Abstract
Despite an array of governmental and organisational interventions at regional, national and global levels, poor maternal and neonatal health outcomes remain as both human rights and developmental concerns in many regions of the world. The majority of the burden of maternal and neonatal morbidities and mortalities can be found in sub-Saharan Africa, including Ghana. Understanding the reasons underlying this on-going problem is essential if long-term improvements of maternal and neonatal health are to be achieved.
Drawing upon theories of ecological systems, bioecological theory socioecological model, cultural care theory, maternal engagement, human rights-based perspective and social exchange theory, this study employed a pragmatic paradigm and mixed methods approach to explore the paradoxes of factors impacting maternal health service delivery and utilisation in eight selected communities in the Nadowli-Kaleo and Daffiama-Bussie-Issa districts, two of the worst performing districts in terms of maternal health indicators in the Upper West Region of Ghana. Data was collected from three hundred and forty-two participants: pregnant women (n = 80), in the form of questionnaires: adult non-pregnant women (n = 80), opinion leaders (n = 80) and youth leaders (n = 80), in the form of focus groups: and health providers and managerial staff (n = 19, with 8 pariticipating in Phase 1 and 2) and traditional birth attendants (n = 3), in the form of surveys, between February to June 2016 and January to May, 2017. Simple random, key informant and purposive sampling procedures were employed in selecting the participants for the data collection. Qualitative data was analysed using themes and factors. Chi-square test was used to examine the influence of different cultural, economic and demographic characteristics and the health system on utilisation of skilled care by expectant mothers.
The results showed that antenatal care visits, age of the mother, family involvement, and intake of local oxytocin, as well as mothers who utilised alternative sources of care, were associated with birth preparedness and complication readiness (BP/CR) and skilled attendance at birth and place of childbirth. Expectant mothers within the ages of 26 and 40 were less likely not to plan for health facility delivery than those aged 25 years or younger (7.7% vs 17.1%). Pregnant women whose spouses were 30 years and younger were 44.3% less likely to plan to give birth at healthcare settings than those with older husbands. Women who planned for health facility delivery were more likely to achieve it compared to those who had no intentions to give birth at a healthcare setting. Educational attainment of the mothers and the jobs they engaged in for a living had no statistically significant association with birth preparedness and complication readiness (BP/CR). Women who attained primary education or higher were slightly likely to answer “yes” to BP/CR than those who never attended (62.2% vs 58.1%) and expectant mothers who were engaged in farming activities were more likely to respond “no” to BP/CR than those engaged in other economic ventures. Pregnant women who administered local oxytocin in the pregnancy were more likely to experience obstetric complications than their colleagues who did not administer it. While seeking maternal health services was ostensibly the responsibility of the mothers, their decisions were influenced by a number of external factors, including the husband’s expectations, community customs, norms and beliefs and practices associated with pregnancy, low ANC uptake, cultural appropriateness in maternity and delivery care, herbal uterotonics intake and the services of traditional birth attendants. Physician/midwife and health facility logistical shortages were also barriers to service delivery, as were culturally inappropriate maternal health education and promotion activities.
Drawing upon these insights, a new model for understanding the factors influencing maternal health service delivery and uptake in rural Ghana and other low and middle-income countries is presented. Specific strategies that can address the barriers above are identified.
Drawing upon theories of ecological systems, bioecological theory socioecological model, cultural care theory, maternal engagement, human rights-based perspective and social exchange theory, this study employed a pragmatic paradigm and mixed methods approach to explore the paradoxes of factors impacting maternal health service delivery and utilisation in eight selected communities in the Nadowli-Kaleo and Daffiama-Bussie-Issa districts, two of the worst performing districts in terms of maternal health indicators in the Upper West Region of Ghana. Data was collected from three hundred and forty-two participants: pregnant women (n = 80), in the form of questionnaires: adult non-pregnant women (n = 80), opinion leaders (n = 80) and youth leaders (n = 80), in the form of focus groups: and health providers and managerial staff (n = 19, with 8 pariticipating in Phase 1 and 2) and traditional birth attendants (n = 3), in the form of surveys, between February to June 2016 and January to May, 2017. Simple random, key informant and purposive sampling procedures were employed in selecting the participants for the data collection. Qualitative data was analysed using themes and factors. Chi-square test was used to examine the influence of different cultural, economic and demographic characteristics and the health system on utilisation of skilled care by expectant mothers.
The results showed that antenatal care visits, age of the mother, family involvement, and intake of local oxytocin, as well as mothers who utilised alternative sources of care, were associated with birth preparedness and complication readiness (BP/CR) and skilled attendance at birth and place of childbirth. Expectant mothers within the ages of 26 and 40 were less likely not to plan for health facility delivery than those aged 25 years or younger (7.7% vs 17.1%). Pregnant women whose spouses were 30 years and younger were 44.3% less likely to plan to give birth at healthcare settings than those with older husbands. Women who planned for health facility delivery were more likely to achieve it compared to those who had no intentions to give birth at a healthcare setting. Educational attainment of the mothers and the jobs they engaged in for a living had no statistically significant association with birth preparedness and complication readiness (BP/CR). Women who attained primary education or higher were slightly likely to answer “yes” to BP/CR than those who never attended (62.2% vs 58.1%) and expectant mothers who were engaged in farming activities were more likely to respond “no” to BP/CR than those engaged in other economic ventures. Pregnant women who administered local oxytocin in the pregnancy were more likely to experience obstetric complications than their colleagues who did not administer it. While seeking maternal health services was ostensibly the responsibility of the mothers, their decisions were influenced by a number of external factors, including the husband’s expectations, community customs, norms and beliefs and practices associated with pregnancy, low ANC uptake, cultural appropriateness in maternity and delivery care, herbal uterotonics intake and the services of traditional birth attendants. Physician/midwife and health facility logistical shortages were also barriers to service delivery, as were culturally inappropriate maternal health education and promotion activities.
Drawing upon these insights, a new model for understanding the factors influencing maternal health service delivery and uptake in rural Ghana and other low and middle-income countries is presented. Specific strategies that can address the barriers above are identified.
| Original language | English |
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| Qualification | Doctor of Philosophy |
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| Award date | 15 Nov 2018 |
| Publication status | Published - 2018 |
