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Research Proposal [Name] [Institutions Name]

Maternal health in Ghana There is little agreement in extent of metermal deaths in the country du e to the unaviability of relaiable data.Avaible estimates put the level of maternal mortality from predicted ratio of 586to about 210 per 100000 live birth , with considerable differences between the regions .It has been estmated , for example that the depriced northern region have example that the deprived northern regions have examples that the depriced northern regions have MMR over 800 maternal deaths per 100,000 lives births, The most recebt infirmation on the risks associated with the hig maternal mortality in the country comes from the maternalproject indentified postpartum haemorrhhage , severe anaemia, sepsis abd obstructed kabour as omportanty risk facir . Structural factirs that impede treatment og obstructed labour such timely transportation to health facility cost of emergency admissions and health care providers attitude and practices are also important contributoey factor. Efforts have been mafe since the early 1990s the improce the health and well being of expecting mothers abd children through the safe motherhood initiatives(SMI). The components of the (SMI) include antenatal care, family planning and management of abortion complications. Antenatal care coveragehas been generally encouraging eith over 88% of health facilities in Ghana currently oiffering entenatal care services.Concurrently, there has been an improvementin the utilization of professional antenatal services by pregnant women in the last fifteen years, from 82% in 1998 to 92% in 2003. As at 2003, 98% of urban women and 89% of rural women received antenatal care from trained health profeesionals.most women (69%) make at least the four recommended antenatal visits during pregnancy at fisrt vist stands at 3.8 among urban residents and 4.2 among rural residents.

A professional assisted delivery reduces the health risks associated with child birth such as complications and infectons that can cause the death of the mother and or baby. Delivery assistance by trained health professional s continue to be low in Ghana.Nationally ober half (53%) of births still occurs at home under the supervised delivery by mother include problems of transportation to health facility during labor, poverty and socio cultural belief that may discourage giving birth outside the home enviroment. Family planning improves materal health it is an important component of materal health care delivery in the country. The 2003 Ghana demographic and health survey indicate that ther remains a hiher unmet need for family planning. The survey shows that only 25% of currently married women reported using a family plannoing method, with only 19% using modern methods. Unsafe abortion contributres substially to maternal morbidity and morrality. A women puts her health and life at risk as result of unsafe abortion.In Ghana the law prohibits induced abortion unless womans life is endangered by he pregnancy, the focus is impaired, or other circumstances by the law courts,Consequently many induced abortions are not reported. Incresinf access to abortion management and post abortion care are critical challenges that must be addresses in the context of preventing maternal mortality. Supportive Environment Under the primary health care system, Ghana developed a reproductive health policy and a safe motherhood program in the early 1990s to improve the health and well being of pregnant

mothers and children . The focus of the safe motherland program is on reducing maternal morbidity and mortality through: Enhancing access to basic and comprehensive essential obstetric care. Increasing average antenatal care attendance. Provision of post abortion. Reducing unmet need in family planning.

Challeneges Workshops participants identified following as critical facing Ghanaian health system: Institutional arrangement still too weal for effective engagement. Evolving consumer expectation Complex licensing and accreditation procedures. Limited access to capital Poor infrastructure, especially in rural areas Limited business skills of private sector Limited access to training Weak and under resourced regulatory bodies Weak engagement of professional association Major weakness in national health system Fraud occurs at multiple levels of schemes Delayed payments to providers are major impediments to sustainability/ growth. Coverage of the poor is uncompleted

Less than half of private providers were expected to be accredited by end-2009 Regulatory bodies have limited involvement in accreditation and monitoring.

