Factors influencing the utilization of Focused antenatal care services during pregnancy, a study among postnatal women in a tertiary healthcare facility, Ghana

Abstract Aim To assess the factors that influence the utilization of FANC services among pregnant women. Methodology A cross‐sectional quantitative study conducted among 210 postnatal women in Ho Teaching Hospital. Data were entered into Microsoft excel, cleaned and transported to SPSS and analysed. Cross tabulations were used to explore associations between variables. Results The respondents indicated that FANC would enable them to receive comprehensive ANC (74.8%). Higher parity was significantly associated with low utilization of FANC (p = .028). Long distance to the health facility, seeking permission to use FANC was significantly associated with low utilization of FANC (p < .001). Fear associated with witchcraft was associated with low FANC utilization (p < .001).


| INTRODUC TI ON
Most maternal deaths (66%) occurred in sub-Saharan Africa, while 99% of the maternal deaths occurred in low-and middle-income countries as most could have been prevented (WHO, 2014). The primary causes of these maternal deaths were haemorrhage, hypertensive diseases of pregnancy and sepsis and indirect causes, mostly due to interaction between pre-existing medical conditions and pregnancy (WHO, 2014).
In 2001, the World Health Organization (WHO) issued guidance on a new model of Antenatal Care (ANC) called goal-oriented or focused antenatal care (FANC), for implementation in developing countries (Villar et al., 2001) including Ghana. Focused ANC means that pregnant women attend a minimum of four scheduled ANC visits and receive all the WHO recommended comprehensive packages by skilled healthcare providers (WHO, 2014). This new model hinges on the quality of services than quantity of services received by expectant mothers.
Focused antenatal care eliminated the traditional risk assessments and instead stressed on helping women to maintain normal pregnancies (WHO, 2010). In response to this evidence, several countries in sub-Saharan Africa moved to adapt FANC as a way of promoting the health and survival of mothers and babies. Globally, there is a remarkable decline in maternal mortality ratio-MMR (WHO, 2012). Despite this recent decline, Sub-Saharan Africa has the highest MMR in the world, even though there are strategies and interventions that prioritize maternal health (Hogan et al., 2010;WHO, 2012).
In sub-Saharan Africa, maternal mortality ratio (MMR) was estimated to be 500 per 100,000 live births in 2010. To kerb this high rate of maternal deaths, it is estimated that an annual decline in maternal mortality of 5.5% is needed; however, between 1990-2010 the annual decline was only 1.7% in the sub-Saharan region (WHO, 2012). The use of antenatal services in some parts of Africa and the developing world has not been encouraging. Usually, pregnant women come late for the services and make less than the recommended number of focused antenatal care (FANC) visits (Magadi, Madise, & Rodrigues, 1999;Ndidi & Oseremen, 2010). The maternal mortality ratio in Ghana currently stands at 308 deaths per 100,000 live births (WHO, 2019), though this figure is relatively lower compared to the number of maternal deaths that occurred over a decade ago (WHO, 2019).
The role of ANC services in reducing maternal mortality in Ghana has been reported by the World Health Organization (WHO, 2019), yet some women do not attend ANC during pregnancy. The rate of ANC visits varies among pregnant women; this is evident in a study conducted in the Bunkpurugu district of Ghana, where 1.6% of pregnant women attended ANC once, 12.9% between two to four times, 22.6% attended at least five times and the remainder attended more than five times (Konlan et al., 2016). In a few African countries like Nigeria, 77% of the pregnant women start utilizing focused antenatal care in the second trimester (Ndidi & Oseremen, 2010), while in Kenya 45% in the third trimester (Magadi et al., 1999). In Malawi, 48% of the pregnant women start utilizing focused antenatal care in the second trimester (Malawi Demographic and Health Survey, 2010). In terms of number of visits, in the developed countries, 97% of pregnant women make at least one ANC visit and 99% of these pregnant women deliver with skilled birth attendants (Mrisho et al., 2009). The contrary, however, is that, in developing countries, including Ghana, 49% of pregnant women make at least one FANC visit and often two-thirds of these women deliver with unskilled birth attendants (Raatikainen, Heiskanen, & Heinonen, 2007).
In incorporating FANC into maternal and child health services in Ghana, the reproductive health policy and antenatal clinic (ANC) guidelines were revised to include early detection and treatment of all complications arising during pregnancy. Emphasis was laid on assessing birth preparedness and complication readiness, prevention of malaria in pregnancy and prevention of mother to child transmission of HIV (PMTCT). The ANC schedule was reduced from thirteen (13) visits to four (4) comprehensive, personalized visits. FANC concentrates on the quality of care rather than the number of visits and ensures good health during labour and delivery. This puts the relationship of the care provider and the client central to success. The kind of relationship established by the midwife and client such as kindness, respect, privacy, confidence level during antenatal is central to the amount of trust established and the extent of care activities implemented in the absence of the midwife, especially at home (Konlan, Kombat, Japiong, & Konlan, 2018). Developing countries are struggling to achieve quality FANC provision, particularly in rural and peri-urban areas.
Competition for staff and money as well as poor communication with other programmes or components (malaria, HIV, emergency obstetric care) can be found at different levels of the health system, particularly where policies are ill-defined (Baffour-Awuah, Mwini-Nyaledzigbor, & Richter, 2015). Poor communication among healthcare providers, as well as the perception of some women, families and communities about pregnancy being a natural process of life, may lead to underestimation of the importance of FANC (Baffour et al., 2015).
In addition, lack of knowledge about the extent and impact of traditional household and community beliefs and customs, suboptimal maternal nutrition and infant feeding practices as well as the attitudes and behaviours of healthcare providers in FANC clinics such as failing to respect the privacy, confidentiality and traditional beliefs of the women negatively influence the use of FANC (Baffour et al., 2015). The belief and role of witches, a supernatural force that has the tendency to control and manipulate individuals and family towards an evil gain, is a widespread belief in most parts of the African societies. The general belief in this particular evil spirit has the potential to prevent early disclosure of pregnancy and may limit the chance of seeking early focused antenatal care service. Ethnographic studies from Mozambique and southern Tanzania illustrated, for example, that women at an early stage of pregnancy delayed ANC initiation purposely to protect the unborn from witchcraft and sorcery attacks of jealous neighbours and kin (Chapman, 2003;Gross, Alba, Glass, Schellenberg, & Obrist, 2012;Haws et al., 2010). While these factors have been well documented under some jurisdictions, imperative research in the Volta region of Ghana has not specifically documented those factors that influence the utilization of FANC services among pregnant women seeking services in the Ho Teaching Hospital.

