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BACKGROUND: Ghana’s maternal mortality ratio has been declining over the last two decades but at a rather slow pace. Poor access to effective maternity care is identified as one of the key challenges of maternity care. The current study mapped out the pathways to pregnancy care seeking among urban-dwelling adult women in a peri-urban district located in the Greater Accra region of Ghana.
The study was carried out between November 2011 and May 2012 in the Ga East district of Ghana. The Ga East District is a mix of urban, peri-urban, and rural communities with about two-thirds of the district being peri-urban or urban. In 2012, the district’s population was estimated at 276,017. The Taifa-Kwabenya and Madina sub-districts were purposively selected as sites for the data collection. Taifa-Kwabenya was selected because its communities were mainly emerging developments with limited access to publicly managed health facilities that provide pregnancy and delivery care. Residents in this area are known to seek care from other parts of Accra, including Central Accra, Pokuase, Nsawam, and Amasaman in the adjoining districts.12 On the other hand, the Madina sub-district is more urbanized with better access to social services including health care and public transportation. Most of the publicly managed health facilities in the Ga East district are located in the Madina Sub-district and are managed by the District Health Administration. A cross-sectional study design involving a community survey, focus group interviews, and key informant interviews were implemented between November 2011 and September 2012. The survey was administered to 300 adult women who had delivered a live birth within the last 12 months. The communities included in the survey were drawn randomly from a list of all communities provided by the Municipal Health Administration. Maps of the communities were obtained from the sub-municipal public health offices and used to randomly select clusters in each sub-district for inclusion in the survey. In the Taifa-Kwabenya sub-district, 180 women were selected by systematic sampling in the clusters identified for participation in the survey. An additional 120 women were selected, similarly, from the Madina sub-district clusters. The total sample size of 300 women was determined to be adequate to estimate the proportion of women reporting at least four visits of antenatal services within a confidence interval of 95% and a precision of 5%6. More respondents were selected from Madina because it is more densely populated per cluster than in Taifa/Kwabenya. Each respondent endorsed an informed consent document by appending their signature or thumb printing, after they had read the document or it had been read and explained to them by the interviewer in English or other language they understood. To be included in the survey, women should be at least 18 years, lived in the selected community for at least 6 months prior to the survey, and had delivered a live born child within the last 12 months. Trained field staff administered the questionnaires to the women in face-to-face interviews. The survey included three main tools: 1) a household roster describing household and demographic characteristics, 2) a care-seeking tool describing women care seeking behavior, places where care was sought from, barriers and access to care services, and 3) a Standard Patient Cost Questionnaire which documented women’s pathways to care seeking as well as the costs of seeking health care during pregnancy and delivery. The current study formed part of a larger study that also includes qualitative components focusing on beliefs and perceptions about pregnancy and care seeking. Ethical approval (certificate number 045/11-12) was obtained from the Noguchi Memorial Institute for Medical Research Institutional Review Board. Data was checked, coded and then captured electronically, using EpiData 3.1 (EpiData Assoc. Denmark). Analysis was completed using SPSS version 16 (SPSS Inc, Chicago). Data on characteristics of women and their household were summarized using frequencies and mean (standard deviation), as appropriate. Additionally, care seeking behavior and the pathways to accessing care were also summarized using frequencies. A multivariate logistic regression model was used to identify factors associated with simultaneous antenatal care seeking from multiple providers. Hypothesis testing was two-sided and an α-level < 0.05 was considered a statistically significant result.
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