NALERIGU NURSING AND MIDWIFERY COLLEGE

NALERIGU

DEPARTMENT OF MIDWIFERY

ASSESSING THE ATTITUDE AND FACTORS AFFECTING THE PATRONAGE OF

ANTENATAL CARE AMONG PREGNANT WOMEN IN GAMBAGA

SUBMITTED BY:

DOK CYNTHIA RM520180044

KANGMINGNYE FRANCISCA RM520180062

AUGUST, 2021

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 CHAPTER ONE

Introduction

Background of the study

Globally, countries with good indicators in maternal and infant mortality have pregnancy related

complications identified and managed early (World health Organization, WHO, 2016). Antenatal

care (ANC), is given different meanings by different scholars, among others the meaning that

says, “Antenatal care means care before birth and includes education, counseling, screening and

treatment to monitor and to promote the well-being of the mother and fetus (Ambreen & Shah,

2018). Also, ANC is the care that a woman receives during pregnancy that helps to ensure

healthy outcomes for women and newborn (Shafqat, Fayaz, Rahim & Saima, 2015). It is a key

entry point for pregnant women to receive a multiple range of health services such as nutritional

support and prevention or treatment of anaemia, detection and treatment of malaria, and sexually

transmitted infection (Kotoh & Boah, 2019).

Antenatal care provides an opportunity to promote the benefits of skilled attendance at birth and

to encourage women to seek postpartum care for themselves and their newborn. It is also an ideal

time to counsel women about the benefits of child spacing (Manyeh, Amu, Williams &

Gyapong, 2020). The objective of ANC is to ensure that every wanted pregnancy result in the

delivery of a healthy baby without impairing the mother’s health. Antenatal care is one of the

most effective health interventions for preventing maternal morbidity and mortality particularly

in places where the general health status of women is poor (Kotoh & Boah, 2019)

Antenatal care provides standard care for mother–baby package which consists of: at least four

visits of at least 20 min each starting before the last trimester of pregnancy. Diagnostic tests

include: hemoglobin, blood group, urine analysis and syphilis test. Treatment entails: iron and

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folate supplements (60 mg three times a day for 90 days, two tetanus vaccinations, treatment of

malaria and hookworm (Afaya et al., 2020). Normal delivery under the standard practice

includes: haemoglobin, blood group and urine test before delivery, active management of third

stage of labor (Ergometrine) (Abaka-Yawson et al., 2020). Tetracycline eye ointment for the

newborn; iron supplements 3×/day for 14 days after delivery while a routine postpartum check-

up cost in a health center (Nonterah et al., 2019)

Preventing problems for mothers and babies depends on an operational continuum of care with

accessible, high quality care before and during pregnancy, childbirth, and the postnatal period. It

also depends on the support available to help pregnant women reach services, particularly when

complications occur (Manyeh, Amu, Williams & Gyapong, 2020). In Ghana several factors

influence pregnant women utilization of ANC services. Few include; long distance to the health

facility, seeking permission to start and use ANC, are identified factors associated with low

utilization of ANC among pregnant women (Wemakor, 2019). Also, the lack of information and

knowledge towards sexual and reproductive health (SRH) and rights contributes to women

delaying or avoiding attending ANC services (Ahenkorah et al., 2020).

Problem statement

Globally, every minute, at least one woman dies from complications related to pregnancy in a

year. In addition, for every woman who dies in childbirth, around 20 more suffer injury,

infection or disease (WHO, 2016). Studies reveal identified maternal mortality in developing

countries to be mostly due to poor accessibility to maternal health services, poor referral to

appropriate antenatal care, delivery care unit, and inadequacies of available care (Ambreen &

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Shah, 2018). The WHO (2016) report suggested that most of the maternal deaths were

preventable with improved coverage of antenatal care, safe delivery and postpartum care.

