Addressing the Health Needs of Children and Youth in Ghana Challenges and

Prospects
Gloria J. Quansah Asare (BSc., M.B. Ch.B, MPH, Dr.PH)
Reproductive & Child Health Unit1, Ghana Health Service.

I.

Introduction

Ghana adopts the WHO definitions for health, children and youth where, health is defined as a state
of complete physical, mental and social well-being and not merely the absence of disease or
infirmity. From birth to the age of 18 years an individual is considered a child, while the youth are
individuals aged between 15 to 24 years and those aged 10 to 24 years are referred to as young
people. The health and developmental needs for these periods of life vary. Therefore, for
programming purposes, specific groupings namely, under fives (birth to 5 years); school health (5
to 15 years); and adolescent health and development (10 to 19 years) are targeted. The target groups
overlap during programming. In some instances, programmes cover groups before and beyond the
target ages, and benefit or contribute to other programmes. An example is the adolescent health
programme. Even though adolescence covers the period ten to nineteen years, for comprehensive
programming the Adolescent Health & Development (ADHD) programme also targets preadolescents (5-9 years) and young adults (20-24 years) 1

There are strong linkages between child health and reproductive health as well as nutrition, mental
health and other sectors such as Education, Women and Childrens Ministry, youth and
employment and others including private sector and non-governmental organizations. The health
and development of a newborn depends on what happens during pregnancy which falls under the
safe motherhood programme.

Health Needs versus Rights

Defining need is complex and depends on who is making the decision and how need is measured.
The Advanced Oxford Dictionary defines need as a circumstance in which something is lacking or
requires to be done. However, Culyer and Wagstaff [2] show that the need for health care can be
defined in many ways: such as, severity of disease, or the ability to benefit or the minimum amount
of resources required to exhaust the capacity to benefit; and goes on to demonstrate that each of
these meanings affects the distribution of health services differently. Economists express health
need as a burden of disease and measure it in terms of years of quality life lost. But this is based
on assumptions on individual preferences which are often culture-bound. Health workers express
need in terms of mortality or morbidity, but this is influenced by the type of disease and the quality
of the data. Parents and political authorities also define need differently. In a study carried out in
Northern Ghana, mothers and fathers expressed childrens needs in terms of need for healthy foods,
first aid, good water, prevention from mosquito bites, medicines and cleanliness. The Millennium
1

National Family Planning Programme Manager

1

Development Goals (MDGs) and the health sector usually identify health needs from morbidity and
mortality perspectives and these are dependent on availability and quality of data. Thus most
programmes aim at reducing morbidity and mortality
A right, on the other hand, is a persons entitlement to a good, service or liberty. Thus, a rights-based
approach emphasises advocacy, commitment and action to protect children. In addition, the approach puts
the obligation on society rather than a single sector to ensure the health of children. 2 ,3 . Perhaps within the
context of accelerating child survival to achieve the MDGs, a childs rights should be emphasised more than
a childs needs.

II.

Under Five Mortality in Ghana

After decades of steady decline in under-five mortality rates, the latest of a series of four
Demographic and Health Surveys conducted in Ghana (GDHS of 1988, 1993, 1998 and 2003)
indicate a worsening in the nations infant and under-five mortality. There are variations by urbanrural residence, region, wealth quintiles and educational status of mothers. Even though under-five
mortality appears to have stagnated in the wealthiest quintile and improved in the poorest quintile
there exists significant inequality between the poor and the rich, also being significantly higher in
the Northern and Upper West regions and varies between rural and urban areas.
GDHS (2003) reports infant (birth to 11 months) mortality, child (1 to 4 years) mortality and under
five (birth to 4 years) mortality as 64, 50 and 115 deaths per 1,000 live births respectively. Neonatal
(first month of life) and post neonatal (1 to 11 months) are 43 and 21 per 1,000 live births
respectively (Table 1).
Table 1: Age Specific Mortality Rates
Age-specific Mortality

Per 1000 live births

Infant (birth to 11 months)

64

Neonatal (first month of life)

43

Post-neonatal(1 to 11 months)

21

Child (1 to 4years)

50

Under 5(birth to 4 years)

115

Source: GDHS 2003

The data indicate that, one in nine children die before their fifth birthday. Neonatal deaths constitute
approximately two-thirds of infant deaths, while infant mortality also constitutes about two-thirds
of under-five mortality. While mortality between 1-11 months and 1-4 years old have reduced,
neonatal mortality has stagnated and indeed constitutes about a third of all under-five mortality.

