnula, 2S University of Ghana http://ugspace.ug.edu.gh N= [za/2 "2p*q* + zp" (plql +pOqO)] 2/ (pl_pO)2 N: sample size for one sample (cases) Zol2: z value for a two-sided test corresponding to the chosen a Zp: z value for a one-sided test for the chosen p pi: proportion of cases exposed pO: proportion of controls exposed P*: mean estimated proportion (pI +pO)12 q = I-p, pl=pOxORlI +pO (OR -I), where OR is the hypothesized odds Ratio. n = 2p*q*(za/2 + zP) 2/ (pl_pO)Z (Reference: PS sample size calculator) From the literature, odds ratio used was 6.2 PI=24 %,( 0.24) pO=4 %( 0.04), Zb=0.84, Za=1.96. Inserting this into the above equation or using STAT A version 14 or EPI INFO, N, the minimum sample size for the cases was: 55 For controls, using 1c ase to 3 controls, 55x3=165 Total sample size is 220. Adding 10% to cover non-responses and incomplete responses. Total sample size =220+22== 242. 26 University of Ghana http://ugspace.ug.edu.gh All the 77 available cases were however targeted but only 60 agreed or qualified to take part in the study and therefore 182 controls were used. 3.6 Sampling method 3.6.1 Sampling of cases All the cases that have been seen at the Rehabilitation centre beginning 1st January, 2015 were included in the study. From the beginning of the study, records were reviewed to ascertain the presence of the cases. All the incident cases, beginning 2015 were identified from the records. Names of the children, their ages and the contacts of their parents were taken from the records. Sampling of cases was by universal sampling. where all the available incident cases ofep were used. In all 77 cases were contacted, 60 were involved in the study, comprising of 40 who were interviewed face-to-face during a follow-up visit in the course of the study and the remaining 20 through a telephone interviews. The rest could not be reached during the course of the study. 3.6.2: sampling of controls The controls were selected by Simple Random sampling. For each day of the study, the folder numbers of the first 10 Patients between the ages of 0 and 5 years were entered into a random digit generator and the 6 participants picked had their mothers interviewed face to face. This was continued until the total of 182 controls were obtained. 27 University of Ghana http://ugspace.ug.edu.gh 3.6.3: The Inclusion and exclusion criteria for cases Children with cerebral palsy, aged 0-5years who attended Duakwa Rehabilitation centre from January, 2015 to date were included in the study. Cerebral palsy children with deceased mothers, a case not properly diagnosed by either a, Paediatrician or a Neurologist or an experienced Physician and Multiple births were excluded from the cases. 3.7: Data collection tools This study was a pure quantitative study, using semi-structured questionnaires. The questionnaire consisted of 4 parts. Part I was the socio-demographic section, which sought to bring out the socio-demographic characteristics of both the mother and the child with CP, compared with controls. Mother's characteristics such as age, highest educational level. occupation and marital status were the main components of part I. Part 2 covered the maternal factors associated with CP, such as parity, menstrual cycle, and menarche. antenatal attendance, mode of delivery, among others, while part 3 sought to bring out the neonatal factors associated with CPo Part 4 covered the pattern, severity, treatment forms and the impact of treatment on CPo For cases, Part 4 was cross-checked from the available records. Parts I to 3 applied to both cases and controls, whereas part 4 was only applicable to cases. For some of the Maternal 28 University of Ghana http://ugspace.ug.edu.gh and Neonatal factors such as Gestational age, Mother's parity etc., the information obtained was validated by the Antenatal and child health records, if available. 3.8: Data collection techniques The questionnaires were administered by face-to-face interviews to most of the cases and all the controls as well as telephone interviews to few of the cases that could not make it to the facility during the period of the study. The interviews started with the understanding and signing of the consent form and the purpose of the study before the actual questionnaires. Each interview took 10 to 15 minutes. 3.9: Quality control 3.9.1: Research Assistants Six (6) research Assistants, consisting of two community Health Nurses, two (2) Health Information officers from the facility and two community health Nursing students from the Winneba community training school who were on clinical attachment as well as some community volunteers were given a day briefing and training on the collection of data and informed consent. Each question on the questionnaire was read and detailed explanation of what each of them meant was given. One of the Research Assistants was made to translate that into Twi and Fanti. All of us accepted the translation for each question before moving on to the next. This was repeated by selecting Assistants at random to state the meaning of the questions as well as its translation to Twi and Fanti. 29 University of Ghana http://ugspace.ug.edu.gh The general ethics of research, involving voluntary participation, informed consent, confidentialities were all explained to them at length. This training took place in one of the consulting rooms in the facility. Any questions or ambiguities were also addressed. All the research Assistants could speak English, Fanti and Twi. 3.9.2: Pretesting of questionnaires The questionnaires were pretested at the 8egoro Rehabilitation centre of the Salvation Army. This facility sees similar cases seen at the Duakwa Rehabilitation centre. The pretesting was to determine the accuracy and the appropriateness of each question as well as the average duration needed to complete the questionnaires for each participant. Some few corrections were made after pretesting the questionnaires for five cases and five controls. It was realized that, divorce as part of the option for marital status should be divorced. It became necessary to add record review, if available to validate some of the information given which were a bit technical, such as the gestational age of the baby at birth, type ofCP, severity of symptoms, type of treatment. Age oft he Mother and the child, which were initially taken as continuous variables were categorized, after the pretest, when it was realized that, most of the participants could only give their age as a range. 3.9.3: Data Collection Review All the research Assistants converged at one point at the end of the day to review and to discuss the data collected. This was done from the beginning to the end of the study collection to ensure that, every questionnaire was filled adequately and appropriately. The 30 University of Ghana http://ugspace.ug.edu.gh data were cross-checked and double entered by both the Principal investigator and one of the health information officers to ensure accuracy. Data collection review was another step in ensuring quality data. 3.10: Data processing Data from the interviews was entered with excel spreadsheet, after checking for completeness and accuracy of the information. The data was then cleaned by identifying all wrong entries and correcting them using the codes to trace the questionnaire. All the variables were double checked for all the respondents to ensure their correct entry, before importing to SPSS for labelling and identification of any strange entries. The SPSS data was then saved as STAT A file, where all the analyses was done. 3.11: Data analysis All the analyses were done using STAT A version 14.Descriptive statistics was done for all the socio-demographic characteristics of Respondents. Bivariate analysis using Pearson's chi-square was used to test for the association between cerebral palsy and all the independent variables. Univariate analysis was performed for all the variables to determine the magnitude and the strength of the association between each individual variable and CP, using logistic regression analysis. The final model was the multivariate analysis of the statistically signi ficant variables from the crude analysis, using multiple logistic regression to obtain the adjusted odds ratios. Selected variables were also analyzed, controlling for some known confounders. 