BACKGROUND:In 2023, there were 9·9 million births among adolescents aged 15-19 years in low-income and middle-income countries, with an estimated half of those births unintended. Cameroon, Ghana, Malawi, Nepal, and Rwanda stand out as exemplar countries experiencing some of the largest declines in adolescent fertility (ie, the demographic concept of livebirths per woman) globally between 2000 and 2023 relative to countries with similar socioeconomic change during this period. We aimed to examine how these five countries reduced adolescent pregnancy by decomposing declines into key determinants. METHODS:Our analysis leveraged all Demographic and Health Surveys and Multiple Indicator Cluster Surveys available for the five countries between 2000 and 2023. We implemented an Oaxaca-Blinder decomposition analysis of pregnancy among adolescents aged 15-19 years, comparing the earliest and latest years of available data on adolescent pregnancy and influential factors thereof. We implemented an array of sensitivity analyses to assess the robustness of the results of our analysis to different population strata and model specifications. FINDINGS:The largest driver associated with decreases in adolescent pregnancy in all countries was a substantial decline in the adolescent marriage rate, which dropped by between 4·3 and 12·2 percentage points. The second largest factor was increased educational attainment among adolescents, with gains between 1·5 and 3·0 more years of education. Although unmet need for contraceptive use exhibited a statistically significant association with adolescent pregnancy, it was not attributed a large contribution as it did not change substantially during the period of focus. INTERPRETATION:These changes coincide with major policy developments surrounding adolescent marriage and education in the five countries: the legal age of marriage increased, and exemptions were removed to facilitate stronger enforcement of laws; policies making education free (or of low cost) and compulsory were also implemented. Underpinning the policy changes were broad shifts in underlying social norms on gender and other changes to the enabling environment for the policies to have their intended impact. FUNDING:Gates Ventures.

Background: The COVID-19 pandemic disrupted essential health services globally, with profound implications for maternal health in low-resource settings. Antenatal care (ANC), a cornerstone of maternal health, experienced significant service and access challenges, particularly in underserved regions such as Northern Ghana. Objective: To assess the impact of the COVID-19 pandemic on ANC service utilization, access barriers, provider experiences, and the feasibility of alternative care models in the Tamale Metropolitan Area of Ghana. Methods: This was a facility-based, convergent mixed-methods cross-sectional study conducted across four public health facilities. Quantitative data were collected from 240 pregnant women via structured surveys and secondary ANC attendance records from the District Health Information Management System (DHIMS2). Qualitative data were obtained through five focus group discussions with 25 maternal healthcare providers. Descriptive statistics, chi-square tests, and logistic regression were used to analyze quantitative data in Stata 16, while qualitative data were thematically analyzed using the COREQ framework. Results: ANC attendance declined significantly in 2020, with 62.5% of women reporting reduced visits. Fear of infection (73.3%), transport challenges (67.5%), and misinformation were key barriers. Although 52.5% used virtual services, 77.8% faced connectivity issues. Healthcare providers reported staffing shortages, increased workloads, and emotional stress, but also noted improvements in infection prevention practices. Secondary data showed a sharp decline in ANC visits in 2020, followed by a rebound in 2021. Conclusion: COVID-19 disrupted ANC access and delivery in Northern Ghana, exposing systemic vulnerabilities. Despite these challenges, essential care such as supplementation continued. Strengthening digital health infrastructure, emergency preparedness, and community-based models is critical for sustaining maternal health services during future crises. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study did not receive any funding ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Committee on Human Research, Publications and Ethics (CHRPE) of Kwame Nkrumah University of Science and Technology gave ethical approval for this work (Approval No. CHRPE/AP/48722). Additional approval was granted by the Tamale Metropolitan Health Directorate. Written informed consent was obtained from all participants. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All relevant data supporting the findings of this study are included in the manuscript and its supplementary files. Individual level data can be made available upon reasonable request from the corresponding author (rudolph.mensah{at}moh.gov.gh), subject to approval by the Committee on Human Research, Publications and Ethics (CHRPE), KNUST/Komfo Anokye Teaching Hospital.

