Anaemia remains a major global health concern among adolescents. While regional and national studies report varying prevalence, cross-continental evidence is limited. This study examines anaemia prevalence and its determinants among adolescents in Sub-Saharan Africa and India. We analyzed cross-sectional data from 9,820 adolescents (10-19 years) in Burkina Faso, Ethiopia, Ghana, India, Nigeria, Tanzania, and Uganda. Hemoglobin levels were measured using a finger-prick capillary blood and a portable HemoCue device, with anaemia defined according to the World Health Organization's age- and sex-specific cutoffs. Multivariable logistic regression was used to identify factors associated with anaemia. The sample comprised 51.5% females; 56.8% had ≥ 7 years of education, and 91.5% were literate. The mean age was 14.2 years (SD ± 2.7), with 52.8% aged 10-14 years. Overall, anaemia prevalence was 42.0% (95% CI: 40.9-43.1), including 3.9% with severe anaemia. Prevalence varied substantially by country; lowest in Ethiopia (4.9%) and highest in Ghana (73.6%). While the prevalence of anaemia across Sub-Saharan African countries was 43.9%, it was 31% in India. Overall, female adolescents had 15% higher odds of anaemia than males (adjusted odds ratio [aOR] 1.15; 95% CI: 1.04-1.28), while older adolescents 15-19 years had lower odds compared with younger adolescents 10-14 years (aOR 0.87; 95% CI: 0.69-0.94). Adolescents with normal (aOR 0.76; 95%CI: 0.64-0.90) and overweight (aOR 0.79; 95%CI: 0.63-0.97) body mass index (BMI) had lower odds of anaemia than their underweight counterparts. Consumption of eggs and legumes was protective, and residing in Ghana was associated with doubled odds of anaemia (aOR 2.21; 95%CI: 1.74-2.80). Anaemia remains highly prevalent among adolescents in Sub-Saharan Africa and India, particularly among females. Protective correlation of consuming eggs and legumes highlights the potential of targeted feeding interventions. The higher prevalence in younger adolescents underscore the need for age-specific strategies to combat adolescent anaemia. Additionally, underweight status is a risk factor for anaemia; thus, nutrition literacy intervention is imperative for improved nutritional status to reduce adolescent anaemia.

BACKGROUND:While live oral rotavirus vaccines (LORVs) are effective at preventing severe rotavirus gastroenteritis (SRVGE), they perform sub-optimally in the settings with the highest burden. Parenteral rotavirus vaccines could have greater efficacy by bypassing the gut, where interference with LORVs may occur. A novel parenteral rotavirus subunit vaccine (TV P2-VP8) was evaluated in a Phase 3 study for safety, immunogenicity, and relative efficacy in healthy African infants. METHODS:Participating infants were randomized at 6-8 weeks of age to receive either three doses of TV P2-VP8 intramuscularly (IM) plus oral placebo or two doses of ROTARIX® (oral) plus IM placebo. The trial was designed to enroll a total of 8200 participants in two stages separated by an interim analysis conducted upon accrual of a predetermined number of SRVGE cases. Data at interim analysis indicated a low probability of demonstrating TV P2-VP8 superiority compared to ROTARIX in prevention of SRVGE, and the study was closed early. RESULTS:4055 infants were enrolled and provided safety data. TV P2-VP8 was safe and well tolerated, with no safety concerns indicated. Virus neutralizing and IgG binding antibody seroresponses to TV-P2-VP8 were detected in most participants. The crude attack rates of SRVGE in the per-protocol population (n = 3477) were 4.51 % (TV P2-VP8) and 2.57 % (ROTARIX). The relative vaccine efficacy (RVE) against SRVGE for TV P2-VP8 was -77.68 % (95 % CI, -162.38, -21.54). The RVE against SRVGE in the first and second year of life was -91.67 % (95 % CI, -199.20, -24.35) and - 31.97 % (95 % CI, -220.37, 44.49), respectively. The RVE against rotavirus gastroenteritis of any severity was -47.78 % (95 % CI, -89.63, -15.59). CONCLUSIONS:TV P2-VP8 provided inferior protection against SRVGE compared to ROTARIX. The vaccine candidate was safe, immunogenic, and well-tolerated by infants. Continued efforts are needed to identify alternative rotavirus vaccines with improved efficacy in LMICs. TRIAL REGISTRATION:NCT04010448; PACTR201907491834482.

