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FREE MATERNAL HEALTH CARE POLICY AND ACCESS TO SUPERVISED
CARE AT BIRTH: EXPERIENCES FROM THE CENTRAL REGION OF GHANA
HENRIETTA ASANTE-SARPONG
(Student identification number: 10044984)
THE THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN
PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF PHD
DEVELOPMENT STUDIES DEGREE
JULY, 2015
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DECLARATION
I, Henrietta Asante-Sarpong, hereby declare that this thesis, except for references to the
literature which has been duly acknowledged, is the result of my own work undertaken
under supervision. I wish to declare that this work neither in whole nor in part has been
presented anywhere for the award of any academic degree.
STUDENT …………………………………
Henrietta Asante-Sarpong
SUPERVISORS
This thesis has been carried out and submitted with my approval as supervisor:
Rev. Dr. Adobea Yaa Owusu Dr. Ernest Appiah
Date: ………………….……. .. Date: ……………………….
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DEDICATION
I dedicate this PhD thesis to my parents (Mr. Emmanuel Oduro Asante-Sarpong and
Mrs. Felicia Asante-Sarpong) and my husband (Mr. John-Reeves Yemidi) who
encouraged and supported me to pursue and attain this academic height, one of life’s
enviable legacies. Your support and counsel throughout my years of studies is very
much appreciated.
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ABSTRACT
Improving maternal healthcare remains a major public health concern globally but
particularly in Sub-Saharan Africa. In Ghana, maternal mortality continues to be
pervasive and improvements have been rather slow. Investing in supervised and
emergency obstetric care resources has been touted as one major strategy to avoiding
preventable maternal deaths. The clustering of mortality around delivery, and the
dominance of hemorrhage, infections, and hypertensive disorders as major causes of
death, brings out the significance of skilled attendance at birth and immediately after. To
improve access to supervised care at birth, the Ghanaian government in 2003 introduced
the user fee exemption policy for maternal healthcare. Some studies have identified
some level of increase in access to supervised care after the introduction of the policy.
There is however a gap in the literature on community experiences with accessing and
utilizing services under the policy which is critical to understanding utilization patterns.
This study used in-depth/semi-structured interviews and a questionnaire survey to
investigate women and health provider experiences with delivery care use under the
policy in the Central Region of Ghana, a region with worsening skilled attendance at
birth even though it remains one of the policy’s pilot regions. Aday and Andersen’s
(1974) theoretical model of access to medical care was adapted for the study.
The results showed that awareness of the free maternal healthcare policy amongst
mothers was very high (97.3% of respondents). This was however not matched by
comprehensive knowledge on the full benefit package women are entitled to under the
policy particularly emergency delivery and post-delivery services. Generally, use of
delivery care was relatively lower (65%) compared with the very high awareness level.
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Comparing utilization patterns across the study districts, use was higher for women
residing in the Cape Coast metropolitan area than for those in the Assin North municipal
area. Maternal age, religion, parity, place of residence, awareness and knowledge about
the free maternal healthcare policy were identified as main predictors of delivery service
use under the policy.
Findings on women’s delivery experiences under the policy showed that most women
were motivated to access care under the policy because they understood the need for
skilled care particularly around the time of delivery which the policy offers at no cost.
Even though delivery care was largely free as stipulated by the policy, access to and use
of care was hampered by transportation challenges primarily related to poor road
infrastructure and non-availability of regular transport. Health system challenges related
to healthcare infrastructure and personnel and attitudes and competence of staff were
also noted.
The study also found that healthcare providers were enthusiastic about the policy, as it
had offered them the opportunity to provide timely maternity services to clients who
were able to report to facilities early because maternity services are offered for free.
Majority of the midwives interviewed were, however, concerned about limited
infrastructure and medical supplies as well as staff with midwifery skills to cater for the
increasing numbers of women who access care under the policy.
Two important development policy and research agenda have emerged from the results
of the study. With regards to research agenda, the findings have brought to bear the need
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for research into actual gaps in the availability of midwives and projections into future
midwifery requirements to improve women’s access to supervised care at birth.
The main policy recommendation from the work is that there should be increased
education on the full benefit package of the free maternal healthcare policy to ensure
optimum use of ante-natal, delivery and post-natal care (PNC) services among women in
all accredited facilities.
Overall, the study provides a more comprehensive understanding of utilization of
healthcare services under the policy from the micro level. Additionally, it contributes to
current scientific literature and on-going debates regarding fee exemption initiatives for
maternal healthcare and achieving MDG 5 on maternal health.
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ACKNOWLEDGEMENT
In the course of this research work, I have derived a lot of support from various
individuals and organizations. I am sincerely grateful to my supervisors, Rev. Dr.
Adobea Yaa Owusu and Dr. Ernest Appiah for their guidance, suggestions and support
at each stage of the thesis writing process. My sincere thanks also goes to Dr. Sheela
Saravanan, formerly of the Center for Development Research (ZEF), University of
Bonn, Germany, for her keen interest in my work and her immense support and
guidance from the proposal development stage of my work to the completion of my
thesis.
I also wish to thank officials of the Regional and District Health Directorates of the
study region and districts from whom I collected data and held informal discussions for
their time and support. These officials include Dr. J.B Eleeza (Deputy Director of Public
Health, Central Regional Health Directorate), Madam Lydia Owusu (Deputy Director of
Nursing Services Cape Coast Metro Health Directorate), Madam Georgina Asimadi
(Assin North Municipal Director of Health Services) and Ms. Ellen Akaba (Municipal
Public Health Nurse, Assin North Municipal Health Directorate). To Ms. Admire Ataa
Owusu (Assistant Chief Technical Officer- Disease Control unit) of the Assin North
Municipal Health Directorate, I say a very big thank you for your immense support
during the activities that led to the data collection exercise in the Assin North
Municipality.
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I am also grateful to all my respondents and healthcare providers from the study
communities and selected healthcare facilities of the study districts, for their time and
willingness to provide me with the relevant information for the study. I wish to
acknowledge the support of all research assistants particularly Francis Asante-Sarpong
who led the team with his invaluable experience in data collection and analysis to collect
quality data for the study. I am indebted to Dr. Mumuni Abu of the Regional Institute for
Population Studies (RIPS), University of Ghana who tirelessly and patiently supported me
with my quantitative analysis.
Furthermore, I wish to thank the German Academic Exchange Service (DAAD) for their
generous financial support for the entire study period. This research was also partially
funded by an African Doctoral Dissertation Research Fellowship (ADDRF) award offered
by the African Population and Health Research Center (APHRC) in partnership with the
International Development Research Centre (IDRC).
Finally, I am grateful to the entire faculty and staff of ISSER for their support throughout
the programme duration. I also wish to thank my family members and that of my in-laws for
providing me with every support needed during my period of study.
God richly bless you all.
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TABLE OF CONTENTS
Content Page
DECLARATION ................................................................................................................ i
DEDICATION ................................................................................................................... ii
ABSTRACT ..................................................................................................................... iii
ACKNOWLEDGEMENT ................................................................................................ vi
TABLE OF CONTENTS ............................................................................................... viii
LIST OF TABLES ......................................................................................................... xiii
LIST OF FIGURES ......................................................................................................... xv
ABBREVIATIONS AND ACRONYMS ....................................................................... xvi
Chapter one: Introduction .................................................................................................. 1
1.1 Background ......................................................................................................... 1
1.2 Problem Statement .............................................................................................. 5
1.3 Research Questions ........................................................................................... 11
1.4 Research Objectives .......................................................................................... 12
1.5 Significance of the study ................................................................................... 13
1.6 Thesis structure .................................................................................................. 14
Chapter two: Literature review – Healthcare interventions to improve access to
supervised care and determinants of healthcare use ........................................................ 16
2.1. Introduction ........................................................................................................... 16
2.2 Antenatal care ........................................................................................................ 16
2.3. Delivery care ......................................................................................................... 18
2.4. Postnatal care ........................................................................................................ 19
2.5. Fee exemption policy for maternal healthcare ...................................................... 20
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2.6 Effect of fee exemption initiatives ......................................................................... 24
2.6.1 Demand for obstetric services ......................................................................... 25
2.6.2 Health expenditures ........................................................................................ 27
2.6.3 Healthcare outcomes ....................................................................................... 28
2.7 Section summary .................................................................................................... 29
2.8 Determinants of access to and use of skilled care at birth ..................................... 30
2.8.1 Demand-side determinants of access to and use of skilled care at birth ......... 31
2.8.2 Health system determinants of access to and use of skilled care at birth ....... 38
2.8.3 Socio-cultural factors ...................................................................................... 40
2.9 Summary ............................................................................................................ 43
Chapter three: Theoretical background ............................................................................ 45
3.1 Introduction ............................................................................................................ 45
3.2 Theoretical discourse on access to and use of healthcare services ........................ 45
3.3 Conceptual Framework .......................................................................................... 54
Chapter four: Study Area and Methodology .................................................................... 60
4.1 Introduction ............................................................................................................ 60
4.2 Selection of study area ........................................................................................... 61
4.2.1 Criteria for region selection ............................................................................ 61
4.2.2 District level selection..................................................................................... 62
4.3 Study design ........................................................................................................... 63
4.4 Description of study variables ............................................................................... 65
4.5 Target group and sampling approach ..................................................................... 71
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4.6 Primary data collection .......................................................................................... 82
4.7 Data Processing and Analysis ................................................................................ 86
4.8 Ethical considerations ............................................................................................ 89
Chapter five: Mothers’ awareness and knowledge about Ghana’s fee exemption policy
for maternal healthcare .................................................................................................... 90
5.1 Introduction ............................................................................................................ 90
5.2 Socio-demographic Characteristics of mothers ..................................................... 90
5.3 Awareness and sources of information on the free maternal healthcare policy
among women .............................................................................................................. 92
5.4 Mothers knowledge and understanding of maternity services they are entitled to
under the free delivery policy ...................................................................................... 96
5.5 Conclusion ........................................................................................................... 101
Chapter six: Factors influencing the use of delivery services under the free maternal
health care policy ........................................................................................................... 103
6.1 Introduction .......................................................................................................... 103
6.2 Use of delivery services ....................................................................................... 104
6.3 Statistical associations between use of supervised delivery services and mothers
background characteristics ......................................................................................... 104
6.4 Determinants of delivery care use ........................................................................ 110
6.5 Conclusion ........................................................................................................... 119
Chapter seven: The reality with accessing ‘free maternal healthcare services’: Mothers’
delivery experiences....................................................................................................... 121
7.1 Introduction .......................................................................................................... 121
7.2 Socio-demographic characteristics of respondents .............................................. 122
7.3 Experience with care ............................................................................................ 123
7.4 Organization of care ............................................................................................. 131
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7.5 Satisfaction with care ........................................................................................... 133
7.6 Conclusion ........................................................................................................... 135
Chapter eight: Healthcare provider perceptions and experiences with the implementation
of the ‘free delivery’ policy ........................................................................................... 137
8.1 Introduction .......................................................................................................... 137
8.2 Professional background of midwives and key informants ................................. 138
8.3 Healthcare providers’ knowledge about the free delivery policy ........................ 139
8.4 Provision of fee free maternity services to clients ............................................... 140
8.4.1 Collaboration in provision of care ................................................................ 141
8.5 Utilization of supervised care .............................................................................. 143
8.5.1 Increased uptake of facility-based services ................................................... 143
8.5.2 Timely access to supervised care .................................................................. 146
8.6 Challenges to accessing care ................................................................................ 147
8.6.1 Workload and limited number of midwives ................................................. 147
8.6.2 Limited supply of basic as well as emergency infrastructure and supplies .. 148
8.6.3 Delays in reimbursement of funds ................................................................ 149
8.6.4 Community-level delays in getting to the facility......................................... 150
8.7 Conclusion ........................................................................................................... 152
Chapter nine: Discussion, summary of findings, conclusions and recommendations ... 154
9.1 Introduction .......................................................................................................... 154
9.2 Discussion of findings.......................................................................................... 154
9.2.1 Awareness and knowledge about the free delivery policy ............................ 154
9.2.2 Factors influencing delivery care use ........................................................... 157
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9.2.3 Women’s’ experiences with use of free delivery care .................................. 163
9.2.4 Healthcare providers experiences with implementation of ‘free maternal care’
policy...................................................................................................................... 169
9.3 Relating findings to theoretical and conceptual framework ................................ 173
9.4 Summary of findings............................................................................................ 177
9.4.1. Introduction .................................................................................................. 177
9.4.2 Awareness and knowledge about the free delivery policy ............................ 178
9.4.3 Use of delivery services ................................................................................ 180
9.4.4 Mothers’ experiences with accessing free delivery care ............................... 181
9.4.5 Healthcare provider experiences with providing free delivery care ............. 183
9.5 Conclusions .......................................................................................................... 184
9.6 Recommendations ................................................................................................ 188
9.6.1 Increased education on the full benefit package of the free delivery policy 189
9.6.2 Provision of more maternity clinics/door-step supervised care services for
rural women ........................................................................................................... 189
9.6.3 Addressing infrastructural and human resource needs ................................. 190
REFERENCES .............................................................................................................. 192
APPENDICES ............................................................................................................... 206
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LIST OF TABLES
Table Page
Table 4.1: Annual percentage rates of skilled attendance at birth in the Central,
Northern, Upper East and Upper West Regions .............................................................. 61
Table 4.2 Sampled localities in the two study districts .................................................... 77
Table 4.3 Sampled communities and their respective sampled respondents ................... 78
Table 4.3: Categories of health facilities selected for the study ...................................... 80
Table 5.1: Percentage distribution of background characteristics of respondents ........... 91
Table 5.3: Percentage distribution of awareness about policy by rural-urban settings of
study districts ................................................................................................................... 93
Table 5.4: From whom/where did mothers receive information about the free maternal
healthcare policy? ............................................................................................................ 94
Table 5.5: Sources of information about the free maternal healthcare policy by place of
residence (rural/urban) ..................................................................................................... 95
Table 5.6: Percentage distribution of mothers’ knowledge about the benefit package of
fee exemption policy for maternal healthcare .................................................................. 97
Table 5.7: Percentage distribution of knowledge about benefit package of free maternal
healthcare policy by study districts .................................................................................. 98
Table 5.8: Percentage distribution of knowledge on services provided for delivery care
by district and place of residence (rural/urban) ............................................................. 100
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Table 6.1 Percentage distribution of use of free delivery care by marital status ........... 105
Table 6.2: Percentage distribution of use of delivery care by place of residence .......... 106
Table 6.3: Percentage distribution of use of free delivery care by respondent’s level of
education ........................................................................................................................ 107
Table 6.4: Percentage distribution of use of free delivery care by respondent’s religion
........................................................................................................................................ 108
Table 6.5: Percentage distribution of use of delivery care services by mother’s parity
levels .............................................................................................................................. 114
Table 6.6: (Model 1)-Binary logistic regression results of predictors of delivery care use
using background characteristics of mothers ................................................................. 112
Table 6.7: (Model 2) - Binary logistic regression results of predictors of delivery service
use using background characteristics of mothers and their husbands/partners .............. 114
Table 6.8: (Model 3)- Binary logistic regression results of predictors of free delivery
service use using, background characteristics of mothers, husband/partner characteristics
and health policy variables ............................................................................................. 117
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LIST OF FIGURES
Figure Page
Figure 3.1: A Framework for the study of access to health services ............................... 47
Figure 3.2 Conceptual framework of maternal healthcare service utilization ................. 55
Figure 4.1: Map of Study districts ................................................................................... 63
Figure 4.2: Map of the Cape Coast Metropolitan Area showing its localities and health
facilities ............................................................................................................................ 75
Figure 4.3: Map of the Assin North Municipal Area showing the location of its localities
and health facilities .......................................................................................................... 76
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ABBREVIATIONS AND ACRONYMS
ANC Antenatal Care
CAC Comprehensive Abortion Care
CHO Community Health Officer
CHPS Community Based Health Planning and Services
DHMT District Health Management Team
FGD Focus Group Discussion
GDHS Ghana Demographic and Health Survey
GHS Ghana Health Service
GMHS Ghana Maternal Health Survey
GSS Ghana Statistical Service
HIPC Heavily Indebted Poor Country
IRD Institutional Review Board
MDG Millennium Development Goal
MMR Maternal Mortality Ratio
MOH Ministry Of Health
NHIS National Health Insurance Scheme
NMIMR Noguchi Memorial Institute for Medical Research
PNC Post-natal Care
SCI Skilled Care Initiative
TBA Traditional Birth Attendants
WHO World Health Organization
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Chapter one: Introduction
1.1 Background
Improving access to maternal health care services has gained widespread attention
especially after UN member states adopted the Millennium Development Goals (MDGs)
in the year 2000. The fifth goal seeks to reduce pregnancy-related deaths which remain a
major development and public health problem globally.
The situation is however worse for most developing countries of Sub-Saharan Africa
and South Asian countries experiencing a stagnating situation with maternal health. It is
estimated that 99% of all maternal deaths occur in developing countries, with Sub-
Saharan Africa and South Asia accounting for 87% of these deaths. More than half
(56%) of these deaths however occur in Sub-Saharan Africa (World Health
Organization, 2010). For instance the WHO estimates that 1 in 39 adult women in Sub-
Saharan Africa stand the chance of dying through pregnancy related complications in
contrast to 1 in 130 in Oceania, 1 in 160 in Southern Asia and 1 in 3800 among women
in developed countries (World Health Organization, 2012). It is, therefore, not surprising
that improving maternal health has received widespread recognition as part of the United
Nation’s MDGs. According to its goal 5, MDG aims to reduce the 1990 maternal
mortality ratios by three-quarters by the year 2015 and improve universal access to
reproductive healthcare.
Several countries particularly within the developing world have tried to put in place
programmes and interventions for the realization of this goal. Several factors including
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those related to women’s place of residence (Fotso, Ezeh & Oronje, 2008; Gabrysch and
Campbell, 2009), education (Babalola and Fatusi, 2009; Chirdan and Envuladu, 2011),
maternal age (Gabrysch and Campbell, 2009; Doku, Neupane & Doku, 2012), religion
(Gyimah, Takyi & Addai, 2006; Hazarika, 2010) and availability of health care services
(Mpembeni et al., 2007; Bezzano et al., 2008) interact in different ways to affect the
effective use of maternal health care services.
The situation for Ghana is not very different from what pertains in several other
developing countries. Even though the country has witnessed slight declines in its
maternal mortality ratios since 1990, pregnancy-related morbidity and mortality
continue to be pervasive and improvements are not significant enough to meet the
expectations of MDGs on maternal health. The country’s maternal mortality ratio
(MMR) has reduced from 740/100,000 live births in the 1990s to its current figure of
350/100,000 live births (WHO, 2010). Despite these improvements, the national level
decrease in MMR (3.3%) is lower than the targeted 5.5% annual reduction required in
order to achieve MDG 5 by 2015 (WHO, 2012).
The medical causes of maternal deaths are well-known and similar across many
countries world-wide, with postpartum hemorrhage remaining the leading cause of
maternal deaths in most African and Asian countries (Potts, & Hemmerling, 2006; Prata,
Sreenivas, Vahidnia, & Potts, 2009). Other medical causes which may lead to fatalities
include infections, hypertensive disorders, sepsis, eclampsia, unsafe abortions and
obstructed labour (Prata et. al., 2009). The clustering of mortality around delivery, and
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the dominance of hemorrhage, infections, and hypertensive disorders as causes of death,
brings out the significance of access to skilled attendants at birth and immediately after,
and to timely referral for emergency care (Campbell & Graham, 2006).
In Ghana, hemorrhage or severe bleeding remains the leading cause and contributes to
24% of all maternal deaths. Most maternal deaths, therefore, occur during and
immediately after delivery. Deliveries attended by skilled personnel continue to be low
in Ghana at 52.2 percent (Ghana Health Service, 2012). A number of factors, both
systemic and structural have been noted for the seemingly low, inadequate and
inequitable access to skilled care at birth in the literature. These include challenges
associated with inadequate health infrastructure, medical equipment and supplies,
shortage in human resources, high costs of care, negative attitudes of health workers,
socio-cultural beliefs and practices, and bad or non-existent transportation infrastructure
to nearest health facilities (Ansong-Tornui, Armar-Klemesu, Arhinful, Penfold, &
Hussein, 2007; Gabrysch & Campbell, 2009; Gething et al., 2012). Some studies have
therefore recommended for in-depth assessment into how these factors interplay to
affect the performance of any initiative/policy intervention targeted at improving access
to supervised care (Ir, Souk, & Van Damme 2010; Hadley, 2011)
As a stringent measure to improve access to professional care at birth and to reduce
financial constraints to assessing this service at the point of delivery, the Ghanaian
government in 2003 introduced the user fee exemption policy for maternal healthcare.
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The policy exempts all women from paying for maternal healthcare services in public
and mission facilities (MoH, 2004).
Preliminary studies that have evaluated the performance of the policy have typically
relied on utilization rates as a measure of success and in most cases have reported of
increased access and utilization of professional care after the introduction of the policy
(Nyonator and Kutzin, 1999; Asante, Chikwama, Daniels, & Armar-Klemesu, 2007;
Bosu, Bell, Armar-Klemesu, & Ansong-Tornui, 2007; Penfold, Harrison, Bell, &
Fitzmaurice, 2007; Witter, Adjei, Armar-Klemesu, & Graham, 2009). Even though there
has been a general increase in utilization of healthcare services under the policy, there is
evidence that constraints with the limited availability of healthcare infrastructure and
personnel continue to exist in several healthcare facilities. In addition to this,
community-level constraints to accessing care particularly the negative socio-cultural
beliefs and practices about pregnancy and childbirth, and bad or non-existent
transportation infrastructure to nearest health facilities continue to persist in several parts
of Ghana.
A major gap, therefore, to understanding the extent to which women are actually
using/benefitting from the fee exemption policy relates to understanding consumer and
provider voices and experiences with providing and accessing care and how the existing
systemic and community-level constraints affect healthcare use under the policy. Indeed,
some writers have emphasized the need for in-depth studies on local level experiences
on utilization noting that the relationship between implementing fee exemption policies,
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access and health outcomes to individuals and communities is a complex one (Ir, Souk,
& Van Damme, 2010; Hadley, 2011).
This study used Aday and Andersen’s (1974) theoretical model of access to medical care
to fill this knowledge gap by investigating women’s experiences with the use of and
satisfaction with delivery care provision under the free delivery policy. The study draws
on the experiences shared by beneficiary women to assess its implications for
understanding the acceptability and utilization of delivery services provided under the
policy. Health provider experiences with the provision of delivery care under the policy
were also investigated.
While supplementing previous statistical studies on the use of maternal healthcare
services under the policy, this thesis aims to provide in part a qualitative understanding
of utilization of maternal health care services at the micro level from a service provider
and beneficiary’s perspective. Additionally, it will contribute to current scientific
literature and on-going debates regarding fee exemption initiatives for maternal
healthcare and achieving MDG 5 on maternal health.
1.2 Problem Statement
Introduction
In spite of the introduction of free maternal healthcare policy in Ghana to address
financial barriers associated with accessing supervised care at birth, use of supervised
delivery services is still low in the country. Only 52.2% of births in Ghana are attended
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to by a skilled attendant (GHS, 2012). Policies that focus on increasing the availability
of skilled health professionals to supervise deliveries has been identified as key for
addressing fatal emergencies during delivery and the immediate post-partum period
(Campbell & Graham, 2006; Koblinsky, Mathews, Hussein, Mavalankar, Mridha,
Anwar, Achadi, Adjei, Padmanabhan & Van Lerberghe, 2006). Earlier evaluation
studies on the Ghana’s free maternal healthcare policy (Armar-Klemesu, 2006; Witter et
al., 2009) have however identified some implementation bottlenecks which have
affected, effective use and access to supervised maternity services. These include
concerns related to beneficiary knowledge about the benefit package of the policy and
quality of care provided under the policy.
Additionally, well known community-level and health system barriers which can
influence access to supervised care continue to persist in most parts of the country even
after the introduction of fee free maternity services. Ensor and Cooper (2004) alludes to
the fact that use of supervised maternity services is affected by financial barriers to care-
seeking, which interact with community-level barriers (geographical and cultural)
combined with inadequate quality of care within the formal health sector. The ensuing
sub-sections discuss the research problem in detail, identify the research gap and
conclude with the research questions and objectives.
Access to and use of skilled attendance at birth
In Ghana, a little over half (52.2 percent) of pregnant women benefit from professional
delivery assistance (GHS, 2012). The situation for the study region (Central Region) is
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not very different from that of the entire nation. Between 2008 and 2010 for instance,
the region witnessed a continuous decline in skilled attendance rate from 56.3% in 2008
to 52.5% in 2009 and a rate of 51.6% in 2010 (GHS, 2012). Other parts of the country
are equally disadvantaged with respect to having access to skilled attendance at birth.
Data from the 2007 Ghana Maternal Health Survey (GMHS) for instance shows that the
Upper, East, Upper West and Northern regions recorded the lowest proportions of births
receiving professional assistance with Northern region having the least figure of 27.3%
compared to 79.3% in the Greater Accra Region which recorded the highest.
The inadequacy of health personnel is not only limited to maternal healthcare but
remains a general problem nationally. In Ghana, most health facilities are government-
owned and relatively affordable than private ones, but continue to face the challenge of
having inadequate health inputs. For example, the Ghana Health Service estimated in
2009 that nationally, the population-per-doctor and population-per-nurse ratios would be
11,929 and 971 respectively. For population-per-doctor ratios, Central Region had one
of the worst figures with the region having a rate almost twice as high as the national
average (22,877 compared to a national average of 11,929) (GHS, 2010).
Gaps in implementation of free maternal healthcare policy
Preliminary evaluation studies of the delivery fee exemption policy have suggested the
need for critical attention to some implementation gaps. The first relates to gap in
community-level knowledge about the actual benefit package provided by the free
maternal healthcare policy. Concerns on improving remuneration for health staff to
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ensure that they are motivated to provide appropriate care for all women who seek for
services has also been noted (Witter et al., 2009).
Concerns on quality of care provided under the policy have also been raised by an
earlier evaluation study. Witter et al. (2009) have suggested the need for the policy to
give further attention to quality of care particularly with care obtained for the
management of the first stage of labour, use of the partograph and for immediate post-
partum monitoring of mother and baby. A confidential enquiry into the causes of
maternal deaths in Ghana by Tornui-Ansong et al. (2007) also revealed that poor quality
of care received at hospitals resulted in the occurrence of potentially avoidable maternal
deaths.
Other writers have also recommended for the inclusion of both formal and informal
maternal healthcare providers like traditional birth attendants (TBAs) in the
implementation of the policy since it is empirically documented that local communities
have gained widespread trust in the services of TBAs (Arhinful, Zakariah-Akoto, Madi,
Mallet-Ashietey, & Armar-Klemesu, 2006)
There may also be challenges with the effective monitoring and supervision of how the
policy is being implemented at the service provision level regarding the extent to which
women who report for delivery services are provided with the full benefit of the free
delivery package. The policy offers a full delivery package made up of free care for all
normal deliveries, management of all assisted deliveries including Caesarean sections,
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and management of medical and surgical complications arising out of deliveries,
including the repair of vesico-vaginal and recto-vaginal fistulae (Ofori-Adjei, 2007).
Witter et al. (2009) have recommended the need for effective monitoring of maternity
services provided to beneficiaries under the policy, so as to ensure that providers are
passing on full benefits of the delivery fee exemption package to beneficiaries while
they are adequately reimbursed for their loss of revenue.
Community-level and health system barriers to accessing supervised care
There are increasing concerns of persisting socio economic inequities of access to and
the quality of care provided in health care facilities even after the introduction of the
delivery fee exemption policy (Ansong-Tornui, Armar-Klemesu, Arhinful, Penfold, and
Hussein, 2007; Witter, Adjei, Armar-Klemesu, and Graham, 2009). The extent to which
these barriers to accessing care have impacted on utilization has, however, not been
extensively studied. This study therefore tries to answer this question by examining
experiences with accessing care from women beneficiaries and providers of the policy.
Closely linked to low skilled attendance at birth is the low proportion of deliveries that
take place in health facilities. In spite of the introduction of free maternity care, many
women continue to deliver outside health facilities and for that matter without a skilled
attendant. In Ghana, only 54 percent of births are delivered in health facilities of which
40 percent are delivered in public health facilities compared to approximately 10 percent
in private facilities. There are marked rural and urban disparities in access to health
facility deliveries. The 2014 Ghana Demographic and Health Survey estimates that 90
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percent of urban births are likely to be delivered at a health facility compared with 59
percent in the rural area due primarily to the non-availability of health facilities within
reasonable distance (Ghana Statistical Service, Ghana Health Service, & ICF
International, 2015).
Another challenge to increasing the use of supervised care at birth, relates to provider
choices that women themselves make during pregnancy and childbirth. Women’s
preference for non-professionally trained providers’ particularly traditional birth
attendants (TBAs) in Ghana as well other developing countries have been noted in the
literature (Amooti-Kaguna & Nuwaha, 2000; GSS, Noguchi Memorial Institute for
Medical Research, & ORC Macro, 2004; Wagle, Sabroe, & Nielsen, 2004). The 2014
Ghana Demographic and Health Survey estimates almost one-fourth (23%) of births in
Ghana are attended by TBAs and relatives (Ghana Statistical Service, Ghana Health
Service, & ICF International, 2015).
Research gap
Even though it is imperative that challenges with improving access to professional care
at birth within the health system are adequately addressed, one cannot also
underestimate the need for critical attention to community-level factors that hinders
women’s ability to access professional care particularly at birth. This is due to the fact
that both community–level and health system constraints to achieving universal access
to supervised care during pregnancy and childbirth persist even with the introduction of
free delivery care. Ghana’s free delivery policy was introduced to increase and improve
demand for supervised care at the point where healthcare service is delivered.
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Challenges with reaching the service delivery point as well as resource constraints to
providing adequate care at the facility-level could hamper the goal of improving access
to care for all.
Some studies have emphasised the need for critical attention to community-level factors
(distance to health facilities, wealth status, culturally mediated perceptions, etc.) as well
as health system constraints (availability, quality and cost) to addressing women’s
access to care (Gabrysch & Campbell, 2009; Gething et al., 2012) This is even more
important in rural areas where health facilities are sparsely located, transport
infrastructures are very bad or non-existent and the population is predominantly poor.
Earlier studies on Ghana’s fee exemption policy for maternal deliveries have largely
examined its performance in terms of how it has influenced trends in utilization of
maternal healthcare services (Asante et al., 2007; Bosu et al., 2007; Penfold et al., 2007;
Witter et al., 2009). One major gap in the literature on evaluations undertaken on the
policy relates to understanding beneficiary and provider experiences with accessing
healthcare services under the policy. The study intends to fill this knowledge gap.
1.3 Research Questions
Based on the empirical literature that was reviewed and the research gaps identified
thereof in the previous sections, the research questions for the study are the following:
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1. What are the understanding, perceptions and experiences of clients and service
providers about the fee exemption policy for maternal healthcare?
2. What are the individual, community-level and health system factors influencing
use of delivery care under the free maternal healthcare policy?
1.4 Research Objectives
The study broadly seeks to assess beneficiary (women) and provider perspectives and
experiences with delivery care provision under the fee exemption policy for maternal
deliveries in selected districts in the Central Region of Ghana.
Specifically, the study seeks to study and understand the implementation of the free
delivery policy by:
1. Exploring women’s awareness and understanding of the full benefit package of
the free delivery policy in the study districts.
2. Identifying factors that influence use of delivery services among women in
selected study districts
3. Assessing women’s experiences and satisfaction with delivery care received
under the free delivery policy in the study districts.
4. Assessing healthcare provider perceptions and experiences with delivery care
provision under the fee exemption policy particularly regarding resource
availability and how delivery care is organized
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1.5 Significance of the study
Among the eight MDGs adopted by 189 members of the United Nations Summit in
2000, the goal five that seeks to improve maternal health has seen the least progress
globally and nationally. This study contributes to the body of knowledge on improving
equitable access to maternal healthcare services.
Studies on the impact of fee exemption strategies for maternal healthcare have mostly
focused on providing statistical trends of utilization giving less attention to providing a
comprehensive understanding of the experiences of healthcare use within the local
context. Effective use of free delivery care during pregnancy especially through the
NHIS not only has a capacity to provide positive pregnancy outcomes but also has a
potential to have its spill over effects on general healthcare seeking behaviour for
women beneficiaries and their families.
It is, therefore, imperative that insights into local health-seeking experiences is
undertaken to better understand how removal of user fees for maternal healthcare have
influenced the use of delivery services among individuals and communities. The
findings of this study will provide in-depth accounts of women’s experiences with
delivery care received under the fee exemption policy. Understanding user as well as
provider views and experiences with care received under the policy could be useful for
addressing any gaps in implementation of the policy. It will also provide a clearer basis
for policy intervention to enhance access and utilization of delivery services.
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The study also contributes to the development of micro-level baseline information on the
performance of Ghana’s fee exemption policy under the administration of the NHIS.
This will, therefore, help track progress made by the government towards improving
maternal healthcare and achieving MDG 5.
1.6 Thesis structure
The study is organized into ten major chapters. Chapter one provides a general overview
of the study and comprises of the background, the statement of the problem, the research
questions and objectives and the significance of the study. The second chapter provides
a general overview of reproductive healthcare provision in Ghana and also highlights the
background and effect of the free maternal healthcare policy on maternal healthcare
outcomes in Ghana. This is aimed at providing some insights into past and more recent
interventions and policies introduced by the health sector to address the country’s
reproductive and maternal healthcare needs. The rest of the study is organized as
follows. Chapter three surveys related literature on access to and use of maternal
healthcare services and the impact of fee exemption strategies for maternal healthcare
both theoretically and empirically.
Chapter four presents the theoretical background to the study by exploring discourses on
healthcare use and access to healthcare services. It also presents the conceptual
framework for the study adapted from a model for the study of access to medical care by
Aday and Andersen (1974). The framework provides the basis for understanding the
theoretical perspective within which different factors mediate to explain women’s access
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to and use of skilled care at birth in the study area. The fifth chapter outlines the data
collection and analysis process, including country profile, choice of and description of
study areas, sampling design and the methods of analysis.
