A key indicator of obstetric health is adequate antenatal care, which facilitates improved perinatal outcomes for babies and their mothers. Ghana adopted the WHO’s Focused Antenatal Care22 approach in 2001 (Baffour-Awuah, Mwini-Nyaledzigbor, & Richter, 2015). Focused ANC emphasises an individualised, client-centred approach and prioritises the detection of disease rather than just risk assessment (Nyarko et al., 2006). Previous approaches to ANC encouraged more frequent visits (up to 13) during pregnancy, care was provided by different healthcare providers during visits, and women were categorised into risk groups to assess the risk of complications and the required level of care. Under focused ANC, all pregnant women are considered to be at risk, priority is placed on the
22Focus antenatal care includes medical history taking, laboratory investigations (including haemoglobin level estimation), health education, and administration of routine drugs (supplementary micronutrients - folic acid and ferrous sulphate; malaria prophylaxis; Sulfadoxine Pyrimethamine tablets; and tetanus toxoid immunization), treatment of complications such as hypertensive disorders, malaria, haemorrhage, excessive vomiting, premature rupture of membrane, urinary tract infections and vaginitis (Nyarko et al., 2006).
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quality of the visit and at least four visits with well-tailored care to meet the particular needs of the woman, are encouraged (Lincetto et al., 2006). The women are also seen by the same provider on each visit. The detection and treatment of conditions, such as malaria, prevention of mother-to-child transmission of HIV/AIDS, as well as health education on preparation for birth and potential complications, are central to the care given (Nyarko et al., 2006).
One important issue that emerged from this study is that about half of the women made their first ANC visit in the second and third trimesters rather than the first trimester, and one-quarter made fewer than the recommended four visits. This trend has implications for what can be achieved by midwives and other healthcare providers in terms of disease detection, prevention and treatment as it may affect the timing of some routine elements of ANC such as screening for gestational diabetes. For example, a recent study at the Upper East Regional Hospital reported that, compared to women who commence ANC in the first trimester, those who did so in the second trimester were more anaemic (Ahenkorah, Nsiah, & Baffoe, 2016). The content of focused ANC is wide-ranging and captures major conditions that are associated with adverse maternal outcomes (Nyarko et al., 2006).
Other findings of this study that may be partly explained by inadequate ANC visits/care are the rates of low haemoglobin levels found among women on their first visit (57.4% had a haemoglobin level of <10.8g/dl) and the low uptake of malaria prophylaxis (only about 4% completed the recommended four doses). The low haemoglobin levels found in this study is consistent with the findings of Nasiru and Albert (2014) who reported that the rate of anaemia among pregnant women in the same region was 50.4%. One problem that may arise from the poor ANC attendance is that it may be difficult to raise haemoglobin levels to normal limits before term if women present for care relatively late in their pregnancies. Notably, anaemia and malaria together accounted for over 15% of maternal morbidity in the current study and were also associated with about 22% (n = 8) of foetal deaths. Other studies have considered the relationship between moderate-to-severe anaemia and perinatal outcomes. Anaemia in pregnancy has been implicated as a risk factor for adverse outcomes such as perinatal deaths (Ali & Adam, 2011; Nair et al., 2016), post-partum haemorrhage
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(Frass, 2015; Kavle et al., 2008; Nair et al., 2016), low birth weight (Ali & Adam, 2011; Nair et al., 2016) and preterm birth (Ali & Adam, 2011). Increased prevalence of anaemia has also been associated with parasitic infections such as hookworm, schistosomiasis, and malaria in the Upper East Region (Ahenkorah et al., 2016; Fuseini, Edoh, Kalifa, Hamid, & Knight, 2010) and in other parts of Ghana (Tay, Nani, & Walana, 2017). Therefore, early detection and treatment of anaemia is likely to lead to improved outcomes (Ahenkorah et al., 2016).
Maternity care workers surveyed in this study reported that access barriers for pregnant women included long distances to health facilities, a lack of transport and poverty. It is important, therefore, to develop strategies to reach out to women with limited access to care. Although health service user fees in Ghana were removed for ANC, birthing and postnatal care in 2008 (Dzakpasu et al., 2012), women may still be faced with indirect costs associated with transportation, meals and the required personal supplies necessary for health facility care/births. Other unknown access barriers may also be at play. Remedial approaches must target communities with the least access such as those in rural, dispersed settlements and women who are less likely to utilise care (those living in poverty and women without adequate family support). Long-standing approaches that principally rely on pregnant women initiating care-seeking do not appear to have produced satisfactory results in the context of the study settings. Deliberate efforts by healthcare personnel to initiate contact and engage with women from early pregnancy through community outreach programmes may elicit more interest in the health promoting activities of ANC. By identifying sociodemographic characteristics of service users that potentially put them at risk of inadequate use of essential health services, health service personnel may be able to locate and follow-up on pregnant women and offer solutions to address issues.