Malaria remains a major public health problem, especially among children in sub-Saharan Africa. Knowledge of malaria parasite prevalence informs targeted interventions and helps to monitor the effectiveness of those interventions. This study aimed to determine prevalence and factors associated with malaria in children aged 6 months to 10 years in the Greater Accra Region of Ghana. A community-based cross-sectional study was conducted among 8,741 children aged 6–59 months and 8,292 children aged 5–10 years in all 29 districts of the Greater Accra Region of Ghana in October 2020. Systematic random sampling was used to select communities, households and study participants. A structured questionnaire was used to collect data from caregivers. Rapid diagnostic test kits were used to determine the presence of malaria parasites in blood samples collected by fingerprick. Factors associated with malaria RDT-positivity were determined using multivariate logistic regression analysis. Of 8727 children aged 6–59 months and 8279 aged 5–10 years from whom blood samples were obtained, positive results were obtained for 289 (3.3

The World Health Organization (WHO) recommends exclusive breastfeeding for the first six months after birth to ensure child health and survival. Antenatal care provides an opportunity to educate pregnant women on optimal breastfeeding practices. A cluster-randomized control trial in Ghana examined the impact of group antenatal care on breastfeeding knowledge and practice. The study enrolled 1761 pregnant women from 14 health facilities in Ghana. The intervention group (n = 877) received eight group sessions, while the control group (n = 884) received individual, routine care. Data were collected at baseline and post intervention. Pearson’s chi-square test was performed to examine categorical data, while odds ratios were calculated using separate logistic regression models to examine differences between the intervention and control groups over time. Women enrolled in group antenatal care had higher odds of following WHO recommendations to exclusively breastfeed for the first six months (odds ratio [OR]: 3.6, 95% confidence interval [95% CI]: 2.1, 6.3) and waiting to introduce solid food until six months of age (OR: 3.1, 95% CI: 1.5, 6.9). Our results found that women who participated in group antenatal care were more likely to follow the recommendations for exclusive breastfeeding developed by the WHO.

Background Although the majority of Ghanaian women receive antenatal care (ANC), many exhibit low health literacy by misinterpreting and incorrectly operationalizing ANC messages, leading to poor maternal and newborn health outcomes. Prior research in low-resource settings has found group antenatal care (G-ANC) feasible for women and providers. This study aims to determine the effect of G-ANC on increasing maternal health literacy. We hypothesized that pregnant women randomized into G-ANC would exhibit a greater increase in maternal health literacy than women in routine, individual ANC. Methods A 5-year cluster randomized controlled trial was conducted in 14 rural and peri-urban health facilities in the Eastern Region of Ghana. Facilities were paired based on patient volume and average gestational age at ANC enrollment and then randomized into intervention (G-ANC) vs. control (routine, individual ANC); 1761 pregnant women were recruited. Data collection occurred at baseline (T0) and post-birth (T2) using the Maternal Health Literacy scale, a 12-item composite scale to assess maternal health literacy. Logistic regression compared changes in health literacy from T0 to T2. Results Overall, women in both the intervention and control groups improved their health literacy scores over time ( p < 0.0001). Women in the intervention group scored significantly higher on 3 individual items and on overall composite scores ( p < 0.0001) and were more likely to attend 8 or more ANC visits. Conclusion While health literacy scores improved for all women attending ANC, women randomized into G-ANC exhibited greater improvement in overall health literacy post-birth compared to those receiving routine individual care. Life-saving information provided during ANC must be presented in an understandable format to prevent women and newborns from dying of preventable causes. Trial Registry Ethical approval for the study was obtained from the Institutional Review Boards of the University of Michigan (HUM#00161464) and the Ghana Health Service (GHS-ERC: 016/04/19).

