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Birth 1

The study assesses birth preparedness and determinants influencing facility-based deliveries among pregnant women attending the Tamale Teaching Hospital in Ghana. It found that only 43.7% of the 345 respondents were well prepared for birth, with significant factors affecting preparedness including age, education, and antenatal visits. The research emphasizes the need for enhanced education on antenatal care to improve birth preparedness and reduce maternal mortality.

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0% found this document useful (0 votes)

33 views168 pages

Birth 1

Uploaded by

Job Kyeremeh

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Available Formats

Download as PDF, TXT or read online on Scribd

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© University of Cape Coast https://ir.ucc.edu.

gh/xmlui

UNIVERSITY OF CAPE COAST

BIRTH PREPAREDNESS AMONG PREGNANT WOMEN ATTENDING

ANTENATAL CLINIC AT TAMALE TEACHING HOSPITAL

SOLOMON SUGLO

2016

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UNIVERSITY OF CAPE COAST

BIRTH PREPAREDNESS AMONG PREGNANT WOMEN ATTENDING

ANTENATAL CLINICS AT TAMALE TEACHING HOSPITAL

SOLOMON SUGLO

Thesis Submitted to the School of Nursing and Midwifery, College of Health and
Allied Sciences, University of Cape Coast in Partial Fulfilment of the
Requirements for Award of Master of Nursing Degree.

JULY 2016

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DECLARATION

Candidate’s Declaration

I hereby declare that this thesis is the result of my own original research

and that no part of it has been presented for another degree in this university or

elsewhere.

Candidate’s signature………………………. Date……………………………

Name:……………………………………………………

Supervisors’ Declaration

We hereby declare that the preparation and presentation of thesis were

supervised in accordance with guidelines on thesis laid down by the University of

Cape Coast.

Principal Supervisor’s Signature………………. Date……………………………

Name:………………………………………………………….

Co-Supervisor’s Signature……………………. Date……………………………

Name:……………………………………………………….

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ABSTRACT

Evidence indicates that promoting birth preparedness and pregnancy

complications readiness have important roles in combating maternal mortality.

The purpose of the study was to assess birth preparedness and determinants

influencing facility-based deliveries among expectant mothers in the Tamale

Teaching Hospital, Ghana. The systematic random sampling technique was then

used to select pregnant women for the study using structured questionnaires. Data

quality was ensured via crosschecks and double entry of information into the

Statistical Package for Social Sciences (SPSS) software version 20.01 for

analysis. At the 95% confidence interval, a p-value less than 0.05 was deemed

statistically significant. Out of the 345 respondents, 150 respondents were well

prepared for birth representing 43.7%. The χ2 analysis revealed that age (p<0.05),

religion (p<0.05), educational status (p<0.01), level of knowledge on obstetric

risks (p<0.01), number of antenatal visits (p<0.01), marital status (p<0.05),

income level of participants (p<0.01) and cost of services (p<0.01) determined

birth preparedness and the choice of facility delivery among the study women.

Strong determinants of women’s choice of facility for delivery included: higher

education (AOR=1.9, 95% C.I. 1.16-3.04, p=0.01), women with four plus (4+)

ANC visits (AOR=5.4, 95% C.I. 2.54-11.29, p<0.01), women who disagreed to

‘home birthing tradition’ (AOR=2.4, 95% C.I. 1.18-4.85, p=0.02). Proportion of

women who were well prepared for birth and ready for complications was still

found to be low. Education of expectant mothers on issues of antenatal care on

birth preparedness must be stepped up.

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KEY WORDS

Birth preparedness

Complications readiness

Expectant mothers

Maternal mortality

Antenatal clinic

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ACKNOWLEGEMENTS

I would like to express my profound gratitude to Professor Dr. Janet

Gross, Professor Juventus Ziem, Mr. Boakyie Yiadom of University for

Development Studies, Mr. Amandus Ankobil and Dr. Shaibu whose invaluable

support and advice contributed in diverse ways to the completion of this thesis.

My thanks also go to the authors of the various materials that I used in this

study; the Management of the Tamale Teaching Hospital especially to Mad.

Evelyn Dangnikuu, Deputy Director of Nursing Services (DDNS)-Neuro-surgical

Department, Mad. Esther Doe, DDNS of the Obstetrics and Gynaecology

Department for the support they gave me during my data collection process.

I would also like to give special thanks to Dr. Mate Siakwa and Dr. Jerry

Ninnoni; both of the School of Nursing and Midwifery, University of Cape Coast

for their thorough supervision and motivation that enabled me complete this

project work successfully.

I wish to also express my profound gratitude to my uncle, Most Rev

Gregory E. Kpiebaya, the Archbishop Emeritus of Tamale and the Parish Priest of

SS Peter and Paul, Rev. Father Gerald Zienaa for their material and spiritual

support. My profound gratitude also goes to Prof. Dannabang Kuwabong of the

University of Puerto Rico for his editorial suggestions.

I am also indebted to my parents and siblings especially Mr. Joseph Suglo,

my beloved Susana Achaab and my research assistants: Mary-Rose, Adrian,

Patricia, Raymond and Charles.

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DEDICATION

This research work is dedicated to my parents, Mr. and Mrs. Suglo and my

uncle, Most Rev. Gregory E. Kpiebaya, Arch-bishop Emeritus of Tamale for

shepherding my life and academic work.

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TABLE OF CONTENTS

Page

DECLARATION ii

ABSTRACT iii

KEY WORDS iv

ACKNOWLEDGEMENTS v

DEDICATION vi

LIST OF TABLES xi

LIST OF FIGURES xii

LIST OF ABBREVIATIONS xiii

CHAPTER ONE: INTRODUCTION 1

Background of the Study 1

Statement of Problem 5

Purpose of the Study 6

Specific Objectives 6

Research Questions 7

Significance of the Study 7

Delimitation of the Study 8

Limitations 8

Operational Definition of Terms 9

Organization of the Study 10

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CHAPTER TWO: LITERATURE REVIEW 12

Introduction 12

Conceptual Framework-Three Delays Model 12

The Three Delay Model 15

Causes of Maternal Deaths/ Key Factors Affecting Maternal Mortality 15

Health Care Delivery Explanations 17

Antenatal Care 17

Place of Delivery 23

Assistance during Delivery 24

Infrastructure 25

Biological (Medical) Explanations 27

Socio-Economic Explanations 27

Level of Education 27

Financial Background or Employment Status 28

The Concept of Birth Preparedness and Complication Readiness 30

Knowledge of Expectant Mothers and Health Seeking Behaviour 36

Maternal Health Services 41

Barriers to Accessing Early Antenatal Care 46

Obstetric Beliefs among Expectant Mothers 52

Family Support in Birth Preparedness Practices 59

Traditional Ways Family Supports Pregnant Women in Northern Ghana 66

Community Support for Pregnant women 67

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The Essence of the Study/Summary 69

CHAPTER THREE: RESEARCH METHODS 72

Study Design 72

Study Setting 73

Population 74

Sampling and Sample Size Determination 75

Instrumentation 76

Data Collection Process 76

Determination of Level of Preparedness 77

Ethical Considerations 78

Pilot Study 78

Data Processing and Analyses 79

Chapter Summary 79

CHAPTER FOUR: RESULTS AND DISCUSSION 81

Demographic and General Information 81

Obstetric History 84

Knowledge on Pregnancy Related Issues/Obstetric Risk Factors 85

Access to maternal health services 87

Obstetric Beliefs in Pregnancy and Child Birth 89

Family Support for Pregnant Women 90

Benefits of Family Support to the Pregnant Woman 91

Community Support System for Emergency Delivery 92

Determinants of Facility Delivery (Binary Analysis) 94

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Determinants of Facility Delivery (Multivariate Analysis) 100

Measurement of Birth Preparedness 102

Determinants of Birth Preparedness (Binary Analysis) 103

Discussion 108

CHAPTER FIVE: SUMMARY, CONCLUSION AND

RECOMMENDATIONS 124

Summary of the main findings 124

Conclusions 126

Recommendations and Suggested Areas for Further Research 128

REFERENCES 131

APPENDICES 144

A: Questionnaire and Voluntary Consent 144

B: University of Cape Coast IRB Letter 151

C: Introductory Letter from Dean 152

D: GHS` Permission Letter 153

E: Authorization Certificate from Tamale Teaching Hospital 154

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LIST OF TABLES

Table Page

1 Demographic and General Information 82

2 Obstetric History 84

3 Knowledge on Obstetric Risk Factors 86

4 Maternal Health Services 88

5 Obstetric Beliefs in Pregnancy and Child Birth 89

6 Family Support for Pregnant Women 91

7 Benefits of Family Support to the Pregnant Woman 92

8 Community Support System during Emergency Delivery 93

9 Determinants of Facility Delivery 98

10 Determinants of Facility Delivery (Multivariate Analysis) 101

11 Birth Preparedness 102

12 Determinants of Birth Preparedness (Binary Analysis) 105

13 Determinants of Birth Preparedness (Multiple Logistic Regression) 107

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LIST OF FIGURES

Figure Page

1 A conceptual framework showing the three delay model 15

2 A map showing the study area 74

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LIST OF ABBREVIATIONS

ANC: Antenatal Care

BP/CR: Birth preparedness and complication readiness

CmSS: Community Support System

CSG: Community Support Group

DDNS: Deputy Director of Nursing Services

EMOC: Emergency Obstetrics Care

HBLSS: Home Based Life Savings Skills

HCP: Healthy Child Programme

HIV: Head in Vagina

IMPAC: Integrated Management of Pregnancy and Childbirth Care.

LIC: Low Income Countries

MDGs: Millennium Development Goals

MMR: Maternal mortality ratio

MNT: Maternal Neonatal Tetanus

NTDs: Neural Tube Defect

SBA: Skilled birth attendant

SDA: Seventh Day Adventist

SSA: Sub-Saharan Africa

STIs: Sexually Transmitted Infections

TBA: Traditional birth attendant

TTH: Tamale Teaching Hospital

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CHAPTER ONE

INTRODUCTION

Birth preparedness has been considered as a comprehensive strategy

aimed at promoting the timely utilization of skilled maternal health care

especially during childbirth. It is based on the theory that preparing for childbirth

reduces delays in obtaining emergency obstetric care (Kaso & Addisse, 2014b).

Birth preparedness and complication readiness (BP/CR) is the process of planning

for normal birth and anticipating the actions needed in case of an emergency

(Agbodohu, 2013; Solnes et al., 2013). However, BP/CR status and affecting

factors have not been well studied. Thus, this study aimed to fill the gaps by

conducting a study among pregnant women. This introductory chapter is

organized to include: background to the study, thesis statement, and purpose of

the study, objectives, and research questions. It also highlights the national

significance of the study, and particularises the operational definition of terms and

abbreviations specific to this study.

Background to the Study

Adequate health care provision and utilisation for women during

pregnancy is essential to ensure the normal, healthy evolution of the pregnancy

and to prevent, detect, or predict potential complications during pregnancy and/or

delivery (Berrin., Okka., Yasemin., & Durduran, 2016). Good quality care must

be provided by skilled health personnel who are well trained and equipped to

detect potential complications and provide the necessary attention or referral

(Karkee., Lee., & Binns, 2013). Unfortunately, many women in developing

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countries of the world, including Ghana, face increased risk of morbidity and

mortality from pregnancy and other pregnancy related issues (Moran et al., 2006).

Worldwide, 800 women die every day due to pregnancy or child birth related

complications. Almost all maternal deaths (99%) occur in developing countries

and more than half of these deaths occur in Sub- Saharan Africa (Sunnyvale, City,

Musa, & Amano, 2016). In developing countries, specifically Sub-Saharan

countries, skilled care providers are not always readily available. This is

considered as one of the major factors accountable for the current trends of

maternal and child mortality (Byford-Richardson et al., 2013; Moran et al., 2006).

In Ghana, 52% of childbirths were assisted by skilled personnel in 2012

(Adu-Gyamfi, 2012). This means that a significant number of women give birth

alone or are assisted by unskilled birth attendants such as Traditional Birth

Attendance (TBAs) and mother-in-laws. Ghana is one of the countries with a very

high maternal mortality rate, (319 per 100,000 live births) and is striving hard to

reduce the numbers in maternal mortality (World Bank Report, 2015). For

instance, The United Nations (UN) as well as the international community has

resolved through the 5th Millennium Development Goal (MDG) to reduce the

high maternal mortality ratio by three quarters by 2015; however, this goal was

largely unachieved (WHO, 2015a). Cultural beliefs, lack of awareness of

availability of maternal health care utilities, and crippling poverty inhibit

preparation for safe delivery and the post-delivery health guarantees of the mother

and baby in advance (Byford-Richardson et al., 2013). The majority of pregnant

women and their families do not know how to recognize the danger signs of

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complications. When complications occur, the unprepared family wastes a great

deal of time in recognizing the problem, getting organized, getting money, finding

transport, and reaching the appropriate referral facility (Ekabua et al., 2011). This

often results in avoidable delays in obtaining life-saving emergency services that

could prevent maternal deaths.

Birth preparedness is a comprehensive strategy to improve the use of

skilled providers at birth and the key interventions to decrease maternal mortality

(Tura, Afework, & Yalew, 2014). Birth preparedness and complication readiness

(BP/CR) strategies encourage women to be informed of the danger signs of

obstetric complications and emergencies, choose a preferred birth place and

attendant at birth, make advance arrangement with the attendant at birth, arrange

for transport to skilled care site in case of emergency, save or arrange alternative

funds for costs of skilled and emergency care, find a companion to be with the

woman at birth or to accompany her to emergency care, and identify blood donors

in order to facilitate swift decision-making and reduce delays in reaching a care

facility when a problem arises (Nawal & Goli, 2013). Responsibilities for BP/CR

must be shared among all safe motherhood stakeholders, since coordinated effort

is needed to reduce the delays that contribute to maternal and newborn deaths.

According to Kaso and Addisse, (2014b) the major causes of maternal

deaths include postpartum haemorrhaging, hypertension, anaemia, unsafe

abortions, infections and obstructed labour. Although these are the easily and

most identifiable causes of maternal deaths, there are several other determinants

associated with maternal deaths. For example, access to health care is often

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impeded by delays: delays in deciding to seek care, delays in reaching care, and

delays in receiving care (Solnes et al., 2013). These delays also have many

causes, including: logistic and finances, unsupportive policies and gaps in

services, as well as inadequate community and family awareness and knowledge

about obstetric complication issues.

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Statement of Problem

Avoidable maternal morbidity and mortality remains a formidable

challenge in many developing countries like Ghana. Sub-Saharan Africa (SSA)

has been the region with the highest maternal death ratio (Soubeiga et al., 2014).

For example, in 2008, 358,000 maternal deaths occurred worldwide. Ninety-nine

percent of these deaths were in countries of the developing world, of which 57%

were in the SSA including Ghana (Otoo., Habib., & Ankomah, 2015). Current

statistics on maternal mortality rates in Ghana reveal that, 319 deaths occurred per

100,000 live births (World Bank Report, 2015). The situation is even worse in the

deprived regions of Ghana where women give birth at home due to unforeseen

militating factors which compel pregnant women to depend on TBA, village

midwives, members of the families or neighbours who provide unskilled support

(Agarwal, Sethi, Srivastava, Jha, & Baqui, 2010). Ironically, performance review

of Ghana Health Service annual reports for 2009, 2010 and 2011 indicated that

Ghana’s antenatal coverage often exceeded 90% (WHO, 2015a). Analysis on

maternal health also indicated higher coverage in the Northern Region, where

maternal mortality rate has been increasing consistently for the past three years

(Galaa, 2010). Whereas antenatal coverage was as high as 97.1% in the Region,

skilled deliveries were low (31.2%) during the same period (Adu-Gyamfi, 2012).

It is therefore, apparent that there is a huge disparity between attendance for

antenatal services by expectant mothers and patronage of skilled care during

childbirth. It is difficult to tell why the recorded high coverage antenatal care does

not commensurate with patronage of skilled professionals for childbirth. Evidence

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from developing countries like Ethiopia, Bangladesh, and Burkina Faso showed

that counselling given during BP/CR is helpful in improving institutional deliver

utilizations (Tura et al., 2014). Similar studies conducted in Nepal, Burkina Faso

and India also showed that the BP/CR plan improves preventive behaviours and

knowledge of mothers about danger signs, and leads to improvement in care-

seeking during obstetric emergency (Tura et al., 2014; Agarwal et al., 2010 and

WHO, 2015b).

Despite the fact that BP/CR is essential for further improvement of

maternal and child health little is known about the current magnitude of BP/CR

strategies and associated factors in Ghana especially in Tamale. This study,

therefore, aimed at filling this gap by assessing the current status and factors

associated with birth preparedness and complication readiness among pregnant

women attending antenatal clinic at the Tamale Teaching Hospital.

Purpose of the Study

The overall purpose of the study was to assess birth preparedness among

expectant mothers and investigate the determinants influencing birth preparedness

and facility-based deliveries in the Tamale Teaching Hospital.

Specific Objectives

This study specifically:

1. Assessed expectant mothers’ knowledge on obstetric risk factors,

2. Assessed factors associated with delays in seeking early antenatal care,

3. Determined family support for the pregnant woman,

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4. Determined the obstetric beliefs among the study population and

5. Established community support systems for pregnant women.

Research Questions

1. What do pregnant women know about danger signs of pregnancy and

childbirth?

2. What factors influence access to early antenatal care?

3. What family support do pregnant women get during pregnancy and

childbirth?

4. What obstetric beliefs exist among expectant mothers and families?

5. What support systems are in place in the community for pregnant women

in case of emergency childbirth?

Significance of the Study

This study hopes to produce a document that will be used to educate

expectant mothers at antenatal centres. The study seeks to promote skilled care for

all births and encourage decision making before the onset of labour and thereby

reduce delay in deciding to seek care. This study provides information that can be

used to encourage households and communities to put in place emergency

response systems regarding childbirth to avoid delays in seeking timely obstetric

care. The findings of this study may be useful to Ghana Health Service and other

stakeholders in the healthcare system for proactive policy making. The results

also avails information and data for advocacy to promote facility based childbirth

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in rural communities in and outside Ghana and therefore serves as reference

document for further research.

Delimitations (inclusion criteria) of the Study

The study only considered pregnant women within the ages of 11 to 50

years attending the antenatal clinic at the Tamale Teaching Hospital. Women

whose babies were older than six months and expectant/nursing mothers who

were unwilling to participate in the study or were not residents in the study

catchment area were also excluded.

Limitations

The limitations of this study were: information on birth preparedness (BP)

was based on self-reports from study respondents; recall bias is thus likely to be

introduced as women did not have written documents on BP and were likely to

have forgotten older events related to BP practices. To minimize this, women who

had infants more than 6 months of age at the time of survey were excluded.

Secondly, the study was facility based and might thus not indicate the true rate of

BP practice in the community. It was also difficult to establish a temporal

relationship as the study design was cross-sectional.

Despite these limitations, the trained health personnel used in data

collection as research assistants made it less difficult explaining the concepts to

participants and findings from this study are most likely to be valid, reliable and

contribute to the understanding of the factors associated with BP practice in the

study area.

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Operational Definition of Terms

The purpose of this section is to provide definitions for terms used in the

study that are unusual or not widely understood. In addition, common terms that

have special meaning in the study are defined in this section.

Birth Preparedness and Complication Readiness (BPCR): the process of

planning for normal birth and anticipating the actions needed in case of an

emergency. Women who have made funds available for transportation to hospital,

have identified the mode of transportation when labour begins, have already

arranged for a blood donor and have blood in the blood bank are said to be ‘well

prepared’(Markos & Bogale, 2014).

Maternal Mortality Ratio (MMR): the number of maternal death during a given

time period per 100,000 live births during the same period (World Bank, 2015).

Maternal Death: the death of women while pregnant or within 42 days of

termination of pregnancy, irrespective of the duration and the site of the

pregnancy, from any causes related to or aggravated by pregnancy or its

management but not from accidental or incidental causes (Ingvil & Bailah, 2015).

Skilled care: quality care to the woman during pregnancy, childbirth and the

postpartum period and her infant, provided by skilled personnel supported by an

enabling environment (necessary equipment, supplies and medicines and

infrastructure) and functional referral system (Zetterquist, 2012).

Skilled health worker/ Skilled birth attendant (SBA): an accredited health

professional such as midwife, doctor or nurse who has been educated and trained

to proficiency in the skills needed to manage normal (uncomplicated)

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pregnancies, childbirth and the immediate postpartum period, and identify,

manage or refer complications (Nawal & Goli, 2013).

Traditional birth attendant (TBA): traditional, independent (of the health

system), non-formally trained and community based providers of care during

pregnancy, childbirth and the postpartum period. TBAs either trained or not, are

excluded from the category of skilled health workers.

Education: education in this study stands for both formal and informal acquisition

of knowledge regarding birthing and safe motherhood practices.

Community/family support systems: mechanisms for establishing a community-

led structure which tracks all pregnant women, and provides need-based support

for making their pregnancy safer, including timely use of life- saving emergency

obstetric care services (Ekabua et al., 2011).

Organization of the Study

This study is composed of five chapters. Chapter one (1) introduces the

topic and provides the background to the study. It covers the statement of the

problem, the study’s objectives and research questions which guided the study. It

ends with purpose, significance, delimitation, limitation, operational definition of

terms, abbreviations and organization of the research study. Chapter two (2)

reviews the literature on concept of birth preparedness and maternal health from

the global to local context, maternal health services availability and accessibility,

obstetric beliefs in pregnancy and childbirth, family support for pregnant women,

community support system during emergency delivery, and the theoretical frame

work underpinning the study. Chapter three (3) looks at the research methodology

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that was applied to achieve the study’s objectives and analysis of the findings.

The Systematic random sampling procedure was used to select 345 respondents

for the study using a structured questionnaire as the data collection instrument.

SPSS was used to analyze the results. Chapter four (4) is made up of data

presentation, interpretation and analysis, and discussion of the main findings.

Finally, chapter five (5) provides a summary, conclusion, recommendations,

limitations, and areas for future research.

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CHAPTER TWO

LITERATURE REVIEW

Introduction

This chapter discusses published information in birth preparedness and

pregnancy related complications readiness among expectant mothers before,

during and after childbirth. The review is guided by the principles of the three

delay model developed by Thaddeus and Maine (Solnes et al., 2013).

Comprehensive knowledge of these issues are essential to this research as it gives

reliability to views shared globally on the concepts in focus and emphasises the

significance or otherwise of the present study. Current literature reviewed for this

study covered the period from 2000 to 2016 AD. The literature reviewed

included: journal articles (surveys, research papers), books, conference

proceedings and government or corporate reports. Information was sourced from

theses and dissertations, specialized magazines, newspapers and the Internet. The

subtopics discussed in this section consist of conceptual framework-three delays

model, causes of maternal morbidity and mortality globally and locally,

knowledge of expectant mothers on pregnancy related issues and health seeking

behaviours, access to maternal health services, barriers to maternal health

services, obstetric beliefs among expectant mothers, family support for pregnant

women and community support systems availability.

