Utilisation of antenatal care and skilled delivery services among mothers in Nanton District of Northern Ghana: a mixed-method study protocol

BMJ open, Volume 12, No. 12, Year 2022

Interpretation

INTRODUCTION: Maternal morbidity and mortality are a global phenomenon with devastating effects on low-income and middle-income countries among which sub-Saharan Africa (SSA) is the hardest hit. Low utilisation of maternal health services has been recorded in recent times in the Nanton District of Ghana. This has raised concerns about the utilisation of antenatal care (ANC) and skilled delivery (SD) services in the district. However, we found no specific existing literature which has addressed these questions on ANC and SD utilisation in the study setting. Thus, this study seeks to explore the utilisation of ANC and SD services among mothers in the Nanton District of Northern Ghana. METHODS AND ANALYSIS: This will be an observational study. It will use a mixed-method approach, particularly, convergent parallel design to implement the study. This will include quantitative and qualitative aspects using a questionnaire and focus group discussion guide. The planned sample size is 411 participants. The data will be collected at the communities. Before participation in the study, the research team will receive individual written consent from the participants. Descriptive and inferential data analysis will be performed after the data collection. The results will be presented as frequency tables, bar charts and line graphs to indicate the proportions of the outcome indicators. The strength of association among variables will be determined at 95% CI and a significance level of alpha (0.05) will be used. ETHICS AND DISSEMINATION: Ethical clearance has been sought from the Ghana Health Service Ethics Review Board (GHS-ERC 027/03/22). The outcomes from this study may serve as a reference document for the District Health Directorate to use when developing strategies for ANC and SD services. The results will be published in open access and peer-reviewed journals. Ghana is located in West Africa with 16 administrative regions including the Northern region. The Northern region also has 16 districts (Metropolitan, Municipals and Districts). The Nanton District is one of the districts of the Northern region which was carved out of the Savelugu Municipality in 2018. It is about 80 km2 and shares boundaries with the Sagnarigu Municipal to the north, Karaga District to the east, Tamale Metropolis to the west and the Savelugu Municipal to the south. The population is mostly rural. It has 84 communities with a population density of 8.7/km2. The area is predominantly inhabited by the Dagomba ethnic group. The district has a total population of 63 450 inhabitants. The majority of the inhabitants are within the poverty line with low incomes. Thus, making it a challenge in accessing their healthcare when needed. There are 16 health facilities in the district. These include 4 health centres and 12 functional Community-based Health Planning and Service (CHPS) zones to promote health in the district. A CHPS compound is the smallest unit of the health system providing primary healthcare. The services include outpatient care, ANC, child welfare clinics and delivery services. Due to the size of the district, physical accessibility poses a great challenge to vulnerable populations such as women and children. Additionally, the unavailability of a district hospital, poor road network and the weak referral system during health emergencies impacts on essential health services utilisation in the study setting. This will be an observational study using a mixed-method approach and a convergent parallel design to assess the level of utilisation of ANC and SD services by mothers of infants in the Nanton District. According to Creswell and Plano Clark, a convergent parallel design entails that the researcher concurrently conducts the quantitative and qualitative components in the same phase of the research process, weights the methods equally, analyses the two components independently and interpret the results together.15 Thus, this method allows for the simultaneous collection and analysis of quantitative and qualitative data on the research problem. The analysis of data using both methods will be mutually reinforcing. The study participants will be mothers with infants (children under 1 year of age). They will be selected using multistage technique. In the district, there are 84 communities in 2 subdistricts (Nanton and Tampion). Nanton subdistrict has 45 communities while Tampion subdistrict has 39 communities. In each subdistrict, nine communities will be randomly selected. Thus, a total of 18 communities will be included in the study. At each community, about 23 mothers with infants will then be randomly selected to participate in the study. The sample size for the quantitative study will be determined using Cochran’s (1977) formula as follows: n=(Z2PQ)/d2.16 where: n=desired sample size; Z=the standard normal deviation, set at α=0.05 based on 95% CI=1.96; P=sample proportion of ANC attendance (41.9% or 0.419); Q=the acceptable deviation from the assumed proportion=(1−p); d=allowable margin of error=5.0%. With the district having at least eight+ ANC attendance of 41.9%, the estimated sample size is 374. A non-response rate of 10.0% (37) will be included. Thus, a total of 411 participants will be selected and interviewed in this part of the study. For the qualitative study, each focus group discussion (FGD) will have 6–10 participants. The FGDs will be conducted till the point of saturation (sample size). The saturation will be achieved if there is no new information from the participants. After reaching the point of saturation, two additional FGDs will be conducted. A multistage sampling technique will be employed. The first stage will use simple random sampling to select study communities. There are two subdistricts in the study setting. In each subdistrict, nine communities will be randomly selected. We assumed that 18 communities is representative of the entire district. The names of the communities will be listed, placed in an opaque container and thoroughly mixed. Then, the communities will be randomly selected. The second stage will