Yegbe Afia Seiwaa

KWAME NKRUMAH UNIVERSITY OF SCIENCE AND TECHNOLOGY, KUMASI
COLLEGE OF HEALTH SCIENCES
SCHOOL OF PUBLIC HEALTH
DEPARTMENT OF HEALTH POLICY, MANAGEMENT AND ECONOMICS
FACTORS INFLUENCING THE UTILISATION OF ANTENATAL CARE

SERVICES IN THE MANHYIA SUB-METRO, KUMASI
BY
AFIA SEIWAA YEGBE
(PG9908013)
A THESIS SUBMITTED TO THE DEPARTMENT OF HEALTH POLICY,

MANAGEMENT AND ECONOMICS
COLLEGE OF HEALTH SCIENCE, SCHOOL OF PUBLIC HEALTH, IN PARTIAL

FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF
PUBLIC HEALTH IN HEALTH SERVICES PLANNING AND MANAGEMENT
SEPTEMBER, 2015
DECLARATION
I, Afia Seiwaa Yegbe, the author of this dissertation, do hereby declare that with the
exception of references made to the literature and works of other researchers which have
been duly acknowledged, the content of this dissertation is the result of my original work.
SIGNATURE………………………………………DATE……………………………
Afia Seiwaa Yegbe
SIGNATURE…………………………………DATE…………………………………
DR. SAM NEWTON
ACADEMIC SUPERVISOR
SIGNATURE…………………………………DATE…………………………………
DR PETER AGYEI-BAFFOUR
HEAD OF DEPARTMENT
ii
DEDICATION
I dedicate this long essay which represents the hard work and outcome of my entire studies
to the memory of my late mother.
iii
ACKNOWLEDGEMENT
My grateful appreciation goes to God for his protection and how far He has brought me
most importantly towards the completion of my studies.
My thesis supervisor Dr. Sam Newton, I do acknowledge for his consistent motivation,
insightful knowledge and guidance throughout the duration of my studies and critique of
this work.
Finally, my warm appreciation goes to my Husband, Dr. Bona Yegbe, brothers, sisters
and friends for their constant spiritual and moral support which gave me the strength and
motivation to strive.
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TABLE OF CONTENTS
DECLARATION ...........................................................................................................ii
DEDICATION............................................................................................................. iii
ACKNOWLEDGEMENT ............................................................................................ iv
TABLE OF CONTENTS ............................................................................................... v
LIST OF TABLES ......................................................................................................viii
LIST OF FIGURES ...................................................................................................... ix
ABSTRACT .................................................................................................................. x
CHAPTER ONE .......................................................................................................... 1

INTRODUCTION ........................................................................................................ 1
1.1 Background of the Study ..................................................................................... 1
1.2 Statement of Research Problem ........................................................................... 4
1.3 Purpose of the study ............................................................................................ 6
1.4 Conceptual Framework ........................................................................................ 6
1.5 Research Questions .................................................................................................. 7
1.6 Research Objectives ............................................................................................ 8
CHAPTER TWO ......................................................................................................... 9

LITERATURE REVIEW ............................................................................................ 9
2.1 Introduction ......................................................................................................... 9
2.2 Antenatal Care Services............................................................................................ 9
2.3 Knowledge of women on ANC .......................................................................... 13
2.4 Women’s Perceptions of ANC and Reasons for Attending...................................... 14
2.5 Care delivery at the Ante-natal care (ANC) and Post-natal care (PNC) clinics. ....... 17
2.6 Reproductive Concerns and Uncertainties............................................................... 19
2.7 Attendance of health facilities during pregnancy .................................................... 20
2.8 The Direct and Indirect Costs of ANC .................................................................... 22
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2.9 Access to Ante Natal Care .................................................................................... 22
CHAPER THREE ...................................................................................................... 25
METHODOLOGY ..................................................................................................... 25
3.1 Study Design ..................................................................................................... 25
3.2 Study Population ............................................................................................... 25
3.3 Sample size and sampling method ..................................................................... 25
3.4 Data Collection Techniques and Tools ............................................................... 28
3.5 Pretesting .......................................................................................................... 29
3.6 Data Analysis .................................................................................................... 29
3.7 Ethical Consideration ........................................................................................ 29
3.8 Limitations of the Study .................................................................................... 30
3.9 Assumptions ...................................................................................................... 30
CHAPTER FOUR ...................................................................................................... 31

PRESENTATION OF RESULTS ............................................................................. 31
4.1 Introduction ....................................................................................................... 31
4.2 Demographic characteristics of respondents ...................................................... 31
4.3 Knowledge of respondents on ANC ................................................................... 33
4.4 Quality of care and service delivery at facility ................................................... 38
4.5 Factors that help women to access Antenatal Care services or prevent them ...... 44
CHAPTER FIVE........................................................................................................ 48
DISCUSSION OF FINDINGS ................................................................................... 48
5.1 Introduction ....................................................................................................... 48
5.2 Knowledge on ANC .......................................................................................... 48
5.3 Quality of care and service delivery ................................................................... 50
5.4 Factors influencing and inhibiting ANC attendance ........................................... 51
CHAPTER SIX .......................................................................................................... 54

CONCLUSION AND RECOMMENDATIONS ....................................................... 54
6.1 Conclusions ....................................................................................................... 54
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6.2 Recommendations ............................................................................................. 55
6.3 Recommendation for further Research ............................................................... 56

REFERENCE .............................................................................................................. 57
APPENDICES ............................................................................................................. 67
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LIST OF TABLES
Table 1: Background of Respondents … … … … .… 30
Table 2:
How Respondents heard about ANC * Appropriate Time to Access
ANC Services (Crosstabulation) … … … … …33
Table 3:
How Respondents heard about ANC and Number of visits needed
(Crosstabulation) … … … … … … … 34
Table 4:
How Respondents heard about ANC and How often respondents access
ANC services (Crosstabulation) … … … … 35
Table 5: Average number of staff at facility… … … … … 36

Table 6: How often respondents visits the facility and Reception at the facility
(Crosstabulation) … … … … … … 37
Table 7: How often respondents visits the facility and Services rendered at ANC
center (Crosstabulation) … … … … … … 38
Table 8: How often respondents visits the facility and Average time spent at the
ANC center (Crosstabulation)… … … … … 39
Table 9: How often respondents visits the facility and General attitude of staff
(Crosstabulation) … … … … … … 40
Table 10: How often respondents visits the facility and Overall services provided at
ANC center (Crosstabulation)… … … … … 41
Table 11: Descriptive Statistics of cost of transportation and distance from residence
to facility … … … … … … … 42
Permission before attending facility and Influence of permission on quest
Table 12:
for health care (crosstabulation)… … … … … 43
Table 13: Person permission sought from and Influence of permission on quest for
health care (Crosstabulation … … … … … … 44
Table 14: Means of Transportation to the Facility * Distance Motivating Attendance

