Individual and Community Level Factors Related to Contraceptive Access, Family Planning, and Reproductive Health Challenges Among Women in Kumasi, Ghana: A Field Study

Statement of the Problem

Approximately 90% of all births in the world occur in developing countries and about one-fifth of those births are unwanted. To address this issue, some women resort to unsafe abortions. According to existing literature, an estimated 50 million induced abortions are performed annually worldwide, with about 20 million of those abortions performed under unsafe circumstances or by untrained providers, putting women at risk for a number of negative health outcomes and even death.¹ While developing countries have experienced a decline in maternal mortality rates in the last decade, thanks to the 2000 Millennium Development Goals, the current Sustainable Development Goals, and individual country programs and initiatives,¹ progress has been uneven among and within countries. Access to family planning and reproductive health services have far- reaching implications for improving women's health outcomes, yet not all women in Ghana utilize these services.²

Socio-cultural and economic constraints including religion, cost of services, family perceptions, and cultural beliefs, negatively impact the utilization of modern contraceptives, and reproductive health services by women in Ghana.³ Consequently, most women end up experiencing multiple and unintended pregnancies, poor maternal and neonatal health outcomes, and unsafe abortions. In the bid to address these issues, the Ghana Ministry of Health recently launched the Four Year Ghana Family Planning Costed Implementation Plan,⁴ as well as a National Health Insurance Scheme (NHIS).⁵ Despite these efforts, the utilization of modern contraceptives and reproductive health services by women in Ghana, remains low.²

Objective of the Study

The purpose of the field study was to examine individual and community level factors related to contraceptive access, family planning, and reproductive health challenges among women in Kumasi, Ghana. Specifically, we conducted a field- based comparison of women's health-related issues in Kumasi and the US to determine areas of similarities and differences.

Description of Activities

As part of the three-week Georgia State University School of Public Health's study abroad program, students participated in a virtual field study in the summer of 2021. The field study focused on three contemporary public health issues (water and sanitation, HIV, and women's health) and required students to participate in lectures, site visits, field trips and to write a field study report. For the field report aspect of the study, our team chose to focus on women's reproductive health. Due to travel restrictions associated with the COVID disease of 2019 (COVID-19) pandemic, we were unable to travel physically to Ghana. Thus, we had one of our in-country partners at the Suntreso Government Hospital located in Kumasi, use an electronic questionnaire we had created to collect data on our behalf over a period of four weeks prior to the commencement of the three-week study abroad program. We pilot tested the questionnaire with our in-country partner for appropriateness, clarity, and ease of administration as he was the one going to use it for data collection. His feedback was used to revise and finalize the questionnaire.

Setting and Data Collection

The study focused on women of reproductive age who live in Kumasi. Individuals qualified to participate in this study if they self-identified as female, were of reproductive age and accessed the Suntreso Government Hospital's antenatal care clinic, labor ward, post-delivery/recovery ward, or the baby unit.

Using a mixed-methods study design and the face-to-face questionnaire administration format, data was collected from 100 female patients during their hospital visit, using Twi (the predominant language spoken in Kumasi) and English language (depending on what was preferred by participants). Prior to data collection, our in-country partner obtained consent from participants and assured them of the confidentiality of any responses they would provide. Data was collected electronically via Qualtrics⁶ over a period of two weeks. The data collection instrument comprised 20 qualitative and quantitative questions across four domains: i) demographics, ii) contraception access, iii) family planning, and iv) reproductive health challenges.

Data Analysis

Quantitative and qualitative data collected were exported from Qualtrics⁶ to the Statistical Package for the Social Sciences (SPSS) software⁷ and reviewed for duplicate entries, inconsistencies, and completeness. Quantitative data was analyzed using SPSS version 27.⁷ Univariate/descriptive analysis and bivariate analyses using a 95% confidence interval were conducted. Quantitative data with missing values were excluded from calculations. NVivo version 13⁸ was used to conduct qualitative analysis and to identify themes.

Ethical Approval

The field study was approved by the Institutional Review Board of the Kwame Nkrumah University of Science and Technology in Kumasi.

Overall Findings

We found that 69.0% of study participants in Kumasi knew where to go to access birth control services but had little desire to use them. Like the study participant in Kumasi, most women in the US also know where to access reproductive health services but are more desirous and interested in using such services. We also found that while cultural norms and gender roles served as primary barriers to family planning and contraceptive access for women in Kumasi, access to health insurance is the primary barrier in the US.

