SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCE UNIVERSITY OF GHANA, LEGON FACTORS CONTRIBUTING TO LOW POSTNATAL COVERAGE IN GA EAST MUNICIPALITY BY: AUGUSTINA ARTHUR-ARKO (10189587) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF MASTER OF SCIENCE DEGREE IN APPLIED HEALTH SOCIAL SCIENCE DEGRE JULY 2013 University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Augustina Arthur-Arko hereby declare that apart from references to other people’s work which have been duly acknowledged, this dissertation is as a result of my own independent work, under the supervision of Dr.Baah-Odoom. I further declare that this work has not been submitted for the award of any degree in this institution and other universities elsewhere. …………………………………………. Augustina Arthur-Arko (Student) Date:…………………………………… …………………………………………… Dr. Dinah Baah-Odoom (Academic Supervisor) Date: ……………………………………. i University of Ghana http://ugspace.ug.edu.gh ABSTRACT Postnatal period is a very critical stage for both the mothers and their babies. The importance of postnatal care services has been established in various studies globally. Yet postpartum care is the most neglected aspect of women’s health care, not only in developing countries but also in some developed countries. In Ghana 23% of postpartum mothers do not receive postnatal at all. This study seeks to explore contributory factors associated with low postnatal service utilization in Ga East District of Greater Accra Region (GAR).The study design was a cross sectional explorative and qualitative research using focus group discussions. The target population for the study was women in the reproductive age and living in the Municipality. The study used five focus group discussions to determine factors contributing to low postnatal coverage in Ga East Municipality. A purposive sampling was employed to carry out to recruit the participants. The researcher moderated all discussions assisted by one trained assistants. The taped discussions were transcribed and the resulting texts analyzed by using thematic analysis. The study revealed that limited availability of public health facilities, in adequate health professionals like midwives, community health offices and doctors in Abokobi Health Center for instance, lack of knowledge about post natal care, negative staff attitude are the mainreasons for the low utilization of not only PNC services but other health services as well. . The findings of the study will be communicated to both the School of Public Health and the Ghana Health Service. ii University of Ghana http://ugspace.ug.edu.gh DEDICATION This dissertation is dedicated to my husband, Arc. Eric K. Arko, who has been very supportive over the years in both good and difficult times. To my two lovely kids, Erica and Junior whose understanding and encouragement sustained me during this programme. To Miss Gladys Ackon, my beloved for her support and prayers. To my parents, Mr. and Mrs., Arthur, who had also wished me to aspire to reach higher heights in all my endeavours. To my in-laws, Mr. and Mrs. Arko for their advice. iii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT This dissertation was born out of the hard work of some individuals who need to be acknowledged and appreciated. I will like to extend my unconditional gratitude for their contributions and efforts. To Dr. Dina Baah-Odoom, my supervisor, thank you for your guidance, encouragement and support throughout this work. To Dr.Philip Baba Adongo, the head of Department of Social and Behavioural Sciences, School of Public Health To all the staff of the Department of Social and Behavioural Sciences of the School of Public Health, of University of Ghana, thank you so much for the knowledge impacted in me. To Sister Dzifa, l say God richly bless you for your eminence support. To Ga East Municipal Health Management Team especially the director, Dr.Julius Dadebo and deputy director for nursing services, DDNS Rejoice Bansa. To my respondents without whose support this work would not have come on, l say ‘ayekoo’. To my classmates, l say thanks for your friendship and support, it was a privilege knowing you. Lastly, but not the least am highly indebted to the Almighty God who has made all this work possible. iv University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS CONTENT PAGE NUMBER Declaration………………………………………………………………………….. i Abstract…………………………………………………………………………… ii Dedication…………………………………………………………………………. iii Acknowledgement………………………………………………………………….. iv Table of content…………………………………………………………………… v List of figure………………………………………………………………………... ix List of Tables…………………………………………………………………………. x List of Acronyms……………………………………………………………………. xi Operational Definitions…………………………………………………………… xii CHAPTER ONE………………………………………………………………….. 1 1.0 General Introduction…………………………………………………………… 1 1.1 Introduction……………………………………………………………. ………… 1 1.2. Background…………………………………………………………………......... 1 1.3 Statement of problem…………………………………………………………… 3 1.4 Objectives………………………………………………………………………… 5 1.5 Research Questions……………………………………………………………….. 5 1.6 Theoretical Framework (Health Belief Model) ………………………………….. 5 1.7 Conceptual Framework………………………………………………………. 6 1.8 Justification………………………………………………………………….. 8 1.9 Organisation of Study…………………………………………………………. 8 v University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO…………………………………………………………………. 9 2.0 Literature Review………………………………………………………………. .9 2.1 Introduction……………………………………………………………………. 9 2.2 The Health Belief Model………………………………………………………… 9 2.3 Summary of Literature Review………………………………………………….. 17 CHAPTER THREE………………………………………………………………. 18 3.0 Methods…………………………………………………………………… 18 3.1 Introduction……………………………………………………………… 18 3.2 Research Design ……………………………………………………… 18 3.3 Study Area ………………………………………………………... 18 3.3.1. Health Facilities…………………………………………………………. 19 3.4 Variables for the study…………………………………………………….. 20 3.5 Study Population …………………………………………………………… 20 3.6 Ethical Consideration……………………………………………………….. 20 3.7 Sampling……………………………………………………………………… . 21 3.7.1 Sampling Technique………………………………………………………… 21 3.7.2 Sample Size…………………………………………………………….. 21 3.8 Eligibility Criteria………………………………………………… …………. 21 3.9 Data Collection Technique/Strategies…………………………………. 22 3. 10 Data Collection Instruments………………………………………………… 23 3.11 Quality Control………………………………………………………………… 23 vi University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR………………………………………………………………… 24 4.0 Introduction ……………………………………………………………… 24 4.1 Data Analysis………………………………………………… 24 4.2 Findings……………………………………………………. 25 4.2.1 Socio-demographic characteristics of participants…………………………. 25 4.2.2 Cues to Action: Women’s Knowledge about Postnatal Care………………… 27 4.2.3. PerceivedThreats: Risk to Postnatal Non Attendance……………………….. 34 4.2.4 Perceived Benefits: Of Women and their Babies Staying Healthy………………. 35 4.2.5 Perceived Barriers: Access to Postnatal Care Services……………………… 38 4.2.6 Self Efficacy………………………………. ……………………………. 40 4.3 Participants Opinion on Ways of Improving PNC………………………….. 40 4.4 Summary……………………………………………………………………… 42 CHAPTER FIVE …………………………………………………………………. 43 5.1 Introduction……………………………………………..……………………… 43 5.2 Conclusion……………………………………………………………………….. 43 5.3 Recommendation ………………………………………………………………… 44 5.4 Limitation of Study…………………………………………………………… 45 vii University of Ghana http://ugspace.ug.edu.gh REFERENCES………………………………………………………..………… 46 APPENDICES……………………………………………………………………. 49 Appendix 1: Consent Form……………………………………………………… 49 Project Title:………………………………………………………………………. 49 Appendix 2: Focus Group Discussion (FGD) Guide…………………. ………… 52 viii University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Conceptual Framework…………………………………………………………….7 Municipal Map……………………………………………………………………..53 ix University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Demographics of Respondents……………………………………………..25 University of Ghana http://ugspace.ug.edu.gh x LIST OF ACRONMYS ANC - Antenatal Care CWC - Child Welfare Clinic CHN - Community Health Nurse CHO - Community Health Officer EPI - Expanded Programme on Immunisation FGD - Focus Group Discussion GES - Ghana Education Service GHS - Ghana Health Service GMHS - Ghana Maternal Health Survey GSS - Ghana Statistical Service HBM - Health Belief Model MDG - Millennium Development Goals MHMT - Municipal Health Management Team PNC - Post natal Care RCH - Reproductive and Child Health SD - Supervised Delivery WHO - World Health Organization University of Ghana http://ugspace.ug.edu.gh Operational Definitions Postnatal period-begins immediately after the birth of the baby to six weeks. Postpartum-also known as pueperium begins with the delivery of the placenta to six weeks. It also refers to issues concerning the baby. Postnatal care-the skilled care rendered to both mother and baby immediately after birth to six weeks. Knowledge- awareness of women postnatal care services in the Ga East Municipality. Attitude/belief-the importance women in Ga East Municipality attach to post natal care. Access –in terms money, distance, transport and availability of quality postnatal care services Skilled care: “is a quality of care to the women during pregnancy, childbirth and postpartum period and her infant provided by a skilled personnel supported by an enabling environment (necessary equipment, supplies and medicines and infrastructure) and functional referral system” (WHO, 2012). The immediate postnatal period -Covers the first 24 hours from birth, where close direct or indirect supervisionby a skilled attendant is required so that any problems can be identified promptly andappropriate intervention or referral taken. The early postnatal period- The period from Days 2 through 7 xii University of Ghana http://ugspace.ug.edu.gh The late postnatal period -The period from Days 8 through 42. (WHO, 2010) The wardrobe Syndrome -The idea of postpartum women wearing new clothings for postnatal care visits. Supa-nana - A health educational promotion on regenerative health being run on the national televisions. xiii University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE 1.0 General Introduction 1.1 Introduction This chapter provides an overview of the study. The chapter presents the background to the study, problem statement, purpose of the study, research objectives, research questions, significance of the study 1.2 Background Studies have found that the postnatal care period or postpartum period also known as the pueperium begins with the delivery of the baby and the placenta. It is basically the provision of a supportive environment where a mother and her newborn infant and the whole family begin their new life together. (Lakhani, 2006).Postnatal Care also involves the care of the mother and her baby for forty (40) days following delivery and gives an opportunity to assess the mother for any physical, psychological, emotional and social needs. (Lakhani, 2006). The baby is also assessed for any risk factors and physical problems. The end of the post partum period is often considered as six to eight weeks after delivery because the effect of pregnancy on many systems may have resolved by this time and these systems would have largely returned to their pre pregnancy state. However, all organs do not return to their baseline within this period. The return to baseline is not necessarily linear overtime. In some studies, some women are considered post partum for as long as 100days or even 12months after delivery. University of Ghana http://ugspace.ug.edu.gh 2 The need for continuum of care as a core principle of programs for maternal, new born and child health and as means to reducing maternal, new born and child death has been emphasized by recent literature.