CATHARINE OWENS

Factors Associated with Maternal Mortality in Greater Accra Ghana 2016;

Case-Control Study

Public Health

Prospectus: Factors associated with Maternal Mortality in greater Accra Ghana 2016;

Case-control study

Problem Statement

Maternal death is defined as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes’’ (Menendez, Romagosa et al., 2008 p2). Though the causes and risk factors for maternal death are known and preventable, it is a major health problem concentrated in resource-poor regions of the world (Menendez, Romagosa et al., 2008) including Ghana. The reduction of maternal deaths is a key international development goal, therefore health policy and interventions targeted at significantly reducing it should be evidence-based (Khan, Wojdyla et al., 2006).

Ghana documented Maternal Mortality Ratio (MMR) of 350 per 100,000 live births for the year 2012 (Mahama 2013), however some districts for example Osu Klottey sub metro of the Accra Metropolitan area in its report recorded 428 maternal deaths per 100,000 live births at the end of 2012. This is a 39 percent increment on the 309 per 100,000 live births recorded in 2011. According to Addo and Gudu, 2017, the Accra Metropolitan Area, an urban and a commercial metropolis in the Greater Accra region has seen collaborative implementation of health policies and programs geared towards reducing maternal mortality over the past three years. Urban populations are mostly assumed to have access to quality to health care system than their rural counterparts (Addo and Gudu, 2017). However, urban health systems in many low income countries and lower middle income countries (LIC & MIC) have weak to non-existent public health structures (Coast, et al., 2012). They also lack uniform implementation strategies and inadequate infrastructure to improve population health (Coast, et al., 2012). Even though Ghana in collaboration with its development partners has implemented interventions to reduce maternal mortality to achieve the MDG 5 targets, institutional maternal mortality was very high in Osu Klottey Sub Metro for 2016 with majority (80%) of maternal deaths being antenatal clinic attendants (Mahama 2013), Although the causes of Maternal deaths are well established, knowledge on effective management of conditions has not translated into significantly improved outcomes (Coast, et al., 2012) Observations at health institutions in the Accra Metro, show that service delivery factors such as prenatal care coverage and the presence of a skilled attendant at delivery may play significant role in the mortalities and therefore need to be investigated to inform policy decisions if the (Sustainable Development Goal (SDG) goal 5 is to be met.

The causes of maternal deaths in Ghana follow the trends of the developing country with haemorrhage, hypertensive disorders, abortion related complication and septicemia leading the direct in that order (Mensah, Bentil et al., 2011) . This paper will seek to examine whether indeed the socio demographic and service delivery factors that have been associated with maternal mortality are accurate as regards the trends in maternal mortality with various interventions having been put in place.

Purpose

The purpose of this study is to describe and determine the socio-demographic and service delivery factors associated with maternal mortality in the Accra Metropolitan Area. The maternal mortality rates are not the same in every area and therefore the need to investigate whether there are factors that are exclusive to some demography’s.

Significance

Since Ghana missed out on achieving its Millennium Development Goal 5 (MDG 5) target, there has been renewed effort to achieve the Sustainable Development Goals on maternal death reduction, yet very little research has been done on the factors on whose intervention would yield the most impact. As Accra Metro is a high urbanized setting characterized by rural urban migration, with so much pressure on relatively few health facilities (Report 2016), policy makers need more information on the major risk factors in this setting to guide decision making and resource allocation. The information gathered would inform the Metro and Regional Health Directorate on other policy interventions to help reduce maternal death in the Metro. The positive social change implication is to improve the quality of institutional antenatal, intra-partum and post-partum service delivery in the Metropolis and add to the body of knowledge to reduce maternal death.

Background

Selected papers and works relating to factors associated with maternal mortality and how to improve outcomes in West Africa particularly Ghana are described below:

1. Menendez and Romagosa (2008) presented the causes and risk factors of maternal deaths as a major health problem in resource-poor regions of the world.

2. Addo and Gudu (2017) set out the various factors that are associated with the utilization of skilled sevice delivery among women that live in the rural part of northern Ghana.

3. Khan and Wojdyla (2006) demonstrated that reduction of maternal deaths is a key international development goal, therefore health policy and interventions targeted at significantly reducing it should be evidence-based.

4. Mahama (2013) reported that Ghana documented Maternal Mortality Ratio (MMR) of 350 per 100,000 live births for the year 2012.

5. Annual report at Accra Metropolitan area, Ghana (2016) documented 428 maternal deaths per 100,000 live births. This is a 39 percent increment on the 309 per 100,000 live births recorded in 2015

6. Coast and McDaid (2012) reported that urban populations are mostly assumed to have improved access to health care than their rural counterparts, however, urban health systems in many Low Income Countries and Lower Middle Income Countries have weak to non-existent public health structures and lack uniform implementation of strategies and necessary infrastructure.