| Aim
This study assessed the factors that influence the use of focused antenatal care services during pregnancy among postnatal women in the Ho Teaching Hospital of the Volta region of Ghana.

| Study design
A cross-sectional descriptive study that assessed the views of postnatal women on the factors that influenced the utilization of FANC services during pregnancy.

| Setting and population
This study was conducted in the Ho teaching hospital. In the year 2018, the hospital was upgraded from the level of a regional hospital to a teaching hospital following the establishment of the school of medicine at the University of Health and Allied Sciences. The study population for this study were postnatal women who had received ANC services at the Ho teaching hospital. The Ho teaching hospital is located along the Ho to Aflao road. The approximately 400-bed capacity facility has nine wards. The facility also has three major theatres, a mortuary, laundry, and sterilizing department. The hospital serves as the main referral point for smaller facilities in the region and offers other services such as reproductive and child health, family planning services, dental, ear, nose and throat, eye, nutrition rehabilitation, antiretroviral unit, planned home birth, diabetic clinic and a dialysis unit. The facility also has a dispensary, laboratory, catering, public health and general administrative units, as well as an outpatient department (OPD). There are approximately 45 midwives in the Obstetrics & Gynaecology (O&G) department, two O&G specialists and two medical doctors with four house officers who are rotated every 4-5 months. The midwives and doctors run a threeshift duty within 24 hr with a specialist on call at every point in time.
Postnatal women who sort services in the Ho teaching hospital were recruited into the study as they came for routine postnatal service for their babies.

| Sampling and sample size
The sample size (n) of the study was determined by the Snedecor and Cochran (1989) sample size formula: n = Z 2 pq d 2 where Z = standard normal score corresponding to 95% confidence level = 1.96, p = proportion of women in fertility age (0.154), q = 1 − p d = degree of precision The sampling for this study was systematic sampling method.
The estimated sample fraction was calculated to be 3.5. Research assistants recruited every third person, and in instances the person did not consent, the fourth person was recruited. The postnatal service refers to the care rendered to the baby and mother within the period from conception to 6 weeks postconception. All postnatal women who met these inclusion criteria were included in the study.