involve the selection of study participants. At the community level, 23 mothers with infants will then be randomly selected to participate in the study. The selection of participants will be done by inviting all mothers with infants in each community to a particular venue. This will be done with the assistance of community volunteer(s). The total number of mothers with infants who honour the invitation in each community will constitute the sampling frame. They will be assigned unique numbers. The numbers will then be written on papers to represent the mothers and put in an opaque container. The mothers will then be asked to pick one piece of paper from the container. The mothers who will pick numbers from 1 to 23 will become the prospective study participants. This will be repeated in each community. In a situation where the number of mothers in a community are <23, all of them will constitute the study participants. The FGDs will be conducted with selected participants of the beneficiary communities till the point of saturation. The saturation will be achieved if there is no new information from the participants. After reaching the point of saturation, two additional FGDs will be conducted. Participants for the FGDs will be selected purposively to include at least three first-time mothers of infants and three mothers with two or more children with the last child being an infant. In situations where the number of participants falls below the set criteria, the available category participants will be engaged. This will ensure that diverse groups of mothers are involved in each FGD. Thus, this will enrich the quality of the discussions. In our study, an infant is a child between 0 and 11 months of age. A woman between 15 and 49 years of age with an infant is eligible to be included in the study. In addition, the woman should have lived in the community for the past year. A woman without an infant will be excluded. Similarly, women with children aged 1 year and older will be excluded in this study. Additionally, mothers with infants but have not lived in the district for the past year will also be excluded. In addition to the criteria above, women who will take part in the quantitative study will be excluded from the qualitative study. The study will assess both dependent and independent variables to determine their level of association. The dependent variable of the study is the utilisation of ANC and SD by mothers of infants. Mothers of infants who have ANC contacts (attendance) will be divided into four categories: no contact, one to three contacts, four to seven contacts and eight or more contacts. The categorisation will be based on the WHO earlier recommendation of a minimum of four ANC visits in 200617 and the later recommendation of a minimum of eight ANC contacts in 2016 with skilled ANC providers.18 Also, mothers who have eight or more contacts with a skilled provider will be assessed as having adequately used the ANC service as recommended by the new WHO standards. To ascertain this, ANC cards of the mothers will be checked to determine this adequacy or otherwise of the ANC contacts. The mothers of infants who will have less than eight contacts will be deemed as inadequate utilisation of ANC service. Similarly, mothers of infants who delivered at health centre, CHPS compound or hospital by an accredited health professional will be considered as having used SD. The mothers who are delivered by Traditional Birth Attendants, home delivery and delivery in spiritual homes among others by an unaccredited birth attendant will be deemed as unskilled delivery. In this study, we will use the WHO definition of skilled care at birth as being a delivery service provided by an accredited health professional, such as a midwife, doctor or other nurse, who has been educated and trained in the skills necessary to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and to identify, manage and refer complications in women and newborns.19 The independent variables of the study will be centred on the literature review and the modified version of the Anderson behavioural model. Socioeconomic and demographic factors including maternal age, maternal education level, marital status, partner educational level, maternal occupation, religion, parity, average monthly income, use of ANC and health insurance status will be considered. Other variables will include the distance to a health facility, availability of health staff, health supplies, for example, drugs and transport. The qualitative data will be categorised into themes such as knowledge of mothers on ANC utilisation, factors influencing ANC utilisation, knowledge of mothers on SD and factors influencing utilisation of SD services. The other themes include approaches to improve access and use of ANC and SD in the study setting. This is very vital as it will help unravel relevant information from the participants. The complete list of themes that the qualitative section will explore is available in online supplemental file 1. bmjopen-2022-066118supp001.pdf The research team will collect data on participants’ demographic characteristics, socioeconomic, education factors, knowledge on ANC and SD services for mothers of infants will be collected through face-to-face interviews using a questionnaire. Also, FGDs will be conducted for selected participants. The study will employ both quantitative and qualitative research methods to determine the level of utilisation of ANC and SD services by mothers of infants in the district. The study implementation approach is resumed in online supplemental file 2. bmjopen-2022-066118supp002.pdf The quantitative data will be collected through the use of a structured questionnaire. It will be administered to selected mothers of infants. The women will be selected from 18 communities in the 2 subdistricts. For the selection process, any woman between the ages of 15 and 49 years with an infant will be eligible for the study. In the community, any household with a mother having an infant will be eligible for an interview. Qualitative data will be collected using an interview guide (FGD guide). The FGDs will be conducted with at least 6–10 mothers. Participants for the FGDs will be selected purposively to include at least three first-time