Main Report

CHAPTER ONE
INTRODUCTION 1.1 Background of the study From Wikipedia, in 2010, researchers from the University of Queensland in Brisbane, Australia, estimated global maternal mortality in 2008 at 342,900 (down 526,300 in 1980), of which less than 1% occurred in the developed world. More than half of the 600,000 women who die every year from pregnancy-related causes were in the African region which constitutes only 12% of the worlds population and 17% of its births. Maternal mortality ratio in Africa remains the highest in the world with the average actually increasing from 870 per 100,000 live births in 1990 to 1,000 per 100,000 live births in 2001 (Turner, 2011).
Despite the various policy calls to action and international networking amongst development agencies on the topic, in Africa the situation is worsening. In addition to displaying the scale of the gap there is a need for a rapid identification of immediate operational measures which can be taken to redress this glaring inequity. Though much has been learned during the past decade about the causes of maternal death, there is little evidence of significance progress towards the ambitious goal of halving maternal mortality. The WHO (1992) reported that every year, over half a million women continue to lose their own lives to the hope of creating life.
Every minute of every day, a woman in the world dies as a result of complications arising during pregnancy and childbirth (UNICEF, 2008). The majority of these deaths are avoidable and transport has a crucial role to play in achieving the Millennium Development Goal (MDG) 5 of reducing maternal mortality by three-quarters from its 1990 level. 1
Maternal mortality is one of the most sensitive indicators of the health disparity between richer and poorer nations. Maternal mortality refers to those deaths which are caused by complications due to pregnancy or childbirth. These complications may be experienced during pregnancy or delivery itself, or may occur up to 42 days following childbirth (WHO, 1992). These women who die are in the prime of their lives, most often with children and other dependants. Developing countries stand the greatest risk of having obstetric complications being the leading cause of death of women of reproductive age claiming the lives of an estimated 529,000 each year (Freedman, Lynn, et al, 2003). The lifetime risk of dying due to maternal health causes is about one in six in the poorest countries, with about one in 30,000 in the Western World (Ronsmans and Graham, 2006). According to WHO (2007) each year, more than 536,000 women die due to complications developed during pregnancy and childbirth. Death from pregnancy-related causes represents one of the most preventable categories of female death worldwide. Sub- Saharan Africa continue to face a 1 in 13 chance of dying from pregnancy and childbirth, when the risk for women in the industrialised world is only 1 in 4,085 (Turner, 2011). Currently, the level of risk for a woman to die of pregnancy-related cause shows the widest disparity between developed and developing countries of all human development indicators. Sadly, ninety-nine percent of maternal deaths occur in developing countries where the lifetime risk of dying in pregnancy and childbirth is 1 in 76, compared to 1 in 8,000 in industrialized countries (UNICEF, 2005). It is estimated that 75 percent of maternal deaths might be prevented through timely access to essential emergency childbirth-related care. Evidence suggests that most of the obstetric emergencies can be managed if comprehensive Emergency Obstetric Care (EmOC) is reached within 12 hours, with the exception of obstetric haemorrhage which requires attention within 2 hours (UNFPA, 2004). 2
Transport plays a critical role in the effective and efficient delivery of health care. It enables people to access services and health workers to reach communities, especially in sparsely populated rural areas (Babinard and Roberts, 2006). In Ghana, many people in remote areas live a long distance from health facilities. They have little or no access neither to health services nor to health information and education. People have difficulty visiting health centers due to the limited availability of transport and aged vehicles which break down very often on roads. As a result, transport then becomes a critical factor. Poor families walk for hours to reach health facilities because they cannot afford the transport cost or because they can not wait for limited, slow and or uncomfortable transportation services due to roads in poor condition. Transport facilitates; the timely and affordable delivery of basic health, education, water and sanitation services, it connects communities to markets and information, and can empower vulnerable groups (Moleswirth, 2006).
It is becoming accepted that poor access of transport may play a role in maternal deaths and conditions such as fistula, eclampsia, ruptured uterus, severe anaemia, heart failure etc but there is little research available on the veracity of this assertion and what may be the effective interventions. In fact, little mention is made with regards to the causes of maternal death and its relationship with transport. It is based upon this background that this study sought to assess the role of transports intervention in the achievement of the maternal mortality reduction in Ghana, using Ho Municipality of Volta Region as a case study.
1.2 Statement of the problem The role of infrastructure particularly transport is often overlooked in achieving the social MDGs. Yet infrastructure has direct and indirect consequences for health-related development 3
and can both worsen and mitigate health factors. In the area of reproductive health, maternal health can benefit markedly from well planned and executed infrastructure projects.
In the Ho Municipality, more than half of the people live in the rural areas, many of them hours away from the nearest health centres which can be an eternity for a woman in labour. Husbands tend to be mid-wives for their pregnant wives during labour and when complications set in they die in their homes. This situation has become the norm in these rural areas that have poor transport infrastructure. Some people live as far as more than 8km from a health care facility.
Infrastructure development plans in Ghana tend to focus on the construction of a system of national highways and major roads, linking large cities but neglecting small communities that are only reached by poor unpaved feeder roads or paths. These are important routes for the rural people as they travel between health clinics, markets, schools, workplaces and their homes.
Judging from the infrastructural developments that are on-going in Ghana as a whole, little attention is being given to the poor roads that link one village to the other in the rural areas. This has seriously contributed to the high maternal mortality that occurs in the typical villages because of the nature of the roads and unavailable transport. Figures and facts from such a research will help bring to light the role of the poor transport on maternal mortality so as to reduce this problem and also alert authorities in charge of roads and transport to ensure that transport infrastructure policies and programmes should include assessments of the time it takes for women to access maternal health facilities that can deal with obstetric complications.
1.3 Objectives of the study The general objective underlying of the study is to assess the role of Transportation on Maternal Mortality and the Poor Transport Infrastructure of Ho Municipality. To achieve this general objective, the following specific objectives must be met: 1. Investigation of transport availability and its access in maternal health services. 2. Identifying the challenges associated with current health transport management. 3. Exploring the significance of public-private partnership support for transport to the achievement of MDG5. 4. Make recommendations towards reducing the Maternal Mortality Rate.
1.4 Significance of the study This project will be beneficial to the Municipal Health issues in the municipality. The research will also help the Ghana Health Services at Ho to understand the current status of utilization of maternal health services at Ho Municipality by making clear some factors influencing the use of these services in the Municipality. It is hoped that the results of the study will help to improve policymakers understanding of the determinants of maternal mortality in the Municipality and serve as an important tool for any possible intervention aimed at improving the low utilization of maternity care services to help achieve the MDG5. It is also hoped that this research will bring out the challenges of reducing maternal mortality to the government and non-governmental organisations that may seek to help find solution to this problem and how this health issue is related to the Ministry of Roads and Transport. Lastly, the research will help find out the possibility of achieving zero maternal death in the municipality by the year 2015 as health management staff perceived that it is likely to be
achieved in Ghana; a little deviation from the report by African countries MDG Africa Steering Group.
1.5 Justification of the study The impact of constrained mobility on bargaining also has its impact on what comes to be available as resource and service within local constraints. No better demonstration of these constraints can be found than in Africas portrait of Maternal Mortality: constraints on mobility and accessibility have devastating consequences for womens health on the African continent. Maternal mortality is not simply fatal but its often a cruel and harsh lived experience for Africas women (Marzot, 1992).
On the basis of this, it is important for the researcher to experience what the women in the rural parts of Ho Municipality go through because off their poor states of roads. Due to their death occurring most often on their roads and villages and not in the health centres most of the maternal deaths are not recorded and then this has resulted in under- registration of maternal mortalities. This results in the government not getting a true picture of the rate of maternal mortality that occurs in the municipality.
The type of transport used most often by pregnant women to access maternal health service; over-aged motorbike is so dangerous even without pregnancy on these poor roads. The researcher experienced the bad state of the motor bikes which is also expensive to hire to get to the nearest health facility and the tractors containing charcoal which are the only means of transportation from some of the villages to the nearest health facility.
It is only after getting to these villages that the government and all concerned can get the real challenges associated with maternal mortality in these rural areas.
1.6 Methodology Data for the study was derived from two main sources, and these are primary and secondary sources of data. With regard to the primary sources, data was collected from pregnant women and health workers; midwives, community health nurses (CHN), enrolled nurses and health aid workers of the Ho Municipality. More emphasis was placed on primary data source because of its reliability and validity to the research work. Secondary source of data for the study was obtained from reports on the 2010 Annual Performance review of Ho Municipality. Published literature and pamphlets on transportation and maternal mortality was studied to serve as a guide and to provide background information. Information was also sourced from the internet. Qualitative and quantitative research techniques were used in this research. The data collected was analyzed using SPSS version 16 and Microsoft Excel, 2007.
1.7 Scope of the study The study concentrated mainly on the Ho municipality, specifically the four (4) sub municipalities namely; Abutia, Tsito, Kpedze -Vane and Ho - Shia. The study was conducted to assess the role of transport in the achievement of maternal mortality reduction. Ho Municipality can be a representative of the nature or the state of other municipalities across Ghana and so findings from this research can be inferred.
1.8 Limitations of the study In undertaking this research work, the researcher encountered issues which posed as limitations. In conducting the interviews and administering the questionnaires, respondents were hard to meet because they only report to the health facility on their antenatal days and others who do not have their antenatal days could only be accessed at their various communities hardly accessible. Another limitation that was registered was that, due to the poor record-keeping facilities in the health centres, records which would have been seen as valuable secondary data for the researcher were unavailable; for example, reliable death records. The time frame given for the completion of the research work was insufficient.
1.9 Organization of the work The work consists of five (5) chapters. Chapter one (1) is made up of Introduction; Background of the study, Objectives of the study, Justification of the study, Methodology, Hypothesis, Scope of the study, Limitation of the study, and organisation of the work. Chapter two (2) will be the review of literature on Millennium Development Goal five and its theories, transportation and maternal mortality rate from various researchers. Chapter three (3) will consist of methodology and the profile of the Ho Municipality. Chapter four (4) will contain the findings, analysis of the findings and the discussion of the findings of the assessment of the role of transport in the achievement of maternal mortality reduction. And then chapter five (5) will finalise the whole research work.
CHAPTER TWO
LITERATURE REVIEW 2.0 Introduction
Literature review available indicates that a number of research works have been carried out on the subject matter. However, this study is focussed on the literature of Millennium Development Goals, detail information and concepts of Millennium Development Goal five which is one of the main frameworks of the study and reviews on the concepts and theories on current transport management and models.
2.1 Transport management From Chartered Institute of Logistics and transport, transport management is the process of ensuring that passengers and freights are provided with the services they need and are delivered to the right place, at the right time, after the highest possible quality journey and at the right price. The various modes of transport facilitate trade and travel via the movement of people and goods. It is something we frequently take for granted, yet an effective transport network is essential for the social and economic well-being of society. Transport management covers a very diverse range of skills, tasks and specialisations. Whether in the public or private sector, freight or passenger, planning or operations, the dynamic nature of transport makes it a challenging and interesting career choice. Transport touches all our lives in numerous ways, yet its contribution to society is often underestimated. However, in recent years there has been growing evidence that its importance to the UK economy is at last being recognised. Transport will also have to be embedded in the policies of every Government department if targets for reduction in carbon emission are to be met. The transport landscape is therefore changing dramatically and it will 9
need the right people with the right skills to deliver a network that reflects changing priorities in the 21st century.