There is a clear indication that the greatest progress in trends was the fall between 1984-1988 and
1989 to 1993 periods for children one to four years of age. There was also a smaller and
statistically insignificant decrease in post neonatal mortality (1 to 11 months). However neonatal
mortality has increased persistently since the five year period preceding 1988, increasing from 30 to
39 per thousand live births in 2003 for the period 1994-1998 (Figure 1).

Fig. 1: Trends in Ghanas Childhood Mortality Rates

for the five year periods preceding the DHS:
CMR (12 59 months), Post -NMR (1 11 months) and NMR (< 1 month)
Source: 1988, 1993, 1998 and 2003 DHS

90
80
70
60
50
40
30
20
10
0
1984-1988
CMR

1989-1993
Post NMR

1994-1998
NMR

1999-2003

NMR (2003 GDHS)

Over the last two decades, under-five mortality in Ghana has fallen by 28 percent. The above
statistics suggest that the decline in mortality between 12 and 59 months of age accounted for 72
percent of this achievement whereas a drop in mortality between 1 and 11 months contributed 26
percent to the decline. Neonatal mortality does not appear to have changed significantly throughout
this period. There is the need for in-depth analysis on factors contributing to high neonatal
mortality so as to review programme effort to address this situation. There is also the likelihood
that neonatal mortality may have been underestimated.
It is difficult to identify a single factor that significantly contributed to the steady decline in U5MR
after independence to 1978 when the EPI programme was started. More probably it is due to a
combination of factors including the eradication of smallpox, the sustained reduction in poverty,
increased provision of potable water, promotion of oral rehydration therapy, and improvement in
medical care. An analysis of the age-specific rates indicated that the 72 percent drop in child
mortality contributed to the 43/1000 live birth decline in under-five mortality.
The rapid reduction in mortality between 1984 and 1989 is closely associated with increased
immunization coverage, especially against measles. The proportion of fully immunized children
increased from 1 percent in 1978 to 55 percent in 1985 when the EPI programme covered the entire
country. Conversely, the annual measles cases declined steadily from about 120,000 when EPI was
introduced in 1978 to 40,000 in 1989, saving an estimated 1200 lives annually.

The stagnation in under-five mortality is not peculiar to Ghana and has been seen in many subSaharan and South Eastern Asia countries. This stagnation is not likely to be due to HIV/AIDS.
Fortunately, most countries of West and Central Africa are not confronted with a high prevalence of
HIV. Ghana is one of seven such countries in sub-Saharan Africa with a median HIV prevalence of
3.2 percent. 4 Most countries with a high prevalence in HIV/AIDS have experienced stagnation or
reversal of gains made. Moreover, some countries have also experienced economic stagnation.
Causes of Under-five Mortality
Analysis of the causes of under-five mortality indicates that the main factors are: early neonatal
conditions (27%), malaria (25%), pneumonia (20%), diarrhoea (17%) with HIV and measles
contribution 8 and 3% respectively. Overall,, over half (53%) of under-five deaths are related to
malnutrition5 (Fig. 2). GDHS data also show stagnation in the prevalence of stunting (30%), which
is consistently worse in the rural areas and occurs in spite of evidence that the prevalence of
exclusive breastfeeding has risen considerably, from 2% of 4 to 5 month old children in 1993 to
39% of such children in 2003. The median duration of exclusive breastfeeding is two months. The
policy recommends exclusive breastfeeding for six months and the addition of complementary
foods with breastfeeding for up to two years.

Fig. 2: Causes of under -five mortality in Ghana

(contribution of associated malnutrition is shown by the shaded ellipse)
Source: Lancet Child Survival Series with adjustments for Ghana

8%
3%
27%

25%

53%

17%

Early neonatal
Diarrhoea
Pneumonia
Malaria
Measles
AIDS
Malnutrition

20%

Globally, causes of neonatal mortality are known to include prematurity (28%), pneumonia/sepsis
(26%), asphyxia (23%), congenital disorders (8%), Tetanus (7%), diarrhea (3%) and other causes
(7%). Recent data from the Komfo Anokye Teaching Hospital indicate that the causes of neonatal
mortality comprise asphyxia (36%), prematurity (29%), sepsis (9%), Congenital causes (7%), birth
injury (3%) and 16% for other causes6 (Fig. 3).
Fig. 3:Major reported causes of Neonatal Deaths at KATH
Aug 2004 - Jul 2005