mothers of infants and three mothers with two or more children with the last being an infant. In situations where the number of participants is less than the set criteria, the available mothers will be engaged. This will ensure that diverse groups of mothers are involved in the discussions. FGDs will be conducted with selected participants of the beneficiary communities till the point of saturation. After reaching the point of saturation, two additional FGDs will be conducted. The FGDs will be carried out at a serene and conducive environment devoid of interference and distraction. The FGDs will be conducted in the Dagbanli language which is the indigenous language. Tape recorders will be used to record the FGDs. Recorded tapes will be transcribed from the Dagbanli language into English. Content analysis will be employed to analyse the qualitative data. This will be done by categorising the data into various thematic areas as reflected in the interview guide. With this, the researchers will be able to critically analyse the perspectives of participants on the various themes. The study will use a structured questionnaire and FGDs guide to collect the data (online supplemental file 3). The structured questionnaire will be divided into four sections. The first section (A) will cover demographic data of participants, sections B, C and D will contain the three specific objectives. Some of the questions will use the Likert scale of measurement. This scale will be used to determine the opinions of subjects. It will contain a number of statements with a scale after each statement. Participants will be required to select from these statements that represent their opinion or interest. bmjopen-2022-066118supp003.pdf The FGDs guide will contain open-ended questions that will be used to facilitate discussion with specific target groups such as first-time mothers and mothers with previous deliveries. The qualitative data will be categorised into themes such as knowledge of mothers on ANC utilisation, factors influencing ANC utilisation, knowledge of mothers on SD and factors influencing utilisation of SD services. This is very vital as it will help unravel relevant information from the participants. Data will be collected by a four member team: the principal investigator (PI) and three research assistants (RAs). The RAs will be selected based on their understanding and ability to speak fluently the Dagbanli language. Also, their previous experience in surveys will be considered during the recruitment. A 1 day training session will be organised by the PI to educate the RAs on the key issues of the research work. This training will cover areas such as orientation on the data collection tools, issues bordering on data collection ethics (such as privacy and confidentiality) as well as obtaining informed consent before initiation of the interview. In addition, there will be a 1 day pretesting of data collection tools to ensure that they are standard and adequate for the study. The pretest is important as it will help to identify lapses on the tools. Finally, the researcher will adhere to high standards of data quality control. This will be achieved by cross-checking all administered questionnaires daily by the RAs to ensure their completeness and errors for correction. Data from the quantitative study will be analysed using SPSS V.22. After checking for completeness and cleaning, data will be analysed descriptively and inferentially according to the objectives. The results will be presented using tables, graphs and charts. The continuous data will be analysed through the IQRs, means and the SDs. The categorical variables will be presented as frequencies and percentages. The first part will deal with the sociodemographic data that will be summarised with frequencies and percentages. The second portion will be on objective one, which is about the proportion of mothers using ANC and SD services. The results of this objective will be summarised in frequencies and percentages, likewise objectives 2, 3 and 4 which are on; knowledge of mothers on ANC and SD; factors influencing utilisation of ANC and SD and to determine the relationship between ANC attendance and SD. In addition, inferential statistics will be applied to assess the possible relationship between the dependent variables (ANC and SD utilisation) and independent variables (socioeconomic, demographic factors and knowledge). The factors associated with the utilisation of ANC and SD services will be tested with Pearson’s χ2 test and a multivariate logistic regression test. Before conducting the regression analysis, independent variables to be included in the subsequent regression analysis will be selected using the χ2 test. The significance level will be determined by or set at a p value of 0.05. Multivariate analysis including binary logistic regression and χ2 test for bivariate will be used where appropriate. The multivariate analysis will be used to compare the utilisation of ANC and SD services, knowledge of mothers using these services and the factors influencing their utilisation to the demographic characteristics. The results will be presented as OR with 95% CIs to quantify possible associations between the variables. Data generated by the qualitative study will be collected using an interview guide (FGDs guide). After the transcription, the transcripts will be subjected to content analysis based on the various thematic areas of the FGD guide. The participants’ opinions and perspectives under each thematic area will be pulled together and analysed to unravel the context and viewpoints. In relation to knowledge on ANC and SD, participants expressing their opinion on a particular knowledge item more frequently will be considered high knowledge on that item. Similarly, less expression on a particular knowledge item will also be considered low knowledge. Regarding the factors influencing ANC and SD utilisation, the majority of participants stating particular factors will be considered to be priority factors and verse versa. During analysis, the opinions of participants will be represented by numbers assigned to them during the discussion phase so as to differentiate individual as well as community opinions. Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

