University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA, LEGON COLLEGE OF HUMANITIES ANTENATAL AND POSTNATAL HEALTH SERVICES UPTAKE AND CONTRACEPTIVE USE AMONG WOMEN IN GHANA BY DESMOND KLU (10395678) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF PHD DEGREE IN POPULATION STUDIES REGIONAL INSTITUTE FOR POPULATION STUDIES DECEMBER 2017 University of Ghana http://ugspace.ug.edu.gh DECLARATION I hereby declare that, except for reference to other people‘s works which have been appropriately acknowledged, this work is the result of my own research and it has neither in part nor in whole been presented elsewhere for any other degree. …………………………………… DESMOND KLU ………………………………. DATE i University of Ghana http://ugspace.ug.edu.gh ACCEPTANCE Accepted by the College of Humanities, University of Ghana, Legon, in fulfilment of the requirement for the award of PhD Degree in Population Studies Supervisors of Thesis: ………………………………………. PROFESSOR STEPHEN OWUSU KWANKYE ………………………………………. DATE ………………………………………… DR. AYAGA A. BAWAH ………………………………………... DATE ……………………………………… DR. NAA DODUA DODOO …………………………………….. DATE ii University of Ghana http://ugspace.ug.edu.gh ABSTRACT Maternal and child health and family planning are important issues that have population and health implications globally. The use of antenatal and postnatal health care services are important components of maternal and child health care services. The essence of these health care services is to ensure good health of mothers and babies before, during and after birth. Also, the use of modern contraceptives ensures good health of mothers and their babies through good child spacing, reduction in the risk of short pregnancy intervals and prevention of unintended pregnancy. Thus, all the three health components are aimed at ensuring good maternal and child health. However, there are still some knowledge gaps in understanding the relationship among antenatal, postnatal health care and contraception. Studies have shown high utilisation of antenatal and postnatal health care services within the Africa sub region by women, but this is not reflecting in their use of modern contraceptives. Contraceptive education is provided during antenatal and postnatal health care services and studies have shown influence of contraceptive education on contraceptive use, however, the level of women‘s use of modern contraceptive is still low. Therefore, this study aimed at examining the relationship between antenatal, postnatal health care utilisation and modern contraceptive use among women. It also sought to explore the contraceptive education women receive during antenatal and postnatal health care services. The study adopted a mixed methods sequential explanatory design. The quantitative components used three rounds of the Ghana Demographic and Health Survey conducted in 2003, 2008 and 2014. The sample included all postpartum women aged 15-49 years who gave birth in the 23 months preceding the surveys. A total sample of 4,863 postpartum women (GDHS 2003-1,421; GDHS 2008-1,178; GDHS 2014- 2,264) was used for this study. The quantitative analysis was done on the relationship between antenatal, postnatal health care services and contraceptive use and also demographic and socio- economic characteristics of postpartum women. The qualitative component of the study consisted of in-depth individual interview among 30 women on the content, frequency and materials on contraceptive counselling provided during antenatal and postnatal health care. The dependent variable for this study was modern contraceptive use; the intermediate variable was contraceptive counselling and the main independent variables were antenatal and postnatal health care services. The results showed high utilisation of antenatal and postnatal health care services among postpartum women in all the three surveys. However, the proportion of postpartum women using modern contraceptives was not as high as the proportion using antenatal and postnatal health care services. At the bivariate level, high modern contraceptives use was recorded among postpartum women who utilised both antenatal and postnatal health care services. At the multivariate level, the results indicated a high probability of modern contraceptive use among postpartum women who utilised only antenatal health care and both antenatal and postnatal health care services. The qualitative results revealed that women receive contraceptive information on the benefits of using contraceptives during antenatal and postnatal health care service provision. They also receive information on both short and long-term methods of contraception. However, contraceptive counselling is not provided very often and counselling materials are rarely used. The study therefore concludes that there is higher use of modern contraceptives among women who utilize both antenatal and postnatal health care services. The study therefore, recommends that women should always be encouraged to have continuous contact with the health system especially both antenatal and postnatal health care because this has the potential to increase their use of contraceptives and also improve their sexual and reproductive health. iii University of Ghana http://ugspace.ug.edu.gh DEDICATION This work is dedicated to my dear parents Daniel Klu and Bertha Dadzie for their care and support. I also dedicated this work to my lovely and lovely wife Charity Akpene Klu and our wonderful daughter Atarah Aseye Afi Klu. v University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENTS My first thanks go to the Almighty God who rules in the affairs of men for making this work a success. My most sincere gratitude goes to my three supportive thesis supervisors-Professor Stephen Owusu Kwankye, Drs. Ayaga Bawah and Naa Dodua Dodoo, who patiently guided this work to the end. I wish to express my profound gratitude to the Director of Regional Institute for Population Studies, University of Ghana, Professor Samuel Nii. A. Codjoe for giving me the opportunity to pursue my PhD at the institute. Special appreciation also goes to the trustees of RIPS Research Development Fund (RRDF) for granting me financial support for a four- year period. Furthermore, I express my heartfelt appreciation to the faculty members of RIPS especially Professor John A. Anarfi, Drs. Faustina Frimpong-Ainguah, and Adriana Biney. Their advices gave me a deeper insight about my work and gave me focus and direction towards the completion of my dissertation. I am very grateful for their tremendous assistance and I thank the Almighty God for using them to guide my work to a successful end. God in His infinite mercy and grace bless them. The support of Covenant Family cannot be forgotten. I thank God for my Pastor, Stephen Tetteh Oyimer, and his two Associate Pastors, Jacob Aidoo and Owusu Manu for their continuous prayers and encouragement Again, gratitude goes to all staff and students of the Regional Institute for Population Studies. Most especially to all PhD students of the institute for their support and advices to my work and I am very grateful. I will also like to appreciate the staff of the antenatal and postnatal health units, University of Ghana hospital (Legon) and Achimota hospital. I really appreciate the selfless support and assistance during my data collection. I cannot forget my wonderful and receptive respondents. God reward you all accordingly. vi University of Ghana http://ugspace.ug.edu.gh Finally, how can I forget the love, care and support of the love of my life and my ever adorable wife. She has been my backbone from the beginning of this work. God richly bless you my dearest. vii University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS Table of Contents Pages DECLARATION ................................................................................................................................................ i ACCEPTANCE ................................................................................................................................................. ii ABSTRACT ...................................................................................................................................................... iii DEDICATION ................................................................................................................................................... v ACKNOWLEDGEMENTS .............................................................................................................................. vi TABLE OF CONTENTS ................................................................................................................................ viii LIST OF FIGURES ......................................................................................................................................... xii LIST OF TABLES .......................................................................................................................................... xiv LIST OF APPENDICES .................................................................................................................................xvii LIST OF ABBREVIATIONS ........................................................................................................................ xviii CHAPTER ONE ................................................................................................................................................ 1 INTRODUCTION ............................................................................................................................................. 1 1.1 Background of the Study.................................................................................................................... 1 1.2 Statement of the Problem ................................................................................................................... 7 1.3 Research Questions .......................................................................................................................... 12 1.4 Rationale for the Study .................................................................................................................... 12 1.5 Objectives of the Study .................................................................................................................... 15 CHAPTER TWO ............................................................................................................................................. 16 LITERATURE REVIEW ................................................................................................................................ 16 2.1 Introduction ...................................................................................................................................... 16 2.2 Antenatal Health Care Service Utilisation, Contraceptive Knowledge and Contraceptives uptake among women .............................................................................................................................................. 16 2.3 Postpartum Contraception and Reproductive Behaviour among Antenatal Clinic Attendees ......... 21 2.4 Postnatal Health Care Service Utilisation and Contraceptives uptake among women .................... 22 2.5 Demographic and Socio-economic characteristics of postpartum women ...................................... 26 2.6 Contraceptive Counselling given during Antenatal and Postnatal Health Care Services ................ 28 2.7 Theoretical Framework .................................................................................................................... 30 viii University of Ghana http://ugspace.ug.edu.gh 2.7.1 Theory of Triadic Influence ..................................................................................................... 30 2.7.2 Transfer theory ......................................................................................................................... 32 2.8 Conceptualising the relationship between maternal, child health and family planning ................... 34 2.9 Conceptualising the relationship among antenatal, postnatal and modern contraceptive use ......... 36 CHAPTER THREE ......................................................................................................................................... 40 METHODOLOGY .......................................................................................................................................... 40 3.1 Research Design ............................................................................................................................... 40 3.2 Sources of Data ................................................................................................................................ 41 3.3 First phase-quantitative data analysis .............................................................................................. 41 3.4 Sample used for quantitative data .................................................................................................... 42 3.6 Methods of quantitative data analysis .............................................................................................. 43 3.6.1 Univariate analysis ................................................................................................................... 43 3.6.2 Bivariate analysis ..................................................................................................................... 43 3.6.3 Multivariate analysis ................................................................................................................ 44 3.7 Definition/Measurement of Variables .............................................................................................. 45 3.8 Second phase-qualitative data collection and analysis ..................................................................... 46 3.8.1 Study design ............................................................................................................................. 46 3.8.2 Settings and Participants .......................................................................................................... 47 3.8.3 Sample size and selection ........................................................................................................ 48 3.8.4 Ethical and Administrative Clearance ...................................................................................... 49 3.8.5 Data collection process ............................................................................................................ 49 3.9 Data Analysis ................................................................................................................................... 50 CHAPTER FOUR ............................................................................................................................................ 51 UTILISATION OF ANTENATAL, POSTNATAL HEALTH CARE AND CONTRACEPTIVE USE AMONG POSTPARTUM WOMEN AND THEIR BACKGROUND CHARACTERISTICS ...................... 51 4.1 Introduction ...................................................................................................................................... 51 4.2 Uptake of Antenatal and Postnatal Health Care Services ................................................................ 51 4.3 Modern Contraceptive Use .............................................................................................................. 54 4.4 Background characteristics of postpartum women in Ghana ........................................................... 55 4.5 Background characteristics of individual interview respondents ..................................................... 62 CHAPTER FIVE ............................................................................................................................................. 64 ix University of Ghana http://ugspace.ug.edu.gh CONTRACEPTIVE USE IN THE CONTEXT OF ANTENATAL AND POSTNATAL HEALTH CARE SERVICE UTILISATION AND OTHER FACTORS .................................................................................... 64 5.1 Introduction ...................................................................................................................................... 64 5.2 Antenatal and postnatal health care service utilisation and Modern Contraceptive use .................. 64 5.3 Maternal age, antenatal and postnatal health care and modern contraceptive use among postpartum women 70 5.4 Maternal educational level antenatal and postnatal health care and modern contraceptive use among postpartum women ........................................................................................................................... 73 5.5 Partner‘s education, antenatal and postnatal health care and modern contraceptive use among postpartum women ....................................................................................................................................... 75 5.6 Parity, modern contraceptive use and antenatal and postnatal health care among postpartum women 77 5.7 Place of residence modern contraceptive use and antenatal and postnatal health care among postpartum women ....................................................................................................................................... 80 5.8 Ethnicity and Modern Contraceptive use among postpartum women in the context of Antenatal and Postnatal Health Care ................................................................................................................................... 82 5.9 Marital status, antenatal and postnatal health care and modern contraceptive use among postpartum women 84 5.10 Fertility intention, antenatal and postnatal health care and modern contraceptive use among postpartum women ....................................................................................................................................... 86 5.11 Sexual activity modern contraceptive use and antenatal and postnatal health care among postpartum women ....................................................................................................................................... 88 5.12 Exposure to family planning information in the media, antenatal and postnatal health care and modern contraceptive use among postpartum women ................................................................................. 90 5.13 Sex of household head, antenatal and postnatal health care and modern contraceptive use among postpartum women ....................................................................................................................................... 91 5.14 Wealth quintile, antenatal and postnatal health care and modern contraceptive use among postpartum women ....................................................................................................................................... 93 CHAPTER SIX ................................................................................................................................................ 96 INFLUENCE OF ANTENATAL AND POSTNATAL HEALTH CARE AND OTHER FACTORS ON CONTRACEPTIVE USE AMONG WOMEN IN GHANA ........................................................................... 96 6.1 Introduction ...................................................................................................................................... 96 6.2 Examining the relationship between utilisation of antenatal and postnatal health care services and modern contraceptive use among postpartum women in Ghana.................................................................. 97 6.3 Relationship between utilisation of Antenatal, Postnatal Health Care Services and controlling for other factors on contraceptive use among postpartum women in Ghana ................................................... 101 x University of Ghana http://ugspace.ug.edu.gh CHAPTER SEVEN ....................................................................................................................................... 110 CONTRACEPTIVE INFORMATION POSTPARTUM WOMEN RECEIVE DURING ANTENATAL AND POSTNATAL HEALTH CARE SERVICE ........................................................................................ 110 7.1 Introduction .................................................................................................................................... 110 7.2 Components of contraceptive information during antenatal and postnatal health care services .... 111 7.2.1 Contents of Contraceptive Counselling ................................................................................. 113 7.2.2 Frequency of contraceptive counselling................................................................................. 115 7.2.3 Materials used during contraceptive counselling ................................................................... 117 CHAPTER EIGHT ........................................................................................................................................ 123 DIFFERENCES AND SIMILARITIES IN CONTRACEPTIVE COUNSELLING GIVEN TO POSTPARTUM WOMEN DURING ANTENATAL AND POSTNATAL HEALTH CARE SERVICES . 123 8.1 Introduction .................................................................................................................................... 123 8.2 Similarities and Differences in contraceptive counselling during antenatal and postnatal health care service provision ........................................................................................................................................ 124 8.2.1 The Concept of Consensus ..................................................................................................... 127 8.2.2 The Concept of Absence ........................................................................................................ 129 8.2.3 The Concept of Conflict ......................................................................................................... 131 CHAPTER NINE ........................................................................................................................................... 133 SUMMARY, CONCLUSION AND RECOMMENDATIONS .................................................................... 133 9.1 Summary ........................................................................................................................................ 133 9.1.1 Utilisation of Antenatal and Postnatal Health care services and contraceptive use among postpartum women in Ghana ................................................................................................................. 133 9.1.2 Relationship between Antenatal, Postnatal Health care utilisation and modern contraceptive use among postpartum women in Ghana ............................................................................................... 134 9.1.3 Contraceptive information received during antenatal and postnatal health care utilisation ... 135 9.2 Recommendations .......................................................................................................................... 136 9.2.1 Policy Recommendations and Practice Implications ............................................................. 136 9.2.2 Future Research...................................................................................................................... 138 9.3 Conclusion ..................................................................................................................................... 139 REFERENCES .............................................................................................................................................. 141 APPENDICES ............................................................................................................................................... 155 xi University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 2.1: Maternal-Child Health Care Service and Contraceptive Use……………………….36 Figure 2.2: Antenatal, Postnatal Health Care Service and Contraceptive Use ………………….37 Figure 3.1: Graphical summary of Sequential Mixed Method Explanatory Design ……….........40 Figure 4.1: Trend in antenatal and postnatal care services uptake among postpartum women in Ghana (%) …………………………………………………………………………………….....52 Figure 4.3: Percentage distribution of postpartum women by modern contraceptive use from 2003 to 2014 …………………………………………………………………………………………55 Figure 7.1: Thematic network (diagram) on components of contraceptive counselling ………..112 Figure 8.1: Thematic network on similarities and difference in contraceptive counselling …….126 xii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 3.1: Eligible women in the GDHS by year……………………………………………….....42 Table 4. 1: Percentage distribution of background characteristics of postpartum women in Ghana 2003, 2008 and 2014 ……….……………………………………………………………….……..57 Table 4.2 Demographic and Socio-cultural characteristics of Individual Interview respondent…..63 Table 5.1: Modern contraceptive use and ANC and PNC utilization among postpartum women, 2003, 2008 and 2014………………………………………………………………………………..65 Table 5.2: Modern contraceptive use by ANC and PNC utilisation and current ages among postpartum women, 2003, 2008 and 2014………………………………………………………….71 Table 5.3: Modern contraceptive use by ANC and PNC utilisation and educational level among postpartum women from 2003 to 2014…………………………………………………………......74 Table 5.4: Modern contraceptive use, ANC and PNC utilisation by partner‘s educational level among postpartum women, 2003, 2008 and 2014……..……………………………………………76 Table 5.5: Modern contraceptive use and ANC and PNC utilisation by parity among postpartum women, 2003, 2008 and 2014………………………………………………………………………78 Table 5.6: Modern contraceptive use, ANC and PNC utilisation by place of residence among postpartum women, 2003, 2008 and 2014………………………………………………………….81 Table 5.7: Modern contraceptive use and ANC and PNC utilisation by ethnicity among postpartum women, 2003, 2008 and 2014………………………………………………………………….…...83 Table 5.8: Modern contraceptive use, ANC and PNC utilisation by marital status among postpartum women from 2003 to 2014………………………………………………………………………….84 Table 5.9: Modern contraceptive use and ANC and PNC utilisation by fertility intention among postpartum women from 2003 to 2014…………………………………………………………......87 Table 5.10: Modern contraceptive use, ANC and PNC utilisation by sexual activity among postpartum women from 2003 to 2014……………………………………………………………..89 Table 5.11: Modern contraceptive use, ANC and PNC utilisation by exposure to family planning information in the media among postpartum women, 2003, 2008 and 2014…..…………………..91 Table 5.12: Modern contraceptive use and ANC and PNC utilisation by sex of household head among postpartum women from 2003 to 2014………………………………………….………….92 xiv University of Ghana http://ugspace.ug.edu.gh Table 5.13: Modern contraceptive use, ANC and PNC utilisation by wealth quintile among postpartum women, 2003, 2008 and 2014….....................................................................................94 Table.6.1: Results of Binary Logistics Regression showing the relationship between antenatal and postnatal health care utilisation on modern contraceptive use among postpartum women in Ghana, 2003, 2008 & 2014………………………………………………………………………………….97 Table 6.2: Results of Binary Logistic Regression showing the relationship between antenatal, postnatal health care utilisation and controlling for other factors on modern contraceptive use among postpartum women in Ghana, 2003, 2008 & 2014……………………………………104 xv University of Ghana http://ugspace.ug.edu.gh LIST OF APPENDICES Appendix A: Women Questionnaire (GDHS) ……………………………………………….….155 Appendix-B: Interview Guide on Antenatal Care and Contraceptive Use………………….…...160 Appendix-C: Interview Guide on Postnatal Care and Contraceptive Use ……………………….161 Appendix D: Informed Consent Form of Women who attend Antenatal Clinics ………….……162 Appendix E: Informed Consent Form of Women who attend Postnatal Clinics ……………...…167 Appendix F: Minor‘s assent form for participation in this study (15-18 Years) …………......171 xvii University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS ANC Antenatal Care DHS Demographic and Health Service DPT Diphtheria Pertusis and Tetanus GDHS Ghana Demographic and Health Service GHS Ghana Health Service GNSDF Ghana National Spatial Development Framework GSS Ghana Statistical Services HIV/AIDS Human-Immuno-Deficiency Virus/Acquired Immuno-Deficiency Syndrome ICPD International Conference on Population and Development IEC Information Education Communication LAM Lactational Amenorrhea Method MCH-FP Maternal Child Health-Family Planning MDG Millennium Development Goal MMR Maternal Mortality Ratio NDPC National Development Planning Commission NHIS National Health Insurance Scheme NGO Non-Governmental Organisation PHC Population and Housing Census PNC Postnatal Care PPIUD Postpartum Intrauterine Device SDG Sustainable Development Goals STI Sexually Transmitted Infection UNFPA United Nation Population Fund UNICEF United Nation Children‘s Fund UN United Nations WHO World Health Organization xviii University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1 Background of the Study Maternal and child health services together with family planning are important global health issues that have health and population implications. The utilisation of health services is considered a complex and complicated behavioural phenomenon (Becker et al. 1993). Particularly noteworthy about health services utilisation is the uptake of family planning, as well as maternal and child health care. These services help in improving the survival and quality of life of mothers and their children (UNICEF, 2008). Globally, giving women, most especially postpartum mothers, access to family planning services gives them an opportunity to avoid unintended pregnancies and promote healthy spacing of births. Studies have shown that contraceptive use reduces almost 230 million births every year and family planning remains the major primary prevention strategy for unwanted pregnancies (Liu et al. 2008, Singh et al. 2009). In addition, the use of contraceptives has been shown to improve child survival through optimal child spacing, lengthening birth intervals and reducing siblings‘ competition for scarce family and maternal resources (Potts, 1990; Rutstein, 2005; DaVanzo et al., 2007; Yeakey et al., 2009). Antenatal and postnatal health care services and the use of contraceptives are important issues in maternal and child well-being (WHO, 2014). The essence of providing antenatal services is to ensure that women are healthy before delivery through the screening of risk factors associated with pregnancy. Antenatal health care (ANC) also serves as an opportunity to promote the use of skilled attendance at birth and healthy behaviour such as breastfeeding, early postnatal care, and planning 1 University of Ghana http://ugspace.ug.edu.gh for optimal pregnancy spacing. Another essence of the antenatal health care package is to prepare for birth and parenthood as well as to prevent, detect and reduce complications of pregnancy and the effect of unhealthy lifestyles. Antenatal services improve the survival and health of babies directly by reducing stillbirths and neonatal deaths and indirectly by providing an entry point for health contacts with the woman at a key point in the continuum of care. The World Health Organisation recommends a minimum of four antenatal visits, in the first, second and third trimesters and these specifically are within 8-12 weeks, 24-26 weeks, 32 weeks and 36-38 weeks of pregnancy respectively. Globally, the proportion of women receiving ANC at least once during pregnancy was 83 per cent during the period 2007-2014 (WHO, 2015). However, only 64 per cent of pregnant women received the recommended minimum of four visits (WHO, 2015). In sub-Saharan Africa, 77 per cent of pregnant women have at least one antenatal care visit (WHO, 2015). In Ghana, 70 per cent of women reported four or more antenatal visits (AbouZahr et al. 2003). Postnatal health care (PNC) by definition involves the assistance given to every mother and baby for a total of four postnatal visits on the first day (24-hours), third day (48-72 hours), 7-14 days and 6 weeks after birth. It also involves a visit to postpartum women‘s homes by skilled health professionals and identifying issues arising from birth of newborns and health of their mothers (WHO, 2010). The essence of PNC is to provide health care for mothers and children after delivery and prevent any complications that may arise from the delivery. The World Health Organisation‘s 6-6-6-6 model of the timing of postnatal visits provides the following guidelines for postpartum women to follow: 2 University of Ghana http://ugspace.ug.edu.gh  6 to 12 hours after birth  3 to 6 days after birth  6 weeks after birth  6 months after birth Modern contraceptive use among postpartum women also improves maternal and child health through responsible child spacing, lengthening birth intervals and reducing sibling competition for scarce family and material resources (Rutstein, 2005; Hale et al. 2009). Contraceptive use also reduces maternal deaths through the reduction of exposure to incidence of unintended pregnancy, reduction in vulnerability to abortion risks, lowering the hazards associated with high parity pregnancies and reducing risks associated with short birth intervals (Simmon et al. 1990; Liu et al. 2008; Singh et al. 2009; Yadav and Dhillon, 2015). Furthermore, modern contraceptive use among postpartum mothers leads to the prevention of unintended pregnancy and healthy birth spacing (Akinlo et al. 2014, Mengesha et al. 2015). This is possible through the uptake of antenatal and postnatal health care services which serve as one of the major source of information about contraceptives. It also serves as an appropriate time for women to begin considering using contraceptives based on informed choices. The uptake of antenatal and postnatal health care service helps to ensure that women have an understanding of how quickly their ovulation may return after birth and the risks associated with closely-spaced pregnancies and how this can be prevented through the effective use of modern contraceptives (United Nations, 2009). A number of studies have shown that there is a positive relationship between maternal and child health services uptake (antenatal and postnatal care) and contraceptive use (Simmons et al. 1990; Wilkinson et al. 1993; Hotchkiss et al. 1999; Ahmed and Mosley; 2002, Seiber et al. 2005; Ringheim, 2011; Do and Hotchkiss, 2013; Akinlo et al. 2014; Mengesha et al. 2015). The reasons 3 University of Ghana http://ugspace.ug.edu.gh for such a relationship between these three reproductive health services have been well documented. First, the provision of family planning services is often within the milieu of maternal and child health care; thus women who utilize these health services may be exposed to family planning counselling and efforts to promote contraceptive use. The relevance of this mechanism may be for women with high risk of short pregnancy intervals to prevent subsequent pregnancies as health care providers may lay more emphasis on the use of postpartum contraception and the health risks associated with it (Williams et al. 1994). Second, as women take antenatal and postnatal health care services, they begin to have trust in the health care system. This trust can aid in removing social barriers that prevent them from accessing family planning services and contraceptive use. It also offers them the opportunity to use multiple health services within the same system (Do and Hotchkiss, 2013). Moreover, a woman‘s contact with the health care system (antenatal and postnatal) may also reduce cognitive, psychosocial and indirect financial hurdles which come in the form of time and opportunity cost to subsequent contraceptive use (UNFPA, 2009, Do and Hotchkiss, 2013). In addition, there is the belief that women may never get pregnant when they are breastfeeding their children even when they engage in unprotected sex. However, a woman‘s fecundity may return as early as 25 days after delivery (Jackson and Glasier, 2011). While the act of breastfeeding a child interrupts the onset of ovulation significantly (Gross and Burger, 2002), lactating women may ovulate before their first menses. This phenomenon limits their capacity to predict accurately their return to fecundity (Bouchard et al. 2013). Therefore, the exposure of women to family planning counselling and education during the period of antenatal and postnatal health care services 4 University of Ghana http://ugspace.ug.edu.gh provision offers a window of opportunity for these women to demystify beliefs about breastfeeding and lactation practices and fecundity. It will also bring to their understanding the importance of contraceptive use, especially during the postpartum period. For instance, a study on the relationship between the uptake of antenatal care and use of modern contraceptives in Bolivia, Egypt, and Thailand indicated that women‘s use of antenatal and postnatal health care services offer them the opportunity to be counselled on family planning (Zerai and Tsui, 2001). Finally, the utilisation of antenatal and postnatal health care services is likely to contribute to the reduction in infant and child mortality, thereby encouraging mothers to seek and use contraception (Rutstein, 2005, DaVanzo et al. 2007, Yeakey et al. 2009). In countries with developed antenatal and postnatal health care services, family planning information is provided through prenatal clinics, individual and group counselling of expectant parents, immediate and later hospital postpartum period and also through health examination and supplies of various forms of contraceptives (Wallace et al. 1996). For instance, in the United Kingdom, women receive high-quality ANC and PNC health services, as well as postpartum contraceptive counselling. In these developed countries, frequent interactions and contacts with numerous and different skilled health professionals create opportunities for discussing future contraception (Glasier et al. 1996). However, studies have shown that contraceptive advice given during this health service provision in these developed countries is often inadequate and the approach used in discussing contraception was apparently inadequate (Wallace et al. 1996; Glasier et al.1996). During postnatal clinics, women often discussed contraception with midwives and general practitioners. The postnatal ward is seen as an appropriate setting for contraceptive counselling. During these postnatal periods, contraception counselling takes place two weeks after delivery. Thus, in developed countries, the uptake of antenatal and postnatal health care services 5 University of Ghana http://ugspace.ug.edu.gh offers an opportunity to discuss the right method to be used and the correct use of these methods of contraception. Further, in developed countries, there is a creation of antenatal chart sheets. These antenatal chart sheets are documents designed for discussion between antenatal attendees and health service providers. During this antenatal health care service provision, women are made to choose a contraceptive method they prefer to use (Day et al. 2008). The uptake of antenatal and postnatal health care services has resulted in the increase of contraceptive use among women in developed countries. This is a clear indication of a low unmet need for spacing and limiting births. In many European countries, the unmet need is less than 10 per cent (Jassawalla, 2010). This relationship has also led to the rising contraceptive trends, and decrease in fertility prevalence rate in these developed countries. For instance, the contraceptive prevalence rate in developed countries is 61 per cent (United Nations Department of Economic and Social Affairs, Population Division, 2015). A study on the effect of contraceptive counselling in the pre- and post-natal period on contraceptive use after delivery among Italian women found that women who received contraceptive counselling were more likely to use effective contraceptives (Lauria et al., 2014). Similar results were also found among women in Berlin whose contraception uptake during the postpartum period was as high as 73.1 per cent and this came as a result of contraceptive counselling they received during ANC and PNC health care services (David et al. 2015). In developing countries, the use of contraceptives among women who utilize antenatal and postnatal health services is widely varied. That is, the contraceptive behaviour of women in sub- Saharan Africa, Asia, Central and Latin America and the Caribbean has been much different from others in the developed countries. A study by Speizer et al (2013) on the influence of integrated 6 University of Ghana http://ugspace.ug.edu.gh services on postpartum family planning use in urban Senegal found that postpartum women who received family planning information during delivery were more likely to use modern contraceptives relative to those who delivered at the facility but did not receive any family planning information. They also found that exposure to family planning at postnatal health care (child immunization) was not significantly related to postpartum contraceptive use (Speizer et al. 2013). However, a study in Nigeria reported that women who had antenatal and postnatal counselling were more likely to use contraception than those who did not (Ekabua et al. 2010). Studies have indicated that strengthening antenatal and postnatal care in developing countries presents a unique opportunity to reach women with quality family planning information and services and build an interpersonal relation between the women and the health service providers. Moreover, providing family planning counselling based on the needs of women leads to improved contraceptive use and continuation (Koenig et al. 1997). The interaction enables women to accurately plan their reproductive needs and make the right decisions about their contraceptive use during the period of postpartum (Varkey et al. 2004, Do and Hotchkiss, 2013). 