The implementation of the free maternal health policy in rural Northern Ghana: synthesised results and lessons learnt

Translating lessons to reinforce national stillbirth response; multi-stakeholder perspectives regarding priorities and opportunities to deliver quality evidence-based interventions within a limited-resource context in Uganda

BACKGROUND

There is noted increase in attention towards implementation of evidence-based interventions in response to the stillbirth burden in low- and middle-income countries including Uganda. Recent results reporting some of the strategies adopted have tended to focus much attention towards their overall effect on the stillbirth burden. More is needed regarding stakeholder reflections on priorities and opportunities for delivering quality services within a limited resource setting like Uganda. This paper bridges this knowledge gap.

METHODS

Data collection occurred between March and June 2019 at the national level. Qualitative interviews were analysed using a thematic analysis technique.

RESULTS

Identified priorities included; a focus on supportive functions such as the referral system, attention to the demand side component of maternal health services, and improvements in the support supervision particularly focusing on empowering subnational level actors. The need to strengthen the learning for better implementation of strategies which are compatible with context was also reported. A comprehensive and favourable policy environment with the potential to direct implementation of strategies, harnessing the private sector contribution as well as the role of national level champions and patient advocates to amplify national stillbirth reduction efforts for continued visibility and impact were recommended.

CONCLUSION

Great potential exists within the current strategies to address the national stillbirth burden. However, priorities such as improving the supportive functions of MCH service delivery and attention to the demand side need to be pursued more for better service delivery with opportunities including a favourable policy environment primed to better serve the current strategies. This calls for dedicated efforts targeted at addressing gaps within the existing priorities and opportunities for better delivery of national strategies to address the stillbirth burden in Uganda.

Infant mortality in Ghana: investing in health care infrastructure and systems

Child and infant mortality is a global problem. Almost half of deaths of children under age 5 years occur in the neonatal period, the first 28 days of life, with 2.4 million neonatal deaths globally in 2020. Sub-Saharan Africa has disproportionately high numbers of neonatal deaths. Ghana's neonatal mortality rate is 22.8 per 1000 live births and remains behind targets set by the United Nations Sustainable Development Goals. Quality antenatal care, postnatal monitoring, breastfeeding support, and postnatal family planning are important in preventing neonatal deaths. While Ghana has made progress in making care more financially accessible, it has not been matched with the improvements in the critical infrastructure required to ensure quality health care. The improvements have also not eliminated out-of-pocket costs for care, which have hindered progress in decreasing infant mortality. Policymakers should consider investments in health care infrastructure, including expanding public-private partnerships. Policies that improve workforce development programs, transportation infrastructure, and health insurance systems improvements are needed.

Knowledge about unintended pregnancy shortly after childbirth: An issue of ineffective counseling or adherence?

BACKGROUND

Being aware of the possibility of becoming pregnant shortly after childbirth before the resumption of the menstrual period is often overlooked but remains a significant contributor to unintended pregnancies and may lead to maternal and neonatal comorbidities. Exploring the extent of awareness and associated factors could help tailor more interventions toward reducing the rates of short-interval unplanned pregnancies.

OBJECTIVE

This study explores the extent to which Ghanaian women are aware of the possibility of becoming pregnant shortly after childbirth before the resumption of the menstrual period and its associated factors.

DESIGN

A cross-sectional study was conducted using the 2017 Ghana Maternal Health Survey. The women participants were sampled using a two-stage cluster sampling design.

METHODS

We analyzed the 2017 Ghana Maternal Health Survey data of 8815 women who had given birth and received both antenatal care and postnatal checks after delivery in health facilities (private and public) and responded to questions on being aware of short interpregnancy intervals. A multivariable survey logistic regression was used for the analysis.

RESULTS

Of the 8815 women, approximately 62% of women who received both antenatal care and postnatal examinations before discharge reported being aware of short interpregnancy intervals. Postnatal examination before discharge but not antenatal care was associated with a higher awareness of short interpregnancy intervals. Women who received a postnatal examination were more aware of short interpregnancy intervals than their counterparts (adjusted odds ratio = 1.29, 95% confidence interval: 1.03-1.61). Also, awareness of short interpregnancy intervals increased with age, education, knowledge of the fertile period, contraceptive use, and delivery via cesarean section.

CONCLUSION

Over a decade following the initiation of Ghana's free maternal health policy, there remains a significant gap in the awareness of short interpregnancy intervals, even among women who received both antenatal pregnancy care and postnatal examinations before discharge. The unawareness of the short interpregnancy interval observed in approximately 38% of women raises concerns about the effectiveness of counseling or education provided during antenatal care and immediate post-partum care regarding birth spacing, contraceptive use, the timing of resumption of sexual activity, and the extent to which women adhere to such guidance.