7. UNICEF and WHO (2012) cited in Blencowe (2012) indicated that the sub-Saharan African region had Maternal Mortality Ratio of 500 deaths per 100,000 live births as the highest in the world. This has made the region a dangerous place to give birth.

8. Osotimehin (2012) reported maternal death preventable interventions. These include improving access to voluntary family planning, investing in health workers with midwifery skills, and ensuring access to emergency obstetrics care when complications arise.

9. Mensah and Bentil (2011) described the causes of maternal deaths in Ghana. It followed the trends of causes in developing country, with haemorrhage, hypertensive disorders, abortion related complication and septicemia leading the direct in that order.

Conceptual/Theoretical Framework

The conceptual/theoretical framework for this study encompasses the maternal socioeconomic, reproductive/obstetrics factors; disease, infection, social relationships, social inequalities, and social capital which are some of the most important concepts of social epidemiology (Krieger, 2011). Health systems weakness, service delivery factors and cultural factors that are associated with maternal death in this setting. The theory of social capital is very broad and has found a place in public policy, public health and more specifically in epidemiology. This theory is founded on several assertions. Chief among these assertions infers that social relationships are a determinant of health (Begum, Aziz-un-Nisa and Begum, (2003). The external environment and the daily social interactions and support systems play a pivotal role in an individual’s overall health. This theory is also found on the premise that poor social capital is one of the leading causes of physical and mental distress (Krieger, 2011). To elaborate, a strong social connection has been shown to lead to improved all-cause mortality rates. Lack of social connection can have an adverse impact on health outcomes. Moreover, social isolation can lead to the expression of negative social behavior, adverse physical responses, and mental distress.

Social epidemiologists are tasked with identifying the social aspects that affect the pattern of disease distribution and its mechanisms in a populace. Social relationships, social inequalities, and social capital are some of the most important concepts of social epidemiology. Krieger takes the position that social epidemiologists exploit indicators of 'life chances' such as occupation, skills and income which inform on social inequality. The underlying factors linked to social equality are the most important determinants of health. The knowledge, skills, and resources possessed by individuals are factors contributing to the social stratification and consequentially the health outcomes of a given population (Krieger, 2011). Research indicates a social gradient of health whereby most of the individuals with a lower socioeconomic position have been shown to have poor health (Krieger, 2011).

Social capital occurs at different levels. These include the macro-level (social, economic and political aspects of society), mesolevel (organizations and the neighborhood) and the individual context through social interactions. Many ecological studies conducted indicate a positive association between social capital and health outcomes (Mensah, Bentil, Adjepong and Dolo, 2011). The concept of social inequality is of fundamental importance to epidemiology and health research since it is evident that social factors such as level of education and income levels impact access to health and the quality of health care services in a particular region. Epidemiologists can capitalize on this premise to establish health patterns in a given population informed by the socio-economic status of the persons residing there. Social support structures influence help-seeking behavior, adherence to medical treatment and use of health care services (Pearce, 1996).

The theoretical aspects of social capital theory and factors behind them such as social inequalities, social capital, social relationships and work stress will form an integral part of my dissertation research. This is because this theory will to define the research question, elaborate the methodological issues, understand how social factors affect health care outcomes and tailor and implement interventions that address these problems. It is imperative to understand the effect of each of these social factors to maternal health and to answer the research questions below in order to meet the research objectives.

Social Cognitive Theory will be used to emphasize on triadic interaction that can be seen when it comes to individual, behavior, and environment. Many various ways can be employed to make changes in a person’s behavior and such expectation outcome are, self-efficacy, collective efficacy, self-regulation, facilitation and behavioral capability, observational learning, incentive motivation and moral disengagement. (Glanz, Rimmer & Viswanath, 2008).

Research Questions

· Is there a significant difference in survival rates between women in Accra who do and do not have health insurance?

· Is there a significant different in survival rates between women in Accra who do and do not have a median income above 30,000?

· Is there a significant difference in survival rates between women in Accra who do and do not have a high school diploma?

· Is there a significant difference in survival rates between women in Accra who are Married and those who are single?

· Is there a significant difference in survival rates between women in Accra who do deliver at the hospital or at home?

Nature of the Study

The nature of this study will be quantitative; an unmatched case control study. This is appropriate in determining the strength and direction of association between risk factors and maternal death. It would determine the odds ratio and adjusted odds ratio. My population will be women of child birth age living in Accra metropolitan area in Ghana. This work would provide further understanding on risk factors which when tackled would yield the greatest impact on reducing maternal deaths in our setting. The studies will analyze and utilize secondary data.

Possible Types and Source of Information or Data

1. Review medical records (folders) of cases and controls for the period of one year in a hospital.

2. Contact the Greater Accra epidemiologist to get the secondary data

3. Interview with the care supporters (or next of kin) of cases.

4. Interview with controls (clients that delivered in same facilities and survived).

5. Interview with health professionals who played significant roles in the management of cases or controls.

6. Interviews would be conducted using pre-tested structured questionnaires.

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