Conceptual Framework-Three Delays Model

The Three Delays Model was developed by Thaddeus and Maine (1994)

to conceptualize the factors that influence obstetric care utilization and birth

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outcomes. They identified a number of factors related to the three delays that

contribute to poor birth preparedness, resulting in maternal morbidity and

mortality. The model focuses on factors applicable between the start of having

obstetric complications until the time women receive necessary adequate and

appropriate care resulting in better outcomes. They examined how these factors

cause delays in decision making, identifying and reaching medical care and

receiving adequate and appropriate treatment at a health facility. For the purpose

of this thesis, the model has been adapted for use in exploring and understanding

birthing and emergency obstetric care, especially among expectant mothers’

preparedness for birth and barriers to the utilization of health facility during

labour, delivery and the postpartum period in the Tamale Teaching Hospital.

According to Solnes et al., (2013) the first phase of delay indicated the

largest number of factors with numerous barriers that affect preparedness and the

utilization of healthcare services. Utilization and outcomes are influenced by three

main factors: socioeconomic, cultural factors, and perceived accessibility and

perceived quality of care, with main and sub barriers in each factor. For example,

socioeconomic/cultural factors have illness factors (recognition of complications,

perceived severity, perceived aetiology); socio-legal issues (illegal abortion,

sanctions on infidelity); women’s socio-economic status (access to money,

restricted mobility, value of women’s health); and education status (positive/

negative association).

The first factor consists of socioeconomic/cultural factors alongside

perceived accessibility, affordability of care and perceived quality of care. In

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addition, men and family elders often have to decide where women can go for

antenatal care and delivery either to the health facility or traditional birth.

In the phase II of the model developed by Maine (1994), delay in

identifying and reaching medical care focused on how actual accessibility is

influenced by factors including distribution and location of health facilities,

travelling long distances and transportation costs. The phase II contextualized the

challenges encountered by expectant mothers in reaching medical facility for

timely maternal health services. These challenges usually include: weak referral

systems, lack of transportation and bad road networks. Phase III explains causes

of delay in receiving adequate and appropriate treatment based on quality of care

at health facility.

Based on the above explanation the figure below is the adapted three delay

model that guided the literature review on both uncomplicated care and

emergency obstetric care.

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The Three Delay Model

Figure 1: A conceptual framework showing the three delay model (adapted from

Thaddeus & Maine, 1994)

Causes of Maternal Deaths/ Key Factors Affecting Maternal Mortality

MMR (modelled estimate; per 100, 000 live births) in Ghana was last

measured at 319 in 2015, according to the World Bank (Otoo et al., 2015). MMR

is the number of women who die during pregnancy and childbirth, per 100,000

live births (World Bank Report, 2015). A mother's death has profoundly negative

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consequences for her family, particularly for children left without a primary

caregiver. In poorer nations, if the mother dies, the risk of death for her children

under age 5 can increase by as much as 50% (Asante, 2011). Furthermore, for

every maternal death, many more women suffer from injuries, infections and

disabilities related to pregnancy and childbirth. According to the WHO, in the

developing world, over 30 million women suffer each year from serious obstetric

complications as a result of inadequate or inappropriate care during pregnancy,

delivery and the first few critical hours after birth (Mbalinda et al., 2014).

Maternal deaths have both direct and indirect causes. Around 80% of maternal

deaths worldwide is brought about by direct obstetric complications such as

haemorrhage, infection, obstructed and prolonged labour, unsafe abortion and

hypertensive disorders of pregnancy. Indirect causes such as malaria, diabetes,

hepatitis, anaemia and other cardiovascular disorders which are aggravated by

pregnancy can also lead to maternal death (Nawal & Goli, 2013).

Furthermore, maternal tetanus also kills mothers and new born babies

worldwide. If the mother is not immunized with the correct number of doses of

tetanus toxoid vaccine, neither she nor her new-born infant is well protected

against tetanus at delivery. Tetanus is caused by a toxin produced during the

anaerobic growth of Clostridium tetani (Asante, 2011; Galaa, 2010). Infection is

acquired through environmental exposure, of any broken skin or dead tissue such

as a wound or when the umbilical cord is cut, to the spores of the bacteria. These

spores are universally present in the soil (Dellinger et al., 2008). Poverty, poor

hygiene and limited access to health services increase the risk of maternal

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neonatal tetanus (MNT). Since 1989, when the World Health Assembly called for

the elimination of neonatal tetanus (NT), 110 out of 161 developing countries

were thought to have achieved elimination. UNICEF, WHO and UNFPA agreed

in 1999 to set the year 2005 as the target date for worldwide elimination (WHO &

UNICEF, 2009). Hence, the vaccine was given to women of childbearing age and

pregnant women to protect them from tetanus and their new-born infants against

NT. Although these are the easily and most identifiable causes of maternal deaths

by the WHO, there are several other reasons associated with maternal deaths

(Nawal & Goli, 2013). For the purpose of this work, these other factors are

grouped into three: health care delivery explanations, biological (medical)

explanations, and socio-economic explanations.

Health Care Delivery Explanations

Antenatal care

The WHO, (2015) recommended at least four ANC visits for effective

antenatal care. In Ghana, ANC visits are supposed to be six (6). To affirm this, a

number of studies have indicated the existence of an association between the use

of antenatal care and positive maternal outcome (Adu-Gyamfi, 2012). Antenatal

care does not only help women identify complication and potential risks during

pregnancy, but it also gives direction to plan for safe delivery, and hence is a

significant component of maternal health. The significance of ANC visits goes

beyond the pregnancy period because women who seek ANC generally also tend

to seek assistance from a health professional during childbirth. A recent study on

antenatal care estimated that worldwide only 70% of women ever receive any

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ANC, whereas in industrialized countries more than 95% of pregnant women

receive ANC (Karkee et al., 2013). Epidemiological studies have also

demonstrated the benefits of ANC in reducing maternal and perinatal

complications, although the exact components and timing of such ANC has been

difficult to demonstrate (Otoo et al., 2015). This uncertainty leads to the adoption

of antenatal practices that are not comparable and are largely inconsistent between

and within countries. Moreover, there is evidence to show that certain

components of care appear to be more critical than others, whilst some long-held

traditional components have little scientific basis (Berrin &Yasemin, 2016). Also,

there is growing agreement that ANC should be limited to a small number of

specific tests carried out at certain critical times during the pregnancy.

The optimum number of ANC visits for countries with limited resources is

still the subject of considerable debate, the problem being linked not only with

effectiveness but also with costs and other barriers to ANC access (Markos &

Bogale, 2014). Nevertheless, a recent systematic review showed that essential

interventions required by healthy women with no underlying medical problems

can be provided over four visits at specified intervals. The results of the review

also revealed that women in developed countries receiving ANC through this

four-visit model were less satisfied and felt their expectations were not met,

although they did not perceive that the care they received was of lower quality

(Karkee et al., 2013).

Evidence suggests that, given the need for early identification of

underlying problems to ensure efficacious treatment, the first ANC visit should be

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as early as possible in pregnancy, preferably in the first trimester (Kabakyenga,

Östergren, Turyakira, & Pettersson, 2012). At this visit, there should be a general

assessment of the woman’s health, with appropriate remedial action or treatment

of underlying medical conditions, if required, to try to ensure that the woman is as

healthy as possible during pregnancy and for birth. It is also suggested that, given

the lack of sensitivity in predicting problems, especially those that occur during or

around birth, all pregnant women should be encouraged to make a birth and

emergency preparedness plan. An antenatal assessment at around 37 weeks or

near the expected date of confinement/birth is also advisable, to ensure that

appropriate action is taken to prevent problems. Such appropriate action should

include advice on avoiding post maturity and the identification of mal-

presentations, especially breech presentation, in which case an attempt should be

made at external cephalic version. Thus, there is general consensus that all women

with an uncomplicated pregnancy should have a minimum of four visits, as

outlined by Hiluf & Fantahun (2008).

Evidence also indicates that good record-keeping is essential in facilitating

appropriate decision-making and interventions (Debelew, Afework, & Yalew,

2014). These records should be readily available and accessible at all times. The

best mechanism to ensure that essential information is always available is for the

record to stay with the woman. Ensuring the woman can hold her own records is

also a way to encourage women to feel involved in their care. A number of studies

have shown the benefits of hand-held or home-based antenatal care records.

Women who hold their own records are more likely to keep follow-up

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appointments, to ask questions about their health, and to feel in control of their

pregnancy. Therefore, home-based or hand-held records are recommended.

Countries may design their own antenatal care records, but should ensure that all

the essential information is readily available to the caregiver (Urassa, Pembe, &

Mganga, 2012). Family and community membership have been shown to be a

major determinant in access to antenatal care services. Lone or unsupported

pregnant women, especially adolescents, therefore need services that are

specifically targeted to their needs; service providers should do all they can to

seek out such women and take the services to them, if they are unable or

unwilling to attend a clinic (Hiluf & Fantahun, 2008). In other words, in this

computerised age, record keeping can be digitalized and made much more easily

accessible online both to the healthcare provider and patient to expand the

theories of record keeping.

In malarious areas, all pregnant women must sleep under an insecticide-

treated bed-net (ITN). In addition, in areas of stable transmission of falciparum

malaria, all pregnant women must be given intermittent preventive treatment

(IPT) (Omaka-amari, Nwimo, & Alo, 2015). Pregnant women suspected of

having malaria should be assessed and treated in accordance with national

protocols. In the postnatal period, both the mother and the baby should sleep

under an insecticide-treated bed-net (Hiluf & Fantahun, 2008). The deleterious

effects of malaria infection during pregnancy on maternal, foetal and infant health

are caused chiefly by Plasmodium falciparum (Hewitt, 2014). In Africa, at least

25 million pregnancies are threatened by malaria each year, resulting in an

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estimated 2–15% of maternal anaemia (Omaka-amari et al., 2015). Maternal

malaria infection accounts for almost 30% of all the causes of low birth weight

that can be prevented during pregnancy. Maternal malaria infection is estimated to

account for 3–8% of all infant deaths (Mbalinda et al., 2014). In areas of high and

moderate (stable) malaria transmission, adult women acquire immunity, and most

malaria infections in pregnant women are asymptomatic (Omaka-amari et al.,

2015). Nevertheless, these asymptomatic infections contribute to the development

of severe anaemia in the mother, resulting in an increased risk of maternal

mortality and morbidity (Hewitt, 2014). The health of the foetus and infant is

affected by maternal infection during the second half of pregnancy (Soubeiga et

al., 2014). Malarial infection of the placenta and maternal anaemia due to malaria

contribute to low birth weight and preterm birth, which lead to higher infant

mortality and morbidity and impaired development of the child (WHO, 2013).

Stable transmission predominates in Africa south of the Sahara, and consequently

this region bears the greatest burden of malaria infections during pregnancy.

In these areas of high or moderate (stable) malaria transmission, the ill-

health effects are particularly apparent in the first and second pregnancies

exposed to malaria. In areas of epidemic and low (unstable) malaria transmission,

adult women have no significant level of immunity and will develop clinical

illness if they have parasitaemia. Pregnant women with no immunity are at more

risk of dying from severe malarial disease and/or experiencing spontaneous

abortion, premature delivery, low birth weight or stillbirth. All pregnant women

are at similar risk from malarial infection, irrespective of parity. Involuntary

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abortion is common in the first trimester, and prematurity is common in the third

trimester. Other consequences during pregnancy commonly associated with P.

falciparum infection include hypoglycaemia, hyperpyrexia, severe haemolytic

anaemia and pulmonary oedema.

HIV infection diminishes a pregnant woman’s ability to control P.

falciparum infections. The prevalence and intensity of malaria infection during

pregnancy is higher in women who are HIV-infected (Iwelunmor, Ezeanolue,

Airhihenbuwa, Obiefune, & Ezeanolue, 2014). Women with HIV infection are

more likely to have symptomatic disease and to be at increased risk of malaria-

associated adverse birth outcomes. Multigravidae with HIV infection are similar

to primigravidae without HIV infection in terms of their susceptibility to and

negative consequences of malaria infection. The effects of the other three

parasites that cause malaria in humans (P. vivax, P. malaria and P. ovale) are less

clear. There is a need for studies to better define the impact of P. vivax infection

on the health of pregnant women and neonates (Omaka-amari et al., 2015).

Iron-deficiency anaemia is the most common micronutrient deficiency in

the world, affecting more than two billion people globally (Riazi et al., 2012). It

contributes to low birth weight, lowered resistance to infection, poor cognitive

development and reduced work capacity. Pregnant and postpartum women and

children aged 6–24 months are usually the most affected groups. It is highly

prevalent in less developed countries, where, in addition to poor nutrition,

parasitic and bacterial infections can contribute to depletion of iron reserves.

Anaemia in pregnancy is defined as haemoglobin <11g/dl or haematocrit <33%

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(Dellinger et al., 2008). It aggravates the effects of maternal blood loss and

infections at childbirth, and is associated with increased maternal and perinatal

mortality and morbidity. Where anaemia is prevalent, iron deficiency is usually

the most common cause (Karkee et al., 2013).

Place of Delivery

Thaddeus & Maine (1994) stated that the place of delivery has

consistently been found to be associated with reduction in maternal mortality.

Complications during childbirth account for a large proportion of maternal

mortality and the risk of complications and infections causing death of both the

mother and the child can be reduced by appropriate attention and hygienic

conditions during delivery. Hence, deliveries in a safe environment with

assistance of health professionals are one of the key factors to reducing MMR.

Access to health centres, therefore, is a key issue in the reduction of maternal

mortality (Okka, & Durduran, 2016).

Lack of access to a health facility confronts many women especially those

found in rural areas. Studies about place of delivery of women in Nepal found

only 13.5% of childbirths took place in health facilities in rural areas as against

47.8% in urban areas (Nawal & Goli, 2013). Similarly, in these findings only

6.3% childbirths took place in health facilities in mountain regions, in comparison

to 17% and 20.9% in the plains and hill regions, respectively. Likewise, the less

developed far western regions had the lowest proportion of mothers having access

to health facilities during childbirth (8.5%), while women in the central urbanized

regions were also found to have more access to health facilities as 24.4% of them

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delivered their children in health facilities (Tura et al., 2014). This is because in

many remote areas of hilly and mountain regions, travel time has to be measured

in hours or even days rather than minutes because of the topography where most

people travel on foot. There is therefore the need to put efficient transportation

systems in these places to get women to health facilities quickly in order for the

service to be effective. Economic status of these women also appeared to be most

influential in the choice of birth place by women. Women in the higher wealth

quintile delivered their children in health facilities where mothers in the lowest

wealth quintile were 13 times less likely to go to health facilities to deliver (Khan

et al., 2012).

Assistance during Delivery

Poor assistance during delivery resulting in the maternal deaths or the

death of the child has become the blame game for most maternal deaths by

families who have lost daughters through delivery. To Maine (1994), for the

conditions for facilities at birth to be effective, first, delivery should be assisted by

trained health workers who are able to identify the signs of complications and act

appropriately when a problem occurs. However in developing countries, many

women are still assisted in delivery either by traditional births attendants, relatives

or delivered by themselves. Skilled birth attendants should be available to deal

with obstetric emergencies once they have been identified, and on arrival at the

referral facility patients should be observed promptly and appropriate decisions

made to avoid further complications or even death. Kaso and Addisse (2014)

declared the majority of maternal deaths occur due to unexpected complications,

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which would require the availability of emergency obstetric care; thus the

presence of skilled birth attendants for all births is the only way to ensure all those

with pregnancy complications are to be referred for emergency obstetric care. The

presence or availability of skilled birth attendants during labour, delivery and the

early post-partum period could reduce an estimated 16 to 33 percent of deaths due

to obstructed labour and haemorrhage, (Moran et al., 2006).

In Ghana a well-respected village elder who is well informed on the

traditional medical lore associated with childbearing and rearing, traditional

modes of family planning and treatment of infertility and lactation deficiencies is

considered an authority on child delivery and sometimes even called a traditional

midwife. Although some 6,000 traditional midwives, already highly regarded by

members of the community in Ghana have been given medical and paramedical

training, and have proven to be valuable adjuncts to the national health care

system, the large majority of them, however, are untrained in modern maternal

health delivery systems (Otoo et al., 2015). The lowest levels of skilled birth

attendants at delivery in developing countries are said to be in South Asia (29%)

and Sub-Saharan Africa (37%) whilst the highest levels of use of skilled birth

attendance are in Latin America and the Caribbean (83%), and the Central and

Eastern Europe/Commonwealth of Independent States Regions (94%) (Solnes et

al., 2013).

Infrastructure

For women to be able to have a quality place of delivery, access family

planning, antenatal care and postnatal care just to mention a few, a functioning

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health system is required. This consists not only of critical human resources, such

as midwives, doctors, obstetricians, and paediatricians, but also personnel to

effectively manage, remunerate, train, deploy and regulate them. Furthermore,

this also requires an effective infrastructure, medical supply systems and effective

information dissemination: health facility buildings, power supply, clean water,

transportation, medical supplies, and communication. No clear data exist on

availability of electricity and clean drinking water facilities in the health

institutions; however, they are not available in all health institutions (Mekuaninte,

Worku, & Tesfaye, 2016).

The presence and quality of care rendered by the health service providers,

availability of equipment and medical supplies in the health service facility

determines the decision of the needy women to visit the facility. However, this is

still one of the major problems of facilities in the rural areas of developing

countries such as Ghana. Studies done in the Sub-Sahara revealed that 74% of the

respondents were able to receive the services at the facility they visited. However,

out of this only 35.6% reported full satisfaction from the services they received

(Engla, 2010). Respondents who expressed dissatisfaction with the level of

services pointed out the lack of diagnosis of diseases as the prime reason. This

was followed by those reporting lack of free medicines, lack of quality services,

and lack of capable and trained personnel as other reasons for being dissatisfied.

Hence, an overwhelming majority (82%) of women either did not have access or

they do not utilize delivery services in health facilities (Mohamed, 2012).

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Biological (Medical) Explanations

In rich countries, the most important cause of maternal death is "other

direct causes" (21%), which largely includes complications during interventions

such as those related to caesarean section procedures and anaesthesia, followed by

hypertensive disorders and embolism ((WHO, 2015b). Some of the direct medical

causes of maternal mortality include haemorrhage or bleeding, infection, unsafe

abortion, hypertensive disorders, and obstructed labour. Other causes include

ectopic pregnancy, embolism, renal failure, cardiac disorders and anaesthesia-

related risks. Conditions such as anaemia, diabetes, malaria, sexually transmitted

infections (STIs), and others can also increase a woman’s risk for complications

during pregnancy and childbirth, and, thus, are indirect causes of maternal

mortality and morbidity (Soubeiga et al., 2014).

Socio-Economic Explanations

Level of Education

Formal education and knowledge about maternal healthcare facilities and

utilisation determine the behaviour of pregnant women in seeking for care.

Women’s education has been found to be strongly associated with maternal health

care services utilisation. Educated mothers are considered to have a greater

awareness of the existence of maternal health care services and benefited in using

such services and are likely to have better knowledge and information on modern

medical treatment and have greater capacity to recognize specific illnesses

(Debelew et al., 2014). As formal education empowers women, they have greater

confidence and capability to make decision to use modern health care services for

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themselves and for their children. Educated women are better motivated for

seeking health care in comparison to women who are not educated. However,

across all ages and ethnic groups, families sought for help from traditional faith

healers first before ultimately the sick were taken for treatment to health care

providers such as doctors and nurses when the cases became serious a pattern

which exist no matter the background (Iwelunmor et al., 2014).

Aside the formal education exposing women to the ability and knowledge

to access health care services, existing research on health outcomes in poorer

countries showed women’s exposure to media provided them information on

health related issues. Women’s exposure to information through the radio,

television and newspaper in India has been identified as significantly increasing

the utilization rates for all services (Asp et al., 2014).

Financial Background or Employment Status

Poverty is a major factor which can inhibit one’s access to health care, and

feminization of poverty is seen to be one of the most hindering factors of women

the world over especially in developing countries (Kabakyenga et al., 2012). It

inhibits women in their decision making processes and other vital areas of their

lives, of which maternal health cannot be isolated. To be able to have quality

health service there is the need for a sound financial backing. Even how to be able

to take the decision on which service to access depends on one’s status; an

important part of any health system is the mechanism by which health costs are

financed and pooled.

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Women’s economic dependence on men for survival has been a principal

barrier to women’s control over their reproductive behaviour in developing

countries (Tura et al., 2014). Empowering women with more economic

participation and control in their households and communities might be the key to

their achieving control over their own reproductive health. Employment can

increase women’s economic autonomy and reproductive health status because it

raises awareness and provides new ideas, behaviour patterns and opportunities

through interaction with other people outside the home and community. A study

in Kenya reported that the antenatal care visits tend to start earlier for women in

paid employment as they are likely to have greater knowledge about pregnancy

and childbirth due to freedom of movement outside household (Debelew et al.,

2014).

A husband’s occupation can also represent family income as well as social

status, and it is well established that increased income has a positive effect on the

utilization of modern health care services. Differential utilization of health

services by different occupational groups also depicts occupation as one of the

predisposing factors (Kabakyenga, Östergren, Turyakira, & Pettersson, 2011). An

empirical research in rural Bangladesh showed that fathers employed in non-farm

occupations chose trained personnel for delivery more frequently than fathers who

were farmers or members of other occupations (Tura et al., 2014). Another study

in Bangladesh reported that women whose husbands work in business or services

are most likely to be the users of professional healthcare services to treat their

complications (Mbalinda et al., 2014).

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The Concept of Birth Preparedness and Complication Readiness

Birth-preparedness and pregnancy complication readiness is a

comprehensive strategy aimed at promoting the timely utilization of skilled

maternal and neonatal health care (Markos & Bogale, 2014). The key elements of

birth preparedness include: knowledge of danger signs, plans for place of birth,

use of birth attendant, transportation and saving money (Solnes Miltenburg et al.,

2013). In addition, a potential blood donor and a decision maker need to be

identified. This is because every pregnant woman faces the risk of sudden,

unpredictable complications that could end in death or injury to herself or to her

infant. For this reason, pregnancy and childbirth is described in developing

countries as a perilous journey.

Most maternal deaths due to complications during and following

pregnancy and childbirth are preventable, and great strides have been made in

improving maternal health and reducing the number of deaths (WHO, 2015b).