Birth preparedness and complications readiness among women in disadvantaged rural districts of Ghana

INTRODUCTION

Essentially all women and babies irrespective of their economic and social status should reach their full potential for health and well-being. The study assessed the readiness of mothers and their preparedness for birth across three disadvantaged rural districts in Ghana.

METHODS

A multi-centre quantitative survey from January to December 2018 using a multistage sampling approach was employed. Using a structured questionnaire data from mothers attending antenatal and postnatal clinics in three main ecological zones of Ghana were collected. Women who provided informed consent were consecutively recruited until the sample size was achieved. For categorical data, summary tables, proportions and percentage are presented. Multivariate logistic regression analysis determined the effect of selected characteristics on birth preparedness. Ethics approval was obtained from the Navrongo Health Research Centre.

RESULTS

A total of 1058 mothers were enrolled: 33.6%, 33.4% and 33.0% respectively from the Ada west, Upper Denkyira west and Builsa south districts. About 94% of the women had prior knowledge of birth preparedness. Approximately 22.6% (95%CI 20.1, 25. 2) of the mothers were assessed to have poor birth preparedness: 8.0% in Builsa south, 27.8% in Ada west and 31.7% in Upper Denkyira west. Prenatal and postnatal data showed no statistically significant difference in poor preparedness (21.9% vs 23.3%; p-value > 0.05). Maternal age, employment status, religious affiliation and parity were not associated with birth preparedness (p-value > 0.05). Area of study (P < 0.001), educational level (P < 0.016), marital status (p < 0.001) and antenatal contacts (< 0.001) were significantly associated with birth preparedness.

CONCLUSIONS

As an important safe motherhood strategy woman should plan their pregnancy and birth well to reduce maternal and neonatal mortality. Policy initiatives should take into consideration area of residence, education, marital status and antenatal contacts of women.

Situation Analysis of a New Effort of Community-Based Health Planning and Services (CHPS) for Maternal Health in Upper West Region in Rural Ghana

A free maternal health policy started in Ghana in 2008, however, health facility utilization is still low, and out-of-pocket payments (OOPPs) are putting households at risk of catastrophic expenditure. To improve this situation, some rural communities have assigned a midwife to a health post called community-based health planning and services (CHPS), where only assistant nurses are allocated. This study explored the effectiveness of the new approach in Upper West Region, Ghana. We conducted a cross-sectional study and interviewed women who gave birth in the last year. We systematically selected communities matched into four criteria: communities near CHPS (functional CHPS), communities near CHPS with a midwife (advanced CHPS), communities near a health centre, and communities without a health facility in their neighbourhood. In total, 534 women were interviewed: functional CHPS 104, advanced CHPS 131, near health centre 173, and no facility 126. About 78% of the women were 20 to 34 years old. About half of the women incurred OOPP, however, catastrophic payment (household spending > 5% of annual income) was significantly lower in advanced CHPS communities for normal delivery compared with the other three communities. The new local approach of assigning a midwife to CHPS functioned well, improving access to healthcare facilities for childbirth.

Women's views on obstetric fistula risk factors and prevention in north-central Nigeria: an interpretive descriptive study

OBJECTIVE

Obstetric fistula, also known as vesicovaginal fistula or rectovaginal fistula, is an abnormal opening between the vagina and rectum caused by prolonged obstructed labour that causes substantial long-term harm to women. It is most prevalent in low resource settings and although preventative measures have been proposed, they have not, to date, taken women's own views into account. The objective of this study was to explore the views of North Nigerian women on obstetric fistula risk factors and prevention.

DESIGN

This study was conducted using Interpretive Description methodology, which is a qualitative approach underpinned by Symbolic Interactionism. A semistructured questionnaire was used to explore the views of 15 women living with obstetric fistula about risk factors and prevention of the condition. Data were collected in one-to-one in-depth interviews conducted between December 2020 and May 2021. All interviews were audio-recorded and transcribed verbatim, and a thematic approach to data analysis was employed.

SAMPLING AND SETTING

The setting for this study was a fistula repair centre in north-central Nigeria. The sample was formed of a purposively selected 15 women who had experienced obstetric fistula at a repair Centre in north-central Nigeria.

RESULTS

Four core themes emerged from women's views on obstetric fistula risk factors and prevention: (1) Women's autonomy, (2) Economic empowerment, (3) Infrastructure/transportation and (4) Provision of skilled healthcare services.

CONCLUSION

The findings from this study highlight previously unknown women's views on obstetric fistula risk factors and prevention in north-central Nigeria. Analysis of insights from women's voices directly affected by obstetric fistula demonstrated that in their views and experiences, giving women autonomy (decision-making power) to choose where to birth safely, economic empowerment, enhancement of transportation/infrastructure and provision of skilled healthcare services may mitigate obstetric fistula in Nigeria.