A significant canker that has been with us for some years now and continues to be on the ascendency, especially among the youth in Ghana, is the use of substances. Adolescence is a period where adolescents tend to indulge in various behaviours, including substance use, as a result of vulnerability to societal influences. A cross-sectional descriptive study was carried out in the New Juaben Municipality, Ghana, to ascertain the determinants of substance use and its medico-social implications on selected second-cycle students. Two hundred and forty (240) students between 12 and 19 were sampled to participate in the study and interviewed using interviewer-guided pretested questionnaires. The mean age for substance use was found to be 17.80 years. The majority began substance use as early as between 16–18 years (79.5

Introduction:While most postpartum women in Ghana report they would like to limit or space their births, few are using a highly effective method of family planning. We sought to better understand the reasons behind these seemingly contradictory stances. Methods:We interviewed 48 postpartum women who had given birth 3-6 months prior and were seeking childhood immunization services at 2 hospitals in urban Kumasi, Ghana. Participants offered their opinions on previous, current, and future family planning use. Interviews were conducted by a trained, bilingual, female research assistant after the infant's appointment in a private room near the Child Welfare Clinic. Interview data were translated and transcribed verbatim and analyzed thematically using NVivo 14.0. Results:While all participants reported wanting to wait at least 2 years before becoming pregnant again, only 3 were currently using a method of modern contraception. Many of our participants expressed aversion to contraception, driven mainly by the perceived risk of contraception being dangerous to their health and future fertility as reported by members of their social network. Many of those, however, were using either fertility-awareness-based methods, emergency contraception, condoms, or some combination. Those who had had negative personal experience with modern contraceptives were reluctant to use it again due mainly to menstrual side effects. Additionally, some participants had no reason for not wanting to use contraception, they simply do not want to. Discussion:This qualitative study of women in Kumasi, Ghana, provides a framework to better understand family planning readiness and need. Many participants expressed limited knowledge about modern contraception, highlighting the importance of tailoring counseling to address women's unique questions and concerns. Potential contraceptive users appeared open to and curious about modern methods but had been deterred by stories and misconceptions about adverse consequences. Some women simply chose not to use contraception. Ensuring women have complete, unbiased information on which to base their decisions about contraceptive use and method selection represents a promising avenue for future interventions that seek to improve women's ability to meet their fertility goals.

BACKGROUND:Abortion has been legal for multiple indications in Ghana since 1985, and efforts have been made to expand the availability of safe abortion care in the years since. However clandestine, and potentially unsafe, abortions remain common, suggesting numerous barriers to access persist; one possible barrier is poor knowledge of the abortion law among those working in health facilities. Our study aimed to identify levels of legal knowledge among health facility staff across Ghana. METHODS:Data for this paper are drawn from a nationally representative cross-sectional health facility survey conducted in 2018; our analytic sample includes 340 facilities that provide induced abortion and/or postabortion care (PAC). The survey collected data on provision of abortion and PAC, as well as knowledge of abortion legality and recommendations for reducing unsafe abortion. We used descriptive statistics to examine levels of knowledge and recommendations, and logistic regression to assess associations with individual and facility characteristics. FINDINGS:Comprehensive knowledge of the legal indications for abortion was low among health facility staff; just 6% identified all legal indications, and the majority (83%) underestimated the number of conditions under which abortion is legal. Knowledge was higher for more restrictive indications, such as a woman's life being at risk, which was identified by 72% of respondents, than more broadly interpretable indications, such as mental health, identified by 29%. Respondents in facilities providing both induced abortion and PAC had better knowledge of several legal indications than those in facilities providing PAC only. CONCLUSIONS:Health facility staff have significant gaps in their knowledge of abortion legality. Knowledge of the law among this population is highly important for ensuring that abortion care is made available to the fullest extent of the law. Efforts are needed to improve knowledge of the law among providers and facility staff, particularly for indications with broad interpretability.

BACKGROUND:Knowledge of the conditions under which abortion is legal is important so that people can advocate for their right to abortion care. Yet minimal research has explored the association between women's knowledge of abortion legality and the induced abortion care they receive, particularly using population-based survey data. METHODS:Using national survey data collected by Performance Monitoring for Action (PMA) in Côte d'Ivoire and Ghana, we aimed to compare the prevalence of accurate knowledge of abortion legality, factors associated with knowledge of the law, and the association between knowledge of abortion legality and the source of women's induced abortion care in these two settings. We ran bivariate and multivariable logistic regressions to assess the relationships of interest. RESULTS:We found that awareness and knowledge of the abortion law were low in both Côte d'Ivoire and Ghana. In Cote d'Ivoire, women who were older, more educated, and with past abortion experience were more likely to be aware of the law. In Ghana, knowledge of the law did not vary significantly by demographic characteristics. However, in Ghana, knowledge of the law was correlated with women's use of the formal healthcare system for abortion care, with greater use of clinical sources in rural areas. CONCLUSIONS:It is possible that for populations with reduced access to abortion services, such as those in rural areas, knowledge of the law is advantageous for those seeking facility-based abortion care, particularly in settings where abortion is legal for a range of indications. Interventions seeking to improve access to facility-based abortion care in settings where abortion is legal on various grounds should incorporate education on the legal grounds for abortion.