31 University of Ghana http://ugspace.ug.edu.gh 3.12 Ethical considerations 3.12.1: Ethical approving body Ethical approval for the study was obtained from the Ethical Review Committee of Ghana Health Service (GHS), through the school of Public health, University of Ghana. 3.12.2 Study area approval Permission was also sought from the Central Regional Health Directorate of the Ghana Health services, as well as the Territorial Headquarters oft he Salvation Army, Ghana. Prior to data collection, permission was obtained from the Agona East District Director and the Administrators of the Salvation Polyclinic and Rehabilitation centres. 3.12.3: Subjects involved The study involved both the Children with cerebral palsy and selected children without CP as well as the mothers of those children at the Duakwa rehabilitation centre and in the communities in the Agona East District. These subjects were convenient for the study, because of the existence of a Rehabilitation centre in Agona Duakwa which has been managing cases ofCP across the country, since 1990. 3.12.4: Potential risk/benefits There were no potential risks of the study to Participants. , there was no direct benefit to the Participants, but the participation will contribute useful information to public health and policy makers to design and provide appropriate interventions for prevention and management ofCP in Ghana and beyond. 32 University of Ghana http://ugspace.ug.edu.gh 3.12.5: Informed consent The Participants were adequately informed of the purpose of the study, procedures, potential risks, benefits and consequences. It was explained to them that, they were at liberty to withdraw consent for them or their child's participation any time in the course of the study without any penalty. They were made to understand that the information obtained as a result of their participation will be treated as confidential and used only by the investigators and other stakeholders. 3.12.6: Privacy and confidentiality The interviews were strictly confidential and the responses were not shared with anyone who was not part of the study team. Participants were only given codes, no names appeared on any of the information obtained from the Participants. 3.12.7: Data storage/security and usage All the filled questionnaires, after checking for their completeness were stored in a cabinet in the bedroom of the Principal Investigator. After successful entry, they were then kept in the cabinet under lock and key. The Excel spreadsheet, the SPSS data and the STA T A fi les were saved on the Principal investigator's laptop and smart phone, under lock. Copies of each of these files were also sent to the Supervisor as well as shared in the emails of the Principal Investigator and the Supervisor. 3.12.8: Voluntary withdrawal It was adequately explained to the Participants that, their participation was completely 33 University of Ghana http://ugspace.ug.edu.gh voluntary and they may refuse to participate at any point during the discussion. They were also ask to stop the interview if it made them feel uncomfortable and to decline to answer any single question that made them uncomfortable. 3.12.9: Cost/Compensation/payment Participants were neither charged nor paid for their participation in the study. 3.12.10: Conflict of interest There was no conflict of interest on the part of the Principal investigator or any member of the team. 3.12.11: Funding The study was solely funded by the Principal Investigator. Sponsorship was sought from the Agona East District Assembly. 3.12.12: Contact Persons The contact address for the Principal Investigator was as follows: Dr Isaac Adomako, 0245290675/0202016787. For further clarification, Participants could contact Ms. Hannah Frimpong at Ghana Health Service, Ethics Review Committee Administrator. 0207 041 223. 34 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR 4.0: RESULTS 4.1: Introduction This chapter presents all the analyses and the interpretation of the important findings from the study. The chapter seeks to answer the general and all the specific objectives of the study. It is further divided into 4 sub-sections, apart from the introductory section. Section one presents the description of the socio-demographic characteristics of the Participants, using frequencies and percentages, since all the variables were categorical. Section two shows the bivariate analyses of the socio-demographic, maternal and neonatal factors associated with CP, using Pearson's chi-square and reporting p-values. The third section shows the crude odds Ratios in the simple logistic regression analysis. The final section presents the significant factors in the mUltiple logistic regression, detailed case control analysis of some of the signi ficant factors from the multivariate analysis, as well as the pattern of the cerebral palsy cases at the Duakwa Rehabilitation centre. 4.2: Descriptive statistics of the socio-demographic characteristics of the Participants Out of a total of242 mothers interviewed in the study, made up of 60 mothers of children with C P and 182 mothers of children without CP, twenty (20) ofthem, representing 8.25% were teenagers(less than 20 years), with 0.83% of them being less than 15 years old, 35 University of Ghana http://ugspace.ug.edu.gh 46.28% were between the ages of20 and 29 years, 38.43% were between 30 and 39 years, whereas 17(7.03%) were at least 40 years old. 7.88% of the Respondents had no formal education, 56.02% had attained basic education, with 18.67% and 17.43% having secondary and tertiary education respectively. 133. representing 54.36% of all the respondent mothers were married with 19.42% being single mothers. Among them, 2.48% had been Divorced and 23.14% were cohabiting with their male partners. The unemployment rate among the study participants was 21.9%. Christians formed 85.54% of the participating mothers, with 14.05% and 3% being Muslims and Traditionalists respectively. There were no other Religious groups among the study population. 95% Ghanaians were involved in the study with 5% being other Nationals living in Ghana. Among the Ghanaian women, over 81% were Akans, 7.85% were Ewes, 3.72% Gas and 6.61 were from the North, with only one person (0.45%) being an Nzema. In terms of the localities of the Participants, 70.42% of them were permanently residing in Agona and its environs, 16.67% were outside Agona but within Central Region with 12.92% coming from the other Regions of Ghana. 36 University of Ghana http://ugspace.ug.edu.gh Table 2: The Socio-demographic description ofthe study participants. Demographic cbaracteristics Frequency(N= 242) Percentage (%) Motber's Age Less than 15 years 2 0.83 15-19 years 18 7.44 20-29 years 112 46.28 30-39 years 93 38.43 40 years or more 17 7.02 Marital Status Single 47 19.42 Married 113 54.96 Divorced 6 2.49 Co-habiting 56 23.14 Higbest Educational level None 19 7.88 Basic 136 56.02 Secondary 45 18.67 Tertiary 42 17.43 Employment Status Employed 189 78.1 Unemployed 53 Religion 21.9 Christian 207 Muslim 85.54 34 Traditionalist 14.05 1 Other Religion 0.41 0 Etbnicity 0.00 Akan 197 Ewe 81.40 19 Ga 7.85 9 Northern Tribe 3.72 16 Others(Nzema) 6.61 1 Nationality 0.41 Ghanaian 230 Non-Ghanaian 95 12 Locality 5 Within Agona 169 Within Central Region 70.42 40 Outside Central Region 16.67 31 12.92 37 University of Ghana http://ugspace.ug.edu.gh 4.3: Bivariate analysis of the factors associated with CP This section consists of the bivariate analyses ofthe socio-demographic, the maternal and the neonatal mctors associated with cerebral palsy using Pearson's Chi-square generally and Fishers' exact test fur the few instances where the cell population were less than 5.The Chi-square or the Fishers exact as well as the p-values ofall the variables, comparing cases with controls were reported in the table. Chi-squares are reported to two decimal places, while the p-values are reported to three (3) decimal points. From the table, and looking at the p-values, there was a statistically significant association between Cerebral Palsy and the following variables: Mother's highest educational level, Ethnicity, Locality, Employment and Nationality among the socio-demographic mctors. For Maternal metors, significant associations were observed for the age at delivery, parity, antenatal problems, number of ANC attendance and menarche. Sex of the child, birth asphyxia, neonatal jaundice, neonatal convulsions, neonatal admissions and birth order of the child were among the significant neonatal mctors associated with CPo The difference between the sex ratios of CP children compared with the controls was clear from the table. Among cases, there were 73.33% Males (sex ratio of 27S to 100 females) compared to 48.89% males among controls (sex ratio of 96 per 100 females).This difference was statistically significant with a p-value of 0.00 I. 38 University of Ghana http://ugspace.ug.edu.gh T!ble ,}A: Bivariate anal:t;1is of the socio- dm!!!