KWAME NKRUMAH UNIVERSITY OF SCIENCE AND TECHNOLOGY

KUMASI, GHANA

COLLEGE OF HEALTH SCIENCES

SCHOOL OF MEDICAL SCIENCES

DEPARTMENT OF COMMUNITY HEALTH

FACTORS INFLUENCING PERINATAL OUTCOMES AMONG

ADOLESCENT PREGNANCIES IN KASSENA NANKANA MUNICIPALITY,

UPPER EAST REGION

BY

MATTHEW NAAKIYAB LAARI

SEPTEMBER, 2014
 KWAME NKRUMAH UNIVERSITY OF SCIENCE AND TECHNOLOGY
KUMASI, GHANA

FACTORS INFLUENCING PERINATAL OUTCOMES AMONG

ADOLESCENT PREGNANCIES IN KASSENA NANKANA MUNICIPALITY,
UPPER EAST REGION

By

Matthew Naakiyab Laari (Bsc. Nursing)

A thesis submitted to the Department of Community Health

in partial fulfillment of the requirements for the award of degree

MASTER OF PUBLIC HEALTH (POPULATION AND REPRODUCTIVE

HEALTH)

September, 2014

i
DECLARATION
I hereby declare that this submission is my own work towards the MPH, and that

to the best of my knowledge, it contains no material previously published by another

person nor material which has been accepted for the award of any other degree of the

university, except where due acknowledgement has been made in the text.

Student Name and ID: Matthew Naakiyab Laari, 20257653

Signature

Date

Certified by:

Supervisor`s Name: Prof .K. A.Danso

Signature

Date

Certified by:

Head of Dept. Name: Dr. Anthony K. Edusei

Signature

Date

ii
ACKNOWLEDGEMENT
My special thanks go to my supervisor Prof. K. A. Danso for his constructive

advice, criticism and tolerant supervision in helping me to complete this work

successfully. I wish to acknowledge all lecturers and staff of the department of

community health for their guidance. I am also grateful to the Upper East Regional

director of health services for permitting me to carry out the study in the municipality. I

thank the acting director and staff of Kassena Nankana Municipal health directorate and

participants for their support and cooperation. I am grateful to my family and all other

persons who supported me in diverse ways.

Finally I would like to express my appreciation to the authors and publishers from

whose books and articles vital information was extracted for this study.

iii
LIST OF ABREVIATIONS
ANC: Antenatal Care

CWC: Child Welfare Clinic

BECOC: Basic Emergency Obstetric Care

CEOC: Comprehensive Emergency Obstetric Care

MDG: Millennium Development Goal

MHD: Municipal Health Directorate

PRAMS: Pregnancy Risk Assessment Monitoring System

UNICEF: United Nations International Children`s Education Fund

WIFA: Women in Fertility Age

WHO: World Health Organisation

iv
ABSTRACT
Adolescent pregnancies are regarded as the risk factor for adverse perinatal

outcomes. This may be probably due to biological immaturity, unintended pregnancies

and the challenges they often face during pregnancy and the care. There has been

research report of high early neonatal mortality rate from pregnancies of younger

maternal age (15-19years) in the Kassena Nankana Municipality. This appears to be

declining since 2009 probably because of improved health services such as the newborn

care in the municipality. The purpose of the study was to explore the factors that

influence perinatal outcomes in adolescent pregnancies. The sample size was 200

adolescent mothers. Multistage sampling method was used to select the facilities. Simple

random sampling technique was used to select the participants at the facilities. The data

were analysed using STATA version 11 software programme and results presented in

tables. The findings were that prematurity, traditional beliefs and practices, and low

family planning uptake appeared to be more linked to influencing poor perinatal

outcomes among adolescent pregnancies in this study.

A lot more advocacy and sensitisation need to be done by the MHD to discourage

unhealthy cultural practices, low family planning uptake and consumption of alcoholic

beverages among the adolescents. The study also recommends that the MHD intensify

education on family planning uptake by the youth. Youth centres with adolescent

reproductive facilities including sex education and preconception classes need to be

increased by the municipal to optimise good perinatal outcomes among adolescent

pregnancies.

v
TABLE OF CONTENTS

CONTENT PAGE

DECLARATION……………………………….……………………………………..…..ii

ACKNOWLEDGEMENT……………………………………….……………………….iii

LIST OF ABREVIATIONS…………………………………………………………......iv

ABSTRACT……………………………..………………………………………………...v

TABLE OF CONTENT………………. .………………………………………….............vi

LIST OF TABLES…………………………………………. .…………………………...ix

LIST OF FIGURES………….……………………………………………………………x

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

1.0INTRODUCTION…….……………………….............................................................1

1.1Background to the study…………………………........................................................ 1

1.2 Problem statement......................................................................................................... 3

1.3 Rationale for the study...................................................................................................4

1.4 Study objectives.............................................................................................................7

1.4.1 General objective........................................................................................................7

1.4.2 Specific objectives......................................................................................................7

1.5 Definition of terms.........................................................................................................8

CHAPTER TWO…………………………………………………………………………9

2.0 REVIEW OF RELATED LITERATURE.....................................................................9

2.1 The influence of socio-demographic characteristics on perinatal outcomes of

adolescent pregnancies........................................................................................................9

vi
2.2 Health seeking behaviours that influence perinatal outcomes in adolescent

pregnancies........................................................................................................................ 11

2.3 The influence of pregnancy care-seeking behaviour and health care utilisation on

perinatal outcomes.............................................................................................................13

2.4 Summary......................................................................................................................18

CHAPTER THREE……………………………………………………………………...19

3.0 METHODOLOGY......................................................................................................19

3.1 Research design........................................................................................................... 19

3.2 Data collection.............................................................................................................19

3.3 Study area.................................................................................................................... 20

3.4 Study population..........................................................................................................22

3.5 Study variables............................................................................................................ 23

3.6 Sample and sampling technique..................................................................................26

3.7 Data handling...............................................................................................................28

3.8 Ethical considerations..................................................................................................28

3.9 Limitations...................................................................................................................29

3.10 Assumptions.............................................................................................................. 29

3.11 Data analysis..............................................................................................................29

CHAPTER FOUR…………………………….………………………………………….30

4.0 RESULTS....................................................................................................................30

4.1 Demographic characteristics........................................................................................30

4.3 The influence of socio-cultural practices and maternal conditions on perinatal

outcomes............................................................................................................................33

vii
4.4 The influence of health seeking behaviours on perinatal outcomes............................35

4.5 The influence of health care utilisation on perinatal outcomes...................................37

4.5.1 The influence of basic management of baby after delivery......................................39

CHAPTER FIVE…………………………………………………………………..........44

5.0 DISCUSSION..............................................................................................................44

CHAPTER SIX……………………………………………………………………. ……50

6.0 SUMMARY, CONCLUSION AND RECOMMENDATIONS................................. 50

6.1 Summary......................................................................................................................50

6.2 Conclusion...................................................................................................................51

6.3 Recommendations....................................................................................................... 52

LIST OF REFERENCES.................................................................................................. 54

APPENDIX…………………………………………………………….………………...63

viii
LIST OF TABLES

Table 3.1: Background of the Kassena Nankana Municipality (2013)............................. 21

Table 3.2: Sub-municipalities and their populations.........................................................22

Table 3.3: Deliveries (2011-2013).....................................................................................22

Table 3.4: Key study variables………...………………………………………………...23

Table 4.1:Demographic factors......................................................................................... 30

Table 4.2: Perinatal deaths in the sub-municipalities........................................................32

Table 4.3: Socio-cultural factors....................................................................................... 33

Table 4.4: History of Maternal medical conditions...........................................................35

Table 4.5: Health seeking behaviours and perinatal outcomes......................................... 35

Table 4.6: Reasons for mothers not using contraceptives prior to pregnancy...................36

Table 4.7:Health care utilisation and perinatal outcomes..................................................37

Table 4.8: Mothers reasons for home delivery..................................................................37

Table 4.9: Basic management of baby after delivery........................................................39

Table 4.10: The association of socio-demographic factors, health behaviours and health

care utilisation with perinatal outcomes………………………………..………..…........41

ix
LIST OF FIGURES

Figure 1.1: Conceptual approach………………………………………………………….6

Figure 3.1:Municipal map………………………………………………………………..21

x
 CHAPTER ONE

1.0 INTRODUCTION

1.1Background to the study

Infant and child mortality rates mirror the degree of socio-economic progress and

also determine the quality of life of a country. These are essential for monitoring and

evaluating policies, health programmes and population (Paria, 2013).Perinatal outcomes

can pose a public health challenge to the health status and development of the society

(Duvan, 2010). Perinatal outcomes including live births, stillbirths and early neonatal

deaths among adolescent pregnancies are particularly important determinants of infant

mortality and morbidity in life. The impacts of adverse perinatal outcomes are increased

risk of health problems in adulthood (WHO, 2008). A lot of the 3.2 million stillbirths that

occur yearly in the world appear to be more neglected than neonatal deaths and not even

mentioned in the MDG 4. Meanwhile these are also preventable using similar solutions as

for maternal and newborn survival (Yakoob et. al., 2010).

Over 6 million perinatal deaths occur globally each year (World Health

Organization 2006; Carlo et al. 2010).More than 98% of perinatal deaths occur in

developing countries and sub-Saharan Africa has the greatest risk (Lawn, et. al.2011).

Perinatal deaths account for the highest proportion of deaths among children 0-14years

(Lawn, et. al.2011; Carlo WA, Goudar SS, Jehan I et al., 2010).

A considerable progress is made to curtail rising neonatal deaths and to achieve

the Millennium Development Goal 4 target in developed regions, but this is insufficient

in developing regions. Whilst the average annual rates of maternal death (4.2%) and

under-five death (2.9%) decrease faster, the neonatal mortality rate (2.1%) decreases

more slowly (G8 2009; Shiffman2010). At least an estimated 41% neonatal mortality

1
contributes to under-five deaths globally. The perinatal outcomes of young age

pregnancies may be more affected in this regard.

Stillbirths and deaths during the first week of life are 50 per cent higher among

newborns to adolescent mothers than among newborns to mothers in their twenties.

Infants of adolescent mothers are more likely to be premature and have low birth weight

(WHO, 2012). A publication by WHO (2008) suggests that perinatal mortality rate at

birth in adolescent pregnancies is well over 50% in Ghana compared to the lower rate of

women aged 20-29 years old, 38% (Macro international (2008). A true burden of

perinatal outcomes in adolescent pregnancies needs to be clear and further addressed in

Ghana and the Kassena Nankana Municipality.

There is a variation of childbearing adolescent women in African region

depending on cultural, religious, political, economic and other factors. Early pregnancy

has been discussed as an independent risk factor for adverse perinatal outcomes in many

publications (Kurt et.al, 2010). Public health interventions such as intermittent preventive

treatment of malaria, skilled birth attendance and increasing the frequency and quality of

antenatal care have been emphasised as present strategies to reduce pregnancy related

adverse health outcomes of neonates especially among adolescents. Even though, some

factors are known, the discovery of additional unidentified preventable risk factors for

adverse perinatal outcomes among adolescent pregnancies is required to further reinforce

present efforts to reduce perinatal mortality. The aim of this study is therefore to explore

the influence of socio-cultural factors and health service utilisation on perinatal health

outcomes of adolescent pregnancies. The study will help revitalize efforts to reduce child

2
and newborn deaths and to contribute towards achieving Millennium Development Goal

4(MDG-4, Reduce child mortality) in Ghana.

1.2 Problem statement

The growing incidence of teenage pregnancies and its associated adverse perinatal

outcomes has been of great concern to every right-thinking Ghanaian and the people of

Kassena Nankana Municipality. Several factors affect pregnancies which sometimes

result in poor perinatal outcomes such as early neonatal mortality, stillbirth, premature

births and low birth weight. Adolescent pregnancies are suggested to be at increased risk

for these adverse perinatal outcomes. Adolescents may face so many barriers in making

decisions and also receiving health care ranging from prenatal, antenatal and postnatal

period.