AI Digest

Study Justification:

– Maternal morbidity and mortality are global issues, particularly affecting low-income and middle-income countries, including sub-Saharan Africa.
– Low utilization of maternal health services has been observed in the Nanton District of Ghana.
– There is a lack of specific existing literature addressing the utilization of antenatal care (ANC) and skilled delivery (SD) services in the study setting.
– This study aims to explore the utilization of ANC and SD services among mothers in the Nanton District of Northern Ghana.

Study Highlights:

– The study will use a mixed-method approach, specifically a convergent parallel design, to assess the level of utilization of ANC and SD services by mothers of infants in the district.
– The quantitative aspect will involve administering a questionnaire to selected mothers, while the qualitative aspect will involve conducting focus group discussions.
– The study will include 411 participants, with data collected from 18 communities in the Nanton District.
– Data analysis will involve descriptive and inferential analysis, presenting results through frequency tables, bar charts, and line graphs.
– The study has obtained ethical clearance from the Ghana Health Service Ethics Review Board.
– The outcomes of this study may serve as a reference for the District Health Directorate in developing strategies for ANC and SD services.
– The results will be published in open access and peer-reviewed journals.

Recommendations for Lay Reader and Policy Maker:

– Increase awareness and education on the importance of ANC and SD services among mothers in the Nanton District.
– Improve accessibility to healthcare facilities by addressing physical barriers, such as poor road networks and the lack of a district hospital.
– Strengthen the referral system during health emergencies to ensure timely access to essential health services.
– Enhance the availability of health staff, supplies, and resources in health facilities to support the provision of ANC and SD services.
– Promote the use of health insurance to reduce financial barriers to accessing ANC and SD services.
– Develop targeted interventions to address factors influencing ANC and SD utilization, as identified in the study.

Key Role Players:

– District Health Directorate
– Ghana Health Service
– Nanton District Health Facilities
– Community-based Health Planning and Service (CHPS) zones
– Research Team (Principal Investigator, Research Assistants)

Cost Items for Planning Recommendations:

– Infrastructure development (e.g., improving road networks, establishing a district hospital)
– Recruitment and training of additional health staff
– Procurement of health supplies and resources
– Health education and awareness campaigns
– Implementation of referral system improvements
– Support for health insurance coverage
– Research team expenses (e.g., salaries, travel, data collection tools)

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a mixed-method study protocol, which provides a comprehensive approach to gathering data. The study aims to explore the utilization of antenatal care (ANC) and skilled delivery (SD) services among mothers in the Nanton District of Northern Ghana. The study protocol outlines the methodology, including the sample size, data collection methods, and analysis techniques. The study has obtained ethical clearance and highlights the potential impact of the research findings on the development of strategies for ANC and SD services. However, the abstract does not provide specific details on the research questions, hypotheses, or expected outcomes of the study, which could enhance the strength of the evidence. To improve the evidence, the abstract could include a clear statement of the research questions and expected outcomes, as well as a brief summary of the potential implications of the findings for maternal health in the study setting.

