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SCHOOL OF PUBLIC HEALTH 
COLLEGE OF HEALTH SCIENCES 
UNIVERSITY OF GHANA, LEGON 
MATERNAL HEALTH CARE UTILIZATION THROUGH COMMU:\ITY-
BASED INITIATIVES IN PERIURBAN ACCRA 
BY 
ADANNAULOAKUNWAMEME 
(10359287) 
THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN 
P\R riAL FULFlLL,\lENT OF THE REQUIREMENT FOR THE AWARD OF 
PHD PUBLIC HEALH I DEGREE 
JULY 2018 
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DEC LARAT ION 
I, Adanna Uloaku Nwameme hereby declare that, except for the references cited in this 
thesis which have been duly acknowledged, this thesis is a product of my own PhD work 
under the supervision of Prof. Philip Baba Adongo and Dr. Phyllis Dako-Gyeke. I further 
declare that this thesis has not been submitted to this university or to any university 
elsewhere for the award of a degree . 
...... Q~ ........... . ... ...... ..J. .~ (.~ ..\ ..  !.L~. .................. . 
Adanna Uloaku Nwameme Date 
(PhD candidate) 
....~  ..... r:t ..r ..? J.I ..~ . ... ~ .. ~ .. ~. .. 
Prof. Philip Baba Adongo Date 
(Pnmary Supervisor) 
Dr. Phyllis Dako-Gyeke Date 
(Secondary Supervisor) 
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DEDICATION 
This thesis is dedicated to my husband and children. 
To my dear husband. Dr. Charles Emeka Nwameme. for your rock solid presence during 
the course of this PhD programme. Thank you for lovingly providing the much needed 
moral and financial support that has seen me to the end of this journey. I could not have 
asked for a better partner during this worthy undertaking. 
To my darling children, Xavier Maduabuchi, Charis Ivuoma, and Tahlia lvuaku 
Nwameme: you are the reason for which I undertook this endeavor. Thank you for your 
patience and understanding despite my hectic schedule during this process. My prayer is 
that I have been able to act as a role model such that you all will be encouraged to be 
tenacIous in your undertakings. and strive to excel in all that you endeavor to do. 
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ACKNOWLEDGEMENT 
The completion of this thesis has been possible because of a number of individuals who 
have shown me support through their mentorship, contributions and support. 
I wish to express my profound gratitude to Prof. Philip Baba Adongo, my supervisor and 
mentor extraordinaire. Having you guide me has been a truly enriching experience and I 
am a better researcher today for it. To Dr. Phyllis Dako-Gyeke, my second supervisor, 
thank you for your sound advice, and for having confidence in my abilities. 
I would like to also like to thank the Faculty and Staff of University of Ghana School of 
Public Health, who in one way or the other have made contributions that have helped my 
progression to the completion of this thesis. To my colleague, Philip Tabong, for his 
undiluted sense of camaraderie and encouragement; and Virtue De-Gaulle, for her 
indefatigable support throughout the programme. 
FInally, I am immensely indebted to my wonderful parents Dr. Sir Darlington and Barr. 
Lady Uchenna Amamasi, whose unconditional love and unflinching support throughout 
my life has brought me this far. 
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ABSTRACT 
Background: The availability of skilled care during pregnancy, childbirth, and the 
postpartum period ensures the best chances of delivering a healthy infant with no 
complication to the mother. Huge disparities in health exist between urban and rural 
dwellers but recent research has shown that the urban poor sometimes have worse 
maternal health outcomes than rural dwellers. Community-based interventions have been 
shown to foster interactions between pregnant women and health care providers and can 
go a long way in mitigating the adverse effects of urban poverty on maternal health. This 
study aimed to highlight how such mitiatives are able to improve maternal health care 
utilization in a peri-urban settlement in Accra. 
Methodology: This research was a cross-sectional study employing quantitative and 
qualitative methods of data collection and analysis. Four hundred and forty-one (441) 
women who delivered in the past 18 months were randomly sampled from two sub-
districts of the Ga East Municipality for participation in the survey. The purposive 
sampling technique was then used to sample participants for the Focus Group 
Discussions and the In-depth Interviews. Five (5) FGDs (n=35) were conducted amongst 
mothers in the community depending on place of delivery (21), and with the Community 
Health Officers (14), whilst nine (9) lOIs were conducted with formal and informal 
health care providers in the communities. Analysis of the quantitative data was done 
e 
using STAT A l3 and univariable, bivariable and multi variable logistic analysis were 
carried out with p-value of <0.05 seen as significant. The qualitative data were audio-
recorded, transcribed verbatim and thematic analysis was done using the NVivo 110 
software. 
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Results: Socio-demographic characteristics such as employment (p--<O.OI), autonomy 
(p=<O.OOI), and satisfaction with Antenatal Care service provision (p=<O.OOl) were 
found to be the main detenninants of adequate ANC utilization. In addition, employment 
(p=<O.05), decision making (by males) (p=<O.OOI), having had obstetric complications 
(p=<O.OOI) and having ever been visited by a CHO (p=<O.OI) emerged as determinants 
of Postnatal Care utilization in a timely manner. Barriers to maternal health care 
utilization include financial and time constraints, lack of public health care facilities 
within the communities, poor service provision at health care facilities, fear of having a 
Caesarean section, and cultural practices, causing women to access care from private 
facilities and Traditional Birth Attendant centres. There was no effect on ANC and SBA 
service utilization due to CHO home visits, but surprisingly, these visits reduced the 
likelihood of timely PNC service utilization (aOR=O.62, 95% CI=O.40-0.95). Mother 
Support Groups did not have any significant effect on ANC, SBA or PNC utilization. 
Public-private health care partnerships were weak and are dodged by lack of synchronism 
and high attrition rate of Mother Support Group volunteers. 
Conclusion: Although majority of women in these peri-urban communities availed 
themselves of ANC, SBA and PNC services, a substantial number of them utilized these 
services inadequately, and in an untimely manner. In addition, community-based 
activities of formal and informal health care providers had a mixed effect on maternal 
health care utilization and collaborations between them faced challenges requiring a clear 
cut protocol to guide these partnerships. 
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TABLE OF CONTENT 
DECLARA TION ........ . 
DEDICATION ....... . .. ....................................................................................... ii 
ACKNOWLEDGEMENT ......... . .. ............................................................................... . iii 
ABSTRACT ... ............................................................................ ... .. IV 
TABLE OF CONTENT ... . . .. vi 
LIST OF TABLES ........ .. .. .................................................................... xiii 
LIST OF FIGURES .... .. . ......................................... xv 
LIST OF ABBREVIATIONS ............ . .. ........... xvi 
CHAPTER ONE ....... .. . 1 
1.0 INTRODUCTION ........ .. ......... 1 
I . I Introduction .. .. ........ 1 
1.2 Background ..... 
..1 
1.3 Problem Statement .......... .. .. ...................... 7 
I 4 Research Questions .... .. .................. 9 
1.5 Objectives ............. . 
·. .............. 10 
1.5.1 General Objective. 
. ................................... ·· ....................... 10 
1.5.2 Specific Objectives .................................................................................... 10 
1.6 Justification of the Study .................................. .. 
.. .... ···· .. · .. ·· ................... 11 
1.7 Theoretical Underpinnings and Conceptual Framework ................................... 12 
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CHAPTER TWO ...................... . ..................................................•..•................. 16 
2.0 LITERATURE REVIEW.... . .............................................................................. 16 
2.1 Introduction ....................................•••...•.............................................. , ............ 16 
2.2 The Global Situation of Maternal Health ........................................................... 16 
2.3 Causes of Maternal Mortality ............................................................................ 19 
2.4 Maternal Health Initiatives .............................................................................. 22 
2.4.1 The Safe Motherhood Initiative (SMij ....................................................... 22 
2.4.2 Averting Maternal Death and Disability (AMDD) ..................................... 23 
2.4.3 Community-based Interventions to Prevent Maternal Mortality ................ 25 
2.4.4 Maternal Health Initiatives in Ghana ......................................................... 26 
2.5 Antenatal Care ............... . .......................... 28 
2.6 Skilled and Unskilled Attendance at Delivery ................................................... 34 
2.7 Postnatal Care .................................................... .. .................................... 40 
2.8 Rural-Urban Migration and Maternal Health Care ........ . ........................ 41 
2.9 Health Seeking Behaviour for Maternal Health Care ......... .. .............. 42 
2.9.1 Factors Affecting Health-seeking Behaviour and Utilization of Maternal 
Health Services in Peri-Urban Settlements .............................................................. 44 
2.9.1.1 Socia-demographic and economic factors .......................................... 45 
2.9.1.2 Cultural factors ........ ······ ................................ 49 
2.9.1.3 Female autonomy and spousal communication ................................... 51 
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2.9.1.4 Access to quality maternal health care .........................•.•..•................. 53 
2.9.1.5 Access to knowledge and utilisation ofmatemal health services ....... 56 
CHAPTER THREE ......................................................................................................... 59 
3.0 METHODOLOGy ..... . .................................................................................. 59 
3.1 Introduction .......... . . .............................................................................. 59 
3.2 Study Design ... . ...... 59 
3.3 Study Area .... . . .......................................................... 60 
3.4 Quantitative Data Collection ........... . . ................................................. 62 
3.4.1 Sample Size Calculation ... . .. ........................................ 62 
3.4.2 Sampling Procedure .... .64 
3.5 Qualitative Data Collection ...... .. . ................ 65 
3.5.1 Focus Group Discussions (FGDs) ....... . ............... 68 
3.5.2 In-Depth Interviews (IDls) ........... . .. .................................. 69 
3.6 Data Management and Analysis .......... . ············ ........................................... 70 
3.7 Ethical Considerations ............... .. . ......................................... 71 
3.7.1 Ethical Clearance ................. . . ...................... 71 
3.7.2 Informed Consent. 
. ··· .................... 71 
3.7.3 Privacy and Confidentiality .............................................. . · ........... 72 
3.7.4 Risks and Benefits ................................................................... ......... 72 
3.7.5 Dissemination of Results .. ........................................................... .............. 73 
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3.7.6 Quality Control ........... . ......................................................................... 73 
CHAPTER FOUR ........................................................................................................... 74 
4.0 RESULTS ................................................................................................................... 74 
4.1 Introduction ........................................................................................................ 74 
4.2 Socio-demographic Background of Respondents .............................................. 74 
4.3 Reproductive History of Respondents ................................................................ 79 
4.4 Antenatal Care ..................................................................................... . .. 80 
4.4.1 Association between Socio-demographic Characteristics of Respondents 
and Adequate ANC Attendance....... ......... ............ ..... ................................. .. :-;4 
4.4.2 Logistic Regression between Socio-demographic Factors of Respondents 
and Adequate ANC Attendance ................................................................................ 86 
4.5 Antenatal Care Knowledge. Practices and Barriers ..... ............................ 88 
4.6 Delivery Care .... ......... ...................... ....................................................... 94 
4.6.1 Association between Socio-demographic Characteristics of Respondents 
and Skilled Birth Delivery ......................................................................................... 97 
4.6.2. Delivery Care Practices and Barriers .. . ...................................... 99 
4.7 Postnatal Care .. . .......... 102 
4.7.1 Association between Socio-demographic Characteristics of Respondents 
and Timely Postnatal Care ....................................................................................... 103 
4.7.2 Logistic Regression between Socio-demographic Factors of Respondents 
and Timely Postnatal Care ....................................................................................... 106 
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4.7.3 Postnatal Care Practices and Barriers ................................ ··.······ ..... ......... 108 
4.S Community-based Initiatives and Maternal Health Care Utilization ............ 110 
4.S.1 Private-Public Healthcare Collaborations in the Peri-urban Communities .. 114 
CHAPTER FIVE ................................. ... . ....................................................... 1 18 
5.0 DISCUSSION ......................... , " .................................................................. 118 
5,1 Introduction ......... ........................................................................... 118 
5.2 Antenatal Care Utilization in a Peri-urban Settlement... .................................. liS 
5.2.1 Antenatal Care Knowledge, Practices and Utilization .............................. 119 
5.2.2 Barriers to Antenatal Care Utilization ..................................................... 129 
5.3 Skilled Birth Attendance in a Peri-urban Settlement ...................................... 131 
5.3.1 Knowledge, Practices and Utilization of Skilled Birth Attendance .......... 131 
5.3.2 Barriers to Utilization of Skilled Birth Attendance .................................. 137 
5.4 Postnatal Care Utilization in a Peri-urban Seulement.. ...... " .......... "" ............. 139 
5.4.1 Postnatal Care Knowledge, Practices and Utilization........ . ... 140 
5.4.2 Barriers to Postnatal Care Utilization.. .. ................. 144 
5.5 The Influence of Community-based Initiatives on Maternal Health Care Service 
Utilization in a Peri-urban Settlement. .................... , " ............................ 147 
5.5.1 The Community-based Initiatives and Maternal Health Care Utilization 147 
5.5.2 Challenges Faced by Community-based Health Care Collaborations in a 
Peri-urban Setting ..... " ............................ , ................. , .............................................. 151 
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CHAPTER SIX ............................................................................................................... 155 
6.0 SUMMARY, CONCLUSIONS AND RECOMMENDATIONS ............................ 155 
6.1 Introduction ............. . ............................................................................ 155 
6.2 Summary ................ . ................................................................................... 156 
6.3 Conclusions ..................................................................................................... 158 
6.4 Contributions of the Study to Knowledge ....................................................... 158 
6.5 Recommendations .... ... 159 
6.5.1 Recommendations for practice ........................................................... 159 
6.5.2 Recommendations for future research ................. . ............... 161 
REFERENCES ............... .. .......................................................... 162 
APPENDICES ................ .. . ......................................................................... 189 
APPENDIX A: CONSENT FORM FOR QUANTITATIVE DATA COLLECTION 189 
APPENDIX B: QUESTIONNAIRE FOR QUANTITATIVE DATA COLLECTION 
'" ........................ .. ..................................................... 193 
APPENDICE C: CONSENT FORM FOR FOCUS GROUP DISCUSSIONS AND IN 
DEPTH INTERVIEWS AMONG POSTNATAL WOMEN AND HEALTH CARE 
PROVIDERS... ................. ......... .. .................. 209 
APPENDIX D: FGD GUIDE FOR POST-NATAL WOMEN........ . .................... 2 I 2 
APPENDIX E: FGD GUIDE FOR COMMUNITY HEALTH OFFICERS AND IDI 
GUIDE FOR URBAN CHPS COORDINATOR ...................................................... 216 
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APPENDICE F: IDI GUIDE FOR FACILITY HEALTH WORKERS, 
TRADITIONAL BIRTH ATTENDANTS AND MOTHER SUPPORT GROUPS .. 2] 8 
APPENDIX G: ETHICAL APPROVAL LEITER .................................................... 219 
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LIST OF TABLES 
Table I: Methods and Sources of Study Data .................................................................. 60 
Table 2: Summary ofFGD Participants ........................................................................... 68 
Table 3: Summary of illI Participants ........................................................................... 69 
Table 4: Socio-demographic Characteristics of Respondents ......................................... 77 
Table 5: Socio-demographic Characteristics of FGD Participants ................................... 78 
Table 6: Reproductive History of Respondents ................................................................ 80 
Table 7: Antenatal Care Attendance ....... . ......................................................... 83 
Table 8: Adequate ANC attendance by socio-demographic characteristics and 
community-based initiatives... .. ...................... .. ............................................................ 85 
Table 9: Relative odds of adequate ANC attendance by socio-demographic factors and 
community-based initiatives ........ ................................... 87 
Table 10: Delivery care .... .. .. 96 
Table II: Skilled birth delivery by socio-demographic factors and community-based 
initiatives ........ .. ....................... 98 
Table 12: Postnatal Care ............................... .. .. ......................................... 103 
Table 13: Timely Postnatal Care by socio-demographic factors and community-based 
IIlltlatives .................................................................................................................... 105 
Table 14: Relative odds of timely PNC by socio-demographic factors and community-
based initiatives ................................................................... . .. ...... 107 
Table 15: Mothers who had adequate ANC, skilled delivery and timely PNC by 
community initiatives and other factors .......................................................................... III 
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Table 16: Relative odds of having adequate ANC, skilled delivery and timely PNC by 
community initiatives and other factors .......................................................................... ) 12 
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LIST OF FIGURES 
Figure 1: Conceptual framework for improving maternal health care utilization through 
community-based initiatives in periurban Accra .............................................................. 14 
Figure 2: Map ofGa East Municipal ............................................................................... 60 
Figure 3: Contextual representation of influence of community-based initiatives on 
maternal health care utilization .. . .......................................................................... 150 
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LIST OF ABBREVlAT lONS 
ANC Antenatal Care 
BEOC Basic Emergency Obstetric Care 
CHO Community Health Officer 
CHPS Community-based Health Planning and Services 
CHW Community Health Worker 
EmONC Emergency Obstetric and Neonatal Care 
FANC Focused Antenatal Care 
GDHS Ghana Demographic and Health Survey 
HBM Health Belief Model 
ICPD International Conference on Population and Development 
LMICs Low- and Middle- Income Countries 
MDGs Millennium Development Goals 
MHD Municipal Health Directorate 
MHMT Municipal Health Management Team 
MMR Maternal Mortality Ratio 
PNC Postnatal Care 
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SBA Skilled Birth Attendance 
SDGs Sustainable Development Goals 
SMI Safe Motherhood Initiative 
STlsiHIV Sexually Transmitted Infections/Human Immuno-deficiency Virus 
TBA Traditional Birth Attendant 
UNDP United Nations Development Programme 
UNFPA United Nations Population Fund 
UNICEF United Nations Children'S Fund 
WHO World Health Organisation 
WIF.\ Women In Fertility Age 
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CHAPTER ONE 
1.0 INTRODUCTION 
1.1 Introduction 
This chapter provides a background to the study. It encompasses the maternal health care 
situation on global and local scales. It seeks to establish the importance of Antenatal Care, 
Skilled Birth Attendance and Postnatal Care utilization in ensuring positive maternal health 
outcomes. It further examines the place of community-based interventions in the provision 
of maternal health care for underpriviledged women living in peri-urban settlements. The 
chapter goes on to justify the reason for the study, while outlining the objectives to be met. 
The conceptual framework on whieh the study is premised is also described. 
1.2 Background 
Maternal health which encompasses the health of a woman during pregnancy, childbirth. 
and the postpartum period is a fundamental human right for all women 
(WHOIUNFPNUNICEFlWorld Bank, \999). Availability of skilled care before, during, 
and after childbirth is paramount in ensuring the be~t chances of delivering a healthy infant 
with no complication to the mother (WHO, 2016). Global efforts have been made to ensure 
good maternal health care and in 1987, the World Health Organization (WHO) formulated 
the safe motherhood package which comprises of ANC, family planning, safe delivery, and 
essential obstetric care conceived to ensure women's ability to safely carry their 
pregnancies and deliver healthy infants (Mahler, 1987). In 2000, the Millennium 
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Development Goal (MOO) 5 was set to improve maternal health by reducing maternal 
mortality by 75% and achieving universal access to reproductive health between 1990 and 
2015 (WHOIUNICEFIUNFPAlWorld BankJUNPD, 2015). By 2010, the Sustainable 
Millennium Goals were established to spur on the MDG efforts and SDG 3.1 aims to reduce 
worldwide maternal mortality to less than 70/10,000 live births by 2030. In order to achieve 
this goal, the continuum of care needed by pregnant women must be available and 
accessible. 
Antenatal care (ANC) as is traditionally practiced was developed in thc 1900s and is the 
first care offered to expectant women during frequent antenatal visits (WHO, 2005). The 
ANC services are oriented towards preparation for birth and parenthood, in addition to 
prevention, detection. alleviation, or management of pregnancy related problems that 
impact on mothers and babies, other health problems exacerbated by the pregnancy. as well 
as issues arising from unhealthy lifestyles (PMNCH, 2006). Antenatal Care provides an 
opportunity for women and their families to interact with the formal health system and 
access health services geared towards health promotion and preventive care, encourages 
skilled birth attendance and postpartum care, and contributes to good health outcome for 
the mother and child (ACCESS, 2005). 
Conventional Antenatal Care is largely focused on a risk-based approach whereby women 
arc classified based on the likelihood of developing pregnancy-related complications and 
therefore are required to make several antenatal visits to ensure better birth outcomes 
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(ACCESS, 2005). However, several studies have shown that there is no guarantee that 
women with risk factors will develop complications, and vice versa (Vanneste, Ronsmans. 
Chakraborty, & De Francisco, 2000; Yuster, 1995). These repeated visits also pose a 
financial and logistic burden to women; and a strain on resources available at the healthcare 
facilities (Villar & Bergsj0, 1997; WHO, 2002). In a bid to mitigate these challenges, the 
World Health Organisation (WHO) adopted the Focused Antenatal Care (FANC) approach 
in 2002, which aims at targeted assessments and individualised care of pregnant women 
during four ANC visits (PMCH, 2010). Targeted assessments make certain that the 
pregnancy and postpartum periods progress as expected, and ensure early detection and 
management of complications that may arise concerning the mother or the newborn; while 
individualised care provides supportive care and counselling to prepare the women and 
their families for birth and possible complications (ACCESS, 2007). 
Several studies have also revealed that the availability or increase in skilled birth 
attendance results in reduction of maternal and child mortality (Bhutta et a\., 2010; Prata 
et al., 2011; Yakoob et a\., 2011). According to WHO, a skilled birth attendant refers to a 
health professional such as a midwife, doctor or nurse, who is trained and competent in the 
skills needed to manage normal childbirth and the immediate postnatal period, and who 
can Identify complications and provide emergency management and/or refer the case to a 
higher level of health care (WHO, 2004). The postpartum period, interchangeably called 
the postnatal period, generally covers the first 42 days after birth and can be a precarious 
period for a woman, her newborn and her household physiologically, emotionally and 
socially (WHO, 1998). Although most maternal mortality and morbidity as well as neonatal 
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mortality occur during this period, not much priority is given to postnatal care (Ronsmans 
& Graham. 2006). 
Antenatal Care. SBA and PNC service provision are important measures as direct obstetric 
complications such as haemorrhage, hypertension, sepsis, and obstructed labor are 
responsible for 71.4% of all maternal deaths that occur in Africa (Say et a!., 2014) whilst 
over 50% of maternal deaths occur within twenty-four hours of birth (Nour, 2008). On the 
global front, there has been a significant increase in the number of women accessing ANC 
services but the progress in sub-Saharan Africa has been quite slow with only a 4% increase 
between 1995 and 2005 (WHO, 2005). In most African countries, less than 70% of 
pregnant women receive ANC, most of whom only have one or two visits and sometimes 
late in pregnancy (Houweling, Ronsmans, Campbell, & Kunst, 2007). Unfortunately, many 
of the women who do not have access to Antenatal Care are those who need it the most, 
typically poor women m rural areas and urban slums (Zanconato, Msolomba, Guarenti, & 
Franchi, 2006). Similarly, whilst significant strides have been made in developed countries 
with regards to the availability of skilled attendance during child birth, Africa continues to 
lag behind with less than 50% of all births in Africa taking place with a skilled attendant 
(Edouard. 2012) and receiving postnatal care within two days of childbirth (Lawn et aI., 
2014). The maternal mortality rates (MMR) in the sub-Saharan Africa region alone 
accounted for 62% (179,000) of the 289,000 women who died during pregnancy and 
childbirth globally in 2013 (WHOIUNICEFIUNFPAffhe World BanklUN, 2014). In the 
same year, the maternal mortality rate in Ghana was 380 per 100,000 live births which is 
still high, although it was a reduction from 760 in 1990 (WHO et aI., 2014). Improving the 
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health of a woman during this critical stage in life and reducing maternal and neonatal 
death is a global priority. 
Studies show that social detenninants are closely linked with use of maternal health care 
services. In addition to poverty, gender discrimination and poor education (Banks et aI., 
2006; Lawn, Cousens, & Zupan, 2005; WHOIUNICEFIUNFPAlTbe World Bank, 2007), 
there are intra-urban and rural-urban disparities between healthcare accessible to 
individuals dwelling in urban and that operational in rural environments (Wirth et aI., 
2006). A 2007 report from the United Nations Population Fund predicts that the urban 
populations in Africa will double by 2030 with the fastest growing group being the urban 
poor. Moreover, 72% of sub-Saharan Africa's urban population currently lives under slum 
conditions associated with overcrowding and poor sanitary conditions, making them 
susceptible to ill health and diseases (UNFPA, 2007) and predisposing them to poor access 
to quality healthcare; a situation comparable to or less than what is prevalent in rural areas 
(KIDney et aI., 2010). These poor conditions, in addition to insufficient nutrition, lack of 
potable water and poor education invariably result in maternal and child deaths (UNICEF, 
2007). Maternal health care services have been proven to promote the health of mothers 
and their newborns but the urban poor have limited access to maternal health care services 
(Khan et aI., 2012; Matthews et aI., 2010). Where such inequity exists, the 
underpriviledged women can fall between the cracks of health service delivery as a result 
of access barriers and poor quality of available services, and end up with negative health 
outcomes. 
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Community-based interventions have been shown to have positive effects on access to and 
coverage of health care services. as well as on the diminution of health disparities. with the 
provision of health services to individuals who are difficult to reach (Lassi, Das, Salam. 
& Bhuna, 2014). In addition to improving utilization of maternal health care services by 
tackling socio-economic and cultural challenges, and improving the quality of services 
provided. the initiation of community programmes that foster interactions between the 
pregnant women and health care providers can go a long way in mitigating the adverse 
effects of urban poverty on maternal health (PMNCH, 2006). The involvement of 
Community Health Workers (CHWs). sometimes voluntarily, in such attempts at service 
provision has been shown to make a difference in access to health care and health outcomes 
(WHO/GHW A, 20 I 0). In many Low-and-Middle Income Countries, CHWs  are effectively 
involved in interventions geared towards the improvement of maternal and child health 
(Gilmore & McAuliffe, 2013; Lema et al., 2014). 
Furthcnnore, evidence exists that highlights the bcnefits of fostering partnerships between 
public and private health care providers in underserved communities (Thadani, 2014; 
WHO. 2007). Due to the paucity of public health facilities in many urban poor areas, 
private health care facilities like the private hospitals, clinics, phannacies and the 
laboratories tend to fill the gap in the health care delivery services that the public sector is 
not able to meet (Basu, Andrews, Kishore, Panjabi, & Stuckler, 2012). The perception that 
the private health care providers, which are usually profit making, have their services 
tailored for the rich is disputable. This is because the private sector is reported to be the 
main source of treatment for the poor, especially in developing countries, whereas the 
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public sector often provides care for the rich (Basu et aI., 2012; Harding, 2009). This 
situatIOn is also evident in the utilization of maternal health care in urban slums where 
women patronize private health care facilities for various reasons ranging from lack of 
public health care facilities, to dissatisfaction with service provision at available public 
institutions (Bayou, Mashalla, & Thupayagale-Tshweneagae, 2016; Fotso & Mukiira, 
2012). In a bid to enhance provision of affordable and quality health care accessible to all. 
a well planned and executed public-private sector collaboration of health services can help 
address specific costs and investment challenges, improve service provision at affordable 
cost, boost expertise as well as increase infrastructural development and improve modem 
medical technologies (Nikolic & Maikisch, 2006). 
1.3 Problem Statement 
Maternal mortality continues to be a huge public health problem in sub-Saharan Africa 
where 71 % of pregnant women attend at least one ANC clinic but only 44% attend the 
stipulated four times (Kinney et aI., 20 I 0). In 20 IS, about 86% of all maternal deaths 
occurred as a result of direct obstetric conditions such as hypertension and antepartum 
haemorrhage, and these are directly related to inadequate Antenatal Care (GBD 2015 
MMe, 2016; WHO, 2005). For so long, popular opinion was that these conditions affected 
women living in rural areas more than those in the urban areas, but recent research has 
shown that the urban advantage is not all-encompassing as the urban poor sometimes have 
worse maternal health than rural dweIJers (Matthews et aI., 2010). These inhabitants of 
deprived urban environments sometimes find maternal health care services to be 
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inaccessible as more importance has been placed on reproductive health issues concerning 
rural dwellers than has been placed on the urban poor (Fotso, Ezeh, &. Oronje, 2008). 
Despite the fact that in Africa there is an inclination towards allocating the bulk of health 
services to urban areas, the urban poor woman living in a marginalised settlement has poor 
access to health care facilities (IDS. 2016; Magadi. Zulu, & Brockerhoff, 2003). In addition 
to the fact that the peri-urban settlements are informal and as such are deprived of 
government support, their locations are often times inaccessible to health workers and the 
increasing populations of these slums make it difficult for adequate health services to be 
provided (Magadi et aI., 2003). The women in these settlements are also constrained by the 
need to engage in economic activities to survive, poor social support and high cost of health 
care services in urban areas (Fotso, Ezeh, & Oronje, 2008; Magadi et ai., 2003). 
Furthermore, national surveys are neglectful of these slum settlements due to their illegal 
status, thus providing health indicators that are not reflective of the intra-urban disparities 
between the slum dwellers and the non-slum dwellers (Fotso et ai., 2008). As such, the 
urban poor have benefited the least from improvements in maternal health care. 
In Ghana, about 48% of urban dwellers are migrants with one in every six residents in 
Greater Accra Region being a migrant (GSS, 2014). This high incidence of urban migration 
in Ghana has led to an increase in vulnerability to poverty due to high living costs and 
paucity of job opportunities, and its attendant negative effect on health statuses (Novignon, 
Nonvignon, Mussa, & Chiwaula, 2012). In their study done in Accra, Ghana, Fobi) et ai., 
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(2012) found an increase in mortality due to malaria and diarrhoea amongst financially 
vulnerable individuals living in poor environments. The case with maternal health care 
provision in Ghana is not different as the urban poor are usually left out ofmatemal health 
care plans with the urban non-poor and rural pregnant women having higher access to 
maternal services than their marginalised urban poor counterparts. (Matthews et al.. 2010). 
As explosive population growth continues to be the trend in sub-Saharan African cities, 
there is a need to tackle maternal health issues in resource-poor urban settings by 
implementing initiatives that have been shown to reduce maternal mortality and morbidity. 
such as Antenatal Care, Skilled Birth Attendance and Postnatal Care. accessible to pregnant 
women living in this unique environment. 
1.4 Research Questions 
This research work will aim to answer the following questions: 
I. What are the peri-urban women's experiences with the Antenatal Care services 
offered by the health care providers in their communities? 
2. How do pregnant women utilize Skilled Birth Attendance services from the health 
care providers in their communities? 
3. What are the women's experiences with the Postnatal Care services they receive 
from the health care providers," their communities? 
4. How do community-based interventions influence adequate ANC, SBA and timely 
PNC utilization in the peri-urban setting? 
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1.5 Objectives 
1.5.1 General Objective 
The general objective of this research is to investigate the utilization of maternal health 
care services through community-based perinatal care interventions in a peri-urban setting 
in Ga East Municipal. 
1.5.2 Specific Objectives 
The specific objectives are outlined as follows: 
I. To assess the peri-urban women's utilization of Antenatal Care services offered by 
the health care providers in their communities; 
2. To examine the women's utilization of Skilled Birth Attendance services from the 
health care providers in their communities; 
3. To explore the women's utilization of Postnatal Care services offered by the 
health care providers in their communities; 
4. To determine the influence of community-based interventions on adequate ANC, 
SBA and timely PNC utilization in the peri-urban setting. 
1.6 Justification of the Study 
In Ghana, though 95% of pregnant women receive some Antenatal Care, only 57% go 
ahead to deliver their babies in health care facilities while 30.3% of births are attended to 
by Traditional Birth Attendants (GSS/GHS/ICF Macro, 2009). The situation in Greater 
Accra Region is alarming as it is the only region out of the existing ten, that recorded a 
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decline in ANC coverage from 88.'1'10 in 2002 to 85.2% in 2008 (GHS, 2009a). Supervised 
delivery In the region accounts for 53% of all births with TBAs taking 3% of the deliveries 
(GHS. 2009b). 
Over the past two decades some areas of the Greater Accra Region have had a rapid 
increase in population growth with the concomitant spatial expansion into peri-urban 
surroundings and Ga East Municipal in the region is an area experiencing this fast 
population explosion (pehr, 20 I 0). This bas led to poor social and health infrastructure 
provision in the municipal. The Ga East Municipal Health Management Team (MHMT) 
Reproductive and Child Health Report indicates that in 2015, the municipal had an ANC, 
SBA and PNC coverage of 78%, 42% and 54%, respectively (GEMHD. 2016). This 
statistic shows that many women miss out on the benefits of Maternal Health Care to the 
detriment of their health and that of their newborn. However, in this study area, there exists 
a number of community-based interventions tailored towards improving maternal health 
care service delivery to the underpriviledged women living in these communities. These 
include the home visits undertaken by Community Health Officers (CHOs) attached to the 
Community-based Health Planning and Services (CHPS) programme, the Mother Support 
Groups made up offemale volunteers and collaborations between public and private health 
care providers in the communities. 
This study is therefore tailored towards determining bow these community-based 
interventions bridge the gap between communities and facilities and thereby improving 
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maternal health care service utilization in peri-urban settlements. Findings from the study 
will help in the formulation of recommendations towards the strengthening of 
collaborations between public and private health care providers thereby improving delivery 
of perinatal care services in marginalized urban areas. 
1.7 Theoretical Underpinnings and Conceptual Framework 
Research studies are based on theoretical frameworks which form the basis for the problem 
statement of the study, the significance, and the research questions, and provide a 
foundation for the literature review, the research methods and plan for analysis (Grant & 
Osanloo. 2014). Patient utilization of and satisfaction with health care services can be 
explained by a number of theories but this research is guided by the Donabedian Model 
and Weick's Health Communication Theory. 
The Donabedian Model has been used widely as an evaluation framework targeted at 
outcomes of health care provided to individuals (Sardasht, Shourab, Jafarnejad, & Esmaily, 
2014). Formulated in 1966, this framework outlines three standards for the assessment of 
quality of service provided and these arc structure, process and outcome (Donabedian, 
1997). Service delivery interacts with various underlying characteristics of the recipients 
thereby resultmg in positive or negative health outcomes. In this study, this model was used 
to identify the structures in place to enhance the provision of maternal health care services 
to the women in the peri-urban settlements. This includes the channels of communication 
between the community based health care providers and the women in the communities, as 
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well as that between the providers. The process by which the care is given is characterised 
by the ANC. skilled birth delivery and PNC services provided at the community and facility 
levels. The outcomes of the process will include the peri urban women's satisfaction with 
the quality of service provided and its subsequent effect on ANC, skilled birth delivery and 
PNC service utilization. As the Donabedlan Model does not take demographic and socio-
economic factors outside of the health care delivery system into cognizance, this research 
will use it in conjunction with the Weick's Theory to ensure that factors that impact on 
maternal health care utilization at the community level are also addressed. 
The first International Conference on health promotion produced the Ottawa Declaration 
of 1986, which recognised the importance of mediation between social groups and health 
care providers towards the improvement of health (WHO, 1986). Weick's theory highlights 
the fact that communication and processing of information playa vital part amidst social 
groups and inslirutions. The theory emphasises the import of communication between 
healthcarc providers as well as that between clients and health care providers (Raingruber, 
2014; Weick, 1979). The three phases in Weick's theory are enactment. selection, and 
retention: the enactment phase centers on the health challenges being encountered; the 
selection phase dwells on strategies employed to improve on communication; while the 
retention phase deals with mamtaming the learned lessons and putting them into action. 
These were used in this research to describe the challenges encountered with regards to 
utilization of maternal health care services and to communicate its importance to women 
at the community level during the enactment phase. The community initiatives that exist 
as a result of attempts to mitigate these challenges and the influence of socio-demographic 
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characteristics of the women on these intiatives were contextualized at the selection phase. 
In the retention phase. the research sought to highlight the effect of the support offered to 
the women living in periurban communities on utilization of perinatal care services in an 
adequate and timely manner. These two theories have informed my conceptualization of 
the research as shown in Figure I below. 
