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Objective.Apply a "best practices" model to evidence regarding group smoking cessation to inform organizational decisions about adopting such programs. The best-practices model attempts to integrate rigorous review of evidence with context and practical considerations important to organizations contemplating adoption.Data Sources.First, we identified effective practices by systematic literature review with two blinded reviewers to (1) search databases (99.8% agreement), (2) hand search journals with five or more papers selected in first step (99.9% agreement), (3) search reference lists of included papers (99.4% agreement), and (4) contact published experts. Second, model programs, theory, and expert opinion suggested plausible practices. Finally, a practitioner-researcher advisory group suggested practical considerations affecting adoption decisions.Study Selection.All 67 studies included in the review met six requirements: (1) peer reviewed, (2) primary studies, (3) using experimental or quasi-experimental design, (4) compared one or more smoking-cessation interventions that involved two or more group sessions, (5) studied persons 18+ years old, and (6) reported ≥ 6-month point prevalence or continuous abstinence outcomes.Data Extraction.Two independent raters assessed study quality (89.5% agreement). Effective practices consistently exhibited a statistically significant effect. Plausible practices showed consistency across three types of evidence. An advisory group based practicality criteria on critical review and experience.Data Synthesis.Two practices were rated effective: multicomponent behavioral intervention and nicotine replacement therapy. Five practices received plausible ratings: components of behavioral skills, information about smoking, self-monitoring, social support, and four or more sessions of 60 to 90 minutes. The Advisory Group identified 11 practicality questions to assist organizations to make adoption decisions regarding effective and plausible practices.Conclusions.No research evidence guides potential smoking-cessation program adopters regarding program participants, providers, settings, or quality assurance. Reviews to influence practice must consider science and practice (context) to facilitate adoption of best practices.

AbstractNeonatal mortality is one of the leading causes of under-five mortality globally, with the majority of these deaths occurring in low- and middle-income countries. In Ghana, there is a belief in an array of newborn conditions, called Asram, that are thought to have a spiritual, rather than physical, cause. These conditions are predominantly managed by traditional healers as they are considered unable to be treated by allopathic medical providers. Through a series of semi-structured qualitative interviews of medical providers in Kumasi, Ghana, conducted in July–August 2018, this study sought to elucidate perspectives of allopathic medical providers about Asram, including the perceived implications of traditional newborn care patterns on newborn health and higher-level neonatal care. Twenty health care providers participated and represented a tertiary care hospital and a district hospital. Medical providers were universally aware of Asram but varied on the latitude they gave this belief system within the arena of newborn care. Some providers rationalized the existence of Asram in the backdrop of high neonatal mortality rates and long-standing belief systems. Others highlighted their frustration with Asram, citing delays in care and complications due to traditional medical treatments. Providers utilized varying approaches to bridge culture gaps with families in their care and emphasized the importance of open communication with the shared goal of improved newborn health and survival. This study describes the importance of providers being aware of socio-cultural constructs within which pregnant women operate and suggests a focus on the shared goal of timely and effective newborn care in Ghana.

AbstractWhile overall neonatal mortality rates are improving in Ghana, the Ashanti Region has the highest mortality rate in the country. The clinical causes of newborn deaths are well known, yet local beliefs about illness aetiology, cause of death and care-seeking are less well understood. This exploratory qualitative study sought to understand how community members perceive and respond to neonatal illness. Researchers worked with public health nurses, community health nurses and opinion leaders in the Ashanti Region of Ghana to identify women who had lost a baby, either during pregnancy or after delivery. In-depth interviews and focus group discussions were conducted about knowledge, attitudes and beliefs regarding neonatal mortality. The transcripts were coded and analysed using NVivo 10.0. A total of 100 participants were interviewed: 24% reported a previous stillbirth; 37% reported a previous miscarriage; and 45% reported losing a baby who was born alive. Nine per cent experienced more than one type of loss. The local illness of asram – an illness with supernatural causes – was cited as a leading cause of death of newborns. Every participant reported hearing of, knowing someone, or having a child who had become ill with asram. While women gave varying information on symptoms, method of contraction and treatment, all participants agreed that asram was common and often fatal. Four overarching themes emerged: 1) asram is not a hospital sickness; 2) there is both a fear of traditional healers as a source of asram, as well as a reliance upon them to cure asram; 3) there are rural/urban differences in perceptions of asram; and 4) asram may serve as a mechanism of social control for pregnant women and new mothers. Local beliefs and practices must be better understood and incorporated into health education campaigns if neonatal mortality is to be reduced in Ghana.

