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SCHOOL OF PUBLIC HEALTH, COLLEGE OF 
HEALTH SCIENCES, UNIVERSITY OF GHANA, 
LEGON 
SOCIO-CULTURAL PRACTICES INFLUENCING INTRAPARTUM AND 
POSTPARTUM CONTINUUM OF CARE IN THE ASANTE AKIM NORTH 
DISTRICT. ASHANTI REGION 
BY 
JOANA ANSONG 
(10155068) 
THIS THESIS IS SUBMITTED TO THE UNVERSITY OF GHANA, LEGON 
IN PARTIAL FULLFILLMENT OF THE REQUIREMENTS FOR THE 
AWARD OF PHD IN PUBLIC HEALTH 
JULY 2019 
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DECLARATION 
I, Joana Ansong 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 research work 
conducted under the supervision of Professor Philip Saba Adongo, Dr Emmanuel 
Asampong and Dr Irene Kretchy. I further declare that no part or whole of this thesis 
has ever been submitted for the award of any degree in this University or any 
University elsewhere. 
~ ...... . 
Joana Ansong Date 
(Student) 
Prof Philip Baba Adongo Date 
(Primary Supervisor) 
Dr Emmanuel Asampong Date 
(Secondary Supervisor) 
... ~. 
Dr Irene Kretchy 
(Third Supervisor) 
Date 
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DEDICATION 
I dedicate this work to our father in heaven for His unending love and sustenance; and 
to my husband. Daniel Yeboah Ansong, son, Daniel Divine Ansong and daughter, 
Maame Akua Akyema Ansong for their patience and endurance. 
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ACKNOWLEDGEMENT 
I will like to express my profound appreciation to my supervisors, Professor Philip 
Baba Adongo, Dr Emmanuel Asampong and Dr [rene Kretchy for all the patience and 
effort they devoted to developing me academically and to the realization of this thesis. 
My special thanks go to Dr Philip Teg-Nefaah Tabong, my friend and mentor for his 
immense support, encouragement and guidance throughout the process of writing this 
thesis. 
I would also like to appreciate the entire faculty and staff of the School of Public 
Health, especially my Head of Department, Dr Phyllis Dako-Gyeke, Ms. Pearl Aryee 
and Dr Franklin Glozah for their daily encouragement and support throughout 
difficult moments of this study. 
To my research assistants and drivers namely Ms. Virtue De-Gaulle, Mr. Michael 
Tamakloe. Mr Divine Logo, Mr Michael Asiamah, Mr MacDonald Ashong and Mr. 
Kabiru Mohammed Abass of Agogo Hospital, staff of Asante Akim North District 
Health Directorate I say, thank you very much for your hard work and support in 
various ways. 
[ am also indebted to all the mothers, TBAs, traditional medical practitioners, 
midwives and community health nurses in the Asante Akim North District whose 
responses led to the realization of this thesis. I am most grateful to all whose' names 
have not been mentioned here but played various roles in my studies. 
Finally, I am forever grateful to the Almighty God for all He has done to bring me this 
far. I can't thank Him enough. 
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ABSTRACT 
Background: The growing recognition of the critical importance of providing care to 
mothers and newborns and the substantial gaps in coverage that exists have prompted 
a paradigm shift in responding to maternal and new born health issues. Invariably, the 
health care that a mother receives during pregnancy, at the time of delivery, and soon 
after delivery is important for the survival and well-being of both the mother and her 
child. However, evidence suggests that maternal and neonatal deaths are accentuated 
by socio-cultural practices along the intrapartum and postpartum continuum of care 
and several studies have documented this across the globe. However, in Ghana, 
studies on the role socio-cultural practices play along intrapartum and postpartum 
continuum of care remain unexplored. This study, therefore, seeks to identify the gaps 
in the knowledge and practices along the intrapartum and postpartum continuum of 
care in the Asante Akim North District of Ashanti Region of Ghana. 
Methods: This was a descriptive cross sectional study which employed mixed 
sequenllal qualitative and quantitative strategies. An initial explorative study using 
focus group discussions and in-depth interviews was done to explore community 
leaders. health managers and mothers' perceptions and experiences in relation to the 
influence of socio-cultural practices along the intrapartum and post postpartum 
continuum of care. NVivo II was used to analyze the qualitative data and the themes 
and sub-theme converted into a survey questionnaire. A multi stage sampling 
technique was used to sample 439 mothers with infants (0-6 months) from four sub-
districts, based on proportion to popUlation. Quantitative data was analyzed using 
STAT A 14. Multivariable logistic regression to determine associations between 
independent and dependent variables was done. 
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Results: The study found that 65.1 % of women had adequate ANC 4+, 49. JO/o had 
skilled delivery, and 65.4% had received postnatal care at six weeks with only 28.5% 
having achieved complete continuum of care. Women who practiced confinement 
were 2.42 times (95% C\=0.4450-0.7789) more likely to discontinue care at ANC, 
1.98 times (95%CI=O. I 891.0.4000) the relative risk of discontinuing at postnatal than 
those who did not practice confinement. Women who believed in bewitchment during 
pregnancy and postnatal period had relative risk of 2.22 (95% CI=0.3634-0.9234) 
discontinuing at ANC, 1.67 (95% CI=0.4712-0.9178) at delivery and 2.89 (95% 
CI=0.4381-0.8172) during postnatal. Again, women who did not receive home visits 
by health care workers during pregnancy had higher relative risk of discontinuing at 
ANC (RR-1.89, 95% Cl=O.2190-0.9182), delivery (RR-2.71, 95% CI=0.8791) and 
PNC (RR=1.78, 95% C\=0.6981-0.8132). Receiving education on ANC also reduced 
a woman' s relative risk of interruptions along the continuum. Out of 439 participants, 
only 208 (47.4%) were advised to deliver in the health facilities. Women who were 
not advised to have skilled delivery had higher relative risk of discontinuing at 
delivery (RR=2.91, 95% CI=0.4001-0.7211) and PNC (RR=2.88, 95% CI=0.4412· 
0.7219). Women who also reported having experienced bad attitudes from health 
workers were more likely to discontinue at ANC, delivery and PNC. Local practices 
such as use of enema and use of squatting position were reasons attributed to 
accessing unskilled delivery. 
With respect to maternal illness, 241 (55.2%) and 196 (44.8%) sought health care 
from biomedical and non-biomedical facilities respectively. After delivery, 88 
(20.0%) sought health services from traditional healers, a factor affecting neonatal 
health. 
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The study further found that 281 (65.1%) neonates experienced ill health during the 
neonatal period. Difficulty in breathing, 98 (34.3) and fever, 78 (27.3%) were the two 
most reported condition during the neonatal period. Of the 286 who fell sick during 
neonatal period, 201 (70.3%) sought health care whilst 85 (29.7%) did not seek health 
care. Among those who sought health care, 125 (62.2%) used biomedical health 
facilities. 
Conclusion: The study concludes that socio-cultural practices are common in the 
study area and transcends the perinatal period. These socio-cultural practices are 
viewed as indispensable and closely related to people's worldview that illnesses 
during pregnancy, childbirth, neonatal and postnatal period have social and 
supernatural causes. This belief system favoured accessing health care from 
traditional healers. The good interpersonal relationship of TBAs, local beliefs and 
poor services at biomedical facilities pushed expectant mothers towards traditional 
care. Both neonatal and postnatal illnesses were believed to have both biomedical and 
social causes but with social causes given more prominence. Hence, health seeking 
behaviour was directed to\\ard non-orthodox service outlets; thus affecting the 
continuum of care. 
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TABLE OF CONTENT 
DECLARATION ........... . ............................................................... i 
DEDICATION ................................. . a ..................................... • •••••• •••• •••• • .................. "' ••• ii 
ACKNOWLEDGEMENT ...•.................................................................•..•.................. iii 
ABSTRACT .................................................................................................................. iv 
TABLE OF CONTENT ............................................................................................... vii 
LIS T OF TABLES ...................................................................................................... xii 
LIST OF FIGURES .................................................................................................. xiii 
LIST OFABBREVIA TIONS ...................................................................................... xiv 
CHAPTER ONE ............................................................................................................ 1 
INTRODUCTION ......................................................................................................... 1 
I. 1 Background ..................................................................................................... 1 
1.3 Theory and Conceptual Framework ............................................................. 7 
1.4 Research Questions ....................................................... . ..................... 14 
1.5 Study Objectives .................................................................. . ............ 14 
1.5.1 General Objective ................................................................................. 14 
1.5.2 Specific Objectives ...... .. .................................................................. 14 
1.6 Justification of Study... . ......................................................................... 15 
CHAPTER TWO ............. . .... · .... · ........ ·.··•· ........................................... 17 
LITERATURE REVIEW..... ..... . ...... .... .. .............................................................. 17 
2.1 Introduction ................................................................................................ 17 
2.2 Global situation of maternal morbidity and mortality ................................... 17 
2.3 Global situation on Newborn and Child Health ............................................ 19 
2.4 Antenatal Care (ANC) and Maternal Health ............. . ..................... 24 
2.6 Postnatal Care during Peripartum Period ........................ . . .............. 33 
2.7 Interventions to improve maternal and child health ..................................... 34 
2.7.1 The three delays framework/model in maternal health ......................... 34 
2.7.2 Community-based Interventions and its impact on Maternal and Child 
Health 37 
2.7.3 Male involvement in ANC and Perinatal Care ...................................... 39 
2.8 Policies and Legislation to Improve Maternal and Child Health Care in 
Ghana41 
2.9 The Concept ofRMNCH Continuum of Care .... 
········ ..................... 43 
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2.10 Socio Cultural Practices along the Maternal Neonatal and Child Health 
(MNCH) Continuum of Care ................................................................................... 46 
2.10.1 Practices during Pregnancy ................................................................... .46 
2.10.2 Practices during Childbirth ................................................................... .49 
2.10.3 Practices during Postpartum Period ....................................................... 53 
2.10.3.1 Maternal Practices during Postpartum Period ..................................... 53 
2.10.3.2 Neonatal Postpartum Practices ........................................................ 54 
2.10.3.2.1 Cord Care as a Component ofENC ............................................ 55 
2.10.3.2.2 Thermal Care of the Baby ........................................................... 56 
2.10.3.2.3 Early Initiation of Breastfeeding and Exclusive Breastfeeding 
Practices 57 
2.10.3.2.4 Immunization against Preventable Childhood Diseases ............. 59 
2.10.3.2.5 Care of the Body of Neonates ..................................................... 61 
2.11 Recognition of danger signs during neonatal period .................................... 62 
2.12 Availability and utilization of Postnatal Care (PNC) Services ..................... 64 
::: I 3 Summary and Conclusion ............................................................................. 66 
CHAPTER THREE ............ . . ........................................................................ 67 
METHODOLOGy ....... . . ........................................................................ 67 
:u Introduction .... .................................................................................... 67 
3.2 Philosophical underpinnings of the study .................................................... 67 
3.3 Study Design ........ ......................................... . .................. 69 
3.4 Study Area ........................... .. . ................... 70 
3.4.1 Social and Cultural Characteristics of the study area ........... .. .......... 71 
3.4.2 Health information of study area ............................... . ................. 71 
3.5 Quantitative Study...................................................... . .......................... 73 
3.5.1 Study Population ....................... . . ....................... 73 
3.5.2 Sample Size Determination for Quantitative study ............................... 73 
3.5.3 Sampling Procedure for Quantitative Study ............... .. . ........ 75 
3.5.4 Inclusion and Exclusion Criteria for the Quantitative Study ................ 76 
3.5.5 Key Variables in Quantitative Study............................. . ......... 76 
3.5.6 Data Collection Tool for Quantitative Study.... . ................. 79 
3.5.7 Data Collection Strategy ............................. . ·············· ..................... 79 
3.5.8 Quantitative Data Management and Analysis ........ . ........... 80 
3.6 Qualitative Research Approach .......................... .. .. ........ 84 
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3.6.1 Population for qualitative Research ....................................................... 84 
3.6.2 Selection of study participants ............................................................... 84 
3.6.3 Inclusion and Exclusion Criteria for Qualitative Component of the 
Study 84 
3.6.4 Qualitative Data Collection Methods ..................................................... 85 
3.6.4.1 Focus Group Discussions (FGDs) ...................................................... 85 
3.6.4.2 In-depth Interviews ............................................................................ 86 
3.6.5 Data Collection Tools and Procedures for Qualitative Research ........... 86 
3.6.6 Qualitative Data Analysis ...................................................................... 87 
3.7 Data Triangulation .................................................................................... 88 
3.8 Quality ControL ..... ............................................................................ 89 
3.9 Ethical Consideration .. .............................................. 89 
3.10 Study limitation ........ ............................................... 90 
CHAPTER FOUR .. .. .............. 91 
RESULTS ................. .. . ................... 91 
4.1 Introduction ................................................................................ . .. ........... 91 
4.2 Socio-demographic Characteristics (SDC) of Participants .......................... 91 
4.3 Socio·demographic Characteristics ofFGD and IDI Participants ................ 93 
4.4 Knowledge on peri-partum care .................................................................... 93 
4.5 Socio-cultural Practices during perinatal period ........................................... 95 
4.6 Protection of Neonates against Evil Spirits ...... ................................ 105 
4.7 Place of Delivery and Factors associated with Place of Delivery ............... 106 
4.8 Association between Socio-demographic Characteristics of Participants and 
Type of Delivery .................................................................................................... 109 
4.8 Determinants of SkilledlUnskilled Delivery ......... . .. ................... 111 
4.9 Essential Newborn Care Practices .................... . · ............................ 112 
4.10 Continuum of Care from ANC to PNC at Six Weeks ................................ 114 
4.11 Factors associated with Continuum of Care (CoC Completion .................. 114 
4.12 Factor associated with Discontinuity along the continuum of care ............ 116 
4.13 Correlation between Socio-cultural Practices and Health System Factors on 
Continuum of Care ................................................................................................. 1 18 
4.14 Association between Health System Factors and Continuum of Care ........ 121 
4.15 Health Seeking Behaviour (HSB) of Women during Prenatal and Postnatal 
Period 123 
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4.) 6 Assoc iation between socio-demographic characteristics of participants and 
health seeking behaviour ........................................................................................ 126 
4.17 Determinants of Health Seeking Behaviour for Mother ............................. ) 28 
4.18 Health Seeking Behaviour for Neonatal Illness .......................................... 129 
4.19 Association between Socio-demographic Characteristics and Neonatal HSB 
131 
4.20 Determinants of Health Seeking Behaviour for Neonatal U1ness ............... 133 
CHAPTER FIVE ....................................................................................................... 135 
DISCUSSION ....... ...................................................... .. ................ 135 
5.1 Introduction ......................................................................... . .................... 135 
5.2 Socio-cultural practices during pregnancy labour and neonatal period and 
their effects on continuum of care .......................................................................... 135 
5.2.1 Confinement, belief in witchcraft and use of herbs increases risk of 
discontinuity during ANC, skilled delivery and postnatal ................................. 135 
5.2.2 Maternal knowledge on danger signs inhibits neonatal continuum of 
care 139 
5.3 Contextual issues on how knowledge and socio-cultural practices affects the 
continuum of care .................................................................................................. 140 
5A Health Seeking Behaviour during Prenatal, Labour and Postnatal Periods 142 
5.4.1 Preference for Traditional Practices during Labour Affects Util ization 
Skilled Delivery Aflecting Intrapartum Continuum of Care .............................. 143 
5.4.2 Fear l)fCaesarian Section (CS) Affects Intrapartum Continuum of Care 
145 
5.5 Protection of baby against evil and bewitchment: Barrier to neonatal 
continuum of care .................................................................................................. 146 
5.6 Correlation between socio-cultural practices and health system on continuum 
of care I 47 
5.7 Health Seeking Behaviour for Neonatallllness and Determinants ............. 149 
5.8 Contextual Issues about Beliefs, health Seeking Behaviour and Continuum 
of Care for Neonate ............ ...... .............. ............................................ .. .... 151 
............................................................................................................. ... 152 
5.9 Health seeking behaviour of Women during Postnatal period .................... 152 
CHAPTER SiX .... .. ...... 155 
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS. .. ......... 155 
6.1 Introduction..... ............. .................. . .. ........ 155 
6.2 Summary of Findings. ··· .................. 155 
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6.3 Conclusions ................................................................................................. 157 
6.4 Contribution to Knowledge .............•....................................................•.....• 157 
6.5 Recommendations ....................................................................................... 158 
6.5.1 Recommendations for Practice ............................................................ 158 
6.5.2 Recommendations for Policy .............................................................. 159 
6.5.3 Recommendations for Future Research .............................................. 159 
References ............... . .............................................................................. 160 
APPENDICES ......................................................................................................... 192 
Appendix AI: Participants Information and Consent Form - In-depth Interviews 192 
Appendix A2: Participants Information and Consent Form - Focus Group 
Discussion ............................................................................................................. 197 
Appendix A3: Consent form for quantitative survey ............................................. 202 
Appendix B: Questionnaire for Survey ................................................................. 207 
Appendix C: FGD Guide for Community Members .............................................. 216 
Appendix D: [01 Guide for Opinion Leaders and Health Managers ..................... 218 
Appendix E: Ethical Approval Letter .................................................................... 220 
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LIST OF TABLES 
Table 3.1: Study Variables ......................................................................................... 78 
Table 3.2: Dependent Variables .............................. ··· ...... ·· .......................................... 79 
Table 3.3: Breakdown ofIDI participants ................................................................... 86 
Table 4.2: Distribution of Qualitative Study Participants ............................................ 93 
Table 4.5: Place of Delivery ...................................................................................... 107 
Table 4. 6: Association between socio-demographic characteristic ofthe woman and 
SkilledlUnskilied Delivery ......................................................................................... 110 
Table 4. 7: Determinants of SkilledlUnskilied Delivery ........................................... 112 
Table 4.8: Essential Newborn Care received by babies ............................................ 113 
Table 4. 9: Determinants of Completion of CoC  ....................................................... I 15 
Table 4. lOa: Factors associated with discontinuity along the Continuum ................ 117 
Table 4. lOb: Factors associated with discontinuity along the Continuum ............... 118 
Table 4. II: Health System factors affecting Continuum of Care ............................. 120 
Table 4. 12: Association between Health System factors and Discontinuity ............ 122 
Table 4.13: HSB of Mothers during Prenatal and Postnatal Period ......................... 124 
Table 4. 14: Association between socio-demographic characteristics of participants 
and Health Seeking Behaviour. .................................................................................. 127 
Table 4.15: Determinants of Health Seeking Behaviour .......................................... 129 
Table 4. 16: Health Seeking Behaviour for Neonatal Illness ..................................... 130 
Table 4. 17: Association between Socio-demographic Characteristics and Neonatal 
HSB............. . ................................................................................................... 132 
Table 4. 18: Determinants of HSB for Neonatallllness ............................................ 134 
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LIST OF FIGURES 
Figure I. 1: Conceptual framework for sociocultural practices influencing intrapartum 
and postpartum continuum of care ............................................................................... 13 
Figure 3.2: Map of AAN District ................................................................................ 73 
Figure 4.1: Continuum of Care ............................................................ 110 
Figure 5.1: Contextual issues on how Knowledge and Socia-cultural practices affects 
the Continuum of Care.. . ............................................................. 140 
Figure 5.2: Contextual Issues about Beliefs, Health Seeking Behaviour and 
Continuum of Care for Neonate. .. .. . . . . . .. ......... ... .. ................................ 150 
Fig 5.3: Health Seeking Behaviour of Women during Perinatal Period .............. 151 
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LIST OFABBREVIATIONS 
Abbreviation Meaning 
AANDA Asante Akim North District Assembly 
AEPI Accelerated Expanded Programme for Immunisation 
ANC Antenatal Care 
CHO Community Health Officer 
CHN Community Health Nurse 
CHPS Community-based Health Planning and Services 
CoC Continuum of Care 
CS Caesarean Section 
DHIMS District Health Information Management System 
DHMT District Health Management Team 
ENC Essential Newborn Care 
EMC Emergency Medical Care 
EPI Expanded Programme on Immunization 
GHS Ghana Health Service 
GDHS Ghana Demographic and Health Survey 
GMHS Ghana Maternal Health Survey 
GSS Ghana Statistical Service 
HIV Human Immuno-Deficiency Virus 
IMCI Integrated Management of Childhood Illnesses 
IPT Intermittent Preventive Treatment 
LMIC Low Middle Income Countries 
MAF MDG Accelerated Framework 
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MDG MiJlennium Development Goals 
MICS Multiple Indicator Cluster Survey 
MNCHCoC Maternal Neonatal and Child Health Continuum of Care 
NOPC National Development Planning Commission 
NHIS National Health Insurance Scheme 
NMR Neonatal Mortality Rate 
NTBA National Traditional Birth Attendant 
PNC Postnatal Care 
RHD Regional Health Directorate 
RMNCH Reproductive, Maternal, Neonatal and Child Health 
SBA Skilled Birth Attendant 
SCT Social Cognitive Theory 
SDGs Sustainable Development Goals 
SLT Social Learning Theory 
SMAG Safe Motherhood Action Group 
TBA Traditional Birth Attendant 
UHC Universal Health Coverage 
UNICEF United Nations Children's Fund 
WHO World Health Organization 
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CHAPTER ONE 
INTRODUCTION 
1.I Background 
Maternal and neonatal mortality remain serious problems in the developing world. 
The growing recognition of the critical importance of providing care to mothers and 
newborns and the substantial gaps in coverage that exist have prompted a paradigm 
shift in responding to maternal and new born health issues. Invariably, the health care 
that a mother receives during pregnancy, at the time of delivery, and soon after 
delivery is important for the survival and well-being of both the mother and her child. 
Globally, about 830 women die from pregnancy- or childbirth-related complications 
every day and this is unacceptably high (WHO, 2016). It was estimated that in 2015, 
approximately 303, 000 women died during and following pregnancy and childbirth. 
Almost all of these deaths occurred in low-resource settings, and most could have 
been prevented (WHO, 2016). The primary causes of maternal death are 
haemorrhage, hypertension, infections, and indirect causes, mostly due to interaction 
between pre-existing medical conditions and pregnancy. Of the 830 daily maternal 
deaths. 550 occurred in sub-Saharan Africa and 180 in Southern Asia, compared to 5 
in developed countries (WHO, 2016). As at 2015, the risk of a woman in a developing 
country dying from a maternal-related cause during her lifetime is about 33 times 
higher compared to a woman living in a developed country (WHO, 2016). It is 
therefore evident that maternal mortality is a health indicator that shows very wide 
gaps between the rich and the poor, urban and rural areas. both between and within 
countries. 
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Again, 2.9 million neonates die, with three-quarters of these deaths taking place in 
the first seven days oflife (UNICEF, 2012). In fact, the high Neonatal Mortality Rate 
(NMR) constituted a major bottleneck that prevented some countries within the Sub-
Saharan African Region from achieving their set Millennium Development Goal Four 
(MOO) 4. Newborn health also constitutes a human right as specified in the 
Convention of the Rights of the Child (UNICEF, 2013). The common causes of 
neonatal mortality include complications of prematurity, infections, and adverse 
intrapartum events including birth asphyxia and over 60% of the deaths are associated 
with low birth weight (Debes et aI., 2013). 
Although Ghana did not meet its MOOs 4 and 5 targets, it made significant progress 
in reducing maternal and under 5 mortalities (GSS, 2015). However, an examination 
of neonatal, infant, and undcr-5 mortality rates since 1998 reveals that neonatal 
mortality has decreased at a slower pace than infant and child mortality. This has 
resulted in an increase in the contribution of neonatal deaths to infant deaths from 
53% in 1998 to 71% in 2014. Similarly, the contribution of neonatal deaths to under-5 
mortality also increased from 28 percent of under-5 deaths to 48 percent over the 
same period (GSS, 2015). 
Ghana's MDG Acceleration Framework (MAF), Accelerated Expanded Programme 
of Immunization (EPI), Maternal Neonatal and Child Health (MNCH) Continuum of 
Care eCoC) have been some of the strategies employed as the country's action plan to 
redouble efforts to overcome bottlenecks in implementing evidence-based, feasible 
and cost-effective interventions that have proven to work in reducing maternal and 
neonatal mortalities. 
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Again. Community-based Health Planning and Services (CHPS) initiative was 
regarded as key to improving the coverage of MNCH services in Ghana and CoC 
measurement would help to identify whether the improvement is continuous. CHPS 
was adopted in 1999, as a national health policy initiative to reduce the geographical 
barriers to healthcare. Initially focusing on deprived and remote areas of rural 
districts, Community-based Health Planning and Services (CHPS) endeavours to 
transform the primary health care system by migrating from the conventional facility-
based and 'outreach' services to a program of mobile community-based care provided 
by a resident nurse (Yeji et aI., 2015). It is well documented that Community and 
health facility level factors hindered the achievement of the goals envisioned in these 
strategies (MAl'. AEPI, CoC) (NOPC, 2015). 
More of emphasis, cultural and traditional practices, values and beliefs have been 
identified to play an important role in the medical attention-seeking behaviour of 
postpartum mothers as well a, in newborn babies during the postnatal period 
(Bazzano et aI., 2008). Also. socio-cultural practices have been reported to affect 
child ~urvival (Wright et al.. 2014). By virtue of the fact that communities have their 
own unique cultures and traditions, traditional maternal and new-born practices may 
differ from community to community. Good practices need to be identified and 
promoted whilst bad practices must be discouraged (Saaka & Iddrisu, 2014) . 
Maternal and neonatal outcomes are inseparable. The quality of care, both health 
facility based and household based, available during pregnancy, delivery and 
postpartum period has much impact on newborn health (Oako-Gyeke, Aikins, 
Aryeetey, McCough. & Adongo, 2013). Likewise, complications that affect women 
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during pregnancy (intrapartum period) and childbirth also affect foetal and newborn 
health (Dako-Gyeke et aI., 2013). Hence, to ensure better health for newborns, the 
mother and child should be treated as one entity. Any range of interventions that seek 
to prevent perinatal and neonatal deaths must address both maternal and neonatal 
factors along the continuum from pregnancy to the postpartum period (Yeji et a!., 
201 S). This is crucial for Ghana to achieve its unfinished MOO 4 and 5 agenda which 
translates in Sustainable Development Goal Three (SDG 3); ensuring healthy lives 
and promoting well-being for all at all ages by 2030. Target 3.1 indicates a reduction 
in the global maternal mortality ratio to less than 70 per 100 000 live births and target 
3.2 emphasizes ending preventable deaths of newborns and children under 5 years of 
age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 
1000 live births and under-5 mortality to at least as low as 2S per 1000 live births 
(Dora et al.. 2014; WHO. 2015). 
In conclusion. maternal and neonatal mortality still remains a major reproductive 
health issue despite several interventions to reduce its burden and socio-cultural 
practices have been known to affect various facets of the health care system and 
health outcomes. 
1.2 Problem Statement 
In developing countries, evidence suggests that direct consequences of pregnancy and 
childbirth continue to account for most maternal deaths (WHO, 2016c). These 
outcomes are mainly attributed to haemorrhage, sepsis, and hypertensive 
complications (WHO. 2016c). Structurally, these conditions are seen as outcomes of a 
complex web of social, economic. educational, political and cultural factors (Dako-
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Gyeke et al.. 2013). Many of the causes of maternal and neonatal mortalities are 
largely preventable (WHO, 2015). 
Ghana's maternal and neonatal mortality ratios are currently 310 per 100,000 live 
births and 2511 000 live births respectively (GMHS, 2017) ; albeit several 
interventions such as the Child Health Policy and Strategy, Millennium Acceleration 
Framework and Country Action Plan: Maternal Health, Accelerated Expanded 
Programme of Immunization (EPI), with introduction of new and additional vaccines, 
as \\-ell as the Global Funded programmes for Malaria, TB and HIV, continuum of 
care among others (MOH, 2014), introduced to reduce the burden of these mortalities. 
Despite great efforts at the community level through the CHPS strategy, the coverage 
of delivery assisted by skilled birth attendant (SBA) and early postnatal care (PNC) 
still remains relatively low, compared with ANC. According to the Multiple Indicator 
Cluster Survey 2011, the coverage of delivery assisted by SBA and PNC (up to 48 
hours) visit were 68.4% and 41.5%, respectively, whilst the coverage of ANC for four 
times or above reached 86.6% (MICS. 2011;Yeji et ai., 2015). 
Again in Ghana, about 30% of babies are delivered at home (GSS, 2015) and even in 
cases where mothers deliver at a facility, they and their babies return home soon after 
birth, some after a few hours (GlIS, 2013). Maternal and neonatal deaths are 
accentuated by socio-cultural practices along the intrapartum and postpartum 
continuum of care and several studies have documented this across the globe (Abass, 
Sakoalia, & Mensah, 2012; lat, Deo, Goicolea, Hurtig, & San Sebastian, 2015; 
Marchie & Anyanwu, 2009; Okolocha, Chiwuzie, Braimoh, Unuigbe, & Olumeko. 
1998). Practices such as food taboos, consumption of herbal concoctions and 
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preference for traditional medical practitioners for health seeking are some practices 
that are documented as occurring during intrapartum and labour (A bass et aI., 2012). 
Also, women after delivery tend to remain at home and are restricted from going 
outside the home until the eighth day when the child is narned, or for longer periods. 
In many situations mothers do not respond to the first 48- hour visit call or even the 
visits on day 6 or 7. Reasons assigned for non-visits range from lack of knowledge of 
the need to visit to the fact that the "baby was well" and therefore the mother does 
not see the need to visit the facility (GHS, 2013). Even when babies develop 
problems, they are kept at home and often parents do not seek care immediately. 
When they do, it is inappropriate with the exclusive use of traditional medicines as 
first-line treatment (GHS, 2013). 
Essential newborn care (ENe) practices such as clean cord care (cutting and tying of 
the umbilical cord with a sterilized instrument and thread), thermal care (drying and 
wrapping the newborn immediately after delivery and delaying the newborn's first 
bath for at least six hours or several days to reduce hypothermia risk), and initiation of 
breastfeeding within the first hour of birth have mostly been ignored. Elderly women 
who are inclined with traditional beliefs and practices in the community greatly 
influence young mothers of neonates in using all sorts of herbs and other concoctions 
in either treating sick neonates or protecting the newborn from becoming ill. 
The situation is no ditferent in the Asante Akirn North District of the Ashanti Region. 
There has been decreasing trends in the uptake of all the essential services along the 
continuum of care that is from pregnancy through delivery till six weeks after delivery 
for the period 2013 to 2015 as follows: 
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Table 1: Uptake of essential service along tbe intrapartum and postpartum 
continuum of care in Asante Akim Nortb District (2013-2015) 
Year ANC(%) ANC4+(%) Skilled PNC 
DelivcIY(%l (6weeks) (%1 
2013 97.2 92.1 87.7 85.3 
2014 96.7 90.1 85.2 82.7 
2015 92.6 84.5 81.7 81.5 
Source: (DtIIMS) 
The same trend was depicted for maternal and neonatal mortalities and by June 2017, 
maternal mortality rate for the district was 217/100,000 live births whiles neonatal 
mortality rate was 3711000 live births (DHlMS). 
This study is therefore designed to assess the socio-cultural practices influencing 
intrapartum and postpartum continuum of care in the Asante Akim North (AAN) 
District of the Ashanti region of Ghana. An understanding of this is essential to 
develop targeted polices and strategies to improve home care practices and health care 
services to improve the health and survival of women, and newborns. 
1.3 Tbeory and Conceptual Framework 
Theories explain human behaviour (Rotolo et aI., 2016) and are therefore 
indispensable in social science research such as this. Despite the existence of several 
social science theories that explain various aspects of human behaviour, the Social 
Cognitive Theory (SCT) was adopted for this study. SCT was developed by Albert 
Bandura, a psychologist (Bandura, 2005). 
In SCT. learning is viewed as knowledge acquisition through cognitive processing of 
information. In other words, it acknowledges the social origins of much of human 
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thought and action (what individuals learn by being part of a society), whereas the 
cognitive portion recognizes the influential contribution of thought processes to 
human motivation, attitudes, and action (Bandura, 1999). The Social Cognitive 
Theory proposes that behaviour change describes a dynamic, ongoing process in 
which personal factors, environmental factors, and human behaviour exert influence 
upon each other. According to SCT, three main factors affect the likelihood that a 
person will change health behaviour: (1) Self-efficacy, (2) Goals, and (3) Outcome 
expectanc ies. 
If individuals have a sense of personal agency or self-efficacy, they can change 
behaviours even when faced with obstacles. If they do not feel that they can exercise 
control over their health behaviour, they are not motivated to act. or to persist through 
challenges. As a person adopts new behaviours, this causes changes in both the 
environment and in the person. 
Behaviour is not simply a product of the environment and the person, and 
environment is not simply a product of the person and behaviour. SCT evolved from 
research on Social Learning Theory (SL T), which asserts that people learn not only 
from their own experiences, but by observing the actions of others and the benefits of 
those actions. SCT integrates concepts and processes from cognitive, behaviours, and 
emotional models of behaviour change, so it includes many constructs. 
Social Cognitive Theory (SCT) explains the nature of bidirectional reciprocal 
influences through five basic human capabilities: (1) symbolizing, (2) forethought, (3) 
vicarious learning. (4) self-regulation, and (5) self-reflection. Employees use these 
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basic capabilities to self-influence themselves in order to initiate, regulate, and sustain 
their own behaviour. 
Social Cognitive Theory (SCn suggests that humans have an extraordinary 
symbolizing capability that allows them to successfully react and then change and 
adapt to their respective environments (Bandura, 1987). By using symbols, people 
process and transform immediate visual experiences into internal cognitive models 
that in tum serve as guides for their actions. Symbolizing is relevant in imbibing 
cultural norms in the community. 
Bandura argues that people not only react immediately to their environments through 
a symbolic process, but also self-regulate their future behaviours by forethought 
(Bandura, 2005). In particular, people plan courses of action for the near future, 
anticipate the likely consequences of their future actions, and set goals for themselves. 
Through forethought. people in community initiate and guide their actions in an 
anticipatory fashion. Interestingly. the future acquires causal properties by being 
represented cognitively by forethought exercised in the present. 
According to SCT. almost all forms of learning can occur vicariously by observing 
the behaviour of others and the subsequent consequences of their behaviours. People' s 
capacity to learn by observation enables them to obtain and accumulate rules for 
initiating and controlling different behavioural patterns without having to acquire 
these behaviours gradually by risky trial and error (Bandura, 200 I). The acquisition of 
knowledge vicariously is critical for learning and human activities. Human self-
regulatory capability plays the central role in SCT. Accordingly, people do not behave 
to suit the preferences or demands of others. Much of human behaviour is initiated 
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and regulated by internal self-set standards, and by self-evaluative reactions to exerted 
beha,iours (Bandura, 2012). After a person sets specific standards, any perceived 
incongruity between behaviour and the standard, activates self-evaluative reactions. 
These. in tum. serve to further influence subsequent action. The self-reflective 
capability. also called self-reflective consciousness. enables people to think and 
analyse their experiences and thought processes (Akers & Sellers. 20ll). By 
reflecting on their different personal experiences, people can generate a specific 
know ledge about their environment and about themselves. These reinforce 
community norms and socio-cultural practices. 
The second theory that is essential in explaining the sociocultural practices along the 
intrapartum and postpartum continuum of care is the Folk's theory. 
Folk theory situates health care in the context of norms of the society that an 
indi\ idual lives. To be able to gain acceptance in a community one is compelled to 
adopt to normal sociocultural practices (Kleinman, 1978). 
Based on these theories adopted, conceptual framework has been developed to explain 
the sociocultural practices that influence the intrapartum and postpartum continuum of 
care (Figure 1.\). Both SeT and folk's theory agree that socio-demographic 
characteristics such sex, educational attainment, religion, socio-economic status, 
ethnicity and others can influence the type of socio-cultural practices people are 
engaged in. In most African societies, women are not autonomous and are unable to 
take major household level decisions. The perception of causes of illness also affects 
health seeking behaviour. In traditional societies, pregnancy for instance is believed 
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not be sickness and hence any ill - experience during pregnancy is believed to be 
normal and should not warrant health seeking. 
There are practices such as food restrictions during pregnancy and beliefs that 
pregnant women should abstain from going to public place until some ritual are 
performed. These practices also affect health seeking during this period. 
During labour some women deliver at home because of the practice that placenta of 
the baby must buried at home. This practice therefore promotes home delivery which 
affects the continuum of care. 
Also, there can be a reciprocal relationship between the socio-cultural practices along 
the continuum from pregnancy to after birth and the health system factors. As noted, 
the health system can be viewed from a both social and cultural perspective and 
potentially influences sociocultural practices (Kleinman, 1978). Cost of service and 
distance to health facilities have been found to be one of the influencers of health 
seeking behaviour of people. Again, individuals may resort to local practices such as 
the use of herbal concoctions as a way of treating ill-health. Poor attitude of health 
workers to pregnant wom.:n and during labour affect the health seeking behaviour of 
women which invariably affects utilisation of health care from pregnancy to childbirth 
(Ganle, Parker, Fitzpatrick, & Otupiri, 2014; Moyer, Adongo, Aborigo, Hodgson, & 
Engmann,2014). Also, social practices such as preference for squatting have been 
found to be a demand for women during labour and if the health system is unable to 
meet that demand of women, this will definitely affect their choice place for birth. 
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Practices such as confinement during postnatal period also affect the continuum care 
during the puerperal period. Negative beliefs about colostrum and early breastmilk 
lead to women discarding this milk which is very essential for baby's immunity 
during the early stages of life. All these maternal and newborn practices have the 
potential of affecting the health status of the mother and the baby, the health seeking 
behaviour of mother and baby and more importantly. affect the continuum of care as 
illustrated on figure 1.1. 
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Sodo-cultural Practict's along "ontinuum 
Pregnancy 
I Ol,J l.lho<' 
Consumplion of herbal concod,ons 
Preference lor rraditionall\kJical Practitioners for 
health !leCking 
Sc.\ual praclkl" h 
Rt'II~I{lIl" barriers 
During lallou .. 
Prek,.;nce lor Traditional Birth Attendants 
Religious barriers 
Preference lor squatting position 
Home burial of placenta 
Postpartum 
Confinement • Food restrictions 
Socio-demogrHl'hir factor~ --~j------------~ 
Age at birth -..- _. .- 
Rdidon Socio-cultural practices-l'Iiewborn Maternal/Child Health issues 
L",:lofeducation I ,,' "f unstenle lIl,lIc"als for cord cutting 
I'lhnicity • Skilled Obstetric Care at bi.rth l O·ut come Intrapartum and ;. I sc 01 CO" duns Vaseline/sheabutter to dress cord 
AN(· attendWlce --I. • Maternal health . Postpartum Washin~ bab) \I Ith .nap & water within 2 hours of birth 
Parity 1--+1. Essential N~wborn care \ Continuum of I Dlscardmg of colostrum 
SUCitH.. .' L'lllllHllIC status I. Use of alcohol on newborn Health seekmg behaviour for ~ Care 
I. mothers and neonates : i. Maternal and Confinement of newborn Child Health 
'. PercePtions on causes 0 f neonatal illnesses 
t I I Outcomes ~ Health system Issues 
Cost of Sen ic.:.-. 