We test whether the classification of households into poverty categories is meaningfully influenced by the poverty measurement approach that is employed. These classification techniques are widely used by governments, non-profit organizations, and development agencies for policy design and implementation. Using primary data collected in Ethiopia, Ghana, and Uganda, we find almost no agreement in how four commonly used approaches rank 16,150 households in terms of poverty status. This result holds for each country, for urban and rural households, and across the entire socio-economic distribution. Households' poverty rankings differ by an entire quartile on average. Conclusions about progress toward poverty alleviation goals may depend in large part on how poverty is measured.

This study aimed to assess the effects of health education and community-level participatory interventions at the community level and the use of community maternal health promoters on the utilization of maternal health care services in poor rural settings of northern Ghana. A randomized controlled survey design was conducted from June 2019 to July 2020 in two rural districts of northern Ghana. A multistage cluster sampling technique was used to select the participants. Data were collected from a repeated cross-sectional household survey. Descriptive analysis, bivariate and covariates adjusted simple logistic regression analyses were performed using STATA version 16 statistical software. At post-intervention, the two groups differed significantly in terms of ANC (p = 0.001), skilled delivery (SD) (p = 0.003), and PNC (p < 0.0001). Women who received health education on obstetric danger signs had improved knowledge by 50

BACKGROUND:There is a significant literature describing the link between parity and contraceptive use. However, there is limited knowledge about the disaggregation by parity of the type of contraceptives. In this study, we describe the use of contraceptives by parity among women of reproductive age in Ghana, focusing on use of highly effective methods (injection, pill, intrauterine device, implant, and sterilization).METHODS:Using the 2017 Ghana Maternal Health Survey, a nationally-representative cross-sectional household survey, we describe contraceptive method use by number of living children among sexually active women of reproductive age. We then estimated predictors of use of highly effective contraception in a multilevel logistic regression model.RESULTS:Most women in this survey are not using any method of contraception, although this varies by whether or not they have begun childbearing. Contraceptive method use varies by number of living children. Before having children, natural (periodic abstinence and withdrawal) and episodic (condoms) methods dominate. Once a woman has one living child, method preference changes to injectables and implants. Factors associated with using a highly effective method of contraception are: having >3 children, being in a relationship, having had an abortion, being younger than age 30, and having had sexual intercourse within days of answering the survey (p < .001 for all).CONCLUSION:In this analysis, the number of living children a woman has, her age, and timing of last intercourse are the most significant predictors of using a highly effective method of contraception. However, the majority of participants in this study report not using any method of contraception to avoid unwanted pregnancies. Future research that attempts to unpack the disconnect between not wanting to become pregnant and not using contraception is warranted.

Objective: Road construction work involves diverse activities relying on the use of both skilled and unskilled manpower, posing serious risks to workers. This study sought to determine the burden, mechanism and severity of occupational injuries among road construction workers. Methodology: The study design was institution-based descriptive cross-sectional using a questionnaire with closed- and open-ended questions. From Ashanti, Ahafo and Western North regions, 353 road workers reported on work-related injuries, types of injury, body parts injured, day(s) lost to activity and cause of injury from 27th January, 2020 to 4th March, 2020. Results: The workers were primarily young (mean age 32.4 years) and male (97.7%). Most (70.2%) workers were contract/casual staff. Nearly 88% experienced injury the past year with 67.5% experiencing multiple injuries. The body parts most affected included waist/low back (29.9%), forearm/palm (18.9%), leg/foot (17.5%), chest (8.9%) and joints (7.1%). Mechanism of injury included slips/trips (18.5%), use of tools/equipment (13.8%) and overexertion during lifting (10.2%). For injury severity, 88.0% of workers had minor injuries, 8.8% moderate and 3.2% severe injuries. Conclusion: There is high burden of injury among road construction workers in Ghana. Most experienced injury during the past year, with over 4-in-5 having minor injuries. Leading mechanisms were slips/trips, use of tools/equipment and overexertion during lifting. Limitations include biases like memory decay, purposive selection of construction sites and driver over-representation. Hence, recommendations deriving from this study include enforcement of personal protective equipment use, proficiency training in use of tools/equipment and inter-lacing manual handling-related activities with activities that vary worker-postures.