2.1.1 Modes of transport in Ghana From goggle Ghana has only four means of transportation which are road, railway, sea, and air. The road transportation is the principal domestic carrier accounting for around 98% of persons and goods moved. Tro-tros (mini-buses) and mammy wagons (converted pick-up trucks) are very commonly used means of transportation in Ghana. Fast car (Kumasi and Takoradi) is a seven-seater Peugeot hatchback that goes fast to the destination for about twice the price of long distance tro-tros. Taxis can usually be obtained at Taxi ranks like straight taxi that ply a route, just like the larger tro-tro vans, and they take many passengers at once, dropping taxi in which you can ask a taxi driver to take you to a particular destination or chartered taxis which can be hired at most hotels. Access to efficient, affordable and safe transport in the developing world is limited and directly impacts the ability of individuals to seek timely health services. More than 60% of people in poor countries live more than 8km from a healthcare facility.
2.1.2 Transport Management Theory and Models. Narrowing the definition of transport into the area of study it is generically defined as the movement of people and goods by any travel types or models including movement on foot. It encompasses inter-city, urban and rural passenger travel for any purposes and for both private and public travel models (DOT SA, 1996) Transport Management Models
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According to TRANSAID (2001), the transport management system consists of five main areas: policy development, management information, operational management, fleet management and human resources.
Diagrammatic representation of an effective transport management system
Policy
Management information
Fleet management
Operational management
Human resources Fig 2.1 Source: TRANSAID, 2001
Policy development: This sets the rules and guidelines for the management of transport. Management Information System: Refers to the systems put in place for the gathering, analysing, storing, retrieving, and usage of transport data. Fleet Management: It refers to the procurement, maintenance and disposal of vehicles. Operational management: This is concerned with the day to day running of the fleet, including driver training, budgeting and planning. 11
Nancollas (1999), advances the view that concentrating on the management aspect of transport (operational management), brings the greatest sustainable improvements but not technical aspects such as fleet management. The model (Input- Process-Output Model) suggests that the various areas are interdependent and interrelated. Given unequal attention to one model will be at the expense of the other.
Input- Process-Output Model
Fig 2.2 Source: TRANSAID, 2001
Input: This includes maintenances of vehicles, the kilometre travelled and fuel used. This involves money and together with vehicles goes through processing. The main indicators used are kilometre travelled, fuel utilisation and running cost per kilometre. Process: The processing of the inputs is done through operational management, fleet management and guided or moderated by the policy. The main performance indicator is vehicle availability and utilisation. 12
Output: The input produces output, which is service delivery. The main indicator is Needs Satisfaction such as the delivery of any health related services. This model, though from the Google website, would need a feedback to process and input components to rectify service delivery anomalies or enhance performance and also silent on environmental influences that crop up.
2.1.3 Rural Transport Structure According to the World Bank report on rural roads and transport (2000), 70% of world population live in the rural areas. The World Bank defines rural transport as all transport activities that take place at local government and community household levels. It comprises both motorised and non-motorised transport and rural transport infrastructure (e.g. roads). Most literature on transport in developing countries describe rural transport infrastructure as in bad condition, seasonally passable and poorly maintained. This constrains access to social and economic development (1997; Airey 1992; Nancollas 1999). Women have been identified to be the gender group that bear most of the transport burden in rural communities such as fetching water, going to farms and accessing markets and health services (World Bank Rural roads and transport, 2000). Transport burden is particularly onerous for women in rural Africa, who plays predominant roles in both domestic and economic activities, including the production of food and other house hold activities. The provision of rural transport infrastructure and services is inadequate in Sub-Saharan Africa (SSA). As a result, social and economic activities in rural areas take place at high cost in terms of the time and effort involved and the opportunity cost of labour not being available for more productive use. Rural transport services are often inadequate. Passenger and goods transport needs improving to stimulate rural economies and reduce poverty. Understanding existing rural transport systems and constraining factors is a precondition for 13
appropriate policy action to improve rural access and mobility in order to safe and sustain lives in the rural communities. Within the rural travel and transport sub-sector, men and womens experiences of transport and transport services differ. This is because they have different roles, constraints, options, needs and also priorities. Majority of transportation in the rural areas is done on foot and by head load. Women particularly, have to travel long distances to reach fuel wood supplies, health facilities and markets and they do not have access to means of transport besides walking and head loading.
The extent to which the transport burden on women can be improved will depend on the policies affecting rural development and the role of women in the planning of transport and social services. While poor men and women share many of the same problems of limited access to transport services, women are subjected to additional constraints due to: cultural factors limiting their access to available transport facilities, and to the fact that in many rural households the husband or father controls the use of household assets including transport. Access to efficient, affordable and safe transport in the developing world especially is limited and directly impacts upon the ability of individuals to seek timely health services. More than 60% of people in poor countries live more than eight kilometres from a healthcare facility. A study identifies a clear association between infant, child, and maternal mortality rates and distance to healthcare services, and it was found that a 10% increase in distance from a hospital was associated with a two per cent increase in three mortality cases rates (De Silva, 2000). Health services access is poor in developing world but it gets significantly worse in the rural areas, as represented by an example from Ghana where it was found that while 79% of births in urban areas were supervised by a medical practitioner, the rural figure was as low as 33% (Heyen- Perschon, 2005). Women 14
in labour can spend several hours travelling on a makeshift stretcher and over difficult terrain that can induce other health complications for the mother and child. Where access to roads is unavailable, delays of several days are often encountered as families try to raise the money necessary to pay for hiring a vehicle to transport the patient. Emergency transport costs are an overwhelming financial burden for families and this applies even over short distances. Hamlin (2004) argues that the delays in access to health services caused by the difficulties in raising money are one of the important contributors to the occurrence of obstetric fistula and the increased vulnerability among Ethiopian women in Africa. The bias towards infrastructure and large-scale transport still exists in national governments and donor agencies, and is reflected in terms of budgets, personnel and professional training (Hanson, 2004).
While educational disadvantages imposed by mobility and transport impediments on women are likely to be severe, the consequences of their poor access to health services in rural areas are fatal. Clearly, distance is not the only impediment to health care access, treatment fees commonly impose an even greater barrier (Airey, 1995; AU/UNECA, 2005) but in emergencies (where treatment fees are certainly waived in some places and cases) distance and transport failures imposes a critical hurdle (Murray and Pearson 2006). This is illustrated, for instance by work in a region of rural Zimbabwe (Masvingo) where access to transport was an implicating factor in 28% of maternal deaths, as opposed to 3% in urban Harare (Fawcus et al., 1996). Cham et al., (2005) in a study of maternal mortality in a rural area of Gambia, where maternal mortality rates are among the highest in the country, cites specific cases where poor roads and inability to access transport from home to health centre or from health centre to hospital were implicated in subsequent death of the patient. It is been found that in Malawi and Ghana children are at times born on the roadside while pregnant women are walking to the clinic (Grieco, 2005). Again, 15
McCray (2004) in a study of prenatal care in KwaZulu Natal, South Africa, emphasises the significance of the opportunity costs of travel time in remote areas.
2.2 Development Goal The Millennium Development Goals (MDGs) are eight international development goals that one hundred and ninety two (192) United Nations member states and at least 23 international organizations have agreed to achieve by the year 2015. In 2001, recognizing the need to assist impoverished nations more aggressively, UN member states adopted targets. The MDGs aim to spur development by improving social and economic conditions in the world's poorest countries (Wikipedia, 2009). All major international organizations as well as many civil society and private sector organizations supported the call to cut extreme poverty to half by 2015. To make the commitments more manageable, eight (8) MDGs were selected, and a time limit for reaching the goals was set to 2015 to underline the urgency of the commitments (Wikipedia, 2009). Reducing the Maternal Mortality by three quarters between 1990 and 2015 is a specific part of Goal 5 Improving Maternal Health of the eight Millennium Development Goals; it is monitored (Wikipedia, 2009).
2.2.1The Millennium Development Goal Five - Improve Maternal Health Motherhood has threatened to be dangerous endeavour in many parts of the world. A woman living in sub-Saharan Africa has a 1 in 16 chance of dying in pregnancy or childbirth (UNPF, 2006). Worldwide, nearly 600,000 women between the ages of 15 and 49 die every year as a result of complications arising from pregnancy and childbirth. The tragedy is that these women die not from disease but during the normal, life-enhancing process of procreation (WHO, 1999). It is recognised as a serious problem by both policy makers and health care practitioners. Most of 16
these deaths could be avoided if preventive measures were taken and adequate care was available. Sadly to say for every woman who dies, many more suffer from serious conditions that can affect them for the rest of their lives. The death of a woman during pregnancy or childbirth is not only a health issue but also a matter of social injustice. The inclusion of maternal death reduction in the Millennium Development Goals (MDGs) highlights the renewed global commitment to this issue. However, achieving the goal of reducing 1990 maternal mortality ratios by 75 percent by 2015 or, even coming close, will require extraordinary efforts by the international community, the civil sector, and local governments. Securing further funding to study maternal mortality issues, adopting sound policies to strengthen the primary healthcare system, and empowering women to use these services, will all decrease maternal deaths. The MDG 5s aim to improve maternal health reinforces decades of international commitment and national efforts to address the problems associated with reproductive health, and safe motherhood. This effort builds on past global agreements such as the Program of Action of the International Conference on Population and Development (ICPD) held in Cairo in 1994, the Platform of Action of the Fourth World Conference on Women held in Beijing 1995, and the UN International Development Targets established in 1995. For MDG5, countries have committed to reduce the maternal mortality ratio by three quarters between 1990 and 2015. A total of 99% of all maternal deaths unfortunately occurs in developing countries, where 85% of the population lives. More than half of these deaths occur in sub-Saharan Africa and one third in South Asia. The maternal mortality ratio in developing countries is 450 maternal deaths per 100 000 live births versus 9 in developed countries (WHO, 2007).
2.3 Maternal Death Maternal death is defined as the death of a woman while pregnant or within 42 days of 17
termination of pregnancy, irrespective of the duration or site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes and a late maternal mortality is defined as the death of a woman or girl from direct or indirect causes more than one year after termination of pregnancy (WHO, 1992).
From Wikipedia, the free encyclopaedia, maternal death or maternal mortality, also obstetrical death is the death of a woman during or shortly after pregnancy. Maternal mortality was also defined by Sundaram et al (2005) as the death of either a pregnant woman or death of woman within 42days of delivery, spontaneous abortion or termination providing the death is associated with pregnancy or its treatment. In the UK, maternal mortality rates can be calculated in two ways: Through official death certification to the Registrars General (the office for National Statistics and its equivalents). Through deaths reported to the Centre for Maternal and Child Enquiries (MACE). This produces a report every 3years (and this article draws its numbers from that report). The overall maternal death rate for the Enquiry is calculated from the number of deaths assessed as being due to Direct and Indirect causes. However, it is not possible to obtain accurate data on total number of pregnancies. The alternative is to use deaths from obstetric causes/ million maternities that is, pregnancies that have been notified to a doctor. Direct deaths are defined as those related to obstetric complications during pregnancy, labour or puerperium (6weeks) or resulting from any treatment received. Indirect deaths are those associated with a disorder, the effect of which is exacerbated by pregnancy. Late deaths occur 42 days after end of pregnancy
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2.3.1 Measures of Maternal Mortality From a source an Impact source at google website, no one tool can perfectly measure maternal death in all situations. For this reason, multiple measurement approaches are needed. To add to the safe mother-hood basket of tools, Impact has worked to improve existing tools as well as develop new ones. To more efficiently collect data reduce costs, and use fewer skilled personnel to carry out surveys, Impact developed Sampling at Service Sites (SSS). With this method, women are interviewed at busy centres, such as markets or health facilities, about any maternal deaths among their sisters. Allowing respondents to come to the interviewers rather than sending the interviewers to the respondents homes, as traditional household surveys do, reduces both the cost and time required to collect data. Maternal mortality estimates made using this new approach were consistent with those from the 1990-2000 Ghana World Health Survey.
There are three main measures of maternal mortality - the maternal mortality ratio, the maternal mortality rate, and the lifetime risk of maternal death.