Even though the antenatal coverage in the Kassena Nankana Municipality keeps

on improving year by year, perinatal deaths rather seems to decrease steadily. The

Municipal has also performed well to significantly decrease maternal deaths by about

50%. Despite the increased antenatal care services and improved skilled deliveries,

perinatal deaths rather decrease steadily as of 2009. There has been a high neonatal

mortality and the most important causes are direct. The most common causes of neonatal

death include birth asphyxia and injury, infections and prematurity in rural Northern

Ghana. More of the neonatal deaths occur in the first week of life. Studies have shown

that more of this burden is realized in the adolescent deliveries. Young maternal age less

than 20years is about two times associated with this phenomenon in the Municipality.

The study recorded neonatal mortality rate of 39.2 per 1000 live births from births of

young maternal age less than 20years and 22 per 1000 live births from births of mothers

20 years and above (Welaga et.al. 2013). The probable increase in adverse perinatal

3
outcomes particularly in adolescence is perceived to be attributed to biological

immaturity. The problem of perinatal death is probably given little attention. It could also

be attributed to the cultural believe that such a product of conception at that early stage is

not counted as yet a human being and soon forgotten of without records. A lot more

investigation is therefore required to better appreciate the socio-demographic and health

service factors that influence high early neonatal mortality particularly in adolescent

pregnancies.

1.3 Rationale for the study

The study should help reveal unsuspected factors that may be contributing to

perinatal outcomes among adolescent pregnancies in the Kassena Nankana Municipality.

The study will help define areas where concerns of adolescent mothers may need

improvement. It will help strengthen those areas so as to inform Ministry of Health

(MOH) policies for planning effective strategies to prevent adverse perinatal outcomes

associated with adolescent pregnancies. This study will help develop more awareness

campaigns of the complications and deaths due to adverse perinatal outcomes particularly

in early neonates delivered by adolescents.

Possibly, other districts/municipalities which share similar characteristics with Kassena

Nankana Municipality could adopt the findings to help solve perinatal problems of

adolescent pregnancies.

4
Conceptual approach
Literature reveals that potential risk factors of adverse perinatal outcomes are:

indirect and remote factors which include personal characteristics of the woman: age,

education, marital status and parity. Socio-cultural factors such as religious affiliations,

occupation and traditional beliefs and practices like prevention of eating certain kinds of

food. The use of herbal preparations during pregnancy is noted as some of the

contributing factors to adverse perinatal outcomes. Health behaviours such as alcohol

use, the decision to be pregnant and whether to use contraceptive or not are also the

determinants of perinatal outcomes. Health seeking behaviours and health care

utilisatiion are important in determining the outcome of pregnancy. Adequate level of

antenatal attendance of at least greater than four times optimise good perinatal outcomes

since it helps identify high risk mothers and address their needs. The history of maternal

illnesses such as anaemia, malaria, hypertension, diabetes among others determines to a

large extend the outcome of pregnancy.

5
Conceptual approach

Health behaviour Personal

Socio-cultural
 Pregnancy characteristics of
factors
 intention Women
Religion
 Contraceptive  Age
 Occupation
use  Education
 Decision
 Tobacco/cigare  Marital
making
ttes use Status
power of
 Alcohol  Parity
women
consumption
 Beliefs and

traditional
practices

Figure 1.1
Maternal
underlying Source:
conditions: Student Author

Anaemia

Hypertention
 6
Malaria

Diabetes

Perinatal outcomes
 Access
 Too long distance
 High travel cost
 place of residence

Inadequate health care utilization

Quality of service,
 Long waiting time
 High cost
 Attitude of Staff
 Skilled attendance
 1.4 Study objectives

1.4.1 General objective

The main objective of the study is to determine factors that influence perinatal outcomes

among adolescent pregnancies.

1.4.2 Specific objectives

The specific objectives to answer the research questions of the study are to:

1. Determine the socio-demographic factors that influence perinatal outcomes among

adolescent pregnancies?

2. Determine health seeking behaviours influencing perinatal outcomes among adolescent

pregnancies?

3. Determine the influence of health care utilisation on perinatal outcomes among

adolescent pregnancies?

4. Use the findings to make recommendations that will inform the Municipal health

directorate for planning effective interventions to prevent adverse perinatal outcomes associated

with adolescent pregnancies.

7
1.5 Definition of terms
Adolescents: Persons aged 15-19years old

Adolescent pregnancy: Pregnancy in female 15-19years old

Premature birth: The birth of a baby before 37 completed weeks of pregnancy

Perinatal outcomes: live birth, perinatal death

Adverse Perinatal outcomes: stillbirth, perinatal death

Perinatal death: A stillbirth and death occurring during the first 7 completed days of life.

Stillbirth: a baby delivered after 28 weeks gestation without any signs of life

Unmet need for conception: Refers to when a woman in union or sexually active, she can

conceive, does not want to become pregnant within the next two years, but she does not

use any contraception to prevent pregnancy.

Unintended pregnancy: This is a pregnancy that is mistimed, unplanned or unwanted at

the time of conception.

8
 CHAPTER TWO

2.0 REVIEW OF RELATED LITERATURE

Introduction
The review has been organised along the lines of the socio-demographic

characteristics, health seeking behaviours, pregnancy care-seeking behaviour of

adolescents and health care utilisation influencing perinatal outcomes among adolescent

pregnancies. It also includes maternal conditions such as anaemia, malaria, diabetes and

hypertension that have influence on perinatal outcomes.

2.1 The influence of socio-demographic characteristics on perinatal outcomes of

adolescent pregnancies

Socio-demographic characteristics determine the behaviour and general health of

all persons and outcomes of pregnancy in both adolescents and adult mothers. There are

variations in how these influence perinatal outcomes. In adolescent pregnancies, age has

been adjudged a major determinant of adverse perinatal outcomes. Ages below 19 years

and above 35 years are said to be at increased risk of poor perinatal outcomes such as

pre-term, small for gestation, low birth weight babies and high neonatal mortality

(Stewart et al., 2007). A study by Pun and Chauben (2011) suggests that adverse

pregnancy outcomes could be attributed to lower maternal age and underprivileged socio-

economic background, quality of prenatal visits and family supports.

Low level of education has indirect effects on the understanding of nutrition and food

aspects as well as upgrading of the socio-economic conditions. Higher education of the

mother determines to a greater extend the child survival (Walraven et al., 1995; Ansah,

2006). Delivery under unhygienic conditions, the use of non-sterile instrument for cutting

cord and dressing it with cow dung are threats to neonatal survival. Seclusion of 9
both mother and baby soon after delivery contributes to delay in seeking for health when

either of them is probably ill (Kruger, 2007). In Ghana women believe the use of herbs

prior to labour facilitate safe delivery (Debrah, 2010). The frequency of pregnancy during

adolescence is greatly not consistent in Africa. Short birth interval does not give the

mother enough time to recover from the nutritional burden and stress of the preceding

pregnancy, which may lead to poor perinatal outcomes (Dewey& Cohen, 2007). Marital

status has been reported to influence perinatal outcomes. According to Swati (2007)

teenage mothers are more likely to be unmarried compared with adult women. The

findings of a study conducted by Duvan et al (2010) in Turkey instead showed that most

adolescent pregnant women are married and well supported by their families. It therefore

suggests that most of their pregnancies are planned and intended. In some jurisdiction,

young girls are not aware of existence of their legal rights against child marriage. They

may therefore be bound to marry early in life without consent in domestic violence

dominated areas (UNFPA, 2012). The early marriage can lead to complications related to

pregnancy and childbirth as well as poor perinatal outcomes (Auger et al., 2008). In the

view of Charles et al. (2009), sexually transmitted infections such as syphilis and

HIV/AIDS have been connected with poor pregnancy outcomes including spontaneous

abortion, stillbirth, pre-term birth and low birth weight.

Others think otherwise. Whilst a study conducted by Mosha and NapendaelI

(2010) rather agrees that maternal height, maternal total weight during the last two

trimesters and haemoglobin levels has substantial impact on the infant birth weight and

subsequent poor perinatal outcomes, Kurth et al. (2010) on the other hand states that the

chances of delivering an infant with low birth weight is more than doubled for adolescent

10
women compared with mothers older than 16 years. Biological immaturity and

continuous maternal growth may stand for biologic growth barriers for the foetus. This

may result in adverse perinatal outcomes.

However, a study by Nancy and Deanna (1997) in U.S.A revealed that 15-19-

year-olds among blacks face significantly lower risks of delivering low-birth-weight

babies than black women aged 25-29. Additionally, on the face of it poorer birth

outcomes of teenage mothers appear to result largely from their adverse socioeconomic

circumstances, not from young maternal age per se”. Racial difference may not be of any

significance in Ghanaian population and for that matter the study area since almost all of

the inhabitants are from black origin. A clear cut etiology of adverse perinatal outcomes

in adolescent women is difficult to establish. Both biological and socio-demographic

factors are implicated (Duvan et al, 2010).

Teenage mothers again are more at risk of developing anaemia and having

preterm delivery as well as low birth weight. Adolescent mothers are twice as likely to

develop hypertensive problems with less assisted and caesarean deliveries compared to

adults (Pun and Chauhan, 2011). Welaga et al (2013) have demonstrated that multiple

births, gestational age less than 32weeks and first pregnancies have the highest

significant association with neonatal death particularly in the first one week of life.

2.2 Health seeking behaviours that influence perinatal outcomes in adolescent

pregnancies
Some health behaviours do not result from pregnancy itself, but directly

contribute to proximate causes of death and disability in newborns. They also indirectly

contribute to underlying health conditions such as anaemia (James, 2010). These

11
behaviours include tobacco/cigarette smoking and alcohol use, pregnancy intention and

contraceptive use. These are reviewed as follows.

2.2.1 The influence of tobacco/cigarette smoking and alcohol use on

perinatal outcomes
Pregnant adolescents are more likely to smoke and abuse a drug than are older

women (Lule & Rosen, 2008). Research shows that there is a relationship between

mothers who took antibiotics and preterm delivery than those who consumed alcohol

(Bayingana et al., 2010). Exposure to alcohol and tobacco during pregnancy are known to

be associated with low birth weight, birth defects, sudden infant death syndrome and

asthma and respiratory illnesses. Exposure to environmental tobacco smoke may set in

utero and continue throughout development (Marinda and Sharon, 2009).

2.2.2 The influence of pregnancy intention on perinatal outcomes

Unintended pregnancy means a pregnancy that is mistimed, unplanned or

unwanted at the time of conception. The intention of pregnancy is largely determined by

the decision making power of the adolescent mother.

The adverse effects of unintended pregnancy on perinatal outcomes could be

greatly felt. The danger of low birth weight delivery and infant mortality are known to be

higher among unintended pregnancies compared to planned pregnancies (North Carolina

PRAMS Fact Sheet, 2009). A study by Marinda and Sharon (2009) shows that

unintended pregnancy is linked with young maternal age, African-American race, lower

maternal education, and Medicaid use. The findings revealed that over 50% of women

who reported they did not intend to become pregnant were not actively avoiding

pregnancy. Again the findings in the study by Duvan (2010) indicates that majority of the

unplanned adolescent pregnancies are also unintended. This study used adults as a control

12
in which there could be confounding factors. Also using only hospital data may leave out

some socio-cultural factors that affect perinatal outcomes in the adolescents.

2.2.3 The influence of contraceptive use on perinatal outcomes

Early initiation of sexual activity without contraceptive use predisposes

adolescents particularly to high risk of unplanned teenage pregnancies and associated

adverse perinatal outcomes. A major concern is the issue of unintended pregnancies,

unsafe abortion and preterm deliveries (Magadi, 2004). The rate of contraceptive use

among both married and unmarried adolescents remains low globally. Unmet need for

contraception among the youngest age group is high (James, 2010). In sub-Saharan

Africa it is indicative that the incidence of adolescent pregnancies is highest, largely due

to lack of effective contraception for adolescents (Treffers, 2003).