Between 1990 and 2013, maternal mortality dropped globally by 45% according

to the WHO (Nawal & Goli, 2013), nevertheless, every day approximately 800

women still die from causes related to pregnancy and childbirth. In 2013, the

number of maternal deaths worldwide was 289,000 women which had a negative

impact on families, communities and societies with far-reaching effects (Mbalinda

et al., 2014). Out of this, Sub-Saharan Africa nations accounted for 62% of the

deaths and remain the most risky regions in the world for dying of complications

in pregnancy and childbirth. The WHO further mentioned that, 1 out of every 16

women dies of pregnancy related causes compared with only 1 in 2,800 women in

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richer regions (WHO, 2015b). The risk of maternal mortality is highest for girls

under 15, many of whom have no access to maternal healthcare services. Without

the necessary intervention, the WHO predicted that one out of every five women

in Africa will die from pregnancy related complications (WHO, 2015). Hence, it

is necessary to employ strategies such as birth preparedness and complication

readiness to overcome this danger to pregnant women.

According to Karkee et al., (2013), all pregnant women should have both

oral and written plan for birth and dealing with unexpected adverse events, such

as complications or emergencies, that may occur during pregnancy, childbirth or

the immediate postnatal period. Women should discuss and review this plan with

a skilled attendant at each antenatal assessment and at least one month prior to the

expected date of birth. This is to assist women, their partners, and families to be

adequately prepared for childbirth by making plans on how to respond if

complications or unexpected adverse events occur to the woman and/or the baby

at any time during pregnancy, childbirth or the early postnatal period.

Studies in developed countries have shown a positive impact on pregnancy

and birth outcomes when the woman feels in control of the process of pregnancy

and birth (Hiluf & Fantahun, 2008). Making a birth plan has been shown to

facilitate this feeling of self-control and autonomy. Two types of interventions for

developing birth plans are available, each emphasizing a different aspect of care.

Interventions conducted in higher-resource countries focused mainly on the

woman’s psychological and physical comfort (birth plan), while those in lower-

resource countries tended to focus on measures to ensure a safe birth with the

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appropriate attendant and to prepare for emergencies (birth and emergency

preparedness) (Tura et al., 2014). Birth and emergency preparedness is considered

by The WHO and other agencies to be a useful and practical intervention with

several advantages. This group of interventions contributes to increased use of

services by assisting women and their families to plan for child birth (Urassa et

al., 2012).

A birth/emergency preparedness plan includes identification of the

following elements: the desired place of birth; the preferred birth attendant; the

location of the closest appropriate care facility; funds for birth-related and

emergency expenses; a birth companion; support in looking after the home and

children while the woman is away; transport to a health facility for the birth;

transport in the case of an obstetric emergency and identification of compatible

blood donors in case of emergency (Nawal & Goli, 2013). The error in this

argument is based on the assumption that every community/nation has the same

economic ability to meet these recommendations as determined by healthcare

providers in richer nations or looking to imitate richer nations with the resources

to provide these services. There must be alternative services in regard to poorer

nations that are community-driven and initiated than follow dictated external

designs.

Apart from birth and emergency plans, the most critical intervention

promoted by the Safe Motherhood Initiative is to ensure skilled attendance at

delivery for all women. Since 1997, interventions and the list of the process

indicators in support of Safe Motherhood have expanded to include the concept of

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birth preparedness (Asp et al., 2014). This concept encompasses knowledge,

intentions, and actions that affect the timely and appropriate use of life-saving

obstetric care in the developing world. Birth preparedness is viewed as one of

several needed responses to the three-delay model: delays in deciding to seek

medical care, delays in reaching medical care, and delays in receiving treatment

for major obstetric complications (Solnes Miltenburg et al., 2013). Whereas Safe

Motherhood tended to reflect the availability and quality of facility-based care

and care-seeking by the pregnant woman, birth preparedness on the other hand

broadens the scope of the processes conceptualized to be in the pathway to

maternal death or survival. Consequently, the number and type of population

groups targeted for behaviour change interventions related to birth preparedness

have expanded to include pregnant women, family members and community

leaders (Ekabua et al., 2011).

The literature regarding the effectiveness of birth preparedness

interventions to increase use of skilled professionals at delivery is very limited.

For example, Solnes et al., (2013) in their review of more than 150 studies of the

effectiveness of a broad range of behaviour change interventions to change

specific community and household-level behaviours within Safe Motherhood

programs identified only seven studies from projects that aimed to increase use of

health services. The interventions evaluated in the seven studies varied, but all

relied on various health education, communication, participatory, or social

support strategies. In six of the studies that emphasized increasing knowledge of

the danger signs of pregnancy, all reported an increase in participants’ knowledge,

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although statistical testing was not reported in all cases. Three of the seven studies

documented increases in use of skilled delivery care. None of the studies,

however, could attribute these increases to behaviour change interventions due to

limitations in study design, sample size, and the absence of reported data

regarding exposure to the package of interventions. Birth preparedness lacks

evidence regarding the effectiveness of its implementation; nonetheless the

concept has been used widely in Safe Motherhood programs. Kaso and Addisse,

(2014) mentioned that BP/CR is a safe motherhood strategy whose objective is to

promote the timely use of skilled maternal and neonatal care during childbirth or

obstetric emergencies by reducing delays at the first, second, and third stages of

labour and delivery process. BP/CR is a broad and integrative strategy; evidence

related to its comprehensive implementation is scarce. However, its components

are included in the WHO model for antenatal care as part of focus antenatal care

education in clinic setting.

Based on critical primary research in India, WHO and UNICEF (2009)

also recommend antenatal and postnatal home visits to counsel mothers, provide

new-born care and facilitate referral. Emphasized by Ekabua, Ekabua, and Njoku

(2011), in settings where there is prevailing illiteracy, lack of infrastructure and

poor transport systems, the principles and practices of BP/CR have the potential

of reducing the existing high maternal and neonatal morbidity and mortality rates.

In Ethiopia, where BP/CR is barely applied, only 6% of the deliveries are

attended to by health professionals. This situation well explains the maternal

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mortality ratio of 673 per 100,000 live births, which is one of the highest in the

world (Ekabua et al., 2011).

Historical evidence shows that no country has managed to bring its

maternal mortality ratio below 100 per 100000 live births without ensuring that all

pregnant women and new mothers are attended to by an appropriately skilled

health professional during labour, birth and the period immediately afterwards

(Jacobs., et al, 2011). Delay in responding to the onset of labour and such

complications has been shown to be one of the major barriers to reducing

mortality and morbidity surrounding childbirth. Information on how to stay

healthy during pregnancy, the need to obtain the services of a skilled birth

attendant, recognizing signs of the onset of labour, and recognizing danger signs

for pregnancy-related complications and what to do if they arise would

significantly increase the capacities of women, their partners and their families to

take appropriate steps to ensure a safe birth and to seek timely skilled care in

emergencies (Ajediran., et al, 2013). Interventions to reduce the other barriers to

seeking care such as transport costs, perceptions of poor quality of care and

cultural differences, must also be addressed.

Although little empirical evidence exists as yet to show a direct correlation

between birth preparedness and reducing maternal and/or perinatal mortality and

morbidity, limited and small-scale studies suggest that there is considerable

benefit to be gained from this intervention. Given the difficulties in predicting

pregnancy-related complications, providing information, education and advice to

the woman, her family and the community on seeking necessary care is seen as an

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important part of antenatal care (Sunnyvale et al., 2016). Studies show that, while

no clear relationship has been found between improved knowledge and increased

health-seeking behaviour, the adoption of new practices associated with planning

at family and community levels is encouraging (Kabakyenga et al., 2011). The

presence of a person of the woman’s own choice to provide social support during

childbirth has also been shown to have a positive effect. Thus, an important part

of preparing for birth is seeking contact with and obtaining the services of a

skilled birth attendant.

Many programs that aim to improve maternal health have included efforts

to improve preparation for birth and readiness for complications (JHPIEGO,

2004). The IMPAC manual-Pregnancy, Childbirth, Postpartum and Newborn

Care: A Guide for Essential Practice lists some key points to be addressed in

ANC, which include identifying where the woman would go in an emergency and

issues of transport and costs, as well as considering moving closer to care if

‘living far’ from a facility (WHO & UNICEF, 2009). However, greater guidance

is required in terms of identifying which women should be strongly encouraged to

move closer to care prior to labour and identifying the most appropriate facility to

attend in the event of an emergency, recognizing that it may not be the closest

health centre.

Knowledge of Expectant Mothers and Health Seeking Behaviour

Education is very important in analysing the decision of whether to seek

care at health facility or not. Lack of knowledge of the recognition of danger signs

and complications and less perceived severity of pregnancy related problems are

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among the factors that can extend the time to make decision in seeking health

care. In developing countries, more than 60% of women have been given the

knowledge on danger signs during ANC visits (Bintabara et al., 2015). In

southern Tanzania, the more women have knowledge of at least four or more

danger signs, the more they utilize health facilities; those who have no knowledge

of any danger signs and are more likely to use TBAs or relatives. A study done

by Hailu et al., (2011) indicated that women patronize health facilities for delivery

only when they have obstetric complications and those with normal pregnancy

may opt to deliver at home. During the ANC visit, women are often instructed to

deliver at a health facility; nevertheless, they were not given enough information

especially about the importance of expected date of delivery and birth

preparedness. As a result, the women delay in seeking care when premature

labour started.

In addition, women and their families believe in the experience of

previous pregnancy as a tool to determine the decision to seek care (Hailu et al.,

2011). After they realize there is a complication, they then decide to seek care

where the delay varies from two hours to five days. The delay in seeking care is

mainly associated with lack of knowledge of identifying the danger signs.

Mbalinda et al., (2014) demonstrated that rural Vietnamese women, with little

knowledge on complications associated with childbirth, are the ones who deliver

at home. The danger signs are not the actual obstetric complications, but

symptoms that are easily identified by non-clinical personnel. Danger signs of

pregnancy are mainly classified into three categories: the most common key

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danger signs during pregnancy include severe vaginal bleeding, swollen

hands/face and blurred vision. Major danger signs during labour and childbirth

include severe vaginal bleeding, prolonged labour (>12 hours), convulsions and

retained placenta. Major danger signs during the postpartum period include

severe vaginal bleeding, foul-smelling vaginal discharge, and fever (Markos &

Bogale, 2014).

Maternal morbidity and mortality could be prevented significantly if

women and their families recognize obstetric danger signs and promptly seek

health care service during labour, delivery and the early postpartum period under

the supervision of skilled birth attendant (SBA). Evidence suggests that raising

awareness of women about obstetric danger signs would improve early detection

of problems and reduces the delay in deciding to seek obstetric care (Hailu et al.,

2011). It is the essential first step in the appropriate and timely referral to essential

obstetric care. Similarly, because most babies are born at home or are discharged

from the hospital in the first 24 hours, increasing community awareness of the

danger signs of new-born complications is of critical importance for improving

new-born survival. Thus, this has been identified as one of the key strategies for

improving maternal and child health. However, like in many developing

countries, awareness of women about obstetric danger signs remains low (Hailu et

al., 2011). The Ghana Ministry of Health (MOH), Reproductive Health

Department and health bureaus of respective regions have made concerted effort

to promote awareness of mothers about obstetric danger signs aimed to achieving

the MDG 5. They have been applying multiple approaches at local and national

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levels to improve access to health care information throughout the country,

including activities such as training of health care providers and health extension

workers, organizing civil societies, supporting women to women's associations,

increasing access to health facilities and allocating health resources more

equitably among rural and urban areas (Agbodohu, 2013).

Empirical studies of preventive and curative services have often found that

use of health services is related to the availability, quality and cost of services as

well as to the social structure, health beliefs and personal characteristics of the

users. Urassa, Pembe, and Mganga (2012) have shown that women with primary

education and above were two times more likely to be prepared for birth and

complications compared to those who lacked formal education. They also

reported that those who knew three or more obstetric danger signs were three

times more prepared for birth and complications.

Similarly studies conducted in other countries have separately showed a

clear relationship between high education and awareness of danger signs in

Tanzania and in Kenya (Hiluf & Fantahun, 2008). However, their study results

are inconclusive with respect to the influence of other predisposing and enabling

factors, such as women’s age, number of previous pregnancies and access to

health care services/facilities, to mention a few. They further argued that better

educated women are more aware of health problems, know more about the

availability of health care services and use this information more effectively to

maintaining or achieving good health status. Mother’s education may also act as a

proxy variable of a number of background variables representing women’s higher

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socio-economic status, thus enabling her to seek proper medical care whenever

she perceives it necessary. Lack of physical access to health care facilities

presented a fundamental hurdle to receiving care, even in urban settings (Debelew

et al., 2014). Poor quality of care continues to be a major concern in most health

systems, as high patient volume and limited resources combine to constrain

service provision. Even when facilities are accessible and quality services are

available, many women only recognize pregnancy relatively late in gestation

(Urassa et al., 2012).

A mother’s age may sometimes serve as an alternative for the women’s

accumulated knowledge of health care services that may have a positive influence

on the use of health services. On the other hand, because of development of

modern medicine and improvement in educational opportunities for women in

recent years, younger women might have an enhanced knowledge of modern

health care services and place more value upon modern medicine. Also, because

of perceived risk associated with first pregnancy, a woman is more likely to seek

maternal health care services for first order than high-order births (Kabakyenga et

al., 2012). Having more children may also cause resource constraints, which have

a negative effect on health care utilization. One of the important predisposing

factors for utilization of health care is family size. Women from large families

underutilize various health care services because of too many demands not only

on their time but also on their resources if any (Asp et al., 2014).

The costs associated with illness among the poor in Pakistan resulted in

reduced food consumption, withdrawal of children from school, sale of major

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assets, putting children to paid work and even bonded labour, and only 12% were

able to recover from the associated economic shock (Hailu et al., 2011). Within

this context, a resolution to provide universal coverage, defined as access for all

to appropriate promotion, preventive, curative and rehabilitative services at an

affordable cost was endorsed by WHO member states in 2005. Recommended

actions to alleviate barriers to access to health care related mainly to financial

interventions. However, as multiple factors play a role, addressing access costs

alone will not ensure access to health services (Engla, 2010).

Maternal Health Services

The WHO (2015) defined maternal health as the health of women during

pregnancy, childbirth and the postpartum period. Comprehensive awareness on

the occurrence of maternal mortality had been given slight recognition until the

last two decades. Responsiveness on maternal mortality commenced more

seriously in the 1980’s but more specifically 1985 when Mbalinda et al., (2014)

and Alon (2009) published a thought-provoking article titled 'Maternal Mortality,

a neglected tragedy where is the M in MCH?. The article warned the world of the

fact that many countries were neglecting this important problem and that existing

programs were unlikely to reduce the soaring maternal mortality rates.

Instantaneously, various authors went out to find out more. Accordingly, to meet

this critical level of development, nations universally have instituted programs

and policies within their available resources to combat maternal death. However,

regardless of continued high-level political and organizational commitments,

maternal mortality still remains one of the greatest challenges facing the

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developing world, described as a tragedy that has often been neglected or

compromised (Moran et al., 2006).

The progress on the maternal mortality reduction target has been far too

slow, a sad reality that many view as one of the most embarrassing manifestation

of health and social systems failure (Mbalinda et al., 2014). Similarly, MDG

Progress Report and Human Development Report are accused of using various

sources of data having different sample sizes and methodologies to compare

MMR data over a period of time (WHO, 2015a). These are related to the

inefficiencies within the civil registration systems, lack of knowledge of the

pregnancy status of the deceased in addition to inaccurate medical certification of

the cause of death. This staggering maternal mortality figures globally are

burdened with a number of problems due to the fact that all deaths of women of

reproductive age (11-49 years) are not known. Few countries count birth and

death and even fewer register the cause of death and cannot determined whether

or not the woman was pregnant at the time of death (Solnes et al., 2013).

About 26.4% of Ghanaian women who are married or are in consensual

unions lack access to effective family planning, despite their desire to delay

pregnancy and child birth. The unmet need for family planning is greatest among

adolescents (61.6%) who are around 46% more likely to die of the consequence of

pregnancy and childbirths than older women (Crissman et al., 2015). Lack of

access to family planning has a direct connection to unsafe abortions which is a

significant contributor to maternal mortality in Ghana (WHO, 2015a). Providing

women with access to family planning and enabling them to decide how many

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children they want to have and when, prevents maternal mortality by reducing the

number of women dying due to pregnancies they never intended to have (Hailu et

al., 2011). Meeting only 50% of the unmet demand for family planning in Ghana

would reduce the number of unintended pregnancies and significantly reduce the

number of abortions that are particularly high among women with unintended

pregnancies.

Global development assistance to maternal and neonatal health in 2003

was estimated at more than US $663 million. An estimated extra US $1 billion

was assigned three years later in 2006, while an increasing US $6·1 billion

estimated in 2015, is needed to increase coverage to desired levels of curbing

pregnancy related complications and deaths (Allisyn et al., 2006). However, low

financial commitment has also been blamed for the difficulty in halting maternal

related problems and deaths. Despite the commitment expressed with the

Millennium initiative, maternal, new-born, and child health have not been given

financial priority internationally (Ekabua et al., 2011). They mention competition

for funds so fierce that advocates for well-funded disease initiatives even feel the

need to compete for the meagre resources of maternal health. Safe motherhood

programs implemented to deal with maternal related complications tend to

compete for funding with other priorities such as tuberculosis (2·4 million yearly

deaths), malaria (1 million yearly deaths), and HIV/AIDS (3million yearly deaths)

(Skinner & Rathavy, 2009).

Consequently, the WHO has provided a summary of three critical factors

underlying maternal deaths. The first of these vital causes of maternal death in the

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world is lack of access and utilization of essential obstetric services (Jacobs et al.,

2011). There is a negative association between maternal mortality rates and

maternal health care utilization. Estimates suggest that 88 to 98% of all

pregnancy-related deaths are avoidable if all women would have access to

effective reproductive health care services (Hiluf & Fantahun, 2008). Secondly,

the low social status of women in developing countries is critical. The report

indicated low status of women can limit their access to economic resources and

basic education; the impact is that they have limited ability to make decisions,

including a decision related to their health and nutrition. The third and final point

is too much physical work together with poor diet. This is believed to also

contribute to poor maternal health outcomes (Byford-Richardson et al., 2013).

In Ghana’s health system, basic obstetric and antenatal care is provided by

health centres, health posts, mission clinics and private midwifery homes. Each

health centre or post serves a population of approximately 20,000 (Asante, 2011).

In the rural areas, TBAs continue to carry out deliveries, though they are trained

to refer more cases. Comprehensive emergency obstetric care is available from

district hospitals and regional hospitals, as well as national referral hospitals.

Most are run by the Ghana Health Services, though the mission sector plays a

significant role, especially in more remote regions. All care is paid for, unless the

service is exempt or the person has private or public health insurance, though user

fees are subsidized by public inputs into the services (Mutiso, Qureshi, &

Kinuthia, 2008). Financial barriers are believed to be one of the most important

constraints to seeking skilled care during delivery in Ghana. Problems such as

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delays in reimbursing facilities the services provided to clients for conditions

under health insurance have also been found. This meant that exemptions are

available in theory but not always in practice (Agbodohu, 2013).

In Ghana, as in many developing countries, deaths during pregnancy and

childbirth are often linked to the three delays: delays in the home, delays in

accessing the health facility and delays at the health facility (Adu-Gyamfi, 2012).

The first delay is deciding whether to seek care or not. Lack of information and

inadequate knowledge of pregnant women are responsible for the delay in

responding to initial warning signs of complications of pregnancy and danger

signals during labour. Certain traditions and cultures in the country maintain that

women must wait for approvals from male relatives before seeking help (Iliyas et

al., 2010b). The second delay is linked to the constraints that women face in

accessing health facilities. Weak referral linkages as pointed out exist between

community, health centres and district hospitals making it difficult for women in

emergency situations to get the care they need. The situation is made worse by

poor road and communication networks, distant health facility, and a lack of

transportation and inadequate community support (Moran et al., 2006) The third

delay occurs between the time the woman arrives at the health facility and the

facilities response in providing appropriate care. The findings stated health centre

preparedness to respond to obstetric emergencies is generally inadequate in terms

of skilled attendants, equipment, supplies and drugs and motivated staff.

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Barriers to Accessing Early Antenatal Care

Although it is acknowledged that there is no universally accepted

definition of access to health services, Byford-Richardson et al., (2013) defined

access as the timely use of service according to need. Utilization of health care is

used as an operational proxy for access to health care. Access has four

dimensions: availability, geographic accessibility, affordability and acceptability.

Barriers to accessing health services can stem from the demand side and/or the

supply side (Ensor & Cooper, 2004). Demand-side determinants are factors

influencing the ability to use health services at individual, household or

community level, while supply-side determinants are aspects inherent to the

health system that hinder service uptake by individuals, households or the

community.

The need to differentiate demand-side from supply-side barriers is related

to the formulation of appropriate interventions to address both sides concurrently,

because access barriers may not always be mutually exclusive, and may interact

and influence each other. Byford-Richardson et al., (2013) provided a framework

for assessing barriers along the four dimensions of access (each of them having

supply-side and demand-side aspects) whilst Ensor & Cooper (2004) presented a

framework of supply-side and/or demand-side barriers. Waiting time and direct

payment for services are considered mixed supply-side and demand-side barriers

by Ensor & Cooper, (2004). This is because long waiting times indicate a

distribution of staff and equipment not in accordance with need, and the pricing of

services is determined by the health facilities (supply side), meaning that both

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factors are outside the control of the public as users of health services (demand

side).

It is well documented that the unwelcoming staff attitude or poor

interpersonal communication skills as well as complex billing systems at hospitals

impede access to maternal health care. This attitude of health workers creates lack

of assertiveness and low self-esteem among the poor, which increased the

difficulty of accessing services. Restrictions on the tasks that can be performed by

various health staff resulted to limited provision of maternal care services. For

instance, general nurses on certain grounds are restricted from performing certain

life-saving activities for the mere fact that they are not midwives. As a result, a

client in dying need may have to wait until a midwife or a doctor arrives. This

problem is critical in facilities where there are no clear protocols regarding service

delivery (Solnes et al., 2013). The late referral or non-referral to specialist care of

patients who may report with a condition at lower-level health facilities also

served as a barrier to maternal health care.

Teenagers who are pregnant but are not married face dehumanising stigma

(Kaso & Addisse, 2014b). This makes them stay away from essential maternal

health service risking themselves with pregnancy related complications. A lack of

trust by users in health care providers or the intermediates that link the population

with these providers makes people reluctant to use the respective services

(Byford-Richardson et al., 2013). Another barrier to maternal health services is

failure to deliver integrated health services together with complementary

programmes provided to a target group, such as overlooking the opportunity to

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check and update vaccination status or to administer Vitamin A when a child is

brought to the health facility for other services.