Distance to the hCdllh facility 
Anitude of health care workers 
t-
Concerns about quality of care 
Lack of transportation 
Counselling on skilled deliver) 
Figure I. I: Conceptual frame" ork for sociocultural practices influencing intrapartum and postpartum continuum of care 
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1.4 Research Questions 
Four specific research questions that were addressed in this study were: 
I . What are the socio-cultural practices during the continuum of care during 
intrapartum. labour and postpartum period? 
2. How do socio-cultural practices influence health services to affect continuum of 
care? 
3. What is the health seeking behaviour of women along intrapartum and postpartum 
continuum of care? 
4. What is the health seeking behaviour for neonates? 
1.5 Study Objectives 
1.5.1 General Objective 
The general objective of the study is to assess socio-cultural practices that influence 
intrapartum and postpartum continuum of care in the Asante Akim North district. 
1.5.2 Specific Objectives 
The specific objectives of the study are to: 
1. To assess socio-cultural practices during intrapartum, labour and postpartum period; 
2. To examine how socio-cultural practices influence health service factors to affect the 
continuum of care; 
3. To determine the health seeking behaviour for neonatal illness; 
4. To determine health seeking behaviour of women along intrapartum and postpartum 
continuum of care. 
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1.6 Justification of Study 
Healthcare decisions regarding pregnant women and infant care are often influenced by 
community members and confidence in healthcare providers is issue-specific. Again, barriers 
to prompt allopathic care seeking have been found to include sequential care-seeking 
practices, with often exclusive use of traditional medicine as first-line treatment; previous 
negative experiences with health service facilities; fmancial constraints, and remoteness from 
health facilities (Bazzano et aI., 2008). The greatest gap in maternal and newborn care is 
otten during the critical first week of life when most maternal and neonatal deaths often occur 
at home and without any contact with the formal health sector. 
Some unacceptable practices such as unskilled attendants during delivery, unhygienic 
delivery practices, food taboos and superstitions associated with intrapartum and postpartum 
period greatly affect maternal and newborn survival in the Asante Akim North District of the 
Ashanti Region (Anecdotal). This study therefore, seeks to identify the gaps in the knowledge 
and practices along the intrapartum and postpartum continuum of care and to provide inputs 
into developing feasible and sustainable community-based interventions to improve maternal 
& neonatal survival in the Asante Akim North District. 
Mothers. newborns, and children are inseparably linked in life and in health care needs. In the 
past, maternal and child health policy and programmes tended to address the mother and 
child separately, resulting in gaps in care which especially affect neworn babies. Currently, 
policy and programme attention is shifting towards a maternal, newborn and child health 
(MNCH) continuum of care. Instead of competing calls for mother or child, the focus is on 
universal coverage of effective interventions. integrating care throughout the lifecycle and 
building a comprehensive and responsive health system. The MNCH continuum of care can 
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be achieved through a combination of well-defined polices and strategies to improve home 
care practices and health care services throughout the Jifecycle, building on existing 
programmes and packages (Yeji et aI., 2015). It is therefore apparent that an understanding 
of the sociocultural influences on intrapartum and postpartum continuum of care is essential 
to inform policy and strategy formulation in address the big challenge in the Maternal 
Neonatal and Child Health (MNCH) continuum of care. This is an effective approach at 
improving maternal neonatal and child survival in Ghana. 
Ihis study. by assessing socio-cultural factors that influence intrapartum and postpartum 
continuum of care will contribute important and new knowledge to the prevailing maternal 
and newborn care literature and form the basis for strengthening strategies aimed at 
improving the skills of health workers, strengthening health system supports, and improving 
household and community practices and community actions for health. The Maternal 
Neonatal and Child Health (MNCH) continuum of care approach also brings care closer to 
the home through outreach services and promotes referral by strengthening access to and 
improving the quality of services at peripheral and district level facilities. Combining 
effective care in health facilities, healthy behaviours at home and early care seeking for 
illness will have the biggest impact on mother, newborn and child health (Yeji et aI., 2015). 
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CHAPTER TWO 
LITERATURE REVIEW 
2.1 Introduction 
This chapter presents review of literature on intrapartum and postpartum continuum of care. 
The literature covers the burden of maternal and infant mortality globally, in Africa and 
Ghana. This review also covers socio-cultural practices along the continuum of care as well 
as the health seeking behaviour for women and neonates along the continuum. The review 
also takes a critical look at practices during pregnancy, delivery, care of baby after delivery 
as well a<; the mother. 
Sources of literature for this study included key electronic databases, including the Cochrane 
library, EMBASE, Google Scholar and the social science citation index. Additionally, key 
journals were hand searched through tracking references and citations to see if papers have 
be!!n cited by other. more recent papers. In the review, priority is given to the research 
questions in deciding on the most appropriate sources. 
2.2 Global situation of Maternal Morbidity and Mortality 
In September 2000. 189 world leaders signed a declaration on eight Millennium 
Development Goals (MDGs) to improve the lives of women, men, and children in their 
respective countries. Goal Sa called for the reduction of maternal mortality by 75 percent 
between 1990 and 2015. Goal Sa was supplemented by MDG 5b on universal access to 
contraception (UN, 2016). MDGs Sa and 5b have been important catalysts for the reductions 
in maternal mortality levels that have been achieved in many setting (Abalos, Cuesta, Grosso, 
Chou. & Say. 2013). All these were aimed at improving maternal health and reducing 
maternal mortality. Maternal mortality is a sentinel event used globally to monitor maternal 
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health, the general quality of reproductive health care, and the progress countries have made 
toward international development goals (Hogan et al., 2010). Globally, much progress has 
been made to reduce maternal mortality and promote maternal health (United Nations, 2010). 
This has been made possible through the commitment engendered by Goal 5 of the 
Millennium Development Goals. which aimed to reduce maternal mortality ratio by 75% 
between 1990 and 2015 and also captured in the new Sustainable Development Goals 
(Soos). The 17 Soos carry on the work begun by the Millennium Development Goals 
(MOOs), which galvanized a global campaign from 2000-2015 to end poverty in its various 
dimensions. Yet while the MDGs only applied to developing countries, the SDGs apply 
universally to all UN member states, and are considerably more comprehensive and 
ambitious than the MOOs. Despite this, 800 women are reported to still die every day from 
pregnancy and childbirth related causes (WHO et aI., 2014). The majority (>90 %) of these 
deaths occur in low and middle income countries (LMICs) (WHOIUNICEFIUNFPAlWorld 
BanklUNPD, 2015). The lifetime risk of maternal mortality in sub-Saharan Africa is I in 38 
women compared to 1 in 3,700 in developed countries (WHO et aI., 2014). On a daily basis, 
about 830 maternal deaths occur globally. Out of this. 550 occur in sub-Saharan Africa and 
180 in Southern Asia, compared to 5 in developed countries. The risk of a woman in a 
developing country dying from a maternal-related cause during her lifetime is about 33 times 
higher compared to a woman living in a developed country (WHO, 2016). 
In Ghana. although there has been improvement in the maternal mortality, it still remains 
high in spite of continued efforts. In the year 1990, maternal mortality was 6341100, 000 live 
births and this figure had reduced to 319/100,000 live births in 2015. This translates into 
3200 maternal deaths and 2800 deaths for the year 1990 and 2015 respectively. The primary 
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causes of death are haemorrhage. hypertension, infections, and indirect causes, mostly due to 
interaction between pre-existing medical conditions and pregnancy. These deaths occur along 
the intrapartum and postpartum continuum of care (Ronsmans & Graham, 2006). As noted, 
maternal deaths are often clustered around labour. delivery. and the immediate postpartum 
period. with obstetric haemorrhage being the main medical cause of death (Ronsmans & 
(iraham. 2006). Nonetheless. these deaths are accentuated by socio-cultural practices that 
affect health seeking behaviours of women and several studies have documented this across 
the globe (Abass et al.. 2012; Jat et al.. 2015; Marchie & Anyanwu, 2009; Okolocha et aI., 
1998). It is therefore important for studies to document these practices and effective ways to 
improve them to reduce maternal mortality as Ghana takes steps to achieving the sustainable 
development goals (Dora et al.. 2014; WHO, 2015). A Sustainable Development Goal for 
2030 is to reduce the global MMR to 70 per 100,000 births and for no country to exceed two 
times that ratio (140 per 100.000), (Geller et aI., 2018). 
2.3 Global situation 00 Newborn aod Child Health 
There has been quite a remarkable improvement in child survival since 1990. Mortality 
among children aged between 5-14 years decreased by 52% in 2017 while under- five 
mortality decreased by almost 58% from 93/1 000 live births in 1990 to 39/1 000 live births in 
2017. Neonatal deaths. defined as any death that occurs in the first 28 days of life. currently 
account for approximately 44% of all deaths of children under five years of age in low and 
middle - income countries (Seale et al.. 2013). Newborns are at the highest risk of death 
during the first week of life with the greatest of this risk being in the first day (Lawn & 
Kinney. 2012). This high risk in mortality is attributable to the many physiological and 
anatomical changes that occur at birth coupled with the environment and the circumstances 
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surrounding these changes which greatly influence the survival of neonates. Over the last two 
and half decades. a systematic analysis of the progress made indicates that there has been 
limited advancement to reduce the rate of neonatal mortality. For example globally, under -
tivt! mortality decreased by slightly more than two-thirds from 143 per thousand live births in 
1970 to 44 per thousand in 2013. While the mortality of children under -five decreased 
worldwide from 17.6 million in 1970 to 6.3 million in 2013 (Wang. Dwyer -Lindgren, & 
Lofgren, 2013), neonatal deaths decreased just marginally. This number represents an 
increased proportion of neonatal to under- five child deaths from 36% in 2000 to 41% in 
2008 (Lozano et al.. 2011). Since 2003, the global child mortality rate therefore decreased at 
a much faster rate than in the 1970s and 1980s. 
In 2013. about 31.9% of under -five deaths worldwide happened in the early neonatal period 
(age 0-6 days). 9.7% in the late neonatal period (age 7-28 days), 29.4% in the post neonatal 
period (age 29-364 days) and 28.9% between the ages of 1-4 years (Wang, Dwyer -Lindgren 
& Lofgren. 2013). The proportion of child deaths in the neonatal (early and late) period 
increased from 33.4% in 1970 to 41 .6% in 2013 (Wang, Dwyer -Lindgren & Lofgren, 2013). 
Of these deaths, over 90% occur in low -and middle- income countries (LMICS), making the 
risk of death in the neonatal period in LMIC more than six times the risk in high income 
countries (WHO, 2006c; Lawn et aI., 2005). 
Globally all estimated 2.9 million neonatal deaths occur in the first 28 days after birth (J. E. 
Lawn et aI., 2014). These deaths constitute more than half of under-five child deaths in most 
regions of the world and account for roughly 44% of global deaths (UNICEF, 2014a). These 
deaths have been described as the "unfinished agenda" of the 21st century (UNICEF,2014a). 
Since the 1990s, the global neonatal mortality rate (NMR) has decreased by just 37% from 33 
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to 21 deaths per 1000 live births compared with greater than 50% reduction for mortality 
rates among children aged I-59 months (WHO, 2014a). Between 1990 and 2012, Eastern 
Asia achieved over 65% reduction in neonatal mortality compared to only 28% in sub 
Saharan Africa and 17% in Oceania, suggesting a much slower progress in sub Saharan 
Africa (Bhutta et aJ., 2014). In 2013, the ten countries with the highest under -five mortality 
rate were all in sub - Saharan Africa. Neonatal mortality rates ranged from 42.6 (per 1000 
live births) in Mali to 1.2 (per 1000 live births) in Singapore (Wang et al., 2014). 
The NMR ~aries from I (per 1000 live births) in Japan to 49.5 (per 1000 live births) in Sierra 
Leone. Rwanda. with a neonatal mortality of 20.9 (per 1000 live births) is considered the 
country ",ith the fastest annual rate of reduction (ARR) of 5.7% between 2000 and 2012 in 
sub Saharan Africa (Lawn et aI., 2014). The rest of the countries making substantial progress 
are in Asia and Latin America (Lawn et aI., 2014). More than half of neonatal deaths globally 
occur in the five highest burden countries; India (779,000), Nigeria (276,000), Pakistan 
(202,400). China (157,400) and Democratic Republic of Congo (118,100) (WHO, 2014a). 
These countries are also the ones making the least progress in terms of reducing NMR 
(WHO, 2014a). In 2012, ofthe nine countries that had neonatal mortality rates greater than or 
equal to 40, eight were in Sub Saharan Africa (Lawn et aI., 2014). 
Of the several contributors to the burden of neonatal morbidity and mortality preterm birth 
complications are the single largest cause of death, responsible for an estimated 36% of all 
neonatal deaths with intrapartum -related conditions previously called birth asphyxia and 
infections notably sepsis, meningitis and pneumonia each contributing 23% (Bhutta et aI., 
2014). A key observation however is that, the causes of newborn deaths shift as the newborn 
progresses from the early neonatal to the late neonatal period. During the early neonatal 
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period (0-6 days). intrapartum and preterm account for a greater chunk of newborn deaths 
(about 68%). while in the late period (7-27 days), sepsis, preterm and intrapartum related 
conditions account for over three quarters of all newborn mortality, with sepsis and diarrhoea 
contributing more to these deaths in the late than the early neonatal phase (Bhutta et aI., 
2014). 
Closely linked to this challenge is the over 800.000 neonatal deaths among babies born small 
for gestational age attributable to undernutrition (Black et aI., 2013). In 2012, more than 80% 
of neonatal deaths in sub-Saharan Africa and south Asia were of small babies (65% 
attributable to preterm and 19% to term small for gestational age) (Lawn et aI., 2013). Two 
thirds of the Small for Gestational Age (SGA) neonatal deaths were of term low birthweight 
babies. Urgent attention is therefore needed to ensure that all small babies receive appropriate 
newborn care and nutritional support (Lawn et al.. 2013). Small for Gestational Age (SGA) 
are babies that might have grown healthily but are constitutionally small, or might have 
suffered intrauterine growth restriction due to placental insufficiency (e.g. Pre-eclampsia or 
placental malarial, fetal reasons (such as mUltiple births), environmental exposures or 
nutritional factors especially driven by maternal pre-pregnancy nutritional status (Bhutta et 
aI., 2014). Babies born too early (<28 weeks' gestation) have the highest risk of neonatal 
death especially if without specialized newborn care (Blencowe et aI., 2013). Of the 15 
million babies worldwide, that were born preterm in 2012, 85% of them at 32-36 weeks, 
Africa has the highest rates (Blencowe et aI., 2012). Sub Saharan Africa and South Asia 
together harbour the worlds 32 million small for gestational age (SGA) babies. Size at birth is 
a strong predictor of long term health (Barker, 2004). Babies born preterm and SGA have the 
highest risk for stunting in childhood (Ota et aI., 2014) and the prevalence of cardiovascular 
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diseases. obesity and insulin resistance or type 2 diabetes have been linked to pretenn and 
SGA births (Murray et aI., 2012). Globally, a newborn (neonate) refers to an infant from 
birth to 28 weeks after birth. Hence neonatal mortality is a death of infant within this period 
ofhfe (Lawn et al.. 2014). These neonates have a high risk of mortality (Winch et aI., 2005). 
In 2015,5.9 million children under five years died, implying that about 16,000 children died 
every day. Out of these deaths, 2.7 million (45%) were neonates (WHOIUNICEFlUNlWorld 
Bank. 2016). These deaths are also significantly high in sub-Saharan Africa. It has been 
reported that lout of 12 children in sub-Saharan Africa dies before attaining age five as 
compared to lout of 47 children in high income countries (WHOIUNICEFlUNlWorld Bank, 
2016). Studies have also shown that in low resourced countries even if deliveries have taken 
place in health facilities. because of early discharge and poor health care seeking behaviours, 
most newborns die at home and some may not even be reported (Wright et aI., 2014). 
Several condition~ haw been reported to be responsible for neonatal deaths. Some of the 
conditions indude childhood sepsis. hydration, hypothennia, malnutrition, and childhood 
"Iller diseases whil:h are mostly preventable through immunization (Mah-Mungyeh et al.. 
2014: Rajindrajith. Mettananda, Adihetti, Goonawardana, & Devanarayana, 2009; Simmons, 
Ruben'i. Darmstadt. & Gravett, 2010; World health organization, 2006). However, neonatal 
scpsi~ has been reported as a factor that accentuates neonatal deaths from other conditions. 
For example, in the year 2012, 6.1 million neonates were reported to have acquired this 
condition in South Asia and Sub Saharan Africa (Seale et aI., 2013). This condition has high 
ca,.: fatality and has been estimated to be 8%-80% (Kissoon et aI., 2011; Thaver & Zaidi, 
20(9) 
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Despite the high burden of neonatal mortality, it has been noted that about 37-67% of these 
deaths could be prevented with 90% coverage of maternal and child health-related 
programmes globally (UNICEF. 20 13b). Essential Newborn Care (ENC) was introduced as 
strategy to reduce neonatal morbidity and mortality(WHO. 2013a). ENC encapsulate a series 
of interventions such as clean cord care, thermal care, early initiation of breastfeeding, 
exclusive breastfeeding and immunization which aim at reducing neonatal morbidity and 
mortality (Grady et al.. 2011; WHO, 2010). The components of ENC have therefore been 
incorporated into the global strategy of continuum of care framework (Lawn, Zupan, 
Begkoyian. & Knippenberg, 2006). 
Infant mortality in Ghana remains high despite several interventions aimed at reducing these 
deaths. In 2016, infant mortality rate was about 37% which placed Ghana at 165th of 244 
nations from data compiled by the WHO on the health status (WHO et aI., 2014). 
Furthermore. 40% of under- five deaths occurred during the neonatal period. This therefore 
makes this period very critical in health interventions as the causes of such mortalities are 
largely preventable ib indicated in the Ghana National Newborn Health Strategic and Action 
Plan 2014-201S (MoH, 2014a). 
2,4 Antenatal Care (ANC) and Maternal Health 
Antenatal Care (ANC) is one of the three most essential care given to women during 
pregnancy (Mcnellan et aI., 2019) and a key indicator of the Sustainable Development Goal 
(SDG) 3 target 3.1 - reducing the global maternal mortality ratio to less than 70 per 100,000. 
Antenatal care (ANC) was developed in the 1900s and serves as the first care offered to 
pregnant \\omen during a visit to a health facility (WHO, 2005). Expectant women who go to 
health facility for ANC are provided with essential care such as assessing maternal health as 
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well as the health of the foetus in utero. Women are also given some orientation on parenting 
(pMNCH. 2006). ANC provides an opportunity for expectant 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). 
Conventionall]. antenatal care was recommended for developing countries along the path of 
those used in developed countries, with only slight amendments made to fit the local context 
because of its potential of helping to reduce maternal mortality and improving maternal and 
child health (ACCESS, 200S). A standard of four antenatal visits is recommended for a 
healthy pregnant woman from a skilled health care provider (ACCESS, 2005). A skilled 
attendant is defined by the WHO (WHO, 2012b) as a qualified health professional who has 
been trained and educated with expertise to identitY. provide and manage normal pregnancies 
and make referral of difficulties with pregnant women and newborns such as a doctor, 
midwife. or nurse. Skilled providers have also been explained to include doctors, 
nurse/midwives. and community health officer/nurses (ACCESS, 2005). Skilled provider can 
identitY complications and help to manage the situation. Despite the importance of antenatal 
care and all its potential in helping to reduce maternal mortality, antenatal care has been 
underused even when made available (Mcnellan et aI., 2019). 
Globally, it was estimated in 2014 that six out of ten pregnant women made at least four 
ANC visits: nine out often in the Americans; seven out often in the South - East Asia; four 
out of ten in the Eastern Mediterranean and Africa (WHO. 2015). In sub-Sahara Africa, 
pregnant women who make four or more antenatal care visits vary from 12% in Ethiopia 
(WHO. 2015); 35 per cent in Rwanda, 47% in Kenya, 62% in Cameroon to 87% in Ghana 
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(Ghana Health Service. 2015a). Although antenatal coverage is high, the percentage reporting 
at least four visits is low. For instance, in Rwanda, while 98% of women reported at least one 
antenatal care visit, 35% of women reported four or more ANC visits (WHO, 2015). Low 
utilisation of antenatal care services can affect the adequacy of information and services 
given to women reporting for care thus leading to poor maternal mortality outcomes (WHO, 
2015). For instance. evidence from Sub-Saharan African Countries shows that less than half 
of women who utilise antenatal care services were not informed about the danger signs of 
pregnancy complications. These percentages range from 10% in Rwanda, Mali 29%, 
Cameroon 380/0, Uganda 35%, Zimbabwe 49% to 73% in Zambia (WHO, 2015). In Ghana, 
two-thirds of women who utilise antenatal care received information about the danger signs 
of pregnancy complications (Ghana Health Service, 2015a). 
In recent times however there has been a shift in focus from the facility-based routine visits 
by the pregnant women, to a more proactive strategy where every expectant woman is 
assigned to a health worker who will do regular monitoring of the pregnant women. This 
approach known as Focused Antenatal Care (FANC) was championed by the World Health 
Organisation (WHO) in 2002 (PMCH. 2010). 
Antenatal Care (ANC) service provision is important in reducing maternal deaths from 
complkations during pregnancy such as haemorrhage. hypertension, sepsis, and obstructed 
labour. These direct obstetric deaths account for 64% of all maternal deaths that occur in 
Africa whilst over 50% of maternal deaths occur within twenty-four hours of birth (WHO, 
UNICEF, UNFPA, 2014). 
Antenatal Care (ANC) has the potential to prevent direct death as it leads to early detection of 
warning signs for timely interventions (Heredia-Pi, Servan-Mori, Darney, Reyes-Morales, & 
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Lozano. 2016). 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 in the eighth month. and 
then weekly in the final month. culminating in 12 - 13 visits overall (NCPD, CBS & MI. 
1999). In places. where the health facilities are not located in the community, the ANC visits 
may come with some financial obligations to the pregnant woman and her family and this 
have been reported to affect utilization of ANC (Kearns, Hurst, Caglia, & Langer. 2014). 
Despite knowing the importance of timely ANC, study in Zambia found out that some 
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, 2010). 
The poor and vulnerable in society are constantly at the receiving end of poor maternal health 
care. In the industrialized countries, there is widespread utilization of ANC by pregnant 
women with the exception of the underserved groups such as migrants, minority ethnic 
groups, unmarried teenagers, the very poor and those living in isolated rural communities 
(Hagey. Rulisa.. & Perez-Escamilla, 2014). 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 Kenyan study showed that 
female rural dweller started ANC later than other urban dwellers with 66% of pregnant 
women in Nairobi rural dweller starting in their second trimester while 20% started in their 
last trimc,ter, contrary to the WHO recommendations (Kwambai et al.. 2013). Studies in 
India and ;\Iigeria reported that the poor are less likely to initiate ANC early or attend any 
ANC all during pregnancy (Aniebue & Aniebue, 2011; Singh, Pallikadavath, Ram, & 
Alagarajan.2014). 
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2.5 Skilled and Unskilled Birth 
fhe 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 (Hogan et aI., 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 (Magoma, Requejo, Campbell, Cousens, & Filippi, 2010). 
Skilled delivery hill> been reported to reduce the probability of maternal mortality (Tarekegn, 
Lieberman. & Giedraitis, 2014), and recognised in SDG 3 (UN, 2016). Generally, skilled 
deliver} rates are high in developed countries and is estimated to be about 99.5% but the 
situation is different in the developing countries where only about 50% of women use the 
services ora skilled birth attendant. with the rate in Africa being 46.5% (Nesbitt et aI., 2013). 
Skilled birth rates are however, low in developing countries. In SUb-Saharan Africa skilled 
delivery is often less than 50% (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 (Yanagisawa et aI., 2013). 
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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 
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 follow-up 
meetings with health care personnel for supervisory and educational purposes (Bergstrom & 
Goodburn, 200 I). 
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 & Goodbum, 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 al.. 2005). 
TBAs provide maternal care during the perinatal period, and are trusted by pregnant women 
in their communities as they are well-entrenched in the culture and nonns of the communities 
they serve. are 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 (Ensor, 2004). 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 
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ineffective due to high levels of illiteracy, inadequate monitoring and supervision, improper 
linkages with the health care system and non-existent emergency referral systems (Bergstrom 
& Goodburn. 2001; Sibley, Sipe, & Koblinsky, 2004; WHOIUNFPAIUN}CEF, 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 II % of the total 
world population, and 24% of the disease burden worldwide, there are only 3% of all health 
workers globally, with less than 1% 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 (Shiferaw, Spigt, Godefrooij, Melkamu, & Tekie, 
2013). 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 (Wilson et aI., 2012). 
Despite critics' continuous questioning of the usefulness of TBAs, 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 MMR from 
I 500 to 115 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 aI., 1999). Malaysia and Sri Lanka are developing countries that 
have achieved MMR less than 100 by steadily increasing the number of professional 
attendants buttressed by access to essential obstetric care services (Lassi, Das, Salam, & 
Bhuns. 2014). Contrary to these success stories, the training of TBAs in Bangladesh has led 
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to a continued recording of high MMR due to the lack of essential obstetric care (Nessa, 
1(95). Furthermore. a study carried out in Senegal trained midwives and TBAs and found 
that maternal mortality was higher with TBA-assisted births than with midwife-assisted births 
(Kaingu, Oduma & Kanui. 2011). 
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 
countries indicate that over 60% of births that occur in sub-Saharan Africa take place at home 
(PMNCH, 2006). UnderutilizatioJl 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 will be wary of losing respect within 
their communities. or relinquishing control of the delivery process to a birth attendant 
(Asamoah et aI., 2014; Alessandra Nina Bazzano, Kirkwood, Tawiah-Agyemang, Owusu-
Agyei. & Adongo, 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 (Crb~man et aI., 2013; Cheryl 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, Szaszdi, & Glover, 2002; Prata et aI., 2011). A study 
carried out by Khan et al., (2012) in Indian established that family tradition, financial 
challenges and mistreatment by health care facility workers were all reasons given for female 
preference home delivery for health facility delivery. 
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Wom.:n 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 
death~ per 100,000 live births as far back as 2006 (GSS, 2013; Nyarko, Armar-klemesu, 
Deganus. & Odoi-agyarko, 2006). To date, MMR still remains high and these deaths are 
largely due to direct causes such as haemorrhage, unsafe abortion, hypertension in pregnancy, 
s.:psis. ectopic gestation and complications arising from obstructed labour; as well as indirect 
causes comprising of infections such as pneumonia and meningitis, anaemia and HIV I AIDS-
related infections (Der et al., 2013). 
A third of all births in Ghana are assisted by a Traditional Birth Attendant, with or without 
training (Twum-Baah. Nyarko, Quashie. Caiquo, & Amuah, 1994; GSS/GHS/ICF Macro, 
2009) and these attendants are culturally 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 tu 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 at.. 2000). An assessment of the impact this programme has 
made 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 aL. 1993; Smith et al., 2000). 
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2.6 Postnatal Care during Peripartum Period 
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. 2013b) 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 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, 20I3b). 
The services offered for postnatal care include family planning; support for imbibing healthy 
behaviours: education on infant care-giving comprising of hygiene, breastfeeding, 
identification of danger signs and immunization; as well as additional care for babies who are 
preterm or small-for-age (WHO, 20I3b). Immunization 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 (Sarker et aI., 2016a). 
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 
,ituation 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 care visit by the 
sewnd 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% (GHS, 20I3a); 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 
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delivery as was found in studies conducted in Bangladesh and Tanzania (Choudhury et aI., 
2012; Mrisho et al., 2009; Winch et aI., 2005). In the Bangladeshi study, only 24% of women 
living in slum areas had received postnatal care, with just 5% of them having had up to the 
recommended four visits (Choudhury et aI., 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 ANC and PNC interventions 
more efficient (Abouzahr, 1998). 
Critical to the postnatal and care during puerperium is social support and this have been 
documented in various literature. The support often comes from various family members who 
have also been described as the initiators of socio-cultural practices. For instance in Brazil, 
qualitative descriptive findings showed that, puerperal women received support from their 
moth.:rs. mother in-laws, sisters, and aunties and also from their brothers' wives (Dodou et 
aI., 2014). Another descriptive cross-sectional survey in Brazil supported that more than 50% 
()f respondents received support from their mothers, daughters, sisters, mother in-laws and 
'Ist.:r in- la\\s (de Oliveira et aI., 2014). In Syria, support was desired from mothers, sisters, 
and aunties (Abushaikha & Massah, 2012). 
2.7 InternntioDs to improve Maternal and Child health 
This section looks at interventions that have been implemented at global, regional and 
country level to improve maternal and child health services. 
2.7.1 The three delays framework/model in Maternal Health 
At the 1987 launch of the Safe Motherhood Initiative, maternal health experts discussed how 
long a woman would have to have a particular complication before she would die, if 
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untreated. They agreed that for the most frequent complications, women with postpartum 
hemorrhage had less than 2 hours before death; for antepartum hemorrhage, eclampsia, 
obstructed labor, and sepsis, the times \IIould be 12 hours, 2 days, 3 days, and 6 days, 
respectively. These led to the emergence of the three delay model. The framework has three 
levels of delay: first, second and third. 
The first delay is the time between the onset ofa complication and the recognition of the need 
to transport the patient to a facility. [n this delay, early recognition of danger signs and 
symptoms play an important role. Knowledge on complications during the intrapartum and 
postpartum period are essential in reducing this level of delay. In some rural areas gatekeeper 
system makes it difficult for women to take critical health decision such as attending a health 
facility \IIithout the approval of the husband or head of the family. This have reported as 
critical determinants of the delay in seeking health seeking (Gaunt, 2008; Romualdez Jr. et 
al.. 2011). 
rhe second delay is the time that elapses between leaving the home and reaching the facility. 
This delay is affected by the decision making process, proximity to health facilities as well as 
the availability of emergency transportation system. Transportation cost and deplorable road 
network may still serve as a barrier in some instance therefore denying the individual access 
to the free midwifery and delivery services to reduce maternal mortality (Awoonor-Williams, 
Phillips, & Bawah, 2016). In Ghana health service delivery is organized at three levels _ 
national, regional and district. The district level is further divided into a number of sub-
districts and incorporates a community-level health delivery system. Public health services 
are delivered through a hierarchy of hospitals, health centres, maternity homes and clinics 
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including a Community-based Health Planning and Services (CHPS) strategy (GHS, 2016). 
Health services cover primary care through secondary to tertiary services organized at five 
levels: community. sub-district., district. regional and teaching hospitals (specialized), 
Community and sub-district levels provide primary care, with district and regional hospitals 
providing secondary health care. Hence the second delay will occur when a pregnant woman 
try to access any of these service delivery points in Ghana. Providing emergency transport 
system hlb reported as effective in reducing delay in reaching the health facility (Raje, 2018). 
The third delay is the elapsed time from presentation at the facility to the provision of 
appropriate treatment. The determinants of the third delay are related to quality of care, such 
as the number and training of staff members and the availability of blood supplies and 
essential equipment (Awoonor-Williams et aI., 2016). To reduce the third delay WHO 
introduced the Emergency Obstetric and Neonatal Care (EMONC) system to ensure that 
women have access to basic essential care in all health facilities. The WHO EMONC tool 
classifies health facilities as basic or comprehensive EMONC depending on the availability 
of emergency maternal. obstetric and neonatal care services. Basic EMONC health facilities 
art: those that can administer parenteral antibiotics, uterotonic drugs (i.e. parenteral oxytocin), 
parenteral anticonvulsants for pre-eclampsia and eclampsia (i.e. magnesium sulphate), 
manual removal of the placenta, removal of retained products (e.g. manual vacuum 
aspiration) and can perform assisted vaginal delivery (e.g., vacuum extraction, forceps). In 
addition to these six, a comprehensive EMONC facility should be able to perform surgery 
(e.g. caesarean section) and blood transfusion (Fakih et aI., 2016; WHO/UNICEFfUNFPA, 
2009). 
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According to EMONC assessment of health facilities in Ghana in 2011, only 13 of health 
facilities could provide basic EMONC services facilities (leaving a gap of 472) and 76 could 
provide comprehensive EMONC services facilities (leaving a gap of 45) were identified. 
Analysis of the data by facility type revealed that of the 281 hospitals providing deliveries, 76 
(27%) were comprehensive, seven (2%) were basic, 111 (40%) were partial, and 87 (31%) 
were non-EMONC. Of the 509 health centres providing deliveries, two (0.4%) were basic, 
113 (22%) were partial, and 394 (77.4%) were non-EMONC. Of the 136 health clinics 
providing deliveries, one (0.7% was basic, 23 (17%) were partial, and 112 (82%) were non-
EMONe. Of the 164 maternity homes providing deliveries, three (2%) were basic, 28 (17%) 
were partial. and 133 (81%) were non-EMONC (GSS, 2011a). This clearly shows gaps in 
access to maternal and neonatal obstetric care. In Uganda reported gaps in the availability of 
essential infrastructure, equipment. supplies, drugs and staff for maternal and newborn care 
especially at health centers; and the utilization of available antenatal, intrapartum and 
postnatal care services was also reported to be low (Pambid, 20 IS). 
2.7.2 Community-based Interventions and its impact on Maternal and Child Health 
Several interventions have been implemented globally to improve maternal and child health 
service. Community-based intervention is an important component of providing a continuum 
of care for low-resource communities. The health and well-being of women, newborns, and 
children are inherently linked to these community-based interventions. A systematic review 
and two other studies have demonstrated positive effects of community-based interventions 
on increasing access to and coverage of health services in rural area~ (Kumar, Kumar, & 
Darmstadt. 2010: Lewin et aI., 2010; Prost et aI., 2013). Another systematic review also 
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reported that community-based women's education interventions may improve the number of 
women seeking birth at a health care facility (Sharma, Jones, Loxton, Booth, &. Smith, 2018). 
A study conducted in rural Ethiopia where a community sensitization intervention revealed 
an increase in the coverage for most MNH indicators (Wilunda, Tanaka, Putoto, Tsegaye, &. 
Kawakami. 2016). A study in Zambia found that strengthening community-based action 
groups in poor and remote districts through the support of mothers by Safe Motherhood 
Action Groups (SMAGs) was associated with increased coverage of maternal and newborn 
health interventions, measured through ANC, SBA and PNC (Jacobs et aI., 2018). 
Health care provided in communities, as opposed to health facilities, is often provided by 
CHWs and may include home visitations and other intervention packages. The level of 
training CHWs receive, whether they are employed by a nongovernmental organization or the 
government and whether they are paid or volunteer, varies widely between and within 
countries (Adam et a1., 2005). In general, they work in conjunction with frontline health 
workers across the primary health care spectrum to provide health education and promotion, 
distribute commodities, diagnose and manage illness, and provide referrals (Lassi, Kumar, & 
Bhutta, 2018). CHWs arc often the first line of care for many patients, such as in Pakistan, 
where approximately 17% of those who seek health care consult CHWs first (Bhutta et aI., 
2008). lienee a good collaboration with these community-based health workers can improve 
maternal and neonatal health care. 
In Ghana, Community-based Health Planning and Services (CHPS) initiative was regarded as 
a key to improving the coverage of MNCH services (Awoonor-Williams et aI., 2013; 
Nyonator. Awoonor-williams, Phillips, Jones, & Miller, 2005). CHPS was adopted in 1999, 
as a national health policy initiative to reduce the geographical barriers to healthcare. Initially 
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focusing on deprived and remote areas of rural districts, CHPS endeavours to transform the 
primary health care system by migrating from the conventional facility-based and 'outreach' 
services to a program of mobile community-based care provided by a resident nurse 
(Nyonator. Akosa, Awoonor- Williams. Phillips, & Jones, 2008). 
The principal human resources for CHPS are nurses, referred to as community health officers 
(CHOs). Some of them are midwives or have midwifery skills to attend emergency deliveries 
and make referrals should complications arise. CHPS has been reported to be relevant in 
reducing maternal and child health morbidities (Awoonor-Williams et aI., 2004, 2013; 
Johnson et aI., 2015) and uptake of reproductive health services (Adongo et aI., 2013). 
Despite such efforts at the community level in Ghana, the coverage of delivery assisted by 
skilled birth attendant (SBA) and early postnatal care (PNC) is relatively low, compared with 
ANC. According to the Multiple Indicator Cluster Survey 2011, the coverage of delivery 
assisted by SBA and PNC (up to 48 hours) visit were 68.4% and 41.5%, respectively, whilst 
the coverage of ANC for four times or above reached 86.6% (GSS, 2011 b). Whereas 
improvements have been made in ANC and SBA, newborn care remains a challenge although 
continuity in MNCH services reduces neonatal deaths risk and these have largely been 
reported to be due to socio-cultural beliefs and practices (Gogia & Sachdev, 20 10). A study 
in Ghana found that only 8.0% had CoC completion; the greatest gap and contributor to the 
low CoC was detected between delivery and postnatal care within 48 hours postpartum (Yeji 
eta\.,2015a). 
2.7.3 Male involvement in ANC and Perinatal Care 
Traditionally. maternal health issues have predominantly been seen and treated as a purely 
feminine matter (Kinanee & Ezekiel-Hart, 2009). As result, men have traditionally been 
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excluded from MHC services. However. there is increasing interest globally in 
involving all stakeholders in maternal and child health services. One of the strategies 
that has been adopted globally to improve maternal and child health is the involvement of 
males especially partners in these activities. The idea of involving men in antenatal services 
is to increase social support to women during pregnancy and after birth (Agyare, Naab. & 
Osei. 2018) and perhaps maintained after childbirth. Although men may feel involved in the 
antenatal services of their wives, a research finding in Japan however show a relatively poor 
percentage of Japanese men supporting their wives in postnatal periods although there was 
strong support during antenatal visits (Wai et aI., 2016). Thus, support in antenatal visits may 
not necessarily translate in support during labour and delivery. In patriarchal societies, male 
support is crucial in labour and delivery because most of the decisions are made by the 
husband or head of the household. 
