SCHOOL OF NURSING AND MIDWIFERY COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA HEALTH BEHAVIOUR OF PREGNANT WOMEN TOWARDS THE PREGNANCY SCHOOL IN THE GREATER ACCRA REGIONAL HOSPITAL. BY SARAH CHRISTODIA EGYIR (10803554) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MPHIL IN NURSING DEGREE SEPTEMBER, 2021 University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL i DECLARATION DECLARATION I, Sarah Christodia Egyir declare that this thesis is the results of my work conducted under the supervision of Dr Mary Ani-Amponsah and Madam Ernestina Asiedua for the Award of Master of Philosophy Degree in Nursing at the School of Nursing and Midwifery of the University of Ghana, Legon. All of the resources assessed as literature have all been duly referenced. Signature Dr. Ernestina Asiedua (Co-Supervisor) University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL ii DEDICATION This thesis is dedicated to my husband, Mr. James Nkansah for his love and support during this academic journey. I also dedicate this study to my children (Maame Somuah, Nana Ama Fosua and Ohemaa) and my parents (Mr. Egyir and Madam Comfort Ayeh) for their unflinching love, encouragement and prayers. University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL iii ACKNOWLEDGMENT I would like to express my sincere appreciation to Lord God Almighty who has brought me this far by His grace and love. Thank you, Jesus. I very much appreciate my supervisors Dr. Mary Ani-Amponsah and Dr. Ernestina Asiedua, whose guidance, understanding and wealth of knowledge helped me to achieve my goal. I also would like to thank the entire staff of School of Nursing and Midwifery, University of Ghana, Legon for their various support. Additionally, my appreciation goes to the participants who availed themselves for this study and management and staff of the Greater Accra Regional Hospital. Furthermore, I am very grateful to my husband, Mr. James Nkansah, my children, Maame Somuah, Nana Ama Fosuah and Nana Hemaa Nkansah for all the sacrifices, love and support. I want to thank my parents and siblings for their encouragement and prayers. I give God all the Glory University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL iv TABLE OF CONTENTS DECLARATION .............................................................................................................. i DEDICATION ................................................................................................................. ii ACKNOWLEDGMENT ................................................................................................ iii TABLE OF CONTENTS ............................................................................................... iv LIST OF FIGURES ...................................................................................................... viii LIST OF TABLES .......................................................................................................... ix LIST OF ABBREVIATIONS ......................................................................................... x ABSTRACT ..................................................................................................................... xi CHAPTER ONE .............................................................................................................. 1 INTRODUCTION ........................................................................................................... 1 1.1 Background of the Study .............................................................................................. 1 1.2 Problem Statement ............................................................................................................ 5 1.3 Purpose of the Study ......................................................................................................... 7 1.4 Objectives .................................................................................................................... 7 1.5 Research Questions ....................................................................................................... 8 1.6 Significance of the study ................................................................................................... 8 1.7 Definition of terms ........................................................................................................ 9 1.8 Organization of the Study ................................................................................................. 9 CHAPTER TWO ........................................................................................................... 11 CONCEPTUAL FRAMEWORK AND LITERATURE REVIEW .......................... 11 2.1 Justification for the selected theoretical framework ....................................................... 11 2.2 The Information-Motivation-Behavioural Skills Model ................................................. 12 2.3 Literature review ............................................................................................................. 15 2.4 The Health Behaviour-Information of Pregnant Women ................................................ 15 2.4.1 Knowledge of the pregnancy school ...................................................................... 15 2.4.2 Experiences with the pregnancy classes ................................................................. 17 2.4.3 Usefulness .............................................................................................................. 19 2.4.4 Views on number of appointments ......................................................................... 21 2.5 Health Behaviour-Motivation ......................................................................................... 21 2.5.1 Social support received .......................................................................................... 22 University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL v 2.5.2 Motivation to partake ............................................................................................. 24 2.5.3 Impact of education on social support received ..................................................... 25 2.5.4 Quality contact: Client-Midwife............................................................................. 26 2.6 Health Behaviour-Skills .................................................................................................. 29 2.6.1 New skill acquired .................................................................................................. 29 2.6.2 Identification of danger signs ................................................................................. 29 2.6.3 Decision making process ........................................................................................ 30 2.6.4 Benefits of skills gained ......................................................................................... 33 2.7 Health Behaviour ............................................................................................................ 36 2.7.1 Outcome of health behaviour ................................................................................. 36 2.7.2 Expectation ............................................................................................................. 37 2.7.3 Impression .............................................................................................................. 38 2.7.4 Ways of improvement ............................................................................................ 39 2.7.5 Issuing of leaflets.................................................................................................... 42 2.7.6 Summary of literature review ................................................................................. 43 CHAPTER THREE ....................................................................................................... 45 METHODS ..................................................................................................................... 45 3.1 Research design ............................................................................................................... 45 3.2 Research paradigm .......................................................................................................... 46 3.3 Research setting .............................................................................................................. 46 3.4 Target Population ............................................................................................................ 48 3.5 Inclusion Criteria ............................................................................................................. 48 3.6 Exclusion Criteria ........................................................................................................... 49 3.7 Sample Size and Sample Technique ............................................................................... 49 3.8 Data Collection Tool ....................................................................................................... 49 3.9 Procedure for Data Collection ......................................................................................... 50 3.10 Data Management ....................................................................................................... 51 3.11 Data Analysis .............................................................................................................. 51 3.12 Trustworthiness (Rigor) .............................................................................................. 52 3.13 Ethical Considerations ................................................................................................ 53 CHAPTER FOUR.......................................................................................................... 54 STUDY FINDINGS ....................................................................................................... 54 University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL vi 4.1 Demographic Characteristics .......................................................................................... 54 4.2 Organization of Themes .................................................................................................. 55 4.2.1 Health Behaviour Information ................................................................................ 56 4.2.2 Health Behaviour Motivation ................................................................................. 62 4.2.3 Health Behavioural Skills ....................................................................................... 70 4.2.4 Health Behaviour .................................................................................................... 78 4.3 Summary of Findings ...................................................................................................... 87 CHAPTER FIVE ........................................................................................................... 89 DISCUSSION OF FINDINGS ...................................................................................... 89 5.1 Demographic Characteristics .......................................................................................... 89 5.2 Health Behaviour-Information ........................................................................................ 91 5.3 Health Behaviour-Motivation ......................................................................................... 96 5.4 Health Behaviour-Skills .................................................................................................. 99 5.5 Health Behaviour .......................................................................................................... 102 5.6 Evaluation of Theoretical Framework .......................................................................... 