The effect of non-financial barriers, such as lack of health awareness,

apparent unfelt need or lack of opportunity (defined as exclusion from social and

health providers) also play a major role in accessing maternal care. Other non-

financial barriers, such as means of transport, private–public dual practice through

which patients are siphoned off from public health facilities to health workers’

private practices, where they may be subjected to more expensive often irrational

treatments is evident (Jacobs et al., 2011). Staff absenteeism, limited opening

hours that do not allow for dealing with emergencies or working times are not

also convenient for patients, especially working people.

Primary Health Care (PHC) was endorsed in 1978 by WHO member

countries as a paradigm shift designed to reduce inequities in health, partly

through enabling universal access to health services (Byford-Richardson et al.,

2013). While universal coverage is the aim, imperfect health systems suffer from

what is called the “inverse equity hypothesis,” which states that new health

interventions initially reach the socio-economically better-off, while the majority

of the poor benefit only later in time. Because of this time lag, especially in

developing countries that are to a considerable extent dependent on donor funding

for the health sector, targeting is often a preferred strategy (Karkee et al., 2013).

In the absence of universal coverage, there are two main targeting options

for enabling greater access to health services for poor and vulnerable patients,

namely to build the capacity of health care providers to target service provision on

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selected groups (a supply-side strategy), or to reduce the barriers to access and

participation (a demand-side strategy) (Ensor & Cooper, 2004). Interventions

aimed at facilitating access to health services need to be implemented at district

level, as this is known to constitute the most appropriate geographical situation

for PHC. However, consideration should be given to the potentially limited

capacity of district health managers in low income countries. Moreover, because

most barriers to care cannot be overcome by the health sector acting alone, inter-

sectoral collaboration is called for.

Although considered the most neglected aspect of PHC, community

participation should be built into interventions addressing access barriers as it

reduces the power gaps between the population and health systems (Skinner &

Rathavy, 2009). Whatever interventions are developed, monitoring their service

uptake should be an integral part of the strategy. It is assumed that higher levels in

the health sector, such as provincial and national health authorities, set out the

broad policy framework, enforce legislation, ensure provision of a relatively

steady supply of funds, goods and equipment, and conduct monitoring and

supervision of the lower echelons in the health system. Many proposed

interventions take a monetary-incentive approach to addressing access barriers to

health services. Often, these financial incentives are channelled through the

demand-side, seemingly due to donor reaction to governments’ failure to deliver

sufficient health services (Soubeiga et al., 2014).

Given the high levels of illiteracy, knowledge levels about the many

health risks associated with pregnancy and childbirth are low and not informed by

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modern medical practice (Ingvil & Bailah, 2015). As a result of the low level of

knowledge there is poor demand for, and strong mistrust of the preventive

medical model. For example, only one out of four pregnant women seeks out

antenatal care. Social and cultural traditions associated with reproduction – such

as marriage of adolescents as young as 15 years old, frequent and close

pregnancies, and the home birthing tradition all adversely impact decisions to

seek reproductive health care until it is too late to save mothers or their children

(Agarwal et al., 2010).

A woman’s age, number of pregnancies carried, and whether or not she

was married were factors that also play an important role in the utilization of

maternal health care services. Women carrying their first child were probably

more susceptible to difficulties during labour and were more cautious than women

who have had several births. Therefore, women who were pregnant for the first

time were more motivated to utilize maternity care because they did not know

what to expect from the process. Subsequently, as a woman endured more

pregnancies, she would rely on her experience and draw from that knowledge

(Karkee et al., 2013).

A mother’s age may serve as a proxy for the woman’s accumulated

knowledge of health care services, which would have a positive influence on the

use of health services. Older women were more likely to seek maternal healthcare

than younger women (Markos & Bogale, 2014). In a study conducted in Jamaica,

teenagers were more likely not to attend antenatal care or attend it later, when

compared to woman in their twenties (Mekuaninte et al., 2016). In Nigeria,

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women in the middle child bearing ages were more likely to use maternal health

services than women in early and late child bearing (Iliyasu & Sabubakar, 2015).

And so being of older age at marriage is positively associated with the use of

healthcare services. One study in rural India reported that utilization of antenatal

care was higher among women married at 19 or older compared to those married

at less than 19 years (Nawal & Goli, 2013). Early marriage or child marriage is

practiced more often in Africa and Southern Asia. In these areas, a higher

proportion of teenage girls are married to older men, sometimes as early as 9 or

10 years of age, based on religious and cultural beliefs. The girls may be restricted

from seeking healthcare services because of fear or need for permission from a

spouse or in-laws (Campbell, Martinelli-heckadon, & Wong, 2013).

Ethnicity and religion are often considered markers of cultural background

and are thought to influence beliefs, norms, and values in relation to childbirth,

service use, and women's status. Ethnic identity may also be associated with

health beliefs that influence whether care is sought and whether that care is

traditional or biomedical. In a study conducted in Nigeria, it was determined that

ethnicity seemed to make no significant difference in the use of antenatal care;

however, it made a significant difference in the use of skilled assistance and post-

natal care. In the same study, it was found that the level of service utilization was

significantly higher among the Igbo (in the Southeast) compared to the Hausa (in

the North) (Iliyasu et al., 2010). This result reflects the influence of the cultural

and religious beliefs in the north. The Islamic religion may have had a strong

influence on the cultural beliefs and traditions on child birth practices among the

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Hausa in the North. The Igbo seemed to utilise maternal healthcare facilities more

because of their Western style education and Christian religion. Whether or not a

woman is employed is one of the most important factors that positively influenced

the use of maternal healthcare. Women who were working and earning money

may have been able to save and decided to spend on facility delivery (Tura et al.,

2014).

Obstetric Beliefs among Expectant Mothers

Tradition in its technical sense is defined as a tried and tested way of

behaviour with positive results over centuries revealed or unveiled to mankind

(Makic, Martin, Burns, Philbrick, & Rauen, 2013). Rituals and ceremonies

flourish in every culture, and have done so throughout history. Perhaps the two

most ritual-inspiring events are birth and death, events that have seeped into

culture, mysticism, religion and local custom. Rituals governing decisions made

on labour during childbirth flourish the world over. These decisions can be even

more difficult in Ghana where women with varying degrees of education and

incomes have varying degrees of accessibility to certain types of medical care

coupled with the multiplicity of traditions within what we may consider to be one

ethnicity that create barriers. Culture and beliefs play a major role in women’s

decision to seek health care (Kabakyenga et al., 2012).

A study in rural northern Tanzania showed cultural beliefs influenced

home delivery but not the main factors that hinder women from seeking care.

Women deliver secretly at home due to fear of prolonged labour that is perceived

to be the result of having affairs outside marriage during pregnancy (Urassa et al.,

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2012). If she is not delivering in private, the women would have to mention the

name(s) of the man or men she slept with and if she cannot still deliver, then she

would have to go to hospital. This practice is also common among the people of

Northern Ghana especially with the Dagaaba and considered a case of punishment

for adultery. Confessions are believed to be followed often by swift delivery

(source unpublished). In the Ngorongoro district in Tanzania, home delivery is a

cultural norm for normal pregnancy. Women, husbands, TBAs and the elderly

perceived that only women with obstetric complications should deliver at health

facility with assistance of skilled birth attendant (Urassa et al., 2012).

A study done in India revealed that women take local herbal medicine to

stimulate contractions (Agarwal et al., 2010). These herbal medications given in

unquantifiable dosages often result in repeated and strong contractions that

occasionally lead to rupture of the uterus, a probable cause of maternal and new-

born death. Even when women are informed during ANC visits not to take herbal

local medicine, they still take it as a cultural norm. Even though these herbal

medicines are not without benefits experience showed that the adverse effects far

outweigh their benefits. A study in Burkina Faso found that socio-cultural norms

have a strong influence on expectant mothers’ choice of place of delivery (Nawal

& Goli, 2013). Other women choose to turn to their religion when it comes to

having babies. Religion is so integrated into every aspect of life. The growing

faith in the new technology of Western medicine cause modern practices to seem

like a secure option for women, as well. Many of these beliefs have changed and

evolved over time because of information now available to traditional, religious,

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and modern caregivers and also the mothers themselves. However, another study

in rural Gambia noted that during labour, women have to seek advice from elderly

women whom they believed have the experience to decide at what time and where

to go for delivery (Bintabara et al., 2015).

In rural Bangladesh, a study identified that health care patronage is the last

option after traditional approaches fail to curb birth difficulties (Nawal & Goli,

2013). They used to treat illness with traditional ways using untrained TBA or

ignore the illness according to their perception. A study in rural Vietnam found

that socio-cultural factors hinder young couples from making decision and

controlling their own lives (WHO, 2015c). Not long ago, expectant mothers were

restricted from eating snails; it was believed to cause a twist in the mouth of the

unborn baby (Karkee et al., 2013). Also, any intake of honey was discouraged

because it was thought to plug the birth canal. Sweeping at night or climbing

trees by pregnant women makes them vulnerable to the baby’s soul being swept

away and was therefore forbidden (Fischer, 2002). As modern medicine slowly

trickles through Ghana and becomes more popular, superstitions spread less

frequently. However, some communities in Central Africa believe sexual

embarrassment of the pregnant woman will promote labour and customs include

the father of the baby exposing his genetalia to her (Makic et al., 2013).

In parts of Jamaica it is customary to promote labour by giving a pregnant

woman a sweaty shirt to smell (Crowther & Hall, 2015). In parts of India, a jar of

grain is broken in front of a heavily pregnant woman in the belief that she will see

the grain spill before her and her body will respond likewise (Agarwal et al.,

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2010). Ancient Egyptians also incorporated rituals and ceremonies as an integral

part of the pregnancy and birth experience (Crowther & Hall, 2015). Women also

held a great fear of blood; especially blood associated with menstruation and

childbirth, and thus performed ritual cleansings of mother and baby after birth.

One of the more prolific birth related rituals involves the placenta. For most

women giving birth in a hospital in Australia, the placenta is a mere afterthought,

and many do not even see it at all. The disposal of the placenta is part of the ritual

for staff in these settings, the ritual of cleaning up and disposing of birth’s waste.

On the other hand, in a home birth environment, considering the placenta as waste

is almost unheard of; the placenta is given respect and ceremony, be that through

its burial in the yard, honouring it through art, or valuing its healing properties by

consuming it (Crowther & Hall, 2015).

The placenta is given so much power in various parts of the world that the

rituals associated with it can mean the difference of life or death for a new-born

and his/her family or village. The mythology surrounding the placenta brings

ritual and ceremony to the fore of the birth experience in many cultures. In

Northern Sumatra for example, local mythology holds that the placenta lets one of

seven souls the newborn child possesses, so great care and respect is taken in its

treatment (Iliyasu & Sabubakar, 2015). For women in Hungary who wanted no

more children, it was customary to burn the placenta and place the ashes in her

husband's drink, while in Japanese culture it was believed eating the placenta

would increase a woman's fertility (Dal & Knauth, 2014). In Austria and parts of

Italy, it was believed that the blood of a fresh placenta held great medicinal

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properties, for everything from the removal of birthmarks to the cure for epilepsy

(Hassan., Youness., Zahran., & Nady, 2015). Placenta burial is common among

home birth experiences in Australia. Many women say this practice respects the

placenta as a life giving organ, and burial respects that by allowing it to enhance

the life of another living organism.

Placenta burial is a common ritual for many cultures and the mythology

behind these practices can include the belief that evil spirits can enter the home or

village of a new-born child through the placenta, so it is quickly buried to reduce

this risk (Crowther & Hall, 2015). Some cultures like Native Hawaiian, Navajo

and Maori tribes believe by burying the placenta in the homeland, the child is

bound to the land and his/her ancestral heritage (Hassan et al., 2015). In Thai

culture the placenta is salted, jarred and buried under a tree that corresponds to the

symbol of the Asian year of the child's birth. Many believe the spiritual

connection between the placenta and the baby should not be artificially broken.

Among the Kikuyu in Kenya, the placenta and the umbilical cord are believed to

symbolize the attachment of the child to the mother and its roots in the traditional

society (Byford-Richardson et al., 2013).

Other rituals associated with birth in the West are the swaddling, or

wrapping of new-borns, said to make them feel secure. This practice dates back to

second millennium BC in Egypt, where infants were swaddled to protect them

from malevolent spirits, the swaddling disguised the baby as mummified, to fool

the evil spirits that lurked the neighbourhood after the birth of a baby. The

wrapping also symbolized the god Ptah, a god of protection and healing (Otoo et

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al., 2015). In the Tudor period in England, traditional Catholicism encouraged the

practice of classing the child after swaddling, and sprinkling it with protective salt

(Crissman et al., 2015).

Spirituality and religiosity are recognized as important components of

health and well-being. Women have used prayer and other spiritual practices for

their own and others’ health concerns for thousands of years. Most current

literature focuses on the spiritual health of individuals living with chronic

illnesses and those who are terminally ill, whereas there is relatively little focus

on spirituality or religiosity during the childbearing years. However, a study

documented the relationship between religious involvement and health risk

behaviours in childbearing women, concluding that such involvement was

significantly correlated with less-risk health behaviours (Crowther & Hall, 2015).

Although spirituality and religiosity may be related, women may be spiritual

without being religious, and more research on this association is recommended.

Childbearing and motherhood may be ideal contexts in which to enrich

spirituality. Cross-culturally and throughout history, pregnancy and childbirth

have been perceived as spiritual events because of the miraculous processes

involved. Birth narratives provide insights into the connection between

childbearing and spirituality and present significant information. Birth stories

actually offer a powerful and rich source of data (Crowther & Hall, 2015). Greater

emphasis needs to be accorded to valuing of women's stories as data. Attending to

women's spiritual experiences during childbearing is an important way to enhance

care.

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Religious beliefs within the community may also act as a barrier for

seeking care. Khan et al., (2012) found that religious beliefs were a barrier for

ANC utilization in Bangladesh. Husbands and mothers-in-law were usually the

decision makers about ANC and some women also found the idea of ANC to be

shameful, especially if they felt they would be examined by a male worker. A

similar findings was reported among Ethiopian Afar, where women stated during

focus group discussions that only God and their husband could see them naked

(Tura et al., 2014). Pregnant women may prefer consultation with local religious

leaders, traditional healers, and TBAs to seeking care from qualified health

providers.

In rural Gambia, older women in menopause are seen as experts on

pregnancy and childbirth who decide what should be done and their advice is

taken. For example, an older woman may advise a woman in labour to wait until

the next Muslim praying time before seeking care because labour and child birth

takes place at certain times and these times correspond with the Muslim praying

times (Campbell & Graham, 2006). In Uganda, women felt embarrassed to give

birth in a health facility because other members of the community would think

they were not brave enough to give birth on their own (Kabakyenga et al., 2012).

In the study, birth represented a rare opportunity for a woman to demonstrate

pride, courage, and bring honour to her and her husband’s families by her stoic

demeanour. The woman who managed to deliver without indication that she was

in labour and without calling for assistance until the child was born was especially

esteemed.

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Other harmful traditional practices that impact maternal health include

female genital mutilation (FGM), early marriage, early pregnancy, traditional

birth practices such as pushing on the abdomen to hasten delivery, and the use of

certain surgical procedures and concoctions as labour enhancers (Okka &

Durduran, 2016). For example in northern Nigeria, traditional healers make an

incision in the vagina of women who are not making progress in labour (Iliyasu et

al., 2010). This is also practised in Ghana (Otoo et al., 2015). Some ethnic groups

in Sub-Saharan Africa discourage pregnant women from eating meat and eggs,

because it is believed that eating meat during pregnancy will cause her to give

birth to a witch (Soubeiga et al., 2014). Notwithstanding the numerous health

challenges of tradition, spirituality and socio-cultural systems the practices attract

Ghanaian women because of their time-tested methods successfully used by

generations of mothers and grandmothers. Some traditional practices are however

beneficial to the mother and baby. For example, among many cultures in Africa,

women were encouraged to breastfeed their infant for over a year, thus

encouraging the practice of spacing between pregnancies (Soubeiga et al., 2014).

Family Support in Birth Preparedness Practices

Pregnancy, birth and the postnatal period is a time of major psychological

and social change for women as they negotiate their roles as mothers. Supporting

mothers’ emotional wellbeing during the perinatal period is now recognized to be

as important as the traditional focus on the physical health of the mother and child

(Jones et al., 2005). Increasing evidence about early brain development and the

way in which infants develop emotional and behavioural wellbeing within the

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context of their early relationships, has highlighted the particular importance of

building a bond with the unborn baby, and sensitive early care giving (Jones et al.,

2005). Family support can serve as the foundation of security and growth for an

expectant mother and baby. Expert suggests that family support has a positive

impact on the attitude of pregnant women; including women with an unwanted

pregnancy (Haobijam, Sharma, & David, 2010). Family support can help lower

the anxieties associated with pregnancy and provide a feeling of security for

mothers.

Today obstetricians encourage the family's participation during the entire

course of pregnancy. Ideally one or two members must accompany a pregnant

woman during every prenatal visit to her doctor. This will even help the family

members connect with baby and also lend a helping hand to the mother (Theresa,

Abrams, Mcbain, & Link, 2015). Simple gestures of family support and

attachment are of importance during and after pregnancy. The transition to

parenthood focuses explicitly on the emotional and social changes that take place

during pregnancy and the immediate postnatal period and recognizes that this is a

stressful time that involves both men and women making significant

psychological changes and adapting to new roles (Iliyasu et al., 2010). The

relationships of many couples may be severely challenged during this period, and

sometimes break down after the birth of a baby. It has been argued that the

conspiracy of silence that surrounds this period can leave parents feeling that they

are the only ones having a hard time.

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A study that focused on the key features of the transition to parenthood

found that significant numbers of low risk parents experience psychological stress

during this time, and that their concerns were much broader than the issues

addressed by traditional antenatal classes (Agarwal et al., 2010). Most couples are

able to cope with these changes: tiredness, loss of libido, and lack of focus on the

parental relationship until things improve and some level of normality returns. A

recent study conducted in both developed and under developed regions globally

showed that 90% of couples found their relationship deteriorated after their first

baby was born (Haobijam et al., 2010). It was significant that the couples who

were strongly united and romantic in their relationship before the pregnancy

found it harder to adapt to parenthood than those whose relationships were

already faltering. Unfortunately for some couples, their relationship does not

always recover. An Early Years study estimated that around 14% of couples split

up before the baby is born, or the new-born were not living with both their

biological parents (Kabakyenga et al., 2012). Increased recognition of the

significance of the changes taking place for both men and women during the

transition to parenthood, and the importance of preparing new parents for their

new roles underpins the recent development of Preparation for Parenthood

classes, many of which are replacing the more standard ‘antenatal classes’. For

example, a recently developed model focuses on preparing parents for parenthood

by addressing the emotional changes that take place during this period, and

helping parents to address the problems that occur (Iliyasu et al., 2010).

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A range of factors can influence the capacity of mothers-to-be to engage

with their developing baby, including whether the baby was planned for and/or

wanted. The level and nature of the mother’s engagement is indicated by the

mental representations (i.e. mental images) about the developing baby that take

place between the fourth and seventh months of gestation. These mental

representations are shaped not only by the biological changes taking place but

also by a range of psychic and social factors such as the mother’s memories of her

own early relationships, family traditions, hopes, fears and fantasies (Jones et al.,

2005). The bonding with the baby that is indicated by these mental

representations is an important foundation for the mother’s later relationship with

the real baby. Research found that the richness of antenatal maternal

representations was significantly linked with the security of the infant’s

attachment to the parents at one year of age (Jones et al., 2005). Women who had

experienced domestic abuse had significantly more negative representations of

their infants and themselves, and their babies were more likely to be insecurely

attached. Mothers who already had 2-3 children under 7 years and an unplanned

pregnancy had more negative representations (Urassa et al., 2012).

The process of ‘bonding’ refers to the intense emotional connection that

takes place between a mother and a baby (Tura et al., 2014). Although babies are

born ready to socially interact with their parents, a range of factors may interfere

with the capacity of the mother to bond with the baby. While many early

difficulties immediately following the birth may disappear over the first few days

and months, they may also be a sign of pending problems. Overviews of the

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evidence from humans and other mammals suggest that the close body contact of

the infant and his/her mother during the immediate post- birth period influences

the physiology and behaviour of both, and that this takes place as a result of a

range of mechanisms including behavioural programming, secretion of

neuroendocrine substrates and activation of sensory cues, in addition to changes

brought about as a result of breastfeeding (Fischer, 2002). Skin-to-skin contact

between mother and baby after birth reduces crying, improves mother-infant

interaction, keeps the baby warmer, and the extra tactile, olfactory and thermal

cues may stimulate babies to initiate breastfeeding more successfully (Jones et al.,

2005).

New-born babies tend to be more alert within the first two hours of life,

and this should be considered an important time for initiating successful mother

and child interaction. Other methods of promoting bonding and sensitive

parenting that are recommended by the Healthy Child Programme (HCP) include

encouraging mothers to use soft baby carriers, and participation in an infant

massage class. The Ghanaian way of bathing the child, carrying the child and

enclosure of the new mother with the baby until a given number of days can also

help promote mother and baby bonding as this is successful among the Dagaaba

communities (Otoo et al., 2015). The postnatal period involves further emotional

and psychological transitions for new parents. While many of these are similar

for men, a survey of new mothers and fathers showed that men’s feelings and

experiences during this time differed in a number of important ways from those of

women. Both parents, however, viewed parenthood as having a negative impact

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on their sex life due in the part to the associated changes in women’s bodies and

their identities as parents (Soubeiga et al., 2014).

The closeness that many couples experience during pregnancy is often

expected to continue after the baby is born. Following childbirth, however, there

is frequently a polarization of goals and expectations as men and women negotiate

their new roles. It has been suggested that this experience of polarization is

influenced by the ‘motherhood constellation’ which is, a temporary period in

which the mother is pre-occupied with several themes (Campbell et al., 2013).

One of these, the ‘life growth theme’, is biologically driven, making the mother’s

need to keep the baby alive her top priority. Couples are often unprepared for

these fundamental changes in sense of self, and without the recognition that these

transitional changes will affect their relationship; there may be resentment and

blame. For example, after childbirth, the mother may seem more concerned with

the man as a father than as a sexual partner. Although the baby may be the focus,

it is often the fundamental changes in the parents that cause the disunity, and

couples may need to mourn the loss of their close relationship before they can

celebrate their new roles.

In addition, there may be deep tensions between the cultural aspirations of

a contemporary woman living in the developed world and the experience of deep

biological drives associated with motherhood. These tensions may be exacerbated

by the transition from being a competent woman in control of her life to an

incompetent, inexperienced mother (Haobijam et al., 2010). As support networks

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loosen and traditional rituals decline, the challenge to health professionals lays in

ensuring the healthy birth of the social mother and father (Solnes et al., 2013).

