RG966. G3 Op ! bithr C .l G359107 University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA SCHOOL OF PUBLIC HEALTH ASSESSMENT OF WOMEN’S KNOWLEDGE AND ATTTITUDES TO ANTENATAL AND POST NATAL CARE SERVICES IN SEKYERE WEST DISTRICT BY DA VIDAGYAPONG OP ARE (DR) A DISSERTATION SUBMITTED TO THE SCHOOL OF PUBLIC HEALTH, IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF MASTER DEGREE IN PUBLIC HEALTH, UNIVERSITY OF GHANA 1998 -1999 University of Ghana http://ugspace.ug.edu.gh ■Q\ 359107 rS 0?\ University of Ghana http://ugspace.ug.edu.gh DEDICATION This Study is dedicated to My wife, Georgina Opare and my children; William Opare, Angela Opare and Michael Opare, for their inspiration towards this research work. University of Ghana http://ugspace.ug.edu.gh DECLARATION I hereby declare thatihis dissertation is an original work produced by me from research undertaken under supervision. DAVID AGYAPONG OP ARE (DR) ACADEMIC SUPERVISORS: 1. DR. FRANK BONSU 2. DR. PHYLLIS ANTWI VbH University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT To the Director, Prof. Ofosu-Amaah, and staff of the School o f Public Health, University o f Ghana, I render my thanks. The time spent with you learning about Public Health has not been in vain. My academic supervisors Drs. Frank Bonsu and Phyllis Antwi provided high degree o f encouragement, guidance, and very useful suggestions. I cherish their contributions and I am very grateful. A lot o f gratitude goes to Dr. Matilda Pappoe for her support and encouragement. I am indebted to the Sekyere West District Director of Health Services, Dr. Kyei- Faried S., who demonstrated positively his role as a primary field supervisor. His suggestions were very constructive and his concerns were genuine. I am also very grateful to Dr. Appiah Denkyira the Ashanti Regional Director o f Health Services for his useful suggestions and computer assistance and also Dr. Kofi Asare, Brong Ahafo Regional Director o f Health Services for making my going to the school possible. I also wish to acknowledge the support and encouragement I received from the Sekyere West DHMT members: Mr. Michael Dohzie, Mr. Samuel Osei, Mr. Emmanuel Denteh, Ms Ellen Ofosu, Mr. Amponsah, Mr. Amidu, and Mr. Samuel Adu. I am grateful to you all. To Mrs. Sarah Ntiamoah and Mrs. Emelia Sarpong I say a big thank you for all the clerical assistance and also in data collection. Finally I am grateful to Ms. Felicia Annor for taking good care of my children whilst I was at school. To all eminent authors whose work, I have references, I express my gratitude. To the MOH, Ghana UNFPA, other non-governmental organisations and all others who contributed in diverse ways to make the MPH, Ghana programme come true, I say thank you and may God bless you. iii University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS Page Dedication i Declaration ii Acknowledgement iii Table of content iv List of tables vii List of Abbreviations viii Abstract ix CHAPTER ONE 1.0 INTRODUCTION 1 1.1 Background Information 1 1.2 Study Area 3 1.2.1 Location o f the District 3 1.2.2 Boundaries 4 1.2.3 Topography 4 1.2.4 Climate and Vegetation 4 1.2.5 Economic Activities 5 1.2.6 Demography 5 1.2.7 Health Care System Facilities 5 1.2.7.1 Health Facilities 5 1.2.7.2 Antenatal, supervised delivery and PNC services 6 1.3 Statement o f the Problem 6 1.4 Rationale of the study 7 1.5 Operational Definitions 7 University of Ghana http://ugspace.ug.edu.gh 1.6 1.6.1 1.6.2 2.0 2.1 2.1.1 2.1.2 2.2 2 .2.1 2 .2.2 2.2.3 2.3 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10 3.11 3.12 3.13 4 .0 Objectives 8 Main Objectives 8 Specific Objectives 9 CHAPTER TWO Literature Review 10 Antenatal Care 10 Objectives o f ANC 12 Strategies, Activities, and Providers of ANC 12 Postnatal Care 13 Objectives and Activities of Postnatal Care 13 Indicators Used for Risk Detection in Monitoring PNC 14 Suggested Constraints in using PNC services 14 Socio -Economic Value of Women 16 CHAPTER THREE Methodology 18 Study Design 18 Study Population 18 Sample size 18 Sampling Procedure 18 Independent Variables 19 Dependent Variables 19 Data collection Technique and Procedures 20 Practical Training 21 Data Quality 21 Clearance from Local Authorities 21 Data Processing and Analysis 21 Ethical Consideration 22 Limitation of the study 22 CHAPTER FOUR R e su l ts 23 University of Ghana http://ugspace.ug.edu.gh 4.1 Social demographic Characteristics of respondents 23 4.2 Women’s Knowledge about ANC 24 4.3 Women’s Attitude towards ANC 26 4.4 Women’s Knowledge about PNC 28 4.5 Women’s Attitude towards PNC 30 4.6 Constraint for PNC Services 31 CHAPTER FIVE 5.0 Discussions, Conclusion and recommendations 36 5.1 Discussions 36 5.2 Conclusion 38 5.3 Recommendations 38 References 42 Appendix B (Map of Ghana and Map of Sekyere West district profile) VI University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 1.1 National Maternal Health Services Coverage 1987-1993. Table 1.2 Maternal Health Services Coverage in the Sekyere West District. Table 3.1 Selected Sub-District with their corresponding sample sizes. Table 4.1 Social Demographic and Economic Characteristics of respondents Table 4.2 Knowledge of the Benefits for attending ANC Table 4.3 Knowledge of ANC Delivery points Table 4.4 Knowledge of Services Provided at ANC Table 4.5 Knowledge of the cost of ANC services Table 4.6 Opinion on Frequency of attendance at ANC Table 4.7 Attitude on where a woman should attend ANC Table 4.8 Opinion on risk associated with not attending ANC Table 4.9 Knowledge of the Benefits for attending PNC Table 4.10 Knowledge of PNC delivery points Table 4.11 Knowledge on the cost of PNC services Table 4.12 Opinion on the frequency of attendance at PNC Table 4.13 Perceived risk for not attending PNC Table 4.14 Opinion on cost as a constraint to PNC services by respondents Table 4.15 Availability of Health facilities for use by respondents Table 4.16 Time taken to get to the facility Table 4.17 Perception of service providers skill to PNC by respondents Table 4.18 Items required by mothers to enable them attend PNC services Table 4.19 Husband’s support and PNC attendance. Table 4.20 Reasons for not attending PNC University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS 1 WHO World Health Organisation 2 MOH Ministry of Health 3 MCH/FP Maternal and Child Health/Family Planning 4 WIFA Women in Fertility Age 5 TBA Traditional Birth Attendant 6 OAU Organisation of African Unity 7 UN United Nations 8 DHMT District Health Management Team 9 ANC Antenatal Care 10 PNC Postnatal Care 11 FGD Focus Group Discussion 12 PHC Primary Health Care 13 GDHS Ghana Demographic Health Services 14 UNICEF United Nations Children Fund 15 DDHS District Director of Health Services University of Ghana http://ugspace.ug.edu.gh ABSTRACT The study assessed women’s knowledge and attitude towards ANC and PHC in the Sekyere West District. The coverage of ANC has been persistently higher than PNC. Even though the DHMT was aware of the difference, they had no knowledge about the underlying factors. The information was needed by the DHMT, to help improve Information based planning. The main objective was to find out women’s knowledge and attitude towards ANC and PNC as well as any constraints the women might face in the use o f PNC services. The study area is the Sekyere West District; study type was descriptive cross sectional in character. Multistage sampling was used to select the respondent consisting of women who had their deliveries within the last five years. Structured questionnaires and focus group discussions were used in data collection. Data collected were processed and analysed partly manually and partly by using the Epi info software. The main finding were: 1. Most o f the women (about 98%) were married and a greater majority o f them were Christians with low educational level. 2. They had a fair knowledge about ANC and PNC. About 83% o f the respondents knew the correct meaning o f ANC and about 52% knew the correct meaning of PNC. The respondents had fair knowledge about the benefits and delivery points for both ANC and PNC. 3 About two thirds of the respondents have the opinion that a women should attend ANC more than five times and with PNC, 37.6% o f the University of Ghana http://ugspace.ug.edu.gh respondents said a woman should attend more than four times. Most of the respondents (61.6%) think that if a woman does not attend PNC or ANC, the baby and/or mother may die. 4. The study revealed that, cost of PNC services and distance to health facilities for PNC services are not constraints in acquiring PNC services. However, the major constraints were the requirements for attendance at PNC e.g. dresses, new baby dress, new shoe. Gossiping and laziness on the part of the mothers were also contributing factors. The thought that they would be charged; children’s tendency to get sick after immunisation, competition among mothers; having no time and single parenting were other constraints which prevent women from using available PNC services. 5. Poverty ranks first as a constraint for mothers not attending PNC. A more careful look at the results show that, poverty in this context is defined as inability to acquire the items the women consider as requirements for attendance at PNC. Based on the findings from the study, the following recommendations have been made to the DHMT; 1. There should be health education messages to inform women that PNC attendance is not a fashion arena and as such one can attend in any dress or cloth. Furthermore PNC services could be offered at outreach points so that women could use their housedresses. 2. Mothers should be told that, the little fever that may follow University of Ghana http://ugspace.ug.edu.gh immunization is short-lived but the protection is of great benefit to the child. 