105 5.7 Summary of Discussion ................................................................................................ 107 CHAPTER SIX ............................................................................................................ 108 SUMMARY OF THE STUDY, IMPLICATION, LIMITATION, CONCLUSIONS AND RECOMMENDATIONS ................................................................................... 108 6.1 Summary of the study ................................................................................................... 108 6.2 Implication of the Study ................................................................................................ 110 6.3 Implication for Nursing and Midwifery Practice .......................................................... 110 6.4 Implications for Nursing and Midwifery Research. ...................................................... 111 6.5 Implication for Health Policy ........................................................................................ 111 6.6 Limitations of the Study ................................................................................................ 111 6.7 Recommendations ......................................................................................................... 112 6.7.1 The Ministry of Health ......................................................................................... 112 6.7.2 Ghana Health Service ........................................................................................... 112 6.7.3 Greater Accra Regional Hospital.......................................................................... 113 6.8 Conclusion .................................................................................................................... 113 REFERENCES............................................................................................................. 115 University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL vii APPENDICES .............................................................................................................. 129 Appendix 1: Ethical Clearance ............................................................................................... 129 Appendix 2: Letter Of Introduction ....................................................................................... 130 Appendix 3: Interview Guide ................................................................................................. 131 Appendix 4: Consent Form .................................................................................................... 135 Appendix 5: Codes and Descriptions ..................................................................................... 136 University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL viii LIST OF FIGURES Figure 2. 1: The Information-Motivation-Behavioural Skills Model of health behaviour. ...................................................................................................................... 12 Figure 3.1: Location of Ridge Hospital the study facility ............................................... 48 University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL ix LIST OF TABLES Table 4.1: Profile of Participants ..................................................................................... 55 Table 4.2: Organization of Themes and Sub-themes ....................................................... 56 University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL x LIST OF ABBREVIATIONS ANC- Antenatal Care CEC- Childbirth Education Classes FANC- Focused Antenatal Care FMH - Free Maternal Healthcare GAR- Greater Accra Region GARH- Greater Accra Regional Hospital GMHS - Ghana Maternal Health Survey IFA- Iron and Folic Acid IMPAC - Integrated Management of Pregnancy and Childbirth LMIC- Low- and Middle-Income Countries MDG- Millennium Development Goal MMR- Maternal Mortality Ratio NHIS – National Health Insurance Scheme SDG- Sustainable Development Goal UNICEF - United Nations International Children's Emergency Fund USA – United States of America WHO- World Health Organization University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL xi ABSTRACT Antenatal care is viewed as an important point of contact between health workers and women and an opportunity for provision of health education including how to detect pregnancy complications and development of a birth plan to ensure safe delivery at a health facility. Quality antenatal care and education given to pregnant women during antenatal visits could be used as one of the measures to curb maternal mortality since these somewhat preventable maternal deaths have hugely been attributed to the lack of quality contacts between the pregnant women and the professional caregiver. Owing to the fact that little has been done over the years on the health behaviour of pregnant women towards the pregnancy school, the study therefore explored the health behaviour of pregnant women towards the pregnancy school in the Greater Accra Regional Hospital using the theory of Information Motivation-Behavioural-Skill model to guide the research. A qualitative explorative approach was employed. Data were collected from Greater Accra Regional hospital using a purposive sampling method. Fourteen (14) participants who consisted of three (3) pregnant and eleven (11) postpartum women who consented to participate in the study were interviewed face to face using a semi structured interview guide which lasted for 30-45minutes. Data were analysed thematically. Four (4) main themes and eighteen (18) subthemes were formulated from the constructs of the IMB model and the objectives of the study. The results of the study emphasized that, the participants found the information given at the classes to be very useful and had concerns with the time frame of the classes. The findings suggest that although the pregnancy school is a good initiative all stakeholders should support in order to improve it. Future research should focus on the information needs of the husbands and partners attending pregnancy schools. Keywords – Pregnancy school, antenatal care, pregnant woman. University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 1 CHAPTER ONE INTRODUCTION This chapter centres on the background of the study, problem statement, study objectives and significance of the study. It also includes definition of terms, abbreviation organization of the study. 1.1 Background of the Study The season of pregnancy and childbirth ought to be a time of great delight for families. But be it as it may, pregnancy and labour have become a source of disdain and anxiety for many families in poorer countries as a result of poor pregnancy outcomes. WHO (2016), explains antenatal care as the care given to pregnant women and adolescent girls by competent health care professionals in order to guarantee the greatest possible health for both the mother and the baby throughout pregnancy. The WHO envisions that every pregnant woman and her child receives high-quality care during pregnancy, labour and the postnatal period (WHO, 2016). Whereas the ANC scenario in advanced regions remain impressive as highlighted by a study by Rui et al. (2015) which put forth prenatal care as being among the most frequently used health care services in the United States. More than 18 million prenatal visits occurred in the United States. Same cannot be said about the rather bleak outlook when considering third world and poor developing regions despite the relentless effort by international organizations with regards to pregnant women attendance to ANC. Globally, 86% of pregnant women access antenatal care with skilled health personnel at least once, only two in three (65%) receive at least four antenatal visits. In a similar vein, a 2019 report by UNICEF revealed that in sub-Saharan Africa and South University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 2 Asia, where the incidence rate of maternal mortality is high, women received fewer antenatal visits 52% - 46% respectively. Furthermore, there are significant differences in access to four or more ANC visits between rural and urban locations, with a gap of more than 20% in south Asia and Sub- Saharan Africa (UNICEF, 2019). According to the findings of a study conducted in India utilizing data from the National Family Health Survey (NFHS) on women of reproductive age (15–49 years), roughly 33% of pregnant women did not receive ANC during their pregnancy. Comparably, a study conducted by Muleya et al. (2017) in southern Zambia found that increased maternal fatalities due to pregnancy problems might be avoided with high-quality prenatal care. This is further buttressed in a cohort study carried out in Ethiopia, which reported that having four or more Antenatal Care (ANC) visits was significantly associated with 81.2%, 61.3%, 52.4% and 46.5% reduction in postpartum haemorrhage, early neonatal death, preterm labour and low-birth weight, respectively (Hafitu et al., 2018). ANC is one of the three most essential care given to women during pregnancy (WHO, 2016) and a key indicator of the Sustainable Development Goal (SDG) 3 target 3.1 – which is aimed at reducing the global maternal mortality ratio to less than 70 per 100,000 live births. The maternal mortality ratio (MMR) for Ghana is 310 deaths per 100,000 live births (GMHS, 2017). With a ratio of 319 in 2015, Ghana’s target to achieve Millennium Development Goal (MDG) 4 and 5 was unattainable. With the foregoing as a guide, quality antenatal care could be used as one of the measures to curb maternal mortality. Nevertheless, most of the causes of maternal mortality are preventable. Antenatal education has the overall aim of providing expecting parents with strategies for dealing with pregnancy, childbirth and parenthood (Ahlden et al., 2012). The ANC has four basic University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 3 components which includes: identification of risk, prevention and management of pregnancy - related or concurrent diseases; and health education and health promotion. To this end, more specific aims include influencing health behaviour, increasing confidence in women’s ability to give birth, informing about pain relief, and promoting breastfeeding. In this respect, antenatal care provides an important opportunity to prevent and manage concurrent diseases through integrated service delivery (IMPAC, 2016). The care given antenatally has been proven as intervention that saves the lives of pregnant women when accessed adequately (Miltenburg et al., 2015). Health promotion (including birth planning for a facility-based delivery), screening and diagnosis, and disease prevention appropriate to gestational age, health status, and geographic context are among the services performed at the ANC (De Masie et al., 2017). One of the foundations of antenatal care is antenatal education, which strives to improve the health of mothers, newborns, and their families. Women and their families are better prepared for pregnancy, childbirth, and parenthood after receiving health information through antenatal education programs (Taiwo et al., 2013). Pregnancy and its care; labour, delivery, and postpartum care of the mother and baby; role of women during the perinatal period; and psychosocial aspects of pregnancy are among the main areas of interest for women worldwide (Malata et al., 2011). Antenatal care is also seen as a crucial point of interaction between health workers and women, as well as an opportunity for health education – such as how to recognize pregnancy issues – and the development of a birth plan to ensure delivery at a health facility. Pregnant women's health and the health of their unborn children benefit greatly from health education provided to them and their families. There is a significant impact on both the pregnant