Globally, the involvement of men in maternal health programs has been associated with 
positive reproductive health outcomes, such as increase in the use of contraceptives (Bawah, 
2002; Te rete & Larson, 1993) and improved maternal health outcomes (Yargawa & 
Leonardi-Bee, 2015). Despite these benefits, few men participate in maternal health services 
(Natoli, Holmes, Chanlivong, Chan, & Toole, 2012). In Uganda, a study that investigated 
perceived benefits of male attendance of antenatal care (ANC) found that knowledge of three 
or more antenatal care services, obtaining health information from facility health workers, 
and a spouse having skilled attendance at last childbirth were all predictive of increased male 
attendance at ANC. In Kenya, although men were aware of the benefits of their involvement 
10 maternal health, perception of pregnancy support as a female role, negative health worker 
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attitudes. and unfriendly antenatal care services limited male involvement (GanJe & Dery, 
2015). 
Although this global approach has been adopted in Ghana, few studies have documented the 
extent of male involvement in ANC, labour and postnatal care. A study conducted in 
Anomabo in the Central region of Ghana found that only 35%, 44%, and 200A> of men 
accompanied their partners to antenatal care, delivery, and postnatal care services, 
respectively (Craymah, Oppong, & Tuoyire, 2017). In this study, cultural norms. 
unfriendly attitude of health workers and distance to health facility were cited as 
reason for low involvement of males in maternal health services. Another study in 
Ghana found that tend to be involved during their partner's obstetric emergency 
providing financial, emotional and instrumental supports (Story et al., 2017). A 
recent study conducted in Northern Ghana found that males control resources and made 
critical health related decision~ but they found it unnecessary to attend clinics with their 
partners (Aborigo. Reidpath, Oduro, & Allotey, 2018). 
2.8 Policies and Legislation to improve Maternal and Child Health Care in Ghana 
The role of policies and legislations in improving maternal and neonatal health is 
indispensable. These policies and legislation provide direction to the implementation of 
mterventions. Several of such policies and legislation exits and targets specific aspects of 
maternal and neonatal health. These policies and legislation are designed to make health care 
accessible both geographically and financially. 
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Higher costs associated with seeking for supervised maternity services have been noted as 
very critical to uptake of care for many women in Ghana and other developing nations 
(Bahalola & Fatusi. 2009; Moyer, Adongo, Aborigo, Hodgson, & Engmann, 2014). This 
militate against access to skilled maternal health service occasioned by high cost, the free 
maternal health service was incorporated into the National Health Insurance Scheme (NHIS). 
The free maternal health policy was implemented in Ghana in July 2008 under the National 
Health Insurance Scheme (NHIS). The policy allows all pregnant women to have free 
registration with the NHIS after which they would be entitled to free services throughout 
pregnancy, childbirth and three months postpartum. The exemption package covers non-
payment of registration under the NHIS and a comprehensive maternity package. The 
package covers all essential care during ANC, and all forms of delivery. So it include: normal 
deliveries, management of all assisted deliveries, including Caesarean sections, and 
management of medical and surgical complications arising out of deliveries, including the 
repair of vesico-vaginal and recto-vaginal fistulae and post-natal as well as neonatal care for 
the infant for up to six weeks after delivery (Ofori-Adjei, 2007). The policy was one of 
Ghana's key strategies for the achievement of the Millennium Development Goals (MDGs) 
and now, the Sustainable Development Goals (SDGs), specifically the reduction of maternal 
and child deaths and the achievement of universal health coverage (UHC). Before the 
introduction of the fee exemption policy for maternal healthcare in Ghana, it was estimated 
that women paid an average of $12 for vaginal deliveries in public hospitals and $20 in 
mission hospitals. For caesarean section deliveries, women were paying on average $68 in 
public hospitals and $139 in mission hospitals (Levin et a\., 2003). 
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An evaluation of the free maternal health policy showed that it has increased utilization of 
health care and improve the continuum of health care (Dalinjong, Wang, & Homer, 2018). 
This notwithstanding. concerns have been raised about quality of care provided under the 
policy (Witter, Adjei, Armar-Klemesu, & Graham, 2009). In their study they suggested the 
need for the policy to give further attention to quality of care particularly with care obtained 
for the management of the first stage of labour, use of the partograph and for immediate 
postpartum monitoring of mother and baby. Poor quality of care has been reported as 
contributory factor to avoidable maternal death (Say et al.. 2014). 
There are also exemption schemes for children under five year of age on the NHIS system 
which was one of the new addition in the NHI Act (Act 852) of 20 12 (Republic of Ghana, 
2012). This was envisioned as a measure to improve the continuum of care and child health 
services. 
2.9 The Concept of RMNCH Continuum of Care 
The concept of continuum of care has received global attention in recent times. Continuum of 
care encapsulates a broad spectrum of care along reproductive, maternal, newborn and child 
health with linkages to service outlets and delivery approaches (Kerber et aI., 2007). This 
concept refers to systems that integrate and emphasize continuity of care from pre-pregnancy, 
pregnanc). birth, and after delivery (AbouZahr & Berer, 2000). The continuum of care is 
critical for both maternal and child health and therefore plays an important role in reducing 
both maternal and child mortalities (AbouZahr & Berer, 2000; Kerber et aI., 2007). 
Continuum of care has also received prominence in the newly adopted sustainable 
development goals. The Global agenda and strategy for a child (rcn), adolescents and women 
health as captured in sustainable development goals (2016-2030) aims at positioning 
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discussions on maternal mortality issues within a continuum framework of programmes to 
improve maternal and child health globally (WHO, 2016b). This concept embraces a set of 
eight integrated services which are sub-categorized into three domain; clinical care, 
outpatient and outreach services and family and community care (Darmstadt et aI., 2005). 
The clinical care component looks at the reproductive health, childbirth care and newborn 
baby and child care. According to Lawn, Zupan, Begkoyian & Knippenberg (2006), the 
reproductive health emphasis is placed on case management for sexually transmitted 
infections (STls), elective abortion where legal, emergency care and post-abortion care. 
However. the childbirth care looks at skilled obstetric care at birth and essential neonate care 
(hygiene, warmth, breastfeed) and resuscitation, prevention of mother to child transmission of 
HIV and emergency obstetric care as well as immediate emergency care for newborn babies. 
The final component include interventions such as emergency care for newborn babies, case 
management of childhood and neonatal illness, extra care for pretenn babies, including 
kangaroo mother care and care of children with HIV. 
The second component which looks at outpatient care and outreach services is further 
categorized into four groups namely; reproductive health, antenatal care (ANC), postnatal 
care (PNC) and child health. The reproductive group include intervention such as family 
planning, elective abortion where legal, prevention and management of sexually transmitted 
infections and HIV and folic acid and iron supplementation (Lawn, Cousens, & Dannstadt, 
2005). The ANC group includes measures to ensure four-visit focused ANC package that is 
integrated with: malaria prevention, intennittent preventive treatment in pregnancy (lPT), and 
insecticide-treated bed nets, tetanus immunization and prevention of maternal to child 
transmission of HIV. However, the PNC component looks at promotion of healthy 
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behaviours for mother and baby, early detection and referral of complications, extra visits for 
pretenn babies, prevention of maternal to child transmission of HIV including appropriate 
keding and family planning services. The final component (child health) under this category 
involves vaccinations of children, malaria prevention using insecticide-treated bed nets, child 
nutrition, including vitamin A and zinc supplementation, care of children with HIV, including 
co-trimoxazole and integrated management of childhood illness (IMCI), (Lawn et aI., 
2005). 
Finally, the family and community care component of continuum of care involves 
interventions such as adolescent and pre-pregnancy nutrition, including use of iodised salt, 
health education prevention of HIV and STIs, healthy home behaviours for women in 
pregnancy: reduction of workload, recognition of danger signs, emergency preparedness, 
community behaviours. emergency transport, and funding schemes (Lawn et aI., 2006). This 
wmponent also involves skilled care, education about clean delivery, and simple early care 
tilr neonates, including warmth and immediate breastfeeding. It also involves water, 
sanitation. and hygiene, promotion of demand for quality skilled care, recognition of danger 
signs, and care-seeking, case management of diarrhoea with oral rehydration salts, and, where 
use of facility care is low, case management of pneumonia, severe malnutrition, neonatal 
sepsis, and malaria (Lawn et aI., 2005,2006). 
Each stage of the continuum are affected by community and health system related factors, 
hence, to be able to achieve the goals envisioned in this type of health care, it would be 
important to identify barriers and facilitators along the continuum (Kerber et aI., 2007). This 
study is therefore being conducted to identify the socio-cultural practices that may be relevant 
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along the continuum of care in Ghana and how to address these factors to improve maternal 
and neonatal health. 
2.10 Socio Cultural Practices along the Maternal Neonatal and Child Health (MNCH) 
Continuum of Care 
This section of the literature examines the socio-cultural practices that have been documented 
in literature to affect the continuum of care. This review is to help contextualize the current 
study. It has reviewed three stages namely: pregnancy, labour and postnatal care. 
2.10.1 Practices during Pregnancy 
These practices during pregnancy are essential to any study on practice during intrapartum 
and postpartum continuum of care. One area of practices during pregnancy is related to the 
beliefs on what is good and not good for a pregnant woman. This practice has either positive 
or a negative effect on the women and the unborn child since it affects the nutritional status 
of the dual. Food taboos have been identified as key contributing factors to maternal under 
nutrition in pregnancy especially in rural areas (Oni & Tukur, 2012) and therefore should be 
given the needed attention. Food taboos are very common and studies have documented these 
taboos in I thiopia (Huybregts, Roberfroid, Kolsteren, & Van Camp, 2009), Nigeria (Onuorah 
& Ayo, 2003). Malawi (Bolton, 1972), and China (Lee et aI., 2009). In India, a study found 
that pregnant women were provided with green leafy vegetables, rice, bread,jowar, meat, egg 
and fruits like apple and mosambi as part of traditional practices to ensure good maternal and 
child health. However, pregnant women were to avoid food items like ragi, papaya, mango 
and guava during pregnancy and reduced water consumption during the postnatal period 
(Catherin et al.. 2015). Another study revealed some vegetables were prohibited during 
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pregnancy because they are believed to be capable of causing an abortion (Pati!, Mittal. 
Vedapriya. Khan. & Raghavia. 2010). 
In Ghana. a study found that pregnant women were prohibited from eating nutritious foods 
such as snails. ripe plantain, and okra because these foods were believed to be capable of 
causing complications during pregnancy and child birth (Otoo, Habib, & Ankomah, 2015). 
Food restrictions for pregnant women is believed to have socio-cultural significance. In India, 
food which were restricted were believed to be capable of making babies large, making it 
impossible for the women to have vaginal delivery (Ara, Mominul Islam, Kamruzzaman. 
Toufiq Elahi, & SabirHossain, 2013). Once Caesarian Section (CS) was against religious and 
cultural beliefs, these foods were also deemed inappropriate for pregnant women. 
The consumption of herbal concoctions has also been identified as a major factor leading to 
maternal and neonatal deaths in Ghana. Other practices contributing to high still births 
include cultural practices such as seeking permission from husbands/other relations before 
accessing skilled delivery services and heroism, where a pregnant woman is considered 
strong ifshe is able to deliver at home (MoH, 2014c). 
Again, labour and delivery is the shortest and most critical period of the pregnancy-childbirth 
continuum because most maternal deaths arise from complications during delivery. Even with 
the best possible antenatal care, any delivery can become a complicated one and, therefore, 
skilled assistance is essential to safe delivery care. For numerous reasons, many women in 
Ghana do not seek skilled care even when they understand the safety reasons for doing so. 
Some reasons include cost of the service, distance to the health facility, and concerns about 
the qualit) of care (GSS, 20) 5). 
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Intake of herbs during pregnancy is also a common practice during pregnancy. In Australia, 
raspberry leaf are used by pregnant women to strengthen or tone uterus in readiness for 
contraction during labour (Forster, Denning. Wills, Bolger, & McCarthy, 2006). This belief 
therefore made people to prefer traditional medical practitioners to western medicine, hence 
affecting the continuum of skilled delivery during labour. In another study in Nigeria, it was 
reported that more than 2/3 of respondents had used herbal medicines in crude forms or as 
pharmaceutical prepackaged dosage forms. with 74.3% preferring self-prepared formulations 
because the herbs were believed to be safe (Fakeye, Adisa, & Musa, 2009). An earlier study 
in South Africa found that out of229 pregnant women. 55% had used herbal medicine during 
their current pregnancy (Mabina, 1997). In the Middle East, a study found that most pregnant 
women used herbs such as peppermint, ginger, thyme, chamomile, sage, aniseed, fenugreek, 
and green tea (John & Shantakumari, 2015). The use of herbs could have some adverse 
effects on health of the pregnant woman or have some interaction with orthodox medicines 
that women may be put on during pregnancy and also have a consequent for the baby in utero 
(Holst, Nordeng, & Haavik, 2008). This notwithstanding, many patients do not inform their 
doctor~ and nurses about taking herbal preparations (Buhimschi & Weiner, 2009; Burkey & 
Holme ... 2013; Lo & Friedman, 2002). Hence, this will have an effect on the perinatal 
continuum of care. Thus it would be important to explore if these practices are common in 
Ghana and the effect on intrapartum and postpartum continuum of care. 
Another socio-cultural practice during pregnancy is sexual restrictions. Sexual practices are 
also reported to be common during pregnancy. In some Asian societies, sex is prohibited on 
,orne days during pregnancy because it is believed it can induce difficult labour, retained 
placenta and neonatal jaundice (Sychareun et aI., 2012). In the same vain, Liu Hsu & Chen 
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(2013) found in their study among Chinese women that majority stopped engaging in coital 
activities during pregnancy. Pregnant women are also restricted from crossing rivers and this 
practice has been found to be a barrier to accessing ANC (Pradhan et aI., 2010), hence 
causing a break in the continuum of care. 
2.10.2 Practices during Childbirth 
Health seeking behaviour for childbirth is another important consideration in continuum of 
care. Studies have shown that both health facility (skilled delivery) and home delivery are 
common among pregnant women. A key component of the strategy to reduce maternal 
morbidity and mortality has been to increase rates of skilled birth attendance and facility-
based childbirth (WHO, 2008). While global skilled birth attendance rates rose by 12% in 
LMICs over the past two decades, almost one-third of women in these regions still deliver 
without a skilled birth attendant (WHO, 2008). With the persistence in unskilled delivery in 
... ome developing countries, it has been suggested that sustained commitment to improving 
maternal health should be central to the post-2OI 5 development agenda in all countries with 
low level of skilled birth rates (Kendall & Langer, 2015). 
rhe importance of skilled attendance at birth lies in the fact that access to and use of 
rnaternit) care facilities and skilled personnel, particularly skilled attendance, at birth is often 
associated with substantial reductions in mortality and morbidity for the mother over home 
births (Cham. Sundby. & Vangen, 2005; Smith & Sulzbach, 2008; Babalola & Fatusi, 2009; 
Abor. Abekah-Nkrumah, Sakyi, Adjasi, & Abor, 20 II; Tsawe & Susuman, 2014). Despite 
this recognition. not all women seek skilled care during pregnancy or childbirth. In Ghana, 
for example, while the percentage of women making the WHO's recommended four 
antenatal care visits is 87%, skilled attendance at birth is 74% (GSS/GHS/Macro 
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International. 2015). Thus some 26% of women in Ghana still do not receive any form of 
skilled care during delivery. Therefore it has been observed that there is an urgent need to 
develop innovative strategies to scale up interventions that would improve on both access to 
and use of maternal health services by women in Ghana because of the importance of facility 
deliver} in promoting good maternal and child health (Abor et aI., 2011). 
Globally. a number of factors have been identified as barriers to skilled maternal healthcare 
access. Studies have shown that delivering in health facility may be hampered by distance to 
facilities (Moyer et aI., 2013;Yanagisawa et aI., 2013; Ganle et aI., 2014a). Other studies 
indicate that structural factors, including lack of financial or economic resources, 
transportation. and delivery supplies, lack of coordination of referrals between TBAs at the 
community level and facilities, prevent women from using facility-based services (Mills & 
Bo:rtrand. 2005; Seljeskog, Sundby, & Chimango, 2006; ten Hoope-Bender, Liljestrand & 
Mac Donagh, 2006; Mills, Williams. Wak, & Hodgson, 2008; GSS, 2009; Okafor & 
Rizzuto. 2015). Some studies show that barriers to access, especially financial ones, rather 
than traditional beliefs, were the main obstacles to delivery at health care facilities (Griffiths 
& Stephenson, 200 I: Mills et aI., 2008). Other studies also indicate that client's negative 
perceptions of healthcare staff, including reports of unfriendliness at delivery serve as 
barriers to obtaining skilled care (Griffiths & Stephenson, 2001; Mills & Bertrand, 2005; 
Seljeskog et aI., 2006; Okafor & Rizzuto, 2015). These barriers are often confounded by 
delays in the care seeking process. According to Thaddeus and Maine (1994), delay can occur 
at three different levels: (I) delay in decision to seek care, (2) delay in reaching the 
appropriate facility and (3) delay in receiving adequate care in the facility. The reasons for 
the first delay may be late recognition of the problem, fear of the hospital or the costs or lack 
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of an available decision maker (Gabrysch & Campbell, 2009). The second delay has been 
reported to be caused by difficulty in transport and the third delay is often due to difficulty in 
getting blood supplies, equipment and operation theatre (Shah et aI., 2009). 
Despite this, certain socio-cultural practices also influence uptake of skilled delivery. One 
study revealed that communities believed childbirth was a natural event and not a sickness 
and therefore no need for hospital delivery (Jansen, 2006). Again, difficult labour in another 
study was perceived to be due to witchcraft or an infraction on the part of the women in 
which case she is expected to confess (Maimbolwa. Yamba, Diwan, & Ransjo-Arvidson. 
2003). 
Another socio-cultural practice which affects utilization of skilled delivery and preference for 
home delivery is religious barriers. most especially among adherents of Islamic religion. In 
Bangladesh, a study found that women delivered at home or with TBAs because they were 
allowed to wear their purdah (veil) in line with their religious doctrines. Thus their dignity 
were maintained if they gave birth at home (Sarker et aI., 2016). Another study in the 
Democratic Republic of Lao found that pregnant women delivered at home because they feel 
shy and embarrassed when they were attended to by males in biomedical health facilities 
(Sychareun et aI., 2012). In this same study. it was found that the traditional birth practices 
of allowing women giving birth in a squatting position and lying on a "hot bed" after delivery 
inlluenced their preference for home delivery. Generally all these practices affect intrapartum 
and postpartum continuum of care as babies may be denied immunizations that are given at 
birth and ~omen are also denied access to skilled delivery. In Ghana, a study by Bezzano et 
ai. (2008) in the then Kintampo district (currently Kintampo North and South Districts) found 
that women in the district delivered at home instead of seeking for skilled care in health 
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fa..:ilities because they believed that home delivery raised a woman's status in her community, 
while seeking skilled attendance lowered it (Bazzano, Kirkwood, Tawiah-Agyemang, 
Owusu-Agyei, & Adongo, 2008). 
Another practice is preference for Vagina or Caesarean Section (CS) delivery. For example, 
an ethnographic study found that cultural norms, values and social network made people to 
opt for CS to maintain their shape and also avoid the pain in vaginal delivery (Latifuejad-
Roudsari. Zakerihamidi, Merghati-Khoei, & Kazemnejad, 2014). Contrary to this, 
Zakerihamidi, Roudsari, Khoei & Kazamnejad (2014) also found that religious beliefs 
affected the participants' preference for vaginal delivery as it was deemed to be the normal 
form of delivery and a mark of good womanhood. Similar findings emerged in a study in 
Bangladesh where preference for vaginal delivery was found to be one of the reasons for high 
utilization of the services of traditional birth attendants and home delivery as it was known 
that these outlets could not perform CS whilst hospitals unnecessarily subjected women to CS 
on the least delay in labour (Sarker et aI., 2016). 
Ways of disposing the placenta is another socio-cultural practice which is essential in the 
intrapartum period. In Nepal a study found that the placenta is generally buried to offer 
protection to the baby. However, in situation where the placenta does not come out after 
birth, the woman is made to vomit to help expel it or massaging and sitting on the abdomen 
was also done (Jeffery & Jeffery. 1999). In some societies, apart from the abdominal 
massage, hot water and alcohol are applied to the abdomen to aid in the expulsion of the 
placenta (Anderson, Anderson, Franklin, & de Cen, 2004). In Malaysia, massaging of the 
mother's abdomen after the birth is done to facilitate the expulsion of the placenta 
(Laderman, 1999). 
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Gatekeeper system and household arrangements is another practice that affects the continuum 
of care. In many developing countries, decisions are mainly made by husbands, mothers, 
mothers-in-law and grandmothers. as studies in Indonesia, Nepal, Tanzania and Malawi have 
clearly been documented.(Allendorf, 2007: Biweta., 2015; Danforth, Kruk, Rockers, 
Mbaruku. & Galea., 2009; Gipson et aI., 2002: Mrisho et aI., 2007; Seljeskog et aI., 2006). 
Similar gatekeeper systems have been reported in studies conducted in Ghana mainly in the 
rural communities in northern Ghana (Adongo, Phillips, & Baynes, 2014; Nazzar, Adongo, 
Binka., Phillips. & Debpuur. 1995; Rominski et aI., 2014) and urban slum. (Nwameme, 
Phillips, & Adongo. 2014). Consequently, it would be important to explore if similar 
gatekeeping systems are practiced in southern Ghana and how it affects the continuum of 
care. 
2.10.3 Practices during Postpartum Period 
These hm e further been divided into care of the baby and mother along the spectrum from 
birth to 28 days after delivery which marks the end of the neonatal period. This is also sub-
divided into practices relating to the mother and that relating to neonate. 
2.10.3.1 Maternal Prdctices during Postpartum Period 
Th.: postpartum period is characterized by both metabolic and hormonal changes. However, 
views on what this period entails vary across cultures. These beliefs result in the adoption of 
certain practices. For example, among Saudi culture, a woman within the postpartum period 
is deemed to be a sick patient especially the first six weeks after her childbirth (Alharbi & 
Abdulghani, 2014). To that end, socio-cultural beliefs and practices are reported to be very 
common (Sein. 2013). One of the commonest practices noted is confinement for a period. In 
the Hmong tradition in Australia, ""omen are expected to lie near fire in the first three days 
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after birth and also confined for 30 days. This may negatively affect continuum of care 
becaus.: it affects health seeking (Rice. 2000). Malay women are supposed to observe a 44-
day confinement period which is called "dalam pantang" after birth. This is believed to help 
restore their strength (Carol Laderman, 1984). As a result of this believe, both mother and 
baby are constrained from utilizing any health care outside the home. 
Another practice reported to be common is related to food taboos and practices with many 
cultures making distinctions between "hot" and 'cold' foods, where eating of these food are 
inappropriate within some periods of the postpartum (Liu et aI., 2006; Sein, 20\3). In 
Turkey, it was found that women are expected to eat a kind of dessert, called "Bulama~" and 
drink a mixture of grape molasses and butter, wrap their abdomen tightly and avoid sexual 
intercourse for 40 days after giving birth as part of traditional practices (Ge~kil, Sahin, & 
Ege. 2009). In Nepal. postpartum women are given special diet in the postnatal period like 
"kwati·'. "dahichyura" and "gudpakh ", and these food have been reported to be rich in 
calories, vegetables, clarified butter, cashew nuts and coconut (S. Sharma, van Teijlingen, 
Hundley. Angell. & Simkhada, 2016). 
2.10.3.2 Neonatal Postpartum Pmctices 
I'.s,ential newborn care (ENC) practices such as clean cord care (cutting and tying of the 
umbilical cord with a sterilized instrument and thread), thermal care (drying and wrapping the 
newborn immediately after delivery and delaying the newborn's first bath for at least six 
hours or several days to reduce hypothermia risk), and initiation of breastfeeding within the 
first hour of birth were introduced to reduce the morbidities and mortality that occur during 
the neonatal period (WHO. 2012b). Nonetheless, implementing these essential new born care 
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practices have been a challenge as many births still occur at home and high institutional 
newborn mortality have also been documented. 
2.10.3.2.1 Cord Care as a Component of ENC 
Good cord care practices are essential to prevent cord-related infection among neonates. It is 
generally recommended that the umbilical cord should be cut with a sterile or clean 
instrument and tied also with a clean and sterile material as this serves as an opening for easy 
entry for micro-organisms (Grady et al.. 2011). It is also recommended that no substance 
should be applied to the stump of the cord. This practice was borne out of research findings 
that showed no umbilical cord infection among neonate whose cord were cleaned with 70% 
isopropyl alcohol and those with dry cleaning (Aydemir, Alparslan, & Demirel, 2012; Dore et 
al., 1998). However, if the cord becomes soiled, it can be washed with soap and water and 
dried with clean cotton wool or gauze (WHO, 2010). It has also been found that applying 
chlorohexidine could reduce infection and promote healing of the umbilical cord stump and 
several studies have demonstrated this (Mullany et aI., 2006, 2013; Smith, 2013; Tielsch et 
aI., 2007). 
~tudlt:, have however, shown that certain local cord practices make the neonates vulnerable 
to infection. In Zambia, it was found that cords were cut with non-sterile razor blades or local 
grru.s with a sharp edge and charcoal, dust and baby powder applied to facilitate drying. In 
addition, vaseline, cooking oil, breast milk, cow dung and chicken faeces are applied as either 
lubricants or medicine (Herlihy et aI., 2013). Another study in Ethiopia found that applying 
butter or omtment to the cord to enhance drying was a common practice (Degefie, Amare, & 
Mulligan. 2014). A study conducted in the Brong -Ahafo Region of Ghana found that women 
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applied hot water and shea buner to the cord as it is believed to aid in the healing of the cord 
(Moyer et at.. 2012). 
The use of these substances lead to umbilical cord infection (omphalitis) which can further 
result in sepsis with high fatality ( Baqui et a!., 2007). In Bangladesh, unhygienic cord care 
was reported to be a common practices among children delivered at home and 9% of the 
mother reported umbilical stump infection during the neonatal period (Alam et aI., 2008). 
Another study found that home delivery was the main cause of neonatal mortality (Baqui et 
aI., 2016). Hence, it has been recommended that studies on cord care are critical in any cord 
care policy to prevent infection (WHO Chlorhexidine Working Group, 2012) and this would 
document how umbilical cord care is done in the Ghanaian context to guide the design of 
intervention 
2.10.3.2.2 Thermal Care of the Baby 
This involves a system of providing warmth for the neonate to prevent low body temperature 
(hyputhermia). It includes practices such as drying and wrapping the newborn immediately 
alkr delivery and a delay in the first bath for the neonate (Baqui et aI., 2007). This is 
be<:au~e of the inability of neonate to regulate their body temperature efficiently like adults 
(Kumar. Shearer. Kumar, & Darmstadt, 2009). To that end, it is recommended that, 
newborns are thoroughly dried immediately after birth with a clean material and placed on 
the mother's skin to provide warmth. In addition, it is deemed appropriate to delay bathing of 
the baby for at least 24 hours as a measure to prevent hypothermia (Bhuna, Darmstadt, 
H<ban. & Hav.s, 2005). 
Hypothennia is one of the cause of deaths of neonates across tropics (Bhuna et aI., 2005; 
Kumar et al.. 2009). Hospital based studies have shown hypothermia to be very common with 
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a prevalence of between 22-85% (8yaruhanga, Bergstrom, & Okong, 2005; Kambarami & 
Chidede. 2003; Ogunlesi. Ogunfowora, Adekanmbi, Fetuga, & Olanrewaju, 2008). In some 
communities. studies have found prevalence to be as high as 45% in a systematic review 
(Bhutta et aI., 2005). This high prevalence has also been associated with increased risk of 
death among neonates. In Guinea-Bissau for example. hypothermia was found to increase 
risk of mortality by fivefold in the first week of life of a neonate (Sodemann et aI., 2008). 
Despite the importance of keeping babies warm. some studies in Africa found that newborns 
are left unattended on the floor until placenta is delivered. Thereafter they are washed with 
soap and water within \-2 hours after birth contrary to requirements of essential newborn care 
on thennal regulation (Dannstadt, Syed, Patel, & Kabir, 2006; Pagel et aI., 2014). In Ghana, a 
study found that knowledge on keeping newborn warm was universal, however, only 71 % 
experienced a delay 111 drying the body. 79% had delayed wrapping, 93% experienced early 
bathing and \0% were placed skin-to-skin (Hill, Tawiah-Agyemang, Manu, Okyere, & 
KirJ...wood,2010). 
2.10.3.2.3 Early initiation of Breastfeeding and Exclusive Breastfeeding Practices 
Early initiation of breastfeeding is another important component of essential newborn care. 
Brca.<.tfecding should be initiated within \ hour after birth (WHO, 2012a). A systematic 
review and meta-analysis found that initiating breastfeeding after the first one hour increases 
the risk 01 neonatal mortality by twofold (Debes et al., 2013). An analysis of data available in 
63 cuuntries showed that early initiation of breastfeeding is capable of reducing pneumonia, 
diarrhoea.. neonatal sepsis and promote good body temperature (80ccolini. De Carvalho, De 
Oliveira. &: Perez-Escamilla, 2013; Lamberti, Fischer Walker. Noiman, Victora, & Black, 
2011). Evidence across some countries show that many neonatal deaths can be averted just 
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with this practice. In Nepal, initiating breastfeeding within one hour was reported to reduce 
deaths by 19 % (Mullany et at.. 2008). A study in Egypt showed that infants for whom 
breastfeeding \~as initiated early had 26% lower rate of diarrhea than those initiated later 
(Clemens et a\., 1999). Also in Ghana, early initiation was also found to reduce mortality by 
22 % (Tawiah-Agyemang, Kirkwood, Edmond, Bazzano, & Hill, 2008). 
Another related area is exclusive breastfeeding up to six months. Breastfeeding is the 
optimum mode of feeding the human infant. Human breast milk has been found to have 
sufficient nutrients for the infant until about six months (Fewtrell et aI., 2007). This is 
because studies have consistently showed that positive impact of this practice in reducing 
neonatal mortality (Edmond et al.. 2006; Khan, Vesel, Bahl, & Martines, 2014; Mullany et 
aI .• 2008). 
Practices on early initiation of breastfeeding and exclusive breastfeeding vary across 
countries. In South Asia, it was reported that only 41 % of newborns were breastfed within 
one hour of birth (UNICEF. 2014b). This same report revealed that the proportion of women 
who initiated breastfeeding within one hour of birth in India, Pakistan, Nepal and Bangladesh 
were 41%.29%,45% and 47 % respectively (UNICEF. 2014b). In Tanzania, early initiation 
of breastfeeding within one hour of birth was 51 % with vaginal delivery recording 71 % of 
early initiation of hreastfeeding (Exavery, Kante, Hingora, & Phillips, 2015). A study in 
Ghana revealed that delays in initiation of breast-feeding is mainly due to perception ofa lack 
of brea~t milk. performing post-birth activities such as bathing, perception that the mother 
and the baby need rest after birth and the baby not crying for milk, whilst facility bath was a 
major facilitator (Tawiah-Agyemang et aI., 2008). 
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Colostrum is the first milk that is produced by women after delivery and there are several 
beliefs and practices regarding this milk though it contains high level of immunoglobulin 
(Hurley & Theil. 2011). In their study, it was found that there existed community belief that 
culostrum could cause abdominal problems and was therefore discarded and this was done by 
79"10 of the women (Rogers et al.. 2011). 
2.10.3.2.4 Immunization against Preventable Childhood Diseases 
Routine immunization against preventable childhood conditions is one of the strategies used 
to reduce the burden of conditions such as poliomyelitis, measles. tetanus, haemophilus 
influenza type 2. diphtheria, pertussis and tuberculosis. Immunisation is one of the ways of 
preventing diseases especially among children and has contributed to the reduction of 
childhood diseases. It is also one of the important basic health services to all children 
<Mashal. Nakamura. Ki7uki. Seino. & Takano. 2007). The introduction of vaccines has led to 
the reduction of many infectious diseases and most of the vaccines that prevent diseases in 
children are very eftective and safe. Several of these vaccines are developed against bacteria, 
viruses and snllle parasites and new methods and techniques for developing more effective 
vaccine, are becoming available (Ada, 2007). 
When many individuals are vaccinated. there can be protection for all through a process 
known a~ herd immunity (Finn & Savulescu, 20 II). Developing countries contribute about 
95% of the deaths in children under five years old globally, and 70% of these deaths can be 
prevented by immunisation (Mashal et aI., 2007). Good coverage of the early antigens 
following their introduction contributed to a significant decline in the incidence of most 
childhood killer diseases in Ghana (Vision, 2014). The success of the antigens in reducing 
disease and mortality burden provided enough evidence to further introduce new vaccines to 
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cater for other diseases. Based on the burden of some diseases and the possible opportunity to 
avert high infant deaths as well as economic benefits, Ghana began the process to introduce 
the pneumococcal and rotavirus vaccines as well as a second dose of measles in 2009 
(Vision, 2014). A recent study reported a reduction in the incidence of diarrhoeal among 
children under five years as a result of the introduction of the rotavirus vaccine in Ghana 
(Owusu-Sarpong, Agbeshie, & Tabong, 2018). 
Immunization activities continue to grow throughout the 216 districts in Ghana as envisioned 
in the EPI policy. Supply of all the antigens for the infant immunization are often regular 
with minimal cases of shortage reported across the country. Out of the 216 districts in Ghana, 
150 districts (69.7%) have recorded penta3 coverage ~ 80% whilst two districts recorded 
penta3 coverage of <50% (GHS, 2015). This is a remarkable achievement as the pentavalent 
vaccine offers protection for children under five against the five most common "killer 
conditions". The estimated number of un-immunized children was 60,121 (representing 
5.8%) of total annual EPI target and this is a major progress towards reducing the burden of 
vaccine preventable conditions in Ghana as the high coverage offer herd immunity for the un-
immunized. 
These notwithstanding, some beliefs about vaccines have resulted in practice of people 
refusing vaccinations. In the Philippines for example the rumour that tetanus toxoid 
vaccination could cause infertility reduced people's acceptance of the vaccine (Romualdez Jr. 
et aI., 2011). In Nigeria, rumours in the Muslim community that polio could cause sterility 
and be a control measure to reduce population among Muslim community resulted in non-
acceptance of the vaccine (Mangrio, Alam, & Shaikh, 2008). Rumours about alleged long-
term consequences. such as sterility, allergies, or mental health problems, have slowed 
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vaccination campaigns for polio and measles (Feldman-Savelsberg, Ndonko, & Schmidt-
Ehl). 2000; Jegede, 2007). Hence, it would be important to conduct a study to see if such 
beliefs exist in Ghana and how these affect continua of care. 
2.10.3.2.5 Care of the Body of Neonates 
Another practice that occurs during the neonatal period is care of the body which varies from 
culture to culture. An earlier study found that babies are dressed with a sand-filled nappy 
"hal/uk" (35%), and bathed with salt water (40%) in Turkey (Ayaz & Efe, 2008). Among the 
Hindus. a black dot is often applied to the forehead after some rituals on the body to ward off 
evil spirits (Corbett & Callister, 2012; Grewal, Bhagat, & Balneaves. 2008). In other 
customs. both the mother and baby are massaged with special oil which is believed to 
improve the strength of both the baby and mother (Darmstadt & Saha, 2002; Iyengar, 
Iyengar, Martines. Dashora. & Deora, 2008). 
Drinking of alcohol during po~tnatal period is another socio-cultural practice of significance. 
Alcohol is believed to protect the child and hence women are expected to take this with the 
expectation that it \\ould pass through breastrnilk and in some instances, babies are bathed in 
stouts. It is believed to counter jaundice (Mamatoto, 1993). 
The continuous existence of socio-cultural practices is often rooted in beliefs about their 
benefits. Thus. any research on socio-cultural practices along the continuum of maternal 
health care needs to identify why such practices are important to the people and what people 
stand to lose if they give up those practices. In an earlier study, for instance, it was found that 
the "oman stands the risk of getting perinatal depression for failing to adhere to rituals such 
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as mas~age with oil and dietary restrictions (Rodrigues, Patel, Jaswal, & de Souza, 2003). In 
rural India. it was found that pregnant women who did receive ritual and ceremonies 
associated with their status were unhappy (Raman, Srinivasan. Kurpad, Razee, & Ritchie, 
2014). 
2.11 Recognition of danger signs during Neonatal Period 
Generally, newborn deaths result from a combination of medical causes, social factors, and 
health system failures. These factors vary not only by context by also by culture. In most 
settings, newborn health is closely associated with maternal health and therefore often 
inseparable (Bhutta, Lassi, Blanc, & Donnay, 2010). According to Lawn et aI., (2014) the 
primal) causes of neonatal deaths include complications from pre-term birth (36%), intra-
partum related conditions (previously called birth asphyxia; 23%) and infections (notably 
sepsi~. meningitis, and pneumonia; 23%). Intrapartum -related conditions (27%) and pre -
term birth complications (41%) together accounts for almost two thirds of early neonatal 
deaths (0-6 days) while sepsis (37%). preterm (21 %) and intrapartum conditions (13%) 
dominate the causes for the late neonatal phase (Lawn et aI., 2014). During the early neonatal 
period spanning from birth to 6 days, sepsis accounts for 8% of neonatal mortality compared 
to 37% in the late period. From 7-27 days the disease that account for death include; 
pneumonia, tetanus, diarrhea and congenital diseases (Mekonnen, Tensou, Telake, Degefie, 
& Bekele, 2013). 
Recognizing the signs and symptoms or danger signs is therefore important during the 
neonatal period. Generally, danger signs during the neonatal period include: previously 
normal cry became weak/stopped; previously normal baby became drowsy lunconscious; 
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previously nonnal suckling became weak/stopped: baby cold to touch or fever (>99°F): skin 
infection or umbilical infection; abdominal distention or vomiting; and grunt or chest in 
drawing. An earlier study found knowledge on danger signs was low. Participants in that 
<;tudy identified yellow soles (48.0%), not feeding since birth or stopping to feed (46.0%), 
and signs of local infection (37.0%) as the mina dangers during the neonatal period. Despite 
the low knowledge majority (69.0%) of the participants had experienced at least one of the 
danger signs with their baby (Abu-Shaheen et aI., 2019). These manifestations could be due 
birth injuries and infections (Awasthi. Venna, & Agarwal, 2006). 
Birth injuries result from the use of forceps in getting the baby out of the birthing canal. 
Difficult labour and breech babies (presenting shoulders or feet first) may suffer fractures of 
the tender bones due to the pressure exerted in birthing instruments. Another important 
common problem that occurs in pretenn and some full-tenn babies is infant or neonatal 
laundil:l!. a condition caused by an increase in the normal range of bilirubin for newborns. 
