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Determinants of antenatal care

quality in Ghana


Department of Public Administration and Health Services Management,

University of Ghana Business School, Accra, Ghana

Roger A. Atinga and Anita A. Baku

Purpose To achieve Goal 5 of the MDGs, the Government of Ghana introduced the free maternal
health service system to break financial barriers of access to maternal care services. In spite of this,
facility-based deliveries continue to be low due partly to poor quality of antenatal care that prevents
pregnant women from giving birth in hospitals. The aim of this study is to examine factors shaping
quality of antenatal care in selected public hospitals in the country.
Design/methodology/approach 363 expectant mothers were randomly selected for interview.
Women who have previously received antenatal care in the health facilities for at least two occasions
were interviewed. Multivariate logistic regression model were computed to examine correlates of
antenatal care quality.
Findings The odds of reporting quality of antenatal care as good was higher among women aged
between 30 and 34 years. Similarly women with junior/senior high education were more likely to report
antenatal care quality as good. Distance to the health facilities generally influence women perception of
antenatal care quality but the relative odds of reporting quality of care as good attenuated with proximity
to the health facility. Five factors (pleasant interaction with providers, privacy during consultation,
attentiveness of providers, adequate facilities and availability of drugs) emerged as statistically significant
in explaining antenatal care quality after controlling for selected demographic variables.
Originality/value Results of the study generally demonstrate the need to improve maternal
services in public facilities to stimulate utilisation and facility-based deliveries.
Keywords Expectant mother, Antenatal care, Service quality, Health services, Hospitals, Ghana
Paper type Research paper

International Journal of Social

Vol. 40 No. 10, 2013
pp. 852-865
q Emerald Group Publishing Limited
DOI 10.1108/IJSE-2011-0075

The provision of and access to quality healthcare for expectant mothers has been a
complicated problem, especially in the developing world. Inadequate numbers of skilled
birth attendants and medical resources, the social status of women as well as limited
communication and transportation facilities tend to mask the provision of appropriate
quality of maternal healthcare (Chamberlain et al., 2007). The consequence of this has been
high rates of maternal deaths and insecurity for expectant mothers. Maternal mortality is
one of the health indicators with the greatest irreconcilable difference between the
developed and developing countries. Estimates of the maternal mortality ratio (MMR)
suggest 44 per 100,000 live births in Europe and Central Asia compared with 900 in
Sub-Saharan Africa (Paruzzolo et al., 2010). More than half a million women die every year
in childbirth or from pregnancy-related causes globally (World Bank, 2009) with virtually
99 per cent of these maternal deaths occurring in low-income countries (Kvale et al., 2005;
WHO, 2009). Studies have further shown that in most communities, for every woman who
loses her life due to pregnancy, between 15 and 30 women suffer from lifelong illness and
disability (Kvale et al., 2005) which has the potential of causing considerable distress and
excluding the affected women from normal life.

In response to the unacceptable maternal mortalities in the global environment, the

United Nations (UN) in 2000 established an agreed universal framework of international
development goals and targets known as the millennium development goals (MDGs) to
be pursued by governments and civil society to meet the needs of people in the poorest
corners of the world. Eight goals were adopted but goal five, the focus of this study, seeks
to improve maternal health with two targets: the first is to reduce by three-quarters
between 1990 and 2015 the MMR. The second target entails the achievement of universal
access to reproductive health by 2015 (Ahmed and Cleeve, 2004). The MDGs timeline is
almost due and progress towards improving maternal health has been at best startling.
Findings of a recent study suggests that in 2008, there were approximately 358,000
maternal deaths or a MMR of 260 deaths per 100,000 live births worldwide. Of the
estimated total number of maternal deaths, developing countries accounted for
99 per cent (355,000), with the highest MMR of 290 in stark contrast to the developed
nations which is 14 (WHO, UNICEF, UNFPA and the World Bank, 2010).
The slow pace of reduction of maternal deaths despite the implementation of the
MDGs raises some pessimistic questions about the capacity of health systems in the
developing world to find sustainable means of improving health outcomes of expectant
mothers. Even where measures to improve maternity care exist, they are not maintained.
Barriers of access to healthcare, inadequate essential supplies and trained personnel,
lack of emergency transport systems and poor referral services are all responsible for
maternal deaths in developing countries (WHO, 2005). To increase access to and
utilisation of maternal health services, the Government of Ghana introduced an
exemption policy of maternal care at all public health facilities in 2007. The exemption
policy sought to remove financial barriers of access to maternity care in order to reduce
maternal and neonatal deaths (Witter et al., 2007). Following the introduction of the
National Health Insurance Scheme, the exemption policy was incorporated in the scheme
and the benefit package was expanded to cover antenatal, delivery and postpartum
care. In spite of this, health institutions charged with the primary obligation to prevent
maternal deaths seem to be making little gains as most women continue to deliver at
home due partly to poor quality of antenatal care. Estimates suggest that about
95 per cent of women in Ghana receive some antenatal care, yet only 57 per cent of
expectant mothers have their deliveries in health facilities while 42 per cent of births
occur at home (GSS, GHS and ICF Macro, 2009). This suggests some defects in the
quality of prenatal care that prevents pregnant women from having supervised
deliveries. Thus, to attain real and sustainable change, research directed at quality of
antenatal care from the perspective of expectant mothers is necessary. This will enable
political leaders in the country have a clear understanding of the situation and therefore
the need to commit more resources and advocate for appropriate changes to health
service provision in facilities (Kerber et al., 2007).
The question of good quality of antenatal care is one that has attracted different
scholarly views. A wealth of empirical literature reflects progress made in evaluating
antenatal care quality from the perspective of the community and health facility levels.
At the community level economic and physical distance to the health facility constitutes
important factors influencing place of delivery (Campbell et al., 2006; Yanagisawa et al.,
2006). In many ways, scores of women deliver at home because of the constraint of getting
to a health facility in good time. Physical distance is further worsened by the absence of
emergency transportation especially in the rural, remote and peri-urban communities.