3. Most o f the women are Christians, as such a lot o f health education messages could be delivered through the churches. 4. There is the need to intensify health education messages to let mothers know that ANC services are free. 5. The mothers should be taught about time management, so that amidst their perceived tight work schedule they could find time to attend PNC. 6. Husbands should be involved and invited to attend health education sessions because most of the respondents are married and the husbands have influence on their decisions. XI University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE 10 INTRODUCTION 1.1 BACKGROUND INFORMATION Women constitute an important asset crucially for the socio-economic development o f the nation and hence need to ensure their continuous well being. More than 20 percent of the population in developing countries are women in their reproductive years (1). The knowledge acquired at antenatal and postnatal services helps to reduce deaths and complications during and after pregnancy. Maternal mortality is the health indicator, which shows the greatest differential between developing and industrialized countries. The life time risk of death as a result o f pregnancy or childbirth is estimated at one in twenty-three for women in Africa, compared to about one in 10,000 for women in Northern Europe (2). The Safe Motherhood Initiative which was launched at an international meeting in Nairobi, Kenya in 1987, brought attention to the fact that every year an estimated 585,000 women, more than one each minute, die o f pregnancy- related causes. The vast majority occurs in the developing countries (3). Ghana has maternal mortality ratio 214/100,000 live births (4). Complications of pregnancy, childbirth and unsafe abortions are a major cause of death for women o f reproductive age in Ghana. The major causes of maternal deaths include infection, haemorrhage, hypertensive disorders of pregnancy, obstructed labour and complications (5). All Maternal and Child Health/Family Planning (MCH/FP) facilities provide antenatal services, the aim of which is to promote the health of pregnant woman University of Ghana http://ugspace.ug.edu.gh and the birth of a healthy child. The service is comprised of the following activities: • Physical and laboratory examination to monitor fetal growth and detect risk o f pregnancy. • Health education in nutrition, breastfeeding and family planning including AIDs/STDs. • Tetanol toxiod immunization (6). Antenatal Care (ANC)-care during pregnancy provides an important opportunity for discussion between a pregnant woman and a health care provider about healthy behaviour during pregnancy, about recognizing complications that may arise during pregnancy, and about delivery plan that will meet the needs of the individual woman. Antenatal care is also important in the provision of iron/folic acid tablets to prevent and treat anaemia (7). Postnatal care (PNC) refers to care given to mothers and their babies from the end of delivery through to six weeks after delivery. It is therefore, rather unacceptable that ANC coverage should be much higher than PNC coverage in Ghana (MOH, 1993). Table 1.1: National Maternal Health Service Coverage 1987-1993. TYPE OF SERVICE DELIVERY YEAR/PERCENTAGE (%) COVERAGE 1987 1988 1989 1990 1991 1992 1993 Antenatal coverage 56 65 85 85 91 90 87 Supervised delivery coverage 18 19 27 27 29 30 40.6 Post natal coverage 6 9 13 13 14 17 29 Source: MCH/FP Ghana, MOH 1993. 2 University of Ghana http://ugspace.ug.edu.gh With reference to table 1.1, the antenatal care coverage range between 56 and 91% whilst postnatal care coverage ranges between 6% and 29%. It is explicit that there is a gap between ANC coverage and that of the PNC. The situation is no different from that at Sekyere West District (Table 1.2.) The National ANC coverage for 1997 and 1998 are 85.2% and 87.5% respectively and those for PNC for the same period are 34.3% and 37.7% (8). Table 1.2: Maternal Health Service Coverage in Sekyere West District TYPE OF SERVCE DELIVERY YEAR/PERCENT AGE (%) COVERAGE 1997 1998 ANC 75.3 96.2 Supervised Delivery Care 40.2 47.3 PNC 28.0 38.2 Source: Sekyere West DHMT Annual Report 1998. The difference between ANC and PNC coverage could be the result of factors such as lack o f relevant knowledge, negative attitudes of mothers, socio­ cultural factors, geographical inaccessibility and others. However, the gap between the ANC coverage could be reduced if attempts are made to assess women’s knowledge and attitudes to ANC and PNC in the Sekyere West District, and this information used to improve these services. 1.2 STUDY AREA 1.2.1 Location of the District. Sekyere West district has Mampong as the capital. It is located in the Ashanti Region. It is about 57.5 kilometers from Kumasi. The land area is about 2346 sq.km, which constitute about 5.2% of Ashanti Region’s land area. University of Ghana http://ugspace.ug.edu.gh 1.2.2 Boundaries The district is bordered on the south by Afigya Sekyere East District and North West by Ejura Sekeredumasi district. The inhabitants are mostly Ashanti. The northern part of the district is in the Afram Plains. The area predominantly inhabited by migrant farmers is sparsely populated, with about 20% of the district population, but covering about 50% of the district land area. The major towns in the District apart from Mampong are; Asaam Kofiase, Benim, Krobo-Dadiase, Kwamang, Ninting, all are located in the southern part of the district. The northern portion to the district also has the following towns; Birem, Oku Junction and Asubuaso. These lie in the Afram Plains portion o f the district. Mampong, which is the district capital, is centrally placed and easily accessible by road from almost all the major towns. Part of the Afram Plains is however inaccessible most of the time, especially during the rainy season. 1.2.3 Topography The district is partly on a scarp, which runs from south to westwards. The greater part is generally low lying with a few hilly areas, stretching north eastwards into the Afram Plains. Major rivers include the Afram and Offin rivers. 1.2.4 Climate and Vegetation The area experiences both wet and dry seasons. It has a mild climate with a mean annual rainfall o f 81.1 cm. The wet season starts from late February and stretches to September, after which comes the dry season, which begins late October and University of Ghana http://ugspace.ug.edu.gh ends in January. It has semi-deciduous savanna vegetation, which permits the growth of all kinds of crops example cassava, cocoyam and yam. 1.2.5 Economic Activities Farming is the major occupation, however there are a few people engaged in white colour jobs such as banking, teaching and nursing. 1.2.6 Demography The district has a population of 180,615 projected from the 1984 census, the breakdown of the population is as follows: 0-11 months 4% = 7,224 1-23 months 4% = 7,224 24-60 months 12% = 21,673 5-14 years 27% = 48,766 15-49 years (men) 20% = 36,123 15-49 years (women) 20% = 36,123 50-60 years 8% = 14,449 60 + years 5% = 9,030 1.2.7 The Health Care System and Facilities 1.2.7.1 Health Facilities The district has one district hospital located in Mampong and six health centres at Asaam, Kofiase, Kwamang, Krobo, Nsuta and Benim. There are two private maternity homes situated at Beposo and Birem. There are also 5 static MCH/FP points and 6 sub- districts. There are 6 sub-districts and about 122 communities and 60 hamlets in the district. The total number of outreach points is 91, all offering public health services University of Ghana http://ugspace.ug.edu.gh 1.2.7.2. Antenatal. Supervised Delivery and Postnatal Services Antenatal services are offered by all the health centres, on days that suit each Health centres. Pregnant women are examined and progress of the pregnancies monitored. Health education talks are given before the clinics and Tetanol toxiod is given to those who are due. There are two private midwives in the district namely, Philipa and Nyame Adom Maternity Homes, who cater for a large number of antenatal mothers. The Mampong District Hospital is thus the referral point for all the health centres and maternity homes. Supervised deliveries are carried out in all the health centres, which have maternity wings. Some 60 Traditional Birth Attendants (TBAs) have been trained to provide good ANC and delivery services to their clients. The total number of deliveries carried out in 1998 was 3315. Postnatal care services are given in all health centres. New babies are examined and polio at birth and BCG vaccines are given together with health education talks. The total number of mothers who attended postnatal clinics in 1998 was 2679. 1.3 STATEMENT OF THE PROBLEM Safe Motherhood is made up of a series o f charts that outline key issues or problems focusing specifically on the antenatal period, labour, delivery postnatal, family planning and abortion. According to the Sekyere West 1998 Annual Report the coverage of postnatal care is lower than antenatal care with a consistent gap between these two components o f maternal care, over the years. 6 University of Ghana http://ugspace.ug.edu.gh Some studies have identified several factors which contributed to this problem of low coverage of PNC but the broad-based nature of these studies made their findings too general and hence not representative enough to account for all that pertains in all communities within the country. Even though the DHMT was aware of this unexplained gap between high antenatal care coverage and that of postnatal care they had no knowledge of the underlying factors in order to fashion out appropriate strategy in the district. 