Chapter six presents the study results on the background characteristics of the primary
study participants as well as their knowledge and perceptions about the free delivery
policy. The seventh chapter outlines and discusses the main factors influencing delivery
care use under the free maternal healthcare policy in the study areas. Chapter eight
provides detailed accounts of mothers’ experiences with utilization of delivery care
services under the free maternal healthcare policy. The ninth chapter also presents the
results on healthcare provider perceptions and experiences with provision of supervised
care under the free maternal healthcare policy. Lastly, chapter ten provides an extensive
discussion of the findings of the study. It also summarizes the key findings from the
study and makes policy recommendations.
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Chapter two: Literature review – Healthcare interventions to improve access to
supervised care and determinants of healthcare use
2.1. Introduction
A number of policy interventions have been introduced in Ghana to help improve
maternal health outcomes and avoid preventable maternal deaths. This chapter presents
the effect of these policy initiatives under two broad sections. The first section outlines
the effect of ante-natal, delivery and post-natal policies/interventions that have been
introduced in past years to address Ghana’s maternal healthcare situation. These policy
interventions are chosen for discussion as they were all intended to improve and increase
access to supervised maternity care as the free delivery policy whose implementation is
being assessed in this study. The second section provides the background to the
introduction of free delivery policy and the strengths and barriers to the smooth
implementation of the policy. The policy was introduced in 2003 in addition to earlier
initiatives to address financial challenges to accessing supervised care during pregnancy
and childbirth. The chapter ends with a review of empirical literature on the demand and
supply-side determinants of use of supervised care
2.2 Antenatal care
Antenatal care services forms part of the comprehensive maternity care given to
pregnant women and remains an integral part of healthcare provision in Ghana. ANC
services in Ghana, consist of a set of professional check-ups, mostly at a formal health
facility for examining the woman’s obstetric history, screening for any complications,
the testing of urine and blood samples, checking of the fundal height, provision of anti-
malarial prophylaxis tablets and iron supplements and the woman’s blood pressure (GSS
et al., 2009).
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ANC services are mostly provided by Medical doctors, Midwives, Nurses, and
Community Health Officers. To encourage effective use of ANC services, community
health nurses provide outreach services in antenatal care to mostly rural communities as
part of the Community-Based Health Planning and Services (CHPS) strategy. The CHPS
strategy which began as a research project in Kassena-Nakana district in 1994 and was
scaled up to a national-level initiative in 1999, provides cost-effective and adequate
quality basic primary health services to individuals and households within their
communities by engaging them with the planning and delivery of services (Nyonator et
al., 2005).
Access to and utilization of ANC services in Ghana is generally encouraging. According
to the 2007 Maternal Health survey report, 96% of pregnant women received antenatal
care for births that occurred in the five years preceding the survey from a trained
provider (that is a doctor, nurse/midwife or auxiliary midwife). Similarly, the 2008
GDHS reports that 95 percent of mothers received antenatal care from a health
professional with 98 percent of urban mothers receiving care compared with 94 percent
of mothers in rural areas. Utilization of antenatal care for rural mothers has however
improved from 89 percent in 2003 to 94 percent in 2008. The proportion of mothers
taking up the WHO recommended number of ANC visits of at least four was however
lower. Seventy-eight percent of mothers had four or more antenatal visits for their most
recent live birth. This was, however, an improvement over the GDHS of 2003 where
almost seven in ten (69 percent) pregnant women had four or more antenatal care visits
for the most recent birth
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Although private health facilities do provide ANC services, government facilities remain
the major source of healthcare providing free antenatal services since 1997 (Population
Council et al., 2006).
2.3. Delivery care
Ghana like many other low and middle income countries have over the years introduced
interventions that will increase the proportion of births delivered under medical attention
to reduce the health risk of pregnancy and child birth. In Ghana, almost 3 in 5 births (59
percent) are delivered with the assistance of a trained professional (i.e. doctor,
midwife/nurse or community health officer/nurse) (GSS et al., 2009)
The introduction of the CHPS concept which aims at improving healthcare to
underserved areas through community mobilization remains one key intervention
introduced to improve access to supervised care at birth. The CHPS compound mostly
consisting of space for a clinic and living quarters for a health care provider is managed
by Community Health Officers (CHOs) who are mostly nurses with midwifery skills or
midwives who have the capacity to assist deliveries and make referrals should
complication arise. The CHOs reside in local communities and provide clinical services
at the clinic which include ANC and sometimes deliveries and also undertake
household/outreach visits for Family Planning services; health education and
immunization care (GSS et al. 2009).
One major strategic objective that was outlined in the 2007-2011 Reproductive Health
Strategic Plan of the Ghana Health Service was to reduce maternal morbidity and
mortality. The key interventions to achieve this plan include, undertaking activities that
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were aimed to improve access to comprehensive and basic, essential obstetric; improve
the capacity of family and community members in home-based life-saving skills;
increase the proportion of deliveries conducted by skilled attendants; and ensure the
availability of comprehensive abortion care (CAC) services as permitted by law (GHS,
2007).
Home deliveries have, however, not been completely addressed nationally, close to half
of all births (45%) still occur at home (GSS et al., 2009). These births are conducted
with the assistance of a TBA, a relative or an elderly woman in the community (GSS et
al., 2009). According to the GDHS (2008), 38 percent of births are assisted by a TBA
with about one in ten births assisted by a relative or receiving no assistance at all (GSS
et al. 2009). A woman giving birth in an urban area is twice (84%) as likely to be
delivered by a health professional compared to a woman giving birth in a rural area
(43%).
2.4. Postnatal care
Postnatal care is recognized as an integral part of maternity care services provided in
Ghana. Postnatal care services are provided just after delivery and ends six weeks after
delivery. In Ghana, the first postnatal check-up is advised within the first three days of
delivery and subsequent check-ups are made as appropriate (GSS et al. 2009).
The first two days following delivery are especially critical for detecting and monitoring
potential complications that could adversely affect the health of the mother or new-born
baby. Access to and use of postnatal care services is critical considering the fact that
maternal and neonatal deaths are still high in Ghana. According to the GDHS (2008) 57
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percent of mothers receive a postnatal check-up within 24 hours of delivery with 68
percent receiving care within the first two days after delivery. About one in four women
(23%), however, do not receive any postnatal care within 41 days after delivery which
marks almost the end of the postnatal period. Although this coverage is higher compared
to other developing countries, given the almost universal access of antenatal care, the
expected post-natal care is higher.
2.5. Fee exemption policy for maternal healthcare
Introduction
Higher costs associated with seeking for supervised maternity services have been noted
as very critical to uptake of care for many women in Ghana and other developing
nations (Fotso, Ezeh and Oronje, 2008; Babalola and Fatusi, 2009; Gabrysch and
Campbell 2009). Official user charges as well as unofficial charges, transport costs and
time costs interact to result in huge expenditures especially in the event of
complications. Before the introduction of the fee exemption policy for maternal
healthcare in Ghana, it was estimated that women paid an average of $12 for vaginal
deliveries in public hospitals and $20 in mission hospitals. For caesarean section
deliveries, women were paying on average $68 in public hospitals and $139 in mission
hospitals (Levin, 2003).
These amounts may be quiet expensive for majority of Ghanaian women to pay as most
of them are not engaged in economic activities that provide them with adequate income
to cater for their basic needs which include healthcare needs. In Ghana, approximately
90.9 percent of women aged 15 years and above work within the private informal sector
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and are engaged mainly in farming, fishing and petty trading (GSS, 2012). Compared to
the public and private formal sectors, the private informal sector does not provide
consistent and regularly available income to women. Nationally, incomes from formal
employment contribute more (36.3%) to households’ income compared to incomes from
agriculture (10.1%). The scenario is similar for the study region. In the Central Region,
individuals’ earnings from agriculture and fishing non-farm self-employment activities
such as petty trading contribute less to household income than earnings from formal
employment. Agriculture and non-farm employment contribute 6.6 percent and 22.1
percent respectively to household income compared to almost sixty percent (59.7%)
from formal employment (GSS, 2014). For women who would have to depend on their
spouses for the cost of delivery care, a husband’s inability to pay for the service could
result in a decision to deliver at home or with an untrained provider.
There is, therefore, a growing interest particularly in the African region to reduce
financial barriers to healthcare generally but with special emphasis on high priority
services and vulnerable groups. In recent times, countries have adopted innovative
financing mechanisms as fee exemption, cash assistance, voluntary service contributions
and public-private partnerships to improve access to skilled care (Asante at al., 2007;
Hounton et al., 2008; Powell-Jackson et al. 2009; Ridde and Diarra, 2009; Ir, Souk, and
Van Damme, 2010; Ridde, Kouanda, Bado, Bado, and Haddad, 2012)
Free maternal healthcare policy introduced
The government of Ghana in 2003 introduced a delivery fee exemption policy with an
aim to remove financial barriers to accessing supervised care and to improve general
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access to institutional care at birth. The implementation began in the four poorest
regions (Northern, Upper East, Upper West and Central Regions) initially and was
expanded to the remaining six regions in 2005 with the involvement of both public and
private sectors as well as mission facilities in providing free maternity care to all women
(MoH, 2004).
The exemption package covers non-payment of registration under the NHIS and a
comprehensive maternity package. The policy provides an on the spot registration in the
NHIS for women confirmed pregnant without a waiting period and without premium
payment for one year. This allows them to access a comprehensive maternal benefit
package covering antenatal care services (examining the woman’s obstetric history,
screening for any complications, the testing of urine and blood samples, checking of the
fundal height, provision of anti-malarial prophylaxis tablets and iron supplements and
the woman’s blood pressure) (GSS et al., 2009). The policy also provides free care for
deliveries of all kinds (all normal deliveries, management of all assisted deliveries,
including Caesarean sections, and management of medical and surgical complications
arising out of deliveries, including the repair of vesico-vaginal and recto-vaginal
fistulae) and post-natal as well as neonatal care for the infant for up to six weeks after
delivery (Ofori-Adjei, 2007).
Apart from transportation and other supply costs, women do not incur any delivery cost
for delivering at an accredited health facility. Health facilities providing services under
the policy were reimbursed on a per-delivery basis with different fixed rates established
by the Ministry of Health for normal and caesarean deliveries. Public and private
facilities had different reimbursement rates (Ofori-Adjei, 2007).
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The policy has witnessed two major implementation phases. The first phase spanned the
years 2003 to June 2008 with the Ministry of Health as the managing institution. The
bulk of funding during this period of implementation came from the Heavily Indebted
Poor Country (HIPC) funds (Witter et al., 2007). The second phase of implementation
began in July 2008 with care being provided through the National Health Insurance
Scheme when funding available to reimburse facilities for delivery services provided ran
out in 2007.
The introduction of the policy has yielded some positive strides. An economic
evaluation of the policy on households by Asante et al. (2007) for instance revealed that
there was a statistically significant decrease in the mean out of pocket payments for
caesarean section and normal delivery at health facilities after the introduction of the
policy. Cost of delivery care at facilities was, however, not reduced to zero. Witter et al.
(2009) in evaluating the performance of the policy in the year 2009 found that the policy
had reduced the cost of caesarean sections by 28 percent and 26 percent for normal
deliveries. The authors, however, described the policy as an efficient and cost-effective
strategy for improving access to skilled care at birth especially for the poor in society.
Some implementation gaps have, however, been identified. Concerns on quality of care
for instance have also been raised by an earlier evaluation study. Witter et al. (2009)
have suggested the need for the policy to give further attention to quality of care
received particularly with care obtained for the management of the first stage of labour,
use of the partograph and for immediate post-partum monitoring of mother and baby.
The study also identified gaps with the effective monitoring and evaluation of the policy
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towards ensuring that benefactors are receiving the full range of maternity services they
are entitled to under the policy.
2.6 Effect of fee exemption initiatives
In recent times, countries have adopted innovative financing mechanisms such as; fee
exemption, cash assistance, voluntary service contributions, National Health Insurance
(NHI) and public-private partnerships to improve access to skilled care (Hounton et al.,
2008; Powell-Jackson et al. 2009; Witter et al., 2009; Ir, Souk, and Van Damme, 2010).
Countries within the African sub-region that have introduced some form of fee
exemption initiatives include Zambia, Burundi, Burkina Faso, Kenya, Liberia Niger and
Sudan. Burkina Faso for instance introduced an 80 percent subsidy policy for deliveries
in 2006 (Hounton et al. 2008). In the same year, Burundi also introduced free services
for pregnant women and children under five. Kenya announced free delivery care in
2007, with Niger also announcing free care for children in the same year (Ridde and
Diarra 2009). Sudan announced free care for caesarean sections and children in January
2008 (Witter, Armar-Klemesu, & Graham, 2009). Ghana has responded to this call and
has since 2003 implemented a nation-wide fee exemption policy for maternal healthcare.
Several studies have evaluated the effect of fee exemption policies for maternal
healthcare on a number of outcomes, including the demand for/use of obstetric services,
health expenditures, and health outcomes. Studies that have looked at the impact of cost-
reduction or elimination initiatives on demand for obstetric care include studies by
Asante, Chikwama, Daniels, and Armar-Klemesu, (2007); Hounton et al. (2008);
Powell-Jackson et al. (2009); Ridde and Diarra, (2009); Ir, Souk, and Van Damme,
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(2010) and Ridde, Kouanda, Bado, Bado, and Haddad, (2012) have evaluated the effect
of fee exemption initiatives on healthcare expenditures. Other studies by Witter et al.,
(2009) and Ansong-Tornui et al. (2007) have assessed the impact of fee exemption
initiatives on maternal healthcare outcomes.
2.6.1 Demand for obstetric services
Using two qualitative research techniques (key informant interviews and focus group
discussions); Powell-Jackson et al. (2009) explored the experiences of ten districts in
implementing a national incentive programme to promote safe delivery in Nepal. The
incentive packages included a conditional cash transfer to women, an incentive package
to health providers for each delivery attended and free health care in addition to the
conditional cash transfer for women from the 25 least developed districts in the country.
The authors concluded that both design and implementation challenges emanating from
the national level such as bureaucratic delays in the disbursement of funds, difficulties in
communicating the policy, both to implementers and the wider public and the
complexity of the programme’s design had resulted in marked variations in uptake of
services across the study districts. Even though the study provides very useful insights
into possible constraints to effective uptake of services under the initiative, it has not
documented challenges from benefactors of the programme. This study intends to add to
the existing knowledge by exploring beneficiary experiences and satisfaction with
delivery care received under Ghana’s fee exemption policy for maternal deliveries.
Similarly, Ir, Souk, and Van Damme, (2010) assessed the effectiveness of a Voucher
Scheme (financing mechanism for subsidizing the price of health services and products
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to target population groups) introduced by the Cambodian Government in 2007 to
improve access to skilled attendance for poor women in three rural health districts. A
trend analysis of facility deliveries that took place between 2006 and 2008 in the health
districts showed that, deliveries had increased significantly from 16.3 percent in 2006 to
44.9 percent in 2008 after the introduction of the voucher scheme. The authors noted
that even though the scheme had strong potential for reducing financial barriers to
accessing skilled care at birth, other interventions to improving the supply of sufficient
quality maternity services was necessary for the scheme to achieve its full potential.
Hounton et al. (2008) used data from a national census conducted in 2006 in Burkina
Faso to assess the performance of a Skilled Care Initiative (SCI) implemented by the
Ministry of Health and Family Care International, an NGO in Ouargaye district from
2002 to 2005. The initiative put in place a number of interventions and incentives to
strengthen both the demand and supply sides of delivery care. Specifically, their study
evaluated the relationships between accessibility, functioning of health centres and
utilisation of delivery care in the SCI intervention district (Ouargaye) compared with
another district (Diapaga). Similar to other studies that have confirmed possible
increases in healthcare use under cost reduction initiatives, the study also concluded that
the SCI increased uptake of institutional deliveries in the intervention district.
In Ghana, Mills, Williams, Adjuik, and Hodgson (2008) assessed the factors associated
with use of health professionals for delivery following the introduction of the free
maternal healthcare policy in Northern Ghana. Using data from the Navrongo
demographic surveillance system on pregnancy outcomes of 3,433 women, the authors
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used multilevel logistic regression analyses to identify the factors influencing use of
professional care for delivery.
Their results showed that even though 98 percent of women received antenatal care,
only 38 percent delivered with the assistance of health professionals, a finding which is
similar to the national situation even though the national situation is slightly better. The
2008 GDHS reported that 95 percent of Ghanaian women received antenatal care but
only 59 percent delivered with professional assistance (GSS et al., 2009).
Physical access factors such as availability of transport and travel distance to the district
hospital showed statistically significant associations with use of health professionals for
a woman’s last delivery. Awareness about free care for delivery was also statistically
significantly related to use of professional care at birth. Women who were aware that
delivery care was free of charge were 4.6 times more likely to use health professionals
than those who did not know. Even though, the findings provide useful insights into
factors influencing use of professional care at birth, it failed to document factors
influencing the choice of a particular point of delivery among many others where the
policy is in place.
2.6.2 Health expenditures
Ridde, Kouanda, Bado, Bado, and Haddad, (2012) examined the effects of a national
maternal healthcare subsidy policy enacted by the Burkinabe government in 2007
focusing primarily on the extent to which the policy reduced household spending on
facility-based vaginal deliveries and the distribution of its benefits. The study which was
carried out in the Ouargaye district used data from two district cross-sectional household
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surveys conducted before and after the introduction of the policy. As envisaged by the
government of Burkina Faso, the study concluded that the policy was very effective in
reducing household costs for delivery care.
Asante, Chikwama, Daniels, and Armar-Klemesu, (2007) evaluated the economic
outcome of Ghana’s delivery fee exemption policy on households. The authors adopted
a two-stage sampling approach to identify women for a household cost survey. For the
first stage, health facilities operating immunisation programmes and child welfare
clinics in the selected districts were identified. Women who fell into the sampling frame
(comprising of women who had vaginal delivery at a health facility; women who had
vaginal delivery at home or with a TBA; and women who delivered through caesarean
section) were selected from the facilities. In the second stage, the sampled women were
followed to their homes for the administration of the household cost questionnaire.
Having analysed and defined a threshold above which ones payments for maternal
deliveries compared to a given income will be seen as catastrophic, the study came up
with the following conclusions. First, the study revealed that there was a statistically
significant decrease in the mean out of pocket payments for caesarean section and
normal delivery at health facilities after the introduction of the policy. The percentage
was, however, highest for caesarean section.
2.6.3 Healthcare outcomes
In Ghana, Ansong-Tornui, et al. (2007), conducted a confidential enquiry into maternal
deaths occurring before and after the introduction of the universal free delivery policy to
ascertain if pregnancy-related care given at health centres had changed following the
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introduction of the policy. The enquiry utilized reports provided by a panel of experts
who completed maternal death assessments from clinical case notes collected by the
selected health facilities, partographs, laboratory forms and billing accounts. The authors
concluded that clinical care provided before and after the fee exemption policy did not
change, even though women with complications were arriving earlier after the
introduction of the policy. This reinforces the need for increased attention to challenges
confronting health facilities in providing improved maternity services particularly where
care is provided at no cost.
Similarly, an evaluation of Ghana’s delivery fee exemption policy by Witter et al.,
(2009) concluded that the exemptions policy can be described as an efficient and cost-
effective strategy for improving access to skilled care at birth and can be of immense
benefit to the poor in society. The evaluation report, however, recommended for further
attention to some implementation gaps that could hinder the achievement of the desired
goal of the policy. These included issues related to adequate funding, staff motivation,
strong institutional ownership, a clearer understanding of the roles of different
healthcare providers and constraints related to the quality of care provided.
2.7 Section summary
The section above outlined and discussed policies and interventions (including Ghana’s
fee exemption policy for maternal healthcare) that have been introduced to improve
maternal healthcare situation in Ghana and other developing countries. Most of the
initiative and policies introduced had an ultimate goal of improving access to supervised
care during pregnancy, at birth, and during the post-partum period. The strengths and
weaknesses of the policy initiatives were discussed.
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Specifically, on the fee exemption policy for maternal healthcare, the successes and gaps
in the implementation of the policy as outlined by some evaluation studies were
discussed. Earlier studies on Ghana’s fee exemption policy for maternal deliveries have
largely examined its performance in terms of how it has influenced trends in utilization
of maternal healthcare services (Nyonator and Kutzin, 1999; Asante et al., 2007; Bosu et
al., 2007; Penfold et al., 2007; Witter et al., 2009).The subject has been treated with less
attention to understanding how the day to day experiences of beneficiaries in accessing
care under the policy influences utilization patterns within local contexts. This study
added this perspective to the literature by exploring how the experiences of women who
have already benefitted from the policy influenced utilization patterns.
Additionally, some of the empirical studies have also noted the need for further attention
to non-financial barriers and health system constraints that could influence uptake of
maternal healthcare services under various healthcare financing mechanisms (Ir et al.,
2010; Witter et al.,). In line with this, literature on other demand and supply-side factors
(apart from costs) that influences use of supervised delivery services and realizing the
full impact of healthcare interventions was reviewed. This is presented in the next
section
2.8 Determinants of access to and use of skilled care at birth
Studies undertaken in a number of countries particularly in Sub-Saharan Africa suggest
some broad category of factors that influence access to and use of maternal healthcare
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services. These could be grouped broadly under demand-side and supply-side factors
and others which can be classified as intermediate.
The demand-side factors include those associated with the socio-demographic and
household characteristics of the woman (e.g. maternal education, region of residence,
rural-urban residence, marital status, household income, gender roles and responsibilities
etc.) (Babalola & Fatusi, 2009; Gabrysch & Campbell, 2009; Chirdan & Envuladu,
2011; Doku, Neupane & Doku, 2012).
The supply-side factors largely relate to health system constraints which may result in
non-availability of maternal healthcare services or poor quality of care in situations
where services are available (Ansong-Tornui et al., 2007; Mpembeni et al., 2007;
Bezzano et al., 2008).
The intermediate factors are mostly associated with the wider socio-economic and socio-
cultural environment and may have an indirect effect on utilization (e. g., poor
transportation networks and costs of transport, distance to health facilities, myths about
pregnancy and childbirth etc.) (Kyomuhendo, 2003; Blum, Sharmin, & Ronsmans,
2006; Jammeh, Sundby, & Vangen 2011; Rahman et al., 2011; Doku, Neupane and
Doku 2012; Narh & Owusu, 2012).
2.8.1 Demand-side determinants of access to and use of skilled care at birth
Previous studies have demonstrated that certain individual factors of users of healthcare
services can influence how they are able to access and use healthcare services. The
section reviews studies that have highlighted the effect of demand-side factors as
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women’s socio-demographic characteristics and household wealth and socio-economic
status on utilization of maternal healthcare services.
i. Socio-demographic factors
Education
Findings from numerous studies on determinants of use of maternal healthcare services
conducted in developing countries show a near universal and positive association
between maternal education and use of skilled care at birth (Elo 1992; Babalola and
Fatusi, 2009; Gabrysch and Campbell, 2009; Chirdan and Envuladu, 2011; Doku,
Neupane and Doku 2012). Using information from selected number of mothers of new
born babies who were bringing their babies to a child welfare clinic for their first
immunization care, Chirdan and Envuladu (2011) aimed at determining the rate of home
delivery and the presence of a skilled attendant at delivery among women in Jos. The
authors employed the use of a semi structured questionnaire to elicit information
regarding the socio-demographic characteristics of the women, ANC attendance, place
of delivery, method of delivery, and attendant at delivery. The study found among others
that women with lower educational status and grand multiparity level were more likely
to deliver at home than at health facilities. Although Chirdan and Envuladu’s paper
provides an excellent body of knowledge on women’s use of delivery services, it did not
mention the role that supply-side factors as the availability of health facilities and
personnel play in influencing women’s choices for delivery care.
A study by Babalola and Fatusi (2009) also confirmed the strong influence of education
on the use of maternal healthcare services particularly delivery services. The authors
used multi-level analytic methods to examine the determinants of maternal services
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utilization in Nigeria, with a focus on individual, household, community and state level
factors. Their findings also confirmed the critical role of education in determining
women’s use of maternal healthcare services. The authors found that education was the
only individual level variable that was consistently a significant predictor of service
utilization.
The findings of a Peruvian study undertaken by Elo (1992) are also consistent with
previous analysis in Sub-Saharan Africa that have demonstrated the importance of
maternal education in determining the use of maternal healthcare services. Both cross-
sectional and fixed effects models that were employed in this study yielded
quantitatively important and statistically reliable estimates of the positive impact of
maternal schooling on the use of prenatal care and delivery assistance. Gabrysch and
Campbell (2009) review of over eighty existing studies on the determinants of skilled
attendance at delivery in low and middle income countries, demonstrated the strong
association between maternal education, lower parity and increased use of skilled
attendance at birth. Similarly, Fotso, Ezeh and Oronje (2008) found education and parity
as significant determinants of ANC use and delivery with a skilled attendant.
Studies in Ghana have also highlighted the positive role of partner’s level of education
on women’s use of skilled care at birth. Doku, Neupane and Doku (2012), found that the
education level of the woman as well as that of her partner were significantly associated
with a delivery being assisted by a trained assistant. The authors employed the use of
multivariate logistic regression analysis to explore factors determining the type of
delivery assistance and timing of ANC visits among Ghanaian women. In another recent
study in Ghana, Smith, Tawiah and Badasu (2012) using quantitative methodologies to
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explore the relationship between selected socio-economic variables, women’s status and
choice of place of delivery, also found the educational status of women and that of their
partners as core predictors of choice of place of delivery. Both authors used data from
the 2008 Ghana Demographic and Health Survey reports.
Maternal age
Maternal age is a significant factor affecting the use of maternal healthcare services in
some developing economies such as Ghana. An extensive review of studies on the
determinants of skilled attendance at delivery in low and middle income countries by
Gabrysch and Campbell (2009) found a strong association between higher maternal age
and increased use of skilled attendance at birth. On the contrary, another study in
Kathmandu and Dhadig districts of Nepal on determinants of choice of delivery site,
found the age of the mother as not a significant factor in determining a woman’s place of
delivery (Wagle et al. 2004). In Ghana, although the 2003 GDHS found mothers’ age as
not significantly related to their access to trained care during delivery (GSS, NMIMR, &
ORC Macro, 2004) the 2008 edition showed mothers’ age as significantly associated
with a woman’s delivery behaviour (Doku, Neupane and Doku 2012).
Place of residence
The strong influence of place of residence on utilization of supervised delivery care is
consistent with several studies across Africa and other developing countries. A study by
Gabrysch and Campbell (2009) demonstrated the strong association between urban
residence and increased use of skilled attendance at birth having extensively reviewed
eighty studies on determinants of skilled attendance at delivery in low and middle
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income countries. This has been confirmed by other studies in developing countries. Elo
(1992) examined the effect of maternal education on use of maternal healthcare services
in Peru and found that in addition to the effect of maternal schooling on use of prenatal
care and delivery assistance, large differentials were also found in the utilization of
maternal healthcare services by place of residence. Similarly, Hazarika (2010) found
that women living in urban areas in India were more likely to use skilled attendance at
birth than their rural counterparts.
A study by Fotso, Ezeh and Oronje (2008) in Kenya also confirmed the strong influence
of place of residence on frequency and timing of ANC and place of delivery. The
authors studied the maternal healthcare situation in two slum settlements of Nairobi,
using quantitative data from household interviews and a health facility survey. In a more
recent study in Ghana, Doku, Neupane and Doku (2012), found that place of residence
was significantly related to assistance of a trained professional during delivery.
Parity
Some studies on infant and maternal healthcare undertaken in some developing
countries have outlined the strong association between parity and the use of maternal
healthcare services (Wagle et. al., 2004; Fotso, Ezeh and Oronje 2008; Gabrysch and
Campbell 2009; Chirdan and Envuladu 2011). Gabrysch and Campbell (2009) found
lower parity as significantly related to increased use of skilled attendants at birth in low
and middle income countries. Wagle et. al. (2004), however, did not find parity as a
significant factor in determining a woman’s place of delivery in Nepal, a developing
country in Asia.
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Within African, a study by Chirdan and Envuladu (2011) in Jos Nigeria showed that
women with grand multiparity levels were more likely to deliver at home than at health
facilities. The authors tried to determine the rate of home deliveries in Jos and the
presence of a skilled attendant at birth. In two slum settlements in Nairobi Kenya, Fotso,
Ezeh and Oronje (2008) also found parity of the woman as closely associated with
frequency and timing of ANC and with place of delivery. The authors found women
with higher parity being less likely to make the recommended number of antenatal visits.
Wealth status:
Previous studies have demonstrated the significance of women’s economic or wealth
status on use of maternal healthcare services (Smith, Tawiah and Badasu 2012;
Hazarika, 2010). A study in India that explored factors associated with the use of skilled
care at birth found the wealth status of the woman as the most significant factor
influencing use of skilled attendance at birth (Hazarika, 2010). In Ghana Smith, Tawiah
and Badasu (2012) found the wealth status of the woman as a strong predictor of choice
of place of delivery.
Household factors
Some empirical literature have demonstrated the strong linkage between households
wealth levels and influences on women’s delivery site choices and use of skilled care
services (Fotso, Ezeh and Oronje, 2008; Babalola and Fatusi, 2009; Gabrysch and
Campbell 2009; Rahman, Haque, Mostofa, Tarivond and Shuaib, 2011). Gabrysch and
Campbell (2009) found that the strong association between household wealth and
increased use of skilled attendance at birth had been extensively documented in over
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eighty studies they reviewed on determinants of skilled attendance at delivery in low and
middle income countries.
Using data from the 2007 Vanuatu Multiple Indicator Cluster Survey, Rahman et al.
(2011) examined the degree of inequality in utilization of reproductive health services
within the Pacific Islands and found that the economic well-being status of the
household to which women belonged played a critical role in explaining variations in
service utilization. Their analysis revealed marked inequalities in utilization between the
poorest and the richest groups within the wealth quintiles. The authors found that
women in the richest band of wealth were 5.50 times more likely to have received
supervised care at delivery than those in the poorest band.
A study of individual, household and community level determinants of maternal services
utilization in Nigeria, by Babalola and Fatusi (2009), also found that households socio-
economic levels was a consistent significant predictor of a women’s use of maternal
healthcare services. Women from richest households were approximately six times more
likely to use antenatal services compared to their counterparts from the poorest
households. Another study in two slum settlements in Nairobi, Kenya found that
household wealth was strongly associated with women’s choice of place of delivery
(Fotso, Ezeh and Oronje, 2008) with non-health facility deliveries declining with
decreasing household wealth.
Apart from household wealth, a study in Rakai district of Uganda using qualitative
methods to explore factors that influenced women’s choice of delivery sites, also
documented the social influence of spouses and other relatives on women’s decision
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making (Amooti-Kaguna & Nuwaha, 2000). Most respondents reported that their
husbands had great influence on their choice of delivery place as they provide money
needed for care received. The authors used two popular qualitative methods – Focus
Group Discussions (FGDs) and semi-structured interviews.
2.8.2 Health system determinants of access to and use of skilled care at birth
Women’s access to timely and quality emergency obstetric care services continue to be
critical for improved maternal healthcare particularly in sub-Saharan Africa. The
literature on how health system factors influence use of maternal healthcare is diverse
and generally outlines how factors such as staff attitude, access to healthcare
information, previous use of facility services, costs of care and the availability of
obstetric equipment and supplies affect healthcare use (Mpembeni, Killewo, Leshabari,
Massawe, Jahn, Mushi, and Mwakipa, 2007; Cham, Sundby, & Vangen, 2009; Gabrysch
and Campbell, 2009; Narh and Owusu 2012)
Provision of information on the relevance of skilled care at birth
In Kenya, Fotso, Ezeh, Madise, Ziraba and Ogollah, (2009) used ordered logit models to
identify factors that influence the choice of place of delivery among the urban poor in
two slums of Nairobi. They found that advice received during antenatal care to deliver at
a health facility was a major predictor of place of delivery in the study areas. A similar
result was found in a study in Southern Tanzania by Mpembeni et al. (2007). They
employed quantitative research methodology in a cross-sectional study to assess
determinants of skilled care use at birth in Southren Tanzania and also found advice
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women received to deliver in health facilities during antenatal clinics as strongly
associated with use of skilled care at delivery.
Staff attitude
D'Ambruoso, Abbey, and Hussein, (2005) used qualitative methods to investigate
women’s accounts of interactions with healthcare providers during labour and delivery
with the view to assessing its implications for acceptability and utilization of formal
maternity services in Ghana. The results showed that staff attitude had the greatest
influence on women’s acceptability and utilization of health services. The study revealed
that women were likely to change their place of delivery and recommendations to others
if they experience degrading and unacceptable behaviour from healthcare providers.
Similarly, a study by Bazzano, Kirkwood, Tawiah-Agyemang, Owusu-Agyei, and
Adongo, (2008) in the Kintampo district in the Brong Ahafo region of Ghana showed
that negative treatment by healthcare providers acted as a major barrier to the use of
skilled care at birth.
Previous use of health facility services
Gabrysch and Campbell, (2009) have confirmed that women’s use of facility care in a
previous delivery and antenatal care use in low and middle-income countries are highly
predictive of health facility use for an index delivery, though this could also be
influenced by other factors as the availability of health services. The results from a
recent study in Ghana by Narh and Owusu (2012), also demonstrated the impact of
antenatal attendance on mothers’ delivery behaviour. They found that mothers who
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attended antenatal services three times or more whiles pregnant were more likely to
deliver at health facilities than those who attended antenatal clinics twice or less.
Cost of care
In Ghana, Bazzano et al. (2008) reported in their study that the exorbitant costs of
supplies needed for delivery care acted as a major barrier to the use of skilled care at
birth among women in the Kintampo district of the Brong Ahafo region.
Quality of care
In Ghana, D'Ambruoso, Abbey, and Hussein, (2005) found women’s perceived quality
of care to be received at a health facility as one critical factor that influences women’s
acceptability and utilization of maternal healthcare services. A study in Gambia also
revealed that women faced substantial difficulties in obtaining timely and adequate
emergency obstetric care services due to health system constraints including the
shortage of essential medicines especially antihypertensive drugs, lack of blood for
transfusion and undue delays in getting access to emergency services (Cham, Sundby, &
Vangen, 2009).
2.8.3 Socio-cultural factors
The determinants of access to and use of skilled delivery services include socio-
economic and cultural factors which influences how individuals perceive their own
health and decisions regarding maternal healthcare use. Factors such as; distance,
transportation costs and that of cultural beliefs, norms and practices are widely
documented by several empirical studies across the developing world (Blum, Sharmin,
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and Ronsmans, 2006; Gyimah, Takyi, & Addai, 2006; Bezzano et al. 2008; Jammeh,
Sundby, and Vangen 2011; Narh and Owusu 2012).