I he high level of bilirubin contributes to a change in the colour of the baby's skin and turning 
the babies eyes to yellowish (lves, 2015; Shaw, 2011). Newborn babies nonnally have bluish 
hands and feet and when they stop breathing for 15-20 seconds with resultant bluish skin it is 
referred to as apnea (Moerschel, Cianciaruso, & Tracy, 2008). 
Of the several contributors to neonatal mortality, infections notably, sepsis, meningitis and 
pneumonia) is diagnosed often on clinical signs and symptoms. These signs however, are 
frequently non-specific and may include lethargy or irritability, poor feeding, vomiting, 
respiratory distress, apnea. fever and hypothennia (Wright & Posencheg, 2016). 
Inappropriate and delayed care seeking can contribute to the resulting neonatal mortality. 
Effective strategies to improve neonatal survival requires a clear understanding of neonatal 
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care seeking behaviours and patterns, knowledge. perceived cause and understanding of 
newborn danger signs and symptoms which determine largely how soon they seek care for ill 
newborns. where care will be sought either at home or in a public or private health facility 
and from what sources (Okawa et al.. 2015). The perception of an illness condition and how 
it is defined and interpreted can influence the choice of treatment and care seeking behaviour. 
Before the treatment of any illness condition commences. the symptoms need to be first 
recognized. and defined as serious or dangerous requiring treatment. 
The presenting signs and symptoms will have to be evaluated in the context community 
beliefs about the condition as postulated by the social cognitive theory. In other words, 
beyond the individual defining his or her own symptoms, others within the society defines an 
individual's symptoms as illness and call those symptoms to the attention of the person. 
Several studies described illness conditions labelled as "not- for- hospital". For these 
(llnditions considered as not "physical" but "spiritual" the recommended treatment have to 
therefore social in nature (Engmann et aI., 2012; Kleinman, 1978; Nukunya, 2003). 
In rural Ghana, for example, asram and pun; are regarded as illnesses affecting neonates and 
infants that do not have any clear biomedical equivalents and caused by evil eyes (Okyere et 
al.. 2010). Similarly. convulsions as a result of malarial fever were thOUght to have spiritual 
undertones and negative outcomes of child birth were often attributed to witchcraft in 
Northern Ghana (Adongo, Kirkwood, & Kendall, 2005). 
2.12 Availability and utilization of Postnatal Care (PNC) Services 
There are many reasons for delays in seeking care during the postnatal period. In places 
where the majority of births take place at home, PNC may be unavailable, women may not 
know that such services exist; they have limited access to; and subsequently make limited use 
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of health care services for both themselves and their babies during the period following 
childbirth. Disparities in health seeking behaviour exist especially in LMIC despite WHO's 
recommendations that all women should receive skilled maternity care to avert complications 
and mortalities (Afulani & Moyer, 2016). Health seeking and utilization may be influenced 
by individual. family. community. and contextual factors (Andersen, 1995). Timely 
recognition of perinatal complications and seeking for treatment promptly from trained 
providers are crucial in improving maternal as well as fetal and newborn health (Khanam et 
al.. 2016). In rural Bangladesh, it was reported that community norms require that mother and 
newborn are confined during early neonatal period to up to 40 days. Hence this practice 
affected health seeking behaviour of mother (Winch et aI., 2005). This has been found to be 
the major deterrent to accessing early postnatal services in many communities throughout 
Africa during the postnatal period (Warren. Daly. Toure, & Mongi. 2006). 
Some other reasons for not seeking PNC include misconceptions about the importance of 
PNC or lal;k of a\\areness of PNC and its benefits; cost of health services, transport costs or 
both; distance to health facilities and transport problems; and in some cases fear of wild 
animals on the way to the health facility with a young infant (Mrisho et aI., 2009; Nabukera 
et al.. 2006). Perceived poor quality of available health services with and poor attitude of 
health care providers also deter women from seeking care. This can also include neglect, 
verbal and physical abuse, lack of privacy and poor hygiene (Ganle, 2015; Moyer, Adongo, 
Aborigo, Hodgson, & Engmann, 2014). Limited health management capacity as well as 
referral and communication failures have also been identified at various levels. Health system 
bottlenecks such as insufficient workforce, infrastructure, health information system, supply 
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chain logistics and managerial capacity affect women's access to PNC (Lozano et aI., 
2011). 
2.13 Summary and Conclusion 
From the empirical studies reviewed, the literature is emphatic regarding the strategies that 
have been implemented globally to reduce maternal and child mortality. Maternal and child 
health factors are often determined by multiplicity of factors. Both geographical and financial 
accessibility has been reported as barrier to health care along the perinatal continuum of care. 
However, the introduction of free maternal and child health care has largely ameliorated these 
barriers. 
Ghana has also adopted the global strategy of continuum of care to ensure that pregnant 
women attend ANC, have skilled delivery, receive postnatal care within 48 hours of delivery 
through to six weeks and the neonate and children under five receive the various 
immunization. However, socio-cultural practices have been reported to undermine women 
achieving the continuum of care. It is therefore important to identify these factors and how 
they affect the continuum of care to be able to put in place targeted interventions. 
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CHAPTER THREE 
METHODOLOGY 
3.1 Introduction 
This chapter describes the methodology of the study. It starts by describing the philosophical 
underpinnings of the study from which the study design emerged. The chapter also describes 
the study area as well as the study population. The chapter further provides a description of 
how the sample size was determined and the sampling employed in selecting study 
participants. The data collection techniques and tools are also described in this chapter. The 
chapter conclude by describing how the data collected was analysed and the ethical 
consideration in the study. 
3.2 Philosophical underpinnings of the study 
An important consideration in any research process is the philosophical underpinnings of the 
~tudy as this provides the foundation upon which the study is conceived and the methodology 
that should be employed. Two key philosophical underpinnings that are essentially to be 
cunsidered in a study are ontology and epistemology (Teddlie & Tashakkori, 2010). Ontology 
is a philosophical study of the form and nature of the reality that the researcher investigates 
and how this reality can be measured. Epistemology on the other hand, examines the 
n:lationship between the researcher and the researched (Creswell, 2009). These philosophical 
paradigms therefore often influence the design of the study and the methodology that is often 
employed to acquire the knowledge that the researcher sets to investigate. 
The concept of ontology often leads to dichotomy in study designs (quantitative and 
qualitative) with a most recent design that combines these two strategies (pragmatism). 
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Quantitative study design operates on the positivist philosophy that holds the view that reality 
is one. fixed and can therefore be measured by following a set of laid down objective 
procedures. Qualitative study designs on the other hand operates on the interpretivist 
philosophy that views reality as subjective and mUltiple, as seen by participants in the study 
(Banard, 2006). The concept of epistemology on the other hand looks at how the knowledge 
is acquired by examining the relationship between the researcher and the researched. [n 
adopting the positivist approach to research. which is the quantitative, the researcher embarks 
on the study of the reality by maintaining a distance between himlher and the researched. 
Contrarily to this approach, researchers who hold the view of interpretivists (qualitative) 
adopt strategies which will lessen the distance between himlherself and what is being studied 
(Creswell, 2009). This study will adopt the pragmatism research paradigm which combines 
both positivist (quantitative) and interpretivist (qualitative) paradigms using sequential 
approach (Bowling. 2014). 
Guided by these philosophical stands, my ontological view regarding socio-cultural practices 
aftecting continuum of care could vary between individuals as experiences may vary and be 
shaped by the society one lives in. It was therefore important to get closer to the community 
and the participants to construct this reality and gain a deeper understanding of these 
practices. This therefore informed the qualitative component of this study. After identifying 
these lac tors and how they affect intrapartum and postpartum continuum of care, it was 
IlIlportant to quantify the factors to serve as evidence to guide policy development and 
structuring of interventions. Hence. the identified practices were quantified to show the 
magnitude of the problem in the second phase of the study which was quantitative and as 
required in mixed sequential qualitative and quantitative design (Bowling, 2014). 
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3.3 Study Design 
This was descriptive cross sectional and narrative study employing quantitative methods and 
qualitative research methodologies. A cross-sectional study is a type of survey where data is 
collected from a subset of a given population of interest and at one point in time to help 
address specific research questions (Hall. 2008). A narrative study on the other hand is a 
study that relies on the written or spoken words or visual representation of individuals. These 
approaches typically focus on the lives of individuals as told through their own stories. The 
emphasis in such approaches is on the story, typically both what and how is narrated (Hall, 
2008). 
Quantitative research is suitable for studies that the researcher intends to make of a situation 
through objective measurement and presentations of the findings in numerical form 
(Williams. 2007). However, qualitative research approach is used to undertake a holistic 
study of a phenomenon through getting closer to the phenomenon of interest and the findings 
as presented in textural form (Creswell, 2009; Williams, 2007). Therefore, a mixed 
methodology combines elements of qualitative and quantitative research approaches (e.g., 
use of qualitative and quantitative viewpoints, data collection, analysis, inference techniques) 
for the broad purpose of breadth and depth of understanding and corroboration (Creswell & 
Garrett, 2008: Teddlie & Tashakkori, 2010; Williams, 2007). 
The quantitative part of this study was a survey among postpartum women to identify the 
mtrapartum and postpartum socio-cultural practices and how these practices influence the 
~c\ntinuum of care. The qualitative part of this study on the other hand adopted narrative 
approach to qualitative study to elicit information from community members the various 
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socio-cultural practices, factors influencing those practices, their relevance and effects on 
continuum of care in the Asante Akim North District of the Ashanti Region. 
304 Study Area 
This study v.as conducted in the Asante Akim North District of the Ashanti Region. The 
Asante Akim North District with its capital Agogo is situated at the eastern part of the 
Ashanti Region. Its eastern boarder forms part of the regional boundary dividing the Ashanti 
and Eastern Regions (Figure 3.2). The district covers a total surface area of about I, 217.7 
square kilometres (472.4 square miles) which is about tive percent (5%) of the total area of 
the Ashanti Region, and 0.5 percent of the total area of the country. The built environment 
consists of 369.482 square kilometres with the natural environment forming 848.218 square 
kilometres of the total land area. The district was established by Legislative Instrument 
(L.I) 2057 and it shares boundaries with the Sekyere Kumawu District in the north, Kwahu 
East in the east, Asante Akim South District in the south and the Sekyere East District in the 
\\est. On the South-West lies Amansie East District and on the South-East is Birim North 
District in the Eastern Region (GSS, 20148). 
The district has a population of 69,186 which represents 1.4 percent of Ashanti Region's 
population. The rural areas have a total population of 36,990 representing 53.5 percent of the 
population of the District relative to 46.5 percent residing in urban localities (GSS, 2014). 
The major ethnic groups/cultures identified are Akan but minority ethnic groups include 
Fantis. Ewes, Gas. Moshies. Sissalas, Nzemas, Dagombas and Kussasis and Mamprushies. 
The predominant language is Twi. 
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3.4.1 Social and Cultural Characteristics of the Study Area 
The District has three paramount chiefs (i.e. Agogo, Juansa and Domeabra). The Akan 
culture most especially the Asante culture dominates in the District. However, there are 
migrant settlers mostly from the Northern and Volta regions who also practice their culture 
alongside the Akan (Asante) tradition and culture. The major language spoken in the District 
is Twi. The major festivals celebrated in the District are Adae Kese and Nhyira Kan festivals 
both celebrated by the people of Agogo. These festivals provide a platform for reunion of the 
people, discussion and the implementation of development projects. The festivals also attract 
both local and foreign tourists into the District (GSS, 2014a). 
Majority of the people in the District are mainly Christians (79.7%) followed by Muslims 
who constitute 10.2 percent, traditionalists form 1.2 percent and less than one percent of the 
population (0.7%) practice other religions. Interestingly, 8.2 percent of the population has no 
religion (GSS, 201Ic). 
3.4.2 Health Information of Study Area 
Health care delivery in the district follows the decentralized structure: district, sub-district 
and community level (GHS, 2015). The district is operating with twenty two (22) demarcated 
CHPS zones according to electoral areas. The Afram Plains covers about 40% of these 
communities (GHS, 2015). 
The district has a total of eleven (11) health facilities comprising of one district hospital 
(located at the district capital), and the others are clinics, health centres, Community-based 
Health Planning and Service (CHPS) and some private health facilities. 
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The district is divided into four sub-districts namely; Agogo. Ananekrom, Juansa and 
Amantenaman. Agogo and Ananekrom sub districts includes some portions of the Afram 
Plains where they share borders with Sekyere Afram Plains and Kwahu East Districts (OHS, 
2015). In the Asante Akim North District. available data shows that there are more literates 
(79.2%) than non-literates (20.8%) (GSS, 2014a). However, in terms of non-literates, females 
formed the majority (64.7%) while males represent 35.5 percent and this figure could be 
much higher for the rural areas within the district. The utilisation of maternal health services 
is low in the district a~ compared to other districts in the Ashanti Region. For instance, the 
coverage for antenatal registrants in 2015 was 90.2 % (2,854) as against 96.7 % (2,939) in 
2014; a drop of 6.5%. Pregnant women making four visits to the antenatal clinic were 71.6% 
(2.042) in 2015 as against 109.3% (3,311) in 2014 and 125.7% (3882) in 2013 respectively 
(GHS.2015). 
rhe tolal births (TBAs inclusive) recorded for 2015 in AAN District was 2,869 (90.7%) as 
compared to 2,927 (95.0%) in 2014 and 2,872 (95.7%) in 2013. There was a decrease of 
4.3% in 2015 as against 2014 (AAN-DHMT. Annual Report. 2015). Supervised deliveries in 
2015 was 2,687(84.9%) as compared to 2,681 (87%) in 2014 and 2,632(87.7%) in 2013 
(GHS, 2015). 
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.. 
-~---~ 
,.-~ANEKROM 
.~'.j 
<"'~" . , 
_/ M , 
~AGOGO 
... A~~~EN~IW. ) , 
-A.ANSA 
1't Legend -..,1'._ 
.A • HA"",..,....,N A --
Figure 3. 2: Map of AAN District 
3.5 Quaotitative Study 
3.5.1 Study Populatioo 
A study population is the total of all the individuals who have certain characteristics and are 
(If interest to a researcher (Bowling, 2014). The population for the quantitative aspect of this 
s1Udy included postnatal women who had passed the postpartum period (40 days after 
delivery). lbis is because this period forms the most critical period where most maternal and 
neonatal mortalities occur and therefore very essential stage of the continuum of care (Lawn 
et aI., 2006). This population has been estimated to be 3, 162 (GHS, 2015). 
3.5.2 Sample Size determioatioo for Quaotitative Study 
lbe sample size for the quantitative aspect of the study was determined using the Yamane's 
formula for population proportion (Yamane, 1967). Yamane's formula combines Cochran 
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fonnula for detennining sample size for a cross-sectional survey with categorical outcome 
(Cochran, 1977) with provisions to cater for both population-related adjustments and 
proportion of outcome variable of interest. 
Z2 p(1-p)N 
n ........... (I) zZp(l-p)+Ne" . 
Where: 
n= the minimum sample size 
Z is the standard nonnal variate for population distribution. In this study, a 95% confidence 
interval will be used. Hlerefore. a 5% type I error was allowed and the level of significant 
placed at p <0.05. At p<O.OS. Z =1.96. 
p= 8% (0.08) proportion of postpartum women who completed intrapartum and postpartum 
continuum of care (Yeji et al., 2015); N=the population of postpartum women within their 
puerperium in Asante Akim North District is 3,162 (GHS, 2015) ; e= 5% or 0.05. 
e= the margin of error to be tolerated which has been set at 5% or 0.05. 
Since both the numerator and denominator for equation (I) contain Z2p (1 - p), equation (I) 
can be ~implitied to: 
N 
n =t .;Ne2 .............. (2) 
Therefore, submitting the figures above into equation (2) 
3162 
n 
1 + 3162 * 0.052 
n=399+ 10% non- response (NR) = 439 
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The 10% was used because previous studies have reported that in a study using this 
population. the research should anticipate a non-response rate of between 5-10%. Hence. in 
this study the maximum non-response rate was considered to cater for this eventuality 
(Bhutta et aL 2014; Kinney et al.. 2010). Bowling (2014) has also argued that increasing the 
sample size above the computed minimum sample size does not essentially cater for non-
response rates but increases the precision level in the study. In that regard. increasing the 
sample size above the minimum sample size also increased level of precision and reduced 
sampling error. 
3.5.3 Sampling Procedure for Quantitative Study 
Multi stage ,ampling procedure was employed in the quantitative aspect of this study. The 
first stage of the sampling involved determining the sub-districts in the Asante Akim North 
LJi.,tricl. Four sub-districts are located in the entire district. For each sub-district communities 
were randomly selected. Structural listing of eligible participants was done in the selected 
communities (Figure 3.1). All houses were listed in the second process and eligible 
individuals in the various household were listed. This was done in all the four sub-districts. 
The total number of eligible people (women with children up to 6 months) per sub-district 
""as used to allocate the number of people to be selected for the study in each of the sub-
districts. Hence the allocation was done proportional to the size of the eligible individual in 
the sub-district. In each household, eligible mothers were given unique numbers which were 
randomly generated using Microsoft excel (random numbers generator) and individuals 
bearing those numbers were contacted and interviewed. Where a selected individual refuse to 
participate in the study, resampling was conducted to replace such individuals. 
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Asante Akim North 
District 
-- ~­ ,,- ~­
Agogo sub- Ananekrom 
district s u b-d istrict i 
~~ --
J communities J commulllties 
Structural Structural 
Figure 3.1: Sampling procedure 
3.5.4 Inclusion ami Exclusion Criteria for the Quantitative Study 
rhl: study included mothers with babies aged six months and below irrespective of their 
religiou~ affiliatilln or ethnic backgrounds. Mothers who were qualified and listed but were 
unwilling to participate in the study were excluded. The study also excluded mothers who 
were listcd and sampled but were unwell at the time of data collection. 
35.5 Key Variables in Quantitative Study 
The variablc'i in this study were divided into independent and dependent variables. An 
independent variable is defined as those variables that a researcher manipulates to measure 
the effect of the manipulation on another variable. A dependent variable on the other hand is 
the variable that responds to the effects of independent variables (Fan, 20 I 0; Leatham, 2012). 
By purposefully manipulating the value of an independent variable, the researcher hopes to 
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cause a response in the dependent variable to establish the relationship and the strength of 
that relationship (Fan. 2010). 
The independent variables in this study"" ill include (Table 3.1): 
Socio cultural practices along the intrapartum and postpartum continuum of care: 
(food taboos, sexual restrictions, religious barriers) 
ii. Socio-demographic factors: mother's age at birth, parity, education, ethnicity, 
religion; ANC attendance, Socio-economic status 
iii. Ne""bom care practices 
The dependent variables include Crable 3.2): 
Skilled delivery 
Health seeking behaviour for neonates and mother 
iii. bsential Newborn Care 
iv. Continuum of care 
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Table 3.1: Study Variables 
! Variables Operational Definition Level of Categories 
i Measurement 
Independent "ariables 
~ 
\gc Completed chronological age Continuous 19-29, 30-39, 
computed from birth and numeric 40-49 
but was 
categorized 
Religion Religious inclination Categorical Christian, 
Muslim, 
traditional. 
others 
Marital status Any distinct options that describe Categorical Married, Single, 
the woman's relationship with a Divorced, 
significant other. Separated 
Widowed 
Parity Number of pregnancies the woman Numeric 1-10, 11-20 
has had 
safe cord care, Keeping the cord dry and use Nominal Safe, Unsafe 
prescribed medication on the stump 
of cord 
Early initiation Putting the infant to breast within Nominal Early initiation, 
of 30 minutes after birth late initiation 
breastfeeding 
Delayed This is done to keep the baby warm Nominal Delayed, not 
bathing and prevent hypothermia del::ty 
Use of ANC Attending ANC for current Nominal ANC registrant, 
Services pregnancy Not a r~istrant 
Postnatal Checkup for mother and baby Nominal Type of care 
checklJ!l within 2 days after delivery 
Food taboos A deliberate avoidance of a food Nominal Yes or No 
item for reasons other than simple 
dislike from foodpreferences. 
Confinement Mother and newborn are restricted Nominal Yes or No 
from going out for up to 7 days. 
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Table 3 .2.' Dependent Variables 
IDependent Operational Definition Level of Categories 
I Variables Measurem 
I ent 
Health seeking Where a mother will regularly seek Nominal Biomedical 
for health care for any pregnancy- (Orthodox), 
related or neonatal ill-health Non-biomedical 
(Non-orthodox) 
Delivery assisted Type of delivery Nominal Skilled, 
by skilled birth Unskilled 
attendants 
Essential new born Neonate receiving essential cares Composite Adequate, 
care by WHO standard score inadequate 
Continuum of care Defined as ANC 4+, skilled Composite Continuum, 
delivery, postnatal with 48 hours, 2 score discontinued 
weeks and 6 weeks 
3.5.6 Data Collection Tool for Quantitative Study 
Structured questionnaire was designed and used as a data collection tool for the quantitative 
part of this study. The questionnaire covered areas such as socio-demographics, practices 
along the perinatal period and health seeking behaviour. The questionnaire also elicited 
infomlation on knowledge on danger signs during pregnancy, essential newborn and the 
actual practice of these care in the last child (Appendix B). The questionnaire was designed in 
English language with inbuilt check to ensure consistency. Skip patterns were incorporated 
into the design of the questionnaire to ensure people do not answer questions they are not 
supposed to answer based on the responses to a previous question. 
3.5.7 Data Collection Strategy 
There are basically two modes of administering questionnaire in a survey. These include 
interviewer administered and self-administered (Bowling, 2014). This study adopted the 
interviewer administered method. In this approach, the principal investigator and the 
research assistants read out the questions and the possible answers to the participants. The 
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interviewer then checked the selected option of the participants. This method of 
administering questionnaire has been reported to be easy with lower non-response rate than 
the self-administered where the questionnaire is either emailed or posted to the study 
participants (Bowling, 2014). 
3.5.8 Quantitative Data Management and Analysis 
All completed questionnaire were received by the Principal Investigator (PI) and validated for 
correctness. Completed questions which were veritied were stored in secured place until the 
entire questionnaires were completed. A data entry screen was designed using Microsoft 
access with inbuilt checks. The data entry screen was also accessed by an independent person 
to ensure it was robust enough to prevent errors during data entry. Each questionnaire was 
th.:n given a unique lD after which the data was entered into the MS access and the data was 
Imported into STAT A 14 for analysis. Continuous variables were categorized into ranges 
\\ith intervals <1.'> required. Categorical variables such as sex. educational attainment, 
ethnicity, and religion retained their categorization during analysis. In select cases, such as 
ethnicity, they were reclassified as either being Akan or Non-Akan because some the ethnic 
group~ have very small representation making statistical analysis very fluid (Johnelle Sparks, 
Sparks, & Campb.:ll. 2012). Socio-economic status was measured using wealth index score 
which is reported to be a better estimator for socio-economic status than education and 
income levels (Bowling, 2014). To determine wealth index, the research had to first conduct 
principal components analysis of household assets and possessions to determine which 
variable should be included in the model to determine wealth of household. In this study, data 
was collected on household assets and possession such as having a bicycle(s), motorbike, 
television and a car, DSTV, computers, phones, materials used in housing, possession of 
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domestic animals such as goats. sheep. cattle and pigs. These household assets and 
possessions may be correlated in an unknown and complex way. When a set of variables are 
correlated in a complex and unknown way along several dimensions. Principal Component 
Analysis (PCA) is employed to reduce those variables by assessing which variables behave in 
d ,imilar manner. Based on the variables and their relationship to each other, PCA creates a 
new set (If variables, each called a principal component (Fry, Firestone, & Chakraborty, 
2014). 
USing this strategy. household assets and possessions collected during the study were 
assigned weights based on principal components analysis and the resulting scores were 
,tandardized to a standard normal distribution. Information on assets and possessions that 
.... ere binary variables (which elicited "No" and "Yes" responses) were recoded as either 0 or 
I where 0 means the household does not have the asset in question whilst I represents the 
household owing the asset. However, for continuous variables such as the number of animals 
~uch as fowls. sheep. goats, and cattle that an individual has, their absolute values were 
maintained before running the PCA. After the PCA, variables with eigenvalue (measure of its 
power to explain variation between participants) above one were put together to determine 
the wealth of an individual. Usually, a factor is considered important and worthy of 
indusion/retention in the scale if its eigenvalue exceeds the threshold of>1 (Bowling, 2014). 
In all. 16 household assets and possessions were retained in the final model to determine the 
.... ealth of households. Based on these aggregate scores, individuals and their households were 
put into five quintiles. Asset based wealth measures allows ranking of households and have 
bt:en shown to be more stable, i.e. less sensitive to transient fluctuation than other proxy ways 
ofdeterrnining socio-economic status (Howe, Hargreaves, & Huttly, 2008). 
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Knowledge was also measured at two levels. At first. an individual's knowledge was 
measured at specific dimensions such as their ability to identify essential newborn care 
practices and danger signs of newborn. This was done to ascertain specific areas that may be 
relevant to highlight in health education and behavioural change communication strategies. 
Afterwards, weighted scores were developed to put an individual into having good 
knowledge. For essential newborn care. participants who had 75% or more of the correct 
answers were classified as having good knowledge. For the danger signs, participants who 
were able to identify three or more of the danger signs were classified as having good 
knowledge. This model has previously been used in a similar study and found to be a 
,Ialistically significant way of classifying knowledge of study participants. A Cronbach 
Alpha index was computed to test the reliability of this measurement strategy (Berhea. 
Belachew, & Abreha. 2018). This gave rise to Cronbach Alpha of 0.79 with an inter-item 
correlation of 0.76 both of which were within the acceptable limit (Streiner & Norman, 2003, 
2008). 
L:ssential newborn care was analysed at two levels. At the first level, the mothers were asked 
to indl.:ate if the essential care (wrapping of the baby immediately after birth to provide 
warmth, putting the baby on the mother, cutting of cord, initiation of breastfeeding with 30 
minutes after birth) were known to them. After the reporting of the proportion at the 
individual level, a mean was computed for entire categories of care classified as essential 
newborn care. Based on that a composite (weighted average) score was developed and babies 
were then classified as having received essential newborn care or not. Respondents who 
scored above the average were classified as their babies receiving essential newborn care 
\\hilst those whose score fell within the mean and below were classified as not receiving 
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<!ssential newborn care. A Cronbach Alpha index was computed to test the reliability of this 
measurement strategy. This gave rise to Cronbach Alpha of 0.87 with an inter-item 
correlation of 0.84 both of which were within the acceptable limit (Streiner & Norman, 2003, 
2008). This meant that the model developed was reliable. 
Continuum of care was defined as having attended ANC 4+, had skilled delivery and 
postnatal care with 48 hours of delivery, two weeks and six week (Mcnellan et al.. 2019; Yeji 
et al .. 20\5a). Women were classified as having discontinued if they did not meet these 
criteria. Hence the relative risk was computed for discontinuation at the three levels; ANC, 
delivery and postnatal care. 
Descriptive statistics was used to present the proportions on socio demographic 
characteristics of the respondents at the univariate level. This was followed by a bivariate 
analysis using Chi-square test. Bivariate analysis or models was used to predict an association 
between an independent and dependent variable (Mishra & Min, 2010). Pearson's chi-square 
test of independence was performed to test for individual independent association (p<0.05) 
between the independent and dependent variables. 
rhe multivariable logistic regression was done at two levels. The first was to establish the 
crude level of association between the independent variables and the dependent variables for 
categorical variables. For this study, all independent variables were added to the first model 
to establish the crude relationship with the dependent variables at various levels of 
mea...urement in accordance with study objectives. Afterwards, variables which were 
significant in the first model at the bivariate analysis level were moved to another model to 
adjust for the effects of those variables. A p-value of less than 0.05 was deemed to be 
significant. The results of the quantitative data are presented in tables. 
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3.6 Qualitatin Research Approach 
3.6.1 Population for Qualitative Research 
The study population for the qualitative aspect of the study included male and female 
community members, community opinion leaders. midwives in-charge of ANC and PNC 
clinics. district public health nurse and district director of health services, TBAs, and 
Traditional Medical Practitioners at the district. 
3.6.2 Selection of Study Participants 
Purposive sampling was employed in the qualitative component of this study. This is a non-
probabilistic sampling procedure where researchers choose the sample based on who they 
think are appropriate for the study (Green & Thorogood, 2004). According to Patton, 
purposive sampling technique is widely used in qualitative research and is appropriate to 
identify and select information-rich cases for the most effective use of limited resources 
(Patton (2002). In performing sampling activities, the maximum variation form of the 
purposive sampling \\as employed to ensure that a wide range of stakeholders was covered 
to provide a holistic view about the study topic (Andale, 2016). The participants included 
those "ho had completed the continuum and those who had discontinued at various levels 
such at ANC. 'Killed birth and PNC such that they could share their experience with the 
researcher. 
3.6.3 Inclusion and Exclusion Criteria for Qualitative Component of the Study 
The stud} included adults 18 years and above as this is the age for informed consent in Ghana 
(The Constitution of Ghana. 1992) and excluded those who met the inclusion criteria but 
were unwilling to participate in the study. 
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3.6.4 Qualitatin Data Collection Methods 
1\\0 main data collection methods that were used in the qualitative aspect of this study were 
focus group discussions and in-depth interviews. 
3.6.4.1 Focus Group Discussions (FGDs) 
Focus groups are unstructured interviews with small groups of people (usually between 8-12 
people) who interact with each other and the group leader (Mack, Woodsong, Macqueen, 
Guest, & Namely, 2005). 
In this study, FGDs were conducted to corroborate interview data on nonnative ideas and 
practices in the community through the process of triangulation. These were also relevant in 
developing themes, interpretation, exploring concepts derived from individual interviews for 
in-depth details and identifying contradicting infonnation. Eleven (II) FGDs were 
wnducted, 5 among male and 6 among female community members by a rural-urban mix. 
Subsequently, among female community members, 3 of the FGDs were conducted in rural 
communities and another 3 in urban settings. For the FGDs among male community 
members, .:: and 3 sessions were conducted in rural and urban settings respectively. In 
addition. one FGD was organized among pregnant women whose gestation was at least 6 
months and another among women with babies less than six months of age. Each group 
consisted of between 8-10 individuals and the participants sat in a horse-shoe fashion with the 
moderator and rapporteur sitting in the middle. All FGDs were conducted in the community 
at an agreed time suitable for the participants. During FGDs, each participant was given the 
opportunity to make hislher contribution to any question posed before moving to another 
question. Probing methods were used to clarify any unclear point raised or emerging areas of 
interest. 
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3.6.4.2 In-depth Inten'iews 
In-depth interviews (lOIs) involves a one-on-one interaction between a researcher and 
research participant on topic of interest (Plummer. 1983), With this approach, respondents 
have the opportunity to situate their own life experience within the larger social context. In 
this study, twenty two (22) lOIs were conducted. Data analysis was done simultaneously with 
data collection with the aim of stopping the study at the point of theoretical saturation as 
recommended in qualitative studies (Creswell, 2007; Saunders et aI., 2018). All the lOIs 
were conducted by the principal investigator and trained research assistants with expertise in 
conducting qualitative interviews. It took between 30-45 minutes to complete 101 session. 
The breakdown of the participants is showed on table 3.3. 
Table 3.3: Breakdown of IDI partitipants 
(~~gorv Number 
Community Health Officers 4 
Midwives 3 
Sub-district in-charges 4 
District Public Health Nurse 1 
District Director 1 
Opinion leaders 4 
rBA., 2 
Traditional Medical Practitioners 3 
Total 22 
3.6.5 Data Collection Tools and Procedures for Qualitative Research 
Semi-structured FGDs and 101 guides were used to collect the qualitative data for this study. 
FGD guide was used to solicit information on the socio-cultural practices that along the 
intrapartum and postpartum continuum of care, The IDI guides also contained items such as 
perception of neonatal illness, how health care is sought , and h ea Ith servi.c e d e I'I very 
experiences of mothers, NMCH issues in the district. These guides were designed in English 
and translated into Twi. The translation was done using back-to-back 
strategy. In this 
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strategy, an expert proficient in English and Twi first translated the interview guide from the 
English language to the local language. Another expert was also made to retranslate the 
guide from the local language back to English and the two versions compared. This was done 
to ensure uniformity in the data collection tools. 
3.6.6 Qualitative Data Analysis 
The qualitative data were audio-taped using a digital voice recorder. After each interview 
session. the recording was replayed to participants to listen and to make the necessary 
additions, subtractions and clarifications deemed necessary. Maynard & Purvis (1994) have 
indicated that participants listening to tapes after interviews is an important step in qualitative 
data analysis even though this is often overlooked. The taped interviews were transcribed 
verbatim into Microsoft word. 
Analyse~ of data occurred concurrently with data collection. The process included reading 
and rercading of the interviews and focusing on the identification of themes relating to the 
explanations and experiences with socio cultural practices relating to intrapartum and 
postpartum continuum of care at community, health centers and hospitals levels. Data 
(nllected in local language was first translated into English by two people; the interviewer 
and another person and the translation were compared for consistency. Any variations in 
vicM were discussed and resolved by the translators. The transcripts were imported into 
NVivo II for windows for analysis. Thematic analysis was adopted in analysing the data. 
Th~matic data analysis process consists of three interrelated stages namely data reduction, 
data display and data conclusion-drawing or verification (Miles & Huberman, 1994). Guest, 
MacQueen & "amey have also summarised the process of thematic analysis as consisting of 
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reading through textual data. identirying themes in the data, coding those themes, and then 
interpreting the structure and content ofthe themes (Guest, Macqueen, & Namey, 2012). 
A codebook was first created for the main themes and sub-themes from preliminary reading 
through the transcripts. These codebook defined the various code that will be used during 
coding. their definition, when to use and when not to use such a code and examples of 
statements that should be considered for coding into particular codes. These codes were 
turned unto nodes within the software. Following that, a line-by-line reading of all transcripts 
within the NVivo II software was done and relevant portions of statements made by 
respondents coded unto existing nodes and new nodes. The various codes were analyzed into 
themes based on the codes to reflect the content of the data collected alongside the writing 
memos on specific relevant areas. Memoing involves putting down initial ideas, issues, 
observation and patterns that can be connected, compared or contrasted while doing the 
coding (Creswell. 1998). Queries were also run in NVivo to quantiry some of the qualitative 
data and the results exported and added to the qualitative data in the results. The results of the 
qualitative data were then presented in narratives and supported with illustrative quotes from 
respondents. 
3.7 Data Triangulation 
Triangulation essentially means combining two or more views, approaches or methods in an 
investigation in order to get a more accurate picture of the phenomena (Yeasmin, 2012). 
Triangulation is used to ensure that the weaknesses in each single data collection method will 
be compensated by the counter-balancing strengths of another (Teddlie & T ashakkori, 20 I 0). 
Since both quantitative and qualitative data were collected in this study. data triangulation 
strategy was employed to report the findings of this study. For example, the qualitative data 
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was used to support quantitative results on the knowledge regarding birth practices, essential 
newborn care. Also, qualitative data was used to explain some of the reason for some birth 
practices and essential newborn care issues. 
J.8 Quality Control 
Two research assistants were trained on all aspects of the research process. The training was a 
combination of theoretical work and mock exercises in both English and Twi after which they 
were deployed to collect the data. As a quality control measure, 20 samples of people who 
were interviewed by research assistants were re-sampled and re-interviewed using the same 
data collection tools and the data compared for consistency. Field notes were also written 
immediately after each interview. In addition, daily supervision of data collection was carried 
out and re-sampling of some of the respondents was done and re-interviewed by the Principal 
Investigator (PI) to compare with what was conducted by the research assistants. After FGDS 
and IDls the recording were replayed for the participants to make inputs as required in 
member checking (Birt, Scott, Cavers. Campbell, & Walter, 2016). The transcriptions were 
done by the people who conducted the interviews (Research Assistant) and another 
independent person before the transcripts were compared. Where there were variations, these 
were discussed and agreed upon by the transcribers and PI by listening to voices and 
comparing it with the transcriptions. 
3.9 Ethical Consideration 
The protocol for this study was reviewed and approved by Ghana Health Service Ethics 
Committee (GHS-ERC: 006/11117, appendix E). The study commenced only after receiving 
ethical approval from the Institution. 
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Prior to initiation of data collection, regional, district and health facility officials of the Ghana 
Health Service (GHS) in the selected study sites were infonned about the study objectives, 
methods and timelines. Upon arrival in the community. the study team met the GHS officials 
who briefed them about the arrangements at the communities and facilitated meetings with 
the local leaders. After gaining the support of the community leaders, the team, assisted by 
community-based volunteers and an officer of the district health management team, recruited 
study participants. All participants in this study were provided with names and telephone 
numbers of the principal researcher, the academic supervisors and the secretary to the Ethics 
Committee of the Ghana Health Service to contact freely with issues related to the study. 
3.10 Study Limitation 
Although the study has identified socio-cultural practices influencing the intrapartum and 
postpartum continuum of care. it is important to situate the conclusions in the context of the 
limitations of the study. The study was conducted in selected communities across all the four 
sub-district despite the fact that contextual differences may exist in other communities that 
were selected for this study. However, to circumvent the effects of this limitation, for each 
sub-district, communities were randomly selected. 
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CHAPTER FOUR 
RESULTS 
".1 Introduction 
The chapter covers the results of the study. It begins by providing the socio-demographic 
characteristics of both the qualitative and quantitative study participants. Descriptive 
statistical methods are used to present the frequencies and percentage on the background 
characteristics of the participants, after which the results are presented according to the four 
objectives of the study. For each objective, results are presented at the univariable, bivariable 
and multivariable levels of the analysis. The themes that emerged from the qualitative data 
were also embedded into the quantitative results using data triangulation strategies. The most 
telling illustrative quotes were used to support the narratives from the themes that were 
derived from the data during analysis. 
".2 Socio-demographic Characteristics (SDC) of Participants 
The total number of respondents in the study was 439. The modal age group of participants 
was 25-29 years (34.4%) whilst the age group with the least number of participants was 40-
44 years 6 (1.3%). Regarding the religious affiliation of participants, Christians, 399 (90.9%) 
and Moslems. 36 (S.2%) were the majority. Majority, 344 (78.4%) were Akan and 281 
married (64.0%). Husbands were listed as key decision makers by 275 (62.6%) participants. 
In terms of socio economic status, majority were within the "poor" category. However, inter-
category difference was small (Table 4.1). 