lady and her partner's decision-making around the pregnancy. Counselling and health education had the lowest marks in the childbirth University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 4 satisfaction survey, according to a study conducted by Duysburgh et al. (2014) in selected health centres in the Northern Region of Ghana. Only 72% of Ghanaian women of reproductive age delivered at a health facility, according to Dankwah et al. (2019), while women who were not informed about pregnancy problems were more likely to deliver outside of a health facility. The implication is that pregnant women who do not receive adequate health education are more likely to be affected by indirect causes of maternal mortality, even though ANC coverage has increased (Boah et al., 2018). Dankwah et al. (2019) also found in their study that knowledge about pregnancy complications was linked to health facility delivery and hence the need to give increased attention to health education about potential delivery associated complications as part. During pregnancy, social support is critical for both the pregnant mother and her unborn child's health. That being said, only a small percentage of them would suffer from post-partum depression, a condition that can be disastrous for families (Morikawa et al., 2015). Expectant mothers not only undergo physiologic and hormonal changes throughout pregnancy, but they are also mentally encircled by the fear of being unable to cope with the approaching new circumstances. As a result, individuals are in desperate need of social assistance in order to overcome their fears (Maharlouei et al., 2015). In the health sector, prenatal education is known by a variety of names with the geographical location being a key determinant; such as expectant parent classes, antenatal parenthood education, antenatal education, childbirth classes, and antenatal classes (Barimani et al., 2018). Nevertheless, the phrase ‘pregnancy school’ is used in this study since it is a well-known concept in Ghana. The pregnancy school or classes, which began in 2009, is aimed at providing high-quality education to pregnant women and their families, as well as equip them with the necessary information and skills to make timely pregnancy decisions that University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 5 promote the health of the mother and unborn child, and thus contribute to the achievement of SDG 3 target 3.1. It must however be emphasized that, the pregnancy school is not a replacement of the regular ANC but similar to the group antenatal care which serves to promote links between all aspects of Clinical Care and Public Health to provide a holistic care to pregnant women, their partners and babies (Vanotoo, 2016). The pregnancy school also helps to build a friendly and casual collaboration between health providers and pregnant women, as well as their spouses and families, which is sometimes lacking in our hectic antenatal clinic days. One of the goals of the pregnancy school is to encourage male involvement in the care of the women, as well as to educate them on pregnancy and its related conditions, birth preparedness and complication readiness, as well as support for the woman, the baby, family planning, and their fears (Vanotoo, 2016). However, since the introduction of the pregnancy school or classes few studies in Ghana have been conducted on the impact of the pregnancy school on the health lifestyle and decisions, information needs and importance of social support of pregnant women who participate in the pregnancy school with or without their partners. It is against this background that this study will use the theory of Information Motivation Behavioural Skills model developed by Fisher and Fisher (1992, 2000), Fisher and Fisher (1993, 1999) to guide the research in examining the health behaviour of pregnant women towards the pregnancy school in the Greater Accra Region. 1.2 Problem Statement Maternal death and morbidity influence not only the woman's immediate family, but also the community and society as a whole. The Sustainable Development Goal (SDG) of reducing maternal mortality remains a top objective (WHO, 2016). Despite the fact that University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 6 many interventions and policies have been implemented in Ghana to combat this threat, such as Free Maternal Healthcare (FMH), the National Health Insurance Scheme (NHIS), Focus Antenatal Care (FANC) Addo and Gudu (2017) and the pregnancy school, MMR continues to fall short of the Sustainable Development Goal (SDG) 3 target 3.1 of reducing maternal mortality to less than 70 per 100,000 live births (GMHS, 2017). Regardless, of the education given to pregnant women at the ANC, research shows that most pregnant women struggle to operationalize and interpret the information they receive (Jody et al., 2014), implying that health education does not convert into acceptable health behaviours. If pregnant women are unable to comprehend the information provided by health care providers, they may be unable to fully utilize the health system's benefits. Based on clinical evidence, few studies in Ghana, Eghan (2016) have focused on the content of pregnancy schools. However, the majority of people in Ghana have become more informed about health issues. Most pregnant women and their partners get information from a variety of sources, including friends, family, magazines, and social media, which are frequently inaccurate and sometimes misleading. Furthermore, the importance of social support, particularly that of the pregnant woman's partner, plays a major role in the organization of the pregnancy school. Nonetheless, few studies have been conducted on whether the expectant father's information needs are met during the pregnancy school. Few studies Greenaway et al. (2012) conducted in Ghana have assessed the causes of maternal mortality in relation to maternal literacy and most studies that examine a pregnant woman's knowledge of health topics use one-dimensional measure, in the event that she has heard of a specific illness rather than focusing on their overall understanding of the topic. While being aware of illnesses is important, it is unlikely to have the same University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 7 impact on women's health behaviour as having a broad understanding and knowledge of a number of health topics. Furthermore, more questions are left unanswered concerning the quality of antenatal education given by health professionals. However, owing to the launch of the pregnancy school in 2009 and review of associated relevant literature shows limited published work have been done on the health behaviour of pregnant women who attend the pregnancy school in Ghana especially in the Greater Accra Region. To that effect, this work seeks to fill in the gap by finding out how pregnant women who attend the pregnancy school are able to practically use the information received through health education given at the school using the Information- Motivation- Behavioural skills module as a guide. 1.3 Purpose of the Study To explore the health behaviour of pregnant women towards the pregnancy school in the Greater Accra Metropolis. 1.4 Objectives The Objectives of the study were developed based on the constructs of the study. The objectives were to: 1. Assess the information given to pregnant women at the pregnancy school in the Greater Accra Metropolis. 2. Identify the elements that motivate pregnant women towards the pregnancy school in the Greater Accra Metropolis. 3. Describe the skills acquired by the pregnant women at the pregnancy school in the Greater Accra Regional Hospital. 4. Examine the outcomes of the education on the health of the pregnant women who attend the pregnancy school in the Greater Accra Regional Hospital. University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 8 1.5 Research Questions The study addresses the following questions; 1. What information is given to the pregnant women at the pregnancy school? 2. What are the elements that motivates pregnant women towards the pregnancy school? 3. What are the skills acquired during the pregnancy school? 4. What are the outcomes of the health education on pregnant women who attend the pregnancy school? 1.6 Significance of the study The findings are expected to raise awareness about the purpose of pregnancy school which focuses on preparing the pregnant woman physically and psychologically for pregnancy, labour and the post-partum period. Also, the information given at the school will equip the woman and her family with the relevant health knowledge during pregnancy in order to increase the self-confidence. Again, it will enlighten the society on the importance of antenatal care services as well as seeking for professional care, early identification of danger signs, birth preparedness and complication readiness, importance of exclusive breastfeeding, essence of spacing children by using family planning method and how to care for the newborn. This will further help the woman, family and society at large to adhere to the instructions given during the pregnancy school and help to reduce the rate of maternal mortality which is the main aim of the pregnancy school organized for the pregnant woman and her family. This study will help assess the quality of the pregnancy school by examining the impact of pregnancy school on the health behaviour of the pregnant women towards the pregnancy school. Additionally, this study will help identify the importance of social support for pregnant women who attend the pregnancy school especially the support of University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 9 the husband since they are the decision makers and also improve on the relationship between the midwife and the clients. Also, the findings of study will help identify the gaps in the organization of the pregnancy school and improve on it since the wellbeing of the pregnant woman is very crucial because it affects the health of the unborn child as well. Lastly, the findings of the study will offer directions for further studies in this area. 1.7 Definition of terms Midwife- midwife is a person who has completed a midwifery education programme that is recognised in the country where it is located and is based on the ICM Essential Competencies for Basic Midwifery Practice and the framework of the ICM Global Standards for Midwifery Education; who has acquired the necessary qualifications to be registered and/or legally licenced to practise midwifery (ICM, 2017). Pregnancy school- Organization of classes for pregnant women and their partners on a special day aside the normal antenatal clinic day. 1.8 Organization of the Study The study was grouped into six chapters. The first chapter being the introduction of the background information, the problem statement, purpose of the study, objectives of the study both main and specific objectives and research questions, the significance of the study, definition of terms and the organization of the study. The second chapter, involved justification of selection of the model, the explanation of the model and the review of literature using the constructs of the model. The third chapter also dealt with the method that used for the study which includes the research design, the research setting, the target population, inclusion and exclusion criteria, the sample size and the technique used for the sampling, tool used for the data collection, the procedure for the data collection, how the data was analysed and managed, University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 10 rigor and ethical considerations. The findings of the study were presented in the chapter four and the chapter five discussed the findings. Lastly, in chapter six the following were presented; the summary of the study, implication of the study, implication for nursing and midwifery practice and research, recommendation and conclusion. University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 11 CHAPTER TWO CONCEPTUAL FRAMEWORK AND LITERATURE REVIEW This chapter begins with a description of the research model that will guide this study and review of related empirical literature on the health behaviour of pregnant women at pregnancy school. 