SCHOOL OF PUBLIC HEALTH 
COLLEGE OF HEALTH SCIENCES 
UNIVERSITY OF GHANA 
         
BIRTH PREPAREDNESS AND COMPLICATION READINESS AMONG EXPECTANT                                      
MOTHERS AT THE RIDGE REGIONAL HOSPITAL, ACCRA 
 
BY 
DZIFA ADZOA AGBODOHU 
(10233040) 
 
A DISSERTATION SUBMITED TO THE SCHOOL OF PUBLIC HEALTH 
UNIVERSITY OF GHANA, 
IN PARTIAL FULFILMENT FOR THE AWARD OF 
MASTER OF PUBLIC HEALTH DEGREE 
 
JULY 2013 
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DECLARATION 
I, Dzifa Adzoa Agbodohu, declare that this work is as a result of my own original 
research and effort. 
It has not been presented either in whole or part in any university for the award of another 
degree. I admit that other people’s work have been reviewed and have been properly 
acknowledged. 
 
 
 
 
SIGNED………………………………………..DATE………………… 
          Dzifa Adzoa Agbodohu (MPH Resident) 
 
 
 
 
 
SIGNED………………………………………..DATE………………..... 
               Dr. Amos K. Laar (Academic supervisor) 
 
 
 
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DEDICATION 
. 
 
                          To William, Aseye, Mawuyram, William (Jnr.) and Dada. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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ACKNOWLEDGEMENT 
                             
I thank the Almighty God so much for His love and mercies towards me. If it has not 
been the LORD how would I have made it through such a compact course as this? He 
kept me healthy to withstand every stress and obstacle that came my way. 
I wish to acknowledge Dr. Amos K. Laar for his guidance, direction, advice and for the 
time he devoted towards my work. 
I also wish to thank Dr. A. Ankomah who is the Head of Population, Family and 
Reproductive Health Department of the School of Public Health for the help he gave me 
during the research work. 
My thanks go to the authors of the various materials that I used in this study, the 
management of the Ridge Regional Hospital and to Mrs. Regina Kpegah the head of the 
Antenatal Clinic for the support she gave me during my data collection. 
I deeply appreciate my family so much for having to cope with an absentee Mum and 
wife during the period I was at school. 
To Vivian and her husband Kennedy, I am highly indebted to you. May God richly bless 
you. 
Lastly, I’m very grateful to Mr. Edem K.M. Klobodu for all the help he gave me. 
 
 
 
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ABSTRACT 
 Background: Avoidable maternal mortality remains a huge burden more especially in 
sub-Saharan Africa. Expectant mothers are faced with life-threatening complications 
which a birth preparedness and complication readiness plan helps to actively avoid. 
Awareness of danger signs of pregnancy helps an expectant mother to make timely 
decisions to avoid delays that brings about complications that could result in morbidity or 
mortality. 
Objective: The main objective of the study was to assess the knowledge and practices of 
birth preparedness and complication readiness among expectant mothers and specifically 
to determine the association between socio-demographic factors and birth preparedness 
and complication readiness. 
Method: A cross sectional design was employed with a sample size of 400 expectant 
mothers in their 3rd  trimester at the Ridge Regional  Hospital. A simple random sampling 
of pregnant women visiting the RRH was done using the lottery method to select the 
participants. Analysis was done using SPSS version 16.  
Results: Though many of the mothers (77.3%) were aware of the fact that they may need 
blood during labour only 16.4% of mothers actually had blood in the blood bank and 
31.6% said they had arranged for a blood donor.  There was a significant relationship 
between level of preparedness (p-value = 0.008) and educational level, also with ANC 
attendance (p = 0.032). It was observed that almost two-thirds of the respondents knew 
some danger signs and gave one or two examples. Two-thirds did not know anything 
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about Eclampsia or pregnancy induced hypertension. Almost all respondents (96%) had 
identified a close family member as a companion when in labour. 
Conclusion: The respondents’demontrated little knowledge on danger signs in pregnancy  
and many respondents did not know about birth preparedness especially in the area of 
blood donation. It is suggested that strategies be put in place for effective implementation 
of the policy on blood donation so that by the seventh month of pregnancy every 
expectant mother, irrespective of her haemoglobin level must have her blood ready in the 
blood bank to ensure complication readiness. 
It is recommended that the standard for focused antenatal care is fully implemented as 
this will improve upon one on one provision of information and health education on 
danger signs in pregnancy. In doing so, there will be a general increase on the level of 
birth preparedness and complication readiness. 
 
  
 
 
 
 
 
 
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TABLE OF CONTENTS 
Table of Contents 
DECLARATION ............................................................................................................................. i 
DEDICATION ................................................................................................................................ ii 
ACKNOWLEDGEMENT ............................................................................................................. iii 
ABSTRACT ................................................................................................................................... iv 
TABLE OF CONTENTS ............................................................................................................... vi 
LIST OF TABLES ......................................................................................................................... ix 
LIST OF FIGURES ......................................................................................................................... x 
LIST OF ACRONYMS AND ABBREVIATIONS. ...................................................................... xi 
OPERATIONAL DEFINITION OF TERMS ............................................................................... xii 
CHAPTER ONE ............................................................................................................................. 1 
1.1 INTRODUCTION ................................................................................................................. 1 
1.2 BACKGROUND TO THE STUDY ..................................................................................... 3 
1.3 STATEMENT OF THE PROBLEM ..................................................................................... 4 
1.5 JUSTIFICATION TO THE STUDY ..................................................................................... 9 
1.6 STUDY OBJECTIVES ....................................................................................................... 10 
1.6.1 General Objectives ........................................................................................................ 10 
1.6.2 Specific objectives ........................................................................................................ 10 
CHAPTER TWO........................................................................................................................... 11 
2.0 LITERATURE REVIEW .................................................................................................... 11 
2.1Introduction .......................................................................................................................... 11 
2.3The role of Emergency Obstetric Care in Birth preparedness .............................................. 15 
2.4 The Role of Knowledge on Pregnancy and Childbirth in Birth Preparedness ............... 19 
2.5 Health Seeking Behaviour of Expectant Mothers in Birth Preparedness and 
Complications Readiness ........................................................................................................... 20 
2.6 The Influence of Traditional Beliefs on Birth Preparedness .......................................... 23 
2.7 The Influence of Socio-demographic Factors on Birth Preparedness ............................ 25 
2.8 Conceptual Framework................................................................................................... 28 
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2.8.1 Attitudes-Social influence model ............................................................................ 28 
2.8.2 The Three Delays Model ......................................................................................... 29 
CHAPTER THREE ....................................................................................................................... 30 
3.0 METHODS .......................................................................................................................... 30 
3.1 TYPE OF STUDY ............................................................................................................... 30 
3.2 STUDY AREA AND LOCATION ..................................................................................... 30 
The overall Bed complement of the facility is 191. .................................................................. 31 
3.3 THE STUDY VARIABLES ................................................................................................ 31 
3.4 STUDY POPULATION ...................................................................................................... 31 
3.5  SAMPLE SIZE DETERMINATION ................................................................................. 32 
3. 6 SAMPLING METHOD ...................................................................................................... 33 
3.7 DATA COLLECTION TECHNIQUES/ METHODS AND TOOLS ................................. 33 
3.8 DATA PROCESSING AND ANALYSIS .......................................................................... 34 
3.9 Determination of level of preparedness ............................................................................... 34 
3.10 QUALITY CONTROL...................................................................................................... 34 
3.11 ETHICAL ISSUES ............................................................................................................ 35 
3.11.1 Description of Research Burden ................................................................................. 36 
3.11.2 Description of Measures to reduce risk ...................................................................... 36 
3.11.3 Benefits to participants ............................................................................................... 37 
3.11.4 Compensation ............................................................................................................. 37 
3.11.5 Rights of participants and Right to Opt out of the Research ...................................... 37 
3.12 TRAINING OF RESEARCH ASSISTANTS ............................................................... 37 
3.13 PRETESTING ................................................................................................................... 38 
3.14 ACTUAL DATA COLLECTION ..................................................................................... 38 
CHAPTER   FOUR ....................................................................................................................... 40 
4.0 RESULTS ............................................................................................................................ 40 
4.1 Introduction ......................................................................................................................... 40 
4.2 Characteristics of respondents ............................................................................................. 40 
4.3   Reproductive History and History of Antenatal Care ....................................................... 42 
4.4 Knowledge of Danger Signs during Pregnancy .................................................................. 43 
4.5. Knowledge of Danger Signs (Spontaneous /Non Spontaneous Response) ........................ 45 
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4.6 Information on Birth Preparedness ...................................................................................... 46 
4.7.Association of Socio-demographic characteristics and Birth preparedness and 
Complication Readiness ............................................................................................................ 49 
4.8 Availability of Social Support Systems ............................................................................... 51 
CHAPTER FIVE ........................................................................................................................... 53 
5.0 DISCUSSION ...................................................................................................................... 53 
5.1Background Information and characteristics of the study population .................................. 53 
5.2.0 Knowledge on birth preparedness and complication readiness ........................................ 54 
5.2.1 Level of preparedness ................................................................................................... 54 
5.2.2 Antenatal care ............................................................................................................... 56 
5.2.3 Association between Socio-demographic characteristics and Birth preparedness 
and Complication Readiness .................................................................................................. 57 
5.2.4The availability of social support systems for expectant mothers ................................. 60 
CHAPTER SIX ............................................................................................................................. 62 
6.0 CONCLUSIONS AND RECOMMENDATIONS .............................................................. 62 
6.1Conclusions .......................................................................................................................... 62 
6.2 RECOMMENDATIONS .................................................................................................... 63 
6.2.1 Recommendations for Stakeholders (GHS and RRH) .................................................. 63 
6.2.2 Recommendations for future research .......................................................................... 64 
APPENDICES ............................................................................................................................... 72 
STRUCTURED QUESTIONNAIRE ........................................................................................ 72 
CONSENT FORM .................................................................................................................... 78 
VOLUNTEER AGREEMENT FORM ..................................................................................... 81 
 
 
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LIST OF TABLES 
Table4.1: Demographic Characteristics……………………………………………41 
Table 4.2 Reproductive History and History Antenatalcare………………..…......43 
Table 4.3 Knowledge of Expectant Mothers On Birth Preparedness And Complication    
     Readiness……………………………………………………………….45 
Table 4.4 Knowledge of Danger Sign (Spontaneous/ Nonspontaneous Response) 
…………………………………………………………………………………….46 
Table 4.5 Awareness and Resource Mobilization Towards  
    Preparedness……………………………………………………………48 
Table 4.6 Association between Birth Preparedness And Socio- Demographic    
  Characteristics of Mothers……………………………………………….50  … 
Table 4 7 Availability of Social Support Systems ……………………………….55 
 
  
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LIST OF FIGURES 
Figure 1.1 Conceptual Framework………………………………………………8 
  
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LIST OF ACRONYMS AND ABBREVIATIONS. 
ANC ……………………Antenatal Care 
ASE………………….….Attitudes-Social Efficacy 
BP ………………………Birth Preparedness 
BP/CR………………….Birth Preparedness and Complication Readiness 
BPP  ……………………Birth Preparedness Plan/Package 
CR…………………….. .Complication Readiness 
EmOC…………………..Emergency Obstetric Care 
HBLSS………………….Home Based Life Saving Skills 
JHPIEGO………………John Hopkins Program for International Education in           
                                        Gynaecology Obstetrics 
MMR ……………….…Maternal Mortality Ratio 
PNC…………………….Post Natal Care 
RRH…………………….Ridge Regional Hospital 
SBA…………………….Skilled Birth Attendance 
SES……………………. Socio Economic Status 
TBA…………………….Traditional Birth Attendance 
WHO……………………World Health Organization 
  
 
 
 
 
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OPERATIONAL DEFINITION OF TERMS 
 
Birth Preparedness and Complication Readiness (BPCR) is the process of planning 
for normal birth and anticipating the actions needed in case of an emergency. Women 
who have made funds available for transportation to hospital, have identified the mode of 
transportation when labour begins, have already arranged for a blood donor and women 
who already have blood in the blood bank are said to be ‘well prepared’. Any three of the 
above is considered as “well prepared”, less than three is considered as being “less 
prepared”. 
 