i. Maternal Mortality Ratio (MMR) The Maternal Mortality Ratio (MMR) is the most common measure of magnitude of maternal mortality. The rate describes how safe it is to become pregnant and give birth in the geographic area or population for which it is calculated. It measures both the obstetric risk and the frequency with which women are exposed to this risk. It is calculated as the number of maternal deaths in a given period per 100,000 women of reproductive age (usually 15 49 years). Sub-Saharan Africa suffers from the highest MMR at 920 maternal deaths per 100,000 live births, followed by South Asia, with an MMR of 500. This compares with an MMR of 9 in industrialized countries. However, this indicator is often times more difficult to obtain as it requires (periodic) surveys, 19
resulting in often outdated values at best. Maternal mortality ratio represents the risk associated with each pregnancy, i.e. the obstetric risk.
ii. Maternal Mortality Rate This is measured by number of maternal deaths in a given time period per 100,000 women of reproductive age, or woman years of risk exposure in the same time period (WHO, 1992). When comparing, it is important to distinguish this indicator from the earlier mentioned ratio as values will differ significantly for the same population.
iii. Lifetime Risk of Maternal Death It is also the probability of maternal death during a womans reproductive life, usually expressed in terms of odds. In other words it is the probability that a woman will die from complications of pregnancy and childbirth over her lifetime. It takes into account both the maternal mortality ratio (probability of maternal death per childbirth) and the total fertility rate (probable number of births per woman during her reproductive years). Thus in a high-fertility setting a woman faces the risk of maternal death multiple times, and her lifetime risk of death will be higher than in a low-fertility setting. The lifetime risk of maternal death in the developing world as a whole is 1 in 76 compared with 1 in 8,000 in the industrialized world (Khan, Khalid, et al. 2006). This indicator is more complex as it includes fertility as well as obstetric risk. Also from maternity worldwide, there are three main ways in which maternal mortality is measured: Maternal mortality ratio = number of maternal deaths per 100,000 live births during a given time period. This is a measure of the risk of death once a woman or girl has become pregnant. Maternal mortality rate = number of maternal deaths per 100,000 women
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or girls of reproductive age in a given time period. This reflects the frequency with which women and girls are exposed to risk through pregnancy.
Lifetime risk of maternal death: This takes into account both the probability of becoming pregnant and the probability of dying as a result of that pregnancy cumulated across a woman or girls reproductive years. In theory this is a cohort measure but it is usually calculated with period measures for practical purposes. Proportional mortality ratio: Maternal deaths as a proportion of all female deaths of those of reproductive age usually defined as 15 49 years in a given time period. The lifetime risk of maternal death takes into account both the probability of becoming pregnant and the probability of dying as a result of the pregnancy cumulated across a woman's reproductive years (Campbell and Graham 1990). The terms ``ratio'' and ``rate'' are often used interchangeably; for the sake of clarity it is therefore essential, when referring to either of these measures of maternal mortality, to specify the denominator used. Maternal mortality is difficult and complex to monitor, particularly in settings where the levels of maternal deaths are highest. Information is required about deaths among women of reproductive age, their pregnancy status at or near the time of death and the medical cause of death all of which can be difficult to measure accurately, particularly where vital registration systems are incomplete. Maternal deaths are also relatively rare events, even in high-mortality areas, and are prone to measurement error. Therefore, the World Health Organization, UNICEF, the United Nations Population Fund and the World Bank have developed an approach to adjusting these data for underreporting and misclassification and producing model-based estimates for countries that lack national-level data (Khalid, 2006).
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2.3.2 Causes of Maternal Death Factors that contribute to a higher risk of maternal mortality can include biomedical factors, reproductive factors, health service factors, and socio-economic and cultural factors (source: maternity worldwide).
Biomedical Factors: The biomedical causes of maternal mortality are well recognised. Three quarters of maternal mortalities result from the direct obstetric complications of haemorrhage, infection, obstructed labour, hypertension disorders of pregnancy and septic abortion .The remainder are due to other direct causes such as pulmonary embolism or ectopic pregnancy or indirect causes that are aggravated by pregnancy, such as malaria, hepatitis, diabetes mellitus and heart disease. Worldwide the most common cause of maternal mortality is haemorrhage, but the proportion due to each cause varies between regions. It has been estimated that approximately 40% of women may suffer an acute problem in pregnancy, and 9-15% may experience a problem needing higher level care. Other direct causes include: ectopic pregnancy, embolism, anaesthesia related causes and indirect causes include: anaemia, malaria heart disease. Appropriate and timely intervention from a trained professional could prevent the majority of maternal mortalities. Maternal mortalities do not occur instantaneously. If a system is in place to recognise problems promptly and to transport a woman to a healthcare facility where she can receive appropriate and timely treatment then the majority of maternal mortalities could be avoided.
Reproductive factors: The risk of a woman dying in pregnancy and childbirth depends on the number of pregnancies she has in lifetime. The higher the number of pregnancies the greater the 22
lifetime risk of pregnancy related death. Maternal mortality rates are also higher among very young women, those aged 35years and older and those with four or more children.
Health service factors: The prevention of maternal mortality requires access to health care services providing prompt recognition and treatment of pregnancy related complications. However in developing countries there are often inadequate facilities available and a lack of trained staff, equipment and supplies. Additionally, where services do exist, their costs may be prohibitively expensive or the majority of the population.
Socio-economic and cultural factors: The ability of women to command resources and make independent decisions about their fertility, their health and healthcare also has an impact on maternal mortality. Where women are afforded a low status in society their health needs are often neglected, and existing health facilities may not be accessed by women in need. Additionally, lack of education and understanding around health related issues can contribute to delays in seeking care when it is needed or to the inappropriate management of life threatening pregnancy complications. Of the estimated 536,000 maternal deaths worldwide in 2005, developing countries accounted for more than 99 per cent. About half of the maternal deaths (265,000) occurred in sub-Saharan Africa alone, with a third of them occurring in South Asia (187,000). Thus, sub-Saharan Africa and South Asia accounted for 84 per cent of global maternal deaths (UNICEF, 2008). Developing countries stand the greatest risk of having obstetric complications being the leading cause of death of women of reproductive age claiming the lives of an estimated 529,000 each year (Freedman, 2003). The majority of these deaths, however, are preventable. The principal direct determinants of maternal mortality are well established in Fig.1.1. More than 70% of maternal deaths are due to five major complications: 23
haemorrhage (34%), infection (16%), complications of unsafe abortion (4%), Anaemia (4%), hypertension (9%) and obstructed labour (4%) and other causes (30%). There are also direct and indirect determinants of maternal death. Indirect determinants are defined as pre-existing diseases or diseases that develop during pregnancy (not related to direct obstetric determinants) that are aggravated by the physiological effects of pregnancy; the principal indirect determinants in many settings include anaemia, malaria, hepatitis and diabetes (Gelband et al., 2001).
Fig 2.3: WHO Analysis of Causes of Maternal Death- a systematic review Source: Khan (2006)
2.3.3 The Delay Model In the Millennium Project Report of 2005 to the Secretary General, the direct and indirect relationship between transport and health was referred to on numerous occasions. Among other bilateral agencies, USAID has highlighted the importance of transport for urban poor populations (especially slum dwellers) accessing health facilities, which tend not to be located in disadvantaged areas of cities.
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i. The Three Delays Model The three delays model developed by Thaddeus and Maine (1994) identifies delays in seeking, reaching, and receiving care as the key factors contributing to maternal death. The Model is a framework which explains the social factors responsible for maternal death. It set out key time periods in peri-natal complications during which delays can occur that have direct consequences for maternal and neonatal survival. According to UNFPA (2005) women who die in childbirth are likely to experience one of the three delays. Although not directly specified, the transport and mobility of pregnant women are clearly key components of the three delays model of maternal mortality that is pertinent in low-income countries.
The Three Delays Model of Maternal Mortality Source: Thaddeus and Maine, 1994
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1st Delay: Delay in Seeking Care The First Delay is delay in deciding to seek care. It is related to having the knowledge to recognize a life threatening problem and making the decision to go for care, for example for an obstetric complication (Thaddeus and Maine, 1994). Sometimes this occurs because of fear of the hospital or the costs that will result from professional care, lack of recognition that there is a problem, and lack of an available decision maker.
2nd Delay: Delay in identifying and reaching Medical Facility The Second Delay occurs after the decision to seek care has been made. It is a delay in actually reaching the care facility and is usually the result of lack of infrastructure and difficulty in transport. The delay in reaching care results from inaccessibility of health services due to distance, lack of money, or other barriers to access. Again the poor roads that connect villages to health centres and the limited transportation options available make it difficult for women to reach the help they need. The cost of transport and travel to maternity facilities along with associated expenses, such as food, deter poorer rural women from delivering in designated health centres (ICDDR, 2005). A study conducted by Shehu et al., (1997) in rural north-western Nigeria identified vehicle and fuel shortages, coupled with a lack of willingness of owners and drivers to transport women for affordable fares contribute to delays in transportation to appropriate health facilities in cases of obstetric complications. The immediate dangers of poor access in the case of emergency obstetric care are obvious, but longer term health problems for women caused by failure to access timely health care (including obstetric fistula resulting from obstructed labour) are of great concern. Travel costs and
inadequate transport infrastructure, combined with poverty and distance from health outlets are 26
implicit in two of the three factors affecting health service utilization and maternal health outcome set out in this model. 3rd Delay: Delay in receipt of Adequate Treatment The Third Delay is in obtaining care once the woman has reached the facility. It also refers to problems in content and quality of maternal health care services. Inadequacy of resources contributes to this delay model and this may be due to one or a chain of the following events: shortage of medical supplies, lack of equipment, prepayment policies, poor staffing or lack of trained personnel, and incompetence of the available staff or an operating theatre which result in women waiting for many hours at the referral centre. Most maternal deaths occur during labor, delivery, or the first 24 hours after delivery, and most complications cannot be prevented or predicted (Campbell and Graham, 2003). Skilled care during pregnancy, childbirth, and the immediate postpartum period, by health care professionals with appropriate skills has been recognized as one of the key interventions to reduce maternal mortality (WHO, 2004). Although delays in accessing care may be caused by delays in decisionmaking and delay in receiving treatment after arrival at the clinics, remoteness and associated problems of inadequate and costly transport are commonly a substantial contributing factor. In a study by Addis Ababa fistula hospital, among the causes patients gave for failure to obtain early treatment, distance figured above other factors (distance 28.2%, distance and economy 23%, poor knowledge and distance 2.3%): the average time taken to reach the nearest road on foot was five hours (Muleta, 2006). The complex interplay between health and mobility is influenced by many other factors. It is assumed that by stimulating the rural economy for example a greater proportion of the population are able to afford preventive and curative health care (Vlassoff et al; 2004) as well as improving nutrition and access to health information. Research suggests that this process commences by enabling rural people to access technological inputs to raise 27
agricultural productivity, broadening livelihood options by improving urban-rural linkages with wage-labour opportunities and opening up urban markets to rural producers (Musa, 2002). A broadening of livelihood options offered by transport and communications is regarded to raise the value of education and stimulate literacy and skills development among rural people. Road provision arguably directly enables children from more isolated areas to access school (Rao 1994) and supports provisioning of educational establishment. There is again the growing evidence that school attendance among girls is key to reducing morbidity, mortality and fertility (LeVine et al; 1994)
2.4 Maternal mortality rate in Nigeria According to the WHO/UNICEF, in 1995, Nigeria had the third highest number of maternal deaths in the world, approximately 45,000 deaths. By the year 2000 the worrisome death-wave was yet to abate. For every 100,000 live births about 800 women died in the process of child birth. Out of the 27 million Nigerian women of reproductive age back then about 2 million did not survive either pregnancy or childbirth. So appalling has the maternal mortality become that on the 3rd of July, 2008, Nigerian government officials were invited by the UN Special Committee dedicated to the protection of womens rights to explain the deplorable rate of deaths of pregnant women in the country. That year the figure stood at between 1,100 and 1,500 deaths according to the UN. On its part UNICEF in its state of the World Children Report, 2009 stated that one out of nine global maternal deaths occur in Nigeria. Today, Nigeria posts the second largest mortality rate in the world, with about 144girls and women dying every day from complications at childbirth.