Proc:esslSelection Outcome/Retention 
,--- .--__ t___ ~ - -
Behavioural and Socio-economic ~ Health System Level Quality -·-o~-'I 
Communication Characteristics Publiclpnvate health Service Utilisation 
IEC Age care facilities 
Interpenonal Parity Adequate 
-provlder- Religion • Poor provider-dient SABNAC  r· ANC 
client EducatIon I relationship PNC Skilled 
-provider- Employment • Poor infonnation flow Binh 
provider Autonomy I I .• _~O~fh~ism Delivery 
Print media Timely 
Radio and PNC 
televIsIon : Community Level 
SocIal media ~ • Community Health Officers 
-Home Visits 
I· Mother Suppon Groups 
I· Traditional Binh 
I Attendants 
Cultural barriers 
Health seeking behaviour 
Figure 2: Concept~~I.fr~mework for improving maternal health care utilization through 
commUnity-based Imtlatlves to peri urban Accra 
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CHAYfERTWO 
2.0 LITERATURE REVIEW 
2.1 Introduction 
In this cbapter, various literature that bave a bearing to the study subject are reviewed. 
Taking the objectives of the study into account, the review covers the maternal health 
situation on a global scale, as well as in Ghana, and initiatives tbat were established to 
improve maternal health. It also explores existing literature on ANC, SBA and PNC, and 
health seeking behaviours of women in need of these services. Literature documenting the 
effects of rural to urban migration and community-based interventions on maternal health 
care utilisation are also reviewed. 
2.2 The Global Situation of Maternal Healtb 
Maternal mortality is a global public health challenge of vast proportions as one woman 
dies every minute from delivery complications worldwide (APP, 2010). Less than 1% of 
these maternal deaths happen in developed countries with the remaining 99% occurring in 
the developing world (WHO, 2014). Even though there had been a 47% decrease in 
maternal mortality worldwide between 1990 and 20 I 0, the annual maternal mortality ratio 
decline rate has been 3.1%, a far cry from the 5.5% that was needed to achieve the fifth 
Millennium Development Goal (WHO, 2014). Equally as disconcerting is the fact that the 
advancement towards a decrease in maternal mortality has been disproportionate _ while 
some countries have experienced a decrease in maternal deaths, other countries have 
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recorded an increase in maternal mortality ratio (Coeytaux, Bingham, & Langer, 20 II). 
Maternal mortality ratios vary between regions - while the ratio in Europe and Central Asia 
is 44 deaths per 100,000 live births, in sub-Saharan Afiica it is 900 deaths per 100,000 live 
births (WD, 2010). 
A general assumption is that women living in developed nations are not at risk of dying 
from pregnancy-related complications. Pregnancies are at risk of unforeseen 
complications. with 15% of all pregnancies being life-threatening (WD, 2009). Studies 
mdicate that the United States ranks fiftieth in maternal mortality out of 171 countries, 
perfonning poorer than other industrialised nations such as United Kingdom and Canada, 
as well as some developing countries like Vietnam and Albania (Bingham, Strauss, & 
Coeytaux, 2011; Coeytaux et aI., 201l). Statistics also show that maternal mortality in the 
United States more than doubled from 6.6 deaths per 100,000 live births in 1987 to 15 
deaths per 100,000 live births in 2007 (USHRSA, 2009; Xu, Kochanek, & Murphy, 2010). 
In Canada. the maternal mortality ratio in 2011 was 6.1 deaths per 100,000 live births 
(PHAC. 2013) and in the United Kingdom. it was 11.39 deaths per 100,000 live births in 
2008 (CMACE. 20 II). 
The lifetime risk of maternal death in sub-Saharan Africa is 1 in 36, a catastrophe of high 
proportions when compared with I in 4900 prevalent in developed countries 
(WHO'lJNICEFIUNFP AlWorid BanklUNPD, 2015). For every maternal death that occurs 
due to complications, about 15 to 30 women end up having enduring illness and disabilities 
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(Kvale, Olsen, Hinderaker, Ulstein, &: Bergsje, 2005). Even though some countries in sub-
Saharan Africa have reduced their maternal mortality by half since 1990, and more 
headway has been observed in Asia and North Africa (WHO, 2014), in many parts of the 
developing world, more than 33% of pregnant women have no access to Antenatal Care, 
and 57% of deliveries are not attended to by a skilled health care personnel (UNFPA, 
2005). 
In 2005, about 48% of all maternal deaths occurred in India (117,100), Nigeria (58,800), 
the Democratic Republic of Congo (32,300), Afghanistan (26,000), and Ethiopia (22,200) 
(Hill et al.. 2007). China, Sri Lanka, and Malaysia are developing countries that have 
succeeded in reducing their maternal mortality by improving on their health services 
coverage and services provided (Koblinsky, Campbell, & Heichelheim, 1999). On the other 
hand, in Zimbabwe the general decline in health services provision standards has led to an 
increase in maternal mortality over time (Choguya, 2015). 
In Ghana, although considerable progress has been made in reducing the Maternal 
Mortality Ratio from 740 deaths per 100,000 live births in 1990 to 451 per 100,000 live 
births in 2008. the eurrent ratio of 485 deaths per 100,000 live births is a far ery from the 
national 2015 fifth Millennium Development Goal target of 185 deaths per 100,000 live 
births (GSS, 2013). 
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2.3 Causes of Maternal Mortality 
The WHO defines maternal death as "the death of a woman while pregnant or within 42 
days oftennination of pregnancy. irrespective of the duration and the site of the pregnancy, 
from any cause related to or aggravated by the pregnancy or its management but not from 
accidental or incidental causes." (WHOIUNICEFIUNFPAffhe World Bank, 2012). About 
45% of all maternal deaths occur within the first 24 hours post-delivery while 66% occur 
within the first seven days (Nour, 2008). The major causes of maternal mortality include 
haemorrhage (24%), sepsis (15%), unsafe abortion (13%), eclampsia (12%) and obstructed 
labour (8%) (Ronsmans & Graham. 2006). Indirect causes such as anemia, malaria. and 
heart disease are responsible for 20% of maternal deaths while ectopic pregnancy, 
embolism. and complications during anesthesia account for 8% of deaths (Nour, 2008). 
Pre-eclampsia and eclampsia account for 63,000 maternal deaths globally every year 
(WHO. 2005) with women in the developing world having a higher rate than their 
counterparts in thl! developed countries (Goldenberg, McClure, MacGuire. Kamath, & 
Jobe. 20 II). Placenta abruptio and placenta praevia are responsible for 50% of all 
haemorrhages occurring in pregnancies (Shukar-ud-din. Tariq. & Soomro, 2010) while 
sepsis affects 4.4% of all pregnancies leading to almost 6 million cases of puerperal sepsis 
and 77,000 deaths of women in reproductive age (AbouZahr, 2003a). Treatment for 
postpartum bleeding has to be provided within a short space of time as the time interval 
from onset to death of a woman who is haemorrhaging has been estimated at two hours 
(MaIRe, 1991) with the prognosis being even worse where there is associated anaemia in 
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pregnancy (KvAle et aI., 2005). Of the more than 6 million cases of obstructed labour that 
occur worldwide, about 40,000 women die from neglect with 73,000 ending up with 
vesico-vaginal fistulae, while women in reproductive age also experience more than 14 
unsafe abortions for every 100 live births, which translates to 68,000 maternal deaths 
annually (AbouZahr, 2003a). 
Pre-existing health problems such as malaria, HIV/AIDS, anaemia and malnutrition can 
become more grave or complicated during pregnancy with negative effects on mothers and 
their newborn (PMNCH, 2006). There are 10,000 maternal deaths and 200,000 infant 
deaths annually resulting from complications of malaria and anaemia while tuberculosis is 
responsible for 9% of all maternal deaths encountered (WHO, 2005). 
Cultural beliefs surrounding pregnancy and childbirth also have an effect on pregnancy 
outcomes in a positive or negative manner. While some communities encourage pregnant 
women to eat special foods and have rest periods, others do not regard pregnancy as a 
special pcriod in a woman's life thus these women carry on with laborious tasks, and are 
bound by taboos preventing them from eating nutritious foods thus contributing to 
deficiencies emanating from malnutrition and anaemia (PMNCH, 2006). In addition, 
cultural practices such as female genital mutilation lead to complications during delivery, 
thereby increasing the chances of maternal deaths occurring (Banks et aI., 2006). 
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Expectant mothers have the desire for a favourable outcome at the end of their pregnancies 
but newborns are not exempt from problems arising from maternal complications which 
result in about 900,000 babies dying in utero in the last three months of pregnancy in sub-
Saharan Africa. Complicated pregnancies are also known to result in neonatal 
complications such as preterm births, poor foetal growth, congenital infections and foetal 
alcohol syndrome (PMNCH, 2006). 
In resource-constrained environments, high mortality rates have been linked to the 'three 
delays' which have been identified as the delay in the recognition of a life-threatening 
situation; the delay in making a decision to access health care due to such issues as lack of 
knowledge concerning where to access health care, lack of money or the need to obtain 
permission to access health care; and the delay in arriving at the health care facility caused 
by poor transportation (Senah, 2003; Thaddeus & Maine, 1994). A fourth type of delay has 
been proposed to describe the delay in receiving adequate care at the health care facilities 
due to lack of health care staff or poor health care delivery services (Senah, 2003). Safe 
motherhood practices avert most maternal and infant deaths, yet maternal-related deaths 
and disability from preventable causes continue to affect millions of women worldwide. 
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2.4 Maternal Health InitiatiYes 
2.4.1 The Safe Motherhood Initiatiye (SMI) 
In 1985, the state of maternal health in the developing world was brought to light when the 
WHO reponed that 500,000 of its women die annually from pregnancy-related 
complications (Starn, 2006); and a paper written by Rosenfield & Maine (1985) pointed 
out the appalling condition of maternal health in developing countries. Following these, in 
1987 the first international meeting on maternal mortality was held which led to the 
launching of the Safe Motherhood Initiative (SMI) at the Safe Motherhood Conference 
hosted by WHO, United Nations Population Agency (UNFPA) and the United Nations 
Development Programme (UNDP) in Nairobi, Kenya (Rosenfield, 1997). To further raise 
awareness of maternal health issues on a global stage, an Inter-Agency Group for Safe 
Motherhood (lAG) was then fonned to encourage collaborations between international 
agencies and non-governmental organisations (Shiffman & Smith, 2007). 
The goal of the SMI was to decrease maternal mortality and morbidity by 50% by the year 
2000 (PRIME, USAID, PATH, & UNFPA, 1998) by adhering to specific strategies and 
mterventions referred to as the Pillars of Safe Motherhood, which include family planning, 
Antenatal Care, obstetric care, Postnatal Care, post abonion care, and Sexually Transmitted 
Infections/Human Immuno-deficiency Virus (STlslHlV) and malaria control (US AID, 
2006). In addition to the substantial proof confinning that maternal deaths were of huge 
proponions, it was also apparent that there were far reaching consequences on child 
survival, and the health of the family and community as a whole (Lawn et aI., 2005). 
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Progress towards this goal has however been very slow largely due to the wide range of its 
activities targeted at improving maternal health but inadvertently leading to uncertainty 
regarding the focal point of the initiative (Rosenfield. 1997). The lingering challenges 
posed to maternal health issues led to its being included as the fifth of the Millennium 
Development Goals (MDGs) in an effort to strengthen endeavours towards safe 
motherhood (AbouZahr, 2003b). The MDG 5 aimed to improve maternal health by 
reducing maternal mortality by three-quarters. increasing the proportion of births attended 
by skilled health personnel and achieving universal access to reproductive health by 2015 
(UN. 2011). As that landmark year drew near. despite progress reports shown in maternal 
health indicators globally. the poor and vulnerable in the developing countries continued 
to record high maternal mortality ratios with sub-Saharan Africa and Southern Asia 
accounting for 86% of all maternal deaths in 2013 (UN. 2015). These deaths are 
preventable through interventions such as Antenatal Care, Skilled Birth Delivery and Post-
natal Care (UN, 2015). 
2.4.2 Averting Maternal Death and Disability (AMDD) 
In 1999, the Bill and Melinda Gates Foundation gave an award of USSSO million to 
Columbia University to support their Averting Maternal Death and Disability Programme 
(Shiffman & Smith, 2007). The programme encourages the application of human rights 
principles at national and local levels and has formed collaborations with several 
internatIOnal organisations such as UNICEF. UNFPA, CARE, and Save the Children 
(Maine & Rosenfield, 200 I). The focal point of the AMDD programme is on improving 
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the accessibility of Emergency Obstetric Care (EmOC) to all women who encounter 
pregnancy-related complications. rather than on prevention of these complications (Maine 
& Rosenfield. 200 I). The programme countered the maternal health focus on prediction of 
complications. based on the fact that identification of groups of women at high risk of 
complications is not individualised. thus there is the chance of women in this group birthing 
without severe complications while a large number of women in low-risk groups end up 
developing complications (Maine, 1991). Furthermore. the AMDD programme posits that 
the five major causes of maternal death- hemorrhage. unsafe abortion, eclampsia, infection, 
and obstructed labour- cannot be prevented but can be treated; and that adequate treatment 
in a timely manner will prevent most maternal deaths as well as maternal disabilities 
(Maine & Rosenfield. 2001). 
Progress made by the programme is measured using process indicators providing answers 
concerning the availability and distribution of functioning health facilities providing 
EmOC in a given area; the utilization of these facilities by pregnant women; the range of 
services provided by these facilities; and the maternal deaths recorded in these facilities 
(Maine & Rosenfield, 2001). The advantages of these process indicators are that they can 
fit into the health system information of governments thus monitoring progress becomes 
mexpensive; they are not time-consuming as change can be demonstrated in two years or 
less; and they are able to pinpoint problematic areas that need to be addressed such as poor 
availability or utilization of services (Maine & Rosenfield. 200 I). 
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2.4.3 Community-based Interventions to Prevent Maternal Mortality 
The recent interest in community-based interventions is due to the fact that evidence 
suggests that community involvement in health programmes leads to successful outcomes, 
and reduces the costs of running these programmes (Bhuyan, 2004; Maine, 1991; Sakeah 
et aI., 2014). In addition, commun ity-based programmes in rural areas of low- and middle-
income countries (LMICs) have improved reproductive health and child survival and 
achieved equity in access to health care through a combination of outreach efforts and 
community mobilization (Perry & ZulJiger, 2012). The Alma Ata Declaration of 1978 
promotes the creation of links between primary health care service providers and clients 
(Fendall, 1978) by ensuring that the services rendered are of good quality, and that 
communities are well informed on health issues and involved in health promotion actions 
(Lewycka et aI., 2010). 
In Bolivia, the Wanni Project, an intervention focused on maternal and neonatal care, was 
initiated in a poor rural area that lacked health infrastructure to improve perinatal care 
(O'Rourke, Howard-Grabman, & Seoane, 1998). By engaging groups of women to 
recognise and tackle significant maternal and neonatal health issues, the project was able 
to record a reduction in perinatal mortality rate of 73 deaths per 1,000 live births. Likewise 
in Nepal, the Mother Infant Research Activities (MIRA) Makwanpur study sought to 
improve perinatal outcomes through women groups and succeeded in decreasing maternal 
mortality by 78%, and neonatal mortality by 30% in two years (Manandhar et aI., 2004). 
Training of Traditional Birth Attendants (TBAs) and providing them with disposable 
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delivery kits was the focus ofa study carried out in Pakistan where the intervention ann of 
the study recorded less maternal deaths than the control ann, and a 30% decrease in 
neonatal mortality (Jokhio, Winter, & Cheng, 2005). 
2.4.4 Maternal Health Initiatives in Ghana 
Since its adoption of the 1987 Safe Motherhood Initiative, Ghana has put several measures 
in place in attempts to curb bigh maternal mortality. These measures include the inception 
of a safe motherhood task force and training of new midwives, which had resulted in an 
increase in national midwifery enrollment of 13% between 2007 and 2009 (GHS, 2015). 
The High Impact Rapid Delivery (HIRD) approach has also been employed to work in 
tandem with other maternal and child mortality reduction strategies such as Ghana Vitamin 
A Supplement Trials (VAST) Survival Programme, the Prevention of Maternal Mortality 
Programme (PMMP). Making Pregnancy Safer Initiative, Prevention and Management of 
Safe Abortion Prob'Tamme. Maternal and Neonatal Health Programme, the Roll Back 
Malaria Programme which contains the Intennittent Preventive Treatment (lPT) for 
pregnant women; and Emergency Obstetric and Neonatal Care (EmONC) (GHS, 2015; 
MOH.2008). 
Ghana has also involved communities in ensuring that basic health care, including 
reproductive health services, is accessible to all individuals. The Community-based Health 
Planning and Services (CHPS) programme is a health intervention that was successfully 
piloted in 1994 In Navrongo, Upper East Region of Ghana (Nyonator, Jones, Miller, 
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Phillips, & Awoonor-Williams. 2(05). The initiative sought to scale up the success story 
from the Navrongo pilot into a national programme in 2000 to ensure that health care 
services are made accessible, equitable and efficient, and are of good quality (Pence, 
Nyarko. Phillips, & Debpuur. 2007). This method of health care delivery entails the posting 
of a trained nurse known as a Community Health Officer (CHO) to designated communities 
called CHPS zones, to provide door-to-door health care services to community members 
(Binka, Nazzar, & Phillips, 1995; Nyonator, Awoonor-Williams, Phillips. Jones, & Miller, 
2005) and has proven to lead to an improvement in the provision of maternal, reproductive 
and child health services (Nyonator et aI., 2005). The CHOs in the CHPS zones serve as 
community-level basic health care service providers under the supervision of municipal 
health directorates. 
[he urban CHPS pilot which was mitlated in the Ga East Municipal of Greater Accra 
RegIOn in 2011 was designed to tackle obstacles to reproductive health and improve child 
health indicators in peri-urban slum areas in a bid to address health inequalities in the urban 
environment (Adongo et al., 2014). Community Health Workers have been shown to play 
an important role in the identification of expectant women in communities, and in offering 
health promotion information regarding birth and emergency preparedness, the importance 
of ANC and Skilled Birth Attendance, and the benefits of a healthy lifestyle (PMNCH, 
2006). The urban CHPS pilot was started in two CHPS zones in Ga East Municipal with 
the posting of CHOs to these zones and lessons learnt at this stage led to modifications of 
the rural model to suit urban needs and a subsequent scale-up ofthe project (Adongo et a!., 
2014). Community Health Workers aid in establishing links between communities and the 
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health care system, and their ability to mitigate a portion of the ANC service provision 
workload at the facilities has been documented (PMCH. 2010). 
The challenges faced by the government of Ghana with regards to combating maternal 
mortality include setbacks in scaling up maternal health care services; lack of skilled health 
workers, equipments and logistics for the provision of high quality health care; poor 
referral system and high costs of transportation leading to delays in transporting women 
with pregnancy complications to referral centres; inadequate data collection on maternal 
health indicators and poor assessment of instituted maternal health programmes. In 
addition, access barriers encountcred by expectant mothcrs and their families or 
communities are as a result of lack of finance. long distance to health care facilities, low 
level of education. poor health-seeking behaviour, and socio-cultural factors such as 
women's inability to make deciSIons concerning seeking health care (Ghana Health 
Service, 2015). 
2.5 Antenatal Care 
Antenatal Care (ANC) is defined as the health care services provided from conception to 
delivery, to make certain that women experience pregnancy and childbirth in good health, 
and are delivered of a healthy newborn (JHPlEGO, 2004). In the early 1900s, not many 
pregnant women had contact with the health care system before they went into labour as 
many physicians considered foetal studies to be unimportant. Sir John William Ballantyne, 
an obstetrician and teratologist from Edinburgh also known as 'the great apostle of the 
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Antenatal Care movement', played an important role in convincing the medics and the 
public that an interest in antenatal life would serve to improve the quality of life of the 
generations to come (AI-Gailani, 2009). 
The traditional model of ANC was instituted two centuries ago with the aim of educating 
'ignorant' women on child welfare issues due to an attempt to improve on the declining 
manpower of nations (Oakley, 1986). Later on, in the 1950s, ANC became a tool for 
screening women for high risks of complications but its usefulness for this purpose was 
limited as it dealt with ineffective measures with little scientific advantage such as routine 
weight and height checks (Villar & Bergsje, 1997; WHO, 2003). It is also imperative to 
note that some of the women who are classified as low risk experience complications, 
especially during delivery (PMNCH, 2006). 
The delivery and the early postpartum periods are times of the highest risk for a pregnant 
woman and tbe health promotion offered by Antenatal Care during these periods contribute 
to the lowering of maternal and neonatal deaths (Magadi, 2004). In addition to this, 
pregnant women are presented with the opportunity to make contact with the health care 
service where they can obtain integrated care, acquire education on healthy home practices 
and avail themselves of existing referral system options. When done properly, ANC has 
the potential to prevent direct causes of maternal death, as well as to identify and treat 
indirect causes (Kvale et aI., 2005). The ANC schedule is programmed in such a way that 
a pregnant woman will have to make monthly visits in the first seven months, twice a month 
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in the eighth month, and then weekly in the final month, culminating in 12 - 13 visits overall 
(NCPD. CBS & MI, 1999). These number of visits translate to financial and time costs 
which impact negatively on utilization of Antenatal Care services and quality of care given 
(Keams, Hurst, Caglia, & Langer, 2014). A survey conducted in Zambia found out that 
women intentionally initiated ANC late to avoid making several visits to the health care 
facility and to reduce the overall costs of patronising the facilities (Menon. Musonda, & 
Glazebrook,201O). 
Studies have documented the fact that some women access ANC from both orthodox and 
unorthodox sources. In rural Sumatra, Indonesia, pregnant women prefer receiving ANC 
from the TBA as a result of their cultural beliefs, but go ahead to deliver their babies at 
formal health care facilities (Agus & Horiuchi, 2012). Okafor, Sekoni. Ezeiru, Ugboaja, & 
Inem (2014) established in their study conducted in Nigeria that inasmuch as parturient 
women accessed ANC from both the TBAs and the formal health facility, the choice of 
place of delivery was dependent on personal and household reasons, for instance cost and 
decision-making by family members such as husbands and mothers-in-law. Another study 
in Nigeria highlighted the fact that childbirth was occurring in unorthodox settings even 
though the women involved had attended Antenatal Care and the reasons outlined include 
high cost of facility care, scarce transportation, fear of evil spints and prophetic 
admonitions from the church (Etuk, Itam, & Asuquo, 2000). Childbirth for some of these 
women is managed by untrained Traditional Birth Attendants (TBAs) or occurs in churches 
with no emergency obstetric care at hand or no referral system in place to handle any 
complications that may arise (Etuk et al., 2000). Another reason why women preferred the 
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TBAs to the health care facilities was due to the fact that they were able to obtain herbal 
medications from them, which they preferred to the drugs and injections administered at 
the ANC clinics (Okafor et al.. 2014). In the light of these. health education offered to 
women during ANC visits should highlight the necessity for the continuum of care that 
includes skiIled attendance at birth and Postnatal Care. 
As ANC provision in many environments does not meet the compulsory standards (WHO. 
2005). in 2002 the WHO recommended goal oriented ANC services for the provision of 
precise evidence-based interventions for pregnant women, to be carried out at stipulated 
times during the pregnancy (PMNCH, 2006). This recommendation foIl owed trials carried 
out in Argentina. Cuba. Thailand and Saudi Arabia that provided evidence that a targeted 
approach 10 ANC was a more sustainable. comprehensive and effective model (WHO, 
2002). The proposed model for adequate ANC for women experiencing normal 
pregnancies in developing countries mcludes four visits: within the first 12 weeks, at 26 
weeks. at 32 weeks and between 36-38 weeks (Tran, Gottvall, Nguyen, Ascher. & Petzold, 
2012; WHO, 2002). This recommended ANC package of services seeks to provide 
pregnant women with care tailored towards screening for health or socio-economic factors 
that may lead to adverse pregnancy outcomes, timely intervention during pregnancy, and 
proviSIOn of information to pregnant women concerning preparedness for delivery and 
emergencies (WHO, 2002). The tests and procedures provided are limited to those that 
have been scientifically proven to have a positive impact on maternal and neonatal health 
outcomes (Villar et aI., 200 I). The services offered during the four stipulated visits include 
measurements of body weight and height, blood pressure, fundal height and fetal heart rate; 
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vaginal examination; urine protein tests; blood tests for anaemia and HlV; tetanus toxoid 
vaccination; folic acid supplementation; malaria chemoprophylaxis; and counselling on 
birth preparedness, lactation and contraception (WHO, 2002). This new model of ANC bas 
been taunted as the key to improved ANC services in low income countries due to the less 
number of visits entailed for low-risk pregnant women, more time spent in consultation 
with expectant mothers, and clear-cut referral regulations (WHO, 2002). It is also important 
that developing nations with limited resources carry out financial allocations in an efficient 
manner and the reduced number of visits results in less cost incurred by the health facilities 
as well as the pregnant women by way of time, money, working hours lost, and care of the 
other children (Zanconato et al.. 2006). Despite these measures put in place to avert 
maternal deaths, more than 800 women die daily worldwide from perinatal complications 
(WHO et aI., 2012). 
The underpnvileged women in every society are constantly at the receiving end of poor 
maternal health care. In the industrialized countries, there is widespread utilization of 
Antenatal Care by pregnant women with the exception of the underserved groups such as 
migrant'. mmority ethnic groups, unmarried teenagers, the very poor and those living in 
isolated rural communities (WHO, 2005). The dire condition of maternal health in urban 
slums in the developing world has been documented in several studies that highlight the 
poor uptake of ANC services in these resource-deprived urban areas. A study conducted in 
Kenya showed that female slum dwellers started ANC later than other urban dwellers with 
66% of pregnant women in Nairobi slums starting in their second trimester while 20% 
started in their last trimester, contrary to the WHO recommendations (Magadi, 2004). In 
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her review of studies on maternal health amongst slum dwellers in India, Madhiwalla 
(2007) documented that only 55% offemale slum dwellers attended at least 3 ANC visits 
while 74% of female non-slum dwellers did. The same situation was found in Nigeria 
where 44.7% of female slum dwellers availed themselves of Antenatal Care services while 
78.5% of the non-slum dwellers had Antenatal Care (Babalola, 2014). 
Women of reproductive age in Ghana are widely affected by complications arising from 
pregnancy and childbirth leading to a national maternal mortality ratio estimated at 458 
deaths per 100,000 live births (GSS, 2013; Nyarko, Armar-klemesu, Deganus, & Odoi-
agyarko, 2006). These deaths are largely duc to direct causes such as hemorrhage, unsafe 
abortion. hypertension in pregnancy, sepsis, ectopic gestation and complications arising 
from obstructed labour; as well as indirect causes comprising of infections such as 
pneumonia and meningitis, anaemIa and HIV/AIDS-related infections (Der et aI., 2013). 
In 2013, the Ghana Health Service Annual Reproductive and Child health Report stated 
that more than 50% of Ghanaian pregnant women do not attend ANC clinics till their 
second or third trimester (Ghana Health Service, 2013). The well documented advantages 
of ANC are mitigated by challenges due to availability, accessibility, coverage and quality 
of care (Fagbamigbe & Idemudla, 2015; Simkhada, Van Teijlingen, Porter, & Simkhada, 
2008). Thus, in a bid to improve access, quality and continuity of ANC services offered to 
pregnant women, the Government of Ghana adopted the WHO Focused Antenatal Care 
package in 2002 (Nyarko et aI., 2006), and went on to implement delivery fee exemption 
and free medical care policies for expectant mothers through the National Health Insurance 
Scheme in 2003 and 2008, respectively (Biritwum, 2006; Witter, Adjei, Armar-Klemesu, 
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& Graham, 2(09). Even though these measures have been shown to increase Skilled Birth 
Attendance while reducing the cost of perinatal care services (Witter, Arhinful. Kusi, & 
Zakariah-Akoto, 2007), several challenges are posed by situations such as inadequate 
funding, financial constraints on service users due to poor access to health care services or 
transport fees, inadequate workforce in the health sector, lack of motivation of health 
workers, and poor quality of care at the health facilities (Witter et a!., 2009). 
2.6 Skilled and Unskilled Attendance at Delivery 
The WHO defines a Skilled Birth Attendant as "an accredited health professional - such 
as a midwife, doctor or nurse - who has been trained to proficiency in the skills needed to 
manage normal (uncomplicated) pregnancies. childbirth and the immediate postnatal 
period. and in the identification. management and referral of complications in women and 
newborns" (WHO, 2004). The rate of maternal deaths is worsened by inadequate perinatal 
care, poor patronage of ANC and PNC services, and lack of skilled attendance at birth 
(I-logan et a!., 2010). As more than 65% of maternal deaths occur during delivery, the 
importance of having a skilled attendant operating within a setting with adequate health 
care services during the time of birth cannot be overemphasised (Adegoke & Van Den 
Broek, 2009). Despite this, rural and poor urban dwellers in several countries do not have 
a good chance of having access to skilled attendance at birth (Bergstrom & Goodburn, 
2001; Khan et aI., 2012). 
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As a number of studies have shown that Skilled Birth Attendance during delivery leads to 
a decrease in maternal mortality (De Brouwere, Tonglet, & Van Lerberghe. 1998; Hussein 
et al.. 2004), it has therefore been recognised as a process indicator for evaluating progress 
towards Sustainable Development Goal (SDG) 3 (SDSN. 2015; Van Den Broek & 
Falconer. 201 1). In the developed world, skilled attendance at delivery is almost universal 
at 99.5% but the situation is different in the developing countries where only about 50% of 
women use the services of a skilled birth attendant with the rate in Africa being 46.5% 
(Stanton. Blanc. Croft. & Choi. 2007). 
The situation in sub-Saharan Africa is not encouraging as utilisation of skilled birth 
attendance services continues to be poor. making only a slight increase from 42% to 46% 
between 1990 and 2004 (United Nations, 2006). Even though evidence shows that 
madequate maternal health care services results in low utilisation of Skilled Birth 
Attendance (Koblinsky et aI., 2006), women living in resource-poor environments are 
further constrained by poverty, lack of education and rural residence (Asamoah. Agardh, 
Pettersson, & Ostergren, 2014). Other challenges emanate from direct and indirect costs of 
accessing health care, poor transportation services, health facilities that are too far. lack of 
information and unsavoury precedent experiences with health care personnel (Bazzano, 
Kirkwood. Tawiah-Agyemang, Owusu-Agyei. & Adongo, 2008; Koblinsky et aI., 2006). 
The place of Traditional Birth Attendants (TBAs) in the delivery of maternal care services 
has been an issue of long debate in safe motherhood circles. The WHO definition of a 
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Traditional Birth Attendant refers to "traditional, independent (of the health system), non-
fonnally trained and community-based providers of care during pregnancy, childbirth and 
the postnatal period" (WHO, 2004). TBAs are not referred to as skilled birth attendants as 
those who have received any training at all, were trained for only a few days with folIow-
up meetings with health care personnel for supervisory and educational purposes 
(Bergstrom & Goodbum, 2001). Furthermore, studies conducted in Africa and Asia have 
demonstrated that where there are no skilled personnel in close proximity. these 'trained' 
TBAs are unable to reduce the risks of maternal deaths during delivery (Bergstrom & 
Goodburn, 2001; Sibley & Sipe, 2004). Regardless of this, 60 million births occur each 
year in developing countries that are attended to by a TBA or a relative, and in some cases, 
in the absence of any assistance (Knippenberg et aI., 2005). 
TBAs provide maternal care during (he pennatal period, and are trusted by pregnant 
women in their communities as they are well-entrenched in the culture and norms of the 
communities they serve, arc not far from reach, and present the families with the option of 
paying 'in kind' for services rendered (Pyone. Adaji. Madaj, Woldetsadik, & van den Broek, 
2014). It has also been demonstrated that low income women prefer births assisted by 
TBAs or family members (Choguya, 2015). Magadi (2004) found in her study in Nairobi 
slums that although 6% of all deliveries in Nairobi were attended by a TBA, 25% of births 
that occurred in the slums were delivered by a TBA. However, even though TBAs are more 
accessible than health care professionals to pregnant women in their communities, they 
have proven to be ineffective due to high levels of illiteracy, inadequate monitoring and 
supervision, improper linkages with the health care system and non-existent emergency 
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referral systems (Bergstrom & Goodburn. 2001; Sibley, Sipe, & Koblinsky, 2004; 
WHOIUNfPAlUNICEF,1992). 
Many countries in Africa and Asia have a severe paucity of health care workers with fifty-
seven countries in these regions lacking a total of about 4.3 million health workers (WHO, 
2006a). Sub-Saharan Africa faces the greatest challenges as despite having 11 % ofthe total 
world population, and 24% of the disease burden worldwide, there are only 3% of all health 
workers globally, with less than I % of global expenditure on health spent in the region 
(WHO, 2006b). A high health care worker to population ratio is strongly associated with 
maternal and neonatal survival and regions with a low proportion of health workers have a 
commensurate downturn in survival rates (WHO, 2006a). Due to this prevailing situation, 
the training of TBAs has been espoused as an opportunity to provide maternal care in 
resource-constrained areas as a cheaper, more accessible option (Bullough et aI., 2005). 
Despite critics' continuous questioning of the usefulness ofTBAs, several countries have 
recorded successes with reduction in maternal mortality by linking TBAs with the existing 
health system. Between 1950 and 1980, China succeeded in decreasing their Maternal 
Mortality Ratios from 1500 to ) 15 deaths per 100,000 live births by implementing a model 
using village birth attendants with basic training supported by a strong referral system to 
handle obstetric complications (Koblinsky et al.. 1999). Malaysia and Sri Lanka are 
developing countries that have achieved MMRs less than 100 by steadily increasing the 
number of professional attendants buttressed by access to essential obstetric care services 
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(Pathmanathan et al.. 2003). Contrary to these success stories, the training of TBAs in 
Bangladesh has led to a continued recording of high MMR due to the lack of essential 
obstetric care (Nessa, 1995). More recently, a comparative study carried out in Senegal 
among trained midwives and TBAs found that maternal mortality was higher with TBA-
assisted births than with midwife-assisted births (De Bernis et aI., 2000). 
A third of all births in Ghana are assisted by a Traditional Birth Attendant, with or without 
trainmg (Twum-Baah. Nyarko, Quashie, Caiquo, & Amuah, 1994; GSS/GHS/ICF Macro, 
2009) and these attendants are cultumlly regarded as respectable, experienced old women 
with compassIOn for women in labour (Jansen, 2006). Several attempts have been made by 
the government to improve on the services provided by TBAs starting with the 1973 Danfa 
Rural Health Project. which trained and supervised TBAs (Eades, Brace, Osei, & 
laGuardia. 1993). The National Traditional Birth Attendant (NTBA) training programme 
was started in 1989 to standardise maternal health practices offered by the TBAs, improve 
on provision of primary health care to rural environments, and create links between TBAs 
and other health care professionals (Smith et al.. 2000). An assessment of the impact of 
this programme indicates that, though the programme has not been of any benefit to 
maternal and neonatal survival, it could still have a place in health promotion amongst 
pregnant women (Eades et aI., 1993; Smith et aI., 2000). 
More than 30% of births that occur worldwide happen in the homes in the absence of a 
skilled attendant during delivery (WHO, 2008). In addition, data from twenty-three African 
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countries indicate that over 60% of births that occur in sub-Saharan Africa take place at 
home (PMNCH, 2006). Underutilization of maternal health care services by women has 
been associated with socio-cultural beliefs and where a high premium is placed on the 
ability to deliver a child at home, women within these cultures are wary of losing respect 
within their communities, or relinquishing control of the delivery process to a birth 
attendant (Asamoah et a!., 2014; Bazzano et a!., 2008). In a lot of cases, the decision 
concerning place of delivery is made by family members such as husbands and mothers-
in-law, or community leaders such as village heads, soothsayers and traditional healers, 
with no regard to the pregnant woman's opinion (Crissman et aI., 2013; Moyer et aI., 2014). 
Besides this, certain apprehensions within communities concerning facility-based 
deliveries such as fear of invasive procedures like caesarean sections, infertility and death 
also result in women preferring home deliveries over facility-based deliveries (Bailey. 
Sz3.szdi, & Glover, 2002; Prata et aI., 201 I). A study carried out by Khan et aI., (2012) in 
Indian slums established that 'family Iradition', financial challenges and rude treatment by 
health care facility workers were all reasons given by female slum dwellers for preferring 
home delivery over health facility delivery. 
2.7 Postnatal Care 
The postnatal period as defined by WHO begins an hour after the delivery of the placenta 
and ends forty-two days after the birth of the infant (WHO, 2013) and maternal and 
newborn health and survival are dependent on care provided during this period (PMNCH, 
2006). Recommendations by WHO are that women who have delivered babies should 
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receive postnatal care within the first 24 hours, by days 2-3, between days 7-14, and six 
weeks after birth, during which the health status of the mother and the infant are assessed 
(WHO, 2013). The services offered for Postnatal Care include detection of danger signs; 
family planning; support for imbibing healthy behaviours; education on infant care-giving 
comprising of hygiene, breastfeeding, identification of danger signs and immunisation; as 
well as additional care for babies who are preterm or small-for-age (WHO, 2013). 
