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Background: The COVID-19 pandemic has underscored the need for increased vaccine availability and uptake, with vaccine hesitancy posing a significant barrier, particularly among young adults. Evidence from various countries highlight high levels of hesitancy among young people, necessitating targeted interventions. Engaging young adults as key stakeholders in shaping public health strategies is crucial, as their perspectives can enhance vaccine acceptance. This study aimed to assess the overall acceptability of the COVID-19 vaccine among young people and to explore the factors influencing their willingness or reluctance to be vaccinated now and in the future., Methods: This study used qualitative data from 165 young adults in Nigeria, South Africa, and Zambia, to explore their suggestions for policies and strategies aimed at enhancing the acceptance of the Covid-19 vaccination among their age group. Data collection involved focus groups and interviews that explored participants' perceptions and recommendations regarding COVID-19 vaccination acceptability. Thematic analysis was used to analyse the data., Results: Thematic analysis identified several factors influencing vaccine acceptability among young people and suggested recommendations to improve it. The themes included developing targeted communication strategies for accurate vaccine information, offering alternative vaccination methods, promoting vaccine education in schools, and using trusted public figures to share accurate information., Conclusions: Persistent dissatisfaction with vaccine information dissemination underscores the need for more targeted communication strategies among young adults. Recommendations include developing non-injection vaccine options, incorporating vaccine education into school curricula and community programs, and leveraging influential public figures to build credibility. These insights are valuable for designing future programs to enhance vaccine acceptance among adolescents., Competing Interests: Declarations Ethics approval and consent to participate Ethical approval for this study was obtained from the Biomedical Research Ethics Committee of the University of the Western Cape (BM21/10/39). The research was conducted in accordance with the Declaration of Helsinki. We obtained written consent from all participants, with additional consent obtained from parents or guardians for participants under 18 years of age. Consent forms were translated into the relevant local languages and explained verbally to participants. As a token of appreciation for their involvement in the research, IDI participants received airtime compensation, while the FGD participants were provided with snacks and a hot meal and reimbursed for their transport expenses. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Antiretroviral therapy (ART) regimens in African countries, including Ghana, are often faced with the challenge of treatment default. To maximize ART utilization and efficiency among people living with HIV (PLHIV), it is pertinent to ensure that ART-related challenges that clients encounter are identified and addressed holistically. A phenomenological qualitative study of thirty participants recruited through the purposive sampling technique was conducted using in-depth interviews from June to July 2021. Independent coding was done using Atlas ti. Sub-themes were developed from the codes, using the most expressive phrases, and grouped under two broad themes, challenges, and opportunities to maximise ART uptake. Ten different challenges, grouped into the health system and individual constraints were reported. Health system constraints included stigmatisation and discrimination by healthcare workers, queuing outside while waiting to be served, long waiting periods, non-communication of laboratory test results to clients, lack of proper education on side effects associated with ART, and language barrier. Individual constraints included financial constraints, perceived non-improvement in health outcomes, food insecurity, and forgetfulness. Opportunities identified for improved ART uptake were assuring ART clients of improved health outcomes, leveraging the good rapport between ART clients and healthcare providers, leveraging the better counselling services offered to PLHIV at the ART clinic, provision of varied ART treatment regimens to clients, routine communication of laboratory test results to clients, and leveraging clients' satisfaction with ART services at ART clinic. We recommend health system reforms targeting healthcare service delivery to PLHIV to encourage linkage, continuity, and retention in care and augmenting ART regimes with financial and nutritional support while