BackgroundMaternal deaths in Sub-Saharan Africa are largely preventable with health facility delivery assisted by skilled birth attendants. Examining associations of birth