A qualitative analysis of factors influencing the implementation of antiretroviral treatment adherence policy in Ghana: stakeholders perspective

BACKGROUND

The Joint United Nations Programme on HIV/AIDS launched the 90-90-90 initiative. Failure to meet the target reflects the difficulties in successfully implementing HIV treatment policy. There are research gaps in exploring personal and external factors influencing HIV treatment in Ghana. To fill this gap, we explored individual and environmental (interpersonal, community and structural) factors influencing stakeholders' HIV treatment policy implementation in Ghana.

METHODS

Fifteen qualitative semi-structured in-depth interviews were conducted among representatives in different management positions at hospitals, health directorates, the Ghana AIDS Commission, the National AIDS and STI control program, and the National Association of People Living with HIV.

RESULTS

Using thematic analysis, the findings suggest that individual and environmental factors such as attitude towards policy, awareness of HIV treatment policy, training received on policy implementation, difficulties related to patient factors, alternate sources of HIV care, inefficient policy decision-making, monitoring and evaluation of HIV treatment policy, lack of HIV treatment policy implementation training, poor availability of logistics, policy and guidelines, infrastructure, organization of training, and staff availability may hinder successful HIV treatment policy implementation.

CONCLUSION

Several individual and environmental (interpersonal, community and structural) factors seem to influence HIV treatment policy implementation. To ensure successful policy implementation stakeholders need to receive training on new policies, availability of sufficient supplies of material resources, inclusive decision-making, receive supportive monitoring of policy implementation, and oversight.

Ghana's Livelihood Empowerment Against Poverty (1000) Program Seasonally Impacts Birthweight: A Difference-in-Differences Analysis

Objectives: Low birthweight (LBW) prevalence remains high in African countries and evidence of cash transfer impacts on birthweight, particularly by season of infant birth, is limited. This study examines overall and seasonal cash transfer impacts on LBW in rural Ghana. Methods: Data come from a longitudinal, quasi-experimental impact evaluation of the Livelihood Empowerment Against Poverty (LEAP) 1,000 unconditional cash transfer program for impoverished pregnant or lactating women in rural districts of Northern Ghana. LEAP1000 program impacts on average birthweight and LBW were estimated for a multiply imputed sample of 3,258 and a panel sample of 1,567 infants using differences-in-differences models and triple difference models to assess impacts by season. Results: LEAP1000 decreased LBW prevalence by 3.5 and 4.1 percentage points overall and in the dry season, respectively. LEAP1000 increased average birthweight by 94, 109, and 79 g overall, in the dry season, and in the rainy season, respectively. Conclusion: Our findings of positive LEAP1000 impacts on birthweight across seasons and on LBW in the dry season demonstrate the need to take seasonal vulnerabilities into account when designing and implementing programs for rural populations in Africa.

Determinants of Maternal Satisfaction with the Quality of Childbirth Services in a University Hospital in Kumasi, Ghana: A Cross-Sectional Study

Introduction. Rendering quality childbirth services that lead to higher levels of maternal satisfaction is an important goal of every health institution. Despite efforts at enhanced client satisfaction over the years, there are still some quality concerns for health policymakers and managers to address. This study sought to assess maternal satisfaction with childbirth services at a university hospital in Kumasi, Ghana. Methods. We conducted a facility-based cross-sectional study among women in postnatal wards after delivery at the University Hospital, Kwame Nkrumah University of Science and Technology. They were recruited using a systematic sampling method, and their perspective about the quality of childbirth services was assessed using a service quality (SERVQUAL) tool. Linear regression analysis was performed to identify the relationship between SERVQUAL attributes and maternal satisfaction. Statistical significance was set at $p$ value < 0.05 at a 95% confidence interval. Results. Of the 277 participants interviewed, 79.8% (221) were satisfied with the childbirth services. Delays (49.5%), unprofessional conduct from health workers (7.2%), poor facilities (10.8%), and an inadequate number of skilled staff (15.5%) were identified as the challenges mothers encountered at the facility. After adjusting for all the components of the SERVQUAL model, reliability (adjusted $\beta =-3.28$ , $p=0.001$ ) and empathy (adjusted $\beta =2.21$ , $p=0.028$ ) were the most significant predictors of maternal satisfaction with childbirth services. Conclusion. Majority of postnatal women were generally satisfied with the overall childbirth services they received at the University Hospital. The service quality components that significantly predicted maternal satisfaction with childbirth services were “reliability” and “empathy.”

Cost of childbirth in Upper West Region of Ghana: a cross-sectional study

Background

Out-of-pocket payment (OOPP) is reported to be a major barrier to seeking maternal health care especially among the poor and can expose households to a risk of catastrophic expenditure and impoverishment.This study examined the OOPPs women made during childbirth in the Upper West region of Ghana.