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2.5 Maternal mortality rates in Togo In June 2011, the United Population Fund released a report on the state of the Worlds Midwifery. It contained new data on the midwifery workforce and policies relating to newborn and maternal mortality for 58 countries. The 2010 maternal mortality rate per 100,000 births for Togo is 350. This is compared 447,1 in 2008 and 539.7 in 1990. The under -5 mortality rate, per 1,000 births is 100 and the neonatal mortality as a percentage of under 5s mortality rate per 1,000 births is 100 and the neonatal mortality as a percentage of under 5s mortality is 32.
2.6 Impact of maternal death For each of the over five hundred thousand maternal deaths that occur yearly worldwide, an estimated 30 to 50 women suffer pregnancy-related health problems such as vesico-vaginal fistula, infertility, and depression that can be permanently debilitating (WHO, 2001). Women in the developing world have a 1 in 48 chance of dying from pregnancy-related causes; the ratio in developed countries is 1 in 1,800 (WHO, 2001). Therefore the beneficial effects of reducing maternal mortality are of great relevant. Investments in safe motherhood not only improve a womans health and the health of her family but also increase labour supply, productive capacity, and economic well-being of communities. Children whose mothers die or are disabled in childbearing have vastly diminished prospects of leading a productive life (World Bank, 1999). In addition to the health and economic rationale for ensuring maternal and reproductive health is a compelling human rights dimension to reducing death and illness associated with pregnancy and childbirth. Maternal and reproductive health has been codified in multiple international covenants (Cook et al., 2001). Series of studies carried out on the effects of adult deaths on subsequent health and socioeconomic well-being of rural families in the Mat lab sample registration region in Bangladesh, an internationally recognized study area that serves as a 29
unique source of accurate and complete demographic data for a large rural population within a developing setting. These studies have shown that children whose mothers died (whether in childbirth or for another reason) were much more likely to die than children whose fathers died, and both groups were more likely to die than children whose households did not experience an adult death. Most deaths occurred when the children were under one year old. After the first month of life, girls were more likely to die than boys. Another study found that children who lost their mothers were much more likely to be stunted than children who lost their fathers or had both parents living (Greene and Merrick, 2005). Maternal death also affects the children and families women leave behind, and the societies, cultures, and economies to which they can no longer contribute. Thus, decreasing the number of maternal deaths each year will also positively impact families and communities. Again, another studies on household effects of maternal mortality and morbidity found that the death of an adult woman had the biggest effect on household consumption in the poorest households for at least a year following the death and that older children are often either forced to leave school to work to help support the family after an adult in their family has died, or sent to live with their grandparents (Greene, Margaret and Merrick, 2005). Researched conducted by United Nations Food Programme also shows that maternal death also results in hardship for the families of women who are injured. When women cannot work because of health problems, the combination of the loss of their income and the costs of treatment can drive their families into debt. A study in India found that disability reduced the productivity of the female labour force by about 20 percent (UNPF, 2004). Besides, the burden on women associated with frequent or too-early pregnancies, poor maternal and reproductive health, pregnancy complications, and caring for sick children and the elderly drains womens productive energy, jeopardizes their income- earning capacity, and contributes to their poverty. 30
2.7 Transport and Maternal Mortality Transport plays a critical role in the effective and efficient delivery of health care. It enables people to access services and health workers to reach communities, especially in sparsely populated rural areas (Babinard and Roberts, 2006). Transport is also essential for delivering supplies of resources such as drugs and personnel to health centres, and for transferring patients between health facilities and to the different levels of care (Downing and Sethi, 2001). It has a critical role to play because of the need for urgent evacuations to hospital of women who suffer serious problems in childbirth. Dawson and Barwell (1993) further recognised that mobility is crucial for accessing goods and services and that road are simply not enough. Emergency access to care is particularly vital for women and children because many childbirth-related complications are unpredictable and the majority of births in developing countries take place at home (Babinard, Roberts, 2006). Mobility is key for many rural communities to accessing available preventive and curative services, and also supports indirect determinants of health including livelihoods and education (Molesworth, 2005). The difficulties has been that many households do not have reliable, suitable, and affordable transport services essential for access to care during critical prenatal and neonatal periods. According to Hamlin (2004) obstetric fistulas are a preventable through a combination of access to adequate transport services and effective management of child delivery services.
The statement of MDGs which was signed by all the Sub-Sahara African governments, as well as those of aid-giving countries, and developing countries from other parts of the world, in the months following the UN Millennium Summit of September 2000, makes no explicit reference to transport. However it has always been recognized that transport infrastructure and services 31
indeed have an important supporting role to play (UN General Assembly, 2004). Poorer households are often further away from medical facilities and, especially in rural areas of SubSaharan Africa, they typically face long journeys and high opportunity costs to access health care. While uses of roads for medical purposes are seldom likely to be a dominant consideration in the decision about major upgrading investments and their potential impact of health services needs to be recognized. The larger and more difficult part of transports contribution is in bringing people to medical centres, sometime urgently as when a few hours delay in treatment can make the difference between life and death.
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CHAPTER THREE
METHODOLOGY AND PROFILE OF HO MUNICIPALITY
3.0 INTRODUCTION The success and validity of a research depends on the research methodology employed. This chapter deals with the methods and designs that were used during the research work. The methodology section of this research study describes the procedures that were followed in conducting the study and steps involved are illustrated in detail. It covers the research design, study population and sampling procedure, data collection, survey instrument used, administration of the survey instrument used and the procedures adopted in analyzing the data collected. The profile of Ho Municipality was considered in this chapter.
3.1 RESEARCH METHODOLOGY 3.1.1 Research Design The study used a number of approaches including case study, descriptive and exploratory approaches, and all these were adopted to gain a better understanding of the role of transport in the achievement of maternal death reduction. The main motivation for selecting the case study area was because the researchers relative has been a victim of the subject matter from that area and also the municipality has been one of the deprived ones and maternal mortality has also been on the increase. The main objective of using a descriptive research was to depict an accurate profile of events or situation.
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3.1.2 Scope and Population of the Study The scope of this study focuses on pregnant women and health workers in relation to maternal mortality rate. The study is restricted to the Ho municipality amongst all other settlements in Ghana.
3.1.3 Sampling technique The population of the study covered the health workers and pregnant women of Ho Municipality. The researcher chose 50 pregnant women and 50 health workers. All the 50 questionnaires to the pregnant women were administered but the health workers, thus, midwives and nurses for the pregnant women in all the communities were very few in number so 20 questionnaires were answered by the 20 health workers in all the communities. Non-probabilistic sampling techniques were used. A purposive (non-probabilistic) sampling technique was used to collect data from the health workers. This technique was used primarily because of the limited number of staff with expertise in the area being researched. Accidental sampling technique was chosen for the remaining sample population which were the pregnant women
3.1.4 Data Collection technique Data was collected mainly from primary sources by the use of interviews and the administration of questionnaires. The questionnaires were administered in all health facilities that were within Ho Municipality of Ghana Health Service and the communities. Phone calls were also made as follow-up questions and responses needed. Two (2) sets of questionnaires was designed and used for the study. One set for the health workers and the other set for the pregnant women. The questionnaires consisted of items on transport usage in relation to maternal health services. However provision for assistance was put in place for those who needed help in filling up the 34
questionnaire as most of them were rather comfortable in the local dialect (ewe).The questionnaires contained twenty-eight (28) questions for the health workers and that of the pregnant women contained eighteen (18) questions. All were close-ended questions. To ensure reliability in our findings, the researchers interviewees were health workers, women who were not pregnant, pregnant women and their husbands who had extensive knowledge and experience in maternal health services and could not be captured during the administration of the questionnaire. Motorbike and tractor containing charcoal was used by the researcher to get to the various most of the rural areas of the Municipality. Gbedome is one of the villages where the researcher had to sit on a tractor containing charcoal to get to the village and it is a typical place where husbands are midwives for their wives because it is so difficult to get a tractor coming to the way of a health facility. Also it was it was so expensive to access any of these modes of transport used to get to some of these rural areas. When complication sets in the end results will be the death of the woman who wants to bring an additional life and most often their death is not recorded because it does not occur in a health facility. The Municipal Administration has one (1) pickup. There was one ambulance serving the municipality but it is out of use now. Each health facility is supposed to have at least one (1) motorbike but most of the various facilities motorbikes are spoilt and those who still have their motorbikes are very over aged and are very dangerous to use. Kpedze-Vane Sub Municipality has a very large catchment area but there is not a single motorbike to be used at the health facility. Motorbikes are extensively used on normal by most of the communities but during market days the public transport and taxis are available for use. People from Gbedome under the Kpedze-Vane Sub Municipality can have access to tractors and Kia trucks containing charcoal as a means of transport due to the nature of the roads. Borkorvi Kope, Dokpokope, Sekekope, Dokpokope, Tsiamkope all under the Tsito Sub Municipality is no 35
exception from this situation to mention a few. On the average tractors and motorbikes are the most extensively used. During rainy seasons, these areas are highly inaccessible from outside the vicinity.Most of the villages have no midwife available because of these serious transport challenges and Dzologbogame is no exception. Secondary data were gathered from textbooks, journal reports, newspapers and internet.
3.2. DATA ANALYSIS SPSS version 16 and Microsoft Excel were used to analyze data collected. Tables, percentages, bar charts and pie charts were also employed in illustrating the results. Questionnaires administered were first edited and then values corresponding to responses were converted to percentages for easy analysis. Bar charts and pie charts were also used to give pictorial view of responses.
3.3 PROFILE OF HO MUNICIPALITY Ho Municipality is one of the eighteen political/administration districts in the Volta region of Ghana. It is located in the middle zone of the Region. Ho town doubles as the municipal capital and the Regional capital of the Volta Region. There are four (4) Sub-Municipalities under the Ho Municipality. The sub municipalities are Tsito Sub Municipality with 29 communities, Abutia Sub Municipality with also 29 communities, Kpedze-Vane Sub Municipality with 84 communities and Ho-Shia Sub Municipality with 66 communities. Ho Municipal Assembly constitutes the local Government in the Municipality which is headed by a Municipal Chief Executive (MCE). The Municipal Health Directorate (MHD) is a decentralized department under the Municipal Assembly. (GHS HM, 2010)Ho Municipality is 36
bordered on the North by the Hohoe District, west by Asuogyaman District, east and south-east by Adaklu-Anyigbe District, North-west by South Dayi District and North east by The Republic of Togo. (GHS HM, 2010).The Rural-urban split; the composition of the Municipality is made of 65.8% rural dwellers whilst the urban is composed of 34.2%. (GHS HM, 2010) The ethnicity; although the municipality is ethnically diverse, the main ethnic groups are: Ewe (83.9%), Akan (7.6), Guan (4.1%), Ga-Dangme (1.8), Mole Dagbani (1.0%), Grusi (0.7%), all others (0.5%), Gurma (0.3%) and Mande (0.5%). (GHS HM, 2010) Their occupation; the main economic activity in the Municipality is Agriculture. Agricultural activities employ about 64% of the total labour force in the Municipality. Few people are also engaged in the Government set-ups, trading and constructional works. (GHS HM, 2010) The Municipality has an estimated population of 225,026 with an annual growth rate of 1.9%. (Ghana Statistical Service,2010).
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CHAPTER FOUR ANALYSIS AND DISCUSSION OF RESULTS
4.0 Introduction This chapter presents an analysis of the data gathered from the field with the aid of research instruments such as questionnaires and interviews. The research considered the findings which were based on the questionnaires administered and interviews conducted by the researcher in relation to the issue under study.
4.1: Age Distribution Table 4.1: Age Distribution Age 18-25yrs 26-30yrs 31-35yrs 36-40yrs Total Frequency 11 17 13 9 50 Percentage 23.91 36.95 28.26 10.86 100
Source: Authors field work, 2011
Fig 4.1: Age of Pregnant women 38
Source: Authors fieldwork, 2011
The age of the respondent was assessed to find out the distribution of the age categories. 23.91% of the respondents were between 18-25yrs. 36.95% of the respondents were between the ages 2630yrs and this category was the highest for the pregnant women.10.86% of the respondents were within the ages of 36-40yrs. 28.26% of the respondents were between the ages 31-35yrs.
4.2 Average number of children the pregnant women had. 39
Table 4.2: Number of children of pregnant women

