Adherence to the recommended timing of focused antenatal care in the accra metropolitan area, Ghana

Pan African Medical Journal, Volume 33, Year 2019

Interpretation

Introduction: the proportion of antenatal attendants in Ghana who had at least four antenatal visits increased from 78% in 2008 to 87% in 2014. However, it is not known whether these visits followed the recommended timing of focused antenatal clinic attendance in Ghana. We sought to assess the adherence to the clinic schedule and its determinants in the Accra Metropolis. Methods: a cross-sectional study was conducted. Face-to-face interviews were conducted with postpartum women. Multiple logistic regression was used in the analysis of determinants of adherence to the recommended timing of clinic attendance. A p-value of <0.05 was considered statistically significant. Results: among 446 focused antenatal care clinic attendants, 378 (84.8%) had four or more visits. Among these, 101 (26.7%) adhered to the recommended clinic schedule. Women who adhered were more likely to have had education up to Junior High School [AOR=3.31, 95%CI (1.03-10.61)] or Senior High School [AOR=4.47, 95%CI (1.14-17.51)], or have history of abortion [(AOR=3.36, 95%CI (1.69-7.96)]. For every week increase in gestational age at booking at the antenatal clinic, respondents were 34% less likely to complete all four antenatal visits at the recommended times. [(AOR=0.66, 95% (0.60-0.73)]. Conclusion: majority of women receiving focused antenatal care in the Accra Metropolis have four or more visits but only about a quarter of them adhered to the recommended clinic schedule. Having high school education, history of abortion and early initiation of antenatal care were predictors of adherence to clinic schedule. Women should be educated on early initiation of antenatal care to enhance adherence. A hospital based quantitative cross-sectional study was conducted in June 2017. Postpartum mothers from selected hospitals were interviewed on their clinic attendance for FANC. Data were also abstracted from health facility records to determine factors associated with adherence to the schedule for FANC. The study was conducted in the Accra Metropolitan Area (AMA), which is one of the 216 Metropolitan, Municipal and District Assemblies (MMDAs) in Ghana and among the sixteen MMDAs in the Greater Accra Region (Figure 1). The metropolis, is subdivided into ten sub metros. The population of the metropolis is 1,665,086 [11]. There are four public hospitals in the metropolis that provide maternity services. These are the Korle-Bu Teaching Hospital (KBTH), Achimota Hospital, Greater Accra Regional Hospital and the Maamobi General Hospital. All the facilities except KBTH were used for the study. The Korle-Bu Teaching Hospital was excluded because it does not conduct FANC as most of its clients are referrals with medical or obstetric risks. The annual deliveries for the Greater Accra Regional Hospital, Achimota Hospital and the Maamobi General Hospital in the year 2015, were 8432, 3000 and 1926 respectively. This gives a ratio of 6:2:1 annual deliveries. The study participants were first day postpartum mothers, who had had focused antenatal care at the three study sites. Postpartum mothers were recruited since they had completed their antenatal care by virtue of the fact that they have delivered. Postpartum day one was also chosen because the women were in the health facilities and therefore access to their antenatal booklets was easy. More importantly, it enabled the capture of women with poor outcome (e.g. still births) who, very likely, would not have come for postnatal services. Postpartum women whose maternal health records and delivery summaries could not be traced and those who were too ill to be interviewed were excluded. The minimum sample size of postpartum women required was calculated using the formula for cross-sectional study for an infinite population. Map of the Greater Accra Region showing the Accra Metropolitan Area Where, N = required sample size Z1-α/2 = confidence level of 95% (standard value of 1.96), p = percentage of postpartum women who attended all four antenatal visits at the recommended times was assumed to be = 50% = 0.5 (50% was used as it will produce the highest minimum sample size; since we are not aware of any study that captured the proportion of women with correct timing of all four antenatal visits), d = allowable margin of error = 5%. The minimum sample size calculated was 385 and adjusted upward by 20% for incomplete data and inconsistencies to 462. Data were collected over 28 days, hence, 17 study participants were randomly selected from the three hospitals per day. Using the ratio of their annual deliveries, 11:4:2 respondents were recruited daily from the Greater Accra Regional, Achimota and the Maamobi General hospitals respectively for interview. Study participants were recruited from the postnatal wards a day after delivery. Each day, the folders of all mothers who delivered the previous day and had FANC (identified through their antenatal records) were serially numbered. The serial numbers were then written on pieces of papers and put in an opaque envelope. The required daily numbers as indicated above, were picked blindly with replacement. If a number that had been picked already was picked up again it was replaced until a different number was picked. Face-to-face interviews were conducted by trained research assistants who also extracted data on antenatal care. Data were entered into Microsoft Office Excel 2007, imported and analysed with Stata Version 15 (Stata Corporation, College Station, TX, USA. The data entry sheet was designed with appropriate variable definition in place and consistency checks to minimize error during the data entry. The data were doubly entered by two trained research assistants. This helped in detecting any discrepancy by running frequency checks on both sets of data. The data were then cross checked and the necessary corrections were made for accuracy of the final entered data. Mean and standard deviation were calculated for continuous variables that were approximately normally distributed whilst median and range were calculated for continuous variables that were not normally distributed. Student's t-test was used to compare the difference between two means. Categorical variables were summarized as frequencies and proportions. Pearson's chi square test statistic was performed on categorical data to test association between socio-demographic factors, obstetrics and gynaecological history and adherence to timing of focused antenatal care. Multiple logistic regression was used in the analysis of determinants of adherence to the timing of focused antenatal care. Variables that were significant at the bivariate level were included in the logistic regression model. Odds ratio (OR) and 95% confidence intervals (CI) were used to test the strength of association. In all analysis, a p-value of <0.05 determined statistical significance. The primary outcome of interest was adherence to the recommended timing of all four FANC visits by Ghanaian standards [6]. Socio-demographic characteristics and past obstetrics and gynaecological history were the independent variables of interest. Study participants were described as adherent to the FANC timing if they had at least four antenatal visits and had visits falling within all the four recommended time periods for FANC visits. Clients who had less than four visits, or had at least four visits but missed one or more visits at the recommended timing were classified as non-adherent. Clients who had less than 4 visits were excluded from the analysis of measures of association because the focus of the study was to determine whether the timing of antenatal visits by women who have four or more antenatal visits and would ordinarily be said to have had adequate antenatal care was appropriate. To ensure data quality and assure validity and reliability of the information obtained, three research assistants were trained over a 2 day period before pretesting of the questionnaire was carried out. Daily data validation meetings were also held. The questionnaire was pre-tested at the La General Hospital located in the La Dadekotopon Municipality, which adjoins the Accra Metropolitan Area. The La General Hospital serves a population with similar socio-demographic characteristics as the study hospitals. Ethical clearance to carry out the study was obtained from the Ghana Health Service Ethical Review Committee prior to commencement of the study. Administrative approval was obtained from the Greater Accra Regional Health Directorate and heads of the various hospitals. A written informed consent was obtained from each respondent aged 18 years and above. For respondents below 18 years, written informed consent was obtained from their parents/guardians and assent from those respondents.