The use of family planning (FP) methods significantly contributes to improved outcomes for mothers and their offspring. However, the use of FP remains low, particularly in low- and middle-income countries. A cluster randomized controlled clinical trial was implemented in Ghana, comparing group antenatal care (ANC) with routine care. The group ANC intervention included eight meetings where the seventh group meeting incorporated information and discussion regarding methods of FP. Data collection occurred at five time points: baseline (T0), 34 weeks' gestation (T1), 6-12 weeks post birth (T2), 5-8 months post birth, and 11-14 months post birth (T4). At T1, there was a significantly greater increase in the knowledge of FP methods as well as the intention to use FP after the birth among the intervention group. The uptake of FP was significantly higher in the intervention group for all post-birth timepoints except for T4 where the control group had significantly higher rates. The reasons for the diminishing effect are unclear. An increasing uptake of FP methods requires a multifaceted approach that includes increasing accessibility, knowledge, and acceptability as well as addressing societal and cultural norms.

Introduction Epilepsy is a prevalent neurological condition globally, especially in Sub-Saharan Africa. In Ghana, it is one of the top five causes of premature death and disability, impacting children’s neurological development and learning outcomes. Although 25% of epilepsy cases are preventable, many go undiagnosed and untreated. People with epilepsy face social stigma and rejection, hindering their ability to seek healthcare, employment, and social interactions, which worsens their self-esteem and social integration. Purposes The study aims to address the critical gaps in understanding and supporting people living with epilepsy (PLWE), through recording and analysing their experiences, and seeks to inform policy and practice, finally contributing to improve healthcare delivery, reduce stigma, and enhance support systems for PLWE. Methods A qualitative research design was employed for the study. Oral histories (OHs) were conducted with ten PLWE. These interviews encourage interviewees to focus on the life stories and experiences that mean the most to them and can be shared in their own words The interview questions were constructed in English and conducted in English, Twi, Ga and Dangme. Results The residents of Shai Osudoku and Ningo Prampram hold robust religious convictions and engage in profound spiritual practices as is the case throughout Ghana. When faced with health challenges, the PLWE and their caregivers often seek assistance from faith-based spiritual healers, including pastors or religious leaders, as their initial source of support and healing. These healers provide care by offering prayers, spiritual counselling, and incorporating various religious rituals into their healing practices. It was revealed that many PLWE, caregivers and community members perceived epilepsy differently. Some perceived it as a spiritual or demonic disease. Whilst others attributed to curse and disease of witches, idols, or gods. However, the healthcare practitioners perceived epilepsy as a medical condition. Also, it was found that individuals faced challenges, such as stigma and discrimination. Conclusion It is recommended that public education on epilepsy be intensified. Furthermore, there is the need to ensure that PLWE have access to improved healthcare to increase their quality of life.

Abstract Background Inappropriate antibiotic prescriptions are a known driver of antimicrobial resistance in settings with limited diagnostic capacity. This study aimed to assess the impact of diagnostic algorithms incorporating rapid diagnostic tests on clinical outcomes and antibiotic prescriptions compared with standard-of-care practices, of acute febrile illness cases at outpatient clinics in Shai-Osudoku and Prampram districts in Ghana. Methods This was an open-label, centrally randomized controlled trial in 4 health facilities. Participants aged 6 months to <18 years of both sexes with acute febrile illness were randomized to receive a package of interventions to guide antibiotic prescriptions or standard care. Clinical outcomes were assessed on day 7. Results In total, 1512 patients were randomized to either the intervention (n = 761) or control (n = 751) group. Majority were children aged <5 years (1154 of 1512, 76.3%) and male (809 of 1512, 53.5%). There was 11% relative risk reduction of antibiotic prescription in intervention group (RR, 0.89; 95% CI, .79 to 1.01); 14% in children aged <5 years (RR, 0.86; 95% CI, .75 to .98), 15% in nonmalaria patients (RR, 0.85; 95% CI, .75 to .96), and 16% in patients with respiratory symptoms (RR, 0.84; 95% CI, .73 to .96). Almost all participants had favorable outcomes (759 of 761, 99.7% vs 747 of 751, 99.4%). Conclusions In low- and middle-income countries, the combination of point-of-care diagnostics, diagnostic algorithms, and communication training can be used at the primary healthcare level to reduce antibiotic prescriptions among children with acute febrile illness, patients with nonmalarial fevers, and respiratory symptoms. Clinical Trials Registration NCT04081051.

