1.1 INTRODUCTION
In this chapter, the background to the study, problem statement, rationale of the study,
The conceptual framework, the objective of the study and the profile of the study area are reviewed.

1.2 BACKGROUND
This research will be conducted in Asankrankwa, a town in the WassaAmenfi West District.The Wassa West District as one of the Districts in the Western Region of Ghana is located between Latitude 400’N and 500 40’N and Longitudes 10 45’ W and 20 10’W(http://wassaamenfiwest.ghanadistricts.gov.gh ). It Bounded to the north of the district is the WassaAmenfi District, the south by the Ahanta West District, the West by the Nzema East District and the East by MpohorWassa East District. The District has a total land area of 2354 sq. km(http://wassaamenfiwest.ghanadistricts.gov.gh). There are three main vegetational zones: semi deciduous forest, the south-west rainforest and the transitional forest, all of which are suitable for the cultivation of both food and cash crops. The forests of the district are part of the only surviving high forests of Ghana.
The current population of the WasaAmenfi West District is projected at 186,257 at a growth rate of 3.2% per annum which is the region’s growth rate. According to the 2000 population and Housing census, the district’s population was 156,256(http://wassaamenfiwest.ghanadistricts.gov.gh). This was projected at 3.2% within a period of six (6) years which yielded the projected figure in 2006.
The district has a population density of 53.76 people per sq. km
The occupational characteristic of the population has not changed much. Agriculture employs about 75.6% of the active labour force whilst manufacturing and processing employs about 5.4%. This percentage is employed by the two large expatriate timber processing firms located at MansoAmenfi and Samreboi. The services sector employs 7.5% whilst commerce employs about 9.5% of the active labour force. The public sector takes the remaining 2% for workers on government payroll.
Two main hierarchies ofsettlements can be identified. The first involves two major communities, Asankrangwa and Samreboi. They have higher concentration of facilities. These two communities have the highest population levels. Educational facilities are not evenly distributed in the district. Most communities have access to pre-school and basic school facilities. The southern part of the district is deprived of most of these facilities. The only two secondary schools are located in one of the two major communities,Asankrangwa. There is also Midwifery and Health Assistants’ Training school in that same community(http://wassaamenfiwest.ghanadistricts.gov.gh).
The two hospitals in the district are located in the two major communities, Asankrangwa and Samreboi. The other health facilities like clinics and health centres in the district are concentrated in the northern and western parts of the district.The WasaAmenfi West District has 883.6Km length of roads. Out of this figure only 40.0km has been tarred representing 4.5% of total length of roads in the district. The district is greatly handicapped by its poor road network and quality. The poor nature of the roads has adversely affected the delivery of services to the entire district and makes many of the residents prisoners in their own small communities.

It poses a problem to the carting of agricultural and timber products to other major markets in the district. Gravel roads do not last in the district because of the copious nature of the rainfall. The results is that whatever little investment is made on the district roads in terms of maintenance of existing gravelled and feeder roads is whittled away in no time. Regravelled roads do not last more than one month in the district. Roads are constantly prone to flooding during rainy periods, which make them impassable for close to eight months in a year (http://wassaamenfiwest.ghanadistricts.gov.gh).
Poor ANC attendance, together with other health issues, is one of the major public health challenges undermining development in the poorest countries in the world. Today approximately 40% of the world's population, mostly those living in the world's poorest countries is at risk of malaria, anaemia, pre-term delivery and many maternal defaults which are as a result of poor ANC attendance (WHO/UNICEF 2003) . This is found throughout the tropical and sub -tropical regions of the world and causes more than 300 million acute illnesses and at least one million deaths annually (WHO/UNICEF 2003).
Recent estimates of the global poor ANC attendance burden have shown increasing levels of ANC attendance.
Morbidity and mortality, reflecting the deterioration of the ANC attendance situation in Africa during the 1990s. About 90% of all malaria deaths occur in Africa south of the Sahara, and the great majority of them in children under the age of five - Malaria kills an African child every 30 seconds (WHO/UNICEF 2003) of which the ultimate cause is poor ANC attendance. Pregnant women and their unborn children are particularly vulnerable to maternal morbidity and mortality (Brabin 1983). This is because pregnancy reduces the pregnant women’s immunity making them more susceptible to infection; increasing their risk of illness, severe anaemia, spontaneous abortion, etc. Pregnant women may be infected with malaria parasites even if they show no symptoms. These silent infections can have devastating effects on the development of the unborn child. Thus poor ANC attendance in pregnancy is associated with high risk of both maternal and perinatal morbidity and mortality. Poor ANC attendance is one of the leading causes of morbidity and mortality, especially among pregnant women and children under the age of five. In Ghana, poor ANC attendance accounts for 25% of the deaths in children under the age of five years, 13.8% and 10.6% of OPD attendance and admissions respectively among pregnant women and 9.4% of maternal deaths (GHS 2001) . The Ministry of Health estimates that over the past ten years, there have been 2 – 3 million cases of malaria each year, representing 40% of outpatient cases, while severe malaria accounts for 33 – 36 percent of inpatient cases (GSS 2003) .
Controlling the effects of infections in the pregnant woman and her foetus requires a balanced programme of effective case management of malaria illness and prevention of the consequences of asymptomatic infections. These interventions consist of the use of intermittent preventive treatment (IPT), insecticide treated nets (ITN) and the effective case management of the illness at the ANC and PNC services.
ANC service like; intermittent preventive treatment (IPT), helps clear malaria parasites present in the placenta to allow easy transport of oxygen and nutrients. Intermittent preventive treatment (IPT) with Sulfadoxine -pyrimethamine (SP) for malaria has been shown to increase both maternal haemoglobin levels and the infant’s birth weight (Parise et al. 1998; Hommerich et al. 2007). IPT is to be administered to all asymptomatic pregnant women who report at the antenatal clinic in their 2nd and 3rd trimesters (GHS 2003).
Despite the fact that all health facilities that offer ANC services have been providing IPT services since its introduction, there has not been any study to find out the coverage and impact of the service in the Wassa Amenfi West District. IPT coverage and Administration of Antihelminthis is woefully less than the internationally accepted standard. The current goal is to achieve at least 80% of women receiving two doses of IPT during pregnancy. Besides the low coverage of IPT, there is a consistent drop in the number of women who take the first dose due to poor ANC attendance in the Wassa Amenfi West District.
Health care in the Wassa Amenfi West District is rendered through a network of health institutions run by the government, mission and private organisations, with a large contingent of government practitioners and 122 Traditional Birth Attendants (TBA) spread all over the District. The services provided by these health facilities include reproductive and child health services, curative medical and surgical care, health education, promotion and prevention services, and disease control and nutrition services. Emergency obstetric services in the District are mainly provided at the two hospitals; Catholic Hospital and Sarmatex Hospital at Asankrangua and Samreboi respectively. However, all the health centres and the CHIP zones in the district provide some form of maternity services.
The number one cause for outpatient morbidity as well as the major cause of admissions and deaths in morbidity as well as the major cause of admissions and deaths in Wassa Amenfi West is Malaria.