Special efforts should be made to emphasize men's shared responsibility

and promote their active involvement in maternity care. In spite of this, pregnancy

and childbirth continue to be regarded as exclusively women’s affairs in most

African countries. Men generally do not accompany their wives for antenatal care

and are not expected to be in the labour room during delivery (August et al.,

2015). However, men are socially and economically dominant, especially in

Ghana; they exert a strong influence over their wives, determining the timing and

conditions of sexual relations, family size, and access to health care (Asp et al.,

2014). This situation makes men critical partners for the improvement of maternal

health and reduction of maternal mortality. Strategies for involving men include

raising their awareness about emergency obstetric conditions, and engaging them

in birth preparedness and complication readiness (August et al., 2015). This is

based on the premise that increased awareness of men will enable their support

for early spousal utilization of emergency obstetric services. Similarly, preparing

for birth and being ready for complications could reduce all three phases of delay

and thereby positively impact birth outcomes. Studies on the participation of men

in maternal care have been reported mostly from southern part of Nigeria.

Ekabua et al., (2011) reported a high level of awareness and participation

of men in maternity care in Osun state. Likewise, Iliyasu et al., (2010b) reported

that 86% of antenatal clients in University College Hospital, Ibadan, preferred

their husbands as companions during labour, whilst only 7% and 5% favoured

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their mothers and siblings, respectively. However, little such research has been

conducted in northern Ghana-a culturally distinct region contributing

disproportionately to the country’s high maternal mortality ratio.

Traditional Ways Family Supports Pregnant Women in Northern Ghana

Based on personal observation among the Dagaaba, when the female

relatives of a woman notice she is pregnant they greet her one morning just

outside her bedroom door and blow ash in her face. About 2 weeks before she is

to give birth, they call her mother to come and be with her daughter. At this time

the husband move out of the bedroom and the mother sleeps with her pregnant

daughter. The in-laws call for the mother because they believe that there are

things a woman can only talk to her mother about. The pregnant woman’s mother

will talk to her daughter during those two weeks to learn how the pregnancy went

and she will decide if they need a birth attendant or the women of the house can

see to the birth. If the pregnant woman had a difficult pregnancy, then the TBA

will be called.

Women often give birth just squatting down and pushing out the baby.

After birth only very near relatives and very good friends can visit for 2 weeks.

The visit must be short. They believe if a woman talks too much after birth, it is

not good for her. The new mother does not leave the room except to take care of

her bodily functions. Her mother remains in the bed with her day and night. In

the night, after the new mother feeds the baby the grandmother takes the baby and

cares for it and gets it back to sleep. Thus, the new mother gets the rest she needs.

Baby boys remain in the room for 3 months but baby girls remain in the room for

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4 months. The room is kept warm by a portable fireplace. This helps the baby get

strong enough to face the elements. Up until the time the baby can leave the room,

it is called “the stranger”. On the morning when the baby is going to leave the

room, someone gets up very early and goes to the soothsayer to give the baby its

name. In the North, names are often chosen to represent an event in the parents’

life or after a family member, but the parents must go to the village priest to be

sure the name is the right name.

There are many good reasons for these traditions. It is very good to get

some sleep right after giving birth. The new mother staying in the room for 2

weeks is also a good way for her to recover and get some needed rest. Naming

after three or four months just makes sense because of the high infant mortality

rate. Keeping the baby in for 3-4 months also shows concern about infant

mortality.

Community Support for Pregnant Women

The community support system (CmSS) is a mechanism for establishing a

community-led structure which tracks all pregnant women, and provides need-

based support for making their pregnancy safer, including timely use of life-

saving emergency obstetric care services (Ekabua et al., 2011). CmSS consists of

a process where the causes of maternal mortality and morbidity are identified

through a death and disability review in the community. Then, this information is

shared with the community through village meetings led by local volunteers. The

community then identifies their role in preventing avoidable maternal death and

promotes a zero tolerance to maternal deaths and violence against women (Jones

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et al., 2005). Lastly, the community forms a committee known as Community

Support Group (CSG) which establishes linkages with the health system and local

government.

The community becomes a ’watch dog’ in order to prevent harmful

practices. The CmSS process has also identified and addressed the issue of early

marriage and violence against women, which have made an impact on maternal

health outcomes in communities (Campbell et al., 2013). It is a two-way

coordination accountability mechanism between communities (at the village

level) and health care providers and policy makers (at the sub-district level)

established through regular meetings. The result: a greater voice for women and

other community members with regard to the governance of local health systems,

and greater accountability of service providers and local government to

community members for ensuring quality care. Experience suggests that

discussions about preparing for birth should occur not only with pregnant women

but with the communities that support them. The aim is education, motivation,

cohesion and mobilization of pregnant women, families and communities (Ekabua

et al., 2011). Community participatory approaches are most effective. A project

that used such an approach in Cambodia was evaluated and found that community

engagement was a feasible, effective and cost-effective way to introduce birth

preparedness; The project increased referrals to hospital by 281% (Skinner &

Rathavy, 2009).

Another well evaluated example of a birth preparedness intervention is the

Home Based Life Savings Skills (HBLSS) training program devised by the

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American College of Nurses and Midwives to increase access to basic life saving

measures within the home and community and by decreasing delays in reaching

referral facilities where life-threatening problems can be managed (Skinner &

Rathavy, 2009). HBLSS takes into account the social context of childbirth,

focusing on the pregnant woman, her family caregivers, and the home birth

attendant as a team. The model has been implemented in India, Ethiopia, Haiti

and Liberia. An evaluation of the model in rural India found that role-play and

demonstration enhanced retention of knowledge and skills for recognition and

intervention for maternal bleeding and new-born sepsis, but did not change care-

seeking during emergencies (Stanton, 2004). An evaluation of the program in the

Oromia region of Ethiopia found that learning was retained, and after three years,

54% of women giving birth were exposed to the training. Lack of emergency

transport prevented decrease in delays for referral (Skinner & Rathavy, 2009).

The Essence of the Study/Summary

Birth preparedness is viewed as one of several needed responses to the

three delays model, which categorizes the causes of maternal death as the

following: delays in deciding to seek medical care, delays in reaching medical

care, and delays in receiving treatment for major obstetric complications

(Thaddeus and Maine 1994). Knowledge regarding the risks associated with

pregnancy and delivery and the availability of emergency obstetric care, arranging

in advance to have a skilled attendant at delivery, saving money to cover the

expenses associated with an obstetric emergency, advance arrangements for

transportation, and identification of a blood donor in the case of an obstetric

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emergency are all components of birth preparedness, which logically could

decrease one or all of the three delays and increase the likelihood of surviving an

obstetric emergency.

Unfortunately, the literature to date regarding the effectiveness of birth

preparedness interventions to increase use of skilled professionals at delivery is

very limited. For example, Stanton, (2004) review of more than 150 studies of the

effectiveness of a broad range of behaviour change interventions to change

specific community and household-level behaviours within Safe Motherhood

programs identified only seven studies from projects that aimed to increase use of

health services among pregnant women. The interventions evaluated in the seven

studies varied, but all relied on various health education, communication,

participatory, or social support strategies. In six of the studies that emphasized

increasing knowledge of the danger signs of pregnancy, all reported increases in

the knowledge, although statistical testing was not reported in all cases. Three of

the seven studies documented increases in use of skilled delivery care. None of

the studies, however, could attribute these increases to behaviour change

interventions due to limitations in study design, sample size, and the absence of

reported data regarding exposure to the package of interventions.

The WHO (2015) reported that, 1 out of every 16 women dies of

pregnancy related causes in developing countries, compared with only 1 in 2,800

women in developed regions. The risk of maternal mortality is highest for girls

under 15, many of whom have no access to contraception. Without the necessary

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intervention, projections estimate that one in every five women will die in Africa

from pregnancy related complications (Karkee et al., 2013).

Within the Safe Motherhood community, there is growing consensus of

the need to empirically demonstrate the effectiveness of specific interventions

such as birth preparedness before their widespread promotion (Miller et al. 2003).

Despite the great potential for BP/CR to reducing maternal and new-born deaths,

its status is not well known in most of Sub-Saharan Africa, particularly Tamale, in

the Northern Region of Ghana. It is against this background that this study is

necessitated in order to determine birth preparedness among expectant mothers in

the Tamale Teaching Hospital.

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CHAPTER THREE

RESEARCH METHODS

This study assessed the level of awareness, attitude and behaviour of

women to birth preparedness and pregnancy complications readiness among

expectant mothers. The methodological approach used provided insight to: the

study design, study setting and population under study, sampling and sample size

determination. This chapter also throws light on the instrument used for the study

and how it was developed to address the following research questions. The

chapter further describes the mechanisms put in place to ensuring clients’ safety

and confidentiality. Boundaries regarding inclusion and exclusion criteria are set

and the statistical tools for analysis of data expatiated.

Study Design

This study used a descriptive, cross-sectional study design to assess birth

preparedness and pregnancy complications readiness among expectant mothers in

Tamale Central of the Northern Region of Ghana during their most recent

pregnancy and delivery. The cross-sectional design involves the collection of data

at one point in time or multiple times in a short period and was therefore suitable

for this study. The main advantage of cross-sectional designs is that they are

economical and easy to manage. There are, however, problems in inferring

changes and trends overtime using cross-sectional designs.

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Study Setting

The study was conducted at the Tamale Teaching Hospital, located in

Tamale Metropolis. The hospital serves as a referral centre for cases from

regional hospitals, districts hospitals, private hospitals, and several health centres

within and outside the Northern Region. According to the 2014/2015 progress

report, the Tamale Teaching Hospital recorded 2489 expectant mothers who

attended antenatal clinic during the year under review (TTH Annual report, 2015).

Notwithstanding the influential role the facility plays in providing timely obstetric

care to expectant mothers, the Metropolis has been bedevilled by a soaring

maternal mortality rate, as health records from the Northern Regional Health

Directorate revealed that 57 maternal deaths had been recorded for the mid-year

of 2015. This could be as a result of the low number of functional midwives (295)

in the Region; and 7 of these midwives were due for retirement in 2016. This

contributes to poor birth preparedness by expectant mothers at Tamale Teaching

Hospital and in the Metropolis at large.

The Teaching and Regional Hospitals have higher figures than the national

average because most of the very ill patients are usually referred to these tertiary

centres for management. Maternal mortality has previously not been studied at the

Tamale Teaching Hospital, but being the main referral hospital in Northern

Ghana, its institutional figures from internal audits over the past few years have

been unacceptably high. The main causes of 139 audited maternal deaths in The

Tamale Teaching Hospital from 2008 to 2010 were sepsis (19.8%), hypertensive

disorders (18.6%), haemorrhage (15.8%), unsafe abortion (11.5%), obstructed

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labour (5.7%), anaemia (8.7%), sickle cell disease (5.7%) and malaria (5.0%).

The ages of the 139 audited maternal deaths ranged from 14–48 years; with mean

age of 26.5 ± 4.6years. Nearly 50% of the maternal deaths were aged 20–29 years

and about 10% were 14–19 years. Eighteen percent (18%) of the maternal deaths

were from towns over 150km from Tamale (Gummaga et al, 2011). Therefore, the

Tamale Teaching Hospital was chosen as the setting for this study as findings will

contribute to solving maternal mortality and morbidity issues in the catchment

areas.

Figure 2: Map showing the study area

Population

The population under study were women of reproductive ages (11 – 50)

residing within the Tamale Metropolis. For the purposes of the study, all pregnant

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women and mothers who were in the period of exclusive breastfeeding (within 6

months after delivery) qualified to take part in the study. In contrast, pregnant

women who migrated into the Metropolis during data collection were excluded

from the study. Women whose babies were older than six months and

expectant/nursing mothers who were unwilling to be part of the study were also

excluded as participation into the study was voluntary.

Sampling and Sample Size Determination

The sample was obtained from expectant mothers attending antenatal

clinic at the Tamale Teaching Hospital. The population of expectant mothers who

attended antenatal clinic at the Tamale Teaching Hospital during 2013/2014-year

review was 2489 (Annual review report, 2014). Adopting a simplified formula

from Yamane (1967), the sample size for the above population was calculated as

follows: A 95% confidence level and p=.05 were assumed for the equation: 𝑛 =

𝑁
where n is the sample size, N is the population and e is the level of
1 + 𝑁(𝑒)2

2489
precision. Substituting the values in the equation 𝑛 = =345
1 + 2489(0.05)2

To select participants, a systematic random sampling method was used to

calculate the intervals from population of the previous year’s ANC attendance

which was found to be 2489. The interval was determined (2489/345) and found

to be approximately 7. Hence, every seventh mother on the queue who met the

inclusion criteria was selected and included in the study. An average of 125

women reported at the ANC per day and a period of two months was used for the

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entire data collection process by self-administering at least 40 questionnaires per

week until the required sample size of 345 was obtained.

Instrumentation

The main research instrument for the study was a structured questionnaire

personally developed and self-administered to participants who met the eligibility

criteria of the study within the period of data collection. Although the original

questionnaires were in English language, questions were translated into the local

languages during the data collection for those who could not speak English. The

questionnaire consisted of six sections. Section one contained demographic

characteristics of respondents. Sections two and three entailed questions testing

the knowledge of expectant mothers on pregnancy-related issues and factors

influencing maternal health availability and accessibility in the setting

respectively. Section four determined obstetric beliefs among expectant mothers

and sections five and six determined family and community support systems

during childbirth.

Data Collection Process

The study was a facility-based study that made use of respondents

accessing health care at Tamale Teaching Hospital in the Northern Region of

Ghana. During the data collection process, six research assistants were trained to

assist collect the data. The research assistants were given two days training on

research ethics, proper handling and distribution of questionnaires prior to the

field work. The research assistants were tasked to explain the questionnaires to

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participants in participants own native languages and /or dialects to ensure data

accuracy, quality and validity. The pre-trained research assistants with midwifery

skills who were fluent in the local languages collected the data by first providing

privacy and obtaining a verbal consent followed by a written one. However, some

participants were minor (below 18 years of age) and their parental consent and

that of the minors were obtained. The objective of the research was explained to

the participants before self-administration of the questionnaires to them. Their

ANC cards were reviewed to confirm the gestational age and obstetric history.

Information on the questionnaire sought to assess participants’ knowledge on

demographics, BP, support systems, obstetric beliefs and factors influencing BP.

The problems encountered during the data collection process included:

bureaucratic delays obtaining permission at the health facility, language barrier,

and lack of cooperation from some study participants and financial limitations.

Determination of Level of Preparedness

Those who were considered as ‘well prepared’ met at least three of the

following conditions: have made funds available for transportation, have

identified the mode of transportation to hospital when labour begins, have

arranged for a blood donor and have had birth/emergency preparedness plan.

Those who met less than three of the conditions were considered ‘less or ill-

prepared’.

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Ethical Considerations

Ethical clearance was obtained from the following institutions: University

of Cape Coast’s (UCC) Institutional Research Ethics Review Board (with

reference number UCC/IRB/3/40). Permission was also obtained from Tamale

Teaching Hospital, Northern Regional Health Directorate and Department of

Nursing, UCC to conduct the study. The participants were also made aware that

the research was for academic purposes and participation in the study was

voluntary. They could choose to partake in the research or withdraw from it at any

point in time without any punitive measures taken against them. Parental consent

together with participants below the age of 18 was sought because they were

minors. Participants’ safety was guaranteed as the data collection process

followed their normal pattern of daily activities and information obtained from

them was kept strictly confidential. The participants were informed that the

research did not guarantee any direct or short term benefit. It was expected,

however, that the information elicited would inform policies and programmes in

the region to prevent maternal mortality and improve maternal health.

Pilot Study

A pre-test was conducted at the Kings’ Medical Centre (KMC) in the

Kumbungu District of the Northern Region to validate the instrument for the

actual study. Preceding the pilot study, an introductory /clearance letter was given

to the medical superintendent at the Kings’ Medical Centre (KMC) in order to

obtain permission for the pre-test. This permission was granted and questionnaires

were self-administered to 35 volunteer clients at the antenatal clinic after

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obtaining their consent for the trial. Technical words in the questionnaires were

explained to the respondents in their mother tongue with the help of the research

assistants.

Data Processing and Analyses

Data was doubled entered into Microsoft Excel spreadsheet and validated

for data errors. Data was then coded and exported to SPSS version 20.0 for

Windows for analysis (Julie, 2007). Descriptive statistics such as frequencies and

percentages were used to describe or summarise data as well as determine the

level of awareness of respondents on birth preparedness. The Pearson’s chi-square

test was conducted to determine the level of association between birth

preparedness and respective maternal demographic variables such as age,

educational status, marital status, awareness of obstetric risk factors and income

levels. A p-value <0.05 was considered statistically significant. Where significant

relationships existed, such comparative variables were put into a logistic

regression model to ascertain the strength of association between respective

variables. Statistical inferences were drawn based on the data collected and results

presented.

Chapter Summary

This study was conducted at Tamale Teaching Hospital which serves as a

referral centre for cases from regional hospitals, districts hospitals, private

hospitals, and several health centres within and outside the Northern Region. An

institution based cross-sectional study was conducted from February 16, 2016 to

April 16, 2016. Adopting a simplified formula from Yamane (1967) the sample

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size was determined by considering the following assumptions; 95% level of

confidence; 5% marginal error (e=0.05), and non-response rate of 5%. The total

population under study was estimated to be 2489. Thus, the final sample size
𝑁
required was 𝑛 = where n is the sample size, N is the population
1 + 𝑁(𝑒)2

under study and e is the level of precision. Substituting the values in the
2489
equation 𝑛 = =345 participants. For the purposes of the study,
1 + 2489(0.05)2

all pregnant women and mothers who were in the period of exclusive

breastfeeding (within 6 months after delivery) qualified to take part in the study.

In contrast, pregnant women who migrated into the metropolis during data

collection were excluded from the study. Ethical clearance was obtained for the

study from University of Cape Coast’s Institutional Research Ethics Review

Board. Data were collected using a self-administered structured questionnaire.

Data was double entered into Excel, validated for data entry errors and exported

into SPSS version 20.0 for Windows for analysis. Variables having p value ≤ 0.05

in the multivariate analysis were taken as significant predictors for birth

preparedness.

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CHAPTER FOUR

RESULTS AND DISCUSSION

In this chapter, key findings from data collected from the 345 participants

were presented quantitatively. Results were interpreted using descriptive and

inferential statistics. The research questions that guided these interpretations are

as follows: Does knowledge of danger signs of pregnancy predict birth

preparedness? What factors influence access to maternal health services during

childbirth? What family support do pregnant women get during pregnancy and

childbirth? What obstetric beliefs exist among expectant mothers and families?

What support systems are in place in the community for pregnant women in case

of emergency child birth? Participants socio-demographic characteristics were

first examined to find out the influence these may have on the choice of place of

delivery by pregnant women.

Demographic and General Information

Table (1) presents the socio-demographic profile of pregnant women

surveyed. The characteristics analyzed included: age, marital status, educational

status, ethnicity, religion, occupational status and income level.

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Table 1- Demographic and background information of women receiving antennal

and prenatal care at the Tamale Teaching Hospital
Variable N (%)
Age
11-20 68 (19.7)
21-30 188 (54.5)
31-40 77 (22.3)
41-50 12 (3.5)
Ethnicity
Dagomba 180 (52.2)
Gonja 45 (13.0)
Ewe 16 (4.6)
Akan 19 (5.5)
Konkomba 11 (3.2)
Bimoba 10 (2.9)
Gruni 14 (4.1)
Dagaaba 22 (6.4)
Others 28 (8.1)
Religion
Muslim 235 (68.1)
Christian 100 (29.0)
Traditionalist 10 (2.9)
Marital Status
Single 73 (21.2)
Married 250 (72.5)
Widowed 8 (2.3)
Divorced 14 (4.1)
Educational Status
No formal education 110 (31.9)
JHS 75 (21.7)
SHS 56 (16.2)
Tertiary 104 (30.

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Table 1 continued

Occupation
Unemployed/housewife 62 (18.0)
Trader 86 (24.9)
Student 22 (6.4)
Skilled worker 70 (20.3)
Farmer 20 (5.8)
Public/civil service 85 (24.6)

Income level
Low Income (<₵ 400)
243 (70.4)
Middle Income (₵ 500-1500) 90 (26.1)
High Income (₵ > 1500) 12 (3.5)
Level of knowledge
62 (18.0)
Inadequate knowledge
Adequate knowledge 283 (82.0)

The findings from table 1 revealed 54.5% of the study participants were

within the category of 21-30 years, 72.5% were married, 30.1% were without

education, 68.1% belonged to Islam, 52.2% were Dagbamba and Gonjas were

13.0%. With respect to occupation, the findings showed 24% worked in the

civil/public sector, 20.3% were skilled workers, 24.9% traders and only 5.8%

were farmers. However, 18% were unemployed and over 60% of respondents

were not salaried workers and were engaged in businesses with irregular sources

of income. Hence, overwhelmingly 70.4% of the participants were low income

earners, 26.1% represented middle income earners with only 3.5% belonging to

the high income category.

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Obstetric History

This consists of information on the number of times a respondent had been

pregnant (gravidity), the number of deliveries they had undergone (parity), place

of delivery, birth attendant and gestational age as well as the number of visits

made to the antenatal clinic (see table 2 below).

Table 2- Obstetric history of participants attending antenatal clinic at the Tamale

Teaching Hospital
Variable N (%)
Place of delivery of previous child
Home 62 (25.4)
Shrine 4 (1.6)
Way to referral centre 5 (2.0)
Health post/CHPS compound 17 (7.0)
Hospital 156 (63.9)
Birth attendants at delivery of previous child
TBA 39 (16.0)
Mother-In-Laws 34 (13.9)
Passers-By 2 (0.8)
Midwife 136 (55.7)
Doctor 33 (13.5)
Table 2: Obstetric history of participants attending antenatal clinic at the
Tamale Teaching Hospital
Variable N (%)
Mode of delivery of previous child
Spontaneous Vaginal Delivery 206 (84.4)
Vacuum Extraction 1 (0.4)
Caesarean Section 37 (15.2)
Number of visit to ANC
Once 23 (9.4)
Two 24 (9.8)
Three 32 (13.1)
Four Plus 165 (67.6)
Gestational age of current pregnancy before start of ANC
0-3months 131 (38.0)
4-6months 181 (52.5)
7-9months 33 (9.6)
Source of information about birth preparedness
Doctor/Midwife 250 (72.5)
Radio/TV/News Paper 51 (14.8)
Internet 35 (10.1)
TBA 9 (2.6)

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In this study it was uncovered that 101 participants, representing 31.3%

were pregnant for the first time, 28.7% had given birth for the first time, 26.4%

had two children and 13.6% had three or more children. With regards to place of

previous delivery, 63.9% of the study populace delivered in the hospital, 25.4% at

home and 7.0% at a health centre/ CHPS compound. The results revealed also that

55.7% of expectant mothers gave birth with a midwife as birth attendant, 16.0%

were delivered by a TBA, 13.9% by mothers-in-law and 13.5% by a doctor. For

mode of delivery, findings showed that a majority (84.4%) delivered their

previous children naturally. With regard to gestational age of participants’ current

pregnancies at the first visit to ANC, the findings indicated 38.0% reported for the

first ANC visit from 0-3 months pregnant. About 62.1% came for ANC services

late, and this could result in poor preparedness with it attendant problems. In

relation to participants’ source of information on obstetric risks, 72.5% got their

information from a doctor or a midwife.