Methods

We carried out a cross-sectional study and interviewed women who gave birth between January 2013 and December 2017. Data on socio-demographic characteristics, place of childbirth, as well as direct cost (medical and non-medical) were collected from respondents. The costs of childbirth were estimated from the patient perspective. Logistics regression was used to assess the factors associated with catastrophic payments cost. All analyses were done using STATA 16.0.

Results

Out of the 574 women interviewed, about 71% (406/574) reported OOPPs on their childbirth. The overall average direct medical and non-medical expenditure women made on childbirth was USD 7.5. Cost of drugs (USD 8.0) and informal payments (UDD 5.7) were the main cost drivers for medical and non-medical costs respectively. Women who were enrolled into the National Health Insurance Scheme (NHIS) spent a little less (USD 7.5) than the uninsured women (USD 7.9). Also, household childbirth expenditure increased from primary health facilities level (community-based health planning and services compound = USD7.2; health centre = USD 6.0) to secondary health facilities level (hospital = USD11.0); while home childbirth was USD 4.8. Overall, at a 10% threshold, 21% of the respondents incurred catastrophic health expenditure. Regression analysis showed that place of childbirth and household wealth were statistically significant factors associated with catastrophic payment.

Conclusions

The costs of childbirth were considerably high with a fifth of households spending more than one-tenth of their monthly income on childbirth and therefore faced the risk of catastrophic payments and impoverishment. Given the positive effect of NHIS on cost of childbirth, there is a need to intensify efforts to improve enrolment to reduce direct medical costs as well as sensitization and monitoring to reduce informal payment. Also, the identified factors that influence cost of childbirth should be considered in strategies to reduce cost of childbirth.

Health insurance support on maternal health care: evidence from survey data in India

Background

Maternal health care financing is key to the smooth functioning of health systems in a country. In India, maternal health care still persists as a major public health issue. Adequate health insurance could transform the utilization of maternal health care services. Therefore, we aim to examine the health insurance policies that cover maternal health and their performance in India.

Methods

The unit-level data of social consumption on health by the National Sample Survey Organizations, conducted in India (2017–18), are used. Bivariate analysis, logistic regression and propensity scoring matching are applied.

Results

About 14.1% women are covered by health insurance support at the national level. Uninsured women are less likely to receive full antenatal care (ANC) services and institutional delivery. Socio-economic characteristics play a significant role in utilizing maternal health care benefits through health insurance support.

Conclusions

Our study concludes that the health insurance coverage is the most significant contributor to the better utilization of full ANC and institutional delivery at the national level and hindrances in accessing them. There is a need for proactive and inclusive policy development by the Government of India to incentivize public financing through health insurance, which can shrink the challenges of public health burden and reduce the health risk.

Comparative prevalence of hepatitis B virus infection among pregnant women accessing free maternal care in a tertiary hospital in Ghana

Hepatitis B virus infection is endemic in sub-Saharan Africa, and accounts for a significant proportion of morbidities and mortalities in Ghana. Infection with HBV during pregnancy can result in life-threatening complications to both mother and child. To improve their quality of life, the free maternal care was introduced to grant pregnant women cost-free access to antenatal and postnatal services. The study analysed the prevalence of HBV infection among pregnant women receiving free antenatal care in a tertiary hospital in Ghana. This was a retrospective cross-sectional study, where secondary data of pregnant women who accessed free antenatal services at the Trafalga hospital, Ho, from 2016 to 2017 were retrieved from the hospital's database. Data on hepatitis B surface antigen reactivity test, age and period of turnout were analysed with Microsoft Excel and Graph pad prism version 6. A total of 2,634 pregnant women assessed free antenatal care from January 2016 -December 2017, with 10% rise in turnout in 2017. The age of the study population was fairly young, ranging from 13-52 years and mean of 29.87±5.83. The prevalence of HBV infection among pregnant women in the entire study was estimated to be 6.0%, while that of 2016 and 2017 were 5.3% and 6.7% respectively. Turnout for antenatal services peaked in July, which also recorded the highest prevalence of HBV infection among the pregnant women. Our study, first of its kind show an HBV prevalence of 6.0% among a large population of pregnant women who accessed free antenatal services at a tertiary hospital in Ghana. The study evaluates the influence of the free maternal care policy on antenatal attendance and HBV infection rates among pregnant women.

