Identifying Successful Lessons in Reducing Neonatal Mortality in Ghana
Kristin Watkoske, B.S, MPHc
School of Health Sciences
Masters of Public Health Program
Faculty Mentor: Kwame Sakyi, PhD, MSPH
School of Health Sciences
Masters of Public Health Program
My name is Kristin Watkoske and I am a first year Masters of Public Health (MPH) student at Oakland University. I am currently maintaining a 3.73 GPA and began my studies in the Fall of 2017. I graduated from Grand Valley State University with a B.S. in Allied Health Sciences. Since beginning my program, I have been an active member of Oakland University's Public Health Professionals organization, Oakland Public Health Advisory Board (PHAB), and American Public Health Association (APHA). I am also a graduate assistant with Dr. Caress Dean conducting research on cardiovascular disease.
My interest in working in Africa has grown for the past several years, as I was once interested in joining the Peace Corps between my undergraduate and graduate school opportunities. Although I was not ultimately chosen for that adventure, my passion has continued to grow—especially my desire to work in Africa doing research and educating individuals on preventative techniques. This experience will provide me with first-hand experience in both of those areas, with the added bonus of working in Africa. This research project aligns with the core of the MPH program at Oakland University because they both focus on community-based approaches to solve critical health issues. The project will allow me to translate what I have learned from the MPH program into the real world.
After graduating, I look forward to working with an international non-profit organization. This Provost Student Research Award will provide me with the opportunity to prepare myself for the workforce. Many international organizations require experience from a low-to-middle income country. This project gives me experience in the required setting and also teaches me community engagement, and research management that I can utilize in the workforce. Additionally, this project gives me the opportunity to network with other students and researchers in the global health sector. This is important because these connections potentially could lead me to new research opportunities or potential jobs opportunities in the future. This opportunity aligns with Oakland University’s initiative to foster international research, and collaboration in and outside of the University.
This Provost Student Research Award will not only strengthen my professional development and expand my network, but it also allows me to be on the forefront of research to save more newborn lives.
Introduction: Neonatal death rates in Ghana have declined at a much slower pace over the past two decades compared to infant and under-five death rates. The Northern Region of Ghana has decreased neonatal mortality by 67% between 1993-2014. However, other regions in Ghana have only decreased rates ranging from 0.07% to 25%.
Goals: The goal of the project is to identify key factors at national, regional, and community levels that led to the observed variation in reduction of neonatal deaths between regions of Ghana.
Methods: With a team of researchers in Ghana, qualitative semi-structured interviews will be conducted with 30-40 participants possessing experience in programs and policies related to neonatal mortality from the Northern Region of Ghana.
Significance: Lessons learned from how the Northern Region of Ghana reduced newborn deaths could be implemented in other regions of Ghana.
Globally, 2.6 million newborns die within the first 28 days of life (neonatal mortality)1, which accounts for 45% of all under-five deaths2. At 28 deaths per 1,000 live births, Sub-Saharan Africa has the highest newborn death rate worldwide and accounts for 38% of all neonatal deaths3. Reducing the neonatal mortality rates in Sub-Saharan Africa will contribute to the largest decrease in the number of deaths in children under-five globally.
Similar to most Sub-Saharan African countries, Ghana has not seen a significant decline in neonatal mortality in the past two decades. Between 1993 and 2014, Ghana’s neonatal mortality rates have only declined from 40 to 28 deaths per 1,000 live births4. In 2016, Ghana's neonatal mortality rate was 27 per 1,000 live births5. On average, Ghana alone contributes to about 30,000 newborn deaths annually6. Interestingly, within Ghana, there are significant variations in neonatal mortality across Ghana’s ten regions, ranging from the lowest mortality rate in the Northern Region to the highest mortality rate in Ashanti (24-42 deaths per 1000 live births, respectively)7.
Given these discrepancies, our project focuses on how some regions in Ghana have made significant progress in reducing neonatal mortality while others have not. For instance, in the Northern Region of Ghana, a 67% decrease in neonatal mortality has been observed between 1993 and 2014. However other regions, such as the Eastern and Ashanti Regions have seen no change over the past 20 years7. To date, researchers have yet to determine why there has been such a significant difference in neonatal mortality rates between different regions. Learning from the success of the Northern Region of Ghana would inform policymakers of strategies that can accelerate a further decline in other parts of the country.
