Facility-Based Delivery in Ghana: A Three-Part Study of Drivers and Deterrents.

Abstract

Every year approximately 275,000 women die during and shortly after pregnancy, and 2.9 million infants die within the first month of birth. One way to address both maternal and neonatal mortality is to ensure skilled obstetric care at the time of delivery – often achieved in sub-Saharan Africa by encouraging pregnant women to deliver their infants in health care facilities. In this dissertation, “facility based delivery” (FBD) is explored through three separate studies. The first is a systematic review of the literature on FBD in sub-Saharan Africa, finding that maternal education, parity, rural/urban residence, household wealth, distance of the nearest facility, and number of antenatal care visits are the factors most consistently associated with FBD. The second study uses the 2008 Ghana Demographic Health Survey (DHS) to examine access-related factors associated with FBD among women who delivered an infant within the previous year. The Five As of Access framework guided analysis, including an additional category of “Social Access”. In multivariate analysis, affordability was the most important access barrier. Availability, accessibility (with the exception of urban status), acceptability, and social access variables were not strong enough to remain significant in the final multivariate models. However, social access may be working through maternal literacy, health insurance coverage, and household wealth. In the third study, in-depth interviews and focus groups with community members and healthcare providers in northern Ghana were analyzed to explore the issue of maltreatment during FBD. Pursuant to the White Ribbon Alliance’s 7 fundamental rights of childbearing women, respondents reported physical abuse, verbal abuse, neglect, and discrimination. One additional category of maltreatment identified was denial of traditional practices. Unprompted, maltreatment was described by all types of interview respondents in this community, suggesting that the problem is not only widespread but that it is well-known to dissuade some women from seeking facility delivery. In summary, simply encouraging more women to deliver in a facility is unlikely to achieve the desired result of healthier mothers and babies in sub-Saharan Africa. Future research, interventions, and policy experiments are needed that attempt to address the complex, multifaceted issues associated with facility-based delivery.