Birth Inj related

3%

Cong Abn
7%

Others
16%

Sepsis
9%

Prematurity
28%

Asphyxia
37%

Ghana Demographic and Health Survey (GDHS) data also show that throughout the last two
decades children born after birth intervals of less than 24 months have significantly higher underfive mortality than those born after longer birth intervals. Children born after birth intervals of 4
years or longer have the lowest under-five mortality but there is once again a suggestion that the
under-five mortality among this group has stagnated since the early 1990s. The percentage of
women delivering after birth intervals of less than 24 months has itself hit a plateau after years of
steady decline (Fig 4). Benefits of birth spacing to mothers and their infants and children are well
known. For mothers, these include a lower risk of maternal death, puerperal endometritis,
premature rupture of membranes, anaemia and third trimester bleeding, while for the infant or child,
there are lowered risks of death at all ages child, infant, neonatal and foetal deaths, preterm and
low birth weight babies and stunting and underweight.7,8 These have clear implications for
neonatal, child and maternal health and particularly birth spacing through family planning.

Fig. 4: Trends in the under-five mortality rate

during the ten year period preceding the DHS,

by birth interval
Source: 1988, 1993, 1998 and 2003 GDHS

250
200
150
100
50
0
<2 years

2-3 years
1988

1993

1998

4+ years
2003

Programmes directed at under-fives

Programmes for Under- Fives
Child Welfare Services include: promotion of exclusive breastfeeding for the first six months and
weaning diets, immunization, vitamin A supplementation, growth monitoring and nutrition
rehabilitation and curative care for minor ailments and injuries. The integrated management of
childhood illnesses (IMCI) is a broad strategy to reduce under-five mortality and morbidity,
promote growth and development, focusing on the five causes which contribute to 70 percentof
under five deaths: malaria, pneumonia, measles, diarrhoea and malnutrition. The three components
of IMCI are: Improvements in the case management skills of first level health staff; improvements
in the health system required for effective management of childhood illnesses; and improvements in
family and community practices. These also include the safe motherhood programme which covers
care during pregnancy, delivery and in the post natal period as well as family planning and infant

care (including breast feeding), sets the stage for optimal pregnancy outcome and is critical for
good neonatal health.

III.

The School Health Programme

The school health programme targets children between ages 5 and 15 years in schools. School
health service is defined as effective and efficient provision of health service to pupils/students
through schools to prevent, reduce, treat and monitor their health problems/conditions as well as
promote health and well being. It also provides an opportunity to give messages about health and
disease prevention to children that can be spread to their families and communities in which they
live.
The vision and mission of the School Health Programme are as follows:
Vision

A Healthy School Population, Well Informed and Equipped With Life Skills Needed To
Adopt and Maintain Healthy Behaviour, Supported By a Responsive Health System.
Mission Statement

To Provide Accessible Comprehensive Health Services Within The School And

Through Referral To The External Health System. These Services Will Integrate
Preventive, Promotive, Curative And Rehabilitative Activities Including Specific
Interventions That Are Best Carried Out Through The School.

School health is an integral part of the child health programme and a priority area of the health
sector in general. Poor health in school children, e.g. poor nutrition, worm infestation, accidents,
injuries, poor vision, hearing problems, non-use of iodated salt, etc has been recognized to be
important not only for physical development, but also for educational achievement since it leads to
absenteeism and a reduction in active learning capacity. School health services can help to treat,
prevent, reduce and monitor these health problems.
School health services include: screening and examination of school children and food vendors,
immunization, health education on current public health issues, management of minor ailments and
injuries and maintenance of a hygienic school environment. Thus effective school health
programmes are viable means to simultaneously address the inseparable goals of Health for All
and Education for All. Substantial evidence indicates that health influences learning and
education influences health. Increasing evidence also shows that school health programmes offer
high cost-benefit ratios.9

Adolescent Health and Development

Adolescence is the transitional period between childhood and adulthood.
Adolescents (10 to 19 years) and youth (15-24 years) constitute young people (10 to 24 years). In
addition pre-adolescents (ages 5 to 9 years) are targets for comprehensive adolescent health and
development (ADHD) programming.