2.3 The influence of pregnancy care-seeking behaviour and health care utilisation
on perinatal outcomes

Health care utilisation involves the use of health services in terms of clinical,

public health services or the services of medical care professionals. Health care utilisation

is influenced by diverse factors. Health care utilisation behaviour ranges from the use of

preventive services, such as prenatal care or early discovery and screening tests, to

possible surgery or involuntary hospitalisation. The study of health care utilisation

behaviour includes examining the extent to which these services are used. It also spells

out how satisfied clients are with the services.

Pregnancy care seeking behaviours are influenced by variety of factors, the

demand on one side and supply on the other side. These factors may lead to different

choices and inadequate health care utilisation leading to adverse perinatal outcomes. The

13
underutilisation may include low antenatal care attendance and home deliveries. The

influencing factors may include perceived poor staff attitude, poor quality of health

services and inadequate skilled attendants.

2.3.1 The influence of antenatal visits on perinatal outcomes

There is a wide variety of demand and supply faces factors that influence use of

pregnancy care. Mothers in general recognise antenatal services as most useful and

beneficial. Adolescents relatively have less personal autonomy in making health care

decisions. They are more economically underprivileged, have less authority over use of

economic resources, have less mobility (particularly married adolescents), and are more

affected by household cruelty. It is however stated that no evidence shows that

educational level or social and cultural factors such as traditional beliefs have differential

effect on adolescents’ use of pregnancy care (Amponsah 2006; James 2010).

Many factors influence ANC attendance across sub-Saharan African countries

with varying levels among rural and urban areas. These may include: a woman’s and/or

her husband’s level of education; a woman’s occupation; economic status; distance to

health facility; parity, age and stigma of adolescent pregnancy (Pell et.al.2013).

Adolescents face health challenges that have not come to the notice of health workers.

Adolescents may underutilise health services probably because of long waits, distance to

health facilities or unfriendly services. They could also feel ashamed to ask for money for

the cost of the required visits (UNICEF, 2011).

A survey data from sub-Saharan Africa indicate that women often only

commence ANC after the first trimester and do not accomplish the ideal number of ANC

visits. Ghanaian women for instance initiate ANC earlier and are more likely to achieve

14
four ANC visits; all the same the proportion of deliveries in health facilities is lower

compared to Malawi and Kenya (GSS 2008, NSO 2010).

Many scholars have pointed to the fact that successive number of ANC visits (4

times) by a pregnant woman is a prerequisite for good perinatal outcomes. Jesmin.et al

(2012) succinctly put it that ANC visits are associated with increased uptake of facility-

based delivery and improved perinatal survival. The misunderstanding of the concept

about focused ANC has led to several perceived conclusions. However, the issue of

focused ANC and its benefits stresses the fact that there should be quality improvement

in care of pregnant women. It is not necessarily the number of visits. Nyarko et al (2006)

emphasise the need for quality and comprehensive ANC services.

It is noted in a study that a number of factors affect ANC attendance. In Kasena-

Nankana municipality particularly, women walk for up to an hour to reach the nearest

health facility and longer to a bigger health centre. Adolescents and unmarried younger

women hid their pregnancies and delayed ANC visits so as to turn away from the

probable social implications of pregnancy such as exclusion from school, expulsion from

their biological home, partner abandonment, stigmatisation and gossip. Also, few women

in Kenya are cautious of attending antenatal clinic because they would be told of their

HIV status knowing that a positive result has ramifications if their status is exposed to

their husbands. The findings also revealed that communication at health facilities is more

two-way if a woman was relatively affluent or well educated or had a familial

relationship or friendship with the health worker which is more of social context. The

cost of ANC attendance also varies among countries and at different sites. In northern

Ghana, commercial transportation in remote areas is scarce. Women mainly walk to the

15
clinic and travel costs may be minimal. Pregnant adolescents are more likely to be

affected by this situation since they are tied to their parents ‘strings’ and cultural norms in

the society. Though young woman somewhat understood the importance of ANC visits, it

is perceived to be obligatory as a result of the authority of health staff or the vague idea

of it being the ‘law’ in Upper East Region ( Pell et al.,2013).

Perhaps the limited knowledge of young women about antenatal care programmes

and the fear of HIV testing have been further obstacles to efficient antenatal care.

Convincingly adolescent age and antenatal care are directly related for the improvement

of pregnancy outcomes in Central Africa (Kurth et. al. 2010). Poor neonatal outcomes of

teenage pregnancy may be related to non-utilisation of prenatal care rather than their

biological age (Swati, 2007). This was a hospital-based study and might not establish

significant association of adverse perinatal outcomes with socio-cultural factors. These

findings compared the adolescent and adults in which there could be a sampling bias in

terms of differences in age (Mann, 2003). Other studies blame poor perinatal outcomes in

adolescent pregnancies on quality of prenatal care (Pun and Chauhan, 2011).

Place of delivery has potential effect on the outcome of pregnancy. Birth

preparation in adolescents and choice of delivery place may be different from that of

adults since their decisions are largely controlled by the adults and the socio-cultural

norms. Adolescents who are married and live in rural areas of India for instance have low

utilisation of maternity care services. Low utilisation of safe delivery care is higher

among Muslim adolescent women compared with other religions. They however initiate

breastfeeding sooner than other religious groups and this promotes child survival in this

group (Singh, 2012).

16
 The decision of a woman to deliver at health facility is also influenced by husband

and other family members and availability of traditional birth attendant. Therefore in

obstetric emergency situation, every moment of delay in seeking and receiving skilled

care increases the risk of maternal deaths/disability and stillbirths (Abdou, 2011). Other

findings blame characteristics of unfriendly youth services as major barrier of adolescents

concern (Senderowitz, 1999).

2.3.3 The influence of skilled attendance on perinatal outcomes

The vulnerability of babies during birth to various complications demands that all

women and babies have access to childbirth care from skilled care providers. Skilled care

in an enabling environment should provide key interventions during labour and sufficient

essential newborn care such as warmth, early and exclusive breastfeeding, and

cleanliness. It demands that resuscitation should be initiated if the baby does not breathe

within 30 seconds after birth. Aside these, improving linkages with the community, and

promoting simple home behaviours must save lives (Luwei et al., 2007).

Access to skill birth attendance, available and quality EOC also determines the

perinatal outcomes among adolescent pregnancies (Gabrysch et al 2012). Charles et al

(2012), instead talk about minimum UN coverage rates for EOC as are anticipated to be

one Comprehensive (CEOC) and four Basic EOC (BEOC) facilities per 500,000

populations. Presence of these interventions contributes significantly to good maternal

and perinatal outcomes. It may largely depend on availability and adequacy of skilled

staff. The concern now is the adequate skills needed to attend to adolescent pregnant

women in particular during labour (World Health Organization, MPS Department, 2007).

A study by Baiden et al. (2006) suggests that having skilled attendance and

avoidance of infanticides could contribute to reduce neonatal mortality in the Kassena

17
Nankana Municipality. Other scholars think otherwise. Deaths due to preterm birth

complications could be reduced at faster rate and addressing these deaths requires

specific skills, such as for feeding support and Kangaroo Mother Care, and at least some

basic commodities (Liu et al. 2012, Lawn et al 2010). Even though Ipas, a U.S.-based

organisation has trained midwives in the field of reproductive health which has reduced

post abortion complications in adolescents, it appears little is done for adolescents to have

access to skilled delivery care (Senderowitz, 1999).

2.4 Summary
A relevant literature review has been made to provide knowledge on the factors

that influence perinatal outcomes among adolescent pregnancies. There are different

interpretations of these factors by different authors. All that is got from the literature is

that adequate prenatal, antenatal and postnatal care contributes to good perinatal

outcomes. Adverse perinatal outcomes have rippling effect not only in the neonatal life

but in adulthood as well. Factors contributing to this range from personal characteristics

of the adolescents to health care utilisation. These factors include age, marital status,

parity, decision making power of women, history of maternal conditions, alcohol use,

pregnancy intension, contraception, number of antenatal visits, place of delivery and

skilled attendance. It is my hope that this review of literature would not only be used as a

study guide but would add value to findings of the study.

18
 CHAPTER THREE

3.0 METHODOLOGY

Introduction
This chapter describes the specific design that was used in the study. It also

includes the study area, population, and data collection tools and data collection

techniques.

3.1 Research design

The researcher used cross sectional study type. This is because the information

about both risk factors and the outcomes were ascertained during the same period of time.

It could also help identify predictors of multiple perinatal outcomes (Gail A.1995; Mann,

2003). It was a Facility-based study.

Quantitative data collection technique was employed in gathering data. The

research assistants who understand both English and the local dialect collected the data

using structured interviews.

3.2 Data collection

A written structured questionnaire was the tool used. All mothers who were

adolescents and delivered within the given study period were interviewed. The data was

collected from participants during antenatal and child welfare clinics. There was one set

of questionnaire that served as interview guide for research assistants. The written

questionnaire covered issues of perinatal outcomes among adolescent pregnancies found

on the public domain and the literature review. The questionnaire was divided into

sections. Most (95%) of the items were closed questions.

19
3.3 Study area
The Kassena-Nankana Municipality is one of the nine (9) Districts/municipalies

located in the Upper East Region of Ghana. It spreads for 55 kilometers from north to

south and 53 kilometers from east to west. The municipality shares boundaries to the;

North with Kassena-Nankana West District and Burkina Faso, East with Kassena-

Nankana West District and Bolgatanga Municipal, West with the Builsa District and

South with West Mamprusi District (in the Northern Region). The Municipal capital is

Navrongo. This municipal has an estimated population of 113,950 living in 110

communities. It has a population density of 92 persons per square kilometer which shows

a dispersed population. The majority of the population is rural, only 13 per cent of the

population lives in towns. Only Navrongo can be classified as an urban settlement.

The Municipality is made up of seven sub-municipalities namely Navrongo

Central, Navrongo East, Pungu, Manyoro, Kologo, Wuru and Vunania/Kapania. For this

study, five sub municipalities were sampled. The proportion of women in their

reproductive age is 24%. Only the eligible adolescent mothers took part in this study.

There are an estimated 23 health facilities in the Municipality: Municipal Hospital-1,

Health Centres-2, Private Clinic-1, CHAG facility-1, Functioning CHPS -19.

20
Figure 3.1

Table 3.1

Background of the Kassena Nankana Municipality (2013)

TOTAL POPULATION 113,950

0-11 Months 3305
0-59 Months 22790
WIFA 26550
Expected pregnancies 3305
Number of sub-Municipals 7
Number of communities 110
No of Hospitals 1
No of Health Centres 2
No of Clinics 3
No of CHPS Zones 24(19)F

Source: Municipal health directorate profile

21
 Table 3.2

Sub-municipalities and their populations

Sub-municipality Population

Navrongo central 25,752

Pungu 13,674

Manyoro 15,953

Wuru 15,041

kologo 17,092

Vunania/Kapania 9,121

Navrongo east 17,318

Source: Municipal health directorate

Table 3.3

Deliveries (2011-2013)

Year Total deliveries Adolescent deliveries

2011 2179 332

2012 2431 366

2013 2353 342

Source: Municipal health directorate

3.4 Study population

th
The study population was all women of reproductive age (15-49years) as of 30

September 2013. A sample from this population was drawn and consisted of adolescent

mothers who have experienced stillbirth or delivered as of 30th September 2013. They

22
must have been 15- 19years old at the time of delivery and resident in the Municipality

since the last two years as of 30th September 2013.

3.5 Study variables

The dependent variables of interest are stillbirth and early neonatal death. Below are the

independent and dependent variables.