AI Digest

Study Justification:

The study aimed to assess the adherence to the recommended timing of focused antenatal care (FANC) in the Accra Metropolitan Area, Ghana. This is important because although the proportion of antenatal attendants in Ghana who had at least four antenatal visits increased, it is not known whether these visits followed the recommended timing. Understanding the adherence to the clinic schedule and its determinants can help improve the quality of antenatal care and ultimately improve maternal and child health outcomes.

Highlights:

– Among the 446 focused antenatal care clinic attendants, 84.8% had four or more visits.
– Only 26.7% of those who had four or more visits adhered to the recommended clinic schedule.
– Women who adhered to the schedule were more likely to have higher education levels, a history of abortion, and early initiation of antenatal care.
– Gestational age at booking at the antenatal clinic was negatively associated with adherence to the recommended timing.

Recommendations:

– Women should be educated on the importance of early initiation of antenatal care to enhance adherence to the recommended clinic schedule.
– Health facilities should provide clear guidelines and reminders to pregnant women about the recommended timing of antenatal visits.
– Further research is needed to explore other factors that may influence adherence to the recommended timing of antenatal care.

Key Role Players:

– Ministry of Health: Responsible for policy development and implementation of maternal and child health programs.
– Ghana Health Service: Oversees the delivery of healthcare services and can provide guidance and support for implementing recommendations.
– Health facility managers: Responsible for ensuring that health facilities have the necessary resources and systems in place to support adherence to the recommended timing of antenatal care.
– Community health workers: Can play a role in educating and mobilizing pregnant women to seek early and regular antenatal care.