1.2 Statement of the Problem Over the years, there have been significant improvements in the utilisation of family planning, maternal and child health services globally and in Ghana. Results of the latest Demographic and Health Surveys in Ghana (1988-2014) show that there has been a significant increase in antenatal care service provision by skilled providers among mothers from 87 per cent in 1988 to 97 per cent in 2014 (Statistical Service et al. 2015). There has also been an increase in births occurring in health facilities from 42 per cent to 73 per cent between 1988 and 2014 and deliveries attended by a 7 University of Ghana http://ugspace.ug.edu.gh skilled provider also increased from 40 per cent in 1988 to 74 per cent in 2014. There has further been an improvement in postnatal care for mothers over the years, where in 2014 about 93 per cent of women who deliver at a health facility received postnatal check-ups within the first two days of delivery (GSS et al. 2015). Again, in 2014, 73 per cent of women received postnatal care from a skilled health personnel (Nurse, Midwife, Doctor and Community Health Officers) compared to 47 per cent in 2003 (GSS et al. 2015). There has also been a significant improvement in child health over the years. For instance, immunization and vaccination coverage among children has increased. Thus, 76.4 per cent of children of ages 12-23 months were fully vaccinated by age 12 months in 2014, which is slightly higher than that reported in the 1993 GDHS (68.2%). The trend in basic vaccination coverage among children 12-23 months shows that apart from a two per cent decline from 79 per cent in 2008 to 77 per cent in 2014, there has been an increase in the proportion from 47 per cent in 1988 to 79 per cent in 2008. These increases in the uptake of ANC and PNC services may be due to the various maternal and child health policy interventions such as antenatal care fee exemption, delivery care fee exemption and the National Health Insurance Scheme (NHIS). On family planning in general and contraception in particular, the 2014 Ghana Demographic and Health Survey shows that 5.6 per cent of women received family planning services upon their visit to health facilities. Again, data from the six GDHS conducted in Ghana show that current use of family planning methods among married women in Ghana increased from 13 per cent in 1988 to 27 per cent in 2014 (GSS et al. 2015). 8 University of Ghana http://ugspace.ug.edu.gh Despite all these significant improvements in contraceptive use (from 13% to 27%), antenatal and postnatal health care services, reproductive health issues (contraceptive use, maternal and child health care) remain a major health problem in Ghana. For instance, not much has been achieved in terms of preventing or minimizing maternal and child mortality as well as increasing universal access to and usage of family planning methods especially among women. For instance, about 220 million women in developing countries still lack access to family planning services (Cates and Burris, 2010). The last evaluation report in 2015 by the United Nations and the National Development Planning Commission (NDPC) concluded that Ghana has failed to meet Millennium Development Goal 5 on reducing maternal health. Ghana‘s maternal mortality ratio (MMR) stands at 380 deaths per 100,000 live births (Ghana Health Service, 2016) which is still below the MDG target of 185 deaths per 100,000 live births (United Nations, 2000). This means that more needs to be done to be able to achieve by 2030 the new sustainable development goal target of reducing the global maternal mortality ratio to less than 70 deaths per 100,000 live births. Again, more needs to be done for Ghana to meet the SDG target of reducing under-five mortality to 25 deaths per 1,000 live births by 2030 at its 2014 rate of 60 deaths per 1,000 live births. Again, despite the number of studies on contraceptive use among postpartum women who utilize maternal and child health care services (Simmons et al. 1990, Hotchkiss et al. 1999, Zera and Tsui, 2001, Ahmed and Mosely, 2002, Borda et al. 2010, Ekabua et al. 2010, Do and Hotchkiss, 2013, Speizer et al. 2013, Akinlo et al. 2014, Lauria et al. 2014, Achyut et al. 2015, David et al. 2015), there are still some gaps in understanding contraceptive behaviour among these women. Thus, what is missing in the literature are the changes in contraceptive use among postpartum women who are regularly exposed to contraceptive education and counselling during attendance at antenatal and postnatal clinics. 9 University of Ghana http://ugspace.ug.edu.gh In addition, one of the major research gaps that this study seeks to fill is the provision of contraceptive counselling for postpartum women during antenatal and postnatal clinics. A number of studies have focused on the effect of antenatal and postnatal contraceptive counselling on modern contraceptive use. However, these studies focused on general information given during antenatal and postnatal clinics (Vural et al., 2015), the choice of contraceptive methods after counselling (Lauria et al., 2014), and the association between family planning during prenatal care and contraceptive use (Smith et al., 2002; Hernandez et al., 2012). Other studies also focus on the frequency of contraceptive counselling during antenatal clinics (Day et al. 2008) and the contraceptive information given during antenatal clinics (Akman et al. 2010). A search of the available literature did not show any study that focused on details of the contents of the contraceptive counselling given during antenatal and postnatal clinics. Also, little is known about the process and procedure through which contraceptive counselling is carried out and the differences/similarities in the contraceptive counselling given to women attending antenatal and postnatal health care services. This study, therefore, seeks to contribute to knowledge by finding out the details of the content of contraceptive education given to postpartum women and the differences/similarities in the counselling during antenatal and postnatal health care services in order to determine the quality of contraceptive counselling women receive during maternal health care service provision. Further, contraception among women who use antenatal and postnatal health care services most especially is currently unknown in Ghana. Thus, the relationship between antenatal, postnatal health care services and contraceptive use among women is still not well understood, perhaps due to the over-concentration on the study of contraceptive use among married women. This has led to relatively high unmet need for child spacing and family planning among postpartum women 10 University of Ghana http://ugspace.ug.edu.gh compared to currently married women. For instance, 30 per cent of currently married women have an unmet need for family planning compared to 38.6 per cent of postpartum women (women who gave birth 0-23 months) (GSS et al. 2015). Again, a study in 21 low and middle-income countries found 77 per cent of 0-23 months postpartum women in Ghana had unmet need for contraception (Moore et al. 2015). Moreover, there is a high likelihood of postpartum women being exposed to the risk of short pregnancy intervals. This is because optimal birth spacing is often presumed to be achieved through the practice of family planning and the use of contraceptives. With these developments in maternal health in Ghana, short inter-birth intervals are seen to be associated with high maternal, infant and child mortality. The World Health Organisation‘s (2014) technical consultation on birth spacing recommended a birth to conception interval of at least two years to reduce the risk of adverse maternal and infant health outcomes. Another argument is that statistics from the Ghana Statistical Service show a continued increase in the uptake of antenatal and postnatal health services by women, most especially postpartum women in Ghana. However, this increase has not reflected in their contraceptive use during the postpartum period. The key question to ask is, ―If these women utilize these three reproductive health services at the same time in a facility where they have trust in, why is this not reflecting in their contraceptive use?‖ This study, therefore, seeks to find answers to this and other questions about the reproductive health of women in Ghana. 11 University of Ghana http://ugspace.ug.edu.gh 1.3 Research Questions This study seeks to find answers to the following questions: i. What influence does the utilisation of antenatal and postnatal health care services have on contraceptive use among women in Ghana? ii. Are there differences in contraceptive use among women who seek antenatal and postnatal health care services in Ghana? iii. What kinds of contraception information do women who seek antenatal and postnatal health services in Ghana receive? iv. How different is the contraceptive counselling given to women during antenatal health care services from those given during postnatal health care services? 1.4 Rationale for the Study Contraceptive use is key in averting both maternal and infant deaths. Studies have shown that contraception and family planning can reduce about 25 per cent to 40 per cent of maternal deaths by preventing unplanned and unwanted pregnancies (Campbell and Graham, 2006, Cleland et al. 2006). Therefore, studying the relationship between antenatal and postnatal uptake and contraceptive use among women will further highlight the importance of contraception to maternal and child wellbeing. This relationship will also highlight the reasons for contraceptive use or non- use among women who utilize these antenatal and postnatal health care services which complement maternal and child health. This study seeks to contribute to knowledge and literature by examining the trends in modern contraceptive use among women utilising antenatal and postnatal health care services from 2003 to 12 University of Ghana http://ugspace.ug.edu.gh 2014. In addition, this study will contribute to knowledge by providing insights into the various contraceptive counselling given to postpartum women who attend antenatal and postnatal clinics. Also, this study will help in understanding the knowledge postpartum women acquire after going through contraceptive counselling in order to better understand their contraceptive behaviour. Furthermore, postpartum period is critical for women as far as their health and psychological conditions are concerned. However, in most developing countries, postpartum care does not frequently include family planning counselling (Mwangi et al., 2008). Consequently, the risk of untimely or unintended pregnancy will increase if women are unable to obtain effective contraceptive counselling and methods (Rivera and Solis, 1997). Therefore, the antenatal and postnatal period in a woman‘s life affords them with opportunities to influence contraceptive behaviour since women are in close contact with the health care delivery system during pregnancy and the first months of their baby‘s life. There are some policy relevance of this study, this study will provide insights into how effectively family planning services can be fully integrated into maternal and child health care services. The study is also in line towards the achievement of the Sustainable Development Goal (SDG) 3, which ensures healthy lives and promote wellbeing for all at all ages. Specifically, SDG target 3.7 states that by 2030, there shall be universal access to sexual and reproductive health care services including family planning information and education and the integration of reproductive health into national strategies and programmes. Another policy relevance of this study at the global and local level is the adoption of the Family Planning (FP) 2020 programme and Ghana Family Planning Costed Implemented Plan (GFPCIP). th The Family Planning 2020 programme came as a result of the 11 July 2012 London summit on Family Planning. This programme aimed at mobilising global policies, financing, commodity and 13 University of Ghana http://ugspace.ug.edu.gh service delivery commitment to support the rights of an additional 120 million women and girls in the world poorest countries. These girls and women are expected to access contraceptive information, services and supplies without coercion and discrimination by 2020. Ghana has made some policy, financial and programme and service delivery commitments towards FP 2020. In terms of policy commitment, Ghana commits to revising its national health insurance benefit package to include family planning services and supplies. In financial commitment, Ghana is committed to increasing government contribution to buying family planning commodities, thus directly purchasing about one-quarter of all commodities. In programme and service delivery commitment, Ghana commits to community-based nurses to deliver family planning services in rural areas. It also commits to eliminating user-fees for family planning services in public health facilities, increasing demand for family planning, including advocacy and communications as well as improving counselling and consumer care. These commitments have led to the development of the Ghana Family Planning Costed Implementation Plan (GFPCIP 2016-2020) in 2015. This plan has the ultimate goal to improve the health and well-being of its population and the nation through providing high quality, right-based family planning information and services. More specifically, the GFPCIP targets to achieve the following: First, to increase modern contraceptive prevalence rate among currently married women from its current rate of 22.2 per cent to 29.7 per cent by 2020. Secondly, to increase modern contraceptive prevalence rate among unmarried sexually active women from the current rate of 31.7 per cent to 40 per cent by 2020. This will further provide policy makers the needed information in taking decisions on the importance given to contraceptive behavioural change especially among postpartum women. This 14 University of Ghana http://ugspace.ug.edu.gh will be done by informing policy makers as to the kinds of contraceptive counselling given to postpartum women during antenatal and postnatal services, their knowledge and understanding about postpartum contraception in order for them to develop the appropriate policy frameworks. This study will also assist in bringing interventions to reduce various health concerns and fear of side effects of contraceptive use by its recommendations. 1.5 Objectives of the Study The main objective of this study is to establish a relationship between the uptake of antenatal and postnatal health services and contraceptive use among women in Ghana to inform policy decisions on efforts towards achieving improved maternal health outcomes and safe motherhood in the country. The study seeks to achieve the following specific objectives: i. To examine the influence of antenatal and postnatal health care service utilisation on contraceptive use among women in Ghana. ii. To examine the differences in contraceptive use among women who seek antenatal and postnatal health services in Ghana. iii. To explore contraceptive information postpartum women receive during antenatal and postnatal health care service delivery. iv. To examine the differences and similarities in contraceptive counselling given to postpartum women during antenatal and postnatal health care services delivery. 15 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.1 Introduction This chapter shows a systematic review of literature on the relationship between the utilisation of antenatal health care services and uptake of contraceptives among postpartum women; contraceptive counselling during antenatal and postnatal health care services; the relationship between the use of postnatal health care services and uptake of contraceptives among postpartum women. The chapter also reviews various demographic and socio-economic characteristics of these women. Again, relevant theories based on which conceptual frameworks guiding this study have been presented. 2.2 Antenatal Health Care Service Utilisation, Contraceptive Knowledge and Contraceptives uptake among women A relationship has been established between the uptake of antenatal health care services and contraceptive knowledge among women (Bulut and Turan, 1995, Mishra et al. 1998, Abdel-Tawab et al.2008, Igwegbe et al. 2010, Allagoa and Nyengidiki, 2011, Agha and Williams, 2015). Contraceptive awareness and knowledge were found to be high among women attending antenatal clinics in Nigeria, but this did not reflect the corresponding uptake of modern contraceptive methods (Allagoa and Nyengidiki, 2011). Further, a study on family planning information given to postpartum women in Istanbul, Turkey observed that women had little or no information during their postnatal visit. The study also reported that information provided about right family planning methods during postnatal health care was sometimes inaccurate (Bulut and Turan, 1995). Thus, the 16 University of Ghana http://ugspace.ug.edu.gh contraceptive information given during antenatal care is more accurate compared to those provided during postnatal care, and this is likely to improve women‘s knowledge of contraceptives during antenatal periods relative to postnatal periods. Furthermore, a strong association has been established between acceptance of antenatal care and a wider knowledge of contraceptive methods (Mishra et al. 1998, Igwegbe et al. 2010). More specifically, the uptake of ANC among illiterate women serves as an essential means of transmitting contraception knowledge to this group of women. Since knowledge on contraception can translate to use, it is expected that the use of antenatal health care services will influence contraceptive behaviour among women. This goes to strengthen the argument that the uptake of antenatal health care services is associated with better contraceptive attitude. During these antenatal health care services, community health workers discuss the benefits of using contraceptives such as lengthening birth intervals to at least 24 months, and the timing of return to ovulation. In addition, effective use of lactational amenorrhea method (LAM) reduces the risk involved in closely- spaced births that improve the survival of children and health of their mothers. Studies have argued that it is easier to promote child birth spacing among women who attend antenatal health care services as they are comparatively young and can be easily persuaded to prolong their next birth interval. They are also likely to prolong breastfeeding which delays their fertility and promotes child survival (Sahu 1998, Pathak et al. 2000). A study by Abdel-Tawab et al. (2008) in Egypt revealed that information on postpartum contraception was given to pregnant women during their antenatal visits, especially in their third trimester. Again, Information, Education and Communication (IEC) materials are given to these women in the form of leaflets on the use of contraception, birth spacing flyers, and flyers on breastfeeding practices. This highlights the importance of providing 17 University of Ghana http://ugspace.ug.edu.gh contraceptive counselling to pregnant women in their third trimester because it might lead to a greater knowledge about postpartum contraception (Adanikin et al. 2013). Attempts have been made by scholars/researchers to examine the possible linkage between uptake of antenatal care (ANC) and women‘s contraceptive behaviour (Mishra et al. 1998, Soliman, 1999; Smith et al. 2002, Day et al. 2008, Mengesha et al. 2015, Moore et al. 2015). In other words, several attempts have been made to compare contraceptive use between two groups of women: those who take up antenatal health care services and those who do not. The rationale for this comparison is to look at the role played by antenatal health care services utilisation in bringing about positive contraceptive behaviour among women. The National Institute for Clinical Excellence (NICE) provided some guidelines that recommend that not discussing contraception during antenatal period is considered a missed opportunity for the prevention of unintended pregnancies (NICE, 2006, Lopez et al., 2010, Joseph and Whitehead, 2012). Other studies have also demonstrated that integrating contraceptive and family planning services into antenatal care and other postpartum care services offers a broader cultural and universal contraceptive acceptability (Ross and Winfrey, 2001, Zerai and Tsui, 2001). For instance, a study by Akinlo et al. (2014) found that women who received contraceptive counselling during their delivery at a health facility are more likely to use contraceptives during postpartum periods. This improves the ability of health service providers to make a comprehensive assessment of women‘s reproductive health needs. The antenatal period has been suggested to offer the best opportunity not only to discuss the right choice of contraceptive methods, but also the correct usage of this method. This period is seen as more effective compared to the postnatal period because mothers are not distracted by newborns and they have the time to consider all the contraception options. A study by Smith et al. (2000) on 18 University of Ghana http://ugspace.ug.edu.gh the importance of giving contraceptive advice during the antenatal period, reported that although it was useful to discuss contraceptive issues prenatally, it has a little effect on contraceptive use. During these antenatal clinics, awareness about postpartum contraception is usually created in the form of group sessions facilitated by family planning advisors. There is, however, some evidence that some women are very receptive to contraceptive advice given during antenatal periods (Walton et al. 1988), and indeed, these women are more comfortable in discussing contraception during antenatal care periods (Ozvaris et al. 1997). Again, a study conducted by Soliman (1999) in Egypt found that contraceptive advice given to couples during the antenatal period improves couples‘ contraceptive knowledge and subsequently encourages women to use contraceptives. Scholars have argued that the contraceptive education given to women is not exhaustive, even though women receive this contraceptive counselling on individual basis from a trained family planning service provider. This might adversely affect the effectiveness of contraceptive use among these women during their postpartum period (Smith et al. 2002). Studies have also found that provision of antenatal contraceptive counselling is associated with some characteristics, including women‘s primary language; the number of antenatal care visits and the kind of provider consulted have an impact on subsequent contraceptive use (Day et al. 2008). Day et al (2008) further reported that compared to English-speaking postpartum women, non- English-speaking postpartum women (mostly Spanish speaking) were significantly less likely to have a documented antenatal contraceptive plan. This influences their subsequent contraceptive use, as postpartum contraceptive use was higher among English-speaking women relative to non- English-speaking women. Furthermore, postpartum women who had four or more antenatal visits were more likely to have antenatal contraceptive counselling compared to women who visit less than four times (WHO, 2010). Also, women who were cared for by health practitioners and were 19 University of Ghana http://ugspace.ug.edu.gh referred to a family planning counsellor for discussion of various contraception options were both more likely to effectively use contraceptives. It is, therefore, necessary to reach women with family planning counselling early enough during antenatal periods to address the contraceptive needs of these women. Another study in Bangladesh by Tasha et al. (2015) reported that antenatal health care services are more popular and well attended compared to postnatal health care; therefore, offering postpartum modern family planning advice and counselling is seen as a more productive effort. They also argue that antenatal care will be the best and easier way to spread information on postpartum family planning methods. They recommended a full integration of postpartum modern contraceptive counselling into maternal health care programmes, because such integration is likely to increase the use of and access to modern contraceptives and family planning methods among women. Family planning counselling is given to women during antenatal care in group talks. During these counselling sessions, women learn about a range of family planning services, where providers lay emphasis on the essence of continuous family planning counselling and various contraceptive methods available (Guay et al., 1999). A study by Lauria et al (2014) observed that women who have received counselling during antenatal clinics have higher contraceptive use compared to others who did not. Again, it has been found that contraceptive counselling during antenatal is often considered the standard of care since antenatal care services are well utilized especially in developing countries (Piaggio et al. 1998). It was also found that contraceptive counselling is unlikely to occur within settings such as home, and postnatal health centres; hence women who use health services within these settings have few opportunities to receive postpartum counselling (Rama Rao et al. 2013). 20 University of Ghana http://ugspace.ug.edu.gh However, there are studies that have established no relationship between antenatal care use and modern contraceptive uptake among postpartum women (Mengesha et al. 2015). 2.3 Postpartum Contraception and Reproductive Behaviour among Antenatal Clinic Attendees A number of studies have shown a pattern of contraceptive and reproductive behaviour among postpartum women who attended antenatal clinics (Vernon et al. 1993, Santos et al. 1999, Vernon, 2009, Winfrey and Rakesh, 2014). Antenatal periods are often considered to be appropriate times for a woman to start thinking about the size of her family and her contraceptive needs. This situation requires her to get adequate information, advice, and support in order to make the right reproductive and contraceptive decisions. In order to take this right decision, frequent contacts with various health care professionals especially during pregnancy are required (Rawal et al. 2005). A report prepared by Winfery and Rakesh (2014) on the use of family planning in the postpartum period among 36 countries using their various demographic and health surveys revealed that all the countries, with the exception of countries in Europe and Central Asia, had a moderately high level of postpartum contraceptive use at three months of postpartum. The level is 15 points higher among women having four to six antenatal care visits relative to those with no antenatal visit. Examples of these countries include India, Bolivia, Kenya, and Madagascar. The study also noted that countries that have low levels of postpartum contraceptive use have higher level antenatal care visits. Studies have also shown that promoting antenatal health care together with family planning counselling and use of modern contraceptives have significantly improved the quality of health care especially for mothers and their newborns (Matthews et al., 2001, Pallikadavath et al., 2004, Ram and Singh, 2006, Birungi and Onyango-Onma, 2006). In other words, the continuum of care 21 University of Ghana http://ugspace.ug.edu.gh received by women has helped families to adopt healthy reproductive lifestyles (Nikiema et al., 2009), ensures healthy and longer spacing between children (Levitt et al., 2004, Magoma et al., 2011), reduces unmet need for family planning (Briggs et al., 2001), and promotes high contraceptive use and delivery care from skilled health professionals (Jamieson and Buescher, 1992). Further, the continuum of care is needed for couples to have planned pregnancies, provide timely antenatal health care services, and provide adequate postpartum contraception counselling to prevent the occurrence of any complications among women and their newborns. This shows that antenatal contraceptive counselling may still be a promising strategy not only for increasing postpartum contraceptive use, but also improving women‘s reproductive health (Hiller et al., 2002; Rawal et al., 2005). 2.4 Postnatal Health Care Service Utilisation and Contraceptives uptake among women The postnatal period is considered as an appropriate time for women to give thoughts about their family size and contraception, and take the right decisions on their reproductive health. This necessitates the need to frequently have contacts with the health system and this will create opportunities for contraception to be discussed and appropriate contraceptive choices made. Thus, continuous education on the use of contraceptives for mothers is an essential part of postnatal care (Glasier et al. 1996). Although theoretically, family planning counselling is considered to be part of the routine postnatal health care, practically, it is often overlooked as women and health service providers give more attention to the newborn‘s health during these postnatal check-ups (Lagro et al. 2006). Thus, women who take up postnatal health care services miss the opportunity for family planning promotion and contraceptive counselling (Borda, 2006). 22 University of Ghana http://ugspace.ug.edu.gh Studies have shown that the issue of postpartum contraception has been included in postnatal care even though in a limited manner (Bolam et al. 1998, Koblinsky, 2005, Fort et al., 2006, Do and Hotchkiss, 2013, Mengesha et al. 2015). A study by Glasier et al, (1996) indicated that 84 per cent of women discussed the issue of postpartum contraception with a midwife during postnatal health care. However, these discussions are brief, limited and frequently held as mothers are about to be discharged from the hospital. They also reported that although most women discussed contraception with their health service providers at postnatal care, a significant number of them felt that the choice of contraceptive methods was limited to condoms or pills. Based on this outcome, they concluded that postnatal health care is not an appropriate setting to discuss contraception. The reasons are that mothers during this period are more concerned and anxious to establish infant feeding and breastfeeding practices and to learn how to care for their newborns. However, a randomized controlled trial study by Bolam et al. (1998) revealed that one-to-one postnatal contraceptive counselling given to women after delivery has led to a moderate increase in their uptake of contraceptives. Thus, postnatal care still remains an essential window of opportunity in providing access to family planning messages and offers women different contraceptive methods. It is, therefore, important for women to take advantage of the postnatal period to increase the uptake of modern contraceptives during the critical postpartum period (Mengesha et al. 2015). A study on the intensity of postnatal care services and postpartum modern contraceptive use in Kenya, however, found no significant relationship between the two (Do and Hotchkiss, 2013). This postnatal health care service intensity was measured by whether a woman received any check up by a trained health service provider before, immediately after discharge and two months after childbirth. A similar study in Zambia by Do and Hotchkiss (2013) showed postnatal health care service intensity is not a significant predictor of postpartum modern contraceptive uptake among 23 University of Ghana http://ugspace.ug.edu.gh women. This indicates that the postpartum period signifies an essential period for improving access to various family planning services. This is because postpartum women have a high need for various contraceptives and consequently, having multiple contacts with the health facility for postnatal health care services will help meet those needs (Speizer et al. 2013). Indeed, Kariuki et al (2011) found postnatal health care and contraceptive counselling to be a major influence on postpartum first-time mothers in Nairobi deciding on contraception. Other studies have argued that offering contraceptive counselling during postnatal health care visits might not be an appropriate time for such discussion. This is because of the limited number of women attending postnatal check-ups relative to antenatal visits (Glasier et al. 1996, Salway and Nurani, 1998, Adanikin et al., 2013). These women are often fatigued and distracted by a new baby and therefore, engaging in sexual intercourse might be the last thing on their mind, hence their postpartum contraceptive use is low (Shelton et al., 1992, Glasier et al. 1996, Adanikin et al., 2013). Further, in many countries, guidelines for the six-week postnatal care visit mainly focus on checking on the health of mothers, but not on providing various contraceptives and family planning services to these women (Bulut and Turan, 1995, Salway and Nurani, 1998). A hospital-based study in Tunisia showed that, out of 7,686 women who attend postnatal care visits, 56 per cent (4,273) of them accepted a family planning/contraceptive method (Coeytaux, 1989). This goes to emphasize the importance of contraceptive counselling during uptake of postnatal health care services. Again, extending contraceptive choices in the immediate postpartum period had a positive influence on contraception among women who delivered at the hospital (Vernon et al. 1993). Other studies have also examined the effect of a home visit by postnatal clinic-based staff and other community health workers to give contraceptive counselling on women‘s uptake of contraceptives and women‘s reproductive health outcomes (Huntington and Aplogan, 1994, 24 University of Ghana http://ugspace.ug.edu.gh Koblinsky, 2005, Fort et al. 2006, Abdel-Tawab et al. 2008, Mwangi et al. 2008). Again, a study by Abdel-Tawab et al, (2008) in The West Bank and Gaza reported no effect of a home visit by community health workers in the use of contraceptives/family planning methods within six months after birth. Koblinisky (2005), in reviewing 27 articles and reports showed that home visit from professional health-care providers and from community workers with referrals or health facility support was an approach that was effective in promoting the use of contraceptive methods. Additionally, a study by Khan (2003) in Uttar Pradesh, India revealed the training of village workers by their Health Department to give messages on postpartum contraception to young mothers who dwell in cultural environments which have limited access to family planning information. A postnatal family planning orientation package was developed in Kenya with a specific focus on the provision of family planning counselling during postnatal clinics. Staff within Maternal and Child Health-Family Planning (MCH-FP) units was trained to provide these services (Mwangi et al., 2008). The MCH-FP units of the health facilities were well equipped and prepared to provide efficient postnatal care and postpartum contraceptive services. The uptake of postnatal care has also improved MCH-FP knowledge among both providers and mothers and this has resulted in an improvement in the quality of care among mothers, particularly counselling for contraception and ensuring regular postnatal check-ups. Also, there was a substantial improvement in the uptake of contraceptive methods during six weeks of postnatal visits among mothers. These contraceptive methods were intrauterine device, lactational amenorrhoea method, female sterilization and injectables (Mwangi et al. 2008). 