Transportation and distance
Jammeh, Sundby, and Vangen (2011) using qualitative methods explored the major
barriers to emergency obstetric care service use in rural Gambia. The authors identified
transport and cost as major barriers to accessing emergency obstetric care services. In
Nepal, Wagle et al. (2004) found that, women residing in Kathmandu and Dhadig
districts had a higher likelihood of delivering at home if they lived within a distance of
more than an hour to the maternity hospital.
Some studies in Ghana have also identified the close association between availability of
transportation and distance related factors on use of supervised care at birth. Narh and
Owusu (2012), for instance, identified cost of transport and long distance to health
facilities as factors that play significant role in influencing mothers’ delivery behaviour.
The authors found that women in rural areas compared to urban dwellers are more likely
to deliver outside the health facility due to bad roads and the non-availability of regular
transport. The authors conducted a cross-sectional study to examine factors that
influence mothers’ use of health services for supervised delivery in a rural district in the
Eastern Region of Ghana. Similarly, D'Ambruoso, Abbey, and Hussein, (2005) found
proximity of services as one critical factor influencing women’s acceptability and
utilization of maternal healthcare services in the Greater Accra Region of Ghana.
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Cultural practices
A study conducted in Matlab, a rural area in Bangladesh has demonstrated that women
tendered to adhere to traditional childbirth norms which are a major barrier to the use of
skilled attendants at birth (Blum, Sharmin, and Ronsmans, 2006). The authors used
qualitative techniques (key informant and indepth interviews and focus group
discussions) to examine the feasibility of home- versus facility-based delivery from the
perspective of 13 skilled birth attendants. Another study that was undertaken in a rural
district in Western Uganda also found that women’s adherence to traditional birthing
practices and beliefs that pregnancy is a test of endurance remained one major reason
women chose high risk options for delivery even in complications (Kyomuhendo, 2003).
In Ghana, a study by Bezzano et al. (2008) in the then Kintampo district (currently
Kintampo North and South districts) confirmed the strong influence of cultural beliefs in
shaping women’s choice of delivery site. The authors found that most women in the
district delivered at home instead of seeking for skilled care in health facilities because
they believed that home delivery raised a woman’s status in her community, while
seeking skilled attendance lowered it.
Religion
Some studies have also provided evidence on the strong association between religion
and women’s reproductive behaviour. A study in India by Hazarika (2010) found that
Muslim women were less likely to use services than women from other religious
backgrounds. In Ghana, Gyimah, Takyi, & Addai, (2006) for instance, analysed aspects
of the data from the 2003 Ghana Demographic and Health Survey and found that
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religious affiliation was a significant factor in maternal healthcare use with Christian
women more likely to use such services than Moslems and Traditional worshippers.
Whereas the use of prenatal professional care was almost universal (95%) for protestant
women, only 75 percent of traditionalists used professional care during the prenatal
period. Similarly, Doku, Neupane and Doku (2012) found that Christian and Moslem
women were more likely to have trained delivery assistants compared to their
counterparts who practised traditional belief.
2.9 Summary
From the empirical studies reviewed, the literature is emphatic regarding the significant
impact of demand-side factors as maternal education, place of residence, age, parity,
distance to health facilities and costs of transport on utilization of supervised care at
birth. Health system factors such as; the availability of equipment and supplies,
provision of information on maternal healthcare services, staff attitude, quality of care
and costs of care have also been noted as critical to the use of maternal healthcare
services.
Among the factors enumerated in the literature, costs of accessing care features
significantly as a major constraint to accessing care for households (Fotso, Ezeh and
Oronje, 2008; Babalola and Fatusi, 2009; Gabrysch and Campbell 2009; Jammeh,
Sundby, and Vangen, 2011; Narh and Owusu 2012). Addressing challenges associated
with costs is largely beyond the remit of the individual woman. There is, therefore, a
growing interest by national governments particularly within the African region to
reduce financial barriers to healthcare generally but with special emphasis on high
priority services as maternal healthcare. Most of the literature reviewed either focus on
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how demand-side or supply-side factors influence access to maternal healthcare services
but do not explain how they interplay to affect access to services. This study tries to
bridge this knowledge gap by looking at how both individual/household and health
system factors interplay to affect the use of delivery services.
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Chapter three: Theoretical background
3.1 Introduction
The theoretical chapter begins with a discussion on theoretical discourses on healthcare
use and access to medical services. It concludes with an explanation of the conceptual
framework for the study.
3.2 Theoretical discourse on access to and use of healthcare services
The study adopted an integrated conceptual framework developed by modifying Aday
and Andersen’s (1974) theoretical model of access to medical care. Four components of
Aday and Andersen’s model, health policy, characteristics of the healthcare delivery
system, characteristics of the population at risk and consumer satisfaction were adopted.
The framework introduces two additional components, (husband/partner characteristics
and community-level accessibility factors), noted to be relevant for the study context.
The conceptual framework provides the basis for understanding the theoretical
perspective within which different factors mediate to explain women’s access to and use
of supervised care at birth in the study area.
Explanatory models/frameworks for the study of healthcare utilization have been
developed and employed in previous researches. The behavioural model by Andersen
and Newman (1973) is one of the most frequently used frameworks for analysing factors
associated with healthcare use (Phillips, Morrison, Andersen, & Aday, 1998; Sunil,
Rajaram, & Zottarelli, 2006). The model suggests that people’s use of health services is
a function of their predisposition to use of services, factors which enable or impede use,
and their need for health care (Andersen, 1995). The model has received some
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criticisms. For example, it has been criticised for emphasizing on the characteristics of
the population at risk, neglecting those of the health provider. The model also failed to
recognise the role of perception of the efficacy of the health system and of what
constitutes illness, as impeding factors of need (Bour, 2004).
Models developed afterwards took into consideration some of those criticisms. For
instance, Aday and Andersen (1974) added more variables to those captured in the
behavioural model by Andersen and Newman (1973) to develop the framework for the
study of access to medical care. According to the authors, a basic explanation to
studying access to healthcare which includes maternal healthcare may be conceptualized
as proceeding from the promulgation of a health policy objective, through a description
of the characteristics of the healthcare delivery system and of the population at risk to
the actual utilization of healthcare services and consumer satisfaction with these
services. They described the characteristics of the population and of the delivery system
as input factors, and utilization of health services and consumer satisfaction as output
factors, both of which influenced by health policy. Aday and Andersen’s’ model is
presented in Figure 4.1.
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Figure 3.1: A Framework for the study of access to health services
Source: Aday and Andersen, 1974
The framework above highlights the interrelationships between the core components
necessary for operationalizing the concept of access to healthcare. From the diagram,
health policy (as for instance the fee exemption policy for maternal deliveries) may be
seen as intended to directly affect characteristics of the health delivery system as for
instance increasing both financial and infrastructural resources available for specific
Health Policy Financing
Education
Manpower
Organisation
Utilization of health
services - Type
- Site
- Purpose
- Time interval
Characteristics of the
population at risk - Predisposing
Mutable
Immutable
- Enabling
Mutable
Immutable
- Need
Perceived
Evaluated
Consumer satisfaction - Convenience
- Costs
- Coordination
- Courtesy
- Information
- Quality
Characteristics of the
health delivery system - Resources
Volume
Distribution
- Organisation
Entry
Structure
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healthcare needs. A health policy could also be directed at changing certain
characteristics of healthcare delivery for the population at risk for instance, heavily
subsidizing the cost of healthcare for poor and vulnerable groups including pregnant
women and children. The variables specified under health policy therefore relates to
how a given policy can influence healthcare financing, education and information
dissemination to improve manpower capacities and organization of care across different
units of the healthcare delivery system
The second major component, the health delivery system in turn may directly affect
utilization patterns and the satisfaction of consumers with the particular delivery care
being offered. These effects are determined by the structural arrangement (how care is
provided when patients enter a facility) of the facility and not necessarily mediated by
the properties of potential users. The delivery system is characterized by two main
elements namely resources and organization.
Resources are the labour and capital devoted to health care and this includes health
personnel, structures in which healthcare and education are provided, and the equipment
and materials used in providing health services. Organization on the other hand,
describes what the system and individuals working in institutions do with their
resources. It refers to the manner in which medical personnel and facilities are
coordinated and controlled in the process of providing medical services. Organization is
further explained by two core components which are entry and structure. Entry refers to
the process of gaining entrance to the system (e. g. travel time, waiting time etc.).
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Structure, the second component of organization describes the characteristics of the
system that determines what happens to the patient following entry into the healthcare
system (e. g. who he/she sees, how he/she is treated etc.) (Anderson & Newman, 2005)
Further, the healthcare delivery system may also impact on the characteristics of the
population and thereby indirectly affect its utilization of services and consumer’s
satisfaction with care, as for instance the expansion of healthcare infrastructure serving
as an enabling factor for increased access to care.
On the other hand, the characteristics of the population at risk may directly affect use
and satisfaction independent of the health delivery system properties. The model
outlines three major characteristics namely predisposing, enabling and need components
of the individual that could serve as core determinants to the use of healthcare. The
predisposing component includes those variables that describe the ‘propensity’ of
individuals to use services. These include age, sex, religion, education and values
concerning health and illness. The enabling component describes the ‘means’
individuals have available to them for the use of health services. This includes both
resources specific to the individual and his/her family (e. g. income, insurance coverage
etc.) and attributes of the community, (e.g. rural-urban, region). The need component
refers to illness level. Anderson and Newman (2005) describe these characteristics as the
individual determinants of utilization.
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Finally, the double-headed arrow between utilization and satisfaction in the diagram,
suggests a sequence in which over time, the utilization of services invariably influences
a consumer’s satisfaction with the system, and in turn, the satisfaction or dissatisfaction
she experiences from an encounter with care received from a healthcare centre
influences her subsequent use of services. Utilization of health services is characterized
in terms of its type, site, purpose and the time involved. The type of utilization refers to
the kind of service received and who provide it: doctor, nurse, midwife, or pharmacist.
The site of the medical care encounter refers to the place where the care was received for
instance, in a physician’s office, a theatre, hospital/clinic outpatient department,
emergency room etc. The purpose of a visit means whether it was for preventive, illness
related or for emergency care.
The time interval for a visit may be expressed in terms of contact, volume, or continuity
measures. Contact refers to whether or not a person entered the medical care system in a
given period of time; volume referring to the number of contacts and revisits in a given
time interval and continuity referring to the degree of linkage and coordination of
medical services associated with a particular health condition (Aday & Andersen, 1974;
Andersen & Newman, 2005).
Consumer satisfaction on the other hand, refers to the attitudes towards the medical care
system of those who have experienced it. It measures users’ satisfaction with the
quantity and quality of care actually received. Consumer satisfaction is best evaluated in
the context of a specific, recent, and identifiable experience of medical care seeking.
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Dimensions of satisfaction that seem relevant to consider in eliciting peoples subjective
opinions on access to healthcare could include; satisfaction with the convenience of
care, its coordination and cost, the courtesy shown by providers, information given to
the patient about dealing with a condition and the patient’s judgment about the quality
of care received (Aday and Anderson, 1974). Explanations on consumer satisfaction
with healthcare have however been criticized for its subjective nature due to
considerable difficulties in conceptualizing and measuring satisfaction (Sitzia & Wood,
1997; D'Ambruoso, Abbey, & Hussein, 2005).
The present study adapted this model as it highlights the critical role of health policy and
the characteristics of the health care system in influencing healthcare use and this is the
central focus of this work. Additionally, compared to the behavioural model, the model
includes the complexity of healthcare access and use in both developed and developing
countries. The model, however, did not recognize the influence of other core variables
common to most developing and particularly African settings as distance and cost of
travel to a facility, socio-cultural beliefs and the critical role of husband/partner
demographic and socio-economic status in determining healthcare use. These variables
are incorporated in the conceptual framework of the study (Fig. 4.2) which largely
contains aspects of Aday and Andersen’s (1974) model which are relevant to this study.
The choice of the model for this study is also informed by the fact that, the model has
been widely used by several studies in the discipline of public health and health
research. Some studies that looked at health care use particularly regarding health care
access and use within specific interventions adapted different aspects of the model
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(Ivanov, 2000; Bour 2004; Law, Wilson, Eyles, Elliott, Jerrett, Moffat, Luginaah, 2005;
Posse, Meheus, Van Asten, Van Der Ven, & Baltussen, 2008).
Law, Wilson, Eyles, Elliott, Jerrett, Moffat, Luginaah, (2005) for instance employed
Aday and Andersen’s (1974) framework in their study in which they examined local
level variations in access to and utilization of healthcare services across four district
neighbourhoods in Hamilton, Ontario, Canada. The paper, however, suggested an
extension of the framework to include the notion of place and space in explaining
determinants of healthcare use.
Posse, Meheus, Van Asten, Van Der Ven, and Baltussen (2008) used the conceptual
framework adapted from Aday and Andersen’s (1974) framework to examine barriers to
accessing antiretroviral treatment in developing countries by reviewing nineteen studies
that have been undertaken on the subject. The study adapted the ‘health policy’,
‘healthcare delivery system characteristics’ and ‘population characteristics’ components
for the conceptual framework.
Bour (2004), for instance, adapted aspects of Aday and Andersen’s (1974) model as well
as the behavioural model but introduced other variables to explain healthcare use. In his
conceptual framework, he adapted the health policy, patient characteristics and the
healthcare resources aspect of the characteristics of the healthcare delivery system
components of the framework but also introduced other factors as spatial setting,
physical accessibility, physician characteristics, and health outcomes.
Ivanov (2000) examined how Aday and Andersen’s (1974) framework can be applied to
explain prenatal care use and satisfaction with services in St. Petersburg, Russia. The
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author adapted three components of the model namely, characteristics of population at
risk, utilization and patient satisfaction for his study. Using multiple regression and path
analysis methods, the author found that predictors of prenatal care utilization and
satisfaction were different from those posited in the theoretical model. The author
therefore concludes that, the model was more specific to explaining the United States
healthcare system where the model originates from and does not have the potential to
fully explain the situation of other regions of the world.
Andersen (1995) has also developed a more recent model that outlines four major
components explaining healthcare use. These are environment, population
characteristics, health behaviour and outcomes. The model tries to explain the
interrelationships between personal practices, use of health services and health outcomes
as well as the relationship between population characteristics and health outcomes. Bour
(2004) has, however, noted that the model by Aday and Andersen (1974) failed to
recognize the role of health policy and health personnel as critical factors to healthcare
use particularly in developing countries.
A more recent theoretical framework was presented by Andersen and Newman (2005).
The framework emphasizes the importance of three main components in explaining
healthcare use. These are the characteristics of the healthcare delivery system; changes
in medical technology and social norms relating to the definition and treatment of
illness; and individual determinants of utilization. The three factors are specified within
the context of their impact on the healthcare system. The recent model introduces both
demand and supply-side variables that can largely explain healthcare use within the
context of most developing countries but failed to highlight the role of health policy.
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3.3 Conceptual Framework
Figure 3.2 depicts the conceptual framework which supports, informs, and guides the
study. It is an adapted version of Aday and Andersen’s (1974) model. Aspects of the
original model (Fig. 3.1) adopted for the conceptual framework are health policy,
characteristics of the healthcare delivery system, characteristics of the population at risk
and consumer satisfaction. In addition to these, the framework introduces other
components which are relevant to the study context. These fall under the broader
headings of community-level accessibility factors and husband/partner characteristics.
The framework primarily describes the relationship between health policy,
characteristics of the healthcare delivery system as well as that of women of
reproductive age, husband/partner background characteristics, community-level
accessibility factors and consumer satisfaction with care received and use of delivery
services.
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Figure 3.2 Conceptual framework of maternal healthcare service utilization
Source: Author’s conceptual framework, adapted from Aday and Andersen
(1974)
The framework has “utilization of free delivery services” (a component of care provided
under the fee exemption policy for maternal healthcare) as the dependent (outcome)
variable. Influencing delivery service use and showing a relationship with it are the free
maternal healthcare policy, characteristics of women of reproductive age, characteristics
Community-level
accessibility factors
Quality of roads
Travel time
Distance
Beliefs about
pregnancy and
childbirth
Use of ‘free delivery’
care
Information
Delivery services
Husband/Partner
characteristics
Age
Education
Employment status
Parity
Consumer satisfaction
Costs
Convenience
Courtesy
Coordination
Information
Quality
Characteristics
of women of
reproductive
age
Predisposing
Age
Parity
Religion
Education
Ethnicity
Marital status
Employment
status
Enabling
Place of
residence
Insurance
membership
status
Need
Perceived need
for supervised
delivery care
Free maternal
healthcare policy
Education
Service provision
Characteristics of
healthcare
delivery system
Distribution of
staff
Volume of
resources
Organization of
care
Staff competence
Staff attitude
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of the healthcare delivery system, husband/partner characteristics, community-level
accessibility factors and consumer satisfaction.
All the factors outlined in the framework are very critical to understanding the use of
maternal healthcare services particularly from the consumer’s perspective. Health
policy, in this instance the fee exemption policy for maternal healthcare is a very
important determinant of skilled care use at birth. The introduction of fee exemption
indirectly influences healthcare use for the consumer as payments for services received
at the facility level are covered by the policy. The free delivery policy can also directly
affect maternal healthcare service provision in designated facilities if for instance
adequate equipment and supplies are made available as part of the policy intervention.
The healthcare delivery system directly affects utilization patterns and the satisfaction of
consumers with the particular delivery care being offered. These effects are determined
by the structural arrangement (how care is provided when patients enter a facility) of the
facility (Anderson & Newman, 2005).
On the other hand, independent of the healthcare delivery system properties, all the
characteristics of women of reproductive age: predisposing (for instance, age, religion,
education, employment, marital status, parity etc.), enabling (e.g. member of a health
insurance scheme, place of residence) and need (perceived need for supervised delivery
care) are crucial to the utilisation and satisfaction with ‘free delivery’ care in Ghana.
Additionally, the background characteristics of women can also influence how one is
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affected by certain community level accessibility factors influencing maternal healthcare
service use. Some studies have for instance documented the strong relationship between
women’s religion and their health seeking behaviour (Gyimah, Takyi, & Addai, 2006;
Doku, Neupane & Doku, 2012).
The socio-demographic and particularly economic statuses of spouses or partners have
been noted to influence decisions made by women regarding choice of delivery places in
many developing economies. Doku, Neupane and Doku (2012) in their study that
explored factors determinants of type of delivery assistance used by Ghanaian women.
Similarly, Smith, Tawiah and Badasu (2012) using quantitative methodologies to
explore the relationship between selected socio-economic variables, women’s status and
choice of place of delivery, found the educational status of women and that of their
partners as core predictors of choice of place of delivery.
A number of broader community-level accessibility and socio-cultural factors also play
a crucial role in healthcare utilisation in most parts of Ghana particularly in rural areas.
These areas are largely plagued by poor roads and poor transportation network and
peoples adherence to detrimental cultural beliefs about pregnancy and delivery. The
extent to which women are directly or indirectly affected by these factors is also largely
influenced by their spatial location across rural and urban divides (Babalola & Fatusi,
2009; Elo, 1992; Kyomuhendo, 2003).
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In Ghana, there are marked disparities in access to skilled care at birth between rural and
urban communities. Deliveries in urban areas are more than twice as likely as those in
rural areas to be assisted by skilled attendants (86.0% in urban areas, compared with
39.2% for rural areas) (Ghana Statistical Service, Ghana Health Service, & ICF Macro,
2009). Other studies have also confirmed the crucial role of place of residence
(rural/urban) in determining healthcare use (Babalola & Fatusi, 2009; Elo, 1992;
Kyomuhendo, 2003).
The conceptual framework also highlights a relationship between use of ‘free delivery’
services and consumer satisfaction. The relationship suggests a sequence in which over
time or through a one-time experience with the use of delivery services, the satisfaction
or dissatisfaction a woman experiences influences her subsequent use of services.
Consumer satisfaction may be influenced by the quality of care received from an
experienced nurse or midwife, staff attitude, information received on health condition
and how services received were coordinated.
In relation to the original model by Aday and Andersen, (1974) (Figure 4.1), the
conceptual framework for the present study (Figure 4.2) introduces variables on
husband/partner, which to an extent influence use of maternity services in Ghana and
many other developing countries. Again, the influence of community-level accessibility
factors on utilization was not illustrated in the original framework by Aday and
Andersen (1974), but the literature highlights its major role in healthcare use in
particularly developing economies.
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The framework for the present study broadly seeks to explain the dynamics of skilled
care use at birth under a given maternal healthcare policy, and the critical factors to
understanding delivery service use under the policy. It attempts to fill gaps created by
earlier frameworks developed to explain healthcare use, and which indeed have formed
a basis for its structuring.
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Chapter four: Study Area and Methodology
4.1 Introduction
The chapter presents a detailed description of the methodology employed for the study.
It is divided into six broad sections. The first section provides a description of the study
area and the justification for the selection of the area. Section two presents the study
design. This is followed by a description of the variables. The fourth section describes
the study population and the sampling approach. The fifth section outlines the data
collection processes whiles the final section presents the data analysis approaches.
The primary aim of the study was to assess women and healthcare provider perspectives
and experiences with delivery care use under Ghana’s fee exemption policy for maternal
healthcare. The choice of methodology was largely informed by those adopted by
similar studies. Subsequently, both quantitative and qualitative approaches were used.
For the quantitative analysis, Chi-square tests and binary logistic regression models were
employed using indicators such as the woman’s age, education, place of residence,
marital status, employment status, husbands’ education, husbands’ age, husbands’
employment status, awareness and knowledge about the free delivery policy.
Qualitative information was collected on indicators such as the availability of equipment
and supplies; community-level barriers to accessing care; women’s perceptions about
the quality of care received and healthcare provider perceptions about resource
availability for providing care at the facility level. The data were collected using in-
depth and semi-structured interviews. The qualitative information was used to explain
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beneficiary women and healthcare provider experiences with provision and utilization of
supervised delivery care under the fee exemption policy for maternal healthcare.
4.2 Selection of study area
The sub-sections below present a description of why the Central region was selected for
the study as well as how the study districts were chosen. The section also outlines the
design. On selection of the study area, the study included primarily two levels of area
selection; district and localities, which was clustered into urban/rural areas and
with/without health facilities. The final selection included selection of households within
the localities.
4.2.1 Criteria for region selection
The Central Region was purposively selected by the researcher for the study based on
the following reasons: (i) the region was one of the first four pilot regions in which the
fee exemption policy for maternal deliveries was implemented in 2003. (ii) compared to
the three other pilot regions (Northern, Upper East and Upper West), the Central Region
has not witnessed improvements in skilled attendance rate particularly between 2008
and 2010 when services under the policy was administered through the NHIS (Data on
skilled attendance rates for the four pilot regions is presented in Table 5.1).
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Table 4.1: Annual percentage rates of skilled attendance at birth in the Central,
Northern, Upper East and Upper West Regions
Region 2008 2009 2010
Northern 26.0 36.1 36.8
Upper East 40.4 52.6 59.7
Upper West 40.6 36.7 46.5
Central 56.3 52.5 51.6
Source: Ghana Health Service 2009 and 2011 Annual Reports
(iii) The region had a maternal mortality ratio of 520/100,000 live births in 2011 (GSS,
2012), a ratio which is higher than the national average of 350/100,000 live births as at
the year 2012 (WHO, 2012). (iv) In 2012, the region was the second most densely
populated region after the Greater Accra region with a population density of 224 persons
per square kilometers. It had an estimated population of 2,201,863 of which
approximately 52.9 percent was rural (GSS, 2012).
4.2.2 District level selection
The selected districts are Assin North and the Cape Coast metropolitan area. The two
districts (Figure 5.1) were purposively selected from the seventeen districts of the region
for the study. The two districts compared to the others had the highest maternal
mortality ratios in 2012 (GHS, 2013) with Cape Coast having a ratio of 412 per 100, 000
live births and Assin North a ratio of 200 per 100,000 live births. All the other districts
had a ratio of less than 200 per 100,000 livebirths. Additionally, Assin North had a
predominantly rural population whilst the Cape Coast metropolis is predominantly
urban, a scenario that provides an opportunity to assess differences in care received
under the policy within rural and urban settings. The districts also differ in terms of the
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number and category of available health facilities (14 and 20 facilities for Assin North
and Cape Coast respectively). The 20 facilities within the Cape Coast metro comprise 4
hospitals, 2 Health Centres, 1 midwife/maternity home, 7 clinics and 6 CHPS centres.
Assin North on the other hand has only 1 hospital, 6 Health Centres, 3
Midwife/Maternity homes and 4 CHPS centres (GHS, 2013).
Figure 4.1: Map of Study districts
4.3 Study design
The aim of the study was to explore the perceptions and experiences of women and
healthcare providers with delivery care utilization under the fee exemption policy for
maternal deliveries. Previous studies with similar aim employed both quantitative and
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qualitative methods, although quantitative methods were more frequently used. Studies
that looked at the factors that affect healthcare use have mostly used quantitative
techniques such as univariate, bivariate or multivariate logistic regression analysis and
ordered logit models (Elo, 1992; Hounton et al. 2008; Fotso, Ezeh, Madise, Ziraba and
Ogollah, 2009; Hazarika 2010; Smith, Tawiah and Badasu, 2012). Those that
investigated women’s accounts, interactions and experiences with healthcare use have,
however, employed qualitative techniques such as, focus group discussions (FGDs), in-
depth interviews and observations (D'Ambruoso, Abbey, & Hussein. 2005, Amooti-
Kaguna & Nuwaha, 2000). Both quantitative and qualitative methods were employed in
this study to allow for exploring both experiences and predictors of use of delivery care.
Quantitative data was collected through a cross-sectional survey whiles qualitative data
was collected through in-depth interviews. The instruments used in the data collection
were structured questionnaire, semi-structured and in-depth interview guides. The
structured questionnaire was administered to elicit information on knowledge and use of
delivery services under the free delivery policy among women of reproductive age (20-
49 years) with children aged less than one year. The survey collected information on the
socio-demographic characteristics of the women, their wealth status, pregnancy and
delivery history and their knowledge and use of delivery services provided under the
free delivery policy.
Data on women’s experiences and satisfaction with healthcare received under the policy
were collected through in-depth interviews. A cross-section of 16 mothers who delivered
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their most recent birth under the policy was selected. Although Focus Group
Discussions is known to provide some in-depth information on women’s experiences,
the method was not chosen as studies have shown that women were reluctant to talk
about their personal experiences about pregnancy and delivery in a focus group setting
(D'Ambruoso, Abbey, & Hussein, 2005).
Finally, data on healthcare provider perceptions and experiences with service provision
under the policy was collected using semi-structured interview guides. The participants
included in these interviews were Senior/Principal and Junior Midwives from selected
healthcare facilities.
4.4 Description of study variables
4.4.1 Dependent Variable
The dependent variable is use of delivery care under the fee exemption policy. It was
derived from the question, “Did you deliver for free under the ‘free delivery policy’ or
you paid for delivery services?” The dependent variable was measured by using the
labels 1 and 2 with 1 being ‘Delivery for free’ and 2, ‘Delivery not for free’. It is the
main outcome variable of interest in the conceptual framework developed for the study,
4.4.2 Independent variables
The independent variables were selected with reference to previous studies. All variables
selected are captured in the conceptual framework adapted for the study. They comprise
those related to the socio-demographic characteristics of women and their partners
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(Babalola & Fatusi, 2009; Chirdan & Envuladu, 2011; Doku, Neupane & Doku, 2012);
health system and health policy initiatives (Bezzano et. al 2008; Ansong-Tornui et al.,
2007); community-level access factors mostly related to transportation and distance to
facilities and cultural perceptions about pregnancy and childbirth (Kyomuhendo, 2003;
Jammeh, Sundby, & Vangen 2011; Narh & Owusu, 2012).
Socio-demographic characteristics of women and their husbands/partners:
The independent variables selected on the socio-demographic characteristics of women
and their husbands/partners included age, religion, level of education, employment
status, marital status, parity, place of residence and ethnicity. All the variables were
quantifiable and were defined and measured as stated below.
Variable Description
Age Age was defined as total age attained at time of interview. The
individual ages of women were categorized into 3 groups with
ages 20-29 assigned a value of 1, age 30-39 assigned a value of
2 and ages 40-49 assigned a value of 3
Education Education was defined as completed educational status and was
ranked from 1 to 5 with label 1 for No formal education, 2 for
primary education, 3 for Middle/JHS, 4 for Secondary/SHS/
Vocational/Technical education, 5 for higher than Secondary
education.
Employment Employment status was defined as the category of work
respondents were engaged in and was ranked from 1 to 5 with 1
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for ‘unemployed’, 2 Self-employed, 3 Paid employee, 4 Paid
informal worker and 5 Others forms of employment mostly
seasonal employment.
Marital Status The marital status of respondents was ranked into three
categories. Those who were currently married or cohabiting
were assigned rank 1, formerly married, rank 2 and single/never
married women given rank 3.
Parity Parity refers to the total number of live births a woman had and
was ranked from 1 to 5 with 1 for parity one, 2 for parity two, 3
for parity three , 4 for parity 4 and 5 for parity five and above.
Place of residence Place of residence was defined by the location of respondents’
household across rural and urban divides and was ranked 1 and
2 with 1 being urban and 2, rural.
Ethnicity Ethnicity was defined by one’s place of origin and primary
language spoken. It was presented under 5 categories.
Respondents from the Akan ethnic group (Fante, Asante,
Akyem, Brong) were assigned rank 1, Ewes were assigned rank
2. Ga-Adangmes were assigned rank 3, Guans rank 4 and
Hausa’s rank 5. In the quantitative analysis, respondents who
spoke Ga-Adangme, Guan and Hausa were re-coded into one
category as each of them constituted a very small percentage of
the sample which made it difficult to make generalized
conclusions on them.
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Healthcare delivery system characteristics
The variables below were used to assess how existing healthcare delivery system affects
the provision and utilization of care under the free delivery policy. These were analyzed
qualitatively
Availability of skilled attendant: The WHO’s definition of skilled personnel was
applied in this study. WHO defines a skilled attendant as people with midwifery
skills (midwives, doctors and nurses with additional midwifery education) who
have been trained to proficiency in the skills necessary to manage normal
deliveries and diagnose, manage or refer obstetric complications (Hazarika,
2010)
Resource availability for providing services under the policy - availability of
needed equipment, supplies and physical health facility structure
Processes/procedure for providing delivery services under the policy at the
facility level - Healthcare giving processes when a client enters a facility (e. g.
whom he/she sees, how he/she is treated etc.)
Challenges to providing efficient care under the free delivery policy from the
perspective of healthcare providers
Healthcare provider opinions on successes in implementing the free delivery
policy, failures and recommendations for improvement
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Community-level access factors
Community-level access factors considered related to travel time to preferred health
facility measured as the number of hours and minutes spent in reaching preferred facility
to deliver. A second variable considered the cost of transportation to and from preferred
health facility and was measured as the total cost of transportation to and from a
preferred facility where a woman delivered her most recent birth. A final variable looked
at women’s socio-cultural beliefs about pregnancy and delivery and was assessed by the
kind of traditional/cultural treatments women received for themselves and their babies
for their most recent birth.
The free delivery policy
The variables for the free delivery policy were awareness about the ‘free delivery’
policy and knowledge about benefit package for the ‘free delivery’ policy. Awareness of
the free delivery policy was defined as having heard about the existence of the policy
and ranked 1 for a ‘Yes’ and 2 for a ‘No’. Knowledge about the policy was also ranked
as 1 and 2 with 1 referring to answering yes to having knowledge about the full benefit
package of the policy and 2 for answering no to having knowledge about the policy.
Consumer satisfaction variables
The following variables were considered in accessing women’s satisfaction with
delivery care received under the free delivery policy for their index child. Information
on the variables were collected, analyzed and reported qualitatively.
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Variable Description
Information received about delivery and
post-delivery care package
This was defined as women’s views on the
adequacy of information received on
delivery and post-delivery care
Coordination of healthcare among
providers
This was defined as how women perceived
the level of collaboration among healthcare
providers who assisted with deliveries
Convenience of care from the free
maternal policy
Convenience of care was defined by
women’s perceptions of the extent to
which the policy actually and adequately
catered for the costs of delivery
Attitude of healthcare providers
Women’s perceptions about the demeanor
of the healthcare providers towards them
while interacting with them (e.g. respect,
empathy) or looking down on them, being
disrespectful, shouting, etc on them
Quality of care
This was defined as women’s opinions
about how health providers communicate
with clients and address their health-
related concerns. Quality of care also
includes women’s perceptions of the skills
healthcare providers demonstrated while
assisting them
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4.5 Target group and sampling approach
4.5.1 Study participants
The primary study population was mothers of reproductive age (15-49 years) with
children under one year of age. The choice of women with these characteristics was
based on the study goal that aims to examine factors influencing delivery service use
under the ‘free delivery’ policy and the experiences of women who have benefitted from
the policy. The target population therefore served as potential users and benefactors of
services under the policy. Secondly, mothers whose most recent birth occurred 12
months prior to the survey are most likely to recall and give a better account of their
experiences.
A second group of study participants were healthcare providers (senior and junior
midwives), District Public Health Nurses of the selected districts and the Regional and
District Directors of health services for the selected region and districts.
4.5.2 Sample Size Determination
The sample size was calculated by using the formula proposed by Kish (1965) since the
population under study was homogeneous and the total population of mothers with at
least a child under one for the entire study area was not known. The Sample Size is
given by:
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2
2
PQZn
Where:
Z = The standard normal deviation at 95% confidence level (1.96)
P = Estimated prevalence of the problem under study (estimated to be 50%)
Q = 100% - P (or 1-P)
2 = The precision or maximum acceptable error the investigator is willing to
accommodate (5%)
Sample size =384
Assumptions
Non-response rate = 10% of estimated sample size (38)
Final Sample = 384+38 = 422
The total sample size calculated for the study was allocated to the two districts
proportionate to their population sizes based on census data for the districts. The total
population derived for each district was subsequently sub-divided into rural and urban
samples.