Antenatal care
quality in Ghana




For women, this reflects the fact that they are too far to walk (Thaddeus and Maine,
1994) hence they would choose to deliver at home instead of embarking on long and tiring
journey to the health facility. Both functional and structural elements of community and
spousal support for expectant mothers are social assets that contribute to uptake of
antenatal care. Spousal support in particular significantly influences health outcomes of
mothers. WHO (1997) has specifically stressed that the womans husband, a friend or a
relative should constantly accompany her to the health facility. Such a company creates
innate psychological satisfaction of women in their care encounter and foster compliance
with treatment methods. Labour progresses steadily when spousal companion is visible
to the woman (Hodnett et al., 2002; Simbar et al., 2009).
Antenatal care quality is also dependent on a number of supply-side constellation of
factors, which among others include supplies and logistics (drugs and non-drugs),
medical equipment, appropriate technology and capacity to handle maternity cases
(ODonnell, 2007). Preference for facility based delivery is high when there is
appropriate quality of care with the requisite medical facilities such as equipment for
surgery and blood transfusion services (Sarker et al., 2010). When essential medical
equipment and logistics are nominally available, it offers limited confidence for women
to access care let alone birthing in the health facility. The presence of medical facilities
is necessary by not sufficient to stimulate facility based delivery. In order for women to
continually access prenatal and postpartum care, there must be the commitment of
health workers to behave positively towards them. Comparable to service industry
clients, expectant mothers will reluctantly seek care in health facilities where their
previous encounter with health professionals is negative (Kruk et al., 2009;
Magoma et al., 2010). Bad word of mouth feeling of being neglected and feeling of
not being welcomed largely account for the reasons of not using maternal health care
service (Kowalewski et al., 2000; Asuquo et al., 2000; Kruk et al., 2009).
By nature of their condition, expectant mothers expect to be treated humanely in
culturally sensitive and coordinated manner and in a friendly and refreshing
environment during visit to the health facility. Explicit concern from providers
expressed through good interaction with mothers increases their preference for
continuous uptake of antenatal care and subsequent decision to have supervised
delivery. In reproductive health, women satisfaction with maternity care quality is
enhanced when there is opportunity to have access to information relating to their
conditions and treatment (Curry and Singlair, 2002). Exchange of information from
providers very sensitive to the needs of women during pregnancy and labour are very
critical to improve quality of antenatal care (Kwast, 1998). It is further argued that:
[. . .] the ability of women to freely articulate their views on different phases of care, on the
care provided by different health professionals and in different settings provides a richer and
more realistic picture of the care they received (Redshaw, 2008).

In maternity care, a critical factor that underlies the provision of service quality is
attentiveness of providers. The performance of health workers during emergency as
measured by responsiveness to the womans needs is important for life saving.
Responsive care is particularly important to arrest danger signs and obstetrical
complications. In a study by Hsu et al. (2006), it was revealed that respondents were
critical about dignity, prompt attention and confidentiality as the important elements
of responsive services. Responsive services also involve spending less time before