25 University of Ghana http://ugspace.ug.edu.gh 2.5 Demographic and Socio-economic characteristics of postpartum women A number of studies have documented the demographic and socio-economic characteristics of postpartum women who utilize antenatal and postnatal health care and later use contraceptives (Smith et al. 2002, Eliason et al. 2013, Adanikin et al. 2013, Prateek and Saurabh, 2013, Do and Hotchkiss, 2013, Akinlo et al. 2014, Mengesha et al. 2015, Tisha et al. 2015, Rutaremwa et al. 2015, Achyut et al. 2015). These demographic and socio-economic characteristics of women differ much from one setting to another. These characteristics work through antenatal and postnatal care to indirectly influence the subsequent use of modern contraceptives (Zerai and Tsui, 2001). The specific effects of these demographic and socio-economic characteristics on modern contraceptive use as presented earlier are independently mediated by their impact on antenatal and postnatal health care. These demographic and socio-economic factors either at the individual, household or the community levels include, but not limited to the age of the woman (maternal age), mothers‘ education, partners‘ education, occupation, place and region of residence, their marital status, religion, number of children, their exposure to family planning messages through the media, household headship, and household wealth quintile. Demographic and socio-economic factors such as maternal age (age at first birth), parity, and marital status, area of residence, respondent and partner‘s education, and wealth status were found to be significantly associated with antenatal counselling (Mekonnen and Mekonnen, 2002, Day et al. 2008, Eliason et al. 2015, Tisha et al. 2015, Vondee, 2018). For instance, a study by Tisha et al, (2015) among antenatal attendees in Bangladesh recorded a significant association between some demographic characteristics of women and their modern contraceptive use. Thus, their study indicated that modern contraceptive use was significantly highest among women aged 20-24, but lowest among those 35 years and above. Further, a higher likelihood of modern contraceptive use 26 University of Ghana http://ugspace.ug.edu.gh was observed among women having two to four children. Again, modern contraceptive use was higher among women having parity one compared to parity five. The level of women‘s education is a significant predictor of modern contraceptive use. Thus, there has been a steady increase in modern contraceptive use among antenatal women as their level of education increases (Eliason et al. 2013). Eliason et al (2013) also indicated no significant relationship between wealth quintile and modern contraceptive use among women who attended antenatal health care services. A number of studies have documented that women‘s exposure to family planning information in the media is well known to increase the use of modern contraceptives (Westoff and Rodriguez, 1995, Cleland et al. 2006, Islam et al. 2009, Nketiah-Amponsah et al. 2012). There is higher contraceptive use among women exposed to family planning information on all sorts of media platforms such as television, newspapers, and radio (Tisha et al. 2015). Also, educational level of husbands was shown to be a significant predictor of modern contraceptive use among postpartum women. A study by Mengesha et al. (2015), reported that husbands with secondary and higher education have an influence on the use of family planning among postpartum women. Similar findings were reported in studies done in Ethiopia and India (Shah et al. 2006, Haile and Enqueselassie, 2006). 27 University of Ghana http://ugspace.ug.edu.gh 2.6 Contraceptive Counselling given during Antenatal and Postnatal Health Care Services Counselling in general and contraceptive counselling, in particular, is often seen as a major part of public health care as well as maternal health care. The impact of these counselling sessions on health care utilisation is varied (Muehleisen et al. 2007; Warren et al. 2010). During counselling sessions, education is given on issues ranging from breastfeeding, personal hygiene, nutrition, birth spacing, method use, vaccination and immunization and the counselling normally lasts for 30 to 45 minutes. The prenatal and postnatal period is often regarded as the appropriate period for women to receive contraceptive counselling because these periods are highly associated with women frequently contacting the health systems (Akinlo et al. 2013). Further, offering contraceptive counselling during these periods is vital because pregnancy and birth of children may influence a woman‘s preference for contraception (Zapata et al. 2015). Literature has documented that the effectiveness of contraceptive counselling during antenatal and postnatal care depends on some considerations. First, there is a need to strengthen contraceptive counselling during antenatal and postnatal care in order to improve contraception awareness and knowledge level of postpartum women (Day et al. 2008; Hernandez et al. 2012). Secondly, skilled health professionals should be given more training on the job with regard to postpartum contraceptive counselling (Vural et al. 2015; Karra et al. 2017). Further, strategies must be adopted in the community to create more awareness about the merits of using postpartum contraceptives during postpartum period (Lauria et al. 2014; Akman et al. 2010; Engin-Üstün et al. 2007). Last but not least, the involvement of community leaders, chiefs, and other opinion leaders is important in promoting family planning and modern contraception among women during postpartum (Stern et al. 2013; Abraham, 2016). Providing contraceptive counselling during the 28 University of Ghana http://ugspace.ug.edu.gh period of postpartum gives women the opportunity to discuss contraception with the service provider, effective use of modern contraception (Cwiak et al. 2004). One of the essences of offering contraceptive counselling during postpartum period is to ensure that postpartum women have some level of understanding of the safety, efficiency and possible side effects of these methods of contraception. Also, contraceptive counselling has resulted in an increase in the intention and actual use of contraceptives (Day et al. 2008; Saeed et al. 2008; Arrowsmith et al. 2012; Hernandez et al. 2012; Vural et al. 2015; Karra et al. 2017). Thus, antenatal and postnatal period creates a good opportunity to women and health providers not only to discuss the importance of contraception during postpartum but the implications for its use (Borda, 2010). The effective provision of contraceptive services has been considered as one of the means through which the rates of unplanned pregnancies can be reduced and prevent induced abortion (Lee et al. 2011; Yee & Simon, 2010; Hernandez et al. 2012). However, there are still uncertainties with regard to the timing and the content of the counselling session (Winikoff & Mensch, 1991; Day et al. 2008). There are also uncertainties regarding whether the provision of contraceptive counselling during antenatal care is a good health intervention. Studies on the contents of contraceptive counselling reported that during contraceptive counselling, skilled health practitioners talked to women about the benefit and risk involved in using modern contraceptives especially during antenatal care (Kennedy, 1996; Karra et al, 2017). A number of studies have also established that most often counselling is given on immediate Postpartum Intrauterine Device (PPIUD). This is because PPIUD is a convenient and cost-effective modern contraceptive method which women can afford and it can be inserted 4 to 6 weeks after birth (Foreit et al. 1993; Kapp and Curtis, 2009; Grimes et al. 2010). 29 University of Ghana http://ugspace.ug.edu.gh A study in Sri Lanka by Kara et al. (2017) stated that contraceptive counselling given to postpartum women takes place at three different locations. These locations include women receiving contraceptive counselling at the health facility during antenatal care; it can also be received when skilled workers visit homes of postpartum women. The other location is women receiving contraceptive counselling in the labour ward after delivery. During these contraceptive counselling sessions, modern contraceptive leaflets are distributed to women. In conclusion, literature on contraceptive counselling during the provision of antenatal and postnatal health care service suggests that, it is an important part of maternal health and contributes significantly to maternal wellbeing. However, not much attention has been given to the contents, materials use and frequency of the contraceptives education that women receive as this is critical in understanding the contraceptive behaviour of these women. 2.7 Theoretical Framework 2.7.1 Theory of Triadic Influence The theory of Triadic Influence spearheaded by Flay et al. (2009) conceptualized some health behaviours as closely related due to very similar etiologies and experiences that are common to them. For example, utilisation of antenatal, postnatal and family planning services might serve to preserve maternal and child health. Thus, some health behaviours might be considered health-risk behaviours such as non-use of family planning services and antenatal health care services. The non- utilisation of these health services may lead to the risk of unintended pregnancies, pregnancy loss, maternal deaths and pregnancy complications. It can also be clustered into health-promoting behaviours such as simultaneity in the use of modern contraceptives, antenatal and postnatal health services which lead to improved maternal health, proper pregnancy, child spacing and improved 30 University of Ghana http://ugspace.ug.edu.gh child nutritional status. These health behaviours might then be handled and addressed concurrently in interventions. The theory of Triadic Influence stipulates three levels of influence that predict human behaviour. These levels of influence are ultimate, distal and proximal. The ultimate level causes are generally broad and relatively stable and the individual has little or no control over them such as the social and cultural environment. The effects of the ultimate level causes are pervasive in influencing multiple health behaviours and have long lasting effects on a broad variety of behaviours which cut across politics, religion, nutrition, mass media, socio-economic ethnicity and personality (Daly and Farley, 2011, Egger, 2009, O‘Neil et al., 2010). On the other hand, the distal-level influence affects behaviours that individuals are likely to have some control over. The initial level of these distal level causes is at the personal and social levels that include general self-control, addiction to some health risk behaviours such as smoking, alcohol consumption and also participation in religious activities. These reflect the quantity and quality of conduct between individuals and the social situations and cultural environment they live in. Regarding this study, this theory will meaningfully reflect the quality and quantity of conduct between postpartum women and the health system. The quality of health behaviour of women this study will consider is the kind of information and services they receive when they visit these health facilities, and the impact these contacts have had on their reproductive behaviour, especially on contraceptive use. As these contacts are made between individuals and their environment, there are general values, behaviour evaluations and beliefs that might arise out of these contacts. For instance, the expectation of a safe delivery could combine antenatal and postnatal health care uptake to influence beliefs and attitudes towards contraceptive use. 31 University of Ghana http://ugspace.ug.edu.gh The third level of influence is the proximal level which is a precursor to a specific behaviour that is under full control of an individual in his/her interaction with their social environment. The theory argues that individuals‘ decisions, intentions and experiences have a direct impact on a particular behaviour (Flay et al. 2009). For example, a decision of an expectant woman to attend contraceptive counselling session during antenatal clinics is highly predictive of the actual use of contraceptives. 2.7.2 Transfer theory The transfer theory stipulates the application of the lessons learned from one phenomenon to another. This happens if an individual has the ability and capacity to apply acquired knowledge to other domains (Perkins and Salomon, 1992). The theory further states that individuals may transfer their knowledge and experiences from a particular behaviour to another if the domains share similar characteristics (Barnett and Ceci, 2002). Thus, if for instance behaviours are similar in nature, transfer may be more likely in terms of planning and integrating a new behaviour into the existing ones (Curry et al.1994). Basically, transfer is studied in interventions that target a particular behaviour, and the occurrence of any transfer is assessed in other behaviours. For instance, the integration of contraceptive counselling into antenatal and postnatal health services are expected not only to improve contraceptive use, but also to improve women and children‘s health. This theory is usually applied in the health literature that uses randomized control trial method to study health behaviours. For instance, a study by Quintiliuni et al. (2010) studied quantitative features of health behaviour and showed three different patterns of health behaviours among young women. The first pattern of behaviour studied were young women showing little health-promoting behaviour; the second pattern of behaviour observed were young women showing health-risk 32 University of Ghana http://ugspace.ug.edu.gh behaviours and the third were young women showing much health promoting behaviour together with medium health-risk behaviours. This pattern might be explained by the transfer in the sense that the third group of young women adopted the health promoting behaviour and perhaps transferred these behaviours to reduce health risk behaviours. Another randomized control trial study by de Vries et al (2008) used transfer theory to explain multiple health behaviour among three groups of people. The first group was categorized as unhealthy cluster performing few health-promoting behaviour and many health-risk behaviours. The second group was labeled healthy cluster showing many health-promoting behaviours and few health-risk behaviours. The third group was also categorized as those performing selected health- promoting behaviour and low health-risk behaviour. These findings are essential with regard to transfer of health behaviour regardless of whether they are health-promoting or risky for their health. The relevance of this theory to this study is that postpartum women may transfer the knowledge gained on contraception they receive during antenatal and postnatal health care to their contraceptive behaviour. The application of this knowledge will either promote their health or risk their health. 33 University of Ghana http://ugspace.ug.edu.gh 2.8 Conceptualising the relationship between maternal, child health and family planning The framework of concepts establishing the relationship between maternal, child health, and family planning was developed by Ahmed and Mosley (2002) in their study titled ―Simultaneity in the Use of Maternal-Child Health Care and Contraceptives: Evidence from Developing Countries‖. Their study examined the relationship between maternal-child health (MCH) care use and contraceptive use among women. They looked at the interactions that exist between observed independent variables (such as age, educational level of women, educational level of their husbands, the number of children, the proportion of children, and their knowledge of contraceptive method) and observed dependent variables (current and previous contraceptive use, and maternal-child health care use relative to tetanus toxoid, prenatal care, delivery care by trained health personnel and DPT). The framework also looks at how the availability of health service provision (visit of health workers to household and health facilities within the distance of 5 kilometres) determines the simultaneous use of maternal-child health services and contraception. They conceptualized that there is a non- spurious relationship between the use of contraceptives and maternal-child health care services. Their results consistently indicated that the use of contraceptives affects the use of maternal-child health interventions (the opposite is true) independent of common predictor variables. In other words, the use of contraceptives and the use of maternal-child health services are simultaneously related. Based on this conceptual relationship, Ahmed and Mosley (2002) assert that most families tend to develop behaviours for improving the quality of their health and demand fewer children. They also translate these desires into action by adopting contraceptive methods and by using maternal health care services. Thus, the use of one health care intervention encourages the use of other health care services, independent of other factors. This specifically suggests that if both family planning and 34 University of Ghana http://ugspace.ug.edu.gh maternal-child health interventions are available, the probability of adopting both is higher than if only one is available. Health behavioural scientists (Malone, 1991, Smelser and Baltes, 2001) postulate that the adoption of a new behaviour is a process that involves passing through a sequence of changes in behaviour that start with knowledge acquisition and putting this knowledge into practice which culminates into new behaviour. The adoption of a new behaviour (i.e, the use of modern contraceptives) may aid the rapid adoption of a similar behaviour (i.e, the use of maternal and child health care services). In summary, their study provided important information on the factors that influence the use of health and family planning services. This information will assist in health sector planning. As basic health care programmes expand, there is an increase in the demand for health services and improvement in the quality of health care. This leads to considerations of structural changes in health delivery systems, changes in communication and information strategies, and the coordination of health activities with other development programmes. The basic understanding of the relationship between antenatal, postnatal and contraceptive use fosters positive changes in attitudes of women towards the use of modern health facilities, especially in developing countries. The conceptual interrelationship among the use of contraceptives, maternal-child health care use, individual, household and service level factors are shown in Figure 2.1. Ahmed and Mosely (2002) argued a high correlation between contraceptive use and maternal-child health care services. However, this correlation may be due to an independent effect of one on the other (Wilopo and Mosely, 1993, Ahmed and Mosely, 2002) or due to some background characteristics which influence such correlation. In other words, Ahmed and Mosely (2002) mentioned that the relationship between maternal-child health care services (in their case, prenatal care, delivery care by professional health personnel and immunization) and contraceptive use is a spurious one. They, 35 University of Ghana http://ugspace.ug.edu.gh therefore, developed a framework comprising individual level, household level, and policy level factors that influence the relationship between maternal-child health care and use of contraceptives. The conceptualization of the relationship between maternal-child health care and contraceptive use by Ahmed and Mosely carefully guided the development of this study‘s conceptual framework. This framework looked at the relationship between antenatal care, postnatal care (considered as part of maternal and child health care system) and use of modern contraceptives. It also considered certain factors such as personal and household factors mediating this relationship. Figure 2.1: Maternal-Child Health Care Service and Contraceptive Use Observed x Variables Observed y Variables Age of Woman Contraceptive use Current contraceptive use Education of Women Previous Education of Husband Maternal and contraceptive use Child Health Number of Children care use Use of tetanus Proportion of Children toxoid during dead pregnancy Healthy household Prenatal care Economy status of family Delivery care Knowledge of contraceptive Service by trained methods Availability health personnel Health workers visit household Use of DPT Source: Ahmed and Mosely, 2002 36 University of Ghana http://ugspace.ug.edu.gh 2.9 Conceptualising the relationship among antenatal, postnatal and modern contraceptive use Based on the conceptual knowledge on the relationship that exists between maternal-child health care services (antenatal and postnatal health care services) and family planning services (contraceptive use), this study developed a modified framework of conceptual relationship between four concepts of interest. These concepts of reproductive health care are uptake of antenatal health care services, uptake of postnatal health care services, provision of contraceptive counselling and use of modern contraceptives, controlling for other factors that might affect the relationship among these four concepts. The framework in Figure 2.2 illustrates the relationship conceptually. The figure illustrates the relationships that exist between uptake of antenatal, postnatal care services and modern contraceptive use. This relationship is mediated by the contraceptive counselling they receive during antenatal and postnatal health care service. Again, individual level factors are maternal age, parity, maternal educational level, and partner educational level, place of residence, ethnicity, current marital status, and exposure to family planning information in the media. Ahmed and Mosely (2002) argued that women‘s knowledge of contraceptive methods also independently affects their use of contraceptive and maternal and child health care use. Thus, factors such as visit of health workers to women‘s houses and the distance from homes to health facility directly influence the availability of health service. This health service availability then influences effective use of maternal and child health care use such as taking of tetanus toxoid during pregnancy, prenatal care, delivery care by trained health personnel and vaccination against diphtheria, pertussis (whooping cough) and tetanus. Women who go to health facilities 36 University of Ghana http://ugspace.ug.edu.gh for these maternal and child health care services also get the opportunity to seek contraceptive counselling services. Figure 2.2: Antenatal, Postnatal Health Care Service and Contraceptive Use Independent Variables Intermediate Variables Dependent Variable No ANC or PNC use Modern ANC use only Contraceptive Use PNC use only *Contraceptive Both ANC & PNC use Counselling Yes No Individual level factors Maternal Age Maternal educational level Partner educational level Parity Place of residence Ethnicity Current Marital Status Fertility intention Sexual activity Exposure to FP information in the media Sex of Household Head Wealth Quintile *Variable was analysed using qualitative data Source: Modified from Ahmed and Mosely, 2002 37 University of Ghana http://ugspace.ug.edu.gh The framework originally developed by Ahmed and Mosely (2002) conceptually shows the relationship between contraceptive use and maternal and child health care use. However, this relationship is a spurious one as other factors influence the relationship that exists between maternal and child health care and contraceptive use. These factors are the provision of contraceptive counselling, age, education of a woman, husband‘s education, number of children (parity), place of residence, ethnicity, and marital status. Others are fertility intention of the woman, sexual activity and their exposure to family planning message in the media. Again, household factors such as sex of household head and household wealth status are also influencing factors. These factors independently influence women‘s use of contraceptives (either current use or previous use) and maternal and child health care use. One of the shortcomings of the framework developed by Ahmed and Mosley (2002) is that their framework was not guided by theory. However, this study modified a conceptual framework that was guided by two health behavioural theories- theory of triadic influence and the transfer theory. The theory of triadic influence conceptualizes some health behaviour as similar due to the experiences they share. For the purposes of this study, factors such as utilisation of antenatal, postnatal and family planning services are conceptualized to serve the same common purpose to ensure good maternal and child health. The theory again postulates that some factors influence certain health behaviours and these factors comprise mass media, religion, ethnicity and other socio-economic factors. In this study, factors such as age, parity, educational level, and exposure to family planning information in the media are considered as factors that affect contraceptive use. These factors have a lasting influence on health behaviour, over which individuals have little or no control. The theory again argues that some factors interact at the personal and social levels 38 University of Ghana http://ugspace.ug.edu.gh to influence health behaviour. The factors used in the conceptual framework are household headship and household wealth quintile. On the other hand, the transfer theory postulates that the knowledge and experience gained from one health behaviour is transferred to other health behaviours, if these health behaviours share similar characteristics. This study conceptualises antenatal and postnatal health (maternal and child health care) and contraception (family planning) as women‘s reproductive health care. The knowledge and experience that women gain from antenatal and postnatal health care services through contraceptive education may influence their use of modern contraceptives. It is therefore expected from the framework that women who are use antenatal health care only, postnatal health care only and use both antenatal and postnatal health care services will receive contraceptive counselling compared to women who did not use the maternal health care services. It is further expected that, this counselling receive will led to higher modern contraceptive use among women who used either antenatal or postnatal health care services or both relative to those who use none. 39 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODOLOGY 3.1 Research Design This study adopted a mixed method sequential explanatory design. This design is a methodological approach that consists of two distinct phases, that is the quantitative phase followed by the qualitative phase (Creswell et al. 2003). With this design, the researcher first analyses the quantitative results obtained from an existing secondary data (GDHS 2003, 2008 & 2014) in the first phase. In the second phase, the qualitative phase builds on the outcome of the first phase and hence the two phases are connected in the intermediate stages in the study. The rationale for using this approach is that the quantitative data and subsequent analysis provide a general understanding of the research problem and relationships that exist among the variables of interest. On the other hand, the qualitative data refine and explain those statistical relationships by exploring the participants‘ views into more details (Tashakkori and Teddlie, 1998, Creswell, 2003). Figure 3.1 provides a graphical summary of the sequential mixed method explanatory design. Figure 3.1: Graphical summary of Sequential Mixed Method Explanatory Design Quantitative Qualitative Data collection, Data analysis Data collection, Data analysis Quantitative Data Collection Quantitative Data Analysis Qualitative Data Collection Qualitative Data Analysis Interpretation 40 University of Ghana http://ugspace.ug.edu.gh The sequential mixed method explanatory design is characterized by quantitative and qualitative methodology. Thus, this design comprises the collection and analysis of quantitative data followed by collecting and analysing of qualitative data. The purpose for this approach is to use the qualitative results to explain and interpret the findings of the quantitative study. 3.2 Sources of Data 3.3 First phase-quantitative data analysis The study used three rounds of the Ghana Demographic and Health Survey conducted in 2003, 2008 and 2014. The Ghana Demographic and Health Survey is a nationally representative cross- sectional survey which collects information on issues such as housing characteristics and household population, marriage and sexuality, fertility and fertility preferences, family planning, infant and child mortality, maternal health, child and early development. It further includes issues on nutrition of children and women, malaria, HIV and AIDS related knowledge, attitudes, and behaviour, HIV prevalence, adult health and lifestyle, women empowerment and demographic and health outcomes. For the purpose of this study, data on the uptake of antenatal and postnatal health care services, and modern contraceptive use by postpartum women were used to establish a relationship among these three reproductive health concepts. The rationale for using such data is as follows that at the International Conference on Population and Development (ICPD) held in 1994 Cairo-Egypt, Ghana endorsed the Programme of Action of the ICPD and adopted the ICPD definition of reproductive health which has safe motherhood, family planning, and other reproductive health issues as its key components. 41 University of Ghana http://ugspace.ug.edu.gh 3.4 Sample used for quantitative data Postpartum women in their reproductive ages 15-49 who had given birth within the last 0-23 months were selected for this study. This enabled the research to fully examine the relationships among the three variables of interest (ANC, PNC, and modern contraceptive use). Thus, the months following after birth, these women are likely to be in close contact with the maternal health care system and will also be more exposed to family planning or contraceptive counselling, hence may influence their contraceptive use and behaviour. Second, these are women with the highest unmet need for family planning (Obaid, 2009, Borda et al., 2010). This is further consistent with studies that have found that two-thirds of postpartum women within one year of their last birth have an unmet need for family planning (Ross and Winfery, 2001, Widyastuti and Saikia, 2011). In all the three rounds of the GDHS conducted in 2003, 2008 and 2014, women who had their last birth preceding each survey year and observing up to 23 months of postpartum were extracted from the data. The number of eligible women for the three separate surveys is presented in Table 3.1 Table 3.1: Eligible women in the GDHS by year Survey Year Number of eligible women GDHS 2003 1,421 GDHS 2008 1,178 GDHS 2014 2,264 TOTAL 4, 863 Source: Generated from Ghana Demographic Health Survey Data (GSS et al., 2004, 2009, 2015) 42 University of Ghana http://ugspace.ug.edu.gh 3.6 Methods of quantitative data analysis 3.6.1 Univariate analysis The analysis comprises the description of the variables of interest using frequency and percentage distribution tables, diagrams and charts such as bar graphs and pie-charts. It consists of the frequency of women who use antenatal and postnatal health services, and modern contraceptive use. It also includes an analysis of women who do not utilize these health care services. It further describes the background characteristics of women including their current age, educational level, and that of their partners, the number of living children (parity), their place of residence, ethnicity, current marital status, fertility intentions, and sexual activity after birth, exposure to family planning information in the media, sex of the head of household and household wealth quintile. This is intended to understand the socio-demographic and economic characteristics of these women as they relate to the three variables of interest (ANC, PNC, and modern contraceptive use). 3.6.2 Bivariate analysis The bivariate analysis used in this study was to determine the empirical relationship between the variables of interest (ANC, PNC, and modern contraceptive use). Thus, the analysis at this stage seeks to explain the relationships that exist between these variables on one hand and the dependent variable on the other. Again, a chi-square analysis was done relating the control variables (maternal age, woman‘s educational level, partner‘s educational level, the number of living children (parity), place of residence, ethnicity, marital status, fertility intention, sexual activity, exposure to family planning information in the media, number of living children, head of household and household wealth 43 University of Ghana http://ugspace.ug.edu.gh quintile) to the dependent variable (modern contraceptive use) within the context of antenatal and postnatal health care service utilisation. 3.6.3 Multivariate analysis The third stage of analysis specifically uses the binary logistic regression model. The purpose for using this model is because the outcome variable was categorized into two; those who use modern contraceptives and those who do not. Binary logistic regression model was used to identify variables independently associated with modern contraceptive use in the three different survey years. Thus, this regression model was adopted to determine the strength of relationship between modern contraceptive use and antenatal and postnatal health care services uptake while other variables are controlled for. The first model analyses the likelihood of modern contraceptive use among postpartum women who sought antenatal and postnatal health care services in the three survey years. The last model examined the likelihood of modern contraceptive use among postpartum women who sought antenatal and postnatal health care services for the three survey years while controlling for their background characteristics (GDHS 2003, 2008 & 2014). The general binary logistic regression model that was used for the multivariate analyses is as follows: p ( )  Log 1 p βo+β1χ1+……. +βnχn Where; P=Probability of modern contraceptive use (1 if using, else 0) 44 Health facilities with 5km University of Ghana http://ugspace.ug.edu.gh χ1-χn= Main predictor variables [Key independent variables- ANC and PNC] and selected socio- demographic (individual and household) characteristics. βo, β1…..βn= Regression coefficients 3.7 Definition/Measurement of Variables The main independent variable is the uptake of antenatal and postnatal health care services. The study used this statement to measure this variable: i. Whether a woman received maternal health care services (antenatal and postnatal visit) [1=Only PNC use ; 2=Only ANC use ; 3=Both ANC and PNC use ; 4=No ANC or PN C use] The following questions from the Ghana Demographic and Health Survey-Women Questionnaire section were used to measure antenatal and postnatal health care service utilisation. (i) How many times did you received antenatal care for this pregnancy? (ii) I would like to talk to you about checks on your health after delivery, for example, someone asking you about your health and examining you. Did anyone check your health after you gave birth to (NAME)?]