&ral!bic factors. Socio-dm!!!lral!bic £!!e Controls Cbi-square! characteristics N(%) N(%) Fisbers exact P-value Mother's Age Less than I S years 0(0%) 2(1.10%) IS-19yeam 3(S%) IS(8.224%) 20-29 years 22(36.67%) 9O(49.4S%) 6.54 0.162 30-39 years 31(SI.67%) 62(34.07%) At least 40 years 4(6.67%) 13(7.14%) Highest Educationallnel None 1(1.67%) 18(9.94%) Primary 26(43.33%) 109(60.22%) Secondary 23(38.33%) 22(12.IS%) 22.78 <0.001- Tertiary 10(16.67"10) 32(17.68%) Marital status Single 9(1S.OO%) 38(20.88%) Married 28(46.67%) IOS(S7.69%) Divorced 2(3.33%) 4(2.20%) 6.88 0.076 Co-habiting 2 I (3S.00%) 3S(19.23%) Religion Christian S6(93.33%) IS 1(82.97%) Muslim 4(6.67%) 30(16.48%) 3.99 0.136 Traditionalist 0(0%) I(O.SS%) Ethnicity Altan SO(83.33%) 147(80.77%) Ewe 3(S.oo%) 16(8.79%) 12.61 0.013- Ga 6(10.00%) 3(1.6S%) Northerner 1(1.67%) IS(8.24%) Others 0(0%) 1(0.S6%) Locality Within Agona 21(3S.S9%) 148(81.77"10) Outside Agona 17(28.81%) 23(12.71%) SI.S4 <0.001- OutsideCiR 21 (3S.59%) 10(S.S2%) Nationality Ghanaian S3(88.33%) 176(96.70%) Non-Ghanaian 7(11.67%) 6(3.30%) 6.23 0.01 39 University of Ghana http://ugspace.ug.edu.gh Iablll 3B: Bivariate !nalxsis of tbe Maternal factors associated witb CP P-value Maternal Factors Cases (0/.) Controls (-to) Chi-square Parity 20.98 <0.001- Primigravida 29(48.33%) 144(79.12%) Multigravida 31(51.67%) 38(20.88%) Age .t Delivery < 15 years 3(5.17%) 1(0.56%) 25( 13.97".41) 12.98 0.043-15·19 years 2(3.45%) 20·24 years 13(22.41%) 40(22.35%) 25·29 years 19(32.76%) 61(34.08%) 30-39 years 16(27.59".41) 30(16.76%) At least 40 years 4(6.90%) 17(9.50%) ANC Attendance 0.170 No 4(6.67".41) 5(2.78%) 1.89 Yes 56(93.33%) 175(97.22%) No. of ANC once 0(0%) 6(3.41%) 2-4 times 2(3.70%) 26(14.77%) 7.02 0.030- >4 times 52(96.30) 144(81.82%) Place of delivery 1(1.69%) 15(8.43%) 3.19 0.074 Ho melTB A Hospital 58(98.32%) 163(91.57"/0) PRO'\1 No 45(75%) 145(82.86) 1.78 0.182 Yes 15(25%) 30(17.14) Prolonged labour No 41(69.49) 143(79.89) 2.73 0.098 Yes 18(30.51) 36(20.11%) '1ode of delivery Vaginal Delivery 45(75%) 145(82.86%) 1.78 0.182 CIS 15(25%) 30(17.14%) Menstrual cycle Regular 41(69.49".41) 143(79.89".41) 2.73 0.098 Irregular 18(30.51%) 36(20.11%) Menarche Early 17(29.31%) 6(3.35%) 33.89 <0.001- Late 41(70.69% 172(96.65%) 40 University of Ghana http://ugspace.ug.edu.gh Table 3C: Bi-variate analysis of neonatal factors assoeiated withCP Neonatal factors £!!!! Controls Chi-square P-value N(O/.). N (0/0) Sell ofehild Male 44(73.3%) 88(48.9%) 10.86 0.001· Female 16(26.7%) 92(51.1%) Gestational Age at birth Prctenn 12(20.00.4) 20(11.4%) 2.96 0.085 Tenn 48(80.0%) 158(88.6%) Birth upbyxia No 31(51.7%) 165(92.8%) 49.99 <0.001- Yes 29(48.3%) 14(7.2%) Neonatal illness No 23(40.5%) 150(83.8%) 41.71 <0.001- Yes 34(59.5%) 29(16.2%) Jaundiee No 49(81.7%) 178(97.8%) 20.21 <0.001· Yes 1\(18.3%) 4(2.2%) Convulsion No 44(73.3%) 179(98.3%) Yes 16(26.7%) 3(1.7%) 39.06 <0.001· Birth order First 26(44.0%) 61(35.2%) Second 24(40.6%) 42(24.3%) Third 15.24 0.004-5(8.4%) 28(16.2%) Fourth 4(6.8%) 21(12.1%) >4th 0(0%) 21(12.1%) Trauma No 58(96.67%) 160(96.4%) Yes 2(3.33%) 6(3.6%) 0.01 0.920 ·significant p-vaIues 41 University of Ghana http://ugspace.ug.edu.gh 4.4: Simple logistic regression analysis The simple logistic regression analysis shown a statistically significant associations between the following factors and CP: For socio-demographic factors; Highest Educational level of the mother was associated with CP, using no formal education as the reference. From the crude odds ratio, the odds ofa mother with primary education giving birth to a child with CP was 4.29 times as great as the one with no formal education, 18.8 times for secondary education compared to no formal education and 5.62 for Tertiary education compared to none. The overall model was statistically significant with a p-value of 0.0002.Other significant demographic associations were the current employment status of the mother, Ethnicity, Locality and Nationality. The odds of an unemployed mother having a child with CP was 3.56 times that of the employed. Using Akan as the reference, the odds of an Ewe and a Northerner in Ghana having a child with CP was reduced by 45% and 77% respectively compared to being an Akan mother. However, Ga mothers had a higher odds ofhaving a child with CP than other tribes. For Maternal factors, parity, any problems in the Antenatal period and menarche shown significant association for having a child with CP in the crude analysis, with crude odds Ratios of 4.05 for those who had antenatal problems as against those who did not develop any problems. MUltiparous women had a 25% protection against giving birth to a baby with CP, compared to primiparous women. For Neonatal factors, significant associations 42 University of Ghana http://ugspace.ug.edu.gh were observed for gender of the child, neonatal admissions, neonatal jaundice, birth asphyxia, and neonatal seizures. The crude odds ofa Male child having cerebral palsy was about 3 times that ofa female child. The other highly reported maternal and neonatal filctors that did not show significant association with CP in this study included: irregular menstruation, Antenatal problems such as PIH, gestational Diabetes, Ante-partum haemorrhage, trauma in the neonatal period as well as the birth order ofthe child. Among the demographic factors, highest educational level of the mother, marital status and Religion also did not have any significant associations with CP in the simple logistic analysis. The three tables below show the crude odds ratios and the 95% Confidence intervals in the univariate analysis of the association between CP and the various socio-demographic, maternal and neonatal factors. 43 University of Ghana http://ugspace.ug.edu.gh Table 4: Simple logistic regression analyses of tbe socio-demograpbic, Maternal and Neonatal factors associated witb CP, reporting crude odds ratios Table4A. Sodo-demograpbic characteristics Crude Odds Ratio 95% Confidence Int. P-value* (Min Max) Mother's Age Less than 15 years 15-19 years 0.82 (0.22 3.08) 20-29 years Reference. 0.126 30-39 years 2.05 (1.08 3.86) At least 40 years 1.26 (0.37 4.24) "i&hest Educational level None Reference Primary 4.29 (0.55 33.64) 0.0002- Secondary 18.81 (2.31 153.1) tertiary 5.62 (0.66 47.58) Marital status Single 0.89 (0.38 2.05) Married Reference. 