Background
Globally, 61% of the 585,000 annual maternal deaths occur within the postnatal stage whereas more than half of these transpire within the first day of childbirth [
1]. The situation is worrying in sub-Saharan Africa (SSA) where 66% of the global maternal deaths occurred in 2017 [
2‐
4]. Inaccessibility and poor postnatal care (PNC) utilisation account for 99% of maternal mortality in low-middle-income countries (LMICs) including SSA, where majority of childbirths occur at home [
2‐
5].
Similarly, in the Ghanaian context, maternal mortality remains high averaging 310 maternal deaths per 100,000 live births [
6] partly due to inadequate postnatal care especially among rural communities [
7,
8]. Therefore, Ghana can avert the higher maternal morbidity and associated deaths if women are able to meet the WHO recommended early PNC check-up [
9‐
11] which could also facilitate the realization of the Sustainable Development Goal (SDG) 3 [
12]. In LMICs, including Ghana, puerperal infections are sometimes undiagnosed due to inadequate PNC follow-up and most postnatal infections occur after being discharged from hospital, which is mostly 24 h after birth [
2].
Conventionally, postnatal stage begins immediately after childbirth until 6 weeks (42 days) after birth [
13]. The WHO has advised that women should receive at least three postnatal care visits in addition to the first visit which is expected to take place within 24 h of birth. The second visit should fall on day 3, third visit between day 7 and 14, and the last visit before the end of the 6th week [
11]. PNC is critical as it helps health professionals to provide comprehensive reproductive health service for women and their babies [
1,
2,
14]. During PNC, health professionals are able to evaluate and verify bleeding, examine the breast, control anemia, encourage nutrition and insecticide bed nets, and also educate women on early and exclusive breastfeeding and umbilical cord care [
1,
2,
14]. Additionally, through PNC, babies receive services such as birth registration, screening and infection treatment, postnatal growth monitoring and routine immunization services [
1,
2,
14].
In spite of these benefits, most women in rural communities are unable to attend PNC [
2,
15,
16]. The 2014 Ghana Demographic and Health Survey (GDHS) indicated that 74% of mothers living in rural areas were least probable to receive early postnatal check-up relative to other subgroups. Women in rural areas of Ghana travel 4 km more than urban women to reach a hospital [
17]. The same study indicated that a kilometre increase in distance significantly reduces maternal healthcare utilisation [
17]. Additionally, it is known that the distribution of health facilities is skewed towards urban centres in Ghana [
18]. This presupposes that women in rural communities may be challenged in accessing PNC compared to women in urban locations of the country.
Despite the association between geographical location and PNC utilisation, no national study has been done on determinants of PNC among rural residents in Ghana. Although Adu and colleagues [
19] investigated the effects of individual and community-level factors on maternal health outcomes in Ghana and found that rural dwellers were less likely to give birth in health facilities and have PNC compared to urban dwellers, residence was an explanatory variable. Sakeah et al. [
20] also explored the role of community-based health planning and services (CHPS) in influencing PNC visits in rural Builsa and the West Mamprusi districts (both in one of the 16 regions) of Ghana and found that women who attended antenatal clinics at least four times and women who had partners with secondary education were associated with at least three PNC visits.
Health facilities and health personnel are concentrated in urban Ghana [
18] and as such national level study is required to understand the factors affecting PNC of the rural populace in Ghana. It is against this background that this study seeks to determine the prevalence and correlates of PNC utilization among women in rural Ghana. In the light of the global commitment towards ensuring quality life for persons of all ages [
12], this study is of critical public health importance to Ghana. It could guide the Health Promotion and Education Unit and Reproductive and Child Health Department of the Ghana Health Service in preparing and planning for maternal and child health promotion programs that target utilization of maternal health services in rural Ghana.
