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Background: Although antenatal care coverage in Ghana is high, there exist gaps in the continued use of maternity care, especially utilization of skilled assistance during delivery. Many pregnant women seek care from different sources aside the formal health sector. This is due to negative perceptions resulting from poor service quality experiences in health facilities. Moreover, the socio-cultural environment plays a major role for this care-seeking behavior. This paper seeks to examine beliefs, knowledge and perceptions about pregnancy and delivery and care-seeking behavior among pregnant women in urban Accra, Ghana.Methods: A qualitative study with 6 focus group discussions and 13 in-depth interviews were conducted at Taifa-Kwabenya and Madina sub-districts, Accra. Participants included mothers who had delivered within the past 12 months, pregnant women, community members, religious and community leaders, orthodox and non-orthodox healthcare providers. Interviews and discussions were audio-taped, transcribed and coded into larger themes and categories.Results: Evidence showed perceived threats, which are often given socio-cultural interpretations, increased women’s anxieties, driving them to seek multiple sources of care. Crucially, care-seeking behavior among pregnant women indicated sequential or concurrent use of biomedical care and other forms of care including herbalists, traditional birth attendants, and spiritual care. Use of multiple sources of care in some cases disrupted continued use of skilled provider care. Furthermore, use of multiple forms of care is encouraged by a perception that facility-based care is useful only for antenatal services and emergencies. It also highlights the belief among some participants that care from multiple sources are complementary to each other.Conclusions: Socio-cultural interpretations of threats to pregnancy mediate pregnant women’s use of available healthcare services. Efforts to encourage continued use of maternity care, especially skilled birth assistance at delivery, should focus on addressing generally perceived dangers to pregnancy. Also, the attractiveness of facility-based care offers important opportunities for building collaborations between orthodox and alternative care providers with the aim of increasing use of skilled obstetric care. Conventional antenatal care should be packaged to provide psychosocial support that helps women deal with pregnancy-related fear. © 2013 Dako-Gyeke et al.; licensee BioMed Central Ltd.
The qualitative data used for this paper was collected within a larger project that explored pathways by which women accessed pregnancy and delivery care in the Ga East Municipality. The entire study was cross-sectional with survey, cost analysis, and qualitative components. The qualitative part constituted of focus group discussions (FGDs) and in-depth interviews (IDIs). All focus group discussions were conducted as homogeneous groups. FGDs for pregnant women were organized separately based on type of pregnancy care currently used. Women who had delivered within the past 12 months constituted another group, whilst public health care providers constituted a separate group. This study was carried out in the Ga East Municipality located in the north-eastern part of the Greater Accra region. The Municipality is made up of four sub-districts: Madina, Danfa, Taifa and Dome. Ga East area is a mix of urban, peri-urban and rural communities. In 2008, the population was estimated at 294,121, with a growth rate of 4.5%; 76% of the population is urban. The predominant occupations were public service and trading, followed by farming and craftsmanship. The 2008 Annual health Report on the Municipality showed rather low performance on maternal health indicators [33]. For instance, supervised delivery rate was only 38.1% of all deliveries (compared to a national 54%) and antenatal clinic attendance was 69.2% [33]. Both estimates of maternal care were below the national averages. Two of the four sub-districts, Taifa-Kwabenya and Madina were purposively selected as sites for the data collection. Taifa-Kwabenya was selected because it is a developing community. The limited number of public-managed health facilities in this area, hinders access to health care, including pregnancy and delivery care. Residents in this area seek care from Central Accra, Pokuase, Nsawam, and Amasaman in the adjoining districts. On the other hand, Madina is an old, urbanized and established sub-district with relatively better access to health care as the number of health facilities is more and also has better transport access to Central Accra, and other social services. Most of the health facilities in the Ga East area are located in the Madina Sub-district. All participants were purposively selected. Participants included mothers who had delivered within the past 12 months, pregnant women, community members, religious and community leaders, professional public health facility worker and individuals who provide alternative maternity services. The researchers first paid several visits to the facilities of pregnancy and delivery care providers, including public health facilities and TBAs. Through these visits the researchers had the opportunity to interact with providers and also observe the delivery and use of pregnancy related services. Pregnant women who were attending antenatal clinics at the time of researchers’ visits were recruited during regular antenatal sessions. Also pregnant women who went to the TBA for antenatal care were recruited during regular sessions. In addition, mothers who have delivered within the past 12 months and also attended Child Welfare Clinics (CWC) with their babies were recruited during regular CWC sessions at the public healthcare facilities. Healthcare providers within the public health facilities (nurses, doctors and midwives) were recruited at the antenatal clinics during regular working hours. Informal pregnancy-related care providers (herbalist, TBA, and Spiritualist) were identified either through health facility workers, who sometimes collaborate with them, or through women who utilize their services. A total of 55 participants were involved in the FGDs and IDIs. These included 35 women; 17 of the women were pregnant during the time of the study, and women who had delivered had their babies between 3 weeks and 12 months before the time of this study (Table 1). The ages of these women varied between 20 and 42 years. A few of the women were unemployed whilst most were engaged in diverse occupations (trading, factory work, healthcare profession and security profession). Several of the women were also married or living with a partner at the time of the study. In addition, 12 health care professionals, spiritualists (3), herbalist (1) and TBA (1) were also involved in the study. Study participants A set of issues was developed to guide the FGDs and IDIs. Key themes covered included perceptions of risk in pregnancy and associated behaviours; medico-religious perceptions; factors related to utilization of care and treatments; use and non-use of health services; health information; issues regarding coverage, utilization and access. Several of the IDIs were conducted in participants’ homes. All of the FGDs and some IDIs were conducted at convenient spaces within public healthcare facilities. Other IDIs were conducted in the shops or homes of the alternative care providers. IDIs and FGDs were conducted in English and in the local Twi language, where necessary. All FGDs and IDIs were audiotaped and transcribed verbatim. Transcriptions were augmented with the researchers’ field notes made during data collection. The data resulting from the transcriptions were evaluated, coded and analyzed by using thematic analysis. Researchers first extracted broad themes and then followed up with coded themes of the text. Themes established considered statements of meaning that were present in most of the data. In an attempt to ensure the credibility of the results codes and themes were corroborated with results from the quantitative and cost analysis components of the study. Emerging themes and categories were used to address the objectives of this study. Ethical approval for this study was obtained from the institutional review board of the Noguchi Memorial Institute for Medical Research, University of Ghana. Also, the researchers obtained written permission from the Municipal Director of Health Services, Ga East, Accra. In addition, verbal consent was received from all participants after explaining the purpose of the study and their right to withdraw their participation at anytime.
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