Table 3.4

Key study variables

Conceptual Operational Scale of Objective

definition of Definition/Indicator Measurement to be

variable addressed

Age Age in complete years of the Nominal One(1)

mother at the time of

15-17
delivery
18-19

Place of Place where mother resided Nominal One(1)

residence for at least a month before Rural

delivery Urban

Birth interval Number of months interval Nominal One

from one delivery to the next <24months

≥24monyhs

Don’t remember

Gestation Number of months old of Nominal One(1)

pregnancy at delivery <9months

23
 ≥9months

Don’t remember

Traditional Traditional beliefs and Binary One(1)

beliefs and practices mother engaged in Yes

practices during pregnancy No

Maternal Diseases suffered by mother Nominal One(1)

conditions prior to or during pregnancy Anaemia

Malaria

Hypertension

Diabetes

Other(specify)

Alcohol Consumption of alcohol Binary Two(2)

consumption during pregnancy Yes

No

Pregnancy Planned intention of mother Binary Two(2)

intention to or not to be pregnant Yes

No

Contraceptive Mother ever used Binary Two(2)

use contraceptive prior to most Yes

current pregnancy No

24
Mother`s level of Number of Antenatal Nominal Three(3)

Antenatal Visits <6visits

attendance ≥6visits

Place of delivery Place where baby was Nominal Three(3)

delivered Home

Health facility

Client Client impression about care Ordinal Three(3)

satisfaction received at clinics Good

Poor

Perinatal death Baby delivered with no life Binary Perinatal

after 28days of gestation or Alive outcome

dead in first one week of life Dead

Age of baby at Age baby died in days Interval Perinatal

0-1 day
death(neonatal) outcome
1-3days

4-7days

Don’t remember

25
3.6 Sample and sampling technique
In this study, data was collected from 200 participants during antenatal visits and

child welfare clinics using simple random technique. Participants were selected with their

consent just to make sure that they were participating willingly and also relaxed before

answering the questions. Adolescent mothers who wanted to be interviewed privately in

their homes were given the opportunity. Mothers who also wished to seek for their

parent`s or husband`s consent were allowed to do so. The investigator used Confidence

level of 95 %( 1.96).

3.6.1 Inclusion criteria

The study participants comprised of adolescent mothers (15-19years) as of the

end of 30th September 2013.They must have been adolescents (15-19years old) at the

time of delivery and resident in the Municipal since the last two years. Only adolescent

mothers with history of singleton births were interviewed.

3.6.2 Exclusion criteria

Adult mothers who were above 19years old at the time of delivery and not

resident in the Municipal since the last two years. Mothers below 15years were not

included. Mothers who delivered twins in the study period were not interviewed. All

adolescent mothers who met the inclusion criteria at the study period were included and

proportion of perinatal deaths calculated.

3.6.3 Sampling technique

A multi-stage sampling method was employed. It included:

First stage –Simple Random Sampling of five sub-municipalities

Second stage – Simple Random Sampling of ten facilities

Third stage – Systematic Random Sampling of participants

26
Five sub-municipalities out of the seven were selected by simple random sampling using

the “lottery” technique. Two Health facilities (Hospital, Health Center/CHPS Center)

were selected from each sub-municipality by simple random sampling representing 10

facilities in total. At each sub-municipality, the health facilities were assigned numbers.

These were written on separate pieces of papers which were folded and put in a box. The

box was shaken to ensure randomisation. Two neutral persons assisted. Each of them

picked only one folded piece of paper without replacement. The facilities assigned to

those numbers picked were included in the sampling sites. Sampling frame which is a

listing of all the selected facilities were developed and used to calculate the sampling

interval. From this interval, the facility to start with was taken. The investigator then

visited the facility. This was followed by selection of the participants.

At the facility level, a listing of mothers who have delivered two or less years ago

and (in the age brackets of 15-19years) as of 30th September 2013 was done. The number

of participants to be selected from each facility was calculated based on the average

monthly population attendance of the mothers. The investigator selected every participant

using simple random technique till all the required number of participants was got. Only

adolescent mothers who have ever experienced delivery or stillbirth within the specified

study period were interviewed.

3.6.4 Sample size estimation

Sample size was estimated at 200 as follows:

, sample size

Confidence level set at 95% (1.96)

The p-value was set at 0.05.

27
z standard normal deviation set at 1.96

p proportion of adolescent deliveries 15%

d degree of accuracy desired at 0.05

195.9216 196, approximately 200

Sample size was therefore estimated at 200 participants for the study.

3. 6.5 Pre-testing of research tool

To ensure validity of the instruments for the study, the questionnaire was given to

course mates and the supervisor to read through. Suggestions that were made helped the

investigator to modify and restructure the questionnaire appropriately. Pre-test was also

carried out at non-selected facilities which share common characteristics with the

selected ones in the municipality. The necessary modifications were done.

3.7 Data handling

The research assistants were well informed on confidentiality and secrecy of all

information. No names were used in order to preserve confidentiality for all records. All

answered questionnaires were collected at the end of every day. They were put in a

cabinet under lock and key by the investigator. All persons handling the data were keenly

supervised especially during the stage of analysis. The computers for the data analysis

had passwords which were known by only the principal investigator.

3.8 Ethical considerations

This proposal was sent to the KNUST Committee on Human Research,

Publications and Ethics for review and feasible advice. This was to ensure that the rights

of all participants was valued and also in accordance with scientific enquiry. Informed

28
consent was obtained from the participants. The investigator also obtained informed

consent from the head of the health institutions and community leaders.

3.9 Limitations
The study might not cover some adolescents who deliver at home and fail to

attend antenatal and child welfare clinics. The study is concerned with only the perinatal

outcomes and not mothers. Some of the adolescent mothers might have left the area at the

time of data collection to other parts of Ghana for greener pasture and would be missed.

There may be difficulty of recall of events by participants. The study could not also

assess the skill mix or competencies of the skilled staff and logistic strengths of the

facilities.

3.10 Assumptions
It was assumed that the study population is normally distributed and the

participants responded objectively. Also, the adolescent mothers were already familiar

with research activities in the Municipality and were willing to participate fully.

3.11 Data analysis

All returned questionnaires were cross-checked for completeness and corrections

made immediately. A period of one month was used for data collection. The data to

answer the research questions were processed and analysed using statistical software

STATA version11. The multiple choice and dichotomous responses were converted to

percentages. The investigator measured the association between independent variables

and the dependent variable with odds ratio, the observed association between independent

variables and the dependent variable (perinatal outcomes) were tested for statistical

significance using chi square test. For further analysis binary logistic regression was

used.

29
 CHAPTER FOUR

4.0 RESULTS

Introduction
This chapter involves presentation and interpretation of the responses received.

The aim of the responses was to address the research objectives formulated by the

researcher. These include: to determine socio-demographic factors that influence

perinatal outcomes, to determine health seeking behaviours that influence perinatal

outcomes, to determine the influence of health care utilisation on perinatal outcomes

among adolescent pregnancies.

The results have been outlined under the following sub-headings: the influence of

demographic factors, the influence of socio-cultural factors and maternal medical

conditions on perinatal outcomes, the influence of Health behaviours on perinatal

outcomes and the influence of health care utilisation on perinatal outcomes.

4.1 Demographic characteristics

Table 4.1

Demographic factors

Total P- value
Perinatal deaths
Category births (95% CI)
(PNM/1000births)
N (%)
Maternal age(years)
15-17 59(29.5) 2(33.8)
18-19 141(70.5) 4(28.4) P=0.834
Residence
Rural 165(83) 5(30.3) P=0.300
Urban 35(17) 1(28.5)
Marital status
Married 118(59) 4(33.9)
Single 57(27.5) 2(35.1)
Divorced/Separated 11(5.5) P=0.83
Living with partner 14(7)

30
Level of education
No formal education 31(16) 2(64.5)
Primary 152(76) 3(19.7) P=0.240
Secondary/Tertiary 17(8) 1(58.8)
Parity
Nulliparous 159(80) 3(19) P=0.0.069
Multiparous 41(20) 3(73)
Birth interval
<24months 18(9) 2(133)
≥24months 175(88) 4(27) P=0.101
Don’t remember 7(3)
Gestation
<9months 22(11) 3(136) P<0.000
≥9months 174(87) 3(17.5)
Don’t remember 4(2)
Source: Student field survey

In this study all participants were adolescent mothers who have been pregnant as

well as experienced still births or delivery at adolescent age. Within the study period

between October 2011 and September 2013, a sample of 200 adolescent mothers who

delivered were interviewed. They were mothers who had singleton births. Out of the 200,

six experienced perinatal mortality representing 30 per 1000births. One of the deaths

occurred in the first day, three within the first three days and two between the third and

seventh day of life. Over 83% of all the deaths occurred at health facilities.

From table 4.1, the ages of participants at delivery ranged from 15-19years. With

respect to the age distribution, it is seen that most of the participants comprising about

71% were between 18-19years of age and 29% were in the age category of 15-17years

old. Perinatal death rate in the mothers with age groupings 18-19years was 28 per 1000

live births compared to 15-17years group (33 per 1000 live births).

The proportion of adolescent mothers in the rural areas was 83% and in

the urban areas 17%. It also revealed that more of the perinatal cases (30

per 1000 live births) occurred among adolescent mothers in the rural areas

while (28 per 1000 live births) occurred 31

among mothers in the urban areas. Most participants comprising 76% have been educated

to primary level, as much as 16% have no formal education while just 8% have a

secondary or tertiary education. It is seen that most of these participants comprising 59%

were married and thus were given out in marriage at early teenage. About 28% however

were single with 5% Divorced/Separated or widowed while 7% just living with partners.

In assessing their history of delivery, it was observed that most participants (87%)

delivered at 9calender months or greater and 11% delivered at less than 9calender months

and 2% could not remember their gestation. Perinatal death among the mothers who

delivered before 9caleder months were 136 per 1000births while the delivery at 9

calendar months or greater was about 17 per 1000births.

4.2 Perinatal death distribution by sub municipality

This part of the results in the study was to identify areas that perinatal deaths among

adolescent pregnancies are more likely in the municipality.

Table 4.2
Perinatal deaths in the sub-municipalities

Perinatal
Sub-municipality Total births
death/1000births
Navrongo central 57(28.5) 4(70)
Pungu 30(15) 0
Navrongo East 39(19.5) 1(25)
Kologo 38( 19) 1(26.3)
Manyoro 36( 18) 0

Source: Student field survey

Five sub-municipalities were randomly selected in this study. The results of the

findings from the various municipalities are displayed in table 4.2 above. Out of 57cases

from Navrongo central, 4 participants attested to have experienced perinatal deaths. Also,

32
1 perinatal death out of 39 participants and 1 perinatal death out of 38 participants also

were experienced from Navrongo East and Kologo sub-municipalities respectively.

4.3 The influence of socio-cultural practices and maternal conditions on

perinatal outcomes.
The participants perceived socio-cultural practices and the history of maternal medical

conditions that have effect on the perinatal outcomes are shown in the table below.

Table 4.3

Socio-cultural factors
Perinatal Adjusted odds
Total deaths Odds ratio ratio
Category births (PNM (95%CI) (95%CI)
N (%) /1000births
)
Employment status
Clerical/salary worker 7(3.5) 1(142.8) 1
Farming/Fishing 66(33) 3(45.5) 0.28(0.03-3.2)
Trading/small scale 1
12(6)
business
Student 64(32) 1(15.6) 0.09(0.01-1.72)
Unemployed 51(25.5) 1(19.6) 0.12(0.01-2.20)
Religion
Christian 155(78) 3(19.4) 2.9(0.29-30.27)
Muslim 18(9) 1(55.6) 4.8(0.76-30.58)
Traditionalist 23(87) 2(86.9) 1
Others(none) 4(2) 1
Decision making power
of adolescent mother

Parents/in-laws 157(78.5) 4(25.47) 1.9(0.33-10.54)

Couple 43(21.5) 2(46.5) 1
Traditional beliefs and
Practices
Yes 33(16) 3(90.9) 5.5(1.05-28.31) 1.4(0.13-14.87)
No 167(84) 3(17.9) 1
Source: Student field survey
33
 The results in table 4.3 indicates that only 4% participants are formally employed

and on salary. The rest are engaged in farming/fishing (33%), trading and small scale

business (6%). About 32% are students and 26% revealed they have nothing doing.