Health Profile of Adolescents

Most adolescents are said to be healthy because they show low levels of illnesses and deaths as
compared to younger children and adults. To the contrary, the GDHS and other studies reveal the
magnitude of sexual and reproductive health problems of young people. These problems range
from inadequate knowledge to sexual and reproductive health problems to their negative effects on
the development of young people, families and society as a whole. These problems result from the
responses to the developmental changes taking place with the youth and society.
The GDHS 2003 reports the median age for menarche at 13.8 years, age at first sex is 18.3 years
with a minimum at 10 to 12 years, girls appear to initiate sex earlier than boys but at age 20 years
80% of both sexes have had sex. Age at first marriage indicates an increasing trend - from 18.3
years in 1993 to 19.6 years in 2003. Births to teenage mothers constituted 20.3% of the age cohort.
Contraceptive use among adolescents is low (less than 10%) with a high unmet need of 57%. There
is a high knowledge of HIV/AIDS (97%) with lower figures for other specific sexually transmitted
infections (STIs). The female to male ratio of HIV is 4:1 compared to the ratio of the general
population of 2:1, this implies that female adolescents are disproportionately vulnerable to
HIV/AIDS and other STIs (Table 2).

Table 2: Some Characteristics of Adolescents in Ghana

Median age at menarche
Age at first marriage

13.8 years
19.6 (2003)
19.3 (1998)
18.3 (1993)
18.3 years
10-12 yrs
19.3%/25%
38%/48%
80%
20.5 years
23.0%

Age at first sex

Minimum
Boys (15-19 years)/By Age 18 years
Girls (15-19 years)/By Age 18 years
By Age 20 years (both Sexes)
Age at First Birth
Early Births (to mothers below 20 years)

Contraception (15-19 years)

Contraceptive Use
Unmet need
Spacing
Limiting
STI Knowledge
Gonorrhoea: Boys/Girls
Syphillis : Boys/Girls
Herpes
Hepatitis
Other : Boys/Girls
Awareness of HIV/AIDS (Young People)

6.9%
57.0%
53%
4%
45.7%/40.7%
12.4%/10.6%
1%
0.2%
1.7%/1.3%
97%

HIV Infection Female:Male Ratio

(General Population)
Adolescents

2:1
4:1

Contraception (15-19 years)

Contraceptive Use
Unmet need
Spacing
Limiting
STI Knowledge
Gonorrhoea: Boys/Girls
Syphillis : Boys/Girls
Herpes
Hepatitis
Other : Boys/Girls
Awareness of HIV/AIDS (Young People)
HIV Infection Female:Male Ratio
(General Population)
Adolescents

6.9%
57.0%
53%
4%
45.7%/40.7%
12.4%/10.6%
1%
0.2%
1.7%/1.3%
97%
2:1
4:1

Source: GDHS 2003

Fig. 5: Age of Adolecent Pregnancy, 2001-2006

14.6
14.
6
14.
2

14.
2

14.2

14.1

14

13.
8
13.
4

13.2

13

%
Coverage 12.
6
12.
2
11.
8
11.
4
11

2001

200
2

200
3

200
Year 4

200
5

2006

Source: Based on national data of teenage registrants at antenatal clinics

The Adolescent Health & Development Programme
The adolescent health and development programme aims at promoting the health of young people,
preventing and responding to health problems from early, unprotected,
unwanted sex, use and misuse of drugs including cigarettes and alcohol, poor nutrition, endemic
diseases, violence and injuries.
The vision, mission and goal of the Adolescent Health and Development Programme are:
Vision
To have a well-informed adolescent adopting healthy lifestyle physically and
psychologically and supported by a responsive health system.
Mission
To make available appropriate information on young peoples health and provide
comprehensive adolescent health services including reproductive health. These services will
be delivered in a humane, efficient and effective manner by trained, friendly, highly
motivated and client oriented personnel.
Goal
To contribute to improved adolescent health through the provision of adequate health
information and knowledge which will ensure behavioural change and increased utilization

of health services including reproductive health in both public and private health delivery
systems in Ghana.
Key Elements of the Adolescent Health and Development Programme include:
adolescent rights and responsibilities; pre-adolescent and adolescent development, health promotion
for adolescents including life skills education, healthy lifestyle, adolescent nutrition, counselling
towards behaviour change, parenting adolescents, adolescents and family planning, adolescent
pregnancy, childbearing and parenting, Sexually Transmitted Infections; HIV/AIDS; reproductive
health problems affecting adolescent boys and girls, mental health and substance abuse,
discouragement of harmful practices that affect adolescent development; social mobilization for
adolescent reproductive health and appropriate teaching methodologies in ADHD programming.
The major interventions include creating safe and supportive environment, providing accurate
information, building life and livelihood skills, providing counselling services and improved health
services.
The main areas of ADHD programme implementation are: identification and management of
common health problems affecting pre-adolescents and young people, provision of adolescent
focused services including counselling, information, education and communication (IE&C) and
reproductive health issues in general and referrals. Priority strategies include advocacy and
awareness, enhanced opportunities to grow and develop, youth and community involvement,
capacity-building, of stakeholders and institutions, youth friendly service delivery, protection from
harmful practices, resource mobilization, monitoring and evaluation
III.