(Crosstabulation … … … … … … … 45
viii
LIST OF FIGURES
Figure 1: Conceptual Framework… … … … … … 7
Figure 2: Respondent’s view on ANC … … … … … 32
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ABSTRACT
Antenatal care allows for the management of pregnancy, detection and treatment of
complications, and promotion of good health. The objective of the sought to investigate the
factors that influenced the utilization of antenatal care services, factors preventing pregnant
women from accessing Antenatal Care Services as well as the quality of care rendered to
women who access Antenatal Care facilities. Health institutions for the study were
clustered into three; public health facilities, private hospitals and private maternity homes.
A simple random technique was used to select the respondents for the study. 79% of the
respondents asserted that ANC services was the care given to women before birth with
16.9% indicating they heard about ANC from friends and visited the centre for services in
the late first trimester. 34.6% heard about ANC upon a visit to a health institution. 28.9%
of the respondents visited the facility very often but said they were not given a pleasant
reception at the facility. 23.4% of the respondents attended the facility very often and
described the overall services provided as fair. However some of them were of the opinion
that attitudes of some care givers was cold and this could serve as a potential de-motivating
factor for utilising ANC services. The study recommended that staff of the health facilities
should improve their interpersonal skills with their clients and receive them warmly since
it forms part of maximizing their satisfaction.
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CHAPTER ONE
INTRODUCTION
1.1 Background of the Study
One of the targets of the Millennium Development Goals (MDGs) is to reduce by three
quarters, between 1990 and 2015, the maternal mortality ratio in all countries. Maternal
mortality is the most important indicator of maternal health and well-being in any country.
As a result, it has been central to government health sector policies aimed at improving the
overall health of the Ghanaian population especially that of women. The World Health
Organization has defined maternal mortality as “the death of a woman while pregnant or
within 42 days of a termination of a pregnancy, irrespective of the duration and
site of the pregnancy, from any cause related to or aggravated by the pregnancy or
its management but not from accidental and incidental causes.” (WHO, 2004)
The World Health Organization (WHO) estimated that more than 500,000 mothers die
each year because of pregnancy and related complications. It has been found that about 88
to 98 percent of all maternal deaths could be avoided by proper handling during pregnancy
and labor (Brugada, 2011).
Maternal mortality is one of the most sensitive indicator of the health disparity between
richer and poorer nations. The lifetime risk of dying due to maternal causes is about one in
six in the poorest countries, compared with about one in 30,000 in Northern Europe
(Ronsmans, and Graham 2006). In 2005, 536,000 women died of maternal causes
worldwide. Africa, recorded nearly half (270,000) of the world’s pregnancy related deaths,
1
though it has only12% of the world’s population and only 17% of global annual births
(WHO,2003). Ghana, like many African countries, is off-track with respect to MDG 5. The
national target was to reduce the 1990 maternal mortality rate of 214 per 100,000 live births
(national) by three quarters to 54 per 100,000 live births by 2015 but this target has not
been achieved (MOH, 2008).
Antenatal care allows for the management of pregnancy, detection and treatment of
complications, and promotion of good health. However, women rarely perceive
childbearing as problematic and therefore do not seek care which affects the utilization
of maternal services including ANC services (Chandhiok et al. , 2006).
Proper care during pregnancy and childbirth is important to the health of mother and child.
Antenatal care is a major component of comprehensive maternal health care. Antenatal
care facilitates the detection and treatment of problems during pregnancy and provides an
opportunity to inform women, and their families, about their health and the danger signs
associated with a pregnancy. In addition, early and regular contact with a formal health
care system during pregnancy can contribute to timely and effective use of services during
and after delivery or in the event of an obstetric complication. It is during an antenatal care
visit that screening for complications and advice on a range of maternity-related issues take
place.
The World Health Organization now recommends a 4-visit ANC schedule for low risk
pregnancies (WHO, 2007). Other interventions shown to be beneficial to mother and child
include routine iron and folate supplementation in areas with a high prevalence of anemia,
serologic screening for and treatment of syphilis, routine measurement of fundal height,
malaria prevention, and tetanus immunization (Lumbiganon, 1998).
2
Antenatal care according to WHO’s standard for mother–baby package (WHO-MBP)
consists of: at least four visits of at least 20 min each starting before the last trimester of
pregnancy. Diagnostic tests include: hemoglobin, blood group, urine analysis and RPR
syphilis test. Treatment entails: iron and folate supplements (60 mg three times a day for
90 days; two tetanus vaccinations; treatment of malaria and hookworm. Antenatal cost in
a health center is US$ 6.70. Normal delivery under the standard practice includes:
haemoglobin, blood group and urine test before delivery; active management of third stage
of labor (Ergometrine); Tetracycline eye ointment for the newborn; iron supplements
3×/day for 14 days after delivery while a routine postpartum check-up cost in a health
center is US$12.70 (Prata et al. 2010).
Complications of pregnancy and childbirth are major causes of death and disability among
women of reproductive age in developing countries (World Bank, 1993 and World Health
Organization; 1994.). It is estimated that 18% of the total burden of disease for women of
childbearing age in low-income countries resulted from these problems (World Bank,
1993). An estimated 40% of pregnant women in developing countries develop
complications that require the assistance of a trained provider, and 15% require medical
care to avoid death or disability (Dayaratna et al. 2000). Thus, maternal morbidity and
mortality are highly associated with access and quality of obstetric care (Maine et al.,
1999). The consequences of inadequate maternal health care are maternal death or
disability and/or infant death or disability.
One of the principal objectives of achieving the primary health care programmes in
developing countries including Ghana is to improve reproductive and child health services.
3
There is therefore the need to identify and improve those services that are critical to health
of women and girls. These services include antenatal care, delivery, postnatal care and
family planning. Therefore affordable, available and accessible antenatal care services will
enhance and improve utilization.
1.2 Statement of Research Problem
Despite progress in some countries, the global number of maternal deaths per year
estimated at 529,000 or one every minute during the year 2000 has not changed
significantly since the International Conference on Population and Development (ICPD),
according to recent estimates by WHO, UNICEF, UNFPA (2003). Millions more women
survive but suffer from illness and disability related to pregnancy and childbirth (Safe
Motherhood Initiative, 2003).
The average woman in sub Saharan Africa faces a 1:16 life risk of dying in pregnancy and
childbirth, compared with a 1 in 2800 chances for a woman in a developed country. Of the
520,000 estimated deaths each year, over 99% of these occur in developing countries such
as Ghana and nearly half occurs in Africa (WHO 2003). Another 300 million women in
developing countries suffer a long term illness as a result of pregnancy and childbirth (Safe
Mother 2006).
Ghana’s maternal mortality and maternal morbidity rates hover at an unacceptably high
level. While maternal mortality figures vary widely by source and are highly controversial,
the best estimates for Ghana suggest that roughly between 1,400 and 3,900 women and
girls die each year due to pregnancy-related complications. (Maternal and Neonatal
Programme Effort Index, 2002). Additionally, another 28,000 to 117,000 women and girls
will suffer from disabilities caused by complications during pregnancy and childbirth each
4
year (Maternal and Neonatal Programme Effort Index, 2006) and this made Dr. Elias Sory,
the Director-General of Ghana Health service tasked health workers in the country by
saying "You must wake up to the realization that one maternal death is a calamity and
allow the system and standards to work so we can achieve heights countries such as Sweden
and Sri Lanka have reached recording no maternal death." He said this when he was
delivering a speech at 9th Annual General Conference of Medical Superintendents' Group
(MSG) at Ho on October 20th 2010.
Although the global maternal mortality decreased in 2008 by 34%, the rate in Ghana
increased for 3 consecutive years using 2005 as the base year (2005, 2006, 2007 and 2008
with 196, 187, 230, 200 per 100000 live births) prior to the release of the statistics for the
year 2009 by the Ghana Health Service (GHS) and the Ministry of Health (MoH) which
put the maternal mortality ratio at 170 per 100000 live births. (Ghana Health Service Facts
and Figures, 2007; 2009). It can be noted that in the year 2006 there was a decrease of
4.81% but there was a sharp increase in the mortality by 22.94% in 2007 (Ghana Health
service Facts and Figures, 2007; 2009). This increase has not declined fully since there
were minimal reductions of 13.04% and 15% in 2008 and 2009 respectively. This situation
of maternal health instead of improving towards the achievement of the MDG 5 in the year
2015 is rather deteriorating although the Government of Ghana has made a provision for
the care of expectant mothers in the country through the Free Maternal Delivery Care
policy.
5
1.3 Purpose of the study
The policy of the Government of Ghana is to increase the utilization of the antenatal care
and post natal care services but there are still a lot of reports of deteriorating maternal health
and the maternal mortality ratio in the country is also on the rise since there is no significant
reduction in the trend. This puts every potential mother at risk in the country and as such
there is a need for more efforts to be made in other to clear this menace and to also reach
the heights where Ghana can record no maternal deaths in the country.
By studying and bringing out how the host factors influence antenatal service attendance
to the fore, this study will be beneficial as it will contribute to a better understanding of the
level to which these factors influence the neglect which in turn increases the dropout rate.
It is also hoped that this study’s outcome will contribute to the growing body of scientific
knowledge on infant feeding practices.
Finally, the study will help in the realization and achievement of MDG#5 and also to help
in the policy planning processes in other not to bring out policies that will still compromise
on the antenatal care coverage. The research is also intended to serve as a basis for future
research works on similar health issues where guidance could be sought from the basic
documented facts of its content.
1.4 Conceptual Framework
In this framework four major factors are presented as the main factors that contribute to
utilization and satisfaction with Antenatal Care Services (ANC). These are
(a) Socio-economic and demographic factors
(b) Knowledge of the women on Antenatal Care
6
(c) Access factors
(d) Quality factors
All these four factors were interrelated in a way and determined whether a woman could
utilize and be satisfied with Antenatal Care Services.
Quality of
care factors
Access factors Utilization of

