Determinants of antenatal care quality in Ghana

Author: Atinga, Roger A; Baku, Anita A

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Abstract:

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.
Full text:

Introduction

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 ([12] 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 ([34] Paruzzolo et al. , 2010). More than half a million women die
every year in childbirth or from pregnancy-related causes globally ([42]
World Bank, 2009) with virtually 99 per cent of these maternal deaths
occurring in low-income countries ([28] Kvale et al. , 2005; [45] 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 ([28] Kvale et al. , 2005) which
has the potential of causing considerable distress and excluding the affected
women from normal life.

n 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 ([4] 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 ([46] 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 ([44] 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 ([41] 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 ([16] 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 ([25] 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 ([11] Campbell et al. , 2006; [47] 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. For women, this reflects
the fact that they are "too far to walk" ([40] 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. [43] WHO
(1997) has specifically stressed that the woman's 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 ([21] Hodnett et
al. , 2002; [39] 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 ([33] O'Donnell, 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 ([38] 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 ([27] Kruk et al. ,
2009; [31] 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 ([26] Kowalewski et al. , 2000; [7]
Asuquo et al. , 2000; [27] 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 ([15] 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 ([29] 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 ([37] 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 woman's needs is
important for life saving. Responsive care is particularly important to arrest
danger signs and obstetrical complications. In a study by [23] 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 ([9] 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
([38] 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 ([2] 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 ([18] Graham, 2002; [10]
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.

Methodology

Data

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 study's 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.

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 [Figure omitted. See Article Image.] 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. Husband's 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 ([32] 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.

Results

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 [Figure omitted. See
Article Image.]). 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) 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 [Figure omitted. See Article Image.].

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 [Figure
omitted. See Article Image.]). The model contained six independent
variables: age, education, religion, occupation, pregnancy status and
distance from the woman's home to the health facility. The model was
2
statistically significant, (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 R2 =0.139) of the variance of service quality and correctly
classified 77.4 per cent as cases. An upper bound R2 for binary-choice of
0.33 is often preferred ([36] Pindyck and Rubinfeld, 1981). However, a
Pseudo R2 of 0.139 indicates a good fit. The full coefficients of the
independent measures of the model are reported in Table II [Figure omitted.
See Article Image.]. The omitted group indicates the reference category for
which comparisons are made ([17] 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 [Figure omitted. See Article Image.] 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 [Figure omitted. See Article
Image.], there is no doubt that association between the service quality
variables and overall antenatal care quality is confounded by the woman's
demographic profile as shown by changes in the Pseudo R2 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 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 woman's 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 ([44] WHO, 2005; [13] 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 ([8]
Bennet and Brown, 1997; [39] 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 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 [Figure omitted. See Article Image.]). 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 ([1] Addai, 2000; [24] 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
[Figure omitted. See Article Image.]). 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 trimesters.

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 ([30] 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 ([5] 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 [Figure
omitted. See Article Image.]).

Results from the multivariate regression models (Table III [Figure

omitted. See Article Image.]) 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 ([35] 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 ([37] 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 ([43] 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". [14]
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 [Figure omitted. See Article Image.]). The
coefficients reported significant association between attentiveness of
providers and quality of care. This finding supports previous studies ([20]
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
([3] 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 ([6]
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 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.

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Further Reading

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deliver in rural Kenya", Health Economics, Vol. 5, pp. 333-340.

Appendix
Corresponding author

Roger A. Atinga can be contacted at: ayimbillah@yahoo.com

AuthorAffiliation

Roger A. Atinga, Department of Public Administration and Health Services

Management, University of Ghana Business School, Accra, Ghana

Anita A. Baku, Department of Public Administration and Health Services

Management, University of Ghana Business School, Accra, Ghana

Illustration

Table I: Description of variables

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

Table III: Logistic regression models reporting correlates of antenatal care

quality when women background characteristics are controlled

Subject: Pregnancy; Studies; Womens health; Postpartum period; Health

care; Developing countries--LDCs; Health facilities

Location: Ghana

Company / organization: Name: International Bank for Reconstruction &

Development--World Bank; NAICS: 928120

Classification: 8320: Health care industry; 9177: Africa; 9130:

Experimental/theoretical

Publication title: International Journal of Social Economics

Volume: 40

Issue: 10

Pages: 852-865

Publication year: 2013

Publication date: 2013

Year: 2013

Publisher: Emerald Group Publishing, Limited

Place of publication: Bradford

Country of publication: Australia

Publication subject: Business And Economics, Sociology

ISSN: 03068293

CODEN: ISLEBC

Source type: Scholarly Journals

Language of publication: English

Document type: Feature

DOI: http://dx.doi.org/10.1108/IJSE-2011-0075

ProQuest document ID: 1425356002

Document URL: http://search.proquest.com/docview/1425356002?

accountid=25704

Copyright: Copyright Emerald Group Publishing Limited 2013

Last updated: 2013-09-19

Database: Criminal Justice Database; Health Management Database; Social
Science Database

Bibliography