(Kerber, de Graft-Johnson, Bhutta, Okong, Starrs, &Lawn,2007) Postnatal care services are the most neglected programme of the reproductive and child health programmes in the African region and yet a number of serious complications and majority of maternal deaths occur during the postnatal period especially in this part of the world. (Ogwang 2005, Warren, Daly, Toure & Mongi 2006). Many African mothers and their newborns, especially those who deliver at home do not receive postnatal care (PNC) services at all. From twenty-three (23) demographic health surveys (DHS), only 13% received postnatal visit within two days of birth, of the two thirds of the sub-Saharan African women who delivered at home, According to the DHS data in Mali 85% of women who delivered at home received no PNC and in Eritrea, 92% of women who delivered at home received PNC after six weeks of birth. (Warren, Daly, Toure & Mongi 2006). It has been established that mortality can be extremely high on first and second day after birth. Although postnatal has frequently been neglected in trails, new evidence is shaping the development of the post natal package (Bang, Bang, & Reddy, 2005, Haw, Mushi, Mshinda, Tanner, & Schellenberg, 2009). Kerber et al. (2007) proposed that post natal is vital for the reduction of death among mothers and neonates and to support the adoption of healthy behaviors. Postnatal care for mothers and infants should include assessment for mother and infant to identify complications, facilitate referral and counseling in areas such as infant feeding, maternal nutrition and family planning (FP) to promote healthy behaviors (WHO, 1998). For example, the highest risk of death for both the mother and her newborn occurs at the time of childbirth or immediately in the period of birth. It has been established that appropriate postnatal University of Ghana http://ugspace.ug.edu.gh 3 care (PNC) is critical to safeguarding maternal and new born health (Sines, Syed ,Wall & Worley 2007).Of the approximately 130 million infants born annually worldwide, four million infants die in the neonatal period, representing almost 40% of deaths of children under five years of age.(Lawn, Consens &Zupan 2005). According to Abou Zahr and Wardlow (2001), more than two-thirds of neonatal deaths occur in the first seven days of life and of these half die in the first twenty-four hours. This is also the case with maternal deaths where almost two-thirds tend to occur during the PNC period. Strategies to prevent and reduce neonatal deaths have been implemented worldwide, including the provision of postnatal care to mothers and newborns within the first 42 days of life. (Darmstadt, Bhutta, Cousens, Adam, Walker, & de Bernis, 2005). Sines, Syed, Walls and Worley (2007) argued that with the dramatically increased risk of newborn deaths in the first hours and the first days of life, newborns are recommended to receive postnatal health care immediately after delivery. Health professionals are able to detect post delivery problems including potential complication and to provide appropriate treatment promptly, during postnatal care services. In Ghana, postnatal mothers and their neonates are recommended to receive at least two adequate health care checks within the period of 0-3 days and 8-28 days after birth (Ghana Maternal Health Survey [GMHS] 2007, Ghana Statistical Service [GSS] et al., 2009). 1.3. Statement of the Problem The utilisation of postnatal care services is very important to save women and children lives (WHO, 2012). Even though globally maternal mortality due to pregnancy and child birth was reduced by 50% from 1990 to 2010, three hundred and fifty-eight thousand (358,000) women University of Ghana http://ugspace.ug.edu.gh 4 still die from pregnancy related problems every year, worldwide. Most of these deaths occur within 48 hours after birth. Also, each year 7.6 million children under age five die. Sub-Saharan Africa and Southern Asia record the highest maternal, neonatal and under-five mortality rates in the world over. (WHO, 2012). Post natal care utilization is low in Ghana (60%) as in most African countries, especially when compared with other reproductive services like antenatal care (ANC) utilisation which is 95%.(Ghana Demographic Health Survey [GDHS], 2008).Post natal period considered as a critical period for the safety of both mother and newborn, makes it imperative that this huge gap of 35% is bridged. According to the Ga East Municipal Health Management Team (MHMT) Annual Report (2011), although there has been some stead increase in the PNC coverage (from 42% in 2010 to 53% in 2011); it is still below the national coverage. Considering this low utilisation, many post partum women and their newborns living in the Ga East Municipality could be suffering from post delivery complications like sepsis, anaemia and hemorrhage which may eventually claim their lives some of which l am afraid, may go unnoticed especially for those women who deliver at home. In this regard the current study, will like to find answers to this question “What are the factors contributing to low PNC coverage in Ga East Municipality? University of Ghana http://ugspace.ug.edu.gh 5 1.4 OBJECTIVES General Objective To determine the factors contributing to low PNC service utilisation in Ga East Municipality. Specific Objectives 1. To assess the level of knowledge about postnatal care services 2. To examine the women’s threats associated with post natal clinics. 3. To determine access to postnatal service delivery in the municipality. 1.5 Research Questions What is the level of knowledge of women in Ga East Municipality about postnatal care? What are the women’s threats associated with postnatal clinics? How accessible is postnatal care service delivery in the municipality? 1.6 Theoretical framework Health Belief Model The study employed HBM (Becker, 1984) variables to explore the factors affecting low postnatal service utilisation. According to HBM, individuals will take action to ward off, to screen for, or to control an ill health condition if: they regard themselves as susceptible to the condition, they believe it to have potentially serious consequences, they believe a course of action can reduce the susceptibility and seriousness of the condition and when they believe the costs of the action are outweighed by its benefits. University of Ghana http://ugspace.ug.edu.gh 6 1.7 Conceptual Framework Conceptual framework refers to a set of concepts that are linked and described by broad generalizations which are formulated by an individual for a purpose (Rosenstock, 1974). Conceptually, in relation to the current study, mothers will attend PNC clinic or seek for postnatal care services if they have problems like difficulty in lactating or either the newborn or mother is unwell. Mothers will also seek for postnatal care if they are aware of the existence of postnatal care services and perceived that they will get the quality of care that they needed. Perceived Susceptibility; an individual’s perception of her or his risk of contracting a health condition). They believe it to have potentially serious consequences (Perceived Severity; an individual’s perception of the seriousness of a health condition if left untreated. The combination of these is the perceived threats of the health condition (emotive response is fear).They believe a course of action can reduce the susceptibility and seriousness. They believe the costs of the action are outweighed by its benefits (Perceived Benefits; the perceived effectiveness of taking action to improve a health condition and Perceive Barriers; the perceived impediments to taking action to improve a health condition. The above would be achieved if individuals are Cued to take Action and their believe in their personal ability to take action (Self Efficacy; confidence to continue the healthy behaviour and overcome temptations). (Becker & Rosenstock 1984). All the six constructs will be used for this study. University of Ghana http://ugspace.ug.edu.gh 7 Figure 1; conceptual framework based on Health Belief Model Conceptual Framework Source; researcher’s own construction (2013). Cues to Action: Knowledge about post natal care and where the services are available. Barriers to postnatal Cost of transportation, distance, non availability of health facility, quality of postnatal care including negative staff attitude. Behaviour: Postnatal attendance Benefits: Having healthy mothers and babies. Self Effacy: Women’s belief that they can go for postnatal care Services. Susceptibility and severity (threats) Fear of both mother and baby dying, or losing one’s baby University of Ghana http://ugspace.ug.edu.gh 8 1.8 Justification of the study. Though the Ga East Municipal Health Management Team has tried solving the low post natal coverage in their own small way, there has not been much improvement. With La-Nkwatanang Madina Municipality which used to generate the bulk of the data of postnatal services, curved out of Ga East Municipality, the situation may get worse. I am motivated to research and determine factors contributing to low postnatal care coverage and the results will help inform the Municipal Health Management Team come up with a pragmatic measure in arresting the situation, as no published study have been done in this area. 1.9 Organization of the study This study is presented in five chapters: Chapter one consist of the introduction, background information, statement of the problem, objectives, research questions, justification of the study, conceptual framework and the organization of the study. Chapter two is the literature review which entails the theoretical and empirical literature on the subject under study and summary of literature. Chapter three