1.4 RATIONALE OF THE STUDY In the Sekyere West District supervised delivery and postnatal care services are located at the same antenatal care service points. Furthermore, midwives and other personnel providing antenatal care services also provide postnatal care services. Health Education on antenatal care is packaged with postnatal care messages. Resource distribution for ANC match that for PNC. Nevertheless, coverage for PNC is much lower as compared to ANC coverage . Health personnel/workers in the Sekyere West District complain of the low PNC coverage and are o f the feeling that there may be some community related factors that might explain this low coverage. The findings obtained by this study will be used by the DHMT to fashion out appropriate strategies to help improve the coverage. 1 5 OPERATIONAL DEFINITIONS Supervised Delivery: Deliveries handled by trained service providers (Trained Traditional Birth Attendants, Midwives, University of Ghana http://ugspace.ug.edu.gh Nurses, and Doctors both in the public and private sectors). Coverage: The proportion of pregnant women o f the expected number of pregnancies in a year that made use of any o f these maternal health services (Antenatal Care, Supervised Delivery, Postnatal Care). Antenatal Care: Care given to the pregnant woman and the fetus, up to the onset of labour. Post-natal Care: Care given to mothers and their babies from the end o f delivery through to six weeks after delivery. Knowledge: Understanding information about a subject which has been obtained by experience or study, and which is either in a person’s mind or possessed by people generally. Attitude: Feeling of opinion about something or someone or a way o f behaviour that follows from this arid is used for a person’s judgement of behaviour as good or bad. 16 OBJECTIVES 1.6.1 Main Objective To find out women’s knowledge and attitude towards ANC and PNC as well as any constraints they face in their use of PNC services and make recommendations to the DHMT. 8 University of Ghana http://ugspace.ug.edu.gh 1.6.2 Specific Objectives • To find out about women’s knowledge of ANC • To find out about women’s knowledge of PNC • To find out about women’s attitudes toward ANC • To find out about women’s attitudes toward PNC • To find out about women’s constraints in using PNC services. • To make recommendations for improvement of PNC coverage. 9 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO 2.0 LITERATURE REVIEW 2.1 ANTENATAL CARE The rationale for antenatal care is essentially that of screening a predominantly healthy population of pregnant women to detect early signs of, or risk factors for disease, followed by timely intervention (9). Antenatal care is the health care and education given during pregnancy, and is an important part of preventive and promotive health care. The knowledge the pregnant women acquire helps improve their living conditions. In Ethiopia, Kwast and others found that the maternal mortality rate for women who received antenatal care was 2.5/1000 as compared with 10.6/1000 for those who had none (10). The Ghana Statistics Service study in 1994 showed per 100,000 live births maternal mortality o f 207 and 287 respectively for women who received antenatal care and those who did not (11). The Primigravida’s (a woman pregnant for the first time) experience o f ' childbirth is influenced by the knowledge and expectations she has o f childbirth. Her expectations of childbirth are based on the information she gets from the antenatal clinic, the nursing staff and her mother, friends and family (12). During a health education study on pregnant women carried out in South Africa, a disturbing finding was that mothers had very little knowledge about the danger signs that may occur during pregnancy. They did not know the reasons for the examination and tests performed during pregnancy (13). In a study done to assess women’s knowledge and expectations o f childbirth in primigravida’s, it University of Ghana http://ugspace.ug.edu.gh became clear that the respondents had insufficient knowledge of childbirth and the handling of pain during childbirth. This insufficient knowledge can mainly be attributed to the poor attendance o f antenatal preparation classes, inadequate professional counseling and the mother of the primigravida as the primary source of information on childbirth (14). A WHO technical group has recommended a minimum of four antenatal visits for a woman with normal pregnancy. However, some women require more than four visits especially those who develop complication (15). The estimates show that in the developing world, only two in three women receive any antenatal care, less than fifty five percent of the deliveries are attended by skilled personnel and just 40% take place in health institutions. Thus, currently more than 45 million pregnant women, annually, do not receive antenatal care. Some 75 million births still take place at home and almost 60 million without a skilled attendant present. South Central Asia, Western and Eastern African contribute heavily to these numbers, accounting for 49% o f the world’s births and also showing the lowest coverage of care during pregnancy and delivery. Nearly all maternal deaths occur in developing countries and among the most disadvantaged population groups. Greater coverage of care during pregnancy, delivery and the postpartum periods will help reduce deaths and disability of mothers and infants (16). In Ghana, the proportion of expected pregnant women who received ANC was 81.2% in 1995 and 84.4% in 1996. Regional variations revealed the highest coverage as 97.4% by Central Regional and the lowest of 67% by Upper East Region (17). University of Ghana http://ugspace.ug.edu.gh 2.1.1 Objective of ANC Globally, ANC aims to: (i) promote and maintain the physical, mental and social health o f mother and baby by providing education on nutrition, family planning, immunization, STD prevention HIV/AIDS, the danger signs of pregnancy, rest/sleep and personal hygiene. (ii) detect and treat high risk conditions arising during pregnancy whether surgical medical or obstetric. (iii) Ensure delivery of full term baby with minimal stress or injury to mother and baby. (iv) Help prepare the mother to breastfeed successfully, experience normal puerperium and take good care of child physical, pyschologically and socially (18). 2.1.2 Strategies, Activities and Providers of ANC The strategies of ANC are clinic-based services, community- based services and outreach services. The activities of ANC include monitoring o f normal pregnancy, identification of high-risk pregnancy, management o f high-risk pregnancy and complications, referral, immunization and health nutrition education. The providers of antenatal care are TBAs, nurses, midwives, physicians and obstetricians at antenatal care service delivery points at each level. The levels are; community, subdistrict, district, regional and national (19). 2.2 POSTNATAL CARE Postnatal care refers to care given to mothers and their babies from the end of delivery through to six weeks after delivery. 12 University of Ghana http://ugspace.ug.edu.gh Most mothers know the importance of PNC but refuse to attend. A study in Bangladesh found out that 79% of mothers felt that postnatal care is needed, yet only 26% attended the clinic (20). In Ghana, the PNC coverage for 1996 was 32.9%. Regional variations revealed 45% as the highest proportion recorded by Greater Accra and 19.1% as the lowest proportion by Volta Region respectively (21). In 1997, the postnatal coverage nationwide, was 34.3%. Regional variations revealed 49.4% as the highest proportion recorded by Greater Accra and 19.9% as the lowest proportion by Upper East Region respectively (22). In a study done to find out clients satisfaction with postnatal care, women who chose domiciliary care following early discharge, rated their postnatal care better than those women who stayed in the hospital (23). 2.2.1 Objectives and Activities of Postnatal Care • To promote and maintain physical and psychological well being of mother and baby. • To perform comprehensive screening for the detection, treatment and/or referral of complications for both mother and baby. • To provide health education on nutrition, family planning, breastfeeding and immunization of the baby. • To provide family planning services at the different levels of Service delivery (24) 13 University of Ghana http://ugspace.ug.edu.gh The activities carried out include, management of normal puerperium and normal baby, identification and management of complications of puerperium, management o f referrals in puerperal stage, immunization o f babies, breastfeeding promotion and family planning motivation, counseling and services for mothers during puerperium. 2.2.2. Indicators Used for Risk Detection in Monitoring Postnatal Care include: 1. Percentage o f postnatal mothers making a minimum of one visit to service delivery points. 2. Percentage o f postnatal mothers with no previous antenatal care. 3. Percentage of postnatal mothers accepting family planning. 4. Percentage o f postnatal mothers who were supervised during the intrapartum (delivery) stage e.g. by trained health workers . 