Characteristics of Health Facilities, ANC Units, Pregnant Women
Seven health facilities across three levels of health care delivery system were included in this study. All the health facilities provided ANC services, however Focused ANC (FANC), which is an individualised, client centred, comprehensive care, with emphasis on disease detection rather than risk assessment (40) was limited to the hospitals and CHPS compounds. Although health centres had laboratory services, Glucose-6-phosphate dehydrogenase (G6PD) tests were conducted only in the hospital laboratories. MiP and case management guidelines were unavailable in some of the facilities, however, wall charts on IPTp-SP and ITN were visibly displayed on the walls in all the ANC units. Stock outs of SP and ITNs were recorded during the data collection period in some of the health centres (Table 2).
Organisation and Delivery of ANC Services
Owing to the free maternal health care policy in Ghana, all pregnant women are entitled to free enrolment on the National Health Insurance Scheme (NHIS) to enable access to maternal health services. In the hospitals and health centres, a section outside the ANC consulting room was used for recording blood pressure, temperature, weight and height of the pregnant women. A waiting area was also designated for pregnant women to sit and wait their turn, with collective health education organized for them. The hospitals, having two ANC consulting rooms with assigned midwives, practiced FANC. The health centres, having just one ANC consulting room with midwives alternating when on duty did not practice FANC. Services provided to pregnant women in the ANC consulting room included; history taking, physical examination (palpating the abdomen, measuring fundal height, and listening to foetal heartbeat), Point of Care (POC) tests (HIV tests, urine dipstick for protein and sugar, and malaria RDT), administration of treatments (IPTp-SP) and immunizations (Tetanus), case management of some disease conditions (E.g. uncomplicated malaria), distribution of ITN, and health education.
Table 2. Characteristics of Health Facilities and their ANC Units
|
Hospitals
|
Health Centres
|
CHPS Compounds
|
Characteristics
|
HOSP 1
|
HOSP 2
|
HC 1
|
HC 2
|
HC 3
|
CHPS 1
|
CHPS 2
|
Health personnel
|
Facility in-charge
|
Physician
|
Physician
|
PA[1]
|
PA
|
PA
|
Midwife
|
Midwife
|
Pharmacist
|
Yes
|
Yes
|
No
|
No
|
No
|
No
|
No
|
Maternity services
|
ANC services
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Skilled delivery
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Post-natal
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Laboratory and scan
|
Functioning laboratory
|
Yes
|
Yes
|
Yes
|
Yes
|
No
|
No
|
No
|
Ultrasound scan
|
Yes
|
Yes
|
No
|
No
|
Yes
|
No
|
Yes
|
Medical storage space
|
Pharmaceutical storage
|
Yes
|
Yes
|
No
|
No
|
No
|
No
|
No
|
Non- pharmaceutical
|
Yes
|
Yes
|
No
|
No
|
No
|
No
|
No
|
Combined storage
|
No
|
No
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
The ANC Units
|
Health Personnel
|
No. of midwives at ANC
|
3
|
3
|
2
|
3
|
2
|
1
|
2
|
Auxiliary nurses
|
1
|
4
|
0
|
0
|
0
|
2
|
2
|
Student[2] or Rotation nurses[3]
|
6
|
0
|
1
|
1
|
2
|
0
|
1
|
Type of ANC
|
|
|
|
|
|
|
|
FANC
|
Yes
|
Yes
|
No
|
No
|
No
|
Yes
|
Yes
|
Laboratory Tests/P.O.C
|
G6PD Test
|
Yes
|
Yes
|
No
|
No
|
NA[4]
|
NA
|
NA
|
BF[5] for malaria
|
Yes
|
Yes
|
Yes
|
Yes
|
NA
|
NA
|
NA
|
Malaria RDT
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Malaria Guidelines
|
MIP guidelines
|
Yes
|
Yes
|
No
|
No
|
Yes
|
No
|
Yes
|
Case management
|
Yes
|
Yes
|
No
|
No
|
Yes
|
Yes
|
Yes
|
Malaria Wall Charts
|
IPTp-SP
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
ITN
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
MIP Effects
|
No
|
No
|
Yes
|
No
|
No
|
No
|
No
|
ANC session observations
|
No. of observation
|
153
|
137
|
179
|
111
|
39
|
15
|
23
|
Stock of SP and ITN
|
Stock out of SP
|
No
|
No
|
Yes
|
No
|
Yes
|
No
|
No
|
Stock out of ITN
|
Yes
|
No
|
Yes
|
Yes
|
No
|
No
|
No
|
[1] Physician Assistant
[2] Nursing students on clinical practical
[3] Newly graduated nurses serving for one year being assigned to health facilities
[4] Not Available
[5] Blood film
Determining Eligibility of Pregnant Women for IPTp-SP
Six hundred and eighty observations of the ANC clinic sessions between pregnant women and ANC staff were conducted. Some of the observations had pertinent missing data such as current gestational age, and this was mainly due to unfilled sections in the MHRB. Incomplete records were omitted from the analysis. After data cleaning, 657 (96.6%) of the observed cases had complete datasets tools adequate for analysis. Ineligible women as specified in the Ghana MiP policy document were excluded from the analysis, with the derived sub-sample of pregnant women eligible for IPTp-SP being 511. (Figure 1).