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Appropriate sample sizes for the selected districts
Districts Assin North Cape Coast Metropolitan
area
*Total district
populations
161,341 169,894
District population
proportions
161,341 x 100% =48.7%
331,235
169,894 x 100% =51.3%
331,235
District sample sizes (n) 206 (48.7% *422) 216 (51.3%*422)
* 2010 Population and Housing census
For each district, the rural/urban sample sizes were again allocated proportionate to the
rural and urban population proportions reported by the 2010 census data. The rural and
urban sample sizes for the two districts are therefore presented as follows:
Districts Assin North Cape Coast Metropolitan
area
*Total urban population 57,710 130,348
*Total rural population
proportions
103,631 39,546
% district urban
population
57,710 x 100% = 36%
161,341
130,348 x 100% = 77%
169,894
% district rural
population
103,631 x 100% = 64%
161,341
39,546 x 100% = 23%
169,894
District urban sample
sizes (n)
74 (0.36 x 206) 166 (0.77 x 216)
District rural sample sizes 132 (0.64 x 206) 50 (0.23 x 216)
* 2010 Population and Housing census
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4.5.3 Sampling steps for household survey
A multi-staged sampling approach was used to select localities, houses and the primary
respondents for the study. A summary of the sampling approach is presented
diagrammatically and is attached as appendix 5. The sampling technique has been used
in previous Public Health studies (Kyomuhendo, 2003; Amooti-Kaguna, & Nuwaha,
2000; Ridde, & Diarra. 2009; Narh & Owusu, 2012).
The first stage involved the selection of the study localities from the two districts
selected (Cape Coast Metropolitan area and Assin North Municipal area) for the study.
As a first step, the various localities (as defined by the Ghana Statistical Service) of the
selected districts were stratified into two, urban and rural areas. This was followed by
the clustering (putting together) of all rural and urban localities together. In each district
therefore, all localities that fell under the urban part of the district were clustered
together. The same approach was employed for the rural localities.
For the second stage, the individual urban and rural clusters of localities for each district
was further stratified into two, with localities that have health facilities providing
supervised delivery care clustered together and those without facilities providing
supervised delivery services also clustered together. This was followed by the selection
of localities for the respective districts based on their sizes (urban/rural) and the
existence or non-existence of a health facility in the locality (Figures 5.2 and 5.3). A
simple random approach was used. One locality was selected from the rural cluster of
localities with health facilities for each district and another one locality with health
facility for the urban cluster of localities for each study district. The same approach was
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employed in selecting rural and urban localities without health facilities for both study
areas.
Figure 4.2: Map of the Cape Coast Metropolitan Area showing its localities and
health facilities
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Figure 4.3: Map of the Assin North Municipal Area showing the location of its
localities and health facilities
A single locality was selected for each cluster of localities because the population of the
region is largely homogeneous and dominated by Akans with Fante speakers being in
the majority (GSS, 2012). Localities with and without facilities were also selected based
on the assumption that women living within the location of a health facility will tend to
use the services more than those without a facility. Additionally, rural and urban
localities were selected to represent variations in locality sizes and access to maternal
healthcare facilities. The distribution of the selected localities for the study districts is
presented in Table 4.2
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Table 4.2 Sampled localities in the two study districts
District Urban localities Rural localities
Cape Coast Metropolitan
Abura (WF) Abakam (NF)
Ekon (NF) Duakoro (WF)
Assin North Municipal Assin Fosu (WF) Assin Bediadua (WF)
Assin Dompem (NF) Atwerebuanda (NF)
(WF) = With Facility; (NF) = No Facility
Stage three involved the selection of households and eligible respondents. The
identification of households began with a surveillance exercise through the help of
assemblymen and healthcare volunteers in the respective localities. Having identified
households in which mothers eligible for the interviews resided, a complete listing
exercise was carried out for each locality to obtain an updated list of households with
eligible women with children aged less than one. A central point of each locality was
first identified and a household located at the central point was used as a starting point
for the identification of eligible households. The listing exercise provided us with the
opportunity to inform the locality of the study and seek for their assistance and co-
operation in providing us with the necessary survey information.
This was followed by the allocation of the samples to the individually selected localities
from the total samples calculated for each district. The total number of respondents
selected for the study was based on probability proportional to population size within
each segmented area. Based on the population distribution from the 2010 Population and
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Housing Census, a total sample of 206 and 216 were selected for Assin North and Cape
Coast metro respectively. For each district, rural and urban samples were obtained from
the total samples calculated. For each individual district, the calculated rural/urban
sample sizes were allocated to the selected rural and urban localities equally. Table 5.3
provides a breakdown of the sampled population allocated to each community.
Table 4.3 Sampled communities and their respective sampled respondents
District Locality Sampled Population
Cape Coast Metro Abura (U) 83
Ekon (U) 83
Abakam (R) 25
Duakoro (R) 25
Assin North Assin Fosu (U) 37
Assin Dompem (U) 37
Assin Bediadua (R) 66
Atwerebuanda (R) 66
(U) = Urban, (R) = Rural
From the sampling frame of mothers produced for each locality, a simple random
approach (writing the names of each eligible respondent on pieces of papers, shaking
them arbitrarily and selecting the required number from the whole) was later employed
to select the total number of respondents earmarked for each settlement or locality.
During the surveillance exercise and the subsequent production of the list/sampling
frame from which mothers were selected, careful consideration was given to the
following scenarios. In houses that had more than one household, a household that had a
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mother who falls within the sampling frame was selected. In instances where there were
two or more eligible households, both mothers were included in the list if their place of
delivery were different. If they happened to have similar characteristics a simple random
approach was used to select one (tossing of a coin). In some households, therefore, two
women with different characteristics were selected.
In-depth interviews with mothers
In addition to the questionnaire survey, a cross-section of the total number of women
interviewed was selected to share their experiences and accounts with delivery care
received under the policy. From the list of the total number of mothers who participated
in the questionnaire survey in each locality, a new sampling frame of mothers who
delivered their index child under the policy was created for each locality. At this stage,
the study was interested in understanding the experiences of women who actually
assessed delivery services under the policy for their most recent birth. The new sampling
frame was, therefore, created to allow for accurate selection of a sample of women who
had actually used delivery services under the policy.
A simple random approach was then used to select 2 mothers from each locality to share
their experiences with care received under the policy. The approach was used to ensure
that respondents are not selected based on the researcher’s own discretion. A total of 16
mothers who participated in the larger survey were interviewed on their delivery
experiences. Previous studies have used samples that relates closely to the number used
in this study (D’Ambouso et al 2005; Berry, 2006; Aboagye & Agyemang, 2013). The
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authors recognized the fact that qualitative interviews uncover the thoughts, perceptions,
and feelings experienced by informants which is mostly presented in words and not
numbers and, therefore, do not require a very large sample.
Interviews with healthcare providers
Finally, a two-stage approach was used to select healthcare providers who shared their
experiences with the implementation of the policy. The first stage involved the selection
of health facilities that provide antenatal, delivery and immunization/child welfare
services under the free delivery policy in the two districts from a sampling frame of all
categories of facilities that provide the services outlined above. The category of facilities
providing the afore-mentioned services in the study districts is presented in Table 5.3.
Table 4.3: Categories of health facilities selected for the study
District Facility type
Hospitals Polyclinics Health
Centres
Private
Maternity
Centres
Assin North
St. Francis
Xavier hospital
Fosu Fosu Rex Maternity
Clinic
Kushea Cecilia and
Sammy
Memorial
Clinic and
Maternity
Bereku
Bediadua
Central
Regional
hospital
Ewim
Polyclinic
Cape Coast
Central
Reproductive
The Saint
Maternity
Clinic
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Cape Coast
metropolitan
area
Health Centre
University of
Cape Coast
hospital
Adisadel
Health Centre
Baiden Ghartey
Memorial
hospital
Cape Coast
Metropolitan
hospital
To ensure that the specific experiences of the different health facilities is documented, a
simple random approach was used to select one facility (in instances where there is more
than one facility) from each category of facilities accredited to provide maternal and
child healthcare services under the policy.
In the Cape Coast Metropolitan Area, therefore, Cape Coast Metropolitan Hospital was
selected through a simple random approach from the 3 available hospitals. The only
Polyclinic (Ewim Polyclinic) was selected, 1 Health Centre (Adisadel Health Centre)
was selected from the 2 available and 1 Private Maternity Home (Baiden Ghartey
Memorial Hospital) which offers maternity services under the free delivery policy was
selected out of the two available. A similar approach was used for the Assin North
District. The district has only one hospital (St. Francis Xavier Hospital) and one
polyclinic (Fosu Polyclinic) and these were selected. One health Centre (Kushea health
Centre) was randomly selected from the 4 available and finally 1 Private Maternity
Clinic (Cecilia and Sammy Maternity Clinic) was randomly selected from the two
available.
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The second stage involved the selection of midwives from the identified health facilities.
A simple random approach was used to select two midwives, one senior/principal and
one junior in facilities with more than one midwife. A total of 8 midwives’ interviews (2
for each facility level) were conducted for the Cape Coast metropolitan area. In the
Assin North district, interviews were conducted with the sole midwives for the Kushea
Health Centre and Cecilia and Sammy Maternity Clinic as these facilities had only one
midwife at post. Two interviews each (for principal and junior midwives) were
conducted for the selected hospital and polyclinic in the district. The midwives were
interviewed on their knowledge about the policy, organisation and provision of care to
clients at accredited facilities and the strengths and weaknesses of the policy.
4.6 Primary data collection
Recruiting field assistants
The PhD student served as the principal investigator of the study and managed all
fieldwork and data collection and coordination activities. Four research assistants were
recruited to assist in the data collection exercise and one assistant recruited for data entry
and cleaning. In recruiting the research assistants, careful consideration was given to
their level of education (all tertiary level graduates), previous knowledge in interviewing
people and effectively documenting responses and understanding of the language and
culture of the study areas. Two days intensive training on appropriate translation of
questions into the local language, note taking, tape recording of interviews and
techniques for approaching would-be respondents and rapport building before the start
of interviews was given to all research assistants.
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Questionnaire survey with mothers
The questionnaire was first pre-tested to check for its appropriateness in providing the
required feedback from would-be respondents. This was done a week before the start of
final data collection exercise with mothers who had the same characteristics as the study
population but were not residents of the selected study communities. The pretesting was
done at Akotokyire, a locality within the Cape Coast metropolis. A few changes were
made to correct for repetitions and pre-coding errors after the pre-testing exercise.
The pre-tested questionnaire was later administered to 412 mothers out of the 422
sampled for the study as 10 respondents declined to participate in the study. The
questions were prepared in sections. The respondents were interviewed on the following
issues: their knowledge and perceived need of services provided under the free delivery
policy; their place of delivery for the most recent pregnancy; attendant at delivery;
whether they delivered their most recent birth under the free delivery policy or
otherwise; and who influenced their decision to deliver with the policy or otherwise.
Mothers who delivered with the policy were asked for reasons they made that choice.
Those who did not deliver with the policy were also asked to give their reasons for
choosing to deliver outside the free delivery package. There was also a section on the
background information of the respondents that asked questions on age, level of
education of the respondent as well as her partner/husband, marital status, parity,
employment status of the respondent and that of her partner/husband, and the religion
and ethnic affiliation for both the respondent and her partner/husband. All interviews
were conducted in the local Akan language (Twi or Fante)
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In-depth interviews with mothers
A total of 16 mothers who participated in the larger survey and delivered the index
children under the free delivery policy were interviewed on their delivery experiences.
Information collected from the interviews were on their knowledge about the actual
benefit package of the policy; the kind of delivery services they were offered for free;
the services they had to pay for if any; their reasons for delivering with the policy;
community-level barriers to accessing care under the policy; their perceptions of the
quality of care received; and satisfaction or dissatisfaction with care received.
Interviews with healthcare providers
In-depth interviews were held with healthcare providers (1 senior/principal and 1 junior
midwife) selected from the eight different healthcare facilities. They were interviewed
on their knowledge about the policy; the processes involved in providing delivery care
(how delivery care is organized) under the policy at the facility level; their perceptions
on resource availability for providing care under the policy; their assessments of
women’s use of delivery services under the policy; their opinions on the overall
performance of the policy and recommendations for improvement. The interviews were
conducted in either English or Fante depending on which language was appropriate for
the respondent.
Finally, there were semi-structured interviews with selected key informants in health at
the district level. They were the Deputy Director of Public Health at the Central
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Regional Health Directorate, the District Directors of Health for the selected districts
and the Metro Director of Nursing Services and Municipal Public Health Nurse of the
Cape Coast Metropolitan Area and the Assin North Municipal Area respectively. The
afore-mentioned key informants were interviewed on questions related to the Free
maternal healthcare policy’s implementation arrangements at the district. They also
provided information on how maternity services are provided within facilities and their
opinions on the overall performance of the policy. All the interviews were conducted in
English as respondents were well educated and, therefore, could understand and answer
to the questions written in English.
Problems encountered during fieldwork
Problems faced during interviews with mothers
The problems encountered during the household survey were minimal. The fact that all
the respondents were mothers and for some lactating as well, we were fortunate to meet
them in their homes either during the first visit or an arranged one. There was, however,
the challenge of getting them to concentrate fully on the interviews as they had to attend
to their children and other household chores whiles responding to the interviews.
Additionally, due to the large number of households in a house particularly in the rural
communities, issues of confidentiality could have been compromised. In some instance,
neighbours attempted to answer questions for the respondent. We were, however, able to
prevent them from doing so as we explained to them of our need to solicit for the ideas
and opinions of an individual respondent.
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Problem faced during interview with providers and key informants
The main problem encountered with interviewing the midwives had to do with their
availability for an interview due to the very busy nature of their work. Some managed to
grant the interview whiles on duty but others had to be interviewed after several follow-
up schedules. None, however, declined to share their experiences and opinions on
aspects of the free delivery policy as well as the challenges with service delivery under
the policy.
All selected key informants were also contacted and interviewed on scheduled days. The
challenge here was with making the initial contact with these informants because of their
seemingly busy schedules. After the first meetings, however, they were happy to be
available for the interview. One informant specifically visited the office for the
interview even whiles on a well-deserved annual leave.
4.7 Data Processing and Analysis
4.7.1 Analysis of Qualitative data
All qualitative data collected were analyzed using the thematic analysis approach. The
approach involves identifying, analyzing and reporting patterns (themes) within a given
set of data for further analysis (Braun, Virginia, & Clarke, 2006; Hycner, 1985).
The qualitative data comprised primarily interviews conducted with mothers on their
experiences with delivery care received and with healthcare providers on their
experiences with provision of care as well as district level key stakeholders in health.
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The information collected from the interviews were transcribed and translated into
English, then reviewed and coded to identify pertinent themes. All the responses from
the interviews with the mothers were put together in categories of study district,
rural/urban locations, and type of facility in which delivery took place. The responses
from the healthcare providers (midwives) were also categorized by study district, type of
facility and rank of midwife. The responses from the district level stakeholders in health
were categorized by district.
The data were analyzed by reading and re-reading to identify responses relevant to
answering the research objectives. As a first step, the responses given by all respondents
for each question by the healthcare providers and mothers and key informants in health
were put together to assess any similarities and differences. The responses were then
categorised into themes and sub-themes. The themes generated captured something
important about the data in relation to the research objectives and represented some level
of patterned response or meaning within the data set (Braun, Virginia, & Clarke, 2006).
The results were, therefore, discussed according to the pertinent themes. Some of the
findings from the interviews were presented verbatim but the greater proportion was
summarized. Feedback from the qualitative interviews was solely used to answer one
research question that sought to explore the experiences of clients and service providers
about the fee exemption policy for maternal healthcare. Some quotations from the
qualitative interviews were also relevant for explaining findings from the quantitative
analysis.
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4.7.2 Quantitative data analysis
The analysis of the quantitative data involved the computation of percentage and mean
distribution of background characteristics of respondents as well as the level of
awareness and use of delivery services under the free delivery policy. Additionally,
Pearson’s Chi-Square test was used to test for the statistical associations between the
dependent variable ‘use of delivery care under the delivery fee exemption policy’ and
selected independent variables outlined under socio-demographic variables which
included age, marital status, religion, occupation, parity and spatial location variables
namely rural and urban as well as variables on knowledge about the policy.
Furthermore, the binary logistic regression model was used to determine the actual
predictors of use of delivery care under the policy. This model was chosen because the
dependent variable is dichotomous. Three models containing variables of interest were
fitted for the outcome variable (use of delivery care). The first model (Model 1) was
used to assess the association between the socio-demographic characteristics of mothers
and use of delivery services. The second model (Model 2) contained variables on the
socio-demographic characteristics of mothers together with some variables on the socio-
demographic characteristics of the husband/partner (education, employment status and
age). Model 2 was computed to assess the extent to which husband/partner
characteristics could influence the results derived in model 1. A third model (Model 3)
containing variables on the socio-demographic characteristics of the woman as well as
that of their husband/partners and the free delivery policy was also estimated. This was
used to estimate how both health policy and husband/partner background characteristic
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variables moderate the association between mothers’ socio-demographic characteristics
and the outcome variable.
The results of the binary-logistic regression analyses are presented as odds ratios (OR)
with 95 percent confidence intervals (CI). The level of significance (P-level) was put at
five percent. The Statistical Package for Social Sciences (SPSS) software version 20 was
used to analyze the quantitative data.
4.8 Ethical considerations
Ethical clearance for undertaking the study was sought from the Institutional Review
Board (IRB) of the Noguchi Memorial Institute for Medical Research, University of
Ghana. The study protocol and respondent consent forms were reviewed, and approved
by the board with an ethical approval code NMIMR–IRB CPN 113/12-13.
The Central Regional Directorate of the Ghana Health Service and the District Health
Management Teams (DHMT) offices of the selected districts as well as the local
government authorities in the respective districts were consulted before the
commencement of data collection exercise.
Participants for the interviews were also provided with all relevant study information to
assess their willingness to participate in the study. Would-be respondents were not
forced or coerced into participating in the study. To this end, all respondents were
requested to sign or thumb-print a consent form.
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Chapter five: Mothers’ awareness and knowledge about Ghana’s fee exemption
policy for maternal healthcare
5.1 Introduction
One objective of the study was to assess the extent to which women were aware and
knowledgeable about the fee exemption policy. The chapter presents the quantitative
findings emerging from interviews with sampled mothers on the objective. The results
are presented under two broad sections. The first section provides a description of the
socio-demographic characteristics of mothers who were selected for the study. The
second section presents the results from respondents regarding their knowledge and
awareness levels about the free delivery policy and the different sources from which
they received information about the free delivery policy.
5.2 Socio-demographic Characteristics of mothers
Information collected on the socio-demographic characteristics of mothers interviewed
included their age, level of education, marital status, parity, employment status, place of
residence, religion and ethnicity. As shown in Table 1, majority of the mothers were
within the age bracket of 20-29 years (58%) with only 4.4% in the age bracket of 40-49
years. A significant proportion of the respondents were married or cohabiting (87.7%);
had had some level of education (85.4%) with those with Middle/JSS level education
being in the highest proportion (39.6%). Only 2.4 percent had received tertiary level
education.
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Table 5.1: Percentage distribution of background characteristics of respondents
Background Characteristics Frequency Percent
Age
20-29 239 58.0
30-39 155 37.6
40-49 18 4.4
Total 412 100
Highest level of education
Pre-school 22 5.3
Primary 108 26.2
Middle/JSS/JHS 163 39.6
Secondary/SSS/SHS/Tech/Voc 49 11.9
Higher than secondary 10 2.4
Don’t know 6 1.5
No education 54 13.1
Total 412 100.0
Marital status
Married or cohabiting 355 87.7
Divorced/ separated 14 3.5
Widowed 2 0.5
Never married/ never cohabited 34 8.4
Total 405 100
Religious affiliation
Christian 344 83.5
Moslem 45 10.9
Traditionalist/Spiritualist 10 2.4
No religion 13 3.2
Total 412 100.0
Employment status
Unpaid family worker 60 16
Unemployed 5 1.3
Self-employed 218 58
Employee - formal work (paid) 42 11.2
Informal work (paid) 31 8.2
Others 20 5.3
Total 376 100.0
Parity
1 125 30.3
2 109 26.5
3 65 15.8
4 35 8.5
5 and above 78 18.9
Total 412 100.0
In terms of ethnicity, 78.4 percent of the total respondents were Akans with majority
being Fantes. The other Akan ethnic groups mentioned were Asante, Akyem and Bono.
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This finding was not surprising as most residents of the Central Region belong to the
Fante ethnic group. Ewes were the second largest ethnic group (16%) with mothers from
other ethnic groups mostly of northern Ghana decent (Nanumba, Dagomba and Hausa)
forming 3.9 percent of the sample. The mothers were mostly Christians (83.5%).
A greater proportion of the respondents were self-employed (58%) and engaged mostly
in trading activities with only 5.8 percent engaged in formal employment. A little over
half of the mothers (58.5%) resided in urban areas with 41.5 percent residing in rural
localities which also reflect the national trend of increasing urban residence in Ghana.
The proportion of Ghanaians living in urban areas has increased from 43.8 percent in the
year 2000 to 50.9 percent in 2010 (Ghana Statistical Service, 2012)
5.3 Awareness and sources of information on the free maternal healthcare policy
among women
Mothers who were sampled for the study were asked questions related to their general
awareness about the free delivery policy, their sources of information about the policy,
knowledge about different maternal healthcare services a woman is entitled to under the
policy and knowledge about the full maternal healthcare package a woman is entitled to
under the policy. The subsequent paragraphs presents details of responses received on
these questions
5.3 (a) Awareness about policy among mothers in selected districts
Almost all mothers (97.3%) interviewed expressed their awareness of the free delivery
policy. Comparing the two districts, there was no statistically significant difference in
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the respondents’ levels of awareness (98.1% and 96.5% for Assin North and Coast
metropolitan area respectively).
Similarly, awareness about the policy among mothers from rural and urban areas of the
study districts (Table 6.3) showed that mothers residing in both urban and rural localities
for each district had very high awareness levels. Approximately 9 in 10 women in each
area were aware of the existence of the policy (100% for urban Assin North and 96.8%
for urban Cape Coast metro and 96.9 percent for rural Assin North and 95.3 percent for
rural Cape Coast metro). Even though awareness was high for both areas, the percentage
for urban localities was slightly higher.
Table 5.3: Percentage distribution of awareness about policy by rural-urban
settings of study districts
Assin North Cape Coast
Urban Rural Total Urban Rural Total
Awareness about
policy n=78 n=128 n=206 n=163 n=43 n=206
Yes 100.0 96.9 98.1 96.8 95.3 96.5
No 0.0 3.1 1.9 3.2 4.7 3.5
Total (%) 100.0 100.0 100.0 100.0 100.0 100.0
5.3 (b) Sources of information about the policy by district
The main source of information on the policy in both districts was from healthcare
providers, primarily nurses and midwives with 33% of respondents receiving
information on the policy from them. The second major source of information on the
policy was from the radio (32.3%) (Table 6.4)
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Table 5.4: From whom/where did mothers receive information about the free
maternal healthcare policy?
Assin North Cape Coast Total
Sources of information n=206 n=206 n=412
Family 3.8 10.0 6.8
Friends / Community
members
20.4 19.4 19.9
Community leaders 1.9 5.5 3.6
TBAs 0.9 1.5 1.2
Healthcare workers 38.4 27.4 33.0
Radio 31.8 32.8 32.3
Television 2.8 3.5 3.2
Total (%) 100.0 100.0 100.0
Comparing the two districts, however, healthcare workers remained the number one
source of information on the policy for mothers in the Assin North district with
approximately 4 in 10 (38.4%) women receiving information from nurses and/or
midwives whiles the radio is the main source of information for mothers in Cape Coast
metro with approximately 33 percent of respondents receiving information on the policy
from the radio. Friends/Community members also remain an important source of
information on the policy for both districts (20.4% and 19.4% for Assin North and Cape
Coast metro respectively) after healthcare workers and the radio. Television (3.2%) and
TBAs (1.2%) are the least mediums through which women received information on the
policy. The seemingly low contribution of TBAs to disseminating information about the
policy could be attributed to the fact that even though they are noted for assisting with
deliveries in several rural communities in Ghana (Arhinful, et al. 2006) they are not
considered for disseminating information on the policy since the health sector does not
encourage their activities.
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The results from the analyses of the different sources from which mothers received
information about the policy by place of residence (rural/urban) (Table 6.5) shows that
overall healthcare workers remain the main source of information for rural dwellers with
38% percent of respondents receiving information from them.. For women in urban
areas on the other hand, radio (34%) remains their main source of information on the
policy.
Table 5.5: Sources of information about the free maternal healthcare policy by
place of residence (rural/urban)
Place of residence
Assin North Cape Coast Metro Total
Location of Households
Urban Rural Total Urban Rural Total Urban Rural Total
Sources of Information n=78 n=128 n=206
n=163
n=43
n=206
n=241
n=171
n=412
Family 5.1 3.1 3.9 9.2 11.6 9.7 7.9 5.3 6.8
Friends / Community
members 17.9 22.7 20.9
17.8
23.3
18.9
17.8
22.8
19.9
Community leaders 0.0 3.1 1.9
6.7
0.0
5.3
4.6
2.3
3.6
TBAs 1.3 0.8 1.0
1.2
2.3
1.5
1.2
1.2
1.2
Healthcare workers 28.2 45.3 38.8
30.1
16.3
27.2
29.5
38.0
33.0
Radio 39.7 25.0 30.6
31.3
44.0
34.0
34.0
29.8
32.3
Television 7.7 0.0 2.9
3.7
2.3
3.4
4.9
0.6
3.2
Total (%) 100 100 100
100
100
100
100
100
100
In comparing the information source for urban and rural areas of the two study districts,
the data suggests that most women in urban localities of the Assin North district receive
information on the policy from the radio (39.7%) whiles those in rural localities receive
their information from healthcare workers (45.3%). For Cape Coast metro on the other
hand, the radio remains the main source of information on the policy for both rural and
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urban dwellers even though the proportion receiving information through radio in rural
localities is higher (44%) than in the urban localities (31.3%). An equally higher
proportion of women in urban localities in Cape Coast metro also receive information
from healthcare workers (30.1%) compared with 16.3 percent among women in rural
localities.
Friends and community members remained the third major source of information on the
policy with both urban and rural areas of the two districts having almost equal
proportions of respondents receiving information from this source. Almost 18 percent
(17.9% for Assin North and 17.8 % for Cape Coast respectively) of respondents in urban
areas of both Assin North and Cape Coast metro received information about the policy
from friends and community members. For the urban areas, the proportions were 22.7
percent and 23.3 percent for urban Assin North and urban Cape Coast metro
respectively.
5.4 Mothers’ knowledge and understanding of maternity services they are entitled
to under the free delivery policy
Overall, 61.7 percent of the total respondents had comprehensive knowledge about the
entire maternity care package they were entitled to under the policy. Majority were
equally knowledgeable of free care for ANC (92%) and delivery services (95.6%) and
free registration under the NHIS (85.7%) once pregnancy is confirmed.
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Table 5.6: Percentage distribution of mothers’ knowledge about the free maternal
healthcare policy
Knowledge about policy’s benefit package Frequency Percent
Knowledge about full benefit package 254 61.7
ANC services only 379 92.0
Delivery Services 394 95.6
PNC Services 298 72.3
Free Registration under NHIS 353 85.7
Comparing knowledge on the specific services provided under the policy as indicated in
table 6.6, mothers’ knowledge on free postnatal care was lowest (72.3%) when
compared to the other maternity services.
5.4 (a) Knowledge about benefit package of the free delivery policy across study
districts and rural and urban areas of the districts
The study found that approximately six in ten women (61.7%) in the study area were
knowledgeable about the full benefit package of the free maternal healthcare policy.
This proportion of women were knowledgeable about the fact that women were entitled
to free care for antenatal services, all forms of deliveries, post-natal care for up to six
weeks after delivery. An analysis of mother’s knowledge levels across the selected study
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districts revealed that mothers in the Cape Coast metropolis have higher knowledge
(70.4%) than their counterparts in the Assin North district (52.9%).
Table 5.7: Percentage distribution of knowledge about benefit package of free
maternal healthcare policy by study districts
Full
knowledge
about
policy
Assin North Cape Coast Total
Location of
household
Total
Location of
household
Total
Location of
household
Total Urban Rural Urban Rural Urban Rural
n=78 n=128 n=206 n=163 n=43 n=206 n=241 n=171 n=412
Yes 35.9 63.3 52.9 70.6 69.8 70.4 59.3 64.9 61.7
No 64.1 36.7 47.1 29.4 30.2 29.6 40.7 35.1 38.3
Total % 100 100 100 100 100 100 100 100 100
An analysis of women’s knowledge levels by place of residence (rural/urban) revealed
that, for the entire study area rural women were more knowledgeable about the policy
(64.9%) than women residing in urban areas (59.3%). A similar pattern was observed for
the Assin North municipal area. More than sixty percent (63.3%) of women residing in
rural parts of the locality had full knowledge about the free delivery policy compared
with approximately thirty six percent (35.9%) for women in urban areas of the
municipality. For the Cape Coast metropolis, women in urban areas were more
knowledgeable about the full benefit package than rural dwellers but by a slight margin.
Approximately seventy-one percent (70.6%) of women in urban areas had full
knowledge about the policy compared with (69.8%) for women residing in rural areas.
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5.4 (b) Respondents knowledge about free maternity services provided for delivery care
only
An analysis of the study participants’ knowledge on the range of delivery services
offered under the policy showed that more than 8 in 10 women (85.2%) knew that they
did not have to pay for the cost of delivery. The respondents’ knowledge about this
benefit package was higher for both urban and rural women, 86.3% for urban women
and 83.6% for rural inhabitants respectively.
Similarly, the study participants were highly knowledgeable (83.7%) about the fact that
they were entitled to free drugs and other obstetric medical supplies under the policy.
Again both women in rural and urban areas had higher knowledge about this free service
(85.5% for urban women and 81.3% for rural women respectively).
The study respondents were, however, less knowledgeable about the fact that their
babies were entitled to free drugs and any other medical treatments received six weeks
after delivery. A little over half of respondents (58.7%) had knowledge about free care
for their babies, admission and drugs for themselves as well as their babies. Majority of
the respondents were also ignorant about the fact that women were entitled to free care
for caesarean section deliveries and care for any other post-delivery complications. Less
than 5 percent of the study respondents knew that women were entitled to these services
for free under the policy. Ironically, women residing in urban areas had lower
knowledge about free care these services than those residing in rural areas.
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Table 5.8: Percentage distribution of knowledge on services provided for delivery
care by district and place of residence (rural/urban)
Assin North Cape Coast Total
Location of household
Delivery Services Urban Rural Total Urban Rural Total Urban Rural Total
Cost of normal
delivery
n=78 n=128 n=206 n=163 n=43 n=206 n=241 n=171 n=412
Yes (%) 84.6 86.7 85.9 87.1 74.4 84.5 86.3 83.6 85.2
Drugs & medical supply for mother
Yes (%) 82.1 79.7 80.6 87.1 86.0 86.9 85.5 81.3 83.7
Drugs & medical supply for baby
Yes (%) 33.3 71.9 57.3 67.5 32.6 60.2 56.4 62.0 58.7
Surgical charges for caesarean section
Yes (%) 1.3 9.4 6.3 2.5 0.0 1.9 2.1 7.0 4.1
Cost of post-delivery charges
Yes (%) 1.3 2.3 1.9 2.5 7.0 3.4 2.1 3.5 2.7
Laboratory test
Yes (%) 73.1 73.4 73.3 55.2 41.9 52.4 61.0 65.5 62.9
Comparing knowledge on the specific services received for delivery among women
from the two study districts, the trends were similar to those found for the entire study
area. Women from both districts had higher knowledge about free care for normal
deliveries (85.9% for Assin North and 84.5% for Cape Coast metro) and free drugs and
medical supplies for the mother. Women from both urban and rural areas of the study
districts were knowledgeable about free care for normal deliveries even though the
difference in knowledge for the two places of residence was greater for Cape Coast
metro than for Assin North. Whereas 84.6 percent of urban dwellers and 86.7 percent of
rural dwellers were knowledgeable about free care for normal deliveries in Assin North,
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87.1 percent of urban women in Cape Coast and 74.4 percent of women residing in rural
Cape Coast had knowledge about free care for normal deliveries. For the entire study
area, however, urban dwellers had better knowledge (86.3%) about free care for normal
deliveries than rural dwellers (83.6%).
Women from both districts had very low knowledge about free care for caesarean
section with women from Cape Coast metro having even lower knowledge (6.3% and
1.9% for women in Assin North and Cape Coast metro respectively). Comparing
knowledge levels across women in rural and urban areas of the study districts, the data
showed that, women residing in rural Assin North had better knowledge (9.4%) about
free care for caesarean section compared to their counterparts in urban Assin North
(1.3%). In Cape Coast Metro on the other hand, women residing in urban localities had
better knowledge (2.5%) than those from rural areas (0.0%).
5.5 Conclusion
In conclusion, this study found that although level of awareness of the free maternal
healthcare policy amongst mothers is high, it is not matched by comprehensive
knowledge on the full benefit package. Most women are particularly ignorant about fee
exemption for caesarean section deliveries and care for complications arising out of
deliveries. There is, therefore, an urgent need for increased context-specific education on
the range of maternity services provided for free under the policy towards ensuring that
women get access to all the services. These include emergency and life-saving ones as
caesarean section delivery services and care for complications during and after delivery.
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Additionally, there were marked variations in knowledge about the range of services
women were entitled to among respondents from rural and urban areas with rural
women having better knowledge. There is the need for increased education on the policy
by healthcare workers in urban communities.
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Chapter six: Factors influencing the use of delivery services under the free
maternal health care policy
6.1 Introduction
The chapter outlines and discusses the factors that influence delivery care use in the
study areas. Chi-square and logistic regression tests were used to evaluate the
determinants of delivery care use under the fee exemption policy for maternal deliveries.
Pearson’s Chi-Square test was used to test for the statistical association between the
dependent variable (use of delivery services under the fee exemption policy) and
selected independent variables on the socio-demographic characteristics of mothers
which include age, marital status, religion, occupation, parity and spatial location
variables namely rural and urban as well as variables on knowledge about the policy.
Variables on the free delivery policy that were used in the analysis were awareness and
knowledge on the full benefit package of the free delivery policy.
Additionally, binary logistic regression models were used to adjust for confounding
variables in order that the actual predictors of use of delivery care could be determined.
The results of the binary-logistic regression analyses are presented as odds ratios (OR)
with 95 percent confidence intervals (CI). The level of significance (P-level) was put at
five percent. Three models containing variables of interest were fitted for the outcome
variable (use of delivery care). The results on the core determinants of delivery service
care use emerging out of the analysis are presented first in the subsequent paragraphs.
This is followed by a detailed discussion of each of the factors identified.
