Postnatal care utilisation among women in rural Ghana: analysis of 2014 Ghana demographic and health survey

BMC Pregnancy and Childbirth, Volume 21, No. 1, Year 2021

Interpretation

Background: Maternal mortality is high in Ghana, averaging 310 maternal deaths per 100,000 live births in 2017. This is partly due to inadequate postnatal care especially among rural communities. Ghana can avert the high maternal deaths if women meet the World Health Organisation’s recommended early postnatal care check-up. Despite the association between geographical location and postnatal care utilisation, no study has been done on determinants of postnatal care among rural residents in Ghana. Therefore, this study determined the prevalence and correlates of postnatal care utilization among women in rural Ghana. Methods: The study utilised women’s file of the 2014 Ghana Demographic and Health Survey (GDHS). Following descriptive computation of the prevalence, binary logistic regression was fitted to assess correlates of postnatal care at 95% confidence interval. The results were presented in adjusted odds ratio (AOR). Any AOR less than 1 was interpreted as reduced likelihood of PNC attendance whilst AOR above 1 depicted otherwise. All analyses were done using Stata version 14.0. Results: The study revealed that 74% of the rural women had postnatal care. At the inferential level, women residing in Savanna zone had higher odds of postnatal care compared to those in the Coastal zone [AOR = 1.80, CI = 1.023–3.159], just as among the Guan women as compared to the Akan [AOR = 7.15, CI = 1.602–31.935]. Women who were working were more probable to utilise postnatal care compared to those not working [AOR = 1.45, CI = 1.015–2.060]. Those who considered distance as unproblematic were more likely to utilise postnatal care compared to those who considered distance as problematic [AOR = 1.63, CI = 1.239–2.145]. Conclusions: The study showed that ethnicity, ecological zone, occupation and distance to health facility predict postnatal care utilisation among rural residents of Ghana. The study points to the need for government to increase maternal healthcare facilities in rural settings in order to reduce the distance covered by women in seeking postnatal care. The study utilised women’s file of the 2014 GDHS. The 2014 GDHS, which is the current and sixth edition of the surveys, captures information on prevention and treatment of malaria for children under five, women’s reproductive performance, family planning, maternal and child health and other information relevant for maternal and child health policies. The implementing partners of the survey include the Ghana Statistical Service (GSS), the Ghana Health Service (GHS), and the National Public Health Reference Laboratory (NPHRL) of the GHS with technical aid from the Inner-City Fund (ICF) International. The survey adopted the Demographic and Health Survey (DHS) standardised questionnaire which is developed by the Measure DHS programme [16]. The 2014 GDHS used an updated sampling frame which was developed by the Ghana Statistical Service for the 2010 Population and Housing Census. This sampling frame do not include nomadic and institutional populations such as persons in hotels, barracks, and prisons. The survey followed a stratified sampling procedure in order to capture specific indicators at the national level whilst taking into account the rural and urban locations [16]. Firstly, sample points, referred to as clusters constituting enumeration areas (EAs) outlined for the 2010 PHC were selected. This resulted to 427 clusters (i.e. 216 and 211 urban and rural clusters respectively). Secondly, a systematic sampling technique was applied to select households and thereafter, a household listing was undertaken in all the selected EAs. Finally, households to be included in the survey were randomly selected from the list. This led to the selection of approximately 30 households from each cluster. In all, 9656 eligible women (comprising 4753 and 4903 women from urban and rural locations respectively) were identified for the survey. However, a total of 9396 women, consisting of 4602 from urban and 4794 from rural settings were interviewed, leading to 97% response rate. However, the current study was restricted to 1442 rural women with complete information on PNC utilisation and the selected explanatory variables. The study was restricted to rural residents because the 2014 GDHS revealed that the proportion of rural residents (21%) who do not obtain PNC are three times more than urban residents who do not obtain PNC (7%) [16]. Additionally, health facilities and health personnel are concentrated in urban Ghana [18]. Further information about the sampling procedure, pre-testing and field activities are available in the 2014 GDHS report [16]. The outcome variable for this study was “Postnatal Care (PNC)”. According to WHO, postnatal stage starts immediately after childbirth and goes into 6 weeks (42 days) after childbirth [13]. Therefore, in the DHS Women’s Questionnaire, all women who had a birth in the 5 years preceding the survey were asked whether a health care provider checked them after giving birth or within 2 months after birth accompanied by ‘Yes’, ‘No’ and ‘Don’t Know’. However, for precision in responses, ‘don’t know’ responses were excluded from the analysis. ‘No’ was coded as ‘0’ signifying those who did not receive postnatal check-up and ‘Yes’ as ‘1’, thus those who had postnatal check-up. PNC plays a key role in maternal health by giving women access to varied reproductive health services [1, 2, 14]. Sixteen independent variables were selected. These are age, marital status, ecological zone, education, wealth status, religion, ethnicity, occupation, total children ever born, partner’s education, frequency of reading newspaper/magazine, frequency of listening to radio, frequency of watching television, health decision making, holds a valid national health insurance scheme (NHIS) card and getting medical help for self: distance is a problem. For clarity of presentation, education was recoded into no education = 1, primary = 2 and secondary or higher = 3; wealth status was recoded into poor = 1, middle = 2 and rich = 3; region of residence was recoded into the three ecological zones of the country, consisting of Coastal = 1, Middle = 2 and Savanna = 3. Occupation was recoded into not working = 1 and working = 2; religion was recoded into Christian = 1, Islam = 2, Traditionalist = 3 and No religion = 4; total children ever born was recoded into one birth = 1, two births = 2, three births = 3 and four or more births = 4 guided by the current total fertility rate of the country [16]. Partner’s education was recoded into no education = 1, primary = 2 and secondary or above = 3; and finally health decision making capacity was recoded into alone = 1 and not alone = 2. These variables were selected because of their theoretical importance and practical significance to maternal healthcare utilisation [21, 22]. Frequency of reading newspaper/magazine, listening to radio and watching television were included in the analysis because they have been found as significant predictors of antenatal care utilisation and skilled birth attendance [23, 24]. We first computed the distribution of PNC attendance among women aged 15–49 in rural Ghana. This was followed by a bivariate analysis of socio-demographics and PNC attendance among rural women in Ghana with their respective chi-square of independence test. Since our outcome variable ‘PNC utilisation’ was binary, the binary logistic regression was considered appropriate for the study. This estimation technique was used because it gives room for predictions of outcome variables that are dichotomous in nature. The binary logistic regression was fitted to assess correlates of PNC at 95% confidence interval. Our results was presented in adjusted odds ratio (AOR) and any AOR less than 1 was interpreted as reduced likelihood of PNC attendance whilst AOR above 1 depicts an increased likelihood of PNC utilisation. The weighting factor (v005/100000) inherent in the dataset was applied to cater for the survey sampling errors whilst the ‘linktest’ command and goodness-of-fit were applied to assess the fitness of our model (see Additional files 1 and 2: Appendix 1 and 2 for details). Variance inflation factor (VIF) test for multicollinearity was conducted and the results indicated no evidence of multicollinearity among independent variables (see Additional files 3: Appendix 3). All analyses were done using Stata version 14.0. Since the authors of this manuscript did not participate in the actual data gathering processes, we sought no ethical clearance. However, we sought permission to use the data set from Measure DHS. Meanwhile, Measure DHS reported that ethical clearance was obtained from the Institutional Review Board of ICF International and Ethical Review Committee of Ghana Health Service [16]. Also, they ensured that every information that could reveal respondents’ identities were excluded from the dataset before they released the data to the public domain. The data set is freely available to the public at www.measuredhs.org.