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Table 4.1: Socio-demographic characteristics of respondents 
---- - Percentage (%) FrequeDcv (D) 
SOC 
Age(iny~ N=-I39 
100% 
53 12.1 
IS-I~ 
114 26.0 20-24 34.4 
25-29 151 
30-34 84 
19.1 
7.1 
35-39 31 
40-44 6 
1.3 
-15-49 0 
0.0 
EducatiODal attainment 
82 \6.7 No lorma! education 26.9 
Primary 118 40.5 
MiddlelJSS 178 9.8 
Sccondal) 43 4.1 
TertiJl1 18 
Religion 90.9 
Chri,tianil)' 399 
Islam 36 
8.2 
Tradil,,'nal 4 
0.9 
Ethnicity 
78.4 
Akan 344 
'Jnn-,\kan 95 21.6 
\1arital status 
Nc\ 54 12.3 cr married 
Married 281 64.0 
Co-habiting 102 23.2 
Di \ "recd/separated 2 0.5 
OccupatioD 
I'armcr 97 22.1 
frader' 173 39.4 
HOllie"il;: 23 5.2 
C;,jllPublie ,en.I' 18 4.1 
Student 10 2.3 
\ni><ln- 65 14.8 
Other, 53 12.1 
Number of cbildren 
1-3 334 76.1 
<3 105 23.9 
lIulth-related decision making 
Sell 105 23.9 
Ilu,banJ 275 62.6 
Parclll' 54 12.3 
In-La", 5 1.2 
Socio-econnmie status 
Poon:,-.I 88 20.0 
Poor 90 20.6 
Bener 86 19.6 
Le;s poor 88 20.0 
Least poor 87 19.8 
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4.3 Socio-demographic Characteristics of FGD and 101 Participants 
In the qua I·Ita·tlY e as pect of the stud .v'  7'-" people participated in the FGDs with 37 (51.4%) 
being females. 23 (31.9%) had no fonnal education and 51 (70.8%) were adherents of 
Christian religion. Twenty-two (22) lOIs were conducted, majority, 13 (59.1 %) were health 
workers (Table 4.2) 
Table 4.2: Distribution of Qualitative Study Participants 
~ Frequency (n) Percentage (%) 
FGD N=72 100 
Sex 
Male 35 48.6 
Female 37 51.4 
Educational attainment 
No formal education 23 31.9 
Primary 21 29.2 
Middle/JHS 13 18.1 
SHS II 15.3 
Post-secondaryrre rtiary 4 5.5 
Religion 
Christianity 51 70.8 
Islam 21 29.2 
Ethnicity 
Akan 48 66.7 
Non-Akan 24 33.3 
101 N=22 100 
Health workers 13 59.1 
Traditional medical Practitioner, 5 31.8 
Opinion Leaders 4 9.1 
4.4 Knowledge on Peripartum Care 
The results shov.ed that all participants were aware of the need to attend ANC clinic during 
pregnancy, hov.ever 341 (77.7%) indicated they have had some fonn of ANC with only 124 
(36.4%) starting ANC before the 24 weeks gestation (early). In tenns of assessing 
knowledge about practices during the peri-partum period, the findings showed that 
knowledge on wrapping of baby immediately after birth to provide wannth and immunization 
at birth was universal, however, 140 (31.9%) and 288 (65.6%) had knowledge on delay in 
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bathing and exclusive breastfeeding respectively. In all. 298 (67.9%) had good knowledge on 
perinatal practices whilst 278 (63.3%) had good knowledge on danger signs of neonates 
(Table 4.3). 
Table ~.3: Knowledge on perinatal care 
Peri-partu m care Frequency (n) Percentage (%) 
t\NC awurenes, 439 100.0 
AttendedANC 341 77.7 
ANC Booking Gestation (N=34I) 
<20 "eek> 124 36.4 
20-28 "cd, 72 21.1 
>~R \\ccb 145 42.5 
Immediate baby care 
B"b) \\ rapping after birth 429 97.7 
Giving bab) to mother 347 79.0 
Dcla\ in hathing 140 31.9 
Bru,tfeeding initiation and practices 
lnot"";"n of breastl<':cding "ithin one hour after birth 415 94.5 
Use of colostrum 390 88.8 
Demand fceding 325 74.0 
Night k..:ding 436 99.3 
belusi"c breastfL-eding 288 65.6 
Complementary feeding after six months 298 67.9 
Use of herbal preparation during exclusive breast feeding 253 57.6 
I rcatmcnt Ii Ir sore nipple 67 15.3 
( are of umbilical cord 
Sterile cutting of cord 38 8.7 
U!IC 01 spirit to lire" umbilical cord 254 57.9 
Daily c,lre [ll Ltlrd 416 94.7 
Immunization 
Immuni/..1'ltln ,It birth 438 99.8 
Rcason~ t(lr immuni/--'liion 435 
Duration 99.1 cd immunil'ation 361 82.3 
Good Kno\\ ledge (aJhwered "2: 75% of questions correctly) 298 67.9 
Knowledge about danl!cr signs of newborn 
High grade fever 268 
Ditliculty in breathing 61.0 412 
A balw cold to touch 93.8 148 
Vomiting/diarrhoea 33.7 
381 
Cf) ing excessivel) 86.8 
312 
Abnormal jerking movement of limbs and eyes 71.1 208 
l'nable to ti:cd 47.4 
291 
Yc lio" ish discolouration of eyes, palms and soles 66.3 217 
Good knowledge lidentilied > 3 danger signs) 49.4 278 63.3 
Both FGD and 101 participants were able to identitY some of the essential care required 
during the perinatal period. Participants mentioned attending A NC. having skilled birth, 
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protection of the baby against cold and immunization of baby and the pregnant woman as 
essential elements of care required during this period. The following illustrate these points: 
.. We are /Old when a woman is pregnant she will have to go ANC for them to assess the 
mother <lnd baby and give injections to protect both the baby and the mother. But in this 
community some pregnant women do not go because they belief that the medicines given 
to the mother make the babies big so they will not go. My wife even complained about it" 
(Elderly male, FGD). 
"Giving birth at the hospital is one of the things the nurses tell us as pregnant women 
dllring ANC. For me I did not start the ANC early because my mother in-law advised me 
to stay at home for the baby to become matured before I start otherwise people may 
bewitch the baby and the baby will die .. (ANC woman, FGD). 
However some participants were of the view that yellowish discolouration of the eyes and 
palms of the baby are normal and will often resolve with time. Hence knowledge in this area 
was low as also reported in the survey where less than half of the women who participated in 
the survey could identify it as danger sign during neonatal period. The following quotes 
illustrate FGD participant's view about yellowish discolouration of the eyes, palms and soles 
of the neonate: 
.. When YOIl give birth to the baby and the eyes and palms are yellow. it is normal 
bec<lusc of the change in the environment of baby. This will often go away so we do 
not seek medIcal attentionfor it" (Elderly woman, FGD). 
"The yellow bahies" is something that happens You expose the baby to the sun and it 
will disappear. I also have some medicine that I apply on the baby's body for it to 
d,sappear" (TBA. 101). 
4.:; Socio-cultural Practices during Perinatal Period 
About ~43 (55.3%) of the study participants practiced food restrictions, 293 (66.7%) 
practiced confinement. Home delivery was done by 71 (12.5%) with majority having a 
hospital delivery. Better care was the motivation for choice of place of delivery, 264 (60.1 %). 
Regarding decision making on where to deliver, 168 (38.3%) of women made the decision on 
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their own whilst 155 (35.3%) made the decision with their husband. Majority, 437 (99.5%) 
wrapped their baby immediately after birth to provide wannth (Table 4.4). 
Table 4.4: Practices during perinatal period 
Practices Frequency Percentage (Ofo) 
Practices during pregnancy 
Food restriction 243 55.3 
Sex restriction 69 15.7 
Crossing rivers 47 10.7 
Confinement 293 66.7 
Bewitchment 325 74.0 
Health-related dedsion making 
Self 168 38.3 
Husband 57 13.0 
Selflhusband 155 35.3 
Grandmother 32 7.3 
mother in law 26 5.9 
father in law 0.2 
Practices during labour 
Use of enema 217 49.4 
Squattmg 106 24.1 
Immediate birtb care 
Bathing baby 288 65.6 
Putting baby to breast 416 94.8 
Wrapping baby to provide warmth 437 99.5 
Putting baby on mother body to provide warmth 327 74.5 
Applving warm compresses to baby body 242 55.1 
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In FODs and lOIs it was revealed that socio-cultural practices such as not crossing rivers and 
continement made some women not to attend ANC. This was especially so for women who 
lived at places where they had to cross river to the nearest health facility for ANC. Also 
preference for giving birth in the squatting positive was cited as one of the reason for people 
utilizing the TBA outlets. The following quotes support these points: 
"Some of us live in places whl!re you will have to cross a river before you go the 
clini,' for them to assess you and the baby but because we pregnant women are not 
supposed to cross the river. we do not go" (Elderly woman, IDI). 
"Anytime I get pregnant it does not stay, so I was told it is because when you are 
pregnant and you go out people will look at you with evil eyes to spoil your 
pregnan,-J'. So this time when I was pregnant I never moved outside the house and I 
have had successful birth at home" (Postnatal woman, 101) . 
.W I! prefer to give birth in squatting position because it makes it easy for the baby to 
come out. That is the reason why I delivered at the TBA place. In the hospital they 
mt.lkl! you lie down and raise your leg. My first born it was so difficult when I 
delivered in the hospital" (Postnatal woman, FOD). 
In FODs, it emerged that some pregnant women did not take the folic acid they receive 
during pregnancy. This was because of the belief that the drug made their baby big making 
delivery difficult as illustrated: 
"It ljolic acid] gives you appetite for food. When I take all the folic acid given to me 
at the hu~pital I give birth to a big baby so this time around I took only half oft he 
medicine because when the babies are big they suffer in coming out during delivery" 
(Postnatal woman. FOD). 
Food restrictions were also reported during pregnancy. Participants indicated that ripe 
plantain and egg were generally prohibited during pregnancy. Ripe plantain was believed to 
cause false labour whilst egg was forbidden because of the belief that the baby will become a 
thief in future. The following quotes illustrate these points: 
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"bejore myfirst delivery they told me not to eat ripe plantain because when you take 
it vou will feel like you are in labour when the time is not even due ... we shouldn't eat 
e~gs else ~ur babies will become thieves and also they said if you eat snails saliva 
will drool from your baby's mouth, I did all this things but my baby didn't drool 
saliva/rom the mouth" (woman with child under five, FGD) . 
.. ... they said if we eat ripe plantain, when you are in labour you push and push but 
the baby will not come" (woman with child under five, FGD). 
"when the woman is almost due for delivery she must not eat ripe plantain, it is called 
"kyem d3 ,. which means that you will be feeling some sweet sensations in your body 
when you are pushing during pregnancy but the baby will never come out but that 
practict? is now extinct so now we eat the ripe plantain" (Elderly woman, FGD) 
Some participants also believed that eating of egg during pregnancy was forbidden because it 
will make the baby's head soft as illustrated: 
"the reason why you are not supposed to eat egg is because if you deliver. your 
babY'J head becomes very soft, I have tried it and it is true so I had to put a towel in 
hot water to always massage the baby's head until about forty days' time it became 
good so we stopped (woman with child under five, FGD). 
In addition to the above practices during pregnancy, FGDs revealed some practices in 
preparation toward labour. FGDs participants indicated some local herbs are either ingested 
or used as enema in preparation towards childbirth. These herbs are extracts from the leaves 
and bark of some trees in the community. These herbs are described locally as "awuo mre 
aduro" indicating they assist in child births. These herbs enhance contraction thereby making 
the birth process smoother without complication as has also been reported in the quantitative 
data (enema). The following illustrate these points: 
"The "Awuo mre aduro" is given to you in the ninth month and it aids smooth 
delivery" (woman with child under five, FGD). 
"It is herbs or the back ofa  tree "nu bena ", you use it to prepare soup and sometimes 
alter delivery the placenta is retained, you use it. You boil it pour it in bucket and sit 
on it and also drink some" (woman with child under five, FGD). 
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"They normally use some herbs which they add to about seven palm fruits. smoked 
mlldfish and ahout three fingers of plantain to prepare a particular type of soup 
called "Abedru" and they start taking it when the pregnancy is about five to six 
months and they take it till they deliver. It is said that it helps women to have easy and 
smooth delivery ,. (Elderly woman, FGD). 
Another local practice in preparation for labour is having sex. Participants in this study were 
of the view that having sex during pregnancy was essential in ensuring smooth delivery and 
highly recommended for women. Some "ere also of the view that sex restrictions could lead 
one partners to engage in extra marital affairs. Having sex during pregnancy, close to the 
month of delivery was therefore a common practice as only 69 (15.7%) of survey participants 
indicated that they practiced sex restriction during pregnancy. The following quotes support 
these views: 
"The hushund mllst have sex with the woman frequently to open up the place so that 
the woman will have a smooth delivery. The CS is becuuse ofl ack ofs ex during 
pregnancy" (woman with child under five years, FGD) . 
.. Havinj! sex with your partner makes delivery safe and smooth and will also 
prevenlmur husbandfrom going out to have extra marital affairs" (Elderly woman, 
FGD). 
Participants were of the view that baby boys will lie at the right side of the womb whilst girls 
lie at the left side. In addition, when one is pregnant with a boy, the uterus is often bigger 
than female pregnancy. In this regard, when women are pregnant, and the size of the uterus 
appears bigger than the number of months of pregnancy, then it meant that male child was 
expected. The following illuminate these assertions by participants: 
When you are pregnant with a girl there is a place in the womb she sleeps and 
with a boy too, he has a place he sleeps in the womb" (woman with child under five 
FGD). ' 
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... when 10m pregnant with a boy, he lies on the right side oft he womb and girl lies 
on the left side. For the girl, I vomit a lot but a boy I don't, it's only my sales that 
swell" ("oman with child under five. FGD). 
"What I ha\'<.' noticed is that when I am pregnant with a boy I have a big stomach but 
when it is a girl I have a small stomach" (woman with child under five, FGD). 
There was also the bdief that unborn babies can be bewitched by bad or jealous people in the 
community to develop abnormalities in utero. This was cited as one of the reasons for the 
confinement during pregnancy affecting women access to essential health care during 
pregnancy as illustrated: 
"Bad people can bewitch your unborn child so pregnant women will have to stay at 
home. It is une of the reasons why people do not go for antenatal in this community" 
(Elderly woman, FGD). 
Ior Ihal (Jilt: it is like a satanic illness, instead of the baby growing big after forty 
days, Ihe baby will be growing small, sofi body with "Asram" and Ihe fontanelle is 
not clnsinx up so when you are pregnanl you must see those who have these 
medicintJs, they will give you herbs 10 drink and also use to prepare soup so even if 
someone wants to harm YOllr baby after delivery it won't work" (woman with child 
under five, FGD). 
Enema is also given to the expectant woman during labour as it is believed to facilitate 
,mooth delivery. The herbs is administered to the woman when she is about five months 
pregnant and are also given to women who seek health care at TBA outlets as supported by 
the following illustrative quotes: 
"It makes the baby slrong and we have some we administer through the anus, called 
'Awuo mre aduro" and for this one Ihey claim it makes you have smooth delivery. We 
givefrumjive months ofp regnancy" (Postnatal woman, FGD). 
'The herbs are xiven to pregnant women from five months onwards to help in the 
birth process. During labour we also give it if it is delaying. It is because of this that 
some women prefer to come to our facility" (TBA, IDI). 
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Participants in this study revealed some socio-cultural practices after child birth. These 
practices are often geared toward restoring the mother to pre-gestation state and also facilitate 
the growth of the baby. The following illustrate these points: 
··After delivery. they golor some herbs to prepare "Abedru" so that the breast milk 
will come" (woman with baby under five years, FGD). 
There was a belief that women develop internal wound after birth. Hence herbs extracted 
from the bark of a tree "nu bena" are given to the women to enhance healing of the internal 
wound. In the community, it is believed that a woman after giving birth develops wound in 
the stomach which need to be treated using herbs. This is illustrated by these points from 
partie ipants: 
..... when you go to the women who sell medicine in the room and you explain to them 
what you are going through, they can get you some herbs to cook and drink. Some 
help to heal wounds in your stomach after birth" (Postnatal woman, FGD). 
"When a woman gives birth, she develops a wound which will have to be treated. So 
we give the woman the herbs to drink to help in the healing oft he wound. If this is not 
treated, it can affect the woman's health and that of the child" (Postnatal woman, 
FGD). 
Some of the herbs are given as enema to help in contracting the uterus and heal any stomach 
aches after birth as reported in the qualitative data. The following quote illustrated this: 
"We are asked by the doctors and nurses at the hospital not to administer herbs 
through our anus but we do it sometimes because we sometimes suffir stomach 
aches" (Postnatal women, FGD). 
FGD participants indicated food restriction during postnatal period. Certain foods were 
believed to decrease breastmilk production and cause stomach-ache. Food such as oranges 
and ripped plantain were mentioned as prohibited during this period. Okra was also believed 
to cause diarrhoea for breastfeeding babies and hence prohibited as illustrated: 
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"We don 'f eat orange because oft he wounds we get after birth and it also drains 
breast milk and ripe plantain, that one too when you eat it makes you defecate 
frequently Olero will also make the baby have diarrhoea" (women with under- five 
child. FGD), 
"Plantain cause stomach pains and hence women who have delivered are prohibited 
from taking it" (Postnatal woman, FGD), 
There was consensus on the sexual practices after birth, Participants generally agreed that the 
practice vary among couples. However, they indicated that sexual intercourse could begin 40 
days after delivery. Nonetheless, many indicated they start having sex after three month of 
delivery. The following quotes buttress these points: 
"It depends on every individual; I sometimes indulge in sex six months after delivery" 
(Postnatal woman, FGD). 
"You will have to wait for at least forty days before having sex or sometimes for three 
to six months after birth" (Elderly woman, FGD). 
Participants of FGD generally agreed on the need for one to space children and protect 
uneself against unplanned pregnancy. However, there was no consensus on the strategies 
used to prevent unplanned pregnancy. Some participants indicated they use modem 
contraceptive methods whilst other prefers to use natural family planning methods as 
illustrated: 
"What / see is illhe man wants to sleep with you and you don't use any medicine you 
can easily give birth even if you have a small baby already. For me / have a small 
baby so / protect myself using the injectable so that / don't get pregnant" (woman 
with children under five, FGD), 
"/ do not like rhejamily planning method we get from the hospital. / have natural way 
o/protecting myself or / use some herbs we have the community. They are also good 
in protecting women against pregnancy" (Postnatal woman, FGD). 
Some FGD participants were of the view that modem contraceptive could render a woman 
barren and therefore prefer to use natural methods. It was generally the view of some 
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participants that modem contraceptive use will make it difficult for the woman to conceive 
after she has stopped using it. The following quotes illuminate these points: 
"Sometimes when you go for them and you later on decide to give birth and want to 
take it out, it can breuk your womb and render you barren" (women with under five 
year old child, FGD). 
"we are ven' fertile here so we all have children and if anyone is not having a child 
then it is pr~bably the kind ofl ife she had lived and the family planning too ify ou use 
il can destroy your womb because when you use it for a long period oft ime it remains 
in your blood and it will take long to leave your system for you to get pregnant again" 
(woman with child under five, FGD). 
Regarding cord care, it emerged from the study that it was a common practice to dress the 
cord of the baby and smear it with shea butter. This practice was believed to offer protection 
against infection and keep the cord dry. During bathing of the baby, the head is massaged and 
molded. This practice \\as believed to contribute to making the head round as illustrated: 
.. We prepare hoth hot and cold water for the bathing oft he baby and then we use 
shea blltter to massage their whole body and then we use cool water to massage their 
heads .. (Elderly woman, FGD). 
"She measures the cord with her hand and then she will tie it and cut it with the 
blade They use uncooked cocoyam and they make a hole in it and they put water and 
salt in the hole they've lIIade. they put the water on the cord and within three days it 
will COlli': off' (Woman with child under five, FGD). 
Interviewees indicated they have received education on the need to exclusively breastfeed the 
baby for six months. However, majority reported not adhering to these practices because of 
several reasons. Some participants were of the view that the breastmilk was inadequate for 
the baby hence there was the need to give other food supplements such as mashed ken key and 
artificial milk sources. The following support this assertion: 
'" give them food, starting from the fourth month because my breast milk is small. 
Sometimes I mash kenkey, sieve it and add lactogen to it" (Postnatal woman, FGD). 
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Another reason cited for not practicing exclusive breastfeeding was the belief that children 
get thirsty with time. Hence there was the need to provide babies with water. They were also 
of the view that the baby needs variety in hisiher diet. So there was the need to introduce the 
baby to other foods instead of only breastmilk. The following quotes buttress these points: 
.. We as adults do not eat only one food. We take JUJU. banJcu and rice but we expect 
our babies to be eating breastmilk that is not fair. SO. WI.' have to give them soft food 
after som" week" (Elderly woman, FGD). 
"I tried to practice exclusive breastfeeding but at a point in time the weather was too 
hot and as odult we sweat and feel thirty. So. my baby also started feeling thirsty and 
will be crying uncontrollably. So. my mother advised me to give him water and he 
stopped. Since then I have been giving him water and some mashed kenkey" 
(Postnatal woman. FGD). 
Participants also indicated they apply warmth compresses on the fontanelle and genitalia of 
the female baby. Applying warm compresses on the fontanelle is believed to aid in the 
closing of the fontanelle whilst use of warm water on the genitalia of female babies is 
believed to assist in the healing of sore especially in the vulva of babies. To participants, 
female babies are born with sores in their vulva which need to be treated with warm dressing 
to help in the healing process. The following buttress these assertions by participants: 
"1 put towel 11/ hot water and put it the baby's fontanelle then I use the hot water to 
douche the baby 's navel. private part and bUllOCks. I put hot water compresses on the 
jontanelle because it is soft and so when I do that it helps to make it strong and also 
close the gap in the fontanelle. We douche the children because when you give birth 
to baby girl they normally have sores in their private parts" (Postnatal woman, FGD). 
Panicipants also reponed that during bathing babies are massaged with mustard oil and shea 
butter. This practice is believed to make the baby healthy and also prevent the skin from 
becoming "dried up" as illustrated: 
.. WI.' massage the baby with mustard oil or shea bUller to make the baby healthv and 
prewnt drying up oj the skin" (Postnatal woman, 101). . 
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4.6 Protection of Neonates against Evil Spirits 
The study identified practice specifically tailored toward protecting the newborn against evil 
spirits. The baby after birth is confined to the room. The baby should not be taken out in the 
sun for at least a week and in some 40 days after delivery. This was done as a way of 
protecting the baby from evil spirits and the "evil eyes" of people who may be jealous. As a 
result of this practice any condition that the baby develops during the period cannot be treated 
at the health facility. Sending the baby to the health facility will expose the neonate to the bad 
spirit as illustrated: 
"A baby that is born is 110t supposed to be sent out until after one week ofc onfinement. 
This is done to protect the baby from evil eyes" ofp eople. So, in this community, any 
illness before the end oft he first week has to be managed traditionally at home ,. (Elderly 
women. FGD). 
Some (!\Iii spirits exist in the community and can affect the newborn. So, we keep the baby 
in the roomfor one week and more to do all the necessary rituals to protect the baby 
against those spirits and evil people in the community" (Man, FGD). 
Another cultural practice to protect the baby against evil spirits is restricting people from 
touching the baby until the mother is out of the period of isolation following delivery. During 
this period the mother and baby are constantly confined to a room. This practice is believed to 
help to ward otT evil as well as to protect the child from diseases. The following illustrate 
these points: 
"People are not allowed to touch the baby during the period ofc onfinement. This is done 
to protect the baby from evil hands and spirit" (Elderly woman, 101). 
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In some communities. special necklace are put on the baby as a way of warding off evil 
spirits. In others a sharp iron object is kept beside the newborn or an iron object is tied around 
the neck of newborn to also provide protection against evil spirits and bad omen. The 
following illustrate these points: 
"I have this necklace around my baby because it is believed to protect the baby against 
evil .Ipirits. In the night we put light at the entrance to my room to also prevent evil spirits 
from coming into the room" (postnatal woman, FGD). 
"We also put some metal around the neck of the baby or besides the baby to protect the 
child against evil spirits" (Man, FGD). 
4.7 Place of Delivery and Factors associated with Place of Delivery 
The study showed majority of the women 310 (70.6%) had delivered at the hospital or clinic. 
About 55 (12.5%) of the women had their delivery supervised by a Traditional Birth 
Attendant. whilst 71 (16.2%) delivered at home. Majority, 313 (71.3%) therefore had a 
skilled delivery. Better service was cited as the most important reason for the choice of 
delivery point as 254 (60.1 %) indicated this as the primary reason for the place of delivery. 
Self, 168 (38.3%) and joint decision making (husband and wife), 155 (35.3%) emerged as the 
kt:y decision making factors in this study (Table 4.5). 
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Table 4.5: Place of Delivery 
Place of delive and reasons Percenta 
e 0/0 
Place of Birth 
Traditional Birth Attendant (TBA) 55 12.5 
Homc 71 16.2 
Hospital/Clinic 310 70.6 
Private Midwife 3 0.7 
Type of Deliver)' 
Skilled 313 71.3 
Unskilled 126 28.7 
Reasons for choice 
Cheaper 13 2.9 
Proximit} 24 5.5 
Convenience 76 17.3 
Better Service 254 60.1 
Health workers attitude 19 4.3 
Trust 24 5.5 
Had complication 19 4.3 
Health-related decision making 
Self 168 38.3 
Husband 57 13.0 
Selti'llusband 155 35.3 
In-Ia\\s 27 6.2 
Grandparents 32 7.3 
Several rea')ons were cited for home delivery in the qualitative data in addition to what was 
mentioned in the survey. Some women indicated they delivered at home because of the rapid 
OIlS.:t of labour, so they had no time to go to health facility even though it was in their plan to 
have health facility delivery as illustrated: 
......· ume don'( really go into labour before delivery; theirs come impromptu so they 
sometimes hcn'e no option than to deliver at home" (Postnatal woman, FGD). 
Other women had challenges going to the health facility because of distance. Again, the 
negative attitude of health workers also emerged as the driving force for women utilizing the 
service of TBA as was reported by the survey participants. The following quotes buttress 
these points from participants: 
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"It was late in the night and I couldn '( disturb anyone and going (0 the hospital too 
was a problem. so I had to just deliver at home. My husband called the TBA to come 
homt! and deliver me " (Postnatal woman, FGD). 
"The nurses used to shout at them and intimidate them because, they have bushy 
pubic hair on their vagina, they've not prepared themselves neat enough and then 
maybe she doesll 't have money. Also, the nurses insult them so they prefer to go to the 
TBA 's where all these things will not happen" (woman with child under five years, 
FGD). 
"Home delivery is good because the TBAs take their time to pamper but there's no 
such attention at the hospital. At the hospital some oft he nurses behave rude towards 
the patients" (Elderly woman, FGD). 
In addition, respondents in this study utilised the services of TBAs because of what they 
perceive as unnecessary operations in the hospital. To some of them, when you go to the 
hospital and there is any delay in the baby coming out. you will be operated, sometimes 
against your will. unlike the TBAs where you may be given some herbal preparations to 
facilitate vaginal delivery. This was necessary because in their view, motherhood is linked to 
vaginal delivery and women take pride in their ability to give birth through the vagina 
without operation Interviewees were also of the view that babies delivered through the 
vagina are stronger and more intelligent than those delivered through Caesarean Section. The 
follo\\ing quotes illustrate these points: 
"Jo;~v friend went to the hospital and experienced some delay in the baby coming out 
{being delivered} and they perform an operation on her. She was unhappy, so I am 
afraid that may happen to me too" (Postnatal woman, 101). 
"All women prefer vaginal delivery because that makes you a woman and mother. If 
they operate you to remove the baby people do not respect you. Children born 
through the vagina are also stronger and intelligent. That is the reason most of us 
women go to the TBA and not the hospital" (Postnatal woman, FGD). 
"When.1 came. ~here was a delay in the child coming out and the woman gave me 
somethmg to drmk and for some time the baby came out. But if it had been in the 
hospital, they will cut me to bring the baby out" (Postnatal woman. FGD). 
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4.8 Association between Socio-demographic Characteristics of Participants and 
T~'pe of Delivery 
The bivariate analysis using Pearson's and Fishers Exact test show that educational 
attainment (X2=20.52, p<O.OOO I), occupation (X2:2 1.50, p=O.OOI), socio-economic 
status (X2=13.55, p=O.009), health-related decision maker (X2=1O.04, p=O.OI8) and 
number of children (X2=5.95, p=o.OI8) had a significant association with skilled or 
unskilled delivery. Age, marital status, religion, ethnicity did not show any statistically 
significant association with skilled or unskilled delivery (Table 4.6). 
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Table 4. 6: Association between socio-demogrdphic characteristic oftbe woman 
and skilled/unskilled delivery 
Socio-d~mographic Unskilled DcliveJ) Skilled Delivery X2 (p-value) 
Characteristics n{%) n{%) 
\ge (yun) 
15-19 II (20.7) 42 (79.3) 
20-24 36(31.6) 78 (68.4) 6.3 (p=0.277) 
25·29 37 (24.5) 114 (75.5) 
30-34 29 (34.5) 55 (65.5) 
35·39 10 (32.3) 21 (67.7) 
40-14 3 (50.0) 3 (50.0) 
Religion 
Traditional 1(25.0) 3 (75.0) 
Christianit) 113 (2S.3) 286 (71.7) 0.432 (p=O.SI8) 
Islam 12 (33.3) 24 (66.7) 
Ethnicity 
Akan 96 (27.9) 248 (72.1) 0.4905 (p=0.484) 
Non-Akan 30 (31.6) 65 (68.4) 
Educational Attainment 
No lormai education 28 (34.2) 54 (65.S) 
Primary 48 (40.7) 70 (59.3) 20.52 (P<O.OOOI) 
MiddlelJHS 43 (24.2) 135 (75.8) 
Secondary 6(14.0) 37 (86.0) 
Post-secondaryrrertiary 1(5.6) 17 (94.4) 
Marital,latu, 
Never marrie,i II (20A) 43 (79.6) 
Married 78 (27.S) 203 (72.2) 7.01 (p=0.136) 
Cohabiting 36 (35.3) 66 (64.7) 
Widowed/Separated 1(50.0) 1(50.0) 
Occupation 
Farmer 37 (38.1) 60 (61.9) 
frader 50 (28.9) 123 (71.1) 
Hou,ewife 9 (39.1) 14 (60.9) 
CivillPublic Scnanl 21.50 (p=O.OOI) 0(0.0) 18 (100.0) 
Student 6 (60.0) 4 (40.0) 
Ani san 13 (20.0) 52 (SO.O) 
Other"' II (20.8) 42 (79.2) 
Wealth indn 
Poore'" 20 (22.7) 68 (77.3) 
POOr 22 (24.4) 68 (75.6) 
Rener 17 (19.8) 69 (80.2) 
I css poor 13.55 (p=O_009) 34 (38.6) 54(61.4) 
lea." poor 33 (37.9) 54 (62.1) 
Health·related Decision maker 
Self 19 (18.1) 
lIusband 86 (81.9) 13 (24.1) 
Parent, 41 (75.9) 10.04 (p=O.OI8) 93 (33.8) 
In-law' 182 (66.2) 1(20.0) 4 (80.0) 
Number of children 
1-3 86 (25.7) 
>3 248 (74.3) 5.951 (p=O.015) 40(3S.I! 65 (61.9! 
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4.9 Determinants ofSkilledlVnskilled Delivery 
Multi\ ariable logistic regression model showed that women who had middle/JHS level 
education had 3.41 odds of having an unskiIled delivery (aOR=3.41, p=O.OOl, 95% 
CI=1.5623-3.9871), ",hilst women with secondary school education were 2 times likely 
(aOR=2.00. p=O.035. 95%Cl=1.3451-4.8971) to have unskilled delivery compared to those 
who had no formal education. Having post-secondary and tertiary education reduced the 
woman's likelihood of having an unskilled delivery. Traders were also 2.8 times (aOR=2.78, 
p=O.033. 95% CI=O.4012-0.8765) likely to have an unskilled delivery relative to farmers. 
Belonging to the poor socio-economic status increases the likelihood of unskilled delivery by 
2.4 times (aOR=2.45, p=O.OII. 95% CI=1.423 1-5. I 897). Again, having parents and in-laws 
as responsible for making health decisions at the household level increases the likelihood of 
unskilled delivery by 2.19 times (aOR=2.19, p<O.OOO I, 95% Cl=2.1231-11.6685) and 2.22 
times (aOR=2.22, p<O.OO I, 95%Cl=2.0633-1 0.4185) respectively (Table 4.7) 
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Table". 7: Determinants ofSkilled/Unskilled Delivery 
Unadjusted Adjusted SDC 
OR p-value 9S%Cl OR r-\~Iuc 95%CI 
Educational Attainment 
No formal ~JllcJ'i')1l 1.00 1.00 
1.78 0.035 2.1237-5.1287 
Primary 1.96 0.041 2.2559 -7.1166 
Middle/JHS 3.50 0.002 1.2131-3.8714 3.41 0.001 
1.5623-3.9871 
SecondarylSIIS 2.34 0.033 1.4567-5.9123 2.00 0.035 
1.3451-4.8971 
0.45 0.001 2.1854-8.235 I 0.35 0.011 2.0181-7.2465 Post-secondaryrrertiary 
Occupation 
Farmer 1.00 1.00 
Trader 2.95 0.031 0.2981-0.6712 2.78 0.033 0.4012-0.8765 
Housewife 3.53 0.029 0.2310-0.8172 1.32 0.043 0.3412-0.7615 
Civil/Public Servant 0.48 0.981 0.2391-2.0128 0.39 0.998 0.0198-3.8171 
Student 0.56 0.089 0.4871-3.0172 0.48 0.452 0.5105-4.S296 
Anisan 2.52 0.003 0.0152-0.1298 2.34 0.001 0.2671-0.8071 
Others 1.04 0.879 0.5821-4.3881 1.01 0.9871 0.5671-7.7781 
Weahh index 
Poore" 1.00 1.00 
Poor 2.34 0.032 1.2345-7.76 \3 2.45 0.011 1.4231-5.1897 
B.ttu 0.78 0.001 1.1093-3"'394 0.72 0.001 1.8712-5.9871 
Less poor 0.64 0.002 2.7861-1J.8712 0.58 0.003 2.9912-13.8174 
I o:as, poor 0.50 0.053 0.1871-8.1871 0.60 0.051 0.7614-7.8887 
Decision maker 
<;"11 1.00 1.00 
lIu;h,lnJ 0.75 0.012 1.4521-5.9810 0.67 0.011 1.1244-6.7834 
Parents 2.32 0.022 3.1862-10.5641 2.19 <0.0001 2.1232-11.6685 
In·la ..,  2.48 0.0001 3.0521-9.9\23 2.22 <0.001 2.0633-10.4185 
II; u mb.r of children 
1,1 1.00 1.00 
2.40 0.025 2.8172-9.1567 2.39 0.001 2.9812-10.6512 
".9 Essential Newborn Care Prolctices 
The study found that 68.3% of babies had skin to skin contact with their mother immediately 
after birth. 245 (55.8%) were wrapped immediately after birth whilst 285 (64.9%) put the 
baby to breast immediately after birth. About 261 (59.4%) were not bathed immediately after 
birth. Overall. 282 (64.2%) of the babies received all the ten cardinal essential newborn care 
(Table 4.8). 
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Table 4. 8: Essential newborn care received by babies 
------ --------------:R=-ece-:-iv-ed"";,-n-;;(O;;y.,"7)--
Essential :'>lew born Care . ' 
Baby kept skin to skin contact to mother immediately after dehvery 300 (68.3) 
Baby kept warmth by wrapping 245 (55.8) 
Baby not nursed in separate room from mother after delivery 238 (54.2) 
The umbilical cord stump of baby covered with a cloth or bandage 219 (48.9) 
Umbilical cord stump not soiled 284 (66.7) 
Breastfeeding immediately after birth 285 (64.9) 
Feeding baby with colostrum 206 (46.9) 
Received BeG vaccine at birth 219 (49.9) 
Receive OPV vaccine at birth 219 (49.9) 
Baby assessed after delivery 245 (55.8) 
Baby not bathed immediately after birth 261 (59.4) 
Total number who received all essential newborn care 282 (64.2) 
FGD participants were ufthe view that bathing a baby immediately after birth was good a'i it 
ckan~cs the body and was reported as a common practice for births that occur at home or 
utilize the services of TBA. Breastfeeding immediately after birth was not common practice 
as it is believed that the first breastmilk that come out is unwholesome and has to be 
discarded. However, it was unanimously agreed that children should be given immunizations 
after birth to protect against childhood illness. The following quotes illustrate these points: 
"It is important to bath the baby immediately after birth to clean the baby and 
welcome the baby to introduce the baby to bathing It makes the baby fresh" (Elderly 
woman, 101)_ 
"As the first breast milk that comes from the mother it is not good for the baby, so we 
discard it. That is the reason why we delay in the breastfeeding so that the milk will 
be expelled before the mother starts to breastfeed" (Male, FGD). 
These beliefs influenced health system factors to affect the continuum of care for both mother 
and babies. 
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4.10 Continuum of Care from ANC to PNC at Six Weeks 
The study showed that out of the 341 participants who indicated they had attended some form 
of ANC, 306 (77.7%) had 4+ ANC, whilst 313 (71.3%) had skilled delivery. Also 218 
(47.4%) had postnatal care at 48 hours and 125 (28.5%) bad a completed CoC (Figure 4.1). 
1(),J 
I I I I 
Allended ANC 4+ Skilled PNC48 PNC 2 PNC6 Complete 
ANC delivery hours weeks we .. ks COC 
Continuum of care 
Figure 4.1: Continuum of care 
4.11 Factors associated with Completion of Continuum of Care (CoC) 
The study found that women aged 25-29 year had 2.78 odds of completing the CoC, whilst 
those aged 30-34 had 3.92 odds of completing CoCo Women with post-secondary and tertiary 
education had 3.21 odds of completing the COC than those without formal education. Married 
wom('l1 had 3.11 times odds of completing CoCo Housewives had increased odds of 
completing COC (aOR=2.81, p<O.004). Again having 3 or more children and higher socio-
economic status also increased an individual's odds of having a complete CoC (Table 4.9). 