Immunisation of children as a component of Postnatal Care has been responsible for 
averting about 24% of the 10 million deaths that occur annually amongst children less than 
five years old (AbouZahr & Wardlaw, 2001). 
While 98% of women in developed countries make a minimum of one ANC visit (WHO 
&: UNICEF, 2003), 90% of them attend postnatal clinics at least once (Abouzahr, 1998). 
The situation is not as encouraging in sub-Saharan Africa where two-thirds of the pregnant 
women have home deliveries, and just 13% of all women receive a postnatal visit by the 
second day after delivery (PMNCH, 2006). Furthermore, for every ten women who have 
deliveries outside health care facilities, seven do not receive Postnatal Care (Koblinsky et 
aI., 2006). In Ghana, the national PNC coverage was 64.1 % in 2013, far below the national 
target of 90% (Ghana Health Service, 2013); evidence that not all women who utilized 
ANC services went on to access PNC services. In many communities, Postnatal Care is at 
variance with cultural practices that encourage the keeping of babies indoors, especially if 
the birth was a home delivery as was found in studies conducted in Bangladesh and 
Tanzania (Choudhury et aI., 2012; Mrisho et at, 2009; Winch et aI., 2005). In the 
Bangladeshi study, only 24% of women living in slum areas had received Postnatal Care, 
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with just 5% of them having had up to the recommended four visits (Choudhury et al.. 
2012). 
Evidently, Postnatal Care is essential for proper maternal and newborn health care; and 
efforts to improve on maternal and neonatal health outcomes have to be directed towards 
making current ANe and PNC interventions more efficient (Abouzahr, 1998; Pfeiffer & 
Mwaipopo.2013). 
2.8 Rural-Urban Migration and Maternal Health Care 
In major cities of the developing world, the migration of individuals from rural to urban 
settings puts a huge strain on economic and infrastructural growth (Tacoli, McGranahan. 
& Satterthwaite, 2015). More than 70% of the population growth as a result of migration 
occurs outside of the formal planning process, with 30% of urban dwellers in developing 
countries occupying vacant land illegally and forming informal settlements (FIG, 2007). 
With poverty in the urban areas now exceeding that in rural areas (UNFPA. 2007) the 
Impact on health has become evident in addition to the widening disparities between the 
health status of the urban poor and the urban rich (Dye. 2008; Fotso, 2006). Even though 
rural dwellers have been found to have poorer utilization of ANC when compared to urban 
dwellers (Iran et ai., 2012), several studies have documented the deplorable state of 
maternal health in resource-deprived urban areas (Fotso, Ezeh, Madise, Ziraba, & Ogollah, 
2009; Magadi, 2004; Matthews et aI., 2010). Migration to a new milieu poses peculiar 
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challenges to migrants with socio-cultural and environmental barriers that impact on their 
health-seeking behaviour and health care utilisation (Kim, Kreps, & Shin, 2015). 
A study conducted in Peru found that female migrants from rural areas were less likely to 
use maternal services than women who were non-migrant urban dwellers (Subaiya., 2007). 
In Bangladesh, rural-urban migrants had a poorer attendance at Antenatal Care clinics than 
did their non-migrant counterparts (Choi & Robinson, 2009). In their study carried out in 
India, Kusuma, Kumari, & Kaushal (2013) found that only 37% of migrant women had 
access to adequate Antenatal Care services with 53% of all deliveries happening at home, 
and just a quarter of women receiving PNC services. The reasons for these disparities have 
been documented to include poor financial status, lack of education and inadequate 
knowledge of the advantages of perinatal care (Kusuma et aI., 2013; Shaokang, Zhenwei, 
& Bias, 2002). 
2.9 Health Seeking Behaviour for Maternal Health Care 
For so long, health promotion programmes were tailored towards provision of health 
educallon that would encourage positive behavioural changes in individuals but it has 
become increasingly evident that this strategy has not been effective. More research has 
recently been focused on the interplay between community members' interaction with each 
other and the overall effect on the promotion of health-seeking behaviour that benefits the 
mdlviduals (Mackian, 2003). Tipping and Segall (1995) categorised individuals' 
behaviours with regards to their health into two types: the health-seeking behaviour in 
relation to response to illness; and health care seeking behaviour in relation to utilisation 
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of health care facilities. Health-seeking behaviour in relation to response to illness is based 
on the premise that a person's perception of the prevailing social environment has an effect 
on health bebaviomal choices or in their decision to access health care (Mackian, 2003). 
On the other hand. socio-demographic variables such as age, sex, socio-economic status, 
disease pattern. access to and quality of health care services have a bearing on health care 
seeking behaviour in relation to utilisation of health care facilities, and the choice of formal 
or infonnal health care delivery channels (Tipping & Segall, 1995). Individuals have been 
known to seek several sources of health care depending on their peculiar experiences such 
as type of disease; beliefs regarding the causation of the ill health such as 'evil eye', 
infection or accidents; and existing obstacles to utilisation of health care such as lack of 
money or time - all entrenched in cultural decision-making processes (UNICEF, 2008). 
People are known to patronize several sources ofbealth care concurrently, often oscillating 
between self-care. utilization of traditional, spiritual or infonnal health care providers, and 
orthodox health care channels (Macklan, Bedri. & Lovel, 2004). With regards to maternal 
health care, several studies have documented that the decision of where to go, and at what 
stage during the pregnancy lies with husbands or older family members such as mothers-
in-law, grandmothers and family heads (Moyer et aI., 2014; White, Dynes, Rubardt, 
Sissoko. & Stephenson. 2013; Woldemicael & Tenkorang. 2010). 
Women's access to maternal health care is a reflection of societal response to their health 
needs and detennines women's health status and productivity (Hunt & Bueno de Mesquita, 
2011). Women of reproductive age in developing countries are often poor and vulnerable, 
and while these cadre of women are in dire need of adequate maternal care while parturient, 
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more often than not, there is inadequate utilisation of essential maternal health care services 
amongst them (Ethiopian Society of Population Studies, 2008). This inefficient use of 
maternal care services has been narrowed down to barriers due to access and availability, 
cost. and knowledge and attitudes - challenges faced by African pregnant women in 
particular (Africa Progress Panel, 2010). 
2.9.1 Factors Affecting Health-seeking Behaviour and Utilization of Maternal 
Health Services in Peri-Urban Settlements 
A review of literature from global perspectives indicate that an array of factors are 
contributory to poor utilization of health care services and these include socio-demographic 
status. low socio-economic status. lack of physical accessibility, cultural beliefs, low 
educational level attainment of women, large family size and poor health care service 
delivery (Shaikh & Hatcher, 2005). 
2.9.1.1 Socio-delllOgraphic and economic factors 
Several studies have documented the relationship between socio-demographic factors and 
utilization of maternal health services. Thcse factors, although not exclusive to peri-urban 
dwellers. are made more obvious amongst this group due to their lower socio-economic 
status and poorer education than the urban rich dwellers (Shaokang et aI., 2002). As well 
as poorly educated women having a very high risk of maternal mortality when compared 
to educated women (Karlsen et aI., 2011; Pillai, Maleku, & Wei, 2013), the huge 
divergence in educational levels between males and females also leads to high maternal 
mortality rates due to the inability of the women to demand for appropriate health care 
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(McAlister & Baskett. 2006). Furthennore. it has been established that women who have 
some level of education are more likely than their uneducated counterparts to attend 
Antenatal Care clinics (Simkhada, Van Teijlingen. Porter, & Simkhada, 2008). It has also 
been documented that 70% of women that have had at least secondary education deliver 
their babies in a health care facility while 40% of those who have at most, an incomplete 
primary education have health facility deliveries (Magadi, 2004). As well as increasing the 
chances of women appreciating the advantages of pennatal care, education may diminish 
the provider-client power gap that exists between health care professionals and the women 
they care for (Pell et aI., 2013) and reinforce women's ability to demand for appropriate 
care (Furuta & Salway. 2006). 
Relationships have also been established between the age of a woman and birth order, and 
health care faCility delivery. In their study of maternal health care in cities in 23 sub-
Saharan African countnes, Magadi et a!., (2003) established that younger aged women and 
those with higher birth orders were less likely to access Antenatal Care services than older 
women or women with lower birth orders. Results from another study conducted in Peru 
indicated that women with multiple births were less likely to attend 4 or more Antenatal 
Care clinics while pregnant (Subaiya, 2007). In addition, women who are more than 3S 
years old or who have had multiple pregnancies are less likely to have health facility 
deliveries than younger women or women with lower order births. While 60% of 
primiparous women in a Kenyan study were found to have had their babies in a health 
facility. only 37% of women with six children or more, had health facility deliveries 
(Magadi, 2004). Single mothers were however shown to have inadequate maternal care 
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due to their mixed feelings towards the pregnancy showing the association between 
unintended pregnancies and poor maternal health service utilization in slum areas. 
The economic status of a household has been shown to have positive effects on the use of 
matemal health care. A study conducted in Colombia found that mothers from a high socio-
economic background were more likely to initiate and continue with Antenatal Care than 
their poorer counterparts (Yecino-Ortiz, 2008). Likewise in Mali, Gage (2007) found in 
her study that socio-economic problems often times amounted to poor utilization of 
maternal care services. In developing nations, urban dwellers oflow socio-economic status 
encounter considerable challenges in their attempt to access health care services (Galea, 
Freudenberg. & Ylahov, 2005; Magadi et aI., 2003). Studies done in Nigeria and Uganda 
identify distance and finance as key obstacles to health-seeking decision making (Amooti-
Kaguna & Nuwaha, 2000; Onah, Ikeako. & 1I0abachie, 2006). Fotso et aI., (2008) found 
evidence supporting this in their study in slum areas of Nairobi, Kenya were they 
established that female slum dwellers were unable to meet transport expenses to seek 
appropriate maternal health care, and often times waited till serious obstetric complications 
set in. In addition to this, lack of a steady income and the high costs of dwelling in urban 
areas affect the urban poor adversely, and women are particularly affected as they are more 
likely to be involved in informal jobs and commerce preventing them from accessing health 
care during the business hours (Magadi et al.. 2003). 
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The situation IS not different in Ghana where despite the institution of free maternal care 
services, women in the poorer quintiles still access maternal care at a lower rate than those 
in the wealthier quintiles due to direct and indirect causes such as distance, lack of drugs 
and time wasted at the facilities (Arthur, 2012). 
Despite efforts made by several countries to decrease or do away with user fees for health 
care provision, many women are still unable to pay for health care services rendered to 
them (Africa Progress Panel, 2010). In their study in India, Gupta et a!., (2008) found that 
even though quality health care services were geographically accessible to the slum 
dwellers, the financial burden of paying for prescriptions was a barrier to health service 
utilization. More than 50% of women in West Africa named cost as a reason for not 
accessing health care and in Burkina Faso. Cameroon, Guinea and Niger, 60% of the 
women gave th~ same reason (UNICEF, 2009). In addition to direct costs such as facility 
user fees and costs of medication, there are indirect costs such as transportation expenses 
and lost earnings from work, that combine to make access to health care services out of 
reach for economically vulnerable women (Africa Progress Panel. 2010). Although many 
countries have established some fonns of health care plans tailored towards alleviating the 
financial burden brought about by user fees. the cost of registering for these programmes 
has turned out to be prohibitive for some individuals. 
In Ghana, inasmuch as the National Health Insurance Scheme (NHlS) was able to provide 
coverage for over 50% of the Ghanaian population within four years, amongst the less 
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priviledged in the country, this proportion is much less, in part due to the registration fee 
(UNICEF, 2(09). Furthermore, notwithstanding the free maternal health care instituted by 
the Government of Ghana, poor women were still concerned about transportation costs, in 
addition to costs attached to items required by the health facilities for the delivery of the 
baby (Crissman et al., 2013). Similarly, in a study conducted in Bangladesh, Hossain & 
Hoque (2005) demonstrated that 26% of female slum dwellers found informal costs to 
health care prohibitive despite the seemingly free medical services. 
The considerable poor maternal health outcomes found amongst women in the lowest 
wealth quintile. or with the poorest education, dwelling in disadvantaged environments 
highlights the importance of education and financial resources in improving the health 
outcomes of developing nations (Fotso et aJ., 2008). 
2.9.1.2 Cllltllral/Ilclors 
Maternal health choices made by women during pregnancy and delivery directly influence 
maternal and neonatal morbidity and mortality (Evans, 2013). The process of pregnancy 
and chIldbirth is permeated with strong cultural practices and traditional beliefs which have 
an impact on maternal health care utilization (Houweling et aI., 2007; Rice, 2000). There 
are several cultural practices that can lead to negative maternal outcomes and contribute to 
maternal mortality. For instance, taboos related to food consumption such as restrictions to 
meat, eggs, and fish diets may worsen underlying anaemia, placing the pregnant woman at 
risk of death due to haemorrhage (Zepro, 2015). In Nigeria, the Hausa ethnic group 
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traditionally offers salt to pregnant women and hot ritual or coal baths which can 
predispose them to high blood pressure. cardiac failure and bums (Wall. 1998). Other 
practices that place mothers at risk of disability or death include applying fundal pressure 
to hasten the labour process. forced vomiting to initiate the placenta expulsion, use of 
herbal concoctions for treating maternal complications and childbirth in an isolated or 
unsanitary environment (Fofie & Baffoe, 2010; Maimbolwa, Yamba, Diwan, & Ransjo-
Arvidson. 2003). Several times, lack of knowledge of the underlying physiology of 
pregnancy also contribute to cultural definitions of pregnancy-related symptoms, and thus 
leads to inaction (Evans, 2013). Studies carried out in Ghana and Nigeria have 
documented that pregnant women in these countries saw pedal oedema as a sign that a male 
child or twins will be born, and were not able to make the connection between the oedema 
and high blood pressure (Okafor & Rizzuto, 1994; Senah, 2003). 
In cultures where women are chided for appearing weak. utilisation of maternal health care 
services will be negatively affected coupled with the fear women may have of being 
exposed to the possibility of a Caesarean section. or insensitive and unsatisfactory 
treatment from the health care facilities (Maimbolwa et aI., 2003; Okafor. 2000; Sibley et 
al.. 2009). Furthermore, orthodox health care providers are guided by procedures that may 
be at variance with the cultural inclinations of the pregnant women (Berry. 2006; 
Deshpande & Oxford, 2012; Roost, Johnsdotter, Liljestrand, & Essen, 2004). Where TBA 
practices are found, maternal health services offered to women are often tainted by the 
antagonistic environment created by health care workers and TBAs leading to a situation 
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where suspicion, denigration and egotism are propagated to the detriment of the pregnant 
woman (Berry, 2006; Maimbolwa et aI., 2003; Okafor. 2000). 
Migrant women coming from rural areas have strong cultural ties (UNFPA, 2011) and their 
perception of pregnancy and childbirth as a non-illness experience, as well as the lack of 
tolerance of health care providers for traditional beliefs and practices, may lead them to 
place little importance on the need for maternal health care (Atekyereza & Mubiru, 2014). 
Egypt succeeded in increasing the number of women accessing health facility deliveries by 
Improving on the quality of care given at the health care facilities and providing maternal 
health infonnation at the household levels to aid in appropriate decision-making (De 
Bemis, Sherran, AbouZahr, & Van Lerberghe, 2003). 
2.9.1.3 Female autonomy and spou.~al communication 
The common measures used in defining women's autonomy include lack of restrictions to 
movement, ability to earn an income and make economic decisions, lack of domestic 
violence and coercion, and ability to make health care choices (AI Riyami, Afifi. & Mabry, 
2004; Bloom, Wypij, & Das Gupta, 2001; Saleem & Bobak. 2005). The 1994 International 
Conference on Population and Development (lCPD) and the 1995 Fourth World 
Conference on Women made a robust acknowledgement of women's right to health 
including reproductive health (UNFPA, 2014; United Nations, 1996). However. in many 
African countries, women have limited power with regards to making reproductive and 
sexual health decisions with such matters left to the men folk and thus producing a negative 
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influence on utilization of services for maternal and child health care (Greene, 2000). These 
cultures expect that a woman would obtain permission from her husband or other family 
member in order to visit the health care facilities. and where there is a lack of concern for 
the woman's pregnant state, costs of transportation and medical care may become difficult 
issues to deal with (APP, 2010; Women Deliver, 2010). While a study conducted in Nepal 
found that women's autonomy did not have any significant association with maternal health 
care utilization (Furuta & Salway. 2006), another carried out in India established the 
importance of women's autonomy amongst the urban poor with respect to decision making 
regarding maternal health care (Bloom et a!., 2001). Concerning Antenatal Care visits, 
women who playa part in decision-making in their households are more likely to attend 
the clinic four or more times as opposed to women with less decision-making power 
(Subaiya, 2007). Fotso, Ezeh, & Essendi (2009) also found in their study that maternal 
health utilisation was boosted by women's autonomy amongst poor slum dwellers in 
Nairobi. Kenya. In addition, women autonomy has been demonstrated as a determinant of 
Skilled Birth Attendance at delivery in a study carried out in Nepal (Sreeramareddy. Joshi, 
Sreekumaran, Giri, & Chuni, 2006). 
Several studies have been done on the influence of spousal communication on women's 
utilisation of health care. Programmes tailored towards empowering women highlight the 
need for women to have the ability to make health related choices for themselves, while 
those focused on men underline the need for communication and negotiation between 
partners when there is a decision to be made (ICPD, 2004). So much of the efforts to 
involve men in reproductive health issues have been centered on family planning (Prata, 
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Sreenivas, Vahidnia, & Potts, 2009), abortion (Silverman et aI., 20 I 0), sexually transmitted 
infections (Brewer, 2005), and breast-feeding (Stremler & Lovera, 2004) with n::latively 
less attempts made in involving males in maternal health eare issues (Tbapa & Niehof, 
2013). Ensuring that men take part 10 health education programs improves spousal 
communication and encourages positive health-seeking behaviour (Turan, Nalbant, Bulut, 
& Sahip, 200 I). 
Many researchers are of the view that female autonomy only thrives under favorable 
conditions. Several studies have documented that contraceptive use is influenced by female 
autonomy and education. as well as communication with spouses (Do & Kurimoto, 2012; 
K1omegah, 2006; Saleem & Bobak. 2005). Furthermore, the fact that women discussed 
family plannlOg with their spouses has been associated with an increased chance of 
patronising Antenatal Care and skilled delivery care services (Furuta & Salway, 2006). In 
situations where the menfolk are relied upon to make decisions concerning mobility and 
health care expenses, women may not have the ability to seek care by themselves 
(Simkhada, Van Teijlingen, Porter, & Simkhada, 2006). Women who were able to discuss 
health Issues with their husbands were more likely to have discussed their pregnancy and 
birth preparedness with him, and the husbands were also more likely to be in attendance 
during delivery (Thapa & Niehof, 2013). Studies carried out in Pakistan, Bangladesh and 
India established that men's involvement during pregnancy and ANC, and their knowledge 
of maternal health issues was associated with delivery at a health care facility (Agha & 
Carton. 2011; Chattopadhyay, 2012; Story et aI., 2012). It is therefore evident that efforts 
to build up women's ability to wield some influence in the household and enhanced 
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communication between spouses on reproductive health matters lead to better maternal 
health outcomes (Asefa, 2014; Furuta & Salway, 2006). 
1.9.1.4 Access to qlllllily materlfal health care 
In addition to socio-cultural barriers, lack of female autonomy and poor education, 
insufficient provision of health care infrastructure in urban areas leads to the exclusion of 
the disadvantaged from maternal and newborn care (Matthews et al., 2010). Geographical 
and fmancial access to maternal care, as well as the quality of care received are all 
detcnninants of women's utilization of maternal health care services (Bartlett et aI., 2005; 
Gupta et aI., 2008; Zhao et aI., 2012). Ordinarily, health care facilities are supposed to have 
the ability to provide pregnant women with Basic Emergency Obstetric Care (BEOq 
which is compnscd of six cardinal procedures: administration of parenteral antibiotics, 
administration of parenteral oxytocic drugs, administration of parenteral anticonvulsants, 
manual removal of retained products of conception, manual removal of retained placenta, 
and assisted vaginal delivery with vacuum extraction (Fotso et aI., 2008). 
Evidence eXIsts highlighting the fact that where the wealthy and the poor from an urban 
environment use the same health care facility, the ability of an urban poor woman to pay 
for health care services has an impact on the quality of services accessed and the time spent 
at the facilities (Pitchforth et aI., 2006). Poor, uneducated women are occasionally treated 
worse off than their wealthier, educated counterparts by health care providers and this rude 
or neglectful treatment by health care staffJeads to a disinclination of the under-privilcdged 
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to use health care services (Bartlett et aI., 2005; Hulton, Matthews. & Stones, 2007). 
Conversely, a good relationship fostered between patients and health care providers 
ensures bener compliance with Antenatal Care visits (Gabrysch & Campbell, 2009; WHO. 
2002). In addition to this, the quality of care provided with regards to content of care, 
determines the satisfactory use of ANC services as well as early initiation of care (Chama-
Chiliba & Koch, 2013). 
Health care in urban environments is characterised by a large number of private health care 
facilities, and where there are no public health care facilities nearby, female slum dwellers 
tend to patronise these private facilities (More, Alcock, et ai., 2009; More, Bapat, et aI., 
2009). However, their utilization of these facilities is often limited to unregulated and 
poorly qualified providers offering low-priced services, thus leading to dire health 
consequences (Das & Hammer, 2007; Fernandez, Mondkar, & Mathai, 2003). The wide 
difference between the health care available to the urban poor and that available to their 
wealthier, and perhaps rural, counterparts makes it imperative that the definition of access 
to health care for the less priviledged urban dweller be scrutinised closely (Fotso et aI., 
2009). 
The shortage of health care staff globally has led to the WHO estimating that 334,000 
skilled birth anendants need to be trained to acheive not less than 72% coverage of 
deliveries worldwide (WHO, 2005). Of the fifty-seven countries that fall below the critical 
shortage threshold of 2.28 health care professionals per 1000 people, thirty-six are sub-
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Saharan African nations (WHO, 2006b). This leads to inadequate provision of care as 
found in sub-Saharan Africa where only 2S% of women with the lowest socio-economic 
status have a skilled attendant during delivery (WHO et aI., 2012), In a study in Malawi, 
less than ISO;. of clinics were found to be providing 24-hour maternal care due to shortage 
of health care workers, thus placing women with obstetric complications at high risk of 
death or disability (McCoy. McPake, & Mwapasa, 2008). This makes it obvious that even 
though extensive health coverage is important. it is also imperative that the content of the 
maternal care provided is adequate to avert perinatal misfortunes (WHO & UNICEF. 
2010). 
2.9.1.5 Access to knowledge and utilisation ofm aternal health services 
Social support rendered from social networks imbue individuals with the ability to access 
pertinent health care services and imbibe healthy behavioural changes (Uchino, 2004, 
2006). People who are migrants are often neglected and misunderstood by health care 
workers. yet steady social support from family and friends has a positive effect on their 
health-~ceking behaviour leading to enhanced health outcomes (Kim et al.. 201S). In 
addition, many migrant women face language barriers that have a negative influence on 
access to maternal health care services and quality of care received, resulting in patient 
dissatisfaction and poor health outcomes (AlmeIda. Caldas. Ayres-De-Campos, Salcedo-
Barrientos, & Dias, 2013). The ability of health care providers to effectively communicate 
health infonnation to this group of women improves on knowledge and awareness thus 
leading to improved decision-making and satisfaction with service delivery (Nair et aI., 
2014). 
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Studies conducted have shown that women who make more than four Antenatal Care visits 
are more likely to deliver their baby in a proper healthcare facility than those with a lesser 
number of visits (APHRC, 2009; Fotso et al.. 2009). Furthennore. research carried out in 
Kenya and India corroborate the fact that health education received during ANC positively 
influenced women's decisions to deliver in a healthcare facility (Fotso et a!., 2009; Sunil. 
Rajaram, &. Zottarelli. 2006). In India. Indonesia and Ethiopia. it was observed that women 
who utilized ANC services were more likely to access PNC services following child birth 
(Agarwal. Singh, & Garg. 2007; Tesfahun. Worku, Mazengiya. & Kifle. 2014; Titaley. 
Hunter. Heywood, &. Dibley, 2010) thus the importance of Antenatal Care service 
provision cannot be overemphasised. It was also highlighted by Fotso et al. (2009) that the 
women of lowest socio-economic status were more likely to be influenced by this health 
education. Initiating Antenatal Care attendance at the appropriate time allows for adequate 
information concerning the full range of services offered to be passed on to the women 
therefore enabling them to avail themselves of all the benefits of Antenatal Care (Rowe et 
al.. 2008; Zhao et aI., 2012). Poor maternal health literacy is a hindrance to women's ability 
to make informed health decisions, and having the knowledge about where and when to 
seek health care (APP, 2010). 
Antenatal Care attendance and health care facility delivery have proven to have a positive 
outcome on child survival rates as the mothers are more likely to have better health-seeking 
behaviours and take their children to the child welfare clinics (Dixit, Dwivedi, & Ram, 
2013; Pervin et aI., 2012). Childhood mortality in Africa in past years has been as a result 
of malaria, acute respiratory infections, diarrhoeal diseases, and vaccine preventable 
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diseases such as measles and neonatal tetanus (Bryce. Boschi-Pinto. Shibuya, & Black. 
2005). Locales with low immunization coverage and high population density record 
childhood mortality due to measles infections, coupled with diarrhoeal infections on 
account of lack ofpotable water and poor hygiene and sanitation. conditions characteristic 
of slum environments (Magadi. 2004). Reaching the pregnant women in these underserved 
communities with the right information conceming child welfare during Antenatal Care 
will make the children in these areas less vulnerable to these diseases. 
Health initiatives and interventions programmed at the community level have largely been 
targeted at rural populations despite the fact that rural-urban migration has led to the 
springing up ofunderserved communities around the urban areas. There is therefore a need 
for research ID these peri-urban environments to ascertain what initiatives will be of 
maternal health advantage to the women dwelling in these communities. 
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CHAPTER THREE 
3.0 ;\1ETHODOLOGY 
3.1 Introduction 
This chapter is an overview of the methods used in investigating the utilization of maternal 
healthcare through community-based initiatives within a peri-urban context In Accra. It 
provides descriptions of the study design, study area, study population, sample size and 
sampling techniques; tools and procedure for data collection; as well as data analysis 
procedures. 
3.2 Study Design 
Thi, research is a cross-sectional descriptive study that was carried out using a mixed 
method approach involving quantitative and qualitative data collection methods. The 
quantitative data was collected with the use of a questionnaire (Appendix B) administered 
to women who had had deliveries in the past eighteen months prior to the time of data 
collection in the study area. This was to investigate the peri-urban women's utilization of 
maternal care services through community-based perinatal care initiatives. 
The qualitative data collection entailed the use of the phenomenological approach 
todocument the lived experiences of the postnatal women and healthcarc personnel in the 
study area. In addition to buttressing the quantitative data collected, data thus collected was 
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uscd to determine the influence of community-based initiatives on adequate Antenatal Care 
utilization, skilled birth delivery, and timely Postnatal Care utilization in the peri-urban 
setting in Ga East Municipal. The data collection plan is outlined in Table I. 
Table I: Methods and Sources of Study Data 
DATA OUTCOME 
OBJECTIVES METHODS 
SOURCES VARIABLES 
I To assess the peri-urban women's Questionnaire Women Adequate 
utilization of Antenatal Care FGD with ANC 
services offered by the health care deliveries attendance 
providers in their communities in the past 
18 months 
2 To examine the women's utilization Questionnaire Women Skilled Birth 
of Skilled Birth Attendance services FGD with delivery 
from the health care providers in deliveries 
, their communities in the past 
18 months 
3 To explore the women's utilization Questionnaire Women 
of Postnatal Care services offered FGD with 
by the health care providers in their deliveries TimelyPNC 
communities in the past 
i 18 months 
4 To determine thc influence of Questionnaire Women 
community-based intervenllons on FGD with Adequate 
adequate ANC, SBA and timely IDI deliveries ANC 
PNC utilization in the in the past attendance; 
peri-urban setting. 18 months; Skilled Birth 
Health delivery; 
care TimelyPNC 
L .. _L_ ___ personnel 
3.3 Study Area 
The research was carried out in the Ga East Municipal of Greater Accra Region. Ghana 
which is one of the fastest growing slum areas in the nation with a population of 172, I 02 
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people covering an area of 166 square kilometres (GEMHD, 2015). It is located in the 
northern part of Greater Accra Region and is bordered on the west by the Ga West 
Municipal, on the east by La-Nkwantanang-Madina Municipal, on the south by the 
Adentan Municipal, and on the north by the AJruapim South District of the Eastern Region. 
There are four sub-municipals in the municipality namely Dome, Taifa, Haatso and 
Abokobi, a well-known Presbyterian rural community which serves as the capital. Dome, 
Taifa and Haatso are mainly peri-urban settlements predominantly inhabited by rural-urban 
migrants who settle in the Ga East Municipal due to its proximity to the country capital, 
Accra. Many of these migrants come from the three northern regions of Ghana where 
poverty is prevalent. There are various ethnic groups resident in the municipality such as 
the Gas, Akans. Ewes and Fantis from the south of Ghana; and Dagombas and Grushie 
from the north. The sub-municipals have sixteen (16) operational areas that comprise of 
forty-two (42) communities. Health service delivery in the municipality is coordinated by 
the Municipal Health Management Team (MHMT) though the municipality lacks public 
health facilities as there are only six (6) of these out of the thirty-nine (39) health facilities 
operational in the area, with the rest being private facilities. Presently, there are fifteen (15) 
Community-based Health Planning and Services (CHPS) zones in the peri-urban 
settlements of Dome and Taifa, providing basic healthcare services to the community 
members during home visits and outreach programmes. There are four main economic 
activities in the municipality which are commerce, agriculture, service provision and 
industry though a large part of the working force have no employment, highlighting the 
high poverty level prevailing in the municipal (GEMHD, 2015). 
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--
-,' .~ 
l--~ .~. ___ " 
Figure 3: Map ofGa East Municipal 
3.4 Quantitative Data Collection 
The quantitative data was collected using a structured questionnaire administered by 
trained Interviewers. The study population targeted were peri-urban women living in Ga 
Ea~t Municipal who have had deliveries in the year-and-halfprior to the study. 
3.4.1 Sample Size Calculation 
The study entailed the recruitment of women with deliveries in the past eighteen months 
residing in the study area until the sample size of 436 (four hundred and thirty six) 
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respondents was attained. This sample size was calculated using the Yamane formula 
(Yamane, 1967) at 5% precision. and taking into consideration the population of women 
in fertility age range (WIFA) (41,304) in Ga East Municipal (Ga East Municipal Health 
Directorate, 2015), as well as a 10% non-response rate. Furthermore, the Ga East ANC, 
SBA and PNC 2015 coverage of 78%, 42% and 54% (Ga East Municipal Health 
Directorate. 2016), were taken into consideration in the formula below: 
z2p(1-p)N 
n = -z".Zp....,;(1:....:.--p-),...;..+;...N-e~2 
where. n = the minimum sample size, 
z'" the standard normal variate for population distribution. In this study, a 95% confidence 
interval was used, therefore a 5% type I error was allowed and the level of significance 
placed at p <0.05. At p<0.05, Z = 1.96; 
p = the proportion of some relevant characteristic. Since this study was measuring three 
outcome variables. ANC, skilled delivery and PNC, their various proportion were used in 
computing the sample size after which preference was given to the one that resulted in the 
highest sample size; 
N = the popUlation of women in the fertility age group in Ga East Municipal which is 
41.304; 
And, e = the degree of precision assumed to be 5%. 
Usmg the Postnatal Care proportion as the outcome with the highest sample size 
calculation, the sample size arrived at was 416, after including a 10% non-response rate. 
However, the simplified version of the formula is given as: 
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N 
n = 1 + Nez 
Thus. in using this to compute the sample size: 
41304 
n = 1 + 41304.0.052 
n = 396 T 10% non-response rate = 436 respondents. 
This higher sample size was used in the study as it has the advantage oflowering the margin 
of error thereby making the study more reliable (Taherdoost, 2016). 
3.4.2 Sampling Procedure 
The sampling was done using a random sampling procedure. With the sub-municipal 
EnumeralJon Areas serving as a framework. household listings were conducted in two peri-
urban sub-municipals in Ga East Municipality: Dome and Taifa. Following this. each 
household was given a unique identification number and random numbers were generated 
using the Microsoft Excel random number generator to obtain the sample size. Samples 
were chosen proportionately from eaeh sub-municipal to reflect the population size in each 
of the areas. From the household numbers generated, women who had delivered babies in 
the last year-and-half were chosen to reduce the chances of the study being affected by 
recall bias (Esena & Sappor, 2013). In cases where more than one woman was found to be 
eligible in a particular household, only one woman was selected for the study by balloting. 
The inclusion criteria for the study took into account, women who had had deliveries in the 
past eighteen months, and were between the ages of 15 to 49 years old. The exclusion 
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cn.le'na  compn. se d of women with deliveries who were not resident in the Ga East 
Municipal during their pregnancies. and postnatal women outside the WIFA group range. 
The primary outcomes in this study are: 
I. Adequate ANC attendance (having 4 or more ANC visits); 
2. Skilled birth delivery (childbirth at a healthcare facility attended by a skilled healthcare 
worker); and 
3. Timely Postnatal Care (attendance of PNC clinic within the first 24 hours, and by the 
2ndl3rd day after birth). 
The independent variables include age, parity, educational level, working status, and 
female autonomy. 
3.5 Qualitative Data Collection 
Qualitative research is carried out to explore a phenomenon or a matter of interest so as to 
understand it from a certain population's point of view, identify measurable variables, or 
highlight issues that have been hitherto unvoiced (Creswell, 2007). In phenomenology, the 
common issues of the individuals' experiences are stressed with the researcher using data 
collected to develop a complex description of all the lived experiences - narrating 'what' 
was experienced and 'how' it was experienced (Moustakas, 1994). In describing the 
phenomena being studied, researchers need to bracket their personal knowledge about it. 
Some research authorities such as van Manen (1990) are of the opinion that an interpretive 
approach to phenomenology will make it difficult for this to be achievable. LeVasseur 
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(2003) suggests a reflective approach that entails suspension of personal understaDdings to 
encourage inquiry, and this approach was employed during this research. 
In phenomenology, interview guides are developed and used as a protocol to conduct the 
data collection thus the qualitative data for this research was collected using two methods: 
Focus Group Discussions (FGDs) and In-depth Interviews, employing discussion and 
mterview guides as tools. Focus Group Discussions aid in highlighting group opinions of 
issues that affect a community or subgroup of people while defming the range of 
perspectives that exist amongst them (Mack, Woodsong, McQueen, Guest, & Namey, 
2005). In-depth Interviews, on the other hand, are used to elicit individual perspectives 
regarding the structure, processes and outcomes ofa given agenda (Boyce & Palena, 2006). 
These strategies were thus appropriate to aid in extracting detailed information from the 
study participants towards the formation of desired themes and categories. The guides were 
designed in English and where discussions or interviews needed to be conducted in a local 
language, a back-to-back translation of the guide into the local language, Twi, was 
conducted. This was done by engaging an individual with expertise in English as well as 
in Twi to do the first translation after which another language expert was required to 
translate the guide back into English. Any disparities that existed when both translations 
were compared was settled by a third translator. 
Field assistants were recruited and trained using an approach that involved both theoretical 
sessions and mock interviews carried out in English and Twi. Following the training, the 
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field assistants were deployed into the field to collect the required data. The discussions 
and interviews were carried out in environments that were quiet and conducive for the 
respondents. In addition, proper ethical procedures were followed by obtaining consent 
from the respondents to take part in the study, as well as to record the discussions or 
mterviews. 
All the participants in the discussions and interviews were purposively sampled using 
maxllnum variation. Purposive sampling is used in qualitative research to deliberately 
throw light on a research problem and the phenomenon under study and maximum 
variation is an approach used in selecting the sites and respondents to ensure that different 
critena of sites or mdividuais are chosen to reflect any dissimilarities in opinions (Creswell, 
2001). In this research, women who had delivered babies in the past eighteen months 
participated in the discussions. They were chosen based on the places of delivery - health 
care facility or TBA centre - to be able to document the experiences of women based on 
the different choices they make. CHOs participating in FGDs were chosen from the two 
sub districts included in the study to elicit any similarities or differences between the two 
environments. All the interviewees were chosen to reflect the various individuals that make 
contact with the women in the study area during their pregnancies. 