Assessment of IPTp-SP Delivery
Using the study’s defined delivery assessment algorithm, appropriate and inappropriate delivery of IPTp-SP was computed. Figure 2, shows that out of the 511 pregnant women eligible for IPTp-SP, 76.7% (392) were offered the medication by the ANC staff, of which 390 were administered under DOT, with all of them being told their next ANC visit date. IPTp-SP was appropriately administered to 76.3% of the pregnant women. On the other hand, 23.3% (119) of eligible pregnant women were not offered the medication, 37% (44) of which occurred during a period of stock out. Despite the availability of SP in health facilities during the data collection period, almost 15% (75) of all eligible women were not offered the medication.
Factors Influencing Delivery of IPT-SP
To ensure accurate assessment of the factors influencing delivery of IPTp-SP, inappropriate delivery during periods of stock out were filtered out from the denominator of eligible pregnant women. The results from the Pearson Chi–Square analysis showed that years of experience of the ANC staff was an important factor influencing delivery of IPTp-SP (p<0.007). Health workers who had 1-5years experience delivered IPTp-SP appropriately to 88.9% (152) of pregnant women. Type of pregnant woman (first time or continuing ANC client) was found to be significant factor (p<0.0001) affecting delivery of IPTp-SP, with 86.1% (360) of the continuing pregnant women having IPTp-SP delivered to them appropriately. The number of ANC sessions attended by pregnant women (p<0.0001) and gestational age of pregnancy (p<0.0001) were also significantly associated with the delivery of IPTp-SP (Table 3).
Table 3: Factors Influencing Delivery of IPT-SP
|
Delivery of IPTp-SP When in Stock (N=467)
|
Factors
|
Appropriate
|
Inappropriate
|
X2 P-value
|
Type of facility
|
|
|
|
District hospital
|
96 (82.05)
|
21 (17.95)
|
|
Faith-based hospital
|
100 (86.21)
|
16 (13.79)
|
< 0.0001
|
Health Centres
|
178 (86.83)
|
27 (13.17)
|
|
CHPS Compounds
|
16 (55.17)
|
13 (44.83)
|
|
Ultrasound scan
|
|
|
|
Available
|
136 (80.47)
|
33 (19.53)
|
|
Unavailable
|
254 (85.23)
|
44 (14.77)
|
0.183
|
Type of worker
|
|
|
|
Midwife
|
333 (84.52)
|
61 (15.48)
|
|
Rotation nurse
|
57 (78.08)
|
16 (21.92)
|
0.173
|
ANC years of experience
|
|
|
|
< one year
|
131 (76.61)
|
40 (23.39)
|
|
1-5years
|
152 (88.89)
|
19 (11.11)
|
0.007
|
>5 years
|
107 (85.60)
|
18 (14.40)
|
|
MiP Training
|
|
|
|
Yes
|
261 (83.65)
|
51 (16.35)
|
0.907
|
No
|
129 (83.23)
|
26 (16.77)
|
|
Can SP be taken on an empty stomach
|
|
|
|
Yes (Correct)
|
107 (83.59)
|
21 (16.41)
|
0.977
|
No (Incorrect)
|
283 (83.48)
|
56 (16.52)
|
|
IPTp-SP can be given at 16 weeks of gestation irrespective of quickening
|
|
|
|
Yes (Correct)
|
51 (76.12)
|
16 (23.88)
|
0.078
|
No (Incorrect)
|
339 (84.75)
|
61 (15.25)
|
|
Type of Pregnant woman
|
|
|
|
First time ANC
|
30 (61.22)
|
19 (38.78)
|
< 0.0001
|
Continuing ANC
|
360 (86.12)
|
58 (13.88)
|
|
No. of ANC attended
|
|
|
|
Once
|
30 (61.22)
|
19 (38.78)
|
|
Twice
|
68 (88.31)
|
9 (11.69)
|
|
Thrice
|
74 (84.09)
|
14 (15.91)
|
< 0.0001
|
Four
|
69 (84.15)
|
13 (15.85)
|
|
Fifth-sixth
|
90 (90.91)
|
9 (9.09)
|
|
7+ times
|
59 (81.94)
|
13 (18.06)
|
|
Gestational age
|
|
|
|
16-20 weeks
|
64 (67.37)
|
31 (32.63)
|
|
21-25 weeks
|
71 (85.54)
|
12 (14.46)
|
< 0.0001
|
26-30 weeks
|
102 (92.73)
|
8 (7.27)
|
|
31-35 weeks
|
87 (88.78)
|
11 (11.22)
|
|
36+weeks
|
66 (81.48)
|
15 (18.52)
|
|
Determinants of Appropriate Delivery of IPTp-SP
