Abstract
ObjectivesTo explore the “how” and “why” of care decision making by frontline providers of maternal and newborn services in the Greater Accra region of Ghana and determine appropriate interventions needed to support its quality and related maternal and neonatal outcomes.MethodsA cross sectional and descriptive mixed method study involving a desk review of maternal and newborn care protocols and guidelines availability, focus group discussions and administration of a structured questionnaire and observational checklist to frontline providers of maternal and newborn care.ResultsTacit knowledge or ‘mind lines’ was an important primary approach to care decision making. When available, protocols and guidelines were used as decision making aids, especially when they were simple handy tools and in situations where providers were not sure what their next step in management had to be. Expert opinion and peer consultation were also used through face to face discussions, phone calls, text messages, and occasional emails depending on the urgency and communication medium access. Health system constraints such as availability of staff, essential medicines, supplies and equipment; management issues (including leadership and interpersonal relations among staff), and barriers to referral were important influences in decision making. Frontline health providers welcomed the idea of interventions to support clinical decision making and made several proposals towards the development of such an intervention. They felt such an intervention ought to be multi-faceted to impact the multiple influences simultaneously. Effective interventions would also need to address immediate challenges as well as more long-term challenges influencing decision-making.ConclusionSupporting frontline worker clinical decision making for maternal and newborn services is an important but neglected aspect of improved quality of care towards attainment of MDG 4 & 5. A multi-faceted intervention is probably the best way to make a difference given the multiple inter-related issues.
Highlights
Between 1990 and 2015, Millennium Development Goal (MDG) 4 calls for a reduction by 2/3 of the under-five mortality rate; and MDG 5 for a reduction by 3/4 of the maternal mortality ratio [1]
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript
Gaps identified in the quality of care given to pregnant women when they use health facilities include decisions on management, as well as information given to women by frontline providers [17]
Summary
Between 1990 and 2015, Millennium Development Goal (MDG) 4 calls for a reduction by 2/3 of the under-five mortality rate; and MDG 5 for a reduction by 3/4 of the maternal mortality ratio [1]. In Ghana, there is reasonable access to Antenatal Care (ANC) with about 95% of women 15 – 49 years receiving ANC from a skilled provider (value is 95.7% [7] in the Greater Accra region). Delivery by a skilled provider is lower with a national average of 59% [9], and 84.3% in the Greater Accra region [7]. A free maternal care policy was introduced in four regions of Ghana in 2003, and subsequently in 2005 to the whole country to reduce financial access barriers. Quality of service within facilities remained problematic, and is considered to be partly responsible for the persisting high national average maternal mortality rate (MMR) estimated at 451 per 100 000 live births and neonatal mortality rate (NMR) of 30 per 1,000 live births [14,15,16]. Gaps identified in the quality of care given to pregnant women when they use health facilities include decisions on management, as well as information given to women by frontline providers [17]
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