0.083 Divorced 1.88 (0.33 10.77) Co-habiting 2.25 (1.14 4.45) lnemployment 3.56*· (2.63 4.84) Religion Christian Reference. Muslim 0.36 (0.12 1.07) 0.065 Traditionalist 1.00 Ethnicity Akan Reference Ewe 0.55 (0.15 \.97) Ga 5.88 (1.42 24.39) 0.012- Northerner 0.20 (0.03 1.52) Locality Within Agona Ref. Outside Agona 5.21 (2.40 11.32) <0.001- Outside Central 14.80 (6.13 35.71) Nationality 3.87** (1.25 12.03) 44 University of Ghana http://ugspace.ug.edu.gh Tbe Maternal Facton Crude Odd! 9SO/o CgDfidllmie ratio l!!.W!!.! P-value Parity Primigravida Reference Multigravida 0.75** 0.59 0.96 ANCProble1lL'l 4.05·· 2.1S 7.53 Age at DeUvery < IS years 9.63 0.95 98.11 15-19 years 0.27 0.06 t.t9 20-24 years 1.04 0.46 2.35 25-29 years Ref. 0.1 tl 30-39 years 0.75 0.22 2.52 At least 40 years 0.64 0.Q7 5.82 ANC Attendance 5.14** 1.26 20.97 Place of delivery Home!fBA 5.15 0.69 4t.31 hospital Ref. PROM t.61 0.80 3.26 Proloaged labour 1.74 0.90 3.39 PIH 1.22 0.23 6.46 DM 1.55 0.54 4.78 Mode of delivery Vaginal Delivery Ref. CIS 0.75 0.29 1.94 Menstrual cycle Regular Ref Irregular 4.43 0.89 6.43 Menan:be Early Ref Late 0.084·· 0.03 0.22 45 University of Ghana http://ugspace.ug.edu.gh Table4C: The Neonatal racton Crude odds ratios 95%CI P-value· Sex or child Male Ref Female 0.35" 0.18 0.66 Gestational Age at birth Pretenn 1.51 0.23 2.11 Tenn Ref Birth asphyxia 11.03" 5.14 13.11 Jaundice 9.99·· 3.05 32.75 Convulsion 21.70" 6.05 77.76 Neonatal admissions 11.19·· 5.56 22.53 Birth order First 0.75 0.38 1.47 Second Ref. Third 0.31 0.11 0.92 0.064 Fourth 0.33 0.17 0.49 >4th 1.00 Trauma 0.92 0.19 4.19 Table 4C: The univariate analysis oftbe neonatal factors associated with CP Odds ratios are reported with their 95% confidence intervals to show whether it is statistically significant or not. P-wlues* are provided for the overall model for variables with >2 categories. ·significant P-value of the odds ratio in the overall model for categorical variables with more than 2 categories ··significant odds ratios for variables with only 2 categories. 46 University of Ghana http://ugspace.ug.edu.gh 4.5: Multivariate analysis In the final model, the 13 variables that were statistically- significant in the crude odds ratios were used to run the multiple logistic regression and nine (9) variables were significant. These were: the Ethnicity, Locality, Menarche, parity, problems during the Antenatal period, antenatal attendance, Neonatal jaundice, neonatal seizures and birth asphyxia. The highest adjusted odds ratio was observed for neonatal seizures. The odds ofa baby with neonatal seizures developing CP was 29 times higher than that of Babies who did not convulse in the neonatal period, after controlling for all the other significant variables in the study. After controlling for all the other independent variables, the odds ofa baby developing cerebral palsy was 16 times higher ifthat baby had neonatal jaundice. Babies with asphyxia had 21 times the odds of developing CP later in life compared to non-asphyxiated babies, after controlling for all other independent variables in the study. For the antenatal period, attending antenatal clinic was found to offer protection against having a child with CP, after controlling for all other factors. The sex of the child, though significantly associated with CP in the univariate analysis, was not independently associated with CPo The adjusted odds ratio for sex of the child was 0.62 for females, compared to males, which was not statistically significant with a 95% CI of(0.15-2.5). For Ethnicity and Locality of the Mother, which were both categorized with more than 2 levels (Nominal), the p-values for the overall model in the final analysis were statistically 47 University of Ghana http://ugspace.ug.edu.gh significant For the mother's ethnicity, using Akan as the reference, the adjusted odds of any of the other tribes having a child with CP was lower. This was significantly lower among mothers from the Northern tribe. Table 5: Multivariate analysis of the significant socio-demographic. Maternal and Neonatal factors associated with CPo Variable Adjusted odds Ratio 95%CI P-value DEMOGRAPHICS Higbest Educational level None Reference Primary 0.72 0.15 3.45 0.121 Secondary 3.87 0.49 30.23 Tertiary I Employment 4.68 0.93 22.75 Ethnicity Akan Reference Ewe 0.13 0.04 1.16 0.036 Ga 0.23 0.03 4.81 Northerner 0.03 0.02 0.57 Locality Within Agona Reference Within Central Region 9.62 1.77 52.98 0.001 Outside Central region 8.45 0.\0 65.41 Nationality 1.10 0.02 57.23 MATERNAL Parity 0.47 0.23 0.93 Menarche 0.01 0.002 0.84 ANC Problems 3.26 0.76 14.20 ANC attendance 0.60 0.06 0.96 'EONATAL Sex or the Child 0.62 0.15 2.50 "ieonatal Adm. 7.32 1.60 33.41 "ieonatal Jaundice 16.30 1.66 70.88 'eonatal Seizures 29.00 1.55 55.67 Birth asphyua 20.56 3.50 120.33 Highlighted numbers- statistically significant odds ratios, 95% Cis or P-vaIues 48 University of Ghana http://ugspace.ug.edu.gh 4.6: Detailed Case control analysis of some selected significant maternal and neonatal factors This section presents a detailed case control analysis to demonstrate confounding and effect modification of few selected variables. It also presents the pattern of CP in the study population. From the detailed case control analysis of one of the most significant mctors from the study, Neonatal Jaundice, the results from the Stata output shows that, the odds ofa neonate with Jaundice developing Cerebral palsy later in life is 10 times as great as the one who did not have Jaundice and this met is statistically significant with a p-value of <0.00 I.From the table, it is clear that, 18% of all Cerebral palsy kids involved in the study had neonatal jaundice, as against 2.2% of controls. The attributable fraction of exposure was approximately 0.9, which means that, among the kids who developed Neonatal Jaundice, as high as 90% of Cerebral Palsy would have been prevented if they did not develop Jaundice in the neonatal period. An attributable fraction of population of 0.16 in the table means that, in the reference population, 16% of all cases of Cerebral palsy will not occur if neonatal jaundice is prevented. On the other hand, if neonatal jaundice is to be prevented in Ghana, as high as 16% of all CP cases will also be prevented. The analysis also tested the influence of sex of the child on the effect of Jaundice on CPo The test of homogeneity was not significant, implying the absence of an effect modification or interaction between sex and Jaundice in the model. The test of combined odds ratio was however very significant, meaning sex of the child is a confounder in this model. hence the Mantel-Haenszel combined odds ratio of 12.9 is the most appropriate odds ratio to report for this model as opposed to the crude odds ratio and the final interpretation from the model 49 University of Ghana http://ugspace.ug.edu.gh will be that, after controlling for the sex of the child, the odds of a child with neonatal jaundice developing CP is about 13 times as great as that of non -jaundiced kids. From this detailed analysis, it is clear that neonatal jaundice was independently associated with a higher risk ofCP than that seen in the crude analysis. 4.7: Pattern ofCP cases In relation to the pattern of CP cases seen at the Rehabilitation centre, records indicated that, 40.48% were the spastic type, with 30.33% hypotonic, 19.1 % choreo-athetoid and 7.1 % mixed type. In terms of the severity of symptoms, over 50% oft hem were moderately severe, with 28.9% having mild and a little over 20% of them experiencing severe symptoms. Among the CP cases, about 84% of them were currently receiving physiotherapy alone, with about 6% of them receiving the other forms oft reatment such as assisted devices, speech therapy and drugs. None of the study Participants indicated combinational therapy. 50 University of Ghana http://ugspace.ug.edu.gh Fig4:A Pie chart showing the types of CP at Duakwa Rehab. Centre Fig 5: A Pie chart showing severity of Fig.6: Pie chart indicating the types of sym ptoms of CP treatment received by Children with CP at Duakwa 51 University of Ghana http://ugspace.ug.edu.gh CHAPTERS 5.0: DISCUSSIONS 5.1: Introduction The importance of studying cerebral palsy in Ghana comes from the fact that, this disorder impose a huge burden on the immediate and the extended family psychologically, emotionally, financially and socially as there are a lot of myths, misconceptions and superstitions about the condition. Being a chronic non-progressive disorder, it constitutes a major burden on the national health system, however currently in Ghana, not much is being done in preventing and managing this condition. Some few private organizations have been involved in CP management for years and these include the Salvation Army and New Horizon. 