Environmental changes and health in Ghana

The importance or the poverty-environment nexus was stressed by the world Commission on Environment and Development, 1917) Poverty is a major determinant of health. Lack of an adequate income tends to lead to poor levels of nutrition, poor housing conditions, impaired access to health and other services and low levels of education. Together this result in increased exposures to environmental risks factors and an impoverished ability to mitigate their effects on health Poverty is thus one of the most important driving forces in relation to environmental health, and one of the most vital points of intervention and control for environmental health policies. Environmental changes almost always have a greater impact on those who live in poverty. Lack of an adequate income tends so lead to poor levels of nutrition, poor housing conditions, impaired access to health and other services and low levels of education Together these result in increased enclosures to environmental risk factors, and an improved shed ability to mitigate their effects on health. Poverty is thus one of the most important driving in forces in relation to environmental health, and one of the most vital points of intervention and control for environmental health policies. There is a strong link between environmental conditions and poverty in Ghana. The Ghana Poverty Reduction Strategy (2003) regards environmental degradation as an contributory cause of poverty In fact. Environment and poverty are linked in many ways Environmental degradation, in both rural and urban areas, affects poor people the most conversely, it is also the

result of poverty. The poor are highly vulnerable so environmental degradation due to population pressure on marginal farm lands, the rural poor often have no choice but to over-exploit the marginal resources available to them through low-input, low productivity agricultural practices such as overgrazing. soul-mining and deforestation., with consequent land degradation the cost or environmental degradation in Ghana is estimated to be 5.5 of GDP, As water and air pollution, deforestation and desertification continue to take their toll in Ghana. Mary Morgan (2007) estimated the cost of environmental degradation to die economy of Ghana to be 10 percent of CGDP environmental opportunities and challenges must be addressed in Poverty Reduction Strategy Papers (PRSPs) are to be effective in eliminating poverty and forging improved livelihoods and sustainable development Environment and Water resource in Ghana

Ghana as a developing country has been grumbling over the negative impacts of such water resource development project. Examples are the Volta and Kpong dams. Which have impacted negatively on local communities and caused disruptions in the eco-system of the Volta River The irony of the situation is that Ghana now has to find sources of electricity for its increasing development needs And hydropower seems to be the cheapest option as at now However, the environmental impacts of large water resources development projects like dams seem to be a major concern of society no This is one of the reasons why SEA and EIA are seen as tools for minimizing the impact of such water resource development protects in Ghana and most developing countries.

Impacts of water Resource Developments in Ghana Ghana has had its fair share of impacts or water resource development projects there are Iwo

major dams in Ghana, which are used for hydroelectric power generation of damns are the volta dun and the Kpong dams. The volta dam has been the major supplier of electricity for Ghana However, developments arid improved access to this source of electricity has led to inadequacies in supply As at now power from these two dams is unable to satisfy the countries demands and Ghana has now resorted to importing electricity to supplement it needs However, hydropower energy has been identified as one or the best options for electric power Ghana (VRA 199s) As electricity demand is rising, new possibilities of Hydropower production are been exploited Already in 1995, 17 possible dam sites with further capacities (9 120o MW have been identified in Ghana .

Plans are advanced for the construction of a third hydropower dams on the Black volta at the Bui gorge. This newly proposed Bui Dam has faced a lot or opposition both local and international because of the negative effects of the two dams mentioned above. All these hydropower projects involve the use of water resources and therefore ad equate precaution needs to be taken be Ghanians in protecting these water resources. This means that an integrated water resource management approach is needed to solve problems that may arise from such projects m the water resource sector in general as a compliment to project ElA The ability of project EIA to solve some of the impacts or dams have been acknowledged but on a much broader scale. SEA is seen as the best Option for Ghana in at resource management.

Impacts of the Volta and Kpong Dams

Some or the impacts o1 the two dams projects in Ghana. Lack of proper environmental assessment before the construction of these dams led to the many negative impacts outlined in table I of current public and international interest is the abandoned Bui dam protect which is to

be built on the Black Volta at Bui in Northern Ghana This dam which has abandoned, has now generated a lot of opposition both local and international. This is because of its intended local and international reserve and also its proposed effects on the last remaining species of hippopotamus in Ghana.

Public Health changed

An introduction to public health is about the discipline or public health, the nature and scope of public health activity and the changes that face public health in the 21st century. The paper is designed as an introductory text to the principles and practice of public health. This is a complex and multifaceted area, what we have tried to do in this book is make public health easy to understand without making it simplistic. As many authors have stated, public health is essentially about the organized efforts of society to promote, protect and restore the public's health (Last 20o1, Lin et al 2007, winslow 1920). It is multidisciplinary in nature and it is influenced by genetic, physi4al, so.ial, cultural, economical and political determinants of health.