AI Digest

Study Justification:

– Maternal mortality is high in Ghana, particularly in rural communities, due to inadequate postnatal care.
– Meeting the World Health Organisation’s recommended early postnatal care check-up can help reduce maternal deaths.
– No study has been done on the determinants of postnatal care among rural residents in Ghana.

Study Highlights:

– The study utilized the 2014 Ghana Demographic and Health Survey (GDHS) to analyze postnatal care utilization among rural women in Ghana.
– The study found that 74% of rural women had postnatal care.
– Factors such as ethnicity, ecological zone, occupation, and distance to health facility were found to predict postnatal care utilization.
– Women residing in the Savanna zone had higher odds of postnatal care compared to those in the Coastal zone.
– Guan women had higher odds of postnatal care compared to Akan women.
– Working women were more likely to utilize postnatal care compared to those not working.
– Women who considered distance as unproblematic were more likely to utilize postnatal care compared to those who considered distance as problematic.

Recommendations for Lay Reader and Policy Maker:

– Increase maternal healthcare facilities in rural settings to reduce the distance covered by women in seeking postnatal care.
– Improve access to postnatal care for women in rural areas by addressing factors such as ethnicity, ecological zone, occupation, and distance to health facility.

Key Role Players Needed to Address Recommendations:

– Government agencies responsible for healthcare infrastructure development and resource allocation.
– Non-governmental organizations (NGOs) working in maternal and child health.
– Community leaders and local authorities.
– Healthcare providers and professionals.
– Researchers and academics.

Cost Items to Include in Planning Recommendations:

– Construction and renovation of healthcare facilities in rural areas.
– Procurement of medical equipment and supplies.
– Training and capacity building for healthcare providers.
– Outreach programs and community engagement initiatives.
– Monitoring and evaluation activities.
– Research and data collection.
– Advocacy and awareness campaigns.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some areas for improvement. The study utilized a nationally representative dataset, which enhances the generalizability of the findings. The use of binary logistic regression to assess correlates of postnatal care utilization is appropriate. The study also provides adjusted odds ratios to quantify the associations. However, the abstract does not provide information on the sample size or the confidence intervals for the odds ratios, which limits the precision of the estimates. Additionally, the abstract does not mention any limitations of the study or potential sources of bias. To improve the evidence, the authors could include the sample size, confidence intervals, and a brief discussion of limitations and potential biases in the abstract.

Abstract

The study utilised women’s file of the 2014 GDHS. The 2014 GDHS, which is the current and sixth edition of the surveys, captures information on prevention and treatment of malaria for children under five, women’s reproductive performance, family planning, maternal and child health and other information relevant for maternal and child health policies. The implementing partners of the survey include the Ghana Statistical Service (GSS), the Ghana Health Service (GHS), and the National Public Health Reference Laboratory (NPHRL) of the GHS with technical aid from the Inner-City Fund (ICF) International. The survey adopted the Demographic and Health Survey (DHS) standardised questionnaire which is developed by the Measure DHS programme [16]. The 2014 GDHS used an updated sampling frame which was developed by the Ghana Statistical Service for the 2010 Population and Housing Census. This sampling frame do not include nomadic and institutional populations such as persons in hotels, barracks, and prisons. The survey followed a stratified sampling procedure in order to capture specific indicators at the national level whilst taking into account the rural and urban locations [16]. Firstly, sample points, referred to as clusters constituting enumeration areas (EAs) outlined for the 2010 PHC were selected. This resulted to 427 clusters (i.e. 216 and 211 urban and rural clusters respectively). Secondly, a systematic sampling technique was applied to select households and thereafter, a household listing was undertaken in all the selected EAs. Finally, households to be included in the survey were randomly selected from the list. This led to the selection of approximately 30 households from each cluster. In all, 9656 eligible women (comprising 4753 and 4903 women from urban and rural locations respectively) were identified for the survey. However, a total of 9396 women, consisting of 4602 from urban and 4794 from rural settings were interviewed, leading to 