contains the Research Design and Methodology which describes the data collection procedure, study design, study population and sampling techniques. Ethical consideration, eligibility criteria and quality control. Chapter four presents the data analysis and discussion of the research findings. Chapter five is the conclusions, recommendations and limitations of the study for policy makers and future research. Relevant references and appendices are also presented at the end of the dissertation. University of Ghana http://ugspace.ug.edu.gh 9 CHAPTER TWO 2.0 Literature Review 2.1 Introduction This chapter presents a critical review of the literature on factors contributing to low postnatal care. Relevant studies in both developing and developed countries are reviewed with particular emphasis on the findings and methodological issues in developing countries. A search was conducted through published journals, which were relevant to the topic. Some of the thematic areas under review include knowledge, threats associated with postnatal care and access to postnatal care. 2.2 The Health Belief Model (HBM) The Health Belief Model (Becker, 1984) was originally developed by Godfrey Hochbaum in the 1950s as a psychological framework that attempted to discover the variables that accounted for public’s failure to participate in health screening programme for tuberculosis (Hochbaum 1958). Becker and Rosenstock (1984) further developed the model for health promotion. The model is based on the assumption that people’s attitude and beliefs could be used to predict and explain their behaviours. It postulates that individuals will take action to prevent a disease only if they feel at risk and if they believe that something could be done to prevent or moderate its severity. Originally, the model conceived of four main constructs: perceived susceptibility to a disease; perceived severity of the disease; perceived benefits of engaging in behaviours likely to reduce the threat of the health condition and perceived barriers to taking the action. Rosenstock, Stretcher and Becker (1988, 1994) revised and expanded the model to incorporate two additional University of Ghana http://ugspace.ug.edu.gh 10 constructs: cues to action and self efficacy. Below are brief descriptions of the six key constructs of the model. Perceived Susceptibility: is one’s subjective perception of risk contracting s disease. Perceived Severity: are the beliefs about the seriousness of contracting the disease. Perceived Benefit: are the beliefs in the effectiveness of the preventive strategies designed to reduce the threat of the illness. Perceived Barriers: are the potential negative consequences of taking particular action .These barriers may be financial, physical and psychological. Perceived benefits and perceived barriers provide a preferred path of action. Cues to Action: refer to events personal, interpersonal and or environmental experiences that motivate a person to take action. The cues to action can be internal (such as symptom of a disease) or external cues (such as mass media communication- electronic and print, reminders or advice from health care provider(s) and interpersonal interaction with friends, family, etcetera).Cues to action influence threat appraisals and may generate the initial preventive action taking (Becker & Rosenstock, 1984). Self Efficacy: this is the belief in one’s ability to successfully perform the behaviour required to produce the desired outcomes. The self efficacy constructs was directly transferred from Bandura’s 1977 work. According to Becker and Rosenstock (1984) all the six variables independently contribute to one’s decision about their health and the resultant action taken by the person. Additionally, University of Ghana http://ugspace.ug.edu.gh 11 demography, structural and socio-psychological variables, can influence both perceived susceptibility and perceived severity, and perceived benefits and perceived barriers to action. HBM is the oldest and the most widely used model to predict various health behaviours including utilization of postnatal care (PNC). HBM suggests in postnatal care utilization, that women are more likely to seek postnatal care, only if they recognize that either they or the newborn infant is susceptible to ill health; believe the consequences of the illness are serious: if they believe they can successfully carry out the behaviour required to produce the desired outcomes and that the barriers of seeking postnatal care is comparatively minimal. For this study, 15 articles that applied the HBM in an African context to understand postnatal care utilization were reviewed. To obtain the papers, searches of the following electronic database were conducted: BioMed Central (BMC), Google Scholar, Hinari, LANCET, PLOS and PUDMED. Key words used include, (postnatal care utilisation) (Health Belief Model) and ( Global, Africa, Ghana). During the search, the relevant papers cited in the references of the articles were identified and hand searched. This resulted in getting more articles. A study was eligible if it is based on postnatal care and maternal health service utilisation and was published after 2000. Details of the articles are given below; Nabulera, Witte, Muchunguzi, Bajunirwe, Batwala, Mulogo, et al. (2006) discovered through their research that there was low level of knowledge about postpartum care among rural Ugandan women. Most of these women did not know about the importance of postpartum care (PNC) and its benefits. Islam, Islam and Banowary,(2009) however reported in their study on the Garo Tribe of Bangladesh, that majority of Garo women were aware of the ANC and PNC services and University of Ghana http://ugspace.ug.edu.gh 12 about (92%) of the respondents could mention at least one ANC and PNC services offered at the health centers in their local communities. Titaley, Hunter, Heywood and Dibley (2010), in their research done in Indonesia, also identified lack of community awareness about the importance of these services, as some community members perceived health services to be necessary only if obstetric complications occurred. Women in rural Southern Tanzanian though generally positive about antenatal care (ANC) and postnatal care (PNC), also perceived PNC as a service for children of all ages, lasting well beyond 42 days after delivery, discovered ( Mrisho, Obrist, Schellenberg, Haws, Mushi, Mshinda et al.,2009), in their study of rural southern Tanzanian women. Dhakal, Chapman, Simkhada, van Teijlingen, Stephens, & Raja (2007) also reported that (47%), women and their families lacked awareness or do not perceived need for postnatal care. Another study carried out by Nankwanga (2004) revealed that out of 330 participants in the study, 139 (42.1%) did not attend post natal care services at all. Of these, over half (53%) were unaware of PNC services. Fourteen percent (14%) were attending to other family matters and 7.9% thought it was not necessary. Majority 93 (66.7%) of those who attended did so for immunization of their babies. Mohamed (2012) in his study in Zanibar, Tanzania, also revealed that lack of knowledge, emerged strongly as the reason for the delays in decision to seeking care and identifying place of care, which contributed to under utilisation of health facilities during labour, delivery and postpartum period. Titaley, Hunter, Heywood and Dibley (2010), found that the main reason women attended antenatal and postnatal care services was to ensure the safety of both mother and infant’s health. However there were some barriers to the utilisation of postnatal care services. Financial University of Ghana http://ugspace.ug.edu.gh 13 difficulty, in relation to the cost of health services, transportation costs, or both, emerged as the major issue among women who did not fulfill the minimum requirements of four antenatal care services or two postnatal care services within the first month after delivery. The distances from health facilities, in addition to poor road conditions were also major concerns, particularly for those living in remote areas. Mrisho, et al (2009) also stated that the majority of women who gave birth at home delayed in seeking PNC services were mainly to allow the mother and baby to regain energy lost during childbirth, waiting for the baby's cord stump to fall off, lack of money and distance to the health facility . Tao, Huang, Long, Tolhurst and Raven (2009) revealed that only 4.2% and 4.5% of women received one or more postnatal visits at home in County A and County B. Perceived reasons given for this low rate of provision and utilisation of postnatal care, include limited value placed on postnatal care by women and providers, inadequate funding for maternal health care, limited human resources and lack of transport in township hospitals. However, according to Dhaher et al. (2008), the most frequent reason for not obtaining postnatal care was that women did not feel sick and therefore did not need postnatal care (85%). Based on a multivariable analysis, use of postnatal care was higher among women who had experienced problems during their delivery, had a caesarean section, or had an instrumental vaginal delivery than among women who had a spontaneous vaginal delivery. Interestingly the same study did indicate that majority of the women deemed post natal care necessary. A study conducted by Ogwang (2005) in Uganda revealed that 96.1 % of the participants were satisfied with the overall quality of postnatal care services. However before being discharged from the hospital, 48.7 % babies and 40.6 % of the mothers had not been examined, most of the University of Ghana http://ugspace.ug.edu.gh 14 examination done was in labour ward. Health workers tended to concentrate on baby's sex and examination of mothers who had caesarean birth. 49.2% of the babies and 43.9 % of the mothers examined had not been given information. Participants with formal education and caesarean birth better understood instructions on their medications. Mother's perception of quality of postnatal care was more geared towards the care for the baby, danger signs that can occur to the baby and the mother in the postnatal period and accessing family planning services. Other factors that raised concerning for the delivering of high quality postnatal health service, from health providers were identified as inadequate in-service training, weak skills and knowledge of staff, lack of equipment in township hospitals and poor supervision and monitoring.