. The dependent variable of interest in this study is modern contraceptive use after the last childbirth. The information came from the birth and contraceptive use calendar included in the Demographic and Health Survey women‘s questionnaire which records month-by-month all events related to pregnancy, pregnancy outcomes, child breastfeeding, and contraceptive use for 60 months before the survey. For the categorization of modern contraceptive use, women who are using modern contraceptives were included. The modern contraceptive methods for this study include pills, 45 University of Ghana http://ugspace.ug.edu.gh intrauterine device, injections, diaphragm, condom (male and female), female sterilization, norplant and foam or jelly). However, women who used only traditional methods of contraceptives such as withdrawal were taken out of the sample. The reason is that, over the years the proportion of women using traditional methods of contraception has been declining in Ghana. According to statistics from the Ghana Demographic and Health Survey (1988-2014), the proportion of postpartum women using traditional contraception declined from 10 per cent in 1988 to 4.2 per cent in 2014 (GSS et al. 2015). Because of the relatively small proportions in postpartum women using traditional methods, doing separate analyses would not have been meaningful. The measurement of the intermediate variable of contraceptive counselling was done in the qualitative data collection. For the purposes of this study, both individual and household socio-demographic characteristics of women were considered as control variables. On the other hand, the household socio-demographic factors used in this study are sex of household head and household wealth quintile, that is whether these women belong to poor, middle, and rich households as classified in the GDHS. 3.8 Second phase-qualitative data collection and analysis 3.8.1 Study design The study used exploratory design to examine the views of users of antenatal and postnatal health care services on contraceptive counselling they receive. Individual in-depth interview was conducted through the use of semi-structured interview with the intention of giving respondents the chance to express their opinion to reach a deeper understanding of the subject matter (Patton, 2004). All the interviews were done by the researcher after verbal and written consent was sought from the participants. All interviews were done in the English language and were tape- 46 University of Ghana http://ugspace.ug.edu.gh recorded after seeking permission from the participants and transcribed verbatim. The interviews were conducted between June and August, 2017 and each interview lasted 20 - 30 minutes. The interviews commenced with structured questions on respondents‘ socio-demographic characteristics, including age, educational level, educational level of their partners, religion, parity and ethnicity. The interview guide used contained three exploratory subjects as follows: i. Contents of contraceptive counselling provided during antenatal and postnatal health care service delivery. ii. Materials used during contraceptive counselling iii. Frequency of contraceptive counselling 3.8.2 Settings and Participants The study used two hospital settings for the qualitative data collection, specifically their antenatal and postnatal care units. The two hospitals selected the University of Ghana Hospital, Legon and Achimota Hospital, all located in the Greater Accra region of Ghana. The choice of these two hospitals settings was informed by the following: i. These hospitals have well-organized antenatal and postnatal units ii. They have a good record of antenatal and postnatal health care service utilisation iii. They provide regular counselling sessions on contraceptives, family planning, personal hygiene, child care and nutrition. iv. They are easy to reach from the University of Ghana by the researcher 47 University of Ghana http://ugspace.ug.edu.gh 3.8.3 Sample size and selection Thirty participants were recruited from the two hospitals. This comprised nine women who used antenatal health care services only, six women who accessed only postnatal health care services and fifteen women who utilised both antenatal and postnatal health care services. These thirty participants were aged 20-35 years. Three categories of respondents were selected and these are as follows: 1. Women who used only antenatal health care services 2. Those who used only postnatal health care services 3. Those who used both antenatal and postnatal health care services. Also, participants were purposively selected for this study. The eligibility criteria for selecting women using antenatal and postnatal health care services were as follows: For users of antenatal health care service i. Women must be within the reproductive age of 15-49 years ii. They must be in their last trimester of pregnancy iii. They must have at least a child iv. They should have attended antenatal for at least four times For users of postnatal health care service i. Women must be within the reproductive age of 15-49 years ii. They must be regular users of postnatal health care services, at least three visits iii. They must have at least a child 48 University of Ghana http://ugspace.ug.edu.gh 3.8.4 Ethical and Administrative Clearance Ethical clearance was obtained from the Ethics Review Committee of the Ghana Health Service. The Ethics Review Committee is a Research and Development Division of the Ghana Health Service mandated to give authorization to scientific and technical research in the health sector in Ghana. The ethical clearance was further used to obtain authorization and administrative clearance from the authorities of the two selected hospitals (University of Ghana Hospital, Legon and Achimota Hospital). On the field, the first contact was the heads of the antenatal and postnatal care units of the two selected hospitals to seek their permission to recruit antenatal and postnatal health care users. The objective of the research was explained to the selected participants and consent was obtained before conducting the interview. The respondent (s), if literate signed an informed consent form(s) and if illiterate a verbal consent was sought. 3.8.5 Data collection process The researcher upon reaching the health facility introduced himself, the purpose of the study and presented the relevant supporting documents to the appropriate authorities to be able to collect data. Approval and consent was then given by the authorities for data to be collected. An opportunity was then given to the researcher to explain the purpose of the study to the respondents (users of antenatal and postnatal health care services). Some respondents also asked questions and sought clarification concerning the study. With the help of some nurses, the respondents were screened and those who met the selection criteria were selected to participate in the interview. This procedure was followed in other subsequent data collection days since all interviews were not conducted in a day. For those who 49 University of Ghana http://ugspace.ug.edu.gh meet the selection criteria, the informed consent was clearly read out to them to obtain their verbal and written consent before conducting the interview. The informed consent covers issues on the purpose of the study, confidentiality, benefits and possible risks associated with the study, voluntary participation, reimbursement and respondents rights. However, there were some initial challenges faced with the commencement of the interview. Thus some respondents were reluctant to participate in the interview because they thought it will delay them or disrupt their antenatal and postnatal health care services. But for the assurance from the nurses and the midwives they consented to participate in the interview. 3.9 Data Analysis Data were analysed using qualitative analytical software, called the Nvivo. However, the analysis at the initial stage comprises repeatedly reading through the interview transcripts and identifying new themes. To prevent forgetting vital details, transcription was done after the day‘s interview. It is also important to note that maximum attention was paid to important elements like ‗consensus‘, ‗conflicts‘ and ‗absence‘ (Aikins, 2003) within and between responses in order to see differences and similarities in the contents of contraceptive counselling. Again, thematic analysis was used in analysing the data. Data were analysed and presented in themes at three levels as global themes, organizing themes and basic themes (Attride-Stirling, 2001). The global themes are the first level of themes that encapsulate all perspectives under the subject matter (contraceptive counselling). The organization themes are the second level theme that summarizes underlining perspectives into two or more extracted text quotes from the 50 University of Ghana http://ugspace.ug.edu.gh transcripts and also reveals different views about the global theme. The basic themes are the third level themes that are captured as the extracted quotes from the transcripts. 51 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR UTILISATION OF ANTENATAL, POSTNATAL HEALTH CARE AND CONTRACEPTIVE USE AMONG POSTPARTUM WOMEN AND THEIR BACKGROUND CHARACTERISTICS 4.1 Introduction The question that still remains unanswered is the period at which women are expected to commence contraception after birth. It is evident that progress has been made in the utilisation of maternal and child health care services and many women now benefit from antenatal and postnatal health care services provided at the health facilities. These frequent contacts with the health care system create an ideal opportunity in promoting family planning and counselling on contraception (Rossier & Hellen, 2014). However, the flow of contraceptive information and the ability of women to appreciate this education during these health care sessions are sometimes dependent on their demographic, social and economic characteristics which require some analysis. 4.2 Uptake of Antenatal and Postnatal Health Care Services Antenatal and postnatal health care is an important aspect of maternal wellbeing and has an implication on women‘s sexual and reproductive health status especially contraceptive use. Globally, utilisation of antenatal and postnatal health care services has attained universality and the situation in Ghana is not very different. According to statistics from UNICEF (2016), globally, 85 per cent of pregnant women access antenatal care with a skilled health personnel at least once, while data from the Ghana Statistical Service (GSS et al. 2015) indicate 97 per cent of 51 University of Ghana http://ugspace.ug.edu.gh pregnant women accessed antenatal care and 73 per cent of postpartum women received postnatal care from skilled health personnel. Against this background, this section discusses the uptake of antenatal and postnatal health care services among women observing at most two years (0-23 months) of postpartum in Ghana from 2003 to 2014. The trend in the utilisation of antenatal and postnatal health care services is shown in Figure 4.1 Figure 4.1: Trend in antenatal and postnatal care services uptake among postpartum women in Ghana (%) 90 80.1 80 70.4 70 66.4 60 50 None 40 30 24 26.3 Only ANC 20 14.2 Only PNC 10 5.5 4.1 2.3 3.4 1.8 1.5 0 Both ANC & 2003 2008 2014 PNC Survey Years Source: computed by author using the GDHS 2003, 2008, 2014 Figure 4.1 illustrates the proportion of postpartum women who did not utilize antenatal and postnatal health care services, those who utilized only antenatal, only postnatal and both antenatal and postnatal health care services in 2003, 2008 and 2014 in Ghana. It is seen from Figure 4.1 that, the proportion of postpartum women not using antenatal and postnatal health care services has been low. Specifically, this low proportion in 2003 and in 2014 is represented 52 Percentage University of Ghana http://ugspace.ug.edu.gh by 5.5 per cent to 1.8 per cent respectively. Thus, there has been a consistent decline in the proportion of postpartum women who are not utilising these maternal health services. This phenomenon may be explained by the introduction of the free maternal health policy, changing attitudes of antenatal and postnatal health care personnel (Asundep et al., 2014), health insurance, educational attainment of women (Nketiah-Amponsah et al., 2013). Other reasons are the positive perception of women on antenatal and postnatal health care as normal part of pregnancy and after birth (Pell et al., 2013). The trend analysis also illustrates an increase in the proportion of women who used both antenatal and postnatal services from 2003 to 2008, which is from 66.4 per cent to about 80 per cent. However, it must be stated that there was a 10 per cent decline in the proportion of postpartum women who attended both antenatal and postnatal health care services from 80.1 per cent in 2008 to 70.4 per cent in 2014. There are two possible reasons for this decline the issue of sampling, and measurement of postnatal health care utilisation. The total number of postpartum women sampled in 2014 was more than number sampled in 2008. This had a major influence on the proportion of postpartum women. Again, unlike antenatal health care utilisation where data was collected on multiple visits, postnatal health care utilisation on the other hand collected data on only one visit. Therefore combing these two maternal health care services meant there one will have influence on the other. For example, the proportion of women attending postnatal health care decreased from 2008 (3.4%) to 2014 (1.4%) and this might contribute to the decrease among women who attended both antenatal and postnatal health care service between 2008 and 2014. Regardless of this lower proportion of maternal and child health care use between the survey years (2003-2014), the proportion of postpartum women who attend both antenatal and postnatal health care in Ghana has been generally high. The possible explanation for this phenomenon may be increasing skilled health 53 University of Ghana http://ugspace.ug.edu.gh care personnel (Dahiru & Oche, 2015) and increasing trust in the health care system (Do & Hotchkiss, 2013). Further, the results from Figure 4.1 indicate a decreasing trend in the proportion of postpartum women who used only postnatal services, which was from 4.1 per cent in 2003 to 1.5 per cent in 2014. On the other hand, the proportion of women who used only antenatal health services has increased steadily from 24 per cent in 2003 to about 26 per cent in 2014. In summary, the trend analysis shows that there has been a high uptake of antenatal and postnatal health care services among women observing postpartum in Ghana. 4.3 Modern Contraceptive Use Contraception plays an essential role in the reproductive health of women during their postpartum period as it aids in preventing unwanted pregnancy and reducing mortality among children and their mothers (Yadaw & Dhillon, 2015; Kavanaugh & Anderson, 2013; Lindegren et al. 2012; Ringheim et al. 2011). This is possible through delaying subsequent births and lengthening pregnancy intervals. Figure 4.3 discusses modern contraceptive use among postpartum women in Ghana. 54 University of Ghana http://ugspace.ug.edu.gh Figure 4.3: Percentage distribution of postpartum women by modern contraceptive use from 2003 to 2014 90 84.7 85.7 79 80 70 60 50 Not Using Modern 40 Method 30 21 20 15.3 Using Modern14.3 Method 10 0 2003 2008 2014 Survey Years Source: computed by author using the GDHS 2003, 2008, 2014 The general observation is that throughout the three survey years, a relatively higher proportion of postpartum women are not using modern contraceptives in Ghana. It is, however, important to state that while the proportion of postpartum women not using modern contraceptives marginally decreased from 84.7 per cent in 2003 to 79 per cent in 2014, the trend in the proportion of postpartum women using modern contraceptives declined from 15.3 per cent in 2003 to 14.3 per cent in 2008 before increasing to 21 per cent in 2014. 4.4 Background characteristics of postpartum women in Ghana Table 4.1 indicates that in all the three surveys, a relatively higher proportion of postpartum women were within the age group 15-29 years: 55.4 per cent in 2003, 59.5 per cent in 2008 and 52.9 per cent in 2014 compared to other age categories. The categorisation of this age grouping was informed by literature (for example Cohen, 1993; Singh et al, .2010) and this will ensure easy comparison with other studies. This outcome is expected because studies on childbirth 55 Percentages University of Ghana http://ugspace.ug.edu.gh among women have consistently found a higher proportion of births to be mostly occurring among women of 15-29 years. Other studies especially within sub-Saharan African countries indicate the proportion of women likely to give birth and observing postpartum at the same time is most likely to be higher among the 15-29 groups (Cohen, 1993; Singh et al. 2010). On the other hand, postpartum women with the least proportion in all three surveys (2003, 2008 and 2014) were recorded in age group 40-49 years. This may be because women within the age group 40-49 years may be entering their menopause and so only a small percentage of them may still be giving birth. Furthermore, the proportion of postpartum women who had attained secondary or higher level of education has been high. This proportion was represented by 37 per cent in 2003, 44.7 per cent in 2008 and almost 54.2 per cent in 2014. The proportion of postpartum women who had primary level of education throughout the three survey years was the least that is 22.7 per cent in 2003, 24.5 per cent in 2008 and 19 per cent 2014. 56 University of Ghana http://ugspace.ug.edu.gh Table 4.1: Percentage distribution of background characteristics of postpartum women in Ghana 2003, 2008 and 2014 Background characteristics 2003 2008 2014 Current Age Percent N Percent N Percent N 15-29 55.4 788 59.5 700 52.9 1198 30-39 36.7 522 33.3 392 39.5 895 40-49 7.9 112 7.2 85 7.5 171 Maternal Education No Education 40.3 572 30.8 363 26.8 606 Primary 22.7 322 24.5 288 19.0 431 Secondary+ 37.0 526 44.7 526 54.2 1227 Partner’s Education No Education 36.2 514 26.4 310 21.5 487 Primary 8.2 116 9.4 110 18.4 415 Secondary+ 55.6 790 64.3 757 60.1 1361 Parity 1-2 47.0 668 50.2 592 48.2 1091 3-4 28.7 408 31.4 370 30.9 700 5+ 24.3 345 18.4 216 20.9 473 Place of residence Urban 33.5 477 38.6 455 44.6 1009 Rural 66.5 944 61.4 723 55.4 1255 Ethnicity Akan 43.5 618 45.7 538 45.8 1036 Ga/Dangme 7.2 103 4.8 56 5.9 134 Ewe 12.8 182 13.1 154 12.8 291 Mole-Dagbani 17.6 251 20.1 236 19.4 437 Gruma 18.8 267 16.4 193 16.1 365 Marital Status Never Married 3.9 52 6.9 81 9.0 203 Currently Married 90.7 1289 89.4 1052 86.9 1967 Formerly Married 5.6 80 3.7 44 4.1 93 57 University of Ghana http://ugspace.ug.edu.gh Fertility Intention Have Another 62.9 893 66.1 778 58.3 1319 Undecided 2.7 39 4.6 54 9.6 217 No More 34.4 488 29.3 346 32.1 727 Sexual Activity Active in last 4 weeks 40.3 572 39.5 465 48.2 1091 Not active in last 4 weeks- 46.1 655 42.6 502 34.3 778 observing abstinence Not active in last 4 weeks-not 13.6 193 17.9 211 17.5 396 observing abstinence Exposure to FP info in the media Yes 37.3 530 36.9 434 39.6 896 No 62.7 891 63.1 743 60.4 1368 Sex of Household Head Male 74.0 1061 72.7 856 76.2 1725 Female 26.0 370 27.3 322 23.8 539 Wealth Quintile Poor 48.7 692 46.2 544 43.9 994 Middle 20.0 284 18.8 222 19.1 433 Rich 31.3 445 35.0 412 37.0 837 Source: computed by author using the GDHS 2003, 2008, 2014; N=Number of Postpartum Women; Secondary+ =secondary and/or higher education The results also show that in the three surveys (2003-2014), the proportion of partners of postpartum women who have secondary or higher level of education have been generally high. Thus, the proportion increased from 55.6 per cent in 2003 to about 60.1 per cent in 2014. Similar trends were observed among partners of postpartum women who have attained primary education even though they constitute the least proportion. On the other hand, the proportion of those who had no formal education has been low between 2003 and 2014. For instance, the proportion of partners of postpartum women who had no formal education was relatively higher 58 University of Ghana http://ugspace.ug.edu.gh in 2003 (36.2%), but a much lower proportion was recorded in 2014 (21.5%). Overall, there has been a general improvement in the level of education attained by partners of postpartum women in Ghana. Again, a higher proportion of postpartum women with parity 1-2 throughout the survey years compared to other parity categories. More specifically, there has been a general decline in the proportion of postpartum women who had five or more children. Thus, it had a relatively higher proportion of 24.3 per cent in 2003 but in 2008 the proportion was relatively lower (18.4%). However, in 2014 it recorded a relatively higher proportion of 20.9 per cent. Further, a higher proportion of postpartum women had between three to four children both in 2008 (29%) and 2014 (31%). Throughout the three survey years, majority of postpartum women in Ghana were from the rural areas compared to the urban. This outcome may be as a result of the higher rural fertility compared to the urban fertility. However, it is worthy to note that throughout the three survey periods, while the proportion of postpartum women who reside in the urban areas is relatively lower (33.5% in 2003; 38.6% in 2008; 44.6% in 2014), the proportion residing in rural areas has been higher, representing 66.5 per cent in 2003, 61.4 per cent in 2008 and 55.4 per cent in 2014. This trend can be explained within the context of Ghana‘s urbanization trends. Ghana is becoming increasingly urbanized where the number of urban settlements has with population 5,000 or more increased from 41 in 1984 to 388 in 2015 (GNSDF, 2015). This rise in urbanization has been attributed to three demographic processes: rural-urban migration, natural increase in towns and cities (development of peri-urban areas) and also re-classification as villages grow into towns once they attain the threshold population of 5000 or more. 59 University of Ghana http://ugspace.ug.edu.gh Also, a higher proportion of postpartum women in Ghana belong to the Akan ethnic group relative to the other ethnic groups. This can also be explained within the context of the general distribution of Ghana‘s population by ethnicity where the Akan constitute about 47 per cent of Ghana‘s population (GSS et al. 2015). Further, the least proportions of postpartum women in the three survey years belong to the Ga/Dangme ethnic group and other ethnic groups. This trend indicates that the Akan ethnic group is the dominant ethnic group in Ghana. The results of the descriptive statistics in Table 4.1 show clearly that an overwhelming majority of postpartum women in Ghana throughout the three surveys are currently married. However, there is a trend towards reduction in the proportion currently married from 2003 to 2014 (from about 91% to about 87% in 2014). Those who were never married and formerly married represented a small proportion of the postpartum women in each of the survey years. What is quite clear is the result that the proportion of women who had never married were lower in 2003 (3.7%) but higher in 2008 and 2014 representing 6.9 per cent and nine per cent respectively. From Table 4.2, it could clearly be seen that the proportion of postpartum women who have an intention of giving birth to another child was relatively higher in 2003 (62.9%) and in 2008 (66.1%), but was lower in 2014 i.e, 58.3 per cent. For those who are undecided on their fertility intentions, the proportion of postpartum women had consistently increased from 2.7 per cent in 2003 to 4.6 per cent in 2008 to about 10 per cent in 2014. The reason for this may probably be due to the fact that fertility decisions are jointly made by women and their partners; hence, the decision of child birth does not lie only in their hands. Furthermore, the results indicate that relatively lower proportion of postpartum women want no more children compared to those who desire to have another child. With regards to sexually active women, the results show that sexually active postpartum women in the last four weeks marginally lower in 2003 (40.3%) and 60 University of Ghana http://ugspace.ug.edu.gh in 2008 (39.5%). It was, however, higher in 2014 (48.2%). For women observing postpartum abstinence and are not sexually active in the last four weeks, the results show a lower proportion of women throughout the survey years (2003-2014). In addition, smaller proportions (2003:37.3%; 2008:36.9%; 2014:39.6%) of postpartum women in Ghana are exposed to family planning messages compared to those who are not exposed (2003:62.7%; 2008:63.1%; 2014:60.4%). One factor that accounts for this phenomenon is a substantial increase in the ownership of electronic gadgets (Bankole et al. 1996; Parr, 2001). The table also showed an overwhelming majority of postpartum women belong to households headed by males compared to those headed by females. This outcome is expected because, in most communities in Ghana, males are those that take major decisions and are often the breadwinners in their households. Similar findings were reported by the 2010 Ghana Population and Housing Census report, where 65.3 per cent of household heads were males, while 34.7 per cent were females. Finally, the results on their background characteristics showed that the highest proportion of postpartum women are in poor households compared to other categories of household in the three surveys, (48.7% in 2003, 46.2% in 2008 and 43.9% in 2014). On the other hand, the least proportion of postpartum women in Ghana were in households in the middle wealth quintile throughout the survey years. This suggests that the general population within the average economic bracket is few. 61 University of Ghana http://ugspace.ug.edu.gh In conclusion, the key observations from this chapter reveal higher proportion of postpartum women in the three surveys (2003, 2008, and 2014) accessed both antenatal and postnatal health care services. The study further indicated that majority of these women within the ages 15-29 years and has attained secondary or higher level of education. Another important observation was that majority of the women have a desire to give birth to another child and have one to two living children. Again, most of the women were not exposed to family planning information in the media (Television, radio, newspapers, etc.) and belong to households headed by males. Most importantly, high proportions of these women are currently not using modern methods of contraception. 4.5 Background characteristics of individual interview respondents This section describes the socio-demographic characteristics of women used for the qualitative data collection. It describes the characteristics of the qualitative study participants (both ANC and PNC users, only ANC users and only PNC users), namely demographic characteristics (which include age and parity) and socio-cultural characteristics (which include educational background, religion and ethnicity). The results are presented in Table 4.2. A total of 30 women from two hospitals (University of Ghana Hospital, Legon and Achimota Hospital) were interviewed, comprising fifteen users of both antenatal and postnatal health care services and nine users of only antenatal health care services and six users of only postnatal health care services. Results from Table 4.2 show that five women (only ANC users), three women (only PNC users) and 7 women (both ANC and PNC users) are of the ages 20-29 years. This constitutes the highest proportion in terms of age groups. Most of the participants had tertiary (University, polytechnic, etc) level of education (6 women who are only ANC users, 4 women 62 University of Ghana http://ugspace.ug.edu.gh who are only PNC users; 8 women using both ANC & PNC users). The results further indicate that most of the participants had 1-2 children, are Christians and also belong to the Akan ethnic group. Table 4.2: Demographic and Socio-cultural characteristics of Individual Interview respondents Only ANC users (n=9) Only PNC users Both ANC & PNC users (n=6) (n=15) Age N N N 20-29 5 3 7 30-39 3 2 3 40-45 1 1 2 Education Primary 1 0 2 Secondary 2 2 5 Tertiary 6 4 8 Partner’s Edu. Secondary 3 1 3 Tertiary 6 5 12 Parity 1-2 7 5 10 3-4 2 1 5 Religion Christian 8 4 13 Moslem 1 2 2 Ethnicity Akan 4 3 7 Ga/Dangme 2 1 3 Ewe 3 2 4 Mole-Dagbani 0 0 1 Source: Field work, 2017; %= percent accessing antenatal and postnatal health care services; N= Number of women interview in each background category; n= total number of women using antenatal and postnatal health care services 63 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE CONTRACEPTIVE USE IN THE CONTEXT OF ANTENATAL AND POSTNATAL HEALTH CARE SERVICE UTILISATION AND OTHER FACTORS 5.1 Introduction This chapter discusses the use of modern contraceptives in the context of antenatal and postnatal health care service utilisation among postpartum women in Ghana. It also looks at the role played by demographic and socio-economic factors. Thus, the study did a three way cross tabulation analysis to examine how utilisation and non-utilisation of antenatal and postnatal health care services affect the use of modern contraceptives among women with different demographic and socio-economic characteristics. 5.2 Antenatal and postnatal health care service utilisation and Modern Contraceptive use A number of studies have attempted to establish a link between uptake of antenatal and postnatal health care services and modern contraceptive use among postpartum women (Day et al. 2008; Vernon, 2009; Kariuki et al., 2011; Magoma et al., 2011; Adanikin et al., 2013; Do and Hotchkiss, 2013; Winfery and Rakesh, 2014; Mengesha et al., 2015; Moore et al., 2015; Tasha et al. 2015). These studies have argued that the antenatal and postnatal period offers the best opportunity for postpartum women to discuss the right choice of contraceptives and their correct use. Again, these studies have suggested that women are more receptive to contraceptive advice given during antenatal and postnatal health care delivery. It is also important to note that contraceptive behaviour is different among women not using antenatal and postnatal health care 64 University of Ghana http://ugspace.ug.edu.gh services, those using only antenatal health care services as well as those using only postnatal health care services and others utilising both antenatal and postnatal health care services. Table 5.1 presents modern contraceptive use among postpartum women in the context of antenatal and postnatal health care utilisation. More specifically, this section discusses modern contraceptive use among postpartum women who have not used antenatal and postnatal health care services, used only antenatal health care services or only postnatal health care services and other who utilise both antenatal and postnatal health care services with respect to the three different surveys, 2003, 2008, and 2014. Only women who are currently using modern contraceptives were included in the analyses throughout this chapter. Therefore, in each case, subtracting the percentage from 100 shows the corresponding per cent of women not using any modern contraceptive methods. Table 5.1: Modern contraceptive use and ANC and PNC utilisation among postpartum women, 2003, 2008 and 2014 Year No ANC or PNC Only ANC Only PNC Utilised both ANC utilisation & PNC % N % N % N % N 2003 3.8 78 10.6 340 13.8 58 18.1 945 2008 11.1 27 6.6 167 5.0 40 16.1 944 2014 4.8 42 19.3 597 8.6 35 22.4 1591 Abbreviations: ANC= Antenatal care; PNC= Postnatal care; N= Number of postpartum women; % = percent using modern contraception Source: computed by author using the GDHS 2003, 2008, 2014 Datasets 2 [GDHS 2003 (χ =19.475; P-value=0.000)] 2 [GDHS 2008(χ =13.684; P-value=0.003] 2 [GDHS 2014 (χ =12.973; P-value=0.005)] 65 University of Ghana http://ugspace.ug.edu.gh The results from Table 5.1 indicate a statistically significant relationship between utilisation of antenatal and postnatal health care services and modern contraceptives among postpartum women in Ghana between in the three surveys years (2003, 2008 and 2014). There are however, some differences within each year. For example, in 2003, of the 340 women who accessed only antenatal health care service, nearly 11 per cent reported using modern contraceptives. The proportion of women using modern contraceptives was higher by 3.2 percentage points among women who accessed only postnatal health care services (13.8%) relative to those accessing only antenatal health care services. Nearly one-fifth of women who accessed both antenatal and postnatal health care services, however, reported using modern contraceptives as compared to just about four per cent of their counterparts who did not use any antenatal or postnatal health care services. A similar pattern is seen in 2014. For women who used both antenatal and postnatal health care services, a higher proportion (22.4%) reported using modern contraceptives compared to less than five per cent among those who accessed neither antenatal nor postnatal health care services. It is interesting to note that a higher proportion of 19 per cent of women who attended only antenatal health care clinics used modern contraception compared to eight per cent of those who accessed PNC services only in 2014. The results in 2008 show a seemingly different pattern where among those who did not use either antenatal or postnatal health care services, a higher modern contraceptive use (11%) was reported compared to women who accessed either ANC or PNC services at (7% and 5% respectively). However, 16 per cent of women who utilised both antenatal and postnatal health care services used modern contraceptives. Generally, in the three survey years, it could be seen that modern contraceptive use was much higher among women who used both antenatal and postnatal health care services compared to 66 University of Ghana http://ugspace.ug.edu.gh others who used only antenatal, only postnatal and none of these maternal and child health care services. There are three possible explanations for this phenomenon. First, education on contraception is considered an essential component of maternal health care; therefore women who utilize these health care services go through contraceptive counselling (Day et al. 2008). This phenomenon can be explained by the transfer theory, where the knowledge and experiences women acquire during antenatal and postnatal health care services through contraceptive education is being transferred to another behaviour that is contraceptive use. Secondly, integrating contraceptive counselling into routine antenatal and postnatal care offers women the opportunity for multiple counselling which is likely to improve the use of modern contraceptives among them (Adanikin et al. 2013). Lastly, women who are not in regular contact with the maternal and child health care system are not likely to be exposed to frequent contraceptive counselling during antenatal and postnatal health care. It is also important to state that women who utilised both antenatal and postnatal health care services have multiple opportunities to receive education on contraceptives; they might have greater knowledge and better understanding about contraceptives as well as overcome certain socio-cultural barriers and misconceptions about contraceptives. This assertion was confirmed in the qualitative results which show that women who used both antenatal and postnatal health care services had more understanding of contraceptives and better appreciate the role it plays in their sexual and reproductive lives. It also came out clearly in the qualitative results that women who used either antenatal or postnatal health care services only indicated the education they received on contraception did not have any influence on their use of contraceptives and did not change their 67 University of Ghana http://ugspace.ug.edu.gh negative perceptions about contraceptives. The following quotes from the in-depth interview support these assertions: Interviewer: “Alright, ok in your opinion, has the contraceptive counselling you received during postnatal visit influenced your contraceptive use?” Respondent: “Oooh yes, it has, it has because at first I do not even want to hear about family planning because of what happened to my auntie, hmmm, my auntie did one and it had serious effect on her, she was having pains in her abdomen, she also lost weight. So I told myself I will never use one but after my first child and I received more education on it, here I am using one. So it has helped me a lot” (Respondent who used both antenatal and postnatal health care services). Interviewer: “So, are you satisfied so far on the contraceptive/family planning counselling you receive when you came for antenatal care and now postnatal care?” Respondent: “Oooh yes, I am satisfied because I have learnt a lot from it, I was very scared of using it because of the stories I heard that people who use it have pains in their abdomen and they lose weight, but now with the education I am now ok, I don‟t fear anymore” (Respondent who used both antenatal and postnatal health care services). Interviewer: “So in your opinion has the education you received on family planning/ contraceptives helped you?” Respondent: “For me I don‟t know whether to say it has helped me or not because I haven‟t used it before, I use the natural method. My sister used it and she became sick, so I am also afraid to use it. So I don‟t know whether it has helped me or not, I don‟t know” (Respondent who used only antenatal health care services). Interviewer: “In your opinion, has the contraceptive education you receive during postnatal visit influence your contraceptive use?” 68 University of Ghana http://ugspace.ug.edu.gh Respondent: “No, it has not, as for me I am scared, a lot of my friends who used it and their stomach became big, others their feet were swollen, so I told myself that I will never use it, I will never use it” (Respondent who used only postnatal health care services). Based on the quotes from the in-depth interview, the views shared by respondents who accessed both antenatal and postnatal health care services were different from those who utilised either antenatal health care services or postnatal health care services only on the influence of counselling on their use of contraceptives. The interview revealed that women who accessed both antenatal and postnatal health care services acknowledged the positive influence contraceptive counselling have had on their understanding of modern contraceptive use and have allayed their fears on the side effects of modern contraceptives. Further, the education they received clarified misconceptions and myths they had about using modern contraceptives and this has resulted in their use of modern contraceptives. One possible explanation to this phenomenon could be the multiple contraceptive counselling women using both antenatal and postnatal health care services are likely to be exposed to. In other words, if they did not receive any education on contraception during their attendance at antenatal health care, they are likely to receive this education during postnatal health care utilisation. The possibility of missing such education on modern contraceptive use is high when they receive either antenatal or postnatal service only and not both since the counselling may not be held at every session of antenatal or postnatal care service delivery to women. Another revelation from the qualitative interview was the views shared by respondents who reported to have accessed either antenatal health care services or postnatal health care services only. They reported that the education they receive (if any) did not have any impact on their understanding and use of modern contraceptives. The possible explanation for this assertion could be that these women are likely to miss the 69 University of Ghana http://ugspace.ug.edu.gh opportunity to receive multiple counselling because they access only one of the two maternal and child health care services. In conclusion, the results from both the quantitative and qualitative analyses clearly revealed that, there is better understanding and higher use of modern contraceptives among postpartum women who accessed both antenatal and postnatal health care services compared to others who used only antenatal health care services, only postnatal health care services as well as those who used neither antenatal nor postnatal health care services. 