The average woman in sub Saharan Africa faces a life risk of dying in pregnancy and childbirth,

compared with the risk for a pregnant woman in a developed country (Shafqat, Fayaz, Rahim &

Saima, 2015). Multiple micronutrient deficiencies among pregnant women remain a major public

health concern in low-income and middle-income countries (LMICs). Pregnancy places an

additional burden on women’s nutritional requirement, as nutrient needs increase to meet the

demands of both the mother and the developing fetus (Banda, Michelo & Hazemba, 2012)

In Ghana, several factors influence women attitude towards toward ANC including the attitude

of health staff and availability of health staff at ANC on time (Nonterah et al., 2019). But what

pertains in Gambaga among pregnant women’s attitude and identified factors affecting their

utilization of ANC remains unknown. This study is conducted to fill the gap.

Research objectives

Main objective

The main objective of the study is to assess the attitude and factors affecting the patronage of

antenatal care (ANC) among pregnant women in Gambaga.

Specific objectives

1. To determine the factors influencing ANC attendance among pregnant women in

Gambaga

2. To examine the utilization of ANC among pregnant women in Gambaga

3. To assess the attitude of pregnant women towards ANC attendance in Gambaga

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Significance of the study

The findings from the study would provide information concerning women in their reproductive

age understanding of ANC in Gambaga. When these reasons are identified, a more

comprehensive program of health care would be developed by the Health Management Team to

improve upon pregnant women utilization of ANC. The findings from the study would also

suggest to policy makers at the national, regional and District Health Management Team

(DHMT) of missed opportunities in designing programs especially on ANC for women in rural

communities. These findings would help streamline program of health care that would be

beneficial to the mother and the unborn baby.

The findings would also be beneficial to the Ministry of Health, Ghana Health Service and non-

governmental organizations since the information would assist management to tailor their

planning and delivery of information on factors that would prevent pregnant women from

attending ANC in Gambaga. The findings from the study would serve as a baseline data at the

College were nursing and midwifery students and persons interested in researching in similar

areas would use the findings one day.

Definitions of terms

o Antenatal care: Medical surveillance and review performed during pregnancy for the

early detection of possible complications of pregnancy, especially pre-eclamptic

toxaemia, and uterine and foetal abnormalities (medicaldictionary.com).

o Antenatal care utilisation: The act of making practical and effective use of antenatal

care services.

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 CHAPTER TWO

Literature review

Introduction

Literature review focuses on areas relevant to the research topic. This results in development of a

comprehensive picture on what is known on the topic. This research proceeds accordingly to

review literature that is pertinent to the research topic by putting them under sub-headings in

relation to the research objectives.

Factors influencing ANC attendance among pregnant women

In Africa, the scientific evidence has shown that low utilisation of ANC services among pregnant

is influenced by some factors such as low maternal education, teenage pregnancies, multiparity,

unplanned pregnancies and cultural factors (Abaka-Yawson et al., 2020). A significant number

of women in developing countries, particularly in the sub-Saharan countries, do not have the

opportunity to be attended to by skilled personnel during childbirth at health facilities and this

prevents some of them from attending ANC (Kotoh & Boah, 2019). Lack of female education,

inadequate female empowerment, bad attitude of health care workers and long distance to health

facilities in most communities are factors influencing pregnant women choice of ANC (Manyeh,

Amu, Williams & Gyapong, 2020).

Similarly, many socio-demographic and lifestyle factors have been associated with the use of

ANC in general among pregnant women (Abaka-Yawson et al., 2020). In a survey carried out by

Abaka-Yawson et al. (2020) to assess factors associated with ANC use among pregnant women

in Ghana. Findings from the study showed that, parity of pregnant women and long distance to

health care facilities affected pregnant women utilization of ANC.

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Also, mothers’ level of education was a factor influencing the use of ANC for which mothers

with primary educational level were more likely to attend ANC than women who are unable to

read and write. This study further revealed that availability of women’s time is important as

women spend more time on their multiple responsibilities for care of children, collecting water

or fuel, cooking, cleaning, and trade than on their own health (Manyeh et al., 2020). In Repel,

Nigeria Sembelian, family size was a strong determinant of ANC service utilization with greater

household size limiting the use of ANC service (Rosaliza & Muhammad, 2011)

A study done in Taraba State, Nigeria, Victor (2019) identified that women preferred TBAs for

various reasons which included: cheap easily accessible culturally acceptable services and more

compassionate care than orthodox health workers, and for some it was the only maternity they

knew. However, some respondents acknowledged that complications could arise from TBA care.