receiving care, because delays at the point of service delivery have negative effect on
service evaluation (Bielen and Demoulin, 2007).
Variables specific to prenatal care quality are never universal. They exist within the
larger context of health systems performance and the nature and kinds of provider
institutions. The survival or otherwise of women admitted and diagnosed of danger
signs ultimately depend on quality of care received (Sarker et al., 2010). Yet quality of
maternity care is apparently given low preference as one that can contribute to achieving
MDG five. Understanding the factors shaping antenatal care quality by listening to the
voices of mothers could be instrumental in planning services to satisfy their needs and
requirements (Aghlmand et al., 2010). Good quality of maternity care is unlikely to be
attainable unless the voice of the woman is brought into the process of improving
services. Additionally, evidence exist that the provision of effective care to women and
their new born children depends on the functioning of the health system (Graham, 2002;
Bhutta et al., 2010). As a result, improving quality of antenatal services should form an
integral part of efforts to reduce maternal mortality and give confidence to women to
deliver in facilities. This study therefore seeks to examine the factors shaping antenatal
care quality from the perspective of expectant mothers in Ghana.
Data for the study was obtained from a survey of expectant mothers receiving antenatal
care in public hospitals. The study was conducted within two months, May to June 2011.
The hospitals selected provided a variety of maternal health services. They also
provided care to women with high and low risk pregnancies. The hospitals received an
average of 98 daily antenatal visits, from both normal trimester visits and referrals.
Expectant mothers aged between 15 and 39 years were randomly selected for
interview. The team of researchers conducted the survey on selected women who have
had at least two antenatal visits or they have had one life birth in the health facilities
to examine their perception about antenatal services. The aim was to interview only
expectant mothers with a fair understanding of antenatal services in the health
facilities. Women in their puerperal periods with extreme pain were excluded even if
they met the criteria specified above. Also excluded were mothers who were not too
sure about their trimester. Exit interviews were employed to collect data. This method
was found to be suitable since the absence of the providers enabled respondents to
freely articulate their opinions without fear of being judged. To secure the consent of
respondents, each woman was fully made aware of the studys purpose before they
decided whether to participate or opt out.
After an extensive review of the literature, the researchers developed a structured
questionnaire that contained the dependent and independent measures of antenatal
care quality. The questionnaire was pilot tested on a cross section of women at
different trimesters of pregnancies to determine its strength and validity and to clearly
identify women preference areas of antenatal care quality suitable for the study. This
method eventually proved helpful. It enabled us modify some dimension of the original
questionnaire such as medical materials which was split open into medical equipment
and drug availability. Social support was also modified into comfort and
encouragement. The pilot study also helped eliminate all items of the questionnaire
which did not fit neatly into the core purpose of the study.

Antenatal care
quality in Ghana




The final questionnaire carefully nuanced a wide spectrum of areas: the

demographic characteristics of respondents (age, education, religion, occupation,
trimester of pregnancy and distance to health facility) captured in Table I and the
service quality variables of antenatal care: interaction with providers; comfort and
encouragement; privacy of consultation; attentiveness of care; facilities and drugs
present. Each of the service quality variables were captured on five point scale, 1 being
the lowest and 5 being the highest. Husbands company to the health facility which
was introduced in the questionnaire as a control variable was coded as binary, 1 being
Yes and 2 being No. The dependent variable: overall quality of antenatal care was
coded as binary (1 if service quality is good and 2 if service quality is poor).
Trained research graduate assistants with deeper understanding of the dominant
languages (Twi and Ga) spoken in Greater Accra and Eastern regions were recruited to
assist in administering the questionnaire. Interviewing the women based on a language
of their understanding guarded against compliance bias (Mitchell and Carson, 1989).
Multivariate logistic regression models were computed to investigate associations
between the service quality variables as well as women demographic characteristics and
quality of antenatal care. Initially, we performed bivariate analysis to select the service
quality variables that were significantly associated with quality of prenatal care. Six of
the variables were significant and therefore included in the regression model. Four
background characteristics were then selected and entered into the multivariate logistic
regression model as controls. Since women accompanied by their relatives or spouses
are likely to be indifferent or less conscious about quality, we controlled for spousal
company to the health facility to check against spurious relationships.
The mean age of the women was 26.21. A larger number of the respondents aged between
25 and 29 years were reported to be utilising antenatal services than the other age groups
(Table I). 87.9 per cent of the women had at least primary education compared to those who
had no formal education (12.1 per cent). Averagely women with primary and junior/senior
high education reported for antenatal care at the time of the study compared to those with
higher education. Additionally, the study attracted a larger number (83.5 per cent) of
Christians than Muslims (16.5 per cent) which is not surprising given that, in Ghana
Christianity preponderates every sphere of religious faith. In terms of socio-economic
status, the mean occupational distribution was 2.581 with a standard deviation (SD)


Dependent variable

Overall, quality of antenatal care in this hospital is good. This takes the
value 1 if service quality is good and 0 if poor

Independent variables
Age of woman
Table I.
Description of variables

Trimester of pregnancy

Womans age in years since birth

A categorical variable coded, 1 if no education, 2 if primary education,
3 if junior/senior high and 4 if higher education
This categorical variable takes the value of 1 if public sector worker,
2 if private sector worker, 3 if self employed and 4 if unemployed
This was coded 1 if 1-3 months, 2 if 4-6 months and 3 if 7-9 months
Distance in kilometres from womans home to the health facility

of 0.958 and median value of 3. Further, a greater number (43.8 per cent) of the women were
self employed. About 23 and 18 per cent were, respectively, engaged in the private and
public sectors whilst 16 per cent were unemployed. Trimester of pregnancy suggests that
more than half (52.9 per cent) of the women who were in their second trimester reported
higher utilisation of antenatal care at the time of conducting this study compared with
those who were in the first trimester (24 per cent) and third trimester (23.1 per cent). The
average distance to the nearest facility was 2.322 (SD 1.071) as many (37.2 per cent) of
the women shuttle between 4 and 6 km to access antenatal care. Descriptive statistics are
captured in Table II.
To investigate the influence of the women characteristics on quality of antenatal care,
the binary logistic regression was performed reporting coefficients, odds ratio (OR) and
confidence intervals (Table II). The model contained six independent variables:

Explanatory variables


Age ( years)
15-19 (ref)
50 (13.8)
85 (23.4)
103 (28.4)
70 (19.3)
55 (15.2)
None (ref)
44 (12.1)
99 (29.3)
Junior/senior high
176 (48.5)
44 (12.1)
Christian (ref)
303 (83.5)
60 (16.5)
Public sector (ref)
64 (17.6)
Private sector
82 (22.6)
Self employed
159 (43.8)
58 (16.0)
First (ref)
87 (24.0)
192 (52.9)
84 (23.1)
Distance to health facility (km)
1-3 ref
93 (25.6)
135 (37.2)
60 (16.5)
75 (207)
x (16)
Prob. . x 2
Pseudo R 2
Log likelihood
Note: Significant at: *5 and * *1 per cent


Odds ratio

Confidence interval (95%)

0.130 * *



0.120 * *
0.246 *






1.226 * *
0.905 * *






0.797 * *
0.856 * *
1.470 * *



Antenatal care
quality in Ghana


Table II.
Binary logistic regression
of the adjusted ratios of
the odds of reporting
service quality as good



age, education, religion, occupation, pregnancy status and distance from the womans
home to the health facility. The model was statistically significant, x 2(16) 15.925,
p , 0.001 indicating that it was able to distinguish between those who reported quality of
antenatal care as good and vice versa. The model as a whole explained about 14 per cent
(Pseudo R 2 0.139) of the variance of service quality and correctly classified 77.4 per cent
as cases. An upper bound R 2 for binary-choice of 0.33 is often preferred (Pindyck and
Rubinfeld, 1981). However, a Pseudo R 2 of 0.139 indicates a good fit. The full coefficients of
the independent measures of the model are reported in Table II. The omitted group
indicates the reference category for which comparisons are made (Gujarati, 2002). Of the
different age groups, women aged between 30 and 34 years reported quality of antenatal
care in the health facilities as good ( p , 0.001). This age group are also about twice more
likely to report prenatal care as good compared with the other age groupings (OR 1.931).
Perceived quality of antenatal services in the facilities increases with access to higher
education but more likely to be greater among those attaining junior/senior high education
(OR 1.527; p , 0.001) compared with those who acquired higher education
(OR 1.279; p , 0.05). On the whole women with junior/senior high education are
1.5 more likely to report quality of prenatal care as good. With regard to occupation,
women with the highest odds of reporting an episode of antenatal care quality as good are
private sector workers (OR 3.409; p , 0.001) while the unemployed shared similar view
with lesser intensity (OR 2.472).
Of significance is the fact that accessibility has appeared in this study as a strong
predictor of quality. Distance generally predicts quality but this increases with increasing
distance to the health facility. For instance women who stay closer to the health facility
(4-6 km) are twice more likely to report antenatal care quality as good (OR 2.219)
in sharp contrast to those who lived 7-9 km away from the health facility (OR 3.353) and
10 km and above (OR 4.351). This may only suggest that proximity to the health facility
does not in itself strongly influence perceived quality of antenatal care.
Table III presents results of three multivariate regression models. Correlates of
antenatal care quality were determined by controlling for selected demographic
characteristics. In each model, the demographic characteristics were entered first as
control variables. The service quality variables were entered in the second model while
spousal company during antenatal visit was added in the third model. The last control
variable (spousal company during visit) was added to check against spurious
relationships as women accompanied by their husbands to the health facility may have
different conception about quality of care compared to those who do not. From
Table III, there is no doubt that association between the service quality variables and
overall antenatal care quality is confounded by the womans demographic profile as
shown by changes in the Pseudo R 2 values in the models.
In model 2, after controlling for demographic characteristics all the independent quality
measures except pleasant interaction with providers significantly predicted overall
quality of antenatal care ( p , 0.01). However, the relative odds of reporting overall quality
of antenatal care as good is higher for drug availability (OR 2.300). This is followed in
order by adequate facilities (OR 1.957), pleasant interaction with providers
(OR 1.732) and attention given to mothers (OR 1.587). Results in the third model
also reveal that even after controlling for spousal company during visit to the health
facility, all the dimensions of quality except comfort and encouragement from providers
significantly predicted quality of antenatal care. However, the odds of reporting quality of

Model 1
Distance to health facility
Pleasant interaction
Comfort and
Privacy of consultation
Adequate facilities
Drug availability
Spousal company during
x 2(16)
Prob. . x 2
Pseudo R 2
Log likelihood

Model 2



20.453 *


1.606 *
13.318 (4)


