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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

University of Ghana http://ugspace.ug.edu.gh

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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


3

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.


4

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,


5

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


6

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


7

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


8

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,


9

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


10

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.


11

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:


12

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


13

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.


14

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


15

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.


16

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).


17

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


18

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


19

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


20

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


21

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


22

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).


23

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


24

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,


25

(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


26

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


27

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


28

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


29

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.


30

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


31

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


32

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


33

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


34

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


35

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.


36

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


37

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


38

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


39

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


40

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,


41

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.


42

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


43

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


44

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.


45

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


46

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.


47

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


48

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.).


49

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.


50

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.


51

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


52

(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


53

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.


54

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.


55

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


56

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


57

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).


58

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.


59

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


61

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).


62

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


63

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


64

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


65

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


66

(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


67

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


69

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.


70

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:


72

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.


73

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


75

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


76

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


78

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


79

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


80

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


96

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


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)


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



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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



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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


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)



Other Christian (SDA, Jehovah’s Witnesses) -1.188 0.671 0.077 0.305



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)


Formerly in union ((Widowed,


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


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


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


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)



Other Christian (SDA, Jehovah’s

Witnesses) -1.263 0.711 0.076 0.283



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


Formerly in union ((Widowed,


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


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


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


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.


122

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


123

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)


124

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


125

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


126

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).


155

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,


157

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


160

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


167

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


168

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


175

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


176

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


179

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


180

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


181

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


182

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


184

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


186

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


188

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


190

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


191

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


207

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)


208

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


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


209

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


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


211

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)


212

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


mother


6= Gloves

56= Other__________

(SPECIFY)

Q43 Where did you have your

last delivery?

1= Public hospital

2= Private hospital

3= Mission hospital


213

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


mother and baby






8= Laundry services

56= Other__________

(SPECIFY)

Q47 What aspects of care did

you have to pay for?


1= Delivery fee

2= Bed charge

3= Laboratory tests


mother and baby






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


214

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?


1=Long Distance to a facility

2=Lack of knowledge



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?


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)


215

96 = Don’t know


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


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


216

NOT choosing to deliver

for free one more time?


2= Lack of awareness about policy



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)


217

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


218

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


219

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,


220

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…………………


221

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.


222

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………………………………………………………….


223

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


224

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?


225

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


226

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?


227

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


228

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


229

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.


230

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)




Household Selection

Selection of Respondents


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