encouraging status disclosure to a trusted family member., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Background: Antenatal healthcare (ANC) reduces maternal and neonatal deaths in low-middle-income countries. Satisfaction with ANC services and perception of quality of care are critical determinants of service utilization. The study aimed to assess pregnant women's satisfaction with ANC and identify sociodemographic factors associated with satisfaction and their continued willingness to use or recommend the facility to relatives or friends, in Lusaka district, Zambia., Methods: This was a cross-sectional study involving 499 pregnant women in Lusaka district. A combination of stratified, multistage, and systematic sampling procedures was used in selecting health facilities and pregnant women. This allowed the researcher to assess exposure and status simultaneously among individuals of interest in a population. Structured survey instruments and face-face-interview techniques were used in collecting data among pregnant women who were receiving ANC in selected health facilities., Results: Overall, the proportion of pregnant women who were fully satisfied with ANC was 58.9% (n = 292). Pregnant women's satisfaction score ranged from physical aspects (40.9 - 58.3%), interpersonal aspects (54.3 - 57.9%) to technical aspects of care (46.9 - 58.7%). Husbands' employment status (OR = 0.611, 95%CI = 0.413 - 0.903, p = 0.013), monthly household income level of > 3000 - ≤6000 Kwacha (OR = 0.480, 95%CI = 0.243 - 0.948, p = 0.035 were significantly associated with the interpersonal aspects and the physical aspects of care, respectively. Besides, pregnant women who were in their third trimester (above 33 weeks), significantly predicted satisfaction with the physical environment of antenatal care (OR = 3.932, 95%CI = 1.349 - 11.466, p = 0.012). In terms of the type of health facility, women who utilized ANC from Mtendere (OR = 0.236, 95% CI = 0.093 - 0.595, p = 0.002) and N'gombe (OR = 0.179, 95% CI = 0.064 - 0.504, p = 0.001) clinics were less satisfied with the physical environment of care. Place of residence and educational attainment showed significant association with 'willingness to return'. N'gombe clinic (n = 48, 77.4%) received the lowest consideration for 'future care'., Conclusion: Drawing on Donabedian framework on assessing quality of healthcare, we posit that pregnant women's satisfaction with the quality of antenatal care was low due to concerns about the physical environment of health facilities, the interpersonal relationships between providers and pregnant women as well as the technical aspects of care. All these accounted for pregnant women's dissatisfaction with the quality of care, and the indication of unwillingness to return or recommend the health facilities to colleagues. Consistent with Donabedian framework, we suggest that the codes and ethics of healthcare must be upheld. We also call for policy initiatives to reshape the physical condition of ANC clinics and to reinforce healthcare providers' focus on the 'structures' and the 'processes' relevant to care in addition to the 'outcomes'., (© 2023. The Author(s).)

Background: The double burden of malnutrition among children remains a public health challenge in South Africa. In response, the government of South Africa developed the National Health Policy and Implementation Guidelines for school-going children in 2003. This policy was subsequently upgraded to 'The Integrated School Health Programme' in 2012. An element of the programme is the provision of a meal to school-going children on school days. However, evidence suggests that one-third of school-going children continue to have nutritional deficiencies. This study investigated the sociodemographic as well as the nutritional characteristics of school-going children participating in a school health initiative in KwaZulu-Natal Province, South Africa., Methods: This was a retrospective descriptive cross-sectional study involving 1,275 children (50.3% females and 49.7% males) aged 3 to 15 years. Epidemiological data on the screening of the children's nutritional characteristics by school health nurses and school health nutritionists under the integrated school health programme (ISHP) was reviewed and analysed for the study., Results: Nearly half (50.3%) and 49.7% of the population were females and males, respectively. The average age of participants was 8.4 years old. 