SCHOOL OF PUBLIC HEALTH
COLLEGE OF HEALTH SCIENCES
UNIVERSITY OF GHANA
FACTORS AFFECTING PREGNANCY COMPLICATIONS AMONG ANTENATAL
MOTHERS AT MAMPROBI HOSPITAL
BY
YAW KORANKYE WIAFE
(10285974)
A DISSERTATION SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN
PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF
PUBLIC HEALTH (MPH) DEGREE
MARCH, 2022
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DECLARATION
I, Yaw Korankye Wiafe, hereby declare that with the exception of referenced works of other
people, which have been cited and duly acknowledged, this work is an output of my own initiative.
This research work has neither in whole nor in part been presented for an award or a degree
elsewhere.
………………………. Date: 3rd March, 2022
Yaw Korankye Wiafe
(Student)
……………………………..
Dr. Patricia Akweongo Date: 3rd March, 2022
(Supervisor)
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LIST OF ABBREVIATIONS
ANC - Antenatal Care
BMI - Body Mass Index
GDHS - Ghana Demographic and Health Survey
GSS - Ghana Statistical Service
MCH - Maternal and Child Health
MMR - Maternal Mortality Ratio
NHIS - National Health Insurance Scheme
RCA - Root Cause Analysis
SBCC - Social Behaviour Change Communication
SDG - Sustainable Development Goals
SIDS - Sudden Infant Deaths Syndrome
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TABLE OF CONTENT
DECLARATION ............................................................................................................................ ii
LIST OF ABBREVIATIONS ..................................................................................................... iii
LIST OF TABLES ....................................................................................................................... viii
LIST OF FIGURES ..................................................................................................................... ix
ABSTRACT ....................................................................................................................................x
CHAPTER ONE ..............................................................................................................................1
INTRODUCTION ...........................................................................................................................1
1.1 Background of the Study ....................................................................................................... 1
1.2 Problem statement ................................................................................................................. 5
1.3 Justification of the study ....................................................................................................... 6
1.4 Research Questions ............................................................................................................... 7
1.5 General Objective and Specific Objectives ........................................................................... 7
1.5.1 General Objective ........................................................................................................... 7
1.5.2 Specific objectives .......................................................................................................... 8
CHAPTER TWO ...........................................................................................................................11
LITERATURE REVIEW ..............................................................................................................11
2.1 Introduction ......................................................................................................................... 11
2.2 Definition and discussions on Concepts......................................................................... 11
2.2.1 Definition and types of Pregnancy .......................................................................... 11
2.2.2 Definition and Types of Pregnancy Complications ................................................ 14
2.3 Prevalence of pregnancy complications among antenatal women .................................. 18
2.4 Knowledge of antenatal women on pregnancy complications/danger signs................... 23
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2.5 Factors Affecting the prevalence of pregnancy complications ....................................... 26
2.5.1 Socio-demographic factors associated with prevalence of pregnancy complication 26
2.5.2 Obstetric and maternal factors complications ......................................................... 32
2.5.3 Other related factors on pregnancy complications ........................................................... 35
2.6 Summary of Literature ........................................................................................................ 37
CHARPTER THREE .....................................................................................................................39
METHODOLOGY ........................................................................................................................39
3.1 Introduction ....................................................................................................................... 39
3.2 Study design ........................................................................................................................ 39
3.3 Study area ............................................................................................................................ 39
3.4 Target and study population ................................................................................................ 39
3.5 Inclusion Criteria ................................................................................................................. 40
3.6 Sample Size determination .................................................................................................. 40
3.7 Sampling Techniques .......................................................................................................... 41
3.8 Study variables .................................................................................................................... 41
3.9 Data Collection Instruments and Data Collection .......................................................... 43
3.10 Pre-Testing ........................................................................................................................ 43
3.12 Analysis of Data ................................................................................................................ 44
10.13 Ethical Issues ................................................................................................................... 45
CHAPTER FOUR ..........................................................................................................................46
RESULTS ......................................................................................................................................46
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4.1 Introduction ......................................................................................................................... 46
4.2 Socio-demographic characteristics ...................................................................................... 46
4.3 Household Asset Distribution and Wealth Index ................................................................ 49
4.4 Maternal and Obstetric Factors ........................................................................................... 52
4.5 Knowledge on Obstetric Danger Signs ............................................................................... 56
4.6 Bivariate analysis of socio-demographic factors associated with prevalence of pregnancy
complications ............................................................................................................................ 60
4.7 Bivariate analysis of household wealth index and maternal/obstetric health factors .......... 62
4.8 Bivariate analysis of obstetric and maternal factors associated with prevalence of pregnancy
complications ............................................................................................................................ 64
4.9 Bivariate analysis of the relationship between knowledge levels on danger signs and
pregnancy complications ........................................................................................................... 66
4.10 Multivariate analysis of factors associated with Pregnancy complication among pregnant
women ....................................................................................................................................... 67
4.11 Summary of the chapter .................................................................................................... 70
CHAPTER FIVE ...........................................................................................................................71
DISCUSSIONS ..............................................................................................................................71
5.1 Introduction ......................................................................................................................... 71
5.2 Proportion of pregnant women attending antenatal care services reporting pregnancy
complications ............................................................................................................................ 71
5.3 Knowledge of pregnant women on obstetric danger signs ................................................. 74
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5.4 Factors associated with pregnancy complication among pregnant women ........................ 76
CHAPTER SIX ..............................................................................................................................80
6. 1 Major findings and Conclusion .......................................................................................... 80
6.2 Recommendations ............................................................................................................... 80
REFERENCE .................................................................................................................................82
APPENDIX I: PARTICIPANT INFORMATION SHEET ...........................................................93
APPENDIX II: CONSENT FORM ...............................................................................................96
APPENDIX III: DATA COLLECTION TOOL ............................................................................98
APPENDIX IV: ETHICAL APPROVAL ...................................................................................103
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LIST OF TABLES
Table 1: Description Variables for the Study ............................................................................... 42
Table 2: Socio-demographic Characteristics of Respondents ..................................................... 48
Table 3: Distribution of Household Assets and Possession ........................................................ 51
Table 4: Household Wealth Index ................................................................................................ 52
Table 5: Maternal and Obstetric Characteristics among Pregnant Women Utilising ANC Services
....................................................................................................................................................... 54
Table 6: Knowledge about Obstetric Danger Signs in Pregnancy ................................................ 58
Table 7: Relationship Between Demographic Characteristics and Prevalence of Pregnancy
Complication ................................................................................................................................. 61
Table 8: Relationship Between Household Wealth Index and Maternal Factors ......................... 63
Table 9: Relationship Between Maternal and Obstetric Factors and Pregnancy Complication
Prevalence ..................................................................................................................................... 65
Table 10: Relationship Between Danger Signs Knowledge Factors and Pregnancy Complication
Prevalence ..................................................................................................................................... 66
Table 11: Multivariate Analysis of Factors Associated with Pregnancy Complication Among
Pregnant Women ........................................................................................................................... 69
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LIST OF FIGURES
Figure 1: Conceptual Framework on Possible Factors that May Cause the Prevalence of Pregnancy
Complications. .............................................................................................................................. 10
Figure 2: Women with Pregnancy Complications ........................................................................ 55
Figure 3: Types of Pregnancy Complications Observed Among the Women .............................. 56
Figure 4: Maternal and Obstetric Danger Signs Status Among Pregnant Women ....................... 59
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ABSTRACT
Background: The prevalence of maternal mortality continues to be a major health concern across
the world. In Ghana, pregnancy related causes of death in the previous 5-years was 12% of all
deaths among women 15-49 years. Further assessment of the pregnancy-related deaths showed
that more than half of these deaths are as a result of pregnancy-related complications. However,
assessment of the pooled prevalence of pregnancy-related complications among pregnant women
to inform policy is limited.
Objective: This study therefore sought to determine the factors that contribute to pregnancy
complications and to assess the knowledge levels of pregnant women on pregnancy-related danger
signs.
Methods: A facility-based cross-sectional study was conducted among 415 pregnant women who
attended antenatal care services at Mamprobi Hospital using a systematic sampling technique. Data
analysis was done using STATA v.17.0 and the results presented in percentages and proportions.
Regression analysis was conducted to determine the predictors of pregnancy complication at 95%
confidence interval. Results of regression analysis is reported in odds ratio.
Results: All the targeted women participated in the study giving a response rate of 100%. The
study observed a mean age of 31.6 ± 6.6. More than 80% of the women had completed secondary
education with 65% being salary workers/employees. More than half of the women were
multiparous with nearly 65% starting their ANC at second trimester. Average ANC attendance
among the women was 6 ANC visits. Almost all the women (97.5%) had ever heard about obstetric
danger signs with 75% of the women having adequate knowledge about maternal and obstetric
danger signs. About 52% of the women had ever had abortion in the past. The study observed
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pregnancy complication prevalence of 51.8%. The prevalence of pregnancy complication among
the women was significantly determined by age (AOR: 6.1; CI: 1.19-30.76), past record of
pregnancy complications (AOR: 2.5; CI: 1.35-4.49), time of ANC visit (AOR: 6.1; CI: 2.14-17.70)
and family history of pregnancy complications (AOR: 3.6; CI: 1.25-10.40). Other significant
factors included past record of abortion (AOR: 7.8; CI: 4.21-14.32), knowledge about obstetric
danger signs (AOR: 2.4; CI: 1.21-4.88) and experiencing at least one obstetric danger sign during
pregnancy (AOR: 6.6; CI: 3.30-13.29).