Several factors influenced Amhara Region, Northwest Ethiopia women ANC seeking behavior

which included: perceived high cost of (ANC services, conducting a delivery and treatment), and

perceived inadequacy of services provided by the formal health system (Dagnew, et al., 2020).

Another study in India economic disparity along with cultural belief and restrictions determined

care seeking behavior and utilization of health care, resulting in slow decline of child mortality

rate.

A study done in in northern Ghana showed that the probability for use of ANC in women in the

highest wealth index group is higher despite their difference in place of residence and

educational level, women were found to have a higher level of use of ANC among pregnant

women. This depicts that household wealth is a very strong determinant of health service

utilization. In Amhara Region, Northwest Ethiopia, it was been demonstrated that lack of

recognition of health problems were significant reasons for not seeking out antenatal care, which

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accounts for half of the maternal deaths. Perceived quality of care that comprises the quality of

the medical care and experience of the people with the health facility can influence ANC

utilization of pregnant women (Dagnew et al., 2020).

in Ghana, in the North East region, Alebila (2019) revealed that, local belief, availability of

indigenous practices, unsatisfactory services at the health facility, unfriendly attitude of staff at

the health facility, unavailability of staff at the health facility and long waiting time were factors

affecting pregnant women utilization of ANC care.

In Western Kenya, Nganga et al. (2020) revealed that, several factors influence pregnant women

use of ANC services. It was revealed that, pregnant women perceived lack of knowledge about

ANC, fear related to lack of privacy and confidentiality within the health facilities resulted in

them not willing to visit their local clinics, which made them reluctant and led them to delay

seeking ANC. Antenatal care services must be made attractive to women. This can be achieved

by the way pregnant women are treated during ANC visits. If a woman was once treated

offensively in a healthcare facility, the probability of that woman returning to that facility is very

low and she may not be passionate about any instructions provided to her during her visit at that

clinic, should she choose to revisit (Emanuel, Amos & Victoria, 2017; Rosaliza & Muhammad,

2011).

Utilization of ANC among pregnant women

The four visits of ANC have specific activities that are carried out at the antenatal clinic. The

classification of pregnant women into low and high-risk states becomes necessary since it serves

as the corner stone to predicting the complications that pregnant women could have and projects

the best solutions to these possibilities (WHO, 2016). Studies have revealed that, the time and

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ability to detect complications early enough is an indicator for the level of quality of antenatal

care rendered by health care services (Kofie et al., 2019)

The earlier complications are detected, the best prognosis that a pregnant woman could have.

Antenatal care is therefore proactive in nature that seeks to detect pregnancy and birth

complications and to get the pregnant woman also ready and fully prepared for such situations

(Emanuel, Amos & Victoria, 2017; Onasoga, Afolayan & Oladimeij, 2012).

A study in Ghana found that majority of the mothers who attended ANC did not receive adequate

number of visits and initiated the visits later than recommended by the World Health

Organization (Kofie et al., 2019). A similar study done in Nigeria Sembelian found that Nigerian

women tended to obtain care late in pregnancy, and about one third the care was inadequate with

almost half (47 percent) of women attending the ANC clinic in the third trimester. The ANC

Service utilization in Nigeria was significantly influenced by maternal age, where mothers aged

between 25 – 29 years were less likely to utilize ANC service than women who were 35 years

and older. Positive husband attitude towards ANC was also significantly related to ANC service

utilization (Rosaliza & Muhammad, 2011).

A study carried out on reproductive health issues showed that the recorded births, the mothers

made 4 or more antenatal visits, while few made fewer than 4 visits and most did not attend at all

which is contrary to WHO recommendation of visits. This shows that there are marked

differential in the use of antenatal and same as been observed. Thus, giving rise to the need to

identify the factors influencing the utilization of antenatal clinic among pregnant women (Orboi,

Msen & Mallongi, 2019)

A cross sectional study done in Northwest Ethiopia among pregnant women were reported to

have receive antenatal care at least once during their last pregnancy; of these 88 (49.2%) women

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made the first antenatal care visit during their second trimester, while 52 (29%) had four or more

antenatal care follow ups during their last pregnancy. The level of antenatal care utilization was

also found to be high among women with higher economic status, better education, few children,

married women and employed women (Fekadu et al., 2019).