Knowledge
antenatal care
level of
services
women on
Socio-
Demographic
factors
Source: Researcher’s own concept
Fig. 1 conceptual frame work for factors influencing utilisation of Antenatal Care Services
1.5 Research Questions
The study sought to answer the following questions:
1. What is the knowledge level of women on Antenatal Care Services?
7
2. What are some of the factors that help or prevent people from accessing
antenatal Care Services?
3. Does Quality of care rendered to women during Antenatal Care visits
motivate their attendance?
1.6 Research Objectives
1.6.1 General Objective
To determine the factors influencing the utilisation of Antenatal Care Services in
the Manhyia Sub-Metro
1.6.2 Specific Objectives
Specifically, the study sought to achieve these objectives;
 To determine the knowledge level of women about Antenatal Care
Services
 To identify the factors that help women to access or prevents them from
accessing Antenatal Care Services.
 To assess the quality of care rendered to women who access Antenatal
Care.
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CHAPTER TWO
LITERATURE REVIEW
2.1 Introduction
Maternal Health is one of the most significant public health problems in resource poor
settings and reduction in maternal mortality has been identified as essential component of
the United Nation’s Millennium Development Goals and this has caused people to write
about the same topic. This chapter reviews the relevant existing literature about the topic
on what has been done and published by other authors to serve as a yardstick to assess the
outcome of the study.
2.2 Antenatal Care Services
The World Health Organization estimates that 515,000 women die each year from
pregnancy related causes and almost all of these deaths occur in developing countries. Less
than one percent of these deaths occur in developed countries indicating that the
deaths could be avoided if resources and services were available (WHO, 2007)
Antenatal Care (ANC) is a type of care given for women during pregnancy and it is one of
the pillars of maternal health service. The goal of ANC is to prevent health problems of
pregnant women and to ensure that each newborn child has a good start (Banta, 2007).
Preventing problems for mothers and babies depends on an operational continuum of care
with accessible, high quality care before and during pregnancy, childbirth, and the postnatal
period. It also depends on the support available to help pregnant women reach services,
particularly when complications occur (Lincetto et al., 2014). An important element in this
9
continuum of care, they postulated was effective ANC. The goal of the ANC package is to
prepare for birth and parenthood as well as prevent, detect, alleviate, or manage the three
types of health problems during pregnancy that affect mothers and babies: complications
of pregnancy itself, pre-existing conditions that worsen during pregnancy, effects of
unhealthy lifestyles
The WHO antenatal care model recommends that first ANC visit should occur within the
first trimester of pregnancy. The first visit offers an opportunity to establish baseline
information on the general wellbeing of the mother and the pregnancy. It also helps the
expectant mothers assess personally the services provided in the facility and build up their
impression about the establishment (Villar and Bergsjø, 2002). However, while there are
potential benefits to be gained from some of the elements of ANC, with these benefits
significant in developing countries where maternal morbidity and mortality levels are high,
most pregnant women presenting for ANC in Sub-Saharan Africa countries are most likely
to wait until the second andthird trimesters (Carla et al., 2003). Antenatal care (ANC),
along with family planning, skilled delivery care and emergency obstetric care, is a key
element of the package of services aimed at improving maternal and newborn health
(WHO, 2010). Based on ‘reduced but goal-orientated clinic visits’, WHO (2011) developed
the ‘focused’ ANC, which consists of (at least) four visits to a health facility during an
uncomplicated pregnancy.
In Ghana, antenatal coverage has seen a steady rise over the years. From 86.4% in 1999,
10
96.7% in 2000 to 98.4% in 2001. However, the rate of increase is gradually declining from
the year 2002. In year 2002, ANC coverage declined from 93.3% to 91.2% in 2003, to
89.2% in 2004, to 88.7% in 2005 and 88.4% in 2006. (GHS/RCH, 2006)
WHO/UNICEF/UNFPA (2004) in a document indicated that, globally, an estimated 211
million pregnancies and 136 million births occur every year. While they are natural and
usual processes, pregnancy and childbirth put every woman at risk of complications. Most
maternal, foetal and neonatal deaths occur during late pregnancy and the first month of the
child’s life. Complications of pregnancy and childbirth are the leading causes of disability
and death among women in the reproductive age in developing countries. The World
Health Organization (WHO) estimates that about 529,000 women die worldwide every
year in connection with pregnancy and childbirth. Nearly all (99 %) maternal, newborn,
and child deaths occur in low and middle income countries. Moreover, acute morbidity
may affect over 50 million pregnancies/deliveries each year, and severe chronic and
longterm disabilities like fistulas and prolapse affect an estimated 10 million women each
year.
Antenatal care (ANC) for pregnant women by health professionals maintains women’s
health during pregnancy and improves pregnancy outcomes by identifying and managing
pregnancy related complications (Raatikainen et al., 2007). ANC visits are a platform for
delivery of evidence-based clinical interventions, counseling on maternal health, birth and
emergency preparedness. The World Health Organization (2009) recommends all women
with uncomplicated pregnancies to attend four ANC visits during the course of the
pregnancy. During ANC, the WHO recommends that women should receive tetanus toxoid
11
immunization, intermittent preventive treatment of malaria, deworming, iron and folic acid,
and insecticide treated bed nets. The document further postulated that pregnant women can
also be screened for signs associated with high probability of complications and subsequent
specialized care can be arranged. For example, in HIV-endemic countries, antenatal care
includes HIV testing and is an entry point for prevention of mother-to-child transmission
services. Chakraborty et al., (2002) indicated also that antenatal care attendance is also
associated with an increase in facility based deliveries and use of postnatal services.
Although ANC is considered an important intervention for reducing maternal and newborn
mortality, and the achievement of Millennium Development Goals 4 and 5, ANC services
tend to be under-utilized in low-income settings (Pallikadavath et al., 2004). In the light of
all these, Requejo et al. (2012) indicated that among the 69 countries tracked by the
countdown to 2015, the median coverage rate of at least one ANC visit is 88% and four or
more ANC visits was rather 55%.
For many of the essential interventions in ANC, it is crucial to have early identification of
underlying conditions – for example, prevention of congenital syphilis, control of anaemia,
and prevention of malaria complications. Hence the first ANC visit should be as early as
possible in pregnancy, preferably in the first trimester. The last visit should be at around
37 weeks or near the expected date of birth to ensure that appropriate advice and care have
been provided to prevent and manage problems such as multiple births (e.g. twins),
postmaturity (e.g. birth after 42 weeks of pregnancy, which carries an increased risk of fetal
death), and abnormal positions of the baby (e.g. breech, where the baby’s head is not the
presenting part at birth).
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2.3 Knowledge of women on ANC
Health education programmes during ANC services should inform the women about
reproductive health, knowledge related to sexuality, pregnancy, nutrition, family planning,
malaria, S.T.I’s, HIV/AIDS etc. (Barnet et al 2003). Information should indicate where
these services are offered, including the requirements for attending ANC. In Ghana, ANC
including family planning services is provided by both public and private health facilities.
AbouZhar (2003) in her article to the British Medical bulleting stated that “Sound
information is the prerequisite for health action: without data on the dimensions, impact
and significance of a health problem it is neither possible to create an advocacy case nor to
establish strong programmes for addressing it. The absence of good information on the
extent of the burden of maternal ill-health resulted in its relative neglect by the international
health community for many years. Lack of knowledge about the ANC services could be a
major barrier to women’s utilization of ANC services. Due to lack of knowledge pregnant
women are likely to have limited knowledge and experiences in seeking health care. Matua
(2004) and Jewkes et al (2001) cited lack of adequate knowledge and information about
pregnancy, laboratory tests results and dangers of late bookings or not attending ANC at
all, as contributors to the poor utilization of ANC services.
The recommended minimum number of visits for an uncomplicated pregnancy
is four. According to the report of GHS/RCH 2006, achievement for 2006 was 3.3 as
compared to that of 2005 which was 3.4. No region achieved the recommended minimum
of four visits. Ashanti and Central regions each recorded the highest figure of 3.6 visits and
the lowest figure was recorded by Volta, Upper East and Greater Accra as 3.0 visits
(GHS/RCH, 2006)
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Increasing utilization of antenatal services however has not led to the expected
commensurate reduction in maternal mortality rate. A feat which is an indication that there
is an improper or inappropriate utilization of these services. People may attend antenatal
clinics alright but may delay till complications of pregnancy have set in or when they are
about to deliver. In developing countries, most attendance at antenatal clinics takes place
in the 7th and 8 months and women usually averaged only one visit per pregnancy. Patients
may also report to antenatal clinics only when they are ill (Ledward, 1982).
Some factors have been associated with delayed antenatal care. Among them is the study
which stated that pregnancy and delivery in grand multiparas are at higher risk due
to poorer antenatal care and advancing maternal age. found that irrespective of age
and social class, unmarried women were less likely to have planned pregnancy and
to attend antenatal care. They were also likely to miss antenatal care appointments,
but there was no significant effect of marital status on pregnancy outcome as well
as associated poor antenatal care attendance with young age (Blondel et al., 1993).
In New Zealand, Essex et al (1992) also observed that late antenatal care attendance
was associated with single marital status, grand multiparity and young age as well
as low socio economic status, and low education level.
2.4 Women’s Perceptions of ANC and Reasons for Attending
Magoma et al. (2011) in their study concluded that although women’s descriptions of ANC
varied across and within the sites, on the whole, many do not recall receiving all
WHOrecommended procedures. The descriptions were also often vague and focused on
14
the experience of procedures, such as receiving injections or tablets, rather than their aim
or purpose.
Kenyan women focused on palpation, receiving ‘blood booster’ tablets and injections and
were generally less familiar with other procedures or their purpose (such as IPT). Ghanaian
and Malawian women emphasized being weighed and also commonly recalled checking
the position of the baby, and the provision of medicines and injections. In Malawi, women
distinguished ‘blood pills’ from malaria drugs, and recalled being given ITNs. Women in
Ghana reported having their arms ‘tied’, but did not explicitly link this with blood pressure
measurement (National Statistical Office (NSO), ICF Macro (2011)).
Pell et al. (2011) in their study “Social and Cultural Factors Affecting Uptake of
Interventions for Malaria in Pregnancy in Africa” postulated that women described being
injected and tested, but specific mentions of HIV testing were only made frequently in
Malawi, and references to syphilis tests and haemoglobin analysis were rare overall. They
further asserted that, interviews with health workers and observations indicated that, often
as a result of shortages or infrastructure problems, not all the recommended ANC
procedures were carried out for every woman or at every healthcare facility. Lack of
delivery of specific procedures, such as syphilis testing and haemoglobin analysis,
therefore influenced women’s descriptions of ANC.
Pell et al. (2013) in their work “Factors Affecting Antenatal Care Attendance: Results from
Qualitative Studies in Ghana, Kenya and Malawi” indicated that at all the sites, women
stated that they attended ANC to monitor the progress of their pregnancy or to check the
position of the unborn child. In Upper East Region, women attended ANC to identify
15
problems during pregnancy, whereas, in the Ashanti Region, women also highlighted the
importance of taking the medicines provided during ANC to ensure the health of the
pregnancy and the development of the baby. Furthermore, Ghanaian respondents,
particularly in the Ashanti Region, viewed ANC as a normal part of pregnancy: attending
the clinic was simply what women did. In Upper East Region, ANC was often considered
compulsory: a result of the authority of health staff or the vague idea of it being the ‘law’.
The cards, completed by health staff, contain details of ANC attendance and Kenyan
respondents suggested that without the cards, they would encounter problems if they
attended a health facility to deliver: women feared being reprimanded by healthcare staff,
or refused care. Although this played a lesser role in Ghana and Malawi, reference was also
made to ANC cards’ importance for avoiding conflicts with health staff.
Efforts to reduce maternal mortality and morbidity must also address societal and cultural
factors that impact women’s health and their access to services. Women’s low status in
society, lack of access to and control over resources, limited educational opportunities,
poor nutrition, and lack of decision-making power contribute significantly to adverse
pregnancy outcomes. Laws and policies, such as those that require a woman to first obtain
permission from her husband or parents, may also discourage women and girls from
seeking needed health care services – particularly if they are of a sensitive nature, such as
family planning, abortion services, or treatment of STIs. (MNPI)
The study of Prata et al. (2004) indicate that poverty and lack of education cause women
to underutilize maternal health services. Witter et al. (2007) cited in Bhutta et al. (2010,
p.20) gathered and concluded that financial barrier is one of the most important constrain
in Ghana, that is preventing women to seek skilled care during delivery and the introduction
16
of the fee exemption policy proved to be manageable and workable even within the
relatively constrained human resources environment of countries like Ghana.
2.5 Care delivery at the Ante-natal care (ANC) and Post-natal care (PNC) clinics.
The World Health Organization (WHO) defines service delivery as the way inputs are
combined to allow the delivery of a series of interventions or health actions (WHO 2010).
As noted in the World Health Report 2010, “the service provision function of the health
system is the most familiar; the entire health system is often identified with just service
delivery.”
Massoud et al. (2001) represented health service delivery in a system’s perspective, with
inputs, processes, outputs, and outcomes. Some of the core inputs that are deemed
necessary for health care delivery from the systematic point of view are financial resources,
competent health care staff, adequate physical facilities and equipment, essential medicines
and supplies, current clinical guidelines, and operational policies. These inputs must be
available and accessible to have an impact and they also must be used to properly carry out
the system processes to produce desired health outcomes.
Disease prevention priorities project in their article “a preventable tragedy: maternal and
newborn deaths in West Africa” (2007) reiterated that preventing complications through
primary prevention involves maintaining a normal pregnancy and managing mild
complications in essence, good quality of care through routine prenatal care, family and
17
community education, and postpartum care at the primary health care level. Primary-level
care is widely regarded as the crucial entry point to maternity services, and to care before
and after pregnancy. Primary-care health facilities should provide prenatal, delivery
(including managing abortion complications), and postpartum care (including family
planning and post-abortion counseling), as well as care of the newborn. It stated among
other things that the essential elements of routine prenatal care include: screening and
treatment for syphilis, immunization with tetanus toxoid, prevention and treatment of
anemia, and prevention and treatment of malaria with prophylaxis and bed nets. Strong
evidence supports the cost effectiveness of a four visit prenatal schedule that includes
educating women and birth attendants about danger signs and the need for skilled
attendants at delivery. The postnatal period is also the most important time to address
complications that affect the newborn. Effective interventions for the newborn exist and
can be delivered at low cost. Up to 40 percent of neonatal deaths could be averted with
home- and community-based solutions, such as keeping a newborn warm and clean,
breastfeeding regularly, protecting against infection through proper hygiene, and treating
infections with antibiotics in a timely manner. Access to skilled and emergency prenatal
and postnatal care can save many more newborn lives.
Ansong-Tornuiet al. (2007) observed through their research in the Volta and Central
Regions of Ghana that clinical care provided before and after the introduction of the fee
exemption policy did not change, though women with complications were arriving in
hospital earlier after the introduction of the policy. On admission, however, they received
very poor care and this, the clinical panel deduced could have resulted in many avoidable
deaths; as was the case before the implementation of the policy.
18
Houwelinget al. (2007) in their work huge poor-rich inequalities in maternity care: an
international comparative study of maternity and child care in developing countries
observed that the poor–rich inequalities in professional delivery care are much larger than
those in the other forms of care. Reducing poor–rich inequalities in professional delivery
care is essential to achieving the MDGs for maternal health. Very few of the poorest
mothers get professional delivery care irrespective of where they live, although some get
antenatal care.
2.6 Reproductive Concerns and Uncertainties
Previous or ongoing health problems – pregnancy-related or otherwise – prompted women
to seek care at a health facility in early pregnancy (the first or early second trimester).
Through this, Jimon, (2003) in his study asserted that in Ghana, generally, women initiated
ANC in early pregnancy and, from the first visit; ANC was conducted in a problem-focused
manner where health workers reportedly paid attention to women’s complaints and
possible remedies. On the contrary, Malawian and Kenyan women who complained of ill
health during early pregnancy would however generally not attend ANC but rather seek
care at a health facility, without disclosing their pregnancy to staff. Yet, at all the sites,
experiences of previous pregnancy complications motivated women to seek ANC in early
pregnancy. But Kinney (2010) concluded that in Ghana pregnancies were not confirmed
with a test, except in district hospitals, where pregnancy tests were used in cases of
uncertainty with this uncertainty widely experienced in the first trimester, prior to
palpation, extended to both the woman and the health staff. However, as indicated by by
19
Jimmon (2003) earlier, in Malawi and Kenya, this had implications for ANC attendance as
there had been reports of health workers instructing women to return when they were able
to confirm a pregnancy (or the pregnancy was confirmed elsewhere) and perform ANC
procedures.
Given the central role that reproduction often plays in the women’s lives and the stigma
that surrounds infertility in a society, including the implications that childlessness have for
a woman’s relations with a woman’s husband and in-laws, for these women, confirming a
pregnancy was particularly important. Lubbock (2008) posited that any uncertainty around
pregnancy status was pronounced for women who had previously had difficulties
conceiving or bringing a pregnancy to term.
In Malawi, and to a lesser extent in Ghana, there was also the use of traditional and modern
methods of contraception also creates uncertainty about pregnancy linked to confusion
about amenorrhea associated with injectable contraceptives resulted in women being
unclear about their pregnancy status and in some instances led to delay ANC. From this
Magoma, et al. (2010) posited that in Ghana, health professionals linked irregular
menstruation and uncertainties regarding pregnancy to sexually transmitted infections. The
uncertainty and ambiguity surrounding pregnancy, particularly in the first trimester also
had implications for pregnancy disclosure.
2.7 Attendance of health facilities during pregnancy
AbouZhar (2003) in her article to the British Medical bulletin stated that “Sound
information is the prerequisite for health action: without data on the dimensions, impact
and significance of a health problem it is neither possible to create an advocacy case nor to
establish strong programmes for addressing it. The absence of good information on the
20
extent of the burden of maternal ill-health resulted in its relative neglect by the international
health community for many years. Maternal deaths are too often solitary and hidden events
that go uncounted. The difficulty arises not because of lack of clarity regarding the
definition of a maternal death, but because of the weakness of health information systems
and consequent absence of the systematic identification and recording of maternal deaths”.
Efforts to reduce maternal mortality and morbidity must also address societal and cultural
factors that impact women’s health and their access to services. Women’s low status in
society, lack of access to and control over resources, limited educational opportunities,
poor nutrition, and lack of decision-making power contribute significantly to adverse
pregnancy outcomes. Laws and policies, such as those that require a woman to first obtain
permission from her husband or parents, may also discourage women and girls from
seeking needed health care services – particularly if they are of a sensitive nature, such as
family planning, abortion services, or treatment of STIs. Prata et al. (2004)
Witter et al. (2007) gathered and concluded that financial barrier is one of the most
important constrain in Ghana, that is preventing women to seek skilled care during delivery
and the introduction of this fee exemption policy proved to be manageable and workable
even within the relatively constrained human resources environment of countries like
Ghana.
Among the knowledge base on why maternal deaths occur and how to avert them, access
to maternal health services is a primary intervention for achieving better maternal health
outcomes (Bour, 2003). Notwithstanding this, the organization of maternal service and how
21
maternal health service is financed have also been seen to play a part in the health-seeking
behavior in general and outcomes. (Witter et al., 2008).
2.8 The Direct and Indirect Costs of ANC
Attending ANC also entailed indirect costs. Travel costs varied amongst the sites and the
respondents at each site. Dowswell (2010) however, indicated there are also nonmonetary
costs: pregnancy, combined with women’s continued labour demands (that continue up to
delivery and recommenced shortly after), was often an exhausting experience for women
and the journey to health facilities represented a physical burden.
According to Gross et al., (2011), delays in ANC initiation are not however solely due to
the associated indirect and direct costs. The nature of ANC appointment scheduling by
health staff, and women’s understanding of appointments as compulsory also contributes
to delayed initiation.
2.9 Access to Ante Natal Care
Access to ANC is important in helping to modify women’s risk behaviours and promote
positive health practices for adolescents of risk of future unplanned pregnancies and STI
and as such should be accessible to all pregnant women irrespective of social status, age,
race or level of education and HIV status, and whilst simultaneously providing an
environment of trust and confidentiality (Kluge, 2006).
According to Llongo (2004), if adolescents were more knowledgeable about the benefits
of prenatal services, they might make better use of these services. To buttress his point,
22
midwives in his study area also concurred that certain barriers could prevent adolescents
from utilizing prenatal services, similar to utilisation barriers reported by other researchers.
He further suggested that following factors contributed to the perceived inaccessibility of
ANC services
• Stigma and beliefs about social rejection
• Lack of confidentiality
• Cultural beliefs and perceptions about ANC
• Expensive health care services
• Previous health care experiences.
The majority of pregnant women might not be able to afford the maternity fees that are
charged because most of them have financial limitations. Pregnant women in Zimbabwe
pay about (US$25.00) at the PHC clinics. The perceived high fees might influence some
pregnant women to resort to the services of traditional birth attendants (TBAs) which
are cheaper and can be paid in kind (Ikamari 2004). Reynolds et al in (2006) cited
socioeconomic factors contributing to poor ANC attendance and thus also to poor maternal
and neonatal outcomes.
Health financing in Ghana has relied heavily on user fees to cover recurrent costs at health
facility level (salaries and investment costs are financed from the public budget, along with
small subsidies towards administrative and services delivery costs). User fees constitute
12% of total health sector funding (public sector), but the proportion is much more
significant at facility level (Dubbledam et al. 2007). However, there is a long history of
exempting certain categories of users or services. Typically, these exemption categories
have been poorly funded and implemented (Garshong et al. 2001; Nyonator and Kutzin,
23
1999).
The Government of Ghana (GoG) developed a policy which was implemented in Ghana
that aimed to improve access to health services for the poor and the vulnerable, by putting
into place universal exemption from payment of user fees for all delivery care. It was
expected that the policy would remove financial barriers to accessing these services, allow
an increase in professionally attended deliveries and thus a reduction in maternal and
perinatal mortality. The policy was implemented firstly in the four most disadvantaged
regions in 2003 and then extended to cover all regions in the country in 2008.
The exemptions policy was funded through Highly Indebted Poor Country (HIPC) debt
relief funds, which were channeled to the districts to reimburse both private and public
facilities according to the number of deliveries performed each month. A tariff was
approved by the Ministry of Health which set reimbursement rates according to the type of
delivery (such as ‘normal’, ‘assisted delivery’, or ‘caesarean section’) and the facility type,
with mission and private facilities being reimbursed at a higher rate, in recognition of the
fact that they received fewer public subsidies (Ministry of Health 2004).
Despite all these reservations, ANC in developing countries is important especially to
pregnant women. Efficacy of ANC should also ensure dissemination of information on
maintaining good health of pregnancy, danger signs and when and where to go for help
should these appear (Matua, 2004). The goal-oriented ANC guidelines using needfocused
care have been designed to address aspect of quality, adequacy and effectiveness.
24
CHAPER THREE
METHODOLOGY
3.1 Study Design
The study was a cross sectional descriptive study. Cross-sectional studies are carried out at
one time point or over a short period and they are usually conducted to estimate the
prevalence of the outcome of interest for a given population, commonly for the purposes
of public health planning. The study used this design because there was the need to gather
data on the situation over the period of conducting the study. The study was conducted
within a period of four weeks, from September 2014 to October 2014.
3.2 Study Population
The study population was pregnant women and mothers in the post partum period who
resided in the Manhyia Sub-metro. This was calculated using the Ghana Health Service’s
target of Population less than 1 year and expected pregnancy which forms 4% of a defined
population.
3.3 Sample size and sampling method
3.3.1 Sample Size
Stat Calc (Epi info version 7.0.8.3) was used to calculate for the sample size from the
population of 12437, at a confidence level of 95% and confidence interval of 5%. A sample
size of 373 was derived but this study used a sample size of 350.
25
3.3.2 Sampling Methods
A simple random sampling technique was employed in this study.
For the purpose of data collection the facilities were clustered into Government facilities,
private hospitals and private maternity homes. The names of the facilities were written on
pieces of papers and placed in three bowls, bowl ‘A’ representing government facilities,
bowl ‘B’ representing private hospitals and bowl ‘C’ for private maternity homes. The
papers in the bowls were shuffled and two pieces of papers drawn from every bowl. The
names on the pieces drawn were included in the study.
With the government facilities being the majority of service providers in the sub-metro the
simple random sampling method was used to select the subjects for the study. This was
done by writing “yes” on a specified number of pieces of papers and “no” on the same
specified number of pieces of papers and mixed in a bowl, anybody who picked a “yes”
sheet was included in the study whilst the one who picked “no” was excluded from the
study. However, a paper drawn from the bowl was not replaced in other to provide equal
opportunities for subjects.
From the private hospitals, the simple random sampling method was used to select the
subjects for the study. This was done by writing “yes” on a specified number of pieces of
papers and “no” on the same specified number of pieces of papers and mixed in a bowl,
anybody who picked a “yes” sheet was included in the study whilst the one who picked
“no” was excluded from the study. However, a paper drawn from the bowl was not replaced
in other to provide equal opportunities for subjects.
26
From the private maternity homes, a convenient or purposive sampling method was used
to select respondents for the study.
3.4 Data Collection Techniques and Tools
Quantitative data collection method was used. The questionnaires administered during the
survey used the Likert scale.
There were primary and secondary sources of the data collected for this research. Primary
data consisted of all the data personally gathered throughout the study and were related
directly to the study purpose. The methods used to collect the primary data in this study
consisted of surveys and interviews. The primary data was collected through an empirical
study which included a questionnaire which was administered
The entire questionnaire was built in four sections. The first section was made of up of
questions relating to the socio-demographic characteristics of the respondent, the second
section comprised questions relating to the knowledge or respondents on ANC, the third
part contained questions relating to service delivery at the facilities and the fourth part was
made up of questions relating to questions on reasons that motivate pregnant women to
attend ANC. Data collection was facility based and were collected by trained Research
Assistants. An information sheet as well as a consent form were issued out to respondents
for their consideration before taking part in the study. Respondents who were reluctant to
participate in the study were excluded and the anonymity and confidentiality of all
participants duly ensured. The language used was also simple so as to make it easy for the
participants to understand and native language was used to explain the questions to those
who could read and allowed to answer the questionnaire
27
The secondary data was however collected through a theoretical study on the knowledge
of respondents on ANC, factors influencing it and the service delivery at the facilities.
Secondary data involved data that was relevant and had already been collected with a
different purpose but whose conclusions are valuable to the study.
3.5 Pretesting
The study instrument (questionnaire) was pre-tested on a sample of 50 respondents in 2
facilities in Krofofrom, a community of similar characteristics with the study community.
Problems such as ambiguity associated with the questionnaire were modified after the
pretesting.
3.6 Data Analysis
Data from the questionnaires were sorted out and coded accordingly, prior to analysis by
SPSS for windows version 16.0 (SPSS Inc. version16.1, Chicago, Illinois). Descriptive
statistics were be used to generate simple descriptive information such as proportion and
frequencies which were useful in evaluating and making comparisons between the different
variables of the study
3.7 Ethical Consideration
Ethical clearance for this study was obtained from the Human Research Ethics Committee
of Komfo Anokye Teaching Hospital and the Department of Community Health-KNUST,
stakeholders of health and opinion leaders of the community. In addition, consent was
obtained from the various authorities and managements of the facilities to be used as well
28
as individuals who agreed to be part of the study with their privacy and confidentiality fully
assured.
3.8 Limitations of the Study
The limitations of the study are those characteristics of design or methodology that had an
impact or influence on the application or interpretation of the results of this study. Lack of
data or reliable data limited the scope of analysis, the size of the sample, which was a
significant obstacle in finding a trend and a meaningful relationship.
3.9 Assumptions
It was anticipated that the study was going to promote antenatal care attendance by pregnant
mothers and communicate a behavior change which when voluntarily adapted is going to
improve maternal health.
29
CHAPTER FOUR
PRESENTATION OF RESULTS
4.1 Introduction
This section of the study details the results analyzed from responses from the
respondents. It is presented largely descriptively and analytically in the form of tables,
graphs and charts and organized according to the objectives of the study.
4.2 Demographic characteristics of respondents
Table 1: Background of Respondents