Number Children of
Frequency 15 23 12 50
Percentage 30 46 24 100
1 2 4 and above Total
Fig 4.2: Number of children of pregnant women
Table 4.2 reveals the number of children each pregnant woman already had. Twenty-four (24) representing (46%) of the respondent had two (2) children, fifteen (30%) of the respondents had one child while twelve (24%) of the respondent had four (4) and above children. Although some respondents wrote the number of births as the number of children, some had lost two (2), three 40
(3) or all four (4) children due to late detection of some pregnancy illnesses. Two (2) women were victims of this situation but when asked if they could now come to antenatal care services regularly the answer was negative. Hindrances were attributed to transportation problems and financial issues.
4.3 Marital status of the pregnant women Table 4.3: Marital status of pregnant women Marital Status of pregnant woman Single Married Co-habitation Missing Total Frequency Percentage
11 1 15 23 50
22 2 30 46 100
Source: Authors fieldwork, 2011 Fig 4.3: Marital status of pregnant women
Accidental sampling technique was used in selecting the pregnant women; those readily available formed the sample. As shown in table 4.3, 11 (eleven) respondents representing 22% 41
were single but were still searching for men to marry. 15 (fifteen) respondents representing 30% were just leaving with men they were not married to. This was due to financial difficulties which they thought the men could eliminate for them. 1 (one) respondent representing 2% was married traditionally to her husband who was responsible for her care taking thoroughly. 22 (twenty-two) respondents wanted to be silent on their marital status with reasons best known to them. This could be because of their spiritual belief that issues like that must not be revealed to strangers as was gathered during interviewing them.
4.4 Income level of pregnant women Fig 4.4: Income level of pregnant women
When asked about their income levels, as it reflects on table 4.4, 24 respondents representing 48% of the sample size were gaining income of GH10-50 in a month and this was just an estimated figure from them as they were not sure how much they gain exactly from their farm 42
proceeds as most of them who were working were small scale farmers. 20 (twenty) respondents that represents 40% of the sample size were gaining an estimated range of GH51-100 in a month. 3(three) of the respondents that represents 6% of the sample size was gaining an estimated range of GH101-150 in a month. 62% of the respondents specifically 1 (one) respondent was gaining 201 and above. This implies at least one (1) person in the municipality is doing well in terms of income because probably she is a trader who went to settle at one of the main towns in the municipality quite recently. The result from the analysis carried out indicates that the pregnant women had very low income levels which were a confirmation of the fact that almost all the sample observation was unemployed.
4.5 The educational level of the pregnant women Table 4.5: Educational level of the pregnant women
Educational Level No education Primary JHS Total
Frequency 7 39 4 50
Percentage 14 78 8 100
Fig 4.5 Educational level of the pregnant women
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Table 4.5 sets out the various educational levels of the pregnant women. Majority of the respondents, Thirty-nine (39), representing 78% attained primary education and the highest class among this category was class 3 and still cannot write certain basic things. Four (4) of the respondents representing 8% of the sample size attained Junior High education but could not read and write. Seven (7) of the respondents representing 14% of the sample size had no education at all and know nothing about education and how illiteracy can make take wrong dosages of medications given at antenatal. The villages are deprived of so many important infrastructures which even affects the educational level of almost all the people. The Municipality has records of only the deaths that occurred at the Municipal Hospital and the institutional maternal mortality stands as follows:
4.6 Secondary Data from Directorate Table 4.6 Secondary Data from Directorate 44
Year 2008 2009 2010
No of deaths 15 25 12
Maternal mortality rate (MMR) 3.9/1000 live births 5.6/1000LB 2.9/1000LB
Source: (GHS HM, 2010) From the secondary data on table 4.6, there were fifteen (15) maternal deaths in the year in the whole Ho Municipality in the year 2008, twenty-five (25) in 2009, and twelve (12) in 2010. But it was clearly written in the 2010 annual report review that these deaths were the ones that occurred only in their health facilities. This implies that those that had challenges of getting to their health facilities and died in their communities could not be recorded. However, the report did not capture the reasons for these deaths.
4.7 Attendance to antenatal services Table 4.7