Abstract

Ghana is located in West Africa with 16 administrative regions including the Northern region. The Northern region also has 16 districts (Metropolitan, Municipals and Districts). The Nanton District is one of the districts of the Northern region which was carved out of the Savelugu Municipality in 2018. It is about 80 km2 and shares boundaries with the Sagnarigu Municipal to the north, Karaga District to the east, Tamale Metropolis to the west and the Savelugu Municipal to the south. The population is mostly rural. It has 84 communities with a population density of 8.7/km2. The area is predominantly inhabited by the Dagomba ethnic group. The district has a total population of 63 450 inhabitants. The majority of the inhabitants are within the poverty line with low incomes. Thus, making it a challenge in accessing their healthcare when needed. There are 16 health facilities in the district. These include 4 health centres and 12 functional Community-based Health Planning and Service (CHPS) zones to promote health in the district. A CHPS compound is the smallest unit of the health system providing primary healthcare. The services include outpatient care, ANC, child welfare clinics and delivery services. Due to the size of the district, physical accessibility poses a great challenge to vulnerable populations such as women and children. Additionally, the unavailability of a district hospital, poor road network and the weak referral system during health emergencies impacts on essential health services utilisation in the study setting. This will be an observational study using a mixed-method approach and a convergent parallel design to assess the level of utilisation of ANC and SD services by mothers of infants in the Nanton District. According to Creswell and Plano Clark, a convergent parallel design entails that the researcher concurrently conducts the quantitative and qualitative components in the same phase of the research process, weights the methods equally, analyses the two components independently and interpret the results together.15 Thus, this method allows for the simultaneous collection and analysis of quantitative and qualitative data on the research problem. The analysis of data using both methods will be mutually reinforcing. The study participants will be mothers with infants (children under 1 year of age). They will be selected using multistage technique. In the district, there are 84 communities in 2 subdistricts (Nanton and Tampion). Nanton subdistrict has 45 communities while Tampion subdistrict has 39 communities. In each subdistrict, nine communities will be randomly selected. Thus, a total of 18 communities will be included in the study. At each community, about 23 mothers with infants will then be randomly selected to participate in the study. The sample size for the quantitative study will be determined using Cochran’s (1977) formula as follows: n=(Z2PQ)/d2.16 where: n=desired sample size; Z=the standard normal deviation, set at α=0.05 based on 95% CI=1.96; P=sample proportion of ANC attendance (41.9% or 0.419); Q=the acceptable deviation from the assumed proportion=(1−p); d=allowable margin of error=5.0%. With the district having at least eight+ ANC attendance of 41.9%, the estimated sample size is 374. A non-response rate of 10.0% (37) will be included. Thus, a total of 411 participants will be selected and interviewed in this part of the study. For the qualitative study, each focus group discussion (FGD) will have 6–10 participants. The FGDs will be conducted till the point of saturation (sample size). The saturation will be achieved if there is no new information from the participants. After reaching the point of saturation, two additional FGDs will be conducted. A multistage sampling technique will be employed. The first stage will use simple random sampling to select study communities. There are two subdistricts in the study setting. In each subdistrict, nine communities will be randomly selected. We assumed that 18 communities is representative of the entire district. The names of the communities will be listed, placed in an opaque container and thoroughly mixed. Then, the communities will be randomly selected. The second stage will involve the selection of study participants. At the community level, 23 mothers with infants will then be randomly selected to participate in the study. The selection of participants will be done by inviting all mothers with infants in each community to a particular venue. This will be done with the assistance of community volunteer(s). The total number of mothers with infants who honour the invitation in each community will constitute the sampling frame. They will be assigned unique numbers. The numbers will then be written on papers to represent the mothers and put in an opaque container. The mothers will then be asked to pick one piece of paper from the container. The mothers who will pick numbers from 1 to 23 will become the prospective study participants. This will be repeated in each community. In a situation where the number of mothers in a community are <23, all of them will constitute the study participants. The FGDs will be conducted with selected participants of the beneficiary communities till the point of saturation. The saturation will be achieved if there is no new information from the participants. After reaching the point of saturation, two additional FGDs will be conducted. Participants for the FGDs will be selected purposively to include at least three first-time mothers of infants and three mothers with two or more children with the last child being an infant. In situations where the number of participants falls below the set criteria, the available category participants will be engaged. This will ensure that diverse groups of mothers are involved in each FGD. Thus, this will enrich the quality of the discussions. In our study, an infant is a child between 0 and 11 months of age. A woman between 15 and 49 years of age with an infant is eligible to be included in the study. In addition, the woman should have lived in the community for the past year. A woman without an infant will be excluded. Similarly, women with children aged 1 year and older will be excluded in this study. Additionally, mothers with infants but have not lived in the district for the past year will also be excluded. In addition to the criteria above, women who will take part in the quantitative study will be excluded from the qualitative study. The study will assess both dependent and independent variables to determine their level of association. The dependent variable of the study is the utilisation of ANC and SD by mothers of infants. Mothers of infants who have ANC contacts (attendance) will be divided into four categories: no contact, one to three contacts, four to seven contacts and eight or more contacts. The categorisation will be based on the WHO earlier recommendation of a minimum of four ANC visits in 200617 and the later recommendation of a minimum of eight ANC contacts in 2016 with skilled ANC providers.18 Also, mothers who have eight or more contacts with a skilled provider will be assessed as having adequately used the ANC service as recommended by the new WHO standards. To ascertain this, ANC cards of the mothers will be checked to determine this adequacy or otherwise of the ANC contacts. The mothers of infants who will have less than eight contacts will be deemed as inadequate utilisation of ANC service. Similarly, mothers of infants who delivered at health centre, CHPS compound or hospital by an accredited health professional will be considered as having used SD. The mothers who are delivered by Traditional Birth Attendants, home delivery and delivery in spiritual homes among others by an unaccredited birth attendant will be deemed as unskilled delivery. In this study, we will use the WHO definition of skilled care at birth as being a delivery service provided by an accredited health professional, such as a midwife, doctor or other nurse, who has been educated and trained in the skills necessary to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and to identify, manage and refer complications in women and newborns.19 The independent variables of the study will be centred on the literature review and the modified version of the Anderson behavioural model. Socioeconomic and demographic factors including maternal