Background An essential component to improving maternal and newborn outcomes is antenatal care. A trial of group antenatal care was implemented in Ghana where 7 health care facilities were randomized to be intervention sites and 7 control sites continued traditional antenatal care. Group antenatal care, where 10–14 women with similar due dates meet together for visits, includes traditional components such as risk assessment with increased opportunity for education and peer support. The study aim was to assess and report the process evaluation of the implementation of a group antenatal care intervention. Methods Process evaluation data were collected alongside intervention data and included both quantitative and qualitative data sources. Midwives at the health facilities which were randomized as intervention sites completed tracking logs to measure feasibility of the intervention. Research team members traveled to intervention sites where they conducted structured observations and completed fidelity and learning methods checklists to determine adherence to the model of group antenatal care delivery. In addition, midwives facilitating group antenatal care meetings were interviewed and focus groups were conducted with women participating in group antenatal care. Results In the majority of cases, midwives facilitating group antenatal care completed all components of the meetings with fidelity, following best practices such as sitting with the group rather than standing. Across 7 intervention sites, 7 groups (622 pregnant women) were documented in the tracking logs and of these participants, the majority (74%) attended more than half of the meetings, with 32% attending all 8 group meetings. Three themes were identified in both the midwife interviews and focus groups with pregnant women: 1) information sharing, 2) sense of community, and 3) time management challenges. An additional theme emerged from the focus groups with the women: women who had already given birth noticed a disconnect between what they learned and treatment received during labor and birth. Conclusion This process evaluation determined that group antenatal care can be implemented with fidelity in low and middle-income countries. Time management was the biggest challenge, however both midwives and pregnant women found the model of care not only acceptable, but preferable to traditional care. The knowledge shared and sense of community built during the meetings was a valuable addition to the individual model of antenatal care.

Introduction Many women worldwide cannot access respectful maternity care (RMC). We assessed the effect of implementing maternal and newborn health (MNH) quality of care standards on RMC measures.Methods We used a facility-based controlled before and after design in 43 healthcare facilities in Bangladesh, Ghana and Tanzania. Interviews with women and health workers and observations of labour and childbirth were used for data collection. We estimated difference-in-differences to compare changes in RMC measures over time between groups.Results 1827 women and 818 health workers were interviewed, and 1512 observations were performed. In Bangladesh, MNH quality of care standards reduced physical abuse (DiD −5.2;−9.0 to –1.4). The standards increased RMC training (DiD 59.0; 33.4 to 84.6) and the availability of policies and procedures for both addressing patient concerns (DiD 46.0; 4.7 to 87.4) and identifying/reporting abuse (DiD 45.9; 19.9 to 71.8). The control facilities showed greater improvements in communicating the delivery plan (DiD −33.8; –62.9 to –4.6). Other measures improved in both groups, except for satisfaction with hygiene. In Ghana, the intervention improved women’s experiences. Providers allowed women to ask questions and express concerns (DiD 37.5; 5.9 to 69.0), considered concerns (DiD 14.9; 4.9 to 24.9), reduced verbal abuse (DiD −8.0; −12.1 to –3.8) and physical abuse (DiD −5.2; −11.4 to –0.9). More women reported they would choose the facility for another delivery (DiD 17.5; 5.5 to 29.4). In Tanzania, women in the intervention facilities reported improvements in privacy (DiD 24.2; 0.2 to 48.3). No other significant differences were observed due to improvements in both groups.Conclusion Institutionalising care standards and creating an enabling environment for quality MNH care is feasible in low and middle-income countries and may facilitate the adoption of RMC.

