1. 1 Francis Yeji (Navrongo Health Research Centre) Ghana EMBRACE Implementation Research Team on behalf of Ghana EMBRACE Implementation Research Team Continuum of Care in a Maternal, Newborn and Child Health Program in Ghana: “Low Completion Rate and Multiple Obstacle Factors”

2. Background Global Most sub-Saharan African countries have difficulties in achieving MDGs 4 & 5 Ghana Maternal Mortality Ratio: 380/100,000 Neonatal Mortality Rate: 30/1,000 Key Ensuring Continuum of Care (CoC) for mother and newborn is crucial in helping achieve MDGs and beyond 2

3. CoC in MNCH program 3 CoC links key MNCH packages of programs across the pregnancy, delivery, and postpartum stages Each CoC stage builds on the success of the previous stage Focused period of this study

4. Objectives of the study 4 Measure the completi on of CoC from the pregnan cy to six weeks postpart um stages in Ghana 1 Examine the factors associat ed with the completi on of CoC, and discontin uity of CoC 2

5. Methods Study sites Study Design Cross sectional survey 467,000 population in 6 districts 1,500 women (15-49 yrs) selected by two stage random sampling Logistic and multinomial regression analysis 5 Study outcome Completion of CoC:  Antenatal care ≥ 4 times  Delivery assisted by skilled attendant  Postnatal care < 48 hrs, at 2 wks, and 6 wks

6. Participants Background Characteristics Variable Dodowa N (%) Kintampo N (%) Navrongo N (%) Total N (%) Age (mean) Mothers 28.430.028.028.9 Partners 34.134.635.434.8 Education (Mothers) None 192 (38.4)264 (47.8)150 (30.0)606 (39.1) Primary 109 (21.8)105 (19.0)141 (28.2)355 (22.9) Middle/JHS/higher 199 (39.8)183 (33.0)209 (41.8)591 (38.1) Education (Partners) None 86 (19.6)195 (35.3)167 (33.9)448 (30.2) Primary 70 (16.0)35 (6.3)93 (18.9)198 (13.3) Middle/JHS/higher 330 (64.5)258 (46.8)233 (47.3)893 (52.1) Parity 1 145 (29.0)116 (21.0)140 (28.0)401 (25.8) 2 – 3 211 (42.2)231 (41.9)216 (43.2)658 (42.4) 4 – 5 85 (17.0)112 (20.3)110 (22.0)307 (19.8) 6 + 59 (11.8)93 (16.9)34 (6.8)186 (12.0) Marital status Married 134 (26.8)366 (66.3)457 (91.4)957 (61.7) Cohabiting 297 (59.4)94 (17.0)7 (1.4)398 (25.6) Single/Divorce/Widowed 69 (13.8)92 (16.7)36 (7.2)197 (12.7) Wanted Pregnancy Then 216 (43.2)369 (66.9)329 (65.8)914 (58.9) Later 207 (41.4)137 (24.8)150 (30.0)494 (31.8) Not wanted 77 (15.4)46 (8.3)21 (4.2)144 (9.3) 6

7. Gaps identifies in MNCH services 7 Gap is here

8. CoC completion rate 8

9. Factors associated with CoC completion VariableNumber (N=1497)aOR (95%CI) Location (HDSS Site) Navrongo 497 1 Kintampo5000.35 (0.13 - 0.95)* Dodowa5000.76 (0.30 - 1.93) Marital Status Married9101 Cohabiting3950.45 (0.22 - 0.95)* Single/Divorced/Widowed1920.66 (0.28 - 1.60) Mother's religion Christian7901 Islam2090.57 (0.18 - 1.77) Traditional3522.20 (1.05 - 4.60)* Other1460.83 (0.22 - 3.11) Wanted Pregnancy (Timing) Yes then8751 Yes but later4811.69 (1.04 - 2.75)** Not at all1410.82 (0.27 - 2.47) 9 Note: *p< 0.05 **p< 0.01, ***p< 0.001. Adjusted for age and education

10. Variable Number (N=1417)aOR (95%CI) Partner's Education None4331 Primary1940.64 (0.30 - 1.37) Middle4190.99 (0.51 - 1.90) Secondary2211.01 (0.47 - 2.16) Tertiary and above1032.71 (1.11 - 6.57)* Transportation to Delivery place On foot7441 Bicycle/Tricycle/Motorcycle1241.58 (0.86 - 2.90) Car(Public/Private)/Ambulance6071.97 (1.07 - 3.62)* Local Beliefs on child sicknesses All can be treated4951 Some cannot be treated5840.34 (0.21 - 0.61)*** 10 (Continued.)

11. Factors associated with discontinuity of CoC Variable Discontinued at ANC Discontinued at Delivery Discontinued at PNC RR Location (HDSS Site) Navrongo111 Kintampo4.28**15.89***1.99 Dodowa2.87.63**1.32 Marital Status Married111 Cohabitating2.95**1.741.56 Single/Divorced/Widowed3.41*1.61.57 Partner’s education None111 Primary1.141.291.66 Middle0.530.821.05 Secondary0.70.891.12 Tertiary and above0.13**0.24*0.43 Wealth Quintiles Highest111 Fourth2.413.281.78 Middle2.613.59**1.08 Second2.466.17***1.25 Lowest2.637.07***1.34 Woman beliefs about child illness All illness can be treated111 Some illness can't be treated3.25***2.66***2.57***

12. Discussions Only 8% rece ived MN CH servi ces conti nuo usly. The maj or gap was PNC withi n 48hr s 1 CoC com pleti on rate s and the asso ciate d fact ors vari es acro ss geo grap hical locat ions 2 The cont ribut ion of CHF P/C HPS may be the maj or fact or acco unti ng for the diffe renc es 3 12

13. Conclusions & Policy Implications Findings call for attention to interventions within local context aimed at improving coverage of PNC within 48hrs to increase CoC completion rate 13

14. Acknowledgement The Chiefs, health workers, and people of the communities The Ghana Health Service (GHS) – Headquarters – Research and Development Division – Navrongo, Kintampo, and Dodowa Health Research Centers The District Health Management Teams (DHMTs) – Shai-Osudoku, Ningo-Prampram, Kintampo North and South, Kassena Nankana East and West Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo Japan International Cooperation Agency (JICA) Human Development Department JICA Research Institute System Science Consultants Inc., Japan Japanese Organization for International Cooperation in Family Planning (JOICFP) Special thanks: The Ministry of Foreign Affairs in Japan, and The Ministry of Health in Ghana 14

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