Challenges and Gaps in Child Health Programmes

Health problems and needs for the various groupings of children and youth are diverse and have led
to different programme components usually with varied and different sources of external funding.
Consequently, there are different coordinating mechanisms, collaborators and partnerships at
various levels of the health care system. There is low coverage of evidence-based, of effective
interventions fraught with problems with data management and quality.

These have also contributed to weakened linkages between child health and reproductive health and
a worsening of neonatal health indices. For example, in recent years, little or no reference or
funding commitments are made to benefits of child spacing and family planning in child health
programming. There is a need for strengthened collaboration (including resource mobilization),
through effective integration of services within the health sector and with other sectors such as the
Ministry of Women and Childrens Affairs, Education, Agriculture, Local Government among
others as well as private sector including NGOs and Civil Society groups. Community ownership
and partnership in matters relating to health is also crucial.
In general coverage of health interventions is lowest among poor populations, raising questions about
whether the poor should be specifically targeted10. Achieving rapid reductions in mortality requires
universal coverage (99 percent), but poor people are particularly difficult to reach because of
geographical, economic or socio-cultural barriers to care. This calls for a twin-track approach where

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universal coverage is aimed at, but additional investments are made to reach the poor. However, the
selection of the targeting strategy should be done carefully to reduce administrative cost and
stigmatization.

The Under-Fives Programme:

Proven cost-effective interventions are implemented under various programmes in Ghana. These
have to be well targeted to increase coverage. For children under five years, these include use of
insecticide treated bed nets by pregnant mothers and young children to improve neonatal outcome,
breast feeding, immunization to prevent child mortality, clean delivery etc (Table 3).
Table 3: Proven Cost Effective Interventions for Under-Fives Programmes

Major causes of
U5MR
Malaria

Proven cost effective

interventions*
Anti-malaria drugs
ITN

Implemented in Ghana

Diarrhoea

ORS
Breast feeding

Yes
Yes, but median duration of
exclusive breast feeding is
2months
Yes
Yes, sanitation is a growing
problem
Yes
Yes, but dispensing not permitted
at community level
Yes
Yes
Yes
Yes
Yes, but frequency and quality of
foods should be improved

Yes
Yes, but coverage is low

Complementary feeding
Water, sanitation, and hygiene
Acute respiratory
infection

Measles
Malnutrition

Hib vaccine
Antibiotic
Complementary feeding
Vaccination
Vitamin A supplementation
Breast feeding
Complementary feeding

Managing the neonate

1. Preterm
ITN
delivery
IPT
2. Tetanus
Vaccine
Clean delivery
3. Sepsis

Yes
Yes
Yes
Yes, but proportion of professional
skilled attendance low
Yes

Breastfeeding

Source: Bainson K. A., Kwashie S.T., Appah B., Pond B. (2005).

Individual targeting through some means testing involves a large administrative cost and tends to
stigmatize the poor. Categorical targeting i.e. targeting a population group is feasible, because it is
associated with lower administrative cost and low stigmatization. Ghana has adopted this twintrack approach: EPI has been scaled up nationally but UNICEF and USAID have targeted support
to the Upper East region and twenty eight deprived districts respectively. Out of 138 districts the

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coverage is not very great and districts and regions which were previously doing well lack
resources and could show a worsening of indicators and gains made.
The School Health Programme
The major gap in the school health programme is that it does not reach the school age child who is
not in school. Children in this group are very vulnerable and have to be reached. The success of
the school health programme depends on the joint commitment and partnership of the health and
education sectors.
The ADHD Programme
This is a fairly new area and needs support and commitment of all including parents, community,
health workers and the adolescents themselves. Until recently, health service statistics were not
disaggregated by age and sex specifically for this age group, therefore there is very little systematic
data collected for adolescent health programming.
The target group of the ADHS programme is not homogenous. Within the adolescent health and
development programme there needs to be targeting of specific subgroups such as married
adolescents, in school, out of school, urban, rural etc. A holistic programme requires partnership
with other sectors. For example while the health sector focuses on youth friendly service delivery,
the need for education and livelihood skills and economic empowerment has to be available from
the relevant sectors.
IV.