The table 4.3 also shows the participants’ religious background of which most were

christians comprising 78%, 18% were Muslims, 23% were Traditional/Spiritualist while

2% had no religion. It again reveals that the decision making power for participants

responses are that about 79% of major decisions of health care are made by parents/in-

laws in the family for them to seek for health. It was seen in table 4.3 that 21% had major

health seeking decisions made by the adolescent mother and her spouse. Perinatal

mortality resulting from adolescent whom the parents make major decisions was about 25

per 1000births whilst that of the adolescent decision making power was 47 per

1000births.

A higher proportion (84%) of adolescent mothers said they did not engage in

traditional beliefs and practices. About 16% said they were involved in a number of

traditional beliefs and practices among which 2% taboo eggs, 10% took herbal

preparations, 2% each taboo cow milk and pork during pregnancy. A high perinatal

mortality (91 per 1000births) was observed among mothers who said they had been

engaged in traditional practices compared to mothers (18 per 1000births) who did not

engage in traditional practices.

34
Table 4.4: History of Maternal medical conditions

P-value(95% CI)
Total births Perinatal deaths
Category
N (%) (PNM/1000births)

Yes 53(26) 3(56.6) P<0.185

No 147(74) 3(20.4)
Source: Student field survey

From table 4.4, majority (74%) of the mothers reported no history of illnesses

except normal minor disorders of pregnancy. About 26% reported to have suffered

various conditions either prior to or during the pregnancy. Among these conditions were

malaria, anaemia, hypertension and STIs. Perinatal mortality among mothers who had

experienced any of the maternal conditions was about 57 per 1000births while 20 per

1000births was observed in mothers who never experienced any of the major sicknesses

mentioned in this study.

4.4 The influence of health seeking behaviours on perinatal outcomes

Table 4.5

Health seeking behaviours and perinatal outcomes

Perinatal Odds ratio Adjusted

Total
deaths odds ratio
Category births
(PNM/1000 (95% CI) (95% CI)
N (%)
births)
Alcohol use
Yes 17(8.5) 2(125) 5.9(1.01-35.30) 4.9(0.36-65.0)
No 183(91.5) 4(21.9) 1
Pregnancy intention
Yes 49(24.5) 1(20.4) 1
No 151(75.5) 5(33.1) 1.60(0.18-14.42)
Ever used family
planning method
Yes 148(74) 2(13.5)
No 52(26) 4(76.9) 0.20(0.03-0.93) 1.2(0.01-0.75)

Source: Student field survey

35
Table 4.6

Reasons for mothers not using contraceptives prior to pregnancy

P-value
Total births Perinatal deaths
Category
N(%) (PNM/1000births)

Partner opposed 6(11.5) 1(19.2)

Religious prohibition 3(5.8)
Cost is too much 1(1.9) P=0.239
Fear of side effects 28(53.8) 2(71.2)
Inconvenient to use 2(3.8)
Staff attitude 3(5.8)
Wanted to be
9(17.3) 1(111)
pregnant
Source: Student field survey

The results in table 4.5 show clearly that 92% of the adolescents did not consume alcohol

during pregnancy. As seen in table 4.5, the intention of pregnancy influence the adverse

perinatal outcomes by over 25% compared to unintended pregnancies by about 76%.

Unintended pregnancies had 1.64 increased odds of perinatal death (33 per 1000 live

births) compared to intended pregnancies (20 per 1000births).

Again out of 200, 74% had ever used family planning method and the influence on

perinatal death rate among them was 14 per 1000 live births compared to 26% who had

never used family planning method before the most current pregnancy which influence

perinatal death rate resulting in 77 per 1000 births. Among the reasons given by mothers

who said they have never used contraceptives, about 54% indicated it was because of side

effects, proportion of 17% said they wanted to become pregnant and at least 2% said it

was due to the cost which they could not afford

36
4.5 The influence of health care utilisation on perinatal outcomes

Table 4.7

Health care utilisation and perinatal outcomes

Odds ratio Adjusted odds
Perinatal
Total (95% CI) ratio
deaths
Category births (95% CI)
(PNM/1000
N (%)
births)

Antenatal visits
<6visits 10(5) 3(100) 0.04(1.0-2.1) 0.03(0.00-0.35)
≥6visits 190(95) 3(15.7) 1
Discrimination
Yes 14(7) 1(71) 1
No 186(93) 5(27) 0.35(0.04-3.30)
Delivery place
Health facility 176(88) 5(28) 1
Home 24(12) 1(42) 3.91(0.67-22.59)
Skilled
attendance
Health
176(88) 5(28)
professional
TBAs 19(10) 1(53) 0.19(0.33-1.16)
Mother in-laws 5(2)
Client
satisfaction
Good 191(95) 5(26)
Poor 9(5) 1(111) 4.65(0.48-44.59)

Source: Student field survey

Table 4.8

Mothers reasons for home delivery

P-value
Category Frequency Percentage
(95% CI)
Too long distance 1 10
2
Decision maker delayed 7 70 X =3.25,P=0.355
Facility environment 2 20

Source: Student field survey

37
 The results in table 4.7 indicates clearly that an overwhelmingly 95% had

adequate antenatal visits (≥6visits) with a perinatal mortality rate of over 15 per

1000births. Only 5% of the participants had inadequate antenatal visits (<6visits) with a

perinatal mortality rate of 100 per 1000births. The greater number of antenatal visits had

0.04times odds influence of perinatal mortality rate compared to adequate perinatal visits.

That is the antenatal visits of six or more by a pregnant adolescent has about 96%

reduction of experiencing perinatal death. This was significant at P<0.006, OR=0.04,

95%CI (1.0-2.1).

The table 4.7 shows that out of the 200 adolescent mothers, 88% delivered at the

health facilities and were attended by skilled health professionals whilst 12% delivered at

home and attended by TBAs or mother in-laws. Among mothers who delivered at home,

about 70% of them indicated they did so because their decision makers (parents/mother

in-laws) suggested they should delay in reaching the health facility when labour had

already set in.

With regards’ to staff attitude and its influence on adolescent health service

utilisation, 7% of the participants attested to the fact that they were discriminated by the

staff. Greater majority (93%) said the staff and adult mothers were friendly towards them

every time they visited the clinics. For the quality of health services, 95% had perceived

it was good and had experienced perinatal mortality rate of 26 per 1000births. Only 12%

of the adolescents had the opinion that it was poor among which the perinatal mortality

rate was 111 per 1000 births. This was not significant.

38
4.5.1 The influence of basic management of baby after delivery
The investigator sought to determine basic management related facts that influence early

neonatal survival.

Table 4.9

Basic management of baby after delivery

Category Frequency Percentage

Breastfed within 30minutes after
delivery
Yes 189 95
No 11 5
Delayed first bath
Yes 12 6
No 188 94
Bathed with herbs
Yes 22 11
No 178 89
Given herbs to drink
Yes 29 15
No 171 85
Strict seclusion
Yes 192 96
No 8 4

Source: Student field survey

In respect of basic care of the baby after delivery, 95% said breastfeeding was

initiated within 30minutes after delivery while 5% delayed for more than 30minutes.

About 94% bathed the baby early enough after delivery but 6% did not. A proportion of

11% also bathed the babies with herbs and 15% of the babies were given herbs to drink.

Among the adolescent mothers about 96% had a strict seclusion of both mother and baby

for the first one week. Only 4% of the mothers said their babies were not secluded.

In bivariate analysis traditional beliefs and practices, premature delivery(less than

9months), alcohol use during pregnancy, low uptake of any family planning method and

39
less than six antenatal visits were the likely influencing factors of perinatal death among

adolescent pregnancies. The ingestion of herbal preparations during pregnancy was

observed as statistically significant factor that seems to have influenced adverse perinatal

outcomes at P<0.043, {(OR=5.4, 95CI %( 1.05-28.3)}. Mothers who encountered full

term birth were about 90% less likely to experience adverse perinatal outcomes. It

implies about 10% of prematurity in this study could result in perinatal mortality. This

was statistically significant at {(P<0.010, OR=0.11, 95%CI (0.02-0.58)}.

Alcohol consumption by adolescent mothers during pregnancy was associated

with about 6 times increased odds of perinatal mortality compared to mothers who have

not consumed alcohol {OR= 5.96,95%CI(1.01-35.3)}. This was statistically significant at

P<0.049.

Adolescent mothers who said to have ever used family planning method before

becoming pregnant were 84% less likely to experience perinatal mortality compared to

mothers who never patronised any family planning method{OR=0.2,95%CI(0.03-0.93)}.

This was significant at P<0.041. Mothers who had six or more antenatal attendance were

about 96% less likely to experience perinatal death compared to mothers who received

less than six antenatal services. This was significant at p<0.000, {OR=0.04, 95%CI (0.01-

0.21)}.

Even though weakly significant, mothers who have birth interval equal to or greater than

24months were 82% less likely to experience adverse perinatal outcomes compared to

18% of those with shorter birth interval. Mothers with history of maternal sickness

together had about 3times increased odds of perinatal mortality compared to those who

said they did not suffer any of those conditions. This was however not significant. Again

40
delivery at home appears to have about 3times increased odds of perinatal mortality

compared to health facility delivery. This was also not significant.

Table 4.10

The association of socio-demographic factors, health behaviours and health care

utilisation with perinatal outcomes.

Perinatal Odds Adjusted

Total
Category deaths ratio odds ratio
Births
(PNM/ (95% CI)
No (%)
1000births) (95% CI)

Maternal age(years) P=0.835

15-17 59(29) 2(33.8) 1
18-19 141(71) 4(28.36) 0.83(0.148-4.671)
Residence P=0.315
Rural 165(83) 5(30) 0.41(0.072-2.331 )
Urban 35(17) 1(28) 1
Birth interval P=0.064
<24months 18(9) 2(111) 1
≥24months 175(88) 4(23) 0.18(0.03-1.10)
Don’t remember 7(3)
Gestation P<0.010 P<0.037
<9months 22(11) 3(136) 1 1
≥9months 174(87) 3(17) 0.11(0.02-0.589) 1.7(1.14-2.20)
Don’t remember 4(2)
Traditional beliefs P<0.0.043 P=0.005
and practices
5.46(1.05-28.37) 1.4(0.13-
Yes 33(16) 3(90.90)
14.87)
No 167(84) 3(17.9) 1
Mothers medical
P=0.835
condition
Yes 53(26) 3(56.6) 2.88(0.57-14.73)
No 147(74) 3(20.4) 1
Alcohol use during P<0.049 P=0.231
pregnancy
5.96(1.01-35.30) 4.9(0.36-
Yes 17(8) 2(125)
65.01)
No 183(92) 4(21.9) 1
Used any family P<0.049 P<0.029
planning method

41
 Yes 148(74) 4(13.5) 1 1
No 52(26) 2(76.9) 0.20(0.03-0.93) 1.2(0.01-0.75)
Place of delivery P=0.128
Health facility 176(88) 5(28) 1
Home 24(12) 1(42) 3.91(0.676-22.59)
Level of ANC
P<0.000 P<0.8
attendance
<6visits 10(95) 3(100) 1
0.037(0.01-0.21) 0.03(0.00-
≥6visits 190(5) 3(15.7)
0.35)
Client satisfaction P=0.18
Good 191(95) 5(26.1) 1
Poor 9(5) 1(111) 4.65(0.48-44.59)

Source: Student field survey

All variables which were statistically significant in bivariate analysis were further

analysed using binary logistic regression. This was to understand how these variables

influence perinatal outcomes upon interaction. The results showed that mothers who used

alcohol during pregnancy had the highest increased odds (5) of perinatal mortality. This

was however not significant at p<0.231, {OR=4.86, 95 %( 0.36-65.01)}. Mothers who

delivered prematurely (<9calender months) were also about 2times more likely to

experience adverse perinatal outcomes which was statistically significant at p<0.037,

{OR= 1.7, 95%CI (1.14-2.20)}.Babies from mothers who had engaged in traditional

beliefs and practices were about 1.4times increased odds of perinatal death. It was

significant at p=0.005, {OR=1.36, 95%CI, (0.13-14.87)}. Mothers who said they never

used family planning services prior to their pregnancies were 1.2times more likely to

experience perinatal mortality. This was significant at p<0.029, {(OR=1.2, 95%CI (0.01-

0.75)}. Therefore, the patronage of family planning services among adolescents is

significantly associated with perinatal survival. Mothers who had six or more antenatal

visits were about 97% less likely to experience perinatal death compared to mothers who

42
received less than six antenatal services. This was significant at p<0.000, {OR=0.01,

95%CI (0.01-0.35)}. It implies greater number of antenatal visits is associated with good

perinatal outcomes among adolescent pregnancies.