Birth Preparedness and Complication Readiness Matrix delineates the roles of 
policymakers, facility managers, providers, communities, families, and women in 
ensuring that women and newborns receive appropriate, effective, and timely care. It 
outlines plans and actions that can be implemented by each group of stakeholders to build 
an enabling environment for normal and emergency care. 
 
 Delays in deciding to seek care results from failure to recognize signs of complications, 
failure to perceive the severity of illness, cost considerations, previous negative 
experiences with the healthcare system, and transportation difficulties. 
 
Delays in reaching care comes about when distance from a woman’s home to a facility 
or provider, the condition of roads, and a lack of emergency transportation prevents her 
from receiving care early. 
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A delay in receiving care occurs at the facility level.  Unprofessional attitudes of 
providers, shortages of supplies and basic equipment, a lack of healthcare personnel, and 
poor skills of healthcare providers have been identified. 
                                                             
Gravidarity:pregnancy. 
Grand multipara: a woman who has given birth more than five times. 
Multigravida:A woman who has had two or more pregnancies. 
Multipara: a woman who has had two or more children. 
Nullipara: a woman who has never given birth. 
Parity: classification of a woman with regard to the number of children born. 
Primigravida: a woman who is pregnant for the first time. 
Primipara: a woman who has given birth for the first time. 
Secundigravida: a woman who is pregnant for the second time. 
 
 
 
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CHAPTER ONE 
1.1 INTRODUCTION 
 
High levels of perinatal, neonatal and maternal mortality remain major public-health 
challenges in Ghana and the world over. About one third of neonatal deaths occur on the 
first day of life and the majority of maternal deaths occur during labour, delivery, and 
within 24 hours postpartum (Ronsmans & Yinger 2006).  
 
Thaddeus & Maine (1994) proposed that apart from medical causes, there are numerous 
interrelated socio-cultural factors which delay care-seeking and contribute to these 
deaths. Care-seeking is delayed because of the delay in (a) identifying the complication, 
(b) deciding to seek care, (c) identifying and reaching a health facility, and (d) receiving 
adequate and appropriate treatment. 
 
According to Mutiso, Qureshi & Kinnuthia, (2008), close to 15% of pregnant women 
develop life-threatening complications hence the need for emergency obstetric care. 
These complications are unpredictable and may progress rapidly to a fatal outcome. 
Knowledge of danger signs of obstetric emergencies and appreciation of the need for 
rapid and appropriate response when emergencies occur may reduce delay in decision 
making and in reaching health facilities.  
It was observed by Thaddeus & Maine in (1994) that, the causes of these delays are 
common and predictable. However, in order to address them, women and their families as 
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well as the communities, providers, and facilities that surround them must be prepared in 
advance and be very ready for rapid emergency action. 
Based on the above concept, one of the key roles of antenatal care is to provide health 
education on danger signs of pregnancy and delivery, preparation of a birth plan and to 
encourage delivery under a skilled attendant. The World Health Organization (WHO)  
and Ghana Health Service (GHS) now recommends that every pregnant woman should 
receive focused antenatal care in which Birth preparedness and complication readiness 
(BPCR) is a key component (WHO, 2002). 
 
Maternal and Neonatal Health Program (2003) identified BPCR as a safe motherhood 
strategy whose objective is to promote the timely use of skilled maternal and neonatal 
care during childbirth or obstetric emergencies by reducing delays at the first, second and 
third levels. It entails making plans prior to birth to ensure that a pregnant woman is 
prepared for normal birth and complications. Decisions are made and  documented on 
such issues as a desired place for birth, the preferred skilled birth attendant, items 
required for birth, birth companion, getting a compatible blood donor and arranging in 
advance for transport. Other elements of birth preparedness include knowledge of 
expected date of delivery, signs of labour, mobilizing resources to pay for services.  
 
 
 
 
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  1.2 BACKGROUND TO THE STUDY 
Maternal mortality remains a public health challenge worldwide, and the global maternal 
mortality ratio of 342, 900/100,000 live births annually is still unacceptably high (Hogan 
et al., 2010). However a disproportionately high burden of these maternal deaths is borne 
by developing countries such as Ghana, with a maternal mortality ratio of 451 per 
100,000 live births (GSS, GHS, Macro Int. Inc. USA & Ghana Maternal Health Survey, 
2009). These deaths are caused by pregnancy, childbirth or postpartum complications. 
Hiluf & Fantahun (2008), observed that, lack of advance planning for use of a skilled 
birth attendant for normal births, and particularly inadequate preparation for rapid action 
in the event of obstetric complications, are documented factors contributing to delay in 
receiving skilled obstetric care. 
A key strategy that can reduce the number of women dying from such complications is 
making a birth plan that constitutes birth-preparedness and complication-readiness 
measures for pregnant women, their spouses and their families (McPherson, Khadka, 
Moore, Sharma, 2006).  
Birth-preparedness and complication-readiness is a comprehensive package aimed at 
promoting timely access to skilled maternal and neonatal services. The birth-
preparedness package promotes active preparation and decision-making for delivery by 
pregnant women and their families. This emerged from the fact that a pregnant woman 
faces risk of sudden and unpredictable life threatening complications that could end in 
death or injury to herself or to her infant (Kakaire, Kaye & Osinde, 2011). 
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This is because complications such as hemorrhage are unpredictable and highly fatal if 
timely treatment is not obtained. The package of BPCR  is a very important strategy in 
developing countries, where obstetric services are poor. There is also enough  evidences 
from Nepal, Burkina Faso and India  that promoting BPCR improves preventive 
behaviours,  improves knowledge of mothers about danger- signs, and leads to 
improvement in care-seeking during obstetric emergency therefore reducing disability 
and death associated with child birth (Fullerton, Killian & Gass, 2005, McPherson , 
Khadka, Moore & Sharma, 2006 and Moran, Sangli, Dineed, Rawlins & Yameogo, 
2006). 
 
 1.3 STATEMENT OF THE PROBLEM 
 
Worldwide, in 2005, 535,900 women died from causes related to pregnancy and 
childbirth; half of these deaths occurred in sub-Saharan Africa (Hill, Thomas, AbouZahr, 
Walker, Say & Inoue, 2005).The common causes of maternal deaths are hemorrhage, 
postpartum infection, hypertensive disorders, obstructed labor and abortion complications 
(Pembe, Urassa, Carlstedt, Nystrӧm, & Darj 2009). These life-threatening complications 
are treatable thus most of these deaths are avoidable if women with the complications 
have timely access to appropriate emergency obstetric care (WHO, 1994). 
The public health burden of maternal mortality is huge hence improving maternal health 
has received recognition at the global level as evidenced by its inclusion in the 
Millennium Development Goals. 
 
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The global safe motherhood initiative was launched in 1987 in Nairobi Kenya with a goal 
to reduce the maternal mortality by 50% by the year 2000. Many interventions were put 
in place of which the training of Skilled Birth Attendants (SBA) and risk screening at 
antenatal care were widely adopted. 
 
Unfortunately the uptake of SBA is low even in settings where services are available 
(WHO, 2006). Over the years maternal Deaths are thought to occur due to three delays: 
delay in deciding to seek appropriate care; delay in reaching an appropriate health 
facility; and delay in receiving adequate emergency care once at a facility. 
   
In many societies in the world, cultural beliefs and lack of awareness inhibit preparation 
in advance for delivery of the expected baby. Since no action is taken prior to the 
delivery, the family tries to act only when labour begins. The majority of pregnant 
women and their families do not know how to recognize the danger signs of 
complications. When complications occur, the unprepared family will waste a great deal 
of time in recognizing the problem, getting organized, getting money, finding transport 
and reaching the appropriate referral facility. 
 
These delays may be reduced if pregnant women are prepared for birth and 
complications. Birth preparedness and complication readiness is a safe motherhood 
strategy whose objective is to promote the timely use of skilled maternal and neonatal 
care during childbirth or obstetric emergencies by reducing delays at the first, second and 
third levels. 
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Even though the concept of birth preparedness and complication readiness is one of the 
simple, cost effective and most practicable means of reducing maternal mortality, it is not 
widely used by women  and their significant others as evidenced by maternal deaths still 
occurring due to the delays. 
 
Since a study of this nature has not been undertaken in the Region and the whole country 
at large, findings of the study will inform policy makers and stake holders to intensify 
intervention programs to make the concept of birth preparedness and complication 
readiness a very popular and a high cost effective intervention in reducing maternal 
mortality in the Region and the nation at large. 
 
At the end of this study more insight has been gained as to the extent to which expectant 
mothers attending Antenatal Clinic (ANC) at the Ridge Regional Hospital (RRH) are 
aware and for that matter practice BPCR as a means of preventing deaths and 
complications surrounding childbirth. 
 
 
1.4 EXPLANATION OF THE CONCEPTUAL FRAMEWORK 
The diagram below is the conceptual framework of the study. BPCR is a strategy 
designed to help reduce the delays that result in maternal deaths. Socio demographic 
factors such as level of education, parity, age and marital status have an association with 
the level of birth preparedness. It is also believed that these factors as well as support 
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factors which includes family support that is tangible, non tangible and significant others’ 
knowledge and experience on BPCR affects the first delay which is deciding to seek care. 
A woman’s level of knowledge as well as her ability to recognize danger signs early 
enough could also influence her preparedness towards birth. Socio-economic factors such 
as availability of funds to foster preparedness has a direct effect on the 2nd delay which is 
timely arrival at the health facility 
A good social / family support system is an important way in which pregnant women can 
receive tangible and Non tangible support. A contingency plan such as the ability to make 
decisions on place of delivery, arranging for blood donation and having prior transport 
arrangements do have a positive effect on birth preparedness and complication readiness 
as well as the second delay. 
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1.5 JUSTIFICATION TO THE STUDY 
Historical evidence shows that no country has managed to bring its maternal mortality 
ratio below 100 per 100 000 live births without ensuring that all women are attended by 
an appropriately skilled health professional during labour, birth and the period 
immediately  afterwards WHO, 2006. 
 The  WHO in 2006  said that many of the complications that result in maternal death and 
majority that contribute to perinatal deaths are unpredictable, and their onset can be both 
sudden and severe.  
Delay in responding to the onset of labour and complications have been shown to be one 
of the major barriers to reducing mortality and morbidity surrounding childbirth. Studies 
done at various settings to identify means of overcoming the barriers that mitigate 
maternal mortality brought forth a concept of Birth Preparedness and Complication 
Readiness.  Hence its adoption as one of the most important measures to adequately 
reduce the delays identified as being the major causes of maternal mortality Maternal and 
Neonatal Health Program, 2003. 
Despite the great potential of Birth Preparedness and Complication Readiness in reducing 
the maternal and newborn deaths, its status is not well known in most of sub-Saharan 
Africa. The study aimed at identifying the level of BPCR amongst expectant mothers and 
also to assess whether some factors such as education, parity, availability of social 
support systems had any impact or influence on BPCR.The findings of the study will 
positively influence Maternal health care delivery at the RRH thereby reducing maternal 
mortality that results from the three main delays. Therefore, this study assessed the 
knowledge and practices with respect to birth preparedness and complication readiness 
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and factors associated with their practices among expectant mothers attending ANC at the 
Ridge Regional Hospital (RRH). 
 
1.6. STUDY OBJECTIVES 
1.6.1 General Objectives 
To assess the knowledge and practices of birth preparedness and complication readiness 
among expectant mothers at the Ridge Regional Hospital  
1.6.2 Specific objectives 
To assess the knowledge of expectant mothers who are in their third trimester on birth 
preparedness and complication readiness. 
To determine the association between socio-demographic factors and birth preparedness 
and complication readiness. 
To identify the availability of social support systems for expectant mothers. 
 