5.2: Socio-demographic description of tbe Participants The socio-demographic characteristics of cases and controls were compared to determine its significance to CPo Generally, the demographics of the Participants is highly representative of a typical Ghanaian community. Putting it altogether, Teenage mothers formed 8.25% of the study Population, with 0.83% of them being less than 15 years. Among the control mothers, 9.43% of them were teenagers compared with 5% among mothers of children with CPo Using the age at delivery, the teenage pregnancy rate among all the mothers was 13.08% with 8.55% in mothers ofCP, compared with 14.66% among the controls. This is not different from the teenage pregnancy rate of 14% from the 2014 National Demographic and Health survey(GDHS, 2014). Unemployment rate is still ver 52 University of Ghana http://ugspace.ug.edu.gh high in Ghana, especially among women, and this was confirmed in the study with an unemployment rate of 21.9%, similar to that from the 2010 National Population and Housing Census, which reported an unemployment rate of 26% among women in the Reproductive age. Majority of the Mothers had attained at least Primary Education with about 8% of them having no formal education. However the drop-out rate after primary education was over 60%. To further illustrate the highly representativeness of the cases, out of the 60 cases involved in the study, 35.59% were outside Central region, despite the met that, the study was conducted in a Rehabilitation centre in a rural area in the Central region. There were cases across all the other 9 regions. 5.3: Socio-demographic factors associated with CP Among the socio-economic mctors studied, Ethnicity and locality were significantly associated with having a child with CP in the final analysis. Apart from the Ethnicity which is time-fixed, Locality might have changed since the period of pregnancy through to the time of the study. Akans were generally at a higher risks compared to all the other tribes involved in the study, with a significant protection among the Northern tribes. This finding was due to the fact that, Akans constituted a larger group in the study consisting of so many tribes put together. In the study, Akans were the Ashantis, Fantis, the Akuapims, and the Brongs. A different pattern might have been observed ifall these tribes were separated. S3 University of Ghana http://ugspace.ug.edu.gh The other factor that was significant in the crude analysis was the employment. This fmding was important for management because. most of the CP mothers were unemployed. Since the adjusted analysis did not show any significant association between the employment status and a child with CP, it can be hypothesized that, the difference observed in the bivariate analysis might have been influenced by some other factors, such as the age at delivery, employment type etc. or the fact that having a child with CP might have led to the higher unemployment rate compared to the controls. This finding is generally consistent with most other studies that have established a strong association between low socio-economic development and CP (Sundrum, Logan, Wallace, and Spencer, 2005), but in contradiction to a very similar study in Iran, where employment was highly associated with CP(Saadi et aI., 2012), however, in that study, it was not clear whether current employment status of the mother or unemployment before having a child with CPo It was however concluded that. stress from the work place might be the possible effect on bad pregnancy outcome(Saadi et al.. 2012). 5.4: Maternal factors associated with CP Several Maternal factors have been reported to be associated with CPo Most of these factors were involved in the study, and the significant ones in the univariate analysis were: Parity, ante-natal problems. Antenatal attendance and menarche. The different antenatal problems such as Pregnancy-induced Hypertension, Gestational Diabetes, Febrile illnesses etc. did not show any significant associations after controlling for other variables. Menstrual cycle and menarche have been extensively studied in association with CPo According to Badoe 54 University of Ghana http://ugspace.ug.edu.gh et al. (2015) irregular menses was associated with CP with an odds ratio of 4.5(p-value 0.021).Delayed, compare with early menarche is associated with CP(Reddihough & Collins, 2003, Torfs et al 1990).After controlling for all the other variables, Better Antenatal attendance, parity and menarche were independently associated with CP. The effect of good antenatal attendance in preventing CP cannot be overemphasized. Antenatal attendance of 4 or more was associated with over 40% protection against having a child with CPo From this huge impact ofa ntenatal attendance on CP and similar likely effects on other disabilities, there is the need to intensify health education and advocacy for a 100% antenatal attendance in Ghana. During the antenatal visits, health workers screen the pregnant women to identify any high risks pregnancies for prompt management and prevention of pregnancy and delivery complications. Almost all the studies on CP came out with this finding. However, of particular significance is the level of protection obtained in this study. Multiparity was found to be protective against having a child with CP, compared to Primigravidity. Mothers who had delivered before had an adjusted odds of 0.47(95% CI: 0.23-0.97), compared to mothers delivering for the first time. Primigravidity, especially in the elderly (more than 3S years) has been widely studied to be associated with many maternal and neonatal problems. Early Menarche compared to late menarche was associated with higher odds of having a child with CPo 55 University of Ghana http://ugspace.ug.edu.gh 5.5: Neonatal factors associated with CP One variable that was significantly showing lower odds developing cerebral palsy in the crude analysis was the female gender of the child. In other words, male children were at higher risk of developing cerebral palsy. The odds of a female child developing cerebral palsy was 0.35 times that of Males, that is females were 65% protected from CP compared with Male Children. This variable however was not significant after adjusting for all the other variables in the study. The sex of the child is therefore not independently associated with CPo Not many studies have shown this association of the gender of children with cerebral palsy, this association was however mentioned clearly in one Swedish study where, male gender was repeatedly found to constitute a risk factor for cerebral palsy (Saadi et al.; 2012 Hagberg, Hagberg, Beckung, 2001). Saadi et al reported an adjusted odds ratio of0 , 15(95% CI: 0.04-0.51) for female gender compared with male gender (Saadi et al., 2012). Neonatal jaundice, birth asphyxia and neonatal convulsions were the three most significant early neonatal factors associated with CPo In this study, birth asphyxia was found to be independently associated with 21 times higher risk of developing cerebral palsy. Birth asphyxia had been known for a long time as a risk factor for developing Cerebral palsy. Saadi et al. reported an adjusted odds ratio of 10. Badoe et aI, in a similar study in Ghana, also reported an adjusted odds ratio of6.69 for birth asphyxia. S6 University of Ghana http://ugspace.ug.edu.gh Neonatal J.aun.dIc e, especI. ally pathologl.c aI J'a un dI' ce 'thin the first 24 hours of life is a W1 highly documented major cause of cerebral palsy. Almost every study has reported on the significant association between CP and neonatal jaundice. This study did not find anything different from the other studies as the study find the odds ratio for jaundice to be 16(95% CI 1.9848). Neonatal jaundice is a condition that can easily be recognized by any health worker and even the nursing mothers. Prompt diagnosis and treatment using phototherapy and exchange transfusion in severe cases can help reduce kernicterus and associated cerebral palsy. The other neonatal factor independently associated with CP is neonatal seizures. Neonatal seizures was highly associated with CP, with an adjusted odds ratio of29. That is, the children who had seizures in the first month of life had a 29 times