Model 3





0.395 *
2 0.520 *
2 0.216 * *


0.402 *
2 0.651 * *
2 0.168
0.519 * *


2 0.029 * *
2 0.373 *
0.462 * *
0.671 * *


2 0.131
2 0.414 * *
0.521 * *
0.673 * *
0.843 * *


2 5.861 * *
82.999 (6)


0.349 * * 1.418
2 6.384 * * 0.002
11.956 (1)
2 291.534

Note: Significant at: *5 and * *1 per cent

care as good rather increased marginally for drug availability (OR 2.324), adequate
facilities (OR 1.961) and attention of providers (OR 1.684). The results are suggestive
that once the womans background characteristics are held constant, all the independent
measures of quality of care except comfort and encouragement are significant predictors
of antenatal care quality.
Discussion and implication of findings
Attaining MDG five, improving maternal health by 2015 continues to lag behind targets
and timelines (WHO, 2005; Chamberlain and Watt, 2008). The obstacles to attaining this
objective in developing countries are multifaceted and exist within the larger society and
healthcare facilities which have the primary responsibility of avoiding maternal deaths.
One of the incentives for women to utilise maternal health services and subsequently
deliver in the health facility is the provision of good quality of antenatal care. Quality of
antenatal care communicates to expectant mothers that providers have their interest
at heart and seeks to improve their health outcome. When this happens, women can
enthusiastically deliver in health facilities once the reassurance of adequate care is
given. There is no gainsaying that improving accessibility and strengthening quality of
antenatal services are important to cause decline of maternal deaths (Bennet and
Brown, 1997; Simbar et al., 2009).
As antenatal care quality partly provides answers to maternal deaths, there is the
need to identify the factors influencing women perception of prenatal care quality to
guide policy direction. The aim of this study was therefore to examine the correlates of
quality of antenatal care as well as identify service quality variables within the health

Antenatal care
quality in Ghana


Table III.
Logistic regression
models reporting
correlates of antenatal
care quality when
women background
characteristics are



facility that determine antenatal care quality. The results revealed that antenatal care
quality is strongly influenced by women aged between 30 and 34 years. This age group
is approximately twice more likely to report quality of care as good as shown by the
OR. All the other age categories reported negative effects on quality of antenatal care
as indicated by the logistic regression coefficients (Table II). Women aged between
35 and 39 years were less likely to report quality of antenatal care as good as shown by
the lowest OR recorded. The results are generally suggestive that quality of antenatal
care does not discriminate very much according to age of women.
Access to education among women has generally been shown to influence utilisation
of maternal health service (Addai, 2000; Hug and Tasnim, 2007) but association between
women education and perceived quality of antenatal care is under explored in the
literature. Results of this study show significant relationship between women education
and antenatal care quality. Having no junior/senior high education or higher reduces the
likelihood of reporting quality of antenatal care as good (see ORs in Table II). Women
with low educational status have negative perception about quality of antenatal
compared to those with higher education. It is not possible to fully explore this
phenomenon in this study, but the conclusion that can be drawn is that women who
advance in education examine issues of antenatal care from a different spectacle
compared to those without higher education.
A remarkable variation of quality of antenatal care was also established between
the different occupational groupings. Although positive coefficients were reported for
the different occupations of the women, private sector were about three times more
likely to report quality care as good compared to the unemployed who were twice more
likely to report similar episode. It is not clear why women with private businesses who
constitute the largest sample in this study have different conception about antenatal
care quality, but it may be attributed largely to their social status that stimulates
indifference in their service quality perceptions. Contrary to our expectation, women
trimester of pregnancy did not emerge as a significant predictor of antenatal care
quality. However, the odds of reporting quality of care as good was higher for those
who were in their second trimester compared to those who were in the first and third
Distance to health facilities has been documented as an incentive or disincentive
for antenatal visits and delivery. More than 50 per cent of neonatal deaths in
most countries continue to occur after home birth without skilled birth attendant
(Lawn et al., 2005) some of which are attributed to farthest of health facilities with skilled
care attendants. Propinquity to the health facility is therefore most likely influences
women perception of quality and utilisation (Anand and Sinha, 2010). However, findings
of this study reported otherwise. Although distance is a predictor of antenatal care
quality, the odds of reporting quality of care as good diminishes with proximity to the
health facility. For instance, women living 10 km and beyond from the health facility
were four times more likely to report quality of antenatal care as good. Those who were
7-9 km were three times more likely to report similar episode while women relatively
closer to the health facility, 4-6 km were twice likely to rate quality as good (Table II).
Results from the multivariate regression models (Table III) demonstrate that after
controlling for the background characteristics, the quality award dimensions are
substantially related to quality of antenatal care. Emphasis is however placed on the
third model where the demographic characteristics including spousal company to the