Knowledge on Pregnancy Related Issues/Obstetric Risk Factors

Expectant mothers were questioned on whether they knew any danger

signs during pregnancy. This question was asked in order to determine whether

knowledge of danger signs pregnancy predicts birth preparedness (See table 3). A

woman was considered knowledgeable on obstetric danger signs if she

spontaneously agreed to at least three obstetric danger signs before (vaginal

bleeding, swollen hand and face, blurring of vision), during (severe vaginal

bleeding, prolonged labour of >12hr, retained placenta) and after (severe vaginal

bleeding, foul smelling vaginal discharge, high fever) pregnancy; one medical

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condition in pregnancy (hypertension, anaemia, malaria) and one practice

dangerous to pregnancy (intake of concoction, over the counter drugs, fighting).

Table 3- Knowledge on obstetric risk factors of respondents attending antenatal

clinic at Tamale Teaching Hospital
Strongly disagreed Agreed Strongly
disagreed agreed

n (%) n (%) n (%) n (%)

Danger signs pregnant women may experience during pregnancy and birth
Severe vaginal 3 (0.9) 49 (14.2) 207 (60) 86 (24.9)
bleeding
Excessive 6 (1.7)) 79 (22.9) 189 (54.8) 71 (20.6)
vomiting in
pregnancy
Reduced/loss of 2 (0.6) 39 (11.3) 210 (60.9) 94 (27.2)
foetal movement
Oedema 4 (1.2) 86 (24.9) 186 (53.9) 58 (16.8)
Main medical related conditions in pregnancy
Blood pressure 4 (1.2) 40 (11.6) 215 (62.3) 86 (24.9)
(BP)
Malaria 4 (1.2) 34 (9.9) 218 (63.20 89 (25.8)
Anaemia 4 (1.2) 36 (10.4) 207 (60.0) 98 (28.4)
Dangerous practices to both foetus and mother
Intake of locally 6 (1.7) 26 (7.5) 210 (60.9) 87 (25.3)
prepared
concoctions.
Over the counter 7 (2) 14 (4.1) 206 (59.7) 102 (29.6)
drugs
Domestic 2 (0.6) 2 (0.6) 206 (59.7) 123 (35.)
violence
Infection prevention practices

Sleeping under 1 (0.3) 59 (17.1) 163 (47.2) 122 (35.4)

insecticide treated
net

Respondents were probed on danger signs pregnant women may

experience during pregnancy and birth, and 60% agreed to vaginal bleeding,

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54.8% agreed to hyperemisis gravidarium (excessive vomiting in pregnancy),

60.9% to loss of faetal movement and 53.9% agreed to oedema as being obstetric

risks. A majority (87.2%) agreed that high blood pressure was an obstetric

emergency in pregnancy. About 63.2% agreed malaria is a medical condition in

pregnancy while 60.0% agreed to anaemia. Expectant mothers’ knowledge was

also evaluated on dangerous practices to both mother and foetus; about 60%

agreed to locally prepared concoction (kalgutim), 60.9% to over the counter drugs

and 59.7% agreed to domestic violence as practices that could endanger both

mother and foetus. In ensuring infection prevention during pregnancy, 82.6%

agreed to sleep in insecticide treated bed net. Overall, the knowledge of

participants on pregnancy related issues was very good, as 82% exhibited

adequate knowledge compared to 18% with inadequate knowledge.

Access to maternal health services

Access to maternal health services is crucial to ensure safe motherhood

care before, during and after delivery. These services include but are not limited

to: laboratory services, blood bank services, HIV/AIDS/Hep B counselling

services, theatre services and ANC. This section is designed to assess availability,

geographic accessibility, affordability and acceptability of maternal health

services among expectant mothers. See table 4 below for details.

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Table 4- Maternal health services available to participants at the Tamale

Teaching Hospital
Strongly Disagreed Agreed Strongly
disagreed Agree
n(%) n (%) n (%) n (%)
Services available at health facility
Laboratory, blood 3 (0.8) 33 (9.6) 206 (60.6) 100 (29.0)
bank,
HIV/AIDS/Hep B,
counselling, theatre
services and ANC
Barriers to maternal health services
Judgmental attitude 7 (2.0) 109 (31.6) 196 (56.8) 33 (9.6)
of health workers
Lack of ambulance 14 (4.1) 82 (23.8) 184 (53.3) 65 (18.8)
service
Deplorable road 11 (3.2) 97 (28.1) 76 (51.0) 61 (17.7)
network
Reasons for home birth
Home birthing 34 (9.9) 210 (60.9) 81 (23.5) 20 (5.8)
tradition
Poor hospital 31 (9.0) 130 (37.7) 126 (36.5) 58 (16.8)
Infrastructure

Table 4 above showed that 89.6% agreed maternal health services were

available at the facility they went to access care but, over 66.4% of the

participants agreed the judgmental attitude of health staff impeded access to

maternal health services. The study also revealed lack of means of transport

especially ambulance service as a great challenge to accessing emergency health

care as 72.1% agreed they could not access lifesaving care due to this challenge.

Another barrier mentioned in this study was deplorable road network which

68.7% agreed prevented access to maternal health care. These among others were

the reasons why some pregnant women chose to deliver at home instead of at the

health facility, even though 23.5% and 36.5% of participants agreed some

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pregnant women give birth at home due to home birth tradition and poor hospital

infrastructure, respectively.

Obstetric Beliefs in Pregnancy and Child Birth

Every social group in the world has specific traditions, cultural practices,

and beliefs, and probing into religions further could provide an understanding of a

particular culture. Traditional culture plays a major role in the way a woman

perceived and prepared for her birthing experience in this study. This may

positively or negatively affect the use of health care in general and maternal

health in particular (see Table 5).

Table 5- Obstetric Beliefs in Pregnancy and Child Birth

Strongly Disagreed Agreed Strongly
disagreed agreed
n (%) n (%) n (%) n (%)
Obstetric belief
Talisman protects 40 (11.6) 91 (26.4) 107 (31.0) 107 (31.0)
against witchcraft
A man who sees a 40 (11.6) 116 (33.6) 125 (36.2) 64 (18.6)
woman naked in
labour causes
obstructed labour
Early announcement 38 (11.0) 74 (21.4) 123 (35.7) 110 (31.9)
of pregnancy causes
miscarriage
Unassisted birth is a 34 (9.9) 111 (32.2) 125 (36.2) 74 (21.4)
mark of fidelity and
bravery on the part
of the woman
Rituals for safe 14 (4.1) 39 (11.3) 127 (36.8) 165 (47.8)
delivery

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In table 5 above, 62% of the respondents believed a talisman offers

protection to the pregnant woman and her unborn child against diseases and evil

spiritual attacks; however, 38% of the respondents disagreed with this belief.

Similarly, 54.8% of the pregnant women in the study agreed that no man other

than the husband or a doctor should see a woman naked in the process of giving

birth as this could lead to obstructed labour. With respect to early announcement

of pregnancy 67.6% held the belief that the practice could cause miscarriages

whilst 32.4% disagreed. Furthermore, 57.6% of the study populace was of the

view that unassisted birth is a mark of fidelity and bravery on the part of the

woman as opposed to 42.4%. On the other hand, 84.6% of participants as opposed

to 15.4% believed that for a safe delivery, a pastor or imam or traditionalist must

be called in to perform rituals for the woman in labour based on her faith for safe

delivery.

Family Support for Pregnant Women

Pregnancy, birth and the postnatal period are time of major psychological

and social change for women as they navigate their roles as mothers. Supporting

mothers’ emotional wellbeing during the perinatal period is now recognized to be

as important as the traditional focus on the physical health of the mother and

child. Table 6 reports on family support for pregnant women during pregnancy,

labour and the immediate child care.

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Table 6- Family support to pregnant women attending antenatal clinic at the

Tamale Teaching Hospital
Strongly Disagreed Agreed Strongly
disagreed agree
n (%) n (%) n (%) n (%)
Support persons during pregnancy
Mother, mother-in- 12 (3.5) 68 (19.7) 217 (62.9) 47 (13.9)
law and father-in-
law
Husband 164 (47.5) 92 (26.7) 62 (18.0) 27 (7.8)
accompanies wife
to ANC

Respondents identified their mothers, husbands and sisters as people to

depend on to listen to them, give them good advice when they notice a danger

sign and help them feel loved and wanted. In this study, 76.8% of respondents had

support from husbands, mothers, mothers-in-law and fathers-in-law, as against

23.2% who lacked such support. However, 74.2% of respondents disagreed their

husbands accompanied them to antenatal clinic as against 25.8% who were

privileged to have their husbands accompanying them to ANC (see table 6 above

for detail).

Benefits of family support to the pregnant woman

Family support can help lower the anxieties associated with pregnancy and

provide a feeling of security for mothers. Today obstetricians encourage the

family's participation during the entire course of pregnancy. This forms the bases

of table 7 below:

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Table 7- Benefits of family support to the pregnant woman

Strongly Disagreed Agreed Strongly
disagreed agree
n (%) n (%) n (%) n (%)
Adequate support for pregnant women promotes:
Bonding with mother 7 (2.0) 10 (2.9) 259 (75.1) 69 (20.0)
and baby
Good mental state of 5 (1.4) 4 (1.4) 249 (72.2) 87 (25.2)
mother after birth
Early recognition of 4 (1.2) 13 (3.8) 255 (73.9) 72 (20.9)
birth problems

In this study, 95.1% of participants agreed that family support for the

pregnant woman enhances bonding between mother and baby. In respect of stable

mental state after birth, 97.4% of participants agreed that given enabling family

environment to pregnant women during pregnancy could promote a healthy mind

after birth and at the long run minimize post-partum blues. Moreover, whereas

94.8% of participants agreed that adequate family support to the pregnant woman

can result in early recognition of obstetric danger signs thereby ensuring timely

health seeking behaviour, 5.2% disagreed. From these statistics, it is undoubtedly

clear that supporting pregnant women is one of the sure ways of ensuring safe

motherhood care.

Community Support System for Emergency Delivery

The community support system (CmSS) is a mechanism for establishing a

community-led structure which tracks all pregnant women, and provides need-

based support for making their pregnancy safer, including timely use of life-

saving emergency obstetric care services. This information is shared with the

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community through village meetings led by local volunteers. Table 8 examines

the availability of these support systems for expectant mothers.

Table 8- Community support system during emergency delivery for women

receiving antenatal care at the Tamale Teaching Hospital
Strongly Disagreed Agreed Strongly
disagreed Agreed
n (%) n (%) n (%) n (%)
Community leaders who actively support expectant mothers in times of need
The chief, Queen 210 (60.9) 95 (27.5) 32 (9.3) 8 (2.3)
mother and the
assembly-man
Available support in community for pregnant women:
Community support 219 (63.5) 95 (27.5) 26 (7.5) 5 (1.4)
fund for obstetric
emergency
Organized 217 (62.9) 94 (27.2) 29 (8.1) 5 (1.4)
community
transportation
system
Annual durbars to 217 (62.9) 89 (25.8) 28 (8.1) 11 (3.2)
educate community
members on
obstetric risk factor

The study identified a big gap between support persons in the community

and pregnant women as 88.4% of the respondents affirmed that they received

virtually no support from the Chief, Queen-mother and the Assembly persons, as

opposed to 11.6% of participants who were privileged to have support from their

community leaders. With respect to community support fund for obstetric

emergency, 91% of participants indicated that no such funds existed in their

communities for them to rely on in times of need; only 8.9% of the study

populace indicated the availability of support fund in their localities. With regard

to annual durbars to educate community members on obstetric risk factors, 88.7%

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of the participants noted the unavailability of this medium of education in their

communities whereas 11.3% said such durbars existed in their settings (see table

8 above for detailed explanation).

Determinants of Facility Delivery (Binary Analysis)

The level of education is very crucial in a woman’s life in behaviour

change modification. In this study with 345 participants, 101 of them were

primids, whilst 244 had at least one child in the past. With the 244 respondents

with at least one child, it was found that 82 of them were without formal

education and 39 of them representing 47.6% were likely to have given birth at

home, whilst 43 of them representing 52.4%, patronized the health facility for

delivery. Those with low education were 54 in number. Whereas 18 (33.3%) of

them delivered at home, 36 (66.7%) utilized the health facility for delivery. With

regard to the 108 literate participants, 14(23.0%) were likely to give birth at home

whilst 94 (87.0%) in the health facility. Hence, it is apparent that the higher the

educational level of these expectant mothers the higher their patronage of health

facilities for birth and the lower the chances of home delivery (chi-square 27.646,

p< 0.0001). Unlike educational status, marital status showed little influence on

respondents in deciding place of delivery (p-value 0.215). On the other hand, the

influence of knowledge on obstetric risk factors is enormous. The total number of

respondents with inadequate knowledge was 37, out of which 19 (51.4%) of them

delivered at home and 18 (48.6%) gave birth at the health facility. Those with

adequate knowledge were 207 in number, and 52 (25.1%) of them delivered at

home whilst 155 (74.9%) gave birth at the health facility. This implies that

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respondents with adequate knowledge on danger signs of pregnancy related

complications would patronize the facility more (74.9%) compared with those

with inadequate knowledge (25.1%, chi-square 10.46, p<0.005). The number of

times expectant mothers went to the antenatal clinic was also found to have a

great impact on the choice of place of delivery. For instance, 79 mothers went to

the antenatal clinic below the WHO recommendation (at least 4 ANC visits for all

expectant mothers) and 45 (57.0%) participants delivered at home whilst 34

(43.0%) gave birth at a health facility. Out of the 165 respondents who visited

ANC at least 4 times 26 (15.8%) delivered at home whereas 139 (84.2%) gave

birth at the health facility. This means the more clients visited antenatal clinics the

better their chance of delivery at the health facility and vice versa (chi-square

43.963, p< 0.001). With regard to age of the 28 respondents who were within 11-

20 years of age, 17 (60.7%) delivered at home and 11 (39.3%) in the health

facility.

Those within the age group of 21-30 years were 135, out of which 28

(20.7%) gave birth at home whilst 107 (79.3%) delivered at the health facility.

Thos within the category of 31-40 years of age were 70 in number and 21 (30.0%)

of them delivered at home whilst 49 (70.0%) delivered at the health facility.

Lastly, 11 respondents fell within 41-50-year group, out of which 5 (45.5%) gave

birth in the house as opposed to 6 (54.5%) at the health facility (chi-square 19.59,

P<0.0001). The results showed that most of the respondents within 11-20 years

delivered at home whereas those in the category of 21-30 and 31-40 years utilized

the health facility for birth and were also the least to deliver at home. Hence, the

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reason why 60.7% of them in this study gave birth at home compared to their

counterpart above 20 years who mostly utilized facility delivery system.

With regards to religion, 168 of the participants were Muslims and 49

(29.2%) of them delivered at home and 119 (70.9%) gave birth at the health

facility. Christians were 69, with 17 (24.6%) of them giving birth at home and 52

(75.4%) delivering at the health facility. Traditionalists had the least participants

(7), yet with the highest home delivery of 5 (71.4%) and 2 (28.6%) patronizing

health facility delivery. In terms of religion, more Christian women deliver in

health facility than traditional and Islamic women. Furthermore, 157 out of the

244 participants were engaged in low-income generation activities and 60

(38.2%) of them gave birth to their previous children at home whilst 97 (61.8%)

did so at health facilities. Those whose businesses kept them at the middle-income

level were 78; whereas 10 (12.8%) of them delivered their babies at home 68

(87.7%) chose to deliver at the health facility. Only 9 of the respondents earned

high income, out of whom 1 (11.1%) delivered at home as opposed to 8 (88.9%)

opting for health facility delivery. Higher in-come level was therefore a predictor

of facility delivery (chi-square 17.756 p<0.0001).

In respect of means of transport, 127 participants considered transportation

as a challenge; 27 (24.2%) of them gave birth at home whilst 100 (78.7%)

delivered at the health facility. Those who disagreed that means of transport is a

determinant of place of delivery were 117, and 44 (37.6%) of them delivered at

home whilst 73 (62.4%) gave birth at the health facility (chi-square 7.888,

p=0.005), meaning transport was a determinant of choice of place of delivery in

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this study. Another determinant for place of delivery by expectant mothers was

funds for expenses. Majority of participants who disagreed to availability of

community support fund for obstetric emergency delivered more in the house

(46.3%), compared to those who agreed to its availability (24.2%, chi-square

9.942, p=0.002). In the same vein, mothers who agreed to advanced arrangement

of items for delivery in a delivery bag as a predictor of facility delivery patronized

the health facility more (76.8%) compared to those who disagreed (63.2%). With

regard to home birthing tradition as a determinant of place of birth, 167

respondents felt home birth tradition was outdated to determine place of delivery,

and 131 (78.4%) of them therefore gave birth at the health facility while 36

(21.6%) gave birth at home. On the other hand, 77 participants agreed that home

birthing tradition still influence many a pregnant woman regarding choice of

place of delivery, hence, 35 (45.5%) delivered at home and 42 (54.5%) at the

health facility.

Majority of the respondents who agreed that home birthing tradition was a

determinant of place of delivery gave birth at home (45.5%) compared to those

who disagreed (21.6%) (Chi-square 14.588, P < 0.0001). In relation to poor

hospital infrastructure and quality of services, a total of 137 respondents 49 (35.8)

patronized home birth whilst 88 (64.2%) of them did deliver at a health facility.

Those who disagreed to this were 107, out of whom 22 (20.6%) gave birth home

and 85 (79.4%) gave birth at the health facility. Similar to home birth tradition,

participants who thought poor infrastructure influenced the choice of place of

delivery were the most to deliver at home, (35.8) compared with those who

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disagreed to it, (20.6%). Table 9 gives more expatiation to birth determinants of

choice of place of birth.

Table 9- Determinants of facility delivery among women accessing ANC at the

Tamale Teaching Hospital
Variable N Place of delivery Chi- p-value

Home Facility square

n (%) (n) (χ2)

Educational Status
No Education 82 39 (47.6) 43 (52.4)
Low Education 54 18 (33.3) 36 (66.7) 27.646 0.0001
High Education 108 14 (13.0) 94 (87.0)
Marital Status
Single 30 11 (36.7) 19 (63.3)
Married 195 53 (27.2) 142 (72.8) 4.466 0.2150
Widowed 7 1 (14.3) 6 (85.7)
Divorced 12 6 (50.0) 6 (50.0)
Knowledge on obstetric risk factors grouping
Inadequate
knowledge 37 19 (51.4) 18 (48.6) 10.468 0.0001
Adequate
52 (25.1) 155 (74.9)
knowledge 207
Number of ANC visits
<4 visits 79 45 (57.0) 34 (43.0)
4+ visits 165 26 (15.8) 139 (84.2) 43.963 0.0001

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Table 9 Continued

Age of respondent
11-20 28 17 (60.7) 11 (39.3)
21-30 135 28 (20.7) 107 (79.3) 0.0001
31-40 70 21 (30.0) 49 (70.0) 19.590
41-50 11 5 (45.5) 6 (54.5)
Religion
Muslim 168 49 (29.2) 119 (70.8)
Christian 69 17 (24.6) 52 (75.4) 6.745 0.0340
Traditionalist 7 5 (71.4) 2 (28.6)
Income
low income 157 60 (38.2) 97 (61.8)
(₵ <400) 17.756 0.0001
middle income 78 10 (12.8) 68 (87.2)
(₵ 500-1500)
high income 9 1 (11.1) 8 (88.9)
(>₵ 1600)
Means of transport
Agreed 127 27 (21.3) 100 (78.7) 7.888 0.0005
Disagreed 117 44 (37.6) 73 (62.4)
Funds for medical expenses
Agreed 190 46 (24.2) 144 (75.8)
Disagreed 54 25 (46.3) 29 (53.7) 9.942 0.0002

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Table 9 Continued

Birth/emergency preparedness plan

Agreed 108 26 (24.1) 82 (75.9)

Disagreed 136 45 (33.1) 91 (66.9) 2.371 0.1240

Items for delivery

Agreed 138 32 (23.2) 106 (76.8)

Disagreed 106 39 (36.8) 67 (63.2) 5.378 0.0200

Home birthing tradition

Agreed 77 35 (45.5) 42 (54.5)

Disagreed 167 36 (21.6) 131 (78.4) 14.588 0.0001

Poor hospital infrastructure and quality of service

Agreed 137 49 (35.8) 88 (64.2)

Disagreed 107 22 (20.6) 85 (79.4) 6.733 0.0009

Determinants of facility delivery (Binary Analysis)

In binary logistic regression analysis, educational status of women,

number of ANC visits, and home birth tradition were identified as the main

determinants of facility of delivery. Those with formal education were more likely

to deliver in health facilities compared to those without formal education, and as

the level of educational attainment increased, the likelihood of facility delivery

increased (See table 10 below).

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Table 10- Determinants of facility delivery among women accessing ANC at the
Tamale Teaching Hospital
Variable S.E. df Sig. AOR 95% C.I.for AOR
Lower Upper
Age 0.232 1 0.811 1.057 0.671 1.666
Education2 0.247 1 0.011 1.877 1.157 3.044
Religion 2 0.735
Religion(1) 0.943 1 0.673 1.489 0.234 9.461
Religion(2) 0.985 1 0.926 1.096 0.159 7.561
Knowledge2 0.466 1 0.278 1.658 0.666 4.13
ANC2 0.38 1 0.00 5.359 2.544 11.289
Income 2 0.551
Income(1) 1.264 1 0.733 0.649 0.054 7.74
Income(2) 1.265 1 0.938 1.104 0.093 13.17
Means of
transportation 1 0.561 1 0.382 0.612 0.204 1.84
Items Delivery 0.495 1 0.695 0.824 0.312 2.174
Tradition 0.36 1 0.015 2.393 1.181 4.849
Marriage2 0.29 1 0.915 1.032 0.584 1.822
Birth Plan 0.714 1 0.544 1.542 0.38 6.252
Birth Preparedness 0.896 1 0.769 1.301 0.225 7.536
Attitude of health
staff 0.411 1 0.343 0.677 0.302 1.516
Deplorable Road
network 0.477 1 0.986 1.008 0.396 2.57
Cost of services 0.496 1 0.931 0.958 0.362 2.533
Constant 2.499 1 0.043 0.006

Compared to those without any formal education, and lower level of

education, those with higher education were about 1.9 times more likely to deliver

in a health facility (AOR=1.9, 95% C.I. 1.16-3.04, p=0.01). Compared to those

with the number of ANC visits less than four (4), those with four or more (4+)

visits were about 5.4 times more likely to deliver in a health facility (AOR=5.4,

95% C.I. 2.54-11.29, p<0.01). More so, compared to those who agree with the

“home birthing tradition”, those who disagree with it were about 2.4 times more

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likely to deliver in a health facility (AOR=2.4, 95% C.I. 1.18-4.85, p=0.02) ( See

table 10).