| Tool and data collection
A questionnaire was used for data collection. The questionnaire contained 38 items, mainly on demographic, utilization and factors that influence the utilization of ANC services during pregnancy. To ensure that the research questions were not ambiguous, the questionnaire was pre-tested on forty postnatal women in the Ketu South municipal hospital, Aflao. The data collected were subjected to a reliability test on SPSS version 22. This was done to ascertain the respondents' general reaction and, particularly, interest in answering the questionnaire. The questionnaire was modified until it produced a Cronbach's alpha coefficient of 0.801. It can therefore be concluded that the instrument had a high reliability in measuring needed data for the study. Responses from the people showed that the questionnaire was clear and could be understood by others. The questionnaire was made of open-ended questions and closed-ended questions. Some closed-ended questions were largely dichotomous, while others had multiple choices.
Research assistants received 2 days of training on research ethics and on the study tool and data entry. The four research assistants collected data between the hours of 8 a.m. and 4 p.m. each working day during the 3-week period of data collection. The data collected daily were entered into Microsoft excel.
On each day, trained research assistants visited the postnatal clinic of the Ho Teaching Hospital and recruited participants in the study. The data were collected within 3 weeks. Women who sort postnatal services for their babies at the postnatal clinic were recruited to respond to a pre-tested questionnaire after they had received service. It took an average of 15 min to complete a questionnaire. In instances the respondent could not read and write, the research assistant aided them to complete the questionnaire.

| Data analysis
The data were checked for completeness and appropriateness of responses. The data were then entered daily into Microsoft Excel 2016 version and cleaned and transported to statistical package for social sciences version 22 for analysis. Data were analysed as descriptive statistics, and some cross tabulation was done between some demographic variables and the factors that influence the utilization of FANC services among pregnant women. Socio-cultural factors were also cross tabulated against the number of ANC visits made by pregnant women; p < .05 was considered statistically significant.
The number of FANC visits was categorized into dichotomous variables; FANC visits less than four attendance (<4) denoting low utilization and FANC visits of four or more attendance (≥4) denoting adequate utilization. Identification of demographic and socio-cultural variables associated with low utilization was carried out using cross tabulations. Statistical significance, evaluated at 0.05 levels, was assessed with SSPS. Explanatory variables were dichotomized prior to running cross tabulations; Yes or No (0 or 1) responses were assigned to some socio-cultural variables. Demographic variables such as marital status (married and unmarried), parity (nulliparous and multiparous), ethnicity, religion (Christianity and other), gravidity (primigravidae and muiltigravidae) and occupation were also dichotomized. Participating mothers' responses to open-ended questions about barriers associated with low utilization were put into themes and thereafter responses were coded and dichotomized (Yes or No).

| Ethical considerations
Research ethics were obtained from the institute for health research from the University of Health and Allied sciences (UHAS-REC A.1 (19) 17-18). The research was scientifically reviewed by the scientific review committee of the School of Nursing and Midwifery of the University of Health and Allied Sciences, on whose recommendation research ethics certificate was issued. Permission was sort from the management of the Ho Teaching Hospital prior to the commencement of data collection. Research respondents each gave written and verbal consent to participate in the study. The template of the

Institute of Health Research from the University of Health and Allied
Sciences in Ho's template on research ethics, consent form was used as a guide in developing the consent form. Participants who could not sign were made to thumbprint on the section for signature. Most postnatal women (47.1%) have no awareness of FANC. The major sources of information on FANC were from midwives (51.4%), relatives (18.9%), radio (18.0%), traditional birth attendants (0%) and other sources like friends were 11.7%. The responses for reasons behind FANC clinic visit included when there is a problem in the pregnancy (20.5%), as 52.9% indicated when there is no problem.