3.5.1 Focus Group Discussions (FGDs) 
Three (3) FGDs were held amongst postnatal women representing women who had 
deliveries in the facilities and women who chose to deliver with a Traditional Birth 
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Attendant. These women were chosen from those sampled for the quantitative research 
using information from the questionnaire indicating their choices of place of birth. In 
addition to these, two (2) FGDs were held amongst CHOs who work in the study area, and 
who had been employed there for the past two years (Table 2). This was to ensure that the 
information being obtained from the CHOs is based on valid experiences. The FGDs were 
comprised of groups of 6 -10 participants interviewed using FGD guides (Appendices D 
and E) made up of open-ended questions to obtain information regarding Antenatal Care, 
skilled delivery, and Postnatal Care services available to women in these communities. The 
diSCUSSIOns also elicited information on the activities of community based initiatives and 
how they impact on maternal care service utilization in the communities. The participants 
were required to sit in a semi-circular formation with the interviewer and note-taker seated 
in the middle and the timing and venue of the discussions were chosen to ensure that they 
were agreeable to all the participants involved. For each question asked during the 
discussions, each individual was afforded the opportunity to contribute to the forum and 
inductive probing was employed to elucidate on issues raised. The notes taken during the 
discussions were expanded immediately after the sessions. Each discussion lasted for 50 _ 
60 minutes. 
Table 2: Summary of FGD Participants 
Discussion Group Number of Number of 
FGDs Participants 
Mothers with healthcare facility deliveries 2 15 
Mothers with TBA assisted deliveries 6 
CHOs 2 14 
Total 5 35 
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3.5.2 In-Deptb Interviews (IDls) 
A total ofnme (9) In-depth Interviews (lOIs) were also held with key healthcare personnel 
in charge of ANC at two (2) public health facilities and two (2) private health facilities, 
two (2) Traditional Birth Attendants, two (2) members of Mother Support Groups, and the 
urban CHPS coordinator. Interview guides with open-ended questions were used to elicit 
the information needed such as Antenatal Care, skilled delivery, and Postnatal Care 
services available to women in these communities and collaborations between the 
healthcare providers in the communities (Appendix F). The interviews took place at venues 
and tImes conducive to the interviewees, with the accompanying voice recording and note 
taking. Inductive probing was also be used to expound on points raised during the 
interviews and notes taken were expanded soon after the interviews. The duration of the 
interviews were between 40 - 45 minutes. 
Table 3: Summary of 101 Participants 
Iype of Participants Number Interviewed 
Public health care providers 2 
Private health care providers 2 
Urban CHPS Coordinator 
Mother Support Group volunteers 2 
Traditional Birth Attendants 2 
Total 9 
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3.6 Data Management and Analysis 
Quantitative data were entered into the Stata 13" software. All continuous variables such 
as age were categorized into ranges as were deemed appropriate. Other variables such as 
ethnicity. religion, marital status, educational attainment and occupation were collected as 
categorical variables and were used as such during analysis. A univariable analysis of 
background characteristics was carried out and outcomes are reported in total numbers and 
percentages. The chi-square test was used for bivariable analysis to evaluate the association 
between the outcome and independent variables with a p-value ofless than 0.05 considered 
statistically significant. while multivariable logistic regression and calculated adjusted odd 
ratios with 95% confidence intervals were used to measure the strength of the association 
between outcome and independent variables. All the results from the quantitative analysis 
are presented in tables. 
Qualitative data from discussions and interviews were transcribed, coded and analysed 
using the thematic content analysis approach. An initial read through the transcripts was 
Instrumcntal in the development of a codebook. The codebook described the various codes 
and their definitions, outlined what quotes could or could not be categorized under each 
quote. and provided examples to guide these decisions. This analysis was done using the 
Nvivo II ,. statistical software and the first step towards this consisted of transcribing the 
data collected into a Microsoft Word document, after which it was imported into the 
analytical software. The codes from the codebook were used as nodes in the software and 
transcripts were studied line-by-line to select relevant quotes and code them under 
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appropriate nodes. Themes and sub-themes emerged during this process while further 
analysis resulted in the formation of tentative linkages between the concepts and the data. 
All the information thus gathered were used to write up the narrative supported by 
illustrative quotes from the respondents. 
The results from the quantitative and qualitative analysis were triangulated to produce an 
end report, and thus led to reconunendations being made for the improvement of maternal 
health care service utilization in peri-urban areas through community-based initiatives. 
3.7 Ethical Considerations 
3.7.1 Ethical Clearance 
Ethical clearance was sought from, and approved by the Ghana Health Service Ethical 
ReView Board via the School of Public Health, College of Health Sciences, University of 
Ghana after which the study commenced (GHS-ERC 16/11115, Appendix G). 
3.7.2 Informed Consent 
Pnor to data collection, field assistants explained the purpose of the study to the 
respondents, including the procedures involved and any potential risks in participating in 
the study. The respondents were also presented with informed consent forms to obtain their 
assent to participate in the study. These forms also provided the names and phone numbers 
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of the principal researcher, the academic supervisors and the secretary to the ethics 
committee of the Ghana Health Service, in case a respondent had the need to contact any 
of them. In the event that the respondent could not read, the field assistants read the form 
out loud and requested that the individual report back her understanding of consent, 
answered any question raised, and obtained the consent to participate from the respondent. 
Where required, consent for audio-recording was also obtained. Respondents were free to 
decline participation in the study at any point during data collection or interviews. There 
were no health risks to respondents and their confidentiality and privacy were assured. 
3.7.3 Privacy and Confidentiality 
All data collected from the study were confidential. All respondents interviewed were 
a;.si!,.'1led a unique identification number and no names were attached to any study data. In 
addition, study personnel stored data in a secure cabinet to which only authorised personnel 
had access. All digital data were stored in a password protected computer accessible to the 
study team only. 
3.7.4 Risks and Benefits 
Though there were no direct benetits to the study participants, their participation will help 
in making policy recommendations with regards to maternal healthcare service delivery to 
women living in impoverished urban settlements. There were also no anticipated risks to 
the participants in the study. 
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3.7.5 Dissemination of Results 
Results from the study will be disseminated through a variety of platforms which will 
include seminar presentations, policy briefs, peer-reviewed publications in journals and 
debriefing of participating communities and individuals. 
3.7.6 Quality Control 
Three graduate research assistants were recruited and trained on all aspects of the study 
two weeks before commencing on data collection. They were trained by the Principal 
Investigator at the School of Public Health, and were sensitized on proper ethical guidelines 
and the need for confidentiality. The discussion and interview guides were also tested by 
carrying out a pretesting in La-Nkwatanang Municipal- an area with similar characteristics 
like the study area - after which necessary alterations were made to the data collection tools 
to improve on them. There was double entry of quantitative data collected after which the 
data was cleaned to check for errors and outliers. A back-to-back translation of all 
discussions and interviews conducted in the local language, Twi, was also done by two 
mdepcndent researchers proficient in English and the local language. In the event of any 
disagreement. a third researcher was invited to iron out inconsistencies. 
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CHAPTER FOUR 
4.0 RESULTS 
4.1 Introduction 
This chapter presents the quantitative and qualitative results obtained from the study and 
commenCl!S by outlining the socio-demographic data of study participants. The objectives 
of the study and the conceptual framework were taken into consideration in presenting the 
results. Account is given of the effect of the community-based interventions on the 
contmuum of perinatal care from Antenatal Care through delivery to Postnatal Care. The 
success of the perinatal health care services hinges on the fact that a woman is supposed to 
have adequate ANC care, Skilled Birth Attendance at delivery, and timely Postnatal Care, 
and this chapter highlights the results from the study addressing these issues. 
4.2 Socio-dcmographic Background of Respondents 
The total number of respondents that participated in the study was 441. These study 
re~pondents were women in the reproductive age groups and came from varying 
demographic backgrounds as presented in Table 4 below. The respondents' ages ranged 
from 15 to 46 years old. With regards to level of education, 41 respondents (9.3%) had no 
education, 88 (20%) had primary education, and almost half of them were educated up to 
the Junior Secondary School level. Respondents who had Senior Secondary School and 
tertiary education were 92 (21.0%) out of the population. 
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Respondents who were from the Akan ethnic group made up 248 (57.3%) out of the total 
number of participants; the Ewe ethnic group were 111 (25.6%), the GalDangbe ethnic 
group were 34 (7.9%), and all other ethnic groups, including those of Northern origin were 
40 (9.2%). Majority of respondents were Christians as they made up 411 (93.6%) of the 
total, while 21 (4.8%) were Muslims and 7 (1.6%) represented those of other religions. 
Whilst more than half (55.4%) of the respondents were married, 54 (12.3%) were single 
and 142 (32.3%) were cohabiting. 
Respondents who were unemployed made up 138 (31.3%) out of the total. For those that 
were employed, 244 (81.3%) ofthem were engaged in their jobs all year round while 56 
(18.7%) worked seasonally. Of these employed individuals, 284 (95%) were able to spend 
their income as they deemed fit while 15 (5%) did not have the same liberty. 
With regards to decision making, 80 (18.6%) out of the respondents were the major 
decision makers in the household, 153 (35.6%) had their husbands or partners as the major 
decision makers. while 197 (45.8%) out of all respondents made the decisions together 
with their spouses or partners. 
While 43 (9.8%) of the respondents had no access to a cell phone, 396 (90.2%) of them 
had access to personal cell phones, a phone within the household, or made use of a phone 
within the compound or community. 
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Concerning the need for permission from their husbands or partners to move out of the 
house. 251 (56.9%) respondents had to obtain permission while 181 (41.0%) did not 
require permission before leaving the house. 
A little over half of all respondents had a valid NHIS card as 231 (52.4%) of them were 
able to produce it on demand, while 207 (46.9%) did not have the card. 
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Table 4: Socio-demographic Characteristics of Respondents 
Soc:lo-demographic characteristics (SOC) of respondents Frequenq (N) Percent• • (%) 
Age 
<20 13 3.0 
20-24 74 16.8 
25-29 166 37.7 
30-34 126 28.6 
35-39 51 11.6 
40+ 10 2.3 
Higbest level oHormal education 
None 41 9.3 
Primary 88 20.0 
JSS/Middle 218 49.7 
SSS/Secondary 7 I 16.2 
T~ 21 4.8 
Etbnidty 
Abn ~8 57.3 
Ewe III 25.6 
Ga/Dangbe 34 7.9 
~ 40 9.2 
Religion 
Chnstian 411 93.6 
Muslim 21 4.8 
Other 7 1.6 
:\1arilaIUatus 
Unmarned 54 12.3 
Married 244 55.4 
Cohabiting 142 32.3 
Occupation 
Unemployed 138 31.3 
ProliTechIMan 14 
Sales & Services 3.2 198 
SkiliediAnisan 45.0 84 
Un>killedlLabourer 19.1 6 
For ,hr e"'ployrd 1.4 
Work frequency 
Seasonal 56 
All year 18.7 
244 81.3 
Able to spend own income as deemed lit 284 95.0 
Major decision maker in household 
RespondcnI 
lIusbandIPanner 110 18.6 
Both 153 35.6 
Access to c.1I phone 197 45.8 
None 
Personal phone 43 9.8 
Within household 343 78.1 
Within compound/community 46 10.5 
7 
Needs permission from husband to move out of the 1.6 
house 251 56.9 
Have valid 2015-2016 NHIS card 
231 52.4 
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The respondents from the community who participated in the Focus Group Discussions 
were purposefully selected from the study sample. Their socio-demographic 
characteristics, as well as those of the CHOs are summarized in Table 5 below. 
Table 5: Socio-demographic Characteristics ofFGD Participants 
SDC of FGD Participants Number of Participants 
Community Health Officers (CHOs) 
Age (Years) 
<30 years 8 
~30 years 6 
Religion 
Christianity 13 
Islam I 
Marital status 
Married 7 
Single 7 
Yean of Experience 
1-5 5 
>5 9 
Postnatal Women Skilled Delivery Unskilled Delivery 
Age (Years) 
<30 years lO 
~30 years 5 
Religion 
Christianity 13 6 
Islam 2 o 
Marital status 
Married 14 2 
Single I 4 
Parity 
<3 \0 6 
~3 5 o 
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4.3 Reproductive History of Respondents 
Of all the women surveyed, \05 (23.8%) had had one pregnancy, 165 (37.4%) had had two 
pregnancies, 102 (23.1%) had had three pregnancies, and 69 (15.7%) had had four 
pregnancies or more. The median and mean number of pregnancies were 2 and 2.4 
respectively. While 301 (68.3%) of respondents had given birth to up to 2 children, 140 
(31.7%) had given binh to 3 or more children. The median and mean number of children 
given birth to were 2 and 2.2 respectively. 
Three hundred and seventy respondents (84.3%) were not taking any measures to delay or 
prevent pregnancy while 69 (15.7%) were using contraceptives for this purpose. Of these, 
34 (49.3%) have used a contraceptive method for less than 6 months while 35 (50.7%) have 
used the methods for 6 months or more. 
For women currently delaying or avoiding pregnancy, the method of contraception 
employed varied amongst the respondents with the injectables being the most popular 
choice as 30 (43.5%) women opted for this method. The respondents had learnt about 
contraceptives from various sources with most getting their information from Antenatal 
Care clinics, 23 (34.3%), IS (22.4%) from the media, and 10 (14.9%) from Postnatal Care. 
These results are presented in Table 6. 
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Table 6: Reproductive History of Respondents 
Reproductive history Frequency Percentage 
(N) ("10) 
No. of pregnancies ever bad 
1 105 23.8 
2 165 37.4 
3 102 23.1 
4+ 69 15.7 
Median=2. Mean=2.4 
Parity 
I 137 31.0 
2 164 37.2 
3 89 20.2 
4+ 51 11.6 
Median =2. Mean=2.2 
Currently delaying/avoiding pregnancy 69 15.7 
Duration of current contraceptive use 
< 6 months 34 49.3 
6+ months 35 50.7 
Choice of contraception 
InJcctablcs 30 43.5 
Pill 12 17.4 
IUD 9 13.0 
MaleIFcmale condom 6 8.7 
Implants 3 4.3 
Lactational amenorrhoea 3 4.3 
Foam/jelly/diaphragm 3 4.4 
Rhythmic/abstinence method 2 2.9 
Other traditional method 1 1.5 
Sources of knowledge on contraceptive use 
ANC 23 34.3 
Media 15 
PNC 22.4 10 14.9 
Child Welfare Clinic 8 
ellOs 11.9 2 
Other sources 3.0 9 13.9 
~.4 Antenatal Care 
MajOrity of the women surveyed, 432 (98.6%) had been to the Antenatal Care clinic with 
only 6 (1.4%) not utilizing ANC services. The healthcare providers that attended to most 
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of the women were the midwives who catered to 384 (88.9%) ofall visits. The government 
hospitals were the most patronized healthcare facilities by the women with 269 (62.3%) 
ANC attendees while private clinics and maternity homes had III (25.7%) and 5 (1.2%) 
of the ANC attendees visiting respectively. Two hundred and sixty-seven women (62.4%) 
attended their first ANC clinic during their first trimester. 152 (35.5%) started in the second 
tnmester and 9 (2.1%) started in the third trimester. Of the women who attended ANC, 337 
(78.2%) paid an adequate number of visits to the clinic while 94 (2] .8%) did not pay up to 
the minimum number of four visits required. During their pregnancy, only 298 (69%) of 
those who attended ANC reported that they were told about the danger signs in pregnancy 
or where to go in the event of a pregnancy complication (Table 7). 
When asked about their satisfaction with services offered at the ANC clinics they attended, 
219 (53.4%) respondents were pleased with the range of services offered, 392 (95.6%) 
were impressed with the attitude of the nurses, while 264 (64.4%) were of the opinion that 
the level of saDltation was of acceptable standard. The availability of drugs, privacy during 
examinations, and time spent during examinations were services that 255 (62.2%), 238 
(58.1 %), and 219 (53.4%) respondents respectively pointed out as satisfactory. However, 
thiny-one (7.0%) respondents were unhappy with the attitude of nurses at the healthcare 
facilities. 41 (9.3%) felt the time spent dunng examination was inadequate and 22 (5.0%) 
were dissatisfied for other reasons such as high hospital charges, baby not being bathe, 
tardiness of the health care providers, and early closing time at facilities (Table 7). 
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Table 7: Antenatal Care Attendance 
ANC attendance Frequency Percentage 
(N) (0/0) 
Saw anyone for Antenatal Care during last 
pregnancy 432 98.6 
Persons seen for ANC* 
Doctor 157 36.3 
Midwife 384 88.9 
Nurse 182 42.1 
Facilities where ANC was received* 
Govt. Hospital 269 62.3 
Govt. health centre/Community Health Clinic 54 12.5 
Private clinic 111 25.7 
Maternity home 5 1.2 
Age of pregnancy at first ANC 
I st trimester 267 62.4 
2nd trimester 152 35.5 
3rd trimester 9 2.1 
No. of ANC visits 
Inadequate 95 21.8 
Adequate 337 78.2 
Told pregnancy danger signs at ANC 298 69.0 
Told where to go with pregnancy 298 69.0 
complications 
Discussed plans for delivery while pregnant 319 72.3 
Satisfied with the ANC received at health care 410 93.0 
facility 
Services satisfied with* 
Range of services offered 219 53.4 
Attitude of nurses 392 95.6 
Level of sanitation 264 64.4 
A vailability of drugs 255 62.2 
Privacy during examination 238 58.1 
Time spent dunng examination 219 53.4 
Good facility 14 3.4 
Services not satisfied with* 
Attitude of nurses 31 7.0 
Time spent during examination 41 9.3 
Other reasons 22 5.0 
• Multiple responses alJowed 
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4.4.1 Association between Socio-demographic Characteristics of Respondents and 
Adequate ANC Attendance 
A Chi statistical test was carried out to ascertain whether there was an association or 
significant difference in distributions of adequate ANC across each independent variable. 
Where the assumptions underlying the Chi-square test failed, the Fisher's exact test was 
used. Results show that the differences in age, parity. level of education were not 
significant for adequate ANC attendance (p=O.827. 0.310 and 0.129 respectively). 
Conversely, the employment status of the respondents (p=<O.OJ), decision making in the 
home (p=<O.OOI) as well as the need for permission to move out of the home (p=<O.OOI) 
all emerged as significant factors in obtaining adequate ANC. The study found out that 
satisfaction with ANC services provided at the healthcare facilities was a predictor of 
adequate ANC attendance (p=<O.OOI) while being visited by a CHO had no significant 
association with obtaining ANC adequately (p=O.904). These results are presented in Table 
8. 
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Table 8: Adequate ANC attendance by socio-demographic characteristics and community-
based initiatives 
SDC, reproductive history and ANC Total Adequate X2 p-
attendance N(%) ANC(%) value 
--------
Age 0_827 
<20 13 (3.0) 76.9 
20-24 74 (16.8) 73.0 
25-29 166 (37.7) 78.9 
30-34 126 (28.6) 74.6 
35-39 51 (11.6) 78.4 
40+ 10 (2.3) 90.0 
Parity 0,310 
1 137 (31.0) 80.3 
2 164 (37.2) 78.7 
3 89 (20.2) 70.8 
'h 51 (11.6) 72.5 
Higbest level of formal education 0.129 
None 41 (9.3) 70.7 
Primary 88 (20.0) 68.2 
JSS/Middle School 218 (49.7) 79.4 
Senior Secondary 71 (16.2) 83.1 
Tertiary 21 (4.8) 81.0 
~.mployment ~tatus <0.01 
Unemployed 138 (31.4) 68.8 
Employed 302 (68.6) 80.5 
Major decision make" in household <0.001 
Respondent 80 (18.6) 76.3 
Husband/Partner 153 (35.6) 52.3 
Both 197 (45.8) 94.9 
Need permission from partner to move out <0_001 
of the house 251 (58.1) 69.7 
ANC facility attended <0.01 
Gov!. Hospital 265 (60.9) 72.5 
GovtJCommunity HC/Clinic 51 (11.7) 86.3 
PrivateIMatemitv Clinic 119 (27.4) 86.6 
Satisfied ~ilh A:\C; services 
<0.001 
Yes 410 (94.0) 79.3 
Ever \'isited b~ CHO 
Yes 0.904 266 (60.3) 
Total 77.1 
441 {IOO.O) 76.9 
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4.4.2 Logistic Regression between Socio-demographic Factors of Respondents and 
Adequate ANC Attendance 
Binary logistic regression was used to find the relative odds of each outcome variable used 
in the Chi-squarelFisher's tests after adjusting for the effect of age, parity, educational level 
and CHO visits. Women who were employed were 20% less likely to attend ANC 
adequately when compared to the unemployed women (aOR=0.80, 95% CI=0.45-1.41) 
even though this finding was insignificant. In households where the husbands or partners 
were the major decision makers, women were 66% less likely to attend ANC the stipulated 
number of times (aOR=0.34, 95% CI=0.16-0.72) and this was a significant finding. 
However, in households where decisions were made consensually, women were 
significantly found to be 5.9 times more likely to attend ANC for the stipulated number of 
times (aOR=5.89, 95% CI=2.24-15.45). Similarly, women who needed permission to leave 
the home were 42% less likely to attend ANC clinics (aOR=0.58, 95% CI=0.29-1.14). 
Women attending ANC clinics in a government or community clinic had 1.7 times the odds 
of having four or more ANC visits relative to those attending clinics at government 
hospitals (aOR= 1.73,95% CI=0.68-4.42); while those attending ANC at private, maternity 
or NGO clinics had 1.5 times the odds relatively (aOR=1.51, 95% CI=0.77-2.98). 
Satisfaction with ANC services offered increased the chances of utilizing ANC services 
adequately by 42% (aOR=1.42, 95% CI=0.54-3.72). The summary of these results are 
presented in Table 9. 
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Table 9: Relative odds of adequate ANC attendance by socio-demographic factors and 
community-based initiatives 
SDC, reproductin bistory and Odds Ratio {95% Confidence Interval~ 
ANC attendance Unadjusted Adjusted model I Adjusted model 2 
Age p=O.762 p=O.992 
<20 Ref Ref 
20-24 0.81 (0.20,3.25) l.I4 (0.23, 5.55) 
25-29 1.12 (0.29, 4.30) 1.09 (0.23, 5.22) 
30-34 0.88 (0.23, 3.40) 0.89 (0.18,4.5 I) 
35-39 1.19 (0.26, 4.66) 1.10 (0.18,6.69) 
40+- 2.70 (0.24, 30.85) 0.79 (0.04, 14.83) 
Parity p=0.320 p=O.376 
I Ref Ref 
2 0.90 (0.52, 1.59) 0.77 (0.37, 1.59) 
3 0.59 (0.32, 1.11) 0.52 (0.22, 1.22) 
4+ 0.65 (0.31,1.37) 0.46 (0.16, 132) 
Higbest level offormal p=0.I39 p=0.437 
education 
None Ref Ref 
Pnmary 0.89 (0.40, 1.99) 0.86 (0.32, 2.36) 
JSS/Middle School 1.59 (0.75,3.36) 1.42 (0.55, 3.70) 
Senior Secondary 2.03 (0.81, 5.08) 1.53 (0.49,4.84) 
Tertiary 1.76 (0.49, 6.36) 0.57 (0.11, 3.07) 
Employment status p<O.OI p=0.677 p=0.438 
Unemployed Ref Ref Ref 
Employed 1.86 (1.18,2.95) 0.88 (0.47, 1.62) 0.80 (0.45, 1.41) 
Major decision makers in 
housebold p<O.OOI p<O.OOI p<O.OOI 
Respondent Ref Ref 
HusbandIPartner Ref 0.34 (0.19, 0.62) 0.38 (0.17, 0.82) 
Both 0.34 (0.16, 0.72) 5.82 (2.57, 13.20) 6.75 (2.49,18.31) 5.89 (2.24, 15.45) 
Need permission from partner to p<O.OOI p=0.151 
mo\(~ out of the house p=0.114 0.37 (0.22, 0.61) 0.60 (0.30, 1.21) 0.58 (0.29. 1.14) 
ANC fatilil\ attended p<O.OI p=0.296 
Govt. Ho'spital p=0.306 Ref Ref 
Govt./Community HC/Clinic Ref 2.39 (1.03, 5.55) 1.70 (0.63, 4.64) 
PrivateIMatemity Clinic 1.73 (0.68,4.42) 2.45 (1.35,4.42) 1.63 (0.80,3.35) 1.51 (0.77,2.98) 
Satisfied with .\:\C services p<O.OI p=0.466 p=0.475 
3.82 (1.71, 8.55) 1.46 (0.53, 3.99) 1.42 (0.54. 3.72) 
[\o'er visited by CHO p=0.904 p=0.674 
0.97 (0.62, 1.53) 1.13 (0.63, 2.03) 
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4.5 Antenatal Care Knowledge, Practices and Barriers 
Results from the qualitative research show that the respondents have basic knowledge 
about Antenatal Care services and regardless of their choice of birth place, they described 
It as care provided for a pregnant woman and her unborn child in a health care facility. 
Some of the services expected by the women during ANC clinics include blood tests, 
ultrasound scannmg, and profeSSIOnal care in cases that may require surgery. Some 
respondents alluded to the fact that care of the pregnant woman has been a long standing 
cultural practice that has now become institutionalised. These opinions are illustrated by 
the quotes below' 
"'t is how a pregnant woman will go to the hospital to go and see how she and the 
baby are and then check herself like ify ou have enough blood and other things. .,  
(3R years. FGD HJF Del. Dome) 
.. What , understand is that maybe you had an operation duril/g the previous 
childbirth so you have to go for Antenatal Care so that whel/ your time is due the 
doctor CCln tell you ify ou will need to be transferred to a bigger hospital or not. .. 
(24 years. FGD HJF Del. Taifa) 
"'t is when a pregnant woman goes to the hospital to see if the baby is lying down 
well or not and the scan they do ;s what will tell that. In addition, the reason why 
we go for antenatal is that when ),OU have any disease in your blood they can do 
lab and tell you but the TBA cannot tell you that so that is why we go for the 
antenatal. "(37 years, FGD TBA Del) 
"Antenatal is something that has been there for long, ;n our grandmother and 
mothers time. When you get pregnant you go to the hospital or even those who 
deliver people at home they take care oft he women during pregnancy but they have 
not put a name to it so it is the hospital that has named it antenatal and that is how 
we all know and call it . .. (23 years, FGD H/F Del, Taifa) 
Even though about two-thirds of the women accessed ANC services in their first trimester, 
the reasons for which the women went to the hospital varied from feelings of ill health to 
having a previous complication in a past pregnancy. Women who had no signs of ill health 
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delayed going for ANC till later in the pregnancy. Some of the women also needed 
prompting from family members such as the mother-in-law or husband before they started 
attending ANC. For most women who did not go for ANC clinics early in their pregnancies, 
financial and time constraints were given as the reasons for the delay. The narratives that 
follow buttress these points. 
"/t was my in-law who advised me to go in the third month. she did not give me any 
reason but / started feeling sick and she told me to start going. .. (24 years, FGD 
HIF Del, Dome) 
"As for me because ofm y previous complication when / saw that I was pregnant / 
went to the hospital. so / went in thefirst month." (37 years, FGD TBA Del) 
"Please I wenl in my seventh month and it is because there was nothing wrong with 
me. / had no pain or anything in my body. " (28 years, FGD HIF Del, Taifa) 
"/ did not have that much time to go the hospital and / was very strong too so I 
could have stayed at home till about seventh months before going to the hospital 
but / got sick in the fourth month and that is why I went. .. (22 years, FGD TBA 
Del) 
"It is becallse / did not have money. I went when I was two months pregnant but I 
did not have the money so / went back and started in the fourth month . .. (28 years, 
FGDTBA Del) 
Discussions and interviews with health care providers highlighted several other factors that 
were barriers to accessing ANC services. These include lack of public health care facilities 
in the community leading to high costs of services offered by private health care 
institutions, the poor treatment of pregnant women by hospital staff, and fear of Cesarean 
section. Many of these barriers result in the women relying on TBAs for perinatal care 
services, being inconsistent with ANC attendance, and non-compliance to obstetric 
referrals. These points are supported by the following quotes: 
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"Because Dome has no public facility and only private facilities. some of them 
charge high prices so the women prefer going to the TBA than going to the private 
facilities . .. (28 years, CHO, FGD Dome) 
.. We the health workers are our own enemies. We are driving the mothers to deliver 
at home because oft he attitude we show them. We are doing a survey and some of 
the mothers stillf eel hurtf or the way they were treated and disrespected many years 
bade when they had their first child. So ift hey will deliver at home and the TBA will 
have time for them, boil water for them and pamper them, so if the person is not 
educated they will prefer to deliver at home than the hospital. So we the health 
workers are a big part of the problem. we are causing those things . .. (21 years, 
CHO, FGD Dome) 
"For me ifnotfor the way I got sick I would not have gone to the hospital/or the 
antenatal because I don't like the way they are always tallcing about operation and 
the way they shout at us when we go to the hospital. I am very scared of the 
operation so ift hey will not encourage me and they will shout at me it is a very big 
problem in my life. " (22 years, FGD TBA Del) 
"Some oft hem, when you ask them to come back they will not mind you. They wait 
until they have issues before rhey come. Some will come for a tetanus injection and 
when it is time for the next shot they will not show up. She will come when the time 
is past. Also, when you ask them to go for the lab tests and scan they don't go. Most 
oft hem do this because offinancial challenges. Some even come empty-handed and 
you have to use your OWII money to cater for them. When it is time for them to pay 
the bill it becomes a problem. So most of them we do it free for them . .. (IDI 
Maternity Home, Dome) 
"The challenges, IImm",. Number one pertains to some oft hese antenatal cases. At 
times you know that this is not your case so you refer. I don't play with them. 
because I am not after money. I refer any case that has to be taken care of by a 
specialist. Like threatened abortion, women with one or two still births or women 
who delivered and lost the baby. They have tofind out why. But ify ou send them 
away they may not go. They will go to another facility or stay at home and give 
birth. Yet, you will see them going for traditional medicine. They will tell you the 
traditional medicine too is he/ping them so they will be going there." (101 
Maternity Home, Taifa) 
The choice of where to go for ANC services was made based on several factors. Many 
women chose health care facilities where they felt the health care providers were respectful 
and caring, while others chose facilities based on proximity to their places of residence, 
and where the waiting time was not too extensive. The capacity of a health care facility to 
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handle complications in pregnancy was another consideration in choosing a facility for 
ANC. The narratives that follow illustrate these factors mentioned. 
'The reason why I attended antenatal at where I did is because when I go there 
they treat me with respect and they look after me well." (38 years, FGD H/F Del, 
Dome) 
"[The} community hospital is closest 10 me and they treat me well too so that is 
why I went there. " (24 years, FGD HIF Del, Taifa) 
"That is where I attend hospital so I decided to go there when I got pregnant and 
that place too is a big hospital so ify ou have any complications during childbirth 
they can take care of you without having to refer you to any facility . .. (23 years, 
FGD HIF Del, Dome) 
"As for [the} polyclinic. usua/(v there aren't a lot ofp eople so when you go for the 
antenatal you return home on time so that is why I attended the ANC there . .. (23 
years. FGD HIF Del. Taifa) 
While some women were satisfied with the ANC service delivery at their health care 
facility of choice largely because of the sanitary environment and respectful attitude of the 
health care personnel, others were dissatisfied with the services especially where they were 
ignored and treated disrespectfully. Other reasons that led to dissatisfaction include long 
waiting hours. showing some other ANC attendees favoritism, and suggesting Cesarean 
sections which some of the women deem unnecessary. These factors have also led some 
women to seek care from TBAs in addition to care being received from the orthodox health 
care facilities as illustrated below: 
"/ liked the environment, the place was neat and they Ireal you with respecl and 
patience. .. (35 years. FGD HIF Del, Taifa) 
'They shout at us and we keep long Ihere, when you go you will be waiting and 
waiting and they will ignore you . .. (25 years, FGD HIF Del, Dome) 
"U711!re I went to antenatal, what I did not like was that when you wake up early 
and go to the hospital, a soldier will sit at home and when she comes in late they 
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will attend to her because they say it ;s their hospital and I don't like that. I think 
when they come late they shouldjoin the queue." (23 years, FGD HIF Del, Dome) 
.. When you go to the hospital and your date for delivery is past they will schedule 
you for operation but J don't like that too because J have been operated on once 
and I kllow it is not easy because I have lost my strength, I cannot do the things I 
used to do anymore but I like the fact that when ),ou go they give you medicine if 
),ou are notfeeling well or cannot eat." (37 years, FGD TBA Del) 
"I also just go to the hospital and come to this TBA here - I don't take any herbal 
medicine but this TBA has been organizing prayers here. She even does all night 
prayers here alld the person who directed me told me, and I have come to see how 
she pampers the pregnant women who come to deliver here and the doctors in the 
hospital don't do that. All they do is shout on you and say 'push, push' and they 
will push their big hands under you (vagina) saying they want to see the baby but 
this woman does not do that. She is always on me to pray so that is why I came 
here." (37 years, FGD TBA Del) 
Despite the fact that most women felt it was essential to attend ANC at a health care facility, 
they still saw the need to have added spiritual and/or herbal protection during the pregnancy 
period. The prayers were offered to prevent unexpected complications, as well as to guard 
against witchcraft. The herbs are taken to keep the pregnant woman strong and healthy and 
prevent illnesses such as 'asram' (childhood convulsion) in the unborn child. These points 
are illustrated by the narratives below: 
"/ also went for prayers so that / can have safe delivery, have a healthy baby and 
not ha~'e allY complications during pregnancy. .. (24 years, FGD H/F Del, Taifa) 
"/used herbs to prevent ·asram·. "(32 years, FGD H/F Del, Taifa) 
.. When you are taking hospital medicine you must not add herbal medicine so / did 
not take any herbs. But when you get pregnant the witches get very aggressive so / 
wt'ntjor prayers . .. (25 years, FGD TBA Del) 
Focus Group Discussions and In-depth Interviews held with health care providers and 
volunteers elicited that most of them encouraged the women to attend Antenatal Care in 
the health care facilities. The CHOs and Mother Support Group volunteers engage the 
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mothers in their homes. and at a personal level to educate them on the benefits of ANC 
services and proper care during pregnancy. The CHOs and maternity home proprietresses 
also keep a check on the ANC booklets given to women by the health care facilities to 
ensure compliance with ANC instructions. The TBAs encourage the women to go for ANC 
clinics to ascertain that there were no complications hindering them from having a TBA 
assisted delivery. They go a step further to provide spiritual and traditional support for the 
women in the form of prayers and herbal medicines. These points are highlighted by the 
narratives below: 
"For us the community health nurses, when we go to the community and find 
pregnant women, we check their ANC book to see whether the she has been going 
for ANC regularly. And also whether the person has been taking the drugs given to 
her - routine drugs like folic acid and sp. Most of the mothers don't like to take it 
so when you go to the ANC clinic the midwife makes sure you take it in front ofh er. 
They write it in the book so we check everything. When it is important we also give 
education . .. (31 years, CHO, FGD Taifa) 
"We look at their folder to see ift hey are attending antenatal regular(v. For some 
oft hem, you will realize thut they have been to the clinic just once or twice. In that 
case we rebuke them a little before taking care of them. We also look at the scan, 
their blood level and other lab results. "(lDi Maternity Home, Dome) 
.... .s o when they go to the hospital and everything is ole, then they come for me to 
deliver them here. I make them go to the hospital to do the scan because maybe the 
baby might not be lying down well and they have to do the lab too because some of 
them too, they don't have enough blood. That is why I make them go to the hospital 
so thaI they have a safe delivery and a healthy baby too ... 1 ollly do deliveries alld 
prayers, I don't give them allY medicine. .. (IDI TBA 2, Dome) 
" ... my mom makes deliveries. But sometimes, some of them do not go to the 
hospital. I don't know why. Maybe lack ofm oney or something else. Some go to the 
hospital but taking the pills is difficult so we boil herbs for them. So some people 
after going to the hospital come to my mom to take this local ones too. That is what 
we do, but we don't give Antenatal Care, only delivery . .. (lDI TBA I, Dome) 
"I go round and when I see a pregnant women I get closer to her and greet her and 
ask her ifs he has been attending antenatal. Some of them say they attend and some 
oft hem say the pregnancy is not yet old so they are waiting till about 6 months before 
they go. So I talk to them and tell them that they must go for antenatal so that they 
can check them, even for those who don't go to the hospital, I ask about their way of 
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eating and ask if they eat fruits. Some of them say they don 't Ii~e fruits an~ if they 
eat fruits they vomit and others say that they are only able to eat nee so I advISe them 
to eat fruits in addition to their meals so that the baby will be hetllthy. .. (101. MSG 
I) 
4.6 Delivery Care 
Results from the study show that 409 (92.8%) women had skilled attendance at delivery 
with 292 (66.2%) of them choosing to give birth in a Government owned hospital while 99 
(22.5%) women opted for the services ofa private health care facility. Women who had a 
home delivery, either in their own homes or at the TBA's home, were 32 (7.2%) in number. 