Engaging community members in setting priorities for nutrition interventions in rural northern Ghana

This study used "Choosing All Together" (CHAT), a deliberative engagement tool to prioritise nutrition interventions and to understand reasons for intervention choices of a rural community in northern Ghana. The study took an exploratory cross-sectional design and used a mixed method approach to collect data between December 2020 and February 2021. Eleven nutrition interventions were identified through policy reviews, interaction with different stakeholders and focus group discussions with community members. These interventions were costed for a modified CHAT tool-a board-like game with interventions represented by colour coded pies and the cost of the interventions represented by sticker holes. Supported by trained facilitators, six community groups used the tool to prioritise interventions. Discussions were audio-recoded, transcribed and thematically analysed. The participants prioritised both nutrition-sensitive and nutrition-specific interventions, reflecting the extent of poverty in the study districts and the direct and immediate benefits derived from nutrition-specific interventions. The prioritised interventions involved livelihood empowerment, because they would create an enabling environment for all-year-round agricultural output, leading to improved food security and income for farmers. Another nutrition-sensitive, education-related priority intervention was male involvement in food and nutrition practices; as heads of household and main decision makers, men were believed to be in a position to optimise maternal and child nutrition. The prioritised nutrition-specific intervention was micronutrient supplementation. Despite low literacy, participants were able to use CHAT materials and work collectively to prioritize interventions. In conclusion, it is feasible to modify and use the CHAT tool in public deliberations to prioritize nutrition interventions in rural settings with low levels of literacy. These communities prioritised both nutrition-sensitive and nutrition-specific interventions. Attending to community derived nutrition priorities may improve the relevance and effectiveness of nutrition health policy, since these priorities reflect the context in which such policy is implemented.

Why do women attend antenatal care but give birth at home? a qualitative study in a rural Ghanaian District

BACKGROUND

The Sustainable Development Goal Three has prioritised reducing maternal, under-5 and neonatal mortalities as core global health policy objectives. The place, where expectant mothers choose to deliver their babies has a direct effect on maternal health outcomes. In sub-Saharan Africa, existing literature has shown that some women attend antenatal care during pregnancy but choose to deliver their babies at home. Using the Andersen and Newman Behavioural Model, this study explored the institutional and socio-cultural factors motivating women to deliver at home after attending antenatal care.

METHODS

A qualitative, exploratory, cross-sectional design was deployed. Data were collected from a purposive sample of 23 women, who attended antenatal care during pregnancy but delivered their babies at home, 10 health workers and 17 other community-level stakeholders. The data were collected through semi-structured interviews, which were audio-recorded, transcribed and thematically analysed.

RESULTS

In line with the Andersen and Newman Model, the study discovered that traditional and religious belief systems about marital fidelity and the role of the gods in childbirth, myths about consequences of facility-based delivery, illiteracy, and weak women's autonomy in healthcare decision-making, predisposed women to home delivery. Home delivery was also enabled by inadequate midwives at health facilities, the unfriendly attitude of health workers, hidden charges for facility-based delivery, and long distances to healthcare facilities. The fear of caesarean section, also created the need for women who attended antenatal care to deliver at home.

CONCLUSION

The study has established that socio-cultural and institutional level factors influenced women's decisions to deliver at home. We recommend a general improvement in the service delivery capacity of health facilities, and the implementation of collaborative educational and women empowerment programmes by stakeholders, to strengthen women's autonomy and reshape existing traditional and religious beliefs facilitating home delivery.

A multidimensional study of public satisfaction with the healthcare system: a mixed-method inquiry in Ghana

BACKGROUND

Many governments in sub-Saharan Africa have recently sought to improve their health systems by increasing investment in healthcare facilities and introducing social insurance programmes. However, little is known about the impact of these intended improvements on public perceptions about the healthcare systems. This article examines whether and why people of different socioeconomic and ideological backgrounds are satisfied (or not) with the current healthcare system in Ghana from a social ecological perspective.

METHOD

Data were elicited from a cross-sectional mixed-method study conducted in four regions in Ghana in 2018. We used ordinal logistic regression and thematic analysis techniques to analyse the data.

RESULTS

Satisfaction with the healthcare system was generally low. From our quantitative study, intrapersonal factors (e.g., being older and having good health and well-being status); interpersonal factors (e.g., linking social capital); community factors (e.g., living in rural areas); and organisational and public policy factors (e.g., trust in the health system, favouring welfare policies, and being interested in politics) were positively associated with satisfaction with the healthcare system. These were corroborated by the qualitative study, which showed that poor attitudes of health personnel, financial constraints, perceived poor health facilities, and perceived inefficacy of services contribute to dissatisfaction with the healthcare system.

CONCLUSION

Strategies to improve satisfaction with the healthcare system in Ghana should incorporate ecological perspectives by considering factors such as demographic profile, health needs, political orientation, issues of trust in the healthcare system, and the dynamics and impact of social relationships of populations concerned.

Bypassing primary healthcare facilities for maternal healthcare in North West Ghana: socio-economic correlates and financial implications

Background

Bypassing primary health care (PHC) facilities for maternal health care is an increasing phenomenon. In Ghana, however, there is a dearth of systematic evidence on bypassing PHC facilities for maternal healthcare. This study investigated the prevalence of bypassing PHC facilities for maternal healthcare, and the socio-economic factors and financial costs associated with bypassing PHC facilities within two municipalities in Northwestern Ghana.