Cost Items for Planning Recommendations:

– Development and dissemination of educational materials: Cost of designing and printing materials to educate pregnant women on the importance of early initiation of antenatal care.
– Training of healthcare providers: Cost of training healthcare providers on the recommended timing of antenatal visits and how to effectively communicate this information to pregnant women.
– Monitoring and evaluation: Cost of monitoring and evaluating the implementation of the recommendations to ensure adherence to the recommended clinic schedule.
– Community outreach activities: Cost of organizing community outreach activities to raise awareness and educate pregnant women on the importance of antenatal care and adherence to the recommended timing.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is relatively strong, but there are some areas for improvement. The study design is a quantitative cross-sectional study, which provides valuable data. The sample size calculation was appropriate, and data were collected from multiple sources, including face-to-face interviews and health facility records. The statistical analysis was conducted using multiple logistic regression, which helps identify determinants of adherence to the recommended timing of clinic attendance. However, there are a few areas that could be improved. First, the abstract does not provide information on the response rate, which is important for assessing the representativeness of the sample. Second, the abstract does not mention any limitations of the study, which would be helpful for interpreting the findings. Finally, the abstract could provide more details on the measures used to assess adherence to the clinic schedule and the specific recommendations for timing of antenatal visits in Ghana. To improve the evidence, future studies could consider addressing these limitations and providing more comprehensive information.

Abstract

A hospital based quantitative cross-sectional study was conducted in June 2017. Postpartum mothers from selected hospitals were interviewed on their clinic attendance for FANC. Data were also abstracted from health facility records to determine factors associated with adherence to the schedule for FANC. The study was conducted in the Accra Metropolitan Area (AMA), which is one of the 216 Metropolitan, Municipal and District Assemblies (MMDAs) in Ghana and among the sixteen MMDAs in the Greater Accra Region (Figure 1). The metropolis, is subdivided into ten sub metros. The population of the metropolis is 1,665,086 [11]. There are four public hospitals in the metropolis that provide maternity services. These are the Korle-Bu Teaching Hospital (KBTH), Achimota Hospital, Greater Accra Regional Hospital and the Maamobi General Hospital. All the facilities except KBTH were used for the study. The Korle-Bu Teaching Hospital was excluded because it does not conduct FANC as most of its clients are referrals with medical or obstetric risks. The annual deliveries for the Greater Accra Regional Hospital, Achimota Hospital and the Maamobi General Hospital in the year 2015, were 8432, 3000 and 1926 respectively. This gives a ratio of 6:2:1 annual deliveries. The study participants were first day postpartum mothers, who had had focused antenatal care at the three study sites. Postpartum mothers were recruited since they had completed their antenatal care by virtue of the fact that they have delivered. Postpartum day one was also chosen because the women were in the health facilities and therefore access to their antenatal booklets was easy. More importantly, it enabled the capture of women with poor outcome (e.g. still births) who, very likely, would not have come for postnatal services. Postpartum women whose maternal health records and delivery summaries could not be traced and those who were too ill to be interviewed were excluded. The minimum sample size of postpartum women required was calculated using the formula for cross-sectional study for an infinite population. Map of the Greater Accra Region showing the Accra Metropolitan Area Where, N = required sample size Z1-α/2 = confidence level of 95% (standard value of 1.96), p = percentage of postpartum women who attended all four antenatal visits at the recommended times was assumed to be = 50% = 0.5 (50% was used as it will produce the highest minimum sample size; since we are not aware of any study that captured the proportion of women with correct timing of all four antenatal visits), d = allowable margin of error = 5%. The minimum sample size calculated was 385 and adjusted upward by 20% for incomplete data and inconsistencies to 462. Data were collected over 28 days, hence, 17 study participants were randomly selected from the three hospitals per day. Using the ratio of their annual deliveries, 11:4:2 respondents were recruited daily from the Greater Accra Regional, Achimota and the Maamobi General hospitals respectively for interview. Study participants were recruited from the postnatal wards a day after delivery. Each day, the folders of all mothers who delivered the previous day and had FANC (identified through their antenatal records) were serially numbered. The serial numbers were then written on pieces of papers and put in an opaque envelope. The required daily numbers as indicated above, were picked blindly with replacement. If a number that had been picked already was picked up again it was replaced until a different number was picked. Face-to-face interviews were conducted by trained research assistants who also extracted data on antenatal care. Data were entered into Microsoft Office Excel 2007, imported and analysed with Stata Version 15 (Stata Corporation, College Station, TX, USA. The data entry sheet was designed with appropriate variable definition in place and consistency checks to minimize error during the data entry. The data were doubly entered by two trained research assistants. This helped in detecting any discrepancy by running frequency checks on both sets of data. The data were then cross checked and the necessary corrections were made for accuracy of the final entered data. Mean and standard deviation were calculated for continuous variables that were approximately normally distributed whilst median and range were calculated for continuous variables that were not normally distributed. Student's t-test was used to compare the difference between two means. Categorical variables were summarized as frequencies and proportions. Pearson's chi square test statistic was performed on categorical data to test association between socio-demographic factors, obstetrics and gynaecological history and adherence to timing of focused antenatal care. Multiple logistic regression was used in the analysis of determinants of adherence to the timing of focused antenatal care. Variables that were significant at the bivariate level were included in the logistic regression model. Odds ratio (OR) and 95% confidence intervals (CI) were used to test the strength of association. In all analysis, a p-value of <0.05 determined statistical significance. The primary outcome of interest was adherence to the recommended timing of all four FANC visits by Ghanaian standards [6]. Socio-demographic characteristics and past obstetrics and gynaecological history were the independent variables of interest. Study participants were described as adherent to the FANC timing if they had at least four antenatal visits and had visits falling within all the four recommended time periods for FANC visits. Clients who had less than four visits, or had at least four visits but missed one or more visits at the recommended timing were classified as non-adherent. Clients who had less than 4 visits were excluded from the analysis of measures of association because the focus of the study was to determine whether the timing of antenatal visits by women who have four or more antenatal visits and would ordinarily be said to have had adequate antenatal care was appropriate. To ensure data quality and assure validity and reliability of the information obtained, three research assistants were trained over a 2 day period before pretesting of the questionnaire was carried out. Daily data validation meetings were also held. The questionnaire was pre-tested at the La General Hospital located in the La Dadekotopon Municipality, which adjoins the Accra Metropolitan Area. The La General Hospital serves a population with similar socio-demographic characteristics as the study hospitals. Ethical clearance to carry out the study was obtained from the Ghana Health Service Ethical Review Committee prior to commencement of the study. Administrative approval was obtained from the Greater Accra Regional Health Directorate and heads of the various hospitals. A written informed consent was obtained from each respondent aged 18 years and above. For respondents below 18 years, written informed consent was obtained from their parents/guardians and assent from those respondents.