2.1 Justification for the selected theoretical framework In the search for models that would better describe what the research seeks to find out, two models on behaviour were reviewed, namely; the Health Belief Model and the Theory of Planned Behaviour. The health belief model was developed by social psychologists Hochbaun (1958) and Rosenstock (1966) was one of the models to be reviewed. It is used to predict health behaviours thus to understand the failure of people to adopt disease prevention strategies or screening tests for the early detection of diseases. The HBM proposes that a person's belief in a personally threatening illness or disease, along with a person's belief in the effectiveness of the recommended health practise or action, will predict their chance of engaging in or completing the behaviour or action. This model was not used because the beliefs about health conditions was not the focus of this study. The second model reviewed was the Theory of Planned Behaviour (TPB) which was proposed by Ajzen (1985). TPB grew out of Theory of Reasoned Action, which was first proposed by Fishbein and Ajzen (1980). In order to explain all actions over which people have the ability to exert self-control, the theory has to explain how people acquire that ability. The most important component of this paradigm is behavioural intent. Behavioural intentions are influenced by one's attitude toward the likelihood that a particular behaviour would result in the expected outcome, as well as one's subjective evaluation of the risks and advantages of that event. This model was not suitable for the study because constructs of the model do not answer the research questions. The University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 12 information-motivation-behavioural skills model (IMB) was found to be useful for this study because its constructs suites the purpose of the study. The IMB model will also determine the direction and methodology for the research study. The construct and relationship of the IMB model (Figure 2.1). FISHER/FISHER/HARMAN Figure 2. 1: The Information-Motivation-Behavioural Skills Model of health behaviour. Source: Fisher and Fisher (1992). Changing AIDS risk behaviour 2.2 The Information-Motivation-Behavioural Skills Model The Information-motivation-behavioural skills model identifies psychological factors that influence the performance of behaviours that have the potential to harm or benefit one's health (Fisher & Fisher, 1992, 2000; Fisher & Fisher, 1993, 1999). It was originally developed to provide an account of the psychological determinants of HIV risk and preventive behaviour. There are four main constructs of the model namely: the health- related Information, motivation, skills and health behaviour (Fisher & Fisher, 1992, 2000; Fisher & Fisher, 1993, 1999). The IMB model asserts that health-related information, motivation and behavioural skills are important factors of health behaviour performance. Individuals will be more likely to undertake and continue health-promoting behaviours and experience University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 13 better health outcomes if they are well-informed, motivated to act, and have the necessary behavioural skills for effective action (Fisher & Fisher, 1992, 2000; Fisher & Fisher, 1993, 1999). Health Behaviour-Information - According to the IMB model a major factor of health performance is information that is directly related to the performance of health behaviours and that can be easily implemented by an individual in his or her social ecology (Fisher & Fisher, 1992, 2000; Fisher & Fisher, 1993, 1999). In this study, the health behaviour information assessed the knowledge gained and the usefulness of the education. Health Behaviour-Motivation - The IMB model specifies that motivation is an additional determining factor of health-related behaviour performance, and it can influence whether even well-informed people are willing to engage in health-promoting behaviours. According to the model, personal and social motivations are both major elements in health-related behaviour performance (Fisher & Fisher, 1992, 2000; Fisher & Fisher, 1993, 1999). In relation to this work, the health behaviour motivation of the pregnant woman attending the pregnancy school will be ascertained by examining the motivating factors that contributed to the attendance of the pregnancy school. Thus, whether the commitment towards the pregnancy school was because of social support the participants had and also what influenced participants attitude to participate in the pregnancy school. Health Behaviour-Skills - The ability of well-informed and well-motivated persons to effectively implement health promotion behaviours is also determined by their behavioural skills for performing health promotion actions. The behaviour skills component of the IMB model emphasizes on an individual's objective abilities and sense University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 14 of self-efficacy (Rye, 1990, 1998) when doing a specific health-related behaviour. According to the IMB model, health information and motivation influence health behaviour mainly through health behavioural skills. In general, the impacts of health promotion information and motivation are predominantly observed in terms of the application of health-promoting behavioural skill. This is applied to the initiation and maintenance of health-promoting behaviour (Fisher & Fisher, 1992, 2000; Fisher & Fisher, 1993, 1999). The behavioural skills for the pregnancy school will be to describe the skills acquired through the education received in caring for the baby and whether participants were equipped with knowledge that informed their decision making concerning the pregnancy. Health Behaviour - When complex or innovative behavioural skills are not required to perform the health behaviour in question, health promotion information and motivation may have direct effects on health behaviour performance (Fisher & Fisher, 1992, 2000; Fisher & Fisher, 1993, 1999). For example, acquiring information or knowledge gained at the pregnancy school can have direct impact on a person’s health behaviour likewise the motivation. Also, a pregnant woman’s attitude towards the pregnancy school as well as social support gained can affect the health behaviour. In addition, IMB model assumes that health promotion information and motivation as potentially separate constructs. In the sense that well-informed people are not always motivated to engage in health-promoting behaviours, and highly motivated people are not always well-informed about health-promoting practices (Fisher & Fisher, 1992, 2000; Fisher et al., 1994). In the area of the pregnancy school, the health behaviour of the pregnant women will be determined by assessing their adherence to health education given at pregnancy school and the impact on their pregnancy decision and health. University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 15 2.3 Literature review The literature was reviewed using the constructs of the model used and the objectives of the study. The data bases consulted to perform the literature review were, Medline, Wiley Online Library, PubMed, CINAHL, Science Direct, JSTOR and Google Scholar, Articles were included from WHO (World Health Organization). The keywords used in the search for literature were, ‘group antenatal care’, ‘childbirth classes’, ‘motivating factors for attending ANC’, ‘barriers in seeking antenatal care’, ‘benefits of antenatal education’, and ‘pregnant women behaviour towards antenatal education’. 2.4 The Health Behaviour-Information of Pregnant Women Fisher et al. (1992) stated that information that is directly relevant to the performance of health behaviour and that can be easily enacted by an individual in his or her social ecology is a critical determinant of health performance. The information received by the pregnant woman through pregnancy health education which is used to improve maternal and newborn survival and positive pregnancy results is absolutely critical. Information received by pregnant women through pregnancy schools impacts greatly their choices concerning the pregnancy, labour and puerperium. It also enables women to control their health on the basis of the knowledge with which they have been equipped through education. 2.4.1 Knowledge of the pregnancy school According to Taiwo et al. (2013), antenatal education which aims to improve the health of mothers, babies and family, is one of the pillars of pre-natal care. Women and their families are prepared for pregnancy, childbirth and parenthood through health information obtained from antenatal education sessions. On that premise, a study in Northern Iran on pain and anxiety interventions has shown that increased knowledge and skills during pregnancy prepare pregnant women for labour and lead to health promotion. The study University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 16 further asserted that during pregnancy and labour, prenatal education and psychological support are extremely beneficial to pregnant women. The recommendation that all pregnant women be educated (Firouzbakht et al., 2015). Reiterating further, Widarsson et al. (2012) acknowledges that pregnancy is associated with both physical and psychological changes. Hence, women and their families have to bear and are in better position to go through when they are equipped with adequate knowledge on pregnancy and its related issues. Furthermore, on preparing for childbirth, Ricchi et al. (2020) findings revealed that the goal of child education classes is to increase knowledge on pregnancies, labour, delivery, parenthood, care of new-borns and effective pain and fear management techniques. A contrary opinion however, on antennal education for childbirth conducted by Cutajar et al. (2020), discovered that misinformation about contractions and the stages and phases of labour did occur during antenatal education. This in turn underscores the importance of strict adherence to purposeful antenatal education. On the issue of stress and other labour induced complications Hollander et al. (2017), were of the view that several factors that influence the occurrence of post-traumatic stress disorder in women after childbirth. Lack of communication and information throughout the prenatal period were among these causes. Women said that if their caregivers had communicated, clarified, or listened more, their painful birth experience could have been averted. Moreover, the findings revealed that the trauma was caused by interactions rather than interventions. As a result, childbirth educators play critical role in educating women and their support people with objective information and skills to help them navigate the birth process. A comprehensive mental health education that seeks to include the inputs of husbands are seen as beneficial to the pregnant woman. This affirmed in a study by Wei et al. (2015), husbands' exposure to maternal health education and maternal health University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 17 knowledge were the most important predictors of their involvement in maternal care. In contrast to earlier studies, husbands' lack of awareness about maternal health prevented positive participation and interest in maternal issues (Kaye et al., 2014; Ampt et al., 2015). 