(Tao, Huang, Long, Tolhurst & Raven, 2009 ) Many African women and their newborns do not have access to health during early postnatal period, this put them in increased risks of illness, disability and death. The first 24 hours after birth is the most critical and important postnatal period, as most maternal and infant death occur around this time. Yet PNC programmes are among the weakest of all reproductive and child health programmes in the region. To curb this situation, a study by Warren et al.,(2006); Opportunities For Africa’s Newborns, revealed that there are feasible, sustainable and cost effective measures that could be adapted to reach mothers and their newborns, especially for the 18 million African women who deliver at home. For example, about fifteen percent (15%) of women in Madagascar receive a postnatal visit by a health professional at home. The same study also reported that one pilot study done in rural Kenya also have retired midwives facilitating childbirth at home and visit the mother and baby two or three times in the first week. University of Ghana http://ugspace.ug.edu.gh 15 According to Titaley, Hunter, Heywood and Dibley (2010), in their research conducted in Indonesia, limited availability of health services was a problem, in remote areas, especially where the village midwife frequently travels out of the village. Therefore the services of traditional birth attendants (TBA) for antenatal, delivery, and postnatal care were widely used, and their roles in maternal and child care were considered vital by some community members. Singh, Pomades, Mishra, Pallikadavath, Johnson, and Matthews (2012) also revealed in their study carried out in India, that postnatal care services for both mothers and newborns was substantially lower than the care women received during pregnancy and childbirth. The study indicated that only 44% of mothers in India at the time of the survey received any care within 48 hours of birth likewise only 45% newborns received check-up within 24hours. It also indicated that the rich utilise postnatal care services more than the marginalised and mothers who delivered at home were less likely to have received PNC than those who delivered in health facilities. It was also discovered that high inequalities existed in the type of PNC for birth that took place at home compared to facility births. This agreed with Matijiasevich, Santos, Silveira, Domingues, Barros, Marco et al. (2009) findings which also revealed that poorer women, black or mixed within the lower level of education, single mothers, adolescents, smokers women who delivered and those who were not assisted by a physician were less likely to attend postnatal care services. Postnatal visits were also found to be less frequent among women who relied on public health facilities than among private patients that is 72.4% as against 96% respectively. Dhaher , Mikolajczyk , Maxwell and KrAomer (2008), also stated in their study that use of postnatal care was also higher among women who delivered in a private hospital as compared to those who delivered in a public hospital., though there were some regional differences. Another study carried out by Dhakal,et al..(2007) indicated that of 150 women included in the study, half University of Ghana http://ugspace.ug.edu.gh 16 were illiterate and the remaining women had equal numbers of basic education, secondary or tertiary education. Seventy-two percent (72%) of the women were farmers, 25% housewives and 3% working in the formal sector. The proportion of women who had received postnatal care within 42 days after delivery was low (34%). Less than one in five women (19%) received care within 48 hours of giving birth. Of those who received PNC, 65% was attended to by a doctor, (20%) from a nurse or other health workers (16%) Similarly, the majority of women (78%) had received their care in hospital. Mekonnen and Mekonnen, (2002) conducted a research in Ethiopia ,and revealed that only 6 percent of women who delivered in the five years preceding the survey were assisted by a health professional for their most recent pregnancy. What is more interesting and alarming, is the fact that less than 3% of the women who delivered outside a health facility received postnatal care. The study also indicated that women from Addis Ababa are more likely to receive care from a doctor, nurse, or midwife than women from other urban areas or rural areas. Even in Addis Ababa, 83% of women received antenatal care, 71% received delivery care, and only 19% received postnatal care. Utilisation of maternal health care services is lowest in rural areas as only 22% of rural women received antenatal care, and 2 % received delivery or postnatal care. Comparatively 63% of women from the other urban areas received professional antenatal care, 31% received delivery assistance, and 10% received postnatal care. There was little difference in utilisation of postnatal care by age and women who had only one birth in the past five years were also more likely to utilise maternal health care than women who had more than one birth in the same period. Ching, Fowles and Walker (2006) in reviewing postpartum Maternal Care in United States of America, indicated that the neglected aspect of women’s health is postpartum maternal care. The limited national objectives and data related to maternal health is enough evident of this neglect. University of Ghana http://ugspace.ug.edu.gh 17 Their study also revealed that missed opportunities for enhancing the health care of postpartum women occur in the scope of routine postpartum care. Differing perceptions of maternal needs between nurses and new mothers also contribute to inadequate health care. None the less, health professionals who practice in a wide range of health-care settings could assume pivotal positions to contributing to health-care policies and practices that may improve care for postpartum women. Ching, Fowles and Walker (2006) therefore recommended that national health objectives related to postpartum maternal health need to be expanded, to consider maternal morbidities beyond postpartum depression. Such expansion is contingent on expanding national data collection on maternal health status postpartum. Titaley, Hunter, Heywood and Dibley (2010), also recommended an urgent need to improving and making postpartum care services more user friendly and accessible. Trainings of health providers at all levels and health education on the importance of postpartum care services to families were also recommended. 2.3 Summary of Literature Review The body of evidence on the global trend of PNC reviewed has indicated that PNC is one of the most neglected, if not the most neglected aspect of women’s health in the developing world in particular. The literature has also revealed that there is low utilisation of PNC services. Inadequate accessibility health facilities and health care professionals, negative staff attitude of health staff, lack of knowledge, poverty, distance, cultural practices, poor quality of care, and inadequate family support among others were some of the factors highlighted in the literature as barriers to postnatal utilisation. The Health Belief Model was adopted in this study to illustrate the concepts related to factors contributing to low postnatal care utilisation. University of Ghana http://ugspace.ug.edu.gh 18 CHAPTER THREE 3.0 Methods 3.1 Introduction This chapter describes the research methodology. A description of the research design, research setting, target population, sampling size and sampling strategy are given. Research instruments used and the ethical issues relating to the study are also mentioned. 3.2 Research design The study is essentially exploratory. This research design is relevant to the study because of its flexible and change adaptable nature. It is also a valuable means to seek new insight, to ask questions and to assess phenomena in a new light. Its ‘two-phase’ approach makes it easy to implement and straight forward to describe and report. This section therefore, presents an overview of the methods used in collecting and analysing the data for the study. The section further includes the description of the research design, population, sample and sampling techniques, data collection and analysis. 3.3 Study Area All data were collected in five communities in three of the four sub-municipalities within the Ga East Municipality. The communities were Boi in the Abokobi Sub municipality, Dome Ayigbe Town and New Station Area in Dome Sub municipality and Kwabenya Agyigbe Town and Abuomu both in Taifa Sub municipality. The Ga East Municipality lies to the North -eastern part of Greater Accra Region. It is bounded to the North by Akuapim South District, West by Ga West Municipality, East by Madina – La University of Ghana http://ugspace.ug.edu.gh 19 Nkwantang Municipality which until recently was part of Ga East Municipality and to the south by Accra Metropolis. Approximately 276,017 people live in Ga East Municipality. It is currently made-up of four sub-districts namely; Abokobi, Haatso, Taifa, and Dome sub- districts. There are over fifty communities comprising mixed settlements, i.e. urban, peri-urban and rural areas. Fair view of the district reveals public services and trading as dominant in its occupational scene, followed by farming and craftsmanship. Besides, a sizeable proportion of the working forces in the district are unemployed reflecting the high poverty level. Two major festivals, namely Dokobi are celebrated by Sessemi inhabitants and Homowo celebrated by Boi, Teiman and the other communities in conjunction with Teshie and La inhabitants. 3.3.1 Health Facilities The municipality has about seventeen (17) facilities made up of public, quasi, private and Community-based Health Planning Services (CHPS) compound .The breakdown is as follows; One ((1) public (Abokobi Health Center) One (1) quasi (Ghana Atomic Energy Commission Clinic) One (1) CHPS compound (Taifa) Fourteen (14) Private Facilities. For easy access to health care, the municipality has been zoned into CHPS zones which are manned by Community Health Officers (CHOs), as the only one public health facility that Ga East Municipality can boast of is a health center. University of Ghana http://ugspace.ug.edu.gh 20 The Municipal Health Management Team (MHMT) is collaborating well with the fourteen private facilities. (Source; Municipal Health Annual Report 2012). 3.4 Variables for the study The variables for the study include demographic characteristics, knowledge, threats associated with postnatal clinics and access to postnatal care. 3.5 Study population The study population were women in their reproductive age (15-49 years) living in Ga East. This is because they are those who seek postnatal care. The study population consists of 82,805 women. However, it must be stated that a 58 year old grandmother who was originally not part of the study had interesting experience to share with discussants. 