Abstract Background The aim was to explore behavioral factors relating to the prescription and communication of prescription-adherence messages for patients with acute febrile illness, from which to develop a training-and-communication (T&C) intervention to be delivered as part of a clinical trial. Methods The study undertook a content analysis of primary, qualitative data collection using in-depth interviews and focus group discussions, informed by the Capability, Opportunity, Motivation (COM-B) theory of behavior, the Theoretical Domains Framework (TDF), and Behavior Change Wheel (BCW) approach, in health facilities (39 health workers) and communities (66 community members) in the Shai-Osudoku District of Ghana. Results Health workers perceive that prescribers' and dispensers' communication with patients is influenced by the following factors: patient’s educational level, existing disease conditions, health worker's workload, patient's religion, language barrier between health worker and patient, outcome of laboratory results, and medicine availability. Community members’ adherence to prescription was influenced by the availability of money and affordability of medicine (outside of provision by the national health insurance scheme), the severity of the condition, work schedule, and forgetfulness. Conclusions Our study contributes to knowledge on nesting qualitative methods in a clinical trial and reveals factors that affect the antibiotic prescription communication process. Tailored messages for patient-specific needs can shape antibiotic prescription adherence behavior and ultimately contribute to decreasing the incidence of antibiotic resistance.

IntroductionFacility interventions to improve quality of care around childbirth are known but need to be packaged, tested and institutionalised within health systems to impact on maternal and newborn outcomes.MethodsWe conducted cross-sectional assessments at baseline (2016) and after 18 months of provider-led implementation of UNICEF/WHO’s Every Mother Every Newborn Quality Improvement (EMEN-QI) standards (preceding the WHO Standards for improving quality of maternal and newborn care in health facilities). 19 hospitals and health centres (2.8M catchment population) in Bangladesh, Ghana and Tanzania were involved and 24 from adjoining districts served for ‘comparison’. We interviewed 43 facility managers and 818 providers, observed 1516 client–provider interactions, reviewed 12 020 records and exit-interviewed 1826 newly delivered women. We computed a 39-criteria institutionalisation score combining clinical, patient rights and cross-cutting domains from EMEN-QI and used routine/District Health Information System V.2 data to assess the impact on perinatal and maternal mortality.ResultsEMEN-QI standards institutionalisation score increased from 61% to 80% during EMEN-QI implementation, exceeding 75% target. All mortality indicators showed a downward trajectory though not all reached statistical significance. Newborn case-fatality rate fell significantly by 25% in Bangladesh (RR=0·75 (95% CI=0·59 to 0·96), p=0·017) and 85% in Tanzania (RR=0.15 (95% CI=0.08 to 0.29), p<0.001), but not in Ghana. Similarly, stillbirth (RR=0.64 (95% CI=0.45 to 0.92), p<0.01) and perinatal mortality in Tanzania reduced significantly (RR=0.59 (95% CI=0.40 to 0.87), p=0.007). Institutional maternal mortality ratios generally reduced but were only significant in Ghana: 362/100 000 to 207/100 000 livebirths (RR=0.57 (95% CI=0.33 to 0.99), p=0.046). Routine mortality data from comparison facilities were limited and scarce. Systematic death audits and clinical mentorship drove these achievements but challenges still remain around human resource management and equipment maintenance systems.ConclusionInstitutionalisation of the UNICEF/WHO EMEN-QI standards as a package is feasible within existing health systems and may reduce mortality around childbirth. Critical gaps around sustainability must be fundamental considerations for scale-up.

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.

Objective To assess respectful maternity care (RMC) in health facilities. Design Cross-sectional study. Setting Forty-three (43) facilities across 15 districts in Bangladesh, 16 in Ghana and 12 in Tanzania. Participants Facility managers; 325 providers (nurses/midwives/doctors)—Bangladesh (158), Ghana (86) and Tanzania (81); and 849 recently delivered women—Bangladesh (295), Ghana (381) and Tanzania (173)—were interviewed. Observation of 641 client–provider interactions was conducted—Bangladesh (387), Ghana (134) and Tanzania (120). Assessment Trained social scientists and clinicians assessed infrastructure, policies, provision and women’s experiences of RMC (emotional support, respectful care and communication). Primary outcome RMC provided and/or experienced by women. Results Three (20%) facilities in Bangladesh, four (25%) in Ghana and three (25%) in Tanzania had no maternity clients’ toilets and one-half had no handwashing facilities. Policies for RMC such as identification of client abuses were available: 81% (Ghana), 73% (Bangladesh) and 50% (Tanzania), but response was poor. Ninety-four (60%) Bangladeshi, 26 (30%) Ghanaian and 20 (25%) Tanzanian providers were not RMC trained. They provided emotional support during labour care to 107 (80%) women in Ghana, 95 (79%) in Tanzania and 188 (48.5%) in Bangladesh, and were often courteous with them—236 (61%) in Bangladesh, 119 (89%) in Ghana and 108 (90%) in Tanzania. Due to structural challenges, 169 (44%) women in Bangladesh, 49 (36%) in Ghana and 77 (64%) in Tanzania had no privacy during labour. Care was refused to 13 (11%) Tanzanian and 2 Bangladeshi women who could not pay illegal charges. Twenty-five (7%) women in Ghana, nine (6%) in Bangladesh and eight (5%) in Tanzania were verbally abused during care. Providers in all countries highly rated their care provision (95%–100%), and 287 (97%) of Bangladeshi women, 368 (97%) Ghanaians and 152 (88%) Tanzanians reported ‘satisfaction’ with the care they received. However, based on their facility experiences, significant (p<0.001) percentages—20% (Ghana) to 57% (Bangladesh)—will not return to the same facilities for future childbirth. Conclusions Facilities in Bangladesh, Ghana and Tanzania have foundational systems that facilitate RMC. Structural inadequacies and policy gaps pose challenges. Many women were, however, unwilling to return to the same facilities for future deliveries although they (and providers) highly rated these facilities.