age, maternal education level, marital status, partner educational level, maternal occupation, religion, parity, average monthly income, use of ANC and health insurance status will be considered. Other variables will include the distance to a health facility, availability of health staff, health supplies, for example, drugs and transport. The qualitative data will be categorised into themes such as knowledge of mothers on ANC utilisation, factors influencing ANC utilisation, knowledge of mothers on SD and factors influencing utilisation of SD services. The other themes include approaches to improve access and use of ANC and SD in the study setting. This is very vital as it will help unravel relevant information from the participants. The complete list of themes that the qualitative section will explore is available in online supplemental file 1. bmjopen-2022-066118supp001.pdf The research team will collect data on participants’ demographic characteristics, socioeconomic, education factors, knowledge on ANC and SD services for mothers of infants will be collected through face-to-face interviews using a questionnaire. Also, FGDs will be conducted for selected participants. The study will employ both quantitative and qualitative research methods to determine the level of utilisation of ANC and SD services by mothers of infants in the district. The study implementation approach is resumed in online supplemental file 2. bmjopen-2022-066118supp002.pdf The quantitative data will be collected through the use of a structured questionnaire. It will be administered to selected mothers of infants. The women will be selected from 18 communities in the 2 subdistricts. For the selection process, any woman between the ages of 15 and 49 years with an infant will be eligible for the study. In the community, any household with a mother having an infant will be eligible for an interview. Qualitative data will be collected using an interview guide (FGD guide). The FGDs will be conducted with at least 6–10 mothers. Participants for the FGDs will be selected purposively to include at least three first-time mothers of infants and three mothers with two or more children with the last being an infant. In situations where the number of participants is less than the set criteria, the available mothers will be engaged. This will ensure that diverse groups of mothers are involved in the discussions. FGDs will be conducted with selected participants of the beneficiary communities till the point of saturation. After reaching the point of saturation, two additional FGDs will be conducted. The FGDs will be carried out at a serene and conducive environment devoid of interference and distraction. The FGDs will be conducted in the Dagbanli language which is the indigenous language. Tape recorders will be used to record the FGDs. Recorded tapes will be transcribed from the Dagbanli language into English. Content analysis will be employed to analyse the qualitative data. This will be done by categorising the data into various thematic areas as reflected in the interview guide. With this, the researchers will be able to critically analyse the perspectives of participants on the various themes. The study will use a structured questionnaire and FGDs guide to collect the data (online supplemental file 3). The structured questionnaire will be divided into four sections. The first section (A) will cover demographic data of participants, sections B, C and D will contain the three specific objectives. Some of the questions will use the Likert scale of measurement. This scale will be used to determine the opinions of subjects. It will contain a number of statements with a scale after each statement. Participants will be required to select from these statements that represent their opinion or interest. bmjopen-2022-066118supp003.pdf The FGDs guide will contain open-ended questions that will be used to facilitate discussion with specific target groups such as first-time mothers and mothers with previous deliveries. The qualitative data will be categorised into themes such as knowledge of mothers on ANC utilisation, factors influencing ANC utilisation, knowledge of mothers on SD and factors influencing utilisation of SD services. This is very vital as it will help unravel relevant information from the participants. Data will be collected by a four member team: the principal investigator (PI) and three research assistants (RAs). The RAs will be selected based on their understanding and ability to speak fluently the Dagbanli language. Also, their previous experience in surveys will be considered during the recruitment. A 1 day training session will be organised by the PI to educate the RAs on the key issues of the research work. This training will cover areas such as orientation on the data collection tools, issues bordering on data collection ethics (such as privacy and confidentiality) as well as obtaining informed consent before initiation of the interview. In addition, there will be a 1 day pretesting of data collection tools to ensure that they are standard and adequate for the study. The pretest is important as it will help to identify lapses on the tools. Finally, the researcher will adhere to high standards of data quality control. This will be achieved by cross-checking all administered questionnaires daily by the RAs to ensure their completeness and errors for correction. Data from the quantitative study will be analysed using SPSS V.22. After checking for completeness and cleaning, data will be analysed descriptively and inferentially according to the objectives. The results will be presented using tables, graphs and charts. The continuous data will be analysed through the IQRs, means and the SDs. The categorical variables will be presented as frequencies and percentages. The first part will deal with the sociodemographic data that will be summarised with frequencies and percentages. The second portion will be on objective one, which is about the proportion of mothers using ANC and SD services. The results of this objective will be summarised in frequencies and percentages, likewise objectives 2, 3 and 4 which are on; knowledge of mothers on ANC and SD; factors influencing utilisation of ANC and SD and to determine the relationship between ANC attendance and SD. In addition, inferential statistics will be applied to assess the possible relationship between the dependent variables (ANC and SD utilisation) and independent variables (socioeconomic, demographic factors and knowledge). The factors associated with the utilisation of ANC and SD services will be tested with Pearson’s χ2 test and a multivariate logistic regression test. Before conducting the regression analysis, independent variables to be included in the subsequent regression analysis will be selected using the χ2 test. The significance level will be determined by or set at a p value of 0.05. Multivariate analysis including binary logistic regression and χ2 test for bivariate will be used where appropriate. The multivariate analysis will be used to compare the utilisation of ANC and SD services, knowledge of mothers using these services and the factors influencing their utilisation to the demographic characteristics. The results will be presented as OR with 95% CIs to quantify possible associations between the variables. Data generated by the qualitative study will be collected using an interview guide (FGDs guide). After the transcription, the transcripts will be subjected to content analysis based on the various thematic areas of the FGD guide. The participants’ opinions and perspectives under each thematic area will be pulled together and analysed to unravel the context and viewpoints. In relation to knowledge on ANC and SD, participants expressing their opinion on a particular knowledge item more frequently will be considered high knowledge on that item. Similarly, less expression on a particular knowledge item will also be considered low knowledge. Regarding the factors influencing ANC and SD utilisation, the majority of participants stating particular factors will be considered to be priority factors and verse versa. During analysis, the opinions of participants will be represented by numbers assigned to them during the discussion phase so as to differentiate individual as well as community opinions. Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Materials