43
 CHAPTER FIVE

5.0 DISCUSSION
It is often a joyous moment upon safe arrival of a newborn in families. Families

are basic units that make up the nation`s health system. Quality health begins from the

families and extends to society at large. Perinatal care is a complex issue that has a lot of

challenges and needs all the necessary attention to optimise the outcomes. Its impact on

MDG4 emanated the pledges for reduction of under five mortality rate by 2015. Family

values as well as socio-cultural factors, health seeking behaviours and health care

utilisation have influence on perinatal outcomes. Despite so many interventions, adverse

perinatal outcomes appear high among adolescent pregnancies.

With a sample of 200 mothers interviewed, the perinatal mortality rate in this

study was 30 per thousand births. It is apparent from the results that 16% of the perinatal

deaths in this study occurred on the first day of life. About half of the deaths occurred

within first three postnatal days and slightly over 33% occurred between the third and

seventh postnatal days. The death occurred more within the first three days period of the

neonatal life probably as a result of extreme values placed on traditional practices

including strict seclusion that go on in families after a newborn arrives. Factors that

appeared to be leading in influencing perinatal mortality were some traditional beliefs

and practices such as drinking herbal preparations during pregnancy, prematurity and

alcohol use during pregnancy, low patronage of family planning services and the low

level of antenatal attendances.

In bivariate analysis, it was found out that premature birth, unhealthy traditional

practice, the use of alcohol, low family planning uptake and less number of antenatal

attendances were more linked to poor perinatal outcomes among adolescent pregnancies.

44
Less number of antenatal attendance conferred decreased odds of influencing adverse

perinatal outcomes. Therefore, mothers who ever had greater number of antenatal

attendance were more likely to have about 4 percent good perinatal outcomes. Over 83%

of all the deaths happened at the health facilities. Early neonatal mortality in young

maternal age below 20years appears to have reduced since 2009.

A 70% proportion of the adolescents were in the age brackets 18-19years at the

time of delivery. However, perinatal mortality (33.8) appeared more pronounced among

those in the lower age category (15-17years). This implies that the early pregnancies

occur in adolescent with advanced age but the lower age groups are more likely to be at

risk of perinatal death experiences. This result is consistent with a study by Pun and

Chauben (2011) which revealed that adverse pregnancy outcomes could be attributed to

lower maternal age and underprivileged socio-economic background, quality of prenatal

visits and family supports.

The analysis clearly shows that there is higher proportion of adolescent deliveries

in the rural settings with more perinatal mortality than the urban areas. The adverse

perinatal outcomes appear relatively higher among adolescent mothers without formal

education than those with at least primary education and secondary level. These

occurrences conform to a study findings by Walraven et al (1995) that low educational

status of mothers are linked with indirect effects on the nutrition and socioeconomic

implications of the mother and the newborn. Judging from the responses given, perinatal

death seems relatively lower among married adolescents than among single adolescent

mothers though majorities (59%) were married. These findings support the view of

45
Duvan et al (2010) who believe that married adolescents get family support. They may

plan well and are less likely to experience adverse perinatal outcomes.

It was found in this study that most adolescent mothers had delivered once and

had a normal pregnancy length of 9 calendar months. However, the few who delivered

twice in longer intervals were more likely to experience good perinatal outcomes. It may

be that the longer intervals between the pregnancies increase the rest period of the mother

and quality birth preparation. This leads to provision of adequate nutrition for the mother

and the unborn baby. The 83% of the unemployed adolescent mothers did not grant

increased odds of perinatal mortality. It may be due to improved placement of a good

number of community health nurses at every conner of the municipality through the

introduction of the Community-based Health planning and Services (CHPS). This is

contrary to other literatures that associate unemployment status or other forms of poverty

indicators to perinatal death (Pun and Chauben, 2011).

The study found out that traditional religion seems to have conferred increased

odds of influencing perinatal mortality in this age group. However, it was not statistically

significant. Decisions made by the adolescents’ couple appear to have much influence on

perinatal death though not significant. The odds of the influence of major decisions taken

by the adolescent with regards to their health seeking behaviour on the adverse perinatal

outcomes is 1.8folds compared to major decisions made by parents and in-laws. This is

not consistent with other study (Abdou 2011; Senderowitz 1999) that suggests that major

decisions taken by parents and other adult members of the family for women to seek

health services especially at the point of delivery have greater impact on the perinatal

outcomes. This may be because a lot more education on adolescent reproductive health

46
has so much improved in the municipality through the presence of Youth Alive

programme, Navrongo health research center and other non-governmental organizations.

The study also found out those maternal medical conditions even though not

statistically associated, they conferred about 3times increased odds of perinatal death. It

is however, important to note that conditions such as anaemia and malaria did occur in

most of the mothers who experienced perinatal death and conferred impact on pregnancy

which could lead to adverse perinatal outcomes. It may mean that the intermittent

preventive interventions and other nutrition programmes play important role in perinatal

survival.

Alcohol consumption during pregnancy appears to have influence on adverse

perinatal outcomes as it had the highest increased odds on perinatal mortality. This may

be as a result of early and regular exposure to alcoholic beverages to these young

individuals. It therefore beholds on parents and guardians as well as philanthropies in the

municipal to intensify education against alcohol use by the young aged groups. This is

similar to findings from other studies (Marinda and Sharon, 2009) that showed that

alcohol and other drug use have a rippling impact on the perinatal outcomes. Prematurity

seem to have a significant influence on adverse perinatal outcomes. This was significant

in the study. These findings are consistent with other literature (Welaga et al 2013;

Kruger 2007) that have shown that gestational age less than 32weeks and socio-cultural

factors have significant influence on adverse perinatal outcomes.

Unintended pregnancies are more likely to result in adverse perinatal outcomes

compared to desired pregnancies among adolescents. Even though this was not

significant it is important that unintended pregnancies in the adolescents are seriously

47
curtailed. The inadequate antenatal visits less than six times was not significantly

associated with perinatal death.

Other forms of predictors that emanated from the findings were; discrimination

against young mothers, place of delivery, skilled attendance and quality of Health

Services. The issue of discrimination appears to be low as only 7% of the mothers

responded that they were discriminated by staff or adult mothers which were not

statistically associated with perinatal mortality.

A reasonable proportion (88%) of the mothers delivered at health facility and had

skilled staff attended to them. A lot more of the participants expressed they were

impressed with the quality of service given them. This is contrary to the popular

perception that poor staff attitude is a significant factor for inadequate health services

utilisation by adolescents and its negative consequences on perinatal outcomes. With

regards to perceived quality of health services, mothers who said they were impressed

with the quality of health services were 88%. This was not significant. These findings

agree with study conducted by GSS (2008), NSO (2010) that suggests that Ghanaian

women in general initiate antenatal visits earlier and can achieve at least four visits. It is

also contrary to the fact that adolescents may underutilise health services probably

because of long waits, distance to health facilities or unfriendly services (UNICEF,

2011). This may be because of improved health systems in the region. This could be

attributed to improved antenatal and obstetric care that has helped in early detection and

referral of high risk cases where by optimising good perinatal outcomes.

In the binary logistic regression analysis, the study identified prematurity,

traditional beliefs and practices and low family planning uptake as factors that seem to be

48
significantly associated with perinatal mortality among adolescent pregnancies. These

stood out after other factors were controlled. These findings conform to similar works

(Baiden et al 2006; Welaga et al 2013; Kruger 2007).

49
 CHAPTER SIX

6.0 SUMMARY, CONCLUSION AND RECOMMENDATIONS

6.1 Summary
There has been high early neonatal mortality outcomes from pregnancies of

younger maternal age (15-19) years. The purpose of the study was to explore the factors

that influence perinatal outcomes in adolescent pregnancies. The perinatal outcomes

include live birth, stillbirth and death within the first one week of life. These factors

include personal characteristics of the adolescent mothers, socio-cultural factors, and

health behaviours of adolescents and health care utilisation of adolescents. The study also

sought to give recommendations to the MOH policies for planning effective interventions

to prevent adverse perinatal outcomes associated with adolescent pregnancies in the

municipality. The sample consisted of 200 adolescent mothers. Multistage sampling

method was used to select the facilities. Simple random sampling technique was used to

select the participants at the health facilities. The data were analysed using STATA

programme version11 and results presented in tables. The findings were that factors

which appeared to be influencing perinatal mortality in bivariate analysis include;

prematurity, unhealthy traditional beliefs and practices such as drinking herbal

preparations during pregnancy, alcohol use during pregnancy, low patronage of family

planning services and low level of antenatal attendances. However, the binary logistic

regression analysis showed that gestation less than 9 calendar months, unhealthy

traditional beliefs and practices and low family planning uptake were more linked to poor

perinatal outcomes among adolescent pregnancies.

50
It is also evident that decisions made by adults on seeking for health has less influence on

adverse perinatal outcomes compared to decisions made by the adolescents themselves

and their spouses. Discrimination against young mothers at clinics has no significance on

health care utilisation and the consequence on adverse perinatal outcomes. It therefore

seems to have declined according to the findings of this study.

It is recommended that more education be intensified on family planning uptake by the

youth and to reduce their level of alcohol consumption. Youth centres with adolescent

reproductive facilities should also be increased by the municipality to engage the

adolescents during their leisure time.

6.2 Conclusion

Adolescent mothers have a high risk of perinatal mortality. However, there has

been a decline since 2009 probably because of improved health interventions including

newborn care in the municipality. In this study factors that seem to influence perinatal

outcomes among adolescent pregnancies were premature gestation, unhealthy traditional

beliefs and practices low family planning uptake, alcohol use during pregnancy and

inadequate antenatal attendance.

A lot more advocacy and sensitisation need to be done to discourage unhealthy

cultural values and practices, low family planning uptake and consumption of alcoholic

beverages among the adolescents.

51
6.3 Recommendations

The researcher suggests the following recommendations: The Municipality and other

philanthropies should try to increase awareness in the community about early

pregnancies, its adverse effects on perinatal outcomes and ways to prevent it. There is the

need to increase awareness of the benefits of family planning and the consequences of its

low uptake in the community. This will discourage them from fear of side effects in using

family planning methods. It is also important to ensure availability of the contraceptives

services on a wider extent for younger persons and at a free cost. This is achievable

through community based programmes such as using mass media, more involvement of

primary/community based health volunteers and local community leaders.

It could be of greater benefit if a separate counselor possibly from the younger

age group is chosen to discuss and share solutions for perinatal problems in smaller

groups. The counselor should stress the continuation of education and the need for

contraception to postpone further teenage pregnancy, especially in the younger age

group. The counseling sessions should be made accessible at separate areas from other

age group to make sure there is sufficient privacy and to maintain confidentiality every

time, because it is an important concern in this age group. The young age group should be

given enough time to ask questions. Group deliberations will also provide them the

opportunity to learn from the experiences of others in the group and promote the

development of social support networks that can extend beyond pregnancy to prevent

future adverse perinatal outcomes.