Attend Antenatal services
Percentage
Regularly 10.63 Irregularly 51.06 Not at all 38.29 Total 100 Source: Authors fieldwork, 2011
Fig 4.7 Attendance to antenatal services
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The survey seeks to find out how regular the pregnant women visit the antenatal service, the results reveals that twenty four (51.06%) of the respondent have irregular attendances to the antenatal care, eighteen (38.29%) of the respondent dont attend antenatal care and five (10.63%) of the respondent have regular attendance of antenatal care. The high percentage of respondents not been able to attend antenatal services are mainly because of the means of transport that is available is accessible only during market days and hiring motorbikes too are very expensive meanwhile their income gains are very low.
4.8 Problem of transportation 46
Table 4.8: Transportation problem
Transportation problem Observed N 47 3 50 Expected N Residual 25.0 22.0 25.0 -22.0 Chi-square value 38.720 P-value P<0.0001
yes no Total
The result of the survey reveals that forty- seven (94%) of the respondent were in the view that transportation is a problem while three (6.0%) of the respondent sees transportation not as a problem. As shown in table 4.8, majority of the respondents confirmed that transportation is really a problem for pregnant women. The chi-square test of goodness of fit test indicated that there is a significant difference between the observed and the expected frequencies of response categories. The chi-square test confirmed the response that transportation is a problem for the pregnant women.
4.9 Maternal health mortality prevalent in locality Table 4.9: Maternal health mortality prevalent in locality
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Maternal health mortality prevalent in locality Observed N Expected N Residual Chi-square value Yes No Total 47 3 50 25.0 25.0 22.0 -22.0 38.720 P<0.0001 P-value
The result of the survey reveals that forty-seven (94%) of the respondent were in the view that maternal mortality is prevalent while three (6.0%) of the responded were of view that it was not prevalent. The people especially the pregnant women are very much aware of how other pregnant women die in their vicinity in the hands of sometimes traditional birth attendants (TBA) and their husbands who serve as midwives for them when they are in labour. From the researchers observations it was noticed that the pregnant women were afraid to disclose the information concerning the rate of maternal mortality. This was because they feared the repercussion that they believed will befall them following the disclosure of the information to strangers. The chi-square test of goodness of fit test indicated that there is a significant difference between the observed and the expected frequencies of response categories .The chi square test confirmed the response that maternal health mortality is prevalent in the study areas.
4.10 The problem of health facility location for pregnant women Table 4.10: Problem of health facility location for pregnant women
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Is health facility far away from your locality? Observed N Expected N Residual Chi-square value Yes No Total 46 4 50 25.0 25.0 21.0 -21.0 35.28 P<0.0001 P-value
Source: Authors fieldwork
From table 4.10, majority of the respondents confirms health facilities are so far from their vicinity and there is difficulty even in getting access to transport. The result of the survey reveals that forty six (92%) of the respondent were in of the view that health facilities are located far away from their communities while four (8.0%) of the respondent are of the view that their location is not far away from the health facility. The chi square test of goodness of fit test indicated that there is a significant difference between the observed and the expected frequencies of response categories .The chi square test confirm the response that the distance from the study area and the health facility is far-off.
4.11 Transport mode used in accessing health facilities Table 4.11: Transport mode used in accessing health facilities
Transport Mode
Frequency Percentage 49
Public transport
18
36
Motorbike 24 48 Walk 8 16 Total 50 100 Source: Authors fieldwork, 2011
Fig 4.11: Transport mode used in accessing health facilities
Table 4.11 reveals that the widely used mode of transportation is by motorbike representing twenty-four (48%) of the respondents, eighteen (36%) of the respondents were found to travel by public transport while eight (16%) of the respondent travel by foot. Motorbikes are the most common mode of transport that can be used to get access to a health facility. Some pregnant women have to walk a long distance before getting to a health facility and if it is an emergency from these villages, one can imagine the implications. Public transport can only be accessed during market days. The market days occurs every three days and so one can only access the next public transport facility on the next market day. 50
4.12 Accessing the number of transit trips to the health facility Table 4.12: Accessing the number of transit trips to the health facility No of trips to health facility One trip Two trips Three trips four trips Total Source: Authors fieldwork, 2011 Frequency 43 4 1 2 50 Percentage 86 8 2 4 100
Figure 4.12 accessing the number of transit trips to the health facility
Source: Authors fieldwork, 2011 The result of the survey revealed that though transportation is a problem for pregnant women, any mode of transport available to them has a straight route without transit; Forty-three (86%) of the respondent have only one transit trip. This is so because the most widely used form of transport is the motorbike and can be hired to any desired location or place. Only four (8%) of the respondents experienced two trips before getting to their health facility and most often it is with taxis. Two (4%) of the respondents take four trips before they get to a health centre. One 51
respondent, representing 2% of the respondent makes three transit trips before getting to a health a facility.
4.13 Rate relevance of poor state of roads to maternal hazard Table 4.13: Rate relevance of poor state of roads to maternal hazard
Poor state of road to maternal hazard Very Important Important Average Not at all Total Source: Authors fieldwork, 2011
Frequency 45 5 0 0 50
Figure 4.13 Rate relevance of poor state of roads to maternal hazard
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When respondents were asked to rate the relevance of poor state of roads to maternal hazard, 45 (forty-five) out of 50 (fifty) representing 90% answered that it is very important and the rest of the 5 (five) respondents representing 10% said it was just important to handle very well. None went in for the negative or rating this problem as just average. This shows how the poor state of the roads is affecting the people negatively. The maternal health hazard was accessed with respect to the poor nature of road. The entire respondent rated relevance of poor state of roads as a very good contributing factor to maternal health mortality.
4.14 State of roads linking your facility and the community Table 4.14: State of roads linking your facility and the community 53
Rating Frequency Percentage Good 0 0 Fair 9 18 Poor 41 82 Total 50 100 Source: Authors fieldwork, 2011
Figure 4.14 State of roads linking your facility and the community
Table 4.14 reveals 41 (forty-one) of the respondents say that the nature of roads linking the community and health facilities is poor representing 82% of the respondents and none had something good to say about their roads because the various disadvantages they are facing because of the state of their roads. The rest of the 9 (nine) respondents representing 18% could only rate their roads to be in fair shape but none could say anything good about their roads though that option was given in the questionnaire. 54
4.15 Transport challenge facing the health workers Table 4.15: Transport challenge facing the health workers Transport challenges Inadequate vehicle Aged vehicle Poor road Total Frequency 13 2 5 20 Percentage 65 10 25 100
Figure 4.15 Transport challenge facing the health workers
The challenges faced in transport management by health management are represented on table 4.15. As much as thirteen (13) respondents out of twenty (20) representing 65% of the respondents see the biggest challenge facing the health facility as inadequate vehicles. Only two 55
(2) respondent representing 10% rather saw the challenge to be aged vehicles and the rest of the 5 (five) respondents representing 25% saw the challenge to be their poor roads. The result of the health facility management section indicates that inadequate vehicles at health facility are a major challenge, especially when emergency cases arrive at the facility and it is a referral case. Some midwives have taken numbers of tractor operators, KIA drivers, drivers of cars that can travel on these roads to arrive at the facilities to transport the pregnant women to a much better facility for diagnoses and treatment.
4.16 Maternal mortality prevalence Table 4.16 Maternal mortality prevalence High Frequency Percentage maternal mortality Yes No Don't know Total 9 10 1 20 45 50 5 100
As shown on table 4.16, nine (9) of the respondents answered in the affirmative and this represents 45% of the sample. 50% of the respondents answered in the negative and specifically 10 (ten) out of the 20 (twenty) respondents. Only one (1) person said she did not know because she was new to that environment and this portion represents 5% of the sample size. The results revealed that maternal health is partially prevalent but this result is not a true reflection of what happens because deaths that occur outside the Municipal Hospital are not recorded. This makes it look like maternal mortality is not prevalent but it is. Also some 56
respondent were scared to reveal this problem to a stranger in the vicinity as they were not sure what will happen next to them .
4.17 Problem with transportation Figure 4.17 Problem with transportation
Source: Authors fieldwork, 2011 The result indicates that transportation is really a problem as some of them stressed on. Majority of the respondents, 95% of the respondents revealed the seriousness of the transportation problem whiles 5% of the respondents feels otherwise. This shows a true reflection and how they feel and some of them further mentioned they are really suffering because the nature of their roads. 4.18 Nearness to health facility Figure 4.18 Nearness to health facility
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Table 4.18: Nearness to health facility Nearness to health facility Yes No Total Frequency 18 2 20 Percentage 90 10 100
The results of the health facility near to where the health workers are staying revealed that 90% have been given buildings (as the researcher calls it) close to the health facility but only 10% stay far from the health facility. This seems good but the building infrastructures are not in good shapes.
4.19 Possibility of achieving zero maternal death Figure 4.19 Possibility of achieving zero maternal death 58
Table 4.19 Possibility of achieving zero maternal death Achieving zero maternal death Very likely Likely Not likely Total Frequency 15 4 1 20 Percentage 75 20 5 100
The result of the possibility of achieving zero maternal death by 2015 revealed that majority of the respondents, 15 (75%) thinks it is very likely for zero maternal mortality to be achieved in the municipality. 20% of the respondents think it is just likely for the zero maternal mortality to be achieved. They believe everything is possible although the situation looks unsolvable due to the complicated nature of the causes of maternal mortality. Poor state of roads, unavailable vehicles to be used coupled with their low income earning way of life. 5% of the respondents think it is a hopeless situation; maternal mortality can never be zeroed in the municipality and 59
even in Ghana as a whole. The reason for this question was to find out whether the respondents believe or had the hope that maternal mortality rate will decrease or if possible be zeroed.
4.20 Health workers Opinions on transport management Table 4.20: Health workers Opinions on transport management Manage transportation Procure vehicles Engage professionals Frequency 9 0 Percentage 45 0 5 50 100
Outsource 1 Provide good roads 10 Total 20 Source: Authors fieldwork, 2011
Figure 4.20 Health workers Opinions on transport management