2.2.2 Suggested Constraints in Using PNC Services It has been documented that factors contributing to the low PNC coverage could be attributed to attitude of providers. In Kenya, a study unravels the issue that a greater percentage of patients sought health care outside formal facilities because of the poor attitude of service providers (25). Furthermore, cultural attitude and practices may impede a woman’s use of services that are available. Decisions about where to seek care are often made by the husband, mother-in-law, or other relations (26). A number of discrete but inter-related variables appear to influence ANC and PNC coverage. Some are service-related: age, income, social status, family size, morbidity and religion (27). University of Ghana http://ugspace.ug.edu.gh In economic studies, low household income has often been identified as a barrier to the use of PNC services even when these are publicly provided. However, even economically oriented studies have frequently acknowledged the related issue of physical accessibility. Distance to a facility has been cited as a major variable influencing utilization of health care in Iraq and many other settings (28). Researchers of Safe Motherhood have also identified that certain cultural attitudes and practices, like perceptions of women’s role, block the ability of women to get care for themselves, hence impeding their use o f available service (29). An aspect, which influences public experience with the health care delivery system that has been studied is “waiting time”. Long waiting time been identified as a factor that limits acceptability and coverage of health services. There is however, little empirical evidence on the actual time spent in health institutions by the public in developing countries. In a study on “waiting time”, Bamisaiye et al. found that community perception o f waiting time is greater than that expected and staff perception of the time spent in the clinic was considerably less than the actual waiting time (30). In Ghana the 1997 MCH/FP report attributed some of the constraints to the utilization o f PNC services as: (i) Low priority given to postnatal services by Sub-District Health Teams contributing to discontinuity of care. (ii) Inadequate information to mothers on the importance of this service. (iii) Postnatal care services are not offered on a daily basis at all static and outreach sites. University of Ghana http://ugspace.ug.edu.gh (iv) Some socio-cultural and economic factors militate against this service e.g. period of postpartum confinement, transport cost (31). SOCIO-ECONOMIC VALUE OF WOMEN Women play an important role in social and economic development o f their countries as members of the workforce and as the backbone of households. It has been documented that one-fourth of male-headed households rely on female earnings for more than half of a total income (32). Women in most developing nations gather firewood, for cooking, fetch water, and clean the house, thus making tremendous contribution to household maintenance. In Africa, women grow most o f the agricultural produce and as much as 80 percent o f the food (33). Women play critical roles in society - reproduction and nurturing of future generations, household and community and political reasons for all to ensure that their (women’s) rights including health are respected (34). It has been documented that if women’s unpaid domestic labour were to be paid for, the gross national product of most developing countries would increase by one-third, a substantial financial gain (35). The impact o f investing in women can be more productive than investing in men. They tend to bear more responsibility and use more of their acquired resources to benefit their family (36). There is, therefore, the need to prevent morbidity and mortality among women. The WHO is seeking to stimulate a process whereby policies, research and programmes for women’s reproductive health will become responsive to the perceptions and needs of women. This implies more than mere recognition o f the importance of women’s perspectives, but means using that knowledge to alter the focus of research or to change the way services are University of Ghana http://ugspace.ug.edu.gh provided. The assessment of women’s knowledge, and attitude to ANC and PNC is one such effort to make recommendations to the safe motherhood health education programme. 17 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE 3.0 METHODOLOGY To accomplish the objectives of this research, the methodology consisted of the collection and collation of relevant data using scientific techniques, procedures and tools. These methods and procedures are described in the following sections. 3.1 STUDY DESIGN This was a cross sectional descriptive study. 3.2 STUDY POPULATION The study population was women in the reproductive age group who had children below five years, in the Sekyere West District. 3.3 SAMPLE SIZE Using a district population (women in reproductive age group) of 36,123 with a confidence level of 95% and postnatal coverage of 38.2% and a worst acceptable percentage of 32.18%, the Epi Info software gave a sample size of 249, but for convenience, this was rounded up to 250. 3.4 SAMPLING PROCEDURE A multistage sampling procedure was used to select the study units. The whole district has been divided into the existing six health sub-districts namely: Mampong, Nsuta, Oku, Asubuaso, Birem and Kwamang. Three sub-districts were randomly sampled from the six sub-districts. Proportionate samples were selected from these sub districts based on their WIFA population (Table 3.1). In each sub district all the communities were counted and labeled. The communities were randomly selected and arranged in University of Ghana http://ugspace.ug.edu.gh an order such that the first randomly selected community was given number one. The second randomly selected community was given number two. This continued until all the communities in that sub district were selected and numbered. Starting from the first randomly selected community, all women who met the age and parity criteria in the target group were interviewed. This continued until the required target number for that sub district was reached. If the community boundary was reached and the number selected was not up to the required, then the second randomly selected community was entered until the required sample size was attained. Table 3.1: Selected Sub-District with their Corresponding Sample Sizes Subdistrict Population No. of Communities WIFA Population Sample Size Kwamang 254,442 15 5088 58 Nsuta 34,346 31 6869 79 Mampong 49500 52 9900 113 Total 109,288 98 21857 250 3.5 INDEPENDENT VARIABLES The independent variables used were age, religion, educational level, occupation, and marital status. 3.6 DEPENDENT VARIABLES The dependent variables used were: • Women’s knowledge for ANC University of Ghana http://ugspace.ug.edu.gh • Women’s attitude to ANC • Constraints in using PNC services • Women’s knowledge for PNC • Women’s attitude to PNC 3.7 DATA COLLECTION TECHNIQUES AND PROCEDURES The techniques used to collect data were interview by the use o f a structured questionnaire containing both closed and open-ended questions and focus group discussion assisted with a guide. The focus group discussions were used to explore the underlying factors for low PNC coverage. Three focus group discussions were conducted. The findings were transcribed using the notes and the recordings made. Analysis was done manually. Three field assistants who could speak the local language were recruited to help the data collection. They were trained for two days. The two days involved one- day theory and the second day for practical training on the field. For the theoretical training the three interviewers were introduced to the topic, its objectives rationale and data collection techniques. Explanation was provided on community entry, how to introduce themselves to the interviewees, how to ask for consent and how to close the interview. The interviewers were taught basic interview techniques such as questions in a natural, flexible, relaxed manner, how to recognize agreements, disappointments, or surprises and how to translate these into Akan language without losing its meaning. 20 University of Ghana http://ugspace.ug.edu.gh 3 8 PRACTICAL TRAINING This involved the field-testing of the questionnaire in the communities. The field-testing was used to answer the questions as to how many questionnaires, an interviewer can complete in a day, and also the workload. Furthermore, there was a role -p lay in which a trainee assumed the role o f the interviewer and another played the part of the interviewee. Others observed and critiqued. 3.9 DATA QUALITY To ensure completeness, reliability, and validity, the principal investigate/, checked all the data collected on three different occasions. 3.10 CLEARANCE FROM LOCAL AUTHORITIES Since the research was undertaken in communities, permission and clearance were sought from chiefs, opinion leaders, assemblymen etc. before entering the community, some background information was sought, in cases where there are some chiefitancy disputes. 3.11 DATA PROCESSING AND ANALYSIS To ensure good and accurate data processing and analysis, the entire questionnaires were numbered and responses coded. Computer programmes and manual checking using data master sheet were used in the analysis. 21 University of Ghana http://ugspace.ug.edu.gh 3.12 ETHICAL CONSIDERATION Ethical issues were not overlooked in the planning and implementations of the research work. Selected respondents were only interviewed after gaining their permission, and confidentiality was ensured. There were no names on the questionnaires. 3.13 LIMITATIONS OF THE STUDY Recall bias was a limitation. Some could not recall some events, which happened 5 years ago. Furthermore, the element of respondent bias cannot be claimed to have been ruled out completely. However, because of the assurance from interviewers about the confidentiality o f the data, and the intended use of the findings to improve health services in the entire district, it is hoped that responses were genuine. 