UNIVERSITY OF GHANA COLLEGE OF HEALTH SCIENCES CONTINUITY AND FRAGMENTATION OF ANTENATAL AND DELIVERY CARE IN THE VOLTA REGION OF GHANA BY SAMUEL KENNEDY KANGTABE DERY (ID. NO. 10235646) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF PhD PUBLIC HEALTH DEGREE SCHOOL OF PUBLIC HEALTH MARCH 2017 Declaration I hereby declare that this Ph.D. thesis entitled “Continuity and Fragmentation of Antenatal and Delivery Care in the Volta Region of Ghana”, and the work presented in it are my own and has been produced by me as the result of my own original research for the degree of Doctor of Philosophy in Public Health under the supervision of Prof. Moses K. S. Aikins and Dr. Ernest Tei Maya. I have faithfully and accurately cited all my sources, including books, journals, reports, unpublished manuscripts, as well as any other media, such as the Internet etc. ii Abstract Maternal mortality has over the years remained a global health issue with most of the deaths occurring in sub-Saharan Africa. With skilled antenatal care (ANC), many of these deaths can be prevented and as such skilled ANC attendance and skilled delivery have become key global indicators for measuring maternal health programmes across the world. The World Health Organization, until recently (2016) had recommended a minimum of 4 antenatal visits for pregnant women without any medical condition and whose pregnancies were progressing smoothly. This has since been updated to a minimum of 8 ANC contacts for a positive pregnancy experience. Ghana, over the years has been improving on the skilled ANC and delivery indicators with the 2014 Ghana Demographic and Health Survey (GDHS) showing that 87% of the pregnant women received the minimum 4 ANC visits, an increase from the 69% in 2003 while skilled delivery increased from 46% in 2003 to 74% in 2014. However, what remained unanswered is whether these ANC visits were made to several health facilities or to a single facility. In addition, it is unclear whether some pregnant women change their ANC facilities during delivery considering that labour and delivery constitute a critical point in the fight against maternal mortality, since complications during labour and delivery account for most of the maternal deaths in Ghana. In addition, though evidence from other studies show that some pregnant women receive care from multiple facilities, the extent of continuity and fragmentation of care during pregnancy and childbirth have not been quantified in Ghana. This study therefore sought to measure the level of longitudinal continuity and fragmentation of care during pregnancy and childbirth in the Volta Region of Ghana. iii Using National Health Insurance claims data for 2013 in the Volta Region, all the ANC and obstetrics data from all the facilities for the various months were merged into one file, deliveries were identified and classified as cesarean section or vaginal delivery. Visits of all the women that delivered were extracted from the data. Five continuity of care (CoC) indices (MFPC, MMCI, CoC, SECON and PDC) were calculated for each pregnant woman. Extent of repeat visits to each facility (provider continuity) and repeat visits to facilities in a district (district continuity) were calculated to represent the average of the proportion of visits that a facility/district got for all the women who visited the facility/district compared to other facilities/districts that those same women visited. Client-sharing between facilities and districts were identified. Two facilities shared a pregnant woman during ANC if the woman moves from facility of previous visit to the other facility of subsequent visit. A woman is said to have fragmented her care during delivery if she delivers at a facility different from where she sought most of her antenatal care. Five different types of network graphs were constructed using Gephi to help visualize the fragmentation of care among facilities and districts during ANC and delivery. A total of 14,474 pregnant women with a total of 92,095 visits (average of 5 visits per woman) were included in the study with 15.1% delivering by cesarean section (CS). The median maternal age was 27 and those that had CS were slightly older with a median age of 29. Although hospitals constituted 13% of the facilities in the study, they accounted for 73% of all visits and 83% of all deliveries. About 58% of all the pregnant women had perfect CoC: maintaining only one facility throughout ANC and delivery. There were medium to high levels of CoC among the various CoC indices (MFPC: 0.82 ±0.25; MMCI: 0.86 ±0.20; COC: 0.76 ±0.30; SECON: 0.80 ±0.28; PDC: 0.68 ±0.41). In addition, 32% of all the women and iv 78% of those that visited multiple facilities made less than three quarters of their visits to the most frequently visited facility. The average provider (facility) continuity and district continuity in the region were 67% and 81% respectively and varies by districts and type of provider. About 19% of all subsequent visits, 26% of all deliveries, 32% of all CS deliveries, 63% of all deliveries by women with multiple facilities, 73% of all CS deliveries by women with multiple facilities were fragmented among facilities. In addition, 15% of all deliveries (36% among those with multiple facilities) and 20% of all CS deliveries (45% among those with multiple facilities) were performed at facilities that the pregnant women did not receive any ANC services from. Nine percent (8.9) of all subsequent visits, 13% of all deliveries, 20% of all CS deliveries and 30.5% of all deliveries by women with multiple facilities were fragmented across districts. In addition, 51.6% of all deliveries performed at facilities that the pregnant women never received ANC services from were fragmented across districts. Despite the high levels of CoC among the pregnant women, there is high fragmentation during the critical period of labour and delivery among those who visited multiple facilities. This situation seems to be exacerbated by the fact that there is high preference for hospital delivery, resulting in high levels of fragmentation of care during delivery among the various care facilities and across districts in the region, and is even more profound in districts that do not have hospitals, with higher proportions of the women moving from these districts to other districts with hospitals for delivery services. There is therefore the need for concerted effort to guarantee continuity and coordination of care throughout the ANC and delivery period by requiring every pregnant woman to have a primary care provider who will be responsible and accountable for coordinating the care that she receives. v Dedication This work is dedicated to my wife Gabriella N. Dery, my daughters Jessica Bawapagranaa, Jenny Ngmenbuobo, Jacqueline Ngmentero and Joycelyn Song and to my mother Yvonne Dery and my late father Augustine Dery for all the love, support and prayers throughout this academic journey. vi Acknowledgement To God almighty be the glory. I am grateful to the almighty God for life, good health and His continuous guidance, blessings and protection in my life. I would like to express my sincere gratitude to my supervisors: Prof. Moses K. S Aikins and Dr. Ernest Tei Maya for their continuous support of my PhD study and related research, their mentorship, patience, motivation, and immense knowledge. Their professional guidance has been of great benefit throughout the research and writing of this thesis. My sincere thanks also goes to Prof. Richard Adanu (Dean of the School of Public Health), Prof. Thomas Robins, Dr. Cheryl Moyer, Dr. Kathleen Sienko, Dr. Qiaozhu Mei and Dr. Julia Adler-Milstein from the University of Michigan (US), and Dr. Elsie Effah Kauffman (University of Ghana) who provided the opportunity for me to study at the University of Michigan as part of the Ghana-Michigan Post-doctoral And Research Trainee Network (PARTNER II) fellowship during the second year of my PhD work. This project gave me the exposure and provided the foundation for me to undertake this research. I will forever be grateful for this opportunity. I am forever grateful to my family, my wife and children for all the patience, for the sleepless nights, prayers, encouragement and support throughout this journey. I would like to thank my parents, brothers and sisters for supporting me spiritually throughout writing this thesis and my life in general. I thank the Head of Department and staff of Biostatistics especially, and staff of the School of Public Health for the encouragement, support, critique and suggestions during the research work. I thank my fellow course mates for the stimulating discussions, encouragement and support throughout these four years. vii Table of Contents Abstract .................................................................................................................................... iii Dedication ................................................................................................................................. vi Acknowledgement ................................................................................................................... vii List of Abbreviations .............................................................................................................. xvi Operational Definitions ........................................................................................................... xix 1 Chapter 1: Introduction and Background