A multilevel mixed methods study of neonatal mortality in Ghana

Dare, Shadrach (2018) A multilevel mixed methods study of neonatal mortality in Ghana. PhD thesis, University of Glasgow.

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Background: Reducing neonatal mortality rates [NMR] (deaths/1,000 live births within 28 days of delivery) is a key global health goal. Using comparable data from Ghana (West Africa) and Scotland, I investigated NMR, specific causes of death and risk factors in the two countries. By identifying the main causes of excess mortality in Ghana and where they occur, it is hoped more effective strategies can be developed.

Methods: This thesis used a multilevel mixed methods study design. Data on live births were obtained from three Health and Demographic Surveillance Systems (HDSS) in the north, middle and south of Ghana respectively: Navrongo (2004-12; 17,016 live births, 320 deaths); Kintampo (2005-10; 11,207 live births, 140 deaths); Dodowa (2006-14; 21,647 live births, 135 deaths). Comparable Scottish data were obtained from the Information Services Division (1992 to 2015; 1,278,846 live births, 2,783 deaths). Each dataset was analysed by neonatal death (dead/alive), using univariate and multivariable logistic regression. The multivariable analyses adjusted for maternal demographic and obstetric characteristics. Missing data were analysed using multiple imputation techniques. Data analyses were complemented by a researcher-developed questionnaire survey of 71 maternity care providers in the three regions of Ghana followed by face-to-face in-depth interviews with 48 maternity care providers who had experience of prematurity, birth asphyxia, neonatal infection and neonatal death.

Results: The NMRs in the three HDSS were: Navrongo: 18.8; Kintampo: 12.5; and Dodowa 6.2 and in Scotland it was 2.2; the NMR in both countries is reducing. More than 99% of the neonatal deaths in Scotland occurred in the first week compared to 74% in Ghana. The leading causes of neonatal deaths (NMR) in Ghana were infection (4.3), asphyxia (3.7) and prematurity (2.2). In Scotland, they were congenital malformations (0.6), asphyxia (0.4) and prematurity (0.3). Only 88 deaths (0.07) of neonatal deaths in Scotland were due to infection. Ninety-eight percent of babies born in Scotland were born in a health facility compared to 60% of babies born in Ghana (hospital: 38.1%; clinic: 21.1%). In Ghana, babies born in hospitals had a higher risk of neonatal mortality compared to those born at home (NMR-hospital: 15.6; clinic: 7.1; home: 11.8). Most of the neonatal deaths in Ghana occurred at home (54%); there were more deaths among babies who were born in a hospital but died at home (hosp/home) compared to those born at home but died in a hospital (home/hosp). Asphyxia was the leading cause of death among hosp/hosp, and infection was the leading cause of death among hosp/home, home/home and home/hosp.

Neonatal mortality in Ghana was largely influenced by where mothers sought maternity service, or the type of personnel who provided maternity care service. Mothers and babies who were cared for in hospitals by doctors and midwives received relatively better care and proper management of birth complications. Those who were cared for in clinics received basic delivery services and management of uncomplicated asphyxia. Mothers and babies who were cared for at home by traditional birth attendants (TBA) received poor care and poor management of neonatal illnesses based on traditional approaches which increased the risk of death. Women’s maternity choices were influenced by wider societal factors including prominent cultural values, family hierarchical structures and the cost of maternity services, and individual/ family factors including place of residence and availability of transport and beliefs about the cause of disease.

Conclusion: There is considerable opportunity for reducing NMR in Ghana, especially deaths due to asphyxia and infections. Most uncomplicated deliveries should be performed by midwives in community clinics. The number of community maternity clinics should gradually be increased to enable home deliveries by TBAs to be phased out. Facilities should be improved for delivery and postnatal care in hospitals and the proportion of sick babies managed by health care workers trained in their care should be increased. Regular postnatal checks in the community by trained staff should be standard.

Item Type: Thesis (PhD)
Qualification Level: Doctoral
Keywords: Neonatal mortality, maternal health, child health, Ghana.
Subjects: R Medicine > R Medicine (General)
R Medicine > RJ Pediatrics
R Medicine > RJ Pediatrics > RJ101 Child Health. Child health services
Colleges/Schools: College of Medical Veterinary and Life Sciences > School of Health & Wellbeing > Public Health
Supervisor's Name: Mackay, Dr. Daniel F., Gruer, Professor Laurence, Hesselgreaves, Dr. Hannah and Pell, Professor Jill P.
Date of Award: 2018
Depositing User: Mr S Dare
Unique ID: glathesis:2018-30943
Copyright: Copyright of this thesis is held by the author.
Date Deposited: 31 Oct 2018 10:06
Last Modified: 07 Jan 2019 10:14
URI: https://theses.gla.ac.uk/id/eprint/30943

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