Factors found to be significantly associated with appropriate delivery of IPTp-SP in the crude analysis were type of health facility, years of experience as an ANC staff, type of pregnant woman, number of ANC clinic sessions attended and gestational age of pregnant woman (Table 4). In the multivariable logistic regression analysis, type of facility, years of experience as an ANC staff and gestational age of pregnant woman were the predictors that remained significant with appropriate delivery of IPTp-SP. Regarding the type of facility, the faith-based hospital (HOSP 2) (aOR 0.68, 95%CI= 0.275-1.707), the health centres (aOR0.60, 95%CI=0.236-1.545) and CHPS compounds (aOR 0.12, 95%CI=0.039-0.375) had reduced odds of appropriate delivery compared to the district hospital (HOSP 1). Higher odds of appropriate delivery were found among ANC health workers with one to five years’ experience (aOR 3.57, 95%CI=1.564-8.145) and more than five years’ experience (aOR 3.08, 95%CI=1.181-8.028). The odds of appropriate delivery of IPTp-SP increased with increasing gestational age, where pregnant women with gestational ages between 21 to 25 weeks had more than twice (aOR=2.33, 95%CI=1.621-5.343) the odds of appropriate delivery, and those between 26-30 weeks had more than four times (aOR 4.64, 95%CI=1.807-11.918) the odds of appropriate delivery compared to those between 16 to 20 weeks (Table 4).
Table 4: Determinants of Appropriate Delivery
Factors
|
Unadjusted
|
Adjusted
|
|
OR
|
P-value
|
95% CI
|
aOR
|
P-value
|
95%CI
|
Type of facility
|
|
|
|
|
|
|
District hospital
|
1.00
|
|
|
1.00
|
|
|
Faith-based hospital
|
1.37
|
0.387
|
0.6734-2.7756
|
0.68
|
0.418
|
0.2758-1.7075
|
Health Centres
|
0.55
|
0.031
|
0.3175-0.9479
|
0.60
|
0.293
|
0.2362-1.5452
|
CHPS Compounds
|
0.27
|
0.003
|
0.1126-0.6432
|
0.12
|
0.000
|
0.0397-0.3752
|
ANC years of experience
|
|
|
|
|
|
|
< one year
|
1.00
|
|
|
|
|
|
1-5years
|
2.44
|
0.003
|
1.3487-4.4242
|
3.57
|
0.002
|
1.5647-8.1455
|
>5 years
|
1.8
|
0.056
|
0.9841-3.3476
|
3.08
|
0.021
|
1.1818-8.0289
|
Type of Pregnant woman
|
|
|
|
|
|
|
First time ANC
|
1.00
|
|
|
|
|
|
Continuing ANC
|
3.93
|
0.000
|
2.0768-7.4407
|
-
|
-
|
-
|
No. of ANC attended
|
|
|
|
|
|
|
Once
|
1.00
|
|
|
|
|
|
Twice
|
4.78
|
0.001
|
1.9416-11.7928
|
-
|
-
|
-
|
Thrice
|
3.35
|
0.003
|
1.4888-7.5271
|
|
|
|
Four
|
3.36
|
0.004
|
1.4724-7.6742
|
|
|
|
Fifth-sixth
|
6.33
|
0.000
|
2.5897-15.4886
|
|
|
|
7+ times
|
2.87
|
0.013
|
1.2519-6.5995
|
|
|
|
Gestational age
|
|
|
|
|
|
|
16-20 weeks
|
1.00
|
|
|
1.00
|
|
|
21-25 weeks
|
2.86
|
0.006
|
1.3576-6.0495
|
2.33
|
0.044
|
1.0216-5.3434
|
26-30 weeks
|
6.17
|
0.000
|
2.6722-14.2728
|
4.64
|
0.001
|
1.8077-11.9186
|
31-35 weeks
|
3.83
|
0.001
|
1.7919-8.1901
|
2.73
|
0.046
|
1.0158-7.3888
|
36+weeks
|
2.13
|
0.036
|
1.0521-4.3170
|
1.30
|
0.633
|
0.4404-3.8469
|
Determining Eligibility of Pregnant Women for ITN
Evidence of receipt of ITN by a pregnant woman during her current pregnancy at the ANC is indicated through its documentation in the MHRB of the woman. Pregnant women with no documentation of ‘ITN given’ in their MHRB was interpreted as ITN not yet received. Of the 657 ANC sessions observed, 127 of the pregnant women were first time ANC attendees with the remaining 530 being continuing clients. Seventy-nine percent (420) of the continuing clients had “ITN given” documented in their MHRB, with the remaining 21% (110), having no record of ITN given in their MHRB. Defining eligibility for ITN in this study as all pregnant women who have not yet received an ITN, the number of pregnant women eligible for the intervention was 237 as shown in figure 3.