The objective of the study was to ascertain the determinants of modern contraceptive use in Ghana among married women and those living with a partner. Secondary data from the Performance Monitoring and Accountability 2020 Ghana 2015 survey were used for the study. A multivariate logistic regression analysis was used. Modern contraceptive use was 25.5%. The significant predictors of modern contraceptive use were exposure to the media (AOR 2.07, 95% CI 1.20 - 3.55), residence in the Upper East region (AOR 0.26, 95% CI 0.10 - 0.71), final decision makers on contraceptive method either by themselves or jointly (AOR 0.26, 95% CI 0.14 -0.92), return to provider (AOR 6.96, 95% CI 3.59 - 13.49), refer relative or friend to provider (AOR 2.67, 95% CI 1.27 - 5.68), and parity of 5 or more (AOR 4.42, 95% CI 1.49 - 13.12). Media exposure on contraceptives and client satisfaction has the potential to improve modern contraceptive uptake in Ghana.

PurposeTraumatic brain injury (TBI) is a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). Hospital care practices of pediatric TBI patients in LMICs are unknown. Our objective was to report on hospital management and outcomes of children with TBI in three centers in LMICs.MethodsWe completed a secondary analysis of a prospective observational study in children (<18 years) over a 4-week period. Outcome was determined by Pediatric Cerebral Performance Category (PCPC) score; an unfavorable score was defined as PCPC > 2 or an increase of two points from baseline. Data were compared using Chi-square and Wilcoxon rank sum tests.ResultsFifty-six children presented with TBI (age 0–17 y), most commonly due to falls (43%, n = 24). Emergency department Glasgow Coma Scale scores were ≤ 8 in 21% (n = 12). Head computed tomography was performed in 79% (n = 44) of patients. Forty (71%) children were admitted to the hospital, 25 (63%) of whom were treated for suspected intracranial hypertension. Intracranial pressure monitoring was unavailable. Five (9%, n = 5) children died and 10 (28%, n = 36) inpatient survivors had a newly diagnosed unfavorable outcome on discharge.ConclusionInpatient management and monitoring capability of pediatric TBI patients in 3 LMIC-based tertiary hospitals was varied. Results support the need for prospective studies to inform development of evidence-based TBI management guidelines tailored to the unique needs and resources in LMICs.

Road construction activities are hazardous. Workers are exposed to hazards with high probability of illness, injury, disability or death. The objective was to determine road workers' perceptions of occupational hazards, ailments experienced and health seeking behaviour. This was an institution-based descriptive cross-sectional study using open-ended questions. A total of 353 road workers from Ashanti, Ahafo and Western North regions reported work-related hazards and ranked the top-3. Workers in each craft/stratum who gave consent were included in the study and interviewed. They also reported work-related ailments and health-seeking behaviour. The workers were primarily young (mean age 32.4 years) and male (97.7%). Most (70.2%) workers were contract/casual staff. 38 hazards were reported, with the top five being dust (91.5% of workers reported this), extreme temperatures (72.0%), noise (40.5%), fumes (21.8%) and vehicles/trucks (21.1%). Most (86.8%) workers reported a work-related ailment, with the most common being cough (41.1%) and headache (18.9%). Most (87.8%) workers with ailments sought treatment of any kind. Road construction workers in these regions of Ghana have good appreciation of hazards at work and the dangers they pose. Works supervisors should encourage workers on PPE use against dust, noise, fumes and good housekeeping. Regular worker-training on hazards is recommended.

Malnutrition is a public health problem in Ghana, and is estimated to contribute indirectly to more than half of under-five deaths. This study was designed to describe how implementation of the Community-based Management of Malnutrition (CMAM) programme in Ghana differs in the rural and urban parts of the country. A mixed methods approach was used in a community-based survey that studied 497 mothers/caregivers and under-five pairs quantitatively, 25 health service providers qualitatively, and 25 mothers/caregivers qualitatively. Quantitative data were analysed descriptively with Stata 14.0 (Stata Corp, Texas, USA) while the qualitative data were analysed thematically with Atlas.ti, version 7.5 (Scientific Software Development GmbH, Berlin). Programme implementation was assessed using the following variables: availability of CMAM tools, availability of CMAM supplies, organization of out-patient therapeutic and supplementary feeding programmes, personnel availability, availability of community-based components of CMAM and maternal experience with CMAM services. While the number of children alive, provision of nutrition education and counselling, and demonstration of food preparation significantly influenced program effectiveness (p<0.05) in the urban site, no variables were found to do similar in the rural district. The rural facilities were more likely than the urban ones to be without tools. Less than 10% of mothers/caregivers in both study sites acknowledged the availability of the community-based components of CMAM. Programme implementation in the two study districts is poor; in order to ensure that the CMAM intervention translates into a reduced malnutrition burden among children under-five in Ghana, the programme implementation should be revised to address the identified shortcomings.