likelihood of developing cerebral palsy compared to children who did not have seizures. Badoe et al also reported a similar finding. Though this finding has been reported in most to all the studies on CPo the major challenge has been differentiating the seizure as being due to the cerebral palsy as opposed to being a predicting factor of cerebral palsy. Symptoms of CP, which include all forms of seizures can start as early as the neonatal period when CP had not been diagnosed in the child yet. This partly accounts for the highest odds ratio obtained for neonatal seizures obtained in this and many other studies. Another important neonatal factor that came up in this study is neonatal admissions. Neonates admitted were II times likely to have CP than those who were not admitted. Similar findings were also recorded for maternal admissions for the various illnesses during 57 University of Ghana http://ugspace.ug.edu.gh the antenatal period. This fi,Jdings call for the need to intensify awareness towards CP among all categories of health workers, especially at the primary and secondary levels. It appears the problems are identified by the mothers during the antenatal or the neonatal periods, they report to the health mcilities, something is done at the health mcilities, but the children still develop the complications later in life. The cause may be due to a delay in recognition and access to the health mcility from the clients (Mothers and other caregivers), wrong diagnosis and therefore wrong treatment as well as milure or delay in referring for expert management of the cases. Trauma during the neonatal period was one mctor that was tested in this study, but did not show any significant association with CPo Trauma has been reported in some few studies as being associated with CP (Saadi et.al,2015;Badoe et.al,2015). This together with several other recent studies failed to establish this fact. 5.6: The Types, Severity and Treatment options of CP The pattern ofCP from the records review did not show much difference from most of the studies done outside Ghana, which mostly report high proportions of the spastic type among all cases. However, Badoe et al. found a different pattern ofCP among cases seen at the Korle-Bu Teaching Hospital, which recorded a very high proportion of the dyskinetic type, very different from many studies outside Ghana. 58 University of Ghana http://ugspace.ug.edu.gh 5.7: Strengths and Limitations of the study· 5.7.1: The major strengths of this study include • The highly representativeness of the cases and controls in terms ofCP cases in Ghana as well as the Population of children under five respectively. • Cases and controls were selected from the same population source and had simi lar characteristics. Findings were very consistent with similar studies done in Ghana and the world at large. • Use of record review to veritY some of the information given by the mothers, as a means to reduce recall bias between cases and controls. 5.7.2: Some oftbe Limitations oftbis study include Time constraints. The study was for a short period of2 months. • The unavailability and inadequate records in most cases, made it difficult to validate all the information given by the Respondents. Respondents of cases were better at remembering and given the information compared to controls {Recall bias).This was however eliminated or reduced by reducing the age of the children to under 5, the same age limit for child welfare clinic (CWC). S9 University of Ghana http://ugspace.ug.edu.gh CHAPTER 6 CONCLUSIONS AND RECOMMENDATIONS 6.1: Conclusions Most of the fmdings in the study were consistent with what has been reported in the literature. A very few of the results however was the opposite of what has been commonly reported in other studies. The results shown that, cases were highly representative of CP cases seen in Ghana. The socio-demographic description of the controls clearly indicated that, controls represented a true sample ofthe Ghanaian population. In the final analysis, the significant factors associated with CP were: 4 neonatal factors: Neonatal seizures, Birth asphyxia, Neonatal jaundice, neonatal admissions; 3 Maternal factors-early menarche, primiparity and antenatal attendance and 2 socio-demographic factors-Ethnicity and the Mother's locality. All the 4 significant neonatal factors were high risk factors for CP and these were expected. For the maternal factors, the findings for menarche and parity were the opposite of what had been reported in most of the studies reviewed. The other significant factors-ANC attendance, neonatal admissions, Ethnicity and the Localities were new in this study. These were included to test some hypotheses mentioned in the literature as possible associations but had not been tested. In terms of the pattern of 60 University of Ghana http://ugspace.ug.edu.gh CP cases seen at the centre, majority of them were of the spastic type, representing over 40% of all the cases. 6.2: Recommendations 6.2.1: Implications for Clinical practice • There is a need to create more awareness of cerebral palsy in Ghana, especially among health workers by the Ghana Health service and other agencies of the Ministry of Health. Prevention and early recognition of CP requires a good knowledge by mothers, primary health care providers, among others. • The need to enforce accurate diagnoses of problems during the maternal and neonatal period and early referral for expert management, by Clinicians at the health facilities. 6.2.2: Implications for policy • The Ministry of health through its agencies such as CHAG and the Ghana Health Services must organize frequent in-service training to all health workers, especially midwives and Medical officers on the recognition and proper management of birth asphyxia, neonatal seizures, and neonatal convulsions. • The Government of Ghana through the Ministry of health must establish Rehabilitation centres in most districts to include Rehabilitation services in the NHIS. 61 University of Ghana http://ugspace.ug.edu.gh 6.2.2: ImplicatioDs for research: The need for a prevalence study to determine the disease burden in Ghana. More factors associated with CP needs to be investigated. Factors that have not been explored before, such as drugs, contraceptives, use of herbal medications during pregnancy, smoking, alcohol, exercise, fetal presentation, among other factors. More studies needed on the quality of life of children with CP, Quality ofHfe of their Mothers, effect on marriage and mother's reproductive life. • The highly significant association between neonatal convulsion and CP need further studies to distinguish seizures due to CP and seizures causing CPo • The high unemployment rate associated with CP Mothers need further investigation, to determine the difference in the employment rate before and after having a child with CPo THANK YOU. 62 University of Ghana http://ugspace.ug.edu.gh References Africa, C. P. 10 th Anniversary of Cerebral Palsy Africa (CPA). Amiel-Tison C and Pettigrew C (1991): Adaptive changes in the developing brain during intrauterine stress. Brain and Development 13: 67-76. Andersen GL, Irgens LM, Skranes J, Salvesen KA, Meberg A, Vik T. Is breech presentation a risk factor for cerebral palsy? A Norwegian birth cohort study. Developmental medicine and child neurology. 2009; 51 (II ):860-5. Epub 2009/05/28. PMID: 19469792. Asmara., R. H. (2005). Pattern of neurological diseases as seen in outpatient children: the experiences from Orotta., (September 2002), 11-15. Badoe. E .• Sciences, A., & Turan, F. (2015). Classification and Risk Factors for Cerebral Palsy in the Korle Bu Teaching Hospital, Accra: A Case - Control Study Eunice Adei-Atiemo, Onike Rodrigues and Ebenezer Badoe, 135(February), 2015-2017. https://doLorglI0.1542/peds.2014 Bax M, Goldstein M, Rosenbaum P, Leviton A, Paneth N, Dan B, Jacobsson B, Damiano D; Executive Committee for the Definition of Cerebral Palsy. Proposed definition and Baxter. P., Morris, C., Rosenbaum. P., Paneth, N., Leviton, A., Goldstein, M., ... Shea, T. M. O. (n.d.). The Definition and Classification of Cerebral Palsy Contents Foreword Historical Perspective Definition and Classification Document, 1-44. Burton, A. (2015). Cerebral palsy aff ects children across Africa. Prevention is diffi cult since we know little about its. The Lancet Neurology, 14(9), 876-877. https://doi.org/10.1016/S 1474-4422(15)00189-1 Chen, Y.