'Underweight' (p = 0.000), 'overweight' (p = 0.000), 'at risk of overweight' (p = 0.000),'stunting' (p = 0.000),'severe stunting' (p = 0.005), 'wasting' (p = 0.010), and 'obesity' (p = 0.037) were associated with the 'schools that children attended'. School-going children' living conditions were significantly associated with 'normal weight' (p = 0.000), 'underweight' (p = 0.000), and 'underweight' (p = 0.028). However, the social grant to parents/guardians had some positive effects on the percentage of children who reported 'normal weight' (55.4%), 'wasting' (1.0%), 'underweight' (4.0%), and 'at risk of overweight' (20.2%)., Conclusion: Chronic nutritional deficiencies persist among children. Therefore, ISHP implementation must retarget specific regions of the country to ensure that national goals and gains on school-going children nutrition, are met and maintained. Indeed, considering the positive impact of the government's social grant programme on the nutritional status of the children in this study, we recommend policy reforms that will increase parents' and carers' access to means of subsistence in order to meet the health and nutritional needs of children in the study communities., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Modern contraceptive refers to "a product or medical procedure that interferes with reproduction from acts of sexual intercourse". The aim of this study was to assess the relationship between residential status and wealth quintile, and modern contraceptive use among women in Ghana., Methods: We examined residential status and wealth quintile on contraceptive use analysing the 2006, 2011 and 2018 Multiple Indicator Cluster Surveys datasets. A sample of 30,665 women in their reproductive ages (15-49 years) were enrolled in the surveys across Ghana. STATA version 13 was used to process and analyse the data. It examined socioeconomic and demographic characteristics, assessed modern contraceptive use prevalence among women, and used logistic regression models to determine predictors. The results were presented in odds ratio and adjusted odds ratio with 95% confidence intervals. All statistical tests were measured with p < 0.05., Results: In the three survey years, the highest prevalence of modern contraceptive usage was observed in 2011 (27.16%). The odds of using modern contraceptive increased by 19% in rural places (AOR = 1.19; 95% CI = 1.097-1.284) compared to urban places. The likelihood of women in second (AOR = 1.17; 95% CI = 1.065-1.289), middle (AOR = 1.24; 95% CI = 1.118-1.385), and fourth (AOR = 1.25; 95% CI = 1.113-1.403) wealth quintile using contraceptives increased compared to those of low wealth quintile. With the interactive terms, rural-second (AOR = 1.38; 95% CI = 1.042-1.830), rural-middle (AOR = 1.45; 95% CI = 1.084-1.933), rural-fourth (AOR = 1.52; 95% CI = 1.128-2.059), and rural-high (AOR = 1.42; 95% CI = 1.019-1.973) were more likely to use contraceptives compared to urban-low women. Despite lower odds, women of the age groups 20-24 (AOR = 2.33; 95% CI = 2.054-2.637), cohabitaing (AOR = 1.07; 95% CI = 0.981-1.173), secondary or higher education (AOR = 1.55; 95% CI = 1.385-1.736), Central (AOR = 1.48; 95% CI = 1.296-1.682) and Eastern (AOR = 1.48; 95% CI = 1.289-1.695) regions significantly predicted modern contraceptive use., Conclusion: Modern contraceptive use in Ghana is low. Women in rural-rich categories are more likely to use modern contraceptives. Background factors such as age, marital status, educational attainment, and previous child experiences predict modern contraceptive use. It is recommended for the intensification of contraceptive awareness and utilization for all reproductive age women, regardless of education, marriage, or wealth., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Efforts to move towards universal health coverage (UHC) aim to rebalance health financing in ways that increase efficiency, equity, and quality. Resource constraints require a shift from passive to strategic purchasing (SP). In this paper, we report on the experiences of SP in public sector health insurance schemes in nine middle-income countries to understand what extent SP has been established, the challenges and facilitators, and how it is helping countries achieve their UHC goals., Methods: We conducted a systematic search to identify papers on SP. Nine countries were selected for case study analysis. We extracted data from 129 articles. We used a common framework to compare the purchasing arrangements and key features in the different schemes. The evidence was synthesised qualitatively., Results: Five countries had health technology assessment (HTA) units to research what services to buy. Most schemes had reimbursement mechanisms that enabled some degree of cost control. However, we found evidenced-based changes to the reimbursement mechanisms only in Thailand and China. All countries have some form of mechanism for accreditation of health facilities, although there was considerable variation in what is done. All countries had some strategy for monitoring claims, but