Variable Frequency (N=350) Percentage (%)
Age
less than 25 64 18.3
25-29 148 42.3
30 and above 138 39.4
Marital Status
Single 200 57.1
Married 126 36
Divorced 24 6.9
Number of Births
0 141 40.3
1 79 22.6
2 130 37.1
30
Educational Level
Basic Education 40 11.4
SSS/Tech/Vocational 196 56
Tertiary 97 27.7
No education 17 4.9
Occupation
Self Employed 38 10.9
Public/Civil Servant 98 28
Trader 40 11.4
Unemployed 94 26.9
Other 80 22.9
Income Level
Low 142 40.6
Medium 135 38.6
High 73 20.9
Religion
Christian 153 43.7
Muslim 97 27.7
Traditional 57 16.3
Other 43 12.3
Majority (42.3%) of the respondents were between the ages of 25 – 29 years. Their
occupations were farming, 35.1%, trading, 36.5% and some were Artisan, 14.9%. 28% of
the respondents were Public/Civil servants with 26.9%, 11.4% and 10.9% being
31
unemployed, traders and self-employed respectively. Over 90% of the respondents had
formal education. Among those with formal education, 56% attended SHS/Vocational
school, 27.7% having experienced a form of tertiary education and 11.4% having basic
education. Christians formed 43.71% of the respondents with about 57.1% were single,
36.9% married and 6.9% divorced. However, 40.57% were low income earners, 38.57%
were medium income earners and 20.86% being high income earners.
4.3 Knowledge of respondents on ANC
On the view of respondents on what ANC was, 79% of the respondents responded that
ANC services was the care given to women before birth, 16% said it was a service that
promoted healthy pregnancy with 5% indicating that it was care given to pregnant
women from conception to delivery.
32
Respondents view of ANC Frequency
Care given to pregnant women before birth
Services that promote healthy pregnancy
Care given to pregnant women from conception to delivery
5%
16%
79%
Figure 2: Respondent’s view on ANC Source: Field study,