Conclusion: The prevalence of pregnancy complications was comparatively high among the
women who utilised ANC services at Mamprobi hospital. Early initiation of antenatal care services
for pregnant women is an important tool for addressing some of the challenges of early onset of
some pregnancy complication including anaemia in pregnancy and preeclampsia. Midwives as
well as other health workers who engage pregnant women should encourage their clients to always
initiate antenatal care visits at early stage.
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CHAPTER ONE
INTRODUCTION
1.1 Background of the Study
Worldwide, childbearing poses a major risk to the life of a woman (Olonade et al., 2019).
Although childbearing is considered to be healthy in developed countries, this is not the case
for the majority of women around the world. Two percent of women would die during their
pregnancy due to complications if they do not have access to any kind of healthcare (Kenny,
2018). According to World Health Organisation estimates from 2001, complications during
pregnancy and childbirth claim the lives of 515 000 people per year (WHO, 2019). It is
estimated that every year, more than half a million people die as a result of complications
during pregnancy and childbirth even though the overwhelming majority of these deaths can
be avoided (WHO, 2019). Nations agreed at the Millennium Summit in 2000 to reduce
maternal-related deaths by three-quarters around 2015 (WHO, 2002). After 15 years of
implementation of the Millennium Development Goals (MDGs), it was observed that many
countries lagged behind the targets set for various indicators. Despite long-standing
international efforts to reduce maternal mortality, there has been a slow improvement so far. In
2015, there were about 303 000 deaths in pregnancy and birth (UN, 2015). Following this delay
in achieving expected targets, member states within the UN unanimously adopted a revised
goals and targets under the Sustainable Development Goals where some of the goals were
merged with diverse targets. Goal 3 of the Sustainable Development Goal (SDG) seeks to
‘ensure healthy lives and promote wellbeing for all at all ages’ (McArthur et al., 2018).
Maternal health outcome is an integral part of Goal 3 of SDG where member countries are to
reduce maternal mortalities ratios to 70 per 100 000 live births and child mortality to 25 per
1000 live births (McArthur et al., 2018). An assessment of maternal mortality conditions
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globally after the 2015 SDGs resolution showed that maternal mortality was the second leading
cause of death among women of reproductive age in 2016, behind only HIV/AIDS, and was
the leading cause for women aged 15–29 years (WHO, 2019).
Another major concern linked to maternal complications and maternal health is stillbirths.
Every year, it is estimated that 2.6 million births are stillborn around the world, and 3.2 million
live-born children die in their first month (Kochar et al., 2014). Hailemichael et al. (2020)
report that growth-restricted and premature children can face challenges during birth, as well
as childhood disorders, educational, social and health issues later in life. Because of the
emotional toll on households, as well as the related medical and social costs, research into the
early detection of these conditions is more important than ever. Several studies conducted
across different WHO regions have shown that screening women regularly during birth
improves the identification of the tiniest babies from 32% to 77% (Hailemichael et al., 2020;
Tolefac et al., 2017; Athanasakis et al., 2011). According to Smith as cited in Athanasakis et
al. (2011), the case of stillbirth is similar to that of sudden infant death syndrome (SIDS): In
the 1980s, one out of every 500 babies died from SIDS. When a study revealed that sleeping
on the front was a risk factor for the child, a public health initiative was launched in early 2000,
which lowered it by 80–90 % (Young et al., 2018). While a straightforward approach to
mitigate stillbirth is unlikely, one can investigate whether biomarkers for the antecedents of
stillbirth can be developed and used for population-based screening (Athanasakis et al., 2011).
Almost all maternal and child-related deaths (95 %) occur in low-income and lower-middle-
income nations, with nearly two-thirds (65 %) occurring in the region of Africa which includes
Ghana (WHO, 2019). Women who live in poverty or rural areas, as well as women who belong
to ethnic minorities or indigenous peoples, are especially vulnerable (WHO, 2019). In middle
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income countries like Ghana, pregnancy and abortion complications are the leading cause of
death for 15-19-year-old women and adolescent girls (Piane, 2019). The risk of death from
maternal causes is linked to the risk of becoming pregnant as well as the obstetric risk of
contracting a complication and dying during pregnancy, labour or within 42 days after delivery.
Fertility rates are also higher in resource-poor conditions and the chance of dying in labour is
higher, so the lifetime risk of dying from maternal causes is significantly increased. Besides, it
is estimated that 1 in every 41 women die from maternal complications in low-income countries
(Tessema et al., 2017). The Ghana Maternal Health Survey making references from different
sources classifies maternal deaths into three; direct maternal death, non-obstetric maternal
death and unspecified maternal deaths (GSS, 2018). Direct maternal deaths are described as
deaths that occur as a result of obstetric complications during conception, labour or 42 days
after birth or the end of the pregnancy. Non-obstetric complications exacerbated by pregnancy
trigger indirect maternal deaths, while unspecified maternal deaths have an unexplained cause
and occurred during pregnancy, labour or 42 days after delivery. Direct maternal deaths
accounted for two-thirds of all deaths while indirect maternal deaths accounted for more than
a quarter of all deaths (27%) and unspecified maternal causes accounted for 6% in Ghana.
Other diseases, such as those of the immune, digestive and respiratory systems (45 %), as well
as infectious and parasitic disease (24%), were the leading causes of maternal death in Ghana.
These startling figures and facts expose long-standing and systemic health disparities. Firstly,
many of the middle-income countries like Ghana and other developing countries bear a large
share of the brunt of maternal mortality (Der et al., 2013). Again, the level of vulnerability to
maternal mortality among women increases among women who are poor, in minority groups
or are of indigenous sect in rural communities (Hunt & Mesquita, 2012). Besides low-income
countries being at risk of maternal-related deaths, low education, a lack of prenatal visits,
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caesarean delivery, haemorrhage and hypertension were all linked to a higher rate of maternal
mortality (WHO, 2019b). Maternal deaths from complications however are expected to reduce
as early detection of pregnancy complications increases. Diana et al., 2020 report that maternal
mortality could be prevented through early detection including the period preceding pregnancy.
Cameron et al., (2020) in a discourse on early detection pregnancy complications explained
that the main essence of early pregnancy assessment is to help detect any warning signs that
may arise at early stage and coming with a possible solution to address the situation before
escalating into serious complications. Quality antenatal care (ANC) is widely recognized as an
important opportunity for screening and early detection of pregnancy-related complications
such as preeclampsia, anaemia and gestational diabetes. These disorders will result in extreme
morbidity and mortality if detected late or not at all. Haemorrhage, which is often associated
with anaemia and preeclampsia, respectively, are thought to account for approximately 27 and
14% of all maternal deaths worldwide (WHO, 2016). In Ghana, the maternal mortality ratio
(MMR) was estimated at 319 per 100,000 live births in 2015 (Apanga & Awoonor-Williams,
2018) and reduced slightly to 310 per 100 000 live births in 2017 as estimated in the 2017
Ghana Maternal Health Survey (GSS & GHS, 2018). Abejirinde et al., (2018) in an analysis of
the MMR situation in Ghana noted that majority of these deaths are caused directly by
haemorrhage (39%) and hypertensive diseases (35%) as well as unsafe abortions (7%). The
analysis further indicated that indirect causes constitute about 26% and mainly through extreme
anaemia, diabetes and malaria.
Screening is another important tool for assessing the various abnormal conditions that may
arise during the pregnancy (Stahel, 2020). Even though the relevance of screening for
pregnancy complications is widely known, staff shortages, a lack of medical facilities and
supplies and inadequate referral links are all hindrances to pregnant women from detecting
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pregnancy complications at early stage especially among rural areas in Ghana (Abejirinde et
al., 2018). For routine diagnostics, pregnant women are often referred to remote health centres,
laboratories or private facilities. Women may be demotivated to attend ANC and comply with
referrals as a result of the time and resources spent visiting these services, which often result
in late detection and treatment of pregnancy-related complications.
1.2 Problem statement
The study by Der et al., (2013) on pregnancy related causes of death in Ghana in the previous
5-years revealed that about 12% of all death among women 15-49 years were related to
pregnancy. Further assessment of the pregnancy-related deaths showed that more than half of
these deaths were as a result of pregnancy-related complications. The 2017 Maternal Health
Survey estimates Ghana’s pregnancy-related mortality ration at 343 deaths per 100 000 live
births (GSS & GHS, 2018). The survey further indicates that majority (about 62%) of these
deaths are as a result of complications that were not either identified at early stage or was poorly
managed when identified. The Government of Ghana with the quest to reduce the rate of
maternal mortality and limit the rates of pregnancy-related deaths introduced the Free Maternal
Healthcare Policy in 2008 across the country (Ministry of Health, 2008). As explained by
Dalinjong et al., (2018), the focus of the maternal health care policy was to increase access to
maternal health care as a means of addressing all maternal health problems and reducing at a
higher rate the number of maternal deaths among pregnant women. While the policy seeks to
reduce both financial and geographical access, it also seeks to increase the use of skilled
personnel at all levels (prenatal, intra-natal and postnatal) to facilitate easy identification of
complications and addressing them accordingly. However, with more than a decade of
implementation of the policy, the rate of pregnancy-related deaths remains relatively higher
and lagging behind the SDGs.