they vary in complexity and the extent of implementation; three countries have implemented e-claim processing enabling a greater level of monitoring. Only four countries had independent governance structures to provide oversight. We found delayed reimbursement (six countries), failure to provide services in the benefits package (four countries), and high out-of-pocket (OOP) payments in all countries except Thailand and Indonesia, suggesting the schemes were failing their members., Conclusion: We recommend investment in purchaser and research capacity and a focus on strong governance, including regular engagement between the purchaser, provider and citizens, to build trusting relationships to leverage the potential of SP more fully, and expand financial protection and progress towards UHC., (© 2023 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Objective: Despite the growing literature on the barriers to contraceptives use among women, the perspective of female head porters has not been exhaustively researched. Using Bronfenbrenner's socio-ecological theory, we explore the factors that influence the contraceptive decision-making of migrant female head porters in the Kumasi Metropolis and the implications for health policy and planning., Methodology: A case study of female head porters in the Kumasi Metropolis was conducted. We employed a qualitative approach in the collection and analysis of the data. A combination of cluster, purposive, and convenience sampling procedures was used to select 48 migrant female head porters to participate in semi-structured in-depth interviews. The data collected were analyzed using the thematic analytical framework., Results: We found the main barriers to the uptake of contraception among the head porters to include high cost of contraceptives, perceived side effects associated with contraceptive use, and the disapproval of a male sexual partners., Conclusion: The findings indicate that head porters' contraceptive decision-making is largely influenced by their social and economic circumstances. To address these, we recommend a carefully tailored approach, starting with a free National Health Insurance Scheme (NHIS) enrollment policy for all head porters in the country. There is also the need for the Ghana Health Service, and NGOs in health to work together to create effective awareness among female head porters on the benefits and misconceptions of contraception by incorporating culturally appropriate education that would facilitate the adoption of positive attitudes towards contraception. Additionally, NGOs in health in collaboration with the health facilities should initiate a process that encourages joint reproductive health decision-making among partners which recognises the added value of men's participation. We argue that men's active participation in contraception decision-making could potentially address their scepticism towards uptake., Competing Interests: The authors declare no conflict of interest., (© 2022 The Author(s).)

Universal Health Coverage (UHC) as a health policy goal is gaining added currency in the policy agendas of many Low and Middle-Income Countries (LMIC) following the onslaught of the coronavirus (COVID-19) pandemic. The goal of UHC is to ensure that every citizen has access to quality healthcare services that they need without suffering financial hardship. Whereas most industrialised countries have achieved UHC through the implementation of various traditional health financing mechanisms, most LMIC have not made significant progress in providing financial protection against the costs of illness for majority of the population due to limited fiscal space and or lack of political commitment to raise government revenues and increase fiscal space for health. While the onslaught of COVID-19 refreshes the call for reform of countries' health financing policies to reflect the healthcare needs of the population, the debate about the type or combination of health financing models to employ in LMIC has yet to reach a consensus. This review critically analyses five health financing models to ascertain their appropriateness in providing financial risk protection against the cost of illness, especially in this era of COVID-19. Given the limited fiscal space for health in LMICs, we argue that one viable pathway towards achieving UHC is the adoption of an adaptive mix of diverse pooling mechanisms. Moreover, because the creation of fiscal space is context-specific, and UHC is a political issue rather than technical, securing strong political support is necessary for improving the governance and institutional frameworks for health and ensuring sustained economic growth to respond to the fiscal demands of health systems., (© 2022 John Wiley & Sons Ltd.)