3.6 Ethical Consideration: Permission and invitation to participate. Permission was sought from the Municipal Director of Health Service of Ga East since my research topic was within his domain. Permission to conduct FGDs in the communities was sought from community leaders. Information about the objectives of the discussion and the purpose of the overall study were provided to each potential participant. Confidentiality with regard to their participation and anonymity with regard to their stored data were assured, and each participant was asked for her verbal consent to participate in the focus group discussion. Permission to audio-record the discussions was also sought and obtained. In the FGDs, each participant was assigned a unique pseudo-name to protect their identity. Participants did not receive any monetary incentive for University of Ghana http://ugspace.ug.edu.gh 21 participating in the discussions. However, two cakes of soap were provided as a token of appreciation for their participation. This study was approved by the Ghana Health Service ethical review committee. 3.7 Sampling 3.7.1 Sampling technique Participants were purposively selected by the principal investigator for FGDs through Community Health Officers (CHOs).The CHOs helped with the recruitment of participants through informal links. They identified postnatal women during their home visiting activities and informed them about the study. The dates and venues convenient to both the interviewer and mothers were communicated to those post natal women who were interested in taking part of the study. The venues were where the CHOs usually hold the Child Welfare Clinics (CWC) in the respective communities. 3.7.2 Sample size A total of forty-one participants participated in the study. 3.7.3 Eligibility criteria Inclusive criteria: all women with one or more children under five years, who are resident in the municipality for at least twelve (12) months and individual’s willingness to participate. University of Ghana http://ugspace.ug.edu.gh 22 3.8 Data Collection Techniques or Strategies Data for the study included both primary and secondary data. Focus group discussions (FGDs) were used to obtain primary data from respondents with the help of two (2) research assistants trained on the focus group discussion guide and on interview techniques. Five focus groups made up of between 8 participants in four groups and 10 participants in the other one group were conducted. Focus Group Discussion Guide (FGD) were used to collect the data for this study because they have traditionally been employed in the social sciences and have much to offer studies on health related issues (Pope & Mays, 2006). FGD highlight (sub) cultural values or group norms; and so makes FGD a data collection technique particularly sensitive to cultural variables. Also FGD gives a collective shared meaning through which a community sustains a particular view of some aspects of the world. (Moscovici, 1984). The FGDs were used to explore the women’s subjective knowledge about postnatal care services. All FGDs were audio recorded, conducted in the Twi language, and transcribed into English and notes taken on verbal and non-verbal communication. A prepared guide was used to ensure that discussions covered all the important themes of the study. The venues were the Reproductive and Child outreach sites for each community. During the data collection permission was sought before the notes taking and the audio-recording. Participants used fictitious names during the focus group discussion. The focus group guide was used to elicit information on the following themes - knowledge about postnatal care, source of knowledge about postnatal care, timing of postnatal care kinds of services rendered, reasons for failure to attend postnatal, risk of failure of PNC attendance, access to postnatal and improving postnatal are services. The researcher first explained the aims of the focus group sessions and established the ground rules for the sessions before discussing the issues.The participants were encouraged to freely express their views. University of Ghana http://ugspace.ug.edu.gh 23 Participants were gathered in a semi-circle around the interviewer. Questions were posed to the group at the same time and every group member was free to volunteer a response; moving the digital voice recorder closer to the respondent who was speaking. Each question was fully discussed before moving to the next question. In some cases follow up questions were asked to probe to get clearer understanding of issues. Sessions lasted between one (1) hour and one (1) hour forty-five minutes. Transcription started 24hours after the focus group discussions. Appropriate and relevant documents were reviewed to complement the primary data sources. 3.9 Data collection instrument A focus group discussion guide, a digital voice recorder, field notebook and a field diary were used in collecting the data. 3.10 Quality control To ensure the quality outcome of the study, the following were done. An independent coder was employed to code about 30% of the transcripts, selected at random, using the coding scheme of the researcher. It is expected that there should be more than 80% agreement in codes (ie the concordance rate). The data was analysed manually, by the researcher. The next chapter is on data analysis and the findings of the study. University of Ghana http://ugspace.ug.edu.gh 24 CHAPTER FOUR ANALYSIS OF DATA AND PRESENTATION OF FINDINGS 4.0 Introduction In this chapter the results of the study are described and the analyses of the data presented. The findings are reported according to the three themes, that is their knowledge, risk of failure to postnatal attendance and access to postnatal care. The background of respondents and the socio- demographic characteristics of participants are also reported. To do this, the researcher conducted focus group discussions. The chapter is organized by sections in accordance with the research questions. Each of the sections contains quotations that depict the general ideas. 4.1 Data Analysis The five Twi focus group discussions were transcribed verbatim, and later translated into English language for ease of interpretation. The limitation was that a considerable amount of information was lost. The data were analyzed according to the aims of the research. Transcripts were analysed using basic deductive approach (Maykut & Morehouse, 1994). The data analysis involved a systematic categorizing and summary of the descriptions to provide a logical framework and themes that characterized and explained the participants’ view on postnatal care services. Initially, the transcripts were read in detail in order to be familiar with the content and then initial codes for emergent themes were generated. The codes were reviewed then grouped into broader categories that reflect the ideas that could help to structure and explain the views and experiences of the participants. The categories were used as the initial coding frame. The coding frames were applied across the transcripts and new University of Ghana http://ugspace.ug.edu.gh 25 themes that address the research questions were generated. The themes were then explored for connections and higher order themes constructed. The relationships among the ways themes co- occur within participants’ accounts were noted. Extracts that demonstrate or capture the essence of the relevant points relative to the research question and literature were selected and used as examples. 4.2 Findings The findings are reported according to the three themes of the study. Each of the sections contains quotations that depict the general ideas. 4.2.1 Demographic Distribution of Participants. Table 1 Demographic Characteristics of respondents Submunicipal/communities Age Structure Educational level Occupation No.of Children. Abokobi Sub municipal Boi Community 20-38years 4 Senior High 4 Junior High 1 Primary 1None 6 Petty Traders 2 Hairdressers 2Unemployed 1-4 University of Ghana http://ugspace.ug.edu.gh 26 Taifa Sub municipal Kwabenya Ayigbe Town Community Abuomu Community 20-38years 21-31years 2 Senior High 3 Junior High 2 Primary 1 None 7 Junior High 1 Primary 3 Petty Traders 1 Hairdresser 4 Unemployed 4 Petty Traders 1 Seamstress 1Quarrier 2 Unemployed 1-5 1-6 Dome Sub municipal Ayigbe Town Dome New Station Area 20-58years 24-48years 1Post Sec. 2 Senior High 3 Junior High 1 Primary 1 None 4 Tertiary 2PostSecondary 2 Senior High 1 Civil Servant 2 teachers 1 Secretary 2Businesswomen 1Hairdresser 1 Seamstress 1-4 1-3 University of Ghana http://ugspace.ug.edu.gh 27 A total of forty-one people participated in the Focus Group Discussion. The demographic factors identified in this research were age, level of education, occupation and number of children of the participants. The oldest participant was 58years (who was originally not part of the study but as an observer, had interesting experience to share with discussants) and the youngest 20 years old. Majority of the respondents have some education ranging from primary to tertiary education, while a few had no formal education. Most of the participants were engaged in petty trading, with quite a sizable number being unemployed and a few of them being civil servants. More than half of respondents had between one and two children, while only a few had at least five children, with the mean number of children being three (3). Interestingly all the participants were married. 4.2.2 Cues to action; Women’s Knowledge about Postnatal Care. On this theme the researcher used three questions to arrive at it. These questions are on the timing, frequency and kinds of services rendered during postnatal care. The postnatal period is the most critical period, in the life of mother and baby, (Sines et al., 2007). It is therefore of great importance that women get to know when to seek for postnatal care especially those who deliver at home. Majority knew about the existence of postnatal care, so they sought for postnatal care services when they delivered. Most of them who knew about it got their information from Community Health Officers (CHOs) and Community Health Nurses (CHNs) during Home Visits and Child Welfare Clinics (CWC). The following illustrate their knowledge and source of knowledge about PNC. University of Ghana http://ugspace.ug.edu.gh 28 ‘…..the weighing nurses came to my house and during conversation asked when l delivered. I told them a week ago and they asked if l had sought for postnatal care service l said no, then they promised to come for me and my baby the following day to take me to the clinic and true, true they came for us. (Anerley, 26 year mother of three, Boi.30th May, 2013). . l went to weighing (CWC) with my child at six weeks at Kekele (Madina Polyclinic) and the CHN asked if l had gone to see the midwives l said no, and she asked me to go with my baby to see the midwives at the maternity unity, who checked my blood pressure and my baby’s weight. (Adjoa Atta, 24 year mother of one, in FGD.Kwabenya Ayigbe Town 4th As for me, it was my co-tenant who asked me to go for post natal after two weeks June, 2013). (Ama Achiaa, 21year mother of one, in FGD.Abuomu 11th However, some of the participants claimed they did not know about the existence of PNC. Quite a sizable number of participants mostly first time mothers, who had given birth to their first children even in hospitals, said they did not seek for postnatal services because they did not know about it. These responses gleaned from the discussion demonstrate their lack of knowledge about the PNC. June, 2013 University of Ghana http://ugspace.ug.edu.gh 29 ‘…as for me l would have gone to see the doctor if l had known or the doctor or the nurses had asked me to go back after a day or two. Or anytime at all that they ask me’. (Akweley, 24 years, first time mother (Focus Group Discussion, Kwabenya Abuomu. 