The government should make a commitment to the investment and structural changes needed in the delivery system. High priorities could include rationalization of direct payments from the NIIIS to the Ministry oil Health and the Ghana Health Service; paying more attention to public health issues; and improving coordination among vertical public health programs, programs of other health-related sectors, and the NIHS benefits package. Similar efforts by the Ministry of Health and the Ghana Health Service to expand delivery system capacity are critical, given concerns about physical and human infrastructure access, misdistribution of resources, and quality.

Beyond political willingness, commitment, and ability, a sine qua non for success is the establishment f an accountable, culturally and politically sensitive, and effectiveness reform process that holistically deals with the wide set of issues underlying any major health reform effort. Health financing cannot be viewed in isolation from other health system issues. Taking a holistic view is particularly important given many of the identified weaknesses in the management, organization, and incentives of the entire health care delivery system, including public health programs. ii Ghana is to achieve universal coverage, NHIS enrollees must have effective access to services when they need them, and services must be both physically and financially accessible in addition to being medically appropriate and effective. This process must be informed by data and analysis. Election years are challenging times for all countries. However, now would he an ideal time to get the reform process established and moving,

so that the needed analyses can be conducted and policy options casted. Acting now would allow for difficult political decisions to be made right after the December 2012 election, in sufficient time to avoid the bankruptcy of the NIJIS in 2013.

Administrative issues are often tedious and deal with operational, as opposed to the more interesting structural, issues. If the NHIS wants to expand coverage, become an active purchaser, and effectively regulate the health sector, it must upgrade its information systems and deal with previously identified nuts and bolts administrative issues. These issues include the same which are defined above.

A RESEARCH PROPOSAL ON FACTORS THAT CONTRIBUTE TO LOW PATRONAGE OF FAMILY PLANING IN GHANA.

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Introduction

Background Information

In the early days, human societies had creation of as many children as possible, a

central value. Today however, relatively few societies can afford this perspective,

resulting in increased attempts to limit and manage the birth rate of their families of

which Ghana is no exception.

The negative effect of high fertility rate on women and their children, and the

benefits of fertility control are well known. Too many or too closely spaced

pregnancies, and pregnancies of a woman at too young or too old an age, give rise to

health risks for mothers and the infant, with associated higher maternal and

neonatal mortality rates. The health of other children in the family is also affected.

These factors, among others provide health rationale for fertility regulation and

family planning, which is now considered an essential element of preventive health

care. The benefits from fertility regulation relate to the broader issue of the status of

women. The ability of a woman to control her own fertility is one of her basic and

important rights. It is presumed that a better regulated sexuality and fertility affects

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the status of the women socially and economically. This is perceived to be reflected

in their educational, health, and economic status coupled with independence to take

decisions on their role and be responsible for the total well-being.

Even though, trends of increase in contraceptive use have been acknowledged

widely (RAND, 1998; Ann et. al, 2002), currently an estimated 650 million or 62

percent of the more than one billion married or in-union women in reproductive age

are using contraceptives (RAND, 1998). Whereas in the developed nations, 70

percent of married women use contraceptive only 60 percent can be attributed in

developing nations.

The problem Statement: The problems of unmet need of family planning for the less developed nations is considered as a major impediment to the development of its people, especially the vulnerable groups including women and children. The multiplicity of factors and the complex nature of the environments of developing nations, regarding access, influences decision on health services, and contraceptive measures for that matter, even though extensively examined by many scholars, have still not been subdued.

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Research Questions 1. How does the background of women in the district influence their knowledge on contraceptive use and choice? 2 To what extent does the socio-economic characteristics of women influence their decisions on contraceptive use in the district? 3 What factors account for the low patronage of family planning methods in the district? 4 What effect does staff attitude have on access to family planning services by Women, in public service point in the district?