2014
Table 2: How Respondents heard about ANC * Appropriate Time to Access ANC
Services Cross tabulation
Appropriate Time to Access ANC Services
Immediately
pregnancy is
detected First Second Third
Trimester Trimester Trimester Total
How From Count 56 59 19 33 167

Respond Friends
ents % of
heard Total 16.0% 16.9% 5.4% 9.4% 47.7%
about
ANC
33
From Count 38 0 24 0 62
Relatives
% of
Total 10.9% .0% 6.9% .0% 17.7%
During a Count 42 39 40 0 121

visit to a
health % of
institution Total 12.0% 11.1% 11.4% .0% 34.6%
TOTAL Count 136 98 83 33 350
% of
Total 38.9% 28.0% 23.7% 9.4% 100.0%
Source: Field study, 2014

From the table, 16.9% (n=59) heard about ANC from friends and visited the centre for
services in the late first trimester but 16% (n=56) heard from friends but visited the facility
immediately pregnancy was detected. 11.4% (n=40) heard about ANC during a visit to a
health institution but visited the facility in the second trimester.
Table 3: How Respondents heard about ANC * Number of visits needed?

Crosstabulation
Number of visits needed?
One Two Three

Total
34
How From Count 32 36 99 167
Respondents Friends
heard about 47.7%
ANC % of Total 9.1% 10.3% 28.3%
From Count 38 24 0 62
Relatives
% of Total 17.7%
10.9% 6.9% .0%
During a Count 0 0 121 121

visit to a
health
34.6%
institution % of Total .0% .0% 34.6%
TOTAL Count 70 60 220 350
100.0%
% of Total 20.0% 17.1% 62.9%

From the table, 34.6% (n=121) heard about ANC upon a visit to a health institution and
the stipulated number of visits they indicated to be 3 visits. 28.3% (n=99) of the
respondents heard of ANC from friends and indicated that the number of stipulated visits
was 3 times. However, 10.9% (n=38) of the respondents heard of ANC from relatives and
indicated that the stipulated number of visits was once.
35
Table 4: How Respondents heard about ANC * How often respondents access
ANC services Cross tabulation
How often respondents access
ANC services
Four
Once Twice Thrice times
Total
How From Count 19 75 56 17 167

Respondents Friends
heard about
ANC % of
Total 5.40% 21.40% 16.00% 4.90% 47.70%
From Count 0 0 62 0 62
Relatives
% of
Total 0.00% 0.00% 17.70% 0.00% 17.70%
During a Count 39 0 42 40 121

visit to a
health
institution % of
Total 11.10% 0.00% 12.00% 11.40% 34.60%
TOTAL Count 58 75 160 57 350
% of
Total 16.60% 21.40% 45.70% 16.30% 100.00%
From the table, 17.7% (n=62) heard about ANC from friends and had visited the ANC
center thrice, whilst 11.4% (n=40) heard of ANC upon a visit to a health institution and
36
had visited the ANC centre four times. However, 11.1% (n=39) had visited the facility once
but also heard of ANC upon a visit to a health institution.
4.4 Quality of care and service delivery at facility
Table 2: Average number of staff at facility

Frequency Percent
1 102 29.1
2 74 21.1
3 75 21.4
4 99 28.3
TOTAL 350 100
Source: Field survey, 2014
The mean was 2.49 and the standard Deviation was 1.184
From the table above, 29.1% of the respondents reported that usually met a health worker at
the facility to attend to them, with 28.3% reported that they met up to four health workers
in the facility who attended to them.
37
Table
3: How often respondents visits the facility * Reception at the facility
(Crosstabulation)
Reception at the facility
Cordially Cold
heartedly other
Total
How often Not Count 0 17 39 56

respondents
visits the Regularly
facility
% of Total .0% 4.9% 11.1% 16.0%
Regularly Count 75 0 64 139
% of Total 21.4% .0% 18.3% 39.7%
Very often Count 16 101 38 155
% of Total 4.6% 28.9% 10.9% 44.3%
TOTAL Count 91 118 141 350
38
Table
% of Total 26.0% 33.7% 40.3% 100.0%
From the table, 28.9% (n=101) of the respondents visited the facility very often but
indicated that they were cold heartedly received at the facility. 21.4% (n=75) often visited
the facility and were always cordially received. However, 11.1% (n=39) were not regular
at the facility and could however not describe the reception at the facility.
4: How often respondents visits the facility * Services rendered at ANC center
(Cross tabulation)
Management
of minor
Immuniz Health
ailments
ation education
Screening Total
How often Not Count 56 0 0 0 56
respondents Regularly
visits the facility