Counseling on reproductive health should also be made more effective at primary

level of their education since majority become pregnant and drop out of school at this

52
stage. It will also help to prevent unintended pregnancies and the consequences on

perinatal outcomes.

There should be more education for pregnant adolescents on the effects of

traditional practices especially the first one week of the neonatal life. The Municipal

health directorate together with the municipal assembly should discourage the household

values and practices for pregnancy intentions among the adolescents.

The young pregnant women differ in numerous aspects from adults; routine perinatal care

programmes may be insufficient for their needs. Policies should be tailored towards this

age group. Pregnant teenagers should therefore be encouraged to visit health facilities

more often for healthcare since study reveals that it drastically reduces perinatal cases.

MOH in Ghana need to have sex education policy implemented at the very grass root

level of the communities.

Suggestions for further research

A further study could be carried on this topic done using a case control design or a

greater percentage of perinatal cases. Prospective study could also be done. The perinatal

mortality is soon becoming rare though a significant challenge to all persons and health

service delivery. It would also be very important if such a study could be replicated in

Municipalities/districts with similar characteristics.

53
 LIST OF REFERENCES

Abdou, J. Johanne, S. and Siri, V. (2011) “Barriers to Emergency Obstetric Care

services in perinatal Deaths in Rural Gambia: A Qualitative In-Depth Interview

Study,” ISRN Obstetrics and Gynecology, vol.2011, Article ID 981096, 10

pages, 2011 doi:10.5402/2011/981096:131-4

Amponsah, H. (2006) Assessing Antenatal Care on pregnancy outcome in Obuasi

municipality, Kwame Nkrumah University of Science and Technology, Kumasi.

Ansah, T.O. (2006) Determinants of perinatal and neonatal mortality in Ejura Sekyere

dumase district. Ashanti Region, A case control study. Unpublished thesis,

Kwame Nkrumah University of Science and Technology, Kumasi

Auger, N. Daniel, M. Platt, R.W., Cheng Luo, Z., Wu, Y. & Choiniere, R.(2008) The

joint influence of marital status, inter-pregnancy interval, and neighbourhood on

small for gestational age birth: a retrospective cohort study. BMC Pregnancy and

Childbirth 8, 7

Baiden, F., Hodgson, A., Adjuik, M., Adongo, P., Ayaga, B. and Binka, F. (2006) Trend

and causes of neonatal mortality in the Kassena–Nankana district of northern

Ghana, 1995–2002. Tropical Medicine & International Health, 11: 532–539. doi:

10.1111/j.1365-3156.2006.01582.x

Bayingana, C. Muvunyi, C. and Charlene, W. J. (2010) Risk factors of preterm delivery

of low birth weight in an African population. Journal of Clinical Medicine and

Research Vol. 2(7), pp. 114-118, July 2010. ISSN-2141-2235.Academic Journals

Available online http://www.academicjournals.org/JCMR

54
Carlo WA, Goudar SS, Jehan I et al. (2010) Newborn-care training and perinatal

mortality in developing countries. New England Journal of Medicine 362, 614–

623.

Charles, A., Sia M., Jan H., Joanna R., Matthews M.,and Nynke van den Broek (2012)

Status of Emergency Obstetric Care in Six Developing Countries Five Years

before the MDG Targets for Maternal and Newborn Health PLoS One. 2012;

7(12): e49938.

Debrah, E. (2010) Description of primary causes of stillbirth as pertains in Offinso South

municipality of Ashanti region. Published thesis, Kwame Nkrumah University of

Science and Technology, Kumasi.

Dewey K.G., Cohen, R.J. (2007) Does birth spacing affect maternal or child Nutritional

status?A systematic literature review. Program in International and Community

Nutrition, Department of Nutrition, University of California, Davis, CA 95616-

8669, USA. Maternal Child Nutr. 2007 Jul; 3(3):151-73.

Duvan, C.I,Turhan, N.O., Onaran Y., Gümüş I.I.,Yuvaci, H., Gözdemir,E. (2010)

Adolescent Pregnancies: Maternal and Foetal Outcomes.Fatih University,

Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey.

The New Journal of Medicine 2010; 27: 113-116.

Gabrysch, S., Zanger, P. and Oona, M. R. Campbell (2012) Emergency obstetric care

availability: a critical assessment of the current indicator. doi:10.1111/j.1365-

3156.2011.02851.x. Volume 17 no 1 pp 2–8 January 2012. Tropical Medicine and

International Health G8. 2009. G8 Leaders Declaration: Responsible Leadership

55
 for a Sustainable Future Online

at:http://www.g8italia2009.it/static/G8_Allegato

/G8_Declaration_08_07_09_final,0.pdf,

Gail, A. (1995) Epidemiology in nursing practice.St Louis Missouri, U.S.A, Mosby-

Year Book Inc. pp.78-80.

Ghana Statistical Service (GSS), Ghana Health Service (GHS), ICF Macro (2009).

Ghana Demographic and Health Survey (2008) Accra, Ghana: GSS, GHS, and ICF

Macro

Ghana Statistical Service (GSS) GHSG, and ICF Macro (2009) Ghana Demographic

and Health Survey 2008

James, E. R. (2010) World Health Organization. Department of Making Pregnancy

Safer. Position paper on mainstreaming adolescent pregnancy in efforts to make

pregnancy safer. WHO/MPS/10.03 Geneva, Switzerland

Jesmin, P.et al. (2012) Association of antenatal care with facility delivery and perinatal

survival –a population-based study in Bangladesh.BMC Pregnancy Childbirth.

2012; 12: 111. PMCID: PMC3495045 doi: 10.1186/1471-239312111

Kassena Nankana Municipal Health Directorate: Reproductive and child health

records: 2011- 2013.

Krüger, C. (2007) "Neonatal health in Tanzania – current situation and future outlook"

Masters, Curtin University of Technology. Available at htt://carstenkruegernet/

attachments/Essay-File/Essay-4-Neonatal-Health.pdf,(Accessed on 26 July, 2013

at 12:30am).

56
Kurth. F., Bélard, S., Mombo-Ngoma, G., Schuster, K., Adegnika A.A, et al. (2010)

Adolescence as risk factor for adverse pregnancy outcome in Central Africa.

ACross-Sectional Study. PLOS ONE 5(12): e14367. doi:10.1371/journal.Pone.

0014367 Available at

st
www.ncbi.nlm.nih.gov/pubmed/21188301, (Acessed on 1 March, 2013

at 9:09am)

Lawn, J.E., Mwansa-Kambafwile, J., Horta, B.L., Barros, F.C., Cousens, S. (2010)

‘Kangaroo mother care’ to prevent neonatal deaths due to preterm birth

complications’. Int J Epidemiol i1–i10.

Lawn, J.E, Blencowe, H., Pattinson, R., Cousens, S., Kumar, R., et al. (2011)

Stillbirths: Where? When? Why? How to make the data count? Lancet 377: 1448–

1463.

Lawn, J. E., Kate, K.,Christabel, E., and Simon, C.(2010) 3.6 Million Neonatal

Deaths—What Is Progressing and What Is Not? 0146-0005/10/$- Elsevier Inc.

371 doi:10.1053/j.semperi.2010.09.011

Liu, L., Johnson, H.L., Cousens, S., Perin, J., Scott, S., et al. (2012 ) Child Health

Epidemiology Reference Group of WHO and UNICEF: Global, regional, and

national causes of child mortality: an updated systematic analysis for 2010 with

time trends since 2000. Lancet 379(9832): 2151–2161. doi: 10.1016/S0140-

6736(12)60560-1.

57
Luwei, P., Margareta, L.,Vincent, F., Judith, S. (2007) Child Care –World Health

Organisation.Opportunities for Africa’s Newborns. Available at www.who.int/p

mnch/media/publications/aonsectionIII_3.pdf.(Accessed on 11 july,2013 at

6:07pm).

Magadi, M. (2004) Poor Pregnancy Outcomes among Adolescents in South Nyanza

region of Kenya. Opportunities and Choices Reproductive Health Research

Programme, Southampton Statistical Sciences Research Institute, University of

Southampton, U.K,

Mann, C. J. (2003) Observational research methods, Research design II: cohort,

Cross sectional and case-control studies. Emerg Med J 2003; 20:54–60.Available

at emj.bmj.com (Accessed on 18 April, 2013.at 11:00AM)

Miranda, M.L. and Edwards, S.(2009).Strategic Opportunities for Improving Pregnancy

Outcomes in Guilford County, NC. Children’s Environmental Health Initiative

Nicholas School of the Environment. Duke University, U.S.A

Mosha, T. C. E. and Napendaeli, P.(2010) Factors Influencing Pregnancy

Outcomes in Morogoro Municipality, Tanzania Journal of Health Research

Volume 12, Number 4, October 2010 249 Department of Food Science and

Nutrition, Sokoine University of Agriculture, P.O. Box 3109, Morogoro

Nancy, E. R. and Deanna, L. P. (1997) Maternal Age and Birth Outcomes: Data from

New Jersey (Family Planning Perspectives, Volume: 29:268-272 & 295, 1997)

National Statistical Office (NSO) ICF Macro (2011) Malawi Demographic and

Health Survey 2010. Zomba, Malawi, and Calverton, Maryland, USA: NSO and

ICF Macro.

58
Navaneetham, K. and Dharmalingam, A.(2002) Utilisation of maternal health care

services in southern India. Social Science and Medicine 55(10): 1849–1869. doi:

10.1016/S0277-9536(01)00313-6.

Nyarko, P.et. al. (2006) Acceptability and Feasibility of Introducing the WHO

focused antenatal care package in Ghana. Frontiers in Reproductive Health

Program, Population Council,Noguchi Memorial Institute for Medical Research,

Tema General Hospital, Ghana Health Service, Reproductive and Child Health

Unit, Ghana Health Service. Ghana.

North Carolina PRAMS Fact Sheet (2009).North Carolina State Center for

Health Statistics, Unintended Pregnancies, (2004-2006).Oestergaard, M.Z.,

Inoue, M., Yoshida, S., Mahanani, W.R., Gore, F.M. et al. (2011) Neonatal Mortality

Levels for 193 Countries in 2009 with Trends since 1990: A Systematic Analysis

of Progress, Projections, and Priorities. PLOS Med 8(8): e1001080.

doi:10.1371/journal.pmed.1001080

Paria, D. (2013) Present socio-economic scenario; incident of infant mortality in

West Bengal. Radix International J Res Soc Sci 2013; 2(2):1-25.

Pell, C., Meñaca, A., Were, F., Afrah, N.A., Chatio, S., et al. (2013) Factors Affecting

Antenatal Care Attendance: Results from Qualitative Studies in Ghana, Kenya

and Malawi. PLOS ONE 8(1): e53747. doi:10.1371/journal.pone.0053747

Pun, K.D., Chauhan, M. (2011) Outcomes of Adolescent Pregnancy at Kathmandu

university hospital, Dhulikhel Hospital. Kathmandu Univ Med J 2011; 33(1)503.

59
Senderowitz, J. (1999). Making reproductive health services youth friendly research

program and policy series. FOCUS on Young Adults Attn: Communications

Advisor 1201 Connecticut Avenue NW Suite 501 Washington DC 20036, U.S.A.

Available on http//www.pathfind.org/focus.htm (Accessed on 5July, 2013 at 8:

00A.M.)

Shiffman, J. (2010) Issue attention in global health: the case of newborn survival.

the Lancet 375: 2045–9.