Background In low- and middle-income countries (LMICs), the continuum of care (CoC) for maternal, newborn, and child health (MNCH) is not always complete. This study aimed to evaluate the effectiveness of an integrated package of CoC interventions on the CoC completion, morbidity, and mortality outcomes of woman–child pairs in Ghana. Methods and findings This cluster-randomized controlled trial (ISRCTN: 90618993) was conducted at 3 Health and Demographic Surveillance System (HDSS) sites in Ghana. The primary outcome was CoC completion by a woman–child pair, defined as receiving antenatal care (ANC) 4 times or more, delivery assistance from a skilled birth attendant (SBA), and postnatal care (PNC) 3 times or more. Other outcomes were the morbidity and mortality of women and children. Women received a package of interventions and routine services at health facilities (October 2014 to December 2015). The package comprised providing a CoC card for women, CoC orientation for health workers, and offering women with 24-hour stay at a health facility or a home visit within 48 hours after delivery. In the control arm, women received routine services only. Eligibility criteria were as follows: women who gave birth or had a stillbirth from September 1, 2012 to September 30, 2014 (before the trial period), from October 1, 2014 to December 31, 2015 (during the trial period), or from January 1, 2016 to December 31, 2016 (after the trial period). Health service and morbidity outcomes were assessed before and during the trial periods through face-to-face interviews. Mortality was assessed using demographic surveillance data for the 3 periods above. Mixed-effects logistic regression models were used to evaluate the effectiveness as difference in differences (DiD). For health service and morbidity outcomes, 2,970 woman–child pairs were assessed: 1,480 from the baseline survey and 1,490 from the follow-up survey. Additionally, 33,819 cases were assessed for perinatal mortality, 33,322 for neonatal mortality, and 39,205 for maternal mortality. The intervention arm had higher proportions of completed CoC (410/870 [47.1%]) than the control arm (246/620 [39.7%]; adjusted odds ratio [AOR] for DiD = 1.77; 95% confidence interval [CI]: 1.08 to 2.92; p = 0.024). Maternal complications that required hospitalization during pregnancy were lower in the intervention (95/870 [10.9%]) than in the control arm (83/620 [13.4%]) (AOR for DiD = 0.49; 95% CI: 0.29 to 0.83; p = 0.008). Maternal mortality was 8/6,163 live births (intervention arm) and 4/4,068 live births during the trial period (AOR for DiD = 1.60; 95% CI: 0.40 to 6.34; p = 0.507) and 1/4,626 (intervention arm) and 9/3,937 (control arm) after the trial period (AOR for DiD = 0.11; 95% CI: 0.11 to 1.00; p = 0.050). Perinatal and neonatal mortality was not significantly reduced. As this study was conducted in a real-world setting, possible limitations included differences in the type and scale of health facilities and the size of subdistricts, contamination for intervention effectiveness due to the geographic proximity of the arms, and insufficient number of cases for the mortality assessment. Conclusions This study found that an integrated package of CoC interventions increased CoC completion and decreased maternal complications requiring hospitalization during pregnancy and maternal mortality after the trial period. It did not find evidence of reduced perinatal and neonatal mortality. Trial registration The study protocol was registered in the International Standard Randomised Controlled Trial Number Registry ( 90618993 ).