Discussion
This study aimed at investigating the prevalence and correlates of PNC utilisation among women aged 15–49 in rural Ghana. In the multivariate regression model, four variables showed significant association with PNC and these are ecological zone, ethnicity, occupation and whether distance to health facility was problematic or otherwise. The direction of significance of these variables are discussed in this section of the manuscript. On ecological zone, we realised that women who resided in the Savanna zone were more probable to utilise PNC as compared to those in the Coastal zone. Comparatively, the Coastal zone is well resourced and endowed with more health facilities and health workforce compared to the Savanna zone [
25]. However, this study plausibly strengthens the position of the socio-behavioural model that healthcare utilisation do not only depend on availability of health facilities or services but personal assessment of the need for the service, personal traits and beliefs [
26,
27]. Ecological variation has similarly been observed as a determinant of PNC in Malawi [
28]. Specifically, they noted that the odds of utilising PNC was 46% less among women in the central region and 53% less among women in the southern region than women in the northern region of Malawi [
28].
Our study revealed that Guan women were more probable to utilise PNC than the Akan. Several studies have also found disparity in maternal healthcare utilisation across ethnic lines [
29‐
32]. In explaining differentials in maternal healthcare utilisation across ethnicity, scholars argue that ethnicity has a link with social stratification in most contexts, and people who belong to ethnic minorities tend to be marginalised and discriminated against, and this adversely affect their prospects of utilising available services and opportunities [
33]. However, our study failed to provide reasons why the Guan, being minority, were more inclined to PNC as compared to the Akan. Hence, further studies on ethnicity and utilisation of PNC in Ghana may be required.
We observed that women who were working were more probable to utilise PNC as compared to those not working. The results are in line with a Uganda based study by Ndugga, Namiyonga and Sebuwufu [
34] who realised that unemployed women had lower odds of attending postnatal care compared with women who were working. Our results are also congruent with Malawian based study which noted that mothers who were working were 44% more likely to be checked by a professional health worker within 42 days of delivery than women who were jobless [
28]. A plausible explanation is that unemployed women are likely to be less endowed economically and as a result may be dissuaded from utilising healthcare due to the associated cost even if such services are recommended by health workers [
35,
36]. This may underscore the exigency to create employment avenues and opportunities for women in order to enhance their prospects of utilising PNC.
Finally, in agreement with a previous study [
34], the present study revealed that women who viewed distance to health facility as unproblematic were more likely to utilise PNC as compared to those that perceived it as problematic. Malawi based study also indicated that women who perceived that distance to health facility was not a hindrance to their access to health care were more likely to attend early postnatal care than those who perceived distance to the facility as a problem [
37]. Izudi et al. [
38] also contended that long distances limit the willingness and ability of postpartum women to seek PNC due to the physical difficulties of travel and high cost of motorized transport. The finding highlights the need to reconsider the availability and citing of maternal healthcare services. During the postnatal period, women may be recovering from childbirth and they may not have enough strength to cover long distances [
39]. As such, increasing maternal healthcare centers in rural communities and citing these facilities at shorter intervals within communities can substantially reduce the challenge posed by distance.
Strengths and weaknesses
The study utilises data from a nationally representative survey and applies rigorous analytical procedures in estimations. Another key strength of the study is its focus on rural women, a group that have not received much attention as far as studies on PNC in Ghana is concerned. The limitations of the study include the cross sectional study design, which do not allow causal inference. There is also a possible recall bias on the part of the surveyed women.
Conclusions
This study investigated factors associated with PNC among rural residents in Ghana. The study showed that ethnicity, ecological zone, occupation and distance to health facility predict PNC utilisation among rural residents of Ghana. The study has policy and practical implications on maternal healthcare provision in Ghana. First, the study points to the need for government to increase maternal healthcare facilities in rural settings in order to reduce the distance covered by women to access PNC. Second, enhancing empowerment and economic opportunities of women may be required to improve PNC utilisation among the rural populace of Ghana. Further study, preferably qualitative, may be needed to unveil the ethnic driven variation in PNC utilisation among rural women in Ghana.
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