Singh, P.K., Rai, R.K., Alagarajan, M., Singh, L. (2012) Determinants of maternity care

services utilization among married adolescents in rural India. PLoS ONE 7(2):

e31666. doi:10.1371/journal.pone.0031666

Stewart, C.P.,Katz J., Khatry ,S.K., LeClerq, S.C., Shrestha, S.R., West, K.P., Jr. &

Christian, P.(2007). Preterm delivery but not intrauterine growth retardation is

associated with young maternal age among primiparae in rural Nepal. Maternal

Child Nutrition. 3(3):174-185.

Swati, M. (2007) Teenage deliveries and risk of adverse outcomes: a hospital based case

Control Study / Swati Mahajan. – Suva, Fiji: UNFPA Office for the Pacific,

2007.Ministry of health. United Nations population fund secretariat of the Pacific

Community. USP Library Cataloguing-in-Publication Data

Treffers, P. E. (2003) Teenage pregnancies, a worldwide problem.[Dutch].

Nederlands Tijdschrift voor Geneeskunde., 147, (47) 2320-2325

UNICEF (2011) The State of the World’s Children. 3 United Nations Plaza.

New York, NY 10017, USA Available at www.unicef.org

United Nations population fund (2012) Marrying too young. End

Child 60
 Marriage.ISBN-10: 1618000144, ISBN-13: 978-1-61800-014-9. New York,

UNICEF, WHO, the World Bank, the United Nations Population Division (2011) Levels

and Trends in Child Mortality. Geneva: UNICEF.Pg 10.

Welaga, P., Moyer, C.A, Aborigo, R., Adongo, P., Williams, J., et al.(2013) Why are

babies dying in the first month after birth?. A 7-year study of neonatal mortality

in northern Ghana PLoS ONE 8(3): e58924.doi:10.1371/journal.pone.0058924

Available at http://www.plosone.org/article/info%3Adoi% 2F10.1371%2Fjournal.

pone.0058 24 (Accessed on 27March, 2013 at 8:22pm).

World Health Organization (2008) Adolescent Pregnancy, Department of Making

Pregnancy Safer, WHO/HQ MPS NOTES, Volume 1, No.1, October 2008

World Health Organization (2006) Neonatal and Perinatal Mortality:

Country, Regional and Global Estimates. Geneva

WHO (2012) Adolescent pregnancy. Fact sheet N°364 Available at

www.who.int/entity/mediacentre/factsheets/fs364/.../index.htm (accessed on 1

March, 2013 at 8:42am)

WHO (2010) UN Secretary-General Launches Global Effort on Women’s Health.

Governments and stakeholders join in urgent effort to reduce deaths in childbirth,

leading up to September Summit on Millennium Development Goals. Available at

www.who.int/pmnch/activities/...press releases/en/index.html (Accessed on

01/3/13 at 9:20am)

Walraven, G.E, Mkanje, R.J.B., Roosmalen, J., van Dongen, P.W.J., Dolmans, W.M.V.

(1995) Perinatal mortality in home births in rural Tanzania. Eur J Obstet

Gynecol Reprod Biol 1995; 58`

61
World Health Organization (2011)WHO statement on antenatal care. Geneva:

World Health Organisation.

Yakoob, M.Y., Lawn, J.E., Darmstadt, G.L., et al. (2010): Stillbirths: epidemiology,

evidence and priorities for action. Semin Perinatol; 34:387-394

62
 APPENDIX

Questionnaire
Kwame Nkrumah University of Science and Technology, College of Health Sciences,
School of Medical Sciences, Department of Community Health

Topic: Factors influencing Perinatal Outcomes among Adolescent

Pregnancies in Kassena Nankana Municipal, Navrongo.

INTERVIEW INFORMATION

DATE OF INTERVIEW |__|__| Day |__|__| Month |__|__||__|__| Year

RESULT * |__|

INTERVIEWER NAME ______________________________________

SUPERVISOR ______________________________________

CHECKED BY ______________________________________

ENTERED BY 1) ____________________________________

2) ____________________________________

CHILD`S AGE _____

RESPONDENT’S IDENTIFICATION
FACILITY NAME:

RESPONDENT COMMUNITY NAME:

63
Good ………………………… My Name is ………………………………………
We are working on a study concerned with perinatal outcomes in the municipal. You
have been selected as one of the participants to this study and we would very much
appreciate your participation. The interview will take about 20 minutes. We would be
grateful to ask you some questions about this subject matter. The interview is not meant
to appraise your performance but to plea for your assistance in finding factors that may
be contributing to perinatal outcomes. You are not under obligation to answer any
question you are not comfortable answering. We will ensure strict confidentiality. No
names or forms of identification are required. Please respond objectively to the following
questions/statements.
CONSENT:
Signature/Thumbprint…………………………........................................................

May I begin the interview now?

NO QUESTIONS AND CODING CATEGORIES SKIP

FILTERS

PART 1:SOCIO-DEGRAPHIC CHARACTERISTICS

I would like to start by asking you a few questions about yourself.

Q1 Please tell me your date of |__|__| day |__|__| month

birth or your current age in |__|__||__|__| year
years. |__|__| age (completed years)
Don’t know………………….88
Q2 At what age did you deliver |__|__| age (completed years)
your most current baby Don’t know…………………...88

Q3 Place of residence Rural ...……………………........1

Urban.…………….…..………..2
Q4 What is your marital status? Married….…..………..…….......1
Single…………..…...……..…...2
Divorced/Separated....................,3
Living with partner…………….4
Other(specify)….........................5
Q5 What is the highest level of None…………..……………......1
school you attended? Primary........................................2
Secondary…………..….…….....3

64
 Tertiary........................................4
Other(specify)…………..…...…5

Q6 What is your occupation? Clerical/salaried worker………..1

Farming/Fishing………….…….2
Trading/Small scale business..…3
Artisan……………………….…4
Casual worker………..….…......5
Student.…………………….......6
Unemployed…..……..…………7

Q7 What is your religion? Christian…………….....……….1

Muslim……………..……..........2
Traditional/Spiritualist…………3
Hindu……………….……….....4
No religion …………………….5

Q8 How many times have you Once…………………………....1

delivered? Twice……………..……………2

Q9 How many months old was |__|__| number

your pregnancy when you Don’t know……………. ...…..88
delivered?

Q10 What is the time interval <24months………...…………...1

between the most current ≥24months……….…...…….....2
delivery and the previous one Not applicable..……...………....3
if any?

Q11 Have you ever suffered any Yes…………..…………………1

medical condition? No……………...…………….…2

Q12 Which of the following Anaemia………………………..1

sickness did you have during Malaria……………..…………..2
Hypertension …..………………3
that last pregnancy?
Diabetes……..……....................4
Other(specify……..………........5

Q13 Were you engaged in any Yes…………………..…………1

traditional beliefs and
No………………….…………..2 Skip
practices during your
to
pregnancy
Q15

Q14 What traditional beliefs and Taboos eggs……….……….......1

practices were you engaged Takes herbal preparations…..….2
in during your pregnancy Others(specify)………………....3

65
Q15 Who in the family usually Myself…………………. ...……1
make major decisions for My husband………..……...…....2
woman to seek health Both of us……..……….. ...…....3
service? Parents…..………………….…..4
In-laws…………...………….…5
Other(specify)……………….....6
PART2 :HEALTH BEHAVIOURS
SectionA: Maternal smoking and alcohol consumption during pregnancy

Q16 Did you use Yes…………………..………....1

tobacco/cigarettes during No…………………..………….2
your pregnancy?
Q17 Have you consumed any Yes…………………..…….…...1
alcoholic beverages during No…………………..…..……....2 Skip
the most current pregnancy? to
Q18
Don`t know…….……..……....88 Skip
to
Q18
Q18 How often do you use Practically everyday…………....1
alcoholic beverages? 1-2times a week……………..…2
3-4times a week……………..…3
1-2times a month……………....4
Less than once a month………..5
Don`t know………………….…6
SectionB:Pregnancy intention and contraceptive use

Q19 Did you intend to be Yes……………………………..1

pregnant for the child we talk No…………………..…………..2
about?
Q20 Did you use any Yes……………………………..1
contraceptive method prior No...…………………………….2
to the most current
pregnancy?
Q21 If no to question Q19, why Partner opposed…...…………....1
didn`t you use any family Religious prohibition…………..2
method? Knows no method……………...3
Knows no source to get the
method………………………....4
Fear of side-effects………..........5
Lack of access/too far …………7

66
 Costs too much……...…....….....8
Inconvenient to use……….........9
Staff attitude…..……………....10
Other(specify)..……..………...11
PART3:HEALTH CARE UTILISATION
Section A: Level of ANC Attendance

Q22 Where is your usual place of Drug store……………………...1

seeking for health services Herbalist/traditional healer…….2
Health facility……………….....3
when you or family member
Others (specify)…….....…….....4
is ill?

Q23 Did you see anyone for Yes…………..……..….…….....1

antenatal care for your No…………….…….....………..2 Skip
previous pregnancy we talk to
about? Q31

Q24 Whom did you see? Doctor ……..………………......1

Nurse/midwife ………………...2
Auxiliary midwife ……………..3
Community health worker……..4
Other (specify)…………....…....5

Q25 How many times did you Less than 6 visits……………….1

receive antenatal care during Greater than 6visits….…………2
the pregnancy we talk about?

Q26 How many months pregnant |__|__| number

were you when you first
Don’t Know………….............88
received antenatal care for
that last pregnancy?

Section B: Quality of Health Services and staff attitude

I wish to ask you few questions about care you received during the ANC visits.

Q27 What is your impression Very Good…...………..………..1

about the procedures carried Good…...…………..………….. 2
out on you during each Fair…..……………..…………..3
session of the health facility Poor…...…………..……………4
visits? Very poor…………......……..…5

Q28 How did the staff relate to friendly……………....................1

you during your visits to the Unfriendly……………………...2
clinics?
67
Q29 Have you ever been Yes…………………..………....1
discriminated at the health No…………………..………….2 Skip
facility during any visits for to
care? Q31
Q30 Who discriminated against Adult mothers…………….........1
you? Health staff……………..............2

Section D: Place of Delivery, Skilled Attendants and Perinatal Outcomes Now

I would like to talk to you about all the pregnancies that you have had in your
lifetime. By this I mean all pregnancies and all the children born to you, whether
they were born alive or dead. I understand that it is not easy to talk about children
who have died, or pregnancies that have terminated before full term, but it is
extremely important that you tell us about all of them so that we can develop
programmes that would help improve perinatal outcome in the future.

Q31 Where did you deliver? Home ………………………......1

Health facility…………….……2

Q32 If delivered at home, What Too long distance……………....1

factors influence your choice High travel Cost …………….....2
Decision maker (specify)……....3
of delivery place?
Attitude of health staff………....4
Facility charges……..……….....5
Facility environment…..…....6
Other(specify)…..…………..7

Q33 Who did the delivery of your Health professional.….……..….1

baby TBA/others…………..................2

Q34 What was the mode of Spontaneous………..……....…..1

delivery of your baby Assisted……..……...………......2
Caesarean section……………....3

Q35 If delivered at home how was Cut by…………………..............1

the cord separated and treated Dressed by……………………...2
after delivery?

Q36 How was your baby managed Baby kept warm………………..1

the first one week after Breastfed within 30minutes after
birth …………………………....2
delivery (tick as many as
Delayed first bath....……….…...3
possible)
Bathed with herbs.......................4
Given herbs to drink…………...5
Other (specify)…....……………6

68
Q37 What was the weight of the <2500g……..…………………..1
baby at birth? >2500g…..……………………..2

Q38 Was the baby alive up to one Yes…………………………..…1

week? No…………………..…………..2

Q39 If no to Q38, after how long Within a day……………………1

was baby dead? 1-3days……………....................2
4-7days……….........…………...3
Don`t remember………..………4

Q40 If no to Q38, where did death Home………….……………….1

occur? Health facility……..……….…..2

Q41 Suggest ways by which good …………………………………

perinatal outcomes among …………………………………
…………………………………
adolescent pregnancies can
…………………………………
be improved
…………………………………
…………………………………
………………………………

Thank you
69