22 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR 4.0 RESULTS The results o f both questionnaire and focus group discussions are presented below: 4.1 Social and Demographic Characteristics Table 4.1 SOCIO- DEMOGRAPHIC AND ECONOMIC CHARACTERISTICS OF RESPONDENTS Characteristic Frequency Percentage Aee(vears) Under 20 20 8.0 20-35 178 71.2 Above 35 52 20.8 Occupation Farmers 101 40.4 Traders 101 40.4 Civil Servants 4 1.6 Hairdressers 12 4.8 Others 4 1.6 Unemployed 28 11.2 Religion Christians 213 85.2 Moslems 12 4.8 Traditionalist 5 2.0 No religion 20 8.0 Education Primary 48 19.2 Middle 134 53.6 Post secondary 17 6.8 No education 5 2.0 46 18.4 Marital status Married 243 97.2 Not Married 7 2.8 Table 4.1 shows that most of the respondents (71.2%) were between 20-35 years of age, 20.8% were above 35 years and only 8.0% were below 20 years. The University of Ghana http://ugspace.ug.edu.gh respondents were predominantly farmers (80.8%), with quite a few of them being unemployed. Some 85.2% were Christians. Most of the respondents had been to school but majority of them, (53.6%) attended middle school. When the respondents were asked about their marital status it was found out that 97.2% of them were married. 4.2 WOMENS KNOWLEDGE ABOUT ANTENATAL CARE Of the 250 respondents 207 (82.8%) knew the correct meaning of antenatal care. This is encouraging because most of the respondents had been to school and 96.4% attended ANC the last time they were pregnant. When the respondents were asked about the benefits o f antenatal care, the following responses given are presented in Table 4.2. Table 4.2: KNOWLEDGE ON THE BENEFITS FOR ATTENDING ANC Benefits of Antenatal Frequency of Responses* N-250 Percentage Maintaining of normal pregnancy 169 27.8 Identification of high -risk pregnancy 180 29.7 Giving immunization 146 24.1 Health nutrition 107 17.6 No response 2 0.3 Other 3 0.5 Total 607 100 * Multiple responses, hence 607 24 University of Ghana http://ugspace.ug.edu.gh Table 4.3: KNOWLEDGE OF ANC DELIVERY POINTS Service Point Frequency of responses* N=250 Percentages Hospital 178 58.9 Health Center 33 10.9 Clinic 61 20.3 Maternity Home 30 9.9 Total 302 100 *Multiple responses, hence 302. An appreciable number (99.2%) knew some of the benefits of attending ANC (Table 4.2). Out of the 250 respondents, 53.2% gave three responses, which were considered acceptable. Regarding ANC service points, 58.9% mentioned Hospital, and 20% said clinic, with a few mentioning maternity home. During a focus group discussion, the participants also mentioned hospital, health center, maternity home and TBA as service points for ANC. This implies that, the women had a fair knowledge about where to attend ANC services. Table 4.4: KNOWLEDGE OF SERVICES PROVIDED AT ANC Services Frequency of responses* N=250 Percentage Measure the heart beat of the baby 101 17.0 Measures the blood pressure of the mother 173 29.1 Measures the position of the baby 158 26.5 Checks the stool, urine of mother 94 15.8 Checks the stomach of the mother 65 10.9 No response 4 0.7 Total 595 100 * Multiple response, hence 595. From the study, 29.1% of the respondents knew measuring o f a mother’s blood pressure as a service at the antenatal care service point. Only 10.9% knew that 25 University of Ghana http://ugspace.ug.edu.gh there is stomach examination of the mother. Out of the 250 respondents, 61.6% gave more than three responses, which were considered acceptable. Table 4.5: KNOWLEDGE OF COST OF ANC SERVICES COST Frequency of responses Percentage Free 36 14.4 Between 2 to 5 thousand cedis 166 66.4 Between 5 to 10 thousand cedis 23 9.2 More than 10 thousand cedis 5 2.0 No response 8 3.2 I don’t know 12 4.8 Total 250 100 The respondents gave various figures as the cost o f antenatal services. Most of the respondents (66.4%) mentioned between two and five thousand cedis. Only 14.4% knew that ANC services were are free. Some of them (4.8%) did not know the cost of ANC services (Table 4.5). 4.3 WOMEN’S ATTITUDE TO ANC From the study, 98% of the respondents were o f the opinion that a woman should receive antenatal care when pregnant. A greater number of them (68.8%) were of the opinion that a pregnant woman should attend ANC more than 5 times. Only 27.2% of the women thought a pregnant woman should attend ANC five times or less often (Table 4.6) 26 University of Ghana http://ugspace.ug.edu.gh Table 4.6: OPINION ON FREQUENCY OF ATTENDANCE AT ANC No. of Times Frequency of responses Percentage One 7 2.8 Two 7 2.8 Three 16 6.4 Four 15 6.0 Five 23 9.2 More than five 172 68.8 No response 5 2.0 I don’t know 5 2.0 Total 250 100 Table 4.7: ATTITUDE ON WHERE A WOMAN SHOULD ATTEND ANC. Facility Frequency response * N=250 Percentage Hospital 65 15.8 Health Center 190 46.4 Maternity Home 146 35.6 TBA 4 1.0 Untrained TBA 0 0.0 Other 5 1.2 Total 410 100 * Multiple responses, hence 410 Table 4.8: OPINION ON RISKS ASSOCIATED WITH ATTENDING ANC. Risk Factors Frequency of responses* N=250 Percentage Death o f mother 147 32.7 Death of baby 167 37.2 Cord prolapsed 62 13.8 Retained placenta 55 12.3 Others 18 4.0 Total 449 100 * Multiple responses, hence 449. 27 University of Ghana http://ugspace.ug.edu.gh From Tables 4.7 and 4.8, about 47% of the respondents were of the opinion that pregnant women should attend ANC at a health center, and quite a number believed death of the baby was an associated risk for not attending ANC, followed by the death o f the mother. Those who thought otherwise mentioned haemorrhage, malpresentation and the fact that the mother could be sick, as some of the associated risks for not attending ANC. 4.4 WOMEN’S KNOWLEDGE OF PNC Of the 250 respondents, 50.4% attended PNC, the last time they delivered and when asked about the meaning of postnatal care, 51.2% gave acceptable responses. Table 4.9: KNOWLEDGE OF THE BENEFITS FOR ATTENDING PNC Benefits Frequency of responses* Percentage Immunization of baby 189 39.1 Advise the mother on how to breastfeed baby 142 29.4 Checks any complication after delivery 108 22.4 Advise the mother on family planning 42 8.7 I don’t know 2 0.4 Total 483 100 *Multiple responses, hence, 483. From Table 4.9, majority of the respondents (99.6%) knew at least one benefit of PNC. Very few (8.7%) could mention that mothers are given advice on family planning. A greater majority (65%) could mention more than three benefits of PNC, which were considered acceptable. Only 0.4% do not know anything about the benefits of PNC. 28 University of Ghana http://ugspace.ug.edu.gh During a focus group discussion on the issue o f the benefits of PNC, majority of the participants said PNC is beneficial because the providers check the health of the baby, “inject the baby against diseases,” and physically examine the mother. The impression created by the participants indicated that woman generally knew PNC services are beneficial. Table 4.10: KNOWLEDGE OF PNC DELIVERY POINTS. Delivery point Frequency of responses* N=250 Percentage Hospital 22 7.1 Health Center 181 58.4 Clinic 25 8.1 Maternity Home 73 23.5 TBA 9 2.9 Total 310 100 ^Multiple responses, hence 310 From Table 4.10, most of the respondents knew health center as a delivery point for PNC and most of (57%) mentioned more than three delivery points which were considered acceptable. Table 4.11: KNOWLEDGE ON COST OF PNC SERVICES. Cost Frequency Percentage Free 59 23.6 One thousand 64 25.6 Between one to two thousand cedis 56 22.4 Between two to five thousand cedis 26 10.4 Between five to ten thousand cedis 18 7.2 Other 15 6.0 No response 12 4.8 Total 250 100 From Table 4.11, some 23.6% of the respondents knew that PNC services were free but a greater majority (65.6%) knew that an amount was collected. From the 29 University of Ghana http://ugspace.ug.edu.gh interview, 81.2% of the respondents knew some of the procedures carried out at PNC. In a focus group discussion, mothers were asked what they knew to be the cost of PNC services. One participant said, “The charges is not much, only paracetamol is charged”. 4.5 WOMEN’S ATTITUDE TOWARDS PNC From the study, 95.8% of the women had the opinion that a woman should attend PNC after delivery and 37.6% of the respondents thought a woman should attend PNC more than 4 times (Table 4.12). Moreover, most o f the respondents (62.4%) thought a pregnant woman should attend PNC four times or less. Table 4.12 OPINION ON FREQUENCY OF ATTENDANCE AT PNC No. of Times Frequency Percentage One 55 22.0 Two 25 10.0 Three 26 10.4 Four 34 13.6 More than four 94 37.6 Other 12 4.8 No response 4 1.6 Total 250 100 Table 4.13 PERCEIVED RISK FOR NOT ATTENDING PNC Perceived Risk Frequency of responses* N=250 Percentage Bleeding from cord 86 18.9 Death of mother 135 29.6 Death of baby 146 32.0 Bad breastfeeding habits 69 15.1 Other 20 4.4 Total 456 100 30 University of Ghana http://ugspace.ug.edu.gh ^Multiple responses, hence 456. 