BackgroundAntimicrobial misuse is common in low-income and middle-income countries (LMICs), and this practice is a driver of antibiotic resistance. We compared community-based antibiotic access and use practices across communities in LMICs to identify contextually specific targets for interventions to improve antibiotic use practices.MethodsWe did quantitative and qualitative assessments of antibiotic access and use in six LMICs across Africa (Mozambique, Ghana, and South Africa) and Asia (Bangladesh, Vietnam, and Thailand) over a 2·5-year study period (July 1, 2016–Dec 31, 2018). We did quantitative assessments of community antibiotic access and use through supplier mapping, customer exit interviews, and household surveys. These quantitative assessments were triangulated with qualitative drug supplier and consumer interviews and discussions.FindingsVietnam and Bangladesh had the largest proportions of non-licensed antibiotic dispensing points. For mild illness, drug stores were the most common point of contact when seeking antibiotics in most countries, except South Africa and Mozambique, where public facilities were most common. Self-medication with antibiotics was found to be widespread in Vietnam (55·2% of antibiotics dispensed without prescription), Bangladesh (45·7%), and Ghana (36·1%), but less so in Mozambique (8·0%), South Africa (1·2%), and Thailand (3·9%). Self-medication was considered to be less time consuming, cheaper, and overall, more convenient than accessing them through health-care facilities. Factors determining where treatment was sought often involved relevant policies, trust in the supplier and the drug, disease severity, and whether the antibiotic was intended for a child. Confusion regarding how to identify oral antibiotics was revealed in both Africa and Asia.InterpretationContextual complexities and differences between countries with different incomes, policy frameworks, and cultural norms were revealed. These contextual differences render a single strategy inadequate and instead necessitate context-tailored, integrated intervention packages to improve antibiotic use in LMICs as part of global efforts to combat antibiotic resistance.FundingWellcome Trust and Volkswagen Foundation.

IntroductionGhana adopted the revised WHO recommendation on intermittent preventive treatment in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP) in 2012. This study has assessed the effectiveness and safety of this policy in Ghana.MethodsA total of 1926 pregnant women enrolled at antenatal care (ANC) clinics were assessed for birth outcomes at delivery, and placental histology results for malaria infection were obtained from 1642 participants. Association of reduced placental or peripheral malaria, anaemia and low birth weight (LBW) in women who received ≥4 IPTp-SP doses compared with 3 or ≤2 doses was determined by logistic regression analysis.ResultsAmong the 1926 participants, 5.3% (103), 19.2% (369), 33.2% (640) and 42.3% (817) of women had received ≤1, 2, 3 or ≥4 doses, respectively. There was no difference in risk of active placental malaria (PM) infection in women who received 3 doses compared with ≥4 doses (adjusted OR (aOR) 1.00, 95% CI 0.47 to 2.14). The risk of overall PM infection was 1.63 (95% CI 1.07 to 2.48) in 2 dose group and 1.06 (95% CI 0.72 to 1.57) in 3 dose group compared with ≥4 dose group. The risk of LBW was 1.55 (95% CI 0.97 to 2.47) and 1.06 (95% CI 0.68 to 1.65) for 2 and 3 dose groups, respectively, compared with the ≥4 dose group. Jaundice in babies was present in 0.16%, and 0% for women who received ≥4 doses of SP.ConclusionThere was no difference in the risk of PM, LBW or maternal anaemia among women receiving 3 doses compared with ≥4 doses. Receiving ≥3 IPTp-SP doses during pregnancy was associated with a lower risk of overall PM infection compared with 2 doses. As there are no safety concerns, monthly administration of IPTp-SP offers a more practical opportunity for pregnant women to receive ≥3 doses during pregnancy.

