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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.
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