SummaryThis study aimed to explore pregnant women's attitudes towards the inclusion of a lay companion as a source of social support during labour and delivery in rural central Ghana. Quantitative demographic and pregnancy-related data were collected from 50 pregnant women presenting for antenatal care at a rural district hospital and analysed using STATA/IC 11.1. Qualitative attitudinal questions were collected from the same women through semi-structured interviews; data were analysed using NVivo 9.0. Twenty-nine out of 50 women (58%) preferred to have a lay companion during facility-based labour and delivery, whereas 21 (42%) preferred to deliver alone with the nurses in a facility. Women desiring a companion were younger, had more antenatal care visits, had greater educational attainment and were likely to be experiencing their first delivery. Women varied in the type of companion they prefer (male partner vs female relative). What was expected in terms of social support differed based upon the type of companion. Male companions were expected to provide emotional support and to 'witness her pain'. Female companions were expected to provide emotional support as well as instrumental, informational and appraisal support. Three qualitative themes were identified that run counter to the inclusion of a lay helper: fear of an evil-spirited companion, a companion not being necessary or helpful, and being 'too shy' of a companion. This research challenges the assumption of a unilateral desire for social support during labour and delivery, and suggests that women differ in the type of companion and type of support they prefer during facility deliveries. Future research is needed to determine the direction of the relationship – whether women desire certain types of support and thus choose companions they believe can meet those needs, or whether women desire a certain companion and adjust their expectations accordingly.

AbstractPrevious research has described the evil eye as a source of illness for pregnant women and their newborns. This study sought to explore the perceptions of the evil eye among mothers whose newborns had experienced a life-threatening complication across three regions of Ghana. As part of a larger, quantitative study, trained research assistants identified pregnant and newly delivered women (and their newborns) who had survived a life-threatening complication at three tertiary care hospitals in southern Ghana to participate in open-ended, qualitative interviews about their experiences in March–August 2015. All interviews were audio-recorded and transcribed verbatim into English and analysis using the constant comparative method of theme generation. A total of 37 mothers were interviewed, 20 about neonatal illnesses and 17 about maternal illnesses. Six of the 20 mothers interviewed about their newborn's illnesses spoke at length about the evil eye being a potential cause of newborn illness. The evil eye was described in a variety of terms, but commonalities included a person looking at a pregnant woman, her newborn baby, the baby's clothes and even the mother's food, causing harm, even unintentionally. Prevention required mothers covering themselves while pregnant and keeping the baby away from others until it was old enough to ward off the evil eye. Treatment required traditional medicine, yet some indicated that allopathic medicine could help. The evil eye appears to serve a social control mechanism, encouraging pregnant women to dress modestly, stay indoors as much as possible and behave appropriately. The evil eye is a pervasive, universally understood phenomenon across three regions of Ghana, even amongst a hospitalized population receiving allopathic health care for life-threatening complications of childbirth. Understanding the role of the evil eye in newborn illness attribution is important for clinicians, researchers and programmatic staff to effectively address barriers to care seeking.

BACKGROUND: In high income countries, guidelines exist recommending gestational age thresholds for offering and obligating neonatal resuscitation for extremely preterm infants. In low- and middle- income countries, this approach may be impractical due to limited/inconsistent resource availability and challenges in gestational dating. Scant literature exists on how clinicians in these settings conceptualize viability or make resuscitation decisions for premature infants. METHODS: Qualitative interviews of interprofessional neonatal clinicians were conducted in Kumasi, Ghana, at Komfo Anokye Teaching Hospital and Suntreso Government Hospital, and in Addis Ababa, Ethiopia, at St. Paul's Hospital Millennium Medical College. Transcribed interviews were coded through the constant comparative method. RESULTS: Three discrete major themes were identified. The principal theme was a respect for all life, regardless of the likelihood for survival. This sense of duty arose from a duty to God, a duty to the patient, and a duty intrinsic to one's role as a medical provider. The duty to resuscitate was balanced by the second major theme, an acceptance of futility for many premature infants. Lack of resources, inappropriate staffing, and historically high local neonatal mortality rates were often described. The third theme was a desire to meet global standards of newborn care, including having resources to adopt the 22–25-week thresholds used in high income countries and being able to consistently provide life-saving measures to premature infants. CONCLUSIONS: Neonatal clinicians in Ghana and Ethiopia described respect for all life and desire to meet global standards of newborn care, balanced with an awareness of futility based on local resource limitations. In both countries, clinicians highlighted how wide variations in regional survival outcomes limited their ability to rely on structured resuscitation guidelines based on gestational age and/or birthweight.

To improve maternal health requires action to ensure quality maternal health care for all women and girls, and to guarantee access to care for those outside the system. In this paper, we highlight some of the most pressing issues in maternal health and ask: what steps can be taken in the next 5 years to catalyse action toward achieving the Sustainable Development Goal target of less than 70 maternal deaths per 100 000 livebirths by 2030, with no single country exceeding 140? What steps can be taken to ensure that high-quality maternal health care is prioritised for every woman and girl everywhere? We call on all stakeholders to work together in securing a healthy, prosperous future for all women. National and local governments must be supported by development partners, civil society, and the private sector in leading efforts to improve maternal-perinatal health. This effort means dedicating needed policies and resources, and sustaining implementation to address the many factors influencing maternal health-care provision and use. Five priority actions emerge for all partners: prioritise quality maternal health services that respond to the local specificities of need, and meet emerging challenges; promote equity through universal coverage of quality maternal health services, including for the most vulnerable women; increase the resilience and strength of health systems by optimising the health workforce, and improve facility capability; guarantee sustainable finances for maternal-perinatal health; and accelerate progress through evidence, advocacy, and accountability.