Thus far, several community and policy-based interventions have been implemented to reduce neonatal deaths in Ghana. The extent to which these interventions were adopted, the strategies that were used, and the socio-cultural context in which they occurred may explain the differences in the reduction of neonatal mortality across different parts of the country. For instance, the Ministry of Health revised the Anti-Malaria Drug Policy for Ghana in 2009. This policy was implemented to provide safe, effective, and appropriate anti-malaria treatment to the population8. They were able to determine that insecticide-treated mosquito nets (ITN) are the most effective way to prevent the spread of malaria. By 2014, prevalence of malaria in 6-59 month old children ranged from 11%, in the Greater Accra Region, to 40% in the Northern Region of Ghana7.In this case, the policy-based intervention was the key to implementing an effective preventive measure that lowered prevalence of the disease in its applied regions. In addition, community-based approaches have resulted in positive outcomes for newborns. These approaches include strengthening community health centers9, promoting community engagement, and community health workers (CHW) addressing risk factors, such as birth asphyxia, infections at the community level, and educating mothers on cleanliness, prevention and early detection of disease10. Researchers have found that 41-72% of newborn deaths and 60% of under-five deaths can be prevented with community-based methods11. Ghana accelerated its community health worker program by creating Community-Based Health Planning and Service (CHPS) compounds, which are most prevalent in the Northern Region and one other region. Collectively, there are 155 compounds between the two regions. Currently an additional 55 are being built in these regions12. This intense focus on the Northern Region may partly explain it progress.
Over the past two decades, neonatal mortality rates have declined at a much slower pace compared to infant and under-five mortality rates, making it a relevant health issue that should be addressed, especially in Ghana: recall that Ghana experiences 30,000 newborn deaths annually1,6. Providing resources and knowledge will assist in continuing the decrease of neonatal mortality rates in other Sub-Saharan African countries, which will result in the preservation of numerous lives.
The primary goal of this study is to determine how and why neonatal mortality reduced significantly in the Northern Region of Ghana but not in other parts of the country. The specific objectives are:
to identify national and regional level policies, and program strategies that contributed to the decline in neonatal mortality rate, and
to identify key community-based approaches that contributed to the decrease in neonatal mortality rates in the Northern Region of Ghana.
The study is part of a larger evaluation study that is been led by Dr. Sakyi and a team of researchers from Johns Hopkins and the University of Ghana. They are using quantitative methods to identify key neonatal health interventions that have saved the most lives in the past twenty years. My project will provide the contextual understanding of why certain interventions and policies were successful at the community level.
This study will provide insight into successful strategies, community-based approaches, and policies that have been implemented over the past two decades to reduce neonatal death in Ghana. Savannah Signatures, the funding organization, will use the results to identify successful strategies from the Northern Regions in order to guide the implementation of interventions in other regions of Ghana.
Setting and participants:
Ghana is a country in West Africa that is 92,098 square miles in area. The population of Ghana is 25.5 million people, across 10 regions13. This study will be conducted in the Northern Region of Ghana. A total of 30-40 participants will be recruited from the Ministry of Health, Ghana Health Services, non-government organizations (NGOs), community health workers and community leaders. The inclusion criteria include participants that can provide historical information about programs and policies that have been implemented in the Northern Regions of Ghana over the past 20 years. The exclusion criteria include not being involved in neonatal health interventions in the Northern Region of Ghana.
The study design is qualitative with in-depth semi-structured interviews and a review of government and NGO reports on neonatal health programs and policies.
Participants will be recruited through snowball sampling beginning with national and regional government officials who will recommend other participants involved with neonatal health interventions in the Northern Region of Ghana14. The procedure for data collection will include the 30-40 audio recorded, in-depth, semi-structured interviews that will last between 20-30 minutes each. A team of researchers will conduct the qualitative interviews in English and the local language. The team includes Prince Owusu (Co-director of the Center for Learning and Childhood Development (CLCD)), two undergraduate students from Brown University, a graduate student from Johns Hopkins, and myself. The key topics of the interview will include program history, policies, policy implementation process, programmatic inputs, community engagement, best practices and success stories that relate to neonatal mortality in the Northern Regions of Ghana.
The audio transcripts will be transcribed. Data analysis includes thematically analyzing the interviews, using a deductive approach to develop a codebook. It will also consist of content analysis of the program documents to identify the implementation of key policies and strategies used. After the analysis, the research team will develop a timeline from 1993-2014 plotting the coverage levels of neonatal interventions and successful programs/policies that made the most impact on the Northern Region.