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6.2 Use of delivery services
Out of the 412 mothers interviewed, 65percent (n=268) reported having delivered their
most recent birth under the fee exemption policy even though awareness about the
policy was almost universal 401 (97.3%) among respondents. Comparing the two
districts, utilization of delivery services was lower for the Assin North Municipal Area.
In all, 54.4 percent (n=112) of mothers at Assin North delivered their most recent babies
with the policy compared with 75.7 percent (n=156) delivering with the policy in Cape
Coast Metropolis. The relatively lower use of care by women in the Assin North
municipality, which is a largely rural district, compared to Cape Coast highlights the
well-known inequities in access to care by place of residence with rural dwellers mostly
at a disadvantage. Place of residence has been found to constitute a major determinant of
healthcare use as it shapes individual opportunities and exposure to healthcare resources
(Fotso, Ezeh, & Oronje, 2008; Gabrysch & Campbell, 2009)
6.3 Statistical associations between use of supervised delivery services and mothers
background characteristics
From the Chi-square tests, the variables that had a statistically significant relationship
with the use of delivery care under the policy for the entire study area were marital
status, place of residence, education, religion, and parity.
At the bivariate level, women who were single had the greatest likelihood of delivering
for free under the policy rather than paying for delivery services. (Table 6.1)
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Table 6.1 Percentage distribution of use of free delivery care by marital status
Marital status
Use of free delivery policy
Delivered for
free
Paid for
delivery Total
n=262 n=143 n=405
Married or cohabiting 64.2 35.8 100.0
Divorced/ separated 42.9 57.1 100.0
Widowed 0.0 100 100.0
Never married/ never cohabited 82.4 17.6 100.0
Total % 64.7 35.3 100.0
Pearson chi-square = 11.263, p=0.010
Earlier studies have confirmed a strong relationship between marital status and use of
supervised delivery services (Mekonnen & Mekonnen, 2003; McTavish, Moore, Harper,
& Lynch, 2010). The association between marital status and use of delivery care under
the policy was statistically significant (Pearson chi-square = 11.263, p=0.010).
The association between place of residence and use of delivery care under the policy
was highly statistically significant (Pearson chi-square = 32.612, p=0.000) with mother’s
residing in urban areas were more likely to use care than those in rural areas (Table 7.2)
and the reasons may not be far-fetched. Most urban settlements in Ghana receive a better
share of healthcare resources (Gething et al., 2012). There is, therefore, the likelihood of
one getting easy access to facility care in an urban area than in a rural area. Distance to
nearest healthcare facility and poor transportation network linking communities to
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nearest healthcare facilities were also noted as major challenges to accessing care for
women living in rural and remote areas of the Assin North district. A mother from
Beduadia, a remote community in the Assin North district remarked,
“It is quite far to travel to Fosu (referring to the district capital) and the
road is also very bad and slippery during the rainy season. Several women
therefore prefer to deliver with Dada Quansah, the TBA in this community. I
think one would only go to Fosu when there is a complication or have been
advised to do so because she will give birth to twins”. (Mother 1, Assin
Bediadua)
The quotation is suggestive of the fact that women in rural areas are conscious of the
transportation challenges they face in accessing formal healthcare services. As an
alternative, these women will opt for the services of trained or untrained TBAs who are
within reasonable distance from their places of abode. They, however, recognize the fact
that certain births can only be handled by trained healthcare professionals and will
therefore seek for supervised care when necessary in spite of the transportation
challenges
Table 6.2: Percentage distribution of use of delivery care by place of residence
Use of delivery services
Place of residence Delivered for free Paid for delivery Total
n=268 n=144 n=412
Urban 76.3 23.7 100.0
Rural 49.1 50.9 100.0
Total 65.0 35.0 100.0
Pearson chi-square = 32.612, p=0.000
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The chi-square test shows that the association between education and use of delivery
services under the policy was not statistically significant (chi-square = 12.506, p =
0.052). There are, however, variations in utilization depending on a woman’s level of
education. Mothers who had received a higher than secondary education were more
likely to use free delivery services compared to those with secondary and other
relatively lower levels of education.
Table 6.3: Percentage distribution of use of free delivery care by respondent’s level
of education
Use of free delivery services
Level of education Delivered for free Paid for delivery Total
n=237 n=122 n=359
Pre-school 54.5 45.5 100.0
Primary 56.5 43.5 100.0
Middle/JSS/JHS 69.9 30.1 100.0
Secondary/SSS/SHS/Tech/
Voc.
77.6 22.4 100.0
Higher than secondary 80.0 20.0 100.0
Don’t know 66.7 33.3 100.0
Total 66.0 34.0 100.0
Pearson chi-square = 12.506, p=0.052
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The scenario observed is in line with the widely documented fact that use of services
increase with increased level of education in Ghana and other African settings (Elo
1992; GSS et al., 2004; Babalola and Fatusi 2009, Gabrysch and Campbell 2009, GSS et
al., 2009). In terms of education, it has been noted that most inhabitants of the Central
region have lower levels of education even though the region can boast numerous
educational institutions (GSS, 2008). In line with this scenario, the proportion of the
study participants who had received tertiary level education was relatively small.
Similarly, mothers’ religion (chi-square 47.162, p = 0.000) and the total number of live
births women had (parity) (chi-square =15.734, p = 0.003) were statistically significant
in explaining use of supervised delivery services under the policy (Tables 7.4 and 7.5)
Table 6.4: Percentage distribution of use of free delivery care by respondents
religion
Use of free delivery services
Religious affiliation Delivered for
free
Paid for
delivery
Total
n= 268 n=144 n=412
Catholics 83.3 16.7 100.0
Orthodox Christians 47.3 52.7 100.0
Pentecostal/Charismatic Christians
Other Christians (SDA, Jehovah’s
Witnesses)
Moslem
68.7
75.4
84.4
31.3
24.6
15.6
100.0
100.0
100.0
Traditionalists/Spiritualists 60.0 40.0 100.0
No religion 61.5 38.5 100.0
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Total 100.0 100.0 100.0
Pearson chi-square = 47.162, p=0.000
The likelihood of usage was higher for Moslems than all categories of Christians and
Traditional worshippers.
Table 6.5: Percentage distribution of use of delivery care services by mother’s
parity levels
Parity
Use of delivery care
Delivery for free Delivery not for free Total
n= 268 n= 144 n= 412
1 70.4 29.6 100.0
2 69.7 30.3 100.0
3 72.3 27.7 100.0
4 57.1 42.9 100.0
5 and above 47.4 52.6 100.0
Total 65.0 35.0 100.0
Pearson chi-square =15.734, p = 0.003
On parity, use of delivery services generally reduces with increasing births. Women with
four or more births were less likely to access supervised care under the policy compared
to those with less than four births. Earlier studies have confirmed a strong association
between lower parity and use of maternal healthcare services (Overbosch et al., 2004;
Gabrysch & Campbell, 2009).
Some of the variables were not statistically associated with the use of supervised
delivery care under the policy. A mother’s employment status (Pearson chi-square =
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6.255, p = 0.181) and age (Pearson chi-square = 0.099, p = 0.951) were not statistically
associated with the use of delivery services under the policy. The employment status of
women did not appear to be significant partly because services provided for under the
policy are cost-free. This, therefore, suggests that irrespective of a woman’s employment
and socio-economic status, she can access services under the policy.
Comparing the variables that were significantly associated with delivery care use
between the study districts, Cape Coast metropolitan area had most of the statistically
significant variables still remaining significant for the district. The variables that had a
statistically significant relationship with delivery service use in the metropolis were
education (Chi-square 16.371, p = 0.012), marital Status (Chi-square 9.130, p = 0.028),
religion (Chi-square 36.639, p = 0.000) and parity (Chi-square 22.530, p = 0.000) whiles
only one variable, place of residence (Chi-square 25.739 p = 0.000) was significantly
related to delivery care use statistically in the Assin North municipal area. This suggests
that whereas the individual characteristics of women residing in relatively urban areas
could influence their reproductive behaviour, women in relatively rural areas would
consider how the physical environment within which they live affects their access to
maternity services.
6.4 Determinants of delivery care use
Three binary logistic regression models were used to identify the determinants of
delivery care use under the delivery fee exemption policy. The first model (Model 1)
was used to assess the association between the socio-demographic characteristics of
mothers and use of delivery services. The second model (Model 2) containing variables
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on the socio-demographic characteristics of mothers as well as that of their
husband/partner was computed to assess the extent to which husband/partner
characteristics could influence the results derived in model 1. A third model containing
variables on the socio-demographic characteristics of the woman as well as that of their
husband/partners and variables on the free delivery policy was also estimated. The final
model (Model 3) was used to estimate how health policy and husband/partner
background characteristic variables moderate the association between mothers’ socio-
demographic characteristics and the outcome variable.
The results presented in (Table 6.6, Model 1) which contains variables on the socio-
demographic characteristics of the women confirmed parity, religion, marital status,
maternal age and place of residence as significantly related to delivery care use under
the free maternal healthcare policy. The regression results showed a statistically
significant relationship between age and use of delivery services for mothers aged 20-29
years (p = 0.013).
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Table 6.6: (Model 1)-Binary logistic regression results of predictors of delivery care
use using background characteristics of mothers
*RC means Reference Category
Variable B S.E. Sig. Odds Ratio
Age Group (*RC= 40-49)
20-29 -1.727 0.697 0.013 0.178
30-39 -0.864 0.640 0.176 0.421
Parity (RC = 5 and above)
1 1.225 0.458 0.008 3.405
2 1.380 0.420 0.001 3.974
3 1.428 0.464 0.002 4.171
4 0.764 0.512 0.136 2.146
Religion (RC = Muslim)
Christian (Catholic) -0.329 0.655 0.615 0.719
Christian (Orthodox) -1.924 0.525 0.000 0.146
Other Christian (SDA, Jehovah’s
Witnesses) -1.068 0.532 0.045 0.344
Christian (Pentecostal/Charismatic) -0.543 0.495 0.273 0.581
Other (Traditional/Spiritual/No religion) -1.209 0.707 0.087 0.299
Education (RC = Other - Vocational,
Technical)
No education 0.019 0.849 0.982 1.019
Primary 0.006 0.830 0.994 1.006
Middle/JHS 0.571 0.822 0.487 1.771
Secondary/SHS 0.877 0.877 0.318 2.403
Higher than Secondary 1.171 1.400 0.403 3.226
Ethnicity (RC = Other (Ga-Adangme,
Guan, Hausa)
Akan 0.426 0.544 0.433 1.531
Ewe 0.717 0.595 0.228 2.049
Marital Status (RC= Single (Never
married, Never-cohabited)
Married/cohabiting -1.153 0.513 0.024 0.316
Formerly in union (Widowed,
Divorced/Separated) -2.170 0.768 0.005 0.114
Residence (RC = Rural)
Residence (Urban) 1.272 0.267 0.000 3.566
Employment Status (RC =Other – seasonal
work – stone quarrying)
Unemployed 0.766 1.062 0.471 2.151
Self-employed 0.348 1.051 0.741 1.416
Employee (Paid) -0.006 1.386 0.997 0.994
Informal work (paid) 1.063 1.584 0.502 2.896
Constant 1.002 1.560 0.521 2.723
Nagelkerke R2
0.302
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From the odds ratios, mothers aged 20-29 and 30-39 were 0.178 and 0.421 respectively
less likely to use delivery services than those aged 40-49. The likelihood of using
delivery care under the policy was lower for mothers who were married or co-habiting
and mothers who were either widowed, divorced/separated compared to those who were
single. Mothers residing in urban areas were 3.57 times more likely to use delivery
services under the policy than those in rural areas. Mothers with 1, 2 and 3 births had
higher odds of delivering with the policy than those with five or more births. Orthodox
Christians and other Christians of the Seventh Day Adventist (SDA) group and
Jehovah’s Witnesses were less likely to deliver with the policy compared to Muslims.
The relationship between mother’s education ethnicity and employment status and
delivery care use was not significant statistically.
Model 2 contained variables on the socio-demographic characteristics of mothers as well
as that of their partners. As presented in Table 6.7, all the background characteristics of
mothers identified as predictors of delivery service use in model 1 still remained
statistically significant except for the marital status of the mother. The results showed
that the variables on husband/partner characteristics introduced (age, education and
employment status) were not statistically significant predictors of delivery service use.
The introduction of those variables was, however, important as it helped to increase the
adjusted coefficient of determination (R2) from (0.302) in model 1 to (0.380). This
implies that 38% of the variation in use of delivery care under the policy in the study
localities can be explained by the independent variables (age, parity, religion, marital
status and place of residence) used in model 1.
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Table 6.7: (Model 2) - Binary logistic regression results of predictors of delivery
service use using background characteristics of mothers and their
husbands/partners
Variable B S.E. Sig.
Odds
Ratio
Age Group (*RC= 40-49)
20-29 -2.433 0.853 0.004 0.088
30-39 -1.307 0.748 0.081 0.271
Parity (RC = 5 and above)
1 1.609 0.592 0.007 4.998
2 1.675 0.555 0.003 5.338
3 1.542 0.571 0.007 4.675
4 1.178 0.622 0.058 3.248
Religion (RC = Muslim)
Christian (Catholic) -0.538 0.769 0.484 0.584
Christian (Orthodox) -2.203 0.657 0.001 0.110
Other Christian (SDA, Jehovah’s Witnesses) -1.188 0.671 0.077 0.305
Christian (Pentecostal/Charismatic) -0.286 0.609 0.638 0.751
Other (Traditional/Spiritual/No religion) -0.489 0.915 0.593 0.613
Education (RC = Other - Vocational,
Technical)
No education -0.238 0.944 0.801 0.788
Primary -0.799 0.927 0.389 0.450
Middle/JHS 0.194 0.917 0.832 1.214
Secondary/SHS 0.851 1.031 0.409 2.343
Higher than Secondary -1.336 1.595 0.402 0.263
Ethnicity (RC = Other (Ga-Adangme, Guan,
Hausa)
Akan 1.055 0.675 0.118 2.873
Ewe 1.148 0.730 0.116 3.151
Marital Status (RC= Single (Never married,
Never-cohabited)
Married/cohabiting -2.086 1.263 0.099 0.124
Formerly in union ((Widowed,
Divorced/Separated) -1.728 1.555 0.267 0.178
Residence (RC = Rural)
Residence (Urban) 1.159 0.333 0.000 3.188
Employment Status (RC =Other – seasonal
work eg. Stone quarrying)
Unemployed 1.088 1.293 0.400 2.969
Self-employed 0.370 1.283 0.773 1.448
Employee (Paid) 1.546 1.814 0.394 4.691
Informal work (paid) 1.359 1.824 0.456 3.891
Education of Partner/husband (RC = Other -
Vocational, Technical)
No education -0.234 0.965 0.808 0.791
Primary 1.458 0.965 0.131 4.297
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Middle/JHS 1.556 0.922 0.092 4.740
Secondary/SHS 0.848 0.934 0.364 2.336
Higher than Secondary 2.025 1.271 0.111 7.573
Husband Employment Status (RC=Other
Seasonal work – e.g. construction labourers,
spare driving)
Unpaid Family worker 0.276 0.743 0.711 1.317
Unemployed 1.123 1.284 0.382 3.075
Self-employed 0.636 0.681 0.350 1.889
Employee (Formal work paid) 1.296 0.895 0.148 3.654
Informal work (paid) 1.130 0.864 0.191 3.096
Age of husband 0.023 0.019 0.209 1.024
Constant -0.632 2.535 0.803 0.532
Nagelkerke R2
0.380
*RC means Reference Category
Model 3 (Table 6.8) contained variables on the socio-demographic characteristics of the
woman and that of the husband or partner as well as variables on the free delivery
policy. The results as presented in Table 6.8 identifies religion, parity, place of residence
and maternal age as wholly or partially statistically significant predictors of delivery
service use. The model identifies place of residence and religion as variables which had
the highest statistically significant levels (0.000). Maternal age and parity also had some
statistically significant relationship with use of delivery care under the policy. The
results identified a statistically significant relationship between use of delivery services
and parity levels 1, 2 and 3. There was, however, no statistically significant relationship
between use of delivery services under the policy and having four children (p =
0.078).There was also a statistically significant relationship between use of delivery care
for mothers aged 20-29.years (p = 0.003) when compared to mothers aged 40-49. but
not for age There was, however, no difference in use of delivery care between mothers
aged 30-39 (p = 0.075) and those in the age bracket 40-49.
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For religion, there was a highly statistically significant relationship (p = 0.000) with use
of care for orthodox Christians (Presbyterian, Methodist, Anglican) as compared to
Moslems. The results did not show any statistically significant relationship between
religion and use of delivery care among women from the other Christian groups
(Catholics, Pentecostal/Charismatic, SDA and Jehovah’s Witnesses) as well as those
who were traditional/spiritual worshippers or those who had no religion.
In addition, awareness and full knowledge about the free maternal healthcare policy by
women were also found to be statistically significant predictors of delivery service use.
There was an even higher statistically significant relationship between knowledge about
the policy (p = 0.001) and use of delivery services than with mere awareness about the
policy (0.022).
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Table 6.8: (Model 3)- Binary logistic regression results of predictors of free delivery
service use using, background characteristics of mothers, husband/partner
characteristics and health policy variables
Variable B S.E. Sig.
Odds
Ratio
Age Group of women (RC= 40-49)
20-29 -2.672 0.899 0.003 0.069
30-39 -1.399 0.786 0.075 0.247
Parity of women (RC = 5 and above)
1 1.664 0.618 0.007 5.283
2 1.855 0.578 0.001 6.390
3 1.743 0.613 0.004 5.713
4 1.127 0.641 0.078 3.087
Religion of women (RC = Muslim)
Christian (Catholic) -0.641 0.815 0.431 0.527
Christian (Orthodox) -2.569 0.713 0.000 0.077
Other Christian (SDA, Jehovah’s
Witnesses) -1.263 0.711 0.076 0.283
Christian (Pentecostal/Charismatic) -0.166 0.644 0.797 0.847
Other (Traditional/Spiritual/No religion) -0.452 0.979 0.644 0.636
Education of women (RC = Other -
Vocational, Technical)
No education -.032 0.958 0.973 0.968
Primary -.851 0.942 0.366 0.427
Middle/JHS .132 0.932 0.888 1.141
Secondary/SHS .969 1.043 0.353 2.634
Higher than Secondary -1.529 1.666 0.359 0.217
Ethnicity of women (RC = Other (Ga-
Adangme, Guan, Hausa)
Akan 1.067 0.738 0.148 2.905
Ewe 1.002 0.786 0.203 2.724
Marital Status (RC= Single (Never
married, Never-cohabited)
0.252
Married/cohabiting -2.368 1.426 0.097 0.094
Formerly in union ((Widowed,
Divorced/Separated) -2.319 1.707 0.174 0.098
Residence of women (RC = Rural)
Residence (Urban) 1.333 0.350 0.000 3.793
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Employment Status of women (RC
=Other –seasonal work eg. Stone
quarrying)
Unemployed 1.550 1.347 0.250 4.714
Self-employed 0.593 1.334 0.657 1.809
Employee (Paid) 2.612 1.965 0.184 13.629
Informal work (paid) 1.542 1.960 0.432 4.673
Education of Partner/husband (RC =
Other - Vocational, Technical)
No education -0.428 0.996 0.667 0.652
Primary 1.644 0.989 0.096 5.177
Middle/JHS 1.828 0.957 0.056 6.222
Secondary/SHS/Technical 1.073 0.958 0.262 2.925
Higher than Secondary 2.118 1.319 0.108 8.317
Husband Employment Status (RC=Other - Seasonal work –
construction labourers, spare driving)
Unpaid Family worker 0.205 0.804 0.799 1.227
Unemployed 1.148 1.362 0.400 3.150
Self-employed 0.579 0.742 0.435 1.784
Employee (Formal work paid) 1.854 0.965 0.055 6.386
Informal work (paid) 1.200 0.929 0.196 3.320
Age of husband 0.022 0.019 0.262 1.022
Awareness about policy by women (RC
= No)
Awareness about policy(Yes) 2.626 1.147 0.022 13.820
Full knowledge about policy by women (RC = No)
Full Knowledge (Yes) 1.094 0.326 0.001 2.985
Constant -3.902 2.953 0.186 0.020
Nagelkerke R2
0.433
The odds of delivering with the policy was 2.985 times higher for mothers who had full
knowledge about the policy relative to those who did not have full knowledge about the
policy. Similarly, mothers who were aware of the existence of the free maternal
healthcare policy were 13.820 times more likely to use delivery services under the
policy than those not aware of the policy. Maternal education, ethnicity and employment
status were not observed as statistically significant predictors of delivery service use
under the policy.
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The likelihood of using delivery care under the policy was lower for mothers aged 20-29
compared to those in the age bracket of 40-49 (Odds ratio (OR) = 0.069, p = 0.003).
Mothers who already had 1, 2 or 3 children were more likely to deliver their index child
under the policy than those with five or more births. Mothers living in urban areas were
3.793 times more likely to use delivery services under the policy than those living in
rural areas (OR = 3.793, p = 0.000).
The introduction of variables on the fee exemption policy (awareness and full
knowledge of the free delivery policy’s benefit package) was relevant as those variables
were also significant in explaining delivery care use under the policy. Additionally,
model 3 was an improvement over models 1 and 2 as the adjusted coefficient of
determination (R2) increased further to close to 45% (0.433) (Table 7.8) compared to
0.302 (Table 7.6) for model 1 and 0.380 (Table 7.7) for model 2. This implies that even
though the socio-demographic characteristics of women can to an extent explain
variations in use of delivery services under the delivery fee exemption policy, utilization
patterns could be better enhanced if beneficiary women are adequately informed about
the policy and its benefit package.
6.5 Conclusion
The chapter has outlined and discussed key individual and policy-related factors
affecting supervised delivery care use among women in the study areas. The core
determinants of use of delivery care identified from the regression analysis were
maternal age, religion, marital status, parity, place of residence; awareness and
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knowledge about the fee exemption policy. Service improvement interventions that take
cognisance of these factors are likely to have an impact on utilisation of supervised care
under the delivery fee exemption policy. Most of the variables on the background
characteristics of women used in model one continued to remain statistically significant
predictors of delivery service use in models 2 and 3 when the partner/husband
characteristics and health policy factors were introduced respectively. This suggests that
policy and programme interventions towards improving the performance of the policy
should critically consider these socio-demographic characteristics of women.
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Chapter seven: The reality with accessing ‘free maternal healthcare services’:
Mothers’ delivery experiences
7.1 Introduction
Sixteen women who delivered their most recent babies under the free delivery policy
were selected for in-depth interviews on their delivery experiences. The women were
selected through simple random sampling approach from the 412 mothers who
participated in the questionnaire survey. Eight respondents were selected for each of the
two study districts with four residing in rural localities and the remaining four residing
in urban localities. The sampling approach involved first, the creation of a new sampling
frame of mothers who delivered their index child through the policy from the list of the
total number of mothers who participated in the questionnaire survey in each locality. A
simple random approach was then used to select two mothers from the new sampling
frame from each locality to share their experiences with care received under the policy.
Previous studies have used samples that relates closely to the total number (16) used in
this study (D’Ambouso et al 2005; Berry, 2006; Aboagye & Agyemang, 2013).
By use of an in-depth interview guide, the selected women were interviewed on their
knowledge about the actual benefit package of the free delivery policy; the kind of
delivery services they were offered for free; the services they had to pay for, if any; their
reasons for delivering with the policy; community-level barriers to accessing care under
the policy; their perceptions of the quality of care received; and satisfaction or
dissatisfaction with care received.
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The data collected was analyzed using the thematic analysis approach. After reading
through the interview transcripts for a number of times to understand the respondents’
experiences with receiving delivery care and their perceived satisfaction and/or
dissatisfaction with care received, five major themes were identified. These are desire to
benefit from supervised care, transportation and distance concerns, competence of
attendants, availability of equipment and supplies and co-ordination of health personnel.
The subsequent sub-sections highlight the background characteristics of women who
participated in the interviews as well as a detailed presentation and discussion of the
issues emerging from the various themes.
7.2 Socio-demographic characteristics of respondents
The participants were between the ages of 20 and 43 years, which conform to acceptable
age for reproduction (Hill, Tawiah-Agyemang, & Kirkwood, 2009). Six of the
participants were between the ages of 20-30; seven were in the age bracket of 30-40
with three between the ages of 40 and 43. All the respondents were married except for
one. Majority (12) were Christians, with three Muslims and one traditional worshipper.
The educational level of the study participants was generally low. Majority, (13) had
received education to the junior secondary-level. Two had primary-level education, with
none receiving education to the senior secondary level. Only one participant had
received tertiary level education which possibly reflects the national situation of level of
education in the Central Region. Thirteen out of the sixteen participants reported being
married with majority (9) already having two or more children. Three of the respondents
had two children at the time of the interview whiles the remaining four had just had their
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first births. The majority of the participants (11) were self-employed; two were engaged
in formal employment whilst the remaining three were unemployed. They all spoke
Fante (the local dialect of the region).
7.3 Experience with care
7.3.1 Attitudes towards skilled care
One assumption of this study was that more women will choose to deliver under the
delivery fee exemption policy because it is free. In view of this, respondents were asked
to indicate why they chose to deliver their index babies under the policy. Most of the
respondents (10 out of 16) mentioned the importance of receiving supervised care as the
number one reason for delivering with the policy. They were particularly interested in
having a successful pregnancy outcome which they considered could best be obtained
within a facility setting and through the assistance of a skilled professional like a
midwife, nurse or a doctor. The accounts of two respondents on the relevance of skilled
care at birth are presented below:
“I have given birth twice at home but bled a lot afterwards and had to be
rushed to Fosu hospital (referring to St. Francis Xavier hospital) when the
bleeding was not stopping. One can never compare delivering at home to
that at the hospital. My sister (referring to the interviewer), doctors and
nurses are the only people with the requisite knowledge for handling
deliveries. Now that we do not have to pay anything to receive hospital care
I will recommend that all pregnant women deliver at a hospital” (Mother 2,
Assin Bediadua)
“It is important to deliver in a hospital. Nurses are professionals and can
tell when a woman needs to have an operation to save her life and that of
her baby. I was in labour for three days and had to deliver through
Caesarean Section (CS). You can imagine what could have happened if I
chose to deliver at home. I would have opted to deliver in a hospital even if I
was going to pay” (Mother 2 Ekon, Cape Coast Metropolitan area)
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Majority of the respondents were particularly encouraged that the policy indeed provides
free delivery care once a woman gets to a designated facility.
“I did not have to pay for anything when I went to deliver. I was given all
the medicines that I needed to take after I had been discharged free of
charge. Even mackintosh was given for free at the hospital (Mother 2, Assin
Fosu)”
“I will recommend for other women to go in for free care under the health
insurance. I delivered through an operation but was not asked to pay for
anything as my friend had told me.” (Mother 1, Assin Bediadua)
The women were therefore desirous to benefit from free care and also expressed the
need for other women to take advantage of services provided under the policy. Some
women however added that they voluntarily made some monetary payments to the
nurses and midwives who attended to them as a form of saying thank you. They did not
see this as payment for care received as they were not charged by the nurses and
midwives for their services.
7.3.2 Availability and accessibility to skilled care
Apart from these, some respondents also considered the proximity of health facilities to
their places of residence in deciding to deliver with the policy. This was particularly so
for those living in urban communities. Most urban communities in Cape Coast
metropolis had facilities that offered maternity care under the policy. Women living in
urban communities would mostly choose facilities that were located within or closer to
their communities. For those living in rural communities that had no delivery facilities
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on the other hand, many would choose to attend a facility located at a nearby urban
community.
For women in rural areas however, the possibility of experiencing complications at birth
could force some women to deliver at a facility no matter how far the facility is to the
woman’s place of residence. A mother from Atwerebuanda in the Assin North
municipality puts it this way:
“It is quite a distance to get to a health facility at Fosu (referring to the
district capital) so several women choose to deliver with a TBA who has
been assisting several women to deliver. Women who experienced
complications in a previous birth or have been told to be carrying twins or
triplets however have no option but to go to the hospital at Fosu to deliver
as the TBA is not equipped to do operation for them it becomes necessary”
(Mother 2 Atwerebuanda).
For women residing in remote or rural areas, the long distance between communities and
available facilities would prevent them from seeking for supervised care if there were no
complications with the delivery process. Women who anticipate a possible complication
due to previous birth history or have been advised by trained personnel to deliver in a
facility will normally overlook the distance barrier and seek for professional delivery
services.
Previous studies have identified transport and cost related barriers as major contributory
factors to accessing emergency obstetric care services in many developing economies
(Ononopkono et al., 2013; Jammeh et al., 2011). The data showed that one major factor
that influenced utilization of delivery services among women who participated in the
study was the availability of appropriate transportation infrastructure. Generally women
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in the Assin North district particularly those residing in rural communities, expressed
concern about some transportation challenges they face in accessing care. Testimonies
of rural women attest to the lack of regular transport to health facilities due largely to the
poor nature of the roads; high cost of fares and the long distances between communities
and health facilities.
“The road is very bad and so several women prefer to deliver in the
community with Dada Quansah (referring to a popular male TBA) or the
midwife at the health centre if she is around. I think one would only go to
the hospital at Fosu when there is a complication” (Mother 1, Assin
Bediadua)
“The road was slippery because it is not tarred and so the driver had to take
his time so we do not get stuck in the mud or veer off into the bush. We
therefore spent more time than we would have otherwise spent. My pain
even worsened as we bumped into one pothole after another. I had no
option than to go to Fosu since the midwife had advised me to do as I was
pregnant with three babies”. (Mother 1, Atwerebuanda)
Even though some women from the Assin North district considered transportation
challenges as a barrier to utilization of care under the policy, it was evident from their
submissions that they were willing to overlook the transportation challenges and seek for
supervised care at distant facilities if they had been advised to do so by a nurse or
midwife due to possible complications that may arise. In the Cape Coast metropolitan
area however, all the women who participated in the study did not see the nature of the
roads or the availability of vehicles especially during the day as a barrier to accessing
care. This is because the metropolis is more urbanized with tarred roads connecting most
parts of the city. They were however concerned about the availability and cost of
transport at night when one has no option but to charter a vehicle to a facility. A mother
from Ekon expressed this concern as follows:
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“The roads are ok but it is difficult and expensive to get a car (taxi) at night.
It is however easy to get one during the day” (Mother 1, Ekon)
7.3.3 Availability/competence of staff
A key factor that influenced the respondents’ choice to deliver under the policy was
encouragement received from healthcare providers to deliver with the policy at ANC
clinics. A mother from Ekon highlights the contribution of nurses in encouraging
women to utilize services under the free delivery policy:
“At UCC hospital, they (referring to nurses and midwives) always
encourage pregnant women to get the NHIS card to enjoy free care. Since
they want to get more pregnant women to register under the NHIS, they
have decided to look after those with the cards first before those who do not
have it” (Mother 1, Ekon: Cape Coast Metro. Area)
The accounts of women on care received at the facility during their last delivery suggest
that most of them considered the availability and competence of a trained healthcare
professional as critical to receiving a positive or negative pregnancy outcome. One
common attitude of some healthcare professionals mentioned by the study participants
related to their concerns about judgments by health workers for women to deliver
through caesarean sections even when there is the possibility for women to deliver
through the normal way. They perceived the behavior as one deterring several women
who would have otherwise sought for facility-care from doing so. The narrations below
provide examples of the women’s reporting:
“…………………They (referring to nurses or midwives) push us to go for
Caesarean sections even when one can deliver through the normal way. I
witnessed a situation where a lady who was being prepared for a CS pushed
and delivered her baby herself without the operation” (Mother 2, Assin
Fosu)
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“We got to the hospital around 4:30am and met a midwife on duty. She
offered me a bed and came to examine me and the progress of labour. She
told me I will deliver through an operation but as the pains intensified, I
pushed hard and the first baby came out. She then rushed to assist me. I
delivered the second one some minutes after the first one. A doctor came in
just when I had finished delivering to observe me and I heard him querying
the nurse for telling me that I will have an operation even though I could
deliver through the normal way” (Mother 1, Duakoro).
“Several women prefer to deliver with TBAs in the communities to avoid
having an operation if they choose to come to the hospital. The nurses are
too quick to ask you to deliver through an operation. The TBAs are patient.
Several women have delivered safely through the normal way with them”
(Mother 2, Assin Bediadua)
A respondent from Assin Fosu also expressed concern about the manner in which a
doctor carried out her caesarean section operation.
“Another attitude the doctor showed was that whiles stitching my cut after
removing the baby this doctor was busily chatting with the nurses and other
hospital workers who were around and not concentrating on what he was
doing. I was therefore unduly delayed with the performance of the
operation. When I was finally brought to the ward, I realised that my thighs
were swollen and had become hard and heavy. Even on the third day when I
was discharged I had a lot of difficulty walking until after several days”.
(Mother 1, Assin Fosu)
The mothers associated staff competence with the age and years of work of a healthcare
provider and perceived that older healthcare providers were more competent than their
younger counterparts. For one mother who delivered at a hospital in Assin Fosu, the
negligence with which a doctor assisted her to deliver through caesarean section did not
surprise her as she considered the doctor as relatively young and therefore inexperienced
in conducting caesarean section deliveries.
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“The doctor was quiet young and I realised he did not have much
experience in his work. During the operation he cut my stomach very
deeply. The cut was also too long. It was almost from one side of my
stomach to the other. He also removed the baby with some kind of force and
I could even feel some pain as he did so” (Mother 1, Assin Dompem)
A mother from Duakoro in the Cape Coast metropolis also expressed a similar opinion.
She said:
“I think that more matured midwives should be employed in our facilities to
assist with deliveries. Most of the younger midwives are not experienced”
(Mother 2, Duakoro)
7.3.4 Availability of equipment and supplies
The availability of obstetric equipment and supplies has been empirically shown to
affect use of maternity services (Alvarez, Gil, Hernandez, & Gil, 2009; Campbell and
Graham, 2006). The availability of desired healthcare infrastructure and medication
influenced women’s choice of health facilities for delivery in particularly, the Cape
Coast metropolis where the categories of healthcare facilities are relatively more in
number. The perception that hospitals are equipped with most of the needed obstetric
infrastructure increased women’s desire to deliver with hospitals.