Methods

A quantitative cross-sectional design was implemented between December 2019 and March 2020. Multistage stratified sampling was used to select 385 mothers receiving postnatal care in health facilities for a survey. Using STATA 12 software, bivariate analysis with chi-square test and binary logistic regression models were run to determine the socio-economic and demographic factors associated with bypassing PHC facilities. The two-sample independent group t-test was used to estimate the mean differences in healthcare costs of those who bypassed their PHC facilities and those who did not.

Results

The results revealed the prevalence of bypassing PHC facilities as 19.35 % for antenatal care, 33.33 % for delivery, and 38.44 % for postnatal care. The municipality of residence, ethnicity, tertiary education, pregnancy complications, means of transport, nature of the residential location, days after childbirth, age, and income were statistically significantly (p < 0.05) associated with bypassing PHC facilities for various maternal care services. Compared to the non-bypassers, the bypassers incurred a statistically significantly (P < 0.001) higher mean extra financial cost of GH₵112.09 (US$19.73) for delivery, GH₵44.61 (US$7.85) for postnatal care and ₵43.34 (US$7.65) for antenatal care. This average extra expenditure was incurred on transportation, feeding, accommodation, medicine, and other non-receipted expenses.

Conclusions

The study found evidence of bypassing PHC facilities for maternal healthcare. Addressing this phenomenon of bypassing and its associated cost, will require effective policy reforms aimed at strengthening the service delivery capacities of PHC facilities. We recommend that the Ministry of Health and Ghana Health Service should embark on stakeholder engagement and sensitization campaigns on the financial consequences of bypassing PHC facilities for maternal health care. Future research, outside healthcare facility settings, is also required to understand the specific supply-side factors influencing bypassing of PHC facilities for maternal healthcare within the study area.

Quality of care in the free maternal healthcare era in sub-Saharan Africa: a scoping review of providers' and managers' perceptions

BACKGROUND

Free maternal healthcare financing schemes play an essential role in the quality of services rendered to clients during antenatal care in sub-Saharan Africa (SSA). However, healthcare managers' and providers' perceptions of the healthcare financing scheme may influence the quality of care. This scoping review mapped evidence on managers' and providers' perspectives of free maternal healthcare and the quality of care in SSA.

METHODS

We used Askey and O'Malley's framework as a guide to conduct this review. To address the research question, we searched PubMed, CINAHL through EBSCOhost, ScienceDirect, Web of Science, and Google Scholar with no date limitation to May 2019 using keywords, Boolean terms, and Medical Subject Heading terms to retrieve relevant articles. Both abstract and full articles screening were conducted independently by two reviewers using the inclusion and exclusion criteria as a guide. All significant data were extracted, organized into themes, and a summary of the findings reported narratively.

RESULTS

In all, 15 out of 390 articles met the inclusion criteria. These 15 studies were conducted in nine countries. That is, Ghana (4), Kenya (3), and Nigeria (2), Burkina Faso (1), Burundi (1), Niger (1), Sierra Leone (1), Tanzania (1), and Uganda (1). Of the 15 included studies, 14 reported poor quality of maternal healthcare from managers' and providers' perspectives. Factors contributing to the perception of poor maternal healthcare included: late reimbursement of funds, heavy workload of providers, lack of essential drugs and stock-out of medical supplies, lack of policy definition, out-of-pocket payment, and inequitable distribution of staff.

CONCLUSION

This study established evidence of existing literature on the quality of care based on healthcare providers' and managers' perspectives though very limited. This study indicates healthcare providers and managers perceive the quality of maternal healthcare under the free financing policy as poor. Nonetheless, the free maternal care policy is very much needed towards achieving universal health, and all efforts to sustain and improve the quality of care under it must be encouraged. Therefore, more research is needed to better understand the impact of their perceived poor quality of care on maternal health outcomes.

Is the National Health Insurance Scheme helping pregnant women in accessing health services? Analysis of the 2014 Ghana demographic and Health survey

BACKGROUND

Increasing the use of healthcare is a significant step in improving health outcomes in both the short and long term. However, the degree of the relationship between utilization of health services and health outcomes is affected by the quality of the services rendered, the timeliness of treatment and follow-up care. In this study, we investigated whether the National Health Insurance Scheme (NHIS) is helping pregnant women in accessing health services in Ghana.

METHODS

Data for the study were obtained from the women's file of the 2014 Ghana Demographic and Health Survey. All women with birth history and aged 15-49  constituted our sample (n = 4271). We employed binary logistic regression analysis in investigating whether the NHIS was helping pregnant women in accessing health service. Statistical significance was set at <0.05.