4.6 CONSTRAINTS FOR POSTNATAL CARE Table 4.14. OPINION ON COST AS A CONSTRAINT TO PNC SERVICES BY RESPONDENTS. Risk Factors Frequency Percentage Very high 19 7.6 High 24 9.6 Just enough 133 53.2 Cheap 37 14.8 Free 30 12.0 Others 3 1.2 No response 4 1.6 Total 250 100 Table 4.14 presents responses obtained from women, when asked the question, what do they think of the charges for PNC? From the Table, 53.2% of the respondents said PNC charge was just enough and 7.6% said it was very high. When the respondents were asked about affordability, 5.4% said they were not able to pay for the services the last time they used the service. Table 4.15: AVAILABILITY OF HEALTH FACILTIES FOR USE BY RESPONDENTS. Risk Factors Frequency of responses* N=250 Percentage Hospital 57 19.8 Health center 224 77.8 Health post 3 1.0 Clinic 4 1.4 Total 288 100 ^Multiple responses, hence 288. Most of the respondents (77.8%) said they have a health center facility available for their use (Table 4.15). However, 14% o f the respondents stayed very far from University of Ghana http://ugspace.ug.edu.gh the facility and 2.8% get to the facility by vehicle. For about 1.0% o f the respondents, they spent more than two hours getting to the facility whilst 89.6% got to the facility in less than 30 minutes (Table 4.16). Most of the respondents (97.2%) got to the facility by foot. In a focus group discussion, the participants were o f the opinion that the facilities are not far and they got there by walking. They even said at times the nurses came to their community to attend to them. One participant even said “at times they (the service providers) even have to wait for them” Table 4.8: TIME TAKEN TO GET TO THE FACILITY. Time Frequency Percentage Less than 30 minutes 224 89.6 Between 30 minutes and 1 hour 20 8.0 One to two hours 4 1.6 More than two hours 2 0.8 Total 250 100 From the study, 95.6% if the respondents assessed the attendants care to be nice with only 11 respondents (4.4%) saying service providers were not friendly. As indicated in Table 4.17, 40.8% of the respondents assessed the skills o f the attendant to be very good. The same impression was obtained from the focus group discussion, when the greater majority o f the participants considered providers o f PNC services as very good. Table 4.17 PERCEPTION OF SERVICE PROVIDERS SKILL TO CARRY OUT PNC BY RESPONDENTS. Skills Frequency Percentage Excellent 50 20.0 Very good 102 40.8 Fair 95 38.0 Bad 3 1.2 Total 250 100 32 University of Ghana http://ugspace.ug.edu.gh Table 4.18: ITEMS REQUIRED BY MOTHERS TO ENABLE THEM ATTEND PNC SERVICES. ____________ ______ Requirements Frequency of responses* N=250 Percentage New cloth 193 24.8 A new footwear 172 22,1 Anew bag 188 242 A new baby dress 180 23.2 Others 44 5.7 Total 777 100 *Multiple responses, hence 777. In order o f importance, new dress, new footwear, new bag and new baby’s dress were given as the requirements for attending PNC (Table 4.18) and 40% of respondents could not attend PNC because o f these requirements. During a focus group discussion the respondents also unanimously acknowledged that the requirements for PNC are, a new bag, a new cloth, new hair style, money and a new baby’s dress. A fair proportion of the respondents (36.8%) owned up that they could not afford PNC services the last time they had to attend. Various reasons were given. From the interview most o f the respondents (60%) could not afford the service because of poverty and 23.3% said because they were not gainfully employed. Various reasons were given for not being able to attend PNC, including poverty, no support from husband and because of gossiping. On the other hand, 65.1% o f the respondents agreed that their husbands supported them financially, or encouraged them to attend PNC. Only one respondent said the husband discouraged her (Table 4.19). 33 University of Ghana http://ugspace.ug.edu.gh Table 4.19 HUSBAND’S SUPPORT AND PNC ATTENDING. Support Frequency of responses* N=250 Percentage No support 20 7.7 Support financially 170 65.1 Discourages me 1 0.4 Encourages me 70 26.8 Total 261 100 * Multiple responses, hence 261. Table 4.20 REASONS FOR NOT ATTENDING PNC. Reasons Frequency of responses* Percentage Poverty 150 18.9 Competition 54 6.8 Shyness 30 3.8 Laziness 95 11.9 “Child not sick” 40 5.1 “Child will be sick” 70 8.8 “Thinks I will be charged” 50 6.3 Gossiping 104 13.1 Have no time 50 6.3 Single parenting 20 2.5 “Will ask my husband’s name” 15 1-9 No dressing 111 14.0 “Too frequent hospital” 3 0.4 Total 792 100 * Multiple responses, hence 792. Respondents gave a number of reasons for not attending PNC (Table 4.20). Majority of the women gave reasons such as poverty, no dressing, gossiping, laziness, “think will be charged”, ‘have no time’ for not attending PNC. During focus group discussions the mothers who did not attend PNC the last time they delivered also gave as reasons, “I had no money to buy new cloth, new baby dress and new shoe”, “I thought I was going to be charged”, “Some mothers and nurses University of Ghana http://ugspace.ug.edu.gh laugh at you if you are a teenager and you do not have husband,” “I was in school and did not want my friends to know”, “My husband did not support me”. Gossiping was mentioned by some of the mothers. Others said they did not know the importance of PNC coupled with the fact that they are traders and farmers and have no time. The attitude of the service providers was mentioned as a deterrent for a lot mother. Quite a few of them said they did not understand why a baby should become sick after immunization. Others also said they wait for a long time at the facility before they are attended to. Few of the respondents said they do not have husbands so they feel shy when they are asked about their husband’s name. Impressions from their responses indicate that the main reasons why mothers did not attend PNC are health care related, social and economic. Poverty seems to be a factor, which prevents most mothers from attending PNC. 35 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE 5.0. DISCUSSION, CONCLUSION AND RECOMMENDATIONS 5.1 DISCUSSION SOCIAL, DEMOGRAPHIC AND ECONOMIC CHARACTERISTICS. From Table 4.1, most o f the respondents (71.2%) were between 20 and 30 years and only 8% were below 20 years. This is in conformity with Ghana Demographic and Health Survey 1998 report where high proportions o f the women are in the younger age group, with more than half of them under 30 years (37). This means that most of the respondents were within the best age bracket to have children. Most o f the respondents were farmers and traders (80.8%). The consequences o f this are that they might be too busy to attend to health care services. Employment rate is high, 88.8 % of the respondents are employed, a situation which could contribute to affordability of health care in the district. It is interesting that 85% were Christians. This could be a useful information to the DHMT, since educational messages could be passed on through the churches. Most of the respondents have had some level of education with most o f them (71.85%) having attended either primary or middle school while 18.4% were uneducated. This is not too different from figures from the Ghana Demographic and health Survey (1998) which gave 28.9% as women with no education (37). With this low level o f education, most of them might not be gainfully employed in the civil service. A greater majority of the respondents were married. This is an added information to the DHMT because in times where educational 36 University of Ghana http://ugspace.ug.edu.gh messages are given to the women, the husbands should be involved because the husband could have influence on their wives’ decisions. • WOMEN’S KNOWLEDGE ABOUT ANTENATAL CARE Most o f the respondents (82.8%) knew the correct meaning of antenatal care and also have fair knowledge about the services being rendered at the antenatal service point. Moreover, most of them attended ANC the last time they were pregnant. This is contrary to a study, which was done to assess women’s knowledge and expectations of childbirth in South Africa. This study found that the women had insufficient knowledge about childbirth and this was attributed to poor attendance to antenatal service (14). Furthermore, during a health educational study in South Africa on pregnant women, a disturbing finding was that the women did not know the test performed during antenatal care (13). Most o f the respondents knew the hospital as an antenatal delivery point. This is useful information, which the DHMT could use to send a lot of health information on antenatal care. Quite a few of the respondents 14.4% knew that antenatal care is free. This means the DHMT has to intensify its health education messages to let them know that it is free because according to MOH policy antenatal care services should be free for four visits. • WOMEN’S ATTITUDE TOWARDS ANC. From the study, most of the respondents, (98%), had the opinion that a pregnant woman should receive antenatal care. It is not surprising that the antenatal coverage in the district was very high that (96.2%) in 1998, according to the DHA Annual Report (1998). Most of the respondents (68.8%) have the opinion University of Ghana http://ugspace.ug.edu.gh that a pregnant woman should attend antenatal care more than five times, this is in line with the WHO recommendation of a minimum of four visits for a woman with normal pregnancy (15). In addition, about 70% of the respondents had the opinion that if a woman does not receive antenatal care the baby or the mother could die. This means the women fear death. As study conducted in Ethiopia by Kwast and others found that, the maternal mortality was high for women who did not attend antenatal care (10). • WOMEN’S KNOWLEDGE OF PNC. Most of the respondents (51.2%) knew the correct meaning of PNC. When asked about the benefits of PNC, the highest response 39.1% was immunization. This is a strength that the district could build on. It shows that the immunization programme is going on well in the district. The respondents have a fair knowledge about the benefits of PNC but surprisingly only 50.4% did attend PNC the last time they delivered. This is in line with a study done in Bangladesh, to evaluate maternal and child services. In the study 79% of the women felt PNC was necessary but only 26% did attend (20). When asked about the delivery points, most of the respondents, (97.1 %), said the formal sector and 67% of the respondents gave more than three correct answers, which was considered acceptable. This means the respondents had adequate knowledge about where PNC services are delivered. Interestingly, although the TBA programme is going on in the country and the Government has invested a lot of money, only 2.9% of the respondents knew TBA as delivery point for PNC. University of Ghana http://ugspace.ug.edu.gh • WOMEN’S