Plasmodium falciparum in pregnancy is a major cause of adverse pregnancy outcomes. We combine performance estimates of standard rapid diagnostic tests (RDT) from trials of intermittent screening and treatment in pregnancy (ISTp) with modelling to assess whether screening at antenatal visits improves upon current intermittent preventative therapy with sulphadoxine-pyrimethamine (IPTp-SP). We estimate that RDTs in primigravidae at first antenatal visit are substantially more sensitive than in non-pregnant adults (OR = 17.2, 95% Cr.I. 13.8-21.6), and that sensitivity declines in subsequent visits and with gravidity, likely driven by declining susceptibility to placental infection. Monthly ISTp with standard RDTs, even with highly effective drugs, is not superior to monthly IPTp-SP. However, a hybrid strategy, recently adopted in Tanzania, combining testing and treatment at first visit with IPTp-SP may offer benefit, especially in areas with high-grade SP resistance. Screening and treatment in the first trimester, when IPTp-SP is contraindicated, could substantially improve pregnancy outcomes.

Objective: Rates of maternal and neonatal death remain high in the Global South, especially in SubSaharan Africa. In addition, indicators vary significantly by geography. This study aimed to understand what communities in northern Ghana with frequent maternal and newborn deaths or near deaths (nearmisses) perceive to be the causes. As part of a larger study, four communities in Ghana's Northern Region were identified as areas with high concentrations of deaths and near-misses of mothers and babies. Design: Stakeholders were interviewed using in-depth interviews (IDIs) and focus-group discussions (FGDs). Field workers conducted 12 FGDs and 12 IDIs across a total of 126 participants. Setting: This exploratory descriptive study was conducted in the East Mamprusi District in the Northern Region of Ghana, in the communities of Jawani, Nagboo, Gbangu and Wundua. Participants: FGDs were led by trained field workers and attended by traditional chiefs and their elders, members of women's groups, and traditional birth attendants in each of the four study communities. IDIs, or one-on-one interviews, were conducted with traditional healers who manage maternal and neonatal cases, community health nurses, and midwives. Measurements and findings: Qualitative data were audio-recorded, transcribed, and thematically analyzed using the Attride-Sterling analytical framework. Discussions focused on where blame should be attributed for the negative outcomes of mothers and babies - with blame either being directed at the actions or inactions of the mothers (behavioral), or at the larger factors associated with poverty (situational) that necessitate mothers' behavior. For example, some respondents blamed women for their poor diets, while others blamed the lack of money or household support to buy nutritious foods. Blame was rarely attributed to the fathers despite local gender norms of males being the household decision-makers with regard to spending and care-seeking. Key conclusions: These findings contribute to a small but growing body of literature on the blaming of mothers for their own deaths and those of their newborns - a phenomenon also described in highincome countries - and is supported by blame attribution theories that explain the self-protective nature of victim-blaming. Implications for practice: These results carry important implications for education and intervention design related to maternal and neonatal mortality, including more focused efforts at incorporating men and the larger community. More research is warranted on blame attribution for these adverse outcomes and its effects on the victims. (C) 2020 Elsevier Ltd. All rights reserved.

Background Pregnancy is an important period to promote healthy behaviors, prevent and identify diseases early and treat them to maximize the health and development of both the woman and her unborn child. A new World Health Organization antenatal care model recommends the initiation of antenatal care visit within the first trimester of gestation. This study sought to examine the timing of initiation of antenatal care among first-time mothers and associated factors in rural Southern Ghana. Methods Information on gestational age, timing of antenatal care, demographic and socioeconomic status of 1076 first-time mothers who gave birth in 2011 to 2013 in the Dodowa Health and Demographic Surveillance System were included in the study. The time of initiation of antenatal clinic attendance was calculated. The associations between dependent and independent variables were explored using logistic regression at 95% confidence interval in STATA version 14.2. Results The mean gestational age at which the first-time mothers initiated antenatal care attendance was 3 month. Maternal age, level of education and household socioeconomic status were statistically significantly associated with timing of initiation of antenatal care attendance. Conclusion Although more than half of the study participants initiated ANC visit in the first trimester of pregnancy, a high proportion also started ANC attendance after the World Health Organization recommended period. Maternal age is significantly associated with timing of initiation of antenatal care visit among first-time mothers; older women were more likely to initiate antenatal care visit in the first trimester of gestation compared to the younger women.