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With the numerous benefits of having adequate knowledge about pregnancy complications and
how it can be managed, it is expected that pregnant women would seek to know more about
their pregnancy status and its related conditions. However, different studies have suggested
that general knowledge about pregnancy complications is relatively low (Hibstu & Siyoum,
2017; Jewaro et al., 2020). Assessment of previous reports of the Mamprobi Hospital shows
that more than 35% of all pregnant women initiate their ANC attendance at second to third
trimester. It is well noted that when ANC visit is initiated early, it helps in identifying early
complications which helps in managing it before getting out of hands. In all, a total of 5,962
antenatal visits were done at least once in both 2018 and 2019 and later increased to 7,111 in
2020. However, in 2018, 61.3% of the women who attended ANC services had at four antenatal
visits. The four or more antenatal visits in the facility decreased from 61.3% 2018 to 38.4% in
2019 and 21.3% in 2020 (GHS/Ayawaso East Municipal, 2021). The annual report further
noted that most of the women who did less than four visits started relatively late. For this
reason, the rate of pregnancy related complications mostly at delivery increased by 5.2%.
Furthermore, the report showed that the facility recorded institutional maternal mortality ratio
of 112 deaths per 100 000 live births in 2018 and all these were because of pregnancy-related
complications. The causes of these pregnancy related complications are however not clearly
defined. Similarly, there is limited information on the estimated knowledge levels of pregnant
women on pregnancy-related complications and other danger signs. This study is therefore
seeking to provide some relevant answers to these know gaps which may help in defining
appropriate interventions towards it.
1.3 Justification of the study
Late start of antenatal services affects effective introduction of appropriate interventions that
seeks to reduce the risk of maternal complications. Raising awareness of pregnant women on
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the danger signs may improve early detection of problems and reduces the delay in deciding to
seek obstetric care. It may further help create awareness among stakeholders of the health care
facility on factors affecting early detection of complications in pregnancy among antenatal
mothers for proper measures and interventions to be put in place. In the quest to reduce
pregnancy complications among women, it is important to understand whether women in
general have adequate knowledge about pregnancy complications and its effect. Studies on
knowledge level among pregnant women on pregnancy complications is limited in the
Ablekuma South District of Greater Accra region. This study will therefore bridge the
knowledge assessment gap in the district and further provide a platform for similar studies to
replicated in other districts.
1.4 Research Questions
1. What proportion of pregnant women who attend antenatal care services report
pregnancy complications?
2. What is the knowledge level of pregnant women attending antenatal care services on
obstetric danger signs?
3. What is the socio-demographic factors associated with pregnancy complications among
antenatal mothers at Mamprobi Hospital?
4. What are the maternal and obstetric factors associated with pregnancy complications
among antenatal mothers at Mamprobi Hospital?
1.5 General Objective and Specific Objectives
1.5.1 General Objective
The main objective of this study is to determine the factors affecting pregnancy complications
among antenatal mothers in Mamprobi Hospital.
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1.5.2 Specific objectives
1. To estimate the proportion of pregnant women attending antenatal care services who
report pregnancy complications.
2. To determine the level of knowledge of pregnant women attending antenatal care
services on obstetric danger signs.
3. To determine the socio-demographic factors associated with pregnancy complications
among antenatal mothers at Mamprobi hospital.
4. To determine the maternal and obstetric factors associated with pregnancy
complications among antenatal mothers at Mamprobi Hospital
1.6 Conceptual framework
The conceptual framework (Figure 1) of this study is developed from the Root Causes Analysis
(RCA) model as per the revised framework for health interventions and studies (UNC Medical
Centre, 2020). The Root Cause Analysis Model which was originally developed by Brennan et
al, (1991) indicates that the need for the application of the root causes analysis arise with
increasing complexity of health issues within the global context. Global and local health
dynamics and the frequent occurrence of mortalities and morbidities is cause for an immediate
effort to understand why the frequent occurrence of these health challenges. The assessment
by UNC Medical Centre shows that the RCA helps organizations and institutions to identify
main health problems and strategically design an intervention that focuses and addresses the
root problem rather than proposing a solution to the outcomes. Deming (2002) reiterates that
“to find problems is not enough. It is necessary to find the cause behind the problem and build
a system that minimises future mistakes”. Deming further describes the RCA as a tool that helps
to answer critical questions on why a particular health problem keeps occurring in a particular
location. It is evident from various applications of this model that the model addresses three
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main issues; what happened, why it happened and the consequences. The RCA further assumes
that systems and events are interrelated. An action in one area triggers an action in another, and
another, and so on.
In the application of RCA model in this study, it is important to understand why pregnancy
complications continue to occur among antenatal women who visit Mamprobi Hospital. The
framework describes three levels of the problem by applying the three-prong stages; what
happened (the main problem), why it happened (the root cause) and the consequences of the
problem (effect). In this study, what happened is denoted by pregnancy complications. In
analysing the concept of why the problem happened, this study outlines four key potential
causes of pregnancy complications. First, the study identifies demographic characteristics of
the antenatal women as one major root cause of pregnancy complications among the women.
The demographic factors that are being studied and linked to pregnancy complications are age,
religion, occupation, marital status, education etc. Another expected root cause to pregnancy
complication is socio-cultural and community factors. These factors are determined by either
a belief system in the community that affects utilization of antenatal care services at early stage
of pregnancy or other factors that influence the uptake of maternal health services. The
prevalence of pregnancy complications can also be attributed to some health-service factors
that may be related to health workers or systems or logistics in the health facility that either
increases or decreases access and quality of care. The final root cause that is linked directly to
the problem of pregnancy complication is the maternal health factors that seek to assess how a
woman’s parity, attendance to ANC service and knowledge about obstetric danger signs.
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Causes Problem Effect
Pregnancy
Complications
among
Antenatal
Mothers
Socio-demographic
Factors:
Age
Marital Status
Religion
Education
Occupation
Residence
Household income
Maternal and
Obstetric factors:
Parity
Gravidity
ANC attendance
Presence of pregnancy
complication
History of pregnancy
complication
Family History
Age of first pregnancy
Knowledge on
danger signs
Any idea of danger signs
Prevention of danger signs
Treatment of danger signs
Maternal
morbidity
and
mortalities
Figure 1: Conceptual Framework on possible factors that may cause the prevalence of pregnancy
complications.
Source: Author’s own construct
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CHAPTER TWO
LITERATURE REVIEW
2.1 Introduction
The chapter presents the various concepts and literature about study. In this chapter, the study
discusses the general concept on pregnancy and the various types or forms of complications
identified in pregnancy. Further discussions on the three main objectives of the study are done
with focus on various literature on each section. The chapter is therefore divided into four parts
with the first two parts focusing on definition of concepts and the prevalence of pregnancy
complications in general (from global perspective through Ghana’s context). The third and
fourth component discusses the knowledge level of women on pregnancy complications and
the factors that influence the prevalence of pregnancy complications among pregnant women.
The chapter concludes with a summary of key highlights of the literature discussed and the
gaps that have been identified in each of the key sections discussed. The main source of
information for this literature included PubMed, Google Scholar, African Journal online and
other reports of development partners.
2.2 Definition and discussions on Concepts
The various concepts on pregnancy are discussed under this section of the study. The definition
and types of pregnancy is first discussed in this section and later followed by discussions on
pregnancy complication’s definition and types.
2.2.1 Definition and types of Pregnancy
Pregnancy, also known as gestation, is the period when one or more children develop in the
womb of a woman. Multiple pregnancies produce more than one child, such as twins (Kelly &
Dennis, 2019). Bašić-Kes, (2019) explains that the outcome of any pregnancy may either be a
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live birth, a still birth or sometimes either a spontaneous miscarriage or induced abortion.
However, for live births and/or still births, it is expected that the pregnancy may last for a
period of 37-40 weeks before the delivery of the baby (Dines & Kattah, 2020). The
development of the baby in the womb goes through a number of processes which mostly starts
with the fertilization of the embryo. At week ten (10), the developed embryo is now considered
as foetus until delivery. Pregnancy in general is associated with a number of signs and
symptoms which mostly causes a lot of changes in the life of the pregnant woman. Kelly &
Dennis, (2019) highlight some of the key changes as tender breast, early morning sickness
which mostly comes in the form of nausea and vomiting, frequent urination and hunger.
Pregnancy is divided into three trimesters, each of which lasts about three months. According
to Sotiriadis et al. (2019), the risk of miscarriage (the natural death of an embryo or foetus) is
greatest during the first trimester. They added that movement of the foetus may be felt around
the middle of the second trimester. If high-quality medical care is provided at 28 weeks, more
than 90% of babies can survive outside of the uterus (Mei et al., 2019). Prenatal care has been
shown to improve pregnancy outcomes (Aziz et al., 2020). Prenatal care may include taking
extra folic acid, abstaining from drugs such as tobacco and alcohol, exercising regularly, having
blood tests and having regular physical examinations. Pregnancy complications can include
high blood pressure, gestational diabetes, iron deficiency anaemia, severe nausea and vomiting
(Aziz et al., 2020). Labour starts on its own when a woman is “at the term” in the ideal
childbirth. Babies born before 37 weeks are considered “preterm” and are at a higher risk of
developing health issues such as cerebral palsy. Babies born between weeks 37 and 39 are
referred to as “early term”, while those born between weeks 39 and 41 are referred to as “full
term”. Babies born between weeks 41 and 42 are considered “late-term”, while those born after
42 weeks are considered “post-term”. It is not recommended to induce labour or perform a
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caesarean section before 39 weeks unless it is necessary for medical reasons (Triay & Lambert,
2010).
The complexity of pregnancy and its uniqueness has resulted in different discussions into the
various types that are classified under it. Different authors have explained in different terms
what pregnancy is all about. However, not all of these types may have a direct link with
pregnancy complications. One of the major types of pregnancy that may directly linked to
pregnancy complications as discussed by Ross et al., (2018) is the molar type of pregnancy.
With molar pregnancy, it is established that there is an abnormal development of both the
placenta and embryo. In most cases, the molar type results in serious complications because of
the deformity of the placenta and sometimes the embryo. When the abnormally is the
pregnancy is only detected in placenta with the absence of an embryo, it is classified as
complete molar pregnancy, however, when the abnormality is in both the placenta and the
embryo, it is termed as partial molar. In most cases, molar pregnancies results in either
miscarriages or induced abortion. Layden & Madhra, (2020) also discussed another form of
pregnancy which is the ectopic or tubal pregnancy. Ectopic or tubal pregnancy is another
complicated form of pregnancy that may lead to the death of both the mother and the baby if
not managed well. In this case, the pregnancy is formed outside the main cavity of the uterus
with the embryo surrounding the fallopian tube. The development of the baby in such
pregnancies is affected which has the potential of causing serious harm to the mother. Similar
to the molar type, this pregnancy mostly end-up in miscarriage or induced abortion. The ectopic
or tubal pregnancy can further be categorised as intra-abnormal pregnancy especially when the
embryo in the fallopian tube causes tear or rupture (Kirkpatrick et al., 2017).
Multiple pregnancies have also been explained by Ochsenbein-Kölble, (2019) as another
important type that, though not directly linked, may lead to complications. Ochsenbein-Kölble
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explains that even though multiple pregnancies especially twins are mostly received as good
news, it comes with a lot complications especially when dieting is not well managed.
Another type of pregnancy that has a higher risk of causing pregnancy complications is the
breech pregnancy. Kaul & Rami, (2020) explain that the breech pregnancy occurs when the
head of the foetus is at the top of the uterus rather than facing down. In this situation, the feet
of the foetus which is expected to be pointing down faces up as against the normal position of
any foetus. At the point of delivery, the foetus or the baby is expected to have the head facing
down to the cervix to facilitate smooth and safe delivery. The presence of a breech pregnancy
automatically defiles the natural system of delivery which is mostly called spontaneous vaginal
delivery (SVD). However, unless there is a change at the final stage, all breech pregnancies
result in caesarean sections if the pregnancy is detected early and reported at the hospital. The
caesarean section is a measure of averting any possible mortality related to the condition.
Nonetheless, if a woman does not report to the facility for antenatal care services or report once
and does not continue for effective monitoring, there is the possibility of the mother making an
attempt to deliver through the normal SVD and may result in serious complications which may
eventually end up as a referred case to a facility or probably death. It is therefore important all
these forms of pregnancies are reported to appropriate facilities for proper monitoring by
gynaecologist.
2.2.2 Definition and Types of Pregnancy Complications
Ellfolk et al., (2020) in discussing pregnancy complications indicates that major health
problems that pregnant women face or go through during the period of pregnancy is classified
as pregnancy complications. Ellfolk et al., (2020) further indicated that the term pregnancy
complication is not limited to the occurrence of health problem to only the mother but to the
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baby as well or sometimes the two (both mother and unborn child) may suffer some health
problems. It is again explained that the occurrence of pregnancy complications may manifest
in different forms. Additionally, the prevalence of a health problem which is used to define
pregnancy complication may either occur prior to pregnancy or occur in the course of the
pregnancy. In each case, it is the effect of the health problem to both the mother and the baby
is analysed. Several studies have looked at different forms of pregnancy complications and
how they affect the wellbeing of the pregnant mother and her unborn child.
Preeclampsia is classified as one of the major pregnancy complications that affects women in
general especially in the third world countries (Brown & Al., 2018). The existence of
preeclampsia has been dated back since 2200 BC with first incidence reported to be in Egypt
(Chesley, 2015). However, the existence of preeclampsia is recognised for only a little over
100 years now (Roberts & Bell, 2013). Roberts & Bell, (2013) further explains that the increase
in preeclampsia cases and the rate of impact on maternal health conditions necessitated a
number of research into the problem. Brown. et al,, (2018) in their study on preeclampsia
explained that preeclampsia is one of the commonest maternal challenges associated with
pregnancy disorder, which occurs as a result of the onset of proteinuria and hypertension during
pregnancy. Preeclampsia continues to remain a major maternal health challenge in pregnancy
globally among all pregnancy-related risk conditions and increases the risk of mortality among
mothers (Eiland et al., 2012). The incidence rate and burden of health is significantly high in
developing countries compared to developed countries (Bilano et al., 2014). Say et al., (2014)
explains that nearly 14% of all maternal morbidities and 27.1% of all maternal mortalities are
as a result of preeclampsia. Though different studies have shown different results of
preeclampsia prevalence, largely, most of the studies have put preeclampsia prevalence
between 2-14% (Ghulmiyyah & Sibai, 2012; Wagnew et al., 2016; Macedoa et al., 2020).
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However, in Ghana, studies conducted have shown relatively higher prevalence of
preeclampsia among pregnant women. Adu-Bonsaffoh et al., (2017) in a study in Korle-Bu
observed a preeclampsia prevalence of 21.4% while Ahenkorah et al., (2019) in a similar study
in Bolgatanga recorded a preeclampsia prevalence of 25.4%.
Another pregnancy complication that is common among women in developing countries is
miscarriages. Rowe & Hawkey, (2019) in discussing miscarriages in pregnancy as a
complication explained that miscarriages normally occurs when there is an abrupt end or
unexpected end of any pregnancy and this may even be termed as premature abortion. Rowe
& Hawkey explain that more than a quarter of all pregnacies mostly result in miscarriages.
Most often, these miscarriages occur at the point when the woman has no idea of her pregnancy
status. Rowe & Hawkey further indicated that between 10-20% of all pregnancies that women
are mostly aware of end in miscarriage and that nearly 90% of all these miscarriages occur
before week 12 of the pregnancy. However, Martin et al., (2019) further indicates there are
some extreme cases where less than 2% of those who experience miscarriage may have late
miscarriage which mostly occur between 16-20 weeks of gestation. Wahabi et al., (2018) in a
study on how to use progestogen as a means of treating miscarriages explained that between
15-20% of all pregnancies result in spontaneous miscarriage. The study discussed some of the
signs of miscarriages to include vaginal bleeding which may not come with any abdominal
pain, closure of the cervix and rising temparature in some cases. Women who experience
miscarriages are largely affected psychologically expecially when they have waited for quite
some time to have a child.
Hypertensive disorder (high blood pressure) is another pregnancy complication that is
increasingly affecting women. Berhe et al., (2020) noted that when chronic high blood pressure
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is not well managed, the risk of maternal and child morbidity and mortality increases over time.
Hypertensive disorders (high blood pressure) is prevalent in about 10% of all pregnancies in
the United States and about 13% in all pregnancies globally (Leeman et al., 2016). It is known
as one of the most common complications in pregnancy and has been the root cause of about
7% of all maternal mortalities (Centers for Disease Control and Prevention., 2019). An
assessment of hypertensive disorders among women within reproductive age by Bateman et
al., (2012) shows that about 7.7% of all women who get pregnant develop severe hypertensive
disorder. Bello et al., (2021) discussed hypertensive disorder under chronic hypertension and
gestation hypertension. An assessment of the two types of hypertension among 139,389
pregnant women showed that 14.3% of the women developed chronic hypertension while the
prevalence for gestational hypertension was 13.8% (Bello et al., 2021).
Anaemia in pregnancy is another equally observed pregnancy complication that continues to
threaten the life of women. Berhan & Berhan, (2014) in a study on anaemia among pregnant
women noted that in developing countries, it is one of the commonest three major pregnancy
complications among antenatal women. An assessment by the World Health Organization,
(2011) on global estimates on conditions among pregnant women indicates that nearly 56% of
all women in less developed countries develop anaemia during the last trimester of pregnancy.
Wemakor, (2019) in a study on anaemia in pregnancy in Northern Ghana stated that the
prevalence of anaemia in pregnancy is becoming a burden for both antenatal women and health
workers who assist in managing anaemia conditions. Wemakor in his study observed that as
high as 50.8% of all the pregnant women who participated in the study had anaemic conditions.
The study further noted that anaemia condition increases with an increase in gestation week of
the pregnancy and that more than two-thirds of the conditions occur in the final trimester.
McClure et al., (2014) in analysing why anaemia conditions in pregnancy continues to rise in
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sub-Saharan Africa noted that the level of iron intake is very limited among pregnant women.
Most women tend to depend largely on carbohydrate foods with little or no iron rich foods.
Beatty et al., (2017) argues that in places where animal protein, fruits and vegetables are
common and easily accessible, cultural practices and other belief systems prevent pregnant
women from utilising these products to boost their iron content and consequently increase their
blood level.
2.3 Prevalence of pregnancy complications among antenatal women
The prevalence of pregnancy complications or danger signs is discussed in this section at two
different levels. First, this review looks at the pooled prevalence of all complications in
different studies while the second part discusses pregnancy complication specific prevalence.
Law et al., (2015) conducted a retrospective comparative study among pregnant women aged
15-49 years to determine the prevalence of pregnancy complications and its effect on healthcare
cost in developed countries. The study which utilised secondary data (maternal records of
pregnant women) of 322,141 pregnant women observed a pooled prevalence (number of
pregnant women with at least one complication) of 46.9%. Further analysis was done in the
study to determine which pregnant complication is more predominant among the pregnant
women. The study observed that foetal abnormality was the most predominant complication
with 24.7% of the women experiencing this complication. Additionally, about 16% of the
women had early or threatened labour while 10.6% and 7.2% of the women had haemorrhage
and diabetes or abnormal glucose tolerance respectively. Mwilike et al., (2018) in another study
in Tanzania using urban women observed that 17.4% of the women who visited the facility for
antenatal care services had pregnancy complications. Those with pregnancy complications,
majority (91%) were diagnosed in health facilities while the other 9% were seen by the women
themselves.
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Paul Jean Sengoma et al., (2017) also conducted a facility-based cross-sectional study in
Uganda to determine the prevalence of pregnancy-related complications among pregnant
women. The study was conducted between 2014 – 2015 and recruited 817 pregnant women
who were utilising antenatal care services in selected facilities within the northern province of
Kampala. The study observed almost a similar prevalence as in the case of Law et al., (2015)
with a prevalence of 43.1%. However, unlike the study by Law et al., (2015) in the USA where
specific complications prevalence was relatively higher in foetal abnormality and threatened
labour, the study in Rwanda observed different types of pregnancy complications. Among the
reported cases of pregnancy complications in the study areas were anaemia, severe vaginal
bleeding, hypertensive disorder and diabetes. Specifically, the study noted that 14.9% of the
women had anaemia which was mostly detected in the last trimester, 5.6% with severe vaginal
bleeding and 5.3% diagnosed of diabetes. Rulisa et al., (2015) in a study in Rwanda looked at
the prevalence and factors that contribute to maternal near miss among pregnant women who
utilise tertiary health facilities. In the definition of the maternal near miss, the study concluded
that pregnancy complications are generally the contributing factors to maternal near-miss
among the women. These levels of complications generally increased the rate of caesarean
utilization among the women. The prevalence of maternal complications as observed in the
study by Rulisa et al., (2015) was 41.3% while the rate of caesarean utilization was 45%. More
than 85% of the women with maternal complications resulted in caesarean section. On specific
complications (measured as severe maternal morbidity), the study observed that peritonitis,
hypertensive disorder, haemorrhage and cardiomyopathy were top complications among
pregnant women with observed prevalence at 30.2%, 28.6%, 19.3% and 5.2% respectively.
In general, majority of the studies on pregnancy complications have looked at specific
complications and their respective prevalence and associated factors. Studies on preeclampsia
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have extensively been done at different levels especially in Ghana and Africa in general.
Ngwenya, (2017) in a study in Mpilo Central Hospital in Zimbabwean city of Bulawayo
observed that only 1.3% of the women who utilise the facility had preeclampsia. The study
however limited its focus on severe type of preeclampsia without considering the mild one.
Vata et al., (2015) also analysed the prevalence of preeclampsia in Dilla region of Ethiopia and
observed a lower preeclampsia prevalence of 2.2%. When further analysis was done to
determine only severe preeclampsia cases, the study observed similar rate of 1% as in the case
of Ngwenya, (2017). Ngwenya, (2017) used about 7,700 maternal records of pregnant women
and arrived at that conclusion. Another study in Ethiopia by Belay & Wudad, (2019) using
antenatal records of women who utilised some selected facilities over a period of a year
however observed relatively higher prevalence. While Vata et al., (2015) focused on urban
facilities, Belay & Wudad, (2019) looked at both urban and rural women who utilise antenatal
care services. Belay & Wudad, (2019) observed a prevalence of 12.4%, about 10% more than
the observed rate in the earlier study by Vata et al (2015). The size of the sample may play a
role in the observed prevalence of the preeclampsia. While Vata et al. used over 7,700 maternal
health records and recorded relatively lower rate (2.2%), Belay & Wudad, (2019) only sampled
129 pregnant women for face to face and observed relatively higher prevalence (12.4%).
Musa et al., (2018) in a study in Nigeria in the Jos Teaching Hospital observed a preeclampsia
prevalence of 8.8%. Onoh et al., (2020) in another study in Nigeria focusing on severe
preeclampsia observed that 3.4% of the women had severe preeclampsia while 0.6%
experienced eclampsia. In an earlier study in the Calabar Teaching Hospital, Kooffreh et al.,
(2014) estimated the prevalence of preeclampsia and discussed the factors that influence the
prevalence of preeclampsia. In that study, it was observed that only 1.2% of 8,525 women had
records of preeclampsia. Studies in Ghana on preeclampsia have shown relatively higher
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prevalence as compared to that in Nigeria within similar teaching hospitals. While the studies
in the two Nigerian teaching hospitals as reviewed were lower than 10%, the rate in Ghana was
higher than 20%. Adu-Bonsaffoh et al., (2017) in their study in Korle-Bu Teaching Hospital
observed that 21.4% of the women who utilised maternal health services in the facility had
preeclampsia. Ahenkorah et al., (2019) in a different in the Bolgatanga Regional Hospital of
Ghana noted that 25.4% of the women who utilised antenatal care services in the year 2017
reported preeclampsia. Notwithstanding these high prevalences, a study by Fondjo et al.,
(2019) in Kwame Nkrumah University of Science and Technology hospital observed a
prevalence of 4.0%.
Anaemia in pregnancy is another major pregnancy complication women face. In Ghana, the
prevalence of anaemia in pregnancy differs from one study to the other. Anlaakuu & Anto,
(2017) in a study in Sunyani Regional Hospital among antenatal women observed different
levels of anaemia conditions. The study categorised anaemia prevalence into severe, moderate
and mild as per the definition of Ghana Health Service, (2016). For severe anaemia, the study
observed a prevalence of 1.6% while a prevalence of 16.1% was observed for moderate
anaemia and 40.2% for mild anaemia. Wemakor, (2019) also conducted a study in Tamale
Teaching Hospital among women who access antenatal care services. Using analytical cross-
sectional design of 400 pregnant women, the study observed that 50.8% of the women were
anaemic. The study further noted that the prevalence of anaemia increases with increase in
gestation period. Anaemia prevalence in the first trimester was 32.2% and further increased to
53.7% and 77.5% in the second and third trimesters respectively.
Hypertensive disorder continues to be another challenge in Ghana and other developing
countries with relatively high prevalence. In an earlier study by Obed & Patience, (2006), it
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was noted that the general hypertensive disorder prevalence among pregnant women in Ghana
ranges between 6% to 7.5%. However, over a period of time, different studies have shown
higher prevalence. Adu-Bonsaffoh et al., (2017) analysed the prevalence of hypertensive
disorder among pregnant women who visited antenatal care services in Korle-Bu Teaching
Hospital. Among the 1856 pregnant women who were sampled for the study in Korle-Bu
Teaching Hospital, 398 women representing 21.4% were diagnosed with hypertensive
disorder. Gemechu et al., (2020) also did a study on the prevalence of hypertensive disorder of
pregnancy and its associated outcomes in sub-Saharan Africa including Ghana. The study
observed a pooled prevalence of 8% of all hypertensive disorder across the study countries.
Awuah et al., (2020) in a study in Komfo Anokye Teaching Hospital noted that 39.25% of the
pregnant women who participated in the study were diagnosed of hypertensive disorder.
Further analysis of the results showed that 33.3% of the women had gestational hypertension
while 4.8% had chronic hypertension.
Other pregnancy complications in Ghana show different results and outcomes. Ahinkorah et
al., (2021) conducted a desk review of the 2017 Ghana Maternal Health Survey focusing on
induced abortion, miscarriages and still births. Miscarriage was higher among the three
pregnancy complications analysed in this study. The prevalence of miscarriage among pregnant
women in Ghana was 10.8% while induced abortion among the pregnant women was 10.4%.
Polis et al., (2020) also conducted a stratified sampling study using data from 598 facilities
across the country. The study noted that the rate of induced abortion was relatively high among
pregnant women with a rate of 26.8%.
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2.4 Knowledge of antenatal women on pregnancy complications/danger signs
General assessment of knowledge levels among antenatal women on pregnancy complications
is crucial in the study of complications in pregnancy. Different studies have assessed the level
of knowledge among pregnant women on pregnancy complications in developing countries.
Hoque & Hoque, (2011) conducted a study in KwaZulu-Natal province in South Africa among
pregnant women on their knowledge levels on danger signs for major obstetric complications.
The study focused largely on urban women who were relatively younger with a mean age of
26 years. The study noted that 52% of the women knew about some dangers of major obstetric
complications. Ameyaw et al., (2020) tried to find out whether knowledge on pregnancy
complications affects the utilization of skilled delivery. The study analysed the 2014
Demographic and Health Survey of Bangladesh. The study noted that about 53% of the women
who utilise antenatal care services in the health facilities indicated that they had been told of
danger signs in pregnancy. The study however did not estimate the degree of knowledge
whether it is adequate or inadequate. Awareness about danger signs may not be enough to
influence skilled delivery as the study sought to do. Mwilike et al., (2018) did an extensive
analysis of knowledge levels of pregnant women on pregnancy complications. The study which
was conducted in Tanzania enrolled 384 antenatal women in two different health facilities.
General awareness levels of women on danger signs were relatively high with a rate of 57.8%.
However, when detailed assessment of knowledge was done, it was observed that only 31% of
the women had adequate knowledge of danger signs in pregnancy.
Different studies on knowledge about obstetric danger signs have been conducted in Ethiopia
from different regions and with diverse results. Maseresha et al., (2016) conducted their study
in Somali region of Ethiopia using 632 women. The study results showed that only 15.5% of
the women had adequate knowledge about obstetric danger signs. In the Oromia region of
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Ethiopia, Wassihun et al., (2020) also conducted a study to assess the knowledge of antenatal
women. Among the 422 women who participated in this study, 64.7% were able to mention at
least one of the danger signs, however, women with good knowledge were relatively lower
(40.5%) compared to those who were aware of danger signs. Another study by Damme, (2016)
in the Gedo region of Ethiopia looked at knowledge levels of pregnant women who were
attending antenatal care services in some health facilities within the region. The observed
knowledge level in Gedo was relatively higher among the studies that were done in Ethiopia
which have been reviewed. Among the 198 women who participated in the study, 57.5% of the
women had adequate knowledge about dangers signs in pregnancy. The high knowledge levels
observed in this study is largely influenced by the level of educational status of women. Other
key determinants to the knowledge levels included occupational status and access to social
media. Majority (78%) of the women had access to social media and were actively using it.
In Uganda, Kabakyenga et al., (2011) conducted a study on knowledge about danger signs and
bed preparedness practice among 764 rural women who had recently delivered. Through
retrospective approach, the study asked the women to mention at least one of the danger signs
in pregnancy as a means of assessing awareness. The study noted that 72% of the women were
aware of at least one of the danger signs in pregnancy. However, when further assessment was
done to test the knowledge of at least any three of the danger signs, the knowledge score was
far lower than expected with only 19% of the women reporting adequate knowledge on three
or more of the danger signs. Woldeamanuel et al., (2019) also assessed the knowledge levels
of pregnant women and its associated factors in the Tera district of Northern Ethiopia. The
study sampled 563 women and tested their knowledge on key danger signs in pregnancy. The
results of the study analysis showed that 37.5% of the women were more knowledgeable about
obstetric danger signs. Unlike the study by Kabakyenga et al., (2011) which focused on rural
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women, the study by Woldeamanuel et al., (2019) combined both rural and urban women.
Significantly, the rate of knowledge among the pregnant women on obstetric danger signs was
influenced by place of residence (urban) and educational status. Despite involving urban
women in their study, Hibstu & Siyoum, (2017) observed a lower rate compared to
Woldeamanuel et al., (2019). Hibstu & Siyoum, (2017) noted that women who had adequate
knowledge about obstetric danger signs were 21.9%, a rate which is almost the same as the
knowledge rate observed in Kabakyenga et al., study.
A study by Ossai & Uzochukwu, (2015) also had a differnet prespective about knowledge
levels of women on obstetric danger signs. Comparative assessment was done between rural
women and urban women on their level of knowledge about obstetric danger signs. The study
observed that women who were in rural communities had higher knowlegde rates (24.4%)
compared to urban women (16.7%). The determining factors of obstetric danger signs do not
remain at times. In Ghana, an assessment of knowledge levels of pregnant women on
pregnancy danger signs show different results from each other. Aborigo et al., (2014)
conducted a similar study to assess the knowledge levels of women on obstetric danger signs
and the factors that influenced the health seeking behaviour of women in the Kassena-Nankana
District of Northern Ghana. Unlike the others so far reviewed, this study used qualitative
method to solicit information from women who have had at least one delivery. Through focus
group discussions, the women demonstrated good knowledge about dangers signs by
mentioning most of the obstetric danger signs that are commonly known. Some of the dangers
signs that were commonly mentioned are excesive bleeding, waist pains, stomach ache,
frequent vomiting and fever. Generally, source of information from these women was mainly
through health workers. Saaka et al., (2017) also conducted another study on knowledge about
dangers signs and how social behaviour change communication (SBCC) can influence the
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knowledge levels among pregnant women. The study which was conducted in East Mamprusi
District of Northern Ghana sampled 521 antenatal women. Assessment of adequate knowledge
was done using least three obstetric danger signs as indicators for adequate knowledge. The
study therefore observed that 51.2% of the women had adequate knowledge about obstetric
danger signs. However, when further assessment was done to ascertain the difference in
knowledge among those who received SBCC intervention, the study noted that knowledge
levels changed by 2.1 times. Women who received social behaviour change communication
scored 2.1 times more in knowledge score than those who did not receive any SBCC.
2.5 Factors Affecting the prevalence of pregnancy complications
The discussion on the prevalence of pregnancy complications have shown that while there are
lower pregnancy complication rates in some areas, other countries have recorded higher
pregnancy complication rates. Some of the studies on the prevalence tried to look at the reasons
that have caused these variations in rates across the study areas. In some cases, the prevalence
within a given country differs and therefore require further discussions to know why the
difference in prevalence rates among different studies. The discussion on the factors have been
segregated into three: 1). socio-demographic factors, 2). clinical and health service factors; and
3) socio-cultural and community factors. Most of these discussions are done in relation to a
particular pregnancy complication as studies on general complications are limited.
2.5.1 Socio-demographic factors associated with prevalence of pregnancy complication
Different studies have linked several socio-demographic factors to pregnancy complications in
general while other studies have looked at specific pregnancy complications rather than general
assessment. Studies by Luo et al., (2020), Jones et al., (2017) and Rulisa et al., (2015) have all
done a pooled analysis of most of the pregnancy complications in a single study. Luo et al.,
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(2020) in a study in China analysed the rate of pregnancy complications among nulliparous
and multiparous women in a prospective cohort study. Among the nulliparous women, the
study noted that women with advance maternal age (> 35 years) were more likely to develop
maternal complications such as preeclampsia, gestational hypertension and premature rupture
of the membrane as compared to women aged 20-29 years. However, among the multiparous
women, the study noted that an increase in the maternal age of the women resulted in high
occurrence of gestational diabetes mellitus, anaemia, preterm labour and premature rupture
membrane by 3.29, 1.85, 1.89 and 5.14 times respectively. The study by Jones et al., (2017)
in the Hohoe Municipality in Ghana as in the case of Luo et al. also observed only maternal
age as the only demographic factor influencing pregnancy complications. The study observed
that women with age between 35-39 years were more likely to develop pregnancy
complications compared to women aged 20-25 years. Depending on the type of the pregnancy
complications, the rate of risk of complications increased with an increase in maternal age.
Rulisa et al., (2015) also analysed maternal complications and described it within the context
of near miss cases among pregnant women in Rwanda. The study which identified sepsis,
hypertensive disorder and haemorrhage as the main pregnancy complications noted that the
rate of maternal near miss was relatively higher among women who belonged to the lower
socio-economic status/class as well as women who resided in the eastern part of the country.
Specifically, those in the eastern part were noted to be among the rural poor. Sengoma et al.,
(2017) in a study in Rwanda analysed pregnancy-related complications and its effect on the
survival of a woman. The study noted that the prevalence of pregnancy-related complications
was predominant among women who live far from a health facility as well as women belonging
to poor households.
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Beyond the assessment on general pregnancy complications, specific pregnancy complications
and danger signs risk factors have been discussed at different levels. Studies on preeclampsia
have also looked at socio-demographic factors that increases the risk of its occurrence. Bilano
et al., (2014) in their study on preeclampsia risk factors stated that educational status of the
pregnant mother is critical in determining the outcome of preeclampsia. The study observed
that women with secondary or tertiary level education were less likely to develop preeclampsia
as compared to women with no education. A study by Stitterich et al., (2021) which was
conducted in Freetown, Sierra Leone analysed the risk factors that are associated with
preeclampsia and eclampsia among women who are referred for maternal health care services
in the main hospital in Freetown. The study was a case-control with 214 women with
preeclampsia and eclampsia and 458 women within the control group. The study observed that
a number of obstetric and maternal health factors, however, the only socio-demographic factor
that predicted the prevalence of preeclampsia at univariate level was marital status of the
women and the occupation of the women. Women who were in a relationship or married were
56% more likely to experience preeclampsia or eclampsia relative to women who are in no
relationship. Similarly, women who were traders had 29% chances of experiencing
preeclampsia more than women who were not employed. Morikawa et al., (2013) in a study
among pregnant women on preeclampsia noted that women aged 35+ have higher risk of
developing preeclampsia compared to women who are below 25 years. Morikawa et al. study
noted that as a woman’s age increases, the risk of preeclampsia also increases.
Another pregnancy complication that has further reviewed is anaemia as discussed earlier. Li
et al., (2018) also analysed the prevalence and risk factors associated with adverse anaemia in
pregnancy. The study noted that women aged 35 years or more had higher odds of developing
anaemia in pregnancy than women with relatively lower maternal age. With an overall anaemia
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prevalence of 23.5%, Li et al., noted that women with lower monthy incomes levels have higher
risk of having anaemia in pregnancy compared to women with higer income levels.
Additionally, women who reside in rural communities were more likely to have anaemia in
pregnancy compared to their colleagues who reside in urban communities. Wemakor, (2019)
in a study in Northern Ghana analysed factors that influence the prevalence of anaemia among
women. Univariate analysis of the results showed that pregnant women who were Muslims
were more likely to develop anaemic conditions during pregnancy compared to Christians.
Again, the risk of anaemia was relatively higher among women who belong to lower quartile
of household wealth group than women belonging to household with higher wealth.
The study by Ahinkorah et al., (2021) on analysis of the Ghana Maternal Health survey showed
that some socio-demographic factors were significantly dominating the causes of induced
abortion, still births and miscarriages in Ghana. The study observed socio-demographic factors
such education, religion and residence to influence the general study outcome. Under
education, the study noted that women with higher education had higher odds of experiencing
miscarriages than women who have not had any education. The findings on religion were
relatively different at various outcomes. Christian women were observed to have higher odds
of having induced abortion as compared to Muslim, however, in the analysis of miscarriages,
Muslim women were observed to have higher odds of miscarriages than Christian women.
Both induced abortion and miscarriages were found to be relatively higher among women in
residing in urban communities than women who reside in rural communities. Further noted
that, women who are aged 25-34 years experienced more miscarriages as compared to women
with lower age 15-24 years. Baruwa et al., (2021) also looked at the prevalence of induced
abortion and its related factors among women in Ghana. The study observed that the prevalence
of induced abortion was significantly associated with women who had secondary level of
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education, who live in urban communities especially in the cities, who belong to non-Catholic
denominations and those who were single. In general, the rate of induced abortion was higher
among Akans as compared to the other ethnic groups.
In an earlier study by Mote et al., (2010) in Hohoe Municipality, it was noted that some of the
outcome were relatively different from what had been observed in later studies. Mote et al.,
observed that the risk of induced abortion was relatively higher among women who were
married as opposed to the observed result in the study by Baruwa et al., (2021). Mote et al.,
further observed that women who have secondary education were less likely to have induced
abortion, a result that also opposite the finding by Baruwa et al., (2021). However, three results
of this study conformed to most of the studies revealed. Mote et al., noted that the rate of
induced abortion was significantly higher among women who live in urban and peri-urban
communities, women who were married and women in formal employment. Klutsey &
Ankomah, (2014) also did a similar study in the Volta region of Ghana and noted that the odds
of induced abortion among married women reduced by 4% compared to women who were
single while the odds of induced abortion among women with more than two pregnancies were
relatively higher as compared to nulliparous women.
Discussions on hypertensive disorder in pregnancy has also been reviewed in a number of
studies. Tebeu et al., (2011) in a study in Cameroun realised that, the risk of hypertensive
disorder in pregnant among women were significantly associated with two socio-demographic
factors: educational status and occupation. The study noted that women who were illiterates
had 60% chances of having hypertensive disorder compared to women with higher level of
education, i.e., secondary or tertiary. On occupation, it was further noted that the risk of
hypertensive disorder was about 2.8 times higher among housewives compared to women who
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were employed either in the formal sector or self-employed. Meazaw et al., (2020) in a study
on hypertensive disorder in pregnancy among women in sub-Saharan Africa observed that
women with lower educational level (no education or primary level) have higher odds of
developing hypertensive disorders compared to women with tertiary education. The meta-
analysis by Meazaw et al., further concluded that women with advanced maternal age had
higher risk of developing hypertensive disorder compared those with lower maternal age.
Mwanri et al., (2015) also in a similar study in Tanzania noted that the odds of hypertensive
disorder increases with an increase in maternal age and that women above the age 35 years had
higer risk of hypertensive disorder. The study noted that the risk of hypertensive disorder was
higher among urban women than in rural communities. Mekonen et al., (2018) in a study on
pregnancy-induced hypetension in Ethiopia observed that maternal age and education were
significantly associated with the risk of hypertension in pregnancy. The study noted that
women with advanced maternal age were more likely to have hypertension in pregnancy
compared with women with lower maternal age while women with lower educational status
had higher risk of hypertensive disorder compared with women with higher level of education.
Another study in Nigeria by Azubuike & Danjuma, (2017) on hypertension in pregnancy found
age and socio-economic status as the demographic significant factors that are associated with
the study outcome.
A review of the socio-demographic factors have shown that limited analysis has been done on
the factors that looked at general complications and danger signs in pregnancy. Nonetheless,
specific studies in relation to specific pregnancy complications and danger signs have identified
similar results that may apply in most of cases and can equally be applied in this study.
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2.5.2 Obstetric and maternal factors complications
Similar review as was in the case of the socio-demographic factors have been done for obstetric
and maternal conditions that influence the prevalence of pregnancy complications. In this
discussion, a review is first done for general studies that have looked at pregnancy
complications in general and later focused on specific complications as outlined earlier in this
study. The study by Jones et al., (2017) in the Hohoe municipality observed that women with
family history of hypertension and past record of preterm delivery have higher odds of
experiencing some major pregnancy complications than women with no family history of
hypertension and no past record of preterm delivery. Habtei & Wondimu, (2021) in a study on
factors that influence maternal complications and near miss observed that history of pre-
existing medical disorders increases the risk of pregnancy complications and maternal near
miss cases. Additionally, the study noted that women who have had poor preparedness practice
towards birth and complications have higher risk of maternal complications. Terefe et al.,
(2020) in their study on factors that contribute to danger signs and complications in pregnancy
observed that the risk of prevalence of obstetric danger signs and complication are associated
with antenatal attendants and parity. The study noted that women who have had less than four
antenatal visits had higher risk of experiencing obstetric danger signs than women with four or
more antenatal visits. Similarly, women who are primigravida had higher risk of experiencing
obstetric danger signs than women who are multigravida.
The discussions on maternal and obstetric factors in the next sessions discusses specific
pregnancy complications and their respective factors. In most cases, the factors from various
studies and different pregnancy complication outcomes are similar, nonetheless, there are few
results that have been differently observed. Wagnew et al., (2020) in a meta-analysis of a
number of studies on preeclampsia observed that primiparous is a high-risk factor to
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preeclampsia. The study noted that women who are pregnant for the first time have higher risk
of developing preeclampsia and subsequently eclampsia compared to multiparous women. The
analysis of series of studies further showed a significant relationship of previous history of
hypertension and preeclampsia. Wagnew et al., (2020) argued that the risk of preeclampsia is
higher among women who have history of hypertension in their previous pregnancy as
compared to those without any history. Earlier studies in different context have all observed
same results (Duckitt & Harrington, 2015; Tessema et al., 2021). Tessema et al., (2021) further
noted that the outcome of a body mass index has a greater influence on the outcome of
preeclampsia diagnosis. Women who are obese with BMI of more than 24.9 kg per meter
square have higher risk developing preeclampsia than those with lower BMI. O’Brien,.et al.,
(2013) asserted that the BMI factor may be explained by the resistance of insulin which
increases the risk of autoimmune disease, urinal tract infection, hypertension and consequently
preeclampsia.
Stitterich et al., (2021) also in their study on preeclampsia factors observed that women with
family predisposition for preeclampsia had higher odds of having preeclampsia compared to
women with no family predisposition. Similarly, women with past records of hypertension had
higher odds of experiencing preeclampsia in pregnancy relative to women with no past record.
Other significant factors that the study observed a having an association with preeclampsia
include urinary tract infection during pregnancy, presence of prolonged diarrhoea during
pregnancy and inadequate food intake. Gabbe et al., (2016) in their study identified family
history of preeclampsia, obesity, gestational diabetes, pre-existing chronic hypertension and
multifetal gestation as significant factors that are associated with preeclampsia. Fox et al.,
(2019) also in a different study on preeclampsia risk factors noted that women with family
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history of preeclampsia, multifetal pregnancy and with pregnancy intervals of more than 10
years have higher risk of experiencing preeclampsia than their counterpart women.
Different studies have also shown significant results on hypertensive disorders in pregnancy.
Mwanri et al., (2015) in their study noted that women with minimum dietary diversity score
were more likely to develop hypertensive disorder. Again, the study noted with women who
are HIV positive have higher risk of experiencing hypertensive disorder. Tebeu et al., (2011)
in their multiple analysis of risk factors noted that the odds of experiencing hypertensive
disorder was significantly higher among nulliparous women compared to multiparous women.
