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This study aimed to investigate factors that influence antenatal care utilization and their association with adverse pregnancy outcomes (defined as low birth weight, stillbirth, preterm delivery or small for gestational age) among pregnant women in Kumasi. A quantitative cross-sectional study was conducted of 643 women aged 19-48 years who presented for delivery at selected public hospitals and private traditional birth attendants from July-November 2011. Participants’ information and factors influencing antenatal attendance were collected using a structured questionnaire and antenatal records. Associations between these factors and adverse pregnancy outcomes were assessed using chi-square and logistic regression.Nineteen percent of the women experienced an adverse pregnancy outcome. For 49% of the women, cost influenced their antenatal attendance. Cost was associated with increased likelihood of a woman experiencing an adverse outcome (adjusted OR. =. 2.15; 95% CI. =. 1.16-3.99; p=. 0.016). Also, women with > 5 births had an increased likelihood of an adverse outcome compared with women with single deliveries (adjusted OR. =. 3.77; 95% CI. =. 1.50-9.53; p=. 0.005). The prevalence of adverse outcomes was lower than previously reported (44.6 versus 19%). Cost and distance were associated with adverse outcomes after adjusting for confounders. Cost and distance could be minimized through a wider application of the Ghana National Health Insurance Scheme. © 2013 Ministry of Health, Saudi Arabia.
A quantitative cross-sectional study was conducted to investigate factors that influence participation in ANC services and their association with adverse pregnancy outcomes in Kumasi. The study was conducted in two health facilities: the Komfo Anokye Teaching Hospital (KATH) and Manhyia District Hospital (a tertiary and a secondary hospital, respectively). Kumasi is the capital of the Ashanti Region. It has an estimated population of about 1.7 million people (Kumasi Health Profile, unpublished, Joana Tawia Burgesson). KATH is a referral hospital that provides most of the ANC, labor and delivery services. It serves the entire Ashanti Region as well as the bordering Regions. Manhyia District Hospital covers Manhyia North and South and caters to 34.6% of the Kumasi population (Kumasi Health Profile, unpublished, Joana Tawia Burgesson). Additionally, 16 Traditional Birth Attendants (TBAs) trained in caring for pregnant women, delivering babies, and recognizing danger signs necessitating hospital referral were included in this study. TBAs who lived and practiced within the Asokwa health sub-metro participated in this study. Eligible participants were pregnant women, 19 years and older, who resided in Kumasi at the time of conception or moved to Kumasi within 1–2 months following conception and presented to the study hospitals or TBAs for delivery. Women with singleton, spontaneous, vaginal deliveries occurring without complications between July and November 2011 were eligible for enrollment in this study. Women with pregnancy-induced hypertension or pre-eclampsia were excluded because this condition would cause them to attend more than the required number of ANC visits. Potential participants who presented for delivery at the study health facilities were informed of the study by the attending midwives during their admission to the labor ward while the TBAs informed their clients. Informed consent was obtained from all participants who participated in the study. Data from 643 of the 647 women were used for this study. Trained study personnel administered questionnaires to the participants 1-2 hrs following their delivery. Participants were questioned in a private area, no identifying information was recorded and confidentiality was assured. Questionnaires were reviewed for completeness. The Institutional Review Board of the University of Alabama at Birmingham, USA, and the Committee on Human Research, Publications and Ethics, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana, approved the study protocol. A 92-item structured questionnaire was used to ascertain information on: (1) socio-demographics, (2) obstetric and reproductive history, (3) occupation and lifestyle factors, (4) ANC services and treatment received, and (5) perception of quality of ANC services received and level of satisfaction. The socio-demographic section was adapted from the Malaria Monitoring and Evaluation Group [23]. It included questions about health insurance and duration of the insurance. Prior to the commencement of the study, the entire questionnaire was reviewed by six senior midwives for content validity and cultural sensitivity. To improve its reliability, the validated instrument was pre-tested on five pregnant women attending ANC and six new mothers. Following pre-test modifications, twelve new mothers who met the study eligibility requirements pilot tested the questionnaire. The questionnaire was modified accordingly before use. ANC attendance was assessed using data abstracted from the maternal antenatal booklet and responses to the following questions: Barriers to ANC attendance were assessed by asking women whether they did not attend the expected number of antenatal clinic visits because of any of the following reasons; (a) I did not know I had to attend that many times; (b) I could not afford it; (c) lack of insurance; (d) No time to attend; (e) I have had other children without any problems; (f) I was not sick; (g) Hospital too far from where I live; (h) I do not like the attitude of the hospital staff; (i) Fear of knowing my HIV status; (j) Cultural beliefs; and (k) lack of confidence in the services provided. Any adverse outcome was defined as: low birth weight (birth weight <2500 g), preterm delivery (<37 weeks of gestation), and small for gestational age (sex-specific birth weight at or below the 10th percentile for the weight-for-gestational age of an international reference population) [8]. Stillbirth was defined as death of an infant more than 12 h prior to or within 12 h of delivery. Information on low birth weight, small for gestational age and stillbirth was ascertained from the maternity record at delivery and before discharge to the “Lying Inn Ward.” Determination of preterm was based on the response to the question on duration of pregnancy. The data were individually entered into a Microsoft Access 2010 database and imported to SAS. Descriptive statistics of the study participants were computed as frequency distributions (character variables), means and standard deviations (numeric variables). Association of participant characteristics and pregnancy outcomes was assessed using chi-square or Fisher’s exact tests. ANC attendance was categorized as <7 or 8–13 times (Ghana’s standard). Association between barriers, ANC attendance and adverse pregnancy outcomes were examined using chi-square test. Two multivariable models were used to assess the association between the identified barriers and adverse pregnancy outcomes. In the first multivariable model, all the variables in the bivariate model were included irrespective of their level of significance. In the second multivariable model, all variables with a p-value ⩽ 0.20 from the first multivariable model or biologically plausible were included while adjusting for age, marital status and level of education. The change-in-estimate criteria were used to select potential confounders. A variable was considered a confounder if the change in estimate from the crude and adjusted model was at least 10 percent [24]. Crude and adjusted odds ratios (ORs) with 95% confidence intervals (CI) and p-values were calculated using logistic regression. All tests were two-sided and p-values ⩽ 0.05 were considered statistically significant. SAS® 9.2 (SAS Institute, Cary, NC, USA) was used for analyses.
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