health facility are controlled. In the last model it can be inferred from the coefficients
that pleasantness of interaction with mothers is significantly associated with quality of
antenatal care. Provider interaction with mothers is particularly important, because, in
the healthcare environment, it is considered psychodynamic and therapeutic thereby
increasing greater satisfaction with quality of care (Perla, 2002). This suggests the need
for health providers to use decent languages when dealing with expectant mothers.
Providers should not scold the views of mothers. Rather, they should rather allow
them enough degree of freedom to express themselves without fear (Redshaw, 2008).
A pleasant interaction may nevertheless cause remorse for women preference for one
health facility than another.
Findings of the study also highlight the importance that mothers attach to privacy
during consultation in determining quality of antenatal care. Although the coefficient
for privacy of consultation is reported to be negative, it is still statistically significant
in explaining antenatal care quality. This suggests women require that providers
provide privacy through the provision of private rooms (WHO, 1997). It also re-echoes
the need to give women enough isolation to divulge information about their
conditions. One of the reasons why privacy and confidentiality is so important to many
women is the concept of social treat perception. Chapman (2006) found that women
strategically utilise plural health care systems (traditional and biomedical) in order to
minimise both social and biological harm. In other words, women with deep seated
cultural backgrounds may find it inappropriate divulging information in an open
environment or in the presence of other unknown people. Therefore, care should
always be taken to establish maximum privacy during consultations with expectant
mothers. Perhaps, large consultation rooms housing at least two skilled professionals
should be partitioned into single occupancy consulting rooms. By so doing, women are
more inclined to divulge nitty-gritty information relating their conditions.
Expectant mothers gauge antenatal care quality by taking into consideration attention
given by health providers as highlighted in the regression results (Table III). The
coefficients reported significant association between attentiveness of providers and
quality of care. This finding supports previous studies (Graner et al., 2010) that friendless
and attention of providers correlate with women judgement of the health facility and the
decision to give birth. In the health seeking process, every patient would expect to be given
care akin to their personal experience at home, but this expectation is likely to be greater
for expectant mothers who need to be comforted at all times. To improve attention towards
expectant mothers, more qualified health providers particularly doctors and midwives
with sufficient understanding of their health needs should be stationed in the different
health facilities providing maternal care. This remedy is reinforced by the fact that in the
healthcare setting in Ghana, health consumers generally prefer to see a doctor because
they perceive that doctors are competent enough to make diagnosis, provide appropriate
treatment and achieve prompt recovery without complication (Agyepong, 1999).
In Ghana, women have high preference for delivering in private health facilities due to
the presence of sophisticated medical equipment and amenities. Such private facilities
with their comfortable seating and beds characterised by attractive environments often
lure women to patronise their services. This implies quality care is tied to availability of
equipment (Andersen, 1995). It is therefore not surprising that tangible factors such as
amenities in the health facility has appeared in this study as significant in explaining
antenatal care quality. This calls for health managers to invest in medical equipment and

Antenatal care
quality in Ghana




maintain proper environmental quality. Indeed, the provision of adequate facilities

and equipment offers an excellent opportunity to meet or exceed mothers expectations.
It also boosts their morale and adds value to the health facility. It is even more important to
acquire necessary equipments and facilities, because, health consumers in their healthcare
encounter look for tangible physical evidence such as amenities/facilities to form their
experience of service quality. Another crucial finding of the study relates to the manner in
which drug availability is strongly associated with quality. The implication is that since
maternal care in the country is free, mothers prefer that drugs are readily available
anytime they report for antenatal care. The absence of prescribed drugs can affect their
experience of service quality.
Conclusion and further research
The findings suggest that women aged between 30 and 34 years were about twice more
likely to report antenatal care quality as good compared to the other age groups.
Additionally, the higher a woman advances in education, the more likely it is that such a
person would perceive quality of antenatal care as good. A possible reason is that they are
more likely to understand and cope with providers attitude and service provision in the
health facilities better than those who are less or not educated. Additionally, although
occupation is determinant of quality, women working in the private sector and the
unemployed were more likely to report quality of care as good compared to those who were
self employed. After controlling for the demographic characteristics of the women
including spousal company to the health facility, it is found that all the variables except
comfort and encouragement of service providers were significant determinants of
antenatal care quality. While findings of the study look promising, they need to be
interpreted with caution due to some limitations. Our inability to collect data on the income
levels of the women is a limitation. Indeed, since income is an economic empowerment tool,
there is the likelihood that high income earners may have different conception of quality.
Future studies should include this variable in their analysis. Additionally, the present
study sampled and interviewed woman who have had at least one life birth in the health
facilities. Studies interested in this subject matter should extend the sample to cover those
reporting home deliveries.
Addai, I. (2000), Determinants of use of maternal-child health services in rural Ghana, Journal
of Biosocial Science, Vol. 32, pp. 1-15.
Aghlmand, S., Lameei, A. and Small, R. (2010), A hands-on experience of the voice of customer
analysis in maternity care from Iran, International Journal of Health Care Quality
Assurance, Vol. 23 No. 2, pp. 153-170.
Agyepong, I. (1999), Reforming health service delivery at district level in Ghana: the perspective
of a district medical officer, Health Policy and Planning, Vol. 14 No. 1, pp. 59-69.
Ahmed, A. and Cleeve, E. (2004), Tracking the MDGs in Sub-Saharan Africa, International
Journal of Social Economics, Vol. 31 Nos 1/2, pp. 12-29.
Anand, S. and Sinha, R.K. (2010), Quality differentials and reproductive health service
utilisation determinants in India, International Journal of Health Care Quality Assurance,
Vol. 23 No. 8, pp. 718-729.
Andersen, R.M. (1995), Revisiting the behavioural model and access to medical care: does it
matter?, Journal of Health Social Behaviour, Vol. 36 No. 1, pp. 1-10.