 
 
 
 
 
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 CHAPTER TWO 
2.0 LITERATURE REVIEW 
2.1 The Concept of Birth Preparedness and Complication Readiness 
The birth of a baby is a major reason for celebration around the world. Societies expect 
women to bear children and honor women for their role as mothers. Yet in most of the 
world, pregnancy and childbirth is a perilous journey (Ransom & Yinger, 2002). World 
Health Organization (WHO) in 2004 estimated that 529,000 women die annually from 
maternal causes. Ninety-nine percent of these deaths occur in the less developed 
countries. The situation is most dire for women in sub-Saharan Africa, where one of 
every 16 women dies of pregnancy related causes during her lifetime, compared with 
only 1 in 2,800 women in developed regions. Without the necessary intervention the 
WHO projected the figure to one of every 5 women in Africa (WHO, 2004). 
According to Hiluf & Fantahun (2008), every pregnant woman faces the risk of sudden, 
unpredictable complications that could end in death or injury to herself or to her infant. 
Pregnancy related complications cannot be reliably predicted (JHIPEGO, 2001). Hence, 
it is necessary to employ strategies to overcome such problems as they arise. Lack of 
advance planning for use of a skilled birth attendant for normal births, and particularly 
inadequate preparation for rapid action in the event of obstetric complications, are well 
documented factors contributing to delay in receiving skilled obstetric care.  
Iliyasu, et al (2010) stated that birth-preparedness and complication readiness is a 
comprehensive strategy aimed at promoting the timely utilization of skilled maternal and 
neonatal health care. The key elements include: knowledge of danger signs; plan for 
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where to give birth; plan for a birth attendant; plan for transportation and plan for saving 
money. In addition, a potential blood donor and a decision maker need to be identified. 
This is because every pregnant woman faces the risk of sudden, unpredictable 
complications that could end in death or injury to herself or to her infant. Mutiso et al. 
(2008) mentioned that birth preparedness and complication readiness is a safe 
motherhood strategy whose objective is to promote the timely use of skilled maternal and 
neonatal care during childbirth or obstetric emergencies by reducing delays at the first, 
second and third levels. In a skilled care approach, birth preparedness includes 
identifying a skilled provider and making the necessary plans to receive skilled care for 
all births. Complication readiness (emergency funds, transport, blood donor and 
designated decision-maker) receive greater emphasis in emergency obstetric care 
programs. Birth preparedness has been globally endorsed as an essential component of 
safe motherhood programs to reduce delays for care (JHPIEGO, 2004). Stating Ekabua, 
Ekabua, Odusolu, Agan,   Iklaki & Etokidem , (2011), in a setting where there is 
prevailing illiteracy, lack of  infrastructure, poor  transport system, and the principle and 
practice of birth preparedness and complication readiness (BPCR) in a third world where  
access to skilled care providers are unpredictable have the potential of reducing the 
existing high maternal and neonatal morbidity and mortality rates.  
 
In many societies in the world, cultural beliefs and lack of awareness inhibit preparation 
in advance for delivery of the expected baby. Since no action is taken prior to the 
delivery, the family tries to act only when labour begins. The majority of pregnant 
women and their families do not know how to recognize the danger signs of 
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complications. When complications occur, the unprepared family will waste a great deal 
of time in recognizing the problem, getting organized, getting money, finding transport 
and reaching the appropriate referral facility (Moore, Copeland, Chege, Pido & Griffiths 
,2002).  For some of the complications such as severe hemorrhage, a few minutes matter 
to save life, while for others hours, or even days may be tolerable but with the prognosis 
getting worse as time elapses (White Ribbon Alliance for Safe Motherhood/ India 2002; 
Kitilla, 2001). 
 
In Ethiopia, only 6% of the deliveries are attended to by health professionals. This 
situation well explains the maternal mortality ratio of 673 per 100,000 live births, which 
is one of the highest in the world (Central Statistical Agency, 2010). Studies revealed that 
hemorrhage, hypertensive disorders and ruptured uterus were among the causes of 
maternal deaths. 
Despite the great potential of Birth Preparedness and Complication Readiness in reducing 
the maternal and newborn deaths its status is not well known in most of sub-Saharan 
Africa (Central Statistical Agency, 2010). Preparing for a safe delivery may include 
factors related to identifying and reaching care at the onset of labour, identifying and 
reaching care if a complication should arise, or planning to move closer to care before 
labour if emergency referral is not feasible. It is also important to consider that, with 
increasing urbanization, women living in peri-urban and urban settings may move when 
near term to their village of origin to deliver at their mother’s home. So preparation for 
labour is also relevant in urban and peri-urban antenatal clinics.  
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Many programs that aim to improve maternal health have included efforts to improve 
preparation for birth and readiness for complications (JHPIEGO, 2004). The IMPAC 
manual ‘Pregnancy, Childbirth, Postpartum and Newborn Care’: A guide for essential 
practice’ lists some key points to be addressed in ANC, which include identifying where 
the woman would go in an emergency and issues of transport and costs, as well as 
considering moving closer to care if ‘living far’ from a facility (WHO, UNFPA, 
UNICEF, World Bank, 2006). However, greater guidance is required in terms of 
identifying which women should be strongly encouraged to move closer to care prior to 
labour and identifying the most appropriate facility to attend in the event of an 
emergency, recognizing that it may not be the closest health centre.  
 
Experience suggests that discussions about preparing for birth should occur not only with 
pregnant women but with the communities that support them. The aim is education, 
motivation, cohesion and mobilization of pregnant women, families and communities. 
Community participatory approaches are most effective. A project that used such an 
approach in Kampong Chang in Cambodia was evaluated and found that community 
engagement was a feasible, effective and cost-effective way to introduce birth 
preparedness. The project increased referrals to hospital by 281% (Skinner & Rathavy, 
2009). 
 
Another well evaluated example of a birth preparedness intervention is the Home Based 
Life Savings Skills (HBLSS) training program devised by the American College of Nurse 
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Midwives to increase access to basic life saving measures within the home and 
community and by decreasing delays in reaching referral facilities where life-threatening 
problems can be managed (Sibley, Buffington, Beck & Armbruster, 2001). HBLSS takes 
into account the social context of childbirth, focusing on the pregnant woman, her family 
caregivers, and the home birth attendant as a team. The model has been implemented in 
India, Ethiopia, Haiti and Liberia. An evaluation of the model in rural Uttar Pradesh, 
India, found that role-play and demonstration enhanced retention of knowledge and skills 
for recognition and intervention for maternal bleeding and newborn sepsis, but did not 
change care-seeking during emergencies (Fullerton et al., 2005). An evaluation of the 
program in the Oromia region of Ethiopia found that learning was retained and after three 
years 54% of women giving birth were exposed to the training. Lack of emergency 
transport prevented decrease in delays for referral (Sibley, Buffington, Tedessa & 
McNatt, 2006). 
 
2.2 The role of Emergency Obstetric Care in Birth preparedness 
The Dinajpur Safe Mother Initiative in Bangladesh was designed to test the impact of 
several interventions on use of government obstetric services. CARE implemented a 
community mobilization program that included birth planning and support for funding 
and transportation, in addition to strengthening Emergency Obstetric Care (EmOC) 
services, during 1998-2001. In areas that received all interventions ‘met need’ increased 
by 24%, compared to 13% in communities where only basic EmOC services were 
upgraded, and no change in communities with no intervention. Successful systems had a 
high degree of community motivation and participating households. Some villages raised 
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enough money to purchase their own van or village ‘ambulance’ and others also 
established a system of listing blood groups of members so they could be mobilized to 
donate when needed (Hossain & Ross, 2006). 
 
In a remote region of Nepal, the Birth Preparedness Package (BPP) covered four areas of 
birth planning – Antenatal Care (ANC), care of mother and newborn, danger signs and 
financial and transport preparations. The package included a flip chart used to 
systematically work through these areas with women. In addition, pregnant women were 
provided with a key chain made up of laminated cards containing similar messages and 
illustrations for use by both literate and illiterate women. There was improvement in 
knowledge and newborn care practices but no significant change in the use of EmOC, 
suggesting that other barriers also need to be addressed (McPherson et al., 2006). 
 
Again in Nepal, women’s groups were facilitated through ten participatory meetings over 
one year addressing issues of pregnancy and childbirth. Many of the women’s groups 
established community fund schemes and transport systems with stretchers for use during 
obstetric emergencies. The intervention was implemented as a cluster-randomized 
controlled trial, which found significantly lower maternal deaths among women in 
women’s groups compared to controls (69 versus 341 per 100,000 live births) 
(Manandhar et al., 2004). So there is potential for women’s groups to provide support to 
families to enable a woman to travel closer to care near term. 
  
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The Maternal and Neonatal Health Program of JHPIEGO implemented a district-based 
model service-delivery system in Koupéla, Burkina Faso, during 2001-2004. In a survey 
to assess the effect of birth preparedness and complication readiness, of the 180 women 
who had given birth within 12 months of the survey, 46% had a transport plan, and more 
than 83% had a plan to save money (Moran et al., 2006). 
 
In Tanzania, communities were supported to form their own plans for emergency 
transport. Of 50 villages, 32 developed transport plans which included written action 
plans, emergency funds, or community transport systems. A similar project engaged with 
local leaders to help 10 of 12 villages develop functional plans for emergency transport 
which included the use of locally available transport, emergency funds and equipping 
health staff with radios or phones. Successful communities offered assistance to other 
villages. Complications treated at the district referral hospital increased from 4 to 15% 
(Ahluwalia, Schmid, Kouletio & Kanenda, 2011). 
 
There are some examples of community-based emergency response teams to provide 
initial pre-hospital care and facilitate transport to health care. These include community 
motivators, mobilizes or contact persons who facilitate emergency transport and liaise 
with health centres. In one such example in Sierra Leone, men were chosen for this role 
because they were considered to have more time available and were able to move more 
freely between villages, particularly at night. They received three days of training and 
organized action groups of volunteers who would assist transporting women by hammock 
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(Olaniran, Offiong, Ottong, Asuquo & Duke, 2009). Despite some positive anecdotal 
evidence, the impact of motivators on reducing maternal mortality appears to be 
relatively small, labour intensive in some settings, and difficult to sustain. 
 
In Cambodia, lay community “First Responders” were trained to respond to landmine 
injuries in regions of poor communication and transportation infrastructure. As part of the 
program, local villagers were trained to provide basic first aid and mobilize health care. 
As a result, trauma mortality rates reduced from 40% to less than 10% in three years. 
Recently this model has been adapted to respond to obstetric emergencies. ‘Delivery Life 
Support’ aims to build a chain-of-survival network similar to that for trauma by linking 
midwives and Traditional Birth Attendants (TBAs) into the existing trauma response 
system. “First Responders” are trained to assist with basic life support during obstetric 
emergencies and trauma paramedics at local health centres are also trained in emergency 
obstetrics (Chandy, Steinholt & Husum, 2007). 
 
It is clear from these evaluations that, to be effective, birth preparedness/complications 
readiness cannot be an independent intervention but must be implemented with other 
efforts to strengthen the quality of maternal health care at community and referral levels. 
  
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2.3 The Role of Knowledge on Pregnancy and Childbirth in Birth Preparedness 
Home birth remains a strong preference and often the only option, for many women in 
the developing world. A large proportion of these home deliveries take place without 
professional attendants (bij de Vaate et al., 2002). Provision of a health worker with 
midwifery skills at every birth is considered a crucial intervention for safe motherhood, 
yet the WHO estimates that 47% of births in the developing world are assisted only by 
TBAs, family members, or no one (WHO 2012).  
 
Usually, all pregnant women have to be screened for antenatal syphilis, anemia, pre-
eclampsia and other common complications of pregnancy. However, Myer & Harrison 
(2003) noted that in the rural Hlabisa district of South Africa none of the women 
demonstrated any understanding of the potential benefits of such programs. In these 
circumstances, the possible benefits associated with antenatal services appear to be of 
secondary importance to the necessity of procuring an antenatal attendance card. 
Orinda, Kakande, Kabarangira, Nanda & Mbonye, (2005) believe that women in Africa 
are poorly informed about the risks of pregnancy and the importance of antenatal care, 
while being coerced by the structure of the health care system into using facility-based 
services for labour and delivery. This scenario, high-lighted by poor communication 
between lay women and providers, sharply influences pregnant women’s perceptions of 
antenatal care services and helps to shape their service utilization, reinforcing views of 
antenatal care as a nuisance and of labour and delivery as requiring facility-based care. 
While these approaches to antenatal care provision and utilization may help contribute to 
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safer childbearing through facility-based delivery, they also serve to limit women’s 
understandings of health and health risks during pregnancy. Women’s understandings of 
health in pregnancy contribute to late antenatal health seeking and inadequate attendance 
partners, which contribute in turn to avoidable prenatal deaths. Findings from a previous 
study by Kabakyenga, Ostergren, Turyakira & Pettersson, (2011) revealed that 
knowledge of obstetric danger signs and birth preparedness are strategies that enhance the 
utilization of skilled care during low-risk births and emergency obstetric care in 
complicated cases in low income countries. The presence of skilled attendants at births 
and availability of emergency obstetric care have been shown to greatly reduce maternal 
deaths that occur due to obstetric complications. 
 