-N., Liao, S.-F .• Su, L.-F., Huang, H.-Y., Lin, C.-C., & Wei, T.-S. (2013). The etTect oflong-term conventional physical therapy and independent predictive factors analysis in children with cerebral palsy. Developmental Neurorehabilitation, 16(5), 357-362. https://doi.orgl10.3109/17518423.2012.762556 Chen K. Baram TZ, Soltesz I. Febrile seizures in the devel- oping brain result in persistent modification of neuronal excitability in limbic circuits. Nat Med 1999;5:888-94. 63 University of Ghana http://ugspace.ug.edu.gh th Data and Statistics-Cerebal Palsy-COC(20 14) ,assessed 25 May ,2017. Data and Statistics -Cerebral Palsy-COC(20I 5),assessesd ISm September,2016 Donald, K. A., Samia, P., Kakooza-mwesige, A., Bearden, D., Donald, K. A., Neuro, M. P., ... Neuro, M. P. (2014). Pediatric cerebral palsy in Africa: A systematic review Pediatric Cerebral Palsy in Africa: A Systematic Review, 21(January), 30-35. Ghana Statistical Service (GSS). 2013a. Population Projections. Accra, Ghana: GSS. Ghana Statistical Service (GSS). 2013b. 2010 Population and Housing Census: National Analytical Report. Accra, Ghana: GSS. GhanaGhana Statistical Service (GSS), Ghana Health Service (GHS). and ICF Macro. 2009. Ghana Demographic and Health Survey 2008. Accra, Ghana: GSS, GHS, and ICF Macro. Ghana Statistical Services(GSS),Ghana Health Service(GHS),and ICF Macro.201 5 Ghana Demographic and Health Survey.Accra,Ghana:GSS,GHS,and ICF Macro Ghana Population and Housing Census(201 0) Hagberg, B., Hagberg, G., Beckung, E., et al. (2001) Changing panorama of cerebral palsy in Sweden. VIlI. Prevalence and origin in the birth year period 1991-94. Acta Paediatrica. 90. 27/-277. do;: 10 .10801080352501300067532 Hasegawa, J., Toyokawa, S., lkenoue, T., Asano, Y., & Satoh, S. (2016). Relevant Obstetric Factors for Cerebral Palsy: From the Nationwide Obstetric Compensation System in Japan, 1-13. hnps:lldoi.org/\ 0.1 371ljournal.pone.0 148122 Hasegawa J, Sekizawa A, Ikeda T, Koresawa M, Ishiwata I, Kawabata M, et al. Clinical risk factors for poor neonatal outcomes in umbilical cord prolapse. J Matern Fetal Neonatal Med 2015: 1-24. Epub 2015107103. doi: 10.3109/14767058.2015.1058772 PMID: 26135792. Hasegawa J, Sekizawa A, Ikeda T, Koresawa M, Ishiwata I, Kawabata M, et al. Clinical risk factors for poor neonatal outcomes in umbilical cord prolapse. J Matern Fetal Neonatal Med. in press. Hasegawa J, Sekizawa A, Ishiwata I, Ikeda T, Kinoshita K. Uterine rupture after the uterine fundal pres- sure maneuver. Journal of perinatal medicine. Ahead of print. Hernandez-reif, M., Field, T., Largie, S., Manigat, N., & Seoanes, J. (2005). Cerebral 64 University of Ghana http://ugspace.ug.edu.gh palsy symptoms in children decreased following massage therapy, 175(5),445-456. https:lldoi.orgll0.1 080/0300443042000230546 Holbrook BD, Phelan ST. Umbilical cord prolapse. Obstetrics and gynecology clinics of North America. 2013; 40(1):1-14. Epub 2013/03/08. doi: 10.1016/j.ogc.2012.11.002 PMlD: 23466132. Jacobsson B, Hagberg G. Antenatal risk mctors for cerebral palsy. Best practice & research. 2004; 18 (3):425-36. Epub 2004/06/09. doi: 10.1 0 16/j.bpobgyn.2004.02.0 11 PMlD: 15183137. Jang, W., Development, E. C., Hernandez-reif, M., Field, T., Largie, S., Manigat, N., .,. Rassatiani, M. (2013). The effect oflong-term conventional physical therapy and independent predictive mctors analysis in children with cerebral palsy. Journal of Chemical Information and Modeling, 16(5),357-362. https:lldoi.orgllO.3109/17518423.2012.762556 Leviton, A. (1993) Preterm birth and cerebral palsy, is tumor necrosis mctor the missing link? Developmental Medicine & Child Neurology, 35,1101-1106. Mohammed, M. (2009). THE FREQUENCY OF EPILEPSY AMONG CEREBRAL PALSY CHILDREN: A PROSPECTIVE STUDY FOR, 7, 1-21. Nelson KB, Blair E. Prenatal Factors in Singletons with Cerebral Palsy Born at or near Term. The New Englandjournalofmedicine. 2015; 373(10):946-53. Epub 2015/09/04. doi: 10.10561NEJMra1505261 PMlD: 26332549 .. Nelson KB, Ellenberg JH. Predictors of epilepsy in children who have experienced febrile seizures. N Engl J Med 1976; 295:1029-33. Petterson, B., Nelson, K.B., Watson, L., et al. (1993) Twins, triplets, and cerebral palsy in births in Western Copyright © 2012 SciRes. OPEN ACCESS H. R. Saadi et al. 1 Open Journal of Preventive Medicine 2 (2012) 350-358 Australia in the 1980s. British Medical Journal, 307, 1239-1243. doi:l0.1136Ibmj.307.6914.123 PSYchological impact of cerebral palsy on families The African perspective. (2014). Reddihough, D. S., & Collins, K. J. (2003). The epidemiology and causes of cerebral palsy, 7-12. Report C., Jr, H. L., Joshi, A., Lorenz. Z., Miller, F., Dabney, K., '" Pa, P. (2013). Pediatrics & Therapeutics Pediatric Cerebral Palsy Life Expectancy: Has Survival 6S University of Ghana http://ugspace.ug.edu.gh Improved Over Time?, 3(1), 6-11. https:lldoi.org/10.41721216I-066S.I00014 Saadi, H. R .. Sutan, R., Dhaher. A. M., & Alshaham, S. A. (2012). Maternal and foetal risk factors of cerebral palsy among Iraqi children: A case control study, 2(3). 3So- 358. Statement, P. (2006). Identifying Infants and Young Children With Developmental Disorders in the Medical Home: An Algorithm for Developmental, 118( I). https:lldoi.org/10.1542/peds.2006-1231 Sundrum, R., Logan, S .• Wallace, A. and Spencer, N. (2005) Cerebral palsy and socioeconomic status, a retro- spective cohort study. Archives of Diseases in Childhood, 90,15-18. Terra, V. C., Cysneiros, R. M., Schwartzman. J. S., Teixeira, M. C. T. V, Arida, R. M .• Cavalheiro, E. A., '" Albuquerque, M. D. E. (20 II). Mothers of children with cerebral palsy with or without epilepsy: a quality oflife perspective, 33(S), 384- 388. https:lldoi.orglI0.3109/09638281003611052 Torfs CP, van den Berg BJ, Oechsil FW and Cummins S (1990): Prenatal and perinatal factors in the etiology of cerebral palsy. Journal of Pediatrics 116: 61 S -619. Vestergaard, M., Pedersen, C. B., Sidenius, P., & Olsen, J. (2007). Original Contribution The Long-Term Risk of Epilepsy after Febrile Seizures in Susceptible Subgroups, 165(8),911-918. https:lldoi.orglI0.1093/ajelkwk086 Vestergaard M, abel C, Henriksen TB, et al. The Danish National Hospital Register is a valuable study base for epidemiological research in febrile seizures. J Clin Epidemiol2005; 59:61~. 66 University of Ghana http://ugspace.ug.edu.gh APPENDICES APPENDIX 1: THE PARTICIPANTS CONSENT FORM INFORMATION AND CONSENT FORM PARENTS OF THE PARTICIPATING CHILRDREN Dear Parent, My name is Dr. Isaac Adomako, and I am a student of the school of public health, University of Ghana. We are conducting a study on the maternal and neonatal factors associated with cerebral palsy. We recognize that some of the information collected and discussed during this interview may be of personal nature, but, the benefit of your participation is that you will contribute useful information to prevention of cerebral palsy and policy makers to design and provide appropriate services with regards to prevention and management ofc erebral palsy in Ghana and beyond. Your opinions and experiences are important to us. We want you to be honest and truthful in answering our questions. Your participation is completely voluntary and you may refuse to participate at any point during the discussion. You may ask me to stop the interview if it makes you feel uncomfortable, or you may also decline to answer any single question if it makes you uncomfortable. The interviews are strictly confidential so your responses will not be shared with anyone who is not part ofthe study team and there are no risks involved to the participants during this study. Your name will not appear on any of our notes or any of the reports. You will not be charged nor will you be paid for your participation in the 67 University of Ghana http://ugspace.ug.edu.gh study. The data will be collected by means ofindividual interviews which will last between 20 to 30 minutes. Do you have any questions about the study? The contact address for the Principal Investigator is as follows: Dr. Isaac Adomako, contact number: 0245290675. For further clarification, you can contact Ms. Hannah Frimpong at Ghana Health Service, Ethics Review Committee Administrator. 