Prospects and Way Forward:

Commitment to the health and welfare of children has been demonstrated by all governments and
has always been a priority area of the health sector programme. The vulnerability of mothers and
young children has led to resource mobilization for maternal and child health services by the health
sector. While much progress has been made in the area of child health including school health and,
in recent years, adolescent health and development, there are many challenges to be overcome. It is
clear that to reduce under-five mortality, future investments should be directed mainly at reducing
neonatal mortality and mortalities due to malnutrition, malaria and pneumonia including scaling up
of IMCI. A review the Child Health Policy (for under-fives) is currently ongoing. This will
include new and emerging issues such as the pentavalent vaccine which is already in use with
newer ones expected to be introduced by 2011, strengthen community systems and programs to
address the high neonatal death rates. The Adolescent Health and Development and the School
Health programme documents need to be implemented nationwide. The contribution of other sector
policies such as free compulsory basic education (FCUBE), the feeding programme, the early
Childhood and Development Policy etc. are all positive moves to improve child health especially
through inter-sectoral collaboration.
The analysis of under fives programmes in Ghana also indicate that future investments should
mainly be directed at reducing neonatal mortality and mortalities due to malnutrition, malaria and
pneumonia. Even though the contribution of HIV/AIDS is minimal, the disease should be closely
monitored because of its potential to worsen. Crucial linkages between reproductive and child

12

health programmes need to be strengthened to improve neonatal, under-five, and adolescent health
in particular. |Lessons learnt from the child survival components of GOBI-FFF (growth
monitoring, oral rehydration, breast feeding, immunization, complementary feeding, family
planning and female education) should integrated in the programming. Unfortunately, it appears
that in the case of family planning, the benefits of birth spacing, is receiving less attention in
programming for child health. .

Using the rights based approach, advocacy should be promoted to foster effective inter-sectoral
collaboration, resource mobilization, integration of health programmes with community based
services such as the Community-based Health Planning and Services (CHPS) programme and
national development agendas such as the Ghana Poverty Reduction Strategy. These translated into
greater political commitment will foster ownership of programmes and strategies at all levels and
improve resource mobilization and utilization towards the achievement of national l health goals
for the children and youth in Ghana.

Ministry of Health, Ghana Health Service, UNFPA (2005): National Adolescent Health & Development Programme:
Training Manual for Health Care Providers in Ghana
2

Culyer, A.J. and A. Wagstaff.(1993). Equity and Equality in Health and Health Care.

J.Health Econ.12:431-57

Bainson K. A., Kwashie S.T., Appah B., Pond B. (2005). An Analytic Review of IMCI in the Context of Child Health
in Ghana: A Key Area Review Report for the Annual Health Sector Review 2005.
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Ghana Health Service 2006. National HIV/AIDS Control Programme, Sentinel Site Report

www.thelancet.com Neonatal Survival Series 1. vol. 365 March,2005 (accessed 10 March, 2005)

Addo-Yobo E.O.D., MD FGCP MWACP MSC DTCH, Specialist Paediatrician/Senior Lecturer

Department of Child, SMS-KNUST/KATH, KUMASI, Presentation- Reducing Birth Asphyxia Through Skilled
Attendance At Birth A Vital Key To Reducing Infant Mortality: Presented at the Reproductive and Child Health
Biannual Review Meeting, Busua Beach Resort, Western Region Ghana, September 26th 2007.
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Conde-Agudelo A., Effect of Birth Spacing on Maternal and Perinatal Health: A Systematic Review and MetaAnalysis. Rutstein, S. Johnson & Conde-Agudelo A. Systematic Literature Review and Meta-Analysis of the
Relationship between Inter pregnancy or Inter birth Intervals and Infant and Child Mortality. Reports submitted to
CATALYST Consortium, October 2004
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Conde-Agudelo, A. and Belizan, J.M. Maternal morbidity and mortality associated with interval: Cross sectional
study. British Journal (Clinical Research Ed.) 321 (7271): 1255-1259. Nov. 18, 2000.
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Ghana Health Service (2005): Guidelines for Provision of School Health Service in Ghana
Gwatkin, D. (2001). The Need for Equity-oriented Health Sector Reforms. Int J. Epid, 30:720-23

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