ATTITUDE TOWARDS PNC Most of the respondents (96.8%) had the opinion that a woman should attend PNC but this did not reflect in the PNC coverage in the district. The PNC coverage was 38.2% according to the DHA annual report for 1998. Most of the respondents, (61.6%) had the opinion that the perceived risk for not attending PNC is the death of the mother and baby. The respondents had the opinion that mothers should attend PNC services more than four times. This is in line with WHO recommendation of minimum of four visits (15). • CONTRAINTS FOR USING PNC SERVICES Most of the respondent had access to health center, and the distance to a health facility was reasonable according to 84% of the respondents. In the study 97.2% of the respondents got to the nearest health facility by foot and 89.6% got there in less than 30 minutes. This means that distance to a health facility was not a problem in the district. This is contrary to what has been found by other studies (28), which found distance as a barrier to health care utilization. Moreover, while most of the respondents, 95.6% judged the attendants care to be very nice, this is contrary to a study done in Kenya where a greater percentage o f patents sought health care outside the formal sector because of poor attitude of service providers (25). The findings indicate that about 95% of the women can afford PNC services. However, poverty ranks first as a constraint for mothers, not attending PNC. A more careful look at the results show that poverty, in this context is defined as inability to acquire the items the women consider as requirements for attendance at PNC. A greater majority, 94.3% of the women had mentioned new University of Ghana http://ugspace.ug.edu.gh dresses for the mother and baby, new shoe as requirements for attending PNC and 36.8% could not afford these items. Thus 60% of the respondents attributed it to poverty. CONCLUSION By the use o f structured questionnaire and focus group discussion in assessing women’s knowledge and attitude towards ANC and PNC and the possible constraint in the use of PNC services, it has been found that the respondents have a fair knowledge o f ANC and PNC. Furthermore they have a positive attitude towards ANC and PNC. Poverty ranks first as a constraint for mothers not attending PNC, but a more careful look at the results shows that poverty in this context is defined as inability to acquire the maternal items considered as requirements for attending PNC. RECOMMENDATION. After assessing women’s knowledge and attitude towards ANC and PNC and the possible constraints in the use of PNC services in the Sekyere West District, the following recommendations are offered to the DHMT. A greater majority of the women are married and since husbands have influence over their wives, the husbands should also be targeted during health educational messages to the women. Most of the women are Christians, in view of this, the Churches could be used to deliver health educational messages to the mothers. University of Ghana http://ugspace.ug.edu.gh There is the need to intensify health educational messages to inform the mothers that ANC services are free because only about 15% o f the respondents knew that ANC services are free. Majority of the women know that Hospital are ANC delivery points so it is recommended that most of the health educational messages on ANC be passed on through the hospital to the women. Most o f the women have the opinion that if one does not attend ANC or PNC the mother or the baby will die. This fear could be put in health educational messages to entice the women to use the service. The district should let the women know that PNC services could also be obtained from the TBAs. There should be health educational messages to tell the women that ANC and PNC attendance is not a fashion arena as such one can bring any dress. Furthermore, PNC could be done at the outreach point so those women could bring their housedress to prevent competition amongst the women. There should be PNC service for teenage mothers to prevent the increasing gossiping among the mothers. Furthermore, the names of the husbands should be asked tactfully not to embarrass those who do not have husband. There is the need to educate mothers that, the little increase in temperature that may follow immunization is short-lived and the protection is much more beneficial. There is the need to educate mothers on time management so that they could apportion their time very well and attend PNC services and should be told that their time will not be wasted when they come to the facility. University of Ghana http://ugspace.ug.edu.gh REFERENCES. 1. United Nations (1998). United Nations Populations Chart. United Nations Populations Division. Department of International Economic and Social Affairs. New York. STESA/SERA/106/Add/l. 2. Cleone, R. (1992). Antenatal and Maternal Health. How effective is it? A review of the Evidence. Safe motherhood. Maternal and Child Epidemiology Unit, London school of Hygiene and Tropical Medicine, p.6. 3. Ministry o f Health (1997). Initiatives in Reproductive Health Policy. Ghana Vol.2 (2). p .l. 4. Ghana Statistical Service, (1994). Ghana Demographic and Health Survey. Calverton, Maryland p. 5. 5. Ministry o f Health, (1994). Guidelines o f Health Education on Safe Motherhood, Ghana, p. 10. 6. Ministry of Health (1991). Maternal and Child Health Family Planning. Annual Report, Ghana p. 13. 7. WHO (1997). Coverage of Maternal care, Family and Reproductive health. Geneva. 8. MOH, (1998). MCH/FP Annual Report. Ghana p.4. 9. Cleone, R. (1992). Antenatal care and Maternal Health: How effective is it? A review of the evidence. Safe Motherhood p. 10. 10. Kwast, B. E. (1985). Epidemiology of Maternal Mortality in Addis Ababa, a community-based study. Ethiopian Medical Journal. 23(1) p. 16 11. Ghana Statistical Service, (1994). Infant, Child and Maternal study in Ghana Accra p. 10. 42 University of Ghana http://ugspace.ug.edu.gh 12. Bester, M. B; Nolte A.G. (1992). Knowledge and Expectations of Childbirth in the Primigravidas. Curationis, South Africa. 15(4) p 10-15. 13. Bester, M. B; A. G. (1992). Health Education in Pregnant Women. South Africa. 15(2) p 1-4. 14. Bester, M. B; Nolte A G. (1992). Knowledge and Expectations o f childbirth in the Primigravidas. Curationis, South Africa. 15(4) p i0-15. 15. WHO (1996). Antenatal Care Report of a Technical Working Group. WHO/FRH/MRS/96-8. Geneva. 16. WHO (1997). Coverage of Maternity Care. Family and Reproductive Health Geneva. 17. MOH (1996). MCH/FP Annual Report pp7 and 8. 18. Ghana National Reproductive Health Service Policy and Standards, (1997) pp. 3 and 4. 19. Ghana National Reproductive Health Policy and standards, (1997) p.4. 20. Islam, M.A; and Niesen, C, C. (1993). Maternal and Childhealth services; Evaluating mothers perceptions and participation. International Center for diarrhoea disease research. Bangladesh Public Health, p. 243-9. 21. MOH (1996). MCH/FP Annual Report. Ghana p. 15. 22. MOH (1997). MCH/FP Annual Report. Ghana p. 10. 23. Kenny, P; (1993). Satisfaction with Postnatal care. The choice o f home or Hospital. Scotland, p. 143-53. 24. MOH (1997). MCH/FP Annual Report. Ghana p. 15. 25. Nwabu, G.M; (1986). Health care decisions at the household level. Results of a Rural Health Survey in Kenya. Social Science and Medicine. 22 (3) p. 315-19. 43 University of Ghana http://ugspace.ug.edu.gh 26. Thaddeus, S; and Maine, D; (1990). Too Far to walk, Maternal Mortality in Context. Columbia University center for population and family health. New York. p. 16. 27. Philips, D. R. (1960) Health and Health care in the Third World. Essex. Longman Group. 28. Habib, O.S, and Vaughan, J.P. (1986). The Determinants of Health Services Utilisation in Southern Iraq a Household interview survey. Journal of Epidemiology. (15) pp395-403. 29. Leslie, J. and Gupta, S (1989). Utilisation of formal services for maternal nutrition and health care, International center for research on women. Washington D.C. 30. Bamisaiye B, (1986). Waiting times and its impact on service acceptability and coverage at an MCH clinic at Lagos, Nigeria. Journal of Tropical Paediatrics. 32.158-61. 31. MOH (1997). MCH/FP Annual Report. Ghana p. 16. 32. Agarwal A. (1997). Engendering Adjustment for 1990. Report o f a Commonwealth Expert Group on Women and Structural Adjustment. London Commonwealth Secretariat. 33. Stars. A. (1987). Preventing the Tragedy of Maternal Deaths. A Report on International Safe motherhood conference, Nairobi. New York. World Bank, WHO, UNFPA p. 16 34. OAU/UNICEF, (1992). Africa’s Future. Background sectoral papers. Dakar. 35. Tinker, A. and Koblinsky, M (1994). Making Motherhood Initiative Proposals for action. World Bank Discussions papers. 44 University of Ghana http://ugspace.ug.edu.gh 36. Herz, B. and Measham, A. (1987). The safe Motherhood Initiative Proposals for action. World Bank Discussions papers. 37. Ghana Statistical service, (1998). Ghana Demographic and Health Survey. Calverton, Maryland p. 5. 45 University of Ghana http://ugspace.ug.edu.gh Appendix A. ASSESSMENT OF WOMEN’S KNOWLEDGE AND ATTITUDES TO ANTENATAL CARE AND POSTNATAL CARE SERVICES IN THE SEKYERE WEST DISTRICT. QUESTIONNAIRE INTRODUCTION 1. Name o f sub-district........................................................................................... 2. Name of community............................................................................................. 3. House Number.................................................................................................... 4. Date..................................................................................................................... 5. Name of interviewer....................................................................................... 