RESULTS

Most women had subscribed to the NHIS [67.0%]. Of the subscribed women, 78.2% indicated that the NHIS is helping pregnant women in accessing healthcare. Women who had subscribed to the NHIS were more likely to report that it is helping pregnant women in accessing health service [aOR = 1.70, CI = 1.38-2.10]. We further noted that women who had at least four antenatal visits were more likely to indicate that NHIS is helping pregnant women in accessing health services [aOR = 3.01, CI = 2.20-4.14]. Women with secondary level of education [aOR= 1.42; CI: 1.04-1.92] and those in the richest wealth quintile [aOR = 3.51; CI = 1.94-6.34] had higher odds of indicating that NHIS is helping pregnant women in accessing healthcare. However, women aged 45-49 [aOR = 0.49; CI = 0.26-0.94], women in the Greater Accra [aOR = 0.29; CI = 0.16-0.53], Eastern [aOR = 0.12; CI = 0.07-0.21], Northern [aOR = 0.29; CI = 0.12-0.66] and Upper East [aOR = 0.17; CI = 0.09-0.31] regions had lower odds of reporting that NHIS is helping pregnant women in accessing health services.

CONCLUSION

To enhance positive perception towards the use of health services among pregnant women, non-subscribers need to be encouraged to enrol on the NHIS. Together with non-governmental organizations dedicated to maternal and child health issues, the Ghana Health Service's Maternal and Child Health Unit could strengthen efforts to educate pregnant women on the importance of NHIS in maternity care.

How does it affect service delivery under the National Health Insurance Scheme in Ghana? Health providers and insurance managers perspective on submission and reimbursement of claims

INTRODUCTION

In 2003, the Government of Ghana launched the National Health Insurance Scheme (NHIS) to enable all Ghanaian residents to have access to health services at the point of care without financial difficulty. However, the system has faced a number of challenges relating to delays in submission and reimbursement of claims. This study assessed views of stakeholders on claims submission, processing and re-imbursement under the NHIS and how that affected health service delivery in Ghana.

METHODS

The study employed qualitative methods where in-depth interviews were conducted with stakeholders in three administrative regions in Ghana. Purposive sampling method was used to select health facilities and study participants for the interviews. QSR Nvivo 12 software was used to code the data into themes for thematic analysis.

RESULTS

The results point to key barriers such as lack of qualified staff to process claims, unclear vetting procedure and the failure of National Health Insurance Scheme officers to draw the attention of health facility staff to resolve discrepancies on time. Participants perceived that lack of clarity, inaccurate data and the use of non-professional staff for NHIS claims vetting prolonged reimbursement of claims. This affected operations of credentialed health facilities including the provision of health services. It is perceived that unavailability of funds led to re-use of disposable medical supplies in health service delivery in credentialed health facilities. Stakeholders suggested that submission of genuine claims by health providers and regular monitoring of health facilities reduces errors on claims reports and delays in reimbursement of claims.

CONCLUSION

Long delays in claims reimbursement, perceived vetting discrepancies affect health service delivery. Thus, effective collaboration of all stakeholders is necessary in order to develop a long-term strategy to address the issue under the NHIS to improve health service delivery.

Institutional delivery and associated factors among women in Ghana: findings from a 2017-2018 multiple indicator cluster survey

Background

Institutional delivery is essential in reducing maternal morbidity and mortality. We investigated the prevalence of institutional delivery and associated factors among women in Ghana.

Methods

National representative data from the 2017–2018 Ghana Multiple Indicator Cluster Survey was used for the analysis. The study included 3466 women, ages 15–49 y, who had a live birth in the last 2 y. Descriptive statistics were used to assess the prevalence of institutional delivery while multivariate logistic regression was used to assess the relationship between our variables of interest and institutional delivery.

Results

The prevalence of institutional delivery among women in Ghana was 77.89% (95% confidence interval [CI] 75.29 to 80.50). High-income households (adjusted odds ratio [aOR] 2.13 [95% CI 1.36 to 3.35]), attending antenatal care at least four times (aOR 2.37 [95% CI 1.54 to 3.65]) and knowing one's human immunodeficiency virus status (aOR 1.41 [95% CI 1.08 to 1.84]) were associated with higher odds of institutional delivery. Living in rural areas (aOR 0.43 [95% CI 0.27 to 0.67]), multiparity (aOR 0.59 [95% CI 0.41 to 0.85]) and no health insurance (aOR 0.57 [95% CI 0.44 to 0.74]) were associated with lower odds of institutional delivery.

Conclusions

The government of Ghana may need to focus on increasing health insurance utilization and antenatal care attendance in order to increase the coverage of institutional delivery.

