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Effect of continuum-of-care intervention package on improving contacts and quality of maternal and newborn healthcare in Ghana: a cluster randomised controlled trial
  1. Sumiyo Okawa1,2,
  2. Margaret Gyapong3,4,
  3. Hannah Leslie5,
  4. Akira Shibanuma1,
  5. Kimiyo Kikuchi1,6,
  6. Francis Yeji7,
  7. Charlotte Tawiah8,
  8. Sheila Addei3,
  9. Keiko Nanishi1,9,
  10. Abraham Rexford Oduro7,
  11. Seth Owusu-Agyei8,
  12. Evelyn Ansah4,10,
  13. Gloria Quansah Asare11,
  14. Junko Yasuoka1,12,
  15. Abraham Hodgson10,
  16. Masamine Jimba1
  17. on behalf of Ghana EMBRACE Implementation Research Project Team
    1. 1Department of Community and Global Health, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
    2. 2Cancer Control Center, Osaka International Cancer Institute, Osaka, Japan
    3. 3Dodowa Health Research Centre, Dodowa, Ghana
    4. 4Institute of Health Research, University of Health and Allied Sciences, Ho, Ghana
    5. 5Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
    6. 6Institute of Decision Science for a Sustainable Society, Kyushu University, Fukuoka, Japan
    7. 7Navrongo Health Research Centre, Navrongo, Ghana
    8. 8Kintampo Health Research Centre, Kintampo, Ghana
    9. 9Office of International Academic Affairs, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
    10. 10Research and Development Division, Ghana Health Service, Accra, Ghana
    11. 11Headquarters, Ghana Health Service, Accra, Greater Accra, Ghana
    12. 12Research and Education Center for Prevention of Global Infectious Diseases of Animals, Tokyo University of Agriculture and Technology, Tokyo, Japan
    1. Correspondence to Professor Masamine Jimba; mjimba{at}


    Objective To evaluate the effect of a continuum-of-care intervention package on adequate contacts of women and newborn with healthcare providers and their reception of high-quality care.

    Design Cluster randomised controlled trial.

    Setting 32 subdistricts in 3 rural sites in Ghana.

    Participants The baseline survey involved 1480 women who delivered before the trial, and the follow-up survey involved 1490 women who received maternal and newborn care during the trial.

    Interventions The intervention package included training healthcare providers, using an educational and recording tool named ‘continuum-of-care card’, providing the first postnatal care (PNC) by retaining women and newborns at healthcare facility or home visit by healthcare providers.

    Outcome measures Adequate contacts were defined as at least four contacts during pregnancy, delivery with assistance of skilled healthcare providers at a healthcare facility and three timely contacts within 6 weeks postpartum. High-quality care was defined as receiving 6 care items for antenatal care (ANC), 3 for peripartum care (PPC) and 14 for PNC.

    Results The difference-in-difference method was used to assess the effects of the intervention on the study outcome. The percentage of adequate contacts with high-quality care in the intervention group in the follow-up survey and the adjusted difference-in-difference estimators were 12.6% and 2.2 (p=0.61) at ANC, 31.5% and 1.9 (p=0.73) at PPC and 33.7% and 12.3 (p=0.13) at PNC in the intention-to-treat design, whereas 13.0% and 2.8 (p=0.54) at ANC, 34.2% and 2.7 (p=0.66) at PPC and 38.1% and 18.1 (p=0.02) at PNC in the per-protocol design that assigned the study sample by possession of the continuum-of-care card.

    Conclusions The interventions improved contacts with healthcare providers and quality of care during PNC. However, having adequate contact did not guarantee high-quality care. Maternal and newborn care in Ghana needs to improve its continuity and quality.

    Trial registration number ISRCTN90618993. 

    • quality in health care
    • maternal medicine
    • community child health

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    • Collaborators The Ghana EMBRACE Implementation Research Project Team Authors: Yoshiharu Yoneyama; Ebenezer Appiah-Denkyira; Masamine Jimba; Abraham Hodgson; Gloria Quansah Asare; Evelyn Ansah; Junko Yasuoka; Keiko Nanishi; Akira Shibanuma; Kimiyo Kikuchi; Sumiyo Okawa; Margaret Gyapong; Sheila Addei; Vida Kukula; Doris Sarpong; Clement Narh; Seth Owusu-Agyei; Kwaku Poku-Asante; Charlotte Tawiah; Yeetey Enuameh; Kwame Adjei; Emmanuel Mahama; Abraham Oduro; John Williams; Cornelius Debpuur; Francis Yeji; Evelyn Sakeah; Peter Wontuo; Akiko Hagiwara; Sakiko Shiratori; Yusuke Kamiya.

    • Contributors SO, MG, AS, KK, FY, CT, SA, KN, ARO, SOA, EA, GQA, JY, AH and MJ conceived and designed the study. SO, MG, FY, CT, SA, ARO and SOA conducted interventions and collected data. SO analysed, interpreted the data and drafted manuscript. SO, HL, AS, KK, EA, AH and MJ interpreted data. SO, MG, HL, AS and MJ contributed to the revision of manuscript. AH and MJ are the study guarantor. All authors approved the final version of the manuscript.

    • Funding This paper was funded by the Japan International Cooperation Agency (JICA) Human Development Department and JICA Research Institute (

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Ethics approval The study was approved by the Ethics Review Committee of Ghana Health Service, the Institutional Review Boards of Dodowa HRC and Navrongo HRC, the Institutional Ethics Committee of Kintampo HRC in Ghana and the Research Ethics Committee of Graduate School of Medicine, the University of Tokyo in Japan.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement Data are available on reasonable request.

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