Background: Over the years, governments and stakeholders have implemented various policies/programmes to improve maternal health outcomes in low-middle-income countries. In Ghana, Community Health Officers were trained as midwives to increase access to skilled maternal healthcare. The government subsequently banned traditional birth attendants from providing direct maternal healthcare in 2000. Despite these, there is an unprecedented utilisation of TBAs' services, including herbal uterotonics. This has attempted to defeat stakeholders' campaigns to improve maternal health outcomes. Thus, we explored and highlighted herbal uterotonic consumption in pregnancy and birth and the implications on maternal and newborn health outcomes in North-Western Ghana., Methods: This was an exploratory qualitative study that investigated traditional birth attendants (n = 17) and healthcare providers' (n = 26) perspectives on the intake of herbal uterotonics in pregnancy and childbirth in rural Ghana, using in-depth interviews. A combination of convenience, purposive and snowball sampling procedures were employed in selecting participants., Results: Findings were captured in two domains: (1) perceived rationale for herbal uterotonic intake, and (2) potential adverse impacts of herbal uterotonic intake in pregnancy and labour, and nine topics: (i) confidence in unskilled attendance at birth, (ii) cost and a shortage of essential medicines, (iii) herbal uterotonics as a remedy for obstetric problems, (iv) herbal uterotonics facilitate birth, (v) attraction of home birth for cultural reasons, (vi) affordability of herbal uterotonics, (vii) unintended consequences and adverse outcomes, (viii) risks using herbal uterotonics to manage fertility and (ix) risks using herbal uterotonics to facilitate home birth., Conclusion: The findings have suggested that the intake of non-conventional herbal uterotonic is widespread in the study area, although the constituents of the herb are unknown. However, complex and multiple factors of healthcare cost, desire for homebirth, unawareness of the negative effects of such substances, perceived way of addressing obstetric problems and cultural undertones, among others, accounted for herbal uterotonics consumption. We also encourage research into the constituents of 'mansugo' and the potential benefits and adverse effects. We recommend qualitative studies involving previous users of this herbal uterotonic to inform policy and healthcare provision., (© 2022. The Author(s).)

Despite a growing burden of stroke in low-middle-income countries, research on patient's experiences and access to rehabilitation services remains limited. This study explores the experiences of stroke patients in relation to access and use of stroke rehabilitation services, coping strategies and strategies to improve care in Ghana. A cross-sectional study was conducted. A total of 136 adult stroke patients hospitalised and subsequently discharged in three major referral hospitals in Ghana participated in the study. A paper-based questionnaire was used to collect data. Data were inputted into STATA version 12, cleaned and analysed using descriptive statistics and Chi-Square tests. Findings showed that stroke patients experience stroke differently. Early detection (awareness) of stroke symptoms at onset was low (29.4%). Hypertension was the major (58.1%) predisposing risk factor for stroke, followed by diabetes (14.7%). Multiple barriers impede access to outpatient rehabilitation services: high cost of medications (43.4%), transportation constraints (10.3%), long waiting time (6.6%), forgetfulness about appointment (4.4%), limited education on rehabilitation (20.6%), lack of community support (12.5%) and ineffective communication with healthcare providers (5.2%). Recommended strategies to improve access to rehabilitation care included public education on stroke and its associated risk, reduction in the cost of drugs and increased stroke rehabilitation funding by the NHIS, especially for physiotherapy consultation and training support to caregivers on patient care. Given the difference in stroke experience and barriers in accessing rehabilitation care, multi-level health policy and service delivery reforms are needed to improve access to rehabilitation care, including national public awareness campaigns on early signs of stroke and subsidised cost of stroke rehabilitation., (© 2020 John Wiley & Sons Ltd.)

Background: Maternal mortality remains a significant public health challenge in many low and middle-income countries, including Ghana. From Ghana's 2017 Maternal Health Survey verbal autopsy data, we examined the predictors of maternal mortality in Ghana., Methods: A total of 1240 deaths of women aged 15-49 were involved in the survey across all regions in Ghana. Binary and multivariate logistic regression analyses were employed; confidence level was set at 95%., Results: The results show that the prevalence of maternal death was 13.2% (164/1240). After adjusting for potential covariates, women aged 20-29 years (aOR = 4.270, 95%CI= 1.864 - 9.781, p=0.001), bled during labour/delivery (aOR= 0.241, 95%CI = 0.059 - 0.992, p=0.049), and those who used traditional/herbal medicines during pregnancy were more likely to die compared to non-users (aOR= 3.461, 95%CI = 1.651 - 7.258, p=0.001)., Conclusion: Our findings highlight the need to intensify maternal education regarding the value to be gained by increasing skilled healthcare during complications in pregnancy to allow effective management of complications during labour/delivery. Also, education for pregnant women and their families on possible adverse effects of using unapproved traditional/herbal medicines during pregnancy as well as a need to seek timely care before the onset of labour to allow healthcare providers ample opportunity to address labour and birth complications, is urgently required., (© 2020 John Wiley & Sons Ltd.)