Asuquo, E.E.J., Etuk, S.J. and Duke, F. (2000), Staff attitude as barrier to the utilisation of
University of Calabar Teaching Hospital for obstetric care, African Journal of
Reproductive Health, Vol. 4 No. 3, pp. 69-73.
Bennet, V. and Brown, L. (1997), Myles Text Book for Midwives, 13th ed., Churchill-Livingstone,
Bhutta, Z.A., Chopra, M., Axelson, H., Berman, P., Boerma, T., Bryce, J., Bustreo, F., Cavagnero, E.,
Cometto, G., Daelmans, B., de Francisco, A., Fogstad, H., Gupta, N., Laski, L., Lawn, J.,
Maliqi, B., Mason, E., Pitt, C., Requejo, J., Starrs, A., Victora, C.G. and Wardlaw, T. (2015),
Countdown to 2015 decade report (2000-10): taking stock of maternal, newborn, and child
survival, Lancet, Vol. 375 No. 9730, pp. 2032-2044.
Bielen, F. and Demoulin, N. (2007), Waiting time influence on the satisfaction-loyalty
relationship in services, Managing Service Quality, Vol. 17 No. 2, pp. 174-193.
Campbell, O.M.R., Graham, W.J. and The Lancet Maternal Survival Series Steering Group (2006),
Maternal survival 2: strategies for reducing maternal mortality: getting on with what
works, Lancet, Vol. 368, pp. 1284-1299.
Chamberlain, J. and Watt, S. (2008), Education for safe motherhood: a save the mothers
advocacy initiative, Leadership in Health Services, Vol. 21 No. 4, pp. 278-289.
Chamberlain, J., Watt, S., Mohide, P., Muggah, H., Trim, K. and Kyomuhendo, G.B. (2007),
Womens perception of their self-worth and its role in access to health care, International
Journal of Gynaecology and Obstetrics, Vol. 98 No. 1, pp. 75-79.
Chapman, R. (2006), Chikotsa secrets, silence and hiding: social risk and reproductive
vulnerability in central Mozambique, Medical Anthropology Quarterly, Vol. 20 No. 4.
Curry, A.C. and Singlair, E. (2002), Assessing the quality of physiotherapy services using
SERQUAL, International Journal of Healthcare Quality Assurance, Vol. 15 No. 5,
pp. 197-205.
Graham, W.J. (2002), Now or never: the case for measuring maternal mortality, The Lancet,
Vol. 359, pp. 701-704.
Graner, S., Mogren, I., Duong, L., Krantz, G. and Klingberg-Allvin, M. (2010), Maternal health
care professionals perspectives on the provision and use of antenatal and delivery care:
a qualitative descriptive study in rural Vietnam, BMC Public Health, Vol. 10, p. 608.
GSS, GHS, and ICF Macro (2009), Ghana Demographic and Health Survey 2008: Key Findings,
Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF Macro,
Calverton, MD.
Gujarati, D.N. (2002), Basic Econometrics, McGraw-Hill College, New York, NY.
Hodnett, E.D., Lowe, N.K., Hannah, M.E., Willan, A.R., Stevens, B., Weston, J.A., Ohlsson, A.,
Gafni, A., Muir, H.A., Myhr, T.L., Stremler, R. and Nursing Supportive Care in Labor Trial
Group (2002), Effectiveness of nurses as providers of birth labour support in
North American hospitals; a randomized controlled trial, Journal of American Medical
Association, Vol. 288, pp. 1373-1381.
Hsu, C.C., Chen, L., Hu, Y.W., Yip, W. and Shu, C.C. (2006), The dimensions of responsiveness of
a health system: a Taiwanese perspective, BMC Public Health, Vol. 17 No. 6, p. 72.
Hug, M.Z. and Tasnim, T. (2007), Maternal education and child healthcare in Bangladesh,
Matern Child Health Journal, Vol. 13, pp. 43-51.
Kerber, K., de Graft-Johnson, J.E., Bhutta, Q., Okong, A., Starrs, A. and Lawn, J. (2007),
Continuum of care for maternal, newborn, and child health from slogan to service
delivery, Lancet, Vol. 370 No. 9595, pp. 1358-1369.