Measurement of birth preparedness

For a mother to be considered ‘well prepared for birth’, she must meet at

least three of the following (Markos & Bogale, 2014): knowledge regarding the

risks associated with pregnancy and delivery and the availability of emergency

obstetric care; arranged in advance items for birth in the delivery bag; saved

enough money to cover the expenses associated with an obstetric emergency;

advanced arrangements for transportation; arranged for birth attendant and had a

companion to place of delivery (Refer to table 11).

Table 11- Birth Preparedness among women accessing ANC at the Tamale
Teaching Hospital
Agreed Strongly Disagreed Strongly
Agreed Disagree
n (%) n (%) n (%) n (%)
Measures for emergency prepared for child birth
Means of 11 (3.2) 157 (45.5) 121 (35.6) 56 (16.2)
transportation
Funds for medical 9 (2.6) 66 (19.1) 116 (33.6) 154 (44.6)
expenses
Birth plan 59 (17.1) 142 (41.2) 98 (28.4) 46 (13.3)
Items for birth in 52 (15.1) 107 (31.0) 100 (29.0) 86 (24.9)
delivery bag

Birth Preparedness

Prepared 150 (43.7)

Unprepared 195 (56.3)

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In this study, 48.2%of respondents had made advanced arrangements for

means of transportation as an emergency measure for birth, whilst 51.8% had not.

With regard to funds for expenses associated with an obstetric emergency, 21.8%

of participants were prepared whereas 78.2% were ill-prepared. It was also

uncovered in the study that 41.7% respondents had had a birth plan as opposed to

58.3%. In respect of items in a delivery bag as a measure for emergency

preparedness 46.1% of participants were adequately prepared whilst 53.9% were

not. For overall preparedness for birth 150 respondents were well prepared

representing 43.7% whilst 195 respondents were ill-prepared representing 56.3%.

In other words, 43.7% of the participants met at least three of the requirements

needed for birth preparedness whereas 56.3 fell below adequate preparedness for

birth.

Determinants of Birth Preparedness (Binary Analysis)

The study revealed that respondents who were poorly prepared for birth

were those with minimal to no formal education, and the well prepared ones were

respondents with high education. Education was found in the study to be integral

and directly proportional to birth preparedness, so the higher the education the

higher the preparedness for birth. Similarly, participants who were equipped with

adequate knowledge on obstetric risk factors were much more prepared compared

to their counterpart with inadequate knowledge.

Moreover, antenatal attendance also had a positive influence on birth

preparedness as participants who attended ANC at least four times were well

prepared for birth compared to their colleagues who visited ANC below the

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required four times or not at all. For instance, among participants who visited

ANC at least four times 55.2% were prepared for birth whereas among

participants who made less than four ANC visits, only 29.1% were prepared for

birth. Hence, the more visits respondents made to antenatal clinics, the more they

acquired knowledge regarding preparedness for birth (chi-square 14.550,

p<0.0001). In reference to age of respondents, the findings in this study showed

ill-birth preparedness among clients below 20 years and those above 40 years,

with only 25.0% level of preparedness for the both age categories. On the

contrary, participants in their middle ages were more ready for birth, unlike their

counterparts at the two extremes. Religion also played a key role in this study

concerning birth preparedness. Among Christians, 52.0% were prepared for birth

compared with 41.7% of Muslim participants. Respondents who were neither

Christians nor Muslims and were categorized as traditionalists were 100%

unprepared for birth as indicated in the findings.

This could be due to some practices peculiar to this group of people that is

not friendly to modern birth preparedness practices. In relation to income level

among respondents with low income, 32.1% were prepared for birth, 68.9% of

middle income earners and 83.3% of high income earners were prepared for birth.

Apparently, as income level increased, there was a corresponding increment in the

level of birth preparedness. Therefore, participants in the high income group were

much more prepared for birth than those in the low and middle income levels

(chi-square 44, p< 0.0001). Another factor that was in congruence with level of

income was high cost of services. Out of the 345 expectant mothers who partook

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in this study, 255 agreed that the cost of accessing health (demand side) and

services fee at the facility (supply side) was a challenge to them in their effort to

preparing themselves toward birth. This was obvious, as 64.3% of them in the

study were not prepared for birth at the time of data collection, due to high cost of

services. In a nutshell, the determinants for birth preparedness include:

educational status (chi-square 28.471, p < 0.0001), level of knowledge (chi-square

17.898, p < 0.0001), numbers of ANC visits (chi-square 14.550, p < 0.0001), age

(chi-square 14.475, p= 0.0002), religion (chi-square 10.949, p= 0.004) and

income level (chi-square 44.208, p < 0.0001), and high cost of services (chi-

square 23.356, p < 0.0001). On the other hand, marital status, attitude of health

staff and home birthing tradition did not determine preparedness in this study

nevertheless cannot be ignored as they were relevant in other studies. Table 12

below gives further detail and statistical representation of determinants of birth

preparedness.

Table 12- Determinants of birth preparedness among expectant mothers attending

ANC at the Tamale Teaching Hospital
Variable N Birth Preparedness Chi- p-value
square
Prepared Unprepared
(χ2)
n (%) n (%)
Educational status
No Education 110 32 (29.1) 78 (70.9)
Low Education 75 24 (32.0) 51 (68.0) 28.471 .0001
High Education 160 94 (58.8) 66 (41.2)
Marital status
Single 73 21 (28.8) 52 (71.2)
Married 250 120 (48.0) 130 (52.0) 8.627 .0350
Widowed 8 3 (37.5) 5 (62.5)
Divorced 14 6 (42.9) 8 (57.1)

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Table 12 continued
Knowledge on obstetric risk factors grouping
Inadequate 62 12 (19.4) 50 (80.6)
knowledge 17.898 .0001
Adequate 283 138 (48.8) 145 (51.2)
knowledge
Number of ANC visits
<4 visits 79 23 (29.1) 56 (70.9)
4+ visits 165 91 (55.2) 74 (44.8) 14.550 .0001
Age of respondent
11-20 68 17 (25.0) 51 (75.0)
21-30 188 92 (48.9) 96 (51.1)
14.475 .0002
31-40 77 38 (49.4) 39 (50.6)
41-50 12 3 (25.0) 9 (75.0)
Religion
Muslim 235 98 (41.7) 137 (58.3)
Christian 100 52 ((52.0) 48 (48.0)
10.949 .0004
Traditionalist 10 0 (0.0) 10 (100)
Income
Low Income 243 78 (32.1) 165 (67.9)
Middle Income 90 62 (68.9) 28 (31.1)
44.208 .0001
High Income 12 10 (83.3) 2 (16.7)
Attitude of health staff

Agreed 229 92 (40.2) 137 (59.8)

Disagreed 116 58 (50.0) 58 (50.0) 3.025 .0820
High cost of services
Agreed 255 91 (35.7) 164 (64.3)
Disagreed 89 58 (65.2) 31 (34.8) 23.356 .0001
Home birthing tradition
Agreed 101 40 (39.6) 61 (60.4)
Disagreed 244 101 (45.1) 134 (54.9) .872 .3500

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Determinants of Birth Preparedness (Binary Logistic Regression Analysis)

In binary logistic regression analysis, formal educational status of women,

knowledge about obstetric risk factors, income level, and cost of medical services

were found to be the main determinants of birth preparedness. Formal education,

knowledge about obstetric risk factors, and cost of medical services were found to

have protection against unpreparedness before delivery (Refer to table 13 below).

Table 13- Determinants of birth preparedness among expectant mothers attending

ANC at the Tamale Teaching Hospital
S.E. Df Sig. AOR 95% C.I.for AOR
Lower Upper
age 0.228 1 0.363 1.23 0.787 1.923
Education2 0.211 1 0.03 0.633 0.419 0.957
religion 2 0.997
religion(1) 13252.01 1 0.999 0.00 0.00 .
religion(2) 13252.01 1 0.999 0.00 0.00 .
Knowledge2 0.512 1 0.018 0.298 0.109 0.812
ANC2 0.358 1 0.469 0.772 0.383 1.557
income 2 0.018
income(1) 1.154 1 0.103 6.547 0.682 62.806
income(2) 1.152 1 0.425 2.507 0.262 23.971
Tradition 0.339 1 0.22 1.516 0.78 2.946
Marriage2 0.284 1 0.101 0.628 0.36 1.095
Attitude 0.34 1 0.554 1.223 0.628 2.382
Cost 0.427 1 0.00 0.157 0.068 0.363
Constant 13252.01 1 0.998 1.05E+11

Compared to women without any formal education and low educational

level, those with high educational level had about 40% protection against

unpreparedness before delivery (AOR=0.6, 95% C.I. 0.42-0.96, p=0.03). Mothers

with adequate knowledge had about 70% protection against unpreparedness

before labour (AOR=0.29, 95% C.I. 0.11-0.81, p<0.02) while mothers who

disagreed with high cost of medical services at health facilities had about 84%

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protection against unpreparedness before labour (AOR=0.16, 95% C.I.0.07-0.36,

p<0.01).

Discussion

This study identified that most of the respondents were over 20 years of

age. This was predictable because most women marry at this age and would like

to have babies during this period in life to continue their generation. This

notwithstanding, a significant number of the participants was below the age of 20.

Despite the fact that risk of maternal death for mothers within this category in

low-and middle-income countries doubles that of older females 21-40, this group

of very young adolescents is often beyond the reach of national health, education

and maternal health services (Markos & Bogale, 2014; Cooke & Tahir, 2013).

Markos and Bogale (2014) stated that older women were more likely to seek

maternal healthcare than younger women. Similarly, in Nigeria, women in the

middle child-bearing ages were more likely to use maternal health services than

women in early and late child-bearing ages. And so, being of older age at

marriage is positively associated with the use of healthcare services (Cooke &

Tahir, 2013).

A study in rural India also reported that utilization of antenatal care was

higher among women married at 19 or older compared to those married at less

than 19 years of age (Nawal & Goli, 2013). Early marriage or child marriage is

practiced more often in Africa and Southern Asia. The western world is no

exception, where teenagers marry and/or just live together against their parents’

wishes. Under such circumstances, these girls may be restricted from seeking

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healthcare services because of fear or need for permission from a spouse or in-

laws (Campbell et al., 2013).

Women who had at least primary education were more likely to be

prepared for birth and its complications compared to those who did not. These

findings have also been observed in the study conducted in Mpwapwa district

Tanzania, rural Uganda, North Ethiopia and Indore City India (Agarwal et al.,

2010). This observation might be due to the fact that educated women knew the

importance of planning for birth, adhere to counselling provided at ANC, and also

have the capability of making decisions on issues related to their health. Hence, as

educational level of these expectant mothers increased, there was a corresponding

increase in the likelihood of facility delivery.

This study further revealed that respondents who were poorly prepared for

birth were those with no formal education, and the well-prepared ones were

respondents with higher education. Education was found in this study to be

integral and directly proportional to birth preparedness. Another study by Urassa

et al., (2012) showed that women with formal primary education and above were

two times more likely to be prepared for birth and complications, compared to

those who lacked formal education. The high level of birth preparedness of the

educated women might be related to the fact that women who are educated are

more likely to be financially sound and also have better negotiating power and are

able to make their own decisions in matters concerning their health than women

who are uneducated.

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Another reason why better educated women were more prepared for birth

is their ability to better understand health messages and search for more

information regarding health issues. According to Kabakyenga et al., (2011),

similar studies conducted in Tanzania and in Ethiopia have shown clear

relationships between high education and awareness of danger signs of

pregnancy. Hence, better educated women are more aware of health problems,

know more about the availability of health care services and use this information

more effectively to maintain or achieve good health status. Mbalinda et al., (2014)

also reported that women’s education is a key determinant of maternal healthcare

utilization. Similarly, Indian women with high school education and above were

found to be 11 times more likely to use antenatal care compared to illiterate

women (Agarwal et al., 2010). Education of women is therefore likely to enhance

autonomy so that women could develop confidence and capabilities to make

decisions regarding their own health.

In terms of religion, the study revealed that more Christian women were

likely to deliver in a health facility than traditional and Islamic women. This could

be as a result of certain beliefs and practices by Muslims and traditionalists that

encourage home delivery. In many communities in northern Ghana, it is

personally observed that, a woman with her first pregnancy, it is customary to

deliver at home and undergo some rituals deemed necessary for survival of both

mother and her new born. In a study conducted in Nigeria, the level of

preparedness for birth was significantly higher among the Igbos (in the south) and

the minority tribe compared to the Hausas (in the north) (Iliyasu et al., 2010). The

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Islamic religion may have had a strong influence on the cultural beliefs and

traditions on child birth in the north. Also, some women in this study chose to

turn to their deities when it comes to having babies, similar to Ancient Egyptian

women who incorporated rituals and ceremonies as an integral part of the

pregnancy and birth experience by tuning to Meskhenet, a goddess associated

with the place of birth, and respect for her was essential for a normal birth

(Crowther & Hall, 2015). It is also personally observed in the study catchment

area, the new brand of Pentecostalism interferes with timely health care utilisation

as women see pastors, prophets and general overseers for special anointing when

it comes to pregnancy and birth. For Catholics, belief in the Virgin Mary cannot

be overemphasized.

Women who had a salaried job were more likely to be prepared for birth

and its complications compared to women who were not employed at the time of

the survey. This finding was comparable with the studies conducted in Southern

Ethiopia and Uganda (Asp et al., 2014). This might be due to the fact that paid

employment meant a greater likelihood of having cash that can be used to prepare

for birth and its complications.

The study uncovered that a significant number of the participants were

pregnant for the first time. Being pregnant for the first time could pose significant

risk on the novices preparing for birth and birth experiences, but literature

indicated that because of perceived risk associated with first pregnancy, a woman

is more likely to seek maternal health care services for first order than high-order

births (Kabakyenga et al., 2012). Having more children may also cause resource

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constraints, which could have a negative effect on health care utilization. This

explained why participant with larger family size in this study under-utilize

maternal health services. Women from large families underutilize various health

care services because of too many demands not only on their time but also on

their resources if any. Findings from this study showed that very few women

booked for ANC visits during the first trimester and those who did so were more

likely to be prepared for birth and its complications compared to those who

booked after first trimester. In contrast, a study in Nigeria found that those who

booked late were more likely to be prepared for birth and its complications

(Ekabua et al., 2011). The difference in these findings may be due to the fact that

at the Tamale Teaching Hospital, counselling on birth preparedness is done at

each ANC visit and repeated counselling among those who book early for ANC

may lead to adherence to counselling.

Also, the study in Nigeria was done at health centres where preparedness

may not be effective compared to that of a teaching hospital. This study found

that women who attended ANC at least four times were more likely to be

prepared for birth and its complications compared to those who attended less

often. This suggests that attending many antenatal care services visits was an

opportunity to inform pregnant women and help to plan for the important

components of birth preparedness. At the Tamale Teaching Hospital, antenatal

care guidelines and counselling on birth preparedness are required in all visits and

so it is expected that women who attended four or more ANC visits received

repeated counselling on how to prepare for birth.

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On account of mode of delivery, it was evident in this study that majority

of the respondents delivered their previous children spontaneously; however,

some pregnant participants delivered through unnatural some methods. Even

though most of those deliveries were conducted by skilled birth attendants (SBA),

a significant number of pregnant women still patronized the services of unskilled

birth attendants including mother-in-laws, TBAs, and herbalists. These findings

were consistent with that of Adu-Gyamfi, (2012) who reported that 52% of

childbirths were assisted by skilled personnel in a Ghanaian study.

In some overseas health systems, a previous caesarean section (C/S) could

be considered as an indication for a repeat caesarean section, but successful

vaginal birth can be achieved safely for both mother and infant (Crowther & Hall,

2015). This depends on the gynaecological structures of the woman whether it is

too narrow or normal, and why the initial caesarean section was done. All things

being equal, vaginal birth should therefore be considered as an option for all

women with a history of previous caesarean birth, who present for antenatal care.

When a caesarean section needs to be considered, the associated risks and benefits

should be clearly explained to the woman. Health professionals should understand

that some women may not want to consider a caesarean section despite

explanation of the likely outcomes. This may be because of their cultural or

religious beliefs. Some women considering caesarean section may also be afraid

that they will lose a soul or be afraid of this intervention for other reasons.

Japanese women tend to view a caesarean section as posing a great burden to a

postpartum woman and may prefer to avoid this intervention (Crowther & Hall,

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2015). The fear of blood loss and possible transfusion may serve as deterrent to

certain religious groups especially, Jehovah witness. Others may object C/S due

to the risks of infections especially in HIV endemic areas (Crowther & Hall,

2015).

Ghana, being one of the countries with highest maternal mortality in the

world and striving hard in reducing maternal mortality, had resolved through the

3rd Sustainable Development Goal (SDG) to reduce the high maternal mortality

ratio by three quarters by 2015. However, this goal is largely unachieved due to

inadequate preparedness for birth and lack of skilled care providers (WHO,

2015a). This is considered as one of the major factors accountable for the current

trends of maternal and child mortality in the Tamale Metropolis, where health

records from the Northern Regional Health Directorate revealed that 57 maternal

deaths had been recorded for the mid-year of 2015. According to the Northern

Regional Health Directorate’s Quarterly reports (2016), the whole Northern

Region had only 295 functional midwives. Even though this number is woefully

inadequate 7 of these midwives are due for retirement in 2016. This contributes to

poor birth preparedness at ANCs in the Tamale Metropolis.

As the occurrences of complications during the process of child birth are

unpredictable, every woman needs to be aware of the key danger signs of

obstetric complications during pregnancy, delivery and the postpartum period.

This knowledge will ultimately empower them and their families to make prompt

decisions to seek care from skilled birth attendants. In this study, women who had

knowledge on obstetrics danger signs were more likely to be prepared for birth

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and its complications compared to those who did not have such knowledge. This

can be explained by the fact that knowing obstetrics danger signs may encourage

women to be prepared for birth because they know that when any danger sign

occurs, they are likely to be attended to if they are in a hospital. It was also

observed that women who prepared for birth and its complications were more

likely to deliver at a health facility compared to those who did not prepared. The

findings were in agreement with that of Moran et al., (2006) who stated that

women who prepared for birth are more likely to know where to go for childbirth

and tend to know the importance of having safe delivery which is usually

available at health facility. Empowering pregnant women with knowledge

therefore, will go a long way to improve on facility delivery. Studies in southern

Tanzania also showed that the more women have knowledge of at least four or

more danger signs the more they utilize a health facility compared to those who

have no knowledge of any danger signs (Bintabara et al., 2015).

Maternal morbidity and mortality could be prevented significantly if

women and their families recognize obstetric danger signs and promptly seek

health care services during labour, delivery and early postpartum period under the

supervision of a SBA. Evidence suggested that raising awareness in women about

obstetric danger signs would improve early detection of problems and reduce the

delay in deciding to seek obstetric care (Hailu et al., 2011). Similarly, because

most babies are born at home or are discharged from the hospital in the first 24

hours, increasing community awareness of the danger signs of new-born

complications is of critical importance for improving new-born survival. Thus,

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this had been identified as one of the key strategies for improving maternal and

child health (Tura et al., 2014).

Access to maternal health services is crucial to ensuring safe motherhood

care before, during and after delivery. Access has four dimensions: availability,

geographic accessibility, affordability and acceptability (Tura et al., 2014)).

Barriers to accessing health services can stem from the demand side and/or the

supply side. Demand-side determinants are factors influencing the ability to use

health services at the individual, household or community level, while supply-side

determinants are aspects inherent to the health system that hinder service uptake

by individuals, households or the community (Ensor & Cooper, 2004).

The findings from this present study showed that the majority of the study

women were aware of the existence of maternal health services such as laboratory

services, blood bank services, HIV/AIDS/Hep B counselling services, theatre

services and ANC. On the other hand, respondents said there were concurrent

challenges accessing these services due to some intractable barriers. The majority

felt the judgmental attitude of health staff impeded access to maternal health

services. This agrees with the findings of Asp et al., (2014) who reported that

unwelcoming staff attitude, poor interpersonal skills as well as complex billing

systems at hospitals increased the difficulty of accessing services especially in

developing countries. This could breed lack of trust by users in health care

providers or the intermediates that link the population with these providers,

making people reluctant to use the respective services. The study also revealed

lack of means of transport especially ambulance service as a major challenge to

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accessing emergency health care. Another barrier mentioned in this study was

deplorable road network which prevented many participants from accessing

timely maternal health care services. Those who were determined to seek

emergency life saving care were also faced with some delays leading to late

reporting to the health facility.

In Ghana, as in many developing countries, deaths during pregnancy and

childbirth are often linked to the three delays: delays in the home, delays in

accessing the health facility and delays at the health facility (Asante, 2011).

According to him, the first delay is deciding whether to seek care or not. The

report indicated lack of information and inadequate knowledge as responsible for

the delay in responding to initial warning signs of complications of pregnancy and

danger signals during labour. Certain traditions and cultures in the country

maintain that women must wait for approvals from male relatives before seeking

help (Fischer, 2002). The second delay is linked to the constraints that women

face in accessing health facilities. Weak referral linkages as pointed out exist

between community, health centres and district hospitals, making it difficult for

women in emergency situations to get the care they need. The situation as

mentioned is made worse by poor road and communication networks, distant

health facilities, and a lack of transportation and inadequate community support

(Ekabua et al., 2011). The third delay identified occurs between the time the

woman arrives at the health facility and the facilities response in providing

appropriate care. Facility preparedness to respond to obstetric emergencies is

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generally inadequate in terms of skilled attendants, equipment, supplies and drugs

and motivated staff (Asante, 2011).

Every social group has specific traditions, cultural practices, and beliefs

and probing into religions further provide an understanding of a particular culture.

Traditional culture played a major role in the way a woman perceived and

prepared for child birth experience; this may positively or negatively affect the

use of health care in general and maternal health in particular (Okka and

Durduran, 2016).