11th ‘….l am a Liberian l do not have any relative here and l did not even know how to bath a newborn baby. The midwife who delivered me asked me not to bath my baby till his cord falls off, and l did what l was told, so if she had asked me to see the doctor or come for a check -up with my baby l would. It was my co-tenant who told me that when my baby is six weeks old l should take him for weighing and l did that.’ June,2013).’ (Naa,,28 years, first time mother, Focus Group Discussion, Dome New Station Area.6th Lack of knowledge about the PNC services could be a barrier to women’s utilisation of postpartum services. From the discussion it is clear that first time mothers were particularly ignorant about the PNC. It is interesting to note that Health Workers who attended to the mothers during delivery did not tell them about the PNC. This has also been reported in other studies, (Dhaher et al. 2007, Mrisho et al. 2009, Nankwang 2004 & Titaley et al. 2008). June,2013).’ Given the intensive sensitization by the Reproductive and Child Health Unit of the Ghana Health Service, it is not surprising that majority knew about PNC. However it was clear from the study, that first time mothers were particularly ignorant about PNC. Many of the women who participated in the research delivered in private health facilities where PNC is not emphasised because, the service is suppose to be free and so it did not make commercial sense to the private provider. Anecdotal evidence suggests that private health facility emphasises, Antenatal Care University of Ghana http://ugspace.ug.edu.gh 30 (ANC) and Supervised Delivery other than PNC. Mrisho et al. (2009) contradicted this finding in their study of women and health care providers in rural Southern Tanzania, where those who delivered at private hospital enjoyed postnatal services more as compared to those who delivered at public hospital. The timing of postnatal care is very crucial in postnatal service delivery, as the first hours, days and weeks after childbirth are dangerous times for both mother and newborn infant. Sines et al. (2007) recommended that newborns receive postnatal health care immediately after delivery. Of those women who knew about postnatal care services, majority of them did not know, how early and how often they have to seek for postnatal care services. This was evident in the responses. ‘…once and that is six weeks.’ (Esi, 27 year mother of three, in FGD, Dome New Station.6th ‘…Oh its once a month, after giving birth.’ June, 2013).’ (Mansa, 30 year mother of four, in FGD, Kwabenya Ayigbe Town.4th Most women were of the view that, postnatal care services are sought once and at six weeks, thus confusing it with the timing of Child Welfare Clinic (CWC) the reason could be because CWC begin around the same time, that post natal period ends, six weeks.CWC is a branch of reproductive and child health services, which seeks to the welfare of children less than five years. To the newborn child CWC usually begins at six weeks then monthly up to 5years.Child Welfare Clinic provides services like growth and development monitoring (usually referred to as weighing by mothers),immunization, registration of babies, physical examination and June 2013).’ University of Ghana http://ugspace.ug.edu.gh 31 counseling of mothers in the care of their children (Offei & Quansah,2009). I believe this confusion of women is as a result of lack of knowledge about post natal care. This finding agrees with Mrisho et al. (2009) where most women confused the PNC services with the monthly immunization. However, two of the participants, were of the view that postnatal care services are sought twice after delivery that is at two weeks and six weeks. Though Ghanaian women are recommended to receive at least two adequate health care checks within the period of 0-3 days and 8-28 days after birth [GMHS 2007, GSS et al2009). This was not the case from the study. I think this is so because most women do not actually know when to seek PNC services as there was no difference between women with tertiary education and those with basic and post-basic education, concerning timing and frequency of PNC. This clearly shows that the Reproductive and Child Health Unit of the Ghana Health Service, needs to reconsider their health educational talk topics to include the timing and frequency for seeking postnatal care. Again from the study, it was evident that most of the participants did not know of the kinds of services rendered during postnatal care. They are of the view that postnatal care is solely for their newborns, as health providers tend to pay much attention to the newborn infants as compared to the mothers, as only the mothers blood pressure are checked and a few questions asked about the mother, with the health providers assuming all is well with the postnatal woman. This was evident in the responses that they gave: ‘…..the nurses checked my BP and asked me to tell the doctor if I had a problem, and since me and my baby were fine, I just told the doctor we were fine. The doctor took my baby, smiled at him, examined him, gave him back to me and asked me to take good care of him, then we left.’ University of Ghana http://ugspace.ug.edu.gh 32 (20 year mother of one, in FGD, Dome Ayibge Town.4th ‘……..the midwife took my baby and weighed him and asked me to take good care of him. June, 2013). She asked how I was feeling. I said I was feeling fine and that was it. She did not do anything for me personally’. (27 year mother of three, in FGD. Boi 30th ‘……the nurses ask you whether you are having pains and ask about your baby, May,2013) they then take your BP and weight and also your baby’s weight and temperature and ask you to go and see the doctor. The doctor looks at what the nurse has written in your folder and gives you blood tonic and ask you to take good care of yourself and your baby.’ (Mercy, 21year mother of one, in FGD in Abuomu 11th This is also the case in Tanzanian, where postnatal services target the newborn with little emphasis on the mothers as revealed by M June, 2013) Participants mentioned the kinds of services rendered at postnatal care as checking of mothers’ blood pressure, weighing of babies, giving of injections against tuberculosis and polio, examination of both mother and baby and counselling on the care of the newborn. These are some of the services rendered at CWCs as compared to palpation of the post partum uterus to expel any blood clots, feeling whether the uterus is gradually going back to its non gravid state observing the locia to see whether it is bright red signifying some bleeding supporting the new risho et al (2009) in their study. University of Ghana http://ugspace.ug.edu.gh 33 mother to position and attach the newborn baby to the breast and observing how the baby suckles and conselling accordingly, among other services rendered at post natal clinics. Sankofa’s Interesting Experience (Sankofa was originally not part of the study. She accompanied her daughter to the discussion. However, as an observer, she shared her experience with the discussants. An experience worth sharing) Sankofa was a 58 year old Cert ‘A’ Teacher who retired from the Ghana Education Service (GES) because her husband was sick and bedridden. She had four children and a grandchild. She narrated her PNC experience with nostalgia. This is how she summarized her story: ‘You see, during our time when you go to show “yourself” to the doctor or midwife two and six weeks after you give birth, the midwife had time for you. She will examine both the mother and baby from head to toe. For example, you the mother, the midwife will put you, on a bed, screen you then ask you to undress, she then look at your breasts press it a little to see if there is enough breast milk, then press your stomach (abdomen) to see if you have any pains and to see if there are dirty blood in your womb. They even look at your pad to know the colour of the blood (lochia) that is coming. And your baby too, they will measure his head with a tape measure, check for the cord, they sometimes smell it. Oh madam during our time dierrr, the midwives had love for us and their job. But today’s midwives, they just check your BP and weight, weigh your baby and that’s it’. (Sankofa, Dome Ayigbye Town.4th June, 2013). University of Ghana http://ugspace.ug.edu.gh 34 Sankofa’s experience demonstrates the crucial role the health worker plays for the access, knowledge and quality PNC services. For instance the availability of a midwife giving the right information about the importance of post natal care services and rendering adequate post natal care checks to her clients will go a long way to improve post natal care utilization. 4.2.3 Perceived threats: risks to postnatal care non- attendance On this theme the researcher used two questions to arrive at it. These questions were on the consequences of failure to receiving postnatal care services and what will make women to seek postnatal care. There was a universal belief that failure to seek postnatal care could result in unfortunate consequences, the woman or her newborn infant or both of them may become sick, disabled or die from birth complications. Below are some of their responses. ‘...If you refuse to attend post natal, you or your baby can die through infections.’ (Mary, 30 year mother of four, in FGD, Kwabenya Abuoom, 11th June, 2013). ‘..mothers and their babies may not get the needed care which can affect them later in life for instance if you had a difficult labour’ (Janet 33year mother of three, in FGD, Dome New Station Area.6th Despite the general belief that failure to seek postnatal care could be detrimental to both mother and baby and to a large extent the family, quite a number of the participants will only seek for June, 2013). PNC services when there is something wrong with their babies or themselves. This was evident in some of their responses: University of Ghana http://ugspace.ug.edu.gh 35 ‘....if you deliver yourself (normal vaginal delivery) and there is nothing wrong with the mother and her baby, there is no need for to go to the clinic for the nurses to be shouting at you for nothing. You see most of the nurses are very rude and they talk to people anyhow, hmmmm! As if they feed you at home.’ (Ama 26 year mother of three in FGD, Boi.29th May, 2013). ‘... My baby felt very hot so l had to see the doctor two days after delivery and my baby was admitted for over two weeks. It was good that l went to see the doctor, on the second day if l had waited for one more day l would have lost my baby.’ (Akpene, 25 year mother of two in FGD, Boi.29th Some women will seek for postnatal care when they feel that they are at risk of losing their lives or that of their babies or they have difficulty with breastfeeding. As noted elsewhere (Dhaher et al., 2008, Haws et al., 2009) caesarean delivery or perennial incision women are more likely to seek PNC services. May, 2013). 4.2.4 Perceived benefits: of women staying healthy and having healthy babies. The researcher used two questions to arrive at this theme. The questions were on the advantages of PNC, what PNC does to help their babies and the importance of PNC to women in the respective communities. Almost all the participants believe that postnatal care services are good for the health of both the mother and the baby as it helps in early detection of any abnormality in the newborn baby and afterbirth complication of the mother for appropriate and timely treatment. These are few responses from the participants; University of Ghana http://ugspace.ug.edu.gh 36 ‘…. Its good for our babies because if there is anything wrong with our babies, it will be detected early and appropriate treatment given’. ‘…hmmmm...I think it is good, because if you go and there is something going wrong inside you, the midwives would see and treat you early so that it does doesn’t get worse. But if you stay at home and don’t go and something is happening inside you, you will not know’. ‘… It is very important because the injections that they give to our babies during weighing help protect them against getting sick’. ‘…It is very important to us women because getting sick after giving birth is not good koraa (at all). If God is not on your side, you can die early and if you die who will take care of your children for you?’ ‘…may be during delivery something went wrong with you the mother which you may not know so if you don’t go and see the midwife, you die just like that.’ Though majority of the participants were of the view that postnatal care services were very important to both mother and the baby, they were not satisfied with the kind of services they received. This was evident in their responses: ‘….the PNC per say, has a lot of advantages to both the mother and her baby if the health care provider will do their work well. Like doing a thorough physical examination for both mother and baby.’ (30 year mother of three in FGD, Kwabenya 4th ‘..l expected the doctor to examine my baby, like checking his blood group June, 2013). University of Ghana http://ugspace.ug.edu.gh 37 but no laboratory test was done for my baby’. (28 year old, civil servant mother of two, in a FGD, Dome New Station Area.6th With most women now viewing quality care, to include right information, good communication and attitude of health professionals as discovered by (Tunc alp , Hindin, Adu-Bonsaffoh, &, Adanu 2012), it was not surprising when majority were not satisfied with the PNC that they were offered. One person however said that postnatal is not important because the nurses did not inform the mothers at antenatal about it. June, 2013). Another participant was of the view that postnatal care is not of much importance even to the health care provider, because most health care providers are most of the time, in a hurry when attending to postnatal women. ‘…. we just take cars to the hospital for postnatal care only to be asked questions about our babies. They just check the mothers BP and if there is nothing wrong with it, ask you to eat well, and take good care of the baby. Even to the midwives, it seems their priority is with the baby.’ So if I see that there is nothing wrong with me and my baby ,why should l waste money on dropping (taxi) and go for ‘nothing’, l will wait for six weeks and go for weighing rather’. (Pat, 30 year mother of three, in FGD, Boi, 29th May, 2013). I think that though most women do not know what PNC services entail, they expect more from the health care providers than what they are currently being offered. If the women know what to expect from the health care providers, the women will perhaps ask questions when some services are omitted by the health care providers. University of Ghana http://ugspace.ug.edu.gh 38 4.2.5 Perceived barriers: access to postnatal care services. On this theme the researcher used two questions to arrive at it. These questions are on reasons of failure to postnatal care services and difficulty in accessing postnatal care. Quite a number of the participants knew about the importance of postnatal care services but failed to go for the services for a number of reasons. Majority of the participants mentioned inaccessibility of the health facility as a major constraint to their PNC access. This was evident especially from the responses of respondents from communities in the Dome sub municipality which has no public health facilities. Equally worth mentioning was the quality of care they receive. Quality of care at facilities relates to issues such as negative staff attitude and the PNC care proper. Respondents from Boi cited negative staff attitude as a great barrier for post natal utilization especially in the only public health facility in the Abokobi Sub municipality. Finally, financial constraints were also mentioned especially by the respondents from Abuomu. The following demonstrate the various reasons represented in the responses. ‘…there is no government hospital from Abuomu here, down to Taifa and Dome’. ‘..Cost of transportations and the distance, you see in Dome here, there is no government hospital. So those of us who do not have money to go to private hospital, we have to wake up early and go to wait in long line, (queue)at Achimota or Alpha. Waaaa sister’. ‘….another reason is that, there is no doctor at Abokobi Health Centre, so when you go there especially in the afternoon or night, the nurse would not even look at you, they just tell you to go to either Alpha Hospital (now Pentecost hospital) or Ridge.’ (32 year mother of four, in FGD, Boi 29th May, 2013).’ University of Ghana http://ugspace.ug.edu.gh 39 On negative staff attitude, Maame, 32year old mother of five had this to say, as she narrated her ordeal at the hands of a doctor, because she delivered at home. Maame’s Ordeal ‘….I was embarrassed by one doctor when l went for postnatal after my fifth delivery. My mother in-law is a trained Traditional Birth Attendant in my hometown, a village in the Central Region. She has helped me with the deliveries of all my five children. I returned to join my husband two weeks after delivery. My baby and I were sick, so my husband took us to the hospital. The nurses took my BP and my baby’s weight and asked us to go and see the doctor. When the doctor asked me where I delivered and I told him, he became very angry. And he said ‘ahhhhh! In this age and time do we deliver at home?’ He decided that he would not attend to me and only advised me to take water and fruits. He only examined the baby and gave her some medicines. But I knew I was very sick within me, hmmmm…I was dying inside so I called my mother in-law who asked me to buy some herbs and boil and drink, had it not been for those herbs, I may have been dead by now. Who knows? You see, sister, is not always a person’s desire to give birth at home oo, sometimes, circumstances beyond you. But me, if l should ever give birth again, l will use the herbs my mother-in-law gave me. l don’t ever want to go through that humiliation again (Maame, 32year old, table top petty trader in FGD, Dome Ayigbe Town.4th I think this was an unfortunate scenario which should not have happened especially in a government hospital. Whereas the people of Bangladesh are thinking of incorporating home visiting of women who deliver at home by health profession ( June, 2013).’ Baqui, Ahmed, Arifeen, Darmstadt, Mannan, Rosecrans et al. 2009, Warren et al., 2006), here in Ghana, women who deliver at home University of Ghana http://ugspace.ug.edu.gh 40 and visit the hospitals for postnatal care, are being discouraged from seeking postnatal care services by poor attitude of health care providers. Other studies have reported negative staff attitude as barrier to health care service utilisation. (Nabulera et al., 2006) Other reasons why most women do not seek for postnatal care were identified as laziness on the part of the mother, after pains and lack of family support. One participant however said most women also use traditional medicine after birth. This finding have been reported in other studies where traditional practice is well inculcated in the postpartum period.( Mekonnen & Mekonnen 2002,Tao et al 2009, Thi 2004, Titaley et al 2010 ). 4.2.6 Self efficacy: women’s ability to seek care It was evident during the focus group discussion that many women had confidence in themselves that they could seek for PNC. The ‘wardrobe syndrome’ is not an issue with most women in Ga East Municipality, as they do not actually mind going to the health facility with any neat dress or cloth that they have. 4.3. Participants opinion on ways of improving postnatal services in the municipality. From the discussions, the participants made some suggestions as to how they think postnatal care could be improved, participants were of the view that availability of a public health facility, at least one district hospital, positive staff attitude, availability, of skilled personnel, quality of postnatal care, edu-entertainmet on the importance of PNC services on our electronic media and skilled health providers visiting postnatal mothers at their homes to render PNC services will go a long way to improving postnatal care in the municipality. Some of the responses they gave were: University of Ghana http://ugspace.ug.edu.gh 41 ‘…Most of us in Dome here do not have money to visit private hospital, so if Dome could also get her own government hospital, like Kekele in Madina, it will help us a lot. (30 year mother of two, in FGD Dome Ayibgye Town. 4th ‘…If some nurses can visit us at home after delivery and check on we and our babies.’ June, 2013). (24 year mother of two in FGD.Dome Ayigbye Town 4th ‘…Health education on PNC like ‘supa nana’ should be shown on TV so that people get to know what post natal care services entails. Or even the ‘tele nurse’ can be educating us on the importance of post natal care from time to time, June, 2013).’ (Olive, 28 year first time mother in FGD, Dome New Station Area.6th Sankofa the 58 year old retired teacher, who shared her postnatal care experience in case one, also had this to say, June, 2013).’ … ‘today’s midwives should be taught to do proper post natal care services like before. Yes they need to go back and do the proper thing. (Sankofa)’ University of Ghana http://ugspace.ug.edu.gh 42 4.4 Summary The findings show that majority,39 (95.1%) of the participants think that PNC is very necessary and important to both the mother, the newborn and the family as a whole but women fail to seek PNC services due to a number of reasons. From the focus group discussions it was evident that limited availability of public health facilities, inadequate health professionals like midwives, and doctors in Abokobi Health Center for instance, are the main reasons for the low utilisation of not only PNC services but other health services as well. Lack of knowledge about PNC services, negative staff attitude, distance, financial constraints in terms of poverty and cost of transportation, also came up strongly as reasons for failure in seeking postnatal care services. Other reasons were inadequate support from the family members and the use of traditional medicine. Interestingly, quite a number of participants, 8(19.5%) attributed the failure of women seeking PNC services to laziness on the part of postnatal mothers. University of Ghana http://ugspace.ug.edu.gh 43 CHAPTER FIVE 5.0 Introduction This chapter concludes the study and makes the necessary recommendations. The limitations to the study have also been mentioned. 5.1 Conclusion This study sought to determine the factors contributing to low PNC service utilisation in Ga East Municipality. To be able to do this, a qualitative approach was used to carry out this study. The findings of the data collected through focus group discussions were presented in thematic areas and the issues discussed. Again all the variables in the socio-demographics of the participants, did not show any impact on the utilisation of PNC services. The study showed that women’s knowledge of postpartum care is a very essential predictor of postnatal care services utilisation, especially for first time mothers. Most of the first the mothers did not seek for PNC services because they were not aware of the service. The findings also indicated that health care providers do not provide sufficient information on the merits of postnatal care and the demerits of failure to seek PNC. Findings further showed that health care providers are not rendering quality PNC services to women as they should, for instance the physical examinations that need to be conducted during PNC are not completely done. Most health care providers only check the blood pressure of the postpartum mothers. As a result some of the participants were not satisfied with the PNC services they received. University of Ghana http://ugspace.ug.edu.gh 44 This shows that there are shortcomings in the basic PNC services provided to postpartum women. Finally, findings from the study revealed that accessibility in terms of availability of health facility, availability of professional health personnel, cost of transportation and distance, in addition to negative attitude of health care providers are preventing postnatal mothers, especially those who deliver at home from utilising PNC service. Lack of social support from family members, was also enough reason for the failure of some women from seeking PNC services. 5.2. Recommendations The recommendations made from this study are as follows: 1. Based on the findings it will be recommended that the public health facility in the municipality is provided with doctors as urgently as possible. 2. It was clear from the study that there are shortcomings in the PNC services being rendered by health care providers currently. Therefore it will be recommended that the contents of PNC services be reconsidered to meet women’s needs especially emotional, psychological and physical needs. 3. Although majority of the participants were aware of PNC, almost all of them did not know what goes into postnatal care. It will therefore be recommended that the Health Educational Unit of the Ghana Health Service, come out with educational programmes that will portray the importance of PNC and what women are to expect from the health care providers during PNC visits. It could be in the print or electronic media. University of Ghana http://ugspace.ug.edu.gh 45 4. Best practices being practiced in other developing countries like Madagascar and Bangladesh, where trained professionals and retired midwives visit postnatal mothers regularly during the first week after delivery, could be emulated by Ghana. 5. For further research it will be recommended that views of health care professionals considering the low utilization of postnatal care are researched into. 5.3 Limitation of the study. It was quite difficult getting participants especially in the urban areas where most people are always on the move. More so when people realised that they were not going to receive money for their participation, they opt out. Another limitation was that Ga East Health Administration had not upgraded their profile to reflect the municipal’s new status. The Municipal Public Health Nurse helped the researcher to tease out data to reflect the current status from the Municipal Health, Annual Report, 2012. A considerable amount of information was lost due to the verbatim transcription of the five Twi focus group discussions and its translation into English. University of Ghana http://ugspace.ug.edu.gh 46 REFERENCES Abbas, M.K.(2012).Analysis of Factors that Contribute to Utilization of Health Facilities during Labor, Delivery and Postnatal Period in Zanzibar. Unpublished master’s thesis… Abou-Zahr, C.L., & Wardlaw, T.M.(2003). Antenatal care in developing countries: promise, achievements and missed opportunity: an analysis of trends, levels and differentials, 1990-2001. Geneva: World Health Organization. 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Warren C., Daly P., Toure L., Mongi P. (2006). Postnatal care. In J.Lawn & K.Kerber (Eds.), Opportunities for Africa’s Newborns,(pp.79–90). Cape Town, South Africa: Partnership for Maternal, Newborn and Child Health. World Health Organization.(1998). Report from WHO consultation on the needs of women and their newborn during postpartum period. Geneva: WHO. World Health Organization. (2012). Essential interventions, Commodities and Guidelines for Reproductive, Maternal, Newborns and Child Health: Geneva: WHO. University of Ghana http://ugspace.ug.edu.gh http://dx.doi.org/10.1016/j.midw.2009.10.001� http://dx.crossref.org/10.1186%2F1471-2393-10-61� 49 APPENDICES Appendix 1 Consent Form Project Title FACTORS CONTRIBUTING TO LOW POSTNATAL COVERAGE IN GA EAST MUNICIPAL. Institutional Affiliation: School of Public, College of Health Science University of Ghana Legon Background Personal Introduction: Principal investigator is Augustina Arthur – Arko, currently a Masters student of the School of Public Health, Legon and conducting a study on Factors Contributing to Low Postnatal Coverage in Ga East Municipality. The study is for academic purposes and the requirement for the award Master of Science degree in Applied Health Social Science degree and supervised by Dr. Dinah Baah – Odoom of school of public health, University of Ghana, Legon. University of Ghana http://ugspace.ug.edu.gh 50 Procedure An interview will be conducted using focus group discussion guide. The interview would be tape recorded with your permission. This tape-recorded would be kept until the time the degree has been awarded after which it would be destroyed. Risks and Benefits There is no reasonable foreseeable harm that may arise from participating in this research while benefits that may arise include a greater contribution to the development of reproductive policies. It will also create personal awareness of the factors of low postnatal care. Right to Refuse Although there are no known risks associated with the research protocols, if you feel uncomfortable you have the liberty to opt out. You are also at will to withdraw from participating if you desire to do so. Anonymity and Confidentiality: You are assured that the information collection will be handled with the strictest confidentiality, will not be shared with third parties not directly involved in the research and thus will be used purely for academic purposes. University of Ghana http://ugspace.ug.edu.gh 51 PARTICIPANT I ………………………………………………………. Having been adequately informed about the purpose, procedures, potential risks and benefits of this study, I have had the opportunity to ask questions and any questions I have asked have been answered to my satisfaction. I know that I can refuse to participate in this study without any loss or benefit to which I would have otherwise been entitled. Having gone through the consent form thoroughly I agreed to enroll in this study. Name of Participant………………………………………………………………… Signature or Right thumb print………………………………… Date ………………………… Interviewer’s Statement: I have explained the procedure to be followed in this study to the clients in the language that they understand best and they have agreed to participate in the study. Signature ………………………………… Date ……………………………………… University of Ghana http://ugspace.ug.edu.gh 52 Appendix 2 Focus Group Discussion Guide The factors contributing to low postnatal care coverage Date of interview……………………………………………. Name of interviewer…………………………………………………. 1. Demographic Data: Age, Education level, Occupation and Number of children 2. How early do women go for postnatal care (PNC) services? ( in what day or month after delivery) 3. How often do they go for PNC? 4. What kinds of services do they receive in PNC? (Are they satisfied)? 5. What do women think PNC does to help their babies? 6. How important is PNC to women in Ga East Municipality? 7. What may be the reasons why women do not go for PNC? 8. What in your opinion are the advantages? (b) And disadvantages for not going for PNC? 9. What are the difficulties in accessin