Demographic Information

Of the study participants in Kumasi, 79.0% were Akan, 17.0% were Northerners, 1.0% was Ewe, 1.0% was Ga, and 2.0% were of mixed ethnicity. With regards to age, 5.0% of study participants were under the age of 20 years, 47.0% were between the ages of 21 and 29 years, 46.0% were between the ages of 30 and 39 years, and 2.0% were between the ages of 40 and 49 years. When it came to marriage, 67.7% of study participants were married, 31.3% were single, and 1.0% was divorced. By way of geographic location, 89.0% of study participants lived in an urban area while 11.0% lived in a rural area. Regarding educational attainment, 4.0% of study participants had ever attended school, 2.9% had completed primary school, 43.6% had completed junior secondary/high school, 32.7% had completed senior secondary school, and 16.8% had completed university. Over three-quarters, (86.3%) of study participants were employed, and their occupations included trader (cited 32 times), entrepreneur (cited 16 times), and hairdresser (cited 11 times).

Contraceptives

Regarding contraceptives, 69.0% of study participants in Kumasi knew where to access birth control services and 74.0% actually had access to birth control services. Factors cited for the underutilization of birth control were no interest in use (cited 13 times), don't like it (cited 4 times), and side effects (cited 1 time). A little over half (58.0%) of study participants indicated that they use a modern form of birth control. The most used methods are intramuscular injection (27.5%) and condoms (25.5%). Most of the participants (98.0%) also indicated that they are comfortable talking to their health care provider about contraceptives. Those who were uncomfortable also stated they ‘have no intention of ever using birth control’ and they ‘don't like birth control.’ No study participant was pressured by their provider to use a specific birth control method.

Family Planning and Reproductive Health Challenges

Results for family planning practice showed that 28.0% of study participants in Kumasi had been pregnant five or more times. Very few (5.0%) had five or more living children, 21.0% said none of their pregnancies were planned, and 65.7% said they were planning on having more children. A little over half (58.8%) of study participants indicated that they had ever been diagnosed with a pregnancy-related health condition. The most common diagnoses were anemia (34.3%) and gestational hypertension (16.7%). Not many (39.0%) study participants knew of someone who had died during childbirth. Those who knew (6.9%) stated that it was mostly (6.9%) due to hemorrhaging. When asked about abortion, 33.3% of study participants stated that they had ever had an abortion. With regards to how the abortions were done, some said with over-the-counter medication (cited 17 times), at the hospital (cited 12 times), or both (cited 4 times). On the issue of antenatal care, 99.0% of study participants said they saw their doctor at least once during their last pregnancy and 82.3% said they saw their doctor eight or more times during their last pregnancy. Most study participants (80.8%) indicated that they saw their doctor at least once after delivery and 81.3% of those participants said they made two to three additional follow-up visits after delivering.

Birth Control and Sociodemographics

Linear regression analysis and cross-tabulation were conducted to examine the relationship between birth control use (independent variable), age, marital status, education, ethnic group, and urban living environment (dependent variables). We found that there was a greater likelihood of birth control use among study participants in Kumasi of all age groups with the exception of women in the 30-39 age group. There was also a greater likelihood of birth control use among women of all educational levels, Akans, and Northerners. However, none of these associations were statistically significant as shown in Table 1. The bivariate analysis further showed that there was an increased likelihood of abortion among study participants who had ever attended school, were of the Northern ethnic group, married, and within the 40-49 age group. While most of these relationships were also not statistically significant, the association between abortion and the 40-49 age range was significant (p = 0.044) based on a 95% confidence interval (Table 2).

When it came to the knowledge of where to obtain birth control by age, 57.4% of study participants in the 21-29 age group knew where to access birth control. For the remaining age groups, the affirmative response to knowing where to access birth control was 78.0% or higher. The results also showed that 75.3% of urban study participant residents compared to 63.6% of rural residents had access to birth control, and 29.2% of the urban residents had been pregnant five or more times compared to 18.2% of rural residents. We found that 9.2% of rural study participant residents compared to 4.5% of urban residents had five or more living children.

Strengths and Limitations

There were some limitations with the study. A limitation was the ability to translate English words like “intramuscular implant” and “intrauterine device (IUD)” into Twi. Our in-country partner addressed this challenge by describing the contraceptive methods to participants. An additional challenge was poor internet connectivity. Unstable connections interrupted in-country partner's ability to smoothly collect data electronically. This challenge was addressed by switching between two internet service providers during questionnaire administration. Since the field study focused primarily on Kumasi and used a convenient sample, results cannot be generalized to the entire population of Ghana.

Recommendation for Faculty, Students, and Professionals

Researchers looking to conduct a similar study should sample other areas or regions in Ghana in addition to Kumasi in order to have a larger population size for comparison. There are misconceptions about birth control and family planning in Kumasi that need to be dispelled. Future field studies could focus on this area. Overall, students learned about the culture of Ghana as well as women's reproductive health issues in the country.