Background: Previous research has highlighted widespread public mis/perceptions that portray women with disabilities (WWDs) as asexual, less likely to marry, and often not interested in childbearing. However, evidence from high-income settings shows that many WWDs are sexually active and do have or want to have children. Notwithstanding this, very few studies have focused on understanding childbearing desires and motivations among WWDs in low-income settings. This qualitative research explored childbearing desires and motivations among WWDs in Ghana., Methods: A cross-sectional qualitative study was conducted with WWDs aged 18-49 years in Northern Ghana. The distribution of participants by disability types were as follows: physical disability/impairment (n = 37); visual impairment (n = 11); speech and hearing impairment (n = 14); epilepsy (n = ten); and albinism (n = five). A pre-tested open-ended thematic topic guide was designed and used to conduct in-depth interviews. Interviews were tape-recorded and later transcribed for analysis. Transcripts were coded using QSR NVivo 11 software. Thematic content analysis techniques were used to analyse and present the data., Results: Nearly all the WWDs interviewed were sexually active, desiring to have children, and intended to have as many children as they could support. Strong desire to experience the joy of motherhood; fear of social insecurity; fear of old age economic insecurity; desire to challenge stigma and negative stereotypes about disability, sexuality and motherhood; and desire for self-actualisation, were key motivations for childbearing., Conclusion: Our findings challenge existing negative public perceptions about the status of WWDs in relation to sexuality, childbearing and motherhood. More importantly, our findings suggest that if the Sustainable Development Goals related to universal access to sexual and reproductive healthcare are to be attained, WWDs must be targeted with quality sexual and reproductive healthcare information and services.

Background: Despite the many maternal healthcare policy programmes in Ghana such as free the antenatal care (ANC) and the fee-exemption policy under the National Health Insurance Scheme, among others, the country has yet to make substantial improvements in addressing low skilled care utilisation in pregnancy and delivery. From previous studies, maternal mortality has been linked to women's healthcare decision-making power at the household level in many low and middle-income countries. Thus, a pregnant women's ability to choose a healthcare provider, act on her preferences, and to be sufficiently financially empowered to take the lead in deciding on reproductive and pregnancy care has significant effects on service utilisation outcomes. Therefore, we explored rural community-level barriers to seeking care related to obstetric complications and delivery from the perspectives of mothers, youth, opinion leaders and healthcare providers in Nadowli-Kaleo and Daffiama-Bussie-Issa districts in the Upper West Region of Ghana., Methods: This exploratory qualitative study was based on the narratives of women, health providers and community stakeholders regarding the expectant women's autonomy to decide and utilise maternal care. To achieve maximal diversity of responses, purposive sampling procedures were followed in selecting 16 health professionals, three traditional birth attendants and 240 community members (opinion leaders, youth and non-pregnant women) who participated in individual depth interviews and focus group discussions., Results: Women's lack of autonomy to seek care without prior permission, perceived quality care of traditional birth attendants, stigmatisation of unplanned pregnancies and cultural beliefs associated with late disclosure of childbirth labour all delayed mothers timely use of skilled care in the study communities. These barriers compounded problems arising from communities that are geographically isolated from hospital care., Conclusions: Decisions about seeking maternal care were usually made by the expectant woman's husband and family without providing adequate support to pregnant women during the latter stages of pregnancy and delivery. We conclude that this is primarily a cultural issue. The study recommends a change in the approach to community-level health education campaigns for maximum impacts through the increased involvement of men and families in health service delivery and utilisation.