Innovations

Based on the provided information, here are some potential innovations that could improve access to maternal health in the Nanton District of Northern Ghana:

1. Mobile Health Clinics: Implementing mobile health clinics that can travel to remote areas of the district to provide antenatal care and skilled delivery services. This would help overcome the challenge of physical accessibility and reach vulnerable populations.

2. Telemedicine: Introducing telemedicine services that allow pregnant women to consult with healthcare professionals remotely. This would enable women in remote areas to access medical advice and support without the need for travel.

3. Community Health Workers: Training and deploying community health workers in the district to provide basic maternal health services, education, and referrals. These workers can bridge the gap between communities and healthcare facilities, improving access to care.

4. Health Education Programs: Implementing comprehensive health education programs that focus on maternal health, including the importance of antenatal care and skilled delivery services. These programs can be conducted in collaboration with community leaders and local organizations to ensure cultural sensitivity.

5. Strengthening Referral Systems: Improving the referral system in the district to ensure timely and efficient transfer of pregnant women to higher-level healthcare facilities when needed. This would involve establishing clear protocols, training healthcare providers, and improving communication channels.

6. Infrastructure Development: Investing in the development of healthcare infrastructure in the district, including the construction of a district hospital. This would improve the availability and quality of maternal health services, making them more accessible to the population.

7. Financial Support: Implementing financial support programs, such as health insurance schemes or subsidies, to reduce the financial barriers to accessing maternal health services. This would help ensure that cost is not a hindrance for pregnant women seeking care.