“I decided to go to University of Cape Coast hospital because the place is
beautiful. The hospital has the needed staff and equipment to take care of all
pregnant women who go there. There are enough beds in the wards. They
have all the necessary equipment for caesarean section deliveries. Even the
floors in the wards are tiled and always neat” (Mother 2, Abura)
“Most of the hospitals have a lot more obstetric equipment needed for all
forms of delivery be it normal or caesarean section. They also have the
necessary drugs for both mother and baby. The wards and beds are also
many to accommodate more women compared to what is available in the
health centers and clinics” (Mother 2, Ekon)
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“I chose St. Francis because it is the biggest hospital in the municipality
with adequate staff, and other equipment needed to assist all women to
deliver safely (Mother 1, Atwerebuanda)”
Women were concerned about the availability of adequate quantities of basic obstetric
equipment and supplies as beds and medication for both mother and newborn baby in
their decisions to deliver at specific hospitals. They were also concerned about receiving
care from professional staff who they perceive to be adequately available in hospitals
than other lower level facilities. Other women were also particularly concerned about
the sanitary conditions and the beauty of the facilities they visit for maternity services.
The testimonies of women also suggest that the limited availability of even basic
obstetric supplies in lower level facilities have resulted in regular referrals to the
relatively few hospitals. This unduly increases the workload of these facilities.
Respondents from both study districts shed light on this common practice.
“Equipment available for maternity services is inadequate at Adisadel
(referring to a health centre). The beds there are woefully inadequate. On
the day, I delivered a certain woman came in some few minutes after I had
arrived. She was asked to go to Interbertin (referring to Cape Coast
Regional hospital) because there was no bed. Even gloves that nurses will
wear whiles assisting us to deliver are sometimes not available” (Mother 2,
Abura).
“I was referred from the polyclinic to St. Francis because I needed to have
my baby through an operation. The polyclinic does not have a doctor to do
the operation. All pregnant women who deliver through an operation are
referred to St. Francis or sometimes Interbertin (Central Regional hospital)
where there are doctors to do the operation” (Mother 1, Assin Fosu).
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7.4 Organization of care
The women who participated in the study were further asked to share their experiences
with how the different cadre of staff who attended to them coordinated to provide
healthcare services. They shed light on how they were catered for by healthcare
personnel at every stage of the healthcare delivery process.
Their responses suggest that health staff coordinated well in providing care. Most of the
respondents were of the opinion that providers understood their individual roles and
acted accordingly as and when their services were needed.
“The nurses and doctors work together and play their respective roles very
well. They work professionally” (Mother 2, Assin Dompem).
“All the workers worked closely together and performed their individual
roles diligently. When it was time for morning devotions, the nurses in
charge arrived on time to lead the session; those assigned to take care of us
in the wards did their work professionally. During my operation two doctors
and two other midwives worked together to perform the operation as my
case was an emergency. Those working in the lab and the dispensary also
did their work diligently” (Mother 2, Abura)
They also understood coordination in provision of care as when other staff who were not
directly in charge of providing a particular type of care, willingly and promptly provide
support to an attending healthcare professional
“……..After the examination, the midwife informed me that I was
discharging some greenish fluid which is not normal. Additionally, the baby
was not positioned with the head down and that also requires an emergency
attention. She therefore called on the two other midwives who were
attending to the other pregnant women outside. They quickly came to the
ward to see to me and assisted the first midwife to prepare me for the
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theatre. They actually put me on a stretcher and pushed me to the theatre.
The two midwives, together with the first one assisted the doctor who did the
operation. They cleaned me after the operation and pushed me back on the
stretcher to the award. I was sincerely grateful to them and I realized that
midwives support themselves especially when they have to attend to an
emergency situation” (Mother 1, Ekon).
Regarding the extent to which services rendered to women were entirely free, all the
participating women confirmed that irrespective of the level of facility in which they
delivered all medical services they were offered were at no cost.
“I did not pay for anything when I went to deliver. The operation was free,
admission fee free. The drugs given to me and my baby after delivery was
also free” (Mother 2, Assin Dompem)
“……….I was admitted for 3 days but did not pay for it. The nurses who
assisted me to deliver did not charge me. I was given drip for free. The
nurses did not charge me for bathing my baby and giving him an injection. I
was given some drugs to take at home before I was discharged. Again, I was
not asked to pay for them” (Mother 1, Assin Bediadua)
They were however concerned about the long list of items they had to carry along to the
facility to deliver which are not covered under the policy. These items include bed
sheets, toilet soaps, washing detergents, sanitary pads, Flask, methylated spirit, baby
diapers, parazone, toilet rolls and cot sheets. To many, even though delivery care was
free, several women cannot afford to purchase all the items and therefore will not
consider delivering through the policy. A mother from Assin Bediadua therefore called
for the policy to support in the provision of some of the items.
“The items we are asked by the midwives to present for delivery are too
many and some are expensive. I wish that government makes some of the
items available to us for free through this initiative. Alternatively, we can be
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given some money to add to what we have to make it easier for us to buy all
the needed items” (Mother 2, Assin Bediadua)
The testimonies from the respondents suggested that all maternity services are not
entirely free under the policy. Twelve out of the sixteen respondents reported having
paid for certain ANC services when they were pregnant. The services they paid for were
primarily for laboratory and scan tests and drugs not covered under the National Health
Insurance Scheme.
“I paid 5 cedis for lab test. I also took a scan which I paid for when the
pregnancy was about six months old” (Mother 2, Assin Fosu)
“………There were times that I had to pay for lab tests and some drugs that
they say the NHIS does not cover” (Mother 1, Abura)
7.5 Satisfaction with care
In describing their satisfaction with services received for their most recent birth, the
study participants shared their experiences on the quality of care received. These
included their experiences on some health system factors such as the presence of
competent staff, staff attitude, availability of supplies and how hygienic the facility was.
These factors have been noted to influence quality of care (Thaddeus & Maine, 1994).
The views expressed were similar for both study districts.
Regarding the study participants’ encounter with health staff, the women reported of
both positive and negative experiences with their encounter with healthcare providers.
Some praised them for their professionalism, patience and advice. Some of the
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testimonies also points to clients’ dissatisfaction with the hostile attitude and the
seemingly unprofessional conduct of some providers.
“I was very satisfied with the standard of care I received. The hospital has
all the necessary equipment needed for a safe delivery for every woman who
goes there to deliver. I was even more satisfied with the useful advice given
by nurses on how to take care of my twins and myself and the need to adopt
a Family Planning method so I do not get pregnant too early after the first
one”. (Mother 2, Atwerebuanda).
“The nurses were very patient. They attended to me promptly anytime I
needed some help” (Mother 1, Abura)
“I was not satisfied at all with the care I received at the hospital. I do not
think the doctor had received the necessary training. The attitude of nurses
too is bad. They do not only shout on us but also our relatives who
accompany us to the hospital”. (Mother 2, Assin Fosu).
Some respondents however felt that the seemingly hostile attitude exhibited by some
healthcare workers could be the result of the increased workload they had to cope with.
A mother who delivered at the Cape Coast Metropolitan hospital puts it this way,
“We however need to be patient with them (referring to nurses and
midwives) since they have so many of us to take care of at the same time”
(Maame Esi, 35 year-old mother of twins, Abura, Cape Coast)
On the level of hygiene of facilities, again the mothers expressed both positive and
negative experiences. The experiences shared were similar irrespective of the level of
facility in which a woman delivered her baby.
“The quality of care received at the hospital was good. The ward where I
slept was good and neat, toilet and bath was also neat, delivery place neat
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and all equipment needed available. It is only the attitude of staff (shouting
on me most of the time) that I found to be very bad”. (Mother 2, Ekon, Cape
Coast)
“I will say that privacy is not good especially at the delivery room. You
sometimes have 3 women delivering at the same time on all 3 beds
available. This leads to a situation where they can see each other. The
bathrooms available are also only 2 and this is not adequate (sometimes
two people bath at the same time). The same thing applies to the toilet.
Considering the numbers of people that visit the hospital, these facilities are
inadequate”. (Mother 2, Abura)
In describing their satisfaction or dissatisfaction with the quality of care received, most
women perceived the quality of care to be good if healthcare infrastructure as well as
medical supplies were adequately available to cater for their obstetric needs.
Additionally, they described the quality of care in terms of staff competence and
perceived quality of care to be good if staff competently and patiently catered for them.
7.6 Conclusion
The testimonies of women regarding their delivery experiences under the free maternal
healthcare policy shows that indeed the policy is addressing financial barriers to
accessing care. The study participants were particularly enthusiastic about the initiative
as it had offered them the opportunity to access supervised care at birth, which they
deem very critical for a successful pregnancy outcome. They were however worried
about other non-financial barriers affecting better access and use of services under the
policy. Certain facility-related challenges including the unavailability of adequate
infrastructure and personnel, competence of skilled staff and the attitude of some
healthcare professional however continued to influence the women’s access to
supervised care at birth. Secondly, community level barriers, primarily related to
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availability of efficient and regular transportation to facilities providing free care
affected supervised delivery services use for particularly the rural women.
Although improving financial barriers to accessing supervised care is critical, other
facility-related barriers particularly regarding the availability of adequate and competent
staff and healthcare infrastructure should be rigorously pursued by government.
Additionally, although improving access to supervised care at the point of delivery is
critical to improving maternal healthcare outcomes, it is necessary to underscore the
importance of addressing community-level barriers particularly transportation
challenges which greatly affect the timeliness with which women access free supervised
care to avert preventable maternal deaths and morbidities. Increasing access to delivery
care under the policy for rural/underserved areas through improved road networks and
available emergency transport is highly recommended.
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Chapter eight: Healthcare provider perceptions and experiences with the
implementation of the ‘free delivery’ policy
8.1 Introduction
The chapter presents and discusses healthcare provider perceptions and experiences with
provision of supervised care under the free delivery policy. A total of fourteen (14)
midwives and five (5) district level experts in reproductive and maternal health were
interviewed on how the free delivery policy was being implemented at the district and
facility-levels. The study intended to interview sixteen (16) midwives, two each from
eight selected health facilities in the study districts but two of the facilities in the Assin
North municipal area had single midwives managing those facilities. Using a semi-
structured guide, the respondents were interviewed on their knowledge about the policy,
organisation and provision of care to clients at accredited facilities and the strengths and
weaknesses of the policy. The data collected was analysed using the thematic analysis
approach which involves identifying, analyzing and reporting patterns (themes) within
the data (Braun, Virginia, & Clarke, 2006).
Eight major themes were identified after reading and re-reading the transcribed data to
understand the responses given by the midwives and key informants. These were
knowledge about the free delivery policy among healthcare providers; collaboration with
supporting staff; and administrative support. The others were access to supervised care
for women; workload and limited number of midwives; inadequate infrastructure and
medical supplies; distance and transportation challenges and delays in receiving
payments for services from the NHIS.
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The chapter presents the results under two broad sections. The first section briefly
describes the background and professional characteristics of the midwives and the
healthcare experts interviewed. The second presents data on the main and sub-themes
that emerged from analysing the transcribed data.
8.2 Professional background of midwives and key informants
Eight of the fourteen midwives were in the rank of principal/senior midwives whiles six
were junior midwives/midwifery officers. The senior midwives had been providing
midwifery care for a period of between ten and twenty-one years with the juniors having
worked for between five and ten years. All were trained midwives even though majority
began their profession as nursing officers. They were primarily responsible for providing
ANC services, assisting with normal deliveries and postnatal care services. The two
midwives from the Assin North municipal area who were the only ones in charge of a
health centre and a private maternity clinic were also engaged in treating minor ailments
as malaria and diarrhoea.
The key informants in health were made up of the Deputy Director of Public Health at
the Central Regional Health Directorate who had worked for twenty-one years as a
public health specialist. The others were the two District Directors of health services of
the selected districts who were also public health specialists and two senior public health
nurses of the study districts.
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8.3 Healthcare providers’ knowledge about the free delivery policy
All the midwives as well as key informants interviewed were aware of the existence and
implementation of the free delivery policy. The midwives had been briefed about the
policy at workshops or meetings organized by the offices of the regional or district
directorate of health or have read about it from memos that were circulated by their unit
heads at the facilities. They reported that the briefing sessions clearly outlined the
requirements that clients should meet before they are offered free care, the maternity
services to be provided for free under the policy and how to accurately document for
services that have been rendered to clients towards ensuring that the facilities are
reimbursed for their services on time by the NHIA. A midwifery officer at the St.
Francis Xavier hospital at Assin Fosu outlined the range of services that women were
entitled to under the policy as follows,
“Under the free maternal healthcare policy, a woman is entitled to free
consultation at antenatal clinics, free treatment, free examination, and free
treatment for STIs in case a client has contracted one. Every form of
delivery is free, normal delivery free, caesarean section free, retained
placenta free. Post-natal care is also free up to 6 weeks after delivery.
(Junior midwife, Assin Fosu).
The midwives however gave divergent responses on the range of neonatal and post-natal
services that mothers and their babies were entitled to under the policy and the duration
within which they can access these services. Out of the 14 midwives interviewed 4 were
of the view that only babies were entitled to free care after delivery. With regard to the
length of period that mothers and babies can access free postnatal services, few
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mentioned up to two weeks after delivery whiles the majority maintained that mothers
and their babies can access free services for up to six weeks after delivery.
The feedback received from the midwives can partly explain why mothers who took part
in the questionnaire also had lower knowledge about free PNC services (compared to
other maternity services provided for free under the policy). Majority of the respondents
reported receiving information on the policy from nurses and midwives. All key
informants interviewed were however aware that mothers and their babies were entitled
to free PNC care for the first 6 weeks after delivery as stipulated in the free delivery
policy guidelines document.
The differences in knowledge on PNC care under the policy between the midwives and
key informants could be attributed to a gap in knowledge transfer on the policy from the
national to the local. Healthcare providers at the local level could possibly be
interpreting the policy wrongfully. As earlier mentioned, information on the policy and
guidelines for its implementation was produced at the national level. The information
was then shared with the offices of the regional and district directorates. Representatives
of these directorates later shared the information with heads of the different units of
healthcare facilities who in turn disseminated to relevant healthcare providers.
8.4 Provision of fee free maternity services to clients
The midwives who were interviewed were asked to share their experiences regarding the
actual provision of services to clients who visit the facilities to access care under the
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policy. They shared their experiences on how care is provided when women visit the
facilities, use of services by women, challenges to effective provision of care to clients
and how they were coping with the challenges.
8.4.1 Collaboration in provision of care
From the interviews with the midwives and maternal healthcare experts at the regional
and district levels, two regimes of support to ensure the smooth implementation of the
policy at the district and facility levels emerged. One form of support was provided by
the regional and district directorates of health whiles the second was provided by health
facilities through midwives, nurses and other relevant paramedic staff.
The regional and district directorate of health played two key roles towards ensuring that
women receive adequate and efficient care under the free delivery policy. Firstly, the
two offices coordinated the securing and disbursement of needed medical equipment and
supplies to all facilities providing care under the policy. Secondly, the district offices
have the responsibility of reviewing healthcare utilization claims submitted by all
facilities before it is forwarded to a National Health Insurance office at the district or
regional level for facilities to be reimbursed for services that they have rendered to
clients.
All the midwives interviewed were fully aware that for a woman to access maternal
healthcare services under the policy, she would need to present a scan or a urine test
result of confirmation of pregnancy. Having presented the pregnancy results, they
(midwives) fill out and issue a form with the woman’s demographic and pregnancy
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information to the woman to be presented at the DMHIS office or an NHIS desk at a
facility for registration under the NHIS. As part of the registration process, the woman is
issued with a card which she has to present at a facility to be able to access free care. All
the midwives had undertaken this exercise for several women who visited their facilities
to access maternity care.
The midwives also outlined how they collaborate with other facility staff to provide
care. They reported that at least a midwife at post together with nurses and other
paramedic staff was vital to ensuring that women who visit facilities to deliver received
the necessary care they deserve. In Assin North for instance, one key informant reported
that the district recognizes the key role midwives play in ensuring that women deliver
safely. For every facility that provided maternal healthcare services therefore, at least
one midwife was assigned to provide professional care to mothers and their babies. In
most instances the midwife worked closely and with the assistance by nurses, lab
technicians, pharmacists and health assistants.
The midwives confirmed that they worked closely with staff of other units that provide
healthcare services to clients. In addition, they worked closely with some private
laboratory centres that offer free laboratory services to people registered under the NHIS
as well as staff from the district offices of the NHIA to provide the necessary care to
women who visit the facilities. A principal midwife from a hospital in Cape Coast
illustrates it as follows,
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“The midwives and nurses in this facility work closely with the different
units to provide care to the women. The workers of almost every unit in
this facility, OPD, pharmacy, accounting, lab etc. are aware of this policy
and their specific roles in providing care to our clients. There are also
NHIA claim officers who work in this hospital. These officers come here
(referring to the labour ward) regularly to collect claim forms and
educate us (midwives) on any amendments to the services that we are
providing under the policy and how to fill out the claim forms correctly”.
They were however worried that staff that support with emergencies such as the
ambulance unit were not adequately equipped and officially recognized as a core part of
the cadre of staff that should be available at all times to assist with emergencies.
8.5 Utilization of supervised care
The respondents perceived that, there are a number of positive benefits of the free
delivery policy for both mothers and healthcare providers even though some midwives
expressed concern about overutilization of services by women who already have many
children. The sub-themes that emerged from the analysis of what the healthcare
providers perceived as the benefits of the policy included increased uptake of facility-
based services, women reporting early at facilities during pregnancy and at the time of
delivery and better and efficient care provision by providers.
8.5.1 Increased uptake of facility-based services
The midwives, particularly those from the Assin North municipal area were happy that
the policy has provided an opportunity for both rich and poor women to access
supervised delivery services and reported that uptake of care was overwhelming. One
midwife from Assin North exclaimed when asked to share her view on uptake of free
delivery services and said:
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“Heii, the numbers are more than necessary as we constantly educate
mothers who come for ANC services on the need to register with the policy
and access care for free. We sometimes feel very tired attending to several
women who come from Assin Fosu and other neighbouring communities.
We work for longer hours now. The number of women accessing this
service has increased dramatically (Principal midwife, St. Francis Xavier
hospital, Assin Fosu).
A section of the midwives and key informants were however concerned about the fact
that the policy may lead to increasing birth rates as some women who already have five
or more children continue to give birth because care is received at no cost. One junior
midwife from a Health Centre in Cape Coast was particularly concerned that the
introduction of the policy has led to a reduction in uptake of Family Planning services.
She stated her concern as follows:
“We have witnessed a drastic rise in the number of pregnant women
seeking care. We now have women who already have 5 or 6 children
coming in to access free care. It wasn’t like this in the past. Family
Planning use is going down. Some women prefer to get pregnant and
receive free care than to be paying for family planning services” (Junior
midwife, Cape Coast)
One key informant in Cape Coast corroborated her concern and recommended the urgent
need for Family Planning services to be offered at no cost as it is for maternity services.
If some midwives perceive use of free maternity services by women who already have
many children as a deliberate attempt to abuse the system because care is provided at no
cost, then this can possibly influence their attitude towards such clients
Another form of abuse mentioned by some of the midwives related to the increasing
visits made by pregnant women outside their scheduled dates of visitation even when
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they do not require any urgent care. A principal midwife at a hospital in Assin Fosu
shared her experience.
“……You will ask a pregnant woman to come for her next visit in one
month time, unless she is sick but you see her coming again after two
weeks with the excuse that she thought her next review was in two weeks’
time. We have been reliably informed by their own colleagues that some of
them come around to take medicine for their sick friends and family
members who do not have NHIS cards”
Further analysis of the interviews with the midwives revealed that some clients do not
adequately understand that the policy was introduced to primarily cater for maternity
services. They reported that some clients understood free delivery care as going to a
facility to deliver without having any money on them apart from that taken for
transportation. Some midwives were particularly worried that some women assumed
that they will be offered free food and drinks before delivery. To them pregnant women
are required to eat to have the needed energy to deliver their babies. A junior midwife in
Cape Coast illustrates her experience and suggests some possible solutions.
“Because of this free service, most women come to the facility with no
money on them” They should know that they may have to purchase an
item or eat before delivery. I have personally bought ‘koko’ (porridge)
and malt for several women who came to deliver on empty stomach. I will
therefore recommend that women are adequately informed that the policy
does not offer food. On the other hand, facilities can also be provided with
some milo, milk and sugar so that we can at least prepare some beverage
for women who can in on empty stomach and without money to buy food”
From these concerns, health facilities have a responsibility of educating women on the
importance of adhering to the guidelines put in place regarding times to visit facilities to
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access services and the health implications of collecting and sharing their medications
with relatives for whom the medicines have not been prescribed. Additionally, there is
the need for increased education on the core maternity services provided under the
policy.
8.5.2 Timely access to supervised care
The ability of women to seek supervised care early enough because it is free was
identified as one key benefit of the policy by both the midwives and key informants.
Aside the fact that, the policy had provided easy access to supervised care for all
women, the midwives were particularly happy that possible complications can be
averted so that the stress and tensions and anxieties that come with dealing with
complicated deliveries is avoided. One principal midwife shared her experience on a
delivery which would otherwise have resulted in a complication or even death if the
woman had delayed in visiting a facility because of the cost involved. The woman in
question reported to the facility on time when she started experiencing labour
contractions. On arrival, she was examined by the midwife and the necessary
information on the pregnancy and progress of labour was taken and everything was fine
until the time of delivering the baby. She recalled:
“…………….I realized the baby was descending but with the face up
instead of being down. The position was therefore not normal. The woman
then started passing stool. I cleaned her with more than 4 pieces of toilet
roll. I quickly called on three other nurses to help me. I increased the
infusion (IV line) to give her more energy to push the baby out. The
woman finally delivered, but with the babies face still up. After delivery I
quickly cleaned up the baby (gave particular attention to the nostrils ears
and eyes), applied some oil on her body, wrapped her and put her on the
mother’s abdomen for some warmth……” (Senior midwife, Cape Coast
Metropolitan hospital).
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8.6 Challenges to accessing care
One assumption made in this study was that healthcare providers may be confronted
with a number of challenges in providing care under the policy. Four sub-themes
emerged from analysing the discussions on the providers’ perceptions on challenges
affecting the smooth implementation of the policy. Three of the themes related to
challenges that affected providers in their quest to provide care whiles the fourth related
to community-level barriers that affect women in accessing care. The provider-related
sub-themes were workload and limited number of midwives; inadequate infrastructure
and medical supplies; and delays in reimbursement of funds. The sub-themes are
discussed below.
8.6.1 Workload and limited number of midwives
It was realised from the discussions with the midwives that, they did appreciate the fact
that they were confronted with some challenges in providing care to the increasing
numbers of women seeking care at the facilities since the introduction of the free
delivery policy. They reported of extended hours of work and the limited number of
midwives as the two major constraints to providing quick and adequate care to all clients
who report at the facilities. They were however coping and some shared the strategies
that they have adopted during the interview. For many they rely on the help they receive
from nurses and other Health Assistants even though they mentioned that these
assistants are not always available. A senior midwife at a private maternity clinic at
Assin Fosu had adopted a different approach to increase the number of health staff
assisting her. She said:
“When it comes to availability of the skilled staff to assist me, I will say
that I do not have a problem at all. I have personally trained some people
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in nursing and midwifery skills to assist me”. I derive so much satisfaction
in saving the lives of mothers and their babies and hence my adoption of
this strategy to make sure that every woman who comes here receives the
needed care”
The senior midwife believed that those she had trained on the job had the capacity to
provide the necessary pregnancy-related care to their clients. Even though within the
particular context, the strategy adopted may have proven to be effective in addressing
the challenge of limited staff with midwifery skills, the suitability of the approach raises
concern about the provision of skilled care. Even though the midwives were coping, it
can be argued that the policy has limited capacity to deal with the increasing workload
for professional staff due to increased demand for services.
8.6.2 Limited supply of basic as well as emergency infrastructure and supplies
One theme related to barriers in the implementation of the policy was the issue of
limited or unavailability of both basic and emergency drugs and other obstetric supplies.
Several studies in Ghana and other low and middle income countries have documented
the effect of available equipment and supplies for healthcare on uptake of maternity
services (Alvarez, Gil, Hernandez, & Gil, 2009; Campbell & Graham, 2006). A key
informant at the Regional health directorate also noted that occasionally some facilities
run short of basic/essential equipment like gloves even though the regional or district
supplies some to the facilities as soon as they are notified.
All the midwives interviewed except for the midwives from the St. Francis Xavier
hospital at Assin Fosu expressed concerns about how inadequacies in the supply of
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obstetric supplies affect their ability to offer the best of care to clients. The St. Francis
Xavier hospital is managed by the Christian Health Association of Ghana (CHAG)
which regularly provides the hospital with the needed drugs and other supplies required
by the facility. All 13 midwives mentioned the urgent need for government to provide
more ambulances for referral cases in both study districts.
There were variations in the infrastructure and obstetric supply needs of the different
health facility levels. The midwives working in hospitals and Polyclinics were
particularly concerned about inadequate supply of blood to cater for emergencies and
incubators for new born care. Those working in the Health Centres on the other hand
expressed great concerned about expansion of available infrastructure for maternity care
and increased supply of basic but essential supplies as gloves, mackintosh and drugs. A
midwife from a Health Centre in Assin Fosu shared the following,
“The delivery room is extremely small and this affects my movement when
assisting a woman to deliver. You can imagine how it feels like to
concentrate on the woman you are assisting and at the same time
managing with the little space you have around the delivery bed”
8.6.3 Delays in reimbursement of funds
All the study respondents mentioned delays in receiving payments from the NHIA for
services rendered as a critical factor influencing regular and improved healthcare service
provision to clients. They perceived the delays to be the result of mistakes and
inaccuracies in information provided on completed forms on the part of healthcare
providers as well as undue delays and bureaucracies in the processing of claims on the
part of the NHIA at the district and regional levels. For instance, a junior midwife at a
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health centre in Assin North municipal area attested to the fact that some of them have
challenges completing the claims forms by sharing a personal experience. She said,
“I have had some of my claims being rejected by the health insurance
office on several occasions. I think we have challenges with filling out the
claim forms correctly” (junior midwife, Assin North Municipal Area)
A key informant at the Assin North district corroborated the midwive’s submission and
added,
“Currently, all the health facilities send their NHIS office claims to the
municipal office for us to review them before we forward them to the NHIS
regional office. We started doing this when we realised that some facilities
lack the capacity to complete the forms appropriately even though they have
been trained on how to fill them” (Key Informant, Assin North Municipal
Area)
All but one midwife of a private maternity clinic in Assin North did not perceive the
delays as always bad. To her the payment received for accumulated arrears could be
equated to receiving bulk payment for an investment made which could be invested back
into the facility to improve overall access to services by more women.
8.6.4 Community-level delays in getting to the facility
Midwives from the Assin North district and a section of the key informants expressed
concern about circumstances outside the facility that sometimes prevent women from
seeking supervised care early enough to avoid complication or even death. These
included transportation challenges, either that the roads are bad, that some women
cannot afford the cost of transport or are staying too far from the nearest health facility.
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For instance, a key informant at the Central Regional Health Directorate was particularly
concerned about limited access to supervised care by women in rural communities due
to the deplorable state of the roads that links these communities to available healthcare
facilities. In the same vein, a senior midwife at a Polyclinic in the Assin North district
was not only concerned about the nature of the roads and long distances women in
neighbouring communities have to travel to get to the facility but also the increasing cost
of transportation. She reported that several women are not able to adhere to scheduled
times to visit the facility for follow-up check-ups simply because they cannot afford the
cost of transport.
Similarly, the midwife of a health centre in a rural community in Assin North was not
only concerned about the deplorable state of the roads but the long distance women have
to travel on the bad roads before they get to her facility. To her the answer to improving
access for women living in remote areas does not only lie in reconstructing the roads
that links communities to health facilities but also through the establishment of more
health facilities within reasonable distance to rural communities.
All the midwives in the Cape Coast metropolitan area however did not perceive the cost
of transport, the nature of the roads or the time that it takes women to get to the facility
as a major barrier to accessing supervised care under the policy. This is because most
roads in the metropolis are in good condition with most roads linking the different
localities and suburbs to most healthcare facilities tarred.
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8.7 Conclusion
The findings from the interviews with the healthcare providers raise urgent policy and
programmatic issues regarding the effective implementation of the free delivery policy.
First, distance to nearest facility and poor road network are noted to hamper use of
delivery care in most rural areas. The Assin North district is a largely rural district with
healthcare facilities providing supervised delivery services located very far from several
communities. The quality of the roads joining these communities to the available
facilities is also poor (untarred with deep potholes) with some becoming dangerous to
use during rainy seasons as they become very slippery.
Programmes and policies to address the transportation challenges in accessing free care
by rural communities should be considered to improve access for poor rural women.
Additionally, efforts to establish health facilities equipped with the needed equipment
and staff to provide supervised maternity services within reasonable distances in the
Assin North district should be rigorously pursued.
Secondly, the availability of adequate number of midwives to provide the needed care to
women remained a challenge in both study districts. Central as well as local government
need to step up efforts at increasing the training and effective deployment of staff with
the requisite skills to both rural and urban facilities. Additionally, to foster the
promptness with which health personnel attend to the maternity needs of women which
could be deadly in the event of delays, government should increase the availability of
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accommodation needs of healthcare personnel particularly for those working in rural
communities.
Finally, the discussions with the healthcare providers also brought to light the urgent
need of addressing challenges with the healthcare referral system. In view of the fact
that many healthcare facilities at both rural and urban areas do not have adequate
professional staff (doctors and midwives) to attend to emergencies, many resort to
referring women to hospitals mostly located at the district capital or the regional capital.
The unavailability of ambulance services to transport women to these facilities was
noted to be a critical barrier to providing prompt and efficient maternity care to women
in the study districts. Campbell and Graham (2006) have emphasised that the timeliness
with which people gain access to appropriate emergency obstetric care facilities is
crucial to the success of providing emergency obstetric care services. To address the
transportation challenges associated with accessing emergency care at birth, the DHMTs
of the study districts could work closely with the existing transportation system taxis
through the Ghana Private Road Transport Union (GPRTU) to assist in transporting
women to healthcare facilities.
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Chapter nine: Discussion, summary of findings, conclusions and recommendations
9.1 Introduction
The chapter is divided into three broad sections. The first section discussed the
quantitative and qualitative findings emerging from the study. The discussion section
ends with an analysis of how the findings relate to the theoretical and conceptual
frameworks underpinning the study. The second section gives an overall summary of the
major findings emerging from the study. The final section provides a conclusion to the
study and outlines key policy and programmatic recommendations.
9.2 Discussion of findings
The discussion is presented under the four specific objectives presented in the study. To
a large extent the findings emerging from the study were related to the literature
reviewed. On the objective that looked at factors influencing delivery care use under the
free maternal healthcare policy, emphasis was placed on factors that showed statistically
significant relationship with utilization of delivery care. Equal attention was however
also placed on findings that run contrary to expectations.
9.2.1 Awareness and knowledge about the free delivery policy
The study found that almost all the women interviewed were aware of the existence of
the policy with approximately nine out of every ten mothers knowing about the policy.
Majority received this information from either healthcare providers (nurses/midwives)
or through radio broadcasts. Women from both study areas had equally high awareness
levels (98.1% for Assin North and 96.5% for the Cape Coast metropolis).
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The seemingly very high awareness levels about the free delivery policy could be partly
attributed to the fact that, the second phase of implementation of the policy begun
through a governmental directive of free delivery care in 2008 and the message was
extensively disseminated by the media and healthcare workers at all levels of healthcare
delivery in Ghana. This finding is similar to what was observed in a study in Niger, a
West African nation like Ghana (Ridde & Diarra, 2009). The authors undertook a
process evaluation of an NGO intervention to abolish user fees for pregnant women and
children under five in 2 health districts and 43 health centres in Niger. The authors found
widespread information dissemination on the initiative by the NGO across beneficiary
communities as one of the major strengths of the success of the initiative.
Mothers’ knowledge about the policy’s full benefit package was however not as high as
that of awareness levels with approximately six in ten mothers having knowledge about
the full range of maternity services provided for free under the policy. Comparing
knowledge levels across the study districts however, mothers from the Cape Coast
metropolis were more knowledgeable about the policy’s benefit package than those in
Assin North. The findings suggest that women residing in largely urban areas are likely
to have better access to healthcare information and services, a hypothesis which has
been confirmed by previous studies in Ghana and in parts of Africa (Fotso, Ezeh, &
Oronje, 2008; Gething et al., 2012). Even though the disparities exist, the finding
reflects the positive side of urbanization. Cape Coast remains the regional capital for the
Central region and like other metropolitan areas has a larger share of social services
including healthcare services. Considering that the metropolis has the largest number of
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healthcare facilities with some serving as referral centres, several women from even
rural areas could access care from facilities within the metropolis.
Ranking mothers’ knowledge levels on the range of maternity services they were
entitled to under the policy, postnatal care services was the component that most
mothers in both districts did not know that they could access for free across districts and
across rural/urban areas. Additionally, the majority of respondents (approximately 95%)
were ignorant of receiving free care for caesarean section deliveries and complications
arising out of deliveries even though the policy offers free care for all types of
deliveries. The feedback from in-depth interviews conducted with a cross-section of the
respondents on their delivery experiences revealed that most women presume free
delivery care as referring to free care for normal deliveries only as information
disseminated to these women is mostly not explicit on free care for all categories of
deliveries. A similar scenario was observed by Powell-Jackson, Morrison, Tiwari,
Neupane, and Costello (2009) in Nepal where challenges with effectively
communicating the content of a maternal healthcare financing policy to both
implementers and benefactors remained a major constraint to the effective
implementation of the program.
An analysis on knowledge about the policy between women residing in rural compared
to urban areas revealed that rural inhabitants were more knowledgeable than urban
inhabitants. The finding is contrary to what has been found in other developing countries
such as Kenya, Tanzania, Burkina Faso Malawi and Ivory Coast (Fotso, Ezeh, & Oronje,
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2008; Gabrysch & Campbell, 2009). The findings of these studies have suggested that,
urban dwellers have better access to healthcare information and resources than rural
dwellers since majority of healthcare infrastructure are located in urban areas. The
opposite scenario observed in this study could be attributed to the source from which
women in rural areas received information about the policy. The findings on the
different sources from which women received information about the policy showed that
majority of women residing in rural areas (45.3%) received information on the policy
from nurses and midwives who are the primary providers of maternity care.