Feasibility of proposed study:
I will be working with a team of researchers and students from Ghana, Johns Hopkins, and Brown University. Of the 30-40 interviews, I will be conducting 10-15, focusing on community health workers, local leaders, and government officials during my time in Ghana. While in Ghana, there will be an extensive team of CLCD members who have agreed to provide support. Once I return from Ghana, I will conduct the document review.
My mentoring faculty, Dr. Kwame Sakyi, has an extensive history of under-five and neonatal mortality research conducted in Ghana10,15, and is the director of the Center for Learning and Childhood Development. He is the Co-Principal Investigator (Co-PI) on the large evaluation study. Dr. Sakyi will be in Ghana during data collection. Dr. Laar is the PI of the project, a Senior Lecturer at the University of Ghana School of Public Health, and a Technical Advisor at CLCD- Ghana.
After the research is complete there will be a report produced for Savannah Signatures, and the Center for Learning and Childhood Development. Savannah signatures is the funding organization and CLCD is the implementing organization for this project. In addition, we plan on disseminating the results of the study at the American Public Health Association (APHA) Conference in 2019.
Neonatal Mortality Unicef Data. Unicef.org. https://data.unicef.org/topic/child-survival/neonatal-mortality/#. Updated January 2018. Accessed February 5, 2018.
Wang H, Liddell CA, Coates MM, et al. Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990–2013: A systematic analysis for the global burden of disease study 2013. The Lancet. 2014;384:957-979.
Africa Key Facts and Figures for Child Mortality. Usaid.gov. https://www.usaid.gov/sites/default/files/documents/1860/Africa%20Key%20Facts%20and%20Figures.pdf. Published 2013. Accessed February 5, 2018.
Ghana Statistical Service, Ghana Health Service, ICF International. Ghana Demographic and Health Survey 1993. Calverton, Maryland, USA, 1993.
Mortality rate, neonatal (per 1,000 live births). Data.worldbank.org. https://data.worldbank.org/indicator/SH.DYN.NMRT.Updated 2018. Accessed February 8, 2018.
Unicef Ghana. Unicef.org. https://www.unicef.org/ghana/media_8404.html. Published 2014 . Accessed February 5, 2018.
Ghana Statistical Service, Ghana Health Service, ICF International. Ghana Demographic and Health Survey 2014. Rockville, Maryland, USA, 2014. Accessed February 5, 2018.
Anti-Malaria Drug Policy for Ghana. Ghana Health Service.org. http://www.ghanahealthservice.org/downloads/anti_malaria_drug_policy_for_ghana.pdf. Updated 2009. Accessed February 8, 2018.
Henry P, Emma S, Meike S, et al. Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 6. Strategies used by effective projects. Engaging Communities for Improving Mothers’ and Children’s Health. Reviewing the Evidence of Effectiveness in Resource-Constrained Settings. [city], [state]:JoGH; [Year of Copyright]: [page]-[range]. Accessed February 5, 2018.
Emma S, Paul F, Kwame S, et al. Comprehensive review of the evidence regarding the effectiveness of community–based primary health care in improving maternal, neonatal and child health: 3. Neonatal health findings. Engaging Communities for Improving Mothers’ and Children’s Health. Reviewing the Evidence of Effectiveness in Resource-Constrained Settings. [city], [state]:JoGH; [Year of Copyright]: [page]-[range]. Accessed February 5, 2018.
Haines, A., Sanders, D., Lehmann U., et al. Achieving child survival goals: Potential contributions of community health workers. The Lancet. 2007;369:2121-2131. Accessed February 5, 2018.
Construction of 55 new CHPS compounds begins. Ghana News Agency (GNA). 2017. Published Apr 27, 2017. Accessed February 14, 2018.
Facts about Ghana. Africa Facts.org. https://africa-facts.org/facts-about-ghana/. Published February 2, 2016. Accessed February 14, 2018.
Dudovskiy J. Snowball sampling. Research Methodology. https://research-methodology.net/sampling-in-primary-data-collection/snowball-sampling/. Updated 2017. Accessed February 14, 2018.
Adjei AA, Winch P, Laar A, et al. Insights into the affordable medicines facility-malaria in Ghana: The role of caregivers and licensed chemical sellers in four regions. Malaria Journal. 2016;15:263.
All of the money from the Provost Student Research Award is solely for the research in Ghana. The remaining research budget will be paid through personal funds.