Materials

N/A

Innovations

Based on the provided information, here are some potential innovations that could improve access to maternal health:

1. Mobile Health (mHealth) Applications: Develop mobile applications that provide pregnant women with reminders and information about the recommended timing of antenatal clinic attendance. These apps can also include features such as appointment scheduling, educational resources, and access to healthcare professionals for virtual consultations.

2. Telemedicine Services: Implement telemedicine services that allow pregnant women to consult with healthcare providers remotely. This can help overcome barriers such as transportation and long waiting times, making it easier for women to seek timely antenatal care.

3. Community Health Workers: Train and deploy community health workers to educate pregnant women about the importance of early initiation of antenatal care and the recommended clinic schedule. These workers can provide personalized support and guidance, ensuring that women understand the benefits of adhering to the schedule.

4. Public Awareness Campaigns: Launch public awareness campaigns to raise awareness about the importance of antenatal care and the recommended timing of clinic attendance. These campaigns can use various media channels, such as radio, television, and social media, to reach a wide audience and promote behavior change.

5. Incentives for Adherence: Introduce incentives, such as vouchers for essential baby items or discounts on healthcare services, to encourage pregnant women to adhere to the recommended clinic schedule. These incentives can serve as motivators and rewards for attending antenatal care appointments on time.

6. Improved Health Facility Infrastructure: Invest in improving the infrastructure of health facilities, particularly in underserved areas, to ensure that pregnant women have access to quality antenatal care services. This can include expanding and renovating clinics, providing necessary equipment and supplies, and increasing the number of healthcare providers.

7. Collaboration with Non-Governmental Organizations (NGOs): Partner with NGOs that focus on maternal health to implement innovative programs and interventions. These organizations often have expertise and resources to support initiatives aimed at improving access to antenatal care.

It is important to note that the implementation of these innovations should be context-specific and tailored to the needs and resources of the Accra Metropolitan Area in Ghana. Additionally, continuous monitoring and evaluation should be conducted to assess the effectiveness and impact of these interventions on improving access to maternal health.

AI Innovations Description

The study titled “Adherence to the recommended timing of focused antenatal care in the Accra Metropolitan Area, Ghana” aimed to assess the adherence to the clinic schedule for antenatal care and its determinants in the Accra Metropolis. The study found that while the proportion of antenatal attendants who had at least four antenatal visits increased over the years, only about a quarter of them adhered to the recommended clinic schedule.

