Adherence to the recommended timing of focused antenatal care in the Accra Metropolitan Area, Ghana

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.


Introduction
Antenatal care, an essential component of safe motherhood programme, entails systematic medical supervision of the pregnant woman until she goes into labour or until she is delivered of her baby via elective caesarean section. It seeks to ensure that every wanted pregnancy results in safe delivery of a healthy baby and a good outcome for the mother as well [1]. Antenatal care helps in the identification of conditions that are associated with poor maternal and perinatal outcomes thereby helping to provide preventive and curative health services for the pregnant woman and the fetus [2].
Antenatal care is critical to delivering the appropriate medical care according to the patients risk status and also serves as an avenue to educate expectant mothers on nutrition, personal hygiene and birth preparedness as well as provide them with physical and psychosocial support. All these benefits dovetail into an opportunity to prevent or minimize complications during pregnancy, delivery and the puerperium and also prepares expectant mothers to take care of their children physically, psychologically and socially [3]. The main types of antenatal care are the traditional and focused antenatal care. The World Health Organization (WHO) has recently introduced the Positive Pregnancy Experience Module of antenatal care [4]. The traditional antenatal model consists of monthly visits for the first six months, a visit every two to three weeks for the next two months, and weekly thereafter until delivery [5]. The Ghanaian version had women paying monthly visits up to 28 weeks, fortnightly visits from 28 to 36 weeks followed by weekly visits until delivery [6]. The WHO introduced Focused Antenatal Care (FANC) in 2002 to replace the traditional one which involved many visits and was not evidence based. For FANC, pregnant women without any medical or other significant health-related risks, or pregnancy related complications, four antenatal visits at specific gestational ages with targeted interventions are enough to meet their antenatal needs [7]. Ghana adopted FANC in 2002. The first visit should occur before 16 weeks.
The second visit is between 20 to 24 weeks. The third visit is between 28 to 32 weeks and the fourth visit at 36 to 40 weeks [6]. In Ghana, the government has exempted fees for four visits for women attending antenatal clinics and also for delivery care. This is to remove intra-facility cost of antenatal care as an impediment to antenatal care [8]. A minimum of four antenatal visits is used as a proxy for adequate antenatal visits in Ghana. The proportion of pregnant women in Ghana who had at least four antenatal visits increased from about four in five in 2008 [9] to about nine in ten in 2014 [10]. What is not known however is how many of these women adhered to the recommended schedule for all four visits and the factors associated with this adherence. We sought to determine the adherence to the schedule for FANC and its associated factors among antenatal clinic attendees in the Accra Metropolitan Area.

Methods
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.

Discussion
The proportion of women having focused antenatal care in the Accra to incomplete focused antenatal intervention schedule [12]. Late reporting for the booking antenatal visit has also been associated with women who do not receive adequate education on danger signs of pregnancy. This figure is however higher than the 25% of pregnant women in Uganda whose booking visit occurred before 16weeks [13].
This difference may be attributed to the differences in socio-demographic characteristics between Ghana and Uganda. The 40% respondents who had their booking visit before 16 weeks is better than the 64% of antenatal women who present for their booking visit in the third trimester that was recorded in Kenya [14].
The Kenyan study was however in a rural community and also a community survey was used where access to patients antenatal records may be a challenge.
The proportion of women attending focused antenatal care in the Accra Metropolitan area and having at least four visits was about 85%. This is similar to the 87% national figures for Ghana and [10] Vietnam [15] antenatal attendants but higher than the 48% recorded in Uganda [13].

Conclusion
This study has shown that while over eight out of ten women  Table 1: socio-demographic characteristics of post -partum women who received focused antenatal care in the Accra Metropolitan Area in 2017 Table 2: obstetric and gynaecological characteristics of post-partum women who received focused antenatal care in the Accra Metropolitan Table 3: socio-demographic characteristics of women who attended 4 or more focused antenatal visits in the Accra Metropolitan Area by adherence to timing of visits Table 4: past obstetric and gynaecological history of post-partum women who attended four or more focused antenatal care in the Accra Metropolitan Area by recommended timing of visits Table 5: socio-demographic factors influencing correct timing of four or more focused antenatal visits among postpartum women in the Accra Metropolitan Area