2.4 Health Seeking Behaviour of Expectant Mothers in Birth Preparedness and 
Complications Readiness  
Health seeking behavior is related to utilization of health services, which is a complex 
behavioural phenomenon. Empirical studies of preventive and curative services have 
often found that use of health services is related to the availability, quality and cost of 
services as well as to the social structure, health beliefs and personal characteristics of the 
users (Chakraborty , Islam, Chowdhury, Bari & Akhter , 2003).  Urasser, Lindmark & 
Nystrom (2012) in their earlier studies have shown that women with primary education 
and above were two times more likely to be prepared for birth and complications 
compared to those who lacked formal education. It is also reported that those who knew 
three or more obstetric danger signs were three times more prepared for birth and 
complications. Similarly studies conducted in other countries have separately showed a 
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clear relationship between high education and awareness of danger signs in Tanzania and 
in Kenya (Hiluf & Fantahun, 2007 & Pembe, et al., 2009). 
 
Mothers’ education is of importance in explaining the utilization of health care services. 
Female education retains a net effect on maternal health service use, independent of other 
women’s background, characteristics, household’s, socio-economic status and access to 
health care services. However, the study results are inconclusive with respect to the 
influence of other predisposing and enabling factors, such as women’s age, number of 
previous pregnancies and access to health care services/facilities to mention but a few. It 
is further argued that better educated women are more aware of health problems, know 
more about the availability of health care services and use this information more 
effectively to maintain or achieve good health status. Mother’s education may also act as 
a proxy variable of a number of background variables representing women’s higher 
socio-economic status, thus enabling her to seek proper medical care whenever she 
perceives it necessary (de Groot, van Roosmalen, van Dongen & Borm, 1996).  
Myer & Harrison (2003) noted that lack of physical access to health care facilities 
presents a fundamental hurdle to receiving care, even in urban settings. Poor quality of 
care continues to be a major concern in most health systems, as high patient volume and 
limited resources combine to constrain service provision. Even when facilities are 
accessible and quality services are available, many women only recognize pregnancy 
relatively late in gestation. Despite these insights, little is known about antenatal care 
utilization and the health-seeking behavior of pregnant women more generally, in rural 
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areas. These qualitative findings provide important preliminary insights into the 
combination of factors shaping antenatal health-seeking behaviors. 
  
It is well recognized that women’s current age plays an important role in the utilization of 
medical services (Chakraborty et al 2003). Mother’s age may sometimes serve as a proxy 
for the women’s accumulated knowledge of health care services that may have a positive 
influence on the use of health services. On the other hand, because of development of 
modern medicine and improvement in educational opportunities for women in recent 
years, younger women might have an enhanced knowledge of modern health care 
services and place more value upon modern medicine. Also, because of perceived risk 
associated with first pregnancy, a woman is more likely to seek maternal health care 
services for first order than high-order births. Having more children may also cause 
resource constraints, which have a negative effect on health care utilization. One of the 
important predisposing factors for utilization of health care is family size. Women from 
large families underutilize various health care services because of too many demands not 
only on their time but also on their resources if any. 
 
It is also well known that increased income has a positive effect on the utilization of 
modern health care services. Husband’s occupation can be considered a proxy of family 
income, as well as social status. Differences in attitudes to modern health care services by 
occupational groups depict occupation as a predisposing factor. Alternatively, viewing 
occupation as proxy to income, which enables acquisition of more and better health care, 
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depicts it as an enabling factor. Besides the 2005/06 Uganda Demographic and Health 
Survey (UDHS) revealed that women in Kampala were most likely to receive ANC 
services especially urine and blood tests. Women with secondary education and those in 
higher wealth quintiles were also more likely than other women to receive key ANC 
services (UBOS and Macro Org. 2007). 
 
2.5 The Influence of Traditional Beliefs on Birth Preparedness 
“Tradition” in its technical sense means truths or principles of a divine origin revealed or 
unveiled to mankind (Marty, 2004). Traditional knowledge or belief was defined as 
knowledge of local people and their everyday life. Traditional cultural practices reflected 
values and beliefs held by members of a community for periods often spanning 
generations. Every social group in the world has specific traditions, cultural practices, 
and beliefs. Some are based on religious beliefs and probing into religions further will 
provide an understanding of a particular culture. Traditional culture played a major role 
in the way a woman perceived and prepared for her birthing experience - this may 
positively or negatively affect the use of health care in general and maternal health in 
particular (Greene, 2007).  
 
Religious beliefs within the community may act as a barrier for seeking care (Yousuf, 
Ayelew & Seid, 2011). Syed, Khadka, Khan & Wall (2008) found that religious beliefs 
were a barrier for ANC utilization in Bangladesh. Husbands and mothers in-law were 
usually the decision makers about ANC and some women also found the idea of ANC to 
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be shameful, especially if they felt they would be examined by a male worker. A similar 
study was done among Ethiopian Afar, where women stated during a focus group that 
only God and their husband could see them naked (Yousuf et al., 2011). Religious beliefs 
can also be the main reason for delayed referral to health services and preference for 
home delivery (Yousuf et al., 2011). 
 Pregnant women may prefer consultation with local religious leaders, traditional healers, 
and traditional birth attendants (TBAs) over seeking care from qualified health providers. 
In rural Gambia, older women in menopause are seen as experts on pregnancy and 
childbirth. When consulted, they usually decide what should be done and their advice is 
taken. For example, an older woman may advise a woman in labour to wait until the next 
Muslim praying time before seeking care. “Labour and child birth takes place at certain 
times, and these times correspond with the Muslim praying times. It was around midday 
and the next praying time was 2:00 pm so we thought she will deliver by then. After 2:00 
pm she still did not deliver, then we decided to look for transportation to take her to the 
health center” (Cham, Sundby & Vangen, 2005). Another example is a study among 
Uganda women who felt embarrassed to give birth in a health facility because other 
members of the community would think they were not brave enough to give birth on their 
own (Ndyomugyenyi, Neema & Magnussen, 1998). In a study among the women of 
Benin, birth represented a rare opportunity for a woman to demonstrate pride, courage, 
and bring honor to her and her husband’s families by her stoic demeanor. The woman 
who managed to deliver without indication that she was in labour and without calling for 
assistance until the child was born was especially esteemed (Sergent, 1990 as cited in 
Kyomuhendo, 2003). 
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Other harmful traditional practices that impact maternal health include female genital 
mutilation (FGM), early marriage, early pregnancy, traditional birth practices such as 
pushing on the abdomen to hasten delivery, and the use of certain surgical procedures. 
For example in northern Nigeria, traditional healers make an incision in the vagina on 
women who are not making progress in labour (McCarty & Maine, 1992). The practice is 
also in Ghana, though for other reasons. Some ethnic groups in Sierra Leone discourage 
pregnant women from eating meat and eggs, because it is believed that eating meat 
during pregnancy will cause her to give birth to a witch (Offor, 2010). There were 
however, some traditional practices that were beneficial to the mother and baby (Raven et 
al., 2007). For example, among many cultures in Africa, women were encouraged to 
breastfeed their infant for over a year, thus encouraging the practice of spacing between 
pregnancies (Offor, 2010). 
 
2.6 The Influence of Socio-demographic Factors on Birth Preparedness 
Women’s education has been found to be one of the key determinants of maternal 
healthcare utilization (Celik & Hotchkiss, 2000; Navaneetham & Dharmalingham, 2002; 
Pallikadavath et al., 2004). Chakraborty et al. (2003) confirms the importance of 
women’s education in the utilization of health care services in developing countries. In 
India for example, women with high school education and above were 11 times more 
likely to use antenatal care compared to illiterate women (Navaneetham & 
Dharmalingham, 2002). In Mali, low maternal women’s education has also been found to 
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be an obstacle to the improvement of maternal healthcare utilization (Gage, 2007). 
Education of women likely enhanced autonomy so that women could develop confidence 
and capabilities to make decisions regarding their own health (Navaneetham & 
Dharmalingham, 2002). Educated women were more aware of health problems, knew 
more about the availability of health care services, and used information to achieve good 
health status (Chakraborty et al., (2003). 
 
A woman’s age, number of pregnancies carried, and whether or not she was married were 
factors that also play an important role in the utilization of maternal health care services 
(Chakraborty et al., 2003; Pallikadavath, Foss & Stone, 2004). Women carrying their first 
child were probably more susceptible to difficulties during labour and were more 
cautious than women who have had several births (Raj, Saggurti, Balaiah & Silverman, 
2009). Therefore, women who were pregnant for the first time were more motivated to 
utilize maternity care because they did not know what to expect from the process 
(Pallikadavath et al., 2004; Singh, Rai, Alagarajan & Singh, 2012). Subsequently, as a 
woman endured more pregnancies, she would rely on her experience and draw from that 
knowledge (Singh et al., 2012). 
 
In a study conducted in Karnataka, India, there were no significant differences in the 
likelihood of receiving antenatal care between first and second order birth, but it was an 
important predictor for women who had four or more births. In this later group the 
probability of receiving antenatal care was reduced by 60 % (Navaneetham & 
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Dharmalingham, 2002). Age was highly correlated with parity (number of pregnancies) 
and, in some settings, with educational level (Gabrysch & Campbel, 2009). A mother’s 
age may serve as a proxy for the woman’s accumulated knowledge of health care 
services, which would have a positive influence on the use of health services. Older 
women were more likely to seek maternal healthcare than younger women (Chakraborty 
et al., 2003). 
  
In a study conducted in Jamaica, teenagers were more likely not to attend antenatal care 
or to attend it later, when compared to woman in their twenties. Babalola & Fatusi (2009) 
found that in Nigeria, women in the middle child bearing ages were more likely to use 
maternal health services than women in early and late child bearing. And so being of 
older age at marriage is positively associated with the use of healthcare services. One 
study in rural India reported that utilization of antenatal care was higher among women 
married at 19 or older compared to those married at less than 19 years (Pallikadavath et 
al., 2004). Early marriage or child marriage is practiced more often in Africa and 
Southern Asia. In these areas, a higher proportion of teenage girls are married to much 
older men, sometimes as early as 9 or 10 years of age, based on religious and cultural 
beliefs ( Babalola & Fatusi, 2009; UN,2004) The girls may be restricted from seeking 
healthcare services because of fear or need for permission from a spouse or in-laws. 
Ethnicity and religion are often considered markers of cultural background and are 
thought to influence beliefs, norms, and values in relation to childbirth, service use, and 
women's status (Gabrysch & Campbel, 2009). Ethnic identity may also be associated 
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with health beliefs that influence whether care is sought and whether that cares is 
traditional or biomedical (Glei, Goldman and Rodriguez, 2003). In a study conducted in 
Nigeria, it was determined that ethnicity seemed to make no significant difference in the 
use of antenatal care, however, it made a significant difference in the use of skilled 
assistance and post- natal care. In the same study, it was found that the level of service 
utilization was significantly higher among the Igbos (in the south) and the minority tribe 
compared to the Hausas (in the north). This result reflects the influence of the cultural 
and religious beliefs in the north. The Islamic religion may have had a strong influence 
on the cultural beliefs and traditions on child birth of the Hausas in the north (Babalola & 
Fatusi, 2009).  
 
Whether or not a woman is employed is one of the most important factors that positively 
influenced the use of maternal healthcare (Chakraborty et al., 2003). Women who were 
working and earning money may have been able to save and decided to spend it on a 
facility delivery (Gabrysch & Campbel , 2009). 
 