While 338 (76.6%) respondents had a midwife in attendance at delivery, 20 (4.5%) had the 
TBA in attendance while 9 (2.0%) birthed their children alone. Complications during birth 
wcre experienced by 47 (10.7%) of the participants. Sixty-eight (15.5%) women had a 
Caesarean section done while 371 (84.5%) women had vaginal deliveries (Table 10). 
After the delivery of the baby, 391 (88.7%) respondents had support with exclusive 
breast feeding. For 265 (61.6%) of the respondents, the baby was put to the breast within 
an hour of birth while 138 (32.1 %) respondents had the breastfeeding initiated within 24 
hours. The support received came from various sources with midwives, nurses and CHOs 
rendering support to 211 (54.1%), 128 (32.8%) and 20 (5.1%) women respectively. 
Traditional Birth Attendants were a source of support for 5 (\.3%) women while 4 (\.0%) 
women were assisted by volunteers from the Mother Support groups. After delivery, 245 
(59.9%) women were discharged home within 24 hours (Table 10). 
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Table 10: Delivery care 
Delivery and neonatal care practices Frequency Percentage 
(N) <".) 
Place of birth of child 
Govt. Hospital 292 66.2 
Govt.lCommunity Health Centre 18 4.1 
Private facility 99 22.5 
Respondent'slother homeffBA 32 7.2 
Assisted in delivery of child· 
Doctor 74 16.8 
Midwife 338 76.6 
Nurse 150 34.1 
TBA 20 4.5 
Nobody 9 2.0 
Had complications during delivery 47 10.7 
Had Caesarean Section 68 15.5 
Had vaginal delivery 371 84.5 
Time to first breastfeeding of baby after birth 
< I hour 265 61.6 
< 24 hours 138 32.1 
> 24 hours 27 6.3 
Had support with exclusive breastfeeding of 391 88.7 
baby 
Sources of support for exclusive breastfeeding 
Doctor 5 1.3 
Midwife 211 54.1 
Nurse 128 32.8 
Community health officer 20 5.1 
Relative/friends 17 4.4 
TBA 5 1.3 
Mother Support Group 4 1.0 
Time discharged from facility after birth 
Wllhin I hour 34 8.3 
Within I day 211 51.6 
Within I week 142 34.7 
More than a week 6 1.5 
Don't remember 16 3.9 
Total 441 100.0 
• Multiple responses allowed 
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4.6.1 Association between Socio-demographic Characteristics of Respondents and 
Skilled Birth Delivery 
To ascertain whether there was an association or significant difference in these 
distributions of skilled birth delivery across each independent variable, a chi square 
statistical test was conducted. Results from the study show that even though a large 
percentage of respondents had skilled attendance at birth, the differences in age were not 
significant at 95% significance level (p=0.085). A lower proportion of respondents who 
had 4 or more children had skilled birth delivery but parity did not emerge as a predictor 
of having skilled birth attendance (p=O.065). The proportion of women with skilled birth 
delivery increased with higher level of education attained but this was not found to be 
significant at 95% confidence interval (pc=O.296) (Table II). 
Results also show that employment status, decision making in the household, and the need 
for a partner's permission to move out of the house were not significant for skilled birth 
delivery (p=0.437, 0.801 and 0.709 respectively). Receiving specific instructions from a 
health worker to deliver at a health facility and ever been visited by a CHO were not found 
to be predictors for skilled birth delivery (p=0.732 and p=0.S24 respectively) while the 
choice of place of birth was found to be significant at 95% significance level (p=<O.OO I) 
(Table II). 
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Table 11: Skilled birth delivery by socio-demographic factors and community-based 
initiatives 
SDC, reproductive history and SBA Total SBA Xl p-
N ~·/o~ ~%~ value 
Age 0.085 
<20 13 (3.0) 76.9 
20-24 74 (16.8) 87.8 
25-29 166 (37.7) 95.2 
30-34 126 (28.6) 93.7 
35-39 51 (11.6) 94.1 
40+ 10(2.3) 90.0 
Parity 0.065 
I 137 (31.0) 92.0 
2 164 (37.2) 95.1 
3 89 (20.2) 94.4 
4+ 51 (11.6) 84.3 
Highcst level of formal education 0.296 
None 41 (9.3) 85.4 
Primary 88 (20.0) 90.9 
JSSlMiddic School 218 (49.7) 93.6 
Senior Secondary 71 (16.2) 95.8 
Tertiary 21 (4.8) 95.2 
Employment status 0.437 
Unemployed 138 (31.4) 91.3 
Employed 302 (68.6) 93.4 
Major decision makers in bousehold 0.801 
Respondent 80 (18.6) 93.8 
Husband/Partner 153 (35.6) 91.5 
Both 197 (45.8) 92.9 
Necds permission from partner to move out 0.709 
of the house 251 (58.1) 92.4 
Given specific instructions by health 0.732 
worker to deliver at health facility 291 (66.0) 92.4 
Place of birth of child <0.001 
Home 27 (6.1) 3.7 
Gov!. Hospital 292 (66.4) 98.3 
Govt.lCommunity health centre 18(4.1) 100.0 
PrivatelMatemitylNGO facility 103 (23.4) 99.0 
Ever visited by a CHO 266 (60.3) 92.1 
Total 0.524 441 (100.0) 92.7 
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4.6.2. Delivery Care Practices and Barriers 
Results from the qualitative data show that while many women perceived the need to give 
birth in a health care facility, others had cause to make different choices. The health care 
providers and women were able to proffer some of the reasons to include the desire to birth 
in the squatting position, as well as delivery skills and low cost of services provided by 
TBAs. The spiritual protection also offered by the TBAs played a big role in women's 
choice of the TBA centre as a birthing option. The quotes below illustrate these points: 
"Sometimes the position is a barrier. Some want 10 squal but when Ihey go 10 the 
hospital they always want them to lie down. Most of the mothers don 'I like that, 
they want to squat so that they will feel comfortable. So those who want to squat 
will deliver by the help of the TBA or a family member. " (30 years, CHO, FGD 
Taifa) 
" ... The bill they will pay at the hospital will be about twice what they will pay at 
the TBA. The TBAs don't normally charge. Formerly they were taking soap and 
olherlhillgs but now they take something small ... Yes, they have time for them. They 
cook herbal medicine for them and at the end of the day the women pay something 
small. That is why our women like them. " (30 years, CHO, FGD Dome) 
"And this woman [TBA] 100, when she helps you deliver you don 'I feel any pain 
after delivery. I just delivered yesterday but! don't feel like I just delivered. ! feel 
very slrong but if il had been the hospital! could not feel like this. My first child! 
delivered him in the hospital but when I finished I could not sit straight, ! had to sit 
011 one side of my buttocks. They inserted their hands so much into me that the 
whole place was sore but this woman does not do that. .. (25 years, FGD TBA Del) 
"Most of the TBAs are also spiritual prophetesses so they like to go there. They 
believe the TBA will break every spiritual barrier. Yes, the TBAs pray with them 
and do deliverance for them. Some even allow you to go to the hospital for a CIS. " 
(29 years, CHO, FGD Dome) 
Some women also made their choice to avoid being disrespected by hospital staff or having 
a Caesarean section at the health care facility. The outcomes have however not been 
entirely successful as they would have one believe. Birth complications such as the 
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umbilical cord around the neck, physical deformity and still births have arisen in such 
birthing centres. These points are buttresses by the narratives that follow: 
'" want to say that the nurses should talk to us with respect. When we come they 
talk to us rudely so they should talk to them to stop that. Also the way they are quick 
to say we should do operation- they should stop it because not all of us can give 
birth at exact~v the nine months. Some people exceed so they should relax on the 
operation because we are scared ofi t so when you say that, we will not even come. .. 
(37 years. FGD TBA Del) 
"The woman here has patience and she has been pampering us. J have seen a 
woman who has had two operations previously and the hospital said they will do 
un operation for her but when she came here the woman helped her deliver the 
baby and my own sister had an operation for her previous child but this woman 
helped her deliver normally so that is why J came here. .. (37 years, FGD TBA Del) 
"The complication J had I\'as that I did not get my baby, it was born dead. She 
[TBAJ said the baby was a/ready dead in my stomach because the cord was around 
the baby's IIeck. " (23 years, FGD TBA Del) 
While most of the women who gave birth in health care facilities were discharged within 
forty-eight hours of delivery, some ofthc women who opted for delivery at the TBA centres 
recounted how the TBA went extra miles in their provision of services. This included 
providing accommodation. cooking and catering to the needs of the new mother, as well as 
care of the newborn as highlighted by the quotes below: 
'" have been here for the past two weeks after delivery, J don't have anyone to bath 
the baby for me so I stay here for aUllty [TBA} to bath the baby for me until mv 
mother comes and then I will/eave . .. (18 years, FGD TBA Del) . 
"I have beell here for the pasl three mOlllhs after I had my baby and il is because 
when' sleep I forget and sometimes sleep on the baby so I have been asked to slay 
here so Ihal I can be monitored not to sleep on my baby. .. (22 years, FGD TBA 
Del) 
Following delivery, women are expected to initiate exclusive breastfeeding of their infants 
within an hour of birth per the WHO regulation. The study elicited that the health care 
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providers and community volunteers educated the women on the importance of exclusive 
breastfeeding and provided support to them in the initial stages. Family members are also 
solicited to support the mothers with the breastfeeding process as illustrated below: 
"During ANC they educate them on the importance of it and when we also go to 
the community we educate them on it. Those who deliver at the facility are initiated 
into it immediately after delivery. But those who do not deliver at the facility, we 
educate them when we meet them in the community. We also educate them at CWC 
on exclusive breastfeeding." (28 years, CHO, FGD Dome) 
"In my community they have mother support groups, some of which are 
hairdressers. So when they are pregnant and/or deliver and they go to fix their hair, 
they tell them about exclIL~i\'e breastfeeding. Most of them too are in the 
communities so they go their homes and talk to them about exclusive 
breastfeeding. "(29 years, CHO, FGD Dome) 
.. We always educate them that there are benefits of breastfeedillg so a lot 0/ them 
are interested and they do it. So we educate them on diet and we inform their 
husbands and family to support them because some of the women don't have the 
helping hand and you know it comes from the brain. If the woman always has to 
stress up she will be unable to produce enough milk so we ask their husbands to 
support them." (Midwife, IDI H/F, Taifa) 
.. We go from house to house educating the women on the need to g%r ANC when 
they ure pregnant and to also go for weighing. We also teach them how to hold 
their newborn babies and e\'en how to breast feed them . .. (101, MSG 2) 
Discussions with the women however highlighted the fact that despite efforts by the health 
care workers, the opinion of the mothers and mothers-in-law took precedence in the 
households. and more often than not, these matriarchs were not in support of feeding the 
babies solely on breast milk and offered other supplementary feeds such as water and baby 
formula. This was based on the premise that breast milk alone was not sufficient to sustain 
the child and that exclusively breastfed infants grew up to be picky eaters. In addition, the 
need to go back to the place of work was another reason why mothers did not continue with 
exclusive breastfeeding. These are illustrated by the following quotes: 
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"As for me, when / got home my mother in law gave the baby water and she said 
she will not do that Ihing ofn ot giving the child water. .. (24 years, FGD HIF Del, 
Dome) 
"/ have observed thai when you do the exclusive breastfeeding for the baby and 
now you want to give them food after six months they don 'I like to eat so / think it 
is not good to do it. .. (38 years, FGD HlF Del. Dome) 
"/ usually breastfeed my children exclusively for six months but as for this baby, / 
had to go to work so / started giving her food in the third month . .. (39 years, FGD 
HIF Del, Dome) 
4.7 Postnatal Care 
Of all the women interviewed. 437 (99.1 %) were advised to go to a health care facility for 
Postnatal Care and 415 (94.1%) attended Postnatal Care clinics. One hundred and twelve 
(24.1 %) women received the advice to attend Postnatal Care from nurses and CHOs. Only 
15 (3.6%) respondents attended the first PNC clinic within the first 24 hours afterbirth, 70 
(16.9%) attended within 1-3 days and 24 (5.8%) attended within 4-6 days. Forty-seven 
(10.7%) of the women had a complicated delivery during childbirth. Over a six-week 
period, 123 (30.6%) women had had only one visit to the PNC clinic, 222 (55.2%) had had 
two visits while 57 (14.2%) had had three visits or more. One hundred and eighty-five 
(42.0%) respondents were visited at home by health care personnel after delivery; of the 
women that received these visits, 175 (94.6%) were visited by CHOs while 10 (5.4%) were 
visited by other health care personnel such as nurses, and community health volunteers 
(Table 12). 
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Table 12: Postnatal Care 
Postnatal Care Frequency Percentage 
(N) (0/.) 
Advised to go for PNC after delivery 437 99.1 
Who advised PNC· 
Doctor 36 7.8 
Midwife 295 63.6 
Nurse/CHO 112 24.1 
Family and friends 21 4.5 
Went to a facility for PNC 415 94.1 
Time after birth before first PNC 
<24 hours 15 3.6 
1-3 days 70 16.9 
4-6 days 24 5.8 
7-14 days 284 68.4 
>14 days 22 5.3 
Had complications during delivery 47 10.7 
No. of check-ups within 6 weeks after birth 
I 123 30.6 
2 222 55.2 
3+ 57 14.2 
Ever visited at home by a health worker 185 42.0 
Type of health worker who visited 
CHO 175 94.6 
Other 10 5.4 
Total 441 100.0 
* Multiple responses allowed 
4.7.1 Association between Socio-demographic Characteristics of Respondents and 
Timely Postnatal Care 
To identify the categories of women who were more likely to attend Postnatal Care in 
a timely manner, a Chi square test was conducted. Results from the study show that 
differences in age, number of children birthed, and educational qualifications are not 
significantly associated with attending Postnatal Care in a timely manner (p=O.085, 
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0.568 and 0.837 respectively). However, being employed and being part of the decision 
making process in the household emerged as significant factors with regards to timely 
PNC attendance (p=<0.05 and <0.001)., while needing permission to leave the house 
was not found to be significant (p=O.706). The place of choice for attending ANC or 
for child delivery, as we1l as having skilled attendance at birth had no significant 
association with attending PNC in a timely manner (p=0.284, 0.966 and 0.656 
respectively) whereas having a complicated birthing experience and being visited at 
home by a CHO both showed a difference at 95% significant level (p=<O.OOI and 
<0.01) (Table 13). 
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Table 13: Timely Postnatal Care by socio-demographic factors and community-based 
initiatives 
SDC. reproductive bistory and PNC Frequency Timely Xl p-
NWo) PNC value 
(%~ 
----~~-
Age 0.085 
<20 13 (3.0) 61.S 
20-24 74 (16.8) 25.7 
25-29 166 (37.6) 37.4 
30-34 126 (28.6) 40.5 
35-39 51 (11.6) 41.2 
40+ 10 (2.3) 20.0 
Parity 0.568 
I 137 (31.1) 36.5 
2 164 (37.2) 36.0 
3 89 (20.2) 42.7 
4t 51 (11.6) 31.4 
Highest level of formal education 0.837 
None 41 (9.3) 29.3 
Primary 88 (20.0) 36.4 
JSSlMiddle School 218 (49.4) 37.6 
Senior Secondary 71(16.1) 38.0 
Tcniary 21 (4.8) 42.9 
Employment status <0.05 
Unemployed 138 (31.3) 44.2 
Employed 302 (68.5) 33.8 
Major decision makers in household <0.001 
Respondent 80(18.1) 38.8 
HusbandIPartner 153 (34.7) 47.7 
Both 197 (44.7) 27.4 
~l'eds permission from partner to move 0.706 
out of the bouse 251 (56.9) 38.3 
ANC facility attended 0.284 
Govt. Hospital 265 (60.1) 35.5 
Govt.lCommuDlty HC/Clinic 51 (11.6) 47.1 
PrivateIMaternity CliniclNGO 119(27.0) 36.1 
Place of birth of child 0.966 
Home 27 (6.1) 37.0 
Govt. Hospital 292 (66.2) 37.7 
Govt.lCommunity health centre 18 (4.1) 38.9 
Private/MaternitylNGO facility 103 (23.4) 35.0 
Skilled birth delivery 409 (92.7) 36.7 0.656 
Had a complicated delivery 47 (10.7) 63.8 <0.001 
Ever visited by a CHO 175 (39.7) 29.1 
Total <0.01 441 (IOo.o! 20.5 
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4.7.2 Logistic Regression between Socio-demograpbic Facton of Respondents and 
Timely Postnatal Care 
A multivariable analysis was conducted to determine the association between attending 
Postnatal Care in a timely manner and the demographic characteristics of the respondents, 
after adjusting for age. parity, education, autonomy, as well as ANC and SBA utilization. 
Results show that respondents who were employed were 18% less likely to attend timely 
PNC than those who were unemployed (aOR=O.82. 95% CI=O.52-1.29) but this finding 
was not signIficant. Where decision making in the home was concerned, women whose 
husbands were the sole decision makers were 1.5 times more likely to attend PNC on time 
(aOR=1.5I, 95% CI=O.85-2.67) while those who made decisions together with their 
spouses were 41% less likely to do the same (aOR=0.59, 95% CI=0.33-1.04). 
Women who had a complicated delivery were 3.9 times more likely to attend PNC on time 
(aOR=3.94, 95% CI=2.01-7.71) and this finding was significant. With regards to being 
visited by a CHO, it emerged that women who were visited were 38% less likely to attend 
PNC on time relative to those who were not visited (aOR=O.62, 95% CI=0.40-O.95). These 
results are presented in Table 14. 
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Table 14: Relative odds of timely PNC by socio-demographic factors and community-
based initiatives 
SOC, reproductive biJtory and Odds Ratio (95-;' Confidence laterva') 
PNC Unadjusted Adjusted model I Adjusted model 2 
Age p=0.078 p-0.093 
<20 Ref Ref 
20-24 0.22 (0.06, 0.74) 0.36 (0.09, 1.45) 
25-29 0.37 (0.12,1.19) 0.79 (0.20, 3.11) 
30-34 0.43 (0.13, 1.37) 0.92 (0.23,3.78) 
35-39 0.44(0.13,1.53) 1.27(0.27,5.93) 
40+ 0.16 (0.02. 1.06) 0.33 (0.04, 3.04) 
Parity p=0.569 p-O.284 
I Ref Ref 
2 0.98 (0.61,1.57) 1.10 (0.62, 1.97) 
3 1.30 (0.75,2.24) 1.42 (0.71, 2.84) 
4+ 0.80 (0.40. 1.58) 0.63 (0.26, 1.53) 
Highest level of formal education p=0.832 p=0.694 
None Ref Ref 
Primary 1.38 (0.62, 3.08) 1.36 (0.56, 3.31) 
JSS/Mlddle School 1.46 (0.70, 3.01) 1.74 (0.77.3.94) 
Senior Secondary 1.48 (0.65, 3.39) 1.36 (0.53, 3.46) 
Tertiary 1.81 (0.61,5.42) 1.39 (0.35, 5.62) 
Employment status p<0.05 p=O.073 p=O.395 
Unemployed Ref Ref Ref 
Employed 0.64 (0.43, 0.97) 0.62 (0.37, 1.04) 0.82 (0.52, 1.29) 
Major decision makers ia 
bousehold p<0.001 p<O.OI p<0.001 
Respondent Ref Ref Ref 
HusbandfPartncr 1.44 (0.83, 2.50) 1.63 (0.82, 3.25) 1.51 (0.85,2.67) 
Both 0.60 (0.35, 1.03) 0.59 (0.31,1.15) 0.59 (0.33, 1.04) 
Ne('d permission from partner to p=0.706 p=O.583 
move out of the house 1.08 (0.73, 1.60) 0.87 (0.52, 1.45) 
ANC facility a"ended p=0.293 p=0.305 
Govt. Hospital Ref Ref 
Govt.lCommunlly HC/Clinic 1.62 (0.88. 2.96) 1.75 (0.75, 4.09) 
Private/Maternity Clinic I 03 (0.66, 1.62) 1.60 (0.73, 3.51) 
Had 'killed birth ddivc1") p=0.658 p=0.446 
0.85 (0.41,1.76) 0.52 (0.09, 2.83) 
Had a compticaled delinry p<0.001 p<O.OOI p<O.OOI 
3.46 (1.84,6.51) 4.17 (1.98,8.80) 3.94(2.01,7.71) 
Ever visited by CHO p<0.01 p<0.05 p<0.05 
0.57 (0.38. 0.85) 0.56 (0.34, 0.90) 0.62 (0.40, 0.(5) 
Ref: Reference category 
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4.7.3 Postnatal Care Practices and Barrien 
Results elicited from the study show that women are offered Postnatal Care services both 
at the community and facility levels. Services offered at the community level by the CHOs 
are not intended to preclude the facility-based care, but are there to serve as an 
encouragement to the post paturient women to seek Postnatal Care in the facilities. and in 
a timely manner. Women who had given birth at the TBA centres are not excluded from 
the care offered by the CHOs and are also advised to avail themselves of the services 
offered at the health care facilities. Various institutions have stipulated intervals between 
the Postnatal Care visits and the mothers are expected to attend all these appointments to 
ensure a positive outcome during the puerperal period.  
.. ... Now we are recording first postnatal within 24 hours when mothers deliver at 
the clinic. When a woman is discharged and goes home, we encourage the CHOs 
to do their home visits. So they are to visit the woman, do physical examination for 
mother alld baby and then refer ifpossible or counsel the mother. So they are doing 
postnatal now. And then we have some TBAs also in the community who also deliver 
babies. So Visiting sllch women will be referred to as first postnatal since they have 
not even been to the hospital. So you do the postnatal for them and if they are 
comingfrom the community you register the second postnatal. "(CHPS coordinator 
101) 
"We render postnatal services on Fridays. All mothers that deliver either [here} or 
olltside when they come we ask them to do routine lab tests like blood level (Hb) to 
know whether they're anaemic or not. We also do urine check to find out if there 
were allY infection ill the course of delivery and thell we treat them. So basically, 
these are the two common things that we do in addition to the physical assessment 
ofm other and baby. They come during the first five days, ten, two weeks and then 
six weeks." (Midwife, IDl HlF Dome) 
"/ give postnatal services to those who deliver here. They come after they've 
delivered. You know postnatal is just after delivery. First 24 hours is a postnatal, 
48 hours is also a postnatal case. So, after they've delivered they come one week, 
which is 7 days. Then / let them come after 2 weeks, then after that they come 6 
weeks . .. (lDl Maternity Home, Taifa) 
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In as much as women in these communities are encouraged to access Postnatal Care, there 
are challenges that are faced by some of them that may prevent them from attending the 
clinics in a timely manner, or even hinder them from attending at all. Financial 
considerations have been found to be a big challenge for some of the women as they have 
to factor in the cost of transportation to the health facility. In cases where the women feel 
that they and their babies are in good health, they see no need to undertake the expenditure. 
In addition. where the women have been visited by a CHO, they also tend to feel that the 
trip to the health care facility has become unnecessary. Fear of being treated badly by health 
care personnel is another reason why women may avoid attending Postnatal Care clinics, 
especially if the child delivery was outside ofa health care facility. Cultural barriers in the 
form of timing for bringing a baby out in public. and the need to display new apparels in 
the face of economic downturn also lead to poor attendance at Postnatal Care clinics. All 
these points are buttressed by the quotes below: 
"And some of the mothers 100, they Ihink that they have delivered so there is no 
need going back to Ihe hospital. Financial problems let them think that once they 
have delivered, they are healthy and the baby is heallhy there is no need going back 
10 the hospital to check all those things. They will tell you that, whatever care will 
be given to them at the hospital we [CHOsj call also give it to her so there is 110 
need going there . .. (31 years, CHO. FGD Taifa) 
"II is because Ihey did nol deliver at the hospital. So they fear that sillce they did 
not deliver althe hospital when they go there alld they are asked why, they will nol 
know what to say. So they are afraid of what they will face when they go to the 
hospitalfor postnatal services." (28 years, CHO, FGD Dome) 
"Hmmm, number one is '/ have delivered and I'm not supposed to go out until 
after sel'en days' or 'my baby has nol beell brought out (outdooring) so / wouldn't 
come '. That is why we want the nurses to go in and visit them and do it for them. 
There is also ignorance, they don't know that it's important to go for the second 
postnatal. Finance is also an issue in the sellse that Ihey cannot afford the 
transportationfares to thefaci/ity." (CHPS coordinator. 101) 
"Some ofI hem also, maybe after delivery they were not able to get new cloth to go 
for postnatal. So even that alone can stop them from going because they need to 
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look good. So if their husband is not able 10 provide that they foel reluctant to go. 
This is because the community will laugh at them that they have just delivered but 
can't even afford to buy a new cloth to wear to postnatal. .. (30 years, CHO, FGD 
Dome) 
4.8 Community-based Initiatives and Maternal Health Care Utilization 
Results showed that age, parity, and educational level were not significantly associated 
with the womt:n's likelihood to utilize adequate ANC, SBA and timely PNC services 
offered at the health care facilities (p=0.22 I , 0.775, 0.299 respectively). Likewise, 
employment status, autonomy and satisfaction with ANC services were not found to be 
significant variables (p=0.123, 0.595, 0.516 respectively). However, the type of facility 
chosen for ANC services (p=<O.O 1), and being visited by a CHO (p=<O.OO 1) had 
significant associations with meeting all three perinatal care requirements. These results 
are outlined in Table 15 below. 
Although women in the communities acknowledged the activities of the CHOs during 
borne visits, they did not readily identify with the role of the Mother Support Group 
volunteers in the community. 
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Table 15: Mothers who had adequate ANC, skilled delivery and timely PNC by community 
initiatives and other factors 
soc. ANC, SBA and PNC Total Adequate Xl p-
N(%) and timely value 
Perinatal 
CareWo~ 
Age 0.221 
<20 13 (3.0) 38.5 
20-24 74(16.8) 14.9 
25-29 166 (37.6) 24.7 
30-34 126 (28.6) 25.4 
35-39 51 (11.6) 31.4 
40+ 10 (2.3) 20.0 
Parity 0.775 
I 137 (31.1) 26.3 
2 164 (37.2) 25.0 
3 89 (20.2) 22.5 
4+ 51 (11.6) 19.6 
Highesl level of rormaleducatloD 0.299 
None 41 (9.3) 14.6 
Pnmary 88 (20.0) 20.5 
JSSlMiddle School 218 (49.4) 25.2 
Senior Secondary 71 (16.1) 29.6 
Tertiary 21 (4.8) 33.3 
Employment ,I. Ius 0.123 
Unemployed 138 (31.3) 29.0 
Employed 302 (68.5) 22.2 
Major decision mabrs In household 0.595 
Responden! 80 (18.1) 25.0 
HusbandlPartner 153 (34.7) 20.9 
Both 197 (44.7) 25.4 
Need permission from partner to move out of 0.086 
tbe hou,,' 251 (56.9) 21.5 
ANC raeilil,· allended <0.01 
GoV!. H~spital 265 (60.1) 19.6 
GoVllColTUTIunlly HC/Clinic 51 (11.6) 35.3 
PrivateiMa!ernity CliniclNGO 119 (27.0) 3J.1 
Satisfied with MC services 410 (93.0) 24.9 0.516 
Ever visiled by CHO 175 (39.7) 15.4 <0.001 
Tolal 441 !,00.02 24.3 
Results of the logistic regression done show that attending ANC clinics in a 
government/community clinic increased the chances of meeting all the requirements of 
perinatal care by 74% (aOR=1.74, 95% CI=0.89-3.39) while private clinic attendance did 
the same by 80% (aOR=1.80, 95% CI=l.09-2.97). Women who were visited at home by a 
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CHO were 54% less likely to have availed themselves of all the perinatal care services 
(p=O.45, 95% CI==O.27-O.74) (Table 16). 
Table J 6: Relative odds of having adequate ANC, skilled delivery and timely PNC by 
community initiatives and other factors 
SOC. ANC. SBA and PNC Odds Ratio (95% Confidence Interval) 
Unadjusted Adjusted model I Adjusted model 2 
Age p-0.238 p=O.066 
<20 Ref Ref 
20-24 0.28 (0.08. 1.01) 0.55 (0.12. 2.51) 
25-29 0.52 (0.16, \.69) \.45 (0.33, 6.31) 
30-34 0.54(0.17.1.79) 1.74(0.39,7.89) 
35-39 0.73 (0.21. 2.59) 3.02 (0.58,15.56) 
40+ 0.4 (0.06. 2.7) I.I 8 (0.12, 11.18) 
Parit~ p=0.769 p=0.332 
I Ref Ref 
2 0.94 (0.56, 1.57) 0.86 (0.46, 1.6) 
3 0.81 (0.43, 1.52) 0.69 (0.32, 1.48) 
4+ 0.68 (0.31,1.51) 0.41 (0.16, 1.09) 
Highest level of formal education p--Q.282 p=0.586 
None Ref Ref 
Primary 1.5 (0.55.4.11) 1.44 (0.49, 4.25) 
JSS/Mlddle School 1.97 (0.79, 4.93) 2.03 (0.75, 5.46) 
Senior Secondary 2.45 (0.9. 6.69) 1.97 (0.66. 5.85) 
Tertiary 2.92 (0.83, 10.22) 2.37 (0.56,10.14) 
Employment status p=O.127 p<0.01 
Unemployed Ref Ref 
Employed 0.70 (0.44, 1.10) 0.45 (0.25, 0.8) 
Major decision maken in 
household p=0.591 p=0.860 
Respondent Ref Ref 
Husband/Panner 0.79 (0.42. 1.5) 0.88 (0.4.1.93) 
Both 1.02 (0.56. 1.86) 1.05 (0.52, 2.11) 
Need permission from partner to p=0.087 p=0.135 
move out of the house 0.68 (0.44, 1.06) 0.66 (0.38, 1.14) 
ANC fuility all ended p<O.OS p<O.OS p<O.OS 
GoVl. Hospital Ref Ref Ref 
GOVl.lCommunity HC/Clinic 2.23 (1.17, 4.28) I.S8 (0.76, 3.26) 1.74 (0.89. 3.39) 
Priv3teIMalemity CliniclNGO 1.85 (1.13,3.02) 1.97 (1.13,3.43) 1.80 (1.09,2.97) 
Satisfied with ANC services p=O.S06 p=0.990 
1.39 (O.SI, 3.78) 0.99 (0.31, 3.13) 
Ever visited by CHO p<O.OOI p<0.001 p<0.05 
0.42 (0.26, 0.69) 0.36 (0.21. 0.63) 0.45 (0.27, 0.74) 
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During discussions and interviews, the health care providers were able to elaborate on the 
influence their activities have had on the women's attitude towards perinatal care. They 
expounded on the fact that women who had special circumstances, such as pregnant 
teenagers, would ordinarily not have gone for ANC clinics but felt encouraged enough to 
finally attend due to the education and support provided by the CHOs during home visits. 
The study also highlighted the fact that women who had received adequate attention in 
their homes were more adept at caring for thcir babies than those who did not have that 
opportunity. The ·quotes that follow buttress these points. 
"The talks and health education we give them helps. We had a client who was a 
teenager and felt shy to come out with the pregnancy because her mates will see 
her. So she had IIOt been to the ANC and the pregnancy was about six months. After 
much tallcing and follow up, she finally went so it helps. " (28 years, CHO. FGD 
Dome) 
"For the women who have been l'isited by the nurses they do their things well 
because the nurses tell them not to give the babies any water and breastfeed them 
for 6 months and they do it. All the women who come to deliver here, the nurses 
come to talk to them and they follow them to their homes to visit them. " (IDI TBA 
2, Dome) 
." For some oft he women, when you go they don't even know how to breastfeed their 
babies and whell you ask them why they will say that it is because they dOll " know 
and they have never been visited by any nurse but for those who are visited by the 
nurses they have been taught how to hold the babies and 1I0t to give them water till 
6 mOllths alld they do it. They say that whell they do it, it makes the children 
healthy. .. (IDI MSG 1) 
Despite the fact that the activities of Mother Support Groups were voluntary in nature, 
some of the volunteers alluded to the fact that some colleagues who had left had done so 
because they were not being paid for their services. They also pointed out that the time 
spent doing the voluntary activities was detrimental to their income generating activities. 
In addition, they opined that they were in need of some financial backing to be able to carry 
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out their activities such as paying for transport for financially constrained women who 
needed to be referred to a hospital. 
"/t is the money, they say there is no money, we are not paid, [The women] say they 
can't do a job where you go for a training and they give you some small money and 
that is the end. You can't put your income generating money aside and go to 
people's houses and talk to them, so that is what I hear some people saying, .. (101, 
MSG 2) 
"The main concern is the money. We need the money to work with because if we 
have some money we, those doing the work. will be motivated because you know 
you can get something small from there. There are times, when the nurse comes 
around / just tell her to go because I may be sitting down thinking of how to get 
mOlley to buy books for my children but / do it jokingly. .. (IDI, MSG I) 
"We need a little money too in this our work - this is because there are some oft he 
women when you go to visit them you will notice that the money to go for ANC. they 
do not have it so it makes it difficult. Let's say if we are given some money and we 
meet such a situation you can give the person some 20 cedis to enable her go to the 
hospital. .. (IDI, MSG 2) 
4.8.1 Private-Public Healthcare Collaborations in the Peri-urban Communities 
There was a paucity of public healthcare facilities in the communities, and as such most 
women had to go outside their communities to access perinatal care services from the 
government hospitals. Some women patronized the private hospitals or clinics, and 
maternity homes within the communities while others opted for the TBA centres in their 
communities as illustrated by the quotes below: 
"They go to the private facilities ... since we don't have a government hospital 
around here. most oft hem go to [the private clinic). .. (32 years, CHO, FGD Dome) 
"So"!e go to the hospital outside the community. We don't have government 
faCIlities here and there is only one maternity. So it is either that woman or that 
hospital. .. (28 years, CHO, FGD Dome) 
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"We don't have a facility in our commUltity so they go to hospitals outside the 
community. Some also go to the TBA . .. (30 years, CHO, FGD Taifa) 
The various stakeholders in the perinatal care delivery at the community level make efforts 
to collaborate with the Municipal Health Directorate (MHO). The Mother Support Groups 
are linked directly to the Community Health Officers who report back to the MHO. The 
maternity homes, private and public health care facilities also report to the MHO In 
addition to reporting to the MHO, the TBAs liaise with the CHOs while providing care for 
their clients. The MHO provides the health care facilities in the communities with essential 
drug~ such as vaccines and malarial prophylaxis, as well as training for proper service 
delivery. In cases where the women have delivered babies in maternity homes or TBA 
centres, the CHOs collaborate with them to ensure that the newborn babies are immunized. 
These points are elaborated by the quotes below: 
"Since at the [municipal] we don't have a lot of public [facilities], most of our 
returns come from the private. So we collect refurns from them and they in turn 
reeeil'e l'accines, SP for malaria among other things. When we are having 
worhhops we give them slots, we don't just focus 011 the public. So we collaborate 
in everything. Our halfy ear review is in the first week ofJ uly and they will all do 
a presentation. We collaborate in everything. .. (CHO coordinator, IDI) 
"Dome has three TBAs so the In-Charge at Dome visits them and then we have 
returns from there too. So they supervise them and visit them once in a while, give 
some gloves and some spirits. Sometimes deliveries come from people who are not 
el'enlrained TBAs. From enquiries we 'vefound one at Tai/a, Abom area and we're 
doing some informal somet/ringfor her. Ministry ofH ealth said we should" 't train 
them again so we are goillg to look at her place. She even delivers more than the 
facility so why would we leave her? So we are going to train her a little and then 
give her something small. Because i/yOl/ tell the women not to go there. they will 
still go. So we collaborate with them . .. (CHO coordinator, IDI) . 