5.3 Maternal age, antenatal and postnatal health care and modern contraceptive use among postpartum women A number of studies especially in sub-Saharan Africa indicate that older women in their reproductive ages relatively use more contraceptives during their postpartum period compared to younger women (Ertem et al., 2001; Egarter et al. 2012; Nketiah-Amposah et al., 2012; Mahmood et al., 2012; Eisenberg et al. 2013). The most common reason for this phenomenon is the belief that modern contraceptives limit their probability of having more children. Therefore, these young women prefer to use short-acting methods of contraception such as pills and injectables compared to the long-acting contraceptive methods. Table 5.2 shows the modern contraceptive use among postpartum women of different reproductive ages in Ghana within the context of antenatal and postnatal health care using the three inter- survey years (2003, 2008 and 2014). 70 University of Ghana http://ugspace.ug.edu.gh Table 5.2: Modern contraceptive use by ANC and PNC utilisation and current age among postpartum women, 2003, 2008 and 2014 Modern contraceptive use Year of Age No ANC & Only ANC use Only PNC Both ANC & survey group PNC use use PNC use % N % N % N % N 2003 15-29 2.7 37 12.6 190 18.9 37 16.4 524 30-39 6.1 33 8.3 121 7.7 13 20.9 354 40-49 0.0 8 6.9 29 0.0 8 16.7 66 Total % 3.8 78 10.6 340 13.8 58 18.1 944 15-29 16.7 18 6.2 97 7.1 28 14.9 557 2008 30-39 0.0 7 8.3 60 0.0 6 17.6 319 40-49 0.0 3 0.0 10 0.0 5 20.6 68 Total % 10.7 28 6.6 167 5.1 39 16.2 944 15-29 10.5 19 20.9 311 15.0 20 25.8 848 2014 30-39 0.0 16 16.3 233 0.0 9 18.4 637 40-49 0.0 7 21.6 51 0.0 5 19.6 107 Total % 4.8 42 19.2 595 8.8 34 22.4 1592 Abbreviations: ANC= Antenatal care; PNC= Postnatal care; N= Number of postpartum women; % = percent using modern contraception Source: computed by author using the GDHS 2003, 2008, 2014 2 [GDHS 2003 (χ =1.945; P-value=0.378)] 2 [GDHS 2008(χ =1.212; P-value=0.546] 2 [GDHS 2014 (χ =14.824; P-value=0.001)] The results from Table 5.2 indicate that it is only in 2014 that there is a statistical significant relationship between antenatal and postnatal health care services utilisation and modern contraceptive use when the age of postpartum women were controlled for. In 2014, among the 19 postpartum women within ages 15-29 who had not used antenatal and postnatal health care services, 10.5 per cent of them reported using modern contraception. However, the proportion was much higher (20.9%) among the 15-29 year olds who utilised only antenatal health care services. Comparing modern contraceptive use among the 15-29 year-old 71 University of Ghana http://ugspace.ug.edu.gh postpartum women who used only postnatal and both antenatal and postnatal health care services, the results showed much higher proportion of modern contraceptive use among users of both antenatal and postnatal health care services. Further, among postpartum women aged 30-39 years, higher proportion of modern contraceptive use was recorded among those who used only antenatal health care services (16.3%) and those who used both antenatal and postnatal health care services (18.4%). Again, similar observation can be made on contraceptive use among the 40-49 year-old postpartum women. That is, a higher proportion of contraceptive use was found among those who used only antenatal health care services and also among those who used both antenatal and postnatal health care services. In other words, none of the women who attended only postnatal health clinic and those who did not attend either antenatal or postnatal health clinic reported using modern contraceptives. Higher modern contraceptive use was recorded among women of ages 15-29 who indicated using both antenatal and postnatal health care services compared to the other age categories. The possible explanation to this is the fact that women of ages 15-29 years, where most births occur, will use contraceptive methods to space their pregnancy through the counselling they receive when they go for maternal health care services. This finding is consistent with a study conducted by Mahmood et al (2011) in India, which found that modern contraceptive use was higher among postpartum women below the age of 30. 72 University of Ghana http://ugspace.ug.edu.gh 5.4 Maternal educational level antenatal and postnatal health care and modern contraceptive use among postpartum women Studies have established consistently that increase in women‘s education plays a pivotal role in increasing contraceptive prevalence rate (Korra 2002; Beekle and Mc Cabe, 2006; Heeks, 2008). Time spent in education reduces a woman‘s demand for children and increases her desire to use contraceptives. Thus, women who have attained higher education are likely to delay conception and hence will adopt modern contraceptives to achieve this (Gordon et al. 2003). Education enables women to better understand and appreciate the importance of contraception especially when observing postpartum. Results from Table 5.3 illustrate the use of modern contraception among postpartum women who are not utilising antenatal and postnatal health care services and those using these health care services controlling for their level of education. 73 University of Ghana http://ugspace.ug.edu.gh Table 5.3: Modern contraceptive use by ANC and PNC utilisation and educational level among postpartum women from 2003 to 2014 Modern contraceptive use Year of Educational No ANC & Only ANC Only PNC Both ANC & survey level PNC use use use PNC use % N % N % N % N No education 1.5 66 7.1 183 7.7 26 10.8 296 Primary 22.2 9 6.3 79 20.0 20 22.8 215 2003 Secondary+ 0.0 3 23.1 78 8.3 12 20.7 434 Total % 3.8 78 10.6 340 12.1 58 18.1 945 No education 0.0 13 3.8 78 0.0 19 10.3 253 Primary 27.3 11 6.4 47 0.0 10 17.3 220 2008 Secondary+ 0.0 3 9.8 41 20.0 10 18.7 471 Total % 11.1 27 6.0 166 5.1 39 16.1 944 No education 9.1 22 17.4 138 5.6 18 14.1 427 Primary 0.0 15 20.3 123 16.7 12 30.6 281 2014 Secondary+ 0.0 4 19.4 335 0.0 5 23.9 884 Total % 4.9 41 19.1 596 8.6 35 22.4 1592 Abbreviations: ANC= Antenatal care; PNC= Postnatal care; N= Number of postpartum women; % = percent using modern contraception; Secondary+ =secondary and/or higher education Source: computed by author using the GDHS 2003, 2008, 2014 Datasets 2 [GDHS 2003 (χ =9.307; P-value=0.010)] 2 [GDHS 2008(χ =4.909; P-value=0.086] 2 [GDHS 2014 (χ =1.816; P-value=0.403)] Table 5.3 shows a statistically significant relationship between the educational level of postpartum women and modern contraceptives only in 2003. The results clearly show that among postpartum women with no formal education, higher modern contraception use was recorded among those who used both antenatal and postnatal health care services (10.8%) compared to those who used none (1.5%), only antenatal (7.1%) and only postnatal health care services (7.7%). Similar observation can be made among other educational levels of these women with the exception of women with secondary/higher level of education where much higher use of 74 University of Ghana http://ugspace.ug.edu.gh modern contraception was found among women who used only antenatal health care services compared to other categories of maternal and child health care users. In summary, higher level of modern contraception use was generally found among postpartum women who utilised both antenatal and postnatal health care services most especially among women who have attained higher/tertiary level of education. This result also supports the fact that highly educated women are in a better position to understand the essence and advantages of using modern contraceptives and their impacts on their sexual and reproductive health. Other studies by Korra (2002) and Beekle and McCabe (2006) found a very strong association between postpartum women‘s education and modern contraceptive use. They found that when a woman stays longer in school, it exposes her to more information on reproductive health and she is able to apply that information to her advantage. The positive effect of a woman‘s education has led to an increase in the use of modern contraceptives. 5.5 Partner’s education, antenatal and postnatal health care and modern contraceptive use among postpartum women Highly educated husbands‘ desire smaller family sizes and as a result will be more tolerant towards their partners using modern contraceptives. Studies have found that husbands‘ educational level is very influential in women‘s contraceptive decisions (Dang, 1995; Kulczycki, 2004; Alpu and Fidan, 2006; Gereltuya et al. 2007; Gubhaju, 2009). Results in Table 5.4 show a statistically significant (p<0.05) association between modern contraceptive use of postpartum women and antenatal and postnatal service use controlling for their partners‘ educational level in Ghana. In 2014, among partners of postpartum women who had no formal education, modern contraceptive use was relatively higher among those who used only antenatal health care services 75 University of Ghana http://ugspace.ug.edu.gh (17.9%). This was followed by 12.2 per cent out of the 352 postpartum women who are reported to have attended both antenatal and postnatal health care clinics using modern contraceptives. Lower use of modern contraceptives was however, found among women who used none of these services (6.2%) and also those who used only postnatal health care services (7.1%). Table 5.4: Modern contraceptive use, ANC and PNC utilisation by partner’s educational level among postpartum women, 2003, 2008 and 2014 Modern contraceptive use Year of Partner’s No ANC & Only ANC Only PNC use Both ANC & survey educational level PNC use use PNC use % N % N % N % N No education 5.2 58 6.7 180 4.5 22 8.3 254 Primary 0.0 9 17.9 28 0.0 7 26.4 72 2003 Secondary+ 0.0 11 14.4 132 23.3 30 21.0 618 Total % 3.8 78 10.6 340 13.6 59 18.0 944 No education 8.3 12 1.7 58 6.2 16 8.1 223 Primary 0.0 4 8.0 25 0.0 5 25.0 76 2008 Secondary+ 18.2 11 9.5 84 5.6 18 17.9 644 Total % 11.1 27 6.6 167 5.1 39 16.1 943 No education 6.2 16 17.9 106 7.1 14 12.2 352 Primary 0.0 9 18.3 120 25.0 4 28.7 282 2014 Secondary+ 6.2 16 20.0 370 5.6 18 24.2 957 Total % 4.9 41 19.3 596 8.3 36 22.4 1591 Abbreviations: ANC= Antenatal care; PNC= Postnatal care; N= Number of postpartum women; % = percent using modern contraception; Secondary+ =secondary and/or higher education Source: computed by author using the GDHS 2003, 2008, 2014 Datasets 2 [GDHS 2003 (χ =1.076; P-value=0.783)] 2 GDHS 2008(χ =5.354; P-value=0.148] 2 [GDHS 2014 (χ =35.369; P-value=0.000)] The observation in the other educational levels of postpartum women‘s partners was somewhat to the contrary. Much higher use of modern contraception was recorded among postpartum women who used both antenatal and postnatal health care services and whose partners have 76 University of Ghana http://ugspace.ug.edu.gh attained primary, secondary and higher levels of education. It is, therefore, essential to state that husbands‘ educational level has an influence on their wives‘ reproductive behaviour and this has been well documented in literature. For instance, a study by Boateng (2006) indicated that husbands with higher education had a positive influence on their wives‘ contraceptive use. Another study by Mengesha et al., (2015) showed a significant association between husband‘s education and use of contraceptives among women in the extended postpartum period. Higher education of husbands promotes the use of contraceptives. Similar findings were reported from studies done in Ethiopia and India (Shah et al. 2006; Haile & Enqueselassie, 2006). These findings highlight the importance of focusing on involving men in family planning efforts because husbands do seem to play a role in deciding family planning methods for their wives. 5.6 Parity, modern contraceptive use and antenatal and postnatal health care among postpartum women Globally, it has been found that postpartum women with a higher number of children relatively use more modern contraceptives compared to other postpartum women with lower parities. A study conducted in Uganda by Asiimwe and Ndugga (2014) discovered that young postpartum women have a stronger desire for more children than older postpartum women, resulting in lower modern contraceptive use among women of ages 15-24 compared with older women between 25 and 34 years. Another study in Turkey which explored the relationship between parity and modern contraceptive use among postpartum women reported that receiving family planning information leads postpartum women with high parity to use modern contraceptives in limiting child birth (Ertem et al., 2001). Table 5.5 computes modern contraceptive use among postpartum 77 University of Ghana http://ugspace.ug.edu.gh women by the number of children they have within the context of antenatal and postnatal health care service utilisation. Table 5.5: Modern contraceptive use and ANC and PNC utilisation by parity among postpartum women, 2003, 2008 and 2014 Modern contraceptive use No ANC & Only ANC Only PNC Both ANC & PNC use use use PNC use Year of survey % N % N % N % N Parity 1-2 4.0 25 15.1 139 21.4 28 15.1 476 2003 3-4 8.0 25 8.6 105 13.3 15 20.8 264 5+ 3.6 28 7.2 97 0.0 16 21.1 204 Total % 5.1 78 10.9 341 13.6 59 18.0 944 1-2 16.7 12 6.1 66 5.9 17 15.5 497 3-4 12.5 8 6.8 59 7.7 13 17.9 290 2008 5+ 0.0 8 7.1 42 0.0 9 14.6 157 Total % 10.7 28 6.6 167 5.1 39 16.1 944 1-2 0.0 7 16.9 290 15.4 13 21.3 781 3-4 6.2 16 20.8 178 9.1 11 27.4 496 2014 5+ 5.3 19 21.9 128 0.0 11 17.5 315 Total % 4.8 42 19.1 596 8.6 35 22.4 1592 Abbreviations: ANC= Antenatal care; PNC= Postnatal care; N= Number of postpartum women; % = percent using modern contraception Source: computed by author using the GDHS 2003, 2008, 2014 Datasets 2 [GDHS 2003 (χ =5.407; P-value=0.067)] 2 [GDHS 2008(χ =1.431; P-value=0.489)] 2 [GDHS 2014 (χ =35.369; P-value=0.002)] From Table 5.5, the results show that there is a statistically significant relationship between parity of women and their contraceptive use in the context of their antenatal and postnatal health care service utilisation at level of 95% in 2014. It should be noted that among postpartum women with one or two living children, about 21 per cent out of 781 who indicated to have used both antenatal and postnatal health care services also used modern contraceptives. This proportion is 78 University of Ghana http://ugspace.ug.edu.gh much higher when compared to modern contraceptive use among other postpartum women who utilised only postnatal health care services (15.4%), only antenatal health care services (16.9%) and users of none of these maternal and child health care services (0.0%). The observation is the same among postpartum women who had parity three to four, where a higher proportion of modern contraceptive use was found among women who used both antenatal and postnatal health care services compared to other antenatal and postnatal health care services categories. The situation is, however, different among women who have five or more children. The results show that about 22 per cent of the 128 postpartum women who reported using only antenatal health care services have also been using modern contraceptives. This was followed by women using both antenatal and postnatal health care services and no antenatal and postnatal health care service use represented by 17.5 per cent and 5.3 per cent respectively. In conclusion, the variation in postpartum women‘s modern contraceptive use with respect to the number of living children they have may depend on the extent to which these women have contact with the maternal health care system, as the results show high contraceptive use among women who use both antenatal and postnatal health care services especially among postpartum women with 1-2 living children. This assertion is consistent with the findings of other studies. For instance, a study by Mahmood et al (2011) found higher postpartum contraceptive use among women with two or less living children. In contrast, a study in Cambodia by Samandari et al. (2010) reported that modern contraceptive use was higher among high parity women compared to others with lower parity because high parity women were more in contact with the health system. The role of antenatal and postnatal health care service provision in encouraging women to use modern family planning is, therefore, quite reflected in these studies and in this current one. 79 University of Ghana http://ugspace.ug.edu.gh 5.7 Place of residence modern contraceptive use and antenatal and postnatal health care among postpartum women Studies have established a relationship between place of residence (rural and urban) of women and their use of contraceptives. Most of these studies have indicated higher use of modern contraceptives among postpartum women who dwell in urban areas compared to their rural counterparts (Omondi and Ayiemba, 2003). The reason is that postpartum women in urban areas have relatively easier access to family planning information and services than those in rural areas. These studies also argue that the length of stay of women in their current place of residence has an influence on their contraceptive decision making. Results from Table 5.6 examine the relationship between modern contraceptive use and antenatal and postnatal health care services utilisation among women while controlling for the effect of their place of residence. From this table, it is only in 2003 that the chi-square test indicates a statistically significant relationship between the type of place of residence of postpartum women and modern contraceptive use in the context of antenatal and postnatal health care service 2 utilisation (χ =7.197, p-value=0.007). Among postpartum women in the urban areas, the results indicate higher (26.1%) use of modern contraceptives among women who attended only postnatal health care clinics compared to other categories of women (both users of antenatal and postnatal health care services: 23.2%, only antenatal health care users: 24.2%, non-use of antenatal and postnatal health care services: 0.0%). It is, however, important to note that the number of urban women who reported using only postnatal services (23) is lesser than the number of urban women who utilised both antenatal and postnatal health care services (419) and only antenatal health care services (33). Therefore, in terms of the proportion, modern contraceptive use was shown to be higher among urban postpartum women who used only 80 University of Ghana http://ugspace.ug.edu.gh postnatal health care services but this might not be a true reflection of the reality considering the numbers involved as compared to the other categories. Table 5.6: Modern contraceptive use, ANC and PNC utilisation by place of residence among postpartum women, 2003, 2008 and 2014 Modern contraceptive use No ANC & Only ANC Only PNC use Both ANC & Year of Place of PNC use use PNC use survey residence % N % N % N % N Urban 0.0 1 24.2 33 26.1 23 23.2 419 2003 Rural 3.9 77 9.1 307 5.7 35 13.9 525 Total % 3.8 78 10.6 340 13.8 58 18.0 944 Urban 0.0 3 0.0 27 0.0 12 18.2 412 2008 Rural 12.5 24 7.9 140 7.4 27 14.5 531 Total % 11.1 27 6.6 167 5.1 39 16.1 943 Urban 0.0 9 20.4 245 20.0 10 21.0 746 2014 Rural 6.1 33 18.2 351 4.0 25 23.6 846 Total % 4.8 42 19.1 596 8.6 35 22.4 1592 Abbreviations: ANC= Antenatal care; PNC= Postnatal care; N= Number of postpartum women; % = percent using modern contraception Source: computed by author using the GDHS 2003, 2008, 2014 Datasets 2 [GDHS 2003 (χ =7.197; P-value=0.007)] 2 [GDHS 2008(χ =2.271; P-value=0.132)] 2 [GDHS 2014 (χ =1.535; P-value=0.215)] On the other hand, modern contraceptive use was found to be much higher (13.9%) among postpartum women dwelling in rural areas who are users of both antenatal and postnatal health care services relative to the other categories. In conclusion, higher use of modern contraceptives was found among urban women who used both antenatal and postnatal health care services compared to rural women. This is to be expected because, women in urban areas have more access to antenatal and postnatal health care services and are likely to benefit from contraceptive counselling when they go for these health care services. This will improve their knowledge and use of modern contraceptives. Similar 81 University of Ghana http://ugspace.ug.edu.gh outcomes were found in a study by Curtis and Neitzel (1996) where modern contraceptive use was high in urban than rural areas. It is argued that the trend in urban-rural difference in contraceptive use among women is due to the urban advantage of easy access to more improved family planning and other reproductive health care services (Gichuhi and Omedi 2013; Palamuleni, 2014). Also, there is limited supply of family planning and other sexual and reproductive health care services in the rural areas. That is, this finding and findings of other studies have established that modern contraceptive use is higher among women in the urban areas largely because they have a better understanding of contraception and family planning partly because of their higher antenatal and postnatal utilisation. 5.8 Ethnicity and Modern Contraceptive use among postpartum women in the context of Antenatal and Postnatal Health Care Studies on the relationship between ethnicity and contraceptive use among women lay more emphasis on the influence of cultural beliefs and practices towards fertility and reproductive health issues (Dehlendorf et al., 2010; Adebowale et al. 2013; Obasohan, 2015). Table 5.7 shows the relationship between modern contraceptive use and antenatal and postnatal health care service utilisation among women while controlling for their ethnicity. The results from Table 5.7 show a statistically significant (p<0.05) association between the ethnic background of postpartum women in Ghana and modern contraceptive use in 2014. The results indicate that with the exception of Ga/Dangme, Gruma and other minority ethnic groups, there is high modern contraceptive use recorded among postpartum women who reported using both antenatal and postnatal health care services. 82 University of Ghana http://ugspace.ug.edu.gh Table 5.7: Modern contraceptive use and ANC and PNC utilisation by ethnicity among postpartum women, 2003, 2008 and 2014 Modern contraceptive use Year of Ethnicity No ANC & Only ANC Only PNC Both ANC survey PNC use use use & PNC use % N % N % N % N Akan 20.0 10 10.8 93 9.5 21 20.2 494 Ga/Dangme 0.0 3 15.0 20 0.0 5 20.0 75 2003 Ewe 0.0 9 16.9 59 22.2 9 21.0 105 Mole-Dagbani 0.0 27 9.8 82 7.7 13 10.2 128 Gruma 3.6 28 6.9 87 22.2 9 14.7 143 Total % 3.9 77 10.9 341 12.3 57 18.1 945 Akan 10.0 10 7.8 77 6.2 16 17.5 435 Ga/Dangme 0.0 2 16.7 12 - - 16.3 43 Ewe 40.0 5 0.0 16 33.3 3 20.8 130 2008 Mole-Dagbani 0.0 4 3.4 29 0.0 14 9.5 190 Gruma 0.0 7 6.1 33 0.0 7 16.6 145 Total % 10.7 28 6.6 167 5.0 40 16.1 943 Akan 0.0 14 19.6 311 10.0 10 25.7 700 Ga/Dangme 0.0 1 12.2 49 25.0 4 18.5 81 Ewe 16.7 6 24.4 78 0.0 3 26.1 203 2014 Mole-Dagbani 0.0 1 16.9 77 0.0 9 18.9 350 Gruma 5.6 18 17.6 68 11.1 9 16.1 217 Total % 4.9 41 19.3 597 8.6 35 22.4 1590 Abbreviations: ANC= Antenatal care; PNC= Postnatal care; N= Number of postpartum women; % = percent using modern contraception Source: computed by author using the GDHS 2003, 2008, 2014 Datasets 2 [GDHS 2003 (χ =9.132; P-value=0.104)] 2 [GDHS 2008(χ =4.208; P-value=0.520)] 2 [GDHS 2014 (χ =14.617; P-value=0.012)] Specifically, among women who utilize both antenatal and postnatal health care service, women who belong to the Ewe ethnic group recorded the highest percentage (26.1%) of modern contraceptive use. This was closely followed by the Akan (25.7%). The corresponding figures for the rest were 18.9 per cent (Mole-Dagbani), 18.5 per cent (Ga/Dangme) and 16.1 per cent (Gruma ethnic groups, and also for the Guan). Similar results were found by other studies. For instance, a study by Addai (1999) on ethnicity and contraceptive use in Ghana reported that the 83 University of Ghana http://ugspace.ug.edu.gh highest use of modern contraceptives was among the Ewe ethnic group compared to other ethnic groups. 5.9 Marital status, antenatal and postnatal health care and modern contraceptive use among postpartum women Until recently, literature on contraceptive use among women has focused mostly on married women because this was where most sexual activities and conception take place. However, some studies have also indicated higher contraceptive use among sexually active unmarried women compared to married women (Clements and Madise, 2004; Nyarko, 2015). Analysis examining the relationship between marital status and use of modern contraceptives in the context of antenatal and postnatal health care service utilisation is shown in Table 5.8. Table 5.8: Modern contraceptive use, ANC and PNC utilisation by marital status among postpartum women from 2003 to 2014 Modern contraceptive use Year of Marital Status No ANC & Only ANC Only PNC Both ANC & survey PNC use use use PNC use % N % N % N % N Never Married 0.0 1 0.0 7 25.0 4 10.0 40 Currently Married 3.9 76 10.7 318 13.7 51 19.2 844 2003 Formerly Married 0.0 1 20.0 15 0.0 3 8.2 61 Total % 3.8 78 10.9 340 13.8 58 18.1 945 Never Married 0.0 4 0.0 9 0.0 4 6.2 65 Currently Married 14.3 21 7.3 150 5.9 34 17.3 848 2008 Formerly Married 0.0 2 0.0 8 0.0 2 6.2 32 Total % 11.1 27 6.6 167 5.0 40 16.2 945 Never Married 0.0 4 16.1 62 100.0 1 23.4 137 Currently Married 5.7 35 19.4 515 6.2 32 22.2 1384 2014 Formerly Married 0.0 2 26.3 19 0.0 2 24.6 69 Total % 4.9 41 19.3 596 8.6 35 22.4 1590 Abbreviations: ANC= Antenatal care; PNC= Postnatal care; N= Number of postpartum women; % = percent using modern contraception; Source: computed by author using the GDHS 2003, 2008, 2014 Datasets 2 [GDHS 2003 (χ =6.489; P-value=0.039)] 2 [GDHS 2008(χ =7.974; P-value=0.019)] 2 [GDHS 2014 (χ =0.309; P-value=0.857)] 84 University of Ghana http://ugspace.ug.edu.gh In 2003 and 2008, the results from Table 5.9 show a statistically significant (p<0.05) relationship between the marital status of postpartum women in Ghana and their use of modern contraceptives in the context of antenatal and postnatal health care services utilisation. In 2003, it is observable that, the proportion of currently married women using modern contraceptives was higher (19.2%) for women who used both antenatal and postnatal health care services relative to other categories of maternal and child health care service use. Different observations can be found among formerly and never married women, that is higher proportion of modern contraceptive use was recorded among formerly married women who reported using only antenatal health care. On the other hand, higher use of modern contraceptives was found among never married women who used only postnatal health care compared to other categories. In 2008, with respect to all the three marital statuses, the results show much higher modern contraceptive use among women who attended both antenatal and postnatal health care services relative to other maternal health care users. However, the use of modern contraceptives was highest (17.3%) among currently married women who used both antenatal and postnatal health care services. In summary, higher use of modern contraception was recorded among currently married women who used both antenatal and postnatal services. This gives an indication that since most births occur in marriages or stable unions, these married women who are in regular contact with the maternal and child health care system are more likely to receive contraceptive education and be encouraged to use contraception compared to unmarried or formerly married women. This finding is inconsistent with the findings of a study by Anasel and Mlinga (2014) in Tanzania. Their study reported that modern contraceptive use is higher among unmarried women compared 85 University of Ghana http://ugspace.ug.edu.gh to their counterparts who were married. The reason was that, unmarried women were having multiple sexual partners and so used contraceptives to prevent unintended pregnancy and sexually transmitted diseases. 5.10 Fertility intention, antenatal and postnatal health care and modern contraceptive use among postpartum women Literature has established that the decision of a woman to bear more children or not has important influence on her contraceptive choices and use. Studies have also established some relationship between fertility intention of postpartum women and their use of modern contraceptives (DeFranco et al. 2007; Watson and Simmons, 2010). Detailed analysis of use of modern contraception among postpartum women with different fertility desires is shown in Table 5.9. 86 University of Ghana http://ugspace.ug.edu.gh Table 5.9: Modern contraceptive use and ANC and PNC utilisation by fertility intention among postpartum women from 2003 to 2014 Modern contraceptive use Year of Fertility No ANC & Only ANC Only PNC Both ANC & survey Intention PNC use use use PNC use % N % N % N % N Have Another 2.0 49 11.4 229 23.1 26 16.3 590 2003 Undecided 0.0 6 0.0 8 25.0 4 23.8 21 No more child 8.7 23 9.6 104 3.6 28 20.7 333 Total % 3.8 78 10.6 341 13.8 58 18.0 944 Have Another 15.4 13 6.7 104 6.7 30 14.2 632 Undecided 0.0 4 0.0 11 - - 5.3 38 2008 No more child 10.0 10 7.7 52 0.0 10 21.9 274 Total % 11.1 27 6.6 167 5.0 40 16.1 944 Have Another 4.8 21 18.8 314 17.6 17 23.1 967 Undecided 0.0 1 13.4 82 0.0 3 16.0 131 2014 No more child 5.3 19 22.4 201 0.0 15 22.8 492 Total % 4.9 41 19.3 597 8.6 35 22.4 1590 Abbreviations: ANC= Antenatal care; PNC= Postnatal care; N= Number of postpartum women; % = percent using modern contraception Source: computed by author using the GDHS 2003, 2008, 2014 Datasets 2 [GDHS 2003 (χ =1.196; P-value=0.550)] 2 [GDHS 2008(χ =0.702; P-value=0.704] 2 [GDHS 2014 (χ =3.339; P-value=0.188)] From Table 5.9, the chi-square test indicates that there is no statistically significant relationship between fertility intention and modern contraceptive use among postpartum women in Ghana in the context of antenatal and postnatal health care services. 87 University of Ghana http://ugspace.ug.edu.gh 5.11 Sexual activity modern contraceptive use and antenatal and postnatal health care among postpartum women A strong association has been established between sexual activity among postpartum women and use of modern contraceptives (Borda et al. 2010; Sok et al. 2016). These studies have argued that if a postpartum woman is active sexually and not using an effective modern contraceptive, she risks getting pregnant before her menstruation. They also established that postpartum women are likely to resume sexual activity before they visit their health provider during the period of postpartum. For instance, a study by Sok et al., (2016) reported that most women resume sex after six weeks of postpartum, but only a small number of them are using contraceptives. Table 5.10, shows the relationship between sexual activity and current use of modern contraceptives among postpartum women within the context of antenatal and postnatal health care services. From Table 5.10, the chi-square test indicates that in all the survey years, there is a statistically significant relationship between sexual activity and modern contraceptive use among postpartum women using antenatal and postnatal health care services in Ghana at p<0.05. In 2003, the results show that modern contraceptive use was relatively higher (31.8%) among postpartum women who were sexually active in the last 4 weeks and have reportedly used only postnatal health care services compared to other maternal and child health care users. However, modern contraceptive use was much lower among postpartum women who were not sexually active in the last four weeks and were observing postpartum abstinence regardless of their use of antenatal and postnatal health care services. 88 University of Ghana http://ugspace.ug.edu.gh Table 5.10: Modern contraceptive use, ANC and PNC utilisation by sexual activity among postpartum women from 2003 to 2014 Modern contraceptive use Year of Sexual Activity No ANC Only ANC Only PNC Both ANC survey & PNC use use & PNC use use % N % N % N % N Active in last 4 weeks 13.6 22 22.1 131 38.1 21 31.7 398 Not active- observing 0.0 51 2.3 177 0.0 24 4.5 403 postpartum abstinence 2003 Not active-not observing 0.0 4 12.5 32 0.0 13 18.2 143 postpartum abstinence Total % 3.9 77 10.9 340 13.8 58 18.0 944 Active in last 4 weeks 27.3 11 14.3 56 9.1 11 29.7 387 Not active- observing 0.0 15 0.0 82 0.0 16 3.1 389 postpartum abstinence Not active-not observing 0.0 2 10.3 29 8.3 12 14.9 168 postpartum abstinence 2008 Total % 10.7 28 6.6 167 5.1 39 16.1 944 Active in last 4 weeks 8.7 23 28.8 274 0.0 7 32.1 789 Not active- observing 0.0 17 5.0 219 5.6 18 5.8 521 postpartum abstinence 2014 Not active-not observing 0.0 2 24.3 103 20.0 10 26.2 282 postpartum abstinence Total % 4.8 42 19.3 596 8.6 35 22.4 1592 Abbreviations: ANC= Antenatal care; PNC= Postnatal care; N= Number of postpartum women; % = percent using modern contraception Source: computed by author using the GDHS 2003, 2008, 2014 Datasets 2 [GDHS 2003 (χ =7.804; P-value=0.020)] 2 [GDHS 2008(χ =11.842; P-value=0.003)] 2 [GDHS 2014 (χ =127.712; P-value=0.000)] Furthermore, in 2008 and 2014, modern contraceptive use was relatively higher among sexually active women who used both antenatal and postnatal health care services. This is represented by a proportion of about 30 per cent and 32 per cent respectively. 89 University of Ghana http://ugspace.ug.edu.gh In conclusion, what is clear from this analysis is the significant role played by antenatal and postnatal health care services in modern contraceptive use among sexually active postpartum women with respect to their sexual and reproductive health in terms of contraception. There is however an issue of time dislocation with regards to women who are sexually inactive. This is because they will not be using contraception during that period of their reproductive life and this clearly explains the empty cells as seen in Table 5.10 and that limitation is duly acknowledged. 5.12 Exposure to family planning information in the media, antenatal and postnatal health care and modern contraceptive use among postpartum women Access to family planning information through the mass media (radio, television, newspaper, magazines, and the internet) by women has been seen as well suited to reach all manner of persons and is believed to change human behaviour including contraception. Studies have established that continuous advertisement of contraceptives in the media has by far increased contraceptive knowledge and helped women to make informed contraceptive choices (Bankole, 1994; Gupta et al., 2003; Kulkarni, 2003; Ajaero et al. 2016). Table 5.11 shows the proportion of postpartum women using modern contraceptives by their exposure to information about family planning in the media and use of antenatal and postnatal health care services. The results in the table, however, do not show any statistically significant relationship between women‘s antenatal and postnatal health care service utilisation and their modern contraceptive use while controlling for their access to family planning information in the mass media. 