Source: Authors fieldwork, 2011 The challenges of transport management that the health management experiences were investigated through the questionnaires. The results from table 4.20 reveal that 50% of the respondent feels good roads are much more important although 45% of the respondents want more vehicles to be procured.
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CHAPTER 5
CONCLUSIONS AND RECOMMENDATIONS
5.0 Introduction 61
This section of the study draws conclusion in the light of the findings and makes appropriate recommendations based on data and information gathered from the pregnant women, health workers, and the husbands of pregnant women as well as secondary data collected from the directorate of Ho municipality.
5.1 Summary In summary, it is significant to know that poor transportation system contributes to the mortality rate in less developed countries. Apart from transportation, other complications that contribute to the increase in maternal mortality are sickness and poor antenatal practices. The mortality rate in less developed countries would have been drastically reduced if road networks and infrastructure were available in their perfect composition.
Non-probabilistic sampling methods were used with convenient sampling for both the health workers and pregnant women. Data gathered from the exercise were analysed using SPSS and Excel 2007.
From the data gathered and analysed, it was found out that: The majority of pregnant women in Ho municipality were in their reproductive ages and already had about two (2) children before the present pregnancy. They were mostly singles or co-habiting instead of being married. They also had a low-income level. It can therefore be deduced that these women live in unfavourable environments exposing them to high vulnerability. Transportation in the Ho municipality was poor since the roads are poor, and the mostly used means of transportation was the motorbike which was used to convey pregnant 62
women to the health facilities. This mode of transportation is unsafe to the health of both the expectant mother and the unborn child. The health facilities are far from the communities. However, if the roads are good, the distance to the health facility will be shortened. Transport poses as a challenge due to inadequate vehicles. The rate of maternal mortality in the municipality was high; however due to superstitious beliefs and fear imposed on the pregnant women, they were reluctant to give the right answers.
5.2
Conclusion and Implications
This study explored the role of transport in the achievement of maternal death reductions. The critical role played by transport in the delivery of health services and for that matter maternal health services is of great relevance as was revealed from the findings of the study. On the issue of accessibility of transport, the findings revealed that the critical role played by transport in the delivery of health services and for that matter maternal health services is of great relevance. No skilled and trained personnel were found to manage such transport asset at the Municipality to enhance effective and efficient health delivery service. This was so because there was only one (1) vehicle to be managed. Besides, health management staffs especially at the sub municipalities were not abreast with transport management systems in place in the service for the management of transport resources. Also, all health management staff asserted that public- private partnership would contribute significantly towards the improvement of transport in relation to the achievement of the Millennium Development Goal 5.
5.3 Recommendations 63
Based on the findings of this study, some relevant recommendations are made. There is the need for all stakeholders to be on board for the strengthening of public transportation system. It should not be left only in the hands of the private sector; government should establish strong policies to provide direction and support. The current Facility Based Ambulance System (FBAS) run by Ghana Health Service and National Ambulance Service (NAS) must be fused together to provide holistic national ambulance services for maternal services as a whole and health delivery service in general.
Again cost of maternal transportation services in emergencies must be borne or absorbed by the National Health Insurance Scheme (NHIS). The municipal Health Service alone cannot meet the transportation needs of all patients including pregnant women. For speedy realisation of the MDG 5 in the municipality, there is the need for collaborative effort to be established between the public and the private sector because the local government alone or the Government of the Republic of Ghana cannot absorb cost of rehabilitation and construction of roads not forgetting the procurement of better modes of transport for the pregnant women. The support could be geared towards road infrastructure development and the release of effective transport management system specialties.
Better and efficient transport services could be organized with the assistance of new intelligent demand responsive technology. With such technology, pregnant women can be transported to health facilities in without delay by a more efficient use of networked municipality fleet and ambulance system to reduce delay instead of depending only upon public transportation system which most often disappoints. 64
Finally, to the Ministry of Roads and Transport the researcher recommends that Transport Planning should involve the local people particularly women and womens groups, Reproductive Health Organisation and Medical Providers.
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KWAME NKRUMAH UNIVERSITY OF SCIENCE AND TECHNOLOGY SCHOOL OF BUSINESS
INTRODUCTION
72
This set of questions is to enable the researcher collect data that would enable her assess the role of Transport in the achievement of Maternal Mortality Reduction (MDG 5) in the Ghana Health Service of Ho Municipal, Volta Region. This exercise is purely academic. Your contribution by way of answering the questionnaire will be highly appreciated. Questionnaire No......... Community........................... No Question Category of Respondent PART A 18 25yrs 1 Age 26- 30yrs 31- 35yrs 36- 40yrs 40 and above One 2 No. of Children Two Three Four and above Single 3 Marital status Married Divorced Co-habitation Unemployed 4 Occupation Artisan Formal Trader Other GH10-50 Income GH51-100 73 1 2 3 4 5 1 2 3 4 1 2 3 4 1 2 3 4 5 1 2 Occupation Marital Children Age Response PREGNANT WOMEN Date................................. Code 1 Fieldname Pregnant women
GH101-150 GH151 - 200 GH200 & above No education
3 4 5 1 2 3 4 5 1 2 3 1 2 3 1 2 3 4 5 6 1 2 3 1 2 1 2 1 2 3 4
Income
Educational level
Primary JHS SHS Tertiary Regularly Irregularly Not at all 1st Trimester 2nd Trimester 3rd Trimester
Education
How regularly do you 7 attend antenatal services? How old is your 8 pregnancy?
Antenatal attendance Trimester
PART B Ho-Shia Sub Municipal 1 Which of this subMunicipal are you coming from? Kpedze-vane Sub Municipal Tsito Sub Municipal Abutia Sub Municipal Sub-Municipal
Is maternal health mortality prevalent in your locality? Do you have problem with transportation in accessing health facility Is health facility far away from you locality?
Yes No Dont know Yes No Yes No
Maternal health prevalence Problem with transportation Nearness to health facility
Which type of transport do Public Transport (trotro) 5 you use most for accessing Private Car maternal health services? Motorbike Walk 74
Transport type
How many transit trips do One trip 6 you make to reach the Two trips health facility? Rate relevance of poor 7 state of roads to maternal hazard Three trips Four trips Very important Important Average
1 2 3 4 1 2 3 4 1 2 3 1 Means to call Road state Bad road hazard Transit trips
Not at all State of roads linking your Good 8 community to the health Fair facility In case 9 of Poor obstetric Through network system personal an phone Sending for a health staff
emergency by what means Through do you call for
mobile 2 3 4 1 2 3
ambulance? 10
Other (specify) Are you given priority for Always public transportation to Sometimes Never health facilities?
Priority
APPENDIX II: SAMPLE INTERVIEW QUESTIONS FOR HEALTH MANAGEMENT STAFF KWAME NKRUMAH UNIVERSITY OF SCIENCE AND TECHNOLOGY SCHOOL OF BUSINESS
INTRODUCTION This set of questions is to enable the researcher collect data that would enable him assess the role of Transport in the achievement of Maternal Mortality Reduction (MDG 5) in the Ghana Health Service of Ho Municipal-Volta Region.
75
This exercise is purely academic. Your contribution by way of answering the questionnaire will be highly appreciated. Questionnaire No......... Facility........................... No Question Category of Respondent Response HEALTH MANAGEMENT KEY INFORMANT PART A Medical Officer 1 Category of Health Staff Medical Assistant Midwife Health Administrator Other (specify) 01- 3yrs 2 Length of service 04- 6yrs 06 -8yrs 08 -10yrs Above 10 yrs JHS 3 Educational Level SHS Tertiary Post tertiary Other(specify) 25yrs and below 4 Age 26- 30yrs 31- 35yrs 36- 40yrs 41- 45yrs Above 45yrs Female 5 Gender Male 76 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 6 1 2 Gender age education Length of service Occupation Date................................. Code 1 Fieldname Health mgt Key informants
PART B Why do pregnant women 1 seek maternal services here? Because it is:
The nearest possible maternal service to attend The best medical service to attend The cheapest service to attend The best with transport system Public Transport (trotro) Private Car Motorbike
1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 1 2 3 4 1 2 3 1
Reason for choice of maternal care
Type of transport used most 2 by pregnant women for accessing maternal health
Transport type
services Walk How many transit trips do One trip 3 pregnant women make to Two trips reach the health facility? Rate relevance of 4 unavailability of vehicles to maternal hazard Rate relevance of poor state 5 of vehicles as maternal hazard Three trips Four trips Very important Important Average Not at all Very important Important Average
Number of transits
Rare vehicle hazard Bad vehicle hazard Road state
Not at all What is the state of roads Good 6 linking your community to Fair the health facility? Rate relevance of poor state 7 of roads as maternal hazard Poor Very important Important Average In case of an obstetric 8 emergency by what means do you call for an ambulance? Challenges Do you have transport Not at all Through network system Through personal call Sending a health staff Yes 77
Bad road hazard
Means to call
management systems in place? Are your transport resources
No Dont Know Yes No
2 3 1 2 3
Transport system Managem ent of transport
managed by professionals?
Do you have enough 3 transport (ambulance) for maternal services in relation to the number of cases that come here?
Yes No Dont Know
1 2 3 Enough ambulance s
Are the vehicles (ambulances) equipped enough to cater for the pregnant women whiles on the way for referrals? Does the management have budgeted funds for the running of your transport resources? When vehicles are not
Yes No Dont know
1 2 3
Ambulance well equipped
Yes No Dont Know Seek regional support Hire a car Use motorbike/bicycle Walk Other (specify) Inadequate vehicles Aged vehicles Poor road network Lack of skills Other (specify) Yes No 78
1 2 3 1 2 3 4 5 1 2 3 4 5 1 2 Maternal health Alternative to no vehicle Transport challenge Budgeted funds
available for pregnant women to be referred, what type of transport is been used? What is the most transport
management challenge you do face?
Is maternal health mortality prevalent in your locality?
Dont know 9 Do you have problem with transportation in accessing health facility 10 Is health facility far away from you locality Health Workers perception Can zero maternal death 1 (MDG 5) be achieved in the Municipal by 2015? Do you have any transport 2 management problems with regards to achieving MDG5? What should be done most to 3 manage transport effectively with respect to maternal health services? Significance of public-private 4 partnership support for transport to the achievement of MDG 5 Yes No Yes No
3 1 2
prevalence Problem with transportati on Nearness to health facility
1 2
Very likely Likely Not likely Impossible Yes No Dont know Procure more vehicles Engage transport professionals Outsource transport services Provide good road networks Other (specify) Very important Important Average Not at all
1 2 3 4 1 2 3 1 2 3 4 1 2 3 4 Publicprivate Transport problems Transport manageme nt Zero death
79
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CHAPTER ONE