"Where they [CHOs} do the weighing isfor us. We have given it to them/ree of 
charge. So they give us thefamily planning injections. That is all they give us. They 
also educate us on new ways of caring for the women and new medicine.1 and 
injections. So we have good collaboration with them." (IDI Maternity Home, 
Dome) 
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"We have community health nurses on secondment to this facility. They handle the 
Child Welfare Clinic on Mondays and Wednesdays. So whenever we identify a 
problem we call one oft hem and handover then they will do the follow up 0/C lUes 
till we get results . .. (Midwife, lDI HlF, Dome) 
"The nurses come here to visit me and when I help deliver the babies too they come 
to inject the babies on their shoulder and pili some medicines in their mouth. They 
also give Ihe mothers the weighing card and they weigh the children here and give 
the mothers the next date to take the child to a hospital. .. (lDl TBA 2, Dome) 
"Sometimes, when I go to some of the homes I see that the babies have rashes all 
over their bodies so I tell the nurse about it and when she comes we go to those 
homes for her to look at it. So the nurse calls the man who does rashes ;n their 
office [Disease Control Officer] and he comes to look at it." (IDI MSG I) 
Findings from the study highlight that even though these various sources of perinatal care 
eXIst in the communities, and collaborate at different levels, the lack of cohesion between 
their activities pose challenges that hinder effective service delivery. These challenges 
include lack of a proper feedback mechanism and non-recognition of maternity homes and 
TBA centres by the orthodox health care practitioners. In addition, despite the fact that the 
health care facilities lack the workforce to follow up on the ANC attendees in keeping with 
the tenets ofFANC, they still do not fully involve the CHOs in the continuum of care for 
ANC attendees at the community level. These points are buttressed by the narratives below. 
"Yes we have CHOs from Ga East district so they go to visit women who have 
problems ... but they report directly to the Ga East district." (Midwife, IDI HlF, 
Taifa) 
"Another challenge we have is that if there is a delay in labor and you refer them 
to another facility, at times there will be insults, insultsfrom our other counterparts. 
Ourcolleaguesfrom the bigger facilities willjust be insulting us the private people. 
They will be insulting us, as if we don't know our left from our right. " (IDl 
Maternity Home, Taifa) 
"The challenge we have with focused [ANe} is the midwifery. We don 'I have 
enough midwives, the technical people to handle it. The midwives who conduct 
delivery are the same group who are assigned 10 antenatal and we don't have 
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enough midwives so in case of illness or when the unexpected happens, there is 
always crisis." (Midwife, IDI H/F, Dome) 
"No, we don 'I talk 10 them unlil we have a problem client. About 70% o/the clients 
who come here are educaled, they know what they are about. And we give them a 
hotline to call so not until we identify a client as having problems we don " involve 
the community health nurses. Jfper chance they go on home visit and get,o know 
Ihose who are pregnalll and not coming to clinic they bring them. But until we 
identify problems we don 'I involve them . .. (Midwife, IDI HIF, Dome) 
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CHAPTER FIVE 
S.O DISCUSSION 
5.1 Introduction 
This chapter eltamines the results of the study in relation to eltisting literature from similar 
studies. It begins by discussing the experience of peri-urban women with Antenatal Care, 
Skilled Birth Delivery and Postnatal Care and how socio-demographic characteristics 
affect utilization of maternal health care. It then goes on to highlight the influence of 
community-based interventions on perinatal care. The discussions are based on the 
premises set by the theories and conceptual framework that were pivotal in carrying out 
the research study. 
S.2 Antenatal Care Utilization in a Peri-urban Settlement 
This section is dedicated to discussing utilization of Antenatal Care services amongst the 
women living in peri-urban settlements in Ga East Municipal, Greater Accra Region, 
(ihana. It covers how socio-demographic factors, satisfaction with service provision, and 
ANC knowledge. practices and barriers affect the attendance of ANC clinics in an adequate 
manner. 
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5.2.1 Antenatal Care Knowledge, Practices and Utilization 
One of the advantages of ANC is the opportunity it provides to offer health information 
appropriate for the parturient and postnatal periods to pregnant women and their families, 
leading to positive health outcomes for the mother and the child (PMNCH, 2006). Results 
from the study show that the majority of women sampled had a basic knowledge about 
ANC and had received counselling from a health care provider at the ANC clinics. They 
alluded to the fact that they attended ANC clinics to keep healthy and check on the 
progression of the fetus. This correlates with findings in a study done by Pell et al.. (2013) 
in Ghana, Kenya and Malawi where women at all the study sites attended ANC clinics to 
keep tabs on the advancement of the pregnancy and on the fetal position. In this study. it 
was however elicited that though about two-thirds of the women initiated ANC in their 
first trimester, many of them did so because they were feeling ill. Pregnancy is largely 
regarded as a normal physiological state and respondents in a study conducted in Pakistan 
were of the opinion that it should be allowed to progress naturally and was not to be 
tampered with by attending ANC clinics (Mumtaz & Salway, 2007). In Papua New Guinea, 
Andrew et aI., (2014) elicited that the pregnant women perceived orthodox medicine as 
curative instead of preventive, and did not see the need to attend ANC clinics if they and 
their fetuses were in good health. Women in the study who had had previous complications 
in their past pregnancies were however likely to initiate ANC utilization on time. This 
correlates with findings in a study done in Uganda where it was observed that women who 
had experienced an obstetric complication in a previous pregnancy were more likely to use 
ANC services and in an adequate manner (Bbaale, 2011). Many pregnant women seem to 
consider ANC services relevant only when ill health occurs and there is a need to dispel 
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this notion amongst them and provide targeted health information on the benefits of early 
initiation of ANC utilization. 
Many of the women interviewed also reported that they availed themselves of ANC 
services at the behest of their mothers-in-law or husbands. A study carried out in Turkey 
pointed out that patriarchal cultures see childbearing as the gender role of women and so 
seeking health care during pregnancy is not necessary unless there was a considerable 
health concern (Ay et aI., 2009). Additionally, it was the responsibility of older women in 
the family to ascertain if the pregnant woman needed medical care or not. It has also been 
demonstrated that the opinion of husbands and older women in the family regarding 
pregnancy care have a big impact on utilizatIOn of perinatal health care by pregnant women 
(Simkhada et aI., 2008). In Pakistan, a study found that women from households in which 
men were the final authority had underutilized maternal health care services perhaps due 
to the fact that the men had poor opinions of ANC provision (Hou & Ma, 2013). 
Furthermore, In a study done in Nepal, it was established that for the most part, mothers-
in-law had a negative influence on ANC utilization for reasons such as expecting the 
daughters-in-law to carry out their domestic chores, poor perception of ANC, financial 
considerations and power play between the women (Simkhada, Porter, & van Teijlingen, 
2010). On the other hand, interspousal communicatIOn has been found to be protective 
where ulllization of ANC services is concerned (Furuta & Salway, 2006; Thapa & Niehof, 
2013). These observations lend credence to the importance of interventions targeted at 
family members especially with regards to older women and husbands. 
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The influence of traditional practices and spirituality on pregnancy care was also 
highlighted in the study. Despite the fact that the women had availed themselves of bio-
medical care. they still saw the need for spiritual and/or herbal fortification during the 
gestation period. This occasionally resulted in women seeking care from the health care 
facilities and the TBAs or spiritual homes. concurrently. Attributing complications in 
pregnancy to supernatural forces predispose women to seeking for care from culturally 
acceptable avenues (Evans, 2013). In this study, it became evident that many of the women 
sought care from Traditional Birth Attendants and spiritual homes because of the prayers 
offered on their behalf and herbal preparations administered to prevent complications, 
facilitate childbirth and ensure a healthy infant. A study conducted in Bangladeshi slums 
elicited the fact that female dwellers tend to hold on to the traditions and beliefs from their 
rural environments despite the fact that they now had access to orthodox medical care 
(Choudhury et al.. 2012). A report by UNFPA (2011) calls for an understanding of the 
socio-cultural underpinnings that gUide a people's way of viewing sexual and reproductive 
health issues and tailoring health care delivery around these traditions sueh that vulnerable 
female migrants are not unduly marginalized. 
Results from the study show that though the number of women who attended ANC clinics 
were in the majority 432 (98.6%), only 337 (78.2%) attended the four times stipulated by 
the World Health Organisation. This is comparable to the national statistics that highlight 
the fact that about 13% of pregnant women have less than four ANC visits even though 
97% of them utilize ANC services (GSS/GHS/ICF International, 2015). Furthermore, the 
statistics for adequate ANC utilization are worse than the national rural coverage of 82%, 
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and falls far below the urban coverage of 93%. In addition, only 267 (62.4%) of the ANC 
attendees in the study started the ANC clinics early in the first trimester of the pregnancy, 
Thus, despite the fact that majority of the women initiate ANC utilization, there are several 
who do not start early enough in the pregnancy, and who do not attain the requisite four 
visits. As the 2015 Millennium Development Goals landmark approached, sixty-nine 
countries were monitored for progress in maternal health care and it was established that 
on the average. 88% of women attended ANC clinic at least once, while 55% attended four 
times or more (Requejo, Bryce, & Victora, 2012). In Sub-Saharan Africa, ANC coverage 
has been on the rise over the past twenty years but the same cannot be said of the number 
of women who attain the stipulated number of four ANC visits as this has remained static 
at 44% over the same period (United Nations, 2011). A study carried out in a slum in 
Ethiopia showed that almost 82% of the ANC attendees had utilized the ANC services four 
or more times while only about half initiated the first visit during the first trimester (Bayou 
et aI., 2016). Similarly, results from another study done in an Indian slum show that about 
96% of the slum dwellers received ANC services with 64% of them initiating ANC visits 
within the first trimester (Hazarika, 2009). Community education of women in the fertility 
age range needs to highlight on the importance of initiating ANC early, and adequately. 
Utilizing ANC services has been shown to have positive effects on women's willingness 
to go through the whole continuum of perinatal care as women who have had at least one 
ANC visit are more likely to have skilled attendance at birth and attend Postnatal Care 
clinics (Jacobs. Moshabela, Maswenycho, Lambo, & Michelo, 2017; PMNCH, 2006). 
This retention in the maternal continuum of care may lead to a decrease in maternal 
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mortality which normally is heightened during child delivery and the puerperal period 
(Chukwuma, Wosu, Mbachu, & Weze, 2017; Ronsmans & Graham, 2006). 
Majority of the countries with poor statistics are in the developing world where maternal 
mortality continues to be of catastrophic dimensions despite the fact that many of them 
bave embraced ANC services as a means of ameliorating the poor maternal and neonatal 
health outcomes being recorded (Chama-Chiliba & Koch, 2013). Socio-demographic 
characteristics influence the use of ANC services to a large extent and may lead to late 
ANC registration and inadequate attendance resulting in missed opportunities for detection 
of conditions that require timely intervention (Chama-Chiliba & Koch, 2013). 
Most of the respondents in this study were in the 25-29 years old age range (37.7%). The 
Ghana 20 I 0 Population and Housing Census reports that maximum fertility amongst 
women of fertility age is attained in this age group (GSS, 2013a). Age is an important factor 
in tbis study as several studies have highlighted the relationship between increasing age 
and poor utilization of maternal health care services (Amano, Gebeyehu, & Birhanu, 2012; 
Khanal, Adhikari, Karkee, & Gavidia, 2014; Nzioki, Onyango, & Ombaka, 2015). In a 
study carried out in Kenya, it was established that women who were younger than 31 years, 
and those who had less than three children, were more likely to utilize ANC services in the 
recommended manner (Nzioki et aI., 2015). Similarly, a study carried out in the slums of 
Bangladesh found that women who were less than 25 years old, were more likely to seek 
ANC services than those who were 25 years and older (Kabir & Khan, 2013). In Kenyan 
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slums. women with three or more children were seen to initiate ANC services late in 
pregnancy whilst also not attending the recommended number of visits (Muindi, Mberu, 
Elung. & Oyolola, 20)6). 
The risk of maternal mortality increases with age as older parturient women are more likely 
to rely on experiences garnered from previous pregnancies rather than seeking ANC 
services, initiate early ANC visits, or attend clinics the requisite number of times (l1Iah, 
Mbaruku. Masanja, & Kahn, 2013; Nzioki et aI., 2015). Conversely, younger women, are 
more likely to be primiparous or have fewer children, thus they tend to be more cautious 
and seek proper maternal health care due to their lack of experience (Birmeta, Dibaba, & 
Woldeyohannes. 2013; Sharma. Sawangdee, & Sirirassamee. 2007). Other studies have 
also laid claim to the fact that as older women are likely to have more children, this 
increases their chances of having ever had a negative experience in the past, while putting 
financial and time constraints on their ability to utilize ANC adequately (Jayaraman. 
Chandrasekhar. & Gebreselassie, 2008; Bibha Simkhada et al.. 2008). Several studies have 
shown parity to be a determinant of maternal health care utilization highlighting the 
association between increasing parity and poor utilization of available perinatal care 
(Ononokpono & Odimegwu, 2014; Sonneveldt, DeCormier Plosky, & Stover. 2013; 
Tarekegn, Lieberman. & Giedraitis, 2014). Health care is commonly sought when the 
mother or newborn falls seriously ill and is in need of critical medical intervention, thereby 
heightening the risk for maternal and newborn mortality (Nzioki et al.. 2015). Conversely, 
Bayou, Mashalla and Thupayagale-Tshwencagae (2016) found out in their study in 
Ethiopia, that women between 15 and 24 years old were more unlikely than older women 
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to have the recommended number of four ANC visits. This was because many of the 
women in this age category were unmarried or had unintended pregnancies, thus 
discouraging them from seeking ANC services in a bid to avoid castigation from service 
providers. 
Respondents in this study have had different levels of education with about half of them 
being educated up to the Junior Secondary level (49.7%). Attainment of educational level 
has been identified as an indication of an individual's social position, and the higher the 
level of education, the better the health and longer the lifespan of people (Morrisson & 
Jutting, 2005). Poor education has been recognized as a factor that makes pregnant women 
vulnerable while predisposing thcm to negative perinatal outcomes (Filippi et aI., 2006). 
Muindi et al. (2016) observcd in their study that women with poor education seek ANC 
services late, and do not attend up to four times throughout the pregnancy. Likewise, among 
Bangladeshi female slum dwellers, the higher the level of education attained, the higher 
the chances of ANC service utilization (Kabir & Khan, 2013). The women who are 
educated are more informed about the need for proper care during pregnancy. In addition, 
they are also more likely to be employed and are therefore in a better financial position to 
access maternal health care. Being educated has also been shown to increase women's 
autonomy, and hence strengthen their decision making position in the household which 
invariably has positive effects on their ability to make proper health care choices for 
themselves (Karlsen et aI., 2011). Furthermore, it has been established in studies that 
educatmg women led to better ANC attendance as well as making the choice of skilled 
birth delivery (Dutamo, Asscfa, & Egata, 2015; Weitzman, 2017). Poor ANC attendancc 
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by educated women in the study area was most likely due to tbe fact that these cadre of 
women where employed and therefore faced time constraints that impeded their ability to 
utilize ANC services. 
While 302 (68.7~o) women in the study were employed, 138 (31.3%) were unemployed. 
Of the women who were employed, majority (95%) were able to spend their money as they 
deemed fit. Women's access to health care services is inhibited by poor financial power 
and restrictions in decision making, leading to delays in seeking for health care (Ahmed, 
Creanga, Gillespie, & Tsui, 2010). In addition, even though economically disadvantaged 
women are most likely to die during the perinatal period, their socio-economic status 
predisposcs them to second-rate health care at the health care facilities. However, results 
from the study highlighted that the women with employment were less likely to have 
adequate ANC visits than their uncmployed counterparts (aOR=0.80, 95% CI=0.45-1.41). 
This is comparable to results from a study done in slums in Bangladesh which indicated 
that women who were working underutilized the maternal health care services when 
compared to their non-working peers (Kamal, 2012). In Nepal, Furuta and Salway (2006) 
IOdicated in their study that with regards to ANC utilization, there was no clear distinction 
between women who were employed and those who were not. Another study was 
conducted among poor female urban dwellers in India which found that employment had 
no statistically significant association with ANC utilization (Bloom et ai., 2001). These 
results are however at variance with those from a review of twenty-eight papers from 
research done in developing countries where female employment was seen to be a positive 
predictor of ANC utilization and early initiation of prenatal care (Simkhada et ai., 2008). 
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Similarly, studies carried out in Nigeria and India elicited that women who were employed 
were more likely to seek and receive adequate ANC services than their unemployed 
counterparts (Babalola, 2014; Bayou et aI., 2016). Results from this study can be explained 
by the fact that migrants to urban areas are more likely to have limited opportunities to 
attend ANC clinics as they are mostly low income earners with time constraints and thus 
find the waiting periods in the health facilities discouraging. 
The study also determined that though many women made decisions together with their 
partners (45.8%), there were those whose husbands were the sole decision makers in the 
home (35.6%) and women who were the decision makers themselves (18.6%). Bloom, 
WypiJ and Das Gupta (2001) found in their study that female autonomy with regards to 
freedom of movement positively influenced maternal health care utilization. In 
concordance. results from this study IDdlcate that women who did not take part in decision 
making ID the household, and those who needed permission to leave the home were 
unlIkely to attend ANC adequately (aOR=0.34, 95% CI=0.16-0.72; aOR=0.58, 95% 
CI=0.29-1.14, respectively). On the other hand, couples who made decisions together had 
increased odds of attending the stipulated four ANC visits or more (aOR=5.89, 95% 
CI=2.24-15.45). Comparatively, a study carried out in a slum area in India demonstrated 
that financial control, freedom to make decisions and ability to leave the home at will were 
all positive predictors of ANC utilization (Bloom et aI., 200 I). In Pakistan, Hou and Ma 
(2013) found that women who had the power to make decisions in their households were 
more likely to utilize maternal health care services. Additionally, women in households 
that had the male partners as the major decision makers were less likely to access maternal 
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health care services. However, in a study conducted in Nepal, results suggest that there is 
no statistical difference between the women who partook in decision making in the 
household and those who did not with regards to uptake of ANC services (Furuta & 
Salway, 2006). 
The study elicited that even though more than 60% of the women attended ANC clinics at 
the Government Hospitals, those who attended clinics at government/community clinics 
and private/maternity clinics were more likely to have attended the stipulated number of 
times (aOR=1.73, 95% CI=0.68-4.42; aOR=1.51, 95% CI=0.77-2.98, respectively). 
Results from a study carried out in a slum in Ethiopia resonate with this finding as it was 
observed that ANC attendees who chose to attend clinics in private health care facilities 
were twice as likely to have received adequate ANC services than their counterparts who 
went to public facilities (Bayou et aI., 2016). Results from this study also revealed that 
satisfaction with the place of ANC attendance was a predictor of adequate ANC attendance. 
Ninety-three per cent of the sampled women were satisfied with the services they received 
from the health care facilities leading to an increase in the chances of utilizing ANC 
services adequately (aOR=1.42, 95% CI=0.54-3.72). Respondents were satisfied with the 
range of services offered, as well as attitude of nurses, level of sanitation, availability of 
drugs, privacy and time spent during examination. Those who were unsatisfied with their 
health facilities of choice complained mostly about the attitude of the nurses and time spent 
during examination. In an Indian slum, Mehnaz et ai., (2016) elicited the fact that ANC 
services were poorly utilized as a result of treatment of the ANC attendees with indignity 
and lack of privacy. A review of literature from developing countries also established that 
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evcn though parturient women expected good health care services such as timely and 
competent consultation. availability of drugs and a clean environment. being treated with 
respect was of utmost importance to them (Srivastava, Avan, Rajbangshi, & Bhattacharyya. 
2015). The quality of services offered to ANC attendees is extremely important as evidence 
has been found that retention of women in the maternal continuum of care is dependent on 
how satisfied the women are with the services they receive (Berhan & Berhan. 2014; 
Chukwuma et aI., 2017). 
5.2.2 Barriers to Antenatal Care Utilization 
Results from the study elicited several reasons why women may not register for ANC 
services on time. or attend the clinics for the stipulated number of times. These barriers 
include financial and time constraints. as well as lack of public health care facilities in the 
communities resulting in the use of costly private health care providers. Studies done by 
Sirnkhada et al.. (20m!) and Asundep et al.. (2013) pointed out the fact that financial 
constraints were a valid reason why women did not attend ANC clinics. Even in cases 
wherc ANC services were free, other expenditures such as travel cost and aux iliary medical 
costs (such as laboratory fees) acted as a deterrent to utilization of the services (Finlayson 
& Downe. 2013). In Kenya, a study done among poor female urban dwellers found out that 
perinatal care services were deemed unaffordable because most of the health care facilities 
that were in proximity were private-owned, which are mostly profit-oriented (Fotso & 
Mukiira, 2012). Considerations with regards to time are also found to impede ANC 
utilization due to the fact that many less privileged women do not have the liberty of taking 
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time off work or might have other children to cater for (Simkhada et aI., 2008; Singh, 
Kumar, Rai, & Singh. 2013). The rigidity of the working hours in the health care facilities 
seems to be detrimental to the maternal health of the pregnant women and the provision of 
perinatal health care may be revamped by rescheduling ANC clinic hours to suit different 
cadres of women in these communities. 
In this study, health facility-related barriers to adequate utilization of ANC services were 
well highlighted. From collective and individual accounts given by the women and the 
health care providers, it was evident that disrespect of the pregnant women, long waiting 
time, favoUritism and lack of competence were factors adversely affecting ANC utilization 
by the women in the communities. The importance of good interpersonal relationship 
between health care providers and their clients has been documented severally. In studies 
carried out in Kenya and India, it was established that women who felt that they were 
treated with indignity and disregard were less likely to adequately utilize ANC services 
(Izugbara, Ezeh, & Fotso. 2009; Mehnaz et aI., 2016). Another research done in a slum in 
Bangladesh elicited the fact that pregnant women made poor use of maternal health 
services due to harsh treatment meted out by health care providers, extensive waiting 
periods at the facilities. class disparities between clients and providers and favouritism 
shown towards clients with higher socio-economic status (Caldwell, Rashid, & Murthy, 
2014). Clearly, there is a need to improve on client-provider relationships in our health care 
institutions if we are to expect women to utilize perinatal care in an adequate manner. 
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5.3 Skilled Birth Attendance in a Peri-urban Settlement 
This section is devoted to discussing Skilled Birth Attendance amongst the women living 
in peri-urban settlements in Ga East Municipal, Greater Accra Region, Ghana. It covers 
how socio-demographic factors. SBA knowledge, practices and barriers affect the 
utilization of skilled attendance at birth. 
5.3.1 Knowledge, Practices and Utilization of Skilled Birth Attendance 
Results from the study show that 92.8% of the participating women had skilled attendance 
at birth. This is in keeping with findings from the national survey that indicate that 93% of 
pregnant women in the Greater Accra Region of Ghana gave birth to their child in a health 
care facility (GSS et aI., 2015). In addition, most of the women who used skilled care 
during delivery chose a government hospital, private health care facility or community 
health centre, in order of preference. This result is similar to fmdings in studies conducted 
In ~lums in India, where the women showed an indination towards giving birth in 
government hospitals followed by private hospitals (Angadi, Hiremath, & Sorganvi, 2013; 
Hazarika, 2009). WHO promotes skilled birth attendance as the 'single most important 
factor in preventing maternal deaths' (WHO/UNFPAlUNlCEF/World Bank, 1999), and it 
has also been shown to avert stillbirth incidents and improve the survival chances of 
newborn children (Lawn et al., 2005). 
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Even though majority of the women in the study opted to have a facility-based delivery, 
about 7% of them chose to patronize the TBAs. Several reasons were proffered for this 
decision and these include their preference for the TBAs traditional birthing skills, as well 
as spiritual protection and social support offered by the TBAs. Some of the women harbour 
the desire to give birth in the traditional squatting position instead of the conventional 
lithotomy position favoured by the orthodox health providers. Even though birthing in the 
squatting position has its benefits as it makes for a shorter first and second stage of labour, 
inadequate perineal support while using this method has been known to lead to a high 
incidence of perinatal injuries such as perineal tears (Elvander, Ahlberg, Thies-Lagergren, 
Cnattingius. & Stephansson, 2015; Z Khan, Mehnaz, Ansari, Khalique, & Siddiqui, 2009). 
Contrariwise, in their study, Nasir, Korejo and Noorani (2007) found that this birthing 
position was associated with fewer perineal tears and less need for instrumentation during 
delivery. The women were appreciative of the TBAs birthing skills during the delivery 
which were said to be less painful as well as less invasive than what pertains in the health 
care facilities. In addition, the TBAs prepared herbal concoctions and offered up prayers 
on the women's behalf. In another study carried out in Ghana, observations by Anafi et aI., 
(2016) are corroborated by that from this study as the women were seen to patronize TBAs 
who also doubled as spiritualists. A study conducted in Nigeria noted that the study 
participants preferred to patronize the TBAs due to their special therapeutic birthing 
services and concoctions offered (Okafor et aI., 2014). 
TBAs are able to provide social support during and immediately after childbirth. While 
60% of women in this study who had facility-based deliveries were discharged within 24 
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hours, women who patronised the TBAs reported being able to stay several weeks or 
months in the TBA centres to receive care for themselves and their babies whenever they 
lacked the necessary support at home. Female urban migrants do not have the social support 
needed after child birth that is existent in rural settings (Moran et al., 2009). In a Kenyan 
study, the researchers pointed out that the TBAs went beyond delivery of the baby. and 
catered to other social and domestic needs of the women (Izugbara et aI., 2009). 
Findings from the study indicate that the age differences between the respondents was not 
significantly associated with their utilization of skilled attendance at birth (p=0.085). In 
addition, the proportion of women in this study who had skilled attendance at birth 
decreased as the number of children increased, but this association was found to be 
insignificant (p=O.065). Conversely, in a study done in a slum in Kenya, it was observed 
that younger women between 20 and 34 years old were more likely to use skilled care at 
birth than their older counterparts (Okang & Henry, 2017). Bhanderi and Srinivasan (2015) 
earned out a study in Indian slums and established that the likelihood of having Skilled 
Birth Attendance decreases with the increasing number of children born as they found that 
90% of women with first pregnancies had facility-based deliveries while only two-thirds 
of those who had had four or more pregnancies did the same. Comparably, a study 
conducted In Nigeria demonstrated that the chances of having skilled attendance at birth 
reduced as the number of children birthed by a woman increased (Ononokpono & 
Odimegwu, 2014). It has been postulated that older women are likely to have more 
children, and depend on their cumulative experience with childbirth, thus opting for home 
or TBA assisted births (Gabrysch & Campbell, 2009). 
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In this study, the effect of education on the utilization ofSBA was found to be insignificant 
even though women who were more educated were proportionately more inclined to 
deliver their babies with skilled assistance (p=O.296). This was similar to results from a 
study conducted in Bangladesh where it was found that with regards to utilizing skilled 
care at birth, being educated was not protective (Islam, Islam, & Yoshimura, 2014). 
Contrary to these findings, in a study carried out in Rwanda, it was established that being 
educated was significantly associated with having skilled attendance at birth (Jayaraman 
et aI., 2008). Likewise, in Indian slums Bhanderi and Srinivasan (2015) and Hazarika 
(2009) established that slum dwellers who were more educated were more likely to deliver 
their babies at the health care facilities when compared to their lesser educated 
counterparts. This trend has been explained by the fact that education provides women with 
the opportunity to make informed health choices and also makes the provider-client 
relationship easier to navigate as the women are able to engage the health care providers 
with more confidence than their poorly educated peers. 
The study did not find being employed to be protective with regards to seeking the help of 
a profeSSIOnal during childbirth (p=0.437). This finding is similar to that from a study 
conducted in Nepal where it was found that women with a job and some degree of control 
over their fmances did not have an advantage over women who were unemployed with 
regards to skilled birth attendance (Furuta & Salway, 2006). However, a study conducted 
in Bangladeshi slums pointed out that the women who were working were more likely to 
have skilled attendance at birth when compare to their unemployed counterparts (Kamal, 
2012). The phenomenon of working women not utilizing skilled birth attendance despite 
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their seemingly better financial status can be explained by the fact that this set of women 
are wont to experience time constraints and may have a lot of financial commitments that 
take precedence over their health needs. 
Women in the study who had freedom of movement or who were involved in decision 
making in their households were not found to be any more likely to have skilled attendance 
at birth than their less autonomous peers (p=O.709, p=O.801, respectively). In Kenyan 
slums. evidence was found that unrestricted female autonomy did not improve maternal 
health care utilization during childbirth (Fotso et aI., 2009). Contrariwise, in their analysis 
of 33 developing countries, Ahmed et aI., (2010) established that women who were 
empowered to make decisions in their households were more likely to have skilled 
attendance at their deliveries than those who were not autonomous. This study also elicited 
that being instructed to deliver the baby in a health care facility was not significantly 
associated with utilization of SBA (p=0.732). This is at variance with findings from 
Kenyan slums where it was observed that receiving advice from health care providers 
during ANC clinics increased the chances of women choosing to have a facility based 
delivery (Fotso et aI., 2009). 
Following childbirth, 97.5% of all respondents were able to establish breastfeeding, with 
88.7% doing so with support from health care personnel (midwives, nurses, doctors and 
Community Health Officers), relatives and friends. WHO recommends that breastfeeding 
should be initiated within an hour after birthing child 
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(WHOIUNICEFITFPRIlUCDavisIFANTAlAEDIUSAID, 2010) and only about three-
fifths of the women did so within this stipulated time frame. This is similar to findings from 
a study done in an Indian slum where almost 60% of the women initiated breastfeeding in 
the first hour afterbirth (Varshney, Kumar, Patel, & Singh, 2012). In slums in Bangladesh, 
only half of the women in the study started breastfeeding their babies within an hour of 
birth (Moran et ai., 2009). Having received counselling on the importance ofbreastfeeding 
during ANC visits has been found to yield favourable results (Varshney et ai., 2012) while 
early inillation of breastfeeding has been shown to lead to increased commitment to 
breastfeeding of infants optimally (Liben & Yesuf, 2016). These facts underline how 
essential it is to ensure that women receive adequate health education when they attend 
ANC clinics. and ample support to initiate early breastfeeding following delivery. 
Socio-cultural factors affect the choices that women make regarding how to breastfeed 
their babies (Rollins et aI., 2016). In this study, the opinion of the older women in the 
families had a profound effect on the ability of the young mothers to exclusively breastfeed 
their babies. There was also a widespread belief that babies needed more than breastmilk 
to be properly nourished, and that breastfed babies were difficult to wean at six months. In 
their study conducted in Nigeria, Agunbiade and Ogunleye (2012) recognized the influence 
of mothers, mothers-in-law and grandmothers on breastfeeding practices. While some 
supported the new mothers with their wealth of experience, others were of the opinion that 
breastmilk was not adequate nutrition for the infant, and also made it difficult to introduce 
complimentary feeds to the children. These findings are further collaborated by that from 
a study carried out in a slum in Kenya which highlighted the view of respondents that some 
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women had insufficient milk supply to satisfy their babies, and that introducing 
complimentary feeds was more difficult to achieve amongst children who had been 
exclusively breastfed (Wanjohi et aI., 2016). These results buttress the importance of 
including mothers and mothers-in-law in community education strategies to ensure that the 
women are able to continue with breastfeeding practices initiated at the health facility when 
they return home after delivery. The need for some women to go back to work was another 
factor that necessitated initiation of pre-lacteal feeds to the babies. In their study in a slum 
in Kenya. Kimani-Murage et al., (2015) observed that mothers had to go back to work soon 
after child binh and thus the need to earn an income negatively impacted on the 
breastfeeding practices. Being employed has been shown to be a determinant for initiatIon. 
continuatIOn and lermmation of breastfeeding (Mirkovic, Perrine, Scanlon, & Grurnrner-
Strawn, 2015; Rollins et ai., 2016). Taking the child to work is not an option for many 
mothcrs as the workplace is largely an unconducive environment for childcare in general, 
and breastfeeding in panicular. 
5.3.2 Barriers to Utilization of Skilled Birth Attendance 
Barriers to SBA that were highlighted by women in the study include lack of finances, 
disrespect by health care providers and fear of having a Caesarean operation. Results from 
the study revealed that the financial implication of having a facility-based delivery was a 
deterrent to SBA, turning women towards TBA assisted binhs where the binh charges were 
much lower. Funhermore, long waiting time and harsh treatment experienced at public 
health care facilities steer pregnant womcn towards more expensive private hospitals and 
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clinics. Even though perinatal care is free in Ghana through the NHIS scheme, many 
private hospitals do not subscribe to the programme (Asundep et aI., 2013) thus leaving the 
poor pregnant women with no choice but to seek the affordable services of the TBAs. In 
this study, more than half of the participants had a valid NHIS card. Some studies have 
established that enrollment into the NHIS programme in Ghana has a positive effect on 
utilization of maternal care services (Dixon, Tenkorang, Luginaah. Kuuire, & Boateng, 
2014; Dzakpasu et aI., 2012; Mensah, Oppung, & Schmidt, 2010). An evaluation done by 
the Ghana Health Service points out the fact that women who were insured were more 
likely to give birth in a health care facility, have skilled attendance at birth, and have a 
Caesarean section done (Health Systems 20/20 Project & GHS, 2009). In addition, insured 
women who did not give birth in the health care facility were more often than not, 
financially disadvantaged and mUltiparous showcasing barriers that still remain as 
opportunity costs. Okafor et aI., (2014) found out in their study carried out in Nigeria that 
financial constraints were a determinant ofTBA services patronage. Likewise, in a study 
done in Indonesia, it was highlighted that in addition to charging much lower fees than the 
health care facilities, the TBAs gave the women the option of paying in instalments or in 
kind (Agus & Horiuchi, 2012). 
Poor treatment meted out to pregnant women by health care providers during child delivery 
is yet another reason why the women in the study chose to utilize TBA services. Equally, 
other studies conducted in urban poor areas discovered that pregnant women patronized 
private health care facilities and TBAs for fear of being treated with disregard or even 
physically abused in the public health care facilities (Bhanderi & Srinivasan, 2015; Khan 
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et ai., 2009; Okang & Kaseje, 2015). Women in the study also expressed the apprehension 
that health care facilities were quick to book pregnant women for Caesarean Sections, thus 
making them to opt for care at the TBA centres during child birth. Similarly, other studies 
have observed that women avoided facility-based deliveries to evade the possibility of 
having an episiotomy or a Caesarean Section (Mrisho et al., 2009; Okafor et aI., 2014). 
Despite acclamations of preferable birthing experiences at the TBA centres, birth 
complications arise which could have been averted if early intervention at an appropriate 
health care facility had been initiated. In this study, complications such as cord around the 
neck, physical deformity of the baby, and still births were reported amongst deliveries that 
look place in TBA centres. 
5.4 Postnatal Care Utilization in a Peri-urban Settlement 
This section IS dedicated to discussing utilization of Postnatal Care services amongst the 
women living in peri-urban settlements in Ga East Municipal, Greater Accra Region, 
Ghana. It covers how socio-demographic factors, and PNC knowledge, practices and 
barriers affect the utilization of Postnatal Care in a timely manner. 
5.4.1 Postnatal Care Knowledge, Practices and Utilization 
Study results show that even though 94.1 % of the women attended PNC clinics, only a 
fifth of them did so within the first three days following child birth. In addition, by the end 
of the puerperal period, only 14.2% of women had had up to three PNC visits. In another 
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study carried out in an Indian slum, it was found that while a little over 40% of women had 
availed themselves ofPNC services within the first seven days following child birth, only 
6% of them had up to 3 PNC visits in total (Patel, Desai, Modi, & Bansal, 2014). However, 
observations from a study conducted in a slum in Bangladesh yielded better results as two-
thirds of the women utilized PNC services within two days postpartum (Srivastava, 
Kishore, & Padda, 2015). The benefits of timely utilization of Postnatal Care within 48 
hours has been widely documented as a means of alleviating maternal and newborn 
mortality. In their study, Ronsmans and Graham (2006) observed that there were a lot of 
maternal deaths during the postpartum period, and that these could be averted by providing 
timely Postnatal Care, and for an adequate duration of time. In addition. Baqui et aI., (2009) 
established in their study that PNC visits on the first and second days following birth led 
to a decrease in neonatal mortality of 67% and 64%, respectively. 