0207 041 223 Consent Form I have been adequately informed of the purpose of this study, procedures, potential risks, benefits and consequences. I understand that I am at liberty to withdraw consent for myI my child's participation any time in the course of the study without any penalty. I understand that the information obtained as a result of my participation will be treated as confidential and used only by the investigators and the Ghana Health Service. The investigators have answered all my concerns. Name: SignaturelThumb-print: ___________ Date DDtOD/DD 68 University of Ghana http://ugspace.ug.edu.gh APPENDIX 2: QUESTIONAIRES FOR THE INTERVIEWS CODE: DATE: Questionnaire on tbe study of tbe maternal and neonatal factors associated witb cerebral palsy. Principal Investigator: Dr Isaac Adomako Supervisor: Dr Anthony Danso- Appiah PART A: SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE MOTHER I .How old are you (Age at your last birthday) a) Less than 15 years b)15- 20 years c) 20-29 years d) 30-39 years elmore than 40 years 2. Marital Status a) Single b) married c) divorced d) co-habiting 3. Highest Educational level a) None b) Primary school c) Secondary school d) Tertiary 69 University of Ghana http://ugspace.ug.edu.gh 4 .What is your Occupation? a) Professional (e.g. Doctor, Teacher, specity .............) b) Artisan (e.g. seamstress, fashion designer etc., specity ..•.................) c) unemployed 5.Religion? a) Christian b) Muslim c) Traditionalist d) others.. specity ........... . 6 Ethnicity a) Akan b) Ewe c) Ga d) Northerner e) others, specity ........... . 7. Place of residence (locality)? a) Agona (around Duakwa and Swedru) b) Within central region c)outside central region, specity ..... . 8. Nationality a) Ghanaian b) Non-Ghanaian, but African c) Others, specity ........ . PART B: Maternal Factors associated witb cerebral palsy 9. What is your parity (how many children have you had); a) I b) 2 c) 3 d) 4 e) >4 10. Did you develop any problems during the ANC period ...................a ) Yes b)No II .If yes to 10, what were the problems (please tick as many as applicable) 70 University of Ghana http://ugspace.ug.edu.gh a) Febrile illnesses b) Pregnancy-induced hypertension c) Diabetes d) bleeding episodes e) skin rashes f) others, specify ............................................ . 12 .At what age did you deliver this child? a) less than 15 years b)15-19 years c)20-24 years d)25-29 years e) 30- 34 years f) 35-39 years g )40years or more 13. Did you attend antenatal clinic at all? Yes [ ] No [ 14. If yes to I I. How many times? a) Once b)2-4 times c)more than 4 times IS. Where did you deliver this index child? a) Home!fBA b) primary health facility (CHPS, health centre) c) secondary (Polyclinic, District Hospital) level facility d) Tertiary level (Regional or teaching Hospital) 16. How long did it take you to deliver after losing liquor (when your water broke?) a) Less than 24 hours (a day) b) more than 24 hours 17. How long did it take you to deliver after the onset of labour? a) Less than 24 hours b) more than 24 hours 18. What was the mode of delivery a) SVD b) Assisted vaginal delivery c) CIS 19. Before you delivered this child, how was your menstrual cycle? a) Regular b) irregular c) cannot remember 71 University of Ghana http://ugspace.ug.edu.gh 20.At what age did you first have your menses(menarche) a)less than 8 years b)8-1O years c)II-14 years d) 15-20 years e) more than 20 years PART C: NEONATAL FACTORS ASSOCIATED WITH CEREBRAL PALSY 21 .How old is the child now? a) less than I month b)l month-6months c)6months-11 months d)I-2 years e)3-S years 22. What is the sex of the child? a) Male [ b) Female [ 23. What was the maturity of the baby at birth (Please cross-check from the records?) a) Extreme preterm (less than 34 weeks) b) Preterm ( 34-37 weeks) c) Term(37-40 weeks d) post term(more than 40 weeks) 24. What type of pregnancy was it? a) Singleton b) Twin Gestation c) Multiple (more than 2, specifY .......... .. 25. If Twin or mUltiple, what happened to the other(s)? a) Died in-utero (died before birth) b) died later in life c) alive and has CP d) alive but not well e) alive and healthy 26. What was the condition of the child at birth? a) stable (cried immediately and was pink) b) unstable, but did not require resuscitation c)required resuscitation d) was referred for intensive care 27. Did the child develop any illnesses during the neonatal period (first month of life?) Yes [ ] No[ ] 72 University of Ghana http://ugspace.ug.edu.gh 28. If yes to 23. which ones (tick the ones that apply?) a) Convulsion b) jaundice c) fever d) excessive vomiting e) cord infection t) others ..... . 29. Was the child admitted in a hospital in the first 1 month ..........y es [ No [ 30. What was the reason for admission? ....................................................................... . 31. What is the birth order ofthis child? a) First b) second c) third d) fourth e) other. specify ... 32. Did the child ever fall or had accident or surgery during the first month yes [ No[ ) 33. If yes to 32, tick the ones that happened a) A fall from height c) surgery d) road-traffic accident e) near-drowning accident 73 University of Ghana http://ugspace.ug.edu.gh PART D: PATTERN OF CPo (RECORD REVIEW FOR ONLY CASES) 34. At what age was the child first diagnosed ofCP? a) less than I month b) 1 month-6 months c) 7months- I year d)more than I year-2 years e)2-5 years 35. What type ofCP does the child have? ......................... . 36. What is the severity of symptoms? a) Mild b) moderate c) severe d) severe with complications 37.ls the child going through any form(S) of treatment .............Y es [ NO [ 38. If yes, what are the type of treatment the child is receiving? The end Thank you, Any Questions? 74 University of Ghana http://ugspace.ug.edu.gh GHANA HEALTH SERVICE ETIIlCS REVIEW COMMITIEE ... 'ase o/reply the ,....~.:!. ... ~ R'CSC81'ch & Development DIVISIon 'lber and date oft his .{'/ \lrl... ... '.·~" Ghana Health Service :s!,Jhould be quoted. ~ (' (~\J ~ P.O. BoxMB 190 ~M~I ...I 5J.'Dur-C -~._.ft ATeclc: r+a 233-302-681 J09 y ... Fax + 233-302-685424 Ref GHSIRDDIERCIAdminlApp(;. Email: ghserc@gmail.com 8 Ref No. . bO·· acAdomako iversity of Ghana 1001 of Public Health ~on, Accra : Ghana Health Service Ethics Review Committee has reviewed and given approval for the implementation of Ir Stu doy Pr otocoI. IS-ERC Number GHS-ERC: 128/02/17 IjectTitie Maternal and Neonatal Factors Associated with Cerebral Palsy: A Study at Duakwa proval Date 23'0 June 2017 )irv Date 22nd June, 2018 IS·ERC Decision Approved 1\ approval requires the following from the Principal Investigator • Submission of yearly progress report of the study to the Ethics Review Committee (ERC) Renewal of ethical approval if the study lasts for more than 12 months, • Reporting of all serious adverse events related to this study to the ERC within three days verbally and seven days in writing. • Submission of a final report after completion of the study • Informing ERC if study cannot be implemented or is discontinued and reas~ns why • Informing the ERC and your sponsor (where applicable) before any publication of the research findings. ase note thatany modification of the study without ERC approval of the amendment is invalid. ~ ERe may observe or cause to be observed procedures and records of the study during and after l 1 cmentation. . Idly quote the protocol identification number in all future correspondence in relation to this approved protocol SIGNED .... 4~!\~ ................................... . DR. CYNTHIA BANNERMAN (GHS-ERC CHAIRPERSON) The Director, Research & Development Division, Ghana Health Service, Accra University of Ghana http://ugspace.ug.edu.gh