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Table 4. 9: Determinants of Completion ofCoC 
soc Vnivariable Multivariable 
Age !UaN! OR (!:value 95%CI OR l2-value 95%CI 
15-1'1 1.00 1.00 
20-24 0.40 0.033 1.2671-3.2615 0.42 0.023 1.8719-4.1289 
25-29 2.13 0.001 1.3298-5.1289 2.78 0.001 1.2561-2.1320 
30-34 3.23 0.001 2.2567-6.2130 3.92 <0.0001 2.7819-4.1289 
35-.9 0.34 0.345 0.2133-12.98\0 0.24 0.345 0.2190-13.1276 
40-44 0.25 0.01 3.1278-9.1201 0.45 0.04 3.9871-8.1291 
Educational Attainment 
1\" lormal eduC3110n 1.00 1.00 
Primary 021 0022 2.1769-9.3743 2.11 0.027 2.1244-10.7834 
\1iddlelJHS 054 0001 0.4451-3.4382 0.4~ 0.002 0.4903-2.9218 
SecondaF)/SIIS US 0.029 0.641l-D.76S1 Ut) 0.017 0.4362-0.986 I 
Post-secondaryffertiary 3.44 0.005 1.8893-3.6850 3.21 0.001 1.9821 -4.388 1 
Marital statu, 
\i~\cr mamed 100 100 
\larried 3.23 0.001 0.7683-0.9123 3. It <0.0001 0.7891 -0.9234 
Co-habitm~ 090 0062 07812-2.8910 0.80 0.076 0.6812-3 1023 
DivorcedJs~'Parated 0.87 0.981 0.3492-46781 0.88 0.9123 0.0254-2.1023 
Religion 
Traditional 100 1.00 
Christianity 129 0.981 08971-14.012 
Islam 0.23 0.789 06781-13.198 
Occupation 
I·armer 1.00 1.00 
II,hicr 0.21 O.O'lX o 6060-2.4464 0.90 0.097 0.6\35-2.3341 
Hou\twife 2.51 0.035 I .065 1-5.8950 2.81 0.004 1.7535-4.3521 
(1\ illPuhlic Servant 026 0.075 03262-4.9060 3.11 0.095 0.3449-2.2478 
Studenl I 10 0.858 03767-3.2298 0.78 0.650 02771-2.2263 
Artisan 048 0.089 05341-15.5330 0.36 0.091 0.1232-116685 
Olhe" 0.58 0.613 0.2341-18.9126 0.57 0.689 
Heal! h-n:lated dec is ion 0.1209-20.1872 
making 
Sell 1.00 
Hushand 0.45 0.078 0.9812-17.0912 
Parenl> 0.67 0.278 0.1298-12.1871 
In-law, 2.34 0.781 0.1786-8.7152 
'umber of children 
1-3 1.00 
>3 1.00 4.23 0.038 4.1524-9.1236 
Wealth indu 3.12 0.D25 4.1426-7.615 
Poorest 100 
Poor 1.00 063 0,019 12968-3.3207 
Bener 268 0.270 131 0.3387-09591 0.450 06483-26578 
uss poor I 17 0642 3.41 05975-2.3068 0.013 0.5033-0.8303 
uast 3.37 oor 0.005 4.75 0.2865-0.8566 0.006 0.4018-0.8199 3.79 0.0001 0.2392-0.8127 
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4.12 Factor associated with Discontinuity along the Continuum of Care 
Tht' study conducted a multinomial logistic analysis to detennine the risk factors associated 
with discontinuity at ANC, delivery and postpartum period. The study found that women 
between the ages of 35-39 and 50-44 years had a higher relative risk of discontinuing ANC, 
delivery and posttlatal care. Being married was also protective factor against discontinuity at 
ANC (RR=0.76. 95CI=0.2981-0.9861). skilled delivery (RR=O.72, 95%CI=0.4901-0.7561) 
and postnatal care (RR=0.69. 95%CI=0.2901-0.6678). Regarding socio-cultural beliefs and 
practices women who indicated they had practiced confinement were 2.42 times 
(95%CI=O.4450-0.7789) more likely to discontinue at ANC. 1.98 times (95%CI=0.1891-
0.4000) the risk of discontinuing at postnatal than those who did not practice confinement. 
Women who also indicated they believed in bewitchment during pregnancy and postnatal 
period had relative risk of 2.22 (95%CI=0.3634-0.9234) discontinuing at ANC. 1.67 
(95%CI=0.4712-0.9178) at delivery and 2.89 (95%CI=0.4381-0.8172) during postnatal 
(Table 4.IOa and 4.IOb). 
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Table 4. lOa: Factors associated with discontinuity along tbe Continuum 
~ Discontinued at ANC Discontinued at Delive!l: Discontinued at PNC 
RR 95%CI RR 95"'. CI RR 95%CI 
Age (years) 
IS-I\! 100 1.00 1.00 
20-24 0.78 0.4512-2.3123 1.88 0.6721-3.1271 0.97 0.5681-11.1092 
25-29 0.88 0.2351-3.4121 0.98 0.3412-2.9812 0.48 0.4468-9.7821 
30-34 0.85 0.1920-5.0124 0.78 0.5123-0.9120 0.55 0.8719-12.8712 
35-39 2.11 0.21Z9-O. 7 345 1.89 0.6129-0.9167 2.34 0.2421-0.8712 
40-44 1.89 0.1201-0.5212 1.77 0.1872-0.6128 1.81 0.3121-0.7812 
Educational 
\ttainment 
l'\iU il)fJn.tI 1.00 1.00 1.00 
educalion 
Primary 0.41 0.0871-3.0189 0.58 0.3888-7.2981 0.66 0.9182-4.3444 
Middle/JHS 0.51 0.2981-5.9810 0.61 0.0182-3.9990 0.81 0.8871-3.9000 
Secondary/SHS 0.68 0.8880-7.8910 0.63 0.0892-1.2221 0.77 0.0191-2.9010 
POSI- 0.80 0.5012-0.9912 0.77 0.0312-0.0912 0.85 0.2431-2.1067 
secondary.Tertiary 
'\1arilal statu~ 
Ne\<!rmarrieo 1.00 1.00 1.00 
Married 0.76 0.2981-0.9861 0.72 0.4901-0.7561 0.69 0.2901-0.6678 
Co-habiling 0.68 0.8781-3.3321 0.66 0.0289-2.0100 0.71 0.0278-2.2298 
Di \ orccJisl"paraleJ 1.18 0.1899-4.3476 0.78 0.8199-7.7788 0.75 0.0881-2.2299 
Rdi~lon 
Traditional 1.00 1.00 1.00 
Chrislianit~ 0.83 0.0119-0.0871 0.75 0.4421-0.9910 0.79 
Islam 0.1332-0.7102 1.43 0.3002-0.8837 1.55 0.2309-0.9902 2.16 
Occupation 0.5010-0.7910 
Farmer 1.00 1.00 
Trader 1.00 0.87 0.1789-0.8881 0.67 0.7788-0.9111 0.71 
House"irc 0.77 0.0189-0.0881 0.2981-0.5698 0.66 0.3980-0.5871 
Ci\il'Public 0.79 0.82 0.2910-0.8882 0.0879-2.8719 0.87 0.2861-3.0091 
Se .... ant 0.85 0.0212-3.3190 
StuJ~nl 1.21 0.0912-0.8789 1.11 0.2817-0.6191 
..\rti'aTl 1.58 0.88 0.1200-0.3312 0.01872-1.9210 0.87 
Other, 0.3178-2.8719 0.79 0.85 0.2910-3.8912 0.2391-2.1892 0.64 0.0872-3.1871 
lIulth-related 0.68 0.8219-6.7810 
drci,ion making 
Sell 100 1.00 
Ilusband n.n 1.00 0.8728-3.8712 0.77 
Parents 0.2381-6.7192 0.81 0.87 0.0187-1.2861 0.7771-5.8901 0.88 
In-Ia", 0.8210-7.8127 0.75 0.68 0.2367-0.8671 0.5690-3.1672 0.69 
Number of 0.5629-8.6142 0.67 0.4020-0.2681 
children 
I·; 1.00 1.00 
0.79 1.00 0.8792-3.2018 0.88 0.5219-7.1897 0.72 0.7621-0.9101 
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Table 4. 110b: Factors associated with discontinuity along the Continuum 
~ Discoatinued at ANC Discontinued at Deli"~'l. 
'Di,~ontinued at PNC 
RR 95%CI RR 95% Cl RR 95%CI 
Poorest 1.00 l.OO 
100 
1.34 0.2781-0.9991 1.77 0.3777-0.6815 1.25 0.2219-0.8910 Poor 
0.68 0.0880-0.0981 0.53 0.1191-0.6821 0.60 0.9201-6.8910 Better 
0,79 0.0566-0.2987 0.69 0.7889-2.8912 0.78 0.8817-6.8170 Lc!>s poor 
I c,L,t poor 0,87 0.0879-0.1289 0.80 0.1928-4.9812 0.81 0.2871-3.3380 
~ocio-cultural 
beliers and 
practice during 
continuum 
None practiced 1.00 1.00 1.00 
Confinement 2.42 0.4450-0.7789 2.11 0.6119-1.7521 1.98 0.1891-0.4000 
Ri ver crossing 2.38 o 1892-0,5682 2.11 0.6720-1.2861 1.87 0,3876-1.5098 
BeHefin 2.22 0.3634-0.9234 1.67 0.4712-0,9178 2.89 0.4381-0.8172 
hcwitchment 
Knowledge on 
immunil~ion 
Yes 1.00 1.00 1.00 
No 2.65 0.1891-0.5567 2, II 0.5012-0.8361 1.89 0.5501-0,8725 
Knowledge on 
danger si gns 
during pregnane) 
Yes 1(10 1.00 1.00 
_"_"_- 1.7'! 0.6123-0.9267 1.86 0.3491-0.9817 1.95 0.2381-0.9672 
4.12.1 Innuence ofSocio-cultural Practices and Health System Factors on 
Continuum of Care 
As has been demonstrated already, socio-cultural practices are reported to be a common 
practil:e in communities in the study. The study also found that the lack of information about 
basi, perinatal care services made people to adhere to the socio-cultural practices. FGD 
participants clearly indicated that the lack of relevant information creates a situation where 
wmmunity members are compelled to uphold socio-cultural practices even if it is inimical to 
health, The following quotes support these views: 
"Wt' hal'£' belief system which we follow but if the health workers come to the 
L'ommunit)' to tell about what is right and the good things to do to enable women and 
children have good health lam sure we will follow. But we don 'f see them come and 
educate us. These days when you put on your radio or television. you see traditional 
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healers talking about their power and how they can heal all conditions. So we believe 
them and go to them jor healing" (Male, FGD) 
Nurses will have to come around the community to educate pregnant women. It is not 
everybody who will go to the antenatal. but I am sure when they ~om~ to the 
community. they will get the information that there is pregnant woman In thIs house 
so that they can visit and educate them" (Elderly woman, 101). 
This study further revealed that bad attitude of health workers was one of the reasons why 
women did not seek for health care at biomedical facility. This was cited as one of the 
reasons for people attending TBA facilities or having home delivery. On the contrary, many 
believed TBAs render better services and their mode of operations is in line with local norms. 
Hence the bad attitude of health workers favoured the utilization of the services of TBA The 
women are also allowed to assume the position of their choice during labour as against the 
practice of making women to lie down in the health facilities. The following quotes illustrate 
how the socia-cultural practices interact with health system factors to affect the continuum of 
care: 
"The TBA who are old women respect and treat us well but, in the hospital" they will 
shout at us. The TBA also knows herbs that can make you have smooth birth. So, we 
compare the two, many of us will like to go to the TBA because of that. I had my first 
child in the hospital, but I did not like the care. That is why this baby was born at 
TBA " (Postnatal woman. FGD). 
"The TBA will make you squat or assume any position that will make you comfortable 
und this is our local practice. Our mothers used that to give birth to us like that but in 
the hospital. they will make you lie down on you back which is difficult. So we prefer 
home delivery or use the TBA " (Postnatal woman, FGD). 
In thl: survey, only 243 (55.3%) of the women indicated they have ever been visited by health 
workers during pregnancy. About 281 (64.0%) revealed they have received some health 
t:ducation at ANC whilst only, 208 (47.4%) were advised to deliver in the health facilities. 
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These clearly corroborates with the qualitative findings which shows that health services 
delivery was not reaching some pregnant women and therefore affected the continuum of 
care. Regarding reasons for homeITBA delivery, better service and poor attitude of health 
workers were mentioned as the topmost reasons (Table 4.11) as also revealed in the 
qualitative data. 
As part of the continuum of care, women after delivery are supposed to receive education on 
immunization and family planning. As showed on table 4.9, 309 (70.4%) of the women 
indicated they had received education on immunization after delivery whilst 291 (66.3%) 
received education on family planning. 
Table 4.12: Health System factors affecting continuum of care 
Health System factors Frequency Percentage 
(n) (%) 
Ever visited by health worker during pregnancy (N=439) 243 55.3 
Received education on ANC (N=439) 281 64.0 
Advised by health worker to have skilled delivery (N=439) 208 47.4 
Received education on skilled delivery (N=439) 217 49.4 
Ih'a~on for HomerrBA delivery (N=126) 
Better Services received at TBA 68 53.9 
Poor attitude of health workers 52 41.3 
Distance to health facility 6 4.8 
PfI~t DeliHry Follow-up (N=439) 
Visited by health worker after delivery 201 45.8 
Educated on PNC 234 53.3 
Linked to Community Health Officer after discharge 198 45.1 
Educated on Immunization 309 70.4 
Educated on Family Planning 291 66.3 
FGD participants revealed that it was important for children to receive immunization. 
However, they were divided in views regarding the use of contraceptives. Some participants 
belJ' eve d'I t was a good thing to do to prevent unwanted pregnancies, whilst others were of the 
view that its use can affect the reproductive health of women and therefore not suitable for 
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women who have plans of having more children in future. As found in the quantitative data, 
only 66.3% of women received education on contraceptives. In the absence of education from 
<!xperts. women many have to rely on the local beliefs about the use of contraceptive. This 
can negatively affect contraceptive uptake affecting the continuum of care. The following 
support these points: 
"For IInmulli=ation of children, we in this community have accepted it and many 
women will send thei~ children 10 hospital for that. Health workers also educate us 
about it. So it is not a problem in this community" (Postnatal woman, FGD). 
"/ advise women who deliver at my facility (TBA) to go to the hospital for 
immuni=ation because / know it is important. The nurses can even come here to give 
the babies the immunization because many oft he women come here and like the way / 
treat them" (TBA, 101). 
Clearly from the statement by the TBA above, nurses visiting the TBA facilities to provide 
immunization to the babies will increase coverage of immunization and will enhance 
continuum of child care after delivery as well as have the potential to improve health seeking 
behaviour. 
4.13 Association between Health System Factors and Continuum of Care 
The study fuund that women who indicated they have never been visited at home during 
pregnancy had higher relative risk of discontinuing at ANC (RR=1.89, 95%CI=0.2190-
O.918:!), delivery (RR=2.71, 9S%CI=0.8791) and PNC (RR=1.78, 95%CI=0.6981-0.8132). 
Receiving education on ANC also reduced a woman's relative risk along the continuum. 
Women who were not advised to have skilled delivery had higher relative risk discontinuing 
at delivery (RR=2.91. 95%CI=0.400 1-0.72 I I) and PNC (RR=2.88, 95%CI=0.4412-0.7219). 
Women who also reported having experienced poor attitude from health workers were more 
likely to discontinue at ANC, delivery and PNC (Table 4.12). 
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Table 4.12: Association between Health System factors and Discontinuity 
Ifealth System Discontinued at ANC Discontinued at delivery Discontinued at PNC 
Factors 
RR 95°;' CI RR 95%CI RR 95% CI 
Ever visited by health worker during pregnancy 
Yes 1.00 - 1.00 1.00 
No 1.89 0.2190-0.9183 2.71 0.4561-0.8791 1.78 0.6981-0.8132 
Received education on ANC 
Yes 1.00 1.00 1.00 
No 2.11 0.3768-5.0912 1.62 0.8719-4.7812 1.59 0.1822-0.7112 
Advised by health worker to have skilled delivery 
Yes 1.00 1.00 1.00 
No 1.22 0.7611-3.8162 2.91 0.4001-0.7211 2.88 0.4412-0.7219 
Poor attitude of health workers 
Yes 1.00 1.00 1.00 
No 0.67 0.6651-0.8712 0.88 0.0128-0.0871 0.78 0.2291-0.8123 
Distance to health facility 
Yes 1.00 1.00 1.00 
No 0.66 0.7162-3.3331 0.82 0.2212-0.6612 1.81 0.2002-0.8771 
Post Delivery Follow-up 
Visited by health worker after delivery 
Yes 1.00 1.00 1.00 
No 0.89 0.6212-2.3190 1.29 0.7877-5.0012 3.12 0.4401-0.8810 
Educated on PNC 
Yes I.I)() 1.00 1.00 
N(l 11.84 0.2870-3.1290 0.56 0.7619=6.8102 2.22 0.0178-0.8991 
Linked to Community Health Officer after discharge 
Yes 1.00 1.00 1.00 
No 0.65 0.7619-8.7192 0.78 0.6789-6.6819 2.29 0.5129-0.7910 
Educated on Immunization 
Yes 1.00 1.00 1.00 
No 0.66 0.6671-7.2190 0.87 0.8719-2.0182 3.12 0.1771-0.6519 
Educated on Family Planning 
Yes 1.00 1.00 1.00 
No 0.55 0.5524-3.1926 0.46 0.7681-6.5541 2.28 0.5412-0.7120 
Both FGDs and IDIs clearly showed that lack of education, distance to health facility and 
poor attitude of health workers was an important consideration in health seeking behaviour 
thu:, affecting the continuum of care. The following illustrate these points: 
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"The distance to the health /acility is also a problem and they do not threat us well ~f fh~ 
hospital. So. we go to place that is closer and where we are allowed to do local thmgs 
(Postnatal woman, FGD). 
"You knuw we have our belie/system and local practices which we willlilce to do during 
pregnancy. labour and care o/the baby. So ify ou go to the hospital and they do not allow 
you to practice and treat you badly. you will stop going to health facility" (Elderly 
woman. IDI). 
4.13.1 Health Seeking Behaviour (HSB) of Women during Prenatal and Postnatal 
Period 
Participants in the survey indicated that people in the community seek health care from 
various health outlets. The three major outlets were government hospital, 155 (35.3%), 
government health centres. 125 (28.5%) and self-medication by buying medicine from 
itinerant drug vendors and drugstore, 146 (33.3%). When participants were asked to name the 
place they sought health care for their most recent illness during pregnancy, majority, 173 
(39.4%) indicated they self-medicated using either herbs or drug from itinerant drug sellers 
with 55% indicating they sought treatment from biomedical health facility. Proximity, 74 
(16.9%) and better services, 233 (53.1 %) were stated as the top two determinants of place of 
health care. In all. 241 (55.2%) and 196 (44.8%) sought health care from biomedical and non-
biomedical respectively. After delivery, 88 (20.0%) sought health from traditional healers. 
Similar reasons were adduced for place of health care during pregnancy and after delivery 
(Table 4.13). 
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Table 4.13: HSB o(Women during Prenatal and Postnatal Period 
He~lth seeking Behaviour Frequency, Percentage Frequency, (%) 
(HSB) n (%) n 
Prenatal Period Postnatal Period 
C~mmo~ places people in community seek health care 
Government hospital 155 35.3 128 29.2 
Government health care 125 28.5 112 25.5 
Self-Medication 146 33.3 83 18.9 
traditional healer 8 1.8 102 23.2 
Others 5 \,1 14 3.2 
Place of last health care during pregnancy and after child birth 
Government hospital 114 26.0 134 30.5 
Government health care 124 28.0 118 26.9 
Private health facility 3 0.9 8 \.8 
Self-medication 173 39.4 78 17.8 
traditional healer 23 5.2 88 20.0 
Others 2 0.5 7 1.6 
Not applicable 6 1.4 
Reasons for choice 
Cheapcr 28 6.4 28 6.4 
Proximity 74 16.9 74 16.9 
Convcnience 65 14.8 65 14.8 
Privacy 5 1.1 5 1.1 
Better Service 233 53.1 233 53.1 
Health workers attitude 3 0.7 3 0.7 
Trust 27 6.2 27 6.2 
Don't know 4 0.9 4 0.9 
Classification of place of health care for most recent ill-health 
Biomedical 241 55.2 
Non-biomedical 196 44.8 
In both lOIs and FGDs, participants indicated that one important consideration for health 
seeking behaviour is the belief about the cause of ill-health. Participants generally believed 
that decision on where to seek for health is often arrived upon by an appraisal of what the 
possible cause of the condition as required in the social cognitive theory. Again, there is a 
perception that any illness suffered during pregnancy is normal and does not require seeking 
health care services but the use of herbal concoctions was enough to remedy the situation. 
Participants were of the view that women who have just given birth will prefer self-
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medication and get help from traditional healers because of the believe that most of the 
conditions that occur during this period are often spiritual in nature. Also, going to the 
biomedical health facility may expose the baby to so many people including evil ones who 
may inflict the baby and the mother with spiritual illness. The spiritual connotation is in line 
with their worldview and the folk's theory which has been adopted for this study. The 
following quotes support these assertions by study participants: 
'The conditions that occur ajier birth are often spiritual, so you need to help for 
traditional people who know about the condition and have treatment for it" (Male, 
IDI).  
.. When you go the hospital, you may meet evil people who will be jealous and give 
spiritual condition to your child. That is why I don't go to the hospital because the 
child is too young to be exposed to people" (Elderly woman, FGD) . 
.. "Pregnancy is a normal thing so when you are sick during pregnancy you just take 
some herbs and you will be okay" (Woman with child, FGD) 
Another consideration in health seeking from IDis and FGDs was quality of care which was 
also clearly demonstrated in the quantitative data. Respondents were of the view that they 
would go to facilities that will provide them with very good medical attention and attend to 
them quickly. Generally, respondents were of the opinion that there were always delays at 
biomedical facilities. Therefore, they prefer to either buy their own medication or use the 
traditional health outlets, which in their opinion relate with the clients better and would 
provide them with quicker care to enable them go home to continue with their work. Some 
were also of the view that because of high attendance at clinics and hospitals, doctors pay 
little attention to patients and sometimes do not request for laboratory test or even examine 
patients to ascertain the cause of the illness. The following support these points by study 
participants: 
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"/ buy medicine from the dru[: peddler who comes around to sell the drugs. This is 
better than goin[: to the hospital or clinic where you will spend the whole day there 
and may not he giwn any better medicine especially when you have insurance card" 
(Elderly woman. FGD). 
"When we are sick. we first buy medicine to talee and go to the hospital when it is not 
better. You know we do not want to send our babies outside, so when you go to the 
hospital you have no option than to expose your baby to people some o/whom may be 
jealous and can inflict the baby with disease" (Postnatal woman, FGD). 
It was therefore important to explore the relationships between socio-demographic 
characteristics of survey participants and health seeking behaviours. 
4.13.2 Association between Socio-demograpbic Cbaracteristics of Participants and 
Healtb Seeking Bebaviour 
Bi-variate analysis to detemline the association between socio-demographic characteristics of 
study participants and their health behaviour was done. The results show that educational 
attainment of participant (X2=12.34, p=O.OI5). occupation (X2=12.74, p=O.047) and socio-
economic status (X1:IO.80, p=O.029) were the only socio-demographic characteristics of 
participants that were statistically significant to their health seeking (Table 4.14). 
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Table .... 1. .. : Association between socio-demographic characteristics of participants and 
health seeking behaviour 
Socio-demographic Non-Biomedical Biomedical Xl (p-value) 
Cllaracteristics n {'Yo! n{'Yo! 
Age (years) 
15-1<) 24 (45.3) 29 (54.7) 
20-24 51 (44.7) 63 (55.3) 3.98 (p=O.552) 
25-29 64 (·U.4) 87 (57.6) 
30-34 35 (42.7) 47 (57.3) 
35-39 19 (61.3) 12 (38.7) 
40-44 3 (50.0) 3 (50.0) 
Religion 
rr aditional 2 (50.0) 2(50.0) 
Christianity 181 (45.6) 216 (54.4) 1.242 (p=O.537) 
"lam IJ (36.1) 23 (63.9) 
Ethnicity 
Akan 150 (43.9) 192 (56.1) 0.6254 (p=O.429) 
Non-Akan 46 (48.4) 49 (51.6) 
Educational Attainment 
No formal education 37 (45.1) 45 (54.9) 
Primary 63 (53.4) 55 (46.6) 12.34 (p=0.015) 
MiddlelJHS 77 (43.8) 99 (56.2) 
Secondary 17 (39.5) 26 (60.5) 
pos!,,,.;wndaryrr ertial) 2 (ll.l) 16(88.9) 
Marital status 
Never married 26 (48.2) 28(51.9) 
Married 118 (42.3) 161 (57.7) 4.11 (p=O.391) 
Cohabiting 51 (50.0) 51 (50.0) 
IN Idowcd/Scparated 1(50.0) 1(50.) 
Oecullation 
Farmer 45 (46.4) 52 (53.6) 
Trader 71 (41.5) 100(38.5) 
llou..'CI" Ie 11 (478) 12 (52.2) 
CivillPublic Servant 12.74 (p=o.o47) 2 (11.1) 16 (88.9) 
Student 6 (60.0) 4 (40.0) 
Artisan 32 (49.2) 33 (50.8) 
Other, 29 (54.7) 24 (45.3) 
Wealth indu 
Poore,! 29 (33.7) 57 (66.3) 
Poor 34 (37.8) 56 (66.2) 
Belter 43 (50.0) 43 (50.0) 
LL'Ss poor 10.80 (p=0.029) 48 (54.6) 40 (45.4) 
I.ea.,! poor 42 (48.3) 45 (51.2) 
Decision maker 
Self 42 (40.0) 63 (60.0) 
Uusband 24 (44.4) 
Parents 30 (55.6) 1.77 (p=O.62 I ) 127 (46.5) 146 (53.5) 
In-Ia", 3 (60.0) 2 (40.0) 
:-.lumber of children 
1-3 148 (44.3) 
>3 186 (55.7) 0.17 (p=O.683) 48 {46.6) 55 (53.4) 
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[n FGDs participants were also of the view that sometimes financial challenges compel 
",omen not to seek for health care for ill-health. Furthermore, some women do not have the 
authority to decide on where to seek health care and have to depend on other household 
decision makers such as husband or in-laws as was also showed by the survey data. The 
following illustrate quotes support these views: 
"Some people are poor and cannot afford to pay hospital bills so when they are sick 
they have to use herbs because those things are available in the community and are 
free" (Elderly woman, FGD). 
"Men in this community want to be viewed as the head of the house. so they make all 
decision at the household level. Ify ou are sick and the man does not allow you or give 
you money to go to the hospital, you cannot just get up and say you are going to 
hospital" (Postnatal woman, FGD). 
Since the qualitative data showed the factors that are often considered in health seeking, it 
was important to assess the determinants of health seeking and this was done using 
multivariable logistic regression model. 
4.14 Determinants of Health Seeking Behaviour for Women 
Multivariab[e analysis shows that 64% of people with primary education were [ikely not to 
seek for health care at biomedical health facility. However, people with post-secondary and 
tertiary education "'ere 2.7 times (aOR=2.7. p=0.001, 95% CI= 1.582[-4.388[) likely to seek 
lor health care at biomedical facilities for their most recent illness. A[so, being public or civil 
servant increases once odds of seeking for health care at biomedical health facility by 3 times 
(aOR=3.1I, p=0.005. 95%=1.3449-2.2478). People belonging to less and least poor wealth 
quintiles had 3.37 and 3.70 respectively odds of seeking health care in biomedical health 
facility (Table 4.15). 
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Table 4. 15: Determinants of Health Seeking Behaviour 
·;OC_ Unadjusted Adjusted 
OR [!:\aluc 95% CI OR Itvalue 9S%CI 
Educational Attainment 
No formal education LOO 1.00 
0.44 0.022 1.1769-8.3743 0.36 0.027 1.1244-6.7834 Primar) 
MiddlelHlS 0.54 0.001 0.4451-3.4382 OA8 0.002 
0.4903-2.9218 
.... 0.4362-0.8861 ~-rondar) ISHS 0.35 0000 0.64 13-0.7651 OAO 0.002 
I'ust-,cwnuar) rre rtiary 3.44 0.001 1.6893-3.6850 2.75 0.001 1.5821-4.3881 
Occupation 
Farmer 1.00 1.00 
·1 rader 1.21 0.580 o 6060-2.4464 1.20 0.590 0.6135-2.3341 
Housewife 251 0035 10651-5.8950 181 0.184 0.7535-43521 
C;vil/Public Servant 3.26 0.045 1.3262-4.'1060 3.11 O.OOS 1.3449-2.2478 
.... tudent L10 0.858 0.3767-3.2298 0.78 0.650 0.2771-2.2263 
Artisan 0.48 0.007 1.5341-15.5330 0.36 0.031 1.1232-11.6685 
Others 0.58 0.613 0.2341-18.9126 0.57 0.689 0.1209-20.1872 
Wealth index 
Poorest 100 100 
poor 0.63 0.219 o 2968-U207 0.68 0.270 0.3387-0.9591 
Better 1.31 0.450 06483-2.6578 1.17 0.642 0.5975-2.3068 
lAss poor 4AI 0.0\3 0.2033-0.8303 3.37 0.006 0.1865-0.7566 
..Y~ __ . 4.75 0.006 0.4018-0.8199 3.79 0.001 0.3392-0.8127 
As has been demonstrated in qualitative data, poverty or financial challenges is a key 
determine of health seeking behaviour for women. This study further assessed the health 
se~king behaviour for neonatal illness. 
·4.15 Health Seeking Bebaviour for Neonatal Illness 
Two hundred and eight-six women (286) representing (65.1%) indicated their neonates had 
experienced ill health during neonatal period. Difficulty in breathing, 98 (34.3%) and fever, 
78 (27.3%) were the two most reported conditions during the neonatal period. Of the 286 
who fell sick during neonatal period, 201 (70.3%) sought for health care whilst 85 (29.7%) 
did not seek for health. Reasons cited for not seeking heath care included: believe that 
condition was not serious, 22 (25.9%), self-medication at home, 18 (21.2%) and financial 
challenges, 17 (20.0%). Among those who sought for health care, 125 (62.2%) used 
biomedical health facilities (Table 4. 16). 
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-11~~lth Seeking Behaviour for Neonatal/Infant Frequency, n Percentage (%) 
Illness 
Child e'perienced sickness during neonatal 
period 
Yes 286 65.1 
No 153 34.9 
Reported s~mptoms (N=286) 
Difficulty/fast breathing 98 34.3 
Fever 78 27.3 
8aby feel cold 58 20.3 
Poor suckling/feeding 28 9.8 
Chest in-drawing 13 4.5 
Lethargy/unconsciousness 8 2.8 
Spasms/convulsions 3 1.0 
Sought Health Care (N=286) 
Yes 201 70.3 
No 85 29.7 
Rea~ons for not seeking health care (N=85) 
Felt condition was not serious 22 25.9 
Received some medicine at home 18 21.2 
Transport problem II 12.9 
Far distance of health facility from home 17 20.0 
Financial challenges 17 20.0 
Place of health care was sought (N=201) 
Hospital/C Imic 125 62.2 
Traditional healerffBA 78 37.8 
Focus Group Discussion (FGD) participants were of the view that neonates were very prone 
to sickness and this was a commonly reported issue in the community. Participants also 
indicated fever, difficulty in breathing and refusal to suckle as the common conditions in the 
community. However, both FGDs and lOis participants were of the view that many women 
will not seek for health care because elderly women and men will often prescribe some local 
remedies for these conditions. The following illustrate these points: 
"Babies body easily become hot and when this happens we use local herbs to apply to 
the hody to make it cold. So, women will not send such children to the hospital 
because a/fear o/bad people bewitching the baby" (Male, FGD). 
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"Fever and difficulty in breathing is common condition of neonates and commonest 
reported conditions in the health facilities. However, many of such cases are treated 
in the community using herbs provided by the elderly in the community" (Female 
health workers, IDI). 
"Conditions that occur when <l baby is born are often local and spiritual in nature, so 
we prefer to go the traditional healers or the traditional birth attendants. There are 
local medicines for these conditions .. (Elderly woman, FGD). 
This survey further assesses the relationship between socio-demographic characteristics of 
mother and the health seeking behaviour for neonatal illness. 
4.]5.1 Association between Socio-demographic Characteristics of Motbers and 
Healtb Seeking Bebaviour for Neonatal Illnesses 
The study found that education attainment (X~=12.34, p=O.025), occupation (X~=12.74, 
p=O.047), wealth index (X2=12.80, 95Cl=O.025), health - related decision maker (X2=48.77, 
p=O.O() 1)  and number of children had statistically significant associations with seeking for 
both biomedical and non-biomedical health care for sick neonates (Table 4.17). 
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Table 4.17: Association between Socia-demographic Cbaracteristics and Neonatal HSB 
Socio-demographic Non-Biomedical Biomedical Xl (p-value) 
Characteri.t ies n(%) nl%) 
Agt (~·ea,.,,) 
IS-19 21 (37.5) 3S (62.5) 
20-24 17(42.5) 23 (57.5) 3.71 (p=O.832) 
25-29 8 (17.2) 39 (82.8) 
30-34 16(S7.1) 12 (42.9) 
;~.1<) 14 (51.8) 13 (48.2) 
11I·~·1 2(40.0) 3 (60.0) 
Religion 
Traditiunal 4 (100.0) o (O.O) 
Christianity 4S (27.6) 118(72..f) 1.242 (p=O.537) 
Islam 29 (80.5) 7 (I9.5) 
fthnicity 
\bn 25 (21.9) 89 (78.1) 0.6254 (p=O.429) 
:'lIn-Akan 53 (59.5) 36 (40.5) 
Educational Attainment 
Nil formal education 26 (49.0) 27 (SI.O) 
Primary 20 (38.4) 32(61.6) 12.34 (p--6.0IS) 
MiddlelJHS 17 (29.8) 40 (70.2) 
Secondary 13 (41.9) 18 (58.1) 
I'o,t·sccondaryff eniary 2 (20.0) 8 (80.0) 
Marital status 
Ne"er married 13 (31.7) 28 (68.3) 
Married 38 (40.4) 56 (59.6) 4.29 (p=O,391) 
Cohabiting 27 (40.3) 40 (59.7) 
Widowed/Separated 0(0.0) 1(100.0) 
Occupation 
I'armer 23 (46.9) 26{53.1) 
Trader 27 (52.9) 24(47.1) 
Housewife 9 (42.8) 12 (57.2) 12.74 (p=0.047) 
Civil/Public Servant 3 (\8.7) 13 (81.3) 
Student 4 (36.3) 7 (63.7) 
Ani san 3 (10,0) 27 (90.0) 
Others 8 (33.3) 16 (66.7) 
Wealth iades. 
Poore"l 32 (82.0) 7 (18.0) 
Poor 27 (87.1) 4 (12.9) 
Hctter 6 (15.0) 34 (85.0) 
L-=ss poor 12.80 (p:O.02S) 7 (16.3) 36 (83.7) 
I e.,-,tpoor 6(12.0) 44 (88.0) 
Htalth.related decision maker 
Self 12 (17.6) 56 (82.4) 
Ilusband 12 (19.0) 51 (81.0) 
Parents 48.77 (p:O.OOI) 49 (73.1) 
In·law, 18 (26.9) 5 (100.0) 0(0.0) 
Number of children 
1·3 10 (11.2) 
>3 79 (88.8) 38.68 (p:0.033) 68 (59.6) 46 40.4) 
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Focus Group Discussion (FGD) participants were of the view that women who have ever 
given birth will often have acquired some experience on how to manage neonatal illness and 
therefore were less likely to seek for health care for the children. Financial challenges also 
emerged as an important consideration in health seeking behaviour. Hence people who were 
poor were likely to manage their sick children at home. This therefore provided the 
explanation to quantitative data showing that people who were less poor sought health care 
from biomedical health facilities as compared to people who were in the poorest and poor 
quintiles. As shown earlier, the presence of an elderly person in the house also reduced the 
chances of the person seeking health care as they are able to manage the condition at home. 
The following quotes illustrate these points: 
"Women who are experienced in child birth and have some children will know how to 
manage illness and therefore will not go the hospital with any small sickness" (Elderly 
woman, FGD) . 
.. When my child was sick I did not go to the hospital because my in-law was around and 
~ave us some concoction which worked very well. The elderly women are experienced 
und able to assist us the young one.\ to take care of children when they are sick" 
(Postnatal woman, FGD). 
Despite the survey showing some relationship between socio-demographic characteristics of 
participant and health seeking behaviour, a multivariable logistic regression was conducted to 
assess the determinants of the health seeking behaviour for neonatal illness as was done for 
the health seeking behaviour for maternal illness. 
4.16 Determinants of Health Seeking Behaviour (HSB) for Neonatal Illness 
The results show that people who had primary education were 2.11 times (aOR=2.1 I. 
p=O.027, 95%CI=2.1244-10.7824) more likely to seek for health at traditional healers 
whilst those with higher education (post-secondary) had less likelihood (aOR=0.45, 
p=O.OOI. 95%CI=1.5821-4.3881) of seeking health care traditional healers. Traders also 
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had 2 times (aOR=2.00, p=O.0031, 95%CI=1.6135-2.3341) the odds of seeking health 
care at traditional healers. In households where in-laws are in-charge of making health 
related decisions. they were 3 times more likely to seek for health care at traditional 
healer. People belonging to higher socio-economic status were more likely to seek health 
care in biomedical facility as compared to those belonging to poorest socio-economic 
status (Table 4.18). 
Table 4. 18: Determinants of HSB for neonatal illness 
"DC Unadjusted Adjusted 
OR r:valuc 95%('1 OR I!:vaJue 95%CI 
[ducational Attainment 
No lormal education 1.00 1.00 
Primary 2.41 0.022 2.1769-9.3743 2.11 0.027 2.1244-10.7834 
MiddleJJHS 0.54 0001 04451-3.4382 0.48 0.002 04903-2.9218 
<;cculldary/SHS 0.35 0089 0.6413-0.7651 0.40 0.097 0.4362-0.8861 
Post-secondaryrre rtiary 0.44 0.001 1.6893-3.6850 0.43 0.001 1.5821-4.3881 
Occupation 
Farmer 1.00 1.00 
Trader 2.11 0.004 1.6060-2.4464 2.00 0.0031 1.6\35-2.3341 
fiuu,cy,ife 2.51 0.035 I 0651-5.8950 1.81 0.184 o 7535-4.3521 
Civil/Puillic Servant 0.26 0.045 1.3262 ..... 9060 3.11 0.005 1.3449-2.2478 
SIlJdcnl 110 0858 03767-3.2298 0.78 0.650 0.2771-22263 
Artisan 0.48 0.005 3.5341-15.5330 0.36 0.031 2.1232-11.6685 
Others 0.58 0.613 0.2341-18.9126 0.57 0.689 0.1209-20.1872 
Health-related decision 
maker 
Self 1.00 \.00 
HushanJ 0.45 0.078 0.9812-17.0912 0.34 0.8715 0.6517-16.9189 
Part':llh 0.67 0.278 0.1298-12.1871 0.62 0.3917 0.5412-13.9817 
In-Ia", 3.34 <0.0001 2.1786-8.8\52 3.18 <0.0001 2.1128-7.1781 
Number of children 
1-3 I.(JO 1.00 
>3 3.23 0.038 4.1524-9.1236 3.12 0.025 3.1426-7.615 
Wraith indu 
Pourest 100 1.00 
Poor 2.63 0.019 1.2968-3.3207 268 0.270 0.3387-0.9591 
Bene. .. 131 0.450 0.6483-26578 1.17 0.642 05975-2.3068 
Less poor 0.41 0.013 0.5033-0.8303 3.37 0.006 0.1865-0.7566 
Least I!!!!r 0.75 0.006 0.4018-0.8199 3.79 0.001 0.3392-0.8127 
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CHAPTER FIVE 
DISCUSSION 
5.1 Introduction 
This chapter discusses the findings of the study and has been structured around the research 
objectives, the two theories adopted for the study which are the Social Cognitive and Folks 
Theories as well as the conceptual framework. Where appropriate, frameworks have been 
drawn to situate the findings in the context of what was conceptualized at the beginning of 
the study. 