Essential Medicines in Universal Health Coverage: A Scoping Review of Public Health Law Interventions and How They Are Measured in Five Middle-Income Countries

Very few studies exist of legal interventions (national laws) for essential medicines as part of universal health coverage in middle-income countries, or how the effect of these laws is measured. This study aims to critically assess whether laws related to universal health coverage use five objectives of public health law to promote medicines affordability and financing, and to understand how access to medicines achieved through these laws is measured. This comparative case study of five middle-income countries (Ecuador, Ghana, Philippines, South Africa, Ukraine) uses a public health law framework to guide the content analysis of national laws and the scoping review of empirical evidence for measuring access to medicines. Sixty laws were included. All countries write into national law: (a) health equity objectives, (b) remedies for users/patients and sanctions for some stakeholders, (c) economic policies and regulatory objectives for financing (except South Africa), pricing, and benefits selection (except South Africa), (d) information dissemination objectives (ex. for medicines prices (except Ghana)), and (e) public health infrastructure. The 17 studies included in the scoping review evaluate laws with economic policy and regulatory objectives (n = 14 articles), health equity (n = 10), information dissemination (n = 3), infrastructure (n = 2), and sanctions (n = 1) (not mutually exclusive). Cross-sectional descriptive designs (n = 8 articles) and time series analyses (n = 5) were the most frequent designs. Change in patients' spending on medicines was the most frequent outcome measure (n = 5). Although legal interventions for pharmaceuticals in middle-income countries commonly use all objectives of public health law, the intended and unintended effects of economic policies and regulation are most frequently investigated.

Socio-cultural factors influencing the decision of women to seek care during pregnancy and delivery: A qualitative study in South Tongu District, Ghana

Many low-income countries still encounter high mortality rates. The use of maternal health care services is known to be a key intervention in reducing maternal death. Despite investment in the healthcare sector, in 2015 Ghana did not meet the Millennium Development Goal 5 of reducing maternal mortality (MM). The Volta Region registered the highest rate of MM, the lowest percentage of antenatal care (ANC) coverage and the lowest percentage of skilled delivery. This is a qualitative study that used focus group discussions and key-informant interviews to explore the views on pregnancy among rural communities in the Volta Region, identify the barriers in accessing ANC and skilled attendance birth and collect views on how to improve the access to maternal care services.Overall, the study argues that members of the community of the rural villages acknowledge the benefits of ANC and skilled delivery, and the potential risk related to home delivery. However, pregnant women in the Volta Region still encounter different kinds of obstacles that prevent them from seeking maternal health care. These obstacles are driven by social and economic constraints, and by the fact that women may still lack voice in the decision-making process, and by low males' participation.

Maternal perceptions of the quality of Care in the Free Maternal Care Policy in sub-Sahara Africa: a systematic scoping review

BACKGROUND

The world aims to achieve universal health coverage by removing all forms of financial barriers to improve access to healthcare as well as reduce maternal and child deaths by 2030. Although free maternal healthcare has been embraced as a major intervention towards this course in some countries in sub-Saharan Africa (SSA), the perception of the quality of healthcare may influence utilization and maternal health outcomes. We systematically mapped literature and described the evidence on maternal perceptions of the quality of care under the free care financing policies in SSA.

METHODS

We employed the Arskey and O'Malley's framework to guide this scoping review. We searched without date limitations to 19th May 2019 for relevant published articles in PubMed, Google Scholar, Web of Science, Science Direct, and CINAHL using a combination of keywords, Boolean terms, and medical subject headings. We included primary studies that involved pregnant/post-natal mothers, free maternal care policy, quality of care, and was conduct in an SSA country. Two reviewers independently screened the articles at the abstract and full-text screening guided by inclusion and exclusion criteria. All relevant data were extracted and organized into themes and a summary of the results reported narratively. The recent version of the mixed methods appraisal tool was used to assess the methodological quality of the included studies.

RESULTS

Out of 390 studies, 13 were identified to have evidence of free maternal healthcare and client perceived quality of care. All the 13 studies were conducted in 7 different countries. We found three studies each from Ghana and Kenya, two each in Burkina Faso and Nigeria, and a study each from Niger, Sierra Leone, and Tanzania. Of the 13 included studies, eight reported that pregnant women perceived the quality of care under the free maternal healthcare policy to be poor. The following reasons accounted for the poor perception of service quality: long waiting time, ill-attitudes of providers, inadequate supply of essential drugs and lack of potable water, unequal distribution of skilled birth attendants, out-of-pocket payment and weak patient complaint system.

CONCLUSION

This study suggests few papers exist that looked at maternal perceptions of the quality of care in the free care policy in SSA. Considering the influence mothers perceptions of the quality of care can have on future health service utilisation, further studies at the household, community, and health facility levels are needed to help unearth and address all hidden quality of care challenges and improve maternal health services towards attaining the sustainable development goals on maternal and child health.