Relevancy of the research questions To determine the knowledge levels of respondents on contraceptive uses and choices in relation to their social backgrounds 2. To assess the extent to which the socio-economic characteristics of the women in Offinso District influence their decisions on the use of family planning methods 3. To identify the factors that account for the low patronage of contraceptive methods in the district and assess the correlates among the women in the district 4. To examine the extent to which staff attitude at public service centres affects womens decision in accessing family planning. 5. To make recommendations to major stakeholders and also suggest areas of further research.

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Literature Review Background to family planning Improving human development is one of the cardinal objectives of the Ministry of Health 5 year programme of work (5YPOW) document with emphasis on providing quality services and empowering people to take control over their reproductive health, especially women (MOH, 2007). The attainment of a reduced and manageable population rate (Gribble, 2008) is a vital integral component of the overnments notional strategy to accelerate the pace of economic development, eradicate poverty and enhance the quality of life of all citizens as outlined in the vision 2020 plan of Action (GSS, 1999; Hogue, 2007). Since 1996, Ghana has been promoting the use of contraceptives (GSS, 2003) and several authors have provided evidence in relation to the access and use of contraceptives and with respect to specific characteristics of the general population.

Knowledge levels of contraceptives and social background

Knowing about contraceptives is presumed to be a first step in stimulating the desire for its use. Assessment of knowledge about contraceptives therefore does not only determine the extent of awareness and sensitization, but further provides the background for which use of the service is further evaluated. Evaluation in this sense relates with the background characteristics, principally social, of users that influence these awareness and sensitization levels. Oral contraceptives (OCs) were the most popular form of contraception for sexually active Canadian women surveyed in

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1998 (Fisher et al, 1998). Seventy-three percent users at the time of the survey expressed a high degree of satisfaction with the pill, although misperceptions were prevalent. Few women knew it was safe for nonsmokers to take the pill after age 35, and that the pill reduces certain cancers. When asked whether taking the pill presented fewer health risks than pregnancy, just 4% strongly agreed. Published literature on the efficacy of contraceptive counseling and education seems to reflect a significant gap between what providers think they offer and what consumers appear to receive. An audit of family planning users in Scotland revealed a 30% discrepancy between the number of women whom clinicians thought they had appropriately counseled and the number of patients who actually understood the teaching (Rajasekar et al, 1999). Oakley estimated that up to one third of women require more individualized counseling to use OCs effectively (Oakley et al, 1994). Getting the good news out about the many benefits of OCs will enable more women

to take advantage of their positive health effects and may help increase compliance (Rosenberg et al, 1998, Jenseen et al 2000, Shulman et al, 2000.) It was discovered that the knowledge of Canadian women on the pill regarding risks, benefits and side effects of the pill remains deficient in several key areas, but was increased by counseling.

According to the recent Ghana Demographic Health Survey, 2003, knowledge of family planning was defined operationally as having heard of a method. The survey, which used an interviewer prompt method, showed that knowledge of contraceptive

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was known by 98 percent of women and 99 percent of men (GSS, 2003) considering that these proportions represented Ghanaians who knew at least one method of contraception. Knowledge about modern and traditional contraceptive have changed over a decade and half ago. Whereas the latter was popular among Ghanaians, the former is now popular even though users of contraceptives use the traditional methods (Clemen et al 2004, Hoque, 2007). It is noted that contraceptive knowledge among unmarried women was found to be 100 percent. Condoms, diaphram, the pill, implant, foam tablet and lactational amenorrhoea were among the methods commonly identified

Extent of Influence of Socio-economic Characteristics on Decision to use Contraceptives Deciding to use modern contraceptives is a difficult decision by most prospective users, especially women. The difficulties arise from the strength of the interplay of influences from close family relations. Furthermore, the economic dependency level of the woman on her close relations affect the decision process for the uptake of contraceptives (Benefo, 2005). The type of work and the amount of income earned by the woman in particular have a strong relation to use of contraceptives (Baiden, F., 2003; Sign, et al, 2003).