5.2 Socio-cultural Practices during Pregnancy Labour, Neonatal Period and their 
etTects on Continuum of Care 
This section discusses findings from the socio-cultural practices that were identified and how 
these influenced health system factors to affect the continuum of care. 
5.2.1 Confinement, belicfs in witchcraft and usc of herbs increases risk of 
discontinuity during ANC, Skilled Delivery and Postnatal Period 
About 66.7% of women who participated in this study indicated they practised confinement 
at the beginning of the pregnancy because of fear of losing the pregnancy through 
bewitchment or evil people inflicting the unborn baby with birth defects. Again those who 
indicated they had practiced confinement during the pregnant were 2.42 times more likely to 
discontinue ANC and 1.98 the relative risk of discontinuity at postnatal level. This socio-
cultural practice emerged as one key barrier to attending ANC. Despite all participants 
(100%) indicating they were aware of the need for ANC, there was still the practice of 
confinement during early pregnancy. This practice often resulted in delay in starting ANC as 
only 36.4% of the study participant started ANC within 24 weeks gestation. The evidence 
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from the 2008 GDHS states that 15% of all pregnancies develop complications and progress 
to become emergencies. hence the need for early identification and consequent early 
management to prevent death during ANC. The coverage of pregnant women who received at 
least one antenatal care visit nationwide dropped by about 5 percentage points, from 95% in 
2008 to 90.6% in 2010 (GSS/GHSlMacro International, 2015). This finding is closely related 
to an earlier study that found that 46.0 % of pregnant women did not seek ANC services 
before 20 weeks gestation (early). (Solarin & Black. 2013). 
Whereas a study conducted in Zambia found out that women intentionally delayed the 
initiation of ANC to avoid making several visits to the health care facility and to reduce the 
overall costs of patronising the facilities (Menon et a\., 2010). this current study clearly 
shows that socio-cultural practice of confinement plays an important role in the early 
initiation of ANC. This finding must be given serious attention if women are to start ANC 
early where they will be expected to have made close to 12-13 visits during pregnancy. The 
ANC schedule is programmed in such a way that a pregnant woman will have to make 
monthly vi~its in the first seven months, twice a month in the eighth month, and then weekly 
in the final month, culminating in 12 - 13 visits overall (NCPD, CBS & MI, 1999). 
Essential health services such as monitoring the growth of the baby in utero, giving tetanus 
injection and the administering of Suphadoxine-Pyrimethamine (SP) to help reduce malaria 
during pregnancy are provided during ANC. Hence a woman starting the ANC late may not 
be able to complete these services as required. For example, every pregnant woman is 
expected to take at least 8 doses of the prophylaxis as per the new WHO recommendation 
(WHO. 2018). There is therefore the need for health care providers to highlight these socio-
cultural practices during health education and also design intervention targeted at reaching 
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those who may be confined at home. This is crucial if Ghana is to achieve universal health 
coverage and access to essential perinatal care as envisioned in the SDGs. 
The study also found that the use of herbs during labour was a common practice. Use of herb 
during labour was believed to facilitate the process and a common practice among women. 
This practice which may not be acceptable in the health care system emerged as barrier to 
facility delivery. In this study, some participants clearly indicated that the herbs were good 
Ii Ir smooth labour and hence women will go to places where their use is acceptable. This 
practice therefore favoured home delivery or using a TBA who have incorporated that into 
routine care they give to pregnant women. Herbal remedies to promote healthy delivery have 
been found to lead to severe bleeding which can be fatal according to a study in Bangladesh 
(Choudhury & Ahmed, 2011). These herbs are also used at places with less expertise in 
managing antepartum and postpartum haemorrhage. Postpartum haemorrhage is one of the 
leading causes of maternal deaths in Ghana and most of these deaths have occurred because 
of delays in referral or seeI..ing health care. A study in Ghana found that pregnant women 
were given herbal medicines by traditional birth attendants to induce labour, augment and 
control bleeding during labour (Otoo et aI., 2015). 
Maternal health choices made by women during pregnancy and delivery directly influences 
maternal ,UlJ neonatal morbidity and mortality (Evans, 2013). The process of pregnancy and 
childbirth is penneated with strong cultural practices and traditional beliefs which have an 
impact on maternal health care utilization (Houweling, Ronsmans, Campbell, & Kunst, 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 on meat, eggs, and fish diets may worsen underlying anaemia, placing the 
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pregnant woman at risk of death due to haemorrhage (lepro. 2015). In Nigeria, the Hausa 
ethnic group traditionally offer salt to pregnant women and "hot ritual" or coal baths which 
can predispose them to high blood pressure. cardiac failure and burns (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 et aI., 2003). Severally, 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 because they did not deliver at 
home, utilisation of maternal health care services will be negatively affected. Again, the fear 
of being exposed to the possibility of a caesarean section, coupled with the negative attitudes 
of health care workers serves as a push factor for women away from biomedical facilities. 
(Maimbolv.a ct aI., 2003; Okafor, 2000; Sibley et aI., 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 prevalent, maternal health services 
offered to women are often tainted by the antagonistic environment created by health care 
\\orkers and TBAs leading to a situation where suspicion, denigration and egotism are 
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propagated to the detriment of the pregnant woman (Berry. 2006; Maimbolwa et aI., 2003; 
Okafor, 2000). 
5.2.2 Maternal knowledge on newborn danger signs inbibits Neonatal 
Continuum of Care 
Knowledge in practice during child birth was good except that less than 10% (8.3%) of 
motht:rs were aware that umbilical cord should often be cut with a sterile item. This 
observation will have to be given some more attention in health education to mothers. Given 
the fact that close to 30% (28.7%) had unskilled delivery either giving birth at home or by a 
TBA, unsafe or unsterile cord cutting practices may be employed which can be a 
predisposition to neonatal infections. Such infections if not detected early and treated may 
result in neonatal sepsis with fatal outcomes. In 2012,6.1 million neonates were reported to 
have developed neonatal sepsis in South Asia and Sub Saharan Africa (Seale et aI., 2013) 
with fatality estimated to be between 8%-80% (Kissoon et aI., 2011; Thaver & Zaidi, 2009). 
Health education to women during ANC or to women generally must highlight the need for 
the umbilical cord to be cut with sterile materials. 
Study participants identified the need for pregnant women to attend ANC to enable them get 
immunization for themselves and their babies. Participants were also able to identify danger 
signs during neonatal period. However less than half (47.4%) recognised that abnormal 
jerking movement of limbs and eyes was a danger sign. Again, less than half (33.7%) 
recognized 'baby cold to touch' as a danger sign. This is often one of the immediate signs of 
severe ill health of a neonate. Subsequently, failure of mothers to recognise this will result in 
delay seeking for health care. This delay will invariably lead to the development of 
complication with fatal outcomes. Delays in seeking health care have often been identified as 
one of the key reasons for neonatal mortalities (Lassi, Middleton. Bhutta, & Crowther, 2016; 
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Waiswa. Kallander, Peterson, Tomson, & Pariyo, 2010), Thus, intervention modalities 
focusing on maternal/parental counselling on the commonest symptoms of illness in the 
newborn and young infants particularly during the ANCIPNC follow-up as well as during 
institutional delivery is very important in order to increase mothers knowledge of recognition 
of illness and hence improve care seeking behaviour of parents/care givers. Given the fact 
that some of the mothers did not attend ANC, community-based strategies and use of mass 
media may be relevant to reach out to people who may use the formal health care system 
5.3 Contextual issues OD how Knowledge and Socio-cultural practices affects the 
ContinuuOl of Care 
This study confirmed the local belief that when a pregnant woman develops oedema of the 
feet it implies the woman will be giving birth to a male child. Because of this belief women 
with oedema tend not to seek health care. It is also a known fact that, pedal oedema is one of 
the cardinal signs of pre-eclampsia, a condition which if not controlled can be fatal for both 
mother and baby (Duley, 2009; Eiland, Nzerue, & Faulkner, 2012). Earlier studies in Ghana 
and Nigeria have documented that pregnant women in these countries saw pedal oedema as a 
sign of carrying a male child or twins and were ignorant about linkages between the oedema 
and high blood pressure (Okafor & Rizzuto, 1994; Senah, 2003). 
The study found that knowledge on danger signs for neonate illnesses is low with only 63.3% 
of the participants being able to identify three or more danger signs. It was particularly low 
for some of the symptoms of serious illnesses, like jaundice 217 (49.4%) in the newborn. The 
inability of \\omen to clearly identify the danger signs during the neonatal period results in 
delays in health care seeking which affects the continuum of care and the health of the 
neonate. The low knowledge on essential care during the neonatal period results in unsafe 
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practices during the neonatal period which can also affect the health of the neonate. Timely 
and appropriate health seeking for neonatal illnesses depend partly on parents'fcare givers' 
recognition and perception of danger signs in the neonates. Providing education to mothers to 
improve their knowledge in recognizing danger signs can help in early seeking of health care. 
Quick and appropriate interventions for neonatal illnesses will prevent neonatal mortality as 
this emerged as the impact of low knowledge and unhealthy socio-cultural practices (Figure 
5.1). The results as illustrated on Figure 5.1, women who believed in witchcraft and practiced 
confinement had an increased relative risk of discounting at ANC and postnatal care. Also, 
the low knowledge of participants leads to unsafe practice such as unsafe cord practices, use 
of herbs during labour. Unsterile cord practices predispose the baby to infection and 
complications. Again. the use of herbs to facilitate labour has been reported to increase risk 
(It severe bleeding (Ononge, Okello, & Mirembe, 2016). Previous studies have shown that 
health education to improve home-care practices, recognition of newborn danger signs, 
demand creation for care by skilled care providers and increased parents'fcare givers' health 
seeking behaviour can lead to significant reduction in newborn mortality (Darmstadt et aI., 
2005; Jimenez Soto et aI., 2012; Lloyd & de Witt. 2013). 
Ghana has implemented key interventions to empower the community to improve neonatal 
and infant health services at the grass root level through the Community-based Health 
Planning strategy. This is a key entry point to improve neonatal health because without these 
initiatives, neonatal conditions may remain unattended to and result in neonatal mortality, 
thus reducing Ghana chance of achieving SDG 3 as it could not also achieve MDG 3 targets 
for child health. 
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- Sector Two Sector Three s~ctor~ Sector On~ Knowledg~ lkllc --O1utc ome Effect .- -Im.p-act_J 
Practices 
Knowledge 
Unsafe/unsterile I Effects 
! Low knowledge on: I • Impact 
cord practices 
cuning cord with sterile . I 
Cord 
Discarding ---1. infections materials ~ ------.. Neonatal Low 
delay in bathing colostrum health 
immediate initiation of , • No rooming-in 
immunity for 
neonates Neonatal 
brcastfccding I • Use of herbs Maternal morbidity 
usefulness of colostrum during labour I complications Maternal 
• use of herbs during labour I (PPH) morbidity 
--- ~~f--- & 
I mortality 
Delay inANC 
Confinement --- Unskilled Ll 
Belicfin Witchcrali delivery 
Discontinuity of 
postnatal 
Neonatal danger signs --------,--
Increasing 
laking of baby rolling ~ ___•  Delay in health I • I risk of 
ofcycs seeking septicaemia 
Baby feding cold to I • Developing 
lauch I Morbidity complications 
Jaundice I 
Figure 5.1: Contextual issues on how knowledge and socio-cultural practices affects the 
continuum of care. 
504 Health Seeking Behaviour during Prenatal, Labour and Postnatal Periods 
This section discusses the findings on the health seeking behaviours and how they affect the 
intrapartum and postpartum continuum of care. The study found that preference for 
traditional practices and fear of caesarian section (CS) affect the intrapartum continuum of 
care. 
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5.4.1 Preference for Traditional Practices during Labour Affects Utilization 
Skilled Delivery Affecting Intrapartum Continuum of Care 
The study found that some mothers prefer to give birth at facilities of traditional birth 
attendants. The study found squatting position is one of the reasons for the use of TBA 
facilities. However, babies born at such places may miss out on immunizations given 
immediately after birth like BCG and OPV. There is therefore the need for the formal health 
system to collaborate with the TBAs to ensure all such babies are immunized. Training of 
Traditional Birth Attendants (TBAs) and providing them with disposable delivery kits was 
the focus of a study carried out in Pakistan where the intervention arm of the study recorded 
less maternal deaths than the control arm, and a 30% decrease in neonatal mortality (Jokhio, 
Winter, & Cheng, 2005). Another reason cited for delivery at TBA is the use of herbs which 
is believed to be effective and facilitate the labour. As found in some studies, women's 
preference for TBAs during pregnancy and labour, compared to the health care facilities was 
due to the use of herbal medications, which was preferred to the drugs and vaccines 
administered at the ANC clinics (Okafor et aI., 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 skilled attendance at birth and postnatal care. Again studies have reported that 
even women who attend ANC still go to deliver at TBA facilities (Sarmento, 2014). As more 
than 65% of maternal deaths occur during delivery, the importance of having a skilled 
attendant in a facility with adequate health care services during the time of birth cannot be 
overemphasised (Adegoke & Van Den Broek, 2009). This study however found that some 
women still prefer unskilled delivery by using TBAs and having home delivery. 
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Community Health Ofticers who are currently responsible for implementing CHPS strategies 
can regularly visit TBA facilities to provide immunization and other essential new born care 
services. The CHPS concept is designed to provide door-to-door care (Pence, Nyarko, 
Phillips, & Debpuur, 2007) and has been found to improve provision of maternal and child 
health care services (Nyonator et aI., 2005). 
People who belong to poor wealth quintile in this study have been found to have increasing 
likelihood of using the services of TBAs. People with less education are also reported to have 
higher odds of seeking for health care from non-orthodox health outlets, However, less 
educated women have a very high risk of maternal mortality when compared to educated 
women (Karlsen et aI., 2011: Pillai. Maleku. & Wei, 2013). 
rhe findings of the study clearly show that women self-medicate and rely on itinerant drug 
sellers in the community for health care. Some of the medicines that are sold by these 
vendors may be counterfeit and therefore may not be potent. Ghana, like every other country 
in the World, also has a problem of ensuring supply chain security in the face of the growing 
threat from counterfeit and unregistered medical products and devices. For example, 
unregi~tcred products are estimated to account for approximately 5% of the Ghana 
pharmaceutical market. The extent of counterfeit medicines on the Ghana pharmaceutical 
market is hard to estimate as no local market surveillance studies on this issue have been 
performed (Osei-Safo et aI., 2014). There is therefore the need to regularly conduct medical 
surveillance studies to estimate level of unregistered product. Stringent measures are required 
to regulate thl.! influx of counterfeit and unregistered medical products and devices. 
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5.4.2 Fear of Caesarian Section (CS) Affects Intrapartum Continuum of Care 
Another barrier to utilisation of skilled delivery is the fear of CS and perceived believe of 
high prevalence of CS. This fear is related to community beliefs that motherhood is generally 
related to vaginal delivery. Hence, women who give birth through CS did not receive the 
same recognition as those who deliver through the vagina. However, since the TBAs do not 
have expertise in performing CS, respondent are of the view that using their outlet is an 
a~surance that one could avoid CS outcome. Ghanaian women's preference for vaginal 
delivery has earlier been documented (Danso et aI., 2009) but this study highlights the 
reasons for their preference. An earlier study had shown that women generally preferred 
vaginal delivery with about 11.6% refusing CS deliveries in developing countries (Chigbu & 
1I0abachie, 2007). Low preference for CS has also been reported across the world in a 
<;) ,tcmatic and meta-analysis of observational studies (Mazzoni et aI., 20 II). 
Per WHO standards, CS rates are generally reported to be higher than the expected 5-15% of 
all births (WHO, 2009). CS rates in Ghana have been reported to vary between 3.3 in rural 
poor women It) 10.8 in urban rich women. A study conducted at the University of Cape Coast 
Teaching Hospital found a CS rate of 26.9% (Prah et aI., 2017). Though there are 
inconsistencies in the rate of CS, it is clear the rates are relatively high. Moving forward, 
there is the need to do case review of CS conducted in different hospitals to inform policy 
direction regarding this process. 
Similar findings emerged in a study in Bangladesh that preference for vaginal delivery was 
one of the reasons for high utilisation of the services of traditional birth attendants and home 
delivery as it was known that these outlets could not perform CS whilst hospital unnecessary 
subjected women to CS on the least delay in labour (Sarker et aI., 2016). 
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5.5 Protection of baby against evil and bewitchment: Barrier to neonatal continuum 
of care 
The study found that some measures are taken to protect the neonate against evil and 
bewitchment at the community. Neonates are perccived to be vulnerable to the "cvil eyes" of 
jealous community members. As a result. neonate and mother are confined for periods 
ranging from one week to about 40 days. During this period, the baby is allowed to either be 
seen or touched by people who are outside the nuclear family. This social practice restricts 
the mother and the neonate from seeking health care outside the home. Hence this prevents 
the continuum of care at the neonatal. In Bangladesh, an earlier study reported that 
confinement of the mother and baby was observed until "noai" ceremony on day 7 or 9 to 
protect the baby against any evil (Winch et al.. 2005). 
The findings of this study need to be given much attention as majority of the practices that 
predispose babies to severe morbidities and even mortalities are still occurring. (Lawn et aI., 
2014b). Data from the World Health Organization show that preterm birth accounts tor 30% 
of global neonatal deaths. sepsis or pneumonia for 27%, birth asphyxia for 23%, congenital 
abnormality for 6%, neonatal tetanus for 4%, diarrhoea for 3%, and other causes for 7% of all 
n.:onatal deaths (Lav.n et aI., 2005). These conditions become fatal during the first week of 
life and require prompt attention. However, neonates with these conditions may not have 
access to good medical care because of the mandatory confinement as a way of protecting the 
baby against evil eyes". In their study in Bangladesh, it was found that 37% of the neonatal 
deaths occurred within 24 hours, 76% within 0-3 days, 84% within 0-7 days, and the 
remaining 16% within 8-28 days (Chowdhury et aI., 2010). Intensifying community-based 
home visit by health v.orker has the potential to identifY such conditions and offer medical 
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advice. Community-based management of neonatal conditions using trained village health 
workers has been shown to be effective in reducing neonatal mortality (Bhutta et aI., 2005). 
5.6 Innuence ofsocio-cultural practices and health system on continuum of care 
About 281 study participants (64.0%) revealed they have received some health education on 
ANC whilst only, 208 (47.4%) were advised to deliver in the health facilities. This clearly 
reinforces the qualitative findings which show that health services delivery was not reaching 
some pregnant women and therefore affecting the continuum of care. With regards to reasons 
for homeffBA delivery. better service and poor attitude of health workers were mentioned as 
the topmost reasons. This implies that the attitude issues coupled with poor services at 
biomedical health facilities is serving as a push factor for people patronizing the services of 
the traditional medical practitioners. This situation has the potential for breaking the 
continuum of care as traditional medical practitioners are unable to provide the essential 
service required during the perinatal period. 
The study revealed that close to one-third of the women has preference for the TBA services 
for delivery. Even though TBAs who were interviewed indicated they educate women to get 
immunization for their babies, it is obvious that some women may refuse, and this can affect 
the continuum of care. in terms of uptake of immunization services. Health workers 
extending outreach services to TBA facilities have the potential of reaching to immunization 
defaulters and thus increasing immunization coverage. Care at the level of outreach and 
outpatient service delivery points improves the survival of women and babies by forming the 
link between households and district hospitals, often serving as the first point of entry in the 
health care system (Drezner, Newbern. Ossa, & Johnson, 2015; Nyaku et aI., 2017; Oryema, 
8abirye. Baguma, Wasswa, & Guwatudde, 2017). 
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This study also brings to bear that even though the challenges of accessibility are being 
addressed by providing more health facilities through the scale up of the CHPS strategy, there 
are still significant issues relating to negative attitud~ of health workers. It is important to 
note that the attention given to women by TBAs is a motivation for many women to access 
their services. It is therefore critical for health facilities to identifY some of the good practices 
of the TBAs and incorporate them into biomedical health care services. Collaboration 
between TBAs and health workers in biomedical facilities may be essential to bridging the 
gap in access to essential service for pregnant women, neonates and postnatal women who 
patronize the services of TBA. In Africa, majority of births and newborn deaths happen at 
home and this will require successful community partnerships, social mobilisation, health 
education and behaviour change communication strategies to bring the situation under control 
(Abdullah, Hort, Butu, & Simpson, 2016; Zielinski, Ackerson, & Low, 2015). Socio-cultural 
determinants such as lack of gender equity in particular and the low status of women in 
households and communities also hinder wom~n's ability to seek care or take action when a 
complication occurs, and this must be given attention in health interventions as we count 
down to 2030 where the SDGs are to be achieved. 
Strategies involve improving the skills of health workers, strengthening health system 
supports. and improving household and community practices and community actions must be 
priorities for promoting health. This approach also brings care closer to the home through 
outreach services and promotes referral by strengthening access to and improving the quality 
of services at peripheral and district level. Combining effective care in health facilities, 
healthy behaviours at home and early care seeking for illness will have the biggest impact on 
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mother, newborn and child health (Nair. Tripathy, Prost, Costello, & Osrin, 2010; Titaley, 
Dibley, & Roberts, 2012). 
5.7 Health Seeking Behaviour for Neonatal Illness and Determinants 
In this study 286 (65.1 %) women reported that their babies tell sick in the first 28 days after 
birth of which 201 (70.3%) sought health care. Of those who seek health care, 37.8% use 
traditional health care outlet. The main reasons for not seeking treatment from health care 
facilities as reported by mothers/caregivers are that the perceived iIIness are not serious and 
the issue of lack of money. These reasons for not seeking health care are similar to an earlier 
~lUdy conducted in Ethiopia (Awoke, 2013). In a related study conducted in Bangladesh, 
30.9% of babies were reported ill during the first 28 days after birth ""ith (84.4% of mothers 
'ieeking health care with good outcomes (Chowdhury, BilIah, Arifeen, & Hoque, 2018). 
Timely and adequate care seeking for illnesses as well as appropriate and timely intervention 
are therefore key elements in improving neonatal health and survival (Quadri et aI., 2013). 
Findings show that respondents often seek for health care from both biomedical and non-
orthodox informal health outlets in times of ill-health during the neonatal period. The 
biomedical facilities are the clinics, health centres and hospital located in the community. The 
informal health care system consists the use of traditional practitioners, spiritualists and other 
community-based outlets where health care are sought, other than designated formal health 
care facilities (Tabong & Adongo, 2013a). These informal sources emerged as important 
source of health care in the community because majority of the illness during the neonatal 
period were deemed to be spiritual in nature. Earlier studies have reported that people will 
often seek for health care from traditional and spiritual healers for condition which are 
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believed to be caused by social or spiritual factors as biomedical remedies are seen as 
ineffective for such situations (Tabong & Adongo, 2013b; Viney et aI., 2014). 
The study also found that in household where mothers and husband are in charge of health-
related decision making. sick neonates were more likely to seek for health care in the 
biomedical facility. However, in household where in-laws are in charge of decision making, 
the sick neonates seek health from traditional healers. The inability of a woman to make 
decision has been earlier reported as a socio-cultural practice which was deeply entrenched in 
cultural norms and negatively affected health behaviour in Ghana (GHS, 2015). Again, 
earlier studies have also reported that decision concerning place to seek health care for 
neonates 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 
women's preference (Crissman et aI., 2013; Moyer, Adongo, Aborigo, Hodgson, Engmann, et 
al.,2014). 
Gatekeeper system and household arrangements have the potential of delaying health seeking 
behaviour in instances where the decision maker is unavailable. In Indonesia, Nepal, 
Tanzania and Malawi grandparents and in-laws have been reported to be key decision makers 
in health seeking which often favour the use of non-medical sources (Allendorf, 2007; 
Biweta. 2015; Danforth, Kruk, Rockers, Mbaruku, & Galea, 2009; Gipson et aI., 2002; 
Mrisho et aI., 2007; Seljeskog et aI., 2006). Similar gatekeeper systems and its influence on 
health seeking have been reported in studies conducted in Ghana mainly in the rural 
communities in northern Ghana (Adongo, Phillips, & Baynes, 2014; Nazzar, Adongo, Binka, 
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Phillips, & Debpuur, 1995; Rominski et aI., 2014) and urban slum in Ghana (Nwameme et 
al.. 2014). 
5.8 Contextual Issues about Beliefs, Health Seeking Behaviour and Continuum of 
Care for Neonate 
The study found that perception about illness was an important consideration in health 
seeking behaviour of neonates. Where the disease condition is perceived not be serious, 
health care is not sought. However, where the disease is perceived to be serious, the family or 
the key decision maker will have to appraise the disease to determine the cause of the 
condition as suggested in the social cognitive theory that has been adopted in this study. If the 
dise:be is believed to be biological in nature, health care will often be sought in biomedical 
health facility. On the other hand, if the disease is perceived to be due to social factors or 
spiritual in nature, health care will be sought at traditional or informal health care providers 
who are believed to be very effective in managing such disease condition. Nonetheless, in 
some instance, the disease condition may be serious, but health care may not be sought 
because of financial constraints and inaccessible health care facilities as found in this study. 
When health care is sought at the biomedical health facility, the neonate will have the 
opportunity to have continuum of care as this creates an opportunity for even babies who 
were born at home by TBAs to receive immunizations. However, when care is sought from 
traditional healers, this opportunity may be lost resulting in break in the continuum of care 
(Figure 5.2). 
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Barriers 10 USB 
Financial 
Distance 
Serious ~--*---
-----~-y-- I 
1- Seek Health Care L ~ Illness 
Perception L ___  ! -- Medical Spiritual 
about illness I - Social 
~ No Health Care i - ~~~---
------! 
Figure S.2: Contextual Issues about Beliefs, bealtb Seeking Behaviour and Continuum of Care 
for Neonate 
5.9 Health seeking bebaviour of Women during Postnatal period 
The study found that when women are sick during the puerperium period they start by self-
medicating with the hope of getting better. This behaviour is partly due to the confinement 
practice that is required for newly delivered women. Going out to seeking for health will 
require exposure of the baby to people which is deemed to be an inappropriate practice since 
it is believed that some evil people may bewitch and harm the baby. Self-medication is 
sometimes done by buying medicines from drugstore and itinerant drug peddlers in the 
community. 
In many communities, modern 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 
aI., 2009: Winch et aI., 2005). This study clearly shows that several health outlets may be 
used depending on the perception about the cause of the condition. These health outlets may 
be used concurrently or in a sequence as illustrated on figure 5.3 
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Fig 5.3: Health Seeking Behaviour of women duriog perinatal period 
Self-medication 
The study found that 64% of women with primary education are less likely to seek for health 
can: at biomedical health facility. However, people with post-secondary and tertiary 
education are 2.7 times (aOR=2.7, p=O.OOI, 95% CI= 1.5821-4.3881) more likely to seek for 
health care at biomedical facilities for their most recent illness. Also, being a public or civil 
servant increases one's odds of seeking for health care at biomedical health facility by 3 
times (aOR=3.l1, p=O.005, 95%=1.3449-2.2478). People who belong to the less and least 
poor wealth quintiles have 3.37 and 3.70 odds respectively of seeking health care in a 
biomedical health facility. Although studies have shown that poor people are more prone to 
complication aftl.T birth (Grote et aI., 2010; Joseph, Liston, Dodds, Dahlgren, & Allen, 2007), 
they were less likely to seek health care at biomedical conditions. Empowering all women to 
be economically productive and sufficient has the potential of bridging the gap in 
inaccessibility due to tinancial constraints. Socio-economic conditions in which they live 
impede healthy choices in health care (Claussen, 2015). 
The findings of this study also clearly show that traditional healers' especially traditional 
birth attendants arc an indispensable point of care for some women. It is therefore very 
relevant to integrate traditional medical practitioners into the primary health care system 
because of the multiple advantages it present". A good collaboration among the traditional 
and orthodox medical practitioners will provide an opportunity for the training of traditional 
medical practitioners in current scientific knowledge and enhance the referral system, which 
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can cater for both biological and spiritual causes of disease and prevent a break in the 
continuum of care. 
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CHAPTER SIX 
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS 
6.1 Introduction 
This chapter provides a summary of the key findings of the study in line with study 
objectives. and relevant conclusions for each of the four objectives that guided this study. It 
further provides the novelty findings in this study as contributions of the study to knowledge. 
It concludes by providing the implications of the study for public health decision-making, 
recommendations ofthe study, suggestions for further research and for policy makers. 
6.2 Summary of Findings 
This study employed mixed quantitative and qualitative approach in research to assess socio-
cultural practices influencing intrapartum and postpartum continuum of care in the Asante 
Akim North District in the Ashanti Region of Ghana. A survey was conducted with 439 
women who had to recall information during their puerperium. The qualitative component of 
this study employed narrative approaches. Purposive sampling was used to recruit 22 people 
for an in-depth intervie ..... In addition, 11 FGDs were conducted to document normative 
aspect of intrapartum and postpartum continuum of care. The main findings of the study 
include: 
I. Socio-cultural beliefs and practices such as bewitchment and confinement increase the 
relative risk of intrapartum and postpartum discontinuity of care by 1.94-2.42. This 
practice resulted in pregnant women not attending ANC and therefore unable to 
receive essential services during pregnancy; 
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2. Women who \\-ere not visited at home during pregnancy had higher relative risk of 
discontinuing at ANC (RR-1.89. 95%CI=O.2190-0.9182), delivery (RR-2.71. 
95%CI=0.8791) and PNC (RR=J.78, 95%CI=0.6981-0.8132). 
3. Women who were not advised to have skilled delivery had higher relative risk of 
discontinuing care at delivery (RR=2.91, 95%CI=0.4001-0.7211) and PNC (RR=2.88, 
95%CI=0.44 12-0. 7219). 
4. Women's preference for delivery at TBA is informed by cultural belief, good/positive 
attitude and special attention given to them. This socio-cultural belief correlates with 
health system factors such as bad attitude of health workers and fear of CS to push 
women towards the utilization of the services ofTBAs 
5. Self-medication and utilization of the services of traditional healers are key health 
seeking practices during prenatal and postnatal period. These practices are informed 
by the spiritual connotation given to illness during these periods. This health seeking 
practices negatively affect the continuum of care. People with lower educational 
attainment, belonging to poorer socio-economic status and having in-laws as 
responsible for making key health related decisions favoured the use of traditional and 
other non-orthodox health outlets; 
6. Illness during neonatal period was common as 286 (65%) of mothers indicated their 
neonates suffered some form of illness, however close to 38% of them who sought for 
health care utilized the services of traditional healers affecting the postpartum 
continuum of care. This health seeking behaviour is also related to the belief that 
majority of illness during the neonatal period are spiritual in nature; 
7. Local beliefs and practices during childbirth interact with poor services at biomedical 
health facilities to push women towards utilizing services of TBAs, a factor that 
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affects the continuum of care for neonates. Reasons being that TBAs are unable to 
provide essential newborn care service such as immunization. 
8. Education and socio-economic status are key determinants of health seeking for both 
neonatal and maternal illness. 
6.3 Conclusions 
The study concludes that socio-cultural practices are common in the study area and transcend 
the perinatal period. These socio-cultural practices are viewed as indispensable and closely 
related to the people's worldview on illnesses during pregnancy, childbirth, neonatal and 
postnatal period have social and supernatural causes. This belief system favours the 
preference for services rendered by traditional healers. The extra care and flexibility in labour 
position creates a situation where women prefer the services ofTBAs. The good interpersonal 
relationship of TBAs, local beliefs and poor services at biomedical facilities push expectant 
mothers towards traditional care. Both neonatal and postnatal illness are believed to have 
both biomedical and social causes but with social causes having prominence. As a result, 
health seeking behaviour is directed toward non-orthodox service outlets which negatively 
affect intrapartum and postpartum continuum of care. 
6.4 Contribution to Knowledge 
I. Protecting pregnancy from evil forces resulted in the practice of confinement and 
consequently late initiation of antenatal care (ANC). This affects the continuum of 
care because pregnant women will not be able to access the full complement of 
essential services [Intermittent Prevention Treatment (lPT) for malaria, monitoring of 
foetal development. haemoglobin levels, blood pressure and urine examination], 
which are provided to detect any abnormalities associated \\ ith pregnancy for prompt 
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management and referrals. ANC has been identitied as a very important component 
of care which has the potential to reduce maternal morbidity and mortality which is 
critical for Ghana's achievement ofSDG targets for maternal mortality. 
2. Encounter with community-based health care provider increases the likelihood of 
achieving complete intrapartum and postpartum continuum of care. Health education 
plays a very important role in ensuring that women have the requisite information 
about the benefits of ANC, skilled delivery, PNC and immunization and as a result, 
access these services. Again, home visits by community health workers (CHOs, 
CHNs) during antenatal and postnatal period can improve health service utilization. 
6.5 Recommendations 
This section looks at recommendations of the study. Recommendations for practice to 
improve prenatal and postnatal continuum of care. Recommendations are also made for 
policy development for maternal and child health. Also, recommendations are made on future 
research area~ to improve maternal and child health services. 
6.5. t Recommendations for Practice 
I. Health workers at the district health directorates should intensify education and advice 
for women on intrapartum and postpartum continuum of care. The education should 
highlight the practices that have the potential to undermine the continuum of care. 
2. Community Health Officers should use visit to TBA outlets as opportunity to provide 
prenatal and postnatal services to women who patronize such places. This has the 
potential of increa~ing immunization coverage for children and ensure continuum of 
health care along the perinatal period because of such women's preference for 
traditional practice in those outlets. 
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3. Staff of Ghana Health Service should consider interacting more with existing social 
groups in the community to help identifY women who may be pregnant and confmed 
to homes. 
6.5.2 Recommendations for Policy 
I. The policy on focused antenatal should be revised to include the recruitment and use 
of Community Health Officers to implement and scale up home-based services. 
2. The findings of this study should inform the revision of existing guidelines to regulate 
the practice of traditional birth attendants by the Ministry of Health as well as in the 
development of strategies and protocols for health education with a focus on negative 
socio-cultural practices. 
3. Ghana Health Service-Family Health Division should design health literacy 
approaches for MCH programmes which considers socio-cultural practices along the 
continuum of care 
6.5.3 Recommendations for Future Research 
I. There should be implementation research on how to increase collaboration between 
mAs and biomedical health facilities. 
2. There should be an implementation research on how to use Community Health 
Officers (CHO)s to bridge the gap in continuum of care especially during the 
postnatal period and the service provided. paid for by the national health insurance 
scheme. 
159 
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APPENDICES 
Appendix AI: Participants Information and Consent Form - In-depth Interviews 
Socio-cultural factors influencing intrapartum and postpartum continuum of care in AAND of 
the Ashanti Region of Ghana 
Purpose 
Hello! My name is _______ and that of my colleague is ______  
We are from School of Public Health, University of Ghana, Legon. We are conducting a 
study on socio-cultural factors influencing intrapartum and postpartum continuum of care. 
The purpose of the study is to identifY the practices that may affect continuum of care to 
enable us develop interventions that improve maternal and child health conditions in the 
district. We will be speaking with a sample of health workers, community health volunteers, 
and community members within Ghana. We hope that the information we will obtain from 
this study will help us to improve maternal and child health. 
Procedure 
We are inviting you to participate in the study to share your knowledge, opinions and 
experiences on socio cultural factors that influence intrapartum and postpartum continuum of 
care. You have been selected to participate in the study because you are a key stakeholder 
with regards to the implementation maternal and child health interventions. 
Your participation in the study is voluntary. If you agree to participate in the study we will 
have a discussion with you. The discussion will last about 45-60 minutes. During the 
discussion, you can refuse to answer any question that you are not comfortable with or 
withdrav. your consent to participate in the study. If you decide not to participate in the study, 
nothing will happen to you, and it will not affect your relationship with any health care 
provider, or your rights to health care services in anyway. However, if you agree to 
participate in this study, it is important for you to be very sincere and honest in your views, so 
we can better understand the situation and how to improve on maternal and neonatal health in 
the communities/districts. The discussions or interviews will be recorded with your 
permission using a digital recorder such that the process can move on fast. The voice 
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recordings will be kept in a safe place till the award of the degree. However the transcriptions 
from the voices will be kept for discarded two years after the award of the degree. 
Risks and Discomforts 
The risks involved in taking part in this study are minimal. These include the inconvenience 
that tht: interview will cause you, and the time that you will spend answering the questions. 
Some of the themes for discussion may seem personal and sensitive. You can however 
choose not to answer any question that you do not feel comfortable to answer. 
Benefits 
There are no direct benefits to you for your participation in the study. However. the 
information that will be obtained from this study will help in addressing issues relating to 
health care in the district and nationwide. Further, all participants will receive a 
reimbursement for any travel expenses they may incur and two bars of soap as a token of 
appreciation for your time. 
Confidcntialit)· 
Any information you share during the discussion will be treated confidentially and no 
personal identifyill~ information concerning you or any person will be presented in the 
analysis or publications of this study. All the information collected will be used only for the 
purposes of this study. The discussion will be tape-recorded so that I can listen carefully to 
everything and accurately write down everything that has been said. After writing out 
everything on the tapes, the tapes would be stored for a period of two years before being 
destroyed. The information would not be shared with anyone and will be used only for the 
purposes of this study. We will not mention any of your names in the report of this study, and 
nobody will be able to trace anything we discussed here back to you. 
All personal information will be kept strictly confidential. We will do everything we can to 
keep your data secure, however, complete confidentiality cannot be promised. Despite all of 
the efforts, unanticipated problems, such as a stolen computer may occur, although it is 
highly unlikely. All data will be coded by numbers and scparated from your name or any 
other way to identify you. The information you provide will be used only in combination with 
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other data, and results will be presented only in aggregated form. The following individuals 
and agencies will be able to look at and copy your research records: the investigator. study 
staff and other medical professionals who may be evaluating the study. and the authorities 
from University of Ghana. 