2.4.2 Experiences with the pregnancy classes According to Mateji et al. (2014), it is critical to understand a patient's experience with health care in order to receive accurate information on the quality of care and to identify problematic areas that could be improved. Also, patient satisfaction reflects the patient's perceptions of several areas of health treatment, such as technical, interpersonal, and organizational components. In order to improve the quality and efficiency of health care during pregnancy, the World Health Organization (WHO) recommends monitoring and evaluating maternal satisfaction with public health care services. Kamil Dhahi et al. (2015) found that one of the common features of healthcare services is assessing patients' satisfaction. The lack of a tour of the maternity ward was linked to the lowest level of happiness in their study. Also, anxiety and depression in three groups of primiparous pregnant women not attending, irregularly attending, and regularly attending childbirth preparation programs. Hassanzadeh et al. (2021) notes that women's satisfaction with childbirth classes is just as crucial as their knowledge. It further remarked that women regard childbirth preparation classes as a constructive procedure for preparing them for childbirth. Again, women who attend on a regular basis report that childbirth preparation classes lessen their worry about labour. The participants in the Vamos et al. (2019) study evaluated the information relevance based on their participants’ personal circumstances, values and views, and gestational age. The findings revealed that it was beneficial to have information arranged in meaningful pieces, such as gestational age and/or trimester, to reduce worry. The vast nature of information was frequently overwhelming and contributed to stress. University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 18 Additionally, the results of a study involving 132 primiparous women in Turkey showed that women who attended childbirth preparation classes had a greater level of knowledge, responded better to their labour pains, and started nursing earlier (Pinar et al., 2018). Another study found that 96.3 percent of women who took childbirth lessons expressed satisfaction with their sessions and found them to be extremely beneficial. These women were most pleased with the facilitator's performance, the utility of relaxation techniques, breathing techniques, and the overall effect of the lessons (Ricchi et al., 2019). Given that one of the predictors of stressful birth is fear and anxiety, taking birthing courses on a routine basis might help women have a better labour experience (Ghanbari-Homayi et al., 2019). According to Meedya et al. (2020), delivering technology-based education has been increasingly popular in the previous decade and may be regarded an alternative to face-to-face education during the COVID 19 pandemic. However, many Iranian women who utilize public health care lack access to a mobile phone or high-speed internet, making education more difficult for those who need it the most. On the other hand, research published by Brixval et al. (2015) concluded that there is insufficient data to determine if prenatal education in small groups is helpful in terms of obstetric and psychosocial outcomes. They advocated for well-conducted, low- bias randomized controlled trials. These studies did not come to the conclusion that childbirth education is worthless. The topics covered, the objectives, the overall number of hours, the amount of time spent on each topic, and other aspects of the classes were all inconsistent. It was impossible to come to any meaningful conclusions. The substance of lessons varied based on the demographics of the students, the sponsors' aims and objectives, and the instructors' points of view (Simkin, 2017). University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 19 2.4.3 Usefulness The mother's physical and emotional readiness for childbirth is aided by childbirth preparation education. Childbirth education programs help mothers overcome their concerns by improving their understanding about pregnancy, childbirth, and the postpartum period (Afshar et al., 2017; Pinar et al., 2018;). This gives them confidence in their capacity to bear labour pain. Stressing further, ample evidence has also indicated that attending childbirth classes lowers anxiety before delivery and promotes appropriate pain responses. A study on a psycho-education intervention by midwives in reducing childbirth fear in pregnant women found that training women can increase their confidence in their ability to cope with childbirth and labour pain (Toohill et al., 2015). The study further reiterated that this helps to reduce medical interventions during childbirth, medical costs, and improve maternal health. Pregnant women frequently attend prenatal education classes to learn about different birthing options, pain management techniques, baby care, postnatal care, breastfeeding, and parenting (Stoll et al., 2012). Marufa et al. (2019) also noted that peer- to-peer information sharing is a significant finding of their research. First-time mothers benefited from hearing from experienced mothers who shared their experiences and learnt about typical discomforts and difficulties. The study also found that knowledge obtained through group prenatal care helped pregnant women become more aware of their own health and empowered to make healthcare decisions. Hence, influencing their family members who might otherwise discourage them from attending check-ups. According to Vilda et al. (2019), medical professionals offering basic information to women from lower socioeconomic backgrounds, will reduce misunderstanding between doctors and patients. A study by Duncan et al. (2017) and Pinar et al. (2018) findings indicated that improving pregnant women's knowledge about labour, delivery, and pain-coping methods University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 20 can improve their self-efficacy in tolerating labour pain. Hassanzadeh et al. (2020) went on to say that improving women's understanding through prenatal education can help them prepare for childbirth. Furthermore, it will enhance their health, and that a lack of information and fear of the unknown during pregnancy and labour causes mothers to be frightened and nervous. After the adjustments for spouse's education, income, occupation, spouse's occupation, spouse's support, and marital satisfaction, the results revealed that the mean scores of childbirth fears, anxiety, and depression were significantly lower in the regularly attending group than in the non-attending group. Pinar et al. (2018) said that mother anxiety, sadness, and dread are linked to issues including preterm birth and low birth weight. Furthermore, babies delivered to mothers who are afraid and nervous are more likely to have weakened immune systems (Kiruthiga et al., 2017). Each childbirth educator went over the three stages of labour and contractions in great detail. As evidenced by the number of information statements, stage one attracted the most attention. Because early labour, established labour, water breaking, and contractions were all mentioned in the first stage. Each educator included definitions for early and established labour, as well as information aimed at teaching women and their partners how to recognise the stages and stay at home until labour is established. The findings of Cutajar et al. (2020) and Ferguson et al. (2012) concluded that antenatal education had a favourable effect in reducing false labour admissions. However, according to Lincetto et al. (2012), antenatal care allows women and their families to obtain relevant information, such as information on healthy pregnancy, safe delivery, newborn care, postnatal healing. In addition, initiation of early breastfeeding, as well as making decisions about future pregnancies and improving pregnancy outcomes. University of Ghana http://ugspace.ug.edu.gh https://ezproxy.ug.edu.gh:2124/doi/10.1111/hsc.13291#hsc13291-bib-0015 PREGNANCY SCHOOL 21 2.4.4 Views on number of appointments Relating to views on the number of appointments, there was general lack of broad- reaching rules or criteria for arranging classes in the literature, the number, manner, and substance of sessions frequently differ (Ricchi et al., 2020). Marufa et al. (2019) used a mixed method approach to conduct qualitative study on group prenatal care experiences among pregnant women in a Bangladeshi community. According to the findings, the service provider generally only has a limited amount of time with each patient. The participants further added that, the providers are only able to answer a few of the patient's concerns or offer just the most basic facts during consultation. In contrast, however, Dinç et al. (2015) found that inadequacies such as too much information given in a short time, educational content tailored to the preferences of trainers rather than the needs of women. Furthermore, insufficient time to discuss transferred information, and non-practical reinforcement of relevant theoretical information may lead to antenatal education failing. Their findings also highlight the disparities in the goals, substance, and duration of prenatal education programs, indicating that current norms and guidelines are insufficient. Furthermore, research from low- and middle-income countries found a negative relationship between satisfaction with services and the length of time women spent at the health facility prior to delivering (Bitew et al., 2015; Srivastava et al., 2015). 2.5 Health Behaviour-Motivation Health behaviour motivation construct focuses on motivational factors which is a person’s personal attitude towards performance of health promotion behaviours. The social support for enactment of health promotion behaviours are all critical influences on performance of health-related behaviour. The purpose of the pregnant school is to help the pregnant woman to develop an attitude of making timely and good decision concerning the pregnancy. The pregnant women are not to be coerced to attend the pregnancy school but University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 22 rather helped to make an informed decision based on the pep talk given at the antenatal clinic to participate in the pregnancy school. Personal motivation- This is a concept under the motivation constructs in the IMB model which focuses on intrinsic factors (of the pregnant women) that informs their attitude towards attendance of the pregnancy school. Considering the findings from Rasouli et al. (2016) it was noted that the childbirth preparation classes approach emphasizes on assisting a client in making their own decision to change. This beneficial rather than the client being forced by outside sources with attempts to convince or compel them to change. In motivational interviewing approaches, the findings revealed that the study participants had a key impact in establishing the desire to prepare for delivery by increasing the participants' intrinsic motivation. Exercises in decisional balancing helped women consider the benefits and drawbacks of preparing or not preparing for delivery. This exercise aided their progress in the direction of good development. When women chose to modify their behaviour, the counsellor assisted them in making plans to attend childbirth preparation classes and encouraging them to attend. 