Objectives: In considering explanations for poor maternal and newborn health outcomes, many investigations have focused on the decision-making patterns and actions of expectant mothers and families, as opposed to exploring the 'supply side' (health service provider) barriers. Thus, we examined the health system factors impacting on access to and delivery of quality maternal and newborn healthcare in rural settings., Design: A semistructured qualitative study using face-to-face in-depth interviews with health professionals, and focus group sessions with community members, in eight project sites in two districts of Upper West Region, Ghana, was employed. Participants were purposively selected to generate relevant data to help address the study objective. The survey was guided by WHO standard procedures and Ghana Health Ministry's operational work plan for maternal and newborn care., Setting: Nadowli-Kaleo and Daffiama-Bussie-Issa districts in Upper West Region, Ghana., Participants: Two hundred and fifty-three participants were engaged in the study through convenient and purposive sampling: healthcare professionals (pharmacist, medical doctor, two district directors of health services, midwives, community health and enrolled nurses) (n=13) and community members comprising opinion leaders, youth leaders and adult non-pregnant women (n=240 in 24 units of focus groups)., Results: Results show significant barriers affecting the quality and appropriateness of maternal and neonatal health services in the rural communities and the Nadowli District Hospital. The obstacles were inadequate medical equipment and essential medicines, infrastructural challenges, shortage of skilled staff, high informal costs of essential medicines and general limited capacities to provide care., Conclusion: Implementation of the birth preparedness and complication readiness strategy is in its infancy at the health facility level in the study areas. Increasing the resources at the health provider level is essential to achieving international targets for maternal and neonatal health outcomes and for bridging inequities in access to essential maternal and newborn healthcare., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Despite decades of implementation of maternity healthcare programmes, including a focus on increasing the use of antenatal care (ANC) and concomitant birth preparedness and complication readiness (BPCR), the uptake of ANC continues to be below expectations in many developing countries. This has attendant implications for maternal and infant morbidity and mortality rates. Known barriers to ANC use include cost, distance to health care services and forces of various socio-cultural beliefs and practices. As part of a larger study on BPCR in rural Ghana, this paper reflects on the use of ANC in the study areas from rights-based and maternal engagement theoretical perspectives, with a focus on the barriers to ANC use., Methods: Mixed methods approach was adopted to collect data from 8 study communities from individual in-depth interviews with 80 expectant mothers and 13 health care professionals, and 24 focus groups comprising 240 community members. The qualitative data followed a thematic analytical method, while the quantitative data was analysed using descriptive statistics., Results: The average number of ANC visits were 3.34±1.292, and the majority of expectant mothers (71.3%) enrolled for ANC at the 8th week or later, with the longest delay recorded at the 6th month of gestation. Traditional norms significantly influenced this delay. Likewise, overall use of ANC during pregnancy was shaped by cultural factors related to perceptions of pregnancy, gender-based roles and responsibilities and concerns that ANC would result in an overweighed baby and culturally inappropriate delivery at a health care facility., Conclusion: Greater understanding of the sociocultural barriers to ANC is essential if proposed changes in community-specific health education programs are to facilitate early commencement and increased use of ANC.

Background: Maternal and neonatal morbidities and mortalities have received much attention over the years in sub-Saharan Africa; yet addressing them remains a profound challenge, no more so than in the nation of Ghana. This study focuses on finding explanations to the conditions which lead to maternal and neonatal morbidities and mortalities in rural Ghana, particularly the Upper West Region., Method: Mixed methods approach was adopted to investigate the medical and non-medical causes of maternal and neonatal morbidities and mortalities in two rural districts of the Upper West Region of Ghana. Survey questionnaires, in-depth interviews and focus group discussions were employed to collect data from: a) 80 expectant mothers (who were in their second and third trimesters, excluding those in their ninth month), b) 240 community residents and c) 13 healthcare providers (2 district directors of health services, 8 heads of health facilities and 3 nurses)., Result: Morbidity and mortality during pregnancy is attributed to direct causes such urinary tract infection (48%), hypertensive disorders (4%), mental health conditions (7%), nausea (4%) and indirect related sicknesses such as anaemia (11%), malaria, HIV/AIDS, oedema and hepatitis B (26%). Socioeconomic and cultural factors are identified as significant underlying causes of these complications and to morbidity and mortality during labour and the postnatal period. Birth asphyxia and traditional beliefs and practices were major causes of neonatal deaths., Conclusion: These findings provide focused targets and open a window of opportunity for the community-based health services run by Ghana Health Service to intensify health education and promotion programmes directed at reducing risky economic activities and other cultural beliefs and practices affecting maternal and neonatal morbidity and mortality.