97% response rate. However, the current study was restricted to 1442 rural women with complete information on PNC utilisation and the selected explanatory variables. The study was restricted to rural residents because the 2014 GDHS revealed that the proportion of rural residents (21%) who do not obtain PNC are three times more than urban residents who do not obtain PNC (7%) [16]. Additionally, health facilities and health personnel are concentrated in urban Ghana [18]. Further information about the sampling procedure, pre-testing and field activities are available in the 2014 GDHS report [16]. The outcome variable for this study was “Postnatal Care (PNC)”. According to WHO, postnatal stage starts immediately after childbirth and goes into 6 weeks (42 days) after childbirth [13]. Therefore, in the DHS Women’s Questionnaire, all women who had a birth in the 5 years preceding the survey were asked whether a health care provider checked them after giving birth or within 2 months after birth accompanied by ‘Yes’, ‘No’ and ‘Don’t Know’. However, for precision in responses, ‘don’t know’ responses were excluded from the analysis. ‘No’ was coded as ‘0’ signifying those who did not receive postnatal check-up and ‘Yes’ as ‘1’, thus those who had postnatal check-up. PNC plays a key role in maternal health by giving women access to varied reproductive health services [1, 2, 14]. Sixteen independent variables were selected. These are age, marital status, ecological zone, education, wealth status, religion, ethnicity, occupation, total children ever born, partner’s education, frequency of reading newspaper/magazine, frequency of listening to radio, frequency of watching television, health decision making, holds a valid national health insurance scheme (NHIS) card and getting medical help for self: distance is a problem. For clarity of presentation, education was recoded into no education = 1, primary = 2 and secondary or higher = 3; wealth status was recoded into poor = 1, middle = 2 and rich = 3; region of residence was recoded into the three ecological zones of the country, consisting of Coastal = 1, Middle = 2 and Savanna = 3. Occupation was recoded into not working = 1 and working = 2; religion was recoded into Christian = 1, Islam = 2, Traditionalist = 3 and No religion = 4; total children ever born was recoded into one birth = 1, two births = 2, three births = 3 and four or more births = 4 guided by the current total fertility rate of the country [16]. Partner’s education was recoded into no education = 1, primary = 2 and secondary or above = 3; and finally health decision making capacity was recoded into alone = 1 and not alone = 2. These variables were selected because of their theoretical importance and practical significance to maternal healthcare utilisation [21, 22]. Frequency of reading newspaper/magazine, listening to radio and watching television were included in the analysis because they have been found as significant predictors of antenatal care utilisation and skilled birth attendance [23, 24]. We first computed the distribution of PNC attendance among women aged 15–49 in rural Ghana. This was followed by a bivariate analysis of socio-demographics and PNC attendance among rural women in Ghana with their respective chi-square of independence test. Since our outcome variable ‘PNC utilisation’ was binary, the binary logistic regression was considered appropriate for the study. This estimation technique was used because it gives room for predictions of outcome variables that are dichotomous in nature. The binary logistic regression was fitted to assess correlates of PNC at 95% confidence interval. Our results was presented in adjusted odds ratio (AOR) and any AOR less than 1 was interpreted as reduced likelihood of PNC attendance whilst AOR above 1 depicts an increased likelihood of PNC utilisation. The weighting factor (v005/100000) inherent in the dataset was applied to cater for the survey sampling errors whilst the ‘linktest’ command and goodness-of-fit were applied to assess the fitness of our model (see Additional files 1 and 2: Appendix 1 and 2 for details). Variance inflation factor (VIF) test for multicollinearity was conducted and the results indicated no evidence of multicollinearity among independent variables (see Additional files 3: Appendix 3). All analyses were done using Stata version 14.0. Since the authors of this manuscript did not participate in the actual data gathering processes, we sought no ethical clearance. However, we sought permission to use the data set from Measure DHS. Meanwhile, Measure DHS reported that ethical clearance was obtained from the Institutional Review Board of ICF International and Ethical Review Committee of Ghana Health Service [16]. Also, they ensured that every information that could reveal respondents’ identities were excluded from the dataset before they released the data to the public domain. The data set is freely available to the public at www.measuredhs.org.