% of Total 16.0% .0% .0% .0% 16.0%
Regularly Count 0 104 0 35 139
% of Total .0% 29.7% .0% 10.0% 39.7%
39
Table
Very often Count 42 0 75 38 155
% of Total 12.0% .0% 21.4% 10.9% 44.3%
TOTAL Count 98 104 75 73 350
% of Total 28.0% 29.7% 21.4% 20.9% 100.0%
From the table, 29.7% (n=104) of the respondents regularly attended the facility and
asserted that the major service rendered was the management of minor ailments. 16%
(n=56) were not regular attendants but indicated that the major services rendered were
screening in line with the WHO recommendations. 10.9% (n=38) were often attendants
and indicated that the major service rendered was health education.
5: How often respondents visits the facility * Average time spent at the ANC center
(Cross tabulation)
Average time spent at the ANC
center
Less
than 30
1 1 hour 30 Above 2
minutes
hour minutes hours
Total
40
Table
respondents visits
the facility Regularly
% of Total .0% 11.1% .0% 4.9% 16.0%
% of Total 18.3% .0% 21.4% .0% 39.7%
% of Total 10.9% 10.0% .0% 23.4% 44.3%
TOTAL Count 102 74 75 99 350
% of Total 29.1% 21.1% 21.4% 28.3% 100.0%
From the table, 23.4% (n=82) of the respondents attended the facility very often and
spent more than 2 hours. 21.4% (n=75) were regular attendants who waited for about an
hour and a half. 11.1% (n=39) were not regular attendants and indicated that they waited
for an hour. However, 18.3% (n=64) were regular attendants who waited for less than 30
minutes.
41
Table
6: How often respondents visits the facility * General attitude of staff (Cross
tabulation)
General attitude of staff
Poor Fair Good Excellent
Total

respondents
facility
% of Total 11.1% .0% 4.9% .0% 16.0%
% of Total .0% 10.0% .0% 29.7% 39.7%
% of Total 10.0% 10.9% 23.4% .0% 44.3%
42
Table
TOTAL Count 74 73 99 104 350
% of Total 21.1% 20.9% 28.3% 29.7% 100.0%
From the table, 29.7% (n=104) of the respondents regularly attended the facility and
asserted that the general attitude of the staff they met was excellent. 23.4% (n=82) were
oft attendants and indicated that the general attitude of the staff they met was good, 10%
(n=35) were regular attendants who said the attitude of staff was fair. 11.1% (n=31) were
not regular attendants and indicated that the attitude of staff were poor.
7:How often respondents visits the facility * Overall services provided at ANC
center (Crosstabulation)
Overall services provided at ANC
center
Poor Fair Good Excellent
Total

respondents
facility
% of Total .0% 4.9% .0% 11.1% 16.0%
43
Table
% of Total 21.4% .0% 18.3% .0% 39.7%
Very Count 0 82 38 35 155

often
% of Total .0% 23.4% 10.9% 10.0% 44.3%
TOTAL Count 75 99 102 74 350
% of Total 21.4% 28.3% 29.1% 21.1% 100.0%
From the table, 23.4% (n=82) of the respondents attended the facility very often and
described the overall services provided as fair. 21.4% (n=75) were regular attendants and
described the overall services provided as poor. 11.1% (n=39) were not regular attendants
44
but indicated that the services provided at the ANC was excellent. However, 18.3% (n=64)
were regular attendants and described the services as good.
4.5 Factors that help women to access Antenatal Care services or prevent them
from doing so
Table 8: Descriptive Statistics of cost of transportation and distance from residence to

facility
N Minimum Maximum Mean Std. Deviation
How far respondents live 350 1 12 4.21 3.045
from facility (In
Kilometers)
Cost of transportation to 350 1 12 6.80 3.383
and from Facility (in
GHC)
Valid N (listwise) 350
From the table, the average distance a client lived from the study facility was 4.2 kilometers
whilst the average cost of transportation was GH₵ 6.80.
45
Table 9: Permission before attending facility *Influence of permission on quest for
health care (cross tabulation)
Influence of permission on
quest for health care
Yes No
Total
Permission before Yes Count 96 59 155

attending facility
% of Total 27.4% 16.9% 44.3%
No Count 116 79 195
% of Total 33.1% 22.6% 55.7%
TOTAL Count 212 138 350
% of Total 60.6% 39.4% 100.0%
From the table, 33.1% (n=116) did not seek attendance from anybody before attending the
ANC services but indicated that it could have an effect on their quest for health care.
27.4% (n=96) sought permission before attendance and indicated that the permission did have
an influence on their quest to seek health care.
46
Table 10: Person permission sought from * Influence of permission on quest for health
care (Crosstabulation)
Influence of permission on
quest for health care
Yes No
Total
Person permission Father Count 131 0 131

sought from
% of Total 37.4% .0% 37.4%
Mother Count 57 59 116
% of Total 16.3% 16.9% 33.1%
Husband Count 24 39 63
% of Total 6.9% 11.1% 18.0%
Religious Head Count 0 40 40
47
% of Total .0% 11.4% 11.4%
% of Total 60.6% 39.4% 100.0%
From the table, 37.4% (n=131) of the respondents sought permission from their father and
admitted that this permission had an influence on their quest to seek care. 16.9% (n=59)
admitted they sought permission from their mothers but this had no influence on their
quest to seek care. However, 6.9% (n=24) sought permission from their husbands and this
they admitted had an influence on whether or not to seek care.
Table 11: Means of Transportation to the Facility * Distance Motivating Attendance

(Crosstabulation)
Distance Motivating
Attendance
Yes No
Total
Means of Walk Count 39 81 120