2.5.1 Social support received Another integral concept under the motivation construct in the IMB model is social motivation which focuses on the variables that impact a pregnant woman's decision to attend pregnancy school. This type of assistance might come from the husband, partner, family, and friends. Social deprivation and social isolation negatively affect maternal health, which can lead to an increase in maternal death Upadhyay et al. (2014). Also, social marginalization and isolation have a negative impact on maternal health, which can contribute to an increase in maternal mortality (Morgan et al., 2014). University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 23 Regarding the role men play in reproductive and sexual health WHO (2014), it was noted that a steady increase has been recognized and seen as an important step in meeting men's needs, supporting women's health, and improving family health. Given men's role in decision-making, the importance of involving them in reproductive health programs has gained recognition since the mid-1990s. Furthermore, men's participation in reproductive and sexual health has increasingly been recognized as an important step in meeting men's needs, supporting women's health, and improving family health. Both women and their husbands impacted the decision to use ANC and delivery care although husbands were more influential, especially in teenagers and young adults (Esena et al., 2015). Besides the foregoing, the mother-in-law may have a role in influencing the choice to seek maternal health care (Some et al., 2013). Community-based research in Mali discovered that the traditional belief by mother-in-law in home delivery impacted the delivery location (White et al., 2013). This might be because the study was done in an urban environment, whereas the other three studies were conducted in rural regions where traditional culture still exists and gives the mother-in-law more control over household and health choices (Thapa et al., 2013; White et al., 2013). In Nepal, research on the influence of spouses' participation in prenatal health education programs on maternal health knowledge found that women educated with their husbands had nearly double the knowledge level of women educated alone (Mullany et al., 2009). Fathers who received breast-feeding education and counselling had higher levels of breast-feeding knowledge, more positive attitudes toward early initiation of breast-feeding. Also, the fathers had a higher likelihood of actively supporting exclusive breast-feeding during the antenatal and postpartum periods than fathers who did not, according to a study in rural Vietnam (Bach et al., 2017). Furthermore, a study carried out by August et al. (2016) found that the intervention was associated with increased male University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 24 involvement in maternal care (from 39 % at baseline to 81% postintervention). In this study carried out in Tanzania, where health workers visited families at least four times during a woman's pregnancy and delivered home-based life-saving skills training to those women, their husbands, and other family members. During pregnancy, delivery, and the postpartum period, both men and women showed higher levels of understanding of at least three signals of risk. Similarly, in a community participatory action program in Mozambique, Audet et al. (2016) deployed community health workers to involve males in prenatal care services and improve HIV testing and treatment uptake among the participants. The staff created a male-friendly clinical setting and offered couples therapy sessions. Male companionship during initial prenatal care (from 5% to 34%) and any antenatal care appointment (from 10% to 37%) increased after the intervention. This is also the case as did HIV testing among pregnant women (from 81 percent to 92 percent) and male partner HIV testing during antenatal care appointments (from 9 percent to 34 percent). In addition, accompanying a partner to prenatal care sessions was linked to a considerably higher likelihood of giving birth in a health facility (odds ratio, 19.4). According to a study done by Chikalipo et al. (2018), both men and women prefer to talk about the care of pregnant women. This is most likely because men and women were aware that care had an impact on pregnancy outcomes, necessitating the need for greater knowledge among couples to assist one another. 2.5.2 Motivation to partake Concerning the issue of motivation to partake in the pregnancy school, it was revealed by Yargawa et al. (2015) that women who had support from their spouses and other social relatives were more likely to utilize ANC. This emphasizes the necessity of engaging married men in initiatives aimed at increasing ANC use, as male engagement has been University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 25 shown to enhance maternal health. However, one of the researches included in this analysis revealed that women who are currently single had a higher likelihood of hiring experienced ANC attendants. (Tarekegn et al., 2014.) One explanation is because unmarried women have sole decision-making authority, allowing them to seek and utilize ANC. Tierney et al. (2015) and Nicoloro-Santa et al. (2018) found that health care providers were the most desired source of information because they were perceived to be credible and reliable, which is consistent with previous research identifying them as the most influential sources for women's decision-making during pregnancy. 2.5.3 Impact of education on social support received On the issue of the impact of education on social support received, a study undertaken by Serhatliolu et al. (2018) found that women who engaged in prenatal education with their husbands got emotional support from them during the labour process. According to the data, encouraging women and their spouses to attend childbirth education classes (CEC) is critical. Furthermore, training and counselling will help women develop their problem- solving abilities, expand their knowledge, stimulate active decision-making, raise their sense of control, and boost their self-confidence. Furthermore, regardless of who provided the continuous care, Hodnett et al. (2012) discovered that women who got continuous labour assistance were more likely to give birth spontaneously. The same were less likely to need pain medicines, were more likely to be satisfied. Moreover, when discussing support of partners in labour, positive suggestions were the primary language technique used by all three educators. The positive suggestions include ‘they need to bring that confidence’, that can-do attitude and dads and support partners were the oxytocin warriors, and were seen as keepers of the birth space (Cutajar et al., 2020). The inclusion of positive suggestion is important as parents will form their expectations based on how University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 26 antenatal information is communicated, which may be a key determinant of their subsequent experience (Hollander et al., 2017; Sercekus et al., 2016). According to Leap et al. (2016) in their guide for supporting women and labour for birth mentioned that merely having someone in the room, or being there, was enough to shorten the labour. Touching on the same subject matter Hollander et al. (2017) and Sercekus et al. (2016) also made a very critical observation that positive advice should be included since parents' expectations. To that effect, this will be formed based on how prenatal information is presented, which might be a significant predictor of their later experience women who had previously given birth showed more confidence in giving birth again. Avery et al. (2019) also mentioned that spending time preparing for the delivery through talks with support people, completing a refresher class, or reading material. The findings of the study reveal that, several factors influenced women's sentiments of trust in physiologic labour and birth. Although many women went into pregnancy thinking their bodies were capable of giving birth, a range of perceived supports helped them acquire an inherent feeling that they could accomplish it and that their bodies were designed to give birth naturally. 2.5.4 Quality contact: Client-Midwife Dwelling on the quality of contact between the midwife and her client, Dagmawit et al. (2020), in their acknowledgment of the fact emphasized that the majority of their respondents (87.8%) said that care providers were courteous. Clients who were regarded by health-care personnel were also strongly related with satisfaction, according to the researchers. During the birth, the midwife plays an important role in offering support and encouragement to the lady, as well as developing her confidence in her abilities to execute her new position as mother (Ricchi et al., 2020). In a like manner, midwives and nurses play a critical role in educating pregnant women and their families about childbirth University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 27 options and assisting them in making informed decisions. Women expect antenatal and postnatal care advice as well as delivery preparation training from a nurse or midwife (Laila et al., 2020). Similarly, Gao et al. (2019) found that attending birthing courses was linked to a better interaction with medical personnel and higher breastfeeding success. Contrasting interpersonal relationship with the availability of infrastructure, Mueller et al. (2020) found that interpersonal interactions with nurse-midwives and personal privacy have strong associations with childbirth satisfaction. This is also true with the positive impact of being able to interact with nurse-midwives and having privacy during the hospital stay outweighing the negative impact of not having proper infrastructure. This conclusion is consistent with earlier research, which has found that the procedures surrounding labour have a greater impact on birth satisfaction than material components of care (Ferrer et al., 2016; Srivastava et al., 2015). To this end the WHO acknowledges that appropriate utilization of effective clinical and non-clinical treatments, enhanced health infrastructure, and optimal skills and attitudes of health workers (Tunçalp et al., 2015). Further stressing the point, Avery et al. (2019) noted that women's connections with their maternity care providers, such as doctors, midwives, and other clinic personnel, were crucial in helping women feel prepared for labour and delivery. Notwithstanding the study further revealed that women valued the opportunity to ask questions, learn about pregnancy and what to anticipate during labour and delivery, get parenting and postpartum information, and discuss birth choices. The findings discovered that it was helpful, comforting, and unhurried midwifery care were especially noted, and that women occasionally described a physician or midwife with whom they did not have a strong bond. Women's confidence in labour and birth was boosted by maternity care provider interactions in which they got information, were given alternatives for care, and were University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 28 involved in care decisions and labour and birth plans. Underscoring further, the critically relevant relationship between the expectant woman and the midwife, Nicoloro – Santa et al. (2018) in their research came up that participant provided concrete instances of how they used material that they had obtained and assessed. Participants reported how this knowledge influenced their patient-provider communication experiences by affecting the creation of questions they would subsequently ask their health care providers. Furthermore, prior study has indicated that women who prepare questions for their meetings are more likely to begin patient-initiated dialogues, resulting in patients revealing more information with their health care providers. Furthermore, Børøsund et al. (2014) discovered through their study that their participants felt more confident in their communication with health care professionals. And to that effect increases patients' overall satisfaction with the quality of their health care and their mental and physical health. Attitudinal change is another invaluable construct that the health behaviour motivation assesses. The overall effect of education on the paramount on a number of factors pertaining to how pregnant women make lifestyle changes after they receive the education. Adding to this, Christenson et al. (2018); Connor et al. (2018) stressed that pregnancy is a period when many women are motivated to make health-related changes. This quest may lead to the exposition to extra health information and services, such as information provided by prenatal health care professionals and information found on the internet. This is further seen in the study according to Vamos et al. (2019), which emphasized that health care practitioners who have been educated in patient-centred counselling and cultural competency may treat patients with respect and respond to their needs and concerns. Participants in this study also discussed how such knowledge influenced their health-related decisions, such as nutrition and newborn care. University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 29 Furthermore, this knowledge provided as crucial anticipatory advice, preparing women for future pregnancies, births, and infant-rearing experiences. 