2.7 Attitudes-Social influence model 
A framework for the use of maternal healthcare is the Attitudes-Social influence model 
(ASE) (De Vries & Backbier, 1994). The ASE-model includes the Theory of Reasoned 
Action (Fishbein & Ajzen, 1975) and Social Learning Theory (Bandura, 1986). In the 
ASE- model, there are three main psycho-social factors that have been identified to 
predict behavior intention - attitudes, social influences, and self-efficacy. A person’s 
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attitude towards a specific behavior is a result of the consequences that person expects 
from performing the behavior. For example, attitude may be a deciding factor in whether 
to breastfeed the baby or use bottle milk. Due to social influence as a result of social 
norms individuals may sway them because they are perceived to be an expert in the 
matter at hand. Self-efficacy expectations can be seen as a person’s belief whether she 
can perform the desired behavior and can cope with barriers that may hinder actual 
performance. The implication of the model is that a person’s health behavior can be 
changed, by changing her attitudes, her perception of social norms, social support, and 
her self-efficacy expectations (Amooti-Kaguna & Nuwaha, 2000).  
  
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CHAPTER THREE 
3.0 METHODS 
3.1 TYPE OF STUDY  
This study was a quantitative, descriptive cross sectional study. This design was adopted 
in order for the phenomenon of interest to be investigated as a snap shot of the actual 
situation that exists on the ground. The design also allowed for the selected variables to 
be measured at a single time. It was a facility- based study.  
3.2 STUDY AREA AND LOCATION  
The study was a facility based study that made use of respondents accessing the Ridge 
Regional Hospital within the Greater Accra Region of Ghana. 
The Ridge Regional Hospital was opened by the British around the year 1928.After 
independence in 1957, Dr. Kwame Nkrumah turned the hospital into a women’s hospital 
to treat Obstetrics and Gynaecology cases. During the era of Col.I.K Acheampong, he 
turned the hospital into a District hospital in 1974 in order to ease the pressure in Korle-
Bu.The hospital was later designated Regional Hospital in year1997. It occupies a total 
land area of 15.65 acres. Politically it falls within the Osu Klottey sub-metro of the Accra 
Metropolitan area.As a regional Hospital for the Greater Accra Region, its catchment area 
is the whole of the region with an estimated population of 4,283,322. However the 
immediate catchment area includes the following suburbs: Nima, Maamobi, Kanda, 
Accra New Town, Kotobabi, Osu, La, Adabraka, Airport Residential Area, Legon, 
Achimota and Central Accra. 
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The Ridge Regional Hospital is accredited by the Medical and Dental Council for Ghana 
for the training of House officers in Medicine, Surgery, Obstetrics and Gynaecology, 
Dentistry and also training of post graduate Residents in Paediatrics, Obstetrics and 
Radiology. The ANC services are carried out three times a week that is Mondays, 
Tuesdays and Thursdays however, ANC referrals from other hospitals are accepted from 
Mondays to Fridays. Apart from taking weight measurement, testing of urine and 
checking of blood pressure which is done at one central point for all the clients,instead of 
the cubicle based care (Focused Antenatal Care); History taking, palpation and 
prescription writing are done in individual cubicles with a Midwife in attendance. Cases 
which are beyond the Midwife are referred to the Obstetrician for attention. 
The overall Bed complement of the facility is 191. 
3.3 THE STUDY VARIABLES 
A. Explanatory variables 
Socio-demographic Variables: Age, Marital status, Educational status, Parity, 
Occupation. 
B. Outcome Variables 
Birth Preparedness and Complication Readiness. 
3.4 STUDY POPULATION 
The study population was made up of women within the reproductive age who are 
attending antenatal clinic at the Ridge Regional Hospital and were within the last 
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trimester of pregnancy. Such women made up the study population and this inclusion is 
irrespective of parity, age, educational and economic status. 
  
3.5 SAMPLE SIZE DETERMINATION 
The sample size was determined using the following assumptions level of confidence of 
95% and a margin of error (d) of 5% 0.05.Using the formula for calculating sample size 
for small samples which is stated below: 
 n =  z2 .pq 
          d2 
Where n =minimum sample size, z= confidence level of 95 %( 1.96), p= is the assumed 
practice of BP (0.5) and d is the margin of error 5%  
n = (1.96)2 *0.5 *(1-0.5) 
             (0.05)2 
n = (3.8416*0.25_) 
          0.0025 
n=384.16 ≈384 
By adding 10% non response rate of 384 ≈ 390 approximately 422 expectant mothers in 
the third trimester were expected to be interviewed, however only 400 were recruited 
during the period of data collection. 
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3.6 SAMPLING METHOD 
Simple Random Sampling was employed. In the absence of a sampling frame, the lottery 
method was the most appropriate sampling technique for this study.  Based on the 
antenatal attendance records of the hospital over the years, an average of 100 women 
report at the ANC per day of which 50% are within the last trimester 
Using this information, a lottery method was adopted where fifty (50) cards were marked, 
(forty (40)” yes” and ten (10) “no” these cards were placed in a sack and all the pregnant 
women in their third trimester visiting the ANC  were asked to dip their hands into the 
sack and pick a card.  Those who picked “yes” were interviewed after they gave their 
consent and their ANC cards were marked to avoid interviewing them twice. 
 The data was collected over a period of 5 weeks; since there are 3 ANC days in a week, 
an average of 30 respondents were interviewed per day till the required number was 
obtained. 
 
3.7 DATA COLLECTION TECHNIQUES/ METHODS AND TOOLS 
The study  made use of structured questionnaire (portions of which is adopted from the 
Medical Outcomes Study (MOS) social support survey) which were administered through 
a face to face interview to elicit response from the study participants who fell within the 
eligibility criteria of the study within the period of data collection. Although the original 
questionnaires were in English language, questions were translated into the local 
languages during the interview for those who could not speak English. 
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  3.8 DATA PROCESSING AND ANALYSIS  
Data collected was coded, entered, cleaned and analyzed using SPSS version 16 software 
by two personnel. This was done separately so that comparisons were made during the 
process to ensure that data entry was done accurately. Employing descriptive statistics, 
summaries of frequencies, percentages and measures of association between birth 
preparedness and variables such as educational level, marital status and others were 
explored at the 95% confidence interval. A p-value <0.05 was used to determine 
statistical significance. Association between birth preparedness and socio- demographic 
characteristics was tested using Pearson’s Chi-square.  
 
3.9 DETERMINATION OF LEVEL OF PREPAREDNESS 
Those who were considered as’ well prepared’ met at least three of the following 
conditions: have made funds available for transportation, have identified the mode of 
transportation to hospital when labour begins, have arranged for a blood donor and 
already has blood in the bank. Those who met less than three of the conditions were 
considered ‘less prepared’. 
 
3.10 QUALITY CONTROL 
Three research assistants were recruited to be interviewers as they have basic knowledge 
in research methodology.  The following measures were put in place to ensure the quality 
and validity of the data and findings of the study:  
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1. Research assistants or data collection personnel with the requisite background were 
recruited and trained well (intensively) for the study. 
2. Each day, data was checked on the field to ensure that all information has been 
properly collected and recorded.  
3. Errors and omissions detected were discussed with the respective research assistants 
and the necessary corrections made.  
4. There was regular monitoring by the field supervisor at the study area to review 
questionnaires presented by the field staff for consistency.  Appropriate corrections 
were made.  Data that were clearly inconsistent and corrections could not be made, 
were excluded from processing and analysis since it could affect the consistency and 
validity of the results.   
5. Questionnaires that were excluded as a result of inconsistencies or incompleteness 
were kept for discussion in the final report.  
6. All data collected were entered in SPSS (version 16.0).  
7. The Researcher verified how data had been coded and entered into the computer.  
 
 
3.11 ETHICAL ISSUES 
Ethical clearance was obtained from the Ghana Health Service Ethical Review Board.  
Permission was also sought from the Greater Accra Regional Health Directorate as well 
as the Ridge Regional Hospital Authorities before commencement of the study.  
Participants were told the nature and purpose of the research prior to inclusion in the  
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study. Before the questionnaires were administered the participants were made to 
understand that their participation in the study was purely voluntarily and that they could 
choose to withdraw from the study if they so desired at any point in the data collection 
process.  
They were   made aware of the fact that the information provided will be treated with all 
confidentiality and anonymity since no names will be written on the questionnaires.  
Before the actual commencement of data collection each participant was made to give a 
verbal consent indicating her willingness to be involved in the study. 
  
3.11.1 Description of Research Burden 
Participants were told that they will be interviewed and the responses elicited will be used 
to fill a questionnaire and that the interview will not last beyond 30 minutes. 
 
3.11.2 Description of Measures to reduce risk 
The participants were made aware of the fact that the methods and tools that were used in 
the study posed no risk to them. However, some questions on their obstetric history may 
be embarrassing to them.  They were assured that anonymity and high level of 
confidentiality was applied to every information they provided. Maximum privacy was 
ensured as much as possible and that they had the right not to answer any question they 
were not comfortable with. 
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3.11.3 Benefits to participants 
The participants were informed that the research did not guarantee any direct or short 
term benefit. It was expected however, that the information elicited would inform policies 
and programmes in the region to prevent maternal mortality and improve maternal health. 
3.11.4 Compensation  
It was made known to the participants that, there was neither compensation nor reward 
for participating in the study. Willingness to participate was purely voluntary. 
3.11.5 Rights of participants and Right to Opt out of the Research 
Participants were made to understand that they had the right: 
• To decline enrolling in the study 
• Not to answer questions they are uncomfortable with 
• Withdraw from the study completely and yet not suffer any consequences, 
punitive measures or decline in the quality of care they receive at the facility. 
 
3.12  TRAINING OF RESEARCH ASSISTANTS 
Three (3) Research Assistants with midwifery skills were employed .They were trained 
on; 
- How to administer the questionnaire.  
- Translate technical terms into local language. 
- To respect the dignity and human rights of the participants. 
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- Obtain verbal consent from all participants before questionnaires were 
administered.  
 
 
3.13 PRETESTING 
This aspect was done few days prior to the commencement of the actual data collection 
process.   The questionnaire was pretested on 10 (ten) pregnant women at term of 
pregnancy but attending ANC at Madina Polyclinic (Kekele). This was done to identify 
ambiguities and inconsistencies. Necessary changes were made to bring out clarity of 
questions. 
 
3.14  ACTUAL DATA COLLECTION 
The pre-trained research assistants with midwifery skills who are fluent in the local 
languages collected the data by first providing privacy and obtaining a verbal consent. 
The objective of the research was explained to the participants before conducting a face-
face interview using the questionnaire designed by the researcher. The interview schedule 
included information on the age of the respondent, marital status, level of education, 
occupation, number of deliveries (parity) and number of visits to the ANC with the 
current pregnancy. Their ANC cards were reviewed to confirm the gestational age and 
obstetric history. 
 
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Information on birth preparedness was assessed by asking of their expected date of 
delivery, whether they are aware that labour could start before the due date. It was also 
determined if participants had saved money for any emergency as well as arranging for a 
blood donor. Information was sought on whether they had decided on the facility to give 
birth in and whether they had arranged for transportation should labour occur. 
Their knowledge of danger signs in pregnancy was assessed by asking what danger signs 
of pregnancy they knew, they were then  asked whether they knew that bleeding, change 
in pattern of foetal movement, loosing liqour, swelling of face, ankle and feet, severe 
vomiting, convulsions, severe frontal headaches and difficulty in breathing were the 
danger signs in pregnancy. 
 
In assessing the support systems that are available to them, it was determined whether 
they had someone to accompany them to the hospital when in labour. Also, they were 
asked if they had identified someone to help take care of the children whiles they are in 
hospital as well as to help in taking care of the newborn when they are discharged home. 
                                                         
 
 
 
 
 
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  CHAPTER   FOUR 
4.0 RESULTS 
4.1 Introduction 
In this chapter, key findings from the data collected in line with the objectives of the 
research which is a quantitative study are interpreted and results presented. 
A total of 400 expectant mothers in their third trimester participated in the study. 
 