This study revealed that the use ofPNC services increases consistently with age till the age 
of 40, when there is a decline with only 20% of women in this age group attending PNC in 
a timely manner when compared to 61.5% of women less than 20 years old. In Nepal, 
Khanal et aI., (2014) also noted that as the age of the women increased, there was a correlate 
decrease in the utilization of PNC services. This is similar to observations made by 
Rwabufigiri et aI., (2016) in Rwanda where findings were that older women used less PNC 
services than younger ones. Contrarily, in a Nepalese study, women who were 35 years old 
and above utilized PNC services more adequately than those less than 35 years old even 
though they had poorer ANC clinic attendance (Sharma et aI., 2007). This was largely due 
to the fact that older women skipped ANC visits and depended on their cumulative 
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pregnancy experience during later pregnancies, predisposing themselves to obstetric 
complications that require skilled care during and after birth. Very often, the age of the 
mothers is found to be collinear with the number of children borne. From study results. 
even though women who had two or three children were seen to be more likely to receive 
PNC services than women with only one child, those who had four or more children were 
less likely to do so. In Ethiopia, it was observed that women with four or more children 
were less likely to access PNC services when compared to women who had just one child 
(Workineh & Hailu, 2014). Similarly, Titaley, Dibley and Roberts (2009) noted that 10 
Indonesia. mothers with high order births were less likely to anend PNC visits than those 
with less number of children. With a large sized family, increased financial responsibilities 
and time constramts due to child care become deterrents to utilization ofPNC services. 
Being educated was also found to be positively associated with PNC service utilization as 
women who had any education were seen to be more likely than their uneducated peers to 
utilize PNC services. Similarly, findings from a study in Indian slums found that as 
educational attainment of the women increased, the chances of them accessing PNC 
services, and on time also increased (Awasthi, Chaturvedi, Nandan, Jha, & Mehrotra, 
2012). In addition, a study conducted in Nepal noted that better educated women had higher 
odds of attending PNC clinics than less educated women (Khanal et aI., 2014). These 
findings may be because these group of women are also bener informed about health issues, 
make beneficial health choices as a result, and are confident enough to interact with health 
care personnel at the facilities. In addition, many educated women enjoy unrestricted 
autonomy and do not need permission to leave the house. 
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Women who were employed had lesser odds of accessing PNC services than their 
unemployed counterparts (aOR=O.82, 95% CI=0.52-1.29). Similarly, in Nepal, Shanna, 
Sawangdee and Sirirassamee (2007) found that women who were working were less likely 
to access PNC services than their non-working counterparts. This may be explained by the 
fact that in addition to time constraints experienced by working women, financial 
constraints in the household makes it a necessity for them to be employed thus their non-
working peers may be women who have better financially stable households and can afford 
the time and money required for utilization of PNC services. Furthennore, women who 
work in particular sectors of the economy such as agriculture, may find that the time 
schedules for hospital visits and long waiting times at the clinics may be unfavourable, 
leading to loss of income for the family (Khanal et aI., 2014; Titaley et at., 2010). 
The study found that males being the sole decision makers in the household had a protective 
effect on utilization of PNC services (aOR=1.51. 95% CI=0.85-2.67) while spouses 
making decisions together led to a higher likelihood of underutilization of PNC services 
(aOR=0.59, 95% CI=0.33-1.04). In their study, Shanna, Sawangdee and Sirirassamee 
(2007) found that spousal communication led to increased utilization of Postnatal Care in 
Nepal. However, in Rwanda, Rwabufigiri et aI., (2016) discovered that autonomous 
women were less likely to utilize PNC services than their non-autonomous counterparts. 
They posited that male-headed households had better social and ~conomic advantages than 
households headed by females and thus are in a position to provide maternal health care 
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for the women in their families. Contrary to these submissions, it was discovered in a study 
camed out in Ethiopia that the more decision making power a woman had. the higher the 
likelihood of her utilizing PNC services (Workineh & Hailu, 2014). In general. improving 
on knowledge by involving men in maternal health care education will go a long way in 
increasing PNC utilization. 
Surprisingly, only 37% of women who had skilled anendance at birth anended PNC in a 
timely manner. This correlates to a study done in a slum in Bangladesh which found that 
utilizing skilled anendance at birth and facility based deliveries were not significantly 
associated with utilization of PNC services (Kamal, 2012). The explanation for these 
findings may be that mothers who had babies in health care facilities do not see the need 
10 return especially if they and their babies were healthy. On the other hand, women who 
did not have skilled anendance at birth may see the need to have a postnatal checkup to 
certify themselves and their babies as healthy. Contrariwise, in their study conducted in 
Indian slums, Awasthi et al.. (2012) observed that having facility based deliveries increased 
the likelihood of mothers seeking PNC services on time. This observation stresses the 
importance of the content of the information given to mothers concerning the need for 
timely PNC utilization. Findings from this study also allude to the fact that having had 
complications during child birth increased the chances of accessing PNC services four- fold 
(aOR=3.94. 95% CI=2.01-7.7I). Limenih, Endale and Dachew (2016) found evidence in 
their study carried out in Ethiopia, that women who had undergone Caesarean section, and 
those who experienced obstetric complications were more likely to anend PNC clinics than 
their counterparts who had no complications during delivery. This observation can be 
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explained by the fact that in addition to these women feeling concern for their health, the 
health care providers also lay strong emphasis on the need for them to return for PNC visits 
to ensure that they and their babies remain in good health. 
5.4.2 Barriers to Postnatal Care Utilization 
Several reasons were propounded by the study participants for which women did not attend 
PNC clinics at all, or in a timely manner and these include financial constraints and fear of 
poor treatment meted out by health care personnel. 
A number of studies have shown that limited resources impede access to maternal health 
care (Onah et a\., 2006; Simkhada et aI., 2008; Titaley et aI., 2009). In their research carried 
out in Indonesia, Titaley et aI., (2010) observed that financial constraints were a major 
challenge faced by women in need of PNC services in their study area. To add to the 
financial burden faced by women in this research, social expectations dictate that a mother 
should be clothe in new apparel when she goes to the facility for PNC visits and the shame 
that some women face if their husbands are not able to meet this obligation discourages 
them from attending the PNC clinics. 
Study panicipants also alluded to the fact that some women avoided PNC clinics because 
of their negative experiences with health care provision in the past. Findings from the study 
conducted by Tesfahun et aI., (2014) suppon this observation as the women gave poor care 
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received from health care personnel as a reason for avoiding PNC services. In the same 
vein. women in a study carried out in Uganda also gave poor treatment received from the 
health care professionals as a reason for not utilizing the PNC services (Nankwanga &, 
Philips. 2008). Some of the complaints made by the women include being ignored, shouted 
at, and spoken to rudely. More women in this study who attended ANC in health 
centres/community clinics and in private/maternity clinics were seen to have received 
timely PNC when compared to women who had been to government hospitals for ANC. 
DUring the discussions, the women pointed out the fact that they preferred accessing health 
care from private providers because they were treated with more dignity than in public 
health care facilities. It has been documented in several studies that despite the high costs 
of health care service provision in private facilities. women found it more satisfactory than 
services available in public facilities (Bayou et aI., 2016; Gabrysch & Campbell, 2009; 
Muindi et aI., 2016; Muriithi, 2013). 
Culturally. child birth is deemed a normal experience in life and as such many communities 
do not see the need for medical intervention in a typical life process (Achadi et aI., 2007). 
Results from this study show that the mother and baby being in good health deterred the 
women from attending PNC clinics as they did not see the need to return to the clinics for 
further health checks. Similarly. in a study conducted in Indian slums, it was observed that 
a quarter of the women did not feel the need to patronize PNC services because they were 
in good health (Revathi, Ade, Kv, & Hiremath, 2013). In another study carried out in 
Indonesia, study participants alluded to the fact that a healthy mother had no need to go to 
the hospital for a checkup especially if she had had an uncomplicated delivery (Titaley et 
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aI., 20) 0). The cultural practice of keeping the mother and baby indoors till the traditional 
outdooring ceremony has been done, as noted in this study, also acts as a barrier to timely 
PNC utilization. In Ethiopian slums, Kaba, Taye, Gizaw, & Mitiku (2017) observed that 
the women were reluctant to go out of their homes too soon after birth. There were cultural, 
religious or social restrictions keeping them and their babies indoors for 40-80 days. 
Similarly, in Nepal, postpartum women are forbidden to have any interactions with other 
pcoplc till they were) ) days post-delivery (Karkee. 20) 2) and in India, these segregations 
from society have led to underutilization of PNC services (8andyopadhyay, 2009). There 
is therefore a need for proper education at ANC clinics, following facility based deliveries, 
and dwing home: visits to ensure that the mothers and their families understand the 
importance of utilizing PNC services in a timely manner. This also Wlderlines the need for 
community-based interventions that provide women with the support and information that 
will encourage them to access much needed maternal health services. 
5.5 The Influence of Community-based Initiatives on Maternal Health Care 
Service Utilization in a Peri-urban Settlement 
This section is devoted to discussing the influence of community-based interventions on 
the utilization of perinatal care amongst the women living in peri-urban settlements in Ga 
East Municipal, Greater Accra Region, Ghana. It covers how community-based 
interventions affect the adequacy of Antenatal Care attendance, utilization of skilled 
attendance at birth, and initiation of Postnatal Care in a timely manner. It also discusses 
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the dynamics and challenges of partnerships between private and public health facilities in 
the study area. 
5.5.1 The Community-based Initiatives and Maternal Health Care Utilization 
Community-based interventions identified in the study area include Community Health 
Officers from the CHPS programme, Mother Support Groups, and public-private health 
care facil ity partnerships. About two-fifths of the women in the study were visited at home 
by a CHO and these visits were shown to have no effect on the likelihood of attending 
ANC clinics or on utilization of skilled attendance at birth. Community based interventions 
in resource poor areas involving Community Health Workers, and aimed at providing basic 
health care, health promotion and education, including ANC and Skilled Birth Attendance, 
have been documented as successful in several studies. A community intervention 
involving Village Health Teams and health workers led to an increase in ANC attendance 
and Improved male partner involvement in ANC visits in Northern Uganda (Ediau et aI., 
2013). In Bangladesh, pregnant women who were supported by Community Health 
Workers of the Manoshi Programme were found to have increased odds of having skilled 
attendance at birth. accessing PNC. and feeding their babies the colostrum (Adams, 
Nababan. & Hanifi, 2015). 
Furthermore, findings from the study show that these home visits had a negative effect on 
PNC utilization as the women who were visited at home had 38% less likelihood of 
attending PNC than those who were not visited (aOR=0.62, 95% CI=0.40-0.9S). Focus 
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Group Discussions with the CHOs also highlighted the fact that after the women had been 
paid home visits by the CHOs, they were less inclined to attend PNC clinics. Contrarily, in 
a study conducted in Ethiopia, it was suggested that contact with community health care 
workers led to an increased chance of attending PNC clinics due to increased awareness 
from health education (Tesfahun et aI., 2014). Sharma, Sawangdee and Sirirassamee (2007) 
also observed that health worker home visits were positively associated with utilization of 
PNC services in Nepal. Contrary findings from this study are due to the fact that women in 
the community considered the home visit a proxy for PNC services, and thus did not deem 
it necessary to make additional trips to the hospital. 
Quantitative results from the study did not indicate that the activities of the Mother Support 
Groups had any effect on the utilization of ANC, SBA or PNC services. However, from 
the interviews and discussions. it was evident that the CHOs collaborated with the Mother 
Suppon Groups m providing care for pregnant women and newly delivered mothers and 
their babies m the communities. Members of the MSGs help in identifying pregnant 
women, and mothers and babies who are in need of medical attention, as well as providing 
support for breastfeeding mothers. Mother Support Groups are voluntary in nature and are 
likened to peer counsellors who aim to provide psychological support, counsel and distinct 
health mformation (Morrell, Spiby, Stewart, Walters, & Morgan, 2000). In their meta-
analysis of community based interventions, Rollins et aI., (2016) established that such 
interventions comprising of home visits by Community Health Workers and peer 
counsellors were able to have positive effects on breastfeeding practices. In Nepal, the 
Morang Innovative Neonatal Intervention (MINI) programme trained female volunteers to 
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carry out home visits soon after birth leading to a reduction in neonatal mortality due to 
early detection and treatment of infections (Khanal et at, 2011). Volunteer health workers 
in Kenya were able to improve overall health knowledge oftbe women in the communities, 
as well as ~killed attendance at birth and facility based deliveries (Adam et aI., 2014). In 
addition, Safe Motherhood promoters functioning in rural Tanz31l1a were able to improve 
on timing for ANC registration, skilled attendance at birth and male involvement in 
maternal health issues (Mus hi, Mpembeni, & Jahn, 20 I 0). There is a need to harness the 
potentials of the Mother Support Groups in the study area to the maternal health advantage 
of the women living in these underserved communities. 
Results from the study show that there was a significant level of collaboration between the 
public and private health care providers in the study area. Reports were shared between 
them, and they were able to narrate the Improvements in maternal care utilization as seen 
in the communities as a result of their collaborative activities. The proliferation of private 
hospitals in urban areas due to paucity of public health care institutions, has contributed to 
an increase in facility based delivery care, and the urban poor are not left out in their 
patronage (Kamal et aI., 2016). However, in countries such as Nigeria, Ghana, South 
Africa, Sri Lanka and Spain, where payments for health care services rendered at private 
institutions are made out-of-pocket, this proliferation of private health care facilities leads 
to high costs and invariably to poor access to these services (Asogwa & Odoziobodo, 2016; 
Asundep et aI., 2013). To improve on services rendered to the public and mitigate some of 
the socia-economic challenges they face, governments worldwide have made efforts to 
collaborate with the private sector (Asogwa & Odoziobodo, 2016). Interventions tailored 
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towards collaboratIOns between the public and the private health care providers have been 
shown to be successful in improving health care outcomes. In India for example, a literature 
review on improving tuberculosis control through public-private collaboration noted an 
increase in case notification rate (Dewan et aI., 2006). With regards to maternal health, the 
People's Primary Health Care Initiative (PPHI) was a public-private partnership in Pakistan 
that led to an increase in family planning. ANC and PNC services utilization. as well as 
immunization of mothers and babies (Imtiaz, Farooq, Haq, Ahmed, & Anwar, 2017). The 
urban slum health care project in India is another public-private partnership that was able 
to significantly increase facility ba<;ed deliveries. and reduce maternal and neonatal 
mortality (WHO, 2007). Even though findings from this study suggest that the public-
private partnerships being forged in the study area are weak, as the community women 
seemed oblivious of their existence and health care providers did not have any clear cut 
collaborative protocol, there rcmains a potential in these collaborations that can be 
harnessed to the benefit of maternal health in these communities. 
5.5.2 Challenges Faced by Community-based Health Care Collaborations in a Peri-
urban Setting 
The efforts made by the public and private health care providers in the study area to 
collaborate and coordinate their activities met with a number of challenges. These included 
lack of a proper feedback mechanism, lack of synchronism at various levels of care, non-
recognition of informal health care providers by their biomedical care counterparts, and 
high attrition rate of Mother Support Group volunteers. The health care professionals were 
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of the opinion that the lack of information flow between the different cadres of providers 
was an impediment to proper provision of perinatal care services, and continuum of care 
offered to the women. To ensure that there is continuity in the bealth care service provided 
to a patient, coordination of care between all care providers is of paramount importance 
(Bodenheimer, 2008). This coordination is lacking in the study area due to the informal 
nature of the collaboration between the various cadres of care providers. In their paper, 
Baru and Nundy (2008) noted that government institutions were the principal drivers of 
the health care programmes and policies. thus resulting in the diminishing of the roles 
played by the private sector. A concerted effort needs to be made to improve the flow of 
information withm the levels of health care service delivery in the public sector; and 
between the public and the private health care sectors. 
Results from the group discussions also highlight that CHOs felt that this lack of care 
coordination between the community level care and the facility-based care makes it 
difficult for them to keep track of the health status of the women needing follow-up 
maternal care. The training and orientation offormal health care providers make it difficult 
for them to view Community Health Workers as an essential arm of health care delivery 
(Lehmann & Sanders, 2007). CHW activities are however, an important aspect of health 
care delivery as they aim to ensure that health care services reach individuals living in 
underserved communities (WHO & Global Health Workforce Alliance, 2010). The 
facility-based health care providers in the study area need to be sensitized to the important 
role played by the CHOs at the community level. 
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Furthermore, opinions elicited from the discussions and interviews suggest that the 
proprietors of maternity homes and TBAs felt that the institutional health care providers 
treated them with some level of disregard. Orthodox health care professionals need to 
recognize other care providers that impact health care delivery in their communities, and 
form an alliance with them (WHO, 2004). In their study,lzugbara et aI., (2009) highlighted 
on health care professionals' general lack of respect for TBAs but several studies have 
documented positive results emanating from collaborations between the biomedical care 
providers and the TBAs. In an intervention carried out in Pakistan, training TBAs to carry 
out appropriate and hygienic perinatal care was shown to have resulted in a decrease in 
neonatal and maternal mortality (Jokhio et aI., 2005). In Somaliland, TBAs were linked to 
the formal health care providers and trained to make timely obstetric referrals resulting in 
an increase in Skilled Birth Attendance (Pyone et aI., 2014). Furthermore, efforts made by 
public health care providers to collaborate with the various levels of care within the health 
system. such as the CHOs and private/maternity clinics, and those outside, such as the 
Mother Support Groups and TBAs, can aid in ensuring that women comply with the 
recommended continuum of care, and are provided with psychosocial support where 
needed. 
Despite having the knowledge that their activities were voluntary, members oflhe Mother 
Support Groups were sometimes dissatisfied with the fact that they were not receiving any 
compensation for work done resulting in a high attrition rate amongst them. Many 
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individuals who have migrated to the urban areas did so in search of greener pastures, and 
are less inclined than their rural counterparts to offer their time voluntarily (Adongo et a!., 
20) 4). Studies carried out in urban slums of Bangladesh and India had similar results as 
volunteer female health workers were found to have a high attrition rate on account of poor 
or non-existent pay for services rendered (Alam, Tasneem, & Oliveras, 2012; George, Pant, 
Devasenapathy, Gbosh-jerath, & Zodpey, 2017). Other studies have suggested non-
monetary incentives such as community recognition and periodic training for such 
volunteers (Amare, 2009; Haile, Yemane, &: Gebreslassie. 2014). However with both 
monetary and non-monetary incentives, the question of sustain ability remains, especially 
in these resource-poor environments (Lehmann &: Sanders. 2007). The activities of the 
volunteers add value to the work done by the CHOs and there needs to be a reward system 
put in place to ensure that they feel validated for the services they provide. 
This study has been able to establish that maternal health care utilization is influenced by 
information garnered at the community level from CHOs and Mother Support Group 
volunteers, as well as the experiences of the women at the Traditional Birth Centres and 
health care facilities. Even where the information offered within the communities was 
received wholeheartedly, a negative experience at the health system level still tended to 
lead to poor utilization of MHC services, especially in situations where Traditional Birth 
Centres are readily available. A positive experience at health care facilities led to a higher 
likelihood of utilizing the continuum of care in a proper manner. 
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Positive Health Increased MHC Improved 
System Utilization Maternal Health 
+ Experience Outcomes 
Decreased MHC 
Utilization 
Poor Maternal 
Negative Health Health Outcomes 
System 
Experience TBA Centre 
patronage 
Home Delivery 
Figure 4: Contextual representation of intluence of community-based initiatives on 
maternal health care utilization 
This goes to buttress the point that utilization of maternal health care in underserved 
environments can be positively influenced by a synergetic relationship between community 
level and health system level care providers. 
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CHAPTERSlX 
6.0 SUMMARY, CONCLUSIONS AND RECOMMENDA nONS 
6.1 Introduction 
In this chapter, a synopsis of the study results and discussion is presented, guided by the 
study objectives, and pertinent conclusions drawn. The contributions of the study to public 
health knowledge have been outlined and recommendations that have arisen as a 
consequence of the study proffered. Areas of interest for future research have also been 
proposed. 
6.2 Summary 
This research was carried out using quantitative and qualitative methods to assess maternal 
health care utilization through community based initiatives in a peri-urban area of Accra. 
The key findings of the study are as follows: 
I. Although 98.6% of women surveyed accessed ANC services, only 78% of them 
utilized these services adequately having had up to 4 ANC visits. About 93% of the 
women had skilled attendance at birth, while only 20% attended PNC clinics within 
the first three days following childbirth. At the end of the 42-days puerperal period, 
less than 15% of all women surveyed had had up to three PNC visits. 
2. The study identified several barriers to maternal health care utilization which 
included financial and time constraints, lack of public health care facilities in the 
communities, disrespect of pregnant women by health care providers, long waiting 
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time. favouritism, fear of Caesarean Section, and lack of competence: at the health 
care facilities. Dissatisfaction with services rendered at the public health care 
facilities drove the women to seek for care at the: private clinics despite the higher 
costs, as well as from TBAs. 
3. The study revealed that the services of TBAs are still widely utilized by women 
because of culture, traditional beliefs and practices; and spirituality surrounding 
pregnancy and the birth process influence the women's care seeking behavior for 
maternal health needs. 
4. Women from households in which men were major decision makers were more 
likely to utilize PNC services. 
5. There was no significant effect on utilization of ANC and SBA services due to CHO 
home visits found. These home visits were also found to have a negative effect on 
PNC utilization as the women in the community considered them a proxy for PNC, 
and so did not deem it necessary to make the trip to the hospital. Mother Support 
Group activities had no significant effect on utilization of ANC, SBA or PNC 
services. However, it was evident from the discussions that members of the groups 
collaborated with the CHOs in the provision of care and support for the pregnant 
women and new mothers in the communities. 
6. Even where the information offered at the community level was received 
wholeheartedly, a negative experience at the health system level still resulted in 
poor utilization of MHC services, while a positive experience increased the chances 
of utilizing the continuum of care in a proper manner. 
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7. Challenges dodging community-based health care collaborations include lack of a 
proper feedback mechanism, lack of synchronism at the various levels of care, non-
recognition of informal health care providers by their biomedical counterparts, and 
high attrition rate of Mother Support Group volunteers. Although some 
improvements were seen in maternal health care utilization in the communities due 
to collaborations that exist between the various cadres of health care providers, 
these partnerships were weak and there is a need for a clear cut collaborative 
protocol. 
6.3 Conclusions 
Although majority of women in these peri-urban communities availed themselves of ANC, 
SBA and PNC services, a substantial number of them utilized these services inadequately, 
and in an untimely manner. Many of the women also patronised informal sources of 
maternal health care such as prayer houses and TBA centres while attending cI inics at the 
health care facilities. Barriers to formal maternal health care utilization include financial 
and time constraints, lack of public health care facilities within the communities, poor 
treatment meted out by health care providers, long waiting time, fear of having a Caesarean 
section, and cultural practices. These invanably led to women accessing care from private 
facilities, despite the high cost involved, as well as from TBA centres. In addition, the 
activities of formal and informal health care providers in the communities had a mixed 
effect on maternal health care utilization. Whilst CHO home visits had no effect on ANC 
and SBA utilization, it was found to result in a decrease in PNC utilization. Mother Support 
Groups had no effect on ANC, SBA or PNC utilization but served as an integral support to 
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the CHO activities. Collaborations between the formal and informal health care providers 
in the communities face challenges that include lack of synchronism at the various levels 
of care and high attrition rate of Mother Support Group volunteers. Utilization of maternal 
health care in underserved communities can be improved if measures are put in place to 
consolidate collaborations between community level and health system level care 
providers. 
6.4 Contributions of the Study to Knowledge 
I. This research found that home visits by health workers were detrimental to PNC 
visits as women who were visited at home felt that attending PNC clinics was 
needless. 
2. The study also elicited that women from households in which men were the 
decision makers were more likely to attend PNC clinics when compared to more 
autonomous women. 
3. A link was made between information received at the community level from CHOs 
and Mother Support Group volunteers and the experiences the women had at the 
health care facilities, and their influence on MHC utilization. Where the 
information was backed by positive experiences at the facilities, there was an 
improvement in MHC utilization, whereas negative experiences led to poor MHC 
utilization. 
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6.5 Recommendations 
6.5.1 Recommendations for practice 
I. For public health care facility collaborations to be effective, the Ministry of Health 
needs to put a formal protocol in place that also involves an operational feedback 
mechanism. Reliable technical support should be made available to private health 
care facilities functioning in underserved areas, and this should inciude proper 
regulation and insurance coverage for clients. 
2. TBAs operating in the communities should be involved in the collaborative efforts 
as they can offer invaluable support to women with regards to care compliance. 
3. The Municipal Health Management also needs to address provider-client 
relationships in the public health care facilities by providing workshops tailored 
towards the acquisition of the necessary skills required by health care personnel to 
deal with their clients. 
-I Special considerations need to be made for unique cases such as pregnant teenagers 
and working womcn. Pregnant teenagers are particularly vulnerable as they are 
prone to stigmatisation and so avoid being seen in public places. The Municipal 
Health Management can put in measures to ensure privacy and dignified treatment 
at the health care facilities to encourage them to seek for care in a timely manner. 
Employed mothers also need to be taken into consideration when fixing the timing 
for perinatal care clinics. Staggering the days and time frames for clinic visits will 
provide them with opportunities to avail themselves of the maternal care that they 
need. 
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5. Civil Society Organisations can also provide special education targeted at older 
mothers and women with high parity as utilization of ANC, SBA and PNC showed 
a decline amongst these groups of women. Community education involving male 
partners and elderly women in the communities is also of paramount importance as 
it was elicited in the study that they were influential in decision making regarding 
maternal health care utilization. 
6.5.2 Recommendations for future research 
I. Research can be carried out to test the framework showing the contextual 
representation of influence of community-based initiatives on maternal health care 
utilization, and to establish its relevance in other contexts. 
2. Many studies have been done on male involvement in maternal health. However, 
there is a need to carry out an implementation research targeted at male involvement 
in community-based maternal health care initiatives in peri-urban areas. Involving 
males in the initiatives will lead to more men in underserved environments 
encouraging their partners to utilize available maternal healtbcare. 
3. There should be an implementation research on the use of mHealtb via mobile 
phone technology to foster collaborations between fonnal and infonnal health care 
providers in peri-urban communities, thus improving utilization of maternal health 
care services. 
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AbouZahr, C. (2003a). Global burden of maternal death and disability. British Medical 
Bulletin, 67, I-II. AbouZahr, C. (2003b). Safe Motherhood: A brief history of the 
global movement 1947-2002. British Medical Bulletin, 67,13-25. 
AbouZahr, c., & Wardlaw, T. (2001). Maternal mortality at the end ofa decade: Signs of 
progress? Bulletin oft he World Health Organization. 
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APPENDICES 
APPEl'iDiX A: CONSENT FORM FOR QUANTITATIVE DATA COLLECTION 
Title of study: Maternal Health Care utilization through community-based initiatives in 
peri-urban Accra. 
Introduction and nature oftbe study: Good day! My name IS. . .........•............ and 
I am from the School of Public Health, University of Ghana, Legon. I am conducting a 
study to assess the use of Maternal Health Care services in peri-urban areas. The purpose 
of this research study is to find out how effective community-based initiatives are in 
promoting the use of these services in peri-urban areas. I would also like to know what 
other sources of Maternal Health Care are available in your community. If you decide to 
participate. we will ask you to complete a questionnaire about your experiences with 
Antenatal Care, delivery services and Postnatal Care. The interview is expected to last 45 
minutes. 
Possible Risks and Discomforts 
We do not anticipate any physical risk for participating in the study. The topics discussed 
during the interviews may be sensitive and may be uncomfortable for you to discuss. 
During the interview, you do not have to answer any questions that you do not want to 
answer. If you are not comfortable with the questions asked, you can withdraw from the 
study at any time. Your participation in the study will not affect your right to health care 
provision. 
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Possible Benefits 
Though there is no direct benefit to you as an individual. your participation will help in 
making policy recommendations with regards to Maternal Health Care service delivery to 
women living in your community. 
Additional Cost 
There is no cost for participating in this study. 
Compensation 
There will be a reimbursement for travel costs the participants may incur while taking part 
In the study. 
Confidentiality 
All of the information that we collect dunng the study including any personal information 
about you will be confidential. We will not write your name on any of the information we 
collect and your personal information will be stored separately from study data. We will 
assign you an identification number and only this number will link you to the data we 
collect. Only study personnel will have access to the data, which will be kept in a secure 
location and password protected computer. This information will be destroyed two years 
after completion of study. No paper trail is stored. 
Voluntary ParticipationlWithdrawal 
Your participation is completely voluntary. You have the right to withdraw from the study 
at any time by notifying the study personnel. 
Alternatives to Participation 
Your participation in the study is completely voluntary. The alternative is not to participate 
in the study. 
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Contacts for Clarification 
This research has been reviewed and approved by the Ghana Health Service Ethical Review 
Committee. If you have any questions about the study, you can contact the principal 
investigator. Adanna U. Nwameme on 024-6168214 (email address: 
adanwameme@yahoo.com); the study primary supervisor, Prof. Philip Baba Adongo on 
024-48060 15 (email address:adongophilip@yahoo.com); or the secretary to the GHS 
Ethical review Committee, Madam Hannah Frimpong on 024-3235225 or 050-7041223. 
VOLUNTEER AGREEMENT 
The above document describing the purpose, benefits, risks and procedures for the study 
has been read and explained to me. I have been given an opportunity to have any questions 
about the research answered to my satisfaction. I agree to participate as a volunteer. 
Date Name and signature/mark of volunteer 
If volunteers cannot read the form themselves, a witness must sign here: 
I was present while the purpose, benefits, risks and procedures were read to the volunteer. 
All questions were answered and the volunteer has agreed to take part in the research. 
Date Name and signature of witness 
I certify that the nature and purpose, the potential benefits, and possible risks associated 
with participating in this research have been explained to the above individual. 
Date Name and Signature of Person Who Obtained Consent 
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APPENDIX B: QUESTIONNAIRE FOR QL\~TlTATIVE DATA COLLECTION 
IDENTIFICAn ON 
Name of rctpmdent 
UniqllC ID of respondent 
CHPS zone resident (YeslNo) 
Date of birth of last child 
(ddlmmlyy) 
Date of interview 
Time interview started: I Time interview ended: 
I 
Name of interviewer _. I 
rS;;-;F:;:;-:.c:::;;T=.:::CO-:-;N-=J-:B :::-A-:-"C=K:-:G:::cR=-O=U:-:N=-D------------- - - ------- --
No Questions and filten Coding categories Skip 10 
How old are you? _____- -'years QAGE 
What is the highest level of Connal None ........................ 1 QEDU 
school you anended? Primary ......................2  
ISS ............................3  
Middle SChool... ............ 4 
SSS .............................5  
Tertiary ........................ 6 
Other (specify) ____7  
To which ethnic group do you Asante ..... .. ......................... 1 QETH 
belong? Fanli . . ......... 2 
Akuapem ................ .3 
Sefwi....... . ......... ..4 
Brong............ .. ................. 5 
Nzema ................................. 6 
Ga ........................................... 7 
Dangme .................................. S 
Ewe ........................................ 9 
Guan. .. ........... 10 
Buli .............. 11 
Mamprusi.... . ..... 12 
F rafralGruni ... . ............ 13 
Kas~ene.. .. .......... 14 
Dagbani ..... 15 
WaliIDagari... . ............ 16 
Sissala.. .. ....... 17 
Other (specify)_ _____ IS 
What is your religion? Christianity...... ..1 QREL 
Islam .... 2 
Traditional religion... . ........... 3 
No Religion.... . ....... 4 
Other (specify), _____  
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QMAR 
WUt is your marital status? ~~::::::::::::::::::::::::::::::::::.~ 
Widowed. ............................. 3 
Divorced .............................. ..4 
Separated .................... ·. . ··.·······S 
Coh.bitinRi1ivinli toaether ........ 6 
6 What ia your occ:upation? ~:.=~·.·.·.·····.·.·:,:.::::::::: ... ::iF~. . QOCC +-.. IO 
H.irdressingfDressmaking ........... 3 
Housewife........ ...4 
Farminl.............. .S 
Craftsmanship .........................6  
Construction work... . . .. . ........ 7 
CivillPublic Servant..... .. ........... 8 
Student........ .... .. ............9  
Other (specify): 10 
7 How often do you work during the SeasonallylPart of the year ............... .1 QWRK 
year? Throughout the year ........................... 2 
Once in a while. .................................. 3 
Are you .ble to spend your income yes. .................................................... l-~O QSIN 
as you deem fit? No. ................................................ 2 
9 Wbo else has a say in how your Husband...................... .. ............ .1 QINS 
income is spent? Mother-in-l.w .................................... 2 
Other (specify) 3 
10 How are major decision~ made in RespondenL ...................................... 1 QDEC 
your household? Husband/partner...... .. .............. 2 
Jointly........................ .. ......... 3 
Other (specify): ______  
11 Do you have access to any cell Personal phone .............................. 1 QCELL 
phone? Within the household. ................ 2 
Within the compound... . ........ 3 
Within the community.. .. ....... 4 
None... .. ...... S 
12 Do you need permission from your yes.... ................. .. ........... 1 QPER 
husband to move out of the bouse? No..... .. .......... 2 
13 Do you have a valid NHIS card for yes ....... . .......... 1 QNIC 
201S12016? No ... .. . ............. 2 
(Check the card) 
_______~  _____L -__.  ___ 
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SECTION 2: REPRODUCTIVE HISTORY 
No Questions and tillers Coding categories Skip to 
14 How many pregnancIes have you Number ofpregnancies._ ____  QNPG 
had? 
15 How many childrm have you given Number of children given birth QNCH 
binh to? 10._ ____  
16 Are you or your husbandlpanner Yes. . . . . . .. . . ................ 1 QCON 
:;e~i~: :;t::O:V:;d~ :':! ~~~::.:: .......... ::::::: :: ............. :::::~ -= ~~~ 
getting preaoant? 
17 Which method are you currently Female Sterilization ... I QCMT 
using? Male Sterilization.... .2 
1UD ...............................3  
InjectioD ............................ 4 
Implant ............................S  
Pill .................................. 6 
Male condom ........ , ............ 7 
Female coDdom ................... 8 
Diaphragm ......................... 9 
Foam/Jelly. ........................ 10  
Lactational amen. method ....... 11 
RhythnvPeriodic Abstinence ... 12 
Withdrawal... ..................... 13 
Other modem method ............. 14 
Other traditional method ......... 15 
18 For how long have you been using Number of months method has been in QCPR 
this method? usc _____  
19 How did you learn about this During ANC. ................. 1 QCED 
method? From a Community Health Officer. .... 2 
From the radio ..................................... 3 
From the television .............................. 4 
From a newspaper. .............................. 5 
From a relativelfriend .......................... 6 
Other (specify) 7 
SECTION 3: ANTENATAL CARE 
20 Did you see anyone for antenatal Yes ... I QANC 
care during your last pregnancy? No .. 2 -~41 
21 Whom did you see? SKJLLED PERSONNEL QANP 
Doctor. .. .. ...1 
Anyonc elsc" Midwife ..... .. ....... 2 
Nurse . ..... 3 
Probe to identify each type of person TRAINED PERSONNEL 
and record all mentioned. Community Health Officer ...... ..4 
Health ExtensIOn Worker ........... 5 
OTHER PERSONNEL 
TBA.. .. .......... 6 
Other (specify), _____7  
22 Where did you receive antenatal care PUBLIC SECTOR QANL 
for your last pregnancy? GoV!. Hospital. ....................... 1 
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Govt. Health center. .. . .............. .2 
Anywhere elle? Gov!. Community Health Clinic ... 3 
NGO facility.......... . .. 4 
Probe to identify type( s) of ~ourcej s) PRIVATE SECTOR 
and circle the appropriate code(s). Private Clinic... . . ....... 5 
Maternity Home ............................ ·6 
Name of place· Traditional Birth Attendant... ........ 7 
OTHER(s~iw) 8 
23 Oid you have a maternal health book Yes, seen ............................ .1 QMHB 
(pink book) for your last pregnancy? Yes, but not available ................ 2 
Yes. bullos!. .......................... 3 
Yes, bul disposed of ................ ..4 
No ................................ ·······5 
24~-~any weeks pregnanl were you Months ______  QANW 
when you first received antenatal 
care for your last pregnancy? Don'l know. . .. 99 
25 How many times in lotal did you Number_ ________  QANT 
receive antenatal care during that 
pregnancy? Don't know .................9 9 
26 CHECK THAT NUMBER OF yea................. ..1 QACK 
VISITS IN HEALTH BOOK: 025 
Q25 more than Health Book ............ 2 
Q25 less than Health Book .............. 3 
27 I notice that you mentioned Forgotto bring book ............... 1 QCRC 
receiving a number of ANC visits Health Worker did not write ....... 2 
that is different than are listed In Other (specify) 3 
your book. 