In this study most of the respondents believed in certain superstitious

practices that hither adherence to scientific health education given at the ANC.

Modern ways of providing protection for pregnant women and their unborn

babies such vaccination, taking vitamin supplements could be substituted with

their outdated practices. A similar study was done among Ethiopian Afar, where

women stated during a focus group that only God and their husband could see

them naked (Tura et al., 2014). Pregnant women therefore prefer consultation

with local religious leaders, traditional healers, and TBAs where expectant

mothers assumed autonomy to seeking care from qualified health providers. The

danger here is that when there are obstructed labour issues, these traditionally

skilful birth attendants introduce local medicine (concoctions) to stimulate

contractions. These concoctions, despite their long tested medicinal effects may

also result in repeated and strong contractions leading to rupture of the uterus, a

probable cause of maternal and new-born death (Iliyasu & Sabubakar, 2015).

Majority of participants held the belief that early announcing pregnancy invites

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enemies to destroy it or invokes on the woman ill-health. According to Craig

(2009), respondents who believed in this normally start ANC visit late in order to

protect their pregnancy against miscarriages.

Furthermore, this exposed that unassisted birth is a mark of fidelity and

bravery on the part of the woman. This is in line with a study conducted in

Uganda that reported women felt embarrassed to give birth in a health facility

because other members of the community would think they were not brave

enough to give birth on their own (Kabakyenga et al., 2012). Child-birth

therefore, represents a rare opportunity for a woman to demonstrate pride,

courage, and bring honour to her and her husband’s families by her stoic

demeanour. The woman who managed to deliver without indication that she was

in labour and without calling for assistance until the child was born was especially

esteemed. On the other hand some participants also believed that for a safe

delivery, spiritual leaders must be called in to recite special prayers for the woman

in labour based on her faith, for safe delivery. During obstructed labour, the

pregnant woman was made by these unskilled birth attendants to mention the

name(s) of the man or men she might have slept with during pregnancy in order to

deliver normally. If she could not still deliver then she was made to go to the

hospital by which time she might be near death (Crowther & Hall, 2015).

According to Fischer women have used prayer and other spiritual practices for

their own and others’ health concerns for thousands of years (Fischer, 2002). This

they believe is a prerequisite for safe delivery. However, it is a medium for deadly

delays.

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Supporting mothers’ emotional wellbeing during the perinatal period is

now recognized to be as important as the traditional focus on the physical health

of the mother and child. A study that focused on the key features of the transition

to parenthood found that significant numbers of low risk parents experience

psychological stress during this time and that their concerns were much broader

than the issues addressed by traditional antenatal classes (Jones et al., 2005). The

findings of this study showed majority of respondents had support from husbands,

mothers, mothers-in-law and fathers-in-law. Even though most husband avail

their support to their vulnerable wives during pregnancy few of them followed

them for ANC services. This was ascertained in this current study as majority of

the women affirmed their husbands never followed them to antenatal clinic. On

the contrary, a study carried out in Uganda showed that 42.9% of expectant

mothers reported that they were accompanied by their spouses to the ANC, 35%

had their spouses help them with household chores during the antenatal period

(Mbalinda et al., 2014).

According to Haobijam et al., (2010) couples who were strongly united

and romantic in their relationship before the pregnancy found it harder to adapt to

parenthood than those whose relationships were already faltering. Unfortunately

for some couples, their relationship does not always recover as around 14% of

couples split up before the baby was born. Preparing parents for parenthood by

addressing the emotional changes that take place during this period, and helping

parents to address the problems that occur is therefore paramount. Men generally

do not accompany their wives for antenatal care and are not expected to be in the

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labour room during delivery. Pregnancy and childbirth continue to be regarded as

exclusively women’s affairs in most African countries. However, men are socially

and economically dominant especially in northern Ghana. They exert a strong

influence over their wives, determining the timing and conditions of sexual

relations, family size, and access to health care. This situation makes men critical

partners for the improvement of maternal health and reduction of maternal

mortality. Special efforts should be made to emphasize men's shared

responsibility and promote their active involvement in maternity care.

Strategies for involving men include raising their awareness about

emergency obstetric conditions, and engaging them in birth preparedness and

complication readiness (August et al., 2015). This is based on the premise that

increased awareness of men will enable their support for early spousal utilization

of emergency obstetric services. Similarly, preparing for birth and being ready for

its complications could reduce all three phases of delay and thereby positively

impact birth outcomes. Studies on the participation of men in maternal care have

been reported mostly from southern part of Nigeria (Iliyasu et al., 2010)..

Community Support System consists of a process where the causes of

maternal mortality and morbidity are identified through a death and disability

review in the community. Then, this information is shared with the community

through village meetings led by local volunteers. The community then identifies

their role in preventing avoidable maternal death and promotes a zero tolerance to

maternal deaths and violence against women. Lastly, the community forms a

committee known as Community Support Group (CSG) which establishes

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linkages with the health system and local government (Ekabua et al., 2011). This

study identified a big gap between support persons in the community for pregnant

women. Community initiatives such as support fund, transportation and durbars in

the communities of participants as means of augmenting government’s effort to

combating maternal death were not in existence. These could contribute to the

soaring maternal morbidity and mortality in the study area, rendering impotent the

frantic effort in combating maternal death by the Ghana Health Service, Ministry

of Health and International safe motherhood organizations.

Maternal deaths in the northern part of Ghana could be reduced if

qualified and dedicated Nurses, Midwives and Doctors are ready to serve

humanity in a professional manner. Until road networks in the country are

properly constructed and accessible to all parts of Ghana, the effort to reduce

maternal mortality would be unattainable. This notwithstanding, an evaluation of

community support in rural India demonstration enhanced retention of knowledge

and skills for recognition and intervention for maternal bleeding and new-born

sepsis (Solnes et al., 2013). A program in the Oromia region of Ethiopia found

that learning was retained and after three years 54% of women giving birth were

exposed to the training (Sunnyvale et al., 2016).

Another well evaluated example of a birth preparedness intervention is the

Home Based Life Savings Skills (HBLSS) training program devised by the

American College of Nurses and Midwives to increase access to basic life saving

measures within the home and community and by decreasing delays in reaching

referral facilities where life-threatening problems can be managed (Skinner &

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Rathavy, 2009). HBLSS takes into account the social context of childbirth,

focusing on the pregnant woman, her family caregivers, and the home birth

attendant as a team. The model has also been implemented in India, Ethiopia,

Haiti and Liberia with numerous successes. In order to bridge the gap between

community and pregnant women it is prudent to provide the following key

functions: conducts community surveillance for tracking, registration of

pregnancy to facilitates, birth preparedness including dialogue with husbands and

in-laws in addition to pregnant women; mobilize local funds and resources to

support emergency transportation and referral; promote accountability and

responsiveness through community feedback and advocacy;, and creates an

enabling environment for pregnant women.

The practice and determinants of BP among pregnant women attending

antenatal clinic at the Tamale Teaching Hospital was assessed. Only a few

participants met at least three of the prerequisites for PB: Knowledge regarding

the risks associated with pregnancy, delivery and available emergency obstetric

care; arrangement in advance items for birth in the delivery bag; saving enough

money to cover the expenses associated with obstetric emergency; advanced

arrangements for transportation to referral centre and adequate knowledge on

pregnancy obstetric risks.

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CHAPTER FIVE

SUMMARY, CONCLUSIONS AND RECOMMENDATION

This chapter summarizes the entire study; the findings of the study,

recommendations by the researcher, limitations encountered and direction for

future research.

Summary of the Main Findings

This study provided an overview on birth preparedness among antenatal

clients in the Tamale Teaching Hospital that aimed at promoting the timely

utilization of skilled maternal health care especially during childbirth. The study

women constituted young adults with the majority of them being Muslims in the

low income group and married with at least 9 years of formal education. Majority

of them had their previous deliveries in a health facility under the supervision of a

midwife or a doctor and most of these deliveries were spontaneous vaginal

deliveries. Majority of them had had more than four ANC visits in the index

pregnancy. One interesting finding exposed the low prevalence of birth

preparedness among the rather older cohort of women (40-50 years). Having

being multiparous, such a cohort were expected to have gained an enormous

experience regarding birth preparedness but this study revealed otherwise.

The proportion of women who were well prepared for birth and were

ready for any pregnancy related complications was not satisfactory (43.7%). Even

though respondents were not well prepared for birth, they were well informed on

the various danger signs of pregnancy including: severe vaginal bleeding,

hyperemisis gravidarium, reduced or loss of foetal movement and oedema.

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Identified determinants or predictors of birth preparedness were found to be: age,

education level, number of ANC visits, income status, marital status, knowledge

of key obstetric danger signs and cost of services.

Participants were also well informed on medically related conditions such

as high blood pressure and anaemia. Awareness on available maternal health

services among the study populace was also high. Women with a high level of

education exhibited a stronger awareness of the significance of skilled childbirth

in comparison to their less educated counterparts, hence the need for key

stakeholders to recognise the integral role played by formal education towards

achieving safer delivery patterns amongst women. Similarly, women from good

financial backgrounds demonstrated high awareness of the benefits associated

with utilising skilled antenatal services and hence prepared adequately for birth.

Identified health beliefs that influenced birth preparedness and facility

delivery were: women not allowing any man to see their nakedness except their

spouses; early announcement of pregnancy could lead to miscarriages; wearing of

talisman offer protection to both mother and foetus; safe delivery is assured by

pastors/imams/traditionalists reciting special prayers for women; and the belief

that women who deliver on their own were brave, adorable and faithful to their

spouses. Also, Muslims and traditionalists were largely been influenced by

religions, whilst Christians were least influenced.

Key difficulties faced by women in accessing antenatal services were poor

road and communication networks, distant health facilities, lack of transportation

and inadequate community support. Despite several reports exposing these as

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persistent barriers to maternal and child healthcare, this study showed that efforts

to address such challenges may be elusive. Identified barriers to birth

preparedness and access to facility delivery were: judgmental attitude of health

workers, lack of ambulance services, deplorable road network and high cost of

service. Reasons why participants preferred to deliver at home in this study

included home birthing tradition, judgmental attitude of health workers and poor

hospital infrastructure.

The respondents identified a gap between pregnant women and

community leaders and enumerated the following as weaknesses to support

systems in the community: lack of community support fund for emergency

obstetric care; lack of community transportation system and lack of annual

durbars to educate community members on obstetric risk factors. This study

showed a significant lack of spousal support for women where they needed it

most.

Conclusions

The study purposely designed to assess birth preparedness among

expectant mothers and investigated the determinants influencing facility-based

deliveries in the Tamale Metropolis based on set objectives: assess expectant

mothers’ knowledge on obstetric risk factors; assess maternal health service

availability and accessibility to pregnant women; find out family support for the

pregnant woman; determine the obstetric beliefs among the study population and

establish community support systems for pregnant women.

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Based on demographic characteristics the study established a significant

number of participants below the age of 20 most of who were primids. This group

of young adolescents were poorly prepared for birth and likely to give birth at

home, compared to their counterparts above 20 years who mostly utilize facility

delivery systems. The African Traditional Religion had the least participants (7)

yet with the highest home delivery as all the participants in this category were

unprepared for birth. Hence a significant number of them patronized unskilled

people for delivery as indicated in the findings.

The study showed that most pregnant women came for ANC services very

late, as some of them were reported to the health facility with the foetus head in

vagina, and some on their way to the health facility. Participants who attended

ANC at least four times were well prepared for birth compared to their colleagues

who visited ANC below the required four times or not at all. The study populace

had greater knowledge on obstetric risks related to pregnancy. Maternal health

services were available at the facility but there were also concurrent challenges

accessing these services due to some barriers resulting in the inability of some

pregnant women to access maternal care. Obstetric beliefs regarding childbirth

also played a major role for the three delays in the way the pregnant women

perceived and prepared for birth and this affected maternal health services

utilization. Modern ways of providing protection for pregnant women and their

unborn babies were substituted with obsolete beliefs and practices. Some pregnant

women also preferred consultation with local religious leaders, traditional healers,

and traditional birth attendants (TBAs) to seeking care from qualified health

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providers; particularly common among the Muslim and Traditional cohort of

women. The danger here is that when there was obstructed labour these unskilled

birth attendants introduced local medicine (kalgutim) to stimulate contractions,

resulting in repeated contractions that had the tendency of rupturing the uterus.

The belief that for a safe delivery, a pastor or imam or traditionalist must be called

in to recite special prayers for the woman in labour based on her faith for safe

delivery also hindered seeking timely obstetric care.

Supporting mothers’ emotional wellbeing during the perinatal period is

crucial but most of the respondents lack this all important support from their

husbands. Overall, the level of knowledge of participants in respect of pregnancy

related issues was high but it did not reflect in preparedness for birth.

Recommendations and Suggested Areas for Further Research

Based on the findings of this study and the conclusions drawn, the

following recommendations are made for improving policy, knowledge and

practice as far as birth preparedness is concerned:

o Rigorous education by midwives targeted at pregnant women and their

close associate is critical since study findings indicated a gap in adherence

to birth preparedness practices.

o Midwives should consider assisting expectant mothers to design goal

oriented birth plans, comprising: the desired place of birth; the preferred

birth attendant; the location of the closest appropriate care facility; funds

for birth-related and emergency expenses; a birth --companion; support in

looking after the home and children while the woman is away; transport to

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a health facility for the birth; transport in the case of an obstetric

emergency and identification of compatible blood donors in case of

emergency.

o The Ministry of Health through the Ghana Health Services should create

friendly clinics for the vulnerable group of this study (under aged pregnant

mothers) and extend the free maternal care to cover the demand-side

expenses to enable them patronize maternal health services.

o Special efforts should be made by the government and safe motherhood

organizations to incentivise men who accompany their wives to antenatal

clinics from conception till delivery to emphasize men's shared

responsibility and promote their active involvement in maternity care.

o Health policy makers should partner with chiefs, queen mothers, assembly

persons and community volunteers in fixing obstetric emergency strategies

such as free transport systems for women in labour from their homes to

referral centres. Community members should be thoroughly educated at

organized community durbars to eschew all cultural practices and killer

obstetric beliefs that often lead to delays in seeking emergency obstetric

care as indicated in this study.

o Domiciliary midwifery should also be encouraged and regulated by the

Nurses` and Midwives’ Council of Ghana while strong partnerships are

built between skilled birth attendants and TBAs.

o This study largely depended on facility-based data and might not indicate

the true rate of BP/CR practice in the community. It is therefore

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recommended that a larger prospective cohort study be carried out

nationwide to improve the generalizeability of findings.

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APPENDIX A

QUESTIONNAIRE AND VOLUNTARY CONSENT

I am Solomon Suglo, a student of University of Cape Coast on the Master

of Nursing Programme. I am carrying out research on the topic: Birth

Preparedness among Antenatal Clients in the Tamale Metropolis. Hence, if you

are willing to participate I would like to know what you know and the kind of

preparations you have made during your pregnancy. Information obtained from

you shall be handled with utmost confidentiality. You are not required to mention

your name and the information you provide will not be linked with you in any

way or at any stage of this study. You have the right to participate in or opt out

from the study based on your discretion. Thank you.

VOLUNTEER AGREEMENT
The above document describing the benefits, risks and procedures for the
research titled (Birth Preparedness among Antenatal Clients in Tamale
Metropolis) has been read and explained to me. I have been given an opportunity
to have any questions about the research answered to my satisfaction. I agree to
participate as a volunteer.
Sign. of Respondent………………………Date………………………
Sign. of Witness……………………….
SECTION 1: Socio-Demographic Characteristics. Please Tick The Response
That Is Most Descriptive Of You.
1. Age: (a) 11- 20 years ( b) 21-30 years
(c) 31 -40 years (d) 41-50 years
2. Ethnicity :
(a) Dagomba (b) Gonja (c) Ewe
(d) Konkomba (e) Bimoba (f) Gruni
(g) Dagaaba (h) other (specify)……………………

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3. Religion:
a) Muslim (b) Christian (c) Traditionalist
(d) Others (specify)……………………………………………….
4. Marital Status
(a) Single (b) Married (c) Widowed
(d) Divorced (e) Separated (f) Cohabitation
5. Education Completed
a) No formal education (b) JHS (b) Secondary
(d)Tertiary
6. Income level:
(a) Low income (below 400 cedi)
(b)Middle income (400-1500 cedi)
(c) High income (1600 cedi and above)
7. Occupation ………………………………………….
8. Possible sources of information about birth preparedness: choose the
option applicable to you
(a) Doctor/midwife (b) Radio/TV/News paper
(c) The internet (d) TBA
9. Parity: how many biological children do you have?
a) None (2) One
c) Two (d) Three and above
10. Which of the following places (settings) did you give birth to your
previous child?
a) At home (b) Shrine (c) On the way to referral centre
d) Health post (e) CHPS Compound f) Hospital
g) Not applicable
11. Which of the following birth attendants delivered you of your
previous pregnancy?
a) TBA (b) Mother-In-law/Family Member
(c) Passers-By (d) Midwife
(e) Doctor f) Not applicable

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12. What was the mode of delivery of your previous child?

a) Spontaneous Vaginal Delivery (SVD)
(b)Vacuum extraction (c) Forceps delivery
(d) Caesarean section (C/S) e) Not applicable
13. How many visits did you make to health facility for ANC services
before delivery of your previous child?
(a) Once (b) Two (c) Three
(d) Four (e) Five and above
f) Not applicable
14. How many months old was your current pregnancy during your first
visit for ANC services?
a) O-3 months (b) 4-6months
(c) 7-9 months
Section 2: This section seeks to assess your knowledge on emergency birth
preparedness. You are required to respond to each statement by rating each with
the strength of your agreement with it: agreed (A), strongly agreed (SA),
disagreed (D) or strongly disagreed (SD)
SECTION 2:
KNOWLEDGE OF
EXPECTANT MOTHERS
ON PREGNANCY
RELATED ISSUES
Danger signs pregnant women Agreed Strongly Disagreed Strongly
may experience during Agreed Disagreed
pregnancy and birth include:
15 Severe vaginal bleeding
16 Hyperemisis gravidarium
(severe vomiting)
17 Reduced/ loss of faetal
movement
18 Oedema
The main medically related Agreed Strongly Disagreed Strongly
conditions in pregnancy that Agreed Disagreed
often result in death include:
19 High blood pressure
20 Malaria
21 Anaemia

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I can endanger my life and my Agreed Strongly Disagreed Strongly

unborn child if I patronize the Agreed Disagreed
following practices
22 Locally prepared concoctions
(‘kalgu-tim’)
23 Over the counter drugs
24 Domestic violence
Routine medications given me at Agreed Strongly Disagreed Strongly
ANC to maintain good health Agreed Disagreed
include:
25 Folic acid, fasolate, vitamin
supplements and tetanus
toxoid
Infection prevention practices Agreed Strongly Disagreed Strongly
during pregnancy for all Agreed Disagreed
expectant mothers include:
26 Sleeping in insecticide treated
nets
27 Hand washing with soap
under running water after
visiting toilet and before and
after cooking
Mothers after delivery should Agreed Strongly Disagreed Strongly
know and practice the following Agreed Disagreed
for optimum care of the baby
28 Breastfeed baby with only
breast milk including the first
breast milk for the first 4-6
months
29 Dress cord with normal saline
and keep it clean and dry
SECTION 3: Maternal
Health Services Availability
and Accessibility
The facility I intend to give birth Agreed Strongly Disagreed Strongly
renders the following services: Agreed Disagreed
30 Laboratory services, Blood
bank services,
HIV/AIDS/Hepatitis B
screening /Counselling
services and theatre services.
I have the following in place as a Agreed Strongly Disagreed Strongly
measure for emergency labour Agreed Disagreed
and childbirth:
31 Means of transport to health
facility

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32 Fund for medical

expenses/Active health
insurance
33 Birth/Emergency
preparedness plan
34 Items needed for antenatal
and delivery in my delivery
bag
The barriers to maternal health Agreed Strongly Disagreed Strongly
services and accessibility in my Agreed Disagreed
locality include:
35 Judgmental attitude of health
workers
36 Lack of ambulance services
for emergency referral
37 Deplorable road network
38 High cost of services
I prefer giving birth at home to Agreed Strongly Disagreed Strongly
the hospital because of the Agreed Disagreed
following reasons:
39 Home birthing traditions
40 Poor hospital infrastructure
and quality of service
41 Bad attitude of health
workers
SECTION 4: OBSTETRIC
BELIEFS IN
PREGNANCY AND
CHILDBIRTH AMONG
EXPECTANT MOTHERS
OBSTETRIC BELIEFS Agreed Strongly Disagreed Strongly
Agreed Disagreed
42 A man other than the
husband who sees a woman
naked in labour causes
obstructed labour
43 Childbirth is easy if the
woman and her husband tell
names of all their previous
lovers.
44 Early announcement of
pregnancy causes miscarriage
45 Unassisted birth is a mark of
fidelity and bravery on the
part of the woman

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46 Pre-natal vitamin and

treatment make the unborn
baby’s head grow bigger than
its body.
47 Women who eat meat, eggs
and snails during pregnancy
give birth to witches
48 Wearing of talisman and
amulets offer protection to
pregnancy against witchcraft
49 Pastor/imam/traditionalist
must recite special prayers
for safe delivery
SECTION 5: FAMILY
SUPPORT FOR
PREGNANT WOMEN
Support persons/type of support Agreed Strongly Disagreed Strongly
by family Agreed Disagreed
50 Husband, mother, mother-in-
law and father-in-law
51 My family assists me to avoid
delays at home during
emergency labour
52 My husband usually
accompanies me to ANC
SECTION 6:
COMMUNITY SUPPORT
SYSTEM DURING
EMERGENCY
DELIVERY
In my community the following Agreed Strongly Disagreed Strongly
persons actively support Agreed Disagreed
expectant mothers in times of
need
53 The chief, Queen mother and
the assembly-man
Support systems available in my Agreed Strongly Disagreed Strongly
community for pregnant women Agreed Disagreed
include:
54 Community support fund for
obstetric emergency
55 Organized community
transportation system
56 Annual durbars to educate
community members on
obstetric risk factors through

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role play
Adequate support for pregnant Agreed Strongly Disagreed Strongly
women promotes the following: Agreed Disagreed
57 Bonding with mother and
baby
58 Enhance good relationship
between couple
59 Good mental state of mother
after birth
60 Early recognition of birth
problems

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APPENDIX B
UNIVERSITY OF CAPE COAST IRB LETTER

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APPENDIX C
INTRODUCTORY LETTER FROM DEAN

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APPENDIX D

GHS` PERMISSION LETTER

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APPENDIX E
AUTHORIZATION CERTIFICATE FROM TTH

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