Attitude of pregnant women towards ANC attendance

The level of knowledge and attitudes of pregnant women towards ANC services benefits differs

in different parts of the world. While few studies present pregnant women to have positive

attitude towards ANC, others revealed that, pregnant women had negative attitude towards ANC

care (Ambreen & Shah, 2018).

In Ghana the acceptability and feasibility of introducing the ANC approach, was well accepted

and appreciated. Components such as individualized care, privacy during service delivery and an

emphasis on birth planning were received very positively (Akhtar et al., 2018). Studies have

revealed that, the attitude of pregnant women towards ANC is measured to be one of the

significant factors that permit women to understand their right and condition of health and allow

them to seek for suitable ANC services (Banda, Michelo & Hazemba, 2012).

The attitude of pregnant women towards ANC is often influence by a number of factors. The

attitudes and behaviours of health care providers in ANC clinics compound this problem by

failing to respect the privacy, confidentiality, and traditional beliefs of the women. This may

negatively influence the use of ANC services at large (WHO, 2016). In most health care

facilities, existing opportunities for referral were not completely utilized and client’s awareness

of the process of ANC delivery was poor and was often confused with free delivery policies

(Shafqat et al., 2015). Outreach actions, such as follow-up visits and information sharing, to

ensure client compliance, infra-structure strengthening to ensure availability of space, equipment

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and essential drugs, supplies and equipment to providing ANC services were often found to be

inadequate (Wemakor, 2019).

In Ghana, Ahenkorah et al., (2020) revealed the attitude of pregnant women towards ANC care

was not good. Most of the pregnant women did not attend ANC regularly and the prevalence of

parasitic infections was high among the pregnant women.

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 CHAPTER THREE

Methodology

Introduction

This chapter presents the research methodology that was used to conduct the study. The chapter

explains the various sub headings such as the profile of the study setting, research population and

sample size, research design, sampling technique, data collection method, data collection

instrument, data analysis technique and eethical considerations.

Profile of the study area

The East Mamprusi District (EMD) was established by Legislative Instrument (LI) 1776 (2004)

with the capital located at Gambaga. Gambaga is a historic town lying next to the seat of the

Nayiri, king of Mamprugu, and also the first headquarters of the Northern Territories. It is one of

the oldest districts in the Northern Region. Out of it, the West Mamprusi District was carved in

1988. In 2004, the Bunkpurugu-Yunyoo District was also created to promote developments. It

therefore served as the parent District for West Mamprusi and Bunkpurugu -Yunyoo Districts.

The East Mamprusi District is located in the north-eastern part of the Northern Region. To the

north, it shares boundaries with Talensi and Nabdam Districts, Bawku West and Garu-Tempane

Districts, all in the Upper East Region and to the east is the Bunkpurugu-Yunyoo District. It is

bordered in the west by the West Mamprusi District and to the south by the Gusheigu and

Karaga Districts. It covers a land mass of 1,706.8 square kilometers, representing about 2.2

percent of the total land mass of the region.

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The District lies in the tropical continental western margin and characterized by a single rainfall

pattern brought in by the rain bearing tropical maritime air mass (MT). This occurs between

April and October every year. This is followed by the tropical continental air mass (CT) which

brings about the dry season (Harmattan) and occurs from late November to March. The mean

annual rainfall is between 1000mm to 1500mm with the peak occurring from July to September.

The District experiences a prolonged dry season with the peak occurring between March and

April. Temperature is fairly high with the annual mean temperature ranging from 27.4oC to

35oC depending on the season. The highest temperature is recorded in the dry season while the

lowest is experienced during the Harmattan season.

The District lies within the interior woodland savannah belt and has Common grass vegetation

with trees like dawadawa, baobab, sheanut, etc. Grasses grow in tussocks and can reach a height

of 3 metres or more. There is marked change in the vegetation depending on the two prevailing

climatic conditions. During the rainy season, animals graze on the grasses which serve as feed

for them and hence lessen the burden of animal owners in finding feed for them. Shea tree is of

great economic value for the women who pick the nuts and process it into sheabutter.