4.2 Characteristics of respondents 
 
Sixty-eight percent of the respondents were between the ages 25-34 years. Only 2.5% 
were 40% years and older. Majority of 53% completed at least Junior High School while 
10% completed University education. Only 2.3% did not attend any school.Seventy-eight 
and a half percent of respondents are married and 1% separated.A proportion of 54.3% 
were traders whiles 2.5% were unemployed, 77 representing 19.3% were in formal 
employment and 31 representing 7.8% were housewives (Table 4.1). 
 
 
 
 
 
 
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 Table 4.1: Demographic Characteristics of Respondents 
Demographic Characteristics of 
Respondents Frequency Percent 
Age     
< 20 14 3.5 
20-24 59 14.8 
25-29 136 34 
30-34 136 34 
35-39 46 11.5 
40+ 9 2.5 
Total 400 100.0 
Educational Level     
None 9 2.3 
Primary 59 15 
Secondary 219 53.9 
College 35 8.9 
University 40 10.2 
Other 38 9.7 
Total 400 100.0 
Marital Status     
Married 318 79.3 
Single 54 13.6 
Separated 4 1 
Cohabitating 24 6.1 
Total 400 100.0 
Occupation     
Unemployed 15 2.5 
Trader 217 54.9 
Housewife 31 7.8 
Formal Employment 77 19.5 
Other 60 15.2 
Total 400 100.0 
 
 
 
 
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4.3   Reproductive History and History of Antenatal Care 
This consists of information on the number of times a respondent got pregnant 
(gravidarity) and the number of deliveries one has undergone (parity) as well as the 
number of visits made to the Ante Natal Clinic. 
A total of 52.8% had been pregnant less than two times and 1.3% had more than six 
pregnancies, 178 respondents representing 44.5% recorded  pregnancies between 3-5 
times. 
The number of respondents who had not experienced delivery before are 111 (27.8%), 
278 (69.5%) had delivered between 3-5 times. Only 9 respondents had had 4 or more 
deliveries which represented 2.3%. For those who had Ante natal Care less than 4 times 
43 (10.8%) were recorded and 357 respondents (89.2%) had visited the ANC more than 4 
times.(Table 4. 2).                                                                                                                                  
 
 
 
 
 
 
 
 
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Table 4 2: Reproductive History and History of Antenatal Care 
Reproductive History and History of 
Antenatal Care Frequency  Percent (%) 
Gravidarity     
Primigravida 88 22.1 
Secundigravida 122 30.6 
Multigravida 189 47.4 
Total 400 100.0 
Parity     
Nullipara 110 27.8 
Primapara 155 39.1 
Multipara 129 32.6 
Grand Multipara 2 0.5 
Total 400 100.0 
Number of visits to the ANC     
<4 43 10.8 
≥4 357 89.2 
Total 400 100.0 
 
 
4.4 Knowledge of Danger Signs During Pregnancy 
Expectant mothers were questioned on whether they knew any danger signs of 
pregnancy. This question was asked in order to determine whether they knew that the 
underlying questions were signs of danger during pregnancy in order to ascertain their 
ability to recognize danger signs should they occur. 
 
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The study identified that 68.7% indicated that they knew some danger signs and gave 
examples of them whiles 31.3% of them did not know what danger signs of pregnancy 
were. However when the various signs were mentioned to them, they were aware of them 
except that they did not know that it was a dangerous sign. 
When asked about bleeding, 75.5% were aware that it was a dangerous sign and 23.8% 
were unaware of it; 62.7% did not know that change in pattern of foetal movement was a 
dangerous sign in pregnancy only 37.3% had that knowledge.A total of 65.1% knew that 
loosing liquor was a dangerous sign and 34.9% did not know that.When asked about 
swelling face, ankle and feet 78.5% had that knowledge and 20.5% did not have that 
knowledge. 
Of the total, 60.9% knew that severe frontal headache was a dangerous sign while 39.1 % 
did not know that. 
Two hundred and fifty-eight respondents (65.2%) knew that severe vomiting was a 
dangerous sign of pregnancy and 138 (34.8%) did not know that.Convulsions are a 
definite sign of Eclampsia, 69% (272) did not know that but 31% (122) knew about 
it.When asked about difficulty in breathing, 65.3% (257) were aware that it is a 
dangerous sign as against 34.4% (135) that had no knowledge of it (Table 4.3). 
 
 
 
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Table 4.3: Percentage of Expectant Mothers who Reported Knowledge on Key 
Danger Signs During Pregnancy  
Variable Frequency  Percent (%) 
Do you know any danger signs? 
No 124 31.3 
Yes 272 68.7 
Total 396 100 
Bleeding  302 75.5 
Change in pattern of foetal movement 145 37.3 
Loosing Liquor 257 65.1 
Swelling of face, ankle and feet 314 78.5 
Severe frontal headache 238 60.9 
Severe vomiting 258 65.2 
Convulsion 122 31 
Difficulty in breathing 257 65.4 
 
4.5. Knowledge of Danger Signs (Spontaneous /Non Spontaneous Response) 
Table 4.4 shows the distribution of Danger signs with Spontaneous Response and Non 
Spontaneous Response. Bleeding had the highest response of spontaneous response 
(56.7%), while swelling of face, ankle and feet had the highest Non spontaneous response 
(78.5%).  
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Table 4.4: Knowledge of Danger Signs (Spontaneous /Non Spontaneous Response) 
Danger Signs Spontaneous Response 
Non Spontaneous 
Response 
  Yes Percent Yes Percent 
Anaemia 2 0.5 - - 
Bleeding 230 56.7 302 75.5 
Change in pattern of foetal 
movement - - 145 36.3 
Convulsions - - 122 30.5 
Difficulty in breathing - - 257 64.3 
Headache 5 1.2 238 59.5 
High temperature 1 0.2 - 0.0 
Loosing liquor 43 12.1 257 64.3 
Lower abdominal pain 12 3.0 - - 
Oedema 91 22.4 - - 
Pregnancy Induced 
Hypertension 1 0.2 - - 
Swelling of face, ankle and 
feet - - 314 78.5 
Vomiting 15 3.7 258 64.5 
Total 400 100.0     
Note: Percentages of Non Spontaneous response were done on individual questions 
 
4.6 Information on Birth Preparedness 
The information gathered from this portion of the questionnaire helped to ascertain how 
well prepared a respondent was. A woman was considered ‘well prepared’ if she had 
accomplished  any three or more of the following practices: made funds available for 
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transportation to hospital, have identified the mode of transportation to hospital when 
labour begins, have arranged for a blood donor and already has blood in the blood bank. 
A woman was considered ‘less prepared’ if she accomplished less than three of the four 
practices. 
Other variables in this category are: knowledge of expected date of delivery which had 
89.2%, of respondents saying ‘Yes’ to the possibility of labour to start before due date to 
which 86.1% admitted knowledge of. Identifying the facility one will give birth in to 
which 96.2% pointed out that they will deliver at the Ridge Regional Hospital, some also 
said they would take transfers to clinics or hospitals where their mothers lived outside 
Accra. 
Three hundred and seven respondents were aware that they may need blood during labour 
but only 124 mothers had arranged for a blood donor. Only 16.4% (65) of respondents 
already had blood ready in the blood bank. Three hundred and eighty respondents had 
already identified a companion (their mother, mother-in-law, sister or husband) to take 
them to hospital when in labour. A total of 376 respondents had already packed their bags 
with items needed for the delivery of the baby (Table 4.5). 
 
 
 
 
 
 
 
 
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Table 4.5: Awareness and Resource Mobilization Towards Preparedness 
Variable Frequency Percent (%) 
Awareness of expected date of 
delivery 
Yes 354 89.2 
No 43 10.8 
Total 397 100 
Awareness that labour may start 
before due date 341 86.1 
Availability of funds for 
transportation to hospital 353 88.7 
Identified the facility to give 
birth in 383 96.2 
Identification of mode of 
transportation to hospital at the 
onset of labour  306 77.1 
 Mode of transportationarranged 
for 
Private Car 101 25.3 
Taxi 297 74.2 
Trotro 2 0.5 
Awareness of the need of blood 
during labour 307 77.3 
Already identified a blood donor 124 31.6 
Already have blood in the blood 
bank 65 16.4 
Identified companion to 
accompany to the hospital at the 
onset of labour 380 95.7 
Already packed bag with items 
needed for delivery 376 94.7 
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4.7 Association of Socio-demographic Characteristics and Birth preparedness and 
Complication Readiness 
Table 4.6 indicates that Educational Level, Occupation and ANC Attendance were the 
variables that have significant relationship with the level of preparedness. There was a 
significant relationship between educational level and level of preparedness X2 (1, 
n=393) =6.971, p<.05. Higher Levels of education are associated with lower levels of 
preparedness. Irregular Income earners that is women who were not in formal 
employment  are associated with lower levels of preparednessX2 (1, n=395) = 11.151, 
p<.05. Finally, higher levels of ANC Attendance are associated with lower levels of 
preparedness.X2 (1, n=400) =4.574, p<.05. (Table 4.6). 
 
 
 
 
 
 
 
 
 
 
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Table 4.6: Association between Birth Preparedness and Socio-demographic 
Characteristics  
Demographic 
Characteristics 
Prepared 
Frequency(%) 
Not Prepared 
Frequency (%) 
χ2 
p –value 
Age     
<20 0(0) 7(1.8) 2.746 0.097 
≥20 111(27.8) 281(70.4) 
Marital Status     
Not Married 94(23.7) 220(55.6) 2.731 0.098 
Married 17(4.3) 65(16.4) 
Educational Level     
Less than Secondary 19(4.8) 87(22.1) 6.971 0.008 
Secondary or more 90(22.9) 197(50.1) 
Occupation     
Irregular Income  76(19.2) 242(61.3) 11.151 0.001 
Regular Income 33(8.4) 44(11.1) 
Parity     
1 66(16.7) 199(50.3) 3.879 0.144 
2-4 44(11.1) 84(21.2) 
≥5 1(0.3) 2(0.5) 
ANC Attendance     
<4 6(1.5) 37(9.2) 4.574 0.032 
≥4 105(26.2) 252(63.0)     
 
 
 
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4.8 Availability of Social Support Systems 
This section sought to assess the social support systems that were available to the 
respondents.  
A total of 294 respondents had identified who will be with the children at home whiles 
the mother is in hospital. Eighty-three respondents who are going to be first-time mothers 
did not have the need for anyone to be at home with the children whiles they were in 
hospital. Respondents identified their mothers, husbands and sisters as people they count 
on to listen to them when they need to talk, give them good advice when they notice a 
danger sign, to help them when they were confined to bed and to make them feel loved 
and wanted. 73.8% of the pregnant mothers said they got together with their husbands or 
sisters for relaxation and 73.5% had a good time with them when they needed it (Table 
4.7). 
 
 
 
 
 
 
 
 
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Table 4.7: Availability of Social Support Systems 
Variable  Frequency Percent (%) 
Residence SES 
Family house 85 21.3 
Live with husband only 224 56.0 
Live with husband and some family 
members 72 18.0 
Live alone 19 4.8 
Total 400 100.0 
Identified who will be with the 
children 294 73.5 
Identified an individual who will help 
care for the baby 390 97.5 
Have someone to count on to listen 
when she needs to talk 374 93.5 
Have someone to give  good advice 
when  a danger sign was noticed 373 93.3 
Have someone to help  if confined to 
bed 386 96.5 
Have someone to accompany her to 
the doctor 384 96 
Have someone to love and make her 
feel wanted 389 97.3 
Have someone to get together for 
relaxation 295 73.8 
Have someone to have a good time 
with 294 73.5 
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CHAPTER FIVE 
5.0 DISCUSSION 
5.1 Background Information and characteristics of the study population 
This design was adopted in order for the phenomenon of interest to be investigated as a 
snap shot of the actual situation that exists on the ground. The study was a facility based 
study that made use of respondents accessing the Ridge Regional Hospital within the 
Greater Accra Region of Ghana. 
 