BACKGROUND:Computerized decision support systems (CDSS) and performance-based incentives (PBIs) can improve health-worker performance. However, there is minimal evidence on the combined effects of these interventions or perceived effects among maternal and child healthcare providers in low-resource settings. We thus aimed to explore the perceptions of maternal and child healthcare providers of CDSS support in the context of a combined CDSS-PBI intervention on performance in twelve primary care facilities in Ghana's Upper East Region.METHODS:We conducted a qualitative study drawing on semi-structured key informant interviews with 24 nurses and midwives, 12 health facility managers, and 6 district-level staff familiar with the intervention. We analysed data thematically using deductive and inductive coding in NVivo 10 software.RESULTS:Interviewees suggested the combined CDSS-PBI intervention improved their performance, through enhancing knowledge of maternal health issues, facilitating diagnoses and prescribing, prompting actions for complications, and improving management. Some interviewees reported improved morbidity and mortality. However, challenges described in patient care included CDSS software inflexibility (e.g. requiring administration of only one intermittent preventive malaria treatment to pregnant women), faulty electronic partograph leading to unnecessary referrals, increased workload for nurses and midwives who still had to complete facility forms, and power fluctuations affecting software.CONCLUSION:Combining CDSS and PBI interventions has potential to improve maternal and child healthcare provision in low-income settings. However, user perspectives and context must be considered, along with allowance for revisions, when designing and implementing CDSS and PBIs interventions.

Background: Ghana for years has implemented the Community-based Management of Acute Malnutrition (CMAM) among children in order to reduce malnutrition prevalence. However, the prevalence of malnutrition remains high. This study aimed to determine CMAM coverage levels in the Ahafo Ano South (AAS), a rural district, and Kumasi Subin sub-metropolis (KSSM), an urban district. Methods: The study was a cross-sectional comparative study with a mixed-methods approach. In all, 497 mother/caregiver and child under-five pairs were surveyed using a quantitative approach while qualitative methods were used to study 25 service providers and 40 mother/ caregivers who did not participate in the quantitative survey. Four types of coverage indicators were assessed: point coverage (defined as the number of Severe Acute Malnutrition cases [SAM] in treatment divided by total number of Severe Acute Malnutrition cases in the study district), geographical coverage (defined as total number of health facilities delivering treatment for SAM divided by total number of healthcare facilities in the study district), and treatment coverage (defined as children with SAM receiving therapeutic care divided by total number of SAM children in the study district) and program coverage (defined as number of SAM cases in the CMAM programme ÷ Number of SAM cases that should be in the programme). The qualitative approach was used to support the assessment of the coverage indicators. Data were analyzed using STATA version 14, and Atlas.ti, version 7.5 for the quantitative and qualitative data respectively Results: Geographically, only 6% of the facilities in the urban communities were participating in the CMAM programme as against 29% of rural district facilities. The districts had point coverage of 41% and 10% for the urban and rural districts respectively. The urban setting recorded a SAM prevalence of 52% as against 36% in the rural setting. The proportion of SAM children enrolled in CMAM was higher in KSSM when compared with AAS; 41% and 33% respectively. In both districts, the most likely factors to attract mothers/caregivers to utilize the CMAM services were: ‘free services’ and ‘a cured child.’ The qualitative approach showed that coverage improvement in both districts is hampered by barriers such: distance, transportation cost, lack of trained personnel in the communities for community mobilization and home visits, and insufficient feeds. Conclusion: To improve CMAM coverage, there is the need to train health workers to embark on aggressive health education strategies to encourage mothers/caregivers of malnourished children to utilize CMAM while ensuring that services reach those who need them. Trial registration: This study is approved and registered with The Kwame Nkrumah University of Science and Technology Committee on Human Research, Ethics and Publications ( CHRPE/AP/314/15)