2.6 Health Behaviour-Skills The next construct of the IMB model to examine is the health behaviour skills which asserts that, behavioural skills for performance of health promotion actions are an additional critical determinant of whether well-informed and well-motivated individuals will be capable of effectively enacting health promotion behaviours. 2.6.1 New skill acquired The acquisition of new skills and how they are put to good use by pregnant women is an integral component of the health behaviour skills. Skills learned through childbirth education have the potential to impact positively on the overall wellbeing of the expectant mother. According to Nazik (2017) stretching and posture correction exercises, relaxation methods, massages, and breathing techniques are among the skills taught to women. Adding to this, a similar childbirth education class have been on offer to women in Turkey, Australia (Levett et al., 2019) and in Italy (Ricchi et al., 2020). To reduce neonatal morbidity and death, mothers must be educated on proper newborn care practises. Parents' newborn care practises are key factors of neonatal death (Amolo et al., 2017). 2.6.2 Identification of danger signs Further, the skills also looked to create awareness of danger signs during pregnancy. This is seen in a study carried out by Hibstu et al. (2017) which asserted that participants' awareness of obstetric danger signals was tested by asking them to name the danger signs that can occur during pregnancy, birth, and post-partum. Then, if a woman mentioned at least three significant risk signals for each of the three phases, she was considered informed. Women with at least an elementary education were more likely than those University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 30 without any formal education to be aware of obstetric danger signs. This discovery is in line with prior research conducted in Ethiopia's Tsegedie District, Tigray Region (Haliu et al., 2014). Previous research in Tanzania and Ethiopia likewise found a low prevalence of knowledge of danger signs (Maseresha et al., 2016; Urassa et al., 2012). Because difficulties can emerge at any time throughout pregnancy, every woman should be aware of the danger signs. Vaginal bleeding, severe headaches, visual issues, high temperature, swollen hands/face, and decreased foetal activity are all warning symptoms (Kearns et al., 2014). Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) Tanzania remarked that, taking the proper steps to seek medical help means receiving prompt and adequate care, which lowers maternal mortality and morbidity. When women visit an ANC clinic, they should receive health education on pregnancy, including outcomes, danger signs throughout pregnancy, nutrition, and family planning, and other services (MoH, 2015). Vaginal bleeding was the most frequently stated danger sign of pregnancy (81.2%), maybe because it is the most obvious indicator compared to other signs like decreased foetal movement (Mwilike et al., 2018). Women, their partners, and the community as a whole need to be informed on obstetric danger signs so that they can seek timely care from qualified experts. One of the reasons women fail to recognize and seek appropriate emergency care is a lack of understanding of the significance of symptoms of obstetric complications. As a result, assessing women's awareness of obstetric danger signs and associated factors helps them learn more (Dessu et al., 2018). 2.6.3 Decision making process Birth preparedness and complication readiness is a commonly utilized technique in low- resource nations to encourage the timely utilization of competent maternal and neonatal University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 31 care, particularly during childbirth. Certain important aspects related to child preparedness are regarded as cornerstones of birth preparedness and compilation readiness. These include raising awareness of danger signs; improving problem recognition and reducing delay in seeking care; choosing a birth location and provider in advance; knowing the location of the nearest skilled provider. Obtaining basic safe birth supplies and identifying someone to accompany them to the facility are also relevant (JHPIEGO, 2014). The research further stressed that women in their research who were engaged in group care reported much greater rates of discussing where to deliver with the midwife, planning emergency transportation in the event of a difficulty, and saving money for their birth. For certain features, the husband's engagement in birth preparation was noticeably low. For example, spouses were found to be less involved in organizing transportation to the birth location (52.1%), obtaining a safe delivery kit (21.1%), and arranging for a possible blood donor (21.1%). Husbands frequently assume that health centres will supply all essential delivery supplies. As a result, low birth-preparedness for particular traits may be a result. Birth preparation kits have been shown to be an effective method for reducing maternal mortality in obstetric crises. Noting further however, the study pointed out that in Myanmar spouses are unfamiliar with the features of birth readiness, and awareness should be promoted not only for women but also for their partners. This might be related to the fact that in some regions of Africa, males do not help their pregnant wife since they are perceived as weak if they do (Kaso et al., 2014). According to the study undertaken by Munguiko et al. (2019), it was revealed that pregnant woman who drew and discussed her birth plan with her spouse was nearly 2.0 times more likely to prepare for childbirth than a woman who did not engage her spouse. This is likely due to the fact that the practice enlists the male spouse's participation and University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 32 motivates him to assist his female companion. Furthermore, because it is a cultural practice in most African communities that a man is the family's chief executive and, as a result, he controls the family's income and expenditure. Involving him therefore in child birth planning brings on board the money that is desperately needed to procure all elements of BP. The study further went on to say that pregnant women who were led by their spouses during prenatal appointments were 1.7 times more likely than those who were not escorted to prepare for childbirth. This might be because men who participate in prenatal care are more likely to be educated about birth preparation, which increases the probability that men will assist their women in doing so. Our research also found that respondents who received health education on birth preparedness at an ANC visit were 1.9 times more likely than those who did not to prepare for skilful birth. This is because health education improves a woman's awareness of the importance of preparing for childbirth before the due date (Hiluf et al., 2008). Moreover, because it is impossible to anticipate which pregnant women may have life-threatening obstetric difficulties, one of the most significant interventions in safe parenting has been to encourage all pregnant women to plan to seek expert delivery services as soon as feasible (Mukhopadhyay et al., 2013). Pregnant mothers who received prenatal training had a lower risk of caesarean birth, according to many studies (Cantone et al., 2018). Anxiety experienced at delivery was decreased (Miquelutti et al., 2013), childbirth-related self-efficacy rose, and fear of delivery reduced (Hong et al., 2020) mothers were more active during childbirth, and epidural anaesthesia was used less frequently. Childbirth education classes assist in making decisions regarding labour and delivery, pain management, and breastfeeding and parenting (Simpson et al., 2010; Stoll et al., 2012). Childbirth education programs also teach women how to recognize unforeseen problems that might lead to maternal death, such as gestational hypertension, University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 33 postpartum haemorrhage, and infection (Firouzbakht et al., 2013; Malata et al., 2007; Pinar et al., 2018;). However surprisingly, Afshar et al. (2018) notes that having a birth plan, on the other hand, was not linked to an increased risk of chorioamnionitis, perineal lacerations, or postpartum haemorrhage, all of which may be considered obstetrical interventions. According to section 1.9 of the WHO (2006), healthcare professionals must include information about labour symptoms, danger indications throughout pregnancy, and emergency transport for newborn babies with problems during ANC. It also urges pregnant women to create a birth and emergency preparation plan. Similarly, this was also noted by Lori et al. (2017) in their research study which sought to explain that pregnant women are aware of danger indications in pregnancy and have established a birth and emergency preparation plan, among the process and outcome indicators for these criteria. On a similar premise, Haftom et al. (2015) observed that, including risk indicators in birth preparedness and complication readiness plans during couple prenatal education is important. This, it notes is likely to enhance male partners' engagement in satisfying the expectations of BP/CR. In like manner, a similar study by Chikalipo et al. (2018) highlighted that majority of participants they interviewed during their survey indicated birth preparations and complication readiness plan (BP/CR). This however, concentrated on goods to acquire in preparation for childbirth as a preferred topic, with a minority recommending the addition of danger signs throughout pregnancy. 