| RE SULTS
An appreciable proportion (61.3%) of postnatal women indicated that FANC is useful in establishing a rapport between the pregnant mother and the midwife. Respondents (62.2%) agreed with the notion that antenatal care would help in early detection of risks associated with pregnancy. Also, 64.9% showed that FANC would assist the health worker to distribute information, education and communication materials. The findings showed that 7.2% disagreed and 74.8% of the respondents also agreed with the fact that the FANC would enable them to receive tetanus toxoid vaccine, vitamin A, iron supplementation, insecticide-treated nets, intermittent preventive treatment and hookworm treatment ( the other hand, respondents whose partners were businessmen, civil servants and students patronize FANC more compared with those whose partners were farmers and involved or other occupations (p = .149). Parity was significantly associated with the number of visits to the FANC (p = .003). Postnatal women with a single child alive utilized FANC compared to other women (p = .000).
Participating women who reported having problems of money for transportation made less than required (≥4) visits to FANC (p = .000). Long distance also significantly influenced the number of visits to FANC (p = .000). Participating women who reported having problems of desirability made less than required (≥4) visits to the FANC (p = .000). Waiting to obtain permission was also a factor which significantly resulted in fewer visits to FANC (p = .000).
Participating women who reported having concerns that there will be no midwife available made less than required (≥4) visits to FANC (p = .000). Participating women who reported having problems with limited transportation options made less than required (≥4) visits to FANC (p = .000) ( Table 3).
Fear that wizards may terminate the pregnancy was significantly associated with the number of visits women made (p = .000). In addition, long waiting hours at health facilities was a factor which statistically significantly resulted in greater number making the least number of visits to FANC (p = .000). Similarly, lack of knowledge and no time to attend FANC was a factor which statistically significantly resulted in greater number making the least number of visits to FANC (p = .000). Respondents who reported having problems of being shy and receiving poor attitudes from staff made less than required (≥4) visits to the FANC (p = .000). Those who reported personal reason (just not wanting to make lots of visits) were also significantly less likely to attend FANC (p = .000). Besides, poor amenities were a component that resulted in a greater number of respondents making the required number of visits to FANC (p = .000) ( Table 4). of implementing learnt information than a primiparous woman.

| D ISCUSS I ON
However, in Ghana when pregnancies were cared for based on risk assessment, primiparous women were classified as high-risk pregnancies. In Kenya, Magadi et al. (2000) demonstrated that higher parity was associated with low utilization of FANC services. Again, Ethiopian multiparous mothers were more likely to use FANC services than nulliparous counterparts (Mekonnen & Mekonnen, 2003).
These findings allude to the fact that there is still the need to continue with community sensitization on the need to maximize FANC regardless of parity. There was no significant relationship between educational level of women and the utilization of FANC services. Ho has largely been an urban community with many social interventions that target all cadres of women, especially during pregnancy. During antenatal care, local dialects are used to provide health education to ensure total participation of all women. Besides, local news outlets provide pregnancy education in local dialects on news airwaves. Matsumula and Gubhaju (2001) indicated that low utilization of FANC is associated with low education. The lack of effect of education on utilization of FANC in this study may be due to high levels of low education among the participating women making it hard to show a difference. Moreover, Pallikadavath, Foss, and Stones (2004) argue that education assists in the adequate utilization of FANC service.
There was no significant relationship between marital status and the utilization of FANC services among postnatal women. This may be an indication that the continued empowerment of women, especially in peri-urban areas, is yielding some dividends as women without husbands or partners equally take responsibility for the health of themselves and babies. This finding differs with Tann et al. (2007) that unmarried status influenced less uptake of antenatal care