Background Information on the burden of drowning in Africa is limited. Existing estimates of national drowning death rates are based on small regional studies and exclude intentional, water transport, and flood-related drowning. We established an approach to collect nationally representative data on fatal and non-fatal drowning in Ghana. Methods To include the diversity of exposure to water bodies in Ghana, all 261 districts were categorized into three strata: coastal (districts with ocean coastline), inland water (districts that border or contain major lakes or rivers), or dry (districts that do not have a coastline or major lake/river but may contain small lakes/rivers, dams, wells, etc.). The three strata were sorted by urbanicity, ecological zone, and region. Districts were randomly selected from each strata using proportional to population size sampling. Fifty-two districts were randomly selected covering approximately 28% of the population. Trained data collectors identified all drowning cases in each district by contacting community health workers and gatekeepers, enabling a complete census of the included districts without visiting every household. Results This approach resulted in increased case identification and more complete circumstance information than could be obtained from existing administrative sources, enabling the calculation of national estimates for drowning in Ghana. Conclusion Unique approaches can be used to collect nationally representative drowning data in settings with limited existing data. Such data are critical for the prioritization of resources. Learning outcomes Learn new approach for calculating national drowning estimates in low-resource settings. Identify characteristics of drowning in Ghana and implications for prevention.

Every child has the right to survive, grow and develop. However, in spite of the considerable global gains that have been made in child survival, Sub-Saharan Africa still has the highest child mortality rates and accounts for the greatest burden of mortality globally. The majority of these children die without ever reaching a health facility. The practice of appropriate healthcare-seeking behaviour has a great potential to reduce the occurrence of severe and life-threatening childhood illnesses. Several factors, however, influence healthcare-seeking behaviour, including perceptions of the cause of illness and socio-cultural perspectives. This study seeks to understand local concepts of a traditionally-defined illness complex, Asram, and its influence on healthcare seeking behavior of mothers/caregivers. This qualitative study was conducted from October 2019 to February 2020. Four Focus Group Discussions were conducted with mothers/caregivers of children under-5 and 22 Key Informant Interviews with mothers/caregivers of children who had Asram, health workers at district, facility, and community levels, and Asram healers. Participants were selected from two rural communities, Akutuase and Wioso of the Asante Akim North district in the Ashanti region of Ghana. Data analysis was carried out iteratively throughout data collection, using a thematic analysis approach. The study shows that Asram is a childhood illness complex that is perceived to have been acquired spiritually and/or inherited. Nine types of Asram were described. This childhood illness was said to be treatable by Asram healers who had sub-specialties in treatment approaches that were determined by the Asram type reported. Mothers/caregivers trusted Asram healers and preferred to call on them first. This was found to be the main reason for delays in seeking healthcare for children under-5 who showed symptoms of Asram. Asram is a childhood illness complex that is believed to be better managed outside the health facility setting. This study complements existing knowledge and creates opportunities for further research and the introduction of more effective interventions in the effort to improve child survival in rural communities.

A B S T R A C T Objective: To understand the barriers and facilitators of hormonal contraceptive use among Ghanaian women, in order to help improve contraceptive counseling and reduce the high rates of unintended preg-nancy. Study design: We conducted a nationally representative community-based survey of 4143 women aged 15-49 in 2018, and used descriptive statistics and logistic regression to examine correlates of current hormonal method use, preferred method attributes and their association with method choice, and the role of side effects in hormonal method discontinuation. Results: Hormonal method use (vs. contraceptive non-use) was associated with younger age, higher par -ity and education, but not with union status, wealth or residence. Preferences for key method attributes were associated with choosing particular methods. Most valued attributes were effectiveness at prevent-ing pregnancy, and low risks of harming health and future fertility. These last 2 concerns are echoed in the second most common reason for discontinuation (health concerns). While menstrual changes were a common concern, leading some respondents to discontinue hormonal contraceptives, many were willing to endure these effects. In contrast, having experienced long-term health issues as a perceived result of hormonal method use more than halved the odds of current use. Contraceptive counseling on menstrual changes, other side effects, and impacts on future fertility had not been universally provided. Conclusions: Ghanaian women value hormonal methods for their effectiveness against pregnancy. How-ever, concerns about side effects (particularly bleeding changes), future fertility impairment, and long -term health issues led some women to discontinue hormonal methods. Counseling on these issues was reportedly inadequate. Implications: Identifying barriers to, and facilitators of, hormonal contraceptive use, as well as method attributes important to Ghanaian women, can help to better tailor contraceptive counseling to individual needs, in order to ensure that all women can access the method that suits them best, and decide whether and how to manage side effects, switch methods or discontinue. (c) 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ )