s("H(KIL m" PI'BLIC IIEALTII 
('OU.u;.:o..- H.:ALTH SC,."n:s 
UNIV.:RStTY 0.- GHANA 
A.. ...... l.S.'M.:NT Ofi mE IMPACf OF PREGNAN('Y s(-UOOL ON PREGNANCY 
01 I('OML'iANDSKILI.U) DELIVt:R\ IN N\8DAM DlSTIUCfOF t-PPt:R 
EAST REGION 
B\' 
KOl.oG TIMBllU: JU"'-IA.."t 
10745155 
nil,} DI~ER'rAll()" IS S(-B\UTnm TO THE I-~I\'.:RSITY OF GHANA. 
I.H~IO:"li IN .. ".K .....\  •.•- UI~.ll ....n N. .. OI; H''': R":QIIIK.:\1.:lIj'( tUK H''': 
AWARD OF MASTER OF S<lENl.'E IN MONITORING AND E\" ALUAn", 
(MsqDEGREK 
JII\.20I<l 
DECLARATION 
I, Ko rog Timbre Jo nls hereby declare that this dissertation was written independently. and 
that neither part nor the wboleofthis ,",'OI'iC. has ever been presenled in any institution fo r 
another degree, except references to people' s work which I have duly acknowledged. 
SIGNATURE .. .~ . . ... .. 
1lH. SAMm:L DERY 
(SUPERVISOR) 
DEDICATION 
To the Almighty God. my family especially my sweet wife Oamo1ue Mbamah Rita, my 
daughters Somtim Laudina ZUiongpoka, Somtim Betty Sompogbil and my dear son Timbirc 
Yenitehit Angel Gabriel., Oengbe Tobiga, Madam Marilyn Schuster and My dear late Louis 
John Schuster III who was popularly known in Ghana as Daddy Lou!!. 
DEDICATION 
To the Almiabty God, my family especially my sweet wife Damolua Mbamah Rita, my 
daughters Somtim Laudina Zusongpoka. Somtim Betty Sompogbil and my dear son Timbire 
Yenilehit Angel Gabriel.. Dengba Tobiga. Madam Marilyn Scbusler and My dear late Louis 
John Schuster III who was popularly known in Ghana.s Daddy Lou I! . 
ACKNOWLEDGEMENT 
I wish to express my heartfelt appreciation to my supervisor, Dr Samuel Dcry for his 
professional guidance, understanding. patience and above all his mentorship throughout the 
study. I say thank you and may the Almighty God richly bless you in all your endeavours. 
My profound IJ"8litude a150 goes to the entire 5taft' of the Department of Health Policy 
Planning aDd Management especially the head of department Dr. Patricia Akweango, Or 
Chris Guure , Dr Paulina Atindaana., Dr. Doah Oumorh and the Public Health Monitoring 
and EvahSition cou.rx coordinator, Dr Genevieve Aryeeley for their wuneasurable support. 
Also. my deepest apprc!'(iation soes to the Upper East Regional Director of Health services 
for gnmting me the permission to carry out the study and more particularly the N.bdam 
District Director of Health Services, Madam Meiri Seidu for her motherly care and support 
dwingthestudy 
This work would not have been possible without the support oefamily and friends especially 
Dr. lawyer Somtim Tobiga, Dengba Tobiga. Somlim David Yen, 80mtim James Zoot. 
Madam !ltfarilyn Shuster, Oncmeba Clement., Baba Yahaya • Micheal. AkongyelsoDl. 
Robert., Eric Bad~na, Richwd. I thank all the health workers in the Nabdam di5trict in 
pcticular who did so much in various ways. In addition. my profound gratitude goes to my 
room mates, Apoyongo Maclean. Rober Mensah, Nuhu Kantamah. Apraku Edward and 
more especially Martin Swnani Danko for his ex.cellent computer skills he applied in 
formatting and reading lhroup this .... a rk. I remain very grateful to all members in 
Alexalldl:f K ... .Ipong "Un room 001" for the mutualism we showed each othtr. 
ACKNOWLEDGEMENT 
I wish to express my heartfelt appreciation to my supervisor, Dr Samuel Dery for his 
professiooal guidancc, undersumding, patience and above all his mentorship throughout the 
study. I say thank you and may the Almighty God richly bless you in all your endeavours. 
My profound gratitude also goes to the entire staff of the Depanrnent of Health Policy 
pltnni.ng and Managemenl especially the head of department Or. Patricia Akweango. Dr 
Chris Guure • Dr Paulina Atindaana. Or. Duah Dumorh and the Public Heallh Monitorin, 
and EvalUltion course coordinator, Dr Genevieve Aryeetey for their wuneasurable support. 
Also, my deepest appreciation goes to the Upper East Regional Director of Health services 
for gramin, me the permission to carry out the srudy and more particularly the Nabdam 
District Director ofHeaJth Services, Madam Mciri Seidu for her motherly can: and support 
during the SlUdy. 
This work would not have been possible without the support offamily and friends especially 
Dr. Lawyer Somtim Tobip, Oengba Tabiga, Somtim David Yen, Somtim lames Zoot, 
Madam Marilyn Shuster, Onemeba Clement, Baba Yahaya , MicheaJ . Akongyelsom. 
Robert, Eric Badiena. Richard. I thank aU the health workers in the Nabdam district in 
pan:icular who did so much in various ways. In addition, my profound gratitude goes to my 
room mates, Apoyongo MacLean, Rober Mensah., Nuhu Kantamah. Apraku Edward and 
more e5pCCiaJly Martin Swnani Danko for his excellent computer skills he applied in 
formatting and reading through this work. I remain very grateful to all memben in 
Alexander Kwaponll"Un room 002" for the mutualism we showed each other. 
TABLE OF CONTENTS 
.... i 
DECLARATION ... . 
.... .ii 
DEDICATION ... 
.. iii 
ACKNOWLEDGEMENT .. 
.iv 
TABLE OF CONTENTS ...... . 
vii 
LIST OF TABLES ...... . 
.. . viii 
LIST OF FIGURES ....... . 
LIST OF ABBREVIATIONS .... . .. .ix 
DEFINITION OF TERMS ..... 
ABSTRACT ....... . .. .. "xi 
CHAPTER ONE ..... . 
INTRODUCTION .. . 
l.Is.ckgrouoo .. 
1.2 The Pregnancy School in Nabdam District ... .. .... .4 
1.3 Problem Statement ..... . ....... 7 
1.4 Justification ... .. .• 8 
I .SResearchQuestions ...... . 
1.6 General Objective .... . . ........................ 9 
1.6.1 SpccificObjectivcs .... .. .... 9 
1.7 The Conceptual Framework .... .. ..... 9 
CHAPTER TWO .... 12 
LITERATURE REVIEW .... . .... 12 
2.0lntroduction ... .. .. 12 
2.1 Anaemia in Pregnancy ... .. ................ 12 
2.2 Low Birth Weight .... . .... 13 
2.3 Home Delh·eries. . .................... · ................ ........ 15 
2.4 General Factors l.nf1ucncing Pregnancy Outcomes .. " ...................................... 17 
2.S EnvironrnentalFacto~ .. 18 
2.6 Summary of the Literature ... .. ............... 19 
..... 20 
CHAPTER TI\REE ........ . 
..20 
METHODS 
.... 20 
3.0 Introduction .... . 
. ... 20 
3.1 Study Design ... . 
. ... .. 21 
3.2SrudyArea. .........  
.. .. 22 
3.3 Study Population .. . 
3.4 lneJusion and ExclusionCritcria .. ..23 
3.5 The Exclusion Criteria ........ .. . ... 23 
3.6 Sample Size Detennination ....... .. .. ... 25 
3.7PowerAnalysis ...... .. .. ... 25 
1.8 Data Collection .. .. .26 
3.9D.&aProcessing ....... . .. ...... 26 
3.9.1 Howmissingdatawashandled ....... . .. .......... 26 
3.10 Data analysis ....... . ... 26 
3.11 DifferenceinditTerencesanalysis(DlD) ...... .. ........ 27 
3.12 Matcbing procedures .... . .............. 28 
3.13 Qualityconuol ... . ............... 29 
3.14 Expcctedoutcomeofthe study ... .. .... 29 
3.15 Ethical consideration .. ........... 29 
CHAPTER FOUR .... ...... 31 
RESULTS ... .. .................. .. .......................................... 31 
4.0 Demographic characteristics of pregnant women. . ............................................ 31 
4.1 Differences in mean Hemoglobin (Hb) Concentration between the two groups ..... . 33 
4.2 Differences in mean hinh weight between the control and comparison groups ....... 3S 
4.2.1 Proportion of low birth weigbt..... .. ................................................ 36 
4.3 Proportion of Home deliveries .... .. ................................................ 36 
4.4 Difference in mean Hb concenualion at 36 weeks .. . .......................... 37 
4.4.1lmpact estimates: Propensity Score MatchinS ...................................... .......... 37 
4.5 Assessing quaiity ofmalCbing... ...38 
4.5.1 Results on Quality ofMuching procedures .. .. ..... 39 
4.5.2 Results from Kennel density b81ancing plot ... .. ............... 39 
..... ............. 20 
CHAPTER THREE 
.............. ........ 20 
METHODS ... 
3.0 Introductioo ... . .. ....................... 20 
3.1 Study Design .... . . ... ................ 20 
3.2 Study AmI .... . ..21 
3.3 StudyPopuJation .•.•..... .. .. ... 22 
3.4 Iaclusion and Exclusion Criceria .... . ......... 23 
3.5 The Exclusion Criteria. . ...... 23 
3.6 Sample Size Detcnnination ..... . .. .... .......... 25 
3.7PowerAnalysis ..... . . ....... 25 
3.8 DataColleclion ... . . ....... 26 
3.9 Dala Processlng ... . . ....... ............. 26 
3.9.1 How missing data was handled . ....... 26 
3.10 Data analysis ... ..... 26 
3.11 DifferenceinditTerencesanalysis{DID) .... .. ............................. 27 
3.12M.'chinSprocedures .... . ........... 28 
l.13Quo1ityoonlrol .... . ............... 29 
3 14 Expected outcome of the study ...... . . .................................... 29 
3.15Ethicalcoruideration ..... . ..................... 29 
CHAPTER FOUR .... 31 
RESULTS ... . ................. ....................... 31 
4.0 Demographic characceristics of pregnant women .... 
4.1 Differences in mean Hemoglobin (Hb) Concentration between the two groups ..... 33 
4.2 Differcnees in me&n birth weight between the control and comparison groups ..... 35 
4.2.1 Proportion oflowbirtb weight.... . ................................................. 36 
4.3 Proportion of Home deliveriel .... .. .................................................... 36 
4.4 Difference In mean Hb concentration at 36 weeks ................................................ 37 
4.4.1 Impact estimates: Propensity Score Moochin, ... ................... .... .. . ............. 37 
4.5 AsoossiDaqualityofmal<hing ..................................................... ................. ...... 38 
4.5.1 R=llSonQuaJityofMll<hin,pmced. .................................................... 39 
4.5.2 R=l1S from Kennel density boIuciDa pIoo.. ............ .... . .......................... 39 
.......... 20 
CHAPTER THREE ... 
. .... 20 
METHODS ..... 
3.0lntroduction ... . . ....... 20 
3.1StudyO";gn ... . .. ... 20 
3.2 StudyAru .. .. .. .... 21 
3.3 Study Population .... . ... 22 
3.4lnclusionandExclusionCriteria ..... .. .. 23 
3.5 The Exclusion Criteria ... .. ......... 23 
3.6 Sample Size Oetennination .... .. ....... 25 
3.7PowcrAnal),lis .. . . ...... 25 
J.8Dala Col1ection ... . .26 
J.9DataProcessing ....  . ............. 26 
3.9.1 How mw.ingdata was handled ... .. ........ 26 
3.10 Dataanalysis ... .. ....... .......... 26 
3.11 Difference in diffcrences analysis {DID) ... . ........................... . 27 
J.12Matchinaproccdures .... .. .. 28 
J. I3Qu.a1itycontJ01 .. , .. .. 29 
3.14 Expectcd outcomc: of the study ... 
3. ISEthicaJconsideration .... . ....................... 29 
CHAPTER FOUR .... .. ................ 31 
RESULTS .. .. ............... 31 
4.0 Demoaraphic characteristics ofpregnanl women ........... .............. ................ ........ 31 
4.1 Differences in mean Hemog1obin (Hb) Concentration between the (WO aroups ...... 33 
4.2 Differences in mean birth weight between the control and comparison groups ..... 35 
4.2.1 Proportioooflow birth weiaht ...... .. ..... 36 
4.3 Proportion of Home deliveries .... . ............. 36 
4.4 Difference in mean Hb concentration at 36 weeks .. , ..................... 31 
4.4.1Impactc:st.imates: PropensityScoreMatching ....................... .......... ..... 31 
4.5 Assessin&qualityofnwclUng ... 3R 
4.5.1 Results on Quality ofMalcIUng proced..... .... . ................... 39 
4.5.2 Results from KeMd density balancin& p1ot ... .. ........... 39 
CHAPTER FIVE ...... . ....... ..41 
DISCUSSION OF FINDINGS . .... .41 
S.Olntroduction. .... .... .41 
5.1. Anemia in pregnancy at 36 weeks. . ....•.. .42 
S.2 Lowbirtbweighl .. .. ....... .42 
5.3 Home deliveries among the two groups .... . ....... .44 
5.4 Impact of pregnancy school on anaemia in pregnancy.1 36 weeks . ... .44 
5.5 LimitatioosofIheStudy ..... . 
CHAPTER SIX ... . ......... 46 
CONCLUSION AND RECOMMENDATIONS .. . 
6.1Conclusionoflhestudy ................................. ' .......................... ........... .... ....... 46 
6.2 Recommendations........ . ........ 47 
REFERENCES .... . ..................................•....•. .48 
AFPENDICES ... .. ........................... ........ 52 
Appendix 1 :Da1a~xtractiontoo1.... . ...... 52 
Appendix U: GHS Ethics Committee Appcoval lener .... . ............................. 53 
LIST OF TABLES 
Table 1: Definition of Study ' ·anables .... ...... 24 
Table 2: Definition of indicalors and their mc/lSutt:ment. ... .. ........ 25 
Table 3: Associltton between Demographic CharKteristics and pregnancy school 
.... 32 
Tablc 4: DifTerencea in mean HbJevels ....... .. .. 33 
Table S: Grades of anaemia at 36 weeks among the 1\\01) groups ... . ......... 34 
Table 6: Mean birth weight among the intervention and comparison aroup. Nabdam 
dislrictin2017 .. . ...... 35 
Table 7: Proportion of Home Deliveriu among the two groups ... . ............ 36 
Table 8: T-tnt ~iUllJ on Difference in mean Hb levels before and after pregnancy 
5ChooI .•.... .. ....... 37 
Tab&e9: Propensity score and Nearest Nci&bbour matching results (ATETIATE) .......... 37 
Table 10: Variance Ratios before and after matching .... 38 
LIST OF FIGURES 
&W'e I: PregnancyScbool in Pictures ...... . ......... 6 
gun: 2: Conccpcua.I framework on PreJDIDC), school. place of delivery and Pregnancy 
gure3: Studydaiaoforputicipants... . ......... 20 
SUIC 4: Map ofNabdam district sbowinS health f.citities by sub district .... .. .........• 22 
awe S: Difference anaJysis ofUb at 36 weeks betwef:ll control and intervention group 28 
aure6:P~v.lenceofanaemiabysub-district .... .. ........... 3S 
pc 7: Proportion of low biM weight by preanancy school... .. .................................. 36 
pre 8: Propensity Score Histogram ............. 39 
gure9:Kemeldensitybalancinsplot .... .. ...... 40 
iPlfC 10: Standardised cross covariate between the two groups ............ . ................ 40 
LIST OF ABBREVIA nONS 
ANC Ante_Care 
ATE A_T_IEffect 
ATET Average Treatment Effect on the Trea&e<i (Impitt on the intervention 
group) 
Centre for Disease Control mel Prevention 
Community ~ Health PlaoDin&and Services 
Commuoity.Based Health Planning and Services 
CRS CachoIicRelicfServiccs 
District Health lnfonnation Manaaemcnt System 
GDHS GIwto Demognphie and Health Survey 
GIIS GIwtoHealIhScrvi<e 
GMHS Ghana Matemal Health Survey 
Ot.w.StltisticalService 
Hb Haemoglobin Concentration 
KDUS Kenya Demographic and Health StuVe), 
[ow BirlhWeigbl 
MOl Maternal & child health 
MMR M_ MortaIilyRate 
PNC PostnotalCare 
Propensity score 
Rural EmerplDcy Health Services and Transport 
Sustainable Development Goals 
UNICEF United Nations International Children and Education Fund 
WHA World Health AJoembly 
WHO World Health Orpnis.ation 
DEFINITION OF TERMS 
PftKnancy outcome: Low birth weight and anaemia in preptanc:y. 
Anaemia: Low bacmoalobin co~tion in the blood whicb is <12 gldl for men and <13 
g/dl for women. 
ADaemia in Pregaaaey: Hacmo&lobin concentration less than It Wdl in the blood of any 
prcpantwoman. 
Home Delh'eries: Any delivery conducted outside a health facility or by any person other 
thanaililledbealthsraff 
Prep.ney scbool: It is a type of additional health education for pregnant women in 
addition to the routinc arllcnatal care. 
Sudy lI.krn.do. group The 8fOUP of pregnant women who attended the: pregnam;y 
school within the ItUIIy period 
ControVComparison sroup: Pregnant women who did no! attend the pregnancy school. 
AvenKc Treatment ERect on tile y."uted: The impact of pregnancy school \10 those who 
really benefited from the in&crvention. (RecomlDcnded and reported in 
tbisstud),) 
Propea.lty score: The probability ora WOIllM. benefining from the prq:nancy school aiven 
herbackgroundcharacreristics(obscnedeovariatn) 
ABSTRACT 
Barkground: Several health interventions ha...e been put in pa.ce to improve preJRMlCY 
outcomes all over the world includiPa Gbana. One ofsuch interventions was the Community 
Preanancy School (C-Press) stra1cBY. which was implemented by c.tholie Relief Services 
(eRS) in the Nabdam district from 2014 to 2016 as part of the Rural Emergency Health 
Services and T~ (RES]) project 10 improve matemal and child health. 
Obj«dve: This iNdy &SICISed the impact or the pregnancy school stralegy on pregnancy 
outcomes and home deliveries in the Nabdam district. 
Metbods: A qUl$i-experimentai study desian with retro5pCctive records review of 769 
women wu used out of which 391 of them beocfited from the pregnancy school 
(irMerveotioa group) IIIld 37' did not benefit from the prea:JlIUlCy (coftb'Ol group ). Data 
cxtrlClionk)Ol .... \J3ICIdtocol~dltlonstudy partiCipullS and analysed using, Stata 
version IS. Pearson', Ctti tquare testofastOCiltion was used to determine the auociation 
between dependetlt and independent variablH whilst t-test was UJed to comJ*'C the ml!afl 
difference in Hb leve), at 36 weeks and mean birth weisht amonc the intervention and 
conlrOI group5. Abo, Propensity Score Match.in& procedures with nearest neighbour ai well 
other geftSilivicy analysis were UIIed in de&cnninilll the impact of the pregnancy sehool 
intervention on anacm.ia in prelJ)lDCY. 
Relalts: The JIUd)' found that the impKc ofche pregnancy school wu 34% reduced rislr. of 
Maemia at 36 weeks amone the intervention group (95% CI: 2146. p<O.OOlJ. This resulted 
in • mean Hb diffcrmcc of O.71afd1 betweeft 1he two groups. The proponion of home 
, delivery was also Ins (O.3~.) in the intervention II'OUP compared to 1.S¥. in tbe conb'ol 
group whilst the prevalence of low birth "'''eight was .5.2% in the intervention group 
~ 10 17.5% in theconttolpoup [95%CI: 10.17-10.62; p-value <0.0011. The mean 
binhweiaJ>aofU'O"inlho_lJIOOPwasll .. hip ..... lhocontrolgroup. [9S% 
CI: 56-176; p<O.OOI J 
Conclusion: The pregnancy school b8d a positive impact on pregarwtn.c y outcomes aDd skilled delivery in the N.bdam diatrict. There is therefore the need 10 up the project to 
other communities to impro\'e maternal and child healdt. 
CBAPTERONE 
I!IITRODUCTION 
1.1 Background 
The pregnancy school concept is an innovative way of improving communication between 
bealth staft"and prepant women as weU as relevant stakeholders to ensure holistic package 
of service delivery dwing pregnancy. It is a type of additional bealtheducalion for pregnant 
women to complement routine health education le~P5 they receive from health staff during 
antenatal care. The concept started five years qo in Ghana with the aim of improving 
pregnanq outcomes as well u to help in reducing ma1emal and child mortality (Van-Otoo .• 
2016). 
In the Greater Accra region for instance. the La-Nkwantanang Municipal Health Direc!Orate 
implemented me concept in I different style. Their pregnanc), school grouped the pregnant 
women into levels 100 and 200 where level 100 was for pregnant women whose gestalion 
period was from one to 28 weeks. TIle level 200 on the other hand consisted of pregnancies 
ranging from 29 weeks till delivery. Graduation ceranony was organised for five health 
facilities in the Municipality where certificates were pmcmted 10 women who successful1y 
completed their lessons in the pregnanc), school. Some of Ihe facililies that run the 
pregnancy schools included Danfa Health centre, Madina Polyclinic and Pantanl Hospital 
amoog others (Ghana Heallh Service, 2017). 
In line with this. Catholic Relief Services (CRS) a non-govenunentaI organisat;on 
implemented the technique in a Project dubbed Rural Emcrgcocy Health Services and 
the Nabdwn district. It was implemen~ in 
8S communities in the distrU:t. The project was 
meaIIt to lnaprove MeH indicators in the disttictjust like the MNCHP programme. (Nabdam 
Dillricl HeoIlh DirecIm-aIe, 2019). 
Despite all ~sc intervefttions. pregtUlftCy OUlCOtneS md home: delivery remIIin key public 
bealth issues that 1ft of primary concern especiaUy in deprived and prototypical rural 
communilies. The incidtncc oC anaemie in prqnaDCY, Jow birth weiaht (LBW) and still 
births as \.Yell as home deliveries are still worrying despite the quantum of resoW"CeS been 
invested irMO the seclOr. Olobally. about 15% to 20% oC.u births IUC low birth weight 
(LBW) (Weise, 20120). Abo. a<c<>rding 10 Ihe 2018 Global NUlrilion Report, .bolll 20 
million babies are born ~ith low birth weight every year (Development Initiative Poverty 
Reseaclt Ud. 201 8) Ilowever. the ineide~ of low bUtb weiaht met signif.cantly from 
COWlIly to country. For example. it is as low as 9% in Latin America and as high as 28% in 
South Amca (Weile. 20) 2a). It iii estimated that a female dies every minute in the globe as 
• result ofc hiklbirth complicatiuns mel it is unfortunate 10 mention that nearly half", million 
females die from matmlal. causes e.c:h year and about 99% of fl&alitics happen in 
developing nations. including Ghana(WHO. 2016). 
The challenae of decreasing maternal mortality remains a significant issue not only in 
Ghani,. but aJlO in lIeveral nations: such as Kenya. (Yaya. Bishwajit. Okonofua. &. Uthman. 
2018) 
The 2014 Kenya Demoer-phic and Health Survey (KDHS) reported that there were about 
525/100,000 live births in the malt'mlll monaJiry flllio (MMR). Other estimates plKed the 
ralio81 I.OOO/IOO,OOOlivebirths,whicbisonein2S lifetime riskofmaaernal death(Kenya 
National 8\U'eau of Statistics Nairobi & Ministry. 2015). 
In Sub--s.Mrao Africa, the )W'eVaIeace of low birth wei&bt is about 13% .ad this seems 
&ower in some areas due to under reporting resultinI from home deliverie5 and deliveries at 
Iowerhealtb facilities which may not be officially accounted for. 
Accordioa to G. ... Dcmop.ph.ic and Health Swvey (2014). the prevalence of LBW in 
Ghana wu 11% whilst the Upper East Region recorded about 9% in the same report. 
However, the situMion is very t.d in the Nabdam district In 2017 for instance. the district 
rcconIod 101 low birth weight babies out of94!i live births reprelCntina a hiaher rate of 
10.7%%(0"'" Heolth Service. 2017). In 2018. thepn:volcnco increuedto 12'10(117 out 
993). The prevalence is much higher tban both tbe regional andnationaJ average figures 
which are 11% and 9% respectively within the same period(Ghana Statistical Service/Ghana 
Health Service. 2017). 
With reprds to anaemia in pregnancy. the prevalence in 2012 was about 38% aIobally 
(Weise. 2012b). This is the same as the prevaleuce in Ghana according to the 2014 Ghana 
Demographic and Health Survey. which also pegged the prevalence at 380/,. Once aeain. 
the sihlltion was worse in the Nabdam district with over 45% prevalence of anaemia in 
prelfWlcy (Ghana Health Service. 2017). One of the sub-diltricll called Zanlerigu sub-
diJlrict recorded over 7M"o of mild to severe anaemia in pregnancy which is largely due to 
iron detkiency anaemia. This is a cause to worry because a malnourished mother will give 
birth to a malnourished child. which coukl mult in chronic cycle of malnutrition. It is worth 
noting that, the World Health Organisation his classified the prevalence of IIDMmii u a 
problem of public health sipifica.ce IS follows: No public health problem (:54.9%), mild 
problem (5·19.9%). moderate (20.39"10) and severe public health problem (~40%) 
(WHO/CDC. 2012). This implies that any area or COWltry wicb the prevalence of auemia 
.-I to or ~ater thin 40% has a severe public health problan 10 deal with. In this regard, 
the higher prevalence of 45% anaemia iD pregnancy in the Nabdam distric:t i. a big iSiue 
In addition 10 the issues alreaIdy identified above, bome deliveries are"so COIIUDOD in 
catain parts of the district despite MNCHP intervention put in place to curb the menKC 
among. lntbefirstquartcrof2017a1ooe,IOhomcdeliverie5werercportedintwoofthe 
sub diaricts with the district rccordiat.lOtaI. of 34 home deliveries thal year. The number 
of home deliveries is believed 10 be an WlCIentatement due to Wlder reportina· 
The aim of the research .. to detennine whether the prevalence of anaemia in pregnancy, 
low birth weigM and skilled delivery were different among the intervention group and the 
control group. The study thus ISSeSICd whether the pregnancy ICbool concept was effective 
in reducing anaemia in pregnancy. low birth weiJht, and borne deliveries in the Nabdam 
district. 
1.2 Tbe PregnaDey School fa N.bdam District 
The Pregnancy school stratelY was irnplemmtcd in the Nabdam district by the C.aholic 
Relief Services (CRS) in collaboration with Ghana Hcaith Service since 2014. The concept 
"..as called C-Press which means Community Pregnancy School Session. C-Press was 
supported by the maternal and child health project dubbed the "Rural Emergency Health 
Services aDd Transport (REST project). As the name suggests. the pcegnancy schools were 
organized at Ghana Health Service delivery points within eight (8) piloted communities 
where pregnant women received health educMion in the fonn of classes and group 
discussions. Dunna: the pregnancy school sessi005. several topics relaq to pre&nanCY 
Some of tbcK topics include &DOd maternal nutrition using 
of home delivery. importance of antennaJ c.re artcndance, 
Some facilities introduced. a local millet flour drink called 
Uzoomkom" that wu served to the pregnant women dwina the school JCIIions as a 
motivation for attcndance. 
Sealing arrangements were JUde in a boriesh.oe shape during C-Press sessions lad sessiOGl 
were managed by trained Health staff such as Midwives and Community Health Nurses. 
The horseshoe seatinB arrangemem wall 10 ensure visibility among each other durinl the 
discwsiOJlS or experience sharing. There were abo pregnancy school registen Cor record 
keeping beside the nonnal anlenllal anddclivay regislerSthat captured the necessary 
information on the women and their pregnancy outcomes. Some of the records that were 
docwnentcd in the register included demographic information. ANC and pregnancy school 
attendance. Anaemia status at registralion. anaemia at 36 weeks, as well as piKe of delivery 
and birth wcishl amonB othen were captured. The pregnancy school strategy did not 
consider health staff alone to be experti or "know it all" but it created an avenue for the 
women to share their personal experiences in pregnancy outcomes with other members. 
" ::"" ' 1 
1.3 ProblelllStateratllt 
Since the impkmmlation oflbe preanancY school coocept in the Nabdml district. there has 
Dot beeo lay evaluation of the sttaICgy to critically examine whether it is yieldiDB the 
intended results or not. Without a scientifIC evaluation. it cannot be clearly ascertained 
wbether or not the prqnancy school approach is really contributing positively to maternal 
and child bealth indicators such as anemia in pregnancy. lew birth weight and home 
delivery. Meanwhile. a lot ofresourees have been invested and continues 10 be pumped into 
maternal and ehild health proif8llll. In 2014 for instance, the World Bank inVCiltcd about 
three million United States dollars on Maternal. Child Health and NUlrition Improvemeat 
project (MCHNP) all in the quest to improvinama&emal hcaJth 10 reduce malemal and child 
mortality(OECD. WID," Wo<ld Bank, 2014). 
Moreover. there is no evidence of any sinaIe study in the Nabdam district to compare the 
pregnancy outcomesofprrgnant women who attended the pregnancy school with those who 
did. DOL For instance. it was expected thai pregnant ""'Omen who WIN anKmic during 
antenatal registration will ha\'e their blood hKmoglobin concentration levels improved by 
36 weeks of the preiJllUlC), before delivery, We cannot still tell whether the anaemia status 
of pregnant women who benefited from the proa;ramme were better or otherwise compared 
to thote who did notltlmd the pregnancy school. Similarly. the incidence in home deliveoo 
is not known amana the two groups. It it wonyina that comparison cannot be made to 
ascertain the impact of pregnancy school conc:ept amona the two groups of women for 
infonned decisions to be made in order to improve pregnancy outcomes and skilled delivery. 
In the same vain, low birth weight still persists in the Nabdam district however. it baa not 
been proven whether the phenomena is coming only from pregnant women who did not 
an_ the pregnancy school or lbe figures also include those who attended the pregnancy 
school. 
1.4JuJtin~atio. 
There is • huge koow1edse gap regarding the preanancy iChool concept and pregnancy 
outromes due to limited evah.lion studies on pregnancy school that needs to be tilled. 
This atudy is therefore nocessary 10 contribuie 10 informed decision making on the 
pregnancy school eoacept. Tbere .e two .chools of taught about the effectiveness of the 
pregnancy school coneept. One of them suggests that pregnancy schools are effective in 
improving pregnancy outcomes. This position wu confinned in • study which indicated 
tiw the birth outcomes among a group of women who enrolled for the preJillDCy school 
were becterthan th05e who did nol(Bentil,20l5; Mldhavanprabhakaran" D'Souza. & Nairy. 
2016). Another view is that the effects of antenatal education remain unknown. In 2007. a 
Cochrane systematic review thaI assessed the effects of health education concluded that, the 
effect of antenalal education for childbirth or parenthood or both remains largely unknown 
(Brixval. Axelsen. Andersen. Due. & Koushcde. 2014). With these dual positions. there is 
tbeneedtoucerWn whethcr or not tbc pregnancy tcbool concept is contributing positively 
to the outcome variables in the NIbdam. district. The flDdings of the study will therefore not 
only add to existing body afknowledge and evidences but it will also be useful in deciding 
whether to scale up the pregnancy school stratei)' to other communities in the district or 
1.5 Restareb QUestiODS 
I Is there any difference in mean Hb levels between preanant women who attended the 
pregnancy school and those who did not attend the pregnant:y achool? 
2. Is then:- any difference in mean birth wei&ht among the group of WOlDen who attended 
the pregnancy school MKl those who did not attend the pn:-gn&ncy school? 
Is there any difference in the proportion of home delh'eries among the two IfOUps? 
4. \Vhal is the impKt of the pregnancy school on anaemia at 36 weeks? 
1.6 Geaenl Objective 
To determine the diffcren.ces between pregnancy o\dComes: and proportion of borne 
deliveries among pregnant women who ancoded pregnmcy school and those who did not 
anend the pregnancy school in the Nabdam district. 
1.6.1 SpeclftcObjectives 
Thespccificobjectivesofthestudyincludcd: 
1. To compare the differences in mean hemo,lobin concentnltion levels at 36 weeks unon, 
pregnant women who attended the pregnancy school mel those who did not .nend. 
2. To determine the differences in mean birth weight among pregnant women who 
anended the pregnancy school and those who did not attend the pregnancy school. 
3. To compare the proportions of home deliveries among the two aroups. 
4. To estimate the impect oftbe Jngnancy IChool inlefvenUoa on anaemia at 36 weeks. 
1.7 The Conceptual Framework 
The conceptual framework was adopted from the "Interactive Quality Health Education 
Outcomes Model" by P. Mitchell. S. Frenetic. and 8. Jennings ia 1998 and modified to 
n:flect the local dynamics. It can be ob!letVCd that seven! flC&ors play. role in ddenninmg 
pregnancy outcomes -.d place of delivery. In other words. low birth weight, anaemia in 
pregnancy and home deliveries are associated with many factors and therefore need a 
multifaceted approach to address them. Some of these factors are briefly discuued. here 
because they are potential confounders. which em. affect the outcome variables in this study. 
First of all. maaemal age has a bearing on pregnancy outc:omeI. Okler women from the ages 
oilS 1040 years for instance are at increased risk ofgivina binh to Pftterm ad low birth 
..b abies than younger women. The age of the mother has a bearina on her preanancy 
outcomes.. If a woman is too young or too old. there are negative consequenccs In their 
reproductive outcomes. The older a WOIUD becomes Ibe more Iikcly she will become obeK 
andoouJddcvclopdiabetes,wtUehisassoeialedwithstillblrth(Bentil.20IS). 
Secondly, the socioeconomic:stMUI ofa woman whicb is highly influenced by occupation 
can affect her pregnancy outcome aDd pIKe of delivery. Level of income: is a factor as 
women with low economic IIatUI are more likely to be malnowished during pregnancy. a 
situation which could lad them to brina fonh low birth weight bebies.(Leary. Edmond. 
Floyd, Newton,.I: Thomas, 2017) 
Moreover. tbC'".nty is anothtt important factor. Prim gravidae have increased the risk of 
sufferina fiom more ICvere forms of malaria in pregnancy whidl could lead to LBW than 
inmuldgravido (Leary et a1 .. 2017). 
The occupation of. woman allO has an influcntC on her preifWlcy oulComn. When a 
woman's job exposes her to cnvironmmlill hazards such as pollution, smoke. heavy metals. 
poisonous chemicals and other risk factors among others. she is more Ukely to give birth to 
premature and low birth weight babies (Bentil. 2015). Similarly. women living in highly 
polluted environments are likely 10 suffer some effects 00 their reproductive outcomes. For 
instance, smoking of cigarette by preanant women em le.d to the incidence of low binh 
weight (Hossain a. Trich~ 2(09). 
There is also a positive COI'TClaiion between alcohol iDIake and preanancy oulComes. High 
matemal alcohol eonswnptions can lead to premature births and LBW and could also be a 
risk factor (or cardiovascular disease in the mother. (Nykjaer et aI •• 2014) 
DEMOGRAPmCS 
~----~r-----~ p~~ 
t:NVlRONMESTA L Maritalsu&us 
FACTORS 
EduutioMIkY1lI 
Commllnit) 
SOCIOC ULTURAL 
FACTORS 
RchglO\ls bcl iefs and 
prlCtice, 
SUCIOECONOr.oC 
FACT()fl.~ 
TypcofOccupation: 
f icure 2: Conceptual framework on Preanancy Khool, place o( delivery and Pregnancy 
""'<Om< 
Sour<:<: adopt<d from P. Miu:bell. S. F. ....t i<. UId B. JauaiD&s (1998) UId rnodifl<d by 
_(2019) 
CHAPTER TWO 
LITERATURE REVIEW 
ThcIc are no much evaluation studies on the concept of prean-cy schools apecially in 
ObanL However, there are some related studies on various interventions on anIen8taI care 
and prqnancy outcomes. Thus, the literature review focused mainly on these similar studiei 
some of which ""'ere systematic reviews. 
2.1A1laemiaiaPregunC)' 
Anaemia simply means klw hKmogiobin (Hb) c:ooccntraOOD in the blood. The World 
Health OrganiSltion has different cut off points for anaemia depending on several factors 
such II aae. physiololica1 status II1d sender. With reprds to anaemia in pregnane)', Hb 
ooncenll'ation Jess tban l1i1d1 is an.aemia bUI when it islesstban 7.0gldl it is severe anaemia. 
Globally the pre\'alence is about )8~. (WHO. 2016) which is the same as the prevalence in 
Ghana (Ghana Statistical ServiWGhana Hcalth S""iceJlCF International. 2014). 
Several !lUdies have been conduc1cd 011 the effects of health education on pregnancy 
outcomes inc:1udinS anaemia in prepw1cy.ln January 201 S,. similar study which was done 
in China and published in 2017 found out thai, health eductltion intervention has positive 
cffeets on pregnancy outcomes of patients. The stud)' involved 120 participants who were 
randomly divided into study group and control &roUP comprising 60 members each (Liu. 
Xie. a: Guo. 2017). Another resarch in India showed that the incidence of anarmi. was 
lowered by 35% among pregnant women who received antcDMaI eire dwiJlg pregnancy 
(Misbra etal. • 2016). 
Also in 2012, a rClrOspecti.ve study was perfonncd in lIamadan city in which 264 prenatal 
~lr"nU were selected randomly from 12 health "",e oe ...... The results _ thIl 
prenatal care aad beaith cdueatioa cap positively influence pregnancy outcome. In other 
words, Counselling nutritional support and education may have an important role to play ill 
prepancy outcomes (Parsa., Shobeiri, &. Pane. 2012). 
However, in 20131nOther evaluation study titled"The effect of antenatal education in small 
classes on obfietric and. psycbo4ocial ouICOmCS: a systematic review and meta~analysis 
proIoCol" which reviewed .bout 17 different studies coneluded thai the effectiveness of 
IInwnatal health educalion remain unknown.(Brixval ct aI .• 2014) 
1.1 Low Birth WeiCht 
According to the World Health Orpnisation, low birth weight is defined .. any live binh 
weiJht less lhan 2500 gfama. The prevalence ofLBW is currently between 15% and 2001.. 
Every year. over 20 million low birth weight babies are born in the world. This continuous 
to be a global public health problem that has both short~tenn and long~tenn consequences. 
For instance. Low Birth weip children are three times more likely 10 die compared to 
Donnal babies «WHO. 2014). In recent srudies. LRW is not only a predictor of morbidity 
and mortality but also ihows that LnW babies have increased risk of developing non 
communicable diseases sucb diabetes and cardiovascular disease later in life. Due to the 
xrious~ofthescconsequ('nces, the World Health Assembly in2012 resolved to bring 
down thepn:valence LBWby 30% before thee'" 2025 (Fenwick .. II., 2015; Wei ..,  2012b, 
20121). 
Approximately. 14% of infants in low~income countries weip less than 2.S lea at birth and 
many of theie low birth weight babies are born preterm. Many studies on mortality and 
illness IUllOng )ow-birth- weight infants has focWlCCi on the neonatal. period Md few studies 
_&o0m  .~...  Africa hive generated population-based estimates of pcMt-neonatal CL-Y et II., 2017). 
In a randomized rncarch examining the impw:t of instructional policies during home visits 
on obstetric outcomes such 81 birth weight. 1.178 pregnant females from 21 government 
prenatal care hospitals in Denver City, the United States discovered that the incidente of 
LOW among the intervention IfOUP (2.8%) was smaller than that of the 7.7% in the control 
group., (Lima, 2016). 
Another study in Kenya diIcovered tba, tbcte was 1.42 kg reduction (95% CI 0.95 ~ 1.89 
kg) in gestational weight pin with any intervention compued with control. However. with 
aU the interventions combined, there were no signi6eant differences in birth weight (mean 
difference -SO g. -100 to 0 I). AlIO. dietary intervention apprOKh was found to have the 
largest impact with improved preanancy outcomes compared with the other interventions. 
Thirty-one (31) of the randomised control trials revealed that there was no significant 
difference in birth weight in the other two approaches (·50& of mean birth weight difference) 
(Thongoratinam clal., 2012). 
Moreover. III Australian Researcb Ceatre for Health of Women and Babies (ARCH) also 
conducted a review of29 different studies which were aimed at assessing the effectiveness 
ofc ommunity~based intervention packages in reduc:iog maternal and neonatal morbidity and 
mor&ality; and improving neonatal outcomes. This research found that community-based 
intervention packages decreuc women's morbidity. baby mortality and morbidity, and 
improve care·related results. especially in low-and middlc--income DIlions. It identified the 
lmPJrtance of incorporating maternal and newborn care, which can. be packaged effectively 
for delivery throuah a ranle of community bealth workers and health promotion groups. It 
also showed thaa this approach wuld improve skilled delivery and facilityabased services 
ror maternal and new-born by obout 5% (el 95%; P-value < 0.001 )(Babies, 2015). 
In West Africa specifically Niaeria which hal similar socio economic, reproductive. 
demographic: ad general health cMncteristics like Gbaaa. a study of factors for low birth 
weight was done which showed among others that rnItCmaI age less than 20 years (58.5-;.) 
.... hocmoslobiA leo. than 10 gmIdl (60.5%) ore siplillcaat determinants of LBW 
C'Determinants of Low Birth Weight in Neonates Born In Three: Hospital5 in Brona: Ahafo 
Rqioo,"2016). 
In Ghana,. comparable ~ was conduclCd in the Northern Region to assess the impact 
on important maternal and child health results of the early Project Fives Alive. a domestic 
child survival enhancement project. This evaluation which w.. conducted in 27 health 
facilities in Northern Ghana, employed sensitivity analysis including intenupted time series 
analyses to detenrune whether improved chanlla in the outcomes were due to the 
intervention education in smalLerclaues is s.till questionable (Brixvaletal,,2014). 
2.3 HOllie Deliveries 
Every year, about 60 million women deliver outside the health facility by unskilled anendant 
which is due to several factors and therefore require multifaceted approaches to address. 
Meanwhile. delivery 81 the health facility by qualified health staff can reduce 75% of 
maternal deaths, Several evaluation studies have revealed various findings on the impact of 
interventions put in place to address the issue ofhomedeliverics. One of RICh studies which 
was conducted in the United State of America found that the proportion of home deliveries 
was hiaher among pregnant women who did not receive antenatal care than the intervention 
group thai is 14% and 3% respectively (Darmstadt et aI .• 20(9). 
It was also diJcovered to be associ.acd with eahanced health educmion and hospital triaae 
skills delivery. There was a ....nety of chana<: margins for the distinct classifications. The 
~binatioD of enhanced qualified delivery ranged from 28% to 58%, while modifications 
in PNCi (or health postS and health centers resulled in enhanced participation of 
underweight childrm", child weir.. cliIUc:s (S;"gb et aI .• 2016). 
Moreover. Studies in Kenya and Malawi bave also shown that antenatal attendance during 
prepancy is highly asoc ..1 ed with delivery iD. bealth facilities in several developing 
countries like Ghana, Tanzania, M. ..w i. Kenya. and Burkina Faso (Sahoo, Singh. Gupta. 
Garg. &: Kishore. 201S). In Kenya for eXmlpIe a study revealed that early initi.tionof 
antenatal care amona women within the first trimester is ll5IOCiated with place of delivery. 
Wocnen Slarting ANC xrvices before the !IeOOftd seme_r are more likely to deliver in the 
health care facility compared 10 pregnant women who use antenatal care after the fD'il 
t:rimnter. In Asia and Africa. women who attend ANC four and more times have higher 
chances of de1iverina in health facilities with skilled personnel. In the same vein •• INdy in 
Southern Asia showed that the incidence of home delivery is five times more among women 
who never attended ANC compared to those who attended four plus viiiti (1atobJ. 2010). 
Home or unskilled deliveries are still prevaleat in sub-Saharan Africa espcciaHy in the tW'al 
areas. In line with this, stakeboldersare iooking at the bestappJ'OKhcs inchMiinlresearch 
to be able to make infonned decisions on how to solve the problem. One of such studies 
was conducted in 744 facilities in Northern Ghana. The results studied were early antenatal 
care(ANC).qualifaed delivery. Wlder-five mortality at the facility leve1.and participation 
of tmderweighl children. child wel(are clinics. The research uxd interrupted time series 
analysis and discovered thai beallh education during routine terVices in health centres was 
associated with these variables {Sahoo et aI .• 2OlS). 
They used quasi-experimenLal evaluation srudy design. The pregnancy oUlComes studied 
included timely antenatal care, skilled delivery. children UDder-five mortality in health 
flcilitics aad underweight infants' welfare clinic 8IIlendance. They stratified the data 
-W)'lia by die type of facility _die bil!F' bcallh f. .i Hty such as hoopital. followed by 
health ce:ntm and smaller bealth posts. The major findinas from this study showed that the 
UIOCiation with specific catqory of c~ aDd improved outcomes were sipti&c.nt. For 
lnslance. out of the changes, iDc1udini early ANC. four plus ANC visits, health facility 
delivery as well as immediate postnatal ewe (PNC) were increased in the health posts. 
According to the 2014 Ghana DemOlf8Phic and Hea1th Survey. hca1th racility deliveries 
increased &om 42% to 73% over the last two dcaIdes. This notwithstandina. clo5e to about 
27'% of pregnant women stiU delivered at home (Ghana Stltistical ServiceJOhana Health 
S,rvicellCF In_ona!. 2014). 
2.4 Geaeral .'acton loflue.cia. Pregnancy Outcome. 
The Ghana Maternal Heallh Survey (OMHS) geaera&e$ a &ot of data on maternal health 
including pregnancy outcomes to supplement information from the Ghana Demographic 
and Health Swvey. The ftrst GMHS was conducted in 2007. The IeCOIId survey which was 
conducted in 2017 sampled 27.000 households. The 2017 Ghana Maternal Health Survey 
showed that there was no much variation in prcpancy outcomes among some key maternal 
health indicators 5 years preceding the survey. The findings revealed that about 76% of all 
pregnancies resulted in live births., 2% ill stillbirth. 12% miJcarriaaes whiles 10% of 
pregnancies resulted in abortions. The survey also lmCOvered that there is no much 
difference between the proportions oCtive births with regards to the woman's age at the time 
of the pregnancy. However, women less than 20 years are more likely to have an abonion 
(19'loofpregoancics) while womcn aged betweeo 35 and 49 bave higberchances ofgetting 
a miscamaF (19"/0 ofpregnancies).ln the same vein. rural women have more tive births 
thin uro.n women, whereas women in the urban areas have more miSCarriages and abortion. 
This rural-urban difference is due to variation in lifestyle among the two groups difference 
(Ghana S_ ServKela- Health Servke 2017; _til 2015; Dijk, Anderlto, and 
Stetzer 2010; Kotcy.t II. 2012; WHO 2016). This 
The birth outcome of normal prrgnaDCY is a nonnally a live baby with the recommended 
birth weight which ranges from 2.Skg to 3.5kg in most healthy women irrespective oftbeir 
a:eographical &ocation mel time ofdelivcry. However, different factors could influence the 
delivery of a normal live '-'y. Some of theIe factors include but not limited to 
environmental factors and toeio-dcmognphie r.ctors of the mother. 
2.5 Environmental Facton 
The em'ironment within which a mother livea could expose ber to several f-=tors such as 
iOlOkina. video display terminalJ. and anaeitbctic gases. antineoplastic Medicines as well 
as exposures to lead. seleniwn. and inorpnic mercury and 10 on. Among all these factors, 
cigarette smoking during pregnancy has been found to be the leading environmental factor 
dud. has adverse pregnancy outcomes. For inscance, Mothers who DOke dwing pregnancy 
are twice more likely to live birth to low-birth weiaht babies. In the HIlle vein,.ir pollution, 
exposwe 10 chemicals and stress also have an effect on low birth wei&bt and preterm 
delivery (Hossain & Triche. 2(09). 
Antenatal cducatioo is a very important activity in primary health care given by midwives 
and other health staff. It requires • lot oftime with other resources and is derunded by many 
pregnant ".romen. However. there have been few studies evllluatina ill effectiveness. and 
narly all oftbese studies have been carried oul in North America. Australia. and Northern 
Europe. (Jaddoe, 20(9).Another study in Kansay University found that antenatal education 
result in higher birth weight than women wbo do receive antenatal education (Imar & 
Bacigllupo, 2010; Mary etaI, 2002) (Mary etaI, 2002)(ltziac & Bacigalupo. 2010». 
MethodologitalReview 
A crOlSeCtional evaluation study was done in 2013 in Tanzania on family oriented health 
education programme 10 improve nwemal-infant birth outcomes. The study found thli the 
intervention croup had better outcomes than the control group. (Shimpuku etal, 20ll). Also 
in Ghana, relrospec:thle cohort study design was Uled 10 examine: blrth out~omes in Tema 
General Hospital by Patri~ia Beotle which found that there was no significant difference 
betweea. the two IfOUps. (Patricia Bentle, 2015). Similarly, in 2018 a systematic review of 
40 .-tieles was done in Ethiopia on the effects of antCMtal education on skilled delivay 
showed that women who attended the antenatal education were more likely to deliver at the 
health facility (GedefawFekadu., 20118). 
2.6 So• ••. ,.. or Ibe Literahare 
Tbe literature.bove show that prejpWlcy school or antenatal education generally results in 
improved pregnancy outcomes and skH:ed delivery. The study in United State of America 
showed that the prevalence ofbome delivery ""85 rusher amona the control group(14%) 
compared Co the in1ervention group(3). Another study In South Asia showed that women in 
the control group were five times more likely 10 deliver at home than thoae in the 
intervention group(Jacobs, 2010). Also, studies in Kenya and Malawi revealed that anlCnatal 
education is bighly associated with skilled delivery in developing countries like Kenya, 
Malawi,andGhana. 
Moreover. a study in Denver City of United States discovered thaa the prevalence of LBW 
was lower (2.8%) amoaa the intervention group compared to 7.7% in the control. Another 
study in India revealed that the prevalence of anaemia in pregnancy was lowered by 35% 
among the intervention group. Besides these. a retrospective records review in Hamadan 
City in 2012 mow that antenatal education impact'! positively in pregnancy outcome 
CHAPTER THREE 
METHODS 
l.OlalrocilH'tioli 
This_dcsai>csot.cdcsognoflhen:seard\adesc:n. ..... of _ the """""'" -
pcrlonncd rr-_ -. .. the end. h _the _ popuJoIion fo< IIIis _ . Ihe 
_of,,,,"phnr.the"'size.Ihe_lheilldl,,,,,,,,fo<dtcn:seard\1he 
~foriafOl1MtioftroUcction,thc:dIta~'Cmc"MdevaiUllion.an4thestudy's 
3.1 Sldy Dtsip 
Pregnant women \\hoddl\crcd III 20 17 
Nabdam district were reviewed.. The study compared prepancy outcomes of women who 
attended Ingnancy school with thOle who did not atteod the preanancy school. The main 
purpose was to find out whether mere was any difference in the pregnancy outcomes among 
the two groups as well as me proportion of home deliveries between the two aroups. 1be 
OU1comes of interest in this study were anaemia in pregnancy, low birth weisht and home 
deliveries among the intervention &roup and the control group. 
3.2 Study Area 
The study was carried out ill aU the AiDe health facilities in the Nabdam district that 
conducted deliveries in 2017. The facilities included. the Nanaodi Health Centre. Sakoli 
CHPS. KDtinlaabig CHPS, Pelun", Heald> Centro, Zanlerigu CHPS, Loagre Heald> Centre, 
Pi .... CHPS, DasoblilO CHPS and A)WDfoya Clinic. However, there was no available 
data in Aymlfoya Clinic which was the onJy private health flCility in the district. The 
Nabdam district has five sub districts, 21 health facilities out of which only 9 conduct 
deliveries within the study period. Nabdam Diitrict had 85 commWlities and population of 
39.789(Nabdam Oisttict Heald> 0_, 2017). 
The Nabdam Disui<:1 Asrcmbly woo estoblished in 2012 by L.l.210S. II WOI carved from 
TaIensi-Nabdam District into the Nabdam District with NlIlsodi as its capital. The district 
is situated in UpperEastregion.ltliesbetweenlltitudes 10047 adjacenland 100 57 adjaeent 
to the north oftbe equator; and longitudes 00 31 adjacent and 10 15 adjacent to the west 
Greenwicb meridian. It is bounded to the: north by the Bongo district. to the east by the 
Bawku West district 10 the south and to the west by the municipality of Bolgatanp.. The 
dUtric:lbII353km2ofterritory. 
fip,.4: M."ofN_ _' _hw_l.cililin~."'dmricl 
~ NabdlllPl D,."ict Heall" [)'reclorJll~ 
In this study. the population lII'gcted wen: groups of pregnant women who detivercd. in 
Nabdam distnclm 2017. It included. revleW of all aVaJlable records of prqnanl WOIDCA 
whoanended antmaaal C3'C in the Nabdamdislrictand delivcn:d in the district in 2017 A 
rmewoflhc:dJ""ct2017 ___1 hol945 __d elivacddwi. 
the Rudy penod. However 769 records wert: .vaiIabIe for this study. Out of this, J9I wue 
In the mtcrvCPbon groupwlulsl 371 wtrelnlhem the control group 
3.4lacluioa ..d  Ent.lIioa Criteria 
Recon:b oran pregnant women from the district who delivered iD 2017 weft included in the 
study. Pl'ciQMI Women wbo attended lhe preenancy schoollDd delivered ... fllcility 
outside tbc dilaric:t bur whose delivery records could be obtained were included. 
3.STbeEu. ..... Crite. ... 
ParticiPIDIS with incompIcac infonnatimt oa .,. of the 0UIC0me v.nlbln were excluded 
from Ihc-study. Also, prep.a& WOIDIII wbodid not.ncndANC in the district butonJyc.nr 
Ihere to deliver we~ excluded. from the srudy. Furthermore, pregnant women whole ANC 
and delivery records could not be tnICed at all did nol form part of this study. 
Ag, Aaeofmother independent Continuousbul 
categorised 
Education.Jlevel Educationa11evelofmotber ~--
Occupation Occupationoflhemother :~:~~~:~ Nommal 
Marital status Marital utus of the mother independent cateGorical 
Corwnunity The coIDnuUlity or ...ea where independent Nominal 
the woman stays -
Facility Hcalthfacililywherethct:t.a independent Categorical 
wasextracled 
Subdistrict The sub district of the heallh independent Categorical 
facility 
ANCRegistcnxi Antenata1Careregistration independent Count 
Number number 
DateofANC Oatc of tirst ANC attendance independent categorical 
Rcgi5tration fortbepregnancywhichthe 
mother delivered 2017 
10 Gat.ageal Oestalion age at ANC independent categorical 
registration registration in weeks 
11 -Hbat, reais tration Haemoglobin concentration at independent Continuous ANCregistration 12 No.ofANe Nwnber of visiu by the independent Discrete woman went to the health 
facilityforantennalcare 
13 Pregnancy school Whether the woman enrolled independent SinaI) 
enrolment for the pR:anancy school or 
DOt 
14 Noofpregnanc) Number of pregnancy schoo! independent 
school's Ittendance of the motber 
attendance 
15 Hb at 36 weeb Haemoglobin concentration Dependent Continuou! 
of mother at 36 weeks 
16 Birth weight The weight of the baby at independent Continuous 
binh 
17 Low birth Weight Any binh weight less than 2.5 Dependent Binary 
kg 
18 PlKe of Delivery Skilled 0< wWcilled (Home Dependent Categorical 
delivery) 
Table 2: OretWtioaofindicatorsand lheirmeasurement 
INDICATOR , DEFINITION NUMERATOR DENOMINA DATA 
TOR SOURCE 
Lowbirthweigbt Binhweight No. of live: LBW All live births Odive:ry 
<2,5"" registers 
ANCregister 
and pregnancy 
schoolreister 
AMemiain Pregnanlwomen No.ofpresnant AlIprcgnant ANCregistet, 
Pregnanc)'at wilhHb< 11 gldl women whose HB womcnwbosc reports 
registrMion 3tJegiSiniion <II &leU .. HBwottatod 
registration IItregistraiion 
ADaemiain Prqnmawumcn. No. ofprc:lM"t AlipregJW1! ANCrcgister, 
P_cyat36 withHb<ll g1dl women whoee HB women whose DHIMS 
weeks 3t16Yo'ccks < 11 &ldI8I36 HBwastested 
weeks at 36 weeks 
Proportionol A11deliverica No. ofbomc Total Delivery 
Home Delivcries conductcdb)' deliveries deliveries register8ll.d 
IWItilied pregnancy 
petSOMCl schoolregislet 
p-y 
sc:hoolre&ister 
3.6 S ...p le Size Deferatioation 
A census was done for .U2017 deliveries in the Nabdam district. AUavailablc records of 
the study population wilhin the srudy period Wett reviewed. Out of. total of nine hWldred 
andforty·five(94S)deliveriesthat ....' tfCrecordcdia20 17inthedistrict. ~hwl(lredand 
sixty-nine (769) records were complete. Out of these number. three hwtdred and ninety-
eight (39i) were in the intervemion group whilst 371 served Ii the control in the scud)'. 
3.7 Power ADalysis 
The sample size of 769 (J98 intervention and 371 control) participants with complete 
informM.ion out of 945 deliveries resulted in a power of 99.26% after usumi.q a 0.2 
reduction in anaemia among women who anended the pregnancy school using a type I error 
of 5"_. The 398: 371 pvc a proportion 0(0.48 control to 0.52 intervention which were put 
into STATA for the...aching power calculation. This shows tbaa the study was powered 
enough to detect a significant imJ*:t ofpre~y iCbool OIl anlCmia in pregnancy among 
theinlerVentiongroup. 
Note: SIOIQComntQIfdjOr power; "ptItwrmcc 0.48. tHlIIio (0.52) II (371)" 
3.8 DataCoU«tiolli 
The data was collected from 8 health facilities namely Pitanga CHPS, Oasobligo CHPS, 
Loagre Health centre (lCM), Nangodi Hea11h centre, Pelungu Clinic. Sakoti CHPS. 
Kotintaabig CHPS and Zanlerigu CHPS. An excel daIa extraction tool was used to compile 
me records of women who delivered in 2017 in the Nabdam diSlriCL The data was extracted 
from various n::gisters such as preanancy school register, ANC regisler, delivery register 
and where necessary. the Post-natal register. 
3.9DataPrOcHsiag 
The data was first extracted onlO an excel sheet for proper cleaning, realisnment before 
exponing to a Stata 15 software for recoding and analysis. 
3.9.1 How missing data was bandied 
In every records review. the researcher is most likely 10 face the problem of missing data. 
As a result, measures were pul in place to addleSi this critical issue which could affect the 
findings or the study. Data elements that did not contain complete information on any of tile 
three outcome variables were left out and therefore did nol fonn part of the analysis. 
3.10 Data analysis 
Stata version 15 software was used in analysing the data where Chi-square test of 
association was used to determine whether there was lSSOCiation between. the demographic 
characteristics of participants and categorised Hb levels. birth weipt as well as home 
(Iclivery.DifTerentstatisticalanalysistoolswereusedforthevariowobjectivesintbestudy. 
First of aU, t-test for two sample population means was used to compare the differences in 
the mean haemoglobin concentration (Hb) among the intervention group and control group. 
This was done 10 determine the level of anaemia among the pregnant women before the 
pregnancy school intervention and after the pregnancy school. Thus, Hb at registration was 
used as anaemia before thc pregnanc:yschool intervention and Hbat 36 weeks was the level 
of anaemia after the intervention. This was to detennioe whether there was any difference 
in tenns of the outcome \ mables between the beneficiaries of the pregnancy school and the 
control group. Also, two sample I-Iesl was used to determine if there is any difference 
between the mean binh weight of pregnant women who attended the pregnancy school and 
tbose who did not. 
3.11 Difference in differt'nces analysis (DID) 
The t-test of differences in two population mean was first used 10 obtain the mean difference 
in Hb at registration and at 36 weeks wilh their respective confidence intervals and p-values 
The parallel trend assumption was then used in estimating the: difference-in-differences 
analysis of Hb at 36 weeks. The parallel trend assumption in Difference in Differences 
(OlD) means, in the absence of the program the change that would occur in both the control 
and intervention group will be constant and equal, This was Wladjusted and basic differences 
in differences analysis that was done to see whether there was any difference in mean Hb 
concenrration between the control and tbe intervention group before and after the 
inlenrention. However, the actual impact of the pregnancy school on anaemia was further 
detennined using more rigorous methods such propensity score matching procedure. See 
Figure 5 for illustration on how they OlD was done where: OlD'" [(D-C)-(B-C)] 
A-Hbofcontrolgroupatregistration 
B" Hb of control group at 36 weeks 
c= Hb of intervention group 111 registration, 
J>-.Hb or"rvCldJOO group a 16 weeks 
BasehOFHb"~ 
End IIhe'"" Hhaa36 wtUS 
lib: g/d1 
<:-18.77 
F~ 5: Vt.fIr:nttee Ulfllly.fl.t of Hh aJ 36 weeA:s hdween f..'fmlrul und ''''ervenIIlJn J:Y'oup 
l.ll Ma1dialt proc:eduret 
Mu::hing is any method that equates or try "'balance the dIStribution orcovana1C::S In the 
_ and controt _ . Propensity """" maId>"'8 (PSMJ and ........ "."gIIbow 
rnatdung proc:edwcs were used In several series of sensitIVity analysis 10 decrease the 
(."Ovariatc imbalancebcfween thec:onuol group and the Ifttavention group in the study. 
Propensity score (PS) (or an mdlV1dualts the conditional prob.tnlity orbeUIII.n::Med givca 
~lly score for a prqpwtt woman bcoefittina from the 1nk:fVentlon ~ 64.8%. 1bis 
was dooe in STATA whic:tI mlmmlSedbias in the findingsofthlSstud)'. Propcn$lty score 
28 
replications were done to reduce random error in the estimate. The matching according to 
common suppan made the groups similar such thai any estimated difference could then be 
attributed to the pregnancy scbool intervention. Hence the impKt of the pregJWlcy school 
strategy on anaemia in ptCgJWlCY (at 36 weeks.). However, the kc:nnel matching with 
Regression Adjusted rtSuJts wm: reported because the adjustment made the model more 
robust in detennining the actuaJ imJ*1 of the intervention. 
J.1J QuaUty coDtrol 
In order to get quality data, omy heaJth staff such as Corrununity Health Nurses and 
midwives who an! very familiar with the data source registers were hired and trained to 
collect information. The data extraction instrument was also tested to guarantee that all 
correetionsand adjustments were made before the actual dataoollection processbcgan. 
3.14 Expected outcomc oftbcstudy 
1. The impact of pregnancy school 00 anaemia in pregnancy among pregnant women 
who attended pregnancy school and those who did not attend the pregnancy school 
in the Nabdam district 
2. Proportion of Jowbirth weight between the intervention and control groups 
3. Proportion ofsltilled delivery among the two groups in Nabdam district. 
_' .15 EthicalcoDsideration 
Prior to the conuncncement of the study, ethical clearance was sought from the Ghana 
Health Service Ethics Review committee with approval nwnber GHS-ERe 068104119. A 
formal pennission was also obtained from the Distric:t Direaor of Health Services to plve 
way for the study to be conducted. The data that were extracted from the records were solely 
used for the inlended purposcand the identity of participants was concealed by using codes 
instead of names in order ttl mainlalO confidentiality. Last but not the ~ the research 
team tnemben were poperIy trained and advised 10 be respectful8Ild responsive to all thole 
COQCc:med With the dMa required for this study. These techniques are all supported by • 
guide 10 filed daaa collection that ensured successful data coUection (Kathleen. Natasha 
Mack.Cynthia Woodsong. 2011) 
CHAPTER FOUR 
RESULn 
The reiUlts from the data analysis in this study arc plUmled in this chapter as follows: 
4.0 Demojtraphic characterbtil::, ofprepaotwo.e. 
A total of 769 records of deliveries were reviewed durina the study. Majority oC lhe study 
participants in the intervcruiOD group 221 (S7.64%) and compuiJOll aroup 191 (53.8~) 
were between the ages 20-29 yean with a mean age of 24.7 and 25.1 respectively. More 
than Q{Wooftbe participults were married (91.1-10 versus 93.6%). About 99o/,ofthe women 
in each group had anactiveNHIS card (Table 3}. 
Note: Each var;Qb/~ hod ils own dntoinlnDlor 
Table 3: Association between Demognpbic ChanK:teristics and pregnancy school 
alt<ndonc, 
TOIa' -C(p-value) 
v ....W r Group, N( %) N(-I.) N(-A.) 
Aac cro.,U-l'I) 40. 15(<0.01) 
;~;;*SD: 14.HtO .ltJ2 24.72 
,..." 86(21 .60) 77(2L04) 
118(11.41 
221(57.64) 197(5].1) 511(51.21) 
)0.)4 49(12.31) 5-4(14.7S) 168(1913) ". 36(9.05) 38(10.38) 10(1.14) 
Toto' J91(100) )66{IOO) 164(100) 
NoEducal:.on 171(4U2) IQI(S4.2J) )76{4Q14) 
Primory 61(15 .60) 77(21.10) 138{18.15) 2O.90(.;Q.OOI) 
JHS 94(24.04) 65(1181) 159(210)) 
SHSlTEClVOC 42(10.74) 20(5.41) 62(820) 
T....., 16(4.09) S(1.J7) 21{271) 
T. ..,  391(100) 391(100) 756( 100) 
Ocnp.li. . 
Flnn~ 223(56.46) 2G.&(S6.04) 427(56.26) 
~::~C:~I 1l{3.29) 1S(o.87) 38(5.01) 22(S.51) 33(9.071 SS(7.25) 25.08«0.001) 
Salary Worker 19(4.81) 6(1.6S) 25(3.29) 
Seamstress 29{1.)4) 26(7.14) 5'(7.2S) 
S(\Kk:nc !9(UI) 24(6.59) 43(5 .67) 
Trading 43(1089) )9(IO.71} 12(10.80) 
Wca.,in, :m6.&4) 7(1.92) H(",48) 
Tot.1 399(100) 364(100) 1SJ( IOO) 
ftohriu l Sllhl5 
MlUTied 317{9I.0I) )]7(93.61) ' 47(92.1) 
~:,::e Scparated 33(8.92) 2)(6.)9) 56(7.67) 
370(1OO} 360(100) 7l0(1OO} 
395(99.3) H9(,91 .4) 1)4(95 .45) 27.39 (<0.001) 
NoAcli~e 1(0 7~) 32(1.6) 3S(4.55) 
TO'11 )98(100) 311(100) 769(100) 
Kongo!Pttanea 223(S6.03) 50( 1)48) 173(U.'J 
Nanaoch 5(1.26) 26(7.01) 31(4.03) 
~~u;~ 38(9.5S) 167(45.01) 205(26.66) 2SJ.518 (<0.001) 118( 29.6S) 59(15.9) 177(21.02) 
~::~niu l4(lS2) 69(1'.6 83(10.79) 
398(100) 371(100) 169(100) 
4.1 Differeaces in mean HemogloblD (lib) CODceDtration betweeD tbe two group' 
The study fOWld that there was a 0.71 gld difference in mean Hb levels at 36 weeks between 
the intervention and control ttroup. 
The mean Hb concentration among the intervention group at 36 weeks was 11.12 gfdl whilst 
that of the comparison group was 10.41 gtdl. The mean Hb difference for the two groups at 
registration and 36 weeks was 0.71 g/dl as indicated in Table 4. 
T.able 4: Differences in mean Hb levels 
Category Mean Hb 95% Confidence interval 
(Rid I) 
Pregnancy school 10.98·11.26 
Noprcgnancyschool 10.41 10.18·10.64 
DifTerenceat 36 wks. 0.71 0.47·1.01 <0.001· 
DifTerencesat regiSlralion 0.11 0.13·0.35 0.3661 
Results from the srudy aJso showed significant difference in various grades of anaemia 
among the two groups. The intervention group did not record any case of severe anaemia 
but the comparison group recorded one C~ of severe anaemia. The prevalence of Moderate 
anaemia was 44.8% among the intervention group and 63,4,,"0 amona: the control group. The 
results also indicated thai only 35.9 0;' of the control group were normal compared 10 55.2"'0 
in the inlervention group as shown in TabJe 5 
Table S: Grades of anaemia al 36 weeks among the two groups 
Catqory 
GradttO(Auemia Pregnancy",hool No pregnancy school P-value 
NonnaJ(%) 207(55.2) 47(35.9) <0.001 
Modcratt(%) 161(44.8) 83(63.4) 
Severe(%) 0(0) 1(0.7) 
375(100) 131(100) 
The study alto found a wide variation in the prevalence of anaemia across the varioU$ five 
sub-districts in the Nabdam district with Nangodi recording as high as 70% prevalence of 
all grades of anaemia in pregnancy. The results revealed that the lowest prevalence (32%) 
of anaemia was recorded in Pelungu sub-district. However, all the other sub-distticts 
m:orded anaemia levels above 400.4. 1be overall prevalence of anaemia in pregnancy in the 
Nabdam district in 2017 was 81 high IS 51%. Details on the prevalence of anaemia at 36 
weeks amooa the various five sub-districts can be seen in Figure 6. 
Pre\'dcocc ofA naemia by sub-distric:t 
7' ~ 
55.J 
Sl.2 49 51 
'" "".8 49J 7 - 44.7 .. - - I--
JO 
I I 
~.q ./ ~C~rf ./' ,.,6·'f t ~.$-C-.I ~ 
'" a No ....1  . A.a~. 
F"ipre6:PrevaAenceofanaemiabysub-district 
As lin Table 6. the mean btrth we;ght of the control was 2.834 q whites tNt of the 
intervention group was 2 ~o kg. 'rblS resulted in a difference of 0.116 kg (116 g) which 
was statistically signifw:ana at p-value <. .( }.(101. Refer to section 4.4 (or more details on the 
wffcn:nce In rncanbuthwerghabetweenthetwogroup:. 
T."1e6: Meanbtrthwelgbf.amongthe intervenbonandcompansongroup, Nabdamdistricl 
in 2017 
Category Ddiverifs Mea.birdl 95%CI P-valae 
..~ I(kg) 
I'rqnoncyschool 38'1 2.950 291·2.98 
No pn:pmcy school 354 2834 2.19-2.88 
Diffm:ares S 0.116 0056-<)180 0.0002 
lS 
4.1.1 .....m o ••r  ... b_ ...... 
Assbown tn figure 7, tbc lftWIence of low bir1b weight in the Intervention group was 5.2% 
wbilelbltoflhecompliriSOllwasI7.2%. 
ProportioD of I.,,,, birth w~ht i. Nabd •• District, 2017 
• No~.1 birtbwt"ight _low birO weilJrtt 
100 
90 
~,  .7.0  
il4'"0  
.t 3D 
FIpI"C 7: ProportIon ofkn¥ birth weiaht by pregnancy school 
4J Proportiotl of Home delh'eraes 
The results revealed that only one out of 398 in the inlcrventlOfl group delivered It home 
whilst the control group recorded 28 home deliveries out of 371 deliveries in the district 
(Table 7). 
~ of Home Dcliveric:samonsthctwogRMP 
- Type ofDdivcry _______  Pregaancy Skilled Home Total 95% (:1 P-vaIH AI1I:oded 397(99.7) 1(0.3) 3911(100) Q8.41-9998 
~ <0.801 
school 
Did not -.I 343(92.5) 21(75) 371(100) 89.n-95.03 
JftBIW'CY 
ochool 
/lowTotul 
36 
..... Differeace io mea. Hb coac:entration at 36 weeks 
Results from Heat showed that the difference of 0.1) gldJ in Hb at registration \\'81 not 
Significant (p-O.366). However at 36 weeks, the difference was O.71gldl which Wll5 
statisticall) significlnl (P< 0.001). SeeTllble 8 for details. 
Table 8: Totest results on Difference in mean Hb levels before and after pregnancy school 
Variable DiffatRet- 95%CI P-value Dirra.36 95%CI P·v.lue 
HbCone. 0.11 0.13-0.35 0.3661 0.71 0.44-0.98 0<0.001' 
• Difference after imen'entlOn (36 weekJ) slgniflcanl 
4.4.1 Impact estimates! Prorensity Score Matcbing 
Results from the regression adjusted propensity score matching techniques revealed that. 
the group of women who a"ended the pregnancy school had 34% reduced risk of anaemia 
(9SO/. CI; 21-42 p<O.OI). Table 9 show the raw coefficients where the negative signifies 
reduction in risk of anaemia. This is the average treatment effect on the treated (ATET) 
which is Ihe impaci on lhe intervention W'0up 
Table 9. Propensity score and Nearest Neighbour matching results (ATET/AT E) 
Mattbiag ATE 95-;'0 ATET 95%CI P-value 
Type 
PSM 1:1 -0.31 -0.64-0.23 <0.001 -O.ll .().45- <0.00 1 
0.022 
PSMI:2 '().l2 -0.44.().20 <0.001 -0.32 .().44'().21 <0.001 
NM 1:1 .().35 -0.83-0.11 0.3661 
NM 1:2 -0.33 -0.43- <0.001 
0.217 
PSMRA -0.32 -0.46-0.21 <0.001 ...0.34* '().46'().21 <0.001 
Note ATET: Average treatment eff~ct on Iht Ireflled ATE: Aurage trtatment 
effect 
Note: PSMRA= Propensity Score Matching with RegreSSIOn Adj.tlfm",1 rrttHMl. ATET Is 
hported in this study. 
4.5 A.uasinl quality of Qlat~biDl 
Thc ma&cbingresull$showedtbal.thevarianceratiobetwceolheconlrOl(Wltreak:d)andlhe 
intervention (t~ted) group after match.ina reduced closer to one as shown in Table 10. 11le 
closer the variance is to ace, the better for comparison . According Donald Rubin. the 
difference mt he variaoce ratio after matching sbould not be more th.an 25% to givc a good 
match for bener cstimate.(Rubin. 2012). 
Tablt 10 VIrianceRatios beforeandaftermalching 
Afler Match ioK (ATE) 
Treatcd Untreated Tn.ttd Untreated 
Ratio 
Age 37.38 40.15 093 37.15 36.45 1.01 
Educational 1.17 0.74 1.58 1.07 0.85 1.25 
Occupl.tion 6.65 5.50 120 6.47 5.98 1.08 
MaritalS1alUs 0 .081 0.12 0618 0.084 0 .086 0.98 
Distance 0.081 0.13 0.623 0.084 0.083 1.01 
Note: Varia"ce ralio closed 10 OM snows 0 good mardt ond similarity 
4.5.1 Resu ..... Q.aIity or Makhiq procedures 
~ from lhcpropensrty score matdunc histogram showed tt.l1heie was not much issue 
widllI1e_ oflockofco. ...n  __ wbicbis ......' y .......... wllllpropcasity 
score malching. Tbts means the CODIroI group served as a good coun1erfactual in estirrwtinc 
tIle"'-' oflbe (Kqp1anCy school Figure I show. good..-h .. the propensity score 
bistopn 
4.!U Res.1ts fl'Hl KellIId deasity balu.ciq ,let 
The kennel density balancing plot also showed that lhere was only a moderate overlap 
between Ihe study group and Ute comparison group before maldung. However, there was 
almost a complete overlap between the control and ir*rvcnbon groups after maIdrin& there 
was almost acompletc overlap or merge bctwcco the two groups. nus II'ICIR5 the JIOUPI 
became very simi_ after the matching thereby brinJing the v.-iIIions lhat tRIbally exJlICd 
due 10 covanates Imbalance to almost zero after matching. Hence any ditTc::rmce in the 
esbmation can be attnhuaed to the pregnancy school strategy. Figurc9indicalCsthemaacbcd 
_.-hcdft.-lbe_the"*",_andlhetompui","_. 
i:l!i~ 
... ... ..M 1I .4!> ... 56 • 
~~-. . ~  
.-..... 9. Kcmcldcmity_. .. pIol 
--------__-8 6-M' 
----""---'" 
___O Q"tJ4"Il  
--"""" 
[:=-1 
(""I'M/1Ui "pre.fe1J/ /ho$e who duJ not aIIend the P't:gttuney $dtt}l()/ und fn '.}"''' ,Jrl' rh"" 
prexnonJ wOInt!n who tJllmded the pregnunq M:hotJI 
'-lIIg1Ire 10; Standlrdised cros.s covatlll&e betwo:D the two groo:pe. 
CHAPTER FIVE 
DISCUSSION OF FINDINGS 
5.0 Introd\l~tioQ 
The main purpose ofthc pregnancy school project was to improve maternal and child health 
indicalon such anaemia io pregnancy. Low birth weight and home deliveries in the Nabdam 
district. 
5.1 Summary or the study key rmdinp 
The study revealed that the pregnancy iChool intervention had II positive impact on pregnancy 
outcomes und skilled delivery in the Nabdam district. This include but not limited to the 
(ollowina: 
I. Anaemia in pregoalK)': Tbe pregnaney school strategy reduced the risk of anaemia at 
36 weeks among the in1crvention group by 340/• . Thi. resulted from a difference of 
O.71gldlofHbconcenuationbetweentherwogroupsal36weeks 
2. Birth weight: There: was a differences in mean birth weight between the intervention and 
COntrol group (116J.}The proportioQ of low binh weight was also found to be higher 
among the control group (17.2-10) compared to the intervention group (5.2"'11). 
J. Home delivery: The study also revealed that the proportion of home delivery was higher 
amonl the control group (7.5%) than the intervention lVouP which was only 0.30"-, 
This chaptcr lherefore gives a detailed discllSsion oflhc re:.:ulls from this study withreferenc:es 
to the relevant reviewed literature as well as the rese,m,;her opinion and interpretation of the 
results 
S. t. Aae ..i a i. pregnncy at J6 weeks 
Tbe results from the difference in difference anaJysis revealed thai there was a difference of 
0.71 fldl in mean hemoatohin concentration between the two groups. This means there was 
a positive impact of the pregnmcy school interventioD on anaemia in pregnancy. The 34% 
reduction intberi,kofanaemiacowd be due to the fact that the intervention group had good 
nutrition edtK:ation on how to preserve and consume iron rich foods which improved their 
Hb levels at thiny 36 weeks. It could also be due 10 the fact that the lessonJ from the 
pregnancy school miam have increased their compliance in terms of taking iron 5uppiemeDlS 
duringtheirpregnancy_Thesefindinparesimilartoastudyinlndiawhichfound thatthere 
was a 35% reduction in the risk of anemia in the intervention group in that study (Mishra 
et aI., 2016). However. these findings contradict with a study which was conducted in 
Derunark on the effects of health cducationonpreSoanc:youtcornn(BrixvaletaJ.,2014) 
According to the World Health Organization. any prevalence of anamtia greater than 40% 
(40-59%) in 8 population is. severe public problem. This means, apart from Peluogu sub· 
district. aU the other sub-diSlrlcts per the results recorded prevalence: maher than the WHO 
recommend cut off point for anaemia. Though the intervention reduced the risk of anaemia 
by 34% in the intervention group. the overalJ district prevalence of anaemia was sHU high. 
This could be due to the fact that only about eight out of the 85 communities in the district 
organized the pregnant school. Nearly 52% of the pregnant women had anaemia which 
means by the WHO classification, the Nabdam district as a whole stilt has a public health 
problem in tenns of anaemia in pregnancy. (Challa a: Amirapu., 2016). 
5.2 Low bir1b weipt 
The prevalence of low birth weight among the group of pregnant women who did DOl aHend 
the pregnancy school was about "'-0 rugher than the National prevalence of 9% and allO II 
the upper limit of the currenl World Heahh Orpnisation c1assificatioo of low birth "''eight 
(Gbona Statistical ServkclGIwla Health ServicdlCF Intemalional. 2014; Weise. 20120). 
Tbc 10.,. birth weight nile of 5.2 percent l1li008 the inlCtVCntion group was much smaller 
than the low binh weight incidence of 12 percent reported in the Nabdam District Health 
Directorate's 2018 annual report. This could be due to the fact that pregnant women who 
bc:oefiled from the prtgIlMCy school had good matenW nutrition which improved the birth 
weight of their babies. 
Thctewaadiffereoc:eo(abouIll-l, in the prevaIenceoflowbirth weight between prcgnant 
women who attended the pregnancy and thoie who did not. Almost 95°,4 of the women who 
attcnded the pregnancy school gave birth to normal weight babies against nearly 82% in the 
comparison group. These differences could be partly due to the preanancy school 
intervention which had a positive impact on Low birth weight in the district. Also. the mean 
birth wei&ht of women in the intervention croup wu 116 g higher t1wl those in the 
comparison group. 1bcse results IU'e consilient with • meta-analysis research conducted by 
(Grote et aI., 2010) wh~ the impact of antenatal care ranged from 1.02 to 4. 7S times higher 
among beneficiaries. 
These findings also means that. the impact of the pregnancy school was about five times 
more than whal was found in 3. study by Lima and coUeques in 2016 which was only two 
~ .8°;0 ( 50g) lower in the inter:enlion group. Nearl)' 6% of women in the interVention group 
gave birth to low birth weight as compared to almost 18% in the conuol group. This means 
an increased risk ofmfant mortalily since low birth wciaht babies are three times more likely 
to die than oonnal babtes. The fUldings from thiJ study however disagree with 
'Jb:angarantinnm stud)' in 2012 which showed thai there was no significant difference 
between the intervention and comparisou group in terms of birth weisht.(Thanpratinam. 
2012). 
43 
5.3 Home chUve~ amoDg tbe two groups 
ACCOtdina 10 the 2017 GbIna Maternal Health survey, skilled delivery was 79% in the 
country and 91./. in the Upper East Region .Though the mults showed thai the prevalence 
of home deliveries among both the interVention and control group were lower the national 
figure of about 2ao", it was even much lo""'a' in the intervention group (0.3%) as compared 
to the control group (7.5%). This means the Nabdam district perfonncd better in terms of 
home deliveries than the Upper East Regional figurc of about 9%(Ghana Statistical 
Service/Ghana Health Service, 2017). The reduction In home deliveries to rates lower than 
both the regionaJ and national figures could be due to the pregnancy school intervention. Jt 
could also be due 10 uncieneportina since some of the victims of home deliveries in the 
villages may fail to report to a health faci lity for fear of blame from health staff. 
S.4 Impact of pregDlIncy school on anaemia in pregnancy at 36 weeks. 
Results from the propensity score matching revealed that pregnant women who actually 
attended the pregnancy school had a 34% reduced risk of suffering from anaemia al 36 
weeks in pregnancy. Therefore. the pregnancy school strategy was found to really have a 
positive impact on anaemia in pregnancy in the Nabdam district in 2017. 1bese fmdings in 
the study wefe similar to a study in India which showed that the prevalence of anaemia was 
reduced by 350/. among preg:rwlt women who rtteived a similar intervention during 
pregnancy (Mishraetal.,2016). 
5.5 Limitations ortheStudy 
Despite the findings mentioned above, the study had ~ limitations. One bed to do with 
unobserved factors which might not have been catered for in the model used in the impact 
estimates. For instance. a woman with Wldetected chronic condition could have developed 
anaemia or given birth to a low weight baby. Moreover. spillover effect coWd have affect 
the C'Sti1nlles. Abo, the paraJlel trend asswnptiOQ thai was used in the DID is very difficult 
to satisfy inrcal life situation and this was a limitation to the study. 
One priVak health facility out of the nine facilities in the disbict that conducted deliveries 
in 2017 COUld nol provide complete data for participants during the itudy. Hence, the 
teICIrcber cou&d not tell whether women wbo delivered in that privaae health facility had 
similar~oukomesoroot. 
CHAPTER SIX 
CONCLUSION AND RECOMMENDATIONS 
6.1Conc1usMtlloftbestudy 
The main purpose of the study was to determine the differences in pregnancy outcomes and 
skilled delivery between pregnan! women who attended pregnancy school in Nabdam 
district and those who did not attend the pregnancy school. The study specifically focused 
on comparing the differences in anaemia and mean birth weight as well as proportion of 
home deliveries among the conb'Ot and intervention gfOUps. Impact estimates of the 
pregnancy school on anaemia at 36 weeks was also detennined among the intervention 
group. 
Kl!yFindings: 
1. The mean Hb concentration at 36 is 0.71 aldl hiaher among the intervention group 
than the control group, 
2. There is 34% reduced risk of anaemia among those who attended the pregnancy 
school than in the control group. 
3. The proportion of low birth weight among women who attended the pregnancy was 
5.2% compared with 17.2% in the control group. 
4. The mean birth weight of women in the intervention group was 116g higher than 
those in the control group. 
S. Less than 1% of the pregnancy group delivered at home compued to 7.5% in the 
control group. 
FoIlowincu...c rmdio&1 from thc study, I can conclude that the prcgnancy school stralCg)' 
really itnpecl('d positively OD pregnancy outcomes and wiled deliveries in the Nabdam 
diSlrict. 
6.2 RetO ••t bdaliou 
Based on the findillll above, the following recommendations are made 
1 The pr"qnancy &ebooI stntcl)' should be scaled up to other convnunities in the 
Nabdam district. 
2. QuaJilfltivc COUlpOocnl of this study shouJd be conducted to identify the lessons that 
were learnt during the implementalion of the pregnancy school for informed 
decisions to be m.dc on how to scale up and sustain the concept. 
3. There 5bould be Cap.city buildina; for health staff e5peciaJly midwifes and 
community health nurses on the pregnancy school concept to enhance universal 
heaJlhcovcrage. 
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