Additionally, the risk of hypertensive disorder increases among women with family history of
hypertension and history of hypertension in the woman compared to women with no family
history or history of hypertension. Meazaw et al., (2020) in their study also observed similar
results as other studies on factors influencing the prevalence of hypertensive disorders. The
study noted that primiparous women and those with a family history of hypertension had higher
risk of experiencing hypertensive disorder compared to nulliparous women and women with
no family history of hypertension. Mekonen et al., (2018) also observed the same results as all
studies that, women with family history of hypertension and preeclampsia have higher risk of
pregnancy-induced hypertension. Azubuike & Danjuma, (2017) and Brown et al., (2018) have
all confirmed similar results in hypertensive disorder risk analysis studies. The existence of
family history and past records of hypertension in the woman play a major role in hypertensive
disorder prevalence.
Anaemia studies have also been looked at from different perspectives. The results in these
studies are relatively similar to each other (Li et al., 2018; Fondjo et al., 2019; Wemakor, 2019).
Fondjo et al., (2019) in their study in Ghana also discussed some of the significant factors that
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contribute to the prevalence of anaemia in pregnancy. The study noted that the risk of anaemia
increases with gestational age in that as the gestational age of the pregnancy increases, the risk
of anaemia also increases. The study noted that the higher risk of anaemia was observed in the
third trimester. Additionally, the study noted that women who use tap water rather than purified
water had higher risk of anaemia in pregnancy. Wemakor, (2019) in their anaemia study in
northern Ghana observed that the risk of anaemia is higher among women who are in the third
trimester compared to women in their first and second trimester. The study by Li et al., (2018)
on anaemia observed that the body mass index of pregnant women even prior to pregnancy
possess a lot of risk in developing pregnancy complications especially anaemia.
2.5.3 Other related factors on pregnancy complications
Knowledge about danger signs and other specific complications play significant role in limiting
the occurrence of pregnancy complications among pregnant women. Wensing & Grol, (2019)
have argued that knowledge is the main thrust of every health intervention and that science
cannot thrive without knowledge. They further argue that for any intervention to achieve its
ultimate objective, it is important to situate the intervention within the knowledge cycle of the
people for which the intervention is implemented. Wensing & Grol, (2019) concludes that in
areas where there exists an increased knowledge about a health condition, adherence and
support for such intervention is relatively high. Acknowledging the importance of knowledge
on uptake of health services, Almomani et al., (2021) recommends for a consented effort to
ensure increased knowledge in any health service to facilitate smooth and increased uptake of
the service.
Knowledge studies on pregnancy dangers signs and its relationship on the occurrence of
pregnancy complications have all confirmed the assertion by Wensing & Grol, (2019) and
Almomani et al., (2021). Terefe et al., (2020) also did an extensive assessment of knowledge
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levels of pregnant women on dangers signs and its implication on pregnancy complications.
The study’s main focus was to identify factors that influence the occurrence of pregnancy
complications. Multiple analysis of the results showed that knowledge about pregnancy danger
signs was a major contributing factor in the prevalence of pregnancy complications. The
knowledge result showed that women who had adequate knowledge about pregnancy danger
signs had a reduced risk of experiencing pregnancy complications compared to women with
limited or no knowledge about danger signs. In their analysis, Terefe et al., further elaborated
that women with adequate knowledge were cautious about certain behaviours and lifestyle that
could lead into risk dactors. Adherence to recommended preventive measures were relatively
higher among those with adequate knowledge about danger signs. Fathy & Eittah, (2017) also
did a similar study in Egypt to ascertain whether knowledge about pregnancy danger signs have
any effect on the prevalence of pregnancy complications among pregnant women. The study
noted that knowledge levels among prgnant women were relatively high and that reduced the
risk of pregnancy infection in general.
Other studies have also been done to ascertain the relationship that exist between knowledge
levels on anaemia and the prevalence of anaemia in pregnancy. The study by Wemakor, (2019)
in the northern Ghana also analysed the levels of knowledge and its effect on anaemia. The
study noted that knowledge levels on anaemia was relatively low among the pregnant women.
The study observed that women who had little or no knowledge about anaemia had higher odds
of experiencing anaemia in pregnancy especially during the third trimester compared to women
who had higher knowledge about anaemia and how it occurs. Knowledge on anaemia focused
basically on prevention and management. In northern Ghana, the study noted that intake of
folic acid was relatively low among women with little knowledge since they did not know
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about the importance of the intake of folic acid. In India, Prabhu & Balakrishanan, (2015) also
looked at how an increase in knowledge can improve anaemia conditions in pregnancy.
Appiah et al., (2020) assessed the knowledge of and the adherence to anaemia prevention
among pregnant women in Juaboso in the Western North region of Ghana. The study observed
very low knowledge rate of 13.5% on anaemia among the pregnant women with a high anaemia
prevalence of 43.3%. The study observed that the low levels in knowledge affected the rate of
adherence to preventive measures with only 39.1% showing good practice to anaemia
prevention. The study further noted that the rate of anaemia was significantly higher among
women with low knowledge about anaemia in pregnancy compared to women who had higher
knowledge about anaemia. Augustina et al., (2021) also tried to assess the knowledge levels of
pregnant teenagers and how their knowledge levels affected their adherence and prevalence of
anaemia in pregnancy in some selected health facilities in Indonesia. The study observed
anaemia prevalence of 44% among the teenage pregnant women, a result which was noted as
one of the highest within the country and across several studies. The result of anaemia
prevalence was relatively in line with the knowledge score. Less than half of the teenage
women had adequate knowledge about anaemia. The study observed that, more than 60% of
the pregnant teenagers with anaemia were those who had little or inadequate knowledge about
anaemia. It is evident from these discussions that having adequate knowledge about a particular
pregnancy complication or its related danger signs reduces the risk of the occurrence of that
particular complication in pregnancy.
2.6 Summary of Literature
The literature on the prevalence of pregnancy complications was extensively reviewed and the
results showed that nearly all the studies on complications were limited to specific
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complications. Prevalence studies for pregnancy complications like preeclampsia, anaemia in
pregnancy, hypertensive disorders, etc were easily accessible from various journal cites. Both
meta-analysis and cross-sectional studies discussed prevalence results of a prevailing
pregnancy complication within a given geographical area. However, studies on pooled
pregnancy complications are limited. A scan through various journals showed that only a few
studies have been conducted to assess the general pregnancy complications in pregnant women.
This remains a major gap which this study seeks to address. This study therefore seeks estimate
the proportion of women within the study area who have exhibited at least one of pregnancy
complications.
Similarly, a review of literature has shown that studies on factors influencing pregnancy
complications have been limited to specific pregnancy complication rather than discussing
general factors of pregnancy complications irrespective of the type of complications. The only
two studies that were observed during a review of literature were conducted outside Ghana.
There has not been any general study so far in Ghana and especially in Greater Accra that have
considered general factors influencing pregnancy complications.
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CHARPTER THREE
METHODOLOGY
3.1 Introduction
The method employed in this study was explained in this chapter. The discussion on the
methods starts with the study design employed for this study, the study area, target populations,
sample size estimation and sampling techniques. Other sections discussed in this chapter
include methods of data collection and tools, pre-testing, quality control, variables and analysis
of data. The chapter concludes with highlights of the key ethical issues that are been addressed
in this study.
3.2 Study design
The study employed a facility-based analytical cross-sectional design among pregnant women
attending antenatal care services in Mamprobi Hospital. The study used quantitative method to
collect the data from October – November, 2021. The quantitative data was to estimate the
prevalence of pregnancy complications among the pregnant women and further estimate the
knowledge levels as well as the significant factors for the prevalence of pregnancy
complications.
3.3 Study area
The study was conducted at the Mamprobi Hospital within Ablekuma South District of Greater
Accra region.
3.4 Target and study population
The study population were pregnant women who attended antenatal care services at Mamprobi
Hospital.
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3.5 Inclusion Criteria
Participants for this study included:
a. Pregnant women who were utilising antenatal care services at Mamprobi Hospital
irrespective of the gestation period.
b. Pregnant women who had been referred to the facility for maternal health services
c. Women who were able to provide their antenatal cards
However, the following pregnant women will be excluded from the study:
a. Pregnant women who were due for labour
b. Pregnant women who were indisposed and could not participate in the study.
c. Pregnant women who were not willing to participate in the study.
3.6 Sample Size determination
The study sample size was derived using the Cochran formula (Cochran, 1977) which is:
N = Z²p (1-p)
e2
Where:
N = sample size,
Z= confidence level of 95% (standard value of 1.96),
e = margin of error = 0.05 and
p = prevalence of pregnancy complication = 43.1%; i.e., proportion of pregnant women
presenting with pregnancy complications at antenatal care service in a study by Rulisa et al.,
(2015).
N = (1.96)2 x 0.431 (1-0.431) ≈ 377
0.052
Adjusting for a 10% non-response rate gives, 0.1 * 377= 37.7 ≈38
Therefore, the desired sample size for the quantitative study was 377+38 = 415
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3.7 Sampling Techniques
The study employed simple random sampling method to select participants for the study.
With a total of 415 women surveyed, the study divided the study participants into ten (10)
groups, each group for a day which gave an average of 42 women per day.