1.3 PROBLEM STATEMENT
This has the potential of preventing many pregnant women and their unborn babies from deriving the protection that ANC attendance is thought to provide for women and foetus during pregnancy.
Due to the heavy burden that poor ANC attendance exerts on pregnant women and their infants, and the serious debilitating consequences it can have on the foetus in particular, various policies have been implemented at both international and national levels to control maternal diseases. The World Health Organisation (WHO) adopts the Roll Back Malaria (RBM) strategy in the prevention and management of malaria. The RBM strategy recommends a package of interventions for the control of malaria during pregnancy in areas with stable (high) transmission at the ANC service. The three –pronged strategy include the use of insecticide Personal communication with the Diseases Control Officer, Wassa Amenfi West District treated net (ITN), intermittent preventive treatment (IPT) and effective case management of malaria and anaemia. These strategies have been adopted by Ghana’s Ministry of Health (MOH). Since 1999, Ghana has been involved in this international effort to control malaria under the Roll Back Malaria (RBM) initiative. The objectives of this initiative are to ensure that by the year 2005 at least 60 percent of those at risk of malaria, particularly pregnant women and child ren less than five years, have access to the most suitable and affordable combination of personal and community protective measures such as insecticide treated mosquito nets (ITNs), routine and regular ANC attendance, and prompt, effective treatment for malaria. As well as to ensure that at least 60 percent of all pregnant women who are at risk of malaria, especially those in their first pregnancies, have access to chemoprophylaxis or intermittent preventive treatment (IPT) during ANC sessions.
To date however, there has been limited assessment of the implementation of this policy in rural areas where the greatest burden of malaria is found due to poor ANC attendance. There is therefore the need to ascertain the factors that affect ANC attendance. This study therefore seeks to assess the factors that influence ANC attendance among pregnant women in the Wassa Amenfi West District.

1.4 OBJECTIVES OF THE STUDY

1.4.1 GENERAL OBJECTIVE

To identify factors that contributes to the current increase the incidence of poor ANC attendance among pregnant women in Wassa Amenfi West District and to determine amenability of these problems to be resolved

1.4.2 SPECIFIC OBJECTIVES
The specific objectives of the study were; 1. To determine the possible causes of poor ANC attendance 2. To know the factors affect ANC services delivery 3. To assess the effects this problem has on the pregnant woman and the unborn baby 4. To deduce the necessary measures to be taken to resolve this problem 5. To estimate the general perceptions of ANC in pregnant women in Wassa Amenfi West District.

1.5 RESEARCH QUESTIONS
The following research questions were addressed by the study; 1. What are the possible causes of poor ANC attendance? 2. What factors affect ANC services delivery? 3. What effects has this problem on the pregnant woman and the unborn baby? 4. What are the necessary measures to be taken to resolve this problem? 5. What are the general perceptions of ANC in pregnant women?

1.6 SINIFICANCE OF THE STUDY
Key health-care interventions to promote maternal health are available but the utilization of such interventions is limited in developing countries, and varies between population groups. One such intervention is the use of SP as IPT for malaria among pregnant women which is accessed during ANC session. The IPT policy aims at controlling the risks that malaria presents to the mother, her foetus and the neonate.
Several factors have been identified to influence ANC attendance in pregnant women. The interaction of these multiple factors impact on the delivery of the service. The rationale for this study is to unmask how these multiple factors interact and affect the ANC attendance services in the district. The results from the study, it is believed, will help in contributing to improving the ANC attendance by highlighting the factors that significantly influence the ANC attendance in the district, and suggest ways in which their interactions can be managed to maximize the coverage of the service in the district.
The study may also generate new information on ANC attendance, which will help reduce maternal and fetal morbidity and mortality be extended, replicated and modified to the study of other health services.