Materials

Innovations

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

1. Mobile Health (mHealth) Solutions: Develop mobile applications or SMS-based platforms that provide pregnant women and new mothers with information and reminders about postnatal care, including check-ups and vaccinations. These platforms can also connect women with healthcare providers for virtual consultations or appointment scheduling.

2. Community Health Workers: Train and deploy community health workers in rural areas to provide postnatal care services, including check-ups and education on maternal and newborn health. These workers can conduct home visits, offer support, and refer women to healthcare facilities when necessary.

3. Telemedicine: Establish telemedicine services that allow women in rural areas to consult with healthcare professionals remotely. This can help address the issue of limited access to healthcare facilities by providing timely advice and guidance to women during the postnatal period.

4. Transportation Solutions: Improve transportation infrastructure and services in rural areas to make it easier for women to access healthcare facilities for postnatal care. This could include providing subsidized transportation options or implementing mobile clinics that visit remote communities.

5. Community-Based Maternal Health Programs: Implement community-based programs that focus on maternal health education and awareness. These programs can involve local leaders, traditional birth attendants, and community health workers to promote the importance of postnatal care and encourage women to seek it.

6. Maternal Health Vouchers: Introduce voucher programs that provide financial assistance to women in rural areas, enabling them to access postnatal care services. These vouchers can cover the cost of transportation, consultations, and medications, making healthcare more affordable and accessible.

7. Telemonitoring Devices: Develop and distribute telemonitoring devices that allow healthcare providers to remotely monitor the health of pregnant women and new mothers. These devices can track vital signs and provide real-time data to healthcare professionals, enabling early detection of complications and timely interventions.

8. Public-Private Partnerships: Foster collaborations between the government, private healthcare providers, and non-profit organizations to improve access to postnatal care in rural areas. This can involve setting up mobile clinics, establishing satellite healthcare facilities, or providing training and resources to existing healthcare providers in rural communities.