Assessment of ITN Delivery
Using the study’s defined delivery algorithm, ITN was appropriately delivered to 58.65% (139) of the 237 pregnant women who had not yet received an ITN prior to day of observation (Figure 4). Appropriate delivery was highest amongst first time ANC clients (114) than the continuing clients (25) (Table 4). While 21% (21) of inappropriate delivery occurred during periods of stock out, the remaining 32% (77) of eligible women were not given ITN despite stock availability.
Factors Associated with ITN Delivery
Inappropriate delivery due to stock out was filtered out from the denominator of eligible pregnant women before computing factors influencing delivery of ITN. Pearson Chi-square analysis and Fishers Exact test were conducted to identify factors influencing delivery of ITN. The results showed that, the type of health worker (p=0.018), type of pregnant woman (p<0.0001), number of ANC clinic sessions attended (p<0.0001), and gestational age of the pregnancy (p<0.0001) were significantly associated with delivery of ITN (Table 5). Appropriate delivery of ITN was highest among first time ANC clients (97.44%), compared to continuing clients who have not yet received one (25.25%). Similarly, delivery of ITN decreased with increasing number of ANC attendances (Table 5).
Table 5: Factors Influencing ITN Delivery
|
ITN Delivery When in Stock (N=216)
|
Factors
|
Appropriate
|
Inappropriate
|
X2 P-value
|
Type of facility
|
|
|
|
District hospital
|
49 (71.01)
|
20 (28.99)
|
|
Faith-based hospital
|
32 (51.61)
|
30 (48.39)
|
0.102
|
Health Centres
|
50 (67.57)
|
24 (32.43)
|
|
CHPS Compounds
|
8 (72.73)
|
3 (27.27)
|
|
Type of worker
|
|
|
|
Midwife
|
106 (60.57)
|
69 (39.43)
|
0.018
|
Rotation nurse
|
33 (80.49)
|
8 (19.51)
|
|
ANC years of experience
|
|
|
|
< one year
|
61 (64.21)
|
34 (35.79)
|
|
1-5years
|
42 (57.53)
|
31 (42.47)
|
0.149
|
>5 years
|
36 (75.00)
|
12 (25.00)
|
|
MiP Training
|
|
|
|
Yes
|
92 (62.59)
|
55 (37.41)
|
0.429
|
No
|
47 (68.12)
|
22 (31.88)
|
|
Type of Pregnant woman
|
|
|
|
First time ANC
|
114 (97.44)
|
3 (2.56)
|
<0.000
|
Continuing ANC
|
25 (25.25)
|
74 (74.75)
|
|
No. of ANC attended
|
|
|
|
Once
|
114 (97.44)
|
3 (2.56)
|
|
Twice
|
20 (57.14)
|
15 (42.86)
|
|
Thrice
|
2 (9.09)
|
20 (90.91)
|
<0.000
|
Four
|
1 (7.69)
|
12 (92.31)
|
|
Fifth-sixth
|
1 (9.09)
|
10 (90.91)
|
|
7+ times
|
1 (5.56)
|
17 (94.44)
|
|
Gestational age
|
|
|
|
<15 weeks
|
64 (95.52)
|
3 (4.48)
|
|
16-20 weeks
|
35 (71.43)
|
14 (28.57)
|
|
21-25 weeks
|
14 (58.33)
|
10 (41.67)
|
<0.000
|
26-30 weeks
|
17 (54.84)
|
14 (45.16)
|
|
31-35 weeks
|
7 (25.93)
|
20 (74.07)
|
|
36+weeks
|
2 (11.11)
|
16 (88.89)
|
|