90 University of Ghana http://ugspace.ug.edu.gh Table 5.11: Modern contraceptive use, ANC and PNC utilisation by exposure to family planning information in the media among postpartum women, 2003, 2008 and 2014 Modern contraceptive use Year of Exposure to FP in No ANC & Only ANC Only PNC Both ANC survey the media PNC use use use & PNC use % N % N % N % N Yes 0.0 4 16.9 65 22.7 22 21.7 438 2003 No 4.1 74 9.1 275 8.3 36 15.0 507 Total % 3.8 78 10.6 340 13.8 58 18.1 945 Yes 0.0 2 4.3 23 0.0 13 19.4 396 2008 No 12.0 25 6.9 144 7.7 26 13.8 549 Total % 11.1 27 6.6 167 5.1 39 16.2 945 Yes 0.0 6 15.9 233 0.0 8 21.8 650 2014 No 5.6 36 21.4 364 11.1 27 22.7 941 Total % 4.8 42 19.3 597 8.6 35 22.4 1591 Abbreviations: ANC= Antenatal care; PNC= Postnatal care; N= Number of postpartum women; % = percent using modern contraception Source: computed by author using the GDHS 2003, 2008, 2014 Datasets 2 [GDHS 2003 (χ =0.169; P-value=0.681)] 2 [GDHS 2008(χ =0.217; P-value=0.641] 2 [GDHS 2014 (χ =0.178; P-value=0.673)] 5.13 Sex of household head, antenatal and postnatal health care and modern contraceptive use among postpartum women The relationship between sex of household head and contraceptive use among women is essential especially in developing countries. Studies have suggested that women residing in male-headed households often use little or no modern contraceptives compared to those who reside in female- headed households (UNFPA, 1991; Makajane, 1997; Kabeer et al., 2011). The reason is that 91 University of Ghana http://ugspace.ug.edu.gh households headed by men are often not a conducive setting within which modern contraceptive use could be encouraged and promoted among women. Table 5.12 presents the distribution of postpartum women according to the sex of their household heads, their usage of modern contraception and utilisation of antenatal and postnatal health care services. Table 5.12: Modern contraceptive use and ANC and PNC utilisation by sex of household head among postpartum women from 2003 to 2014 Modern contraceptive use Year of Sex of No ANC & Only ANC use Only PNC Both ANC & survey Household PNC use use PNC use Head % N % N % N % N Male 4.2 71 11.1 289 17.4 46 20.7 646 2003 Female 0.0 7 9.6 52 0.0 13 12.4 298 Total % 3.8 78 10.9 341 13.6 59 18.1 944 Male 15.0 20 8.6 128 3.3 30 17.7 677 2008 Female 0.0 7 0.0 39 11.1 9 12.0 266 Total % 11.1 27 6.6 167 5.1 39 16.1 943 Male 8.0 25 19.7 446 10.0 20 23.4 1235 2014 Female 0.0 17 17.3 150 6.7 15 19.0 357 Total % 4.8 42 19.1 596 8.6 35 22.4 1592 Abbreviations: ANC= Antenatal care; PNC= Postnatal care; N= Number of postpartum women; % = percent using modern contraception Source: computed by author using the GDHS 2003, 2008, 2014 Datasets 2 [GDHS 2003 (χ =0.308; P-value=0.579)] 2 [GDHS 2008(χ =4.581; P-value=0.032)] 2 [GDHS 2014 (χ =3.017; P-value=0.082)] From Table 5.12, the chi-square test indicates that there is a statistically significant relationship (p<0.05) between antenatal and postnatal health care use and modern contraceptive use among postpartum women only in 2008 while controlling for the sex of their head of household. The results show that out of the 677 postpartum women who dwell in male-headed household and also used both antenatal and postnatal health care services, about 18 per cent used modern contraceptives compared to other categories of women who used other maternal health care 92 University of Ghana http://ugspace.ug.edu.gh services. This proportion is the highest relative to those who used only postnatal health care services (3.3%), only antenatal health care services (8.6%), and none of these maternal health care services (15.0%). Also, among postpartum women in female-headed households, the results show that about 11 per cent (only postnatal health care use) and 12 per cent (both antenatal and postnatal) of women used modern contraceptives. Meanwhile, none reported using contraceptives among those not using these maternal health care services and those using only antenatal health care services. The outcomes from this analysis lay emphasis on the essential role played by contraceptive counselling during antenatal and postnatal health services towards women. Most often, women are accompanied by their partners to these maternal health care services and will better understand and appreciate contraception. 5.14 Wealth quintile, antenatal and postnatal health care and modern contraceptive use among postpartum women Wealth quintile and modern contraceptive use have been found to have a strong association (Kayembe et al., 2006; Stephenson et al., 2007; Creanga et al., 2011; Nketiah-Amponsah et al., 2012; Adebowale et al. 2014). These studies found high total fertility rate among postpartum women in the poorest wealth quintile compared to others in the richest wealth quintile. These studies further showed that a higher proportion of postpartum women in the richest wealth quintile are currently using modern contraceptives compared to their counterparts in the poorest wealth quintile. Accordingly, Table 5.13 presents analysis of contraceptive use among postpartum women and antenatal and postnatal health care service utilisation, controlling for their wealth quintile. 93 University of Ghana http://ugspace.ug.edu.gh Table 5.13: Modern contraceptive use, ANC and PNC utilisation by wealth quintile among postpartum women, 2003, 2008 and 2014 Modern contraceptive use Year of Wealth No ANC & PNC Only ANC Only PNC use Both ANC & survey Quintile use use PNC use % N % N % N % N Poor 4.6 65 8.2 245 0.0 21 13.0 361 Middle 0.0 10 18.2 66 12.5 16 16.2 191 2003 Rich 0.0 3 .17.2 29 28.6 21 23.5 392 Total % 3.8 78 10.9 340 13.8 58 18.0 944 Poor 8.0 25 7.6 119 4.3 23 11.6 378 Middle 100.0 1 3.6 28 0.0 5 14.4 187 2008 Rich 0.0 1 5.0 20 9.1 11 21.6 379 Total % 11.1 27 6.6 167 5.1 39 16.2 944 Poor 5.9 34 21.1 246 4.2 24 21.4 691 Middle 0.0 6 15.1 152 0.0 7 25.0 268 2014 Rich 0.0 2 20.1 199 50.0 4 22.4 633 Total % 4.8 42 19.3 597 8.6 35 22.4 1592 Abbreviations: ANC= Antenatal care; PNC= Postnatal care; N= Number of postpartum women; % = percent using modern contraception Source: computed by author using the GDHS 2003, 2008, 2014 Datasets 2 [GDHS 2003 (χ =6.703; P-value=0.035)] 2 [GDHS 2008(χ =0.654; P-value=0.721)] 2 [GDHS 2014 (χ =14.460; P-value=0.001)] Results in Table 5.13 indicate a statistically significant relationship between use of modern contraceptives and antenatal and postnatal health care service utilisation while controlling for their household wealth quintile in 2003 and 2014. In 2003, there is high modern contraceptive use among women who indicated using both antenatal and postnatal health care services (13.0%) 94 University of Ghana http://ugspace.ug.edu.gh especially women who belong to the poor household wealth category. Again, high use of modern contraceptives was found among women who belong to the middle wealth quintile and utilised only antenatal health care services with a proportion of 18.2 per cent. Furthermore, women in the rich wealth quintile who used only postnatal health care services recorded a much higher modern contraceptive use compared to other categories. On the other hand, in 2014, higher use of modern contraceptives were found among women who used both antenatal and postnatal health care services compared to those who use only antenatal, only postnatal health care services and none regardless of their household wealth category. In sum, it was observed that even though antenatal and postnatal health care plays a role in modern contraceptive use among women, this use is higher among women residing in rich households and using both antenatal and postnatal health care services compared to those in poor households. This raises the issue of cost, thus having the ability to afford various modern contraceptive methods. This is especially the situation where women in rich households have increased use of modern contraceptives because they can easily afford it. In conclusion, throughout the analysis in this chapter the results clearly indicate higher contraceptive use among women who utilised both antenatal and postnatal health care services relative to those who used only antenatal health care services, only postnatal health care services and those who did not use these maternal health care services controlling for a majority of the socio-demographic characteristics analysed. This shows the essence of integrating contraception education into maternal and child health care delivery services. 95 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX INFLUENCE OF ANTENATAL AND POSTNATAL HEALTH CARE AND OTHER FACTORS ON CONTRACEPTIVE USE AMONG WOMEN IN GHANA 6.1 Introduction In the previous chapter (chapter five), trivariate analyses were conducted to examine the relationship between utilisation of antenatal, postnatal health care services, selected variables and modern contraceptive use among postpartum women in Ghana. There were statistically significant association between eleven of the variables and modern contraceptive use among postpartum in Ghana. However, a trivariate association between three variables does not necessarily imply a significant relationship between them, because in real life more than one independent variable operates to influence the dependent variable (Tabachnick & Fidell, 2007). It is, therefore, important to carry out a statistical analysis which incorporates more than one independent variable and intermediate variables at a time. The most suitable analytical technique is a multivariate analysis which allows the exploration of the effect of the main independent variable and other control variables on a dependent variable (Tabachnick & Fidell, 2007). In this study, a binary logistic regression model was used to determine the relationship between antenatal, postnatal and other factors with modern contraceptive use among postpartum women in Ghana. It is important to state that binary logistic models were developed based on data from the three Ghana Demographic and Health Survey years (2003, 2008 and 2014). Two different models were built: the first model comprises only the effect of the main independent variables (antenatal and postnatal health care services utilisation) on modern contraceptive use among 96 University of Ghana http://ugspace.ug.edu.gh postpartum women in Ghana. The second model, on the other hand, examines the association of all the variables (main independent and control variables) on the dependent variable. 6.2 Examining the relationship between utilisation of antenatal and postnatal health care services and modern contraceptive use among postpartum women in Ghana Table 6.1 presents the results from the binary regression model used to examine the association between the main independent variables (antenatal and postnatal health care utilisation) and modern contraceptive use. The modern contraceptive use variable was dichotomous with ‗1‘ representing postpartum women who used modern contraceptives after their last birth preceding the survey, and ‗0‘ representing postpartum women who did not use modern contraceptives after their last birth. Table.6.1: Results of Binary Logistic Regression showing the relationship between antenatal and postnatal health care utilisation on modern contraceptive use among postpartum women in Ghana, 2003, 2008 & 2014 2003 2008 2014 Variable OR[95%CI] OR[95%CI] OR[95%CI] Antenatal and Postnatal Visit None 0.19[0.06,0.59]** 0.61[0.18,2.10] 0.18[0.04-0.74]* Only ANC 0.54[0.37,0.80]** 0.37[0.19,0.69]** 0.82[0.65-1.04] Only PNC 0.71[0.33,1.54] 0.29[0.07, 1.18] 0.30[0.09-1.02] Both ANC & PNC (RC) 1.00 1.00 1.00 -2 Log Likelihood 1195.573 949.249 2312.807 Constant 0.22***1 0.19***1 0.29***1 Model % correct prediction 84.7 85.7 79.0 Chi-Square (df) 22.071(3) 16.051 (3) 16.177 (3) 2 Nagelkerke R 0.027 0.024 0.011 Observation 1,421 1,178 2,264 Note: ***= P value < 0.001; **= pvalue<0.01; * p value<0.05 (RC)=Reference Category; C.I=Confidence Interval Source: computed by author using the GDHS 2003, 2008 & 2014 97 University of Ghana http://ugspace.ug.edu.gh The general observation from the regression model in the three survey years (2003, 2008 and 2014) is that accessing only antenatal health care services as well as accessing none of these maternal health care services was significantly associated with the use of modern contraceptives among postpartum women. Specifically, there was a lower probability of modern contraceptive use among postpartum women who utilized only antenatal health care services in Ghana compared to women who accessed both antenatal and postnatal health care services. Again, women who reported using neither antenatal nor postnatal health care services have a lower likelihood of using modern contraceptives compared to women who accessed both antenatal and postnatal health care services. Another important finding this model reveals is that throughout the three surveys, accessing only postnatal health care services was not statistically significant in predicting modern contraceptive use among postpartum women in Ghana. Results from Table 6.1 suggest that in 2003, accessing only antenatal health care services were significant in understanding modern contraceptive use. Women who utilized only antenatal health care services were 46 per cent less likely to use modern contraceptives compared to postpartum women who did access both antenatal and postnatal health care services. The model produced a Nagelkerke R-square value of 0.027; suggesting that 2.7 per cent of the variation in modern contraceptive use is explained by the variables (antenatal and postnatal health care service utilisation) used in the model and 97.3 per cent of this variation is explained by other variables not included in the model. The model also correctly predicted 84.7 per cent of the changes in modern contraceptive use. Furthermore, women not accessing either antenatal or postnatal health care services have the lower odds (81%) less likelihood of using modern contraceptives. In 2008, women who utilised only antenatal health care services were 63 per cent less likely to use modern contraceptives compared to women who accessed both antenatal 98 University of Ghana http://ugspace.ug.edu.gh and postnatal health care services in Ghana. The model correct prediction was 85.7 per cent meaning that the model correctly predicted about 86 per cent of the changes in modern contraception among postpartum women in Ghana. On the other hand, the model showed that only 2.7 per cent of the variations in modern contraceptive use were explained by the utilisation of antenatal and postnatal health care services. Also, the results in Table 6.1 show that in 2014 accessing neither antenatal nor postnatal health care services was significant in predicting modern contraceptive use. Specifically, women who utilized none of these maternal health care services were 82 per cent less likely to use modern contraceptives compared to women who used both of these maternal health services. The model suggests that 1.1 per cent of the variation in modern contraceptive use among postpartum women was explained by the utilisation of antenatal and postnatal health care services. These findings are consistent with literature which showed that antenatal and postnatal service intensity was significant in predicting postpartum contraception in Kenya and Zambia (Do and Hotchkiss, 2013). A significant association was established between antenatal health care service utilisation and postpartum contraceptive use in Bangladesh. The study indicated that more than half (62.4%) of the total antenatal care seekers used modern contraceptive methods in Bangladesh (Tisha et al. 2015). There are two possible explanations for the strong association between antenatal and postnatal care and modern contraceptive use. First, education on contraception is considered an essential component of maternal health care; therefore women who utilize these services go through contraceptive counselling (Day et al. 2008). Secondly, integrating contraceptive counselling into routine antenatal and postnatal care gives women the chance to benefit from multiple counselling 99 University of Ghana http://ugspace.ug.edu.gh which improves the use of modern contraceptives among them (Adanikin et al. 2013). For instance, the qualitative results in this study clearly show users of both antenatal and postnatal health care services acknowledging the positive influence of contraceptive counselling on their contraceptive use. Here are some quotes from the qualitative interview that is consistent with this reasoning. Interviewer: “In your opinion, has the contraceptive counselling you received during antenatal visit influenced your contraceptive use?” Respondent: “Well, I will say yes because I have been reading about it before I got married but I will say the education here made me learn some new things about it and the right method to choose” (Respondent who used both antenatal and postnatal health care services). Interviewer: “Ok, in your opinion, has the contraceptive counselling you received during postnatal visit have influence on your contraceptive use?” Respondent: “I will say yes, I will say yes because I now understand how to use contraceptives correctly, also at first I use to fear a lot but after the education, I don‟t fear doing family planning” (Respondent who used both antenatal and postnatal health care services). The relationship between antenatal and postnatal utilisation and modern contraceptive use was clearly manifested from the qualitative results. The qualitative results show the influential role played by contraceptive counselling in the subsequent use of contraceptives among postpartum women in Ghana. The results also highlight the importance of utilising both antenatal and postnatal health care service and its implications on women‘s contraceptive behaviour. Thus, women‘s attendance at both antenatal and postnatal health care service creates a window of opportunity to receive continuous contraceptive education. This helps the women to better 100 University of Ghana http://ugspace.ug.edu.gh understand the importance of contraceptive use, how to use them correctly, their efficacy and reduces fear of side effects. The quantitative and qualitative findings of this study also highlight the relevance of the transfer theory in explaining antenatal, postnatal health care service and contraceptive use relationships. That is, the knowledge women get from antenatal and postnatal health care service uptake through education on contraception is transferred to actual use of contraceptives. The implication is that postpartum women not using antenatal and postnatal health care services are likely not to get additional information and education on contraceptives. 6.3 Relationship between utilisation of Antenatal, Postnatal Health Care Services and controlling for other factors on contraceptive use among postpartum women in Ghana In the previous section, a statistical relationship was established between utilisation of antenatal and postnatal health care services and use of modern contraceptives. This section attempts to examine the relationship between utilisation of antenatal and postnatal health services, modern contraceptive use and demographic, social and economic characteristics of postpartum women. However, it must be noted that the effect of the demographic, social and economic characteristics will be controlled for. Generally, it could be seen in Table 6.2 that after controlling for the demographic and socio- economic characteristics of the women, only in 2014 was antenatal and postnatal health care services significant in predicting modern contraceptive use. This underlines the influence of background characteristics on antenatal, postnatal health care services and modern contraceptive use. 101 University of Ghana http://ugspace.ug.edu.gh Again, results in Table 6.2 suggests that in 2003 only four (partner‘s educational level, place of residence, sexual activity, and sex of household head) out of the thirteen variables included in the model were statistically significant factors affecting modern contraceptive use among postpartum 2 women at the 0.05 significant level. The model produced a Nagelkerke R value of 0.257; suggesting that approximately 25.7 per cent of the variation in modern contraceptive use is explained by the variables entered in the model. On the other hand, 74.3 per cent of changes in modern contraceptive use among postpartum women in Ghana were explained by variables not included the model. It should also be noted that after the inclusion of the control variables in the model, antenatal and postnatal health care was no longer significant in affecting modern contraceptive use among postpartum women. This suggests that the demographic, social and economic characteristics are also important in affecting modern contraceptive use, thereby neutralizing the effect of antenatal and postnatal health care services on modern contraceptive use. Furthermore, results in 2003 indicate that postpartum women whose partners had no formal education were 40 per cent less likely to use modern contraceptives compared to postpartum women whose partners had secondary or tertiary education. Again, women who resided in urban areas had higher odds (1.91) of using modern contraceptives compared to those in the rural areas. The results from Table 6.2 show that postpartum women who were not sexually active in the last four weeks and are observing postpartum were 91 per cent less likely to use modern contraceptives compared to those who were sexually active in the last 4 weeks. Again, the odds ratio indicates that postpartum women who are not sexually active in the last 4 weeks and also not observing postpartum abstinence were 57 per cent less likely to have used modern contraceptives relative to the sexually active ones. This outcome is expected since ideally, 102 University of Ghana http://ugspace.ug.edu.gh women who are not sexually active and are amenorrheic will not be using contraceptives. Similar findings were reported by other studies especially in developing countries (Somba et al. 2014; Wamala et al.2015; Sok et al.2016). These studies found higher modern contraceptive use among sexually active married and unmarried women. It was also found that the use of pills was the commonest modern contraceptive method used among the married, while condom use was common among unmarried women who are sexually active. Lastly, the sex of household head was significant (p<0.05) in predicting modern contraceptive use among postpartum women in Ghana. From the results, postpartum women dwelling in male- headed households were 1.57 times as likely as to use modern contraceptives as those who dwell in female-headed households. The finding of this study is inconsistent with other studies which found higher contraceptive use among women dwelling in households headed by females (Wickrama, 1990; Adhikari and Podhista, 2010). The studies reported that women dwelling in female-headed households could easily talk to the female head about contraception and their sexual and reproductive health challenges. Again, female household heads better understand the importance of contraception and encourage women to use it. In summary, the results in 2003 indicate that partner‘s educational level, sexual activity, place of residence and sex of household head) were statistically significant in predicting modern contraceptive use among postpartum women at the 0.05 significance level. Again, after the inclusion of the control variables in the model, antenatal and postnatal health care was no longer significant in predicting modern contraceptive use among postpartum women. 103 University of Ghana http://ugspace.ug.edu.gh Table.6.2: Results of Binary Logistic Regression showing the relationship between antenatal, postnatal health care utilisation and other factors on modern contraceptive use among postpartum women in Ghana, 2003, 2008 & 2014 2003 2008 2014 Variables OR [95%CI] OR[95% C.I] OR [95% CI] Antenatal and Postnatal Visit None 0.39[0.11,1.33] 1.00[0.25,4.05] 0.13[0.03,0.56]** Only ANC 0.75[0.48,1.17] 0.50[0.25,1.00] 0.87[0.67,1.12] Only PNC 0.66[0.28,1.56] 0.36[0.08,1.55] 0.47[0.13,1.70] Both ANC & PNC(RC) 1.00 1.00 1.00 Maternal Age 15-29(RC) 1.00 1.00 1.00 30-39 0.89[0.57,1.37] 1.05[0.65,1.70] 0.58[0.43,0.77]*** 40-49 0.49[0.22,1.10] 1.40[0.58,3.40] 0.68[0.40,1.15] Maternal Education No education 0.71[0.44,1.15] 0.61[0.34,1.11] 0.72[0.49,1.04] Primary 1.03[0.69,1.53] 0.95[0.61,1.51] 1.26[0.93,1.71] Secondary+ (RC) 1.00 1.00 1.00 Partner’s Education No education 0.60[0.37,0.97]* 0.54[0.29,1.00]* 0.71[0.48,1.06] Primary 1.43[0.82,2.50] 1.62[0.88,3.01] 1.31[0.90,1.92] Secondary+(RC) 1.00 1.00 1.00 Parity 1-2 0.66[0.35,1.24] 1.13[0.52,2.46] 0.65[0.42,1.01] 3-4 0.73[0.44,1.22] 1.26[0.66,2.41] 1.20[0.83,1.74] 5+(RC) 1.00 1.00 1.00 Place of Residence Urban 1.91[1.20,3.06]** 0.88[0.55,1.41] 0.97[0.73;1.29] Rural (RC) 1.00 1.00 1.00 Ethnicity Akan 0.89[0.53,1.50] 0.54[0.29,0.97]* 1.34[0.91,1.96] Ga/Dangme 1.10[0.54,2.27] 0.60[0.23,1.56] 0.79[0.44,1.42] Ewe 1.06[0.57,1.98] 0.85[0.43,1.69] 1.37[0.88,2.14] Mole-Dagbani 1.32[0.69,2.53] 0.73[0.37,1.46] 1.22[0.82,1.83] Gruma (RC) 1.00 1.00 1.00 Current Marital Status Never Married 0.43[0.12,1.59] 0.98[0.14,6.88] 0.64[0.30,1.37] Currently Married 0.50[0.21,1.21] 1.77[0.34,9.24] 0.44[0.24,0.80]** Formerly Married (RC) 1.00 1.00 1.00 Fertility Intention Have Another 0.91[0.59,1.41] 0.64[0.40,1.02] 1.08[0.80,1.45] Undecided 1.38[0.48,3.94] 0.16[0.03,0.75]* 0.54[0.37,0.85]** No more(RC) 1.00 1.00 1.00 Sexual Activity 104 University of Ghana http://ugspace.ug.edu.gh Active last 4 weeks (RC) 1.00 1.00 1.00 Not active postpartum abst 0.09[0.06,0.15]*** 0.07[0.04,0.14]*** 0.12[0.09,0.17]*** Not sexually active & no 0.43[0.27,0.68]*** 0.44[0.28,0.71]*** 0.76[0.57,1.00]* postpartum abst Exposure to FP info in the media No (RC) 1.00 1.00 1.00 Yes 1.07[0.73,1.57] 1.00[0.65,1.53] 0.78[0.61,1.00] Sex of Household Head Male 1.57[1.01,2. 40]* 0.93[0.58,1.51] 1.17[0.85,1. 60] Female (RC) 1.00 1.00 1.00 Wealth Quintile Poor 0.99[0.57,1.71] 0.69[0.39,1.23] 1.10[0.76,1.59] Middle 1.13[0.68,1.87] 0.79[0.45,1.40] 0.97[0.69,1.38] Rich (RC) 1.00 1.00 1.00 -2 Log Likelihood 990.159 777.979 2021.841 Model % correct prediction 85.5 86.0 79.6 Chi-square (df) 227.485 (26) 187.322 (26) 307.143 (26) 2 Nagelkerke R 0.257 0.263 0.197 Constant 0.85 0.68 1.20 Observation 1,421 1,178 2,264 Note: ***= P value < 0.001; **= pvalue<0.01; * p value<0.05 (RC)=Reference Category; C.I=Confidence Interval Source: computed by author using the GDHS 2003, 2008 & 2014 Results in 2008 suggest that out of the thirteen variables included in the model, only four (partners education, ethnicity, fertility intention, and sexual activity) were significant in 2 predicting modern contraceptive use. The model produced a Nagelkerke R value of 0.263; suggesting that 26.3 per cent of the variations in modern contraceptive use are explained by the variables entered in the model. The model also correctly predicted 86 per cent of the changes in the dependent variable. Again, the results indicate that women whose partners had no formal education were 46 per cent less likely to use modern contraceptives compared to women whose partners had secondary or higher education. This outcome is expected considering the fact that men with higher educational level would have better understanding of contraceptives and be more receptive towards the use 105 University of Ghana http://ugspace.ug.edu.gh of modern contraceptives. The results further showed that Akan women had a lower likelihood (46%) of using modern contraceptives compared to postpartum women who belong to the Gruma ethnic group. Further, fertility intention of postpartum women was significant in predicting modern contraceptive use among them in Ghana. In 2008, the results show that postpartum women who were undecided on their fertility had a lower probability of using modern contraceptives compared to women who did not want to have any children. That is, postpartum women who are undecided on their fertility intention were 84 per cent less likely to use modern contraceptives relative to those whose fertility intention is to have no more children. The finding of this study is consistent with the findings of other studies which have shown fertility intention as an important predictor of modern contraceptive use (Campbell & Campbell, 1997; Bankole & Singh, 1998; Islam & Bairagi, 2003; Roy et al. 2003; Agadjanian, 2005). These studies reported that women who desire more children do not intend to use a modern contraceptive method. Lastly, in 2008, the results indicated that postpartum women who are not sexually active in the last 4 weeks and are observing postpartum abstinence were 93 per cent less likely to use modern contraceptives compared to sexually active postpartum women. On the other hand, sexually inactive postpartum women who are also not observing postpartum abstinence were approximately 56 per cent less likely to use modern contraception compared to sexually active postpartum women. The general observation of the results in 2014 suggest that out of the thirteen variables included in the model, five (antenatal and postnatal health care, maternal age, marital status, fertility intention, and sexual activity) were significant in predicting modern contraceptive use. The 2 model produced a Nagelkerke R of 0.197; suggesting that 19.7 per cent of the variations in modern contraceptive use is explained by the variables entered in the model. 106 University of Ghana http://ugspace.ug.edu.gh Furthermore, the results showed that compared to postpartum women who utilised both antenatal and postnatal health care services, the probability of using modern contraceptives is lower (87%) among postpartum women who accessed neither antenatal health care services nor postnatal health care services. Also, the results indicate a significantly inverse relationship between current age of postpartum women and modern contraceptive use. Thus, as the age of a woman increases the prevalence rate of contraception also decreases. For instance, the odds ratios show that compared to postpartum women within 15-29 years, the likelihood of not using modern contraception is 42 per cent lower among women within the age groups 30-39 years. This statistically significant relationship is consistent with the findings of other studies on age and modern contraceptive use among women (Gupta et al., 2003; Mawajdeh, 2007; Bbaale and Mpugu, 2011; Tisha et al., 2015). According to these studies, modern contraception is mostly prevalent among postpartum women within their 20s and 30s; and that the prevalence decreases drastically beyond 40 years. The reasons for this phenomenon are well documented in literature. Thus, age is used to make the claim that younger women are more dynamic and may be more willing to use modern contraceptives compared to older women. Also, most of these women had reached the older menopause, stopped bearing children and will have little or no need for modern contraceptives. Again, older women (40 years and over) may perceive to have a lower risk of pregnancy due to less frequent sexual activity or lower fecundity. Other studies, however, found no significant relationship between maternal age and modern contraception among women (Agampodi et al., 2009; Mahmood et al., 2011) Marital status was also significant (P<0.05) in predicting modern contraceptive use among postpartum women in Ghana only in 2014. From the results, postpartum women who are currently married were 56 per cent less likely to use modern contraceptive compared to 107 University of Ghana http://ugspace.ug.edu.gh postpartum women who were formerly married (separated, divorced and widowed). This is consistent with other studies on marital status and modern contraceptive use (Ross and Winfery, 2001; Smith et al. 2002; Smith et al. 2009). These studies found that married women often feel societal pressure to give birth to children, so they do not seek family planning services. Further, many married women prefer to delay, space or limit their birth but are currently not using any modern contraceptive methods to achieve that. Again these studies have argued that married women depend highly on the approval of their spouses on modern contraceptives before they use them. On the other hand, non-married women may not seek any approval from their partners in matters concerning modern contraceptive use. However, other studies have found contrasting results, for instance, a study by Hertrich (2017) reported that single women are less likely than their married counterparts to have easy access to and use modern contraceptives. Another study by Anasel and Mlinga (2014) found higher modern contraceptive use among unmarried women who are sexually active compared to their married counterparts. Also, in 2014 the odds ratio indicates that postpartum women who were not sexually active in the last 4 weeks and observing postpartum abstinence were 87 per cent less likely to use modern contraceptives relative to postpartum women who were sexually active in the last 4 weeks. However, other studies have reported that there is early resumption of sexual activity among postpartum women after birth without the use of any modern contraceptive methods (Ndugwa et al. 2011; Borda et al. 2011; Lathrop et al. 2011). In summary, the inclusion of the background characteristics of women‘s background characteristics in the regression model neutralized the effects of antenatal and postnatal health care service utilisation on modern contraceptive use in 2003 and 2008. However, in 2014, using 108 University of Ghana http://ugspace.ug.edu.gh neither antenatal nor postnatal health care services highly predicted use of modern contraceptives among postpartum women even with the inclusion of their background characteristics. Within the Ghanaian context, the results show that the relationship between antenatal and postnatal health care service and modern contraceptive use is highly influenced by women‘s demographic and socio-economic characteristics. In the three survey years, factors such as place of residence, fertility intention, marital status and sexual activity, ethnicity, sex of household head, current age of women and their level of education of their partners were strong predicted of modern contraceptive use. This outcome emphasizes the importance of the theory of triadic influence in health behaviour which examines the three (distal, proximate and ultimate) levels of influence on health behaviour. 109 University of Ghana http://ugspace.ug.edu.gh CHAPTER SEVEN CONTRACEPTIVE INFORMATION POSTPARTUM WOMEN RECEIVE DURING ANTENATAL AND POSTNATAL HEALTH CARE SERVICE 7.1 Introduction Counselling is an essential part of antenatal and postnatal health care services provision. Contraceptive counselling during postpartum creates the platform to discuss contraception and issues on family planning among patients and health service providers. For counselling to be effective, place/location of contraceptive counselling and the quality of information received all play significant roles. Thus, women who received contraceptive information at the hospital were more likely to have received quality information and were highly satisfied compared to women who received it outside the health facility (Dehlendorf et al., 2014; Purcell et al., 2016). Also, their study found that facility-based counselling on contraceptives was highly associated with contraceptive use (Dehlendorf et al., 2014). Further, providing counselling on contraceptives during antenatal and postnatal health care services is essential in bringing about positive reproductive health outcomes, preventing pregnancy complications, and increasing use of contraceptives (Hernandez et al. 2012; Lee et al. 2011). This chapter, therefore, explores contraceptive information women receive during antenatal and postnatal health care services. 110 University of Ghana http://ugspace.ug.edu.gh 7.2 Components of contraceptive information during antenatal and postnatal health care services This section discusses the various components of contraceptive counselling that users of antenatal and postnatal health care service receive. This consists of contents of the counselling, frequency of contraceptive counselling and materials used during counselling sessions. Figure 7.1 shows the thematic network of the analysis. The contents of contraceptive counselling basically cover what is contained in the contraceptive/ family planning messages and advice given to pregnant and postpartum women during antenatal and postnatal health care delivery. Again, the frequency of contraceptive counselling involves the number of times contraceptive counselling is offered to postpartum women upon their visit to antenatal and postnatal health centres. 111 University of Ghana http://ugspace.ug.edu.gh Figure 7.1: Thematic network on components of contraceptive counselling Short-acting methods Rarely (ANC/PNC (Jadelle, pill, injectables, visits) condoms) Prevent unplanned pregnancy Good child Good Child Prevents pr actices spacing Frequency of Very often STIs contraceptive (ANC/PNC co unselling visits) Con tent s of contraceptive CONTRACEPTIVE Good counselling COUNSELLING child Sometimes health (A NC/ PNC visits) Good maternal health Materials used during Papers and counselling documents Reduce risk of short pregnancy Fliers Global theme intervals Pictures No Organising theme materials Long acting methods Basic theme ( I U D , n o r p l a n t , implants, female s t e r i l i s a t i o n Source: Field work, 2017 112 University of Ghana http://ugspace.ug.edu.gh 7.2.1 Contents of Contraceptive Counselling Relating to the theme on contents of contraceptive counselling, nine contents were mentioned by the participants both at the antenatal and postnatal health care units. These were ‗prevention of unplanned pregnancy‘– which was mentioned by ten participants (four from the antenatal unit and six from the postnatal unit); ‗prevents STIs‘–mentioned by three participants (two from the antenatal unit and one from the postnatal unit). The other contents mentioned were long-acting and short-acting contraceptive methods, good child spacing and child care practices, ensuring good maternal health and reducing the risk of short pregnancy intervals. Further, prevention of unplanned pregnancy and the reduction of risk associated with short pregnancy intervals were the dominant basic themes identified in the analysis. The participants indicated that they were counselled that using contraceptives after birth will help prevent any unwanted/unplanned pregnancy. Others also mentioned that they were told that getting pregnant in quick succession is dangerous and using contraceptives is a sure way to avoiding that risk. During the interview, some participants stated the information they received when they were given counselling on contraception. “Oooh, errr they tell us that using contraceptive is good and it will help us to avoid unwanted pregnancies and problems that come with pregnancies” (Respondent who used both antenatal and postnatal health care services). “What they tell us is to do family planning; they tell us to take care of yourself to avoid unwanted pregnancy and some measures you should take to avoid unplanned pregnancies” (Respondent who used only antenatal health care services). “When we use them [contraceptives] it helps us to prevent unwanted pregnancy and it is good for our health” (Respondent who used only postnatal health care services). “I remember they said condom can prevent both pregnancy and STI and pills can only prevent pregnancy” (Respondent who used both antenatal and postnatal health care services). 