 The immediate catchment area includes the following suburbs: Nima, Maamobi, Kanda, 
Accra New Town, Kotobabi, Osu, La, Adabraka, Airport Residential Area, Legon, 
Achimota and Central Accra. However there were respondents from very far places like 
Weija, Sowutuom, Ashalley Botwe, Adenta, Teshie, Ajiringanor, Gbawe, Ofankor 
barrier, Tantra Hills, Tabora Alhaji, Omaajor, Pokuase amongst others. 
The main aim was to assess the knowledge and practices of birth preparedness and 
complication readiness among pregnant women in order to find out how well informed 
they are about dangers in pregnancy in order to avoid the three main delays that cause 
maternal deaths.  
 
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5.2.0 Knowledge on birth preparedness and complication readiness 
5.2.1 Level of preparedness 
Knowledge of danger signs: 
 A very important aspect of assessing BPCR is measuring the spontaneous knowledge of 
essential danger signs of pregnancy as was stated by Hiluf & Fantahun (2008);the study 
found out that 10.9% of the respondents mentioned vaginal bleeding and 2.2% mentioned 
blurred vision and 5.2% mentioned swollen hands/face as danger signs during pregnancy; 
they also said that knowledge of danger signs of obstetric complications is the first step in 
the appropriate and timely referral for emergency care. 
 
The assessment of knowledge was based on the fact that some expectant mothers know 
the danger signs and are able to recognize them of which 68.7% were able to give 
examples. Sixty-seven percent of respondents knew at least one danger sign in a study 
done in East Africa by Mutiso, et al, 2008) which is less than the result with this study. 
A key sign of antepartum haemorrhage is vaginal bleeding; 23.8% of respondents in this 
study were unaware of it. In this same study done by Mutiso et al. in East Africa, 35.8% 
were not aware of it whiles all the respondents in that study completely lacked 
information on danger signs such as fever, convulsions and difficulty in breathing. In this 
study however, about 30% had no knowledge of bleeding. The knowledge of danger 
signs is very important to the pregnant woman as this helps her to recognize the signs and 
symptoms and aids in her decision to seek care on time to avoid delay. 
  
 
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Blood donation: 
 Many of the mothers (77.3%) were aware of the fact that they may need blood during 
labour but only 16.4% of mothers actually had blood in the blood bank and 31.6% said 
they had arranged for a blood donor. It is however observed that about 80% of those who 
already had blood in the bank had anaemia with haemoglobin levels around 7g/dl so were 
cautioned by the midwives that they needed to have blood in the blood bank before 
getting into labour. During the educational health talks, the midwives informed the 
expectant mothers of the importance of having a blood donor in readiness of any 
complications. Despite that only one-third of the respondents had arranged for a donor. In 
a similar study done in Kenya, Mutiso et al., (2008), observed that only 28.7% had 
identified a blood donor which is almost the same in this study. Iliyasu et al., (2010) in 
their study which took place in Northern Nigeria however had only 1.8% of spouses who 
donated blood during a complication and 3.7% donated blood in anticipation of a birth 
complication. The study done by Urassa et al. in Mpwapwa district in Tanzania, (2012), 
however stated that only 8.7% women arranged for a potential blood donor. 
Also, the safest place to give birth is in an emergency obstetric and neonatal care facility 
(EmONC) ( Rogo & Aloo 2001). In this study, 96.2% of respondents have identified the 
facility to give birth and most of those who said they will deliver at the Ridge Regional 
Hospital and others who decided to give birth outside Accra said they will obtain a 
transfer to the clinic/ hospital closest to where they will reside. 
 
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5.2.2 Antenatal care 
One of the most important functions of antenatal care is to offer the expectant mother 
advice and information on birth preparedness and complication readiness (BPCR) 
(Mutiso et al., 2008). It was realized in this study that higher levels of ANC attendance 
are associated with lower levels of preparedness chi-square = 4.574, p =0.032. Sixty-
three percent of respondents who had more than 4 visits were not well prepared for birth. 
This result however is in sharp contrast to the study done in Tanzania which reported that 
respondents who had more than 4 visits were 85.9% prepared for birth (Urassa et al., 
2012). There was a statistically significant association between level of preparedness and 
ANC attendance (p = 0.032; Table 4. 7). 
 
Birth preparedness and complication readiness (BPCR) is a process of planning for 
normal delivery and being prepared to combat any complications should they occur. For 
BPCR to be successful, responsibility must be shared among all stakeholders- policy 
makers, facility managers, healthcare providers, communities, families and women as a 
coordinated effort is needed to reduce the delays that contribute to maternal deaths 
(Ekabua, et al., 2011). Many a time, access to care is impeded by three main delays 
which are delays in deciding to seek care, delays in reaching care, and delays in receiving 
care. The delays have many causes including financial concerns and inadequate 
knowledge about maternal health issues (Thaddeus & Maine 1994). 
 
 
 
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Information on preparedness: 
In this study, majority of the expectant mothers (89.2%) knew their expected date of 
delivery as well as the possibility of labour to start before the due date.  
According to Mutiso et al., (2008), advance transport arrangements reduce delay in 
reaching the health facility. Time is  saved by that gesture as it enables couples know 
what transport is available at different times of the day and how much it will cost so that 
savings could be made to serve that purpose, 74.2%  of the respondents said they have 
arranged with Taxi drivers to pick them to the hospital when in labour. 
 
5.2.3 Association between Socio-demographic characteristics and Birth 
preparedness and Complication Readiness 
 Level of education: 
A higher level of education is the most important factor for increased awareness of 
danger signs as stated by Pembe et al., (2009). In this study, 53% of respondents had 
completed at least Junior High School and 10% completed University education (p-value 
= 0.008). Compared to a study done in Ethiopia where it was observed that educated 
women were twice more prepared for birth than the uneducated ones (Hiluf & Fantahun, 
2008) the illiterates were 25.8% and the educated respondents 74.1%. This might be 
related to the fact that women who are educated are more likely to be financially sound 
and also have better negotiating power and are able to make their own decisions in 
matters concerning their health than women who are uneducated, Urassa et al. (2012). 
Another reason why better educated women are more prepared for birth and complication 
readiness is their ability to better understand health messages and search for more 
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information regarding health issues Kabakyenga et al. (2011). According to Kabakyenga 
et al, (2011) similar studies conducted in other countries have shown separately clear 
relationship between high education and awareness of danger signs of pregnancy in 
Tanzania, (Pembe et al., 2009), Kenya (Mutiso et al., 2008) and in Ethiopia (Hiluf & 
Fantahun, 2007). de Groot et al.(1996) argued that better educated women are more 
aware of health problems, know more about the availability of health care services and 
use this information more effectively to maintain or achieve good health status. Mother’s 
education may also act as a proxy variable of a number of background variables 
representing women’s higher socio-economic status, thus enabling her to seek proper 
medical care whenever she perceives it necessary (de Groot et al., 1996).  
The results indicated that, Educational level, Occupation and ANC attendance had 
significant relationship with the level of preparedness as evident by p<0.05. Age, Marital 
status and Parity did not show any significant relationship with the level of preparedness. 
It is observed that women who knew three or more danger signs were three times more 
likely to be prepared for birth and complications as noted by Urassa et al., (2012). 
 
Antenatal care at regular intervals in the course of pregnancy is important in monitoring 
the physical status of both mother and foetus as it helps in early detection of danger signs 
as well as other diseases and complications. It also offers an opportunity for expectant 
mothers to be counseled and to plan for delivery (WHO, 1994). ANC attendance should 
be at least four times as recommended by WHO. In this study, those who attended ANC 
less than four times were not ‘well prepared’ with a p-value of 0.032. 
 
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Age: 
Age is one of the demographic characteristics used to determine if a respondent was ‘well 
prepared’ or ‘less prepared’. From the study, respondents below the age of 20 years were 
‘not well prepared’ as they had a p-value of 0.097. χ2= 2.746; p=0.097 (12.5%). A similar 
study done in Uganda by Kabakyenga et al., (2011) however revealed that 34.4% women 
less than 25 years were birth prepared. The possible reasons being that the operational 
definitions used to determine being ‘well prepared’ are not the same as those used in this 
study. 
 
Marital status: 
The marital status of the respondents was also used to determine mothers who are ‘well 
prepared’ versus those who are ‘less prepared’. It revealed the fact that being married 
does not necessarily make one ‘well prepared’ for birth and complications p-value 
=0.098.  
Marital status was not a good predictor for birth preparedness as shown in the study done 
in Southeastern Nigeria by Ekabua et al., (2011). 
 
 
Parity: 
 
The p-value for parity in this study is 0.144 which shows that the more respondents had 
children previously did not make them ‘well prepared’ for birth and complications. In 
Southeastern Nigeria, a study done by Ekabua et al., (2011) showed the opposite where 
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parity was seen as a better predictor of knowledge of severe vaginal bleeding as a key 
danger sign during pregnancy than educational level with a p-value = 0.0009 and p = 
0.849 respectively. Also in the same study, it was observed that parity was a highly 
significant predictor (p = 0.0089) of planning to save money followed by awareness of 
birth preparedness (p= 0.0101). This study however did not seek to determine whether 
parity had any effect on knowledge of danger signs of pregnancy but to determine the 
birth preparedness and complication readiness of an expectant mother in her third 
trimester of pregnancy. 
 
 
5.2.4 The availability of social support systems for expectant mothers 
This section sought to assess the social support systems that were available to the 
respondents. The pregnant woman is vulnerable at this time of her life and the availability 
of social support is very crucial for her general wellbeing and that of her baby as well. A 
gainfully employed spouse is expected to give her the needed financial support. Those 
who live in the family house usually have their siblings, mothers, mothers-in-law and 
cousins available to give the necessary support when a pregnant woman needs someone 
to accompany her to hospital or to do her marketing and cooking for her when her health 
does not permit her to do it herself. 
 
Respondents who live with their husbands alone said they were expecting their mothers 
or mothers-in-law, sisters or an aunt as is common in the African extended family 
system/situation to come and live with them as the time of delivery approaches. This 
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same relative they said will help with the care of the new born and the older children till 
the woman is strong enough to take up full care of her children. A total of 294 (73.5%) 
respondents had identified who will be with the children at home whiles the mother is in 
hospital. Eighty-three respondents who are going to be first-time mothers did not have the 
need for anyone to be at home with the children whiles they were in hospital. 
Respondents identified their mothers, husbands and sisters as people they count on to 
listen to them when they need to talk, give them good advice when they notice a danger 
sign, to help them when they were confined to bed and to make them feel loved and 
wanted. 
 
In a study carried out in Uganda, 42.9% of expectant mothers reported that they were 
accompanied by their spouses to the ANC, 35% had their spouses help them with 
household chores during the antenatal period. During the onset of labour, 68.6% are 
accompanied by their spouses to hospital. (Kakaire et al., 2011). This study revealed that 
95.7% of respondents had identified a close family member who is a mother, sister or an 
aunt to accompany them to the health facility when in labour. 
In a related study done by Ekabua et al., (2011), knowledge of availability of community 
support systems was very poor among women surveyed however this aspect of the study 
was not covered in this research. 
 
 
 
 
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CHAPTER SIX 
6.0 CONCLUSIONS AND RECOMMENDATIONS 
6.1 Conclusions  
The study sought to assess the knowledge and practices of birth preparedness among 
expectant mothers.   
 The following key findings were observed:   
Despite the fact that the pregnant women knew about blood donation, only 16.4% already 
had blood.donation arrangements Others simply did not want to do anything about it 
because they thought did not need transfusion during previous pregnancies.  
There was a significant relationship between educational level and level of preparedness 
as well as higher Levels of education being associated with better level of preparedness. 
It was observed that almost two-thirds of the respondents knew some danger signs and 
gave one or two examples. As many as two-thirds did not know anything about 
Eclampsia or pregnancy induced hypertension. 
Majority of the expectant mothers (95%) had identified a companion to hospital when in 
labour, these were their immediate family members or in-laws. 
 
 
 
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6.2 RECOMMENDATIONS 
6.2.1 Recommendations for Stakeholders (GHS and RRH) 
Giving that less than twenty percent of the respondents already had blood in the blood 
banks, It is recommend that the importance of having blood in readiness for any 
complication be emphasized by the Ghana Health Service by improving upon blood 
donation policies in tertiary hospitals. This emphasis should be laid during health 
educational talks at the ANC as it is a very important aspect of BPCR. It is therefore 
suggested that every expectant mother is to donate blood by the seventh month of 
pregnancy as a way of proving birth preparedness and complication readiness. 
 