2.6.4 Benefits of skills gained Having gained the requisite skillset as a result of the prenatal education, an evaluation of the impact such skills bring to bear of the expected mother may be evident in the overall wellbeing of the mother and the baby. Numerous studies have shown that women who attend childbirth education classes are better able to manage anxiety during labour and University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 34 delivery. A study by Herberlein et al. (2016) showed the beneficial effects and thus revealed that moms who attended the GANC in the postpartum period were capable and prepared to handle their own transition to parenthood. Similarly, Berge et al. (2019) found that participants in Minnesota felt they received a lot of knowledge, which prompted them to attempt new health behaviours, and they also suggested that group prenatal care be continued and expanded to additional clinics. It is also refreshing to note that according to Lori et al. (2017) a cohort study on improving health literacy through group antenatal care, there was a significant difference between women enrolled in group antenatal care versus individual antenatal care. This highlighted the differences in terms of preventing problems before delivery, understanding when to seek care, birth preparedness and complication readiness, and intent to use a modern method of family planning. GANC participants increased their health literacy by demonstrating a better knowledge of how to operationalize health education messaging. An empirical research work carried out by Pinar et al. (2018) showed that women who took childbirth preparation classes were better able to adjust to labour discomfort, used less labour medications, and had fewer instrumental births. Furthermore, those engaged in the group ANC style of care were able to report substantially more favourable breastfeeding habits than women receiving individual care. Only 23.5 percent of mothers engaged in personalized care said they discussed infant issues with the midwife during ANC visits. However, the majority of maternal and newborn fatalities occur within the first month of life, with half of all maternal deaths occurring within the first 24 hours and 66% occurring within the first week this is according to a study undertaken by (Lawn et al., 2014). University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 35 Recognising the benefits gained from the prenatal education Rai et al. (2012) revealed that prenatal check-ups enable for the early detection and treatment of problems as well as the education of the expectant woman on how to manage her current pregnancy and the health benefits of spacing pregnancies apart. Difficulties that are addressed at the first indication of a problem can improve outcomes for expecting moms, therefore it is critical for a pregnant woman to be informed enough to seek medical attention for any potential complications. Also, guidance that not only focuses on providing information, but also on preparing women and their partners for delivery, including strengthening women's confidence in their capacity to labour and give birth was issued (National Health and Medical Research Council, 2018). Additionally, women's birth experiences, according to Savage (2001), involve the transmission of wisdom from one who knows to others who need to know. This was demonstrated in the group when one of the women was expecting her third child. The woman offered her birth stories, which were integrated into the birthing educator's curriculum. The woman's experience about a posterior delivery in particular enriched and contextualized the educator's knowledge on prenatal posture for the class (Cutajar et al., 2020). Moreover, according to Kay et al. (2017), when women hear good birth experiences, they learn about the strength and power of delivering and may feel more confident in their physiological ability to give birth. Women who hear bad birth stories, on the other hand, may connect delivery with pain, danger, and dread. In addition, evidence suggests that knowing about delivery lessens fear, boosts confidence, and improves the desire for vaginal birth (Hassanzadeh et al., 2019). According to a research analysis conducted by the University of Canberra's Faculty of Health, Disciplines of Nursing and Midwifery, prenatal education throughout pregnancy decreases anxiety during labour and delivery and improves partner engagement University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 36 (Ferguson et al., 2013). A prenatal course given by the British National Health Service led to significant reductions in stress, anxiety, and depression symptoms among pregnant women and their partner (Warriner et al., 2018). Prenatal education appears to decrease anxiety of labour and post-traumatic stress disorder symptoms after delivery (Isbir et al., 2016). On the contrary, it is well understood that the advantages of prenatal education are difficult to assess in a systematic way, and that more study is needed to establish the true impacts and agree on valid efficacy measures. Data collecting standards, various techniques and types of classes, and the influence of what happens during labour and delivery all appear to be contributing factors (Ricchi et al., 2020). Nonetheless, numerous studies such as the ones carried out by Hatamleh et al. (2019) and Makvandi et al. (2018) agree that women who attend classes have a lower risk of caesarean section. Moreover, they are less likely to request epidural analgesia and use alternative pain relief techniques, are more likely to be present at the hospital in active labour, breastfeed exclusively and for longer, and have a lower risk of postpartum emotional distress. 2.7 Health Behaviour The information-motivation-skill on the health behaviour outcome is important in explaining the relevance of the information and skills the pregnant received at the pregnancy school as well motivating factors that contributed to the attendance of the pregnancy school. 2.7.1 Outcome of health behaviour A study conducted by Lavett (2015) to evaluate the effectiveness of a complementary therapies antenatal education package provides evidence that antenatal education using complementary therapies CM techniques. This includes acupressure; yoga; massage; visualisation/relaxation; breathing techniques; continuous partner support; as well as education about normal birth physiology. To add to these, standard antenatal care is an University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 37 effective and viable method of managing pain during labour, increasing personal control for women, enabling partners and midwives to provide appropriate support. These thereby reduces some medical interventions and increases the normal birth rate. According to Zere et al. (2012), women who attend four or more ANC visits are more likely to deliver with the help of a professional. On the one hand, frequent ANC attendance reduces maternal mortality by assisting in the early detection of obstetric problems, and on the other hand, it influences women's decision to seek expert delivery support. Moreover, information that allows mothers to grow and retain their well-being during pregnancy, as well as not only the dissemination of key information for promoting the health of mothers, but also the areas where the given information will be put into practise. They further said that the mother's cognitive abilities, which will allow her to gather information and utilise it to positively influence her life, are also important (O'Neill et al., 2014). Some antenatal education programmes, in addition to covering physiological changes during pregnancy, also cover emotional changes, but this is said to be less prevalent (Godin et al., 2015; Sercekus & Mete 2010). However, including information on emotional or psychological wellbeing following the delivery of the baby appeared to be more common (Brixval et al., 2016; Duncan & Bardacke 2010; Koushede et al., 2017; Svensson et al., 2009; Visger et al., 2009; Walker & Worrell 2008). 2.7.2 Expectation Indeed, seeking to improve also leads to various expectation. According to Jakubiec et al. (2014) primiparous women experience more stress as they adjust to their new position as a mother who cares for her child. These women are more likely to enrol in childbirth education programs. On the other hand, men and women had equal prenatal information requirements, according to our findings. However, both men and women in this research favoured aspects such as caring for a pregnant woman, giving birth, baby care, and family University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 38 planning. Male participants, on the other hand, were more interested in sex and men's responsibilities during the perinatal period, PMTCT, and family life than female participants, who were more interested in birth readiness (Chikalipo et al., 2018). Conversely, unlike previous research from western contexts, participants did not list emotional support for males as a favoured topic (Smyth et al., 2015). Providing further insight, a couple of studies have divulged how pregnant women evaluate and utilize health information. Participants in this study were aware that information may be inaccurate or biased, and they stated that they confirmed the accuracy of information using various sources. Other research has confirmed the importance of women being aware of potential misinformation outside of the clinical setting. This further stress the need for health care providers to be prepared to counteract patients' false information, particularly in societies where the internet is becoming more prevalent (Bert et al., 2016; Leiferman et al., 2014). In Sweden, Ahlden et al. (2012) polled 1117 women and 1019 partners on their intentions to attend antenatal education programmes. More information on preparation for parenting and newborn care was reported by both women and their spouses than on preparing for the birth itself. Others suggest that women in antenatal education programmes want greater knowledge about newborn care, parenting support, and breastfeeding (Martinez & Delgado, 2013; Moniz et al., 2016). 2.7.3 Impression On the issue of impression in an ever-evolving technological world, research has shown that communication that employs extra resources such as eHealth apps and patient- provider communication that integrates health literacy concepts can be beneficial. These enhance obtaining, understanding, using, and evaluating health information (Best et al., 2018; Wittink et al., 2018). Furthermore, participants also discussed what made health information during pregnancy simple or difficult to grasp, such as the use of common University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 39 language rather than medical jargon (Vamos et al., 2019). According to previous research, clear language and audio and visual aids make health information more understandable (Coley et al., 2018). Woman-centred care in the prenatal context is especially essential, since it enables two-way communication between the health care practitioner and the woman, allowing women to express questions when they don't comprehend information (Ledford et al., 2016; Washington Cole et al., 2016). This study's findings emphasize the importance of health care professionals welcoming and not dismissing women's inquiries in order to improve communication and overall satisfaction with the visit. Smith (2015) express worry about antenatal classes being used to ensure that women were aware of, and hence compliant with, hospital policies and procedures. Furthermore, many claims that class content has always been based on what educators believe women need rather than what women want (Hanson et al., 2009; Svensson et al., 2007; Tighe, 2010). 2.7.4 Ways of improvement In spite of the foregoing, it has been noted that dealing with isolated instances of inconvenience that occasionally characterizes the delivery of the childbirth education would improve confidence of women and increase participation. Highlighting some of the inconveniences, Metinoğlu et al. (2021) notes that inappropriate sounds, background noise, the temperature of the room, inappropriate lighting, and lack of respect for privacy contribute to disturbances in focus. For instance, women who took part in CEC were given knowledge and practices relating to visualization, breathing, and attention methods in this study. These strategies allow these women to tune out external distractions and concentrate only on their bodies and the delivery process. Women's capacity to reach this trance-like state is aided by factors such as prenatal education, a secure and secluded setting, and ongoing support. University of Ghana http://ugspace.ug.edu.gh PREGNANCY SCHOOL 40 Looking at ways to improve current research and standards, health care providers should consider the language they use while delivering care (Mobbs et al., 2018; WHO, 2019). In that same rega