The land is generally slightly undulating with the Gambaga escarpment marking the Northern

limits of the Voltain Sandstone basin. Apart from the mountainous areas bordering the

escarpment, there is also little runoff when it rains. There are different types of rock formation

given the different relief features, which range from flat bottom valleys to steep-sided highlands.

The upper half of the District is underlined by the middle Voltain formation consisting of shale,

mudstone, iron pans and sandstone. The District has good water drainage basin. The White

Volta, which enters the region in the northeast is joined by the Red Volta near Gambaga, The

Nawong and Moba rivers are major perennial rivers in the District.

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There are two major soil types in the District. These are the Savannah Ochrosols and

Groundwater Laterites. The Savannah Ochrosols which covers almost the entire District, is

moderately drained and the upland soils developed mainly on Voltain sandstone. The texture of

the surface soil is sandy to sandy loam with fairly good water retention. The Groundwater

Laterite covers a smaller portion of the District and is mainly found in the southern part of the

District. These are concretionary soils developed mainly from Voltain shale, mudstone and

argillaceous sandstone materials. The texture of the soil is sandy loam which is suitable for the

cultivation of annual food crops such as maize, millet, sorghum, watermelon etc and tree crops

with long gestation period such as sheanut, dawadawa, cashew etc which are of economic

importance.

The Nayiri is the King (overlord)of Mamprugu traditional area and has council of elders who

advise him. The Nayiri is supported by paramount chiefs, Divisional and other sub-chiefs under

him. His paramountcies extend beyond the boundaries of the District and are located in other

Regions and Districts. Notable among the chiefs are the Wulugu Naaba, Wungu Naaba, Soo

Naaba, Kulgu Naaba etc (all in the West Mamprusi District); Yunyoorana and Bunkpurugu

Naaba (in the Bunkpurugu Yunyoo District) and Zuarungu Naaba, Tongu Naaba, Sakuti etc (all

in Upper East Region).

The census sought information on household members who are engaged in agricultural activities,

including the cultivation of crops or tree planting, rearing of livestock or breeding of fish for sale

or family consumption. Information was also collected on their farms, types of crops and number

and type of livestock. The UN recommended definition of a house as a structurally separate and

independent place of abode such that a person or group of persons can isolate themselves from

the hazards of climate such as storms and the sun was adopted.

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The definition, therefore, covered any type of shelter used as living quarters, such as separate

houses, semi-detached houses, flats/apartments, compound houses, huts, tents, kiosks and

containers. Living quarters or dwelling units refer to a specific area or space occupied by a

particular household and therefore need not necessarily be the same as the house of which the

dwelling unit may be a part. Information collected on housing conditions included the type of

dwelling unit, main construction materials for walls, floor and roof, holding/tenure arrangement,

ownership type, type of lighting, source of water supply and toilet facilities. Data was also

collected on method of disposal of solid and liquid waste (GSS, 2020).

Research population and sample size

The study population included pregnant women in Gambaga at the time of the study. They

included pregnant women who were aged at least 18 years and had no conditions that needed

emergency care at the time of the study.

Research design

The research employed a descriptive cross-sectional study design. This type of research designs

gathers data at a single point in time. The research design allows a sub set of the population to be

selected for the study. The advantages of using this type of study design is that, it is cheap and

fast. However, the study design has the disadvantage of producing different results with same

population at a different point in time.

Sampling technique

Simple random sampling technique was employed to sample respondents in Gambaga. Simple

random sampling technique was used in order to avoid bias and to ensure that each study

participant had an equal chance of being selected for the study.

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Data collection method

The data was gathered from both primary and secondary sources. Primary data was obtained

using a structured questionnaire while the secondary data was obtained from reviewed literature

on ANC in Ghana and beyond. Copies of the questionnaires were administered by the

researchers at Gambaga.

Data collection instrument

A structured questionnaire written in English Language was used for the data collection. The

questionnaire was structured based on the research questions. The first part gathered data on the

demographic data of the respondents whilst the second part collected data on the various research

questions. To establish the validity and reliability of the structured questionnaire, the following

steps were taken;

 Establishing objectives that truly reflected the focus and purpose of the study on ANC

 The first draft of the structured questionnaire was examined by our study supervisor. The

purpose of it was to ensure that it asked the information for which it was designed for.