9.2.2 Factors influencing delivery care use
The study also assessed individual and health policy factors influencing delivery care
use under Ghana’s free maternal healthcare policy. The choice of variables for the
analysis was guided by literature as well as factors outlined in the conceptual framework
adapted for the study. Variables related to the individual characteristics of the user,
otherwise referred to as predisposing factors by Aday and Andersen’s (1974) framework
adapted for the conceptual framework such as age, marital status, religion, parity, place
of residence and employment status were used for this study. Two variables on the free
maternal healthcare policy - awareness and full knowledge about the policy were also
used in the study.
In terms of individual background factors influencing delivery service use under the
policy, the study found place of residence, maternal age, religion, marital status and
parity as major predictors of use of supervised care under the policy at the multivariate
level. The findings are consistent with those of studies conducted in Ghana and other
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low and middle-income countries (Babalola & Fatusi, 2009; Gabrysch & Campbell,
2009; Chirdan & Envuladu, 2011; Doku, Neupane, & Doku, 2012). Place of residence
has been found to constitute a major determinant of healthcare use as it shapes
individual opportunities and access to healthcare resources (Fotso et al., 2008; Gabrysch
& Campbell, 2009). In line with what has been reported in earlier studies, (Fotso et al.,
2008; Gabrysch & Campbell, 2009) in all three models run through binary logistic
regression, mothers residing in urban areas were more likely to use supervised delivery
services under the policy than those living in rural areas. In model 1 (Table 6.6), mothers
residing in urban areas were 3.566 times more likely to use delivery services under the
policy. In model 2 (Table 6.7), the odds of delivering with the policy was 3.188 times
higher for urban mothers compared with rural mothers and finally in model 3 (Table 6.8)
mothers residing in urban areas were 3.793 times more likely to deliver under the free
delivery policy.
Studies have shown that urban settlements in Ghana and other developing economies
receive a better share of healthcare resources including supervised maternity services
(Fotso et al., 2008; Gething et al., 2012). Additionally, well-known community-level
barriers including poor transportation networks and distance to available healthcare
facilities could partly explain variations in access to services between women in rural
and urban areas (Ononopkono et al., 2013). Women who participated in the qualitative
study in rural communities in the Assin North district indicated long distances and poor
transportation network linking communities to nearest healthcare facilities as major
barriers influencing use of supervised delivery services for women in rural areas.
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The results on place of residence have very useful implications for effective
implementation of the free delivery policy with regards to improving equitable access to
care for both rural and urban inhabitants. Firstly, it reinforces the need for further
attention to addressing the age-old challenge with better transportation systems linking
communities to healthcare facilities. Secondly, it draws attention to the need for
increased attention to improving access to maternity services for women in rural and
remote parts of Ghana.
Regarding age, the likelihood of using delivery care under the policy was lower for
younger mothers aged 20-29 compared to those in the age bracket of 40-49. Maternal
age has been found to influence use of maternity services even though there is no
consistency in the findings (Doku, Neupane, & Doku, 2012; Ononokpono, Odimegwu,
Imasiku, & Adedini, 2013). The finding from this study is inconsistent with a study that
was conducted in Nigeria (Ononokpono et al., 2013) and at the same time consistent
with another that reviewed the literature on determinants of supervised care use in low
and middle-income countries (Gabrysch & Campbell, 2009). Similarly, in Ghana, Doku
et al. (2012) found that older women were more likely to have their deliveries assisted
by trained personnel within a facility setting. The authors conducted a national level
survey on the determinants of ANC visits and the type of delivery assistant present
during delivery using data from the 2008 GDHS.
Within the study setting, usage of care was lower for younger relative to older mothers
partly because younger mothers who most likely will be having their first or at most
second birth will most likely be very enthusiastic about having a positive pregnancy
outcome and may therefore choose to pay for maternity services which many consider to
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be of a better quality than services provided for free. The Central region has been noted
as one region with the lowest uptake of care under the NHIS and lack of confidence in
the programme has been noted as one major reason (GSS, 2008). Mothers in the older
age group, particularly those who already have many children on the other hand may
have varied expenditures to deal with and may therefore not prefer to add that of an
additional birth if they can receive care at no cost.
On parity however, the results of the study showed that mothers with lower parity had
higher odds of delivering with the policy than those with higher parity. Previous studies
have also confirmed a strong association between lower parity and use of maternal
healthcare services (Overbosch, Nsowah-Nuamah, Van Den Boom, & Damnyag, 2004;
Gabrysch & Campbell, 2009). Even in the context of free delivery care, Mills et al.
(2008) found higher parity as strongly negatively associated with use of supervised care.
Mills et al. (2008) conducted their study in Northern region which is also one of the pilot
regions in which the policy was implemented. Within the study setting usage of care was
lower for mothers with higher parities relative to those with lower parities partly because
ordinarily women with many children have been exposed to a number of childbearing
episodes and therefore will not be too enthusiastic and religious to seek for supervised
care even when it comes at no cost. Additionally, some healthcare providers interviewed
perceived usage of care among women who already had many children as a deliberate
attempt to abuse the system simply because services are provided at no cost. If women
in this category are aware that healthcare providers perceive them as intentionally
abusing services under the policy they may not use the service.
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Regarding religion, the results showed that Christians, primarily Orthodox Christians
had a lower likelihood of delivering with the policy than Moslem women. The finding
on religion could be partly attributed to the fact that Christian mothers compared to
Moslems are generally known to have fewer numbers of children and therefore may not
regularly use maternity services provided by the policy as Muslim women. Previous
studies (Gyimah, Takyi, & Addai, 2006; Hazarika, 2010; Doku et al., 2012) have
confirmed a strong association between religion and health-seeking behaviours during
pregnancy, delivery and the post-partum period across different religious groups. The
findings of these earlier studies on maternity care use among the different religious
groups were however different from the finding in this study. Gyimah et al. (2006) for
instance found women from the Moslem and Traditional religious fraternities as less
likely to use maternal healthcare services compared with Christians.
The study also found that, mothers who were married or co-habiting and mothers who
were either widowed, divorced/separated had a lower likelihood of using delivery
services under the policy compared to those who were single (never married). Ordinarily
single mothers will tend to take advantage of free care as they are not married and
therefore may not have husbands/partners to support them financially especially in cases
where they are not working.
Additionally, single mothers may not have the support of family members throughout
the period of pregnancy and delivery as in the case of married women as the Ghanaian
society including even some healthcare providers generally frowns upon pregnancy
outside marriage. Some of the young single mothers who participated in the study
expressed their disappointment with the negative attitude shown them by healthcare
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providers because they got pregnant out of wedlock. An earlier study by Hill, Tawiah-
Agyemang, and Kirkwood (2009) has confirmed that pregnancy and childbirth among
single women is highly stigmatized. The finding raises concerns for increased education
on the need for families; healthcare providers and the society at large to desist from
stigmatizing pregnant women who are single to enable them continue to access
supervised maternity services.
The study also introduced variables on health policy in the regression analysis as it has
become imperative to look beyond individual and community-level factors in addressing
challenges in access to supervised care at birth. Addressing challenges associated with
accessing care under a given healthcare policy is largely beyond the remit of the
individual woman. The variables introduced (awareness and knowledge about the fee
exemption policy) were significant in explaining delivery care use under the policy.
Aday and Andersen’s hypothesis that utilization of healthcare services can be influenced
by the introduction of a given healthcare policy was therefore confirmed in this study.
Some of the findings of the study were not consistent with certain hypotheses that
explain use of supervised care at birth. Maternal education which has often been
identified as a catalyst to empowering women and exposing them to better use of
healthcare services by previous studies (Overbosch, Nsowah-Nuamah, Van Den Boom,
& Damnyag, 2004; Fotso et al., 2008; Ononokpono at al., 2013) was not found to be a
key determinant of delivery care use in the regression analysis. This could be attributed
to the general low level of education of most indigenous inhabitants of the Central
region. The region has been classified among the poorest regions in Ghana with most
inhabitants of the region not highly educated (GSS, 2008). From the univariate analysis
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for instance, only 13.6 percent and 2.8 percent of the study participants had received
education to the secondary and tertiary levels respectively. Majority of the respondents
(75%) had received either primary or secondary level education. The possibility of
observing marked variations in the healthcare choices of women with primary and junior
secondary level education was minimal.
9.2.3 Women’s’ experiences with use of free delivery care
Chapter eight of the study presented findings on women’s experiences with accessing
delivery services under the free maternal healthcare policy. The study participants’
shared lived experiences on why they chose to deliver under the policy as well as the
benefits and challenges associated with accessing care under the policy. The findings
add to the discourse of health service use under the policy and provide evidence on how
both community-level as well as health system factors affect and influence utilization
patterns. The various themes that emerged from the findings are discussed below.
Motivation to accessing care
The participating mothers cited their desire and ability to receive supervised care under
the policy as the main reason informing their decision to deliver their index babies with
the policy. They appreciated the importance of receiving care from a skilled attendant
especially during delivery since they believed that they have been trained and therefore
are competent in handling any complications that may arise at the time of delivery.
Other factors that motivated them to deliver under the policy were encouragement
received from healthcare providers to deliver with the policy at ANC clinics,
encouragement from husband, recommendations by friends and family members, the
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proximity of a health facility to their place of residence and the fact that they actually
receive free care at birth.
The findings have confirmed that women received facility-based delivery services at no
cost at all accredited facilities as proposed by the policy. They were however obliged to
pay for some items to be presented for delivery which is not covered under the policy.
They also paid for transportation costs, which they were adequately aware that it is not
covered under the policy. Women, who paid some money to healthcare providers, did so
voluntarily. This finding is contrary to what has been reported by other studies that have
recommended the need for effective monitoring of services provided to benefactors
under fee exemption/reduction strategies to ensure that clients receive the full benefits of
an initiative and also do not make out-of pocket payments (Witter et al., 2009; Mubyazi
et al., 2010).
The finding that receiving supervised care remains a major motivating factor for
women’s use of care under the free maternal healthcare policy is consistent with other
studies in low and middle income countries (Campbell & Graham, 2006; Koblinsky et
al. 2006). These studies have highlighted the importance of skilled care at birth. Indeed,
the ultimate goal of several cost reduction or elimination initiatives for maternity care
has been to improve access to supervised care at birth (Ridde & Diarra, 2009; Ir, Souk,
and Van Damme, 2010; Ridde et al., 2012).
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The encouragement and advice received from healthcare providers and family members
particularly the spouses/partners also to deliver under the policy is not common to the
study setting only. The finding is consistent with a qualitative study in Uganda (Amooti-
Kaguna & Nuwaha, 2000) which showed that the kind of delivery site choices women
made was largely influenced by advice received from spouses and other relatives of the
woman. Like other developing economies, in Ghana, decision-making at the household
level, including decisions regarding healthcare choices is mostly male dominated and
sometimes influenced by family members (Jansen, 2006). The finding therefore
reinforces the relevance of targeting men and family members’ particularly older female
relatives in programs and policies aimed at improving maternal and reproductive
healthcare.
This study has confirmed the critical role of distance between communities and health
facilities in influencing access to and use of maternity services particularly in rural areas.
The finding is consistent with a recent study on access to facility-based maternity care in
Ghana that reported that thirty-four percent of Ghanaian women live beyond the
clinically significant two-hour threshold by any means of transport from healthcare
facilities likely to offer emergency obstetric and neonatal care (Gething et al. 2012).
Other studies in some low and middle income country settings (Wagle et al., 2004;
D’Ambrouso et al., 2005) have also highlighted distance and proximity to health
facilities as factors that influence women’s choice of delivery sites.
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Receiving care at the facility
Quality of care received at a facility is influenced by several health system factors such
as the presence of qualified staff, availability of supplies, staff attitude and organization
of care (Thaddeus & Maine, 1994). The study examined how these affect utilization of
delivery services under the policy.
The mothers we interviewed acknowledged that, the attitude shown by healthcare
providers could either encourage or discourage them and other women from accessing
care in future. The findings from the interviews corroborate the widely held view that
staff attitude remains a major consideration to the acceptability and utilization of
healthcare services (D’Ambruoso et al., 2005; Bezzano et al. 2008). Additionally, the
study participants in both rural and urban communities were particularly interested in the
competence of staff attending to them and not necessarily receiving facility-care for free.
This suggest that consumers are conscious of the fact that positive pregnancy outcomes
is largely dependent on the quality of maternity care received from a healthcare
professional and not just having a skilled attendant attending to you.
The respondents also shared their opinions and experiences regarding the availability of
medical supplies and infrastructure for maternity care. The narrations of women who
participated in the study suggest that the different facility levels occasionally lack both
basic and emergency obstetric services for the provision of appropriate maternity
services. This finding is similar to the situation for several low and middle income
countries (Mpembeni et al., 2007; Gabrysch & Campbell, 2009). Even though this
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challenge is common to all facilities, for mothers who received emergency care at
regional and district hospitals, the facilities were better equipped to assist with
emergencies than health centres and private clinics. This was not surprising as facilities
at the regional and district levels serve as referral centres for facilities located at the sub-
district level and even outside the Central Region. These facilities may also be equipped
to provide specialized clinical and diagnostic care.
Barriers to accessing care
Accounts of rural women attest to the fact that delivery care use is greatly influenced by
lack of regular transport, poor road networks, costs of transport and relatively longer
distances between communities and facilities providing free maternity services. Previous
studies have reported on how distance and poor transportation systems influence
healthcare use by either discouraging women from accessing services (Wagle et al.,
2004) or affecting the timeliness with which care is received (Thaddeus & Maine, 1994;
Jammeh, Sundby, & Vangen, 2011). For women residing in rural communities however,
majority of them were ready to surmount the transportation challenges in accessing
supervised care at distant facilities if they anticipate possible complications at birth due
largely to previous birth history.
The study participants residing in urban communities however did not report of
transportation challenges in accessing supervised care. There existed marked
geographical inequities in accessing professional care at birth with rural women having
less access due to the transportation challenges mentioned. The scenario observed in the
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study area is similar to what pertains in most parts of Ghana (Gething et al., 2012).
Cape Coast which serves as the regional capital of the Central Region has better roads
and regular transportation services. Most facilities are also located within reasonable
distance from the communities. The Assin North district on the other hand, being largely
rural have poor road infrastructure linking communities to available healthcare facilities.
The testimonies of the study participants residing in rural parts of the Assin North
district attest to this fact.
Satisfaction with care
In describing their satisfaction with care received under the policy, women who
participated in the study expressed their feelings and opinions regarding the competence
of skilled personnel who assisted them during the delivery process, staff attitude,
availability of medical supplies and the facility environment. Whereas some participants
were satisfied with the seemingly patient and professional attitude shown by health staff,
others were highly dissatisfied with the impatience and unprofessional conduct of some
health staff. Majority of the women however reported of positive attitudes of midwives
and nurses who attended to them. Women who were not satisfied with care received
expressed their unwillingness to deliver again with the particular facilities or
recommend those facilities to other potential clients.
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9.2.4 Healthcare providers experiences with implementation of ‘free maternal care’
policy
The ninth chapter explored healthcare provider perceptions and experiences with the
implementation of the free maternal healthcare policy within the study districts. Four
major themes emerged from the analysis of the findings. The first three themes
highlighted healthcare providers’ awareness and knowledge about the free delivery
policy as well as their experiences with the actual provision of care to women who
report at facilities to access care. The fourth theme discussed the key challenges to
providing efficient care to clients. The sub-themes are discussed below.
Healthcare providers’ knowledge about the free delivery policy
One major theme of the study was on the healthcare providers’ awareness and
knowledge levels about the free delivery policy. Previous studies that have assessed the
level of awareness and use of services under given user fee exemption initiatives have
largely focused on the perspective of the consumer (Hounton et al., 2008; Ir, Souk, and
Van Damme, 2010; Ridde, Kouanda, Bado, Bado, and Haddad, 2012). Ridde et al.
(2012) for instance examined the effects of a national maternal healthcare subsidy policy
enacted by the Burkinabe government in 2007 and concluded that the policy was very
effective in reducing household costs for delivery care. Similarly, Ir, et al. (2010) noted
that the introduction of subsidized care in selected districts by the Cambodian
government in 2007 resulted in a significant increase in facility-based deliveries from
16.3% in 2006 to 44.9% in 2008 for the target districts
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Findings from the current study corroborate the widely held view that the competence
and expertise of providers is also very critical to the use of and acceptance of supervised
maternity care within facility settings (Campbell and Graham, 2006; Gabrysch &
Campbell, 2009). All the midwives and the regional and district level health experts
were aware of the existence of the free delivery policy. They were also able to articulate
the range of maternity services provided for women under the policy.
The midwives from both study districts were however not adequately aware of the
duration for which women were to receive free PNC care under the policy as they
reported different time periods for accessing care. Whereas some reported a two-week
period, others reported a period of six weeks. This finding could explain why a relatively
lower number of mothers who participated in the questionnaire survey were
knowledgeable about receiving free PNC as one of the core maternity services provided
for free under the policy. Healthcare providers remained a major source of information
on the policy for both study districts.
Providing fee free maternity services to clients
Use of institutional maternity services is to an extent influenced by how care is
organized as clients report at facilities (Aday & Andersen, 1974; Aboagye & Agyemang,
2013). The study observed that even though midwives remain the core staff with the
requisite technical and professional competence to provide supervised care for women
who visit facilities to access care, they work closely with other cadre of both clinical and
administrative staff to provide care to clients. Midwives and nurses however remain the
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primary contacts through whom women can receive confirmation of their pregnancies
and subsequently receive their National Health Insurance cards to access care at various
units of a health facility.
The midwives and key informants reported that all other staff who support with
providing maternity services such as out-patient department attendants, lab technicians,
pharmacists, accountants and orderlies have received training and regularly receive
updates on how best to provide care under the policy. They were therefore confident that
most facilities adhere to all requisite procedures involved in providing care under the
policy.
Another dimension of how healthcare was organised under the policy related to the
liberality with which women registered under the policy can be offered the necessary
care at different healthcare facilities which may not be their regular healthcare centres.
This occurs in instances where the women have been referred, arrived with a
complicated case or through the woman’s own volition primarily due to past obstetric
experiences. All the scenarios of transfer was reported to be working perfectly in Cape
Coast metro as the number and range of facilities in the metropolis was higher than
those in Assin North.
Utilization of supervised care
Findings from the current study corroborate the widely held view both empirically and
theoretically that knowledge about available healthcare interventions would influence
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the use of services being provided for under the intervention (Aday & Andersen, 1974;
Thaddeus & Maine, 1994; Gabrysch & Campbell, 2009). The healthcare providers
reported of phenomenal increases in the numbers of women accessing free delivery care
at their respective healthcare facilities as they consistently educate mothers on the
existence of the policy and the benefits of accessing free care under the policy.
Challenges to assessing supervised care
The midwives highlighted some community-level barriers affecting women’s use of
supervised care under the policy. Firstly, findings from this study corroborate widely
held views that women living in rural areas are limited in accessing care due to poor
road networks linking these communities to nearby facilities (Jammeh, Sundby, &
Vangen, 2011). Not only are the roads bad, women in rural parts of Assin North District
are faced with the challenge of having to travel long distances and paying higher
transportation costs to access health care. Previous studies have documented the crucial
role of distance in affecting use of healthcare services (Wagle et al., 2004; D’Ambrouso
et al., 2005; Narh & Owusu, 2012). The distance to be travelled can in the first place
discourage a woman from accessing care and also affect the timely arrival at a facility
(Thaddeus & Maine, 1994). The midwives we interviewed expressed concern about
women living in rural areas having limited access to supervised care under the policy
due to transportation challenges as well as long distances they have to travel to reach
nearby facilities.
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Within the healthcare facility, a number of challenges may also affect the timeliness and
quality of care received by women. One challenge that was commonly reported by all
midwives and the district level healthcare experts interviewed was the limited number of
skilled staff (particularly midwives) to manage the increasing number of women who
visit health facilities to access care. The findings confirm a well-known need to
prioritize the training and equitable deployment of skilled staff to provide the needed
care to the increasing numbers of women who access supervised care daily (Campbell &
Graham, 2006; Filippi et al., 2006; Gerein, Green, & Pearson, 2006).
Additionally, the experiences shared by midwives on their day-to-day activities in
providing care to clients attest to the fact that several facilities lack access to both basic
obstetric supplies as gloves and cleaning detergents and ambulance services to attend to
emergencies. Availability of the requisite healthcare infrastructure and supplies for
improving access to and use of professional care at birth have been documented in the
literature (Campbell & Graham, 2006; Cham, Sundby, & Vangen, 2009).
9.3 Relating findings to theoretical and conceptual framework
The study adopted a theoretical model for the study of access to medical care by Aday
and Andersen (1974) (Fig. 3.1). The model which has been widely used in previous
studies on public health research provided a basis for studying and explaining women
and provider experiences with accessing delivery care under the fee exemption policy
for maternal healthcare. Aday and Andersen’s model guided in the selection of variables
on four key components that influence use of health services. The components are
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women’s socio-demographic characteristics, characteristics of the healthcare delivery
system, consumer satisfaction and the influence of health policy on utilization of
delivery services under the free maternal healthcare policy.
From Aday and Andersen’s (1974) original model, an adapted conceptual framework
driving the study was developed (Fig. 4.2). In addition to the four core components
(factors related to women’s socio-demographic characteristics, characteristics of the
healthcare delivery system, consumer satisfaction and the influence of health policy)
proposed by the authors as influencing healthcare service use, two more components
identified from reviewing the literature as also relevant to explaining use of maternity
services for the study context were added. The two fall under the broader headings of
community accessibility factors and husband/partner characteristics.
Some variables of all four components used from the original model by Aday and
Andersen (1974) were seen to be significantly related to delivery service use. Some
other variables were however not relevant in explaining delivery care use within the
study context. On variables related to the woman’s socio-demographic characteristics
for instance, the findings supported the fact that, the woman’s age, marital status, parity
and religion which have been classified as predisposing factors by Aday and Andersen
(1974) can influence healthcare use.
Other background characteristics of women such as the woman’s employment status,
education and ethnicity were not statistically significant predictors of delivery service
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use. The study found that variables such as education and women’s employment status
which largely influences the economic well-being of the woman may not be critical in
influencing supervised delivery care use in settings where care is provided at no cost as
in the present study. The differences in the applicability of Aday and Andersen’s (1974)
model in relation to the afore-mentioned variables within the study context could
therefore be attributed to the existence of the fee free policy which is largely
implemented within the context of developing economies.
Within the study context, place of residence (rural-urban), also a background
characteristic variable and classified as a user enabling variable by Aday and Andersen
(1974) was by far the most significant individual-level factor influencing use of skilled
care under the free maternal healthcare policy. The variable remained highly statistically
significant (p=0.000) in all three regression models in explaining use of supervised care.
Other user enabling factors of income and insurance coverage status were not presumed
as critical in explaining healthcare use as all study participants had been registered for
free under the National Health Insurance Scheme, the scheme under which the free
maternal healthcare policy is being implemented. As a result of this, income and
insurance coverage status were not included as an independent variable for the analysis.
Regarding the component on consumer satisfaction, the study has confirmed that client
satisfaction or dissatisfaction with care received greatly influences future use of
healthcare services as highlighted in the original model for the study of access to
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medical care. The findings showed that women’s use of care and decisions regarding
future use or recommendation of services to other potential clients would largely be
influenced by their perceived satisfaction or dissatisfaction with service provision
conditions such as the attitudes and competence of personnel and the availability of
healthcare infrastructure and medical supplies.
The study has also confirmed the critical role of health policy in explaining healthcare
use. The healthcare providers interviewed reported of phenomenal increases in the
numbers of women accessing supervised care after the introduction of the free maternal
healthcare policy. Beneficiary mothers who participated in the study also reported that
they were motivated to access supervised care at birth because services were largely
provided at no cost under the free maternal healthcare policy. These finding supports the
critical role of health policy (financing maternal healthcare) in affecting healthcare
utilization pattern as espoused by Aday and Andersen’s (1974) framework of access to
medical care.
In relation to the conceptual framework, the findings have supported the relevance of
introducing the variables on distance and transport (which falls under the broader
determinant of community accessibility factors) introduced in the conceptual
framework. These variables were not articulated in Aday and Andersen’s (1974)
framework which was adapted for the formulation of the conceptual framework.
Findings from interviews with both mothers and healthcare providers have highlighted
the crucial role transportation and distance (community-level accessibility factors) in
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influencing use of maternity services. The challenge of traveling long distances to
nearest healthcare centres coupled with the deplorable nature of roads linking rural
communities to nearest facilities were particularly noted as barriers to effective uptake
of care. An earlier study by Bour (2004), have also confirmed the relevance of physical
accessibility variables in explaining healthcare use within Africa and the developing
world settings.
9.4 Summary of findings
9.4.1. Introduction
This study used in-depth/semi-structured interviews and a questionnaire survey to
investigate women and health provider experiences with delivery care use under
Ghana’s free maternal healthcare policy in the Central Region of Ghana.
Both quantitative and qualitative approaches were employed in the study. Binary logistic
regression models were used to test the significance of variables theoretically and
empirically considered to influence use of facility-based delivery services. To better
understand beneficiary and provider experiences with accessing care under the free
delivery policy however, qualitative interviews were conducted with healthcare
providers (midwives), district level experts in maternal healthcare service provision and
administration, and more importantly birth narratives with mothers who had their index
babies by accessing services under the policy. These provided insights into how the
policy has been beneficial in improving access to supervised care at birth and also
identify major implementation challenges.
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The study adopted an integrated conceptual framework developed by modifying Aday
and Andersen’s (1974) theoretical model of access to medical care to support and guide
the study. The framework embraced both user/individual as well as community-level
characteristics and health system factors in explaining utilization of healthcare services.
By using this framework, the study explored how individual, community and health
system factors collectively influence access to and use of delivery services under the fee
exemption policy for maternal deliveries. A summary of the main findings emerging out
of the study is presented in the subsequent sub-sections below.
9.4.2 Awareness and knowledge about the free delivery policy
The study has established that level of awareness of the free delivery policy amongst
post-partum mothers is high (97.3% of respondents). This however is not matched by
comprehensive knowledge on the full benefit package women are entitled to under the
policy. The respondents were particularly ignorant of receiving free care for caesarean
section deliveries and complications arising out of deliveries.
From the in-depth interviews, some of the healthcare providers who remain the primary
givers of information on the policy to women were equally inconsistent with their
understanding of services women were entitled to after delivery and the duration for
which they can access the services. Whereas majority of the midwives interviewed knew
that mothers and their newborn babies were entitled to free postnatal care for up to six
weeks after delivery as offered by the policy, a few of them reported that the
beneficiary group is entitled to care for up to two weeks after delivery. This could partly
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explain why some of the women were also ignorant about the availability of these
services as majority of them obtained information on the policy from health workers.
This finding is worrying as these services are not only critical and necessary to getting
women to access skilled care but also remove cost and make affordable maternal care.
Comparing awareness level across the study districts, there was a slight variation.
Mothers from the Assin North district (which is largely rural) were better informed
about the policy than those from the Cape Coast metropolis. The policy was introduced
through a governmental directive which was widely disseminated through various media
platforms both nationally and locally. Considering that rural inhabitants are likely to be
poorer and will therefore be more enthusiastic to embrace cost-free care, the message of
free maternity care might have gone down well with them compared to the more
urbanized inhabitants who could relatively afford to pay for services.
Mothers residing in the Cape Coast metropolis were however more knowledgeable
about the policy’s benefit package than those from the Assin North district. This
scenario suggests that residents of urban areas who are mostly better educated and have
healthcare services available and easily accessible to them could be at an advantage in
understanding the range of services being offered under the policy. Additionally, urban
inhabitants have regular and timely access to information from various media platforms
and healthcare providers than rural inhabitants. This finding is directly in line with
findings from similar studies for other developing countries (Ezeh, & Oronje, 2008;
Fotso, Gabrysch & Campbell, 2009; Gething et al., 2012). The results of these studies
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showed that urban dwellers have better access to healthcare information and resources
compared to rural dwellers. Healthcare providers were identified as the main source
from which women received information on the policy. Healthcare providers therefore
need to intensify education efforts in rural communities in particular towards ensuring
that there is increased knowledge about the policy in both rural and urban areas.
9.4.3 Use of delivery services
Use of delivery services under the free delivery policy was relatively lower (65%)
compared to the almost universal level of awareness (97.3%) reported by respondents.
Comparing use of services between the two study districts, use was higher for women in
the Cape Coast metropolis (75.7%) than for those in the Assin North municipal area
(54.4%).
From the bivariate analysis, the principal individual-level factors that had a statistically
significant relationship with use of delivery care under the policy were marital status,
place of residence, education, religion, and parity. For the Cape Coast metropolis
maternal education, marital status, religion and parity influenced delivery service use
whiles only one variable, place of residence was significantly related to delivery care use
in the Assin North municipal area.
A binary logistic regression analysis identified maternal age, religion, marital status,
parity, place of residence; awareness and knowledge about the fee exemption policy as
the core determinants of delivery service use under the policy. Place of residence, was
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found to have the highest statistically significant relationship with use of services with
urban dwellers being more likely to use services than rural dwellers. It could therefore
be concluded that the major barrier to use of delivery services within the study area
relates largely to constraints within one’s place of residence.
Relating the findings to the conceptual framework of the study, the study has established
that, generally within the study setting, community-level factors (place of residence) are
more significant in determining health service use than individual-level factors and
factors related to given health policies. This suggests that even though the policy is
being implemented universally, inequities in access exist between locations. Barriers to
accessing care vary by spatial location, be it rural or urban. In largely urban settings, the
background characteristics of women remained the major factors that influenced service
use; whiles factors related to the place of residence of rural dwellers largely affected
their access to and use of maternity services. Utilization is therefore not always affected
by both individual background and health system characteristics as envisaged by Aday
and Andersen but could vary according to one’s geographical and socio-economic
setting.
9.4.4 Mothers’ experiences with accessing free delivery care
A section of the women who participated in the study shared their experiences on why
they chose to deliver their index babies under the policy as well as the benefits and
challenges associated with accessing care under the policy. The findings from the
interviews showed that most mothers were motivated to deliver under the policy because
of their understanding of the importance of receiving assistance from a skilled attendant
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at birth. They were enthusiastic that the policy had removed financial barriers to
accessing supervised care which they deem necessary for positive pregnancy outcomes.
Other women also decided to deliver under the policy because they were encouraged by
healthcare workers, friends and family members to do so.
The study also found that services provided by healthcare personnel during delivery are
largely free once a woman enters a facility providing care under the policy. This finding
is contrary to what has been found in the implementation of some maternity care
financing initiatives in other developing economies (Witter et al., 2009; Mubyazi et al.,
2010). Even though delivery services were largely free, use of services was however
hampered by certain health system and community-level barriers. Facility-related
challenges including the availability of adequate infrastructure and personnel, the
competence of staff and the negative attitude of some healthcare personnel remained
possible barriers to increasing women’s access to and use of services under the policy.
Additionally, community level barriers, primarily related to poor road networks and the
availability of efficient and regular transportation to facilities providing free care affect
supervised delivery services use for particularly rural women. In spite of the existence of
certain transportation challenges, women residing in poor rural communities were
however willing to ignore the transportation challenges and seek for supervised care if
they have been advised to do so by a healthcare professional due to their birth history or
anticipate a possible complication during delivery.
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9.4.5 Healthcare provider experiences with providing free delivery care
The findings from the interviews with selected midwives and district level experts in
maternal healthcare also confirmed that the free delivery policy is immensely
contributing to increased access to supervised care at birth as the number of women who
patronized the services keeps increasing day after day. The healthcare providers were
however concerned about two major issues hampering the smooth implementation of the
policy. One related to unavailability of facilities equipped with the necessary obstetric
equipment and located within reasonable distance to cater for the maternity needs of
particularly rural women. The second concern related to the limited availability of
professional staff primarily midwives to cater for increasing numbers of women
demanding for supervised care under the policy. This had resulted in increased
workloads for the few available staff.
They were equally concerned about the transportation challenges primarily related to
poor road infrastructure and poor communication system between rural communities and
healthcare facilities located in distant urban towns. The second related to constraints
with providing efficient care by various facilities. They were particularly concerned
about the limited availability of obstetric equipment primarily ambulance services and
skilled staff to provide timely and efficient service to all clients. As outlined in the
conceptual framework of the study, the findings from the interviews with the healthcare
providers and experts have confirmed that health system as well as community-level
factors are as important in influencing healthcare use as socio-demographic
characteristics of users. Similarly, women’s places of residence (individual background
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characteristic) also confirmed the strong influence of community-level and health
system factors on use of delivery services. Feedback from the qualitative interviews
confirmed that women in rural areas compared to urban dwellers had limited access to
delivery care due largely to transportation challenges.
9.5 Conclusions
The present study sought to understand the perceptions and experiences of women and
service providers about use of supervised delivery care under Ghana’s free maternal
healthcare policy. It also explored the individual, community-level and health system
factors that affect women’s access to and use of delivery care under the policy. Two
districts, one largely rural and another largely urban in the Central Region of Ghana
were purposively selected for the study. The districts were selected to allow for
assessing care received within rural and urban setting.
The study employed both quantitative and qualitative methodologies. The study
population comprised of women of reproductive age, healthcare providers and regional
and district level healthcare administrators of the selected region and districts. Data were
collected using in-depth interviews and a questionnaire survey. Pearson’s Chi-Square
test was used to test for the statistical associations between the dependent variable ‘use
of delivery care under the delivery fee exemption policy’ and selected independent
variables. Binary logistic regression models were also used to determine the actual
predictors of use of delivery care under the free maternal healthcare policy. Feedback
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from the qualitative interviews provided insights into women and healthcare providers’
experiences with provision and use of supervised delivery care under the policy.
The study concludes that the introduction of user fee exemption strategy to improve
access to supervised care at birth is relevant to improving maternal health outcomes. The
study however found that addressing cost barriers at the point of use is not adequate to
addressing the challenge of access to supervised care at birth and ultimately reducing
maternal deaths.
Community factors were found to be significantly associated with use of supervised
delivery care under the free maternal healthcare policy. Community-level factors
including poor road infrastructure, lack of regular transport and long distances between
communities and healthcare facilities were identified as barriers to increased uptake of
delivery care. This was particularly predominant in rural areas resulting in marked
variation in access to and use of delivery services between women in rural and urban
areas. To this end, the introduction of variables on distance and transport in the
conceptual framework of the study became relevant. These variables were not
articulated in Aday and Andersen’s (1974) theoretical model of access to medical care
which was adapted for the study.