It is important to note that the implementation of these innovations should be tailored to the specific needs and context of rural Ghana, taking into account cultural sensitivities, infrastructure limitations, and the availability of resources.

AI Innovations Description

Based on the information provided, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Increase the number of maternal healthcare facilities in rural settings: The study found that the proportion of rural residents who do not obtain postnatal care is three times higher than urban residents. To address this disparity, the government should focus on increasing the number of healthcare facilities in rural areas. This would reduce the distance that women have to travel to access postnatal care, making it more accessible and convenient for them.

2. Improve transportation infrastructure: Distance to health facilities was found to be a significant factor affecting postnatal care utilization. To overcome this barrier, it is important to improve transportation infrastructure in rural areas. This could include building and maintaining roads, providing public transportation options, and ensuring that ambulances are readily available for emergency situations. By improving transportation options, women would have easier access to healthcare facilities, including postnatal care.

3. Increase awareness and education: The study identified factors such as education and awareness as important determinants of postnatal care utilization. To address this, it is crucial to increase awareness about the importance of postnatal care among women in rural areas. This can be done through community outreach programs, health education campaigns, and the use of local media channels. Additionally, providing education and training to healthcare providers in rural areas can help improve their knowledge and skills in providing postnatal care.

4. Strengthen the role of community health workers: Community health workers play a vital role in providing healthcare services in rural areas. By strengthening their capacity and providing them with the necessary resources, they can effectively deliver postnatal care services to women in their communities. This can include training programs, regular supervision and support, and the provision of necessary equipment and supplies.

5. Collaborate with local communities and traditional leaders: Engaging with local communities and traditional leaders is essential in addressing cultural and social barriers to postnatal care utilization. By involving them in the planning and implementation of maternal health programs, their support and endorsement can help increase acceptance and utilization of postnatal care services.

Overall, these recommendations aim to improve access to postnatal care for women in rural areas of Ghana, ultimately reducing maternal mortality rates. By addressing the barriers identified in the study, it is possible to develop innovative solutions that can make a significant impact on maternal health outcomes.

AI Innovations Methodology

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

1. Increase the number of maternal healthcare facilities in rural areas: The study highlights that health facilities and health personnel are concentrated in urban areas. To reduce the distance covered by women in seeking postnatal care, the government should invest in establishing more healthcare facilities in rural settings.

2. Improve transportation infrastructure: Inadequate transportation infrastructure can hinder women from accessing postnatal care. The government should invest in improving road networks and transportation services in rural areas to make it easier for women to reach healthcare facilities.

3. Enhance awareness and education: Many women in rural areas may not be aware of the importance of postnatal care or the services available to them. Implementing awareness campaigns and educational programs can help increase knowledge and understanding of the benefits of postnatal care, encouraging more women to seek these services.

4. Strengthen community-based healthcare services: Community-based healthcare services, such as mobile clinics or outreach programs, can bring healthcare services closer to rural communities. By providing postnatal care services directly in the communities, women may be more likely to access and utilize these services.

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 specific indicators that measure access to maternal health, such as the percentage of women receiving postnatal care within the recommended timeframe.

2. Collect baseline data: Gather data on the current status of access to maternal health in rural areas. This can be done through surveys, interviews, or analysis of existing data sources.

3. Develop a simulation model: Create a simulation model that incorporates the various factors influencing access to maternal health, such as distance to healthcare facilities, availability of transportation, and awareness levels. The model should be based on the recommendations mentioned above.

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. Vary the input parameters, such as the number of healthcare facilities or the level of awareness, to see how different scenarios affect access to maternal health.

5. Analyze results: Analyze the simulation results to determine the potential impact of the recommendations on improving access to maternal health. Identify which factors have the greatest influence and assess the feasibility and cost-effectiveness of implementing the recommendations.

6. Refine and validate the model: Refine the simulation model based on the analysis and feedback from stakeholders. Validate the model by comparing the simulation results with real-world data or conducting pilot studies to test the effectiveness of the recommendations.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of different interventions and make informed decisions on how to improve access to maternal health in rural Ghana.

Authors & Co-Authors

Statistics:

Citations: 6

Authors: 7

Identifiers:

DOI: 10.1186/s12884-020-03497-4

Research Areas:

Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health

Study Countries:

Ghana

Study Design:

Case-Control Study, Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female