8. Partnerships and Collaboration: Strengthening partnerships and collaboration between the District Health Directorate, local healthcare facilities, NGOs, and other stakeholders. This would facilitate coordinated efforts and resource sharing to improve access to maternal health services.

It is important to note that the specific recommendations for innovation would require further research, planning, and implementation to assess their feasibility and effectiveness in the context of the Nanton District.

AI Innovations Description

The study protocol described aims to explore the utilization of antenatal care (ANC) and skilled delivery (SD) services among mothers in the Nanton District of Northern Ghana. The study will use a mixed-method approach, including quantitative and qualitative data collection methods. The quantitative data will be collected through a structured questionnaire administered to selected mothers of infants, while the qualitative data will be collected through focus group discussions (FGDs) with selected participants.

The study will assess various factors that may influence the utilization of ANC and SD services, including socioeconomic and demographic factors, knowledge of mothers on ANC and SD, and factors influencing the utilization of these services. The data analysis will involve descriptive and inferential statistics, such as frequency tables, bar charts, line graphs, and tests of association between variables.

The study aims to provide valuable insights into the utilization of maternal health services in the Nanton District and may serve as a reference document for the District Health Directorate in developing strategies to improve access to ANC and SD services. The results of the study will be published in open access and peer-reviewed journals to contribute to the existing literature on maternal health in low-income and middle-income countries, particularly in sub-Saharan Africa.

AI Innovations Methodology

In order to improve access to maternal health in the Nanton District of Northern Ghana, the following recommendations can be considered:

1. Strengthening Community-Based Health Planning and Service (CHPS) Zones: CHPS zones are essential in providing primary healthcare services, including antenatal care and skilled delivery services. Investing in the expansion and improvement of CHPS zones in the district can help increase access to maternal health services for rural populations.

2. Mobile Health (mHealth) Solutions: Utilizing mobile technology can help overcome barriers to accessing maternal health services. Implementing mHealth solutions, such as mobile apps or SMS reminders, can provide pregnant women with information, appointment reminders, and access to healthcare providers, improving their engagement with antenatal care and skilled delivery services.

3. Transportation Support: The lack of transportation infrastructure in the district poses a significant challenge for pregnant women in accessing healthcare facilities. Implementing transportation support programs, such as community-based transportation services or partnerships with local transport providers, can help address this barrier and improve access to maternal health services.

4. Community Education and Awareness: Raising awareness about the importance of antenatal care and skilled delivery services is crucial in improving utilization. Implementing community education programs that target both women and their families can help dispel myths and misconceptions, promote early and regular antenatal care visits, and encourage the use of skilled delivery services.

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

1. Baseline Data Collection: Collect data on the current utilization of antenatal care and skilled delivery services in the Nanton District. This can be done through surveys, interviews, and data from health facilities.

2. Modeling the Impact: Use statistical modeling techniques to simulate the potential impact of the recommendations on improving access to maternal health services. This can involve analyzing the relationship between the proposed interventions and key outcome indicators, such as the number of antenatal care visits and the proportion of skilled deliveries.

3. Data Analysis: Analyze the data collected from the baseline assessment and the modeling exercise to determine the potential impact of the recommendations. This can involve comparing the projected outcomes with the current situation to assess the effectiveness of the proposed interventions.

4. Sensitivity Analysis: Conduct sensitivity analysis to assess the robustness of the results and identify potential uncertainties or limitations in the modeling process. This can involve varying key parameters or assumptions to understand their impact on the projected outcomes.

5. Recommendations and Implementation: Based on the findings of the simulation, provide recommendations for implementing the identified interventions to improve access to maternal health services. Consider factors such as feasibility, cost-effectiveness, and sustainability in the implementation plan.

6. Monitoring and Evaluation: Develop a monitoring and evaluation framework to track the progress of the implemented interventions and assess their impact over time. This can involve regular data collection, analysis, and reporting to ensure continuous improvement and accountability.

By following this methodology, stakeholders can gain insights into the potential impact of the recommended interventions and make informed decisions to improve access to maternal health services in the Nanton District.

Author

Dima Health

Identifiers:

DOI: 10.1136/bmjopen-2022-066118

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants

Study Countries:

Ghana, Multi-Countries

Study Design:

Cohort Study, Cross Sectional Study, Grounded Theory

Study Approach:

Mixed-methods, Qualitative, Quantitative, Systematic Review

Participants Gender:

Female