 Current studies were reviewed to enable us to the discussions

Data analysis technique

The completed questionnaires obtained from the study participants were analysed using

Microsoft Excel 2016. The findings were presented using simple frequencies and percentages

tables as well as charts. In each table or charts simple explanations were given to provide further

meanings on the results presented.

Ethical considerations

Before the data collection from the pregnant women in Gambaga, permission was obtained from

the opinion leaders and informed consent from respondents before questionnaire administration.

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The researchers explained the purpose of the study to the opinion leaders and obtained verbal

consent from respondents before proceeding with questionnaire administration. Participation in

this study was voluntary for the pregnant women. Participants were assured that their responses

were confidential and information that might revealed their identity were not recorded, and only

aggregated data was communicated.

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APPENDIX

Informed consent

This questionnaire is designed to assist the researchers to collect data for a research study on the

topic: Attitude and factors affecting the patronage of antenatal care (ANC) among

pregnant women in Gambaga. Your opinion is very important and your participation is

voluntary. You are at liberty to withdraw from the research any time without any penalty

imposed on you. This is not to evaluate or criticize you, so please do not feel pressured to give a

specific response and do not feel shy if you do not know the answer to a question. Feel free to

answer questions at your own pace.

Do you have any question before we start? (Answer questions).

Section A: Demographic data of respondents

1. Age (years)………………………………………………………

2. Occupational status 1. salaried worker [ ] 2. unemployed [ ] 3. private business [ ] 4. student

[ ] 5. other (specify)…................................................

3. Marital status 1. single [ ] 2. married [ ] 3. separated [ ] 4. Divorced [ ]

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4. Educational status 1. educated [ ] 2. not educated [ ]

5. Parity status 1. 1-2 [ ] 2. 1-4 [ ] 3. 4+ [ ]

Section B: Optimal ANC utilization among pregnant women

6. When did you initiate ANC? 1. first trimester ( ) 2. second trimester ( ) 3. third trimester ( )

7. Why did you initiate it at that time? 1. Didn’t know anything about ANC ( ) 2. Didn’t have

means of transport ( ) 3. Was not feeling well ( ) 4. Husband travelled ( )

8. Do you drive some benefits from ANC? 1. yes ( ) 2. no ( ) 3. do not know ( )

9. If yes probe for benefits…………………………………..

10. Do you know the services provided at ANC? 1. yes ( ) 2. no ( ) 3. do not know ( )

11. If yes, probe for services………………………………………………………

12. How many times should pregnant women attend ANC? 1.Less than 3times ( ) 2. Three to

four times () 3.Less than four times () 4. four to five times ( ) 5. More than five times

13. How many times have you attended so far?................................................................................

Section E: Factors preventing pregnant women from attending ANC

14. Do you know the factors affecting ANC care among pregnant women? a. yes ( ) b. no ( )

15. If yes mention them……………

16.Indicate against each statement the extent to which you agree, disagree or are neutral with the

factors thought to be influencing ANC attendance among pregnant women

Variable Agree Disagree Neutral

Lack of knowledge concerning ANC

Educational status of pregnant women

Occupational status of pregnant women

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 Social and cultural issues in the community

Long distance to health facilities

Parity status of pregnant women

Previous successful home delivery of pregnant women

Availability of TBAs in the communities

Bad staff attitude towards pregnant women

Forgetfulness of pregnant women

Others

Section D: Attitude towards ANC

17. The following statement assess pregnant women attitude towards ANC. State the response

against each

i. I will allow the midwife to check my blood pressure a. yes ( ) b. no ( )

ii. I will continue with ANC even if I am not feeling sick a. yes ( ) b. no ( )

iii. I will deliver my baby in the hospital a. yes ( ) b. no ( )

iv. I will allow doctor or midwife to take my blood for screening of diseases a. yes ( ) b. no

()

v. ANC attendance is good for me and my unborn baby a. yes ( ) b. no ( )

vi. Early antenatal care is good for my pregnancy a. yes ( ) b. no ( )

vii. I will go for antenatal care before the third month of my pregnancy a. yes ( ) b. no ( )

viii. I believe that vitamin supplement is good for the me and to the unborn baby a. yes ( ) b.

no ( )

Thanks so much

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