Antenatal care
quality in Ghana



Kowalewski, M., Jahn, A. and Kimatta, S.S. (2000), Why do at risk mothers fail to reach referral
level? Barriers beyond distance and cost, African Journal of Reproductive Health, Vol. 4
No. 1, pp. 100-109.
Kruk, M.E., Mbaruku, G., McCord, C.W., Moran, M., Rockers, P. and Galea, S. (2009), Bypassing
primary care facilities for childbirth, a population based study on rural Tanzania,
Health Policy and Planning, Vol. 24, pp. 279-288.


Kvale, G., Olsen, B.E., Hinderaker, S.G., Ulstein, M. and Bergsjo, P. (2005), Maternal deaths in
developing countries: a preventable tragedy, Norsk Epidemiology, Vol. 15 No. 2,
pp. 141-149.
Kwast, B.E. (1998), Quality of care in reproductive health programmes: monitoring and
evaluation of quality improvement, Midwifery, Vol. 14 No. 4, pp. 199-206.
Lawn, J., Cousens, S. and Zupan, J. (2005), 4 million neonatal deaths: when? Where? Why?,
Lancet, Vol. 365, pp. 891-900.
Magoma, M., Requejo, J., Campbell, O.M., Cousens, S. and Filippi, V. (2010), High ANC coverage
and low skilled attendance in a rural Tanzanian district: a case for implementing a birth
plan intervention, BMC Pregnancy Childbirth, Vol. 10, p. 13.
Mitchell, R.C. and Carson, R.T. (1989), Using Survey to Value Public Goods: The Contingent
Valuation Method, Resource for the Future, Washington, DC.
ODonnell, O. (2007), Access to health care in developing countries: breaking down demand side
barriers, Cadernos de Saude Publica, Vol. 23 No. 12, pp. 2820-2834.
Paruzzolo, S., Mehra, R., Kes, A. and Ashbaugh, C. (2010), Targeting poverty and gender
inequality to improve maternal health, International Centre for Research on Women,
available at: (accessed 4 February 2011).
Perla, L. (2002), Patient compliance and satisfaction with nursing care during delivery and
recovery, Journal of Nursing Care Quality, Vol. 16 No. 2, pp. 60-66.
Pindyck, R.S. and Rubinfeld, D.L. (1981), Econometric Models and Economic Forecasts,
McGraw-Hill, New York, NY.
Redshaw, M. (2008), Women as consumers of maternity care: measuring satisfaction or
dissatisfaction?, Birth, Vol. 35, pp. 73-76.
Sarker, M., Schmid, G., Larsson, E., Kirenga, S., De Allegri, M., Neuhann, F., Mbunda, T.,
Lekule, I. and Muller, O. (2010), Quality of antenatal care in rural southern Tanzania:
a reality check, BMC Research Notes, Vol. 3, p. 209.
Simbar, M., Ghafari, F., Zahrani, S.T. and Majd, H.A. (2009), Assessment of quality of midwifery
care in labour and delivery wards of selected Kordestan Medical Science University
hospital, International Journal of Health Care Quality Assurance, Vol. 22 No. 3,
pp. 266-277.
Thaddeus, S. and Maine, D. (1994), Too far to walk: maternal mortality in context,
Social Sciences and Medicine, Vol. 38, pp. 1091-1110.
WHO (1997), Maternal and newborn health/safe motherhood, division of reproductive health
care in normal birth, A Practical Guide, Safe Motherhood, Report of a Technical Working
Group, World Health Organization, Geneva.
WHO (2005), Strategy to accelerate progress towards the attainment of international
development goals and targets related to reproductive health, Reproductive Health
Matters, Vol. 13 No. 25, pp. 11-18, World Health Organization.
WHO (2009), World Health Statistics 2009, World Health Organization, Geneva.

WHO, UNICEF, UNFPA and the World Bank (2010), Trends in Maternal Mortality: 1990
to 2008, available at:
(accessed 16 January 2011).
Witter, S., Arhinful, D.K., Kusi, A. and Zakariah-Akoto, S. (2007), The experience of Ghana in
implementing a user-fee exemption policy to provide free delivery care, Reproductive
Health Matters, Vol. 15 No. 30, pp. 61-71.
(The) World Bank (2009), Global Monitoring Report 2009: A Development Emergency, The World
Bank, Washington, DC.
Yanagisawa, S., Oum, S. and Wakai, S. (2006), Determinants of skilled birth attendance in rural
Cambodia, Tropical Medicine and International Health, Vol. 11, pp. 238-251.
Further reading
Graham, W. (1991), Maternal mortality level, trends and data deficiencies, in Feachem, R.G.
and Jamison, D.T. (Eds), Disease and Mortality in Sub-Saharan Africa, Oxford University
Press, Oxford, pp. 101-116.
Hodgkin, D. (1996), Household characteristics affecting where mothers deliver in rural Kenya,
Health Economics, Vol. 5, pp. 333-340.
Corresponding author
Roger A. Atinga can be contacted at:

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Antenatal care
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