2.4 Access to contraceptives and acceptance issues

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For all persons to enjoy a choice among contraceptive options, a range of methods must be readily available. Yet measures of access show serious deficits that depress use of each method. Countries differ both in the number of methods offered and the extent to which each is made available. Information is therefore needed on how these factors have changed over time and how they have affected contraceptive use overall and use of individual methods.( John Ross et al,2002).

Health Workers Attitude and Contraceptive Acceptance by Women There is scanty literature on health workers attitudes on prospective users of contraceptives. Available documentation of staff attitudes has to do with the general provider-clients relations in respect of total quality assurance in services delivery. Contraceptive provision in many settings continues to be based on outdated medical information, unproven theoretical concerns, and provider biases. Studies have found that in some developing countries 25-50% of women seeking contraceptives are refused services until they are menstruating.( Stanback. J. et al 1999). Coupled with effective training, checklists can be important tools for health care workers at various levels to apply the latest WHO medical eligibility criteria and guidelines for contraceptive use. The pregnancy, combined oral contraceptive (COC), depotmedroxyprogesterone acetate (DMPA), and intrauterine device ( IUD) checklists allow health care workers to avoid medical barriers and better provide methods of contraception. .maqweb.org (Dec .2008
Uwww U

Study Methods and Design.

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The study was a descriptive study with a cross sectional design. It involved the collection of both qualitative and quantitative evidence from women of reproductive age, 20 49 years in the Offinso district, Ashanti region, Ghana.

Data Collection Techniques and Tools The data collection technique used was the interview method. The instruments that were used for the women were a questionnaire containing close and open-ended questions and a focus group discussion guide. The questionnaire was used to ascertain a quantitative measure of the characteristics of the respondents on the use of family planning and the focus group discussion guide was employed to derive the qualitative details that would elucidate the quantitative measures. The health workers were also interviewed using a key informant interview guide.

Study Population The study populations were women in their reproductive age from 20 49 years in the Offinso district. The study unit was a woman age 20 49 years who has lived in the Offinso district for at least one year

Sampling Procedure

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A multistage sampling procedure was used in the selection of respondents from the community. For a better representation of the district, ten communities were selected using the communities density per sub-district. Thus, the ten communities were conveniently chosen but randomly selected from the sub-districts. The stratified sampling was therefore, used in deciding on the proportional representation of the population per selected communities per sub-district. In the selected community, the number of houses was determined and by computergenerated numbers, a random sampling was employed to select houses. The researcher entered the chosen houses, where an eligible respondent was enrolled. Where there were more than one eligible respondents residing in the chosen house, the simple random sampling method again was used to select one respondent. Due to their special role and experience, the health workers who work in the family planning clinic and their direct supervisors were purposively selected for interview.

Ethical Consideration An informed consent form was used to seek the consent of respondents of the study. They were assured of confidentiality of their response and the null association of it to them now or in the future. In addition, they were assured that their participation would not affect the relations with health institutions now or in the future and that refusal to participate would not attract any penalty. Further consent was sought from the District Health Management Team, Chiefs,

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Opinion Leaders and identifiable groups before the commencement of the study.

Limitation The instrument could have been limited in determining the anthropological details in relation to the use of contraceptives by the women. Considering the limitation in the use of qualitative tools however, this was minimized through the use of in-depth structured questionnaire , extensive interview during the focus group discussions with the women. Further, the use of local language (TWI), might have led to misunderstanding or misinterpretation of the import of the set questions and therefore led to inaccurate results. These limitations were curtailed to a minimum through training of field workers for standardization of the interpretation of the questions and through close monitoring by researcher of the data collected.

Anticipated impact on potential beneficiaries of the research

The problems and issues will be minimized. Many lives might get saved after the publication of this research. Training and development and family planning might get started by the government. The research might work well for the pregnant women and in a need of guidance for their conditions.

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The research will make people learn about the common mistakes they undergo while going for a child birth. Milestones The study and the issues relating to the problem should be sent to various high officials of Ghana, so that these problems and challenges could be minimized. To bring accuracy in the research as much as much as possible, for reliability of the study.

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References