Rigbt to refuse or witbdraw 
Before participating in the study. please understand that your participation is voluntary. You 
do not need to participate in the research if you do not want to. If you decide not to be part of 
this study. your decision will not affect your relationship with the staff of the Ghana Health 
Service in anyway. You will also not lose any benefits that you would have otherwise been 
entitled. If you agree to take part in the study. you can still withdraw from the study at any 
time and this will not affect you in any way. 
Your participation in this study ends after this interview. 
This study has been reviewed and approved by the Ethical Review Committee of Ghana 
Health Service. If you would like to find out more about the study, you may contact any of 
the following persons: Prof. Philip Baba Adongo (main academic supervisor) on phone 
number: 0244806015, Dr. Emmanuel Asampong (second supervisor) on 02448278453 or 
Secretary to the GHS Ethic Committee, Madam Hannah Frimpong on 0243235225 or 
0507041223 or Joana Ansong (Principal Investigator) on phone number: 0544316017. 
Are you willing to participate in the interview? I. Yes [ 2. No [ 
Do we have your permission to record the interview? I. Yes [ 2. No [ 
I have reviewed the above with the participant and he/she has freely agreed to participate in 
the intcrview. 
Study Participant 
Name _____________S ignaturen-humbprint_ __________ Date_ __  
Person obtaining consent 
Namc. Signature/Thumbprint_ ._ _____D ate_ __  
Method of Communication: 
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I. Read by Self (Interviewee) 
2. Read and Interpreted by interviewer 
3. Consent through witness 
INSTRUCTIONS 
- After presentation, and consent and switching on the recorder, try to make the interview as 
similar as possible to an informal conversation. It is very important the person you are 
interviewing feels comfortable with you. 
- You can change the order of the questions. 
-You should adjust the past/present tense of the questions as appropriate depending on 
whether you are referring to past or present. 
Date of interview .. 
Name of Interviewer. .. 
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Consent Form 
Healtb Worker/Opinion LeaderffBAffraditional Medical Practitioners . 
The nature and purpose as well as the potential risks and benefits of the research on "SOCIO-
cultural practices that influence intrapartum and postpartum continuum of care in the Asante 
Akim North District"' has been read out and carefully explained to me. I have been given an 
opportunity to obtain clarifications about the research to my satisfaction. I understand the 
risks and the benefits associated with participating in this Research. I know that I have the 
right to withdraw from the research at any time that I so desire. I consent voluntarily or agree 
without any persuasion to participate as a volunteer. 
Date Signature or mark of 
volunteer 
For participants who cannot read and write, a witness or legal guardian serves as a 
witness. 
I was present while the nature, purpose, potential risks and benefits as well as procedures 
of the research were read to the volunteer. All questions were answered and the 
volunteer has agreed to take part in the research. 
Date Signature of 
Witness 
I certify that the nature and purpose, the potential benefits, possible risks associated with 
participating in this research have been explained to the above individual. 
Date Signature of Person Wbo Obtained 
Consent 
IN CASE OF FURTHER INFORMATION OR ENQUIRY ABOUT THE RESEARCH 
fI-fl: PRINCIPAL AND CO-RESEARCHERS AS WELL AS ADMINISTRATOR O~ 
HHICS COMMITTEE OF THE GHS CAN BE CONTACTED ON THE FOLLOWING 
NUMBERS RESPECTIVELY: JOANA ANSONG: 0208134549, PROF PHILIP BABA 
AOONGO: 024457706, ADMN. GHS ERC: 030250117817 
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Appendix A2: Participants Information and Consent Form - Focus Group Discussion 
Socio-cultural factor~ influencing intrapartum and postpartum continuum of care in AAND of 
the Ashanti Region of Ghana 
Purpose 
Hello! My name is _______ and that of my colleague is ______  
We are from School of Public Health, University of Ghana, Legon. We are conducting a 
study on socio-cultural factors influencing intrapartum and postpartum continuum of care. 
The purpose of the study is to identify the practices that may affect continuum of care to 
t:nable us develop interventions that improve maternal and child health conditions in the 
district. We will be speaking with a sample of health workers, community health volunteers, 
and community members within Ghana. We hope that the infornlation we will obtain from 
this study will help us to improve maternal and child health. 
Procedure 
We are inviting you to participate in the study to share your knowledge, opinions and 
experiences on socio cultural factors that influence intrapartum and postpartum continuum of 
care. You have been selected to participate in the study because you are a key stakeholder 
with regards to the implementation of maternal and child health interventions. 
Your participation in the study is voluntary. If you agree to participate in the study we will 
have a discussion with you. The discussion will last about 45-60 minutes. During the 
discussion, you can refuse to answer any question that you are not comfortable with or 
withdraw your consent to participate in the study. If you decide not to participate in the study, 
nothing will happen to you, and it will not affect your relationship with any health care 
provider. or your rights to health care services in anyway. However, if you agree to 
participate in this study, it is important for you to be very sincere and honest in your views, so 
we can better understand the situation and how to improve on maternal and neonatal health in 
the communities/districts. The discussions or interviews will be recorded with your 
permission using a digital recorder such that the process can move on fast. The voice 
197 
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recordings will be kept in a safe place till the award of the degree. However the transcriptions 
from the voices will be kept for discarded two years after the award of the degree. 
Risks and Discomforts 
The risks involved in taking part in this study are minimal. These include the inconvenience 
that the interview will cause you, and the time that you will spend answering the questions. 
Some of the themes for discussion may seem personal and sensitive. You can however 
choose not to answer any question that you do not feel comfortable to answer. 
Benetits 
There are no direct benetits to you for your participation in the study. However. the 
information that will be obtained from this study will help in addressing issues relating to 
health care in the district and nationwide. Further, all participants will receive a 
reimbursement for any travel expenses they may incur and two bars of soap as a token of 
appreciation for your time. 
Con tidentiality 
Any information you share during the discussion will be treated confidentially and no 
personal identifying information concerning you or any person will be presented in the 
analysis (If publications of this study. All the information collected will be used only for the 
purposes of this study. The discussion will be tape-recorded so that I can listen carefully to 
everything and accurately write down everything that has been said. After writing out 
everything on the tapes, the tapes would be stored for a period of two years before being 
destroyed. The information would not be shared with anyone and will be used only for the 
purposes of this study. We will not mention any of your names in the report of this study, and 
nobody will be able to trace anything we discussed here back to you. 
All personal information will be kept strictly confidential. We will do everything we can to 
keep your data secure. however, complete confidentiality cannot be promised. Despite all of 
the efforts, unanticipated problems, such as a stolen computer may occur, although it is 
highly unlikely. All data will be coded by numbers and separated from your name Of any 
other way to identify you. The information you provide will be used only in combination with 
198 
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other data. and results will be presented only in aggregated fonn. The following individuals 
and agencies will be able to look at and copy your research records: the investigator, study 
staff and other medical professionals who may be evaluating the study, and the authorities 
from University of Ghana. 
Right to refuse or withdraw 
Before participating in the study, please understand that your participation is voluntary. You 
do not need to participate in the research if you do not want to. If you decide not to be part of 
this study, your decision will not affect your relationship with the staff of the Ghana Health 
Service in anyway. You will also not lose any benefits that you would have otherwise been 
entitled. If you agree to take part in the study, you can still withdraw from the study at any 
time and this will not affect you in any way. 
Your participation in this study ends after this interview. 
This study has been reviewed and approved by the Ethical Review Committee of Ghana 
Health Service. If you would like to find out more about the study, you may contact any of 
the following persons: Prof. Philip Baba Adongo (main academic supervisor) on phone 
number: 0244806015, Dr. Emmanuel Asampong (second supervisor) on 02448278453 or 
Secretary to the GHS Ethic Committee, Madam Hannah Frimpong on 0243235225 or 
0507041223 or Joana Ansong (Principal Investigator) on phone number: 0544316017. 
Are you willing to participate in the interview? I. Yes [ 2. No [ J 
Do we have your pennission to record the interview? I. Yes [ 2. No[ ] 
I have reviewed the above with the participant and he/she has freely agreed to participate in 
the interview. 
Study Participant 
Name _______S ignaturerrhumbprint_ ______ Date ___  
Person obtaining consent 
Name _________  Signatureffhumbprint_ __________ Date ___  
Method of Communication: 
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1. Read by Self (Interviewee) 
2. Read and Interpreted by interviewer 
3. Consent through witness 
INSTRUCTIONS 
- After presentation, and consent and switching on the recorder, try to make the interview as 
similar as possible to an informal conversation. It is very important the person you are 
interviewing feels comfortable with you. 
- You can change the order of the questions. 
-You should adjust the past/present tense of the questions as appropriate depending on 
whether you are referring to past or present. 
Date of interview ... 
Name of Interviewer ... 
200 
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Consent Form 
Adults 18 yean and above 
The nature and purpose as well as the potential risks and benefits of the research on "Socio-
cultural practices that influence intrapartum and postpartum continuum of care in the 
Asante Akim North District" has been read out and carefully explained to me. I have been 
given all opportunity to obtain clarifications about the research to my satisfaction. I 
understand the risks and the benefits associated with participating in this Research. I know 
that I have the right to withdraw from the research at any time that I so desire. I consent 
voluntarily or agree without any persuasion to participate as a volunteer. 
Date Signature or mark of 
volunteer 
For participants who cannot read and write, a witness or legal guardian serves as a witness. 
I was present while the nature, purpose, potential risks and benefits as well as procedures of 
the research were read to the volunteer. All questions were answered and the volunteer has 
agreed to take part in the research. 
Date Signature of Witness 
I certify that the nature and purpose, the potential benefits, possible risks associated with 
participating in this research have been explained to the above individual. 
Date Signature of Person Who Obtained Consent 
IN CASE OF FURTI-IER INFORMATION OR ENQUIRY ABOUT THE RESEARCH 
THE PRINCIPAL AND CO-RESEARCHERS AS WELL AS ADMINISTRATOR OF ' 
ETHICS COMMITTEE OF THE GHS CAN BE CONTACTED ON THE FOLLOWING 
NUMBERS RESPECTIVELY: JOANA ANSONG: 0208134549, PROF PHILIP BABA 
AOONGO: 024457706, ADMN. GHS ERC: 030250117817 
201 
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Appendix A3: Consent form for quantitative survey 
Socio-cultural factors influencing intrapartum and postpartum continuum of care in 
AAND of the Ashanti Region of Ghana 
Purpose 
Hello' My name is _______ and that of my colleague is ______  
We are from School of Public Health, University of Ghana, Legon. We are 
conducting a study on socio-cultural factors influencing intrapartum and postpartum 
continuum of care. The purpose of the study is to identifY the practices that may allect 
continuum of care to enable us develop interventions that improve maternal and child 
health conditions in the district. We will be speaking with a sample of health workers, 
community health volunteers, and community members within Ghana. We hope that 
the information we will obtain from this study will help us to improve maternal and 
child health. 
Procedure 
We are inviting you to participate in the study to share your knowledge. opinions and 
experiences on socio cultural factors that influence intrapartum and postpartum 
continuum of care. You have been selected to participate in the study because you are 
a key stakeholder with regards to the implementation maternal and child health 
interventions. 
Your participation in the study is voluntary. If you agree to participate in the study we 
will have a discussion with you The discussion will last about 45-60 minutes. During 
the discussion. you can refuse to answer any question that you are not comfortable 
with or withdraw your consent to participate in the study. If you decide not to 
participate in the study, nothing will happen to you, and it will not affect your 
relationship with any health care provider. or your rights to health care services in 
an}way. However, if you agree to participate in this study, it is important for you to 
be very sincere and honest in your views, so we can better understand the situation 
and how to improve on maternal and neonatal health in the communities/districts. The 
202 
University of Ghana  http://ugspace.ug.edu.gh
discussions or interviews will be recorded with your permission using a digital 
recorder such that the process can move on fast. The voice recordings will be kept in a 
safe place till the av.ard of the degree. However the transcriptions from the voices will 
be kept for discarded two years after the award of the degree. 
Risks and Discomforts 
The risks involved in taking part in this study are minimal. These include the 
inconvenience that the interview will cause you, and the time that you will spend 
answering the questions. Some of the themes for discussion may seem personal and 
sensitive. You can however choose not to answer any question that you do not feel 
comfortable to answer. 
Benefits 
There are no direct benefits to you for your participation in the study. However, the 
information that will be obtained from this study will help in addressing issues 
relating to health care in the district and nationwide. Further, all participants will 
receive a reimbursement for any travel expenses they may incur and two bars of soap 
as a token of appreciation for your time. 
Confidentiality 
Any information you share during the discussion will be treated confidentially and no 
personal identifying information concerning you or any person will be presented in 
the analysis or publications of this study. All the information collected will be used 
only for the purposes of this study. The discussion will be tape-recorded so that I can 
listen carefully to everything and accurately write down everything that has been said. 
After writing out everything on the tapes, the tapes would be stored for a period of 
two years before being destroyed. The information would not be shared with anyone 
and will be used only for the purposes of this study. We will not mention any of your 
names in the report of this study, and nobody will be able to trace anything we 
discussed here back to you. 
203 
University of Ghana  http://ugspace.ug.edu.gh
All personal information will be kept strictly confidential. We will do everything we 
can to keep your data secure, however. complete confidentiality cannot be promised. 
Despite all of the efforts, unanticipated problems. such as a stolen computer may 
occur. although it is highly unlikely. All data will be coded by numbers and separated 
from your name or any other way to identifY you. The information you provide will 
be used only in combination with other data. and results will be presented only in 
aggregated form. The following individuals and agencies will be able to look at and 
copy your research records: the investigator. study staff and other medical 
professionals who may be evaluating the study, and the authorities from University of 
Ghana. 
Right to refuse or withdraw 
Before participating in the study. please understand that your participation is 
voluntary. You do not need to participate in the research if you do not want to. If you 
decide not to be part of this study, your decision will not affect your relationship with 
the stall of the Ghana Health Service in anyway. You will also not lose any benefits 
that you would have otherwise been entitled. If you agree to take part in the study, 
)'ou can still withdraw from the study at any time and this will not affect you in any 
way. 
Your participation in this study ends after this interview. 
This study has been reviewed and approved by the Ethical Review Committee of 
Ghana Health Service. If you would like to find out more about the study, you may 
contact any of the following persons: Prof. Philip Baba Adongo (main academic 
supervisor) on phone number: 0244806015, Dr. Emmanuel Asampong (second 
supervisor) on 02448278453 or Secretary to the GHS Ethic Committee, Madam 
Hannah Frimpong on 0243235225 or 0507041223 or Joana Ansong (Principal 
Investigator) on phone number: 0544316017. 
Are you willing to participate in the interview? I. Yes [ 2. No 
[ 1 
Do \'of have your permission to record the interview? I. Yes [ 2. No 
[ 1 
204 
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I have reviewed the above v. ith the participant and he/she has freely agreed to 
participate in the interview. 
Study Participant 
Name ___________S ignaturefThumbprint:.-----,Date-
Person obtaining consent 
Name_ __________S ignaturefThumbprint,------....;Date-
Method of Communication: 
l. Read by Self (Interviewee) 
2. Read and Interpreted by interviewer 
3. Consent through witness 
INSTRUCTIONS 
- After presentation, and consent and switching on the recorder, try to make the 
interview as similar as possible to an informal conversation. It is very 
important the person you are interviewing feels comfortable with you. 
- You can change the order of the questions. 
-You should adjust the past/present tense of the questions as appropriate depending on 
whether you are referring to past or present. 
Date of interview ...... , , 
Name of Interviewer. ... 
205 
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Consent Form 
Mothers with Babies not more than 6 months of age 
The nature and purpose as well as the potential risks and benefits of the research on 
"Socio-cultural practices that influence intrapartum and postpartum continuum of 
care in the Asante Akim North District" has been read out and carefully explained to 
me. I have been given an opportunity to obtain clarifications about the research to my 
satisfaction. I understand the risks and the benefits associated with participating in this 
Research. I know that I have the right to withdraw from the research at any time that I so 
desire. I consent voluntarily or agree without any persuasion to participate as a volunteer. 
Date Signature or mark of volunteer 
For participants who cannot read and write, a witness or legal guardian serves as a 
witness. 
I was present while the nature, purpose, potential risks and benefits as well as 
procedures of the research were read to the volunteer. All questions were answered and 
the volunteer has agreed to take part in the research. 
Date Signature of Witness 
I certify that the nature and purpose, the potential benefits, possible risks associated 
with participating in this research have been explained to the above individual. 
Date Signature of Person Who Obtained Consent 
In case of further information or enquiry about the research, the principal and co-
researchers as well as administrator of ethics committee of the GHS can be contacted on 
the following numbers respectively: Joana Ansong: 0208134549, Prof Philip Baba 
Adongo: 024457706, Admn. GHS-ERC: 030250117817 
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Appendix B: Questionnaire for Survey 
SECTION 1: IDENTIFICATION 
Name of interviewee. ____  __________ RNAME 
COMPOUND NAMElID. CMPNAID 
DATE OF INTERVlEW I DAINT 
FIELD WORKER CODE FWCODE 
FIELD SUPERVISOR CODE FSCODE 
RESUL T OF INTERVIEW: RESULT 
DISTRICT 
SUB-DISTRICT 
SUB-DISTRICT CLASSIFICAn ON 
URBAN ........ ........ ..... ........ . ....................... 1 
RURAL. ............. ............ ............ . ....... . ...................... 2 
COMPLETE, INTERVIEW I 
INCOMPLETE, REFUSED 2 
INCOMPLETE. ro BE COMPLETED LATER 3 
OTHER- -- '------.-- - -
(SPECIFY) 
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SECTION 2: BACKGROUND CHARACTERISTICS OF RESPONDENTS 
ECTION 2: BACKGROUND CHARACTERISTICS OF RESPONDf.'\iTS 
No Questions aDd filters Coding Categories Skip 
How old are you 
row? 
(Completed years) 
'Number of 
children 
What is the No Formal education.... . ....................................... 1 
highest level of Primary .................................................................................. 2 
school you Middle/JSS. ............................................................................ .3 
attended? Secondary/SSS.. ...... ............................. . ... 4 
TertiarylHigher......... .. ......... 5 
Vocational........... 6 
Other (speci fY)...... .. ........ 7 
What is your Traditional... ............ .. . ........ 1 
religion? Christianit) ................ . .. ......... 2 
Islam ........................... . .. .... 3 
Other (specifyj ..... .. . .................... .4 
What is your Akan ..................... .. .. ............. 1 
Tribe? Ewe.. .. ............... . . .. 2 
Oa...... . ...................................... . .3 
Dagbani ..................................... . 
Other (;pccifv) ............................... .. . ....... 5 
What" your Never married ................................. . .. .. 1 
manl.J1 "L1IlJS Married. ........................................ . .. .... 2 
now? Living together. ........ . . .. 3 
Divorced. ........... . . .... ~ 
Widowed ... .. . .. 5 
Separated .... .. .. ............................ 6 
Other 
~!:~:.~.......... ........... ....... ............... .. .... 7 
What is your main Trader. . ... ....... .................... .. ............ 1 
occupation? 
Housewife .......................................... :::: .............................. 2 
~=:'~',~~~7""""";"":+"5: 
\\ho makes Father......... . .............................................. 1 
decision on type Motlter...... ........................ . ....... 2 
of health care Husband. ..... .................... .. .. 3 
members of this 
Wfi .... A 
househo Id seek 
o~;i~~~~::·.::::::::·.:::::::::::·.::·.:..... .. ..... 5 
Do \OU have any 
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ofllle following Television 
assets in your Electricity at home 
household 
Radio 
Refrigerator 
VCDIDVD player 
I 
i Bicycle 
Motorbike 
Motor king 
Mobile phone 
DS TV/Multi-TV 
Car 
Live in Own house 
House Roofed with Zinc 
Ess~Dtial newborn care (Warmtb) 
10 The following are Yes No 
newborn care Babies should be wrapped 
practices to ensure immediately after birth to 
warmth of baby maintain warm 
after birth Babies should be put to their 
cord or bed immediately after 
birth 
Babies should put on mother's 
! 
body immediately after birth 
Babies should be bathed 
immediately after birth 
Essential D~wborn Clre (Umbilical stumo care) 
II The following are Yes No 
newborn care Umbilical stump should be left 
practices to care uncovered without any dressing 
for the stump of If the umbilical stump is soiled 
the umbilical cord with baby· s urine or faeces. it be 
washed with water 
Cord stump should be dried 
thoroughly after bathinll: 
Umbilical stump should be 
cleaned with spirit 
Umbilical stump is wound and 
should be dressed daily and 
medicine applied 
Essential newborn careJ.Breastfeedinll:J 
12 Yes No 
[he following Babic, $hould be put to breast 
relate tu best within I hour after birth 
brcastfeed ing Baby should be breastfed on 
practices? demand rather than according 10 
a timetable 
Only breast milk and nothing 
else should be given during the 
first 6 months 
Baby should be breast led during 
I the nights too 
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Baby is protected trom 
infection, 
by giving 'colostrum' (thick 
yellowish furemilk) to baby 
Foods in addition to the breast 
milk should be introduced from 
6 
monthofal!.e 
Passing urine less than 6 times a 
day is III indication that baby 
receives insufficient milk 
Giving herbal preparations 
during the period of exclusive 
breastfceding is not beneficial to 
a healthy baby 
Experience of sore nipple should 
be treated by applying a little 
breast milk on the nipple and 
expose it to air to heal the 
wound 
Essential newborn care (Immunizationt 
13 Yes No 
Babies should be given 
immunizations at birth 
Immunizations protect the baby 
and child against preventable 
diseases 
Immunizations continue until the 
child is five years 
Practicrs durin!! pre!!nancy 
14 Which of the No 
following do you Food restrictions 
practicc~ Sex restriction 
Avoid crossing of rivers 
Avoid been seen b~_some pL'Opk 
Being bewitched 
Attended ANC 
I Number weeks before: tirst ANC L 
Practices durin!! child birth 
15 Where did you TBA.. . ........... 1 
give birth to this Home....... . .........2  
child? Hospital ............................................................ .3 
Private Midwife ...................................................... 4 
16 Why did you Is cheaper ......... , ................................................... 1 
deliver at this Is closer....... " ................................... 2 
place? More convenient......... . .................................. 3 
Better care provided..... . ... 4 
Better attitude from care providers ........................... ... S 
Trusted more. . ............................ 6 
Had a complication ................................................ 7 
I 7 Who took the SCIf................. . .......................................... 1 
decision to use Husband.. .. ................................................ 2 
this facility Self7Husband..... . .............................. 3 
Grandmother ................... " .................................... 4 
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Grandfather .... ............. .5 
Mother·in·law .. . ...............6  
FadJer·in·law .. .. ........ 7 
18 Which of the No 
Following 
practices will you 
(have done) do 
during labour? 
Practices immediately after birth 
19 Which of the Yes No No 
Following 
immediate care 
after birth did you 
practice 
BathiJl& ba~ 
Putting baby to breast 
Wrapping aby to provide 
warmth 
Putting baby on mother body to 
provide warmth 
Applying warm compresses to 
baby body 
Batb Practic:es 
20 Which of the Yes No No dea 
following bathing Massaging the baby with oil before 
practices do you bath 
practiccs~ Tick all that Giving bath to baby with milk 
apply. Two members are not supposed to 
give bath to the baby. 
AddiJl&alcohol to bathing waler 
Use of Denol 
Feedi~Practices 
21 Which is these Yes No No 
feeding practices 
do you do? (Tick 
all thai apply) I 
L-_'--_______ ~ __ ._. .. 
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Giving prelacteal feeds soon after birth like 
su ar water or hon 
Discarding the colostrum (first milk 
roduced 
Giving hot water to evacuate the stool 
Giving home remedies for digestion like 
garlic or ~inJ!:er or herbal leaves 
GivinJ!: of B1coholto baby 
Feeding baby with water used to bath the 
baby I I 
Others (Specify) 
Practices regarding u~hilical cord care 
22 Which of these ~~~ __~  ________~  ________~ ~Y~c'~ __~ ~~~.\~I ____ ·1 
cultural practices Applying ashes or soot or powder or II I 
regarding dry cow dung on the umbilical cord of 
umbilical are the baby __ _ 
applicable to you~ Burying the cord when it dries and 
falls 
Making the father to place his fore 
cord to invert it if the umbilical cord 
is not inverted. 
Applying heat to the umbilical cord to 
make it dry 
Umbilical cord blood is placed in 
the back 
Mana2ement and protection al!ainst 'auDdice 
23 What do you do Yes No 
child against I::.xposing the baby to sun light when 
jaundicc·~ ~th~e~ba~b~y··s.:::ski:!!·n!!.!:tum=s..r..y::,:e.I! ::.::lo:.::w~--:--,-___- 1I-___- -4-___- -I-l 
Giving sugar water to the baby during 
iaundice 
Dressing the baby with yellow clothes 
during iaundice 
Essential Newborn care 
24 Baby kept skin to skin contact to mother Yes.. . ................................... 1 
immediately after delivery No ........................................ 2 
25 Baby kept warmth by wrapping Yes. ....................... ..1 
No........ ....................... ..2 
26 Baby bot nursed in separate room from mother yes ........................................ 1 
after deliverv No ........................................... 2 
27 The umbilical cord stump of baby covered with yes................................. ..1 
a cloth or bandage No ........................................... 2 
28 Umbilical cord stump not soiled yes ....................................... I 
No ........................................... 2 
29 Breastfeeding immediately after birth yes................................... .1 
No ........................................... 2 
30 Feeding baby with colostrum yes ........................................ 1 
No ........................................... 2 
31 Received BeG vaccine at birth yes····· .. ······· .. · ......................... 1 
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No ............... ········· .2 
yes........................ . ....... 1 
32 Ban: asses,cd aftcr delivery 
No......................... . ........... .2 
33 Baby not bathed immediately after birth 
yes ...................................... 1 
No......................... . ............2  
Heath system factors 
34 Ever visited by health worker yes .......................................................... .1 
during prCll1Ianey No ..........••.....................•...........................2  
35 Received education on ANC yes .........••••........................•.................•.•. I 
No ............................................................. 2 
36 Advised by health worker to yes .......................................................... .1 
have skilled delivery No.. . ............•....•.•..•.•....... 2 
37 Received education on skilled Yes ............................•............. 1 
delivery No...... ................................................2  
38 Reason for Home.·1 BA Better Services received at TBA ........................ .1 
1-'3~9'--}-________- +-::P~00~r~a~tt!!:itu~d~e..!:!0~fh7e:.:;a1!!'th7:w::-.:::.:orc!!k::e:r::cs.",.'" ,".:..:' ,:,,:,:,,:~ '-'-'-'-:..:.. .: •..:•;= -2 ___. .,_~_ 
40 Distance tll health facility.. ,_.3 __ 
Post Delivery Follow-up 
41 Visited bv health worker after yes ............ . .... 1 
f.---.,,--+---:--_.:"d-"!el!.:iv==-ery~ ___- +-:-N:.::o"'.'. :..:' .:.;'c ..:·' .:..:.:..:.:.;.:.:c..:c._ __ _ ~ ~ _. __ , ..... 2 
42 Educated on PNC Yes .............. . .. 1 
No ............ . 
43 Linked to Community Health yes ............ . '" ... 1 
Officer after No .. .2 
discharge 
Educated on Immunization 
Educated on Family Planning 
Postnatal care 
44 Received within 48 hour Yes .. .. 1 
No ... 
45 Received two weeks PNC Yes ...... 1 
No ............... . ......... 2 
46 Recehed six weeks PNC yes ...... . •....• 1 
No .. . . ........ 2 
Health Seekin~ Behaviour and Determinant of Health Seekin~ Behaviour 
·n Where do seek for health Self-treatment.. ............ 1 
when you are sick? Traditional healer ............................. " ............. 2 
Public c1inic/HospitaIiHealth center. ........................ 3 
Private practitioner... .......................... . ......... .4 
PharmacistIV endor. . . . . .. ................. . ......... 5 
Other (specify)............ cccc.c..:cc..:..:...".". c ::-6 __f -_--1 
48 Reason for choice Is cheaper.... .......... . ... ' ... 1 
of answer Is closer.. . ..2  
More convenient.. ...... .. ..... 3 
Better care provided..... . ..........4  
Better attitude from care providers.. . ...... 5 
Trusted more................. . .................6  
49 Where did you Government Hospital....... . ................. 1 
seek for health on Government Health Centre. .2 
your most recent Private Health Facility.. . .. 3 
illnc,s') Bought medicine from drugstore/pharmacy.. . ........ .4 
Traditional healer.... . ......... .5 
Spiritual healer. ...... . .......................6  
Others (Specify).... . ................................ . 
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Government Hospital .............. 1 
50 What are the most Go~emment Health Centre...... .. ..........2  
common places 
people seek for Private Health Facility...... . .. .. . .. ..... .3 
health can: in this Bought medicine from drugstore/pharmacy ................4  
community Traditional healer. .. .. . .. , . .. .. ........... 5 
:r~:~~~~')'''''''.'''.'.'.'.'.'.'''.'.'' . ... ........ 6 
51 What do you Is cheaper.............. . ........... 0 
thinks are the ~~:S:~·~~~i·~~·t·............. . .. ···CJ 
reasons for people 
preference? More Privacy provided... ... ............... .. ........... r:=:J 
Better care provided....... ......... .................. . .... r---1 
Better attitude from care providers............... L--J 
T~''''-····::B 
52 Are you registered Yes ... .. ........ 1 
with national No. .. .. 2 
health insurance 
scheme 
53 Do you have a Seen Valid .................. .. .. ................... 1 
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50 What are the most Government Hospital.. ......... .. ........... 1 
common places Government Health Centre........... .. .......... 2 
people seek for Private Health Fadlity ........................................3  
health care in this Bought medicine from drugstore/pharmacy ...............4  
community Traditional heakr .. ......... ................ . .. .5 
Spiritual healer. ...........................................6  
~:--+-:-:c::--:-______- +~O:!!th~ers~cit\ I ...........................................  
51 :Uhankstd oareYotheu Is cheaper.. . ........................... .. ............. CJ 
Is closer................ .......................... ·· .. ·· ...... 0 
reasons for people More convenient..... .. .. .. ... .. ... .... ..... ......................... ,---, 
preference: More Privacy provided.... .............. ... L--J 
Better care provided .......................... ·. . .... c:J 
Better attitude from care providers............ .. .....c :=J 
Trusted more.......... .................. . ... '''8 
52 Are you registered Yes .. . 
with national No .. .. 
health insurance 
sdu,me 
53 Do \ouhave a Seen Valid .. 
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vaJ,J national Seen Invalid .................... -...................................... 2 
health insurance Yes but not available .................................................3  
card 
54 Child experienced yes ....... .. ....................................... 1 
No ... . .........................................2  sickness during 
neonatal period 
Reported Symptoms 
55 Difficulty/fast breathing Ye, ...................................... .1 
No.... .. .........................................................2  
56 Fever Yes. .. ....................................................... 1 
No... . ...........................................................2  
57 Baby feel cold Yes. . . ........................................................ 1 
No.... .. ......................................................2  
58 Poor suckling/feeding yes....... ..................................... ..1 
f-_+-________- +~N_::o:..:.;.: . ..:..;:  ..:.;:  ..:..;: ..:.;: ..:.;c .:.:.:.::.:.;:.:.;-'-'-'-'-'-. ................................ . .. 2 
5'1 Chest in-drawing yes........ ................................. .. . 1 
No...... .. .....................................2  
60 Lethargy/unconsc iousne yes........... ............................ .. .... .I 
ss No......... .. .... 2 
61 Spasms/convulsions yes ....... .. . ...................... 1 
No ............. . .. ........ 2 
62 Sought Health Care yes .................................................. . .. .. 1 
No ................................................. . . .......... 2 
Reasons for Dot seekin2 health 
63 Felt condition was not Yes .. .. ................................................ 1 
serious No ..... . .......................................................... 2 
64 Received some medicine yes ..... .. . .... 1 
at home No ........ .. .. ............................................... 2 
65 Transport problem Yes .. ............................................. 1 
No ........ .. .......2  
66 Far distance of health yes ........ .. ............. 1 
facility from No ...... .. .. ....... 2 
home 
67 Financial challenges Yes .. . ..................... 1 
No ..... .. ... 2 
Place of health care was Sou2ht 
68 Hospital/Clinic Yes .. . ................... 1 
No .. . ......... 2 
69 Traditional healerlTBA Yes .. . ........ 1 
No ....... 2 
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Appendix C: FGD Guide for Community Members 
Demographic Data 
Demographic Data: Age. Sex, Marital status (for how long), Number of Wives (males 
only), Number of children, Educational level, number of child (ren) 
Preparatory Question 
1. Can you share some of the health problems in this community? 
Practices during pregnancy 
2. What do you take care of pregnant women in this community? (probe on 
believes about different types ofp regnancies) 
3. What are the practices in this community during pregnancy? 
a. Probe on food practices. restrictions and reasons for these practices 
b. Probe on sexual practices and reasons for those practices 
c. Probe on use of herbal preparation (types of herbs and reason their use) 
d. Probe on health seeking behaviour and decision making process 
4. What are community beliefs and practices regarding immunizations and 
medication given to pregnant women 
a. Probe on SP 
b. Probe on use of ITNs 
c. Probe on Tetanus 
d. Probe of fesolate and folic acid 
Practices during labour (childbirth) 
5. Where do people prefer to give birth in this community? 
a. Probe on TBA and biomedical 
b. Probe on reasons for choices 
6. What are the various types of practices during labour? 
a. Probe on various types of labour 
b. Probe on induction of labour 
c. Probe on use of herbs 
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d. Probe on cutting on cord (items used, cleanliness and materials used in 
tying the cord) 
e. Probe on removal of placenta 
Practices immediately after birth 
7. What are some of the practices immediately after birth? 
a. Probe on care of the mother 
b. Probe on food practices and reasons for those practices 
c. Probe on care of the cord 
d. Probe on provision of warmth 
e. Probe on initiation ofbreastfeed 
f. Probe on practices regarding colostrum 
g. Probe on bathing of baby 
8 What are some of the community practices within the first 40 days after birth? 
a. Probe on food practices, restrictions and reasons for these practices 
b. Probe on sexual practices and reasons for those practices 
c. Probe on use of herbal preparation (types of herbs and reason their use) 
d. Probe on health seeking behaviour and decision making process 
e. Probe on continements 
9. Can you share with me how you care for the baby within the first 40 days after 
birth? 
a. Probe on feeding practices 
b. Probe on care of the body 
c. Probe on cultural beliefs during that period and what is done 
d. Probe on immunization 
e. Probe on massage of the body 
f. Probe on provision of warmth 
g. Probe on health seeking behaviour 
I U I have finished with my questions. Is there anything else you would want us to 
discuss? 
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Appendix 0: IDI Guide for Opinion Leaders and Health Managers 
Demographic Data 
Demographic Data: Age, Sex, Marital status (for how long), Number of Wives (males 
only), Number of children. Educational level, number of child (ren) 
Preparatory Question 
I. Can you share some of the health problems in this community? 
Practices during pregnancy 
2. What do you take care of pregnant women in this community? (probe on 
believes about different types ofp regnancies) 
3. What are the practices in this community during pregnancy? 
a. Probe on food practices, restrictions and reasons for these practices 
b. Probe on sexual practices and reasons for those practices 
c. Probe on use of herbal preparation (types of herbs and reason their use) 
d. Probe on health seeking behaviour and decision making process 
Practices during labour (childbirth) 
4. Where do people prefer to give birth in this community? 
a. Probe on TBA and biomedical 
b. Probe on reasons for choices 
5. What are the various types of practices during labour? 
a. Probe on various types of labour 
b. Probe on induction of labour 
c. Probe on use of herbs 
d. Probe on cutting on cord (items used, cleanliness and materials used in 
tying the cord) 
e. Probe on removal of placenta 
Practices immediately after birth 
6 What are some of the practices immediately after birth? 
a. Probe on care of the mother 
b. Probe on food practices and reasons for those practices 
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c. Probe on care of the cord 
d. Probe on provision ofwannth 
e. Probe on initiation of breastfeed 
f. Probe on practices regarding colostrum 
g. Probe on bathing of baby 
7 What are some ofthe community practices within the first 40 days after birth? 
a. Probe on food practices, restrictions and reasons for these practices 
b. Probe on sexual practices and reasons for those practices 
c. Probe on use of herbal preparation (types of herbs and reason their use) 
d. Probe on health seeking behaviour and decision making process 
e. Probe on confmements 
8. Can you share with me how you care for the baby within the first 40 days after 
birth? 
a. Probe on feeding practices 
b. Probe on care of the body 
c. Probe on cultural beliefs during that period and what is done 
d. Probe on immunization 
e. Probe on provision of warmth 
f. Probe on health seeking behaviour 
9. I have finished with my questions. Is there anything else you would have love 
us to discuss? 
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Appendix E: Ethical Approval Letter 
Joann Ansong 
Uni""",lY of Ghana 
School of Public Health 
Lege. .. Accra 
The Ghana Hallh Service Elhics Review Committee has n:viowed and Biven 8JIPI'OV&l for dI. implementation of 
\'OW" SWdy Protocol. 
GHS-ERC Number GJlS.ERC: 006f11117 
Project TIde 
-..:p;;,""IDa~ 29" N..-ber 2017 
_~'Y.D ... 2 November 2018 
GHS-ERCDec:isioll ADDroved 
This appnwal Rqllll"11 (be 'ollowio& from Ute Priadpallavtstigator 
• Submission of yearly progn:ss report Drib< IIud)o to the Elhics Review CommIttee (ERC) 
• Renewal of ethical approvil if lite 51., Y lIStS for ""'"' than 12 months. 
• RepOrtina ofe ll ••n ow .-.. events related to dlis study to tho ERe within three days .." 'ally and ,"ven 
doysiawritinl· 
• Submission of aftnllrepon ane,,·.mpldIoDoflltestudy 
• Informing ERe if study cannot be II .plernented or iJ discontinued and reasons why 
• Infunnmg the ERC and your""",' .r (where applicable) hefo", any publication orm. ",search findinp. 
Please note !:hili an)' modl€ic~llon of the !'f"Jdy without ERe approval of the amendment is invalid. 
The ERC may observe or cause to beob.';rved procedunca and...cords ofdle srudy dunng and after implementation 
Kindly qoote the protocol identificati.m number in all future ~spondcnce in relation to this approved protOCOl 
Co; The o.I<:CIO<. Resean:h I. De\ '\opmentDivi.ion, Ghana Health Service. Accnt 
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