Sometimes women may forget 10 
bring their book to ANC; sometime 
the health worker may also not write 
in your book·' Did this happen to 
you? 
MUI.. TILE RESPONSES 
POSSIBLE 
28 During that pregnancy, Yes No QANS 
Were you weighed? Weighed...... I 2 
Was your blood pressure measured? Blood pressure.. I 2 
Was your height measured? Height.... I 2 
Did you give a urine sample? Urine sample.. . .1 2 
Did you give a blood sample? Blood sample ..... 1 2 
Was your stomach measured? Stomach.... . .. I 2 
Did a health worker listen to the Baby heart ratc .. 2 
heart rate of your baby? 
29 Ouring that pregnancy, were you Yel No QC'OU 
counseled by a health worker on: Pregnancy & its complications .... I 2 
Process of pregnancy and its Diet and nutrition.. . ......... 1 2 
complications? Rest and exercise.... .. I 2 
Diet and nutrition in pregnancy? Hygiene.... .. I 2 
Rest and exercise in pregnancy? Danger signs. ........ ... . ........... 1 2 
Personal hygiene? Use of drugs.... . .......... 1 2 
Danger signs in pregnancy? STls and HIV/AIDS.. . ...... 1 2 
Use of drugs in pregnancy? Breast care and breastfeeding. ..... I 2 
Effect orSTls and HIV/AIDS? Labour signs/symptoms ............... I 2 
Care of the breast and breastfeeding? Financial prep... . ....... I 2 
Symptoms and signs oflabour? Skilled birth attendant ................ 1 2 
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Financial preparation for your Tnmsport..... . .................... 1 2 
delivery? Postnatal Care ..................... 1 2 
Using a skilled birth attendant? Family pllDlling.... . ................... 1 2 
Identifying emergency transport Substance abuse. .... . ................. .1 2 
option~? ANC schedule..... . ............... 1 2 
Plans for PostDatal Care? 
Family planning? 
EfTecb of hannful habib such as 
smoking, drug abuse and 
alcoholism? 
Schedule for next ANC visit? 
30 During (any of) your antcoatal care yes .......... . ........ .1 QCOM 
vlsit(s), were you told about the No ...... . . ........ 2-~32 
things to look out for that might 
suggest problems with the 
pregnancy? 
31 Were you told where to go if you had yes .... . ........ 1 QANR 
any of these complications? No .......... . . ......... 2 
32 At the time of this pregnancy, did Yes .. I QPBN 
your household have any bed net? No .. .1 
33 How often did you sleep under a bed Every night .. .I QUBN 
net during that pregnancy? Most RIghts. 
Some nighlS ........... .. 
Rarely ...... . . ... 4 
Never .. . ) 
_. - - _______- 1-__- -1 
34 During that pregnancy, did you take Yes .. . I (JPAM 
any drugs to keep you from getting No .......... . 2-f-+38 
malarIa') Don't know .... 99-f--38 
35 What drugs did you take') SP................... . I QAMD 
ACT........... . ... 2 
MULT lPLE RESPONSES Other (specify) ______- :3 
POSSIBLE Don't know .. 99 
• 36 How many times did you take these Number oftimes_ _ QAMT 
drugs'! 
Don't know.... . .. 99 
37 Did you get the drugs during any ANCVisit......... . ....... 1 QAMS 
antenatal care visit, during another Other health facility visit... ................. 2 
visit to a health facility or from Other (specify) 3 
another source? 
38 During that pregnancy were you yes ................ . ..... 1 QTTD 
given an injection in the arm to No ............... . ...... ~40 
prevent you and the baby from Don't know .... . .. ....... 99 -411 
getting tetanus? 
39 During that pregnancy, how many Number oftimes,_ _____  QTIT 
times did you get this tetanus 
Injection? 
Don·tknow ..... ..99 
40 During this pregnancy, did you take yes ................ . I 
any drug for intestinal worms? No .. ..l. 
Don't know .. 
41 During this pregnancy. did you Ycs. QPPD 
make anv preparations for delivery? No 
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42 If yes, what kind of preparation did Yes No QTPM 
you make? Transport .................. 1 2 
Money...... . . ....... 1 2 
Circle all responses which the Food............... .. ........ 1 2 
mother mentions unprompted, then Clean instruments 
ask, "b then: anything else?" for delivery ................. . 2 
Then read each question and circle Clean cloths ..... . 2 
the appropriate answer Other specify: _______  
43 Did you discuss planning for)'OW" Yes .. . ............. , I QDPD 
delivery with anybody while you No ......... . . .......... 2--j"+45 
were pregnant? 
44 Whom did you plan your delivery Husband ..... ............. 1 QPDL 
with? Mother-in-law .. .. ............ 2 
Mother .3 
Circle all responses which the Friends/relative. . ...4 
mother mentions unprompted. Then CHO............... .. ............ 5 
ask. "1& there anyone else." Community Health Volunteer .......6  
Other health worker ( specify) 
~~_~~ __________ 7 
Other (specify) 8 
Don't know.... .... .............. ...99 
45 Did any health worker give you NONE ..... ..... 1 -.49 QIDL 
specific instructions to deliver at a 
health facility? SKlLLED PERSONNEL 
Doctor .... 2 
Midwife ....... . ........ 3 
Nurse..... .. ......4  
TRAINED PERSONNEL 
Community Health Officer.. .. ....... 5 
Health Exten'lon Worker .............. 6 
Other (specify) 7 
46 Wben did they make this I-trimester .. .................. 1 QTID 
recommendation? 2l1li trimester. ........... 2 
3111 trimester, but before 
MULTIPLE RESPONSES labor staned. .. ........ 3 
POSSIBLE 3nl trimesler, during labor .. .... 4 
Can't remember . . ... 99 
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471 make this R docs not know why .................. 1 QRID Why did they 
recommendation? 
1 :H=;y;;p:e:Sr~tbe~n""s,i'o''n'l'e''d'e''m''a''l'b'l'u''r'r'e''d' 'v''i's'i'o'n'' .'.' :4;  
Previous c-section .......................5  
I I Firstbinh ............................... 6 Bleeding .................................. 7 
Many hOW1i in labor .....................8  
Lack of movement offetus ............. 9 
Diabetes... . .. ........ 10 
Anemia...... .. ...... 11 
Other (specify) 12 
48 Did anyone else recommend IIlat HUiband.............. .. ...... 1 QAlD 
you go to deliver at health facility? Mother-in-I.w........... ...2 
Mother...... . .............. 3 
MULTIPLE RESPONSES Friends/relative ........ ..4 
POSSIBLE Other: 5 
49 Did any health worker visit you at NONE ... 1 QIPD 
home during your pregnancy? SKILLED PERSONNEL 
Doctor .................... 2 
Midwife.. . . ........ 3 
Nurse.. ...... .. .......... 4 
TRAINED PERSONNEL 
Community Health Officer .......... 5 
Health Extension Worker... .. ..... 6 
Mother Support Group Volunteer. .. 7 
Other (specify) 8 
50 What are the complications during Severe headache.. .. . .. .1 QCPG 
pregnancy that need medical Blurry vision....... .............. ..2 
treatment? Reduced/absent fetal movement... ....... 3 
I lagh Blood Pressure.. ...4 
DO NOT READ OUT ANSWERS. Edema of the face/hand,... .. ..... 5 
Convulsions ................................... 6 
Probe: Anything else? Excessive Vaginal Bleeding ............. 7 
Circle all responses mentioned Severe lower abdominal pain ..... 8 
Other (specify) 9 
Don't know...... .. .99 
51 What are the complications in a Excessive vaginal bleedlOg. .. .. I QCOL 
woman during childbirth that needs Foul-smelling discharge ................ 2 
medical treatment? High Fever ..... 3 
Baby's Hand or Feet Come Firsl....4 
DO NOT READ OUT ANSWERS. Baby in abnormal position ........... 5 
Prolonged Labor (> 12 hours).. . .. 6 
Probe: Anythmg else? Retained Placenta... .. ........... 7 
Circle all responses mentioned Ruptured uterus. .. ............... 8 
Prolapsed Cord...... .. ............... 9 
Cord around neck ..................... 10 
Convulsions. . .. .. 11 
Other (Specify)_ _____ 12 
Don't know.... ............ 99 
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52 NONE ...... . .. 1 , QSIC Where did you get information about 
these complications? SK.1LLED PERSONNEL 
Doctor.. ..2 I 
Midwife.... . .. 3 
Nurse ...................... 4 
TRAINED PERSONNEL 
Community Health Officer ..........5  
Health Extension Worker ........... 6 
Other (specify) 7 
53 Where you uti.tied with the yes............ .. ... 1 QSAN 
Antenatal care you received at the No...... .. .... 2 -"55 
health care facility? 
S4 What were you satisfied with? Range of services olTered ................ 1 QRSA 
Attitude of nurses..... ... 2 
MULTIPLE ANSWERS Level of sanitation... . ........ 3 
POSSIBLE Availability of drugs ............ _ ........... 4 
Privacy during examination. ............... 5 
Time spent during examination ........... 6 
Other {lI'C'ifY). ................................... 7 
55 What were you not satisfied with? Range of services offered... .. .. I QRDS 
Attitude of nurses .............................. 2 
Level of sanitation.. .... .. .. .3 
Availability of drugs.... .. ........... .4 
Privacy during examination ................ 5 
Time spent during examination ........... 6 
Other (specify). ................................... 7 
56 For women who did not attend ANC. RANK QNAN 
why did you make thaI decision? LJ Cost too much ............... I 
LJ Facility not open ............. 2 
DO NOT READ OlIT LI Too far/no transportation ... 3 
RESPONSES LI Don't trust facility/poor quality 
service ............................................ 4 
Probe, 'Any other reason? • LI No female provider at 
Record all mentioned, and rank facility .......................................... 5 
according to Importance. LI Husband I family did not 
permit ........................ 6 
LI Nol necessary ................ 7 
LJ Not customary..... .. ... 8 
LIOther(specify) 9 
~ __ 1_ ___________- -1._ ___________- --1._ __- -'_ __- ' 
SECTION 4: DELIVERY CARE 
57 Whcre did you give birth to your HOM!: -f- 60 QPOB 
last child? Your home..... .. ..... J 
Other home ............. 2 
Probe 10 idenlify the type of source FACILITY 
and circle Ihe appropriate code. GoV!. Hospital... .. ......... 3 
GoV!. Health Cen.... .. ....... .4 
GoV!. Community Heallh Center. .. 5 
GoV!. Health Post ........................ 6 
NGO facility..... . .7 
Private facility........... ...8 
On the way 10 facility..... 9 
Other( specify) 10 
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RANK QDLR 58 What was the reason you didn't 
deliver at home? LJ Experienced complication. I 
LJ Facilitiesaresafer ............ 2 
DO NOT READ OUT LJ Free delivery at the facility.3 
RESPONSES LJ Access to the facility ........4  
LJ Bctter care at facilities ...... 5 
Probe, 'Any other reason? ' LJ 0Iher(specify)_ __6  
Record all mentioned, and rank 
according to importance. 
59 Who accompanied you to the health Nobody ...................... · .... ·····l QDLC 
facility? Husband ............................. ·· .. ········2 
Mother-in-law ....................... 3 
Father-in-law .... 4 
Mother/father .. , . . . . . . . . . .5 
Other relative........... . ........... 6 
CHO....................... . ...........7  
Other (specify): 8 
60 What was the reason you dido't RANK QUSD 
deliver in a health facility? LJ Cost too much ................ 1 
LJ Facility not open ............. 2 
DO NOT READ OUT LJ Too far/no transportation ... 3 
RESPONSES LJ Don't trust facility/poor quality 
service ............................................... 4 
Probe, 'Any other reason?' LJ No female provider at 
Record all mentioned, and rank facility .............................................5  
according to importance. LJ Husband / family did not permit.6 
LI Not necessary .................. 7 
LJ Not customary.. . .. 8 
LJOther(specify) 9 
61 Who assisted with the delivery of SKILLED PERSONNEL QADL 
the baby? Doctor .......... . ..1 
Midwife .. ... 2 
Probe, 'Anyone else?' Nurse .... . ..... 3 
TRAINED PERSONNEL 
Probe for the type(s) of person(s) Community Health Officer ............4  
and record all mentioned If Health extension worker ............... 5 
respondent says 'no ODe assisted', OTHER PERSONEL 
probe to determine whether any TBA... . 6 
adults were present at the delivery. Community Health Volunteer ......... 7 
RelatiVe/friends. . ....... 8 
Nobody..... ..9 
Other (speCIfy) 10 
62 During your most rccent delivery, Convulsions...... . ............ I Q[)LS 
did you experience any of the Long labor.. . .................... 2 
following symptoms? Baby hand or feet coming 
first/abnormal position. ................ .3 
Excessive bleeding/shock ...........4  
None of the above. . ... 5- r+ 65 
63 When you experienced these yes............ I QAHF 
symptoms, were you told to go to a No..... .2 - 65 
health facility? 
64 By whom? SKILLED PERSONNEL QWAH 
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Doctor. .................... ············· 1 
Midwife ........................... ·.···2 
Nurse ............................ ····· .. ·· .. ·3 
TRAINED PERSONNEL 
Community Health Officer ............4  
Health extension worker ................ 5 
OTHER PERSONNEL 
TBA .................................. · .. 6 
Community Health Volunteer ........ 7 
Relative/friends ........................ 8 
Nobody... . .................9  
Other (Specl ry) 10 
65 Was your baby delivered by yes ..... . .......... 1 QCSP 
Caesarean section, i.e., did they cut No ........ . . ...... 2-~67 
your belly open to take the baby 
out? 
66 Why did you have a Caesarean Mother was bleeding. ........................ 1 QRCS 
section? Blood pressure was higb .................... 2 
Labour was obstructed ........................ 3 
Baby was too big. ............................. 4 
The umbilical cord was wrapped 
around the baby's neck ....................... 5 
Mother bad a previous ClS ................. 6 
Other (8pCCilY) ................................... 7 
67 Where was the baby placed On the floor ............................. 1 QBPL 
immediately after delivery? In a cot. . .........2  
On the mothcr's abdomctl ............... 3 
With someone else ....................... 4 
Other (specify); 5 
Don't know ............................ 99 
68 Did your baby cry or breathe easily yes ................................ 1 QBCD 
immediately after birth? No.... ........................... 2 -~71 
Don't know .......................... 99 -ft- 71 
69 What was done to help the baby cry Rubbed/massaged. . .. . .......... 1 QABC 
or breathe at the time of birth? Dried.............. .. .............2  
Mouth cleared... .. ...... 3 
PLEASE DO NOT READ OUT Nothing ................... .4 1-----+71 
RESPONSES Other (specify): 5 
Don't know......... . ............ 99 _1+ 71 
Probe, 'Anything else?' 
Record all responses 
70 Who took these measures to help SKILLED PERSONNEL QPCB 
the baby cry or breathe? Doctor .. I 
Midwife ...... ..2 
PLEASE DO NOT READ OUT Nurse ... 3 
RESPONSES. TRAINED PERSONNEL 
Community Health Officer.. .4 
Health extension worker.. 5 
OTHER PERSONNEL 
TBA ... 
Community Health Voluntcer .7 
Relative/friends. . . ..Ii 
Nobody... 9 
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Other (spectfyj, ______ IO 
71 What was QBWM done to keep your baby Dried the baby ................... ·.··.· .. 1 
warm after delivery (within the first Wrapped the baby with clean cloths .... 2 
day after birth)? Put baby beside the mother ...............3  
Kept the baby on bare &kin to skin 
Anything else? contact .................................... · ........ ·.4 
Baabed in warm water. ............... ... S 
Warmed delivery room .................. 6 
MULTIPLE RESPONSES Other (specify) 7 
POSSIBLE Nothing done........ . ........... 8 
Circle all re8DOnses mentioned Don't know ............................. 99 
72 How long after birth did you first Mins L-L-J QTBF 
put your baby to the breast? 
Hours 
If I to 24 hours, record hours. Days 
Otherwise, record days. 
Don't 
know .... .... 99 
Never breastfed ... ..88 -~77 
73 Did you have suppon with Yes. . .. 1 QSEB 
exclusively breastfeeding your No. ......... .. .. .. 2 --+77 
baby? 
74 From whom did you receive this SKILLED PERSONNEL QSSB 
suppon? Doctor ...... ...1 
Midwife .... .. ..... 2 
MULITIPLE RESPONSES Nurse. .......3  
POSSIBLE TRAINED PERSONNEL 
Community Health Officer. ............ 4 
Health extension worker ....... ..5 
OTHER PERSONEL 
TBA ......... . . . . . . . . . . . . . . . . . . 0 
Community Health Volunteer 7 
Relative/friends .. X 
Mother suppon group ..... 9 
Nobody ....... .10 
Other (specify) II 
-I---. 
75 When did you first stan giving food Hours { 1 QTSF 
or drink other than breast mi Ik to Days ( 1 
your baby? Months{ 1 
If less than I hour. record '00' Baby exclusively breastfed unul 
hours. If I to 24 hours. record now .. .... 96 - 77 
hours. OtherwIse, record Don·tknow .... .. 99- f--77 
days/months. 
76 Are you still breastfeeding ? yes ..... ..I QSBF 
No .. ..2 
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77 QTCU How 1008 after delivery was it Hours (,-_-,1,---7'] 
before a health care personnel Days [... . __I L-.-~l 
checked on you and your baby? Nobody 
checked. . ........... 96-+79 
~; .............................................. 99---79 
78 Who checked on you? SKIllED PERSONNEL QWCU 
Doctor ...................... ·.··· .. l 
Midwife.................. . ... 2 
Nune. ................................. 3 
TRAINED PERSONNEL 
Community Health Officer .... . 
Health extension worker .................. 5 
OTHER PERSONNEL 
TBA ..................................... 6 
Community Health Volunteer ......... 7 
Mother Support Group ..................... 8 
Nobody ..................................9  
Other (specify) 10 
79 How long did you stay at the Hours ( I ] QTlC 
facility following your delivery? Days [ I 1 
Months[ 1 1 
Don't know ............................9 9 
80 FOR BIRTHS IN WOMAN'S QPCII 
OWN/OTHER'S HOME: Both 
Before the health professional, 
CHO or 1 BA left your house after Mother only 
the delivery, did he/she check on Baby only 
you and/or your baby's health? 
None 
__________L -____~ ~ .. _____ 
~------------------~------.----
SECTJO' 5: POSTNATAL CARE 
81 Yes .. . ............ 1 QAPN 
No .. . 2 
82 SKILLED PERSONNEL QPPN 
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Doctor ..................... 1 
Midwife ................... 2 
Nurse ...................... ·3 
TRJUNEDPERSONNEL 
Community Health 
Officer ....................4  
Health extension 
Worker .......... < ..........S  
OTHER PERSONNEL 
TBA ........................6  
Community health 
volunteer ................... 7 
Mother support group ...... 8 
Other 
(specify) 9 
83 After the delivery, did you go to a facility/place Yea ...................... 1 QI'N(' 
of delivery for postnatal care? No ........................ 2 -. 88 
84 How many hours, days or weeks after the binh QTPN 
did you first go for PNC? Hours: LU 
Days: LU 
Weeks:LLI 
Don't 
know .............................. 99 
85 Who checked on your and/or your newborn's SKILLED PERSONNEL QPPC 
health at that lime? Doctor. .................... I 
Midwife ...................2  
Anyone elae? Nurse ......................3  
TRAINED PERSONNEL 
Probe for the type(s) of person(s) and record all Community Health 
mentioned. Officer ....................4  
Health extension 
Worker ....................S  
OTHER PERSONNEL 
TBA ......................6  
Community health 
Volunteer ................... 7 
Other (specifYI ___8  
86 How many times did you go for check-up in the Number of limes QNPN 
first 6 weeks? Don't know.... --... -.- 99 
87 What did the health worker/other do during that Examined body.. . . .. I QPCH 
visit to check on your health? Checked breasts... . .. .2 
Checked for heavy bleeding .. 3 
Counseled on danger signs for 
newborns................. . .. 4 
Counseled on breastfeeding .. 5 
Counseled on nutrillon..... .6 
Other (specify) 7 
88 For those who did not go for PNC, why did you RANK QRPN 
not go? LI Costs too much .. 1 
l -' Facility not 01len .. 2 
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DO NOT READ OUT RESPONSES L.I Too farina 
trmsponatioD...... ... . .......... 3 
Probe. 'Any other reason? . L.I Don't tnJst 
Record all mentioned, and rank according to tacility/poor quality service .. 4 
importance. L.I No female provider 
at facility .............................. 5 
L.I Husband I family did 
not permil... ......................... 6 
L.I Not necessary. .... 7 
LI Not customary ..... 8 
L J Other (specify) 9 
H9 Have you been visited at home by a health Yes.. . ... I QHVS 
worker? No.. . ... 2 -ft. 93 
~~O-~~HTo-w~I~OO-g-a~ft~~-y-o-u-r.~li~vmy---w-~--~-u~vi~si~~~?-+7.W~i~th~in-8-w-"~k-..-.- .. -.. -.. -..~ 1--~------tnQ~TUH~Vr1 
Two weeks ............... 2 
Three weeka .................. 3 
Four weeks ................ 4 
Other (5f)ecify) ................ 5 
91 What type of health worker visited you the last Midwife .......................... I QWHV 
time? CHO .......................... 2 
TBA ..........................)  
MULTIPLE RESPONSES POSSIBLE Community Health 
Volunteer ...................4  
Moth~ support group ....... 5 
Otherl~fy): ............ 6 
. .,. .. ~ 
92 What did you speak about the last time you were Care of the newborn. ........... , ()DHV 
visited? Exclusive 
breaslfeeding......... 2 
Health of children. .3 
Health ofadullS... . 4 
General sanitation. . .. 5 
Disease prevention. 
Nutrition.......... ..7 
Other (specify)_ .. ~ __l: < 
93 What are the danger signs/symptoms after giving Fever.... J QDS~ 
birth indicating the need to seek health care for a Unable to suckle/feed. ..2 
baby less than a week old? Difficult/fast breathmg. . . 3 
Diarrhea... .... 4 
Probe, "Is there anything else?" Convulsions. .. . . . . . . .5 
Persistent vomiting.. . .. 6 
Circle all responses mentioned. Yellow 
pahmlsolesleyesljaundice .... 7 
lethargy. . ..... 8 
Unconscioumes5....... .9 
Red/discharging eyes ........ I 0 
Skin pustules ................. II 
Skin around cord is red ...... 12 
Pus from cord.. . ........... 13 
Failure to pass urine ........ 14 
Shlvennglcold babyllow 
temperarure. . . . . .. . .......... I S 
Bluish palms and soles ..... 16 
Very small babylbelow 
normal weight.. ............. 17 
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Baby doesn't cry at birtb .. .18 
Baby cries sbidently .......,  .19 
Other (specify): ___2 0 
Don't know ...................9 9 
94 Did your baby experience any danger QBDS 
IignslsympIOms during the first month following ~:.:::::::::::::::::::::::::::::::::::~~ END 
delivery? 
95 What were the danger signs/symptoms that your QDSS 
baby experienced? Fever ........................ 1 
Unable to suckle/feed. ..... 2 
Circle all responses which the mother mentions Difficult/fut 
unprompted. breathing ..................... 3 
Then a"k., "'s there anything else?" Then read Diarrhea ..................•...4  
each question and circle the appropriate response. Convulsions ................. . 5 
Persistent vomiting .......... 6 
Yellow 
palmslsolesleyealjaundice. .. 7 
Lethargy ......................8  
Unconsciousness ............. 9 
Red/discharging eyes ....... 10 
Skin pustules ................ 11 
Skin aroWld cord is red ..... 12 
Pus from cord ................. 13 
Failure to pass urine ......... 14 
Shivering/cold baby/low 
temperature .............. ..... 15 
Bluish palms and soles ..... 16 
Very small babylbelow 
normal weight .............. 17 
None ......................... 18 
Other, specify: ___1 9 
96 How many episodes of illness did your baby have QNIE 
up to the age of I month? Number LU 
97 Did you seek advice or treatment for the illness Yes... .. .......... 1 QHSB 
outside the home? No ........................ 2 -~ 100 
98 Who was the first health personnel you came in SKILLED PERSONNEL QHPC 
contact with for the problem? Doctor ..................... I 
Midwife...... .. .......2  
Circle all responses which the mother mentions Nurse. .. ... 3 
unprompted. Then ask, "Is there anything else." TRAINED PERSONNEL 
Then, read each question and circle "I" for "yes" Community Health Officer. .. 4 
or "2" for "no." Health Extension Worker. .... 5 
OTHER PERSONNEL 
TBA. . .......6  
Community Health 
Volunteer.... .. ..... 7 
Other (Specify)_ __8  
99 From where else did you seek care? GoV!. Hospital.. .. .... I QHCS 
GoV!. Health Center...... .2 
Circle all responses which the mother mentions GoV!. Community Health 
unprompted. Then ask, "Is there anything else." Center.. .. .... 3 
Then. read each question and circle "I" for "yes" NGO Facility ................. .4 
or "2" for "no." Private facility .......... .......5  
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PbarmIIcy/chemicll shop ..... 6 
Maternity borne ................... 7 
TBA. ................................... ··8 
Herbalist................... .. ... 9 
Other (specify): ___ IO 
100 Wby did YOlloot seek medical help? Expecting self resolution of QNHC 
Ihe iIIness ......................... 1 
MULTIPLE RESPONSES POSSIBLE Health facility 1110 farlno 
transportalion ................. 2 
COSI of treatment/sCl'Vice too 
bigh .............................)  
Don'l trust facilily/poor 
quality of care ............... .4 
Respected family members 
did not permil ................. S 
The traditional birth attendant 
did not allow it.. .............6  
Not customary to seek care 
outside home after 
childbirth ...................... 7 
Other (specify): ___8  
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APPENDICE C: CONSENT FORM FOR FOCUS GROUP DISCUSSIONS AND IN 
DEPTH INTERVIEWS AMONG POSTNATAL WOMEN AND HEALTH CARE 
PROVIDERS 
Title of study: Maternal Health Care utilization through community-based initiatives in 
peri-urban Accra. 
Introduction and aature oftbe study: Good day! My name is ................................... ··and 
I am from the School of Public Health, University of Ghana, Legon. I am conducting a 
study to assess the use of Maternal Health Care services in peri-urban areas. The purpose 
of this research study is to find out how effective community-based intitiatives are in 
promoting Maternal Health Care services in peri-urban areas. I would also like to know 
what other sources of Matemal Health Care are available in your community. If you decide 
to participate, we will ask you to participate in a discussion/interview about your 
experiences with Antenatal Care, delivery services and Postnatal Care. The interview is 
expected to last 45-60 minutes. 
Possible Risks and Discomforts 
We do not anticipate any physical risk for participating in the study. The topics discussed 
during the interviews may be sensitive and may be uncomfortable for you to discuss. 
During the interview, you do not have to answer any questions that you do not want to 
answer. If you are not comfortable with the questions asked, you can withdraw from the 
study at any time. Your participation in the study will not affect your right to health carc 
provision or jeopardise your employment. 
Possible Benefits 
Though there is no direct benefit to you as an individual, your participation will help in 
making policy recommendations with regards to Maternal Health Care service delivery to 
women living in your community. 
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Additional Cost 
There is no cost for participating in this study. 
Compensation 
There will be a reimbursement for travel costs the participants may incur while taking part 
in the study. 
Confidentiality 
All of the information that we collect during the study including any personal information 
about you will be confidential. We will not write your name on any of the information we 
collect and your personal information will be stored separately from study data. We will 
assign you an identification number and onJy this number will link you to the data we 
collect. Only study personnel will have access to the data, which will be kept in a secure 
location and password protected computer. This information wiJ) be destroyed two years 
after completion of study. No papcr trail is stored. 
Voluntary ParticipationlWithdrawaJ 
Your participation is completely voluntary. You have the right to withdraw from the study 
at any time by notifying the study personnel. 
Alternatives to Participation 
Your participation in the study is completely voluntary. The alternative is not to participate 
in the study. 
Contacts for Clarification 
This research has been reviewed and approved by the Ghana Health Service Ethical Rcview 
Committee. If you have any questions about the study, you can contact the principal 
investigator, Adanna U. Nwameme on 024-6168214 (email address: 
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adanwameme@yahoo.com); the study primary supervisor, Prof. Philip Baba Adongo on 
024-4806015 (email address:adongophilip@yahoo.com); or the secretary to the GHS 
Ethical review Committee, Madam Hannah Frimpong on 0243235225 or 0507041223. 
VOLUNTEER AGREEMENT 
The above document describing the purpose, benefits, risks and procedures for the study 
has been read and explained to me. I have been given an opportunity to have any questions 
about the research answered to my satisfaction. I agree to participate as a volunteer. 
Date Name and signature/mark of volunteer 
If volunteers cannot read the form themselves, a witness must sign here: 
I was present while the purpose, benefits, risks and procedures were read to the volunteer. 
All questions were answered and the volunteer has agreed to take part in the research. 
Date Name and signature of witness 
I certify that the nature and purpose, the potential benefits, and possible risks associated 
with participating in this research have been explained to the above individual. 
Date Name and Signature of Person Who Obtained Consent 
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APPENDIX D: FGD GUIDE FOR POST-NATAL WOMEN 
Demograpbk data: Age, Marital status, Occupation, Parity, Educational level, Religion, 
Ethnicity 
A. ANTENATAL CARE 
I. What is Antenatal Care? 
-How did you hear about ANC? 
-Who encouraged you to attend ANC clinics? 
2. Where did you attend Antenatal Care? 
3. Wby did you choose to attend ANC at the place you did? 
4. At what stage in your pregnancy did you go for your first ANC visit? 
5. Wby did you go at that time? 
6. How many times in all did you go? 
7. Did you go anywhere else in addition, and wby? 
8. Did you get any health visits in your home during your pregnancy, and from whom? 
9. What was done for you during your ANC visits (in the facility and at home)? 
10. What advice concerning pregnancy-related complications were you given? 
11. What did you like about the ANC services? 
12. What did you not like about the ANC services? 
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I 3. What pregnancy complications did you experience? 
14. What was done about it? 
15. What are the reasons why women may not go for ANC? 
B. DELIVERY 
16. Where did you deliver your baby? 
17. Ifnot in a facility, why did you make that choice? 
18. Who took the delivery? 
19. What complications did you experience during delivery? 
20. What was done about it? 
2 I. What was the condition of your baby at birth? 
22. How long was it before you were discharged? 
C. POSTNATAL CARE 
23. When did you go for your first postnatal visit? 
22. Where did you go? 
-If you didn't go, why did you choose not to? 
-Why do some women not go for PNC? 
23. What was done for you and your baby? 
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24. Did you get any health Visits at home after your delivery. and from whom? 
-What was done for you and your baby during this visit? 
25. How did you establish (exclusive) breastfeeding? 
26. What difficulties did you experience? 
27. What support did you have from your family? From health workers? From your 
community? 
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EALT H OFFICERS AND IDI 
APPENDIX E: FGD GUIDE FOR COMMUNITY H 
GUIDE FOR URBAN CHPS COORDINATOR 
Demographic Data: Age. Position. Number of working years 
Preparatory Question: 
What services do you provide for community members in your zone? 
ANTENATAL CARE 
I. What is Antenatal Care? What is Focused Antenatal Care? 
2. What training do you have to provide perinatal care services? 
3. What Antenatal Care services do you provide for the pregnant women in your 
communities? 
-What are other sources of Antenatal Care utilized by women in your communities? 
-What are the reasons why they choose to use these sources? 
-What are the barriers to ANC services access faced by women in your communities? 
SKILLED BIRTH DELIVERY 
4. What delivery services do you provide for the pregnant women in your communities? 
-What are other sources of delivery services utilized by women in your communities? 
-What are the reasons why they choose to use these sources? 
-What are the barriers to SBD faced by women in your communities? 
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POSTNATAL CARE 
5. What postnatal care services do you provide for the pregnant women in your 
communities? 
-What are other sources of postnatal care utilized by women in your communities? 
-What are the reasons why they choose to use these sources? 
-What are the barriers to PNC services access faced by women in your communities? 
7. What support do the women have with establishment of Exclusive Breastfeeding? 
COMMUNITY BASED COLLABORATIONS 
8. What community-based activities are in place to support you in your delivery of these 
perinatal services? 
9. How do you collaborate with the fonnal health facilities offering maternal health care to 
women in your communities? 
10. How do you collaborate with the infonnal health facilities offering maternal health care 
to women in your communities? 
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APPE:\DICE F: IDI GUIDE FOR FACILITY HEALTH WORKERS, 
TRADITIONAL BIRTH ATTENDANTS AND MOTHER SUPPORT GROUPS 
Demographic: Data: Age, Position/Occupation, Number of working yearslEducational 
level 
MATERNAL HEALTH CARE 
I. What is Antenatal Care? What ANC services/support do you offer in your 
facility/group? 
2. What is Skilled Birth Delivery? What delivery services/support do you offer in your 
facility/group? 
3. What is Postnatal Care? What postnatal services/support do you offer in your 
facility/group? 
4. What are the challenges of maternal health care faced in your 
facility/maternity/community? (Probe on logistics, workforce, follow up of 
pregnant women and of postnatal women) 
COMMUNITY BASED COLLABORA nONS 
5. How do you collaborate with Community Health Officers in your 
district/community? Other health workers and TBA? 
6. What differences exist between the knowledge and attitude of women who have 
Community Health Officers in their community and those who don't? 
7. What support do the women have with establishment of ExcJusive Breastfeeding? 
8. What are the challenges faced by MSG volunteers working in the community 
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APPE~DJX G: ETHICAL APPRO\' AL LETTER 
Acianlla Uloaku N",.mcme 
School nf Public Health 
llni\·"...iIY of Ghana 
LeBon 
Tta. Ghana Hc.ullh Sconicc Edrin kniew Committee hu reviewed and I,vell .ppro"'I' ror th. implcmentallon or 
yeur Study ProtlXol 
'GHS-wk 7NO-um"""'"be<--rcG=.". .,  ,. .." . j 
""'iccl Till. -Improvbla A_I Care Ublnatlon through Communny-:-Bued 
Inlerventions In Periurban Aecn" 
I--A'-=:Nf(l=,v='''1D tda=---+9I"' "Se '-::.",:::'om=ber=-2016 -----
~•. :.~ ~,__-~.-'.S ept""",'em,~.,. ..... 2017 .==..~~--
OilS-liRe lieci,ion ~p",. ..d  ___ _ 
TIlIa .ppro. ..I Faj.I. ... I~. ..... _1. . from lb. Prfnelpal rn"rolle.IO. 
• Sub,niHion of yearly ~ll'Iport orm. atLIdy 10 th. EthiCi Rc\oiow CommJUK (ERe) 
• Rem,wal orethie"appmvallft/!e lludy ...... C.. .. '"0"""''' 121ROfJlha. 
• Reponing of all IMOU' edvcne eveob ",IDled 10 thi. lIUlIy 10 Ihe ERC wllhin It,," day. vt!m.lly and 
wYtn da)'s in wririn,: 
• Suhmu''Iolon of a linal report after compk-t. oftbc .tudy 
• '"formin, ERC ifotudy.,..,_ "" impl_ or I. dfsoorulnued and 1'0_ wily 
• Infonllin. the ERe and) uur sponaor (wilcre eppl\cabte) before an)' publication or the racan:h tindinp. 
Ple~!IoC noce lhal any modification uf lhe.wdy ~llhoUI ERe appmyll of the amendment i. inv.Ud. 
~ ERC may _rye or c.oux to be obaerved procedun>.l and _. or lhe otudy durinll and ./Iet 
ImplC'mnltal ion, 
Kindly ~Ullie the" prohlC(ll.dcnlificallOft number in .11 furure correspondence in relation to thi. approved pf'OtocOl 
SIU~~C~B";\=I(MAN 
(OIIS·ERC CliAIRPBIt~( IN) 
Cc The DU'OC:lOr. Knc.r~h A Developmcnl Division. Ohana Holdt Service. Accr. 
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