113 University of Ghana http://ugspace.ug.edu.gh Another content of contraceptive counselling that was mentioned was long acting and short acting methods of modern contraception. During the in-depth interviews, the respondents mentioned various types of modern contraceptives that were usually discussed with them during contraceptive sessions. They mentioned that counsellors talked to them about condoms, intrauterine device (IUD), pills, injectables, implants, female sterilization, and norplants. They also stated that education is given on how to use these contraceptive methods and the duration of use. The following quotes from the qualitative interviews tend support to this: “We have different types, some are injectables, others are inserted into your private part and in your arm and we also have condoms. They also talk to us about the jadelle, and the pill. I also know we have some methods you can use for 6 months and others for 5 years” (Respondent who used only antenatal health care services). “Eiiii, mmmm, she told us about condoms, the pill, and the one that you take injections and also the one they will put into our private part and arm. She also said you can use some of them for long period like 6 months to 2 years, and others too for a short period like 2 months, that is all I can remember” (Respondent who used both antenatal and postnatal health care services). The third content found during the interview was good child spacing and child care practices. The respondents reported that they were told using contraceptives ensures good spacing of children since they are not likely to get pregnant soon after birth. They also mentioned that you have enough time to take good and proper care of your child since you don‘t have to worry about pregnancy again. “They tell us we will have time to take care of our babies because we don‟t have to worry about pregnancy” (Respondent who used only postnatal health care services). “They educate us on contraceptives. it helps us and we will know how to at least space the children” (Respondent who used only antenatal health care services). “Yes, so that after birth, you can space your child, and you will have knowledge about not giving birth to unplanned children” (Respondent who used only antenatal health care services). 114 University of Ghana http://ugspace.ug.edu.gh The other contents of contraceptive counselling identified were prevention of sexually transmitted infections (STIs), ensuring good maternal and child health. Some respondents noted that the counsellors stressed the importance of using contraceptives to prevent the risk of getting infected with sexually transmitted infections and also indirectly to ensure both mother and child are healthy. “They tell us about the contraceptives that it helps prevent STIs, and to delay the pregnancy and is good for the health of the mother and the babies” (Respondent who used both antenatal and postnatal health care services). “I also remember they told us that some contraceptives help in preventing sexually transmitted infection” (Respondent who used both antenatal and postnatal health care services). “They tell us it [contraceptives] is good for our health and make our babies too healthy, it can make your baby grow healthy, and you have time for your baby” (Respondent who used only postnatal health care services). 7.2.2 Frequency of contraceptive counselling With regard to the theme on the frequency of contraceptive counselling during antenatal and postnatal health care service delivery, three basic themes were mentioned by the respondents. These were ‗rarely‘, ‗sometimes‘ and ‗very often‘. That is, the number of times women have received contraceptive counselling from their previous to their current antenatal and postnatal health care use. It is also important to note that contraceptive counselling is done in group sessions during the provision of antenatal and postnatal health care services. Further, this contraceptive counselling session is not done in isolation but along with other sessions such as nutrition, personal hygiene and pregnancy and child care practices. 115 University of Ghana http://ugspace.ug.edu.gh Women who mentioned that they received contraceptive counselling ―rarely‖ during antenatal and postnatal visits was one of the basic themes identified. This means that they have received contraceptive education only once in their antenatal and postnatal health care use. They said that the midwife had told them about things other than contraception. This theme appeared in three narratives of the in-depth interviews conducted. “Oooh no, I don‟t, sometimes when I come for antenatal they talk to us about other things like the things we will go through during pregnancy and how to deal with them, it is not every time that they talk to us about contraceptives” (Antenatal health care user). “Oooh no, like I said before, only once and it was an NGO which came and talked to us about it” (Antenatal health care user). “Mmmm, they talked to us about it only once as far as I can remember” (Postnatal health care user). The second theme identified is women who mentioned they received contraceptive information ―sometimes‖. This involves women receiving education on contraceptive two times during their visit to antenatal and postnatal health centres; however they said that they need more education on contraceptives. This was the most dominant basic theme which appeared in nine narratives of the interview. “Errrh, no please, but I remember during my first pregnancy and I came for antenatal, they talked to us two times” (Respondent who used only antenatal health care services). “Oooh, since I started coming here, this is the second time they talk to us about it, but I think they have to talked to us more about it” Respondent who used only post natal health care services). “Oooh, since I came here for check-ups, this is the second time they have talked to us about it” (Respondent who used only postnatal health care services). 116 University of Ghana http://ugspace.ug.edu.gh Another theme found in the analysis is women who indicated that they receive contraceptive information ―very often‖ any time they utilise antenatal and postnatal health care services. Thus, women said that they received contraceptive advice from midwives three or more times during their visit to antenatal and postnatal health centres. “Every time I come to antenatal they talk to us about it” (Respondent who used only antenatal health care services). “Errr, this is the third time, they talk about it, sometimes when we come here, they only talk about the food we have to eat, how to take care of ourselves and the other things” (Respondent who used both antenatal and postnatal health care services) “Mmmm, this is the third time they have talked to us about it” (Respondent who used both antenatal and postnatal health care services). 7.2.3 Materials used during contraceptive counselling Concerning the theme on materials used to educate women on contraceptives during antenatal and postnatal health care service provision, four basic themes were identified in the analysis. These are ‗leaflets‘, ‗papers and documents, ‗pictures‘ and ‗no materials‘. Most of the women reported that no materials were specifically used when providing them with information on contraceptives. In other words, the respondents mentioned that during contraceptive counselling sessions, the midwives/counsellors do not use any materials when educating them on contraceptives. They just give them group talks on family planning without referring to any books and documents. “Errr, they did not use any books, the nurse just comes and talks to us, and when we don‟t understand anything we ask questions” (Respondent who used both antenatal and postnatal health care services). “They just talk to us; they did not use any materials in educating us about contraceptives” (Respondent who used only antenatal health care services). 117 University of Ghana http://ugspace.ug.edu.gh “Errr, they don‟t use any material, the nurse just talks to us‖ (Respondent who used only postnatal health care services). Others also said that during the group session on contraceptives, the midwives usually show them pictures of the various types of modern contraceptives and how they are used. Thus, pictures of methods like the pill, injectables, IUD, female sterilisation, condoms, and implants are shown to them during counselling sessions as well as how to effectively use them. They, however, mentioned that the pictures are not always used during contraceptive counselling sessions. “Errrh, I remember they showed us some pictures of contraceptive methods, but at other times they use nothing, they just talk to us” (Respondent who used only antenatal health care services). “Errrh, sometimes they show us pictures and at other times they use nothing, they just talk to us” (Respondent who used only antenatal health care services). “Mmmm, she has shown us some pictures of the family planning and how we can use it, yes she shows us pictures” (Respondent who used only postnatal health care services). “Errr, yea, I remember, they gave us some papers with pictures of the family planning methods on it and they were telling us how to use them” (Respondent who used only antenatal health care services). Another basic theme under materials used during contraceptive counselling sessions at antenatal and postnatal health centres is the use of leaflets/fliers. This was mentioned by only one respondent during the in-depth interview. This happened when a non-governmental organisation came and talked to them about contraceptives and shared leaflets/fliers to them to read. This suggests that during contraceptive group counselling sessions at antenatal and postnatal health centres, leaflets/fliers are not often used in educating women on contraception. 118 University of Ghana http://ugspace.ug.edu.gh “Oooh, the people who came to educate us were from an NGO, they brought some materials with the methods and their pictures, I even have it in my bag [Respondent shows interviewer the material-leaflet/flier,]” (Respondent who used both antenatal and postnatal health care services). Last but not least is the use of papers and documents as materials for contraceptive counselling during antenatal and postnatal health care provision. The respondents mentioned that sometimes midwives/nurses use papers and other documents when talking to them about contraceptives. Thus, the papers serve as a guide to them in educating them on contraceptives. “They only hold documents and papers when teaching us about contraceptives” (Respondent who used both antenatal and postnatal health care services). “They only hold a book when they talk to us about it [contraceptives]” (Respondent who used both antenatal and postnatal health care services). The content of contraceptive counselling antenatal and postnatal health care users receive includes but not limited to types of modern contraceptives, duration of use and benefits of contraceptives. For instance, respondents mentioned both long-and short-acting methods such as the pill, IUD, condoms, injectables, female sterilisation and implants. They also said that the purpose and the effectiveness of these modern contraceptive methods were discussed with them by midwives during group counselling sessions. This probably suggests that counselling pregnant and postpartum women on the various types of contraceptive methods is essential for making good reproductive health decision and increasing control over their sexual and reproductive health. This helps these women to build on their existing knowledge on types of contraceptive methods, the specific purpose they serve and their efficacy. It also offers them the opportunity to ask questions and seek clarification on some misconceptions they might have 119 University of Ghana http://ugspace.ug.edu.gh concerning the method types. Again, group counselling on types of contraceptive methods offer women the opportunity to share experiences and learn from others‘ experiences as far as contraception is concerned. Duration of contraceptive use was another content of the counselling they received when using the maternal health care services. They mentioned that some contraceptive methods can be used for a long periods of time for example two years, while other methods can be used for a short period for example two months. It was revealed from the interviews that these contraceptive counselling sessions do not take place very often. The women mentioned that they receive much more education in other modules (personal hygiene, best child care practices, nutrition and pregnancy care precaution) when they use antenatal and postnatal health care services relative to education on contraception. It is important to note that receiving counselling on the duration of efficacy of contraceptive methods is critical in women deciding to limit births, stop child bearing and other fertility decisions. Studies have indicated that duration of a method use largely influences the family planning and sexual and reproductive health decisions women take (Creel et al., 2002; Huda et al. 2014; Gosavi et al., 2016). For instance, a study by Huda et al, (2014) in Bangladesh found that women chose the norplant contraceptive method because of its longer duration (5 years) of use and effectiveness it has. Another study by Creel et al. (2002) in Indonesia, also established that women opted for long-acting methods like the norplants after they have received counselling on the methods and were more satisfied with the method. Further, the direct and indirect benefits of contraceptive use were part of the counselling they received. These benefits positively affect the health of the newborns and their mothers by ensuring good child spacing, reduce risk of short pregnancy intervals, prevents unplanned pregnancies, prevents risk of contracting sexually transmitted infections as well as ensuring 120 University of Ghana http://ugspace.ug.edu.gh good maternal and child health. Other studies have highlighted the importance of giving family planning counselling to women during pregnancy and postpartum periods (Bianchi-Demicheli et al., 2006; Ott & Sucato, 2014; Karra et al. 2017). A study by Karra et al. (2017) in Sri Lanka indicated that during antenatal health care use, midwives and other health personnel educate pregnant women on risks and benefits of using contraceptives after birth. Again, an in-depth interview conducted by Bianchi-Demicheli et al. (2006) in Switzerland revealed that the general benefits of contraception, according to the respondents were spacing births, avoiding unplanned pregnancy and protection from sexually transmitted infections. The findings in this study support the assertions and outcomes from these other studies that have been described above. It must, however, be pointed out that, the respondents did not mention any form of risk/side effects of contraceptives as part of the counselling they receive during antenatal and postnatal health care use. Another important outcome from the interview is the kinds of materials midwives/counsellors use during group counselling sessions. The dominant issue that emerged from the interview (for both antenatal and postnatal health care users) was the fact that during the group sessions on contraception, most of the midwives/counsellors do not use any form of materials as reference. However, pictures and info-graphics of various modern contraceptive methods are sometimes showed to them during these group sessions. Studies on contraceptive counselling have established that using materials such as counselling guide/manual, flipcharts, leaflets, drawing, audio, visuals, and info-graphics determines the quality of counselling clients receive (Langston et al. 2010; Johnson et al. 2010; Farrokh-Eslamlou et al. 2014; Inal et al. 2017). These studies have argued that the use of these materials as part of the counselling process has some merit in ensuring the provision of quality contraceptive counselling. Thus, it allows clients to visualise 121 University of Ghana http://ugspace.ug.edu.gh and hear the contraceptive information in order to make informed decisions that meet their sexual and reproductive health needs. The use of materials during counselling also enables clients to receive well organised information on the efficacy, use and possible risk of the contraceptive methods. This study, however, found that most of the counselling sessions lacked the use of relevant materials. This seems to suggest that the provision of effective counselling on contraception during antenatal and postnatal health care might be undermined. This may also negatively affect how these women understand contraceptives and how to effectively use them. To conclude, the qualitative results of this study have provided insight into the contraceptive counselling (the contents, the frequency and the materials used) postpartum women receive during antenatal and postnatal health care attendance. More specifically, the study findings indicated that women are educated on the direct and indirect benefits of using modern contraceptives, the number of times women receive counselling as well as the materials used during antenatal and postnatal health care use. 122 University of Ghana http://ugspace.ug.edu.gh CHAPTER EIGHT DIFFERENCES AND SIMILARITIES IN CONTRACEPTIVE COUNSELLING GIVEN TO POSTPARTUM WOMEN DURING ANTENATAL AND POSTNATAL HEALTH CARE SERVICES 8.1 Introduction This chapter assesses the differences and similarities associated with contraceptive counselling given to women using antenatal health care services as well as postnatal health care services. More specifically, this chapter discusses whether there are elements of ‗conflict‘ (meaning if there are differences or contradictions with regard to contraceptive counselling among antenatal and postnatal women) and of ‗consensus‘ (meaning if there are similarities in the views of respondents concerning contraceptive counselling given during antenatal and postnatal health care). Also, the elements of ‗absence‘ (meaning if there are any well-known issues concerning contraceptive counselling that was conspicuously missing in the interviews) were discussed. Furthermore, a number of studies have argued that providing contraceptive counselling during antenatal health care is more appropriate relative to postnatal health care. The reason is that women using postnatal health care services are more concerned about their new borns; therefore issues on contraception will be the last thing on their minds (Smith et al. 2003; Akinlo et al. 2014). This chapter, therefore, contributes to this knowledge by assessing the differences and similarities in the contents, frequency and materials used during contraceptive counselling sessions at antenatal and postnatal health care service provision. 123 University of Ghana http://ugspace.ug.edu.gh 8.2 Similarities and Differences in contraceptive counselling during antenatal and postnatal health care service provision This section deals with the similarities and differences in the views of women using antenatal and postnatal health care services. Thus, the similarities and differences in the contents of the contraceptive counselling, how often the counselling takes place and the materials used during the counselling sessions. There are three different schools of thought when it comes to offering contraceptive counselling during antenatal and postnatal health care services. The first school of thought asserts that antenatal period is the most appropriate setting for contraceptive/ family planning counselling to be given relative to the postnatal period (Smith et al. 2002; Akinlo et al. 2014; Mengesha et al. 2015; Moore et al. 2015). Scholars further argue that the antenatal period creates a time when counselling about permanent methods of contraception if the woman or couple does not desire any future pregnancies. Also, this period also offers the opportunity to engage husband/male partners in contraceptive/ family planning discussion (WHO, 2006; WHO, 2010b). Again, women during the postnatal period are more concerned about their newborns and, therefore, their concentration is on how to take good care of their babies, hence offering contraceptive counselling during that period is not appropriate (Adanikin et al., 2013). The second school of thought, however, argues that the postnatal period is the most appropriate period for contraceptive counselling. In this period, a woman is exposed to the risk of unintended pregnancy if she is not using any form of contraception, inconsistent or incorrect use of contraceptive methods and discontinuation of contraceptives due to bad experiences (Koblinsky, 2005; Do & Hotchkiss, 2013; Speizer et al. 2013). This unintended pregnancy is highly associated with postpartum depression during and after pregnancy, poor maternal and child 124 University of Ghana http://ugspace.ug.edu.gh health and poor relationship between mother and child (Gipson et al. 2008). PNC is also an appropriate setting where women are counselled on the importance of spacing births through the use of contraceptives (WHO, 2010b, WHO 2014). The last school of thought is of the view that both antenatal and postnatal periods are appropriate for contraceptive counselling to be given to women. It further argues that offering contraceptive counselling for women at many points of contact in the health system assists these women to make informed contraceptive decisions (Kerber et al., 2007; Owili et al. 2017; Iqbal et al., 2017). It is based on this background information that an examination of the differences and similarities in the contents, frequency and materials used during contraceptive counselling at antenatal and postnatal health care services is being done. Figure 8.1 illustrates the similar and diverse views shared by both antenatal and postnatal health care service users on contraceptive counselling. 125 University of Ghana http://ugspace.ug.edu.gh Figure 8.1: Thematic network on similarities and difference in contraceptive counselling Good Child spacing Short-acting Rarely (ANC/PNC methods visits) Prevent unplanned pregnancy Side Effects Good child Prevents pr actices Frequency of Very often STIs contraceptive (ANC/PNC co unselling visits) Con tent s of contraceptive CONTRACEPTIVE Good counselling COUNSELLING child Sometimes health (A NC/ PNC visits) Good maternal Materials used during health counselling Papers and Reduce risk of documents short pregnancy Consensus intervals No Pictures Conflicts Leaflets Long acting materials Absence m e t h o d s Source: Field work, 2017 126 University of Ghana http://ugspace.ug.edu.gh 8.2.1 The Concept of Consensus Despite the fact that contraceptive use may not be the immediate need for women during the antenatal and postnatal period, provision of contraceptive counselling sessions is critical to women‘s sexual and reproductive wellbeing. Studies have found that programmes encouraging contraceptive counselling during antenatal and postnatal health care services are essential in improving women‘s behaviour towards contraception and prevention of unplanned pregnancies (Hernandez et al. 2012; Lee et al. 2011). In this regard, this study discusses ‗consensus‘ or similarity in views among antenatal and postnatal health care users on the component of the contraceptive counselling they receive. In other words, both antenatal and postnatal health care users shared similar views on the contents of the counselling they receive, the materials used during the counselling sessions and the frequency in which the counselling is provided. These views were shared on the benefits of using modern contraceptives comprising ensuring good child spacing, good child practices, preventing unplanned pregnancy and good ensuring maternal health. Others were on the number of times contraceptive counselling has been given during their visit to antenatal and postnatal health clinics and also the material used during the counselling sessions. Most of the participants both in the antenatal and postnatal health care had a consensus that they ‗rarely‘ receive contraceptive education and also in most cases, materials (visuals, audio, flipcharts, and leaflets) are not used when educating them on contraceptives. Here are some quotes that showed „consensus‟ in the views of antenatal and postnatal health care users concerning the benefits of using contraceptives. “Oooh they just told us, we have to do family planning because it will help us, it will help us not to get pregnant early, so that we have time and take care of our children well” Respondent who used only antenatal health care services). 127 University of Ghana http://ugspace.ug.edu.gh “Oooh, err they tell us that using contraceptive is good and it will help us to avoid unwanted pregnancies and problems that come with pregnancies. They also said err, this will help us to take good care of our babies, we will have time to feed our babies” (Respondent who used only postnatal health care services). The dominance of the consensus views shared by both the antenatal and postnatal health care users could be explained by some structural factors and circumstances the researcher found on the field. The organisation and procedures for providing antenatal and postnatal health care service at health facilities could be the reason for the similar views shared by antenatal and postnatal health care users on contraceptive counselling. These antenatal and postnatal health care services usually begin very early in the morning and some of the women arrive late and often miss the opportunity to be educated on contraception. Further, the counselling session is often done in a group session where antenatal and postnatal health care users are combined into one group. In other words, there are no separations between antenatal and postnatal health care users during contraceptive counselling sessions. This clearly manifests the similarities in the views on the content, frequency and materials used during contraceptive education sessions. It is also important to state that there are no known contraceptive counselling guidance and intervention procedure tool developed in Ghana for providing education on contraception at antenatal and postnatal health care centres. However, there are international standards that stipulate guidelines for conducting family planning counselling. Within the framework of Integrating Family Planning Services into Essential Health Packages, the World Health Organisation (2005) provided some guidelines and general principles of counselling in the Decision making tool for Family Planning clients and providers. These guidelines basically talk about two main approaches in conducting family planning counselling. These include the BRAIDED and GATHER approaches. The BRAIDED approach basically involves counselling the clients on the benefits of contraceptive methods, risks of the methods, alternatives to the 128 University of Ghana http://ugspace.ug.edu.gh methods, inquiries about that method, decision to withdraw from using that method and the explanation of the chosen method as well as the documentation of the session for record purposes. On the other hand, the GATHER approach also talked about greeting the clients in a respectful way, asking the clients how you can help them, telling the clients about family planning methods, helping the clients to choose a method, explaining to the clients how to use a method as well as returning for a follow up visit. The use of these approaches is often not adopted during counselling session within the context of antenatal and postnatal health care service provision. Furthermore, during antenatal and postnatal health care service delivery, education on contraceptives is not often provided or given as a separate or standalone session. Rather, comprehensive education is given on nutrition, personal hygienic practices, physical exercise breastfeeding and lactation practices and child care practices. To conclude, these reasons demonstrate clearly why antenatal and postnatal health care users shared similar views on the education they receive on modern contraceptives. 8.2.2 The Concept of Absence Discussion of potential side effects is regarded as a critical part of the process of offering counselling on contraception. This is because virtually every modern method of contraception is considered to have a potential side effect. While some side effects of contraceptives can lead a woman to discontinue the method, other side effects are mild and may disappear with time. It is therefore appropriate to educate women carefully on the possible side effects of contraceptive use. Some of the common side effects include irregularities in menstrual cycles, excessive bleeding, nausea, vomiting, breast tenderness, headaches and weight gain. This study, however found that among the antenatal and postnatal health care users, there was 129 University of Ghana http://ugspace.ug.edu.gh ‗absence‘ of education on the side effects of contraceptive methods and how to deal with them. The absence of discussion on side effects during antenatal and postnatal health care service utilisation has negative implications on contraceptive behaviour of women. These implications are discontinuation of methods, increased misconceptions and myths about modern contraceptives. All these expose postpartum women to risk of unplanned pregnancies and short pregnancy intervals which negatively affect their wellbeing. Furthermore, a number of studies have found that, the side effects of some contraceptive methods came as a result of contraindications, that is, some pre-existing health conditions that predisposes and make women susceptible to side effects (Shortridge & Miller, 2006; Grossman et al. 2011; White et al. 2012; Xu et al. 2014). Xu et al. (2014) indicated that women with pre- existing health condition such as hypertension, cancer and unhealthy lifestyle such as smoking were at higher risk of suffering from side effects if they adopt a family planning method. Therefore, providing education on the side effects of contraceptives will allay the fears of these women, give them better understanding of modern contraceptive methods and help them to make informed choices. In conclusion, this qualitative finding could also be an explanation to the issue of postpartum women being exposed to contraceptive counselling during the uptake of antenatal and postnatal health care services but this does not always reflect in their use of modern contraceptives. Thus, inadequate education on the possible side effects of contraception makes women reluctant to adopt family planning methods because they lack the understanding about issues on family planning. 130 University of Ghana http://ugspace.ug.edu.gh 8.2.3 The Concept of Conflict The concept of conflict in this analysis looked at the differences in the counselling session during antenatal and postnatal health care centres. These differences in views were realised on the opinions shared on the benefits of using modern contraceptives. While some women were of the view that using modern contraceptive after child birth will ensure good health status of the child, others shared contrary opinion. Here are some quotes to support the assertion “Errrm, I know very well that when you use contraceptives, it will help prevent you from getting pregnant early, so you will have time to take care of your baby so your baby will always be healthy” (Respondent who used both antenatal and postnatal health care services). “For me, this contraceptives especially the new ones that are coming, I do not see them affecting my baby in any positive way. If I use them or I do not use them, my baby will still be healthy; I see no relationship between them” (Respondent who accessed only postnatal health care services). Another area where respondent shared varied opinion on modern contraceptive use was the prevention of risk of short pregnancy intervals. Some of these women mentioned that using modern contraceptives is a sure way of preventing short pregnancy interval and the risks associated with such pregnancy. Other women do not think using modern contraceptives do not prevent pregnancy because these contraceptive are not totally safe and cannot guarantee pregnancy prevention. “I have been using contraceptives and it has help to delay my pregnancy, as a result of it, I did not have any problems with all my pregnancies and I am fine, my children are also fine” (Respondent who accessed only postnatal health care services). “It is not totally true that when you use contraceptives, you cannot get pregnant because some of the contraceptives are not safe, it can fail you. So it cannot prevent you from getting pregnant, it has failed me before that is why I am saying it” (Respondent who accessed only antenatal health care services). 131 University of Ghana http://ugspace.ug.edu.gh These conflicting views shared by respondents highlight two issues. First, their personal experiences in using modern contraception has influence their perception about use of modern contraception. Secondly, these certainties and uncertainties about the effectiveness of contraception towards ensuring good maternal and child health may only be addressed through effective contraceptive education when they come into contact with the health care system. However, the qualitative results indicated that there were few differences in the views of antenatal and postnatal health care users concerning the contents, frequency and materials used during counselling on contraception The possible reason for this outcome is the fact that these counselling is usually done by combining antenatal and postnatal health care users into one group. This phenomenon exposes these two distinct women (pregnant women and lactating mothers) to receiving similar education on contraception and as a result, there were few differences in their opinions on contraceptive counselling. 132 University of Ghana http://ugspace.ug.edu.gh CHAPTER NINE SUMMARY, CONCLUSION AND RECOMMENDATIONS 9.1 Summary The study aimed at examining the effects of antenatal and postnatal health care service utilisation on contraceptive use among women in Ghana. It also sought to explore the contraceptive information women receive during utilisation of antenatal and postnatal health care services at health facilities. The study was conducted using three nationally representative surveys - Ghana Demographic and Health Survey (2003, 2008 and 2014) and in-depth interviews of antenatal and postnatal health care users in health facilities. A mixture of quantitative, qualitative and analytical techniques was used in achieving the study objectives. This chapter summarises the major findings from the study, the study limitations and some recommendations for the scientific and policy communities. 9.1.1 Utilisation of Antenatal and Postnatal Health care services and contraceptive use among postpartum women in Ghana The proportion of women utilising antenatal and postnatal health care service has been high across the survey years. More specifically, the study found that the highest proportion of women are the ones utilising both antenatal and postnatal health care services compared to women using only one of these maternal health care services or none of them. This finding is consistent with the global trend on utilisation of maternal health care services. 133 University of Ghana http://ugspace.ug.edu.gh Concerning trends in modern contraceptive use, the study found that modern contraceptive use is still relatively low among postpartum women across the survey years. This finding is similar to the findings within the Africa sub-region where the contraceptive prevalence rate is low. 9.1.2 Relationship between Antenatal, Postnatal Health care utilisation and modern contraceptive use among postpartum women in Ghana The relationship between antenatal, postnatal health care service utilisation and contraceptive use is a spurious one. Thus, this relationship might be influenced by external factors such as the background characteristics of the woman. Based on the quantitative analysis, the findings indicated a higher use of modern contraceptives among women who utilised antenatal and postnatal health care services (especially among women who utilised both antenatal and postnatal health care services) compared to those who do not utilise these maternal health services. The study findings also revealed that among women who utilised both antenatal and postnatal health care services, high contraception was recorded among those within age 15-29 years and 40-49 years. Again, high contraceptive use was recorded among women with higher level of education, women whose partners have attained higher educational level, women with 3-4 children, and women residing in urban areas. High contraceptive use was also found among women who belong to the Ewe ethnic group, currently married women, sexually active women, dwelling in male-headed households and women who dwell in middle and rich households all within the context of using maternal health care services. After controlling for the effect of demographic and social factors at the multivariate level, the outcome showed that there is a high probability of modern contraceptive use among postpartum 134 University of Ghana http://ugspace.ug.edu.gh women who utilize both antenatal and postnatal health care services. However, women who used only antenatal health care services also have a higher probability of using modern contraceptives compared to those who used only postnatal health care services. 9.1.3 Contraceptive information received during antenatal and postnatal health care utilisation There are several components of contraceptive information that women receive during the utilisation of antenatal and postnatal health care services. These components were categorized into different themes. These themes comprise the contents of contraceptive counselling, frequency of contraceptive counselling, and materials used during counselling. On the contents of contraceptive counselling, the results indicate that women (both at the antenatal and postnatal health centres) are counselled on the direct and indirect benefits of using modern contraceptives. These benefits discussed were preventing unplanned pregnancy, sexually transmitted infections, reducing the risks of short pregnancy intervals, ensuring good child spacing and also good maternal and child wellbeing. Another content of contraceptive information given to the women is the various types of modern contraception and duration of their use. The long-acting methods discussed were intrauterine device (IUD), implant and female sterilization. The short-acting contraceptive methods include the pill, injectables and condoms. The women were also told that some of the methods can be active for six months, two months, two years and five years. The frequency of contraceptive counselling was another component of family planning information. Most of the women reported receiving counselling not very often when they go for 135 University of Ghana http://ugspace.ug.edu.gh antenatal and postnatal health care. They mentioned that counselling is often given on other modules such as nutrition, personal hygiene, pregnancy care, child care practices. Further, the study found that very few counselling materials such as audio, visuals, leaflets and documents are used during the counselling sessions. The study also found virtually no difference between the content, frequency and counselling materials used during counselling sessions among antenatal and postnatal health care users. The possible reason for this situation was the fact that the antenatal and postnatal health care users are combined and counselled together. 