Transportation to the
Facility
% of Total 11.1% 23.1% 34.3%
Public Transport Count 90 47 137
48
% of Total 25.7% 13.4% 39.1%
Private car Count 3 17 20
% of Total .9% 4.9% 5.7%
Other Count 47 26 73
% of Total 13.4% 7.4% 20.9%
% of Total 51.1% 48.9% 100.0%
From the table above, 25.7% (n=90) of the respondents used the public transport system
to attend the facility and asserted that the distance was not a barrier in their quest to
access care. 23.1% (n=81) walked to the facility from their residence and asserted that it
was a major barrier in their quest to seek care.0.9% (n=3) used their private cars with the
distance to be covered motivating their attendance, however, 4.9% (n=17) used their own
car but asserted that the distance to be covered does not encourage them to attend the
facility.
49
CHAPTER FIVE
DISCUSSION OF FINDINGS
5.1 Introduction
This chapter discusses the result of the study, the literature review and key variables of the
research.
5.2 Knowledge on ANC
Banta (2007) described ANC as a type of care given to women during pregnancy and it is
one of the pillars of maternal health service an ultimate goal of ANC to prevent health
problems of pregnant women and to ensure that each newborn child has a good start. It
could be noted from this study that the respondents had an idea of what ANC was, since
all the responses agreed with the view of Banta.
Matua (2004), cited that a lack of knowledge about the ANC services could be a major
barrier to women’s utilization of ANC services since they are likely to have limited
knowledge and experiences in seeking health care. This study actually confirmed this
assertion, since all the respondents had heard about ANC. However the disparity arose
from knowledge of the number of visits to be made, the appropriate time to initiate ANC
services as well as the number of visits that had been made as at the time of the study. It
could be noted that the response of the source of the information had a partial effect on the
recommended number of times needed in the period of pregnancy as well as the appropriate
time to initiate the ANC attendance.
50
Also contrary to the assertion by Carla et al. (2002), that while there were potential benefits
to be gained from some of the elements of ANC, most pregnant women presenting for
ANC in Sub-Saharan Africa countries are most likely to wait until the second and third
trimesters. The study found out that an overwhelming 38.9% of the respondents agreed that
the most appropriate time to initiate ANC was immediately the pregnancy was detected.
Again, the findings of this study was in disparity of the WHO (2011) focused ANC. The
focused ANC through the reduced but goal oriented clinic indicated that ANC consists of
at least four visits to a health facility during an uncomplicated pregnancy but this study
found out that the knowledge of women on the required number of visits were postulated
by majority of the respondents to be three times.
On the perceived benefits of ANC, Raatikenen et al. (2007) indicated that Antenatal care
(ANC) for pregnant women by health professionals maintains women’s health during
pregnancy and improves pregnancy outcomes by identifying and managing pregnancy
related complications and Pell et al. (2013) in their study indicated that women stated that
they attended ANC to monitor the progress of their pregnancy or to check the position of
the unborn child. However, whilst majority of the respondents gave responses related to
this assertion, a whopping 29.7% indicated that ANC advocates on healthy diet, which can
possibly hinder further attendance by that sect of people. No respondent in one way or the
other gave any response in line with or closer to the literature of Chakraborty et al., (2002)
which indicated that antenatal care attendance is also associated with an increase in facility
based deliveries and use of postnatal services.
51
5.3 Quality of care and service delivery
Massoud et al. (2001) was of the opinion that some of the core inputs necessary for health
care delivery from the systematic point of view are financial resources, competent health
care staff, adequate physical facilities and equipment, essential medicines and supplies,
current clinical guidelines, and operational policies. These inputs they indicated must be
available and accessible to have an impact and they also must be used to properly carry out
the system processes to produce desired health outcomes. This study looked at care delivery
the average number of staff met at the facility, reception at the facility, services rendered
at the ANC center, the average time spent at the facility and the general attitude of staff.
The WHO antenatal care model recommends that first ANC visit should occur within the
first trimester of pregnancy with the first visit offering an opportunity to establish baseline
information on the general wellbeing of the mother and the pregnancy but Villar and
Bergsjø (2002) indicated that it also helps the impression the expectant mothers assess
personally the services provided in the facility and build up their about the establishment.
By this, the attitude of the staff, the reception at the facility and the average time spent at
the facility plays a very important role in determining the satisfaction and recall of
instructions at the facility. From this study, it was noted that majority of the respondents
couldn’t complain about the reception at the facility although a greater percentage very
often visited the health facility. It can also be noted upon a careful scrutiny that majority
of the respondents did spend more than 2 hours at the facility with 29.7% confirming an
excellent attitude of the staff they meet at the facility.
52
Based on these findings, it can be deduced that these variables have a potency of affecting
the rating of the overall services rendered at the facility since 21.4% and 23.4% rated the
overall services delivery as poor and fair respectively and as indicated by Ansong-Tornui
et al. (2007) may result in complications and avoidable deaths.
On the services provided at the facility, Magoma et al. (2011) in their study concluded that
although women’s descriptions of ANC varied across and within the sites, on the whole,
many do not recall receiving all WHO-recommended procedures. The descriptions were
also often vague and focused on the experience of procedures, such as receiving injections
or tablets, rather than their aim or purpose. This study confirmed the conclusion drawn by
the team since the respondents gave vague answers and could not describe the screening
that are conducted on them at the facility or the minor ailments they claim are managed,
there was also no description off the types of vaccines being given them at the facility with
others indicating they were given health education without a vivid description of what they
were educated on.
5.4 Factors influencing and inhibiting ANC attendance
In as much as preventing problems for mothers and babies depends on an operational
continuum of care with accessible, high quality care before and during pregnancy,
childbirth, and the postnatal period. Lincetto et al. (2014) asserted that it also depended on
the support available to help pregnant women reach services, particularly when
complications occur. The study indicated that respondents who sought permission before
attending the facility admitted the influence of the permission on their attendance therefore
affirming the assertion of Lincetto et al. (2004) that there is the need for social support
which in itself serves as a major determinant of health.
53
Also Witter et al. (2007) concluded that financial barrier is one of the most important
constraints in Ghana, that is preventing women to seek skilled care during delivery and the
introduction of the fee exemption policy proved to be manageable and workable even
within the relatively constrained human resources environment of countries like Ghana. In
Ghana before 2006, pregnant women were charged maternity fees which differ with each
health institution. From 2006, with the advent of National Health Insurance Scheme
(NHIS), any pregnant woman who has registered with the scheme is exempted from
paying. However on 1 July, 2008, the Government of Ghana in order to reduce
the maternal mortality which was high made antenatal and delivery free of charge. With
the advent of this policy, it was projected to remove all the barriers but it couldn’t address
the travel and indirect cost which varied amongst the sites and the respondents at each site.
This study revealed that there were associated costs which came as a result of the distance
that clients had to cover in other to access an ANC facility. This further affirmed the
assertion by Gross et al. (2001) that delays in ANC initiations are partly due to some
indirect costs.
All respondents utilised Antenatal Care services contrary to the GHS/RCH (2005) report
of a decline in ANC coverage. However, this can be as a result of the urban nature of the
sub-metro under study and efforts that are being made on the part of major stakeholders of
maternal health to achieve MDG 5.
This study confirmed the study by Ikamari (2004), that majority of pregnant women might
not be able to afford the maternity fees that are charged because most of them have financial
limitations. It is very evident in this study that whilst majority of the respondents were
income earners per their occupation on the occupational hierarchy, 40.57% were low
54
income earners, further confirming the assertion of Reynolds et al in (2006) that
socioeconomic factors contributed to poor ANC attendance.
Also, the study disapproved of Blonde et al (1993) found that irrespective of age and
social class, unmarried women were less likely to have planned pregnancy and to
attend antenatal care hence they were also likely to miss antenatal care appointments.
It was noted that a vast majority of the respondents (57.1%) of the respondents were single
but attended ANC. And this further disproves the conclusion by Chaibva C.N (2008) that
unmarried pregnant women are less likely to seek antenatal care services due to a lack of
economic social support from parents, guardians or spouses, an assertion which Chaibva
cited WHO (2003).
55
CHAPTER SIX
CONCLUSION AND RECOMMENDATIONS
6.1 Conclusions
6.1.1 Knowledge of respondents on ANC
This segment sought to assess the respondents’ view and knowledge on ANC. It was found
that:
• Majority of the respondents (79%) admitted ANC was the care given to women
before delivery with 16% indicating they heard of ANC from friends and visited
the facility immediately pregnancy was detected.
• Also, on the stipulated number of visits needed, 34.6% of the respondents were of
the opinion that the stipulated minimum number of visits were 3, an answer which
was derived upon a visit to a facility and interaction with care givers with 17.7%
indicating they had visited the facility thrice.
6.1.2 Quality of care and service delivery at facility
This part of the study sought to assess if the services rendered to the subjects at the facility. It
was found that:
• Customer reception by the staff of ANC by the care givers was cold and could serve
as a potential de-motivating factor in utilising ANC services.
• The time spent at the facility by the subjects increased which meant subjects waited
for long before going through the system for care delivery.
• The general attitude of staff improved after the introduction of the policy.
56
• It was also found that subjects felt the overall services provided to them in the facilities
had improved for the better.
6.1.3 Factors influencing or militating against Antenatal Care attendance This part of
the study wanted to identify the alternate reasons why pregnant women do not attend
facilities. It was found that:
• The average cost of transportation to and from the facility was GH₵ 6.80 ($1.8), a
cost which could possibly be a militating factor against attending the facility.
• The quest to seek health care was not dependent on the permission before attendance
meaning if the permission was not granted or not it could not in any way affect the
quest of the subject to seek care. However an overwhelming 34.7% notified their
fathers before attending the facility.
• 51.1% of the respondents indicated that, the distance covered to and from the facility
did not deter them from attending for services.
6.2 Recommendations
Having assessed the gaps (on the basis of the study findings) on the factors influencing the
utilisation of Antenatal Care Services in the Manhyia Sub-metro, the following
recommendations are suggested:
Facilities offering ANC services:
 Staff of the facilities should improve their interpersonal skills with their clients and
receive them warmly since it forms part of maximizing their satisfaction.
 There should be a look at increasing the number of staff at the facilities and the
possibility of applying the LEAN technique to reduce the waste of time in the
57
facility.
 Continuous disseminating of information on antenatal care, delivery and postnatal
care services to enhance accessibility by every pregnant woman.
 Encourage focused antenatal care in line with the stipulations by JHPIEGO
Women attending ANC Clinic:
 Pregnant women should be extensively educated in other to be empowered to have
control over their health and prevent the non-economic barriers that prevents them
from seeking care.
6.3 Recommendation for further Research
The Millennium Challenge Goal 5 is almost due, to be able to achieve this goal there
should be an intensive exploration of the subject area. It is recommended that there
should be a study into the role of the health staff in improving maternal health in the
Manhyia Sub-Metro.
58
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APPENDICES
68
APPENDIX I
INFORMATION SHEET
Information Sheet for study participants
You are being invited to take part in a research study, aimed at assessing the factors
influencing the utilisation of antenatal care services in the Manhyia sub-Metro, Kumasi.
Before you decide to take part, it is important for you to understand why the research is
being done and what it will involved. Please take some time to read the following
information carefully and discuss it with others if you wish. Ask the researcher if there is
anything that is not clear or if you would like more information. Take time to decide
whether or not you wish to take part.
Thank you for reading this.
Who is conducting the study?

The study is being conducted by Afia Seiwaa Yegbe, a student being supervised by Dr Sam
Newton of the Kwame Nkrumah University of Science and Technology, Department of
Community Health, Kumasi.
What is the purpose of the study?

The study is about assessing the factors influencing the utilisation of antenatal care
services in the Manhyia sub-Metro, Kumasi in the realization of the Millennium
Development Goal 5. We will use questionnaires and observations checklist. The field
work for this study begins in September 2014 and will continue until October, 2014.
Why have I been asked to take part?

You have been chosen to present your personal views on antenatal care services in the
submetro
What would be involved?
69
The interview will take place at the facility where you attend your child welfare clinic, or
a place of your convenience if this would make you feel more comfortable. The interviewer
will take you through a semi-structured interview. The interviewer will complete an
interview sheet and take additional notes where necessary. The interview will be relaxed
and informal and it should last not more than 20 minutes. The questions will be asked about
the knowledge on antenatal care services, factors facilitating or inhibiting accessing
antennal care services and the quality of care provided at the antenatal care center.
What happens next?

If you are interested in taking part in this study then consent from will be given to you to sign
or thumb print to affirm your willingness to take part in the study.
Do I have part?
It is up to you decide whether or not to be part. If you do decide to take part you will be
given this information sheet to keep and asked to sign a consent form. If you decide not to
take part you are still free to withdraw at any time and without giving reason.
What are the benefits of taking part?

There may be no direct interview. However, you will be providing useful and important
information, which will contribute to the improvement of maternal health and the quest to
reduce maternal mortality as well as the achievement of the millennium development goal
5 in Ghana generally.
What are the disadvantages of taking part?

You will be asked to provide information on the quality of care provided at the facility as
well as attitude of service providers in the discharge of their duties. You can choose not to
answer a particular question if you wish to do so.
Will my taking part in the study be kept confidential?
70
All information which is collected about you during the course of the study will be kept
strictly confidential. You will be identified by a given code number and no names will be
recorded. This cannot be linked to you in anyway and your name or any identifier will not
be used in any publication or report of this study. However, your participation in this study
is entirely voluntary.
What will happen to the results of the Research study?

The study is for a Masters in Public Health and the results will be presented at scientific
meetings, and published in academic journals. If you wish, you can obtain a copy of the
published results by contacting Afia Seiwaa Yegbe.
You will of course not be identified in any report or publication.
Who is organising and funding this research?

The research is being undertaken by Afia Seiwaa Yegbe, a student at the Kwame Nkrumah
University of science and Technology under the supervision from an academic lecturer.
The student is funding this research.
APPENDIX II CONSENT FORM FACTORS INFLUENCING THE

UTILISATION OF ANTENATAL CARE SERVICES IN THE MANHYIA SUB-
METRO, KUMASI Information Sheet for study participants
You are being invited to take part in a research study, aimed at assessing the factors
influencing the utilisation of antenatal care services in the Manhyia sub-Metro, Kumasi.
Before you decide to take part, it is important for you to understand why the research is
being done and what it will involved. Please take some time to read the following
information carefully and discuss it with others if you wish. Ask the researcher if there is
anything that is not clear or if you would like more information. Take time to decide
whether or not you wish to take part.
Thank you for reading this.
Who is conducting the study?