6. Interviewee’s number...................................................................................... BACKGROUND INFORMATION 7. How old are you?................................................................................ ................ 8. How many children have you given birth to?.................................................... 9. Ethnicity................................................................................................................... 10. Educational status a. Primary school b. Middle school c. SSS/Secondary d. Post secondary e. No education 46 University of Ghana http://ugspace.ug.edu.gh 11. Marital status a. Married b. Separated c. Widowed d. Divorced e. Single 12. Occupation a. Farmer b. Trader c. Civil servant d. Hairdresser/seamstress/apprentice e. Others (state) f. Unemployed 13. What is your religion? a. Catholic b. Anglican c. Methodist d. Presbyterian e. Pentecostal f. Islam g. Traditionalist h. No religion 47 University of Ghana http://ugspace.ug.edu.gh KNOWLEDGE ABOUT ANTENATAL CARE What is antenatal care? a. Health care and education given to a pregnant women b. Health care and education given to a woman in labour c. Health care and education given to a woman during delivery d. Health care and education given to a woman after delivery e. Other (state) f. No response g. I don’t know Did you attend antenatal care when you were last pregnant? Yes/No What are some of the benefits o f antenatal care? a. Monitoring of normal pregnancy b. Identification of high risk pregnancy c. Giving immunization d. Health nutrition education e. No response f. I don’t know What are some of the antenatal service points in this community? a. Hospital b. Health Center/Post c. Clinic d. Maternity Home e. Other (state) f. No response g. I don’t know University of Ghana http://ugspace.ug.edu.gh 5. What are some of the services rendered at the antenatal clinic? a. Measures the heartbeat o f the fetus b. Measures the blood pressure o f the mother c. Measures the position o f the baby d. Checks the stool, urine o f the mother e. Others (state) f. No response g. Don’t know h. Checks the stomach of the mother 6. How much does it cost to get an antenatal care service? a. Free b. Between two to five thousand cedis c. Between five to ten thousand cedis d. More then ten thousand cedis e. No response f. I don’t know ffl. ATTITUDES TOWARD ANTENATAL CARE 1. Do you think a woman should receive antenatal care during pregnancy? YES/NO 2. If yes, how many times do you think a woman should attend antenatal care during pregnancy? a. One b. Two c. Three d. Four e. Five University of Ghana http://ugspace.ug.edu.gh f. More than five g. No response h. I don’t know 2b. If No why? 3. In your opinion, where should a pregnant woman go for antenatal care? a. Hospital b. Health center/clinic c. Maternity Home d. Trained traditional birth attendant e. Untrained traditional birth attendant f. Other (state) g. No response h. I don’t know 4. What do you think are the risks associated with not attending antenatal care? a. Death of mother b. Death of baby c. Cord prolapsed d. Retained placenta e. Others (state) IV: KNOWLEDGE ABOUT POSTNATAL CARE 1. Did you attend postnatal care after your last delivery? Yes/No. If no, give reasons. 2. What is postnatal care? 50 University of Ghana http://ugspace.ug.edu.gh a. Health care given to mother and baby from end of delivery through to six weeds after delivery. b. Health care given to mother from end of delivery through to six weeks after delivery. c. Health care given to a baby from end of delivery through to six weeks after delivery. d. Health care given to baby and mother after delivery. e. Other (state) f. No response g. I don’t know 3. What are some of the benefits of postnatal care? a. Immunization of baby b. Advice the mother how to breastfeed the baby c. Checks any complication after delivery d. Advice the mother on family planning e. Other (state) f. No response g. I don’t know 4. What are some of the postnatal care delivery points in your community? a. Hospital b. Health center/post c. clinic d. Maternity Home e. Trained traditional birth attendant f. Untrained traditional birth attendant University of Ghana http://ugspace.ug.edu.gh g. Other (state) h. No response i. I don’t know What is the cost of postnatal care service? a. Free b. One thousand cedis c. Between one and two thousand cedis d. Between two and five thousand cedis e. Between five and ten thousand cedis f. More than ten thousand cedis g- Other (state) h. No response i. I don’t know Do you know some o f the procedures at postnatal care service? Yes/No If yes what are they? ATTITUDE TOWARDS POSTNATAL CARE Do you think a woman should attend postnatal care after delivery? Yes?No If yes give reasons................................................................................................ If no give reasons................................................................................................. How many times do you think a woman should attend postnatal care? a. One b. Two c. Three d. Four e. More than four University of Ghana http://ugspace.ug.edu.gh f. Other g. No response h. I don’t know i. When one feels like 5. Where do you think a woman should attend postnatal care? a. Hospital b. Health center/post c. Clinic d. Maternity Home e. Trained traditional birth attendant f. Untrained traditional birth attendant g. Respondents Home h. Other (state) i. No response j. I don’t know 6. What do you think are the perceived benefits of postnatal care? a. To immunize the baby. b. To provide health education on nutrition c. To provide health education on family planning and breastfeeding and perform screening for the detection, treatment and /or referral of complications due the mother or baby. d. Other (state) e. No response f. I don’t know 53 University of Ghana http://ugspace.ug.edu.gh 7. What do you think are some of the perceived risk for not attending postnatal care? 1. Bleeding from cord 2. Death o f mother 3. Death o f baby 4. Bad Breastfeeding habits 5. Other (state) 6. No response 7. I don’t know VI: CONSTRIANTS FOR POSTNATAL CARE ATTENDANCE 1. COST OF POSTNATAL CARE SERVICE What do you think of the charges for postnatal service? a. Very high b. High c. Just enough d. Cheap e. Free f. Other (state) g. No response h. I don’t know 2. Were you able to pay the charges the last time you needed postnatal service? a. Yes b. No c. Yes but had to borrow money d. Yes but assisted by relatives University of Ghana http://ugspace.ug.edu.gh PHYSICAL ACCESSIBILTY TO FACILTY 1. What health facilities are available for your use? a. Hospital b. Health center c. Health post d. Clinic e. No health facility f. Other 2. How far is the health facility from your place of residence? a. Very far (more than twenty kilometers) b. Far (between two to twenty kilometers) c. Near (less than two kilometers) 3. By what means do you get to the facility? a. By foot b. By vehicle 4. If by vehicle how easy is it to get a vehicle? a. Readily available b. Have to wait for less than half an hour c. Have to wait between one to two hours d. Have to wait for more than two hours 5. If by foot, how long does it take you to get to the facility? a. Less than thirty minutes b. Between thirty and one hour c. One to two hours d. More than two hours 55 University of Ghana http://ugspace.ug.edu.gh q u a l it y o f s e r v ic e 1 • How did your attendant care for you the last time you were there? a. Was nice to me b. Not friendly c. Shouted on me d. embarrassed me e. Other (state) 2. How can the presence or absence of the required drugs influence your use of the facility? 3. How do you rate the skills o f the service providers? a. Excellent b. Very good c. Good d. Fair e. Bad DRESSING 1. What are some o f the maternal items required for attending postnatal care? a. A new cloth b. A new footwear c. A new bag d. A new baby dress e. Other 2. Could you afford these requirements before attending postnatal care? Yes/No 2b. Give reasons? 56 University of Ghana http://ugspace.ug.edu.gh 3- Could you have gone to the postnatal care without these requirements? Yes/No 4. How does your husband’s support (financial of action) influence your ability to use PNC service? 5. What do you think discourage mothers from attending postnatal care? 57 University of Ghana http://ugspace.ug.edu.gh FOCUS GROUP DISCUSSION GUIDE Participants: Women who did not attend PNC the last time they delivered. 1 • When women get pregnant, where do they seek health services? 2. Where do they go to deliver? 3. Where do they go for PNC? 4. Why do they go there? 5. Why is it that some women do not attend PNC? 6. Why did you not attend PNC the last time you delivered? 7. What do you think o f the charges for PNC services? 8. Were you able to pay for the services the last time you needed it? 9. How far is the health facility from your place of residence? 10. By what means do you get to the facility? 11. How did your attendant care for you the last time you needed the services? 12. What are some o f the maternal items needed for attending PNC? 13. Are there any socio-cultural factors, which prevent PNC activities? 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IRA SEKYI DUMASI . . 3 C — “ “ fV G \J v -tS- C i - ^ v i c 0 1ST. T Koff a sc N 'v. Assam +N\./ I N\ ' / Penten 7 0 0 M 1 00 W MAP 2 U tlf'c itsd Mao o f v 'K Y E R ; W f.’s-T r'IS r . 9*. I lu r o l iu c r ie r H ig h lig h te d l ' 1- <5-5 M iles WELLS DRILLED IN SEKYERE WEST DIST. ASHANTI REGION CONRAD N. HILTON FOUNDATION CMk->-.cn u 'noi n VISION GHANA RURAL WATER PROJECT THIRD QUARTER FY.94 ?_____ Drawn by . j ^ l e - 1 < W.CDCr, D rq .N o . Emml 0 Hills, ijfe ; Zl :7 :9i|WV/AS 02 University of Ghana http://ugspace.ug.edu.gh