Number of ANC attendance p value
Had less than 4 ANC attendance (<4)
Almost all the participating mothers indicated that socio-cultural factors played a greater role in utilization of FANC services.
Distance to the health facility statistically significantly determined both the probability and frequency of attending FANC clinics (p = .000). Long distance to the health facility is indicated as highly associated with few visits. Some women have to travel over long distances to seek health care and this coupled with deplorable roads and inefficient transportation system will invariably influence women's likelihood of attending antenatal ser- vices. An interesting finding was the prevalence of superstition related to pregnancy (5.4%). The study found that participating mothers feared wizards and witches would terminate their pregnancy if they would be seen going for FANC visits; this resulted in a marginally significant number of participating women making less FANC visits. Apparently, witchcraft-related myths are still prevalent in some parts of sub-Saharan Africa. Mathole, Lindmark, Majoko, and Ahlberg (2004) also reported low utilization of FANC due to witchcraft-related fears. This also highlights the need to intensify education to dispel myths and beliefs that impede progress on utilization of FANC.
The study elucidated that seeking permission from the husband or household head to attend antenatal care is significantly associated with low utilization of FANC (6.6%). Other studies showed that participating mothers who were waiting to seek permission made significantly fewer than the required number of visits for FANC (UNICEF 2008;Aarnio, Olsson, Chimbiri, & Kulmala, 2009). In this study, husbands (79%) mostly gave their wife's permission to start utilizing FANC. Male dominance in decision-making on women's reproductive health requires more attention to minimize negative impact whilst maximizing desirable outcome. Thus, instead of women seeking permission they should ask for husband's involvement in antenatal care services. This idea is equally supported by Theuring, Nchimbi, Jordan-Harder, and Harms (2009) who argues that pregnant women who first sought permission from husbands before utilizing FANC services are likely to make fewer than the required number of visits.
Postnatal mothers (85%) expressed concern that their husbands did not take an active role in FANC services. It was noted that although the husbands did not get involved in reproductive health activities, respondents stated plausible benefit if the husbands took an active role. Byamugisha et al. (2011) reported that attracting male partners in focused antenatal services (FANC) is very difficult.
Their findings further revealed that male involvement in antenatal care services plays a major role as they make most decisions for their wives. Simkhada, Porter, and Van Teijlingen (2010) contended that mother-in-laws and mothers alone negatively influence the utilization of FANC services. However, Paredes, Hidalgo, Chedraui, Palma, & Eugenio, 2005 that low utilization of FANC services may not only be influenced by individual mother's characteristics, but also other social neighbourhood such as availability of services within reachable distances, inadequate media exposure and inadequate transport options due to lack of birth preparedness plans. Lee, Yin, and Yu (2009) support this notion by arguing that spouses and mother-in-laws per-  (Pallikadavath et al., 2004;Sharma, 2004 (Nisar & White, 2003).
A small proportion (52.9%) of postnatal women stated that they use FANC services as recommended by the Ghana Health Service and WHO. Focused antenatal care (FANC) provides a package of services that contributes to the health and well-being of a woman throughout her pregnancy, childbirth and the postnatal period (Mamba et al., 2017). The results of this study also demonstrate the fact that respondents have adequate knowledge on the benefits of utilizing FANC services. One of the most prominent benefits cited by participating mothers was that FANC assists in creating a good rapport between health workers and service users. Rapport building amongst women using antenatal care services is a prerequisite for continuation of service utilization (Hollander, 1997 wanting to make many visits also contributed to low utilization of FANC among pregnant women. The general belief in this particular evil spirit has the potential and preventing early disclosure of pregnancy and may limit the chance of seeking early focused antenatal care service. Ethnographic studies from Mozambique and southern Tanzania illustrated, for example, that women at an early stage of pregnancy delayed ANC initiation purposely to protect the unborn from witchcraft and sorcery attacks of jealous neighbours and kin (Chapman, 2003;Gross et al., 2012;Haws et al., 2010). Seeking permission from the husband or the household head to utilize FANC significantly contributed to low utilization of FANC by pregnant women in Ho Teaching Hospital.
This study was mainly a descriptive cross-sectional study that asked postnatal women to recall their experiences of focused antenatal services they sort for care when they were pregnant.
In researchers that involve recall by participants, there is always a general risk of recall bias and the most appropriate method to avert this limitation is to have an observation of pregnant women as they sort focused antenatal care. Nonetheless, this study is useful as it was able to document the postnatal women's perspective of the care rendered to them during pregnancy in the study area. Due to the cross-sectional nature of the study, it is difficult to establish cause-effect relationship between dependent and independent variables as this study mainly used administered questionnaire. Also, pregnant women were recruited when they sort postnatal care services, denoting that this cadre of women might have higher health awareness and therefore might have a relative positive view of focused antenatal care services than those who do not attend postnatal services. Future study is aimed at identifying the study population at home and work communities than those in a health facility.

| CON CLUS IONS
The results showed that some postnatal women have no awareness of FANC even though FANC would assist the health worker to distribute information, education and communication materials. It is therefore imperative to increase public education using mass media channels to ensure hundred participation in FANC services.
Married postnatal women and those cohabiting used FANC more compared with the single, divorced and widowed. Respondents with secondary, tertiary or no educational background used FANC more compared with those with primary and junior high educational background. On the part of the participants' occupation, traders, students and civil servants patronized FANC more compared with those involved in business, farming and other occupations. There is therefore the need to encourage the provision of FANC services at homes and workplaces as most of the people who did not receive FANC services appear to be working in the informal sector of the economy. The primary healthcare intervention already in place in Ghana can be leveraged to ensure that these services are provided through community health nurses and community midwives. Long distance to the health facility, seeking permission to use FANC was significantly associated with low utilization of FANC.

ACK N OWLED G EM ENT
We thank the leadership and management of the Ho teaching hospital for supporting and putting the necessary resources in place for us to collect data in their facility

CO N FLI C T O F I NTE R E S T
The author declare that they have no competing interest.

AUTH O R CO NTR I B UTI O N S
All the authors participated in conception, design, data collection and drafting of this manuscript. All authors approved the final manuscript for publication.

E TH I C A L A PPROVA L
Ethical clearance was obtained from the Institute of Health Research, University of Health and Allied Sciences, to conduct this study (UHAS-REC A.1 (19) 17-18).