71
The study is being conducted by Afia Seiwaa Yegbe, a student being supervised by Dr Sam
Newton of the Kwame Nkrumah University of Science and Technology, Department of
Community Health, Kumasi.
What is the purpose of the study?

The study is about assessing the the factors influencing the utilisation of antenatal care
services in the Manhyia sub-Metro, Kumasi in the realization of the Millennium
Development Goal 5. We will use questionnaires and observations checklist. The field
work for this study begins in September 2014 and will continue until October, 2014.
Why have I been asked to take part?

You have been chosen to present your personal views on antenatal care services in the
submetro
What would be involved?

The interview will take place at the facility where you attend your child welfare clinic, or
a place of your convenience if this would make you feel more comfortable. The interviewer
will take you through a semi-structured interview. The interviewer will complete an
interview sheet and take additional notes where necessary. The interview will be relaxed
and informal and it should last not more than 20 minutes. The questions will be asked about
the knowledge on antenatal care services, factors facilitating or inhibiting accessing
antennal care services and the quality of care provided at the antenatal care center.
What happens next?

If you are interested in taking part in this study then consent from will be given to you to sign
or thumb print to affirm your willingness to take part in the study.
Do I have part?
It is up to you decide whether or not to be part. If you do decide to take part you will be
given this information sheet to keep and asked to sign a consent form. If you decide not to
take part you are still free to withdraw at any time and without giving reason.
72
What are the benefits of taking part?
There may be no direct interview. However, you will be providing useful and important
information, which will contribute to the improvement of maternal health and the quest to
reduce maternal mortality as well as the achievement of the millennium development goal
5 in Ghana generally.
What are the disadvantages of taking part?

You will be asked to provide information on the quality of care provided at the facility as
well as attitude of service providers in the discharge of their duties. You can choose not to
answer a particular question if you wish to do so.
Will my taking part in the study be kept confidential?

All information which is collected about you during the course of the study will be kept
strictly confidential. You will be identified by a given code number and no names will be
recorded. This cannot be linked to you in anyway and your name or any identifier will not
be used in any publication or report of this study. However, your participation in this study
is entirely voluntary.
What will happen to the results of the Research study?

The study is for a Masters in Public Health and the results will be presented at scientific
meetings, and published in academic journals. If you wish, you can obtain a copy of the
published results by contacting Afia Seiwaa Yegbe.
You will of course not be identified in any report or publication.
Who is organising and funding this research?

The research is being undertaken by Afia Seiwaa Yegbe, a student at the Kwame Nkrumah
University of science and Technology under the supervision from an academic lecturer.
The student is funding this research.
73
APPENDIX II CONSENT FORM
Title of project: Factors Influencing the Utilisation of Antenatal Care Services in the
Manhyia Sub-Metro, Kumasi
Name of Researcher: Afia Seiwaa Yegbe
Please cross box or thumbprint where necessary
1) I confirm that I have read and understand the

information
Dated………………………. (vision) for the above study and have had the
opportunity to ask questions.
2) I understand that my participation in voluntary and that I am free to withdraw at

any time, without giving any reason, without my legal rights being affected.
3) I agree to take part in the above study

---------------------------------------------------------------------------------------------------
------- ---- -------- ------ --- --- ------ ------- --

Name of subject Date Signature/ thumbprint
--------- --------- ------ ------ ---- ---- ----- -------- ------

Date Signature
Name of person taking the consent
(if different from researcher)

------ ------ ------ ------- -
--------- ----------- ---------
----- -----
Researcher: Afia Seiwaa Yegbe Date

Signature
1 for subject; 2 for researcher
74
APPENDIX III
QUESTIONNAIRE
SECTION A: SOCIO-DEMOGRAPHIC DATA
1. Age (in completed years) ……………….
2. Name of Residential Community ……………………………………….
3. Marital Status: Single [ ] Married [ ] Divorced [ ] Widowed [ ]
other(specify)………..
4. Number of Births; ………..…
a. Number alive: ………
5. Educational Level: Basic Education [ ] SSS/TECH [ ] Tertiary [ ]
other (specify) [ ]
6. Occupation: Farmer [ ] Public Servant [ ] Civil Servant [ ]Unemployed [ ]
Trader [ ] other (specify)…………….
7. Level of income (please indicate amount per month: < GH¢300 at low;
>GH¢300 but < GH¢700 at medium and > GH¢700 at high Low [ ]
Medium [ ] High [ ]
8. Religion: Christian [ ] Muslim [ ] Traditionalist [ ] others (specify)
………………………….
75
SECTION B: KNOWLEDGE ON ANTENATAL CARE
9. What in your view is Antenatal Care Services?
…………………………………………………………………………….............………
……………………………………………………………………………
10. How did you hear about Antenatal Care Services?
Through friends [ ] Through relatives [ ] During a visit to health institution [ ]
Through the media (print and electronic) [ ] other (specify)…………….
11. When is it appropriate for pregnant women to access Antenatal Care Services?
Immediately pregnancy is detected [ ] 1st Trimester [ ] 2nd Trimester [
3rd Trimester [ ]
12. How many visits should a pregnant make to the Antenatal Care Services during the
entire period of pregnancy?
One [ ] Two [ ] Three [ ] Four and above[ ]
13. How often have you accessed Antenatal Care Services?
Once [ ] Twice [ ] Thrice [ ] 4 times [ ]
As often as there are signs of danger [ ]
76
14. What do you think are some of the benefits of Antenatal Care Services?
………………………………………………………………………………………
………………………………………………………………………………………
………………
SECTION C: SERVICE DELIVERY AT ANC/PNC
15. What is the average number of staff you meet in the facility? …….
16. Do you visiting the health facilities very often for services?
Not Regularly [ ] Regularly [ ] Very Often [ ] other [ ]
17. How well are you received in the facilities?
Cordially [ ] Cold heartedly [ ] other [ ]
18. What services are rendered at the Antenatal Care Services?
Screening [ ] Management of minor ailment [ ]
Immunization [ ] Health education [ ]
Others (specify)……………………………………
19. What is to the average time spent in the facility to access health care?
Less than 30mins [ ] 1hr [ ] 1hr 30mins [ ] above 2hrs [ ]
20. What is the general attitude of staff towards their clients?
77
Poor [ ] Fair [ ] Good [ ] Excellent [ ]
21. How will you rate the overall services that were being provided at the center?
Poor [ ] Fair [ ] Good [ ] Excellent [ ]
SECTION D: REASONS WHY PREGNANT WOMEN DO NOT ATTEND
FACILITIES
22. a) how far do you live from the facility (in kilometers)? ……………….
b) Does that motivate you to attend the facility when time is due?
Yes [ ] No [ ]
23. What is the means of transportation to the Antenatal Care center?
Walking [ ] Public means [ ] Private Car [ ] Others
(Specify)…………………
24. How much (in GH₵) do you pay for to and from the antenatal care center or
estimated cost of transportation?
……………………………………………….
25. a) Do you consult anybody for permission before attending a health facility?
Yes [ ] No [ ]
b) If Yes, Who: Father [ ] Mother [ ] Husband [ ]
Religious Head [ ] other (specify) …………………………..
78
c) Does that have an influence your quest to seek care?
Yes [ ] No [ ]
26. a) Do you have any other reason(s) for not utilizing maternal health services?
Yes [ ] No [ ]
b) If Yes, what is it/what are they?
..............................................................................................................................
......
79

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KWAME NKRUMAH UNIVERSITY OF SCIENCE AND TECHNOLOGY, KUMASI

COLLEGE OF HEALTH SCIENCES

SCHOOL OF PUBLIC HEALTH

DEPARTMENT OF HEALTH POLICY, MANAGEMENT AND ECONOMICS

FACTORS INFLUENCING THE UTILISATION OF ANTENATAL CARE

AFIA SEIWAA YEGBE

A THESIS SUBMITTED TO THE DEPARTMENT OF HEALTH POLICY,

COLLEGE OF HEALTH SCIENCE, SCHOOL OF PUBLIC HEALTH, IN PARTIAL

to the memory of my late mother.

most importantly towards the completion of my studies.

CHAPTER ONE .......................................................................................................... 1

CHAPTER TWO ......................................................................................................... 9

CHAPTER FOUR ...................................................................................................... 31

CHAPTER SIX .......................................................................................................... 54

6.3 Recommendation for further Research ............................................................... 56

Table 5: Average number of staff at facility… … … … … 36

Table 14: Means of Transportation to the Facility * Distance Motivating Attendance

Figure 1: Conceptual Framework… … … … … … 7

Figure 2: Respondent’s view on ANC … … … … … 32

it forms part of maximizing their satisfaction.

1.1 Background of the Study

within 42 days of a termination of a pregnancy, irrespective of the duration and

and labor (Brugada, 2011).

been achieved (MOH, 2008).

complications, and promotion of good health. However, women rarely perceive

of maternal services including ANC services (Chandhiok et al. , 2006).

Antenatal care is a major component of comprehensive maternal health care. Antenatal

malaria prevention, and tetanus immunization (Lumbiganon, 1998).

center is US$12.70 (Prata et al. 2010).

1993). An estimated 40% of pregnant women in developing countries develop

disability and/or infant death or disability.

enhance and improve utilization.

1.2 Statement of Research Problem

significantly since the International Conference on Population and Development (ICPD),

Motherhood Initiative, 2003).

delivering a speech at 9th Annual General Conference of Medical Superintendents' Group

(MSG) at Ho on October 20th 2010.

knowledge on infant feeding practices.

documented facts of its content.

1.4 Conceptual Framework

(a) Socio-economic and demographic factors

(b) Knowledge of the women on Antenatal Care

(d) Quality factors

utilize and be satisfied with Antenatal Care Services.

Access factors Utilization of

Source: Researcher’s own concept

1.5 Research Questions

The study sought to answer the following questions:

1. What is the knowledge level of women on Antenatal Care Services?

antenatal Care Services?

3. Does Quality of care rendered to women during Antenatal Care visits

motivate their attendance?

1.6 Research Objectives

1.6.1 General Objective

To determine the factors influencing the utilisation of Antenatal Care Services in

the Manhyia Sub-Metro

1.6.2 Specific Objectives