Mobilising Faith-based and Lay Leaders to Address Antenatal Care Outcomes in Northern Ghana

"Despite the benefits of antenatal care, evidence from sub-Saharan Africa suggests that women often initiate these services after the first trimester of pregnancy and do not complete the recommended number of visits."

This study examines the potential role of faith-based and lay leaders in increasing early antenatal care (ANC) seeking in the context of maternal, neonatal, and child health (MNCH) in northern Ghana. In Ghana, statistics show that 60% of women attend a first trimester ANC visit; however, in the North only 50% attend a first trimester visit.

Barriers to ANC include cost of transportation, services, and equipment, including providers’ attitudes and the services offered. "Ghana instituted its National Health Insurance Scheme (NHIS) in 2003 – with a primary objective to limit cost as a barrier to accessing MNCH services." Socio-cultural deterrents include traditional power hierarchies in the household and communities and household beliefs and rituals, for example, “prisibu”, which requires first-time pregnant women to formally announce the pregnancy to the community during a ceremony.

Thus, "[e]ngaging community leaders, including lay leaders (such as chiefs), and faith-based leaders (such as pastors, traditional religious practitioners, and imams) has been promoted to shift social norms and traditional practices and improve health MNCH behaviours....This study examines the impact of the Council of Champions (CoC) intervention to mobilise and train faith-based and lay leaders to actively address the socio-cultural barriers that limit the uptake of MNCH behaviours among mothers of children aged 0 to 23 months in the East Mamprusi district of Ghana. The study’s objective was to determine whether the addition of the CoC intervention to a broader community and facility-based MNCH programme would improve the early initiation and regular attendance of ANC."

The CoC intervention was implemented by Catholic Relief Services (CRS) and the Ghana Health Service (GHS) throughout the East Mamprusi district study site from 2011 to 2015. Activities included interventions at household, community, and facility levels using a social behaviour change (SBC) strategy informed by formative research, including: "a household survey with mothers of children under 23 months old, focus group discussions with pregnant women, mothers, fathers, and mothers-in-law, and key informant interviews with community leaders and Ghana Health Service officials."

Healthy Mothers and Newborn Care Committees, formed by the project, mobilised community members to develop community birth plans, manage community-led monitoring of project indicators, and engage men to support critical MNCH behaviours, as well as coordinate emergency transport committees. Traditional birth attendants (TBAs) referred pregnant women to health facilities for ANC, among other services. Education brought pregnant and lactating mothers together on a bi-weekly basis, facilited by mothers practising key MNCH behaviours.

Faith-based leaders (Protestant ministers, traditional African religious leaders, and Islamic imams), village chiefs, traditional medical practitioners, and female leaders known as "queen mothers" or "magazia" formed village-level councils to support modification of the deeply held norms and traditional practices, using “"triple A" approach – assessing the problem, analysing the causes, and taking appropriate and timely action to address them. Councils used community dialogues and identified alternatives that would not limit uptake of ANC, for example, conducting the prisibu ceremony as soon as the woman missed her period. Through home visits, they engage directly with household heads.

To test the CoC intervention, the study employed a pre-test-post-test quasi-experimental design intervention and comparison communities. Between pre- and post-testing, intervention communities received 18 months of CoC intervention.

Of 484 mothers at baseline in the intervention area,510 were sampled at follow-up in the intervention communities, 466 mothers at baseline and 510 at follow-up in comparison communities. t baseline, "[n]early 60% of women reported attending ANC in the first trimester of their last pregnancy. Almost 80% of women reported attending four or more ANC visits during their last pregnancy.... Results from two multivariate logit analyses, which controlled for maternal age, education, ethnicity, parity, employment status, and time to the nearest facility, indicate that improvement in both early ANC and attendance of at least four ANC visits were significantly related to the CoC intervention....Overall, attendance of four or more ANC visits changed by 61.3 percentage points in the intervention area versus the comparison areas between baseline and follow-up data collection rounds."

Among the study's conclusions:

• "Addressing social norms that may serve as barriers to timely care-seeking behaviours is crucial to decreasing maternal and new-born morbidity and mortality.
• This study has demonstrated that training and mobilising faith-based and lay leaders may result in positive changes to the timing and frequency of ANC behaviours for pregnant women in rural underserved communities.
• This study provides insights for development agencies regarding the design of social and behaviour change communication strategies for other technical areas to address barriers to health-seeking behaviours."