Additionally, individual characteristics of women such as their ages, religious affiliation,
parity levels, marital status and place of residence significantly influenced women’s
decisions to deliver under the free delivery policy or otherwise. Place of residence was
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found to have the highest statistically significant relationship (p = 0.000) with use of
delivery care. The finding reinforces the relevance of place and space in explaining
healthcare use as espoused by earlier theoretical and empirical literature (Aday
&Andersen, 1974; Law et al. 2005)
The study has also confirmed the relevance of introducing a health policy as a catalyst to
increase access to healthcare services as proposed by Aday and Andersen (1974) in their
theoretical model for the study of access to medical care. The present study has however
identified the need for reinforcing education on a given heath policy for the intended
population to ensure optimum use of healthcare services. Even though almost all women
interviewed (97.3%) were aware of the free maternal healthcare policy, only 61.7
percent had knowledge about the full range of maternity services provided under the
policy.
Furthermore, the present study identified some health system challenges to the provision
and use of delivery care under the policy. On the part of beneficiary women, the poor
attitude of some health personnel, coupled with the unavailability of facilities within
reasonable distances from their places of residence constituted key obstacles in their use
of services. The healthcare providers on the other hand were burdened with increased
workload due to the limited number of particularly midwives to provide the needed care
coupled with limited supply of both routine and emergency drugs and other obstetric
equipment.
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From the emerging conclusions, a conscious effort by government to simultaneously and
adequately address the multiple individual, community-level and health system factors
influencing use of maternity services under the free delivery policy is recommended.
This would lead to improved access to care for all women across the country.
By systematically highlighting context-specific realities of how free delivery care is
provided for and received at the community level, the study could provide useful
insights to the MoH, GHS, and the NHIS on appropriate policy and programmatic
interventions required to improve service provision under the policy. Finally, the
findings from this study may also be relevant for other low and middle-income countries
implementing cost-reduction or cost-elimination interventions for improved maternal
healthcare outcomes.
The study acknowledges some limitations which should be considered in the
interpretation of the results. First, even though the study was undertaken in a pilot region
in which the fee exemption policy was implemented, the findings cannot be generalized
for the entire region since only 2 districts out of the seventeen (17) existing districts
were selected. Secondly, the findings can best inform decisions regarding effective
implementation of the delivery fee exemption policy at only the micro level. Thirdly, the
study did not consider the effect of other maternal health care factors such as good roads
and availability of health care providers and infrastructure on the utilization of free
delivery care. This is a limitation of the study since in normal life these factors influence
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the utilization of maternal health care services. Future studies should explore the critical
role of these factors on the performance of the policy.
The study however remains significant. The study provides useful insights to
understanding local level experiences with the implementation of the free delivery
policy. The approach used could be adopted for other local and even national level
evaluations on the policy.
9.6 Recommendations
Three main policy and programmatic recommendations become relevant based on the
key findings from the study. They are:
1. The need for increased and target-specific education on the range of maternity
services provided under the free delivery policy particularly delivery and post-
delivery services which are very critical for positive pregnancy outcomes.
2. The need for government to provide more health care services within reasonable
distance to communities and also address transportation challenges to reaching
available facilities providing free maternity services in particularly rural areas as
part of the free delivery package.
3. Addressing gaps in infrastructural and human resource needs of facilities
including effective monitoring of staff attitudes and competence should be
rigorously pursued by government.
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The recommendations are discussed in detail as follows.
9.6.1 Increased education on the full benefit package of the free delivery policy
The study is recommending for increased and target-specific education on the full range
of maternity services women are entitled to under the free delivery policy. It was found
in the study that, even though all the study participants were aware of the existence of
the free delivery policy, this was not matched with comprehensive knowledge of the
range of maternity services women were entitled to especially emergency delivery and
post-delivery care. The following suggestions are recommended to increase and improve
beneficiaries understanding of the free maternal healthcare policy. First, the Ministry of
Health should make available a standardized information pack on the free delivery
policy from which all healthcare providers will learn and adapt in providing care to
clients. This will help ensure that healthcare providers who are at the forefront of service
provision are equipped to provide accurate and adequate information on the free delivery
policy to all clients. The Ministry of Health (MoH) and the Ghana Health Service (GHS)
in collaboration with the National Health Insurance Authority should in turn make
available printed copies of the policy and services rendered under it available at all
facilities providing free care for clients. The document should also be produced in
different languages for community-level education sessions by healthcare workers.
9.6.2 Provision of more maternity clinics/door-step supervised care services for
rural women
In the rural district in particular, access to care was hampered by the poor nature of
roads linking communities to relatively bigger towns where most healthcare facilities are
located. Most of the facilities are also located at longer distances from rural
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communities. To ensure that the policy is implemented effectively, deliberate efforts are
needed to target the women in greatest need of free maternity care, particularly poor
women in rural areas. To address transportation challenges to accessing supervised care
for rural women in particular, more health centres equipped with necessary maternity
services and personnel should be located within reasonable distance between
communities and the few hospitals mostly located at the district capitals. Alternatively,
mobile maternity clinics equipped with necessary obstetric supplies and requisite
obstetric staff could be made available in rural areas.
Additionally, the GHS should improve strategies adopted in distributing midwives
across various facilities. If midwives are equitably distributed, it may be possible to have
at least one midwife or a Community Health Officer (with midwifery skills) at every
CHPS centres to offer supervised maternity services under the fee exemption policy.
This will help improve access to supervised care for rural women in particular. The
study has confirmed that many women are more enthusiastic about receiving supervised
care at birth.
9.6.3 Addressing infrastructural and human resource needs
The study found that implementation of the policy is largely affected by shortages in
skilled staff and the needed infrastructural and medical equipment for the provision of
care. Concerns on competence of staff and staff attitude are also major setbacks to
increased use of free delivery services in the study districts. Even though some
midwives are coping by engaging the services of other health staff, these additional staff
may not be competent enough to offer the needed skilled care that the policy so desires
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to provide. Government through the MoH should therefore increase the production of
midwives and ensure that they are equitably distributed according to the needs of the
various healthcare facilities.
Infrastructural and human resource needs of all level of facilities providing free
maternity care should be rigorously pursued. There is the need for government to
increase funding made available for the procurement of equipment and supplies for both
routine and emergency services, particularly ambulance services. Further research to
identify the actual gaps in the availability of midwives and projections into future
midwifery requirements of the country is needed to effectively address shortages in
skilled attendants. This will contribute to improving equitable access to supervised care
at birth under key interventions like the free maternal healthcare initiative.
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APPENDICES
Appendix 1: Study Questionnaire
WOMEN’S EXPERIENCES WITH GHANA’S FEE EXEMPTION POLICY FOR
MATERNAL HEALTHCARE (“FREE DELIVERY” POLICY)
Questionnaire: Knowledge and perceptions about delivery fee exemption policy
for mothers whose most recent birth occurred within 12 months prior to this
survey
SURVEY INFORMATION AND QUESTIONNAIRE PROCESSING (2013)
QUESTIONNAIRE NUMBER:
Interviewer’s name:
Interviewer code:
Date: Day….. Month…… Year………
Region:
District: 01 Assin North
02 Cape Coast Metropolitan Area
Location of Household: 1= Urban
2= Rural
Household ID …….. …….. …….. ……..
Household address or description
Interview start time……. : …… (HH:MM) Interview end time ……. : ……. (HHMM)
Section A: Background Information
Introduction
The goal of this study is to assess the perspectives and experiences of women and healthcare
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providers with delivery care provision under the fee exemption policy for maternal deliveries. In line
with this, I would like to ask you a few questions about your knowledge and perceptions about the
policy and whether you have used or intend to use delivery services under the policy. The information
you provide will help us understand how women in this community are aware of and understand the
“free delivery policy”, the extent to which they are using delivery services under the policy and their
experiences and views on the overall performance of the policy.
Respondents Informed consent
This interview is voluntary. You have the right not to answer any question, and to stop the interview
at any time or for any reason. You will not be penalised for not taking part in the study. Any
information you will provide will be treated with strict confidentiality and will be sorely used for
academic purposes. You will be required to sign a consent form to this effect if you do agree to the
interview.
Are you willing to take part in this study? Yes……, No…………
I would like to start by asking some questions about your life in general.
QUESTIONS CODING SKIP/NOTES
Q1 In what month and year were
you born?
Month……….
Year …………….
Q2 How old were you on your
last birthday?
COMPARE AND CORRECT
Q1 IF INCONSISTENT
Age in completed years
……………..
Q3 Have you ever attended
school?
1=YES
2=NO
If 2 >> to Q5
Q4 What is the highest level of
school you have completed?
1 = Pre-school
2 = Primary
3 = Middle/JSS/JHS
4 = Secondary/SSS/SHS/Tech./Voc.
5 = Higher than secondary
96 = Don’t know
Q5 What is your current working
status
1 = Unemployed
2 = Self-employed
3 = employee (paid)
4 = Informal work (paid)
56 = Other_____________
(SPECIFY)
Q6 What is your religious
affiliation?
1 = Catholic
2 = Anglican
3 = Methodist
4 = Presbyterian
5 = Pentecostal/Charismatic
6 = Other Christian
7 = Muslim
8 = Traditional
9 = Spiritualist
10 = No religion
56 = Other_____________
(SPECIFY)
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Q7 To which ethnic group do you
belong?
1 = Akan (Fante, Asante, Akyem,
Brong etc.)
2 = Ga/Dangme
3 = Ewe
4 = Guan
56 = Other_____________
(SPECIFY)
Q8 What is your current marital
status?
1 = Married or cohabiting
2 = Divorced/ Separated
3 = Widowed
4 = Never married/Never cohabited
If 2, 3 and 4 >>
Q18
Q9 How many years have you
been married/cohabiting with
your current partner? IF LESS
THAN ONE YEAR,
RECORD MONTHS
____ YEARS ____ MONTHS
Q10 Does your husband/partner
usually live with you or lives
elsewhere?
1=Lives with me
2=Lives elsewhere
Q11 Has your husband ever
attended school?
1= Yes
2=No
96=Don’t know
If 2 >> Q13
Q12 What is the highest level of
school your husband has
completed?
1 = Pre-school
2 = Primary
3 = Middle/JSS/JHS
4 =Secondary/SSS/SHS/Tech/Voc
5 = Higher than secondary
96 = Don’t know
Q13 In what month and year was
your husband born?
Month……….
Year …………….
Q14 How old was he at his last
birthday?
COMPARE AND CORRECT
Q13 IF INCONSISTENT
Age in completed years
……………..
96 = Don’t know
Q15 What is your husband’s
religious affiliation?
1 = Catholic
2 = Anglican
3 = Methodist
4 = Presbyterian
5 = Pentecostal/Charismatic
6 = Other Christian
7 = Moslem
8 = Traditional
9 = Spiritualist
10 = No religion
56 = Other_____________
(SPECIFY)
Q16 To which ethnic group does
your husband belong?
1 = Akan (Fante, Asante, Akyem,
Brong etc.)
2 = Ga/Dangme
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3 = Ewe
4 = Guan
56 = Other_____________
Q17 What is your husband’s
current working status?
1=Unpaid family worker/Farmer
2=Unemployed
3=Self-employed
4=Employee- Formal work (Paid)
5=Informal work (Paid)
56=Other_______________
(SPECIFY)
Q18 Who usually makes decisions
about health care for yourself:
you, your husband/partner,
you and your husband/partner
jointly, your mother or father,
your mother-in-law or father-
in-law, or someone else?
1=Respondent
2=Husband/Partner
3=Respondent and husband/partner
jointly
4=Mother
5=Father
6=Mother-in-law
7=Father-in-law
8= Someone else
________________
(SPECIFY)
Q19 What is the size of your
household?
Number ……………..
Q20 Who is the head of the
household?
1=Husband
2=Wife
3=Daughter
4=Son
5=Father-in-law
7=Mother-in-law
8=Sister
9 =Brother
10=Other relative
56=OTHER
Q21 Does the head of household
reside with you?
1= Yes
2=No
96=Don’t know
Q22 What is your relationship with
the head of the household?
(If husband is household
head, do not ask Q 22a,22b,
22c
1=Head
2=Wife
3=Daughter
4=Daughter-in-law
5=Grandchild
6= Mother
7=Mother-in-law
8=Sister
9=Other relative
10=Adopted/Foster/
Stepchild
11=Not related
12 = Husband
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56=OTHER…………………..
Specify
Q22
a
Has the household head ever
attended school?
1= Yes
2=No
96=Don’t know
If 2 >> Q22c
Q22
b
What is the highest level of
school your household head
has completed?
1 = Pre-school
2 = Primary
3 = Middle/JSS/JHS
4 =Secondary/SSS/SHS/Tech/Voc
5 = Higher than secondary
96 = Don’t know
Q22
c
What is your household
head’s current working status?
1=Unpaid family worker/Farmer
2=Unemployed
3=Self-employed
4=Employee- Formal work (Paid)
5=Informal work (Paid)
56=Other_______________
(SPECIFY)
Q22
d
What is your household
head’s current marital status?
1 = Married or cohabiting
2 = Divorced/ Separated
3 = Widowed
4 = Never married/Never cohabited
Section B: Pregnancy and Delivery History
Now I would like to ask about all the births you have had during your life.
Q23 Do you have any sons or daughters to
whom you have given birth who are
now living with you?
1=YES
2=NO
If 2 skip to Q26
Q24 How many sons live with you? …… sons living at
home
Q25 And how many daughters live with
you?
….. daughters living
at home
Q26 Do you have any sons or daughters
whom you have given birth to and who
are alive but do not live with you?
1=YES
2=NO
If 2 >> Q29
Q27 How many sons are alive but do not
live with you?
…… sons living
elsewhere
Q28 And how many daughters are alive but
do not live with you?
…… daughters living
elsewhere
Q29 Have you ever given birth to a boy or
girl who was born alive but later died?
IF NO, PROBE: Any baby who cried
or showed signs of life but did not
survive?
1=YES
2=NO
If 2 next question
Q30 How many boys have died? ……. Boys died
Q31 How many girls have died? ……. Girls died
Q32 Total number of live births, sum
answers to Q24, 25, 27 and 28 and
enter total
……. Total
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Q32b Total number of deaths, sum answers
to Q30 and 31
……. Total
Section c: Knowledge and perceived need of services under the free delivery policy
Now I would like to ask questions about your awareness about the policy, your perceived need
of maternal healthcare services provided under the policy and your general opinion about the
performance of the policy in this community.
QUESTIONS CODING SKIP/NOTES
Q33 Have you heard about
Ghana’s fee exemption
policy for maternal
deliveries or the ‘free
delivery policy?
1 = Yes
2 = No
If 2 >> Q37
Q34 Where did you get
information about the
policy
1=Family
2=Friends/Community members
3=Community leaders
4=TBAs
5=Health care workers
6=Radio
7=Television
8=Newspaper
9=Village information center
56 = Other__________
(SPECIFY)
Q35 Which maternal healthcare
services are provided for
free/at no cost under the
policy? (Circle all that
apply)
1=ANC services
2= Delivery services
3= PNC services
4= Premium for registering under the
NHIS
5= All the above
56 = OTHER ……………
96 = Don’t know
Q36 What specific services are
provided for free when a
woman goes to a facility to
deliver under the policy?
(Circle all that apply)
1= Delivery fee
2= Bed charge
3= Laboratory tests
4= Drugs and medical supplies for
mother
5 = Drugs and medical supplies for
baby
6= Surgical charges in the case of
caesarean section delivery
7= Cost of post-delivery surgeries,
e.g. repair of fistulae
8= Washing detergents
9= Laundry services
56= Other__________
(SPECIFY)
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Q37 Can you please give us the
date of your last delivery?
Day ….. Month…….. Year……
Q37a Did this pregnancy lead to
a live birth or not?
1 = Yes
2 = No
If 2 skip to Q38
Q37b What is the sex of this
child?
1 = Male
2 = Female
Q38 Did you know about the
free delivery policy before
your last delivery?
1 = Yes
2 = No
Q39 Did you visit a health
facility for antenatal care
for your most recent birth?
1 = Yes
2 = No
If 1 >> Q41
Q40 Why did you not attend
any facility-based ANC
visits?
PROBE. CIRCLE ALL
MENTIONED
1=Distance
2=Lack of knowledge
3= Lack of transportation
4=Permission not granted
5=Costs
6=Perception of quality from women
7=Perception of health worker
attitudes by women
8=Crowding/Waiting time at the
health facility
9 = Had home-based ANC
10= Do not value it
11= Don’t believe it was needed
56= Other____________________
(SPECIFY)
Q41 How many antenatal visits
did you attend for your
most recent birth at a
health facility?
1=1
2=2-3
3=4-6
4=>6
96= DON'T KNOW/REMEMBER
NUMBER
Q42 Were ANC services
provided for free or not for
free?
1 = Free
2 = Not free
Q42a What services were you
charged for? Specify all
1= Pregnancy test
2= Consultation
3= Laboratory tests
4= Drugs and medical supplies for
mother
5= Washing detergents
6= Gloves
56= Other__________
(SPECIFY)
Q43 Where did you have your
last delivery?
1= Public hospital
2= Private hospital
3= Mission hospital
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4=Health centre
5 = Polyclinic
6= Private clinic
7= Maternity home
8= At home
9= TBA’s compound/home
10= Relative’s home
56= Other………………….
(SPECIFY)
96 = Don’t know
Q44 If you received your last
delivery care at a health
facility, which facility is
it? (Ask for the name and
location of the health
facility)
Name of health facility
…………………………………….
Location of facility ………………
(town/city/village)
Q45 Did you deliver for free
under the ‘free delivery
policy’ or you paid for
delivery services
1 =Delivery for free
2= Delivery not for free
Q46 Which aspects of care
received were free? (Circle
all that apply)
1= Delivery fee
2= Bed charge
3= Laboratory tests
4= Drugs and medical supplies for
mother and baby
5= Surgical charges in the case of
caesarean section delivery
6= Cost of post-delivery surgeries,
e.g. repair of fistulae
7= Washing detergents
8= Laundry services
56= Other__________
(SPECIFY)
Q47 What aspects of care did
you have to pay for?
(Circle all that apply)
1= Delivery fee
2= Bed charge
3= Laboratory tests
4= Drugs and medical supplies for
mother and baby
5= Surgical charges in the case of
caesarean section delivery
6= Cost of post-delivery surgeries,
e.g. repair of fistulae
7= Washing detergents
8= Laundry services
56= Other__________
(SPECIFY)
Q48 Did you choose to deliver
any of your previous
children at facilities that
1 = Yes
2 = No
If 2 then move to
Q 50
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will require you to pay for
the service even when the
free delivery policy was in
force?
Q49 What are your reasons for
delivering at facilities that
will require you to pay
even when the policy was
operational?
(Circle all that apply)
1=Long Distance to a facility
2=Lack of knowledge
3= Lack of transportation
4=Permission not granted
5=Costs
6=Perception of quality of care by
clients
7=Perceptions of negative health
worker attitudes
8=Crowding/Waiting time
9 = Had home-based delivery
10= Prefer services of TBA to
midwives and nurses
11= Do not value it
12= Don’t believe that services are
entirely free
56= Other____________________
(SPECIFY)
Q50 (Only ask women who
delivered under the
policy) What are your
reasons for choosing to
deliver your most recent
birth under the free
maternal healthcare
initiative?
(Circle all that apply)
1= Husband encouraged me
2= Was encouraged by friends who
have also used the policy
3= To benefit from free care
4= Was encouraged by health
workers to do so at ANC clinics
5= To enjoy professional care
6= Facility located nearby
7= Had complications delivering at
home with previous birth (s)
8= Had complications delivering a
TBA for previous birth (s)
9 = No response
56= Other ………….
(SPECIFY)
96 = Don’t know
Q51 Who delivered your last
baby? (If more than one
person, please ask for the
main person who managed
the delivery)
1= Medical doctor
2= Public hospital/health centre
midwife
3= Private midwife
4= Community Health Nurse
5= TBA
6= Mother-in-law/mother
7= Village health worker
8= Friend/neighbour
9 = No Response
56= Other ………….
(SPECIFY)
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96 = Don’t know
Q52 (Only ask women who
did not deliver at a health
facility) Why did you not
deliver at a health facility
under the free delivery
policy for your last
delivery?
1=Distance
2= Not aware of the policy
3= Transportation too expensive
4= Husband decided on where I
should deliver
5=Perception of poor quality of
facility service by women
6 = Some health workers exhibit bad
attitudes towards clients
7=Crowding/Waiting time at a health
centre
8= Prefer home-based delivery
9= Preferred to deliver with a TBA
10= Facility too far
11= Don’t believe that the services
are entirely free
56= Other____________________
(SPECIFY)
13 = No Response
Q53 (Only ask women who
DID NOT deliver at a
health facility Do you
have any intentions of
delivering your next baby
for free?
1 = Yes
2 = No
3. Don’t intend to have another baby
4. Not Sure/Don’t know
If 1 >> Q 55
If 2 >> Q 56
Q54 (Only ask women WHO
DELIVERED at a health
facility for free) Do you
have any intentions of
delivering your next baby
for free?
1 = Yes
2 = No
3. Don’t intend to have another baby
4. Not Sure/Don’t know
If 1>> to Q55
If 2 >> Q56
Q55 What are your reasons for
choosing to deliver your
next baby for free under
the free delivery policy?
(Ask respondents to
enumerate all probable
reasons from the list)
1= I am assured of professional care
in the event of complications
2= Staff providing care are very
friendly
3= To benefit from free care again
4= Healthcare providers have
encouraged me to do so
5= All my friends are choosing that
option
6= Facility located nearby
7= Had complications delivering at
home with previous birth (s)
8= Had complications delivering a
TBA for previous birth (s)
56= Other ………….
(SPECIFY)
96 = Don’t know
Q56 What are your reasons for 1=Distance
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NOT choosing to deliver
for free one more time?
(Circle all that apply)
2= Lack of awareness about policy
3= Lack of transportation
4=Permission not granted
5=Services not entirely free
6=Perception of poor quality of
services by women
7= Some health workers exhibit bad
attitudes towards clients
8=Crowding/Waiting time at a health
centre
9 = Prefer to have home-based
delivery
10= Prefer to deliver with a TBA
10= No privacy at the facility
11= Don’t believe it was needed
56= Other____________________
(SPECIFY)
Section C: Household Asset Ownership
We would like you to tell us about assets and property that you or other members of
your household own
Q57
Does anyone in the household
own any of the following?
1=yes
2=no
Q58
Quantity
Q59
If you sold your household
[asset] today, how much would
you receive?
GH¢…………………..
1. Land A.
Hectares
B. Acres
C. Sq
metres
2. Beds (including
mattress)
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3. Mattress
4. Chairs
5. Tables
6. Carpets/mats
7. Electric fans
8. Mobile phones
9. Refrigerators
10. Freezers
11. Electric Irons
12. Coal Irons
13. Clocks
14. Hair Dryers
15. Electric kettles
16. Gas stoves
17. Electric stoves
18. Coal pots
19. Sewing machines
20. Crockery
21. Cutlery
22. Motor vehicles
23. Motor cycles
24. Bicycles
25. Boats
26. Carts
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27. Fishing net
28. Radio/hi-fi
29. Television
30. Video Cassette
Recorder
31. DVD
player/Recorder
Q60
Does anyone in the household
own any of the following?
1=yes
2=no
Q61
Quantity
Q62
If you sold your household
[asset] today, how much
would you receive?
GH¢ …………….
Agricultural Equipment
32. Cultivator
33. Harrow
34. Sprayer
35. Wheel barrow
36. Tractor
37. Tractor plough
38. Tractor planter
39. Tractor trailer
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40. Crop sheller
41. Irrigation pump
42. Watering cans
56.1 Other 1:
56.2 Other 2:
56.3 Other 3:
56.4 Other 4:
HOUSING
Q63 Do you own the house you are staying in?
1=yes, 2=no
Q64 How many rooms does the house hold (exclude bathroom or kitchen)
Q65 What type of toilet do you use?
1=Flush toilet, 2=Pit latrine 3=Pan/bucket 4=KVIP 5=No Toilet (bush/beach)
56=Other (specify) …………………………..
Q66 What material is used to build the walls of your house?
1=Wood/bamboo, 2=Mud bricks, 3=Cement blocks, 4=Stone, 5=Stone tiles,
6=Galvanised iron sheet, 56=other (specify) …………………………………
Q67 What material is used to build the roof of your house?
1=Wood/bamboo, 2=Mud bricks, 3=Cement blocks, 4=Stone, 5=Stone tiles,
6=Galvanised iron sheet, 7=thatch, 8=plastic sheet, 9=asbestos sheets,
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56=other (specify) …………………………….
HOUSEHOLD EXPENDITURE (LAST MONTH)
We would like you to tell us about how much you have spent on each of the following in
the last month:
EXPENDITURE ITEM AMOUNT SPENT
GH¢……………….
Q68 Food expenditure (Actual)
Q69 Food expenditure (imputed – consumption from own
farm)
Q70 Expenditure on housing (actual & imputed)
Q71 Non-food expenditure
Q71a Education
Q71b Health
Q71c Water
Q71d Lighting
Q71e Garbage/refuse collection
Q71f Toilet facility
Q71g Transport
Q71h Funeral donations/gifts
Q71j Other non-food expenditure – payments (as wages,
etc)
Q71k Other non-food expenditure (specify)
1…………………
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Q71l Other non-food expenditure (specify)
2……………………
Q72 Remittances to other household(s)
Total
This is the end of our discussion. Thank you very much for your time. The interview
has been very useful.
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Appendix 2: Interview guide for mothers
In-depth interview for women who have experienced delivery care under the fee
exemption policy for maternal deliveries
BACKGROUND INFORMATION
Age:
Education:
Marital status:
Employment status:
Religion:
Ethnicity:
Parity:
Household head:
Household composition:
Husband’s age:
Husband’s educational level:
Husband’s religion:
Ethnicity of husband:
Husband’s employment status:
DELIVERY INFORMATION
1. Can you please give me the date of your last delivery?
2. Which form of delivery did you experience? (Normal or Caesarean Section)
3. Did you receive care under the ‘free maternal healthcare initiative?
4. In your opinion, which maternal healthcare services is one entitled to for free
under this policy
5. Where did you receive your last delivery care?
6. If you delivered with a health facility, which facility is it?
Name of health facility………………………………………………………….
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7. Where within the facility did the delivery take place, a normal delivery room or a
surgical theatre?
8. Who attended to you during your last delivery? (If more than one person, please
ask for the main person who managed the delivery) Probe to distinguish between
the different categories of providers mentioned.
9. What was the outcome of the delivery? Did you have a live birth or the baby
died sometime after delivery
10. Apart from the delivery care, what other maternal healthcare services did you
receive under the free maternal healthcare policy for your last birth?
11. Did you have to pay for any services during the period of your pregnancy?
12. Please list the services that you had to pay for.
……………………………………………………………………...
………………………………………………………………………
………………………………………………………………………
13. Did you have to pay for any services when you went to deliver?
14. Please list the services that you had to pay for.
……………………………………………………………………...
………………………………………………………………………
………………………………………………………………………
15. Please list all services you received for free at the facility during the period of
your pregnancy
……………………………………………………………………...
………………………………………………………………………
………………………………………………………………………
16. Please list all services you received for free on the day of delivery
……………………………………………………………………...
………………………………………………………………………
………………………………………………………………………
QUALITY OF CARE
1. What would you say about the availability of equipment and supplies used
during your delivery at the health facility in which you delivered?PROBE FOR
FURTHER EXPLANATION
2. What would you say about the availability of health staff who assisted during
your delivery at the health facility in which you delivered? PROBE FOR
FURTHER EXPLANATION
3. How will you describe the attitude of healthcare providers who assisted you
when you went to deliver? PROBE FOR FURTHER EXPLANATION
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4. Please describe the processes you were taken through when you went to deliver.
Narrate all that happened and was said to you.
5. What is your personal view about the quality of care you received at the facility
when you chose to deliver with the free maternal healthcare policy?
CLIENT SATISFACTION
1. Were you satisfied with the level of privacy you received when you went to
deliver for free? Please share your experience with us
2. How coordinated was the care you received among the healthcare providers who
assisted you when you went to deliver? Please explain
3. Will you recommend for others to use maternal healthcare services under the free
maternal healthcare policy? Please give your reasons.
4. Will you recommend for a friend/family member to deliver at the same place you
delivered? Why? Why not?
COMMUNITY LEVEL BARRIERS TO ACCESSING CARE
Transportation/distance
1. What mode of transport did you use to travel to the facility where you received
your last delivery care?
2. If you used more than one mode of travel, which one did you use to travel the
longest distance?
3. What will you say about transport availability to the nearest health facility?
4. Do you consider distance as a contributory factor to the use of supervised
delivery in facilities that provide free delivery care by mothers in this
community?
5. How much time in hours and minutes did it take you to travel from your home to
the facility where you received delivery care?
6. What specific transportation challenges did you encounter when you were
travelling to the facility? Prompt for cost, nature of road means of transport
(vehicle type, motorbike etc.) availability of means of transport.
Socio-cultural factors/gender roles
7. Who usually makes decisions in your household regarding where you should
receive healthcare?
8. Who usually makes decisions in your household about where women should
deliver?
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9. Who decided that you deliver your most recent birth under the “free delivery
policy”?
10. What cultural practices/traditional norms exist in your community about child
birth, particularly with supervised at a health facility?
11. What cultural practices/traditional norms exist in your community about the
treatment/care given to mothers immediately after delivery?
12. How do these practices/norms affect women’s choice for “free delivery” care
from designated health facilities?
13. What cultural practices/traditional norms exist in your community about the
treatment/care given to a baby immediately after delivery?
14. Did you receive any traditional/cultural treatment when you last delivered?
15. If yes, please, tell me what happened/was done.
16. Did your child receive any traditional/cultural treatment after delivering him/her?
17. If yes, please, tell me what happened/was done.
Suggestions/recommendations
What suggestions do you have to improve utilization of supervised delivery services
under the fee exemption policy for maternal deliveries in this district?
Thank you very much for your help, I really appreciate your time and the insightful
experiences shared. Please if there is anything you would like me to know, I would be
pleased to answer it
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Appendix 3: Interview guide for healthcare providers
Semi-structured interviews for Senior/Principal and Junior midwives at the district
level
(A) Background information
1. Current position
2. Specific duties
3. Specialty – midwifery, nursing etc.
4. Length of period worked in delivery and pregnancy-related care
5. Activities he/she undertakes on a ‘typical day’
(B) Knowledge about fee exemption policy for maternal deliveries
6. Have you please heard about Ghana’s fee exemption policy for maternal
deliveries or the ‘free delivery policy?
7. How did you get to know about it?
8. From whom or where did you receive information about the policy?
9. Have you ever seen the full policy as it is?
10. Have you received any briefing/training on the policy?
11. What free maternal healthcare services are women entitled to under this
policy?
(C) Delivery healthcare provision under the “free delivery policy”
Now, I would like to know the processes/procedures for providing delivery services
under the policy for women who report at the facility
12. What condition must a woman satisfy before she is offered delivery services
under the policy?
13. What specific services are women entitled to at the time of delivery?
14. Is this facility able to provide all delivery services that a woman is entitled to
under the policy?
15. If NO, why not?
16. Can you please share your experience on the last two delivery cases you
attended to, from when the woman in labour arrived till she delivered and
was discharged from the hospital?
17. Are there any neonatal services for the infants after the woman had delivered
with the free delivery policy?
18. If YES, what are these services and for how long is the infant entitled to it
19. If NO, why not?
20. How do you assess women’s use of delivery services under the policy since it
was introduced? Is the trend increasing or declining?
21. On average how many deliveries do you attend to in a day?
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22. How do you cope if the numbers are many?
(D) Resource availability for delivery care under the policy
23. What would you say about the availability of equipment and supplies
including emergency services for delivery care under the policy?
24. What will you say about the availability of health staff for maternal
healthcare services in this facility?
25. Apart from challenges related to staff availability and equipment and
supplies, what in your opinion are the other challenges to delivery care
provision under the policy?
26. Why do these challenges persist?
27. Can your share your experience (at least two) on where the facility recorded
some fatalities due to any of these challenges?
(E) Opinions on overall policy implementation, successes, failures and
recommendations
28. What do you think are the strengths of the delivery fee exemption policy
particularly with access to supervised care at birth within this facility?
29. How do you assess the policy’s implementation arrangements in this facility?
30. What in your opinion are the major challenges to delivery service provision
under the policy
31. What suggestions/recommendations do you have for a more effective
implementation of the “free delivery policy” at the facility level?
32. What suggestions/recommendations do you have for a more effective
implementation of the “free delivery policy” within your district?
Thank you very much for your time and for the excellent feedback. The interview has
been very useful
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Appendix 4: Interview guide for district-level key informants
Key Informant Interviews
District level RCH officials – Regional and district directors of health services,
DHMT representatives
(A) Background of key informant
1. Position
2. Specialty
3. Has he/she played any role in the implementation of maternal health
policies in Ghana?
4. Length of period engaged in managing health service delivery related to
maternal and child healthcare
(B) Discussion on Policies on maternal health developed so far
5. Policies on ANC
6. Safe motherhood initiative
7. CHPS Compounds initiative
8. Road map for achieving MDG 5
9. Fee exemption policy for maternal deliveries
10. MDG 5 Acceleration Framework (MAF)
(C) Provision of maternal health services under fee exemption policy for maternal
deliveries
11. The policy and the actual maternal healthcare package it provides
12. How are these services provided in practice to beneficiaries with
particular emphasis on implementation arrangements at regional and
district levels? What are the institutional arrangements for the different
stakeholders involved in its implementation?
13. What are the implementation arrangements at the facility level? What are
the institutional arrangements for the different cadre of healthcare
providers?
14. In your opinion what has been the overall performance of the policy
15. Challenges in service delivery under the policy
16. Recommendations for improvement
(D) Finally, I would appreciate if you can talk a bit on women’s reproductive
healthcare situation in Ghana
17. Main reproductive health needs of Ghanaian women
18. Challenges to effective provision of these needs
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19. Your views on the nation’s response to addressing the reproductive health
needs of Ghanaian women
Thank you very much for your time and for the excellent feedback. The interview has
been very useful.
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Appendix 5: Multi-staged sampling approach
Stage 1
Stage 2
Stage 3
Stratification of localities into two - rural and urban
Cluster of rural localities Cluster of urban
localities
Cluster of localities
with health facilities
Cluster of localities without health facilities
Cluster of localities with health facilities
Cluster of localities without health facilities
2 localities selected (1 for each district)
2 localities selected (1 for each district)
2 localities selected (1 for each district)
2 localities selected (1 for each district)
Household Selection
Selection of Respondents
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