LITERATURE REVIEW 2.0 Introduction

Diagrammatic representation of an effective transport management system

Human resources Fig 2.1 Source: TRANSAID, 2001

Input- Process-Output Model

Fig 2.2 Source: TRANSAID, 2001

METHODOLOGY AND PROFILE OF HO MUNICIPALITY

CHAPTER FOUR ANALYSIS AND DISCUSSION OF RESULTS

Source: Authors field work, 2011

Fig 4.1: Age of Pregnant women 38

Source: Authors fieldwork, 2011

4.2 Average number of children the pregnant women had. 39

Table 4.2: Number of children of pregnant women

1 2 4 and above Total

Source: Authors fieldwork, 2011

Fig 4.2: Number of children of pregnant women

Source: Authors fieldwork, 2011

Source: Authors fieldwork, 2011

Educational Level No education Primary JHS Total

Source: Authors fieldwork, 2011

Fig 4.5 Educational level of the pregnant women

Source: Authors fieldwork, 2011

Year 2008 2009 2010

Maternal mortality rate (MMR) 3.9/1000 live births 5.6/1000LB 2.9/1000LB

4.7 Attendance to antenatal services Table 4.7

Fig 4.7 Attendance to antenatal services

Source: Authors fieldwork, 2011

4.8 Problem of transportation 46

Table 4.8: Transportation problem

Source: Authors fieldwork, 2011

Source: Authors fieldwork, 2011

Source: Authors fieldwork

Motorbike 24 48 Walk 8 16 Total 50 100 Source: Authors fieldwork, 2011

Fig 4.11: Transport mode used in accessing health facilities

Figure 4.13 Rate relevance of poor state of roads to maternal hazard

Source: Authors fieldwork, 2011

Source: Authors fieldwork, 2011

Figure 4.15 Transport challenge facing the health workers

Source: Authors fieldwork, 2011

Source: Authors fieldwork, 2011

4.17 Problem with transportation Figure 4.17 Problem with transportation

Source: Authors fieldwork, 2011

Source: Authors fieldwork, 2011

Source: Authors fieldwork, 2011

Source: Authors fieldwork, 2011

Outsource 1 Provide good roads 10 Total 20 Source: Authors fieldwork, 2011

Figure 4.20 Health workers Opinions on transport management

CONCLUSIONS AND RECOMMENDATIONS

Conclusion and Implications

Ghana Health Service Volta Region Report, 2010.

Turner, J. (2008) Independent Transport and Gender Consultant, UK,(www.wikepedia.com)

UNICEF. (2008). Progress for Children: A Report Card on Maternal Mortality.

KWAME NKRUMAH UNIVERSITY OF SCIENCE AND TECHNOLOGY SCHOOL OF BUSINESS

GH101-150 GH151 - 200 GH200 & above No education

Antenatal attendance Trimester

Yes No Dont know Yes No Yes No

Maternal health prevalence Problem with transportation Nearness to health facility

1 2 3 4 1 2 3 4 1 2 3 1 Means to call Road state Bad road hazard Transit trips

emergency by what means Through do you call for

Reason for choice of maternal care

Rare vehicle hazard Bad vehicle hazard Road state

Bad road hazard

management systems in place? Are your transport resources