Since less than 2% of the expectant mothers  knew about the danger signs of pregnancy 
induced hypertension as per their spontaneous responses and non-spontaneous responses, 
IIt is recommend that focus ANC be practiced fully by ensuring that more weighing 
scales and Blood Pressure apparatuses be provided to the Midwives as well as more 
cubicles so that Focused ANC will be enhancedand not partially at the Ridge Regional 
Hospital as this will improve upon individual health education which will enhance 
knowledge of danger signs. Health education and health promotional talks should be 
intensified by the midwives on important topics such as: Danger signs of pregnancy 
especially convulsions, severe frontal headaches, swelling of face, ankle and feet and also 
loosing liquor. Prior transport arrangement should be emphasized and expectant mothers 
should be allowed to have birth companions as it is part of birth preparedness and 
complication readiness.  
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In order to improve upon the social support systems that the expectant mothers have from 
their family members, the various communities  in which they live must form community 
support systems in order to provide emergency funds, transport and blood donors in 
readiness to assist  needy expectant mothers. 
 
6.2.2 Recommendations for future research 
 Exploring the social support systems available in the community will help create the 
awareness of that need if not already existing as this aspect was not added to the study 
because of time constraints. 
A research can also be done to validate higher levels of education being associated with 
lower levels of preparedness. 
                                                
 
 
 
 
 
 
 
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APPENDICES 
APPENDIX ONE 
STRUCTURED QUESTIONNAIRE 
UNIVERSITY OF GHANA, LEGON SCHOOL OF PUBLIC HEALTH 
TOPIC: Birth Preparedness and Complication Readiness among Expectant 
Mothers at The Ridge Regional Hospital. 
Name or interviewer……………….. 
Questionnaire number……………… 
Date of interview…………………… 
 My name is……………………………………..l am administering this research tool on 
behalf of the Ridge Regional Hospital. We want assess how well prepared you are 
towards birth and how much you know about birth complications and also how ready you 
are to combat it should any occur. 
SOCIO-DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS 
1. Age in years…………………………………… 
2. Education 
Primary              Secondary              College                    University              Others 
3. Marital status 
  
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Married           Single          Separated           Widowed           Divorced              
Cohabitating  
4a.Gravidarity…………….. 
4b. Parity………………….. 
5. Number of visits to the ANC…………………………… 
6. Occupation      
 Trader 
Housewife 
Formal employment 
Farmer 
Others specify………………………………………………. 
 
INFORMATION ON BIRTH PREPAREDNESS 
7. Do you know your expected date of delivery? 
Yes     c                               No  
8. Is it possible for labour to start before due date? 
Yes                                     No 
9. Have you made funds available for transportation to hospital? 
  
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Yes                                     No 
10. Have you identified the facility you will give birth in? 
Yes                                     No 
11. Have you identified the mode of transportation to hospital when labour begins? 
Yes                                     No 
11b. If yes what mode of transportation have you arranged for? 
………………………………………………………………………………. 
12a. Are you aware that you may need blood during labour? 
Yes No   
12b. Have you already arranged for a blood donor? 
Yes                       No 
12c. Do you already have blood in the blood bank? 
Yes                        No 
13. Have you identified a companion to take you to the hospital when in labour? 
Yes                        No 
14. Have you already packed your bag with items needed for the delivery and for the 
baby? 
Yes                        No 
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KNOWLEDGE OF   DANGER  SIGNS   DURING PREGNANCY.  
15a. Do you know any danger signs in pregnancy? 
Yes                          No 
15b.If yes what danger signs do you know………………………………..... 
16. Do you know that the following are danger signs of pregnancy? 
   Bleeding                                                 Yes                     No 
17. Change in pattern of foetal movement:  Yes                        No 
18. Loosing liquor                             Yes                                No 
19. Swelling of face, ankle and feet:   Yes                                No 
20. Severe frontal headaches:               Yes                                  No  
 21. Severe vomiting:                             Yes                                 No  
 22.  Convulsions:                                 Yes                                  No                              
 23. Difficulty in breathing:             Yes                           No 
 
 
 
 
    
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ASSESSMENT OF SOCIAL SUPPORT SYSTEMS 
24a. Is your Spouse gainfully employed? 
Yes                                                       No                       
24b. If yes, Which type of work does he do?…………………………………………. 
25a. Where do you reside? 
Family house                                    Live with husband only 
Live with husband and some family members 
Live alone 
25b.In which area do you reside?.................................................... 
26. Have you identified who will be with the children at home whiles in the hospital? 
Yes                                      No 
27.  Have you identified an individual who will help you care for the baby after he/ she is 
born? 
 Yes                                       No 
28. Do you have someone you can count on to listen to when you need to talk? 
Yes No 
 
29. Do you have someone to give you good advice when you notice a danger sign? 
 
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Yes                                    No 
30. Do you have someone to help you if you were confined to bed? 
Yes No 
31. Do you have someone to take you to the doctor if you needed  it? 
Yes No 
32. Do you have someone to love and make you feel wanted? 
Yes No 
33. .Do you have someone to get together with for relaxation? 
Yes No 
34. .Do you have someone to have a good time with? 
Yes No 
 
 
 
 
 
 
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APPENDIX TWO 
CONSENT FORM 
 
Title of research:                    Birth Preparedness and Complication Readiness among 
Expectant  
                                               Mothers at Ridge Regional Hospital 
Principal Investigator:             Dzifa Agbodohu 
Qualification:                          MPH Resident 
Address;                                School of Public Heath, University of Ghana, Legon.               
                                               Department of Population and Reproductive Health 
                                               P. O. Box LG 13 
                                               Tel. 0243-267148, Email: edzifanam@yahoo.com 
 
General Information about the Research 
The main aim of this research is to explore the Birth Preparedness and complication 
readiness of expectant mothers at Ridge Regional Hospital. 
Description of Research Burden 
You will be interviewed and the responses elicited will be used to fill a questionnaire. 
The interview will not last beyond one hour. 
Description of Measures to reduce risk 
The methods and tools that will be used in the study posed no risk to you. However, some 
questions on your obstetric history may be embarrassing to you. You are assured that 
anonymity and high level of confidentiality will be applied to every information you 
would provide. Maximum privacy will be ensured as much as possible and you have the 
right not to answer any question you are not comfortable with. 
 
 
 
 
 
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Benefits to participants 
The research does not guarantee any direct or short term benefit. It is expected however, 
that the information elicited will inform policies and programmes in the region to prevent 
maternal mortality and improve maternal health. 
Compensation  
There is no compensation for participating in the study. Willingness to participate is 
purely voluntary. 
Rights of participants and Right to Opt out of the Research 
As a Participant, you have the right: 
• To decline enrolling in the study 
• Not to answer questions you are uncomfortable with 
• Withdraw from the study completely and yet not suffer any consequences, 
punitive measures or decline in the quality of care they receive at the facility. 
Contacts for additional information 
For further information/clarification you may ask any questions now or contact the 
following people: 
1. Dr.Augustine Ankomah 
Department of Population, Family and Reproductive Health 
School of Public Health 
University of Ghana, Legon. 
 
2. Dr. Amos Laar 
           Department of Population, Family and Reproductive Health 
           School of Public Health,  
           University of Ghana, Legon. 
Principal Investigator 
  Dzifa Agbodohu 
  Department of Population, Family and Reproductive Health 
  School of Public Health,  
University of Ghana          http://ugspace.ug.edu.gh
80 
 
   University of Ghana,  
    Legon. 
Mobile no:0244841396. 
If you agree to participate in this intervention, initial or right thumb in the spaces below; 
Yes, I agree to the interview/discussion..................................................................... 
No, I do not agree to the interview/discussions  
 
SIGNATURE/RIGHT THUMB PRINT 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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APPENDIX THREE 
VOLUNTEER AGREEMENT FORM 
The nature and purpose of the research on BIRTH PREPAREDNESS AND 
COMPLICATION READINESS AMONG EXPECTANT MOTHERS AT RIDGE 
REGIONAL HOSPITAL has been explained to me. I have been given an opportunity 
to obtain clarifications about the research to my satisfaction. I agree to participate as a 
volunteer. 
 
 ____________________________ 
Date                                                                                   Signature or mark of volunteer 
 
If participants cannot read the form themselves, a witness must sign here: 
 
I was present while the nature purpose and 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, and 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 RESEARCHER CAN BE CONTACTED ON THE FOLLOWING 
NUMBER 
0244841396. 
 
 
 
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82 
 
APPENDIX FOUR 
LIST OF LOCATION OF RESIDENCES OF RESPONDENTS 
Location Frequency Percent 
Asylum Down 9 2.3 
Abeka 2 0.5 
Ablenkpe 2 0.5 
Abokobi 1 0.3 
Achimota 17 4.3 
Adabraka 38 9.6 
Adenta 10 2.5 
Adjiriganor 4 1.0 
Agbogba 3 0.8 
Aggege last stop 1 0.3 
Agiga 1 0.3 
Agboba suncity 1 0.3 
Akoto Lante 1 0.3 
Akweteman 2 0.5 
Alajo 6 1.5 
Alaska 1 0.3 
Amalata 1 0.3 
Amanhia 1 0.3 
Amarhia 2 0.5 
Amasaman 1 0.3 
Anyaa Palestine 1 0.3 
Ashalley Botwe 6 1.5 
Ashieye 1 0.3 
Ashongman Estate 1 0.3 
Awoshie 2 0.5 
Awudome Estate 1 0.3 
Banana inn 1 0.3 
Bubuashie 2 0.5 
Burma Camp 1 0.3 
Cantoment 1 0.3 
Carprice 1 0.3 
Chantan 1 0.3 
Chorkor 1 0.3 
CMB 1 0.3 
Dansoman 11 2.8 
Dome 12 3.0 
Dome Pillar 2 1 0.3 
Dzorwulu 1 0.3 
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LIST OF LOCATION OF RESIDENCES OF RESPONDENTS Cont’d 
East Legon 3 0.8 
Elwak Barracks 1 0.3 
Haatso 2 0.5 
Israel 1 0.3 
James town 1 0.3 
Kanda 24 6.0 
Kaneshie 1 0.3 
Kasoa 9 2.3 
Kokrobite 1 0.3 
Kokomlemle 6 1.5 
Korle Gorno 1 0.3 
Korle Worko 1 0.3 
Kotobabi 5 1.3 
Kwabenya 1 0.3 
Kwashieman 3 0.8 
La 2 0.5 
La Apapa 1 0.3 
La Polyclinic 1 0.3 
Labadi 2 0.5 
Lapaz 11 2.8 
Latebiokoshie 1 0.3 
Lepaz 1 0.3 
Madina 17 4.3 
Mamobi 7 1.8 
Mamprobi 1 0.3 
Mateheko 4 1.0 
New Legon 1 0.3 
Newtown 13 3.3 
Nii Boi town 1 0.3 
Nima 37 9.3 
Nmadjor 1 0.3 
North Kaneshie 3 0.8 
North Ridge 1 0.3 
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LIST OF LOCATION OF RESIDENCES OF RESPONDENTS Cont’d 
Odokor 1 0.3 
Odorkor 2 0.5 
Odorna 2 0.5 
Ofankor 2 0.5 
Ofankor Barrier 1 0.3 
Official town 1 0.3 
Pig Farm 3 0.8 
Pokuase 4 1.0 
Ridge 1 0.3 
Roman Ridge 2 0.5 
Sabon Zongo 1 0.3 
Santa Maria 1 0.3 
Sowutuom 5 1.3 
Spintex 5 1.3 
Sukura 1 0.3 
Tabora 1 0.3 
Tabora Alhaji 1 0.3 
Taifa 1 0.3 
Tantra Hills 2 0.5 
Tema 4 1.0 
Tesano 5 1.3 
Teshie 4 1.0 
Teteku 1 0.3 
Tudu 6 1.5 
Weija 1 0.3 
Total 400 100.0 
 
 
 
 
 
 
 
 
 
 
 
 
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