Based on the study findings, the following recommendations can be developed into an innovation to improve access to maternal health:

1. Education on early initiation of antenatal care: The study found that women who initiated antenatal care early were more likely to adhere to the recommended clinic schedule. Therefore, it is important to educate women on the importance of early initiation of antenatal care to enhance adherence. This can be done through community outreach programs, health education campaigns, and targeted messaging through various media channels.

2. Improving access to antenatal care services: To ensure that women have the opportunity to attend all recommended antenatal visits, it is crucial to improve access to antenatal care services. This can be achieved by increasing the number of healthcare facilities that provide antenatal care services, especially in underserved areas. Additionally, efforts should be made to reduce barriers to access, such as transportation costs and distance to healthcare facilities.

3. Strengthening antenatal care monitoring and follow-up: Healthcare providers should implement systems to monitor and follow-up with pregnant women to ensure they attend all recommended antenatal visits. This can be done through the use of reminder systems, such as text messages or phone calls, to remind women of their upcoming appointments. Additionally, healthcare providers can conduct home visits for women who have missed their appointments to provide necessary support and encourage them to attend future visits.

4. Empowering women through education: The study found that women with higher levels of education were more likely to adhere to the recommended clinic schedule. Therefore, efforts should be made to empower women through education, particularly at the junior high school and senior high school levels. This can be done by providing scholarships, mentorship programs, and vocational training opportunities to ensure that women have the knowledge and skills to make informed decisions about their maternal health.

By implementing these recommendations, it is possible to improve access to maternal health and increase adherence to the recommended timing of antenatal care visits, ultimately leading to better maternal and child health outcomes.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Increase awareness and education: Implement targeted educational campaigns to raise awareness about the importance of antenatal care and the recommended timing of clinic attendance. This can be done through community outreach programs, media campaigns, and partnerships with local organizations.

2. Strengthen healthcare infrastructure: Improve the availability and accessibility of healthcare facilities, particularly in underserved areas. This can involve building new clinics or upgrading existing ones, ensuring they have the necessary equipment and trained staff to provide quality antenatal care.

3. Enhance transportation services: Address transportation barriers by providing reliable and affordable transportation options for pregnant women to reach healthcare facilities. This can include establishing shuttle services, partnering with local transport providers, or implementing telemedicine solutions for remote consultations.

4. Engage community health workers: Train and deploy community health workers to provide antenatal care services and education at the community level. These workers can conduct home visits, organize group sessions, and provide personalized support to pregnant women, ensuring they receive timely and appropriate care.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify key indicators to measure the impact of the recommendations, such as the percentage of pregnant women attending antenatal care within the recommended timing, the number of antenatal visits completed, and the reduction in maternal and neonatal mortality rates.

2. Collect baseline data: Gather data on the current state of access to maternal health services, including the percentage of women adhering to the recommended timing of clinic attendance, the number of antenatal visits completed, and any existing barriers to access.

3. Develop a simulation model: Create a simulation model that incorporates the recommended interventions and their potential impact on access to maternal health. This model should consider factors such as population demographics, healthcare infrastructure, transportation availability, and community engagement.

4. Input data and run simulations: Input the baseline data into the simulation model and run multiple simulations to assess the potential impact of the recommendations. Adjust the parameters of the interventions, such as the coverage of educational campaigns or the number of community health workers deployed, to evaluate different scenarios.

5. Analyze results: Analyze the simulation results to determine the potential impact of the recommendations on improving access to maternal health. Assess the changes in key indicators and identify any trade-offs or unintended consequences that may arise from implementing the interventions.

6. Refine and validate the model: Refine the simulation model based on the analysis of the results and validate it against real-world data. This can involve comparing the simulated outcomes with actual data from pilot projects or similar interventions implemented in other settings.

7. Develop an implementation plan: Based on the simulation results, develop an implementation plan that outlines the specific actions, resources, and timelines needed to implement the recommended interventions. Consider the feasibility, cost-effectiveness, and sustainability of each intervention.

8. Monitor and evaluate: Continuously monitor and evaluate the implementation of the interventions to assess their effectiveness and make any necessary adjustments. Collect data on the indicators identified in step 1 to measure progress and identify areas for improvement.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of different interventions on improving access to maternal health and make informed decisions on how to allocate resources and implement effective strategies.

Author

Dima Health

Statistics:

Citations: 4

Identifiers:

DOI: 10.11604/pamj.2019.33.123.15535

Research Areas:

Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Ghana

Study Design:

Case-Control Study, Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female