9.2 Recommendations 9.2.1 Policy Recommendations and Practice Implications The findings of this study on the relationship between antenatal, postnatal health care service utilisation and use modern contraception among postpartum women gives recognition to the fact that women‘s contraceptive behaviour improves as they have continuous contact with the health system. Of much relevance is the influence of antenatal and postnatal health care services on modern contraceptive use among postpartum women. There is also enough evidence of high utilisation of antenatal health care services in Ghana and to broader extent developing countries relative to postnatal health care services. Based on this, the study recommends that intervention programmes should be put in place to encourage the use of postnatal health care services. These intervention programmes may include home visitation by skilled health workers and experts in family planning to reach out to women who do not use these maternal health services. This will offer these women the opportunity to be educated on contraception. Thus, policies and programmes that will encourage women to be in regular contact with the health care delivery 136 University of Ghana http://ugspace.ug.edu.gh system to be well informed and educated on contraception as well as increase their use of contraceptives should be implemented. During contraception counselling sessions, counsellors should be encouraged to provide detail about the possible side effects and the risks associated with the use of modern contraceptives. This is very important because the findings clearly indicate that education is only given on the benefits of using modern contraceptives. Further, women should be made aware of the potential risks associated with contraception and this awareness will guide them in making informed contraceptive decisions and choices. The education on risk also allays their fears about the erroneous information they might have been fed with from other places or persons. More structural programmes should be put in place to ensure that more time is allocated to contraceptive counselling during antenatal and postnatal health care delivery. This is important for women to have better understanding of the efficacy, effectiveness, benefits and possible side effects of using modern contraceptives. This recommendation is necessary because the study results show that contraceptive counselling is not offered very often during antenatal and postnatal health care service delivery. In addition, contraceptive counselling during these maternal health care services should be done in a more structured way. That is, well trained counsellors should read and display a contraceptive flipchart to the recipients. Visual and audio components should be used to enable the women to see and hear the contraceptive information with clearer understanding. This recommendation is important for the reason that the study found that little or no counselling materials are used during the counselling sessions during antenatal and postnatal service provision. 137 University of Ghana http://ugspace.ug.edu.gh The way and manner contraceptive counselling is offered to users of antenatal and postnatal health care services really provide some answers to the relatively low use of modern contraceptives among postpartum women in Ghana. Thus, there are some challenges concerning offering of contraceptive counselling at antenatal and postnatal health care centres. These challenges include not allocating enough time to talk about contraception, using no or inadequate counselling materials and not giving much details about the possible side effects of contraception. These challenges negatively affect the quality of counselling offered and also the ability of these women to understand and better appreciate the importance of contraception especially during the period of postpartum. The implementation of the above recommendations will help in improving modern contraceptive use among women. 9.2.2 Future Research With regard to future research, one limitation of this study was its failure to do a follow up on the women who received contraceptive counselling. As a result of this, the study could not validate the quantitative results that women who utilise antenatal and postnatal health care services are more likely to use contraceptives. Future research should therefore adopt a follow-up approach to really see the effect of contraceptive education on women‘s contraceptive behaviours. Another limitation of this study is the use of nationally representative cross-sectional data on the topic of interest. The use of three cross-sectional data sets with each of them having a different set of postpartum women makes it very difficult to ascertain the influence of antenatal and postnatal health care on women‘s contraceptive use. Future studies should, therefore, collect longitudinal data on women especially at their younger reproductive ages and track their 138 University of Ghana http://ugspace.ug.edu.gh maternal and child health seeking behaviour and their contraceptive use. This will lead to the reliability and robustness of the results to inform policy. Further, this study was limited in collecting information from skilled health professionals. Information on the structure and procedures of contraceptive counselling, the daily patient-health worker interaction and also the views of these health workers on contraception in the postpartum period should be collected. Therefore, future research should also focus on the views of family planning personnel and health workers in this regard. Moreover, the study was limited in satisfying one of the criteria of causality that is time order. The study could not determine whether women who attended antenatal and postnatal health care services might have been using contraceptives before expose to contraceptive education during the provision of antenatal and postnatal health care services. Finally, future research should endeavour to compare the views of the recipients and providers of counselling within the context of antenatal and postnatal health care service delivery. These views should include but not be limited to the contents, frequency and materials used in offering contraceptive counselling in the health care system. 9.3 Conclusion In conclusion, Ghana as well as most sub-Saharan African countries has the potential of achieving high modern contraceptive prevalence if policies are put in place to ensure that quality and efficient contraceptive education is offered to people especially women in their postpartum period who are exposed to the risk of unintended pregnancy. Laying more emphasis on the important role antenatal and postnatal health care service utilisation play in the contraceptive 139 University of Ghana http://ugspace.ug.edu.gh behaviour of women and to a large extent their sexual and reproductive health is of relevance. In other words, the utilisation of these maternal health care services has the ability to influence contraceptive use among postpartum women. This also has relevance and implications to the realisation of the United Nations Sustainable Development Goal 3. This goal has a target of ensuring that by 2030 there will be universal access to sexual and reproductive health care services. These services include family planning information, education as well as the integration of reproductive health into national strategies and programmes. Furthermore, giving much attention to discussing side effects of modern contraceptive use during the delivery of antenatal and postnatal health care services will help improve contraceptive behaviour among women especially within the Africa sub-region. This will help women to allay their fears and demystify any misconception and beliefs about modern contraception because these have been a bane to modern contraceptive use in the Africa. 140 University of Ghana http://ugspace.ug.edu.gh REFERENCES Abdel-Tawab, N., Loza, S., & Zaki, A. (2008). 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Demographic Research, 18, 233. 154 University of Ghana http://ugspace.ug.edu.gh APPENDICES Appendix A: Women Questionnaire (GDHS) Ghana Demographic and Health Survey Section 1: Respondent's Background Introduction and Consent INFORMED CONSENT Hello. My name is _______________________________________. I am working with Ghana Statistical Service and the Ministry of Health. We are conducting a survey about health all over Ghana. The information we collect will help the government to plan health services. Your household was selected for the survey. The questions usually take about 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the survey, you may contact the person listed on the card that has already been given to your household. Do you have any questions? May I begin the interview now? SIGNATURE OF INTERVIEWER: __________________________ DATE:_________________________ RESPONDENT AGREES TO BE INTERVIEWED . . . . . 1 RESPONDENT DOES NOT AGREE TO BE INTERVIEWED . . . 2 END NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 101 RECORD THE TIME. HOUR . . . . . . . . . . . . . . . . . . . . MINUTES . . . . . . . . . . . . . . . . . . 102 In what month and year were you born? MONTH……………………....... DON‘T KNOW MONTH…………………98 YEAR………………… DON’T KNOW YEAR……………………..9998 155 University of Ghana http://ugspace.ug.edu.gh 103 How old were you at your last birthday? AGE IN COMPLETED YEARS COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISRENT 104 Have you ever attended school? YES………………………………… 1 NO………………………………… 2 105 What is the highest level of school you attended: PRIMARY …………………………….. 1 primary, middle/JHS, secondary/SSS/SHS, MIDDLE ……………………………….. 2 or higher? JSS/JHS ……………………………… 3 SECONDARY………………………….4 SSS/SHS ………………………………5 HIGHER ………………………………. 6 106 What is your religion? CATHOLIC ……………………………01 ANGLICAN ………………………….. 02 METHODIST ……………………….. 03 PRESBYTERIAN …………………….04 PENTECOSTAL/CHARISMATIC……05 OTHER CHRISTIAN …………………06 ISLAM ………………………………….07 TRADITIONAL/SPIRITUALIST………08 NO RELIGION …………………………09 OTHER _______________________ 96 (SPECIFY) 107 To which ethnic group do you belong? AKAN ……………………………………01 GA/DANGME …………………………...02 EWE………………………………........03 GUAN……………………………………..04 MOLE-DAGBANI ……………………...05 GRUSSI ………………………………….07 GRUMA………………………………….08 MANDE………………………………….09 OTHER ______________________ 96 (SPECIFY) 108 Which region do you belong to? CENTRAL ………………………………..01 WESTERN ………………………………02 GREATER ACCRA………………........ 03 VOLTA……………………………………04 EASTERN ……………………………….05 ASHANTI …………………………………. 06 BRONG AHAFO…………………………… 07 NORTHERN …………………………………08 UPPER WEST………………………………..09 UPPER EAST………………………………..10 109 Which type of locality do you dwell? URBAN ………………………………………..01 RURAL ……………………………………….02 156 University of Ghana http://ugspace.ug.edu.gh 110 How many children do you have currently? NUMBER 111 What is your marital status now? SINGLE……………………………...01 MARRIED …………………………..02 LIVING TOGETHER ……………….03 WIDOWED ………………………….04 DIVORCED …………………………05 SEPARATED ………………………..06 112 After the child you expecting now, would HAVE ANOTHER ………………… 1 you like to have another , or would you prefer NO MORE …………………………..2 not to have any more children? UNDECIDED/DON‘T KNOW ……..8 113 When was the last time you had sexual DAYS AGO ………………….1 intercourse? WEEKS AGO …………………2 MONTHS AGO ……………….3 YEARS AGO …………………..4 114 Does your household have: YES NO a) Electricity? ELECTRICITY ………………. 1 2 b)A wall clock? WALL CLOCK ………………. 1 2 c) A radio? RADIO ………………………. 1 2 d)A black/white television? BLACK/WHITE TELEVISION …. 1 2 e) A color television? COLOR TELEVISION …………. 1 2 f) A mobile telephone? MOBILE TELEPHONE …………… 1 2 g)A land-line telephone? LAND-LINE TELEPHONE ………. 1 2 h)A refrigerator? REFRIGERATOR ……………….. 1 2 i) A freezer? FREEZER ………………………… 1 2 j) Electric generator/Invertor(s)? GENERATOR/INVENTOR ……….1 2 k)Washing machine? WASHING MACHINE ……………1 2 l) Computer/Tablets computer? COMPUTER/TABLET ………….. 1 2 m) Photo camera? (NOT ON PHONE) PHOTO CAMERA ……………….. 1 2 n)Video deck/DVD/VCD? VIDEO DECK/DVD/VCD ………… 1 2 o)Sewing machine? SEWING MACHINE………………. 1 2 p)Bed? BED ………………………………….1 2 q)Table? TABLE ………………………………1 2 r) Cabinet/cupboard? CABINET/CUPBOARD ……………1 2 s) Access to the internet in any device? INTERNET ACCESS ………………1 2 115 In the last few months have you YES NO a. Heard about family planning on the radio? RADIO ……………………………………….. 1 2 b. Seen anything about family planning on the television? TELEVISION ……………………………….. 1 2 c. Read about family planning in a newspaper or magazine? MAGAZINE ………………………………… 1 2 157 University of Ghana http://ugspace.ug.edu.gh 116 Sex of household head MALE ………………………… 01 FEMALE ………………………02 117 Did you see anyone for antenatal care for YES …………………. 1 this pregnancy? NO …………………... 2 118 How many times did you receive antenatal NUMBER OF TIMES care during this pregnancy? DON‘T KNOW …………………… 98 119 Where did you receive antenatal care for HOME this pregnancy? YOUR HOME……….. ….A OTHER HOME ……........B PUBLIC SECTOR GOVT. HOSPITAL ………....C GOVT. HEALTH CENTRE/CLINIC …………..D GOVT. HEALTH POST/CHPS ………………..E MOBILE CLINIC …………...F OTHER PUBLIC SECTOR ________________ G (SPECIFY) PRIVATE MED.SECTOR PVT. HOSPITAL/CLINIC….H FP/PPAG CLINIC …………..I MOBILE CLINIC …………..J MATERNITY HOME ………..K OTHER PRIVATE MED.SECTOR………………L __________________ (SPECIFY) OTHER____________ X (SPECIFY) 158 University of Ghana http://ugspace.ug.edu.gh 120 The last time you had sex did you use any method YES……………………………… 1 to avoid or prevent a pregnancy? NO……………………………… 2 DON‘T KNOW ……………… 8 121 What method did you use? FEMALE STERLIZATION ………… A IUD …………………………………………….. B PROBE: INJECTABLES …………………………… C Did you use any other method to prevent IMPLANTS ………………………………… D pregnancy? PILL ……………………………………………..E FEMALE CONDOM …………………….F RECORD ALL MENTIONED DIAPHRAGM …………………………….H FOAM/JELLY …………………………… I LAM ……………………………………….. J RHYTHM METHOD ………………… K WITHDRAWAL …………………………L OTHER MODERN METHOD ……..X OTHER TRADITIONAL METHOD...Y 159 University of Ghana http://ugspace.ug.edu.gh Appendix-B: Interview Guide on Antenatal Care and Contraceptive Use 1. During any of your antenatal visits, did a doctor, nurse or other health care worker talk to about contraception? Probe: Intrauterine device (IUD), sterilization, Implants, injectable, condom, diaphragm etc 2. What are the modes through which you receive contraceptive counselling during antenatal visit? Probe: Videos, Audio, Infographic, Pictures, Magazines and Fliers 3. If you have ever use modern contraceptive before, in your opinion, has the contraceptive counselling you received during antenatal visit have influence your contraceptive use? Probe: Correct use of methods, effective in preventing pregnancy, helped in spacing birth 4a. Have you been receiving contraceptive counselling anytime you go for antenatal clinics? Probe: Less than 4 ANC visits, 4 and more ANC visits 4b. Have you received contraceptive counselling when you attend both antenatal and postnatal clinic during your first birth? 5. How satisfied are you on the contraceptive counselling given to you during antenatal care visits? 6. Apart from receiving contraceptive information in this hospital, where else do you receive contraceptive and other family planning information? Probe: Radio, Television, Internet, Social Media Platforms (Whatsapp, Facebook, Twitter, Instagram etc), Newspaper and Magazines 7. What is the opinion of your husband/partner on the women‘s contraceptive use? Probe: Types of modern contraceptives, side effects, effectiveness and reliability 8. Are there any other issues you would like to talk about concerning what we have just discussed? 160 University of Ghana http://ugspace.ug.edu.gh Appendix-C: Interview Guide on Postnatal Care and Contraceptive Use 1. During any of your postnatal visits, did a doctor, nurse or other health care worker talk to about contraception? Probe: Intrauterine device (IUD), sterilization, Implants, injectable, condom, diaphragm etc 2. What are the modes through which you receive contraceptive counselling during postnatal visit? Probe: Videos, Audio, Info graphic, Pictures, Magazines and Fliers 3. If you have ever use modern contraceptive before, in your opinion, has the contraceptive counselling you received during postnatal visit have influence your contraceptive use? Probe: Correct use of methods, effective in preventing pregnancy, helped in spacing birth 4a. Have you been receiving contraceptive counselling anytime you go for postnatal clinics? Probe: Child Immunization/vaccination clinics, postpartum care, obstetric care etc 4b. Have you received contraceptive counselling when you attend both antenatal and postnatal clinic during your first birth? 5. How satisfied are you on the contraceptive counselling given to you during postnatal care visits? 6. Apart from receiving contraceptive information in this hospital, where else do you receive contraceptive and other family planning information? Probe: Radio, Television, Internet, Social Media Platforms (Whatsapp, Facebook, Twitter, Instagram etc), Newspaper and Magazines 7. What is the opinion of your husband/partner on the women‘s contraceptive use? Probe: Types of modern contraceptives, side effects, effectiveness and reliability 8. Are there any other issues you would like to talk about concerning what we have just discussed? 161 University of Ghana http://ugspace.ug.edu.gh Appendix D: Informed Consent Form of Women who attend Antenatal Clinics Purpose: Good morning/ afternoon. My name is ___________________________________. I am a PhD candidate at the Regional Institute for Population Studies (RIPS), University of Ghana. I am embarking on a research on the various contraceptive information women who attend antenatal clinic receive. The research will also ask these women the means through which they receive this contraceptive information and whether it has influenced their use of contraceptives or not. About 30 women (15 pregnant in their third trimester and 15 women who have given birth and attending postnatal clinics) will participate in this research. It will include women in their reproductive ages (15-49), women in their last trimester of pregnancy, women who have already had at least a child and women who attended antenatal clinic for at least 4 times. You have been invited to participate in this study because you fall within the criteria. If you agree, I would like to include you in this research. Confidentiality: The discussion will be tape recorded. The discussions are strictly confidential so ___________________‘s responses will not be shared with anyone. Her name and personal information will not be given to anyone or kept with the information provided during the in- depth interview. Only the researcher will listen to the tapes to be written down what she and other women will say during the individual interview. After the interview has been written down, the tape will be destroyed. All information she provides will be kept in a locked file and her name will never be used in any research reports that come from this research. Benefits and Risks: The information ________________________ gives me will assist me to gain insight into how contraceptive counselling received during antenatal clinics influence contraceptive use among them. They may also suggest some recommendations which will help to develop policies to further increase the use of modern contraceptives and ensure women develop positive attitudes towards modern contraception. A risk to participating in this research is that __________________________ may be embarrassed by a few of the questions. However, if any of the questions makes her uncomfortable or she does not want to answer, she does not have to respond. There are no direct benefits for her participation, although she will contribute critical information to the scientific and policy environment in order to provide better family planning programmes in Ghana. 162 University of Ghana http://ugspace.ug.edu.gh Voluntary Participation: The opinions and experiences of _______________________ are very essential to this research. You consent is completely voluntary and I will also ask _______________ for her consent as well. ____________________‘s participation is also completely voluntary. If any of the questions make her uncomfortable or she does not have to respond. There are no consequences for you or________________________ if you decline to provide consent. Reimbursement: You will receive a reimbursement of Ghc.10 which will cover transportation and recharge mobile card. Who has reviewed the research? The research has been reviewed by the Ghana Health Service Ethical Review Committee. This is a group that make sure people in studies are treated fairly and properly. Offer to answer questions: I can answer any questions you may have. If I don‘t have the information you require, I will tell you so and, if you wish, I will try to get an answer for you. Do you have any questions? (If yes, note the questions) Yes No Are you willing to participate in the research? Yes No Funding information This research is solely funded by the researcher without any other external support 163 University of Ghana http://ugspace.ug.edu.gh Consent Form (Antenatal Recipients) Participant’s Statement The research and in-depth interview process has been explained to me. I have been given a chance to ask any question I may have. I am content with the answers to all of my questions. I also know that:  My records will be kept private and confidential  I can choose not to be interviewed, not to answer certain questions, and to stop the interview at any time;  If I refuse to be interviewed, there are no consequences to me Code of participant (print): __________________________________ ____________ _________________________ Date Signature of respondent Respondent‘s Thumb print If illiterate A literate witness must sign (if possible, this person should be selected by the participant and should have no connection to the research team). Participants who are illiterate should include their thumb-print as well I have witnessed the accurate reading of the consent form to the potential participant, and the individual has had the opportunity to ask questions. I confirm that the individual has given consent freely. Name of witness (Print):_____________________ _________________ ____________________ Date Signature of respondent Respondent‘s Thumb print 164 University of Ghana http://ugspace.ug.edu.gh Translator’s statement (for Antenatal Recipients) I affirm that I have performed the translation of the summary of the project and the consent document in a language that the participant understands. Printed Name of Translator: __________________ ___________________________ _____________________ Signature of Translator Date I agree to be tape-recorded Yes No Your refusal to be tape-recorded will affect your participation Yes No Interviewer’s statement (for Antenatal Recipients) I, the undersigned, have defined and explained to the participant in a language that she/he understands the procedures to be followed, the risks and benefits involved, and the obligations of the interviewer. Interviewer Name (print):____________________________________ ___________ ____________________________________ Date Signature of Interviewer 165 University of Ghana http://ugspace.ug.edu.gh Who to Contact for Clarification Principal Investigator: Name: Desmond Klu Tel Number: 0241596523 Email: kludesmond12@gmail.com/kludesmond@yahoo.com Project Supervisors Name: Prof. Stephen Owusu Kwankye Tel Number: 0277602486 Email: kwankyes@ug.edu.gh Name: Dr. Ayaga Ayula Bawah Tel Number: 0244714164 Email: aabawah@gmail.com Name: Dr. Naa Ddodua Dodoo Tel Number: 0244574434 Email: nadods@yahoo.co.uk Administrator- Ghana Health Service Ethics Review Committee (Research and Development Division) Name: Hannah Frimpong Tel Number: 0507041223 Email: Hannah.Frimpong@ghs.org 166 University of Ghana http://ugspace.ug.edu.gh Appendix E- Informed Consent Form of Women who attend Postnatal Clinics Purpose: Good morning / afternoon. My name is________________________________. I am a PhD candidate at the Regional Institute for Population Studies (RIPS), University of Ghana. I am embarking on a research on the various contraceptive information women who attend postnatal clinic receive. The research will also ask these women the means through which they receive this contraceptive information and whether it has influenced their use of contraceptives or not. About 30 women (15 pregnant in their third trimester and 15 women who have given birth and attending postnatal clinics) will participate in this research. It will include women in their reproductive ages (15-49) and women who attended postnatal clinic for at least three times. You have been invited to participate in this study because you fall within the criteria. If you agree, I would like to include her in this research. Confidentiality: The discussion will be tape recorded. The discussions are strictly confidential so ___________________‘s responses will not be shared with anyone. Her name and personal information will not be given to anyone or kept with the information provided during the in- depth interview. Only the researcher will listen to the tapes to be written down what she and other women will say during the individual interview. After the interview has been written down, the tape will be destroyed. All information she provides will be kept in a locked file and her name will never be used in any research reports that come from this research. Benefits and Risks: The information ________________________ gives me will assist me to gain insight into how contraceptive counselling received during antenatal clinics influence contraceptive use among them. They may also suggest some recommendations which will help to develop policies to further increase the use of modern contraceptives and ensure women develop positive attitudes towards modern contraception. A risk to participating in this research is that __________________________ may be embarrassed by a few of the questions. However, if any of the questions makes her uncomfortable or she does not want to answer, she does not have to respond. There are no direct benefits for her participation, although she will contribute critical information to the scientific and policy environment in order to provide better family planning programmes in Ghana. Voluntary Participation: The opinions and experiences of _______________________ are very essential to this research. You consent is completely voluntary and I will also ask _______________ for her consent as well. ____________________‘s participation is also completely voluntary. If any of the questions make her uncomfortable or she does not have to respond. There are no consequences for you or________________________ if you decline to provide consent. Reimbursement: You will receive a reimbursement of Ghc.10 which will cover transportation and recharge mobile card. 167 University of Ghana http://ugspace.ug.edu.gh Who has reviewed the research? The research has been reviewed by the Ghana Health Service Ethical Review Committee. This is a group that make sure people in studies are treated fairly and properly. Offer to answer questions: I can answer any questions you may have. If I don‘t have the information you require, I will tell you so and, if you wish, I will try to get an answer for you. Do you have any questions? (If yes, note the questions) Yes No Are you willing to participate in the research? Yes No Funding information This research is solely funded by the researcher without any other external support Consent Form (Postnatal Recipients) Participant’s Statement The research and in-depth interview process has been explained to me. I have been given a chance to ask any question I may have. I am content with the answers to all of my questions. I also know that:  My records will be kept private and confidential  I can choose not to be interviewed, not to answer certain questions, and to stop the interview at any time;  If I refuse to be interviewed, there are no consequences to me Code of participant (print): __________________________________ ____________ _______________________ Date Signature of respondent Respondent‘s Thumb Print 168 University of Ghana http://ugspace.ug.edu.gh If illiterate A literate witness must sign (if possible, this person should be selected by the participant and should have no connection to the research team). Participants who are illiterate should include their thumb-print as well I have witnessed the accurate reading of the consent form to the potential participant, and the individual has had the opportunity to ask questions. I confirm that the individual has given consent freely. Name of witness (Print):_____________________ _________________ _____________________ Date Signature of respondent Respondent‘s Thumb print Translator’s statement (for Postnatal Recipients) I affirm that I have performed the translation of the summary of the project and the consent document in a language that the participant understands. Printed Name of Translator: __________________ ___________________________ _____________________ Signature/Thumbprint of Translator Date I agree to be tape-recorded Yes No Your refusal to be tape-recorded will affect your participation Yes No 169 University of Ghana http://ugspace.ug.edu.gh Interviewer’s statement (for Postnatal Recipients) I, the undersigned, have defined and explained to the participant in a language that she/he understands, the procedures to be followed, the risks and benefits involved, and the obligations of the interviewer. Interviewer Name (print):____________________________________ ___________ ____________________________________ Date Signature of Interviewer Who to Contact for Clarification Principal Investigator: Name: Desmond Klu Tel Number: 0241596523 Email: kludesmond12@gmail.com/kludesmond@yahoo.com Project Supervisors Name: Prof. Stephen Owusu Kwankye Tel Number: 0277602486 Email: kwankyes@ug.edu.gh Name: Dr. Ayaga Ayula Bawah Tel Number: 0244714164 Email: aabawah@gmail.com Name: Dr. Naa Ddodua Dodoo Tel Number: 0244574434 Email: nadods@yahoo.co.uk Administrator- Ghana Health Service Ethics Review Committee (Research and Development Division) Name: Hannah Frimpong Tel Number: 0507041223 Email: Hannah.Frimpong@ghs.org 170 University of Ghana http://ugspace.ug.edu.gh Appendix F: Minor’s assent form for participation in this study (15-18 Years) I am a PhD student from University of Ghana researching on the topic: “Antenatal and Postnatal Health Services uptake and contraceptive use among women in Ghana” and I am asking you to be part of this research. This form will tell you all about the study and will help you decide to be or not to be in the study. Read this paper carefully and ask any questions you may have. You might have questions about what you will do, how long it will take, if anyone will find out how you did. When we have answered all of your questions, you can decide to be or not to be in the study. This is called ―informed consent.‖ Contraceptive Prevalence Rates (CPR) among postpartum women attending postnatal clinics in Ghana is still one of the lowest in the world. There is a need to understand the relationship between the utilisation of postnatal and modern contraceptive use among postpartum women in Ghana. In understanding such relationship, this research therefore seeks to gather the views of women in Ghana who utilized postnatal health care services on the importance of modern contraceptive use after birth. This research also seeks to find out, the type of contraceptive counselling offered at postnatal clinics, the way and manner through which these contraceptive counselling are given and how often these counselling given to women who attend these clinics. This research will also find out from these women the beliefs they have about modern contraceptive and what inform their choice of modern contraceptives. The methodological approach to achieving this is qualitative, with data for the research obtained through individual in-depth interviews (IDIs). The IDIs will be conducted at three carefully selected hospitals in Accra. The selection criteria for the hospitals are (i) the hospital must be providing effective postnatal clinics (ii) the hospital must be offering effective contraceptive counselling during postnatal clinics (iii) the hospital must have a history to regular postnatal clinics attendees. The IDIs will be conducted at the hospitals when these women come for postnatal clinics. There will be no direct benefits for participants of the research; however, a potential indirect benefit will be the knowledge or insight that the research could contribute to solving a health problem in Ghana. A possible cost to participants for their engagement in the research may be their time and effort spent during the interviews. As the research will cover very sensitive topics, some of which may be seen as intrusive and personal, rigorous steps will be taken to ensure that the psycho- emotional affect or any potential discomfort/harm to research participants are minimized. Before 171 University of Ghana http://ugspace.ug.edu.gh the interview begins, participants will be informed that they do not have to respond to any question that discomforts them or cause them any distress. Participants will also be informed that their participation in the research is voluntary and that they can choose to withdraw from the research at any time without any penalty. They would however be encouraged to stay throughout the interview period. Risks and Benefits I do not anticipate any major risks to our participants. Possible risks include worries about confidentiality before and after interview. I will ensure that all confidentiality procedures are explained in details both verbally and in writing. Respondents will be assured of confidentiality of information provided before and after the interview to allay fears concerning confidentiality. Risk to pregnant and postpartum women may include: possible discomfort in answering questions related to sexuality. In addition, participation in the research may put an adolescent at risk of psychological upset especially since they may have to recall some personal experience (s). Interviewer will emphasize that respondents may chose not to answer any of the questions if they so wish, and can stop the interview at any time. Prior to conducting the research, the draft instruments and the proposed data gathering techniques will be pre-tested for their appropriateness and any identified techniques or tool with the potential to cause distress will be altered or removed. All interviews will be held in a private and secured location. Your Rights:  You have the right to carefully read this paper and ask questions before deciding to be or not to be in the study.  You have the right to choose not to be in the study  You have the right to stop participating anytime you want If you have any Questions If you have any questions about the study, call Desmond Klu on 0241596523 Signing this paper means that you have read this or had it read to you and that you want to be in the study. If you don‘t want to be in the study, don‘t sign the paper 172 University of Ghana http://ugspace.ug.edu.gh Code of the Participant (Print) _____________________ _____________________ ___________________ Date Participant‘s Signature Participant‘s Thumb print Interviewer’s Statement and Signature The undersigned interviewer hereby certifies that he/she has discussed the research project with the child participant and has explained the information contained in this document, including the reason for the research, the risks, and the benefits or potential benefits. The undersigned investigator further certifies that the participant was encouraged to ask questions and that all questions were answered. Name of Interviewer (Print): _____________________ _____________________ ______________________ Date Signature The child is less than age eighteen or unable to understand the research: I/we (parent(s) or guardian) _____________________ waive my/our child's assent and take full responsibility for providing permission for participation in this research study. _____________________ ________________________- Date Signature/Thumbprint Translator’s statement (for minors) I affirm that I have performed the translation of the summary of the project and the consent document in a language that the participant understands. Printed Name of Translator: __________________ ___________________________ _____________________ Signature of Translator Date Parental/Guardian Consent Form [Postnatal Recipients-Minor Participants (15-18 years)] 173 University of Ghana http://ugspace.ug.edu.gh The research and interview process has been explained to me. I have been given a chance to ask any questions I may have. I am content with the answers to all of my questions. I also know that:  All records will be kept private and confidential;  My daughter can choose not be interviewed, not to answer certain questions, and to stop the interview at any time;  If my daughter/charge refuses to be interviewed, there are no consequences to me or to her. Name of Parent/Guardian (print):_______________________________ _______________________________ ___________________ Signature/ Thumbprint of parent/guardian Date 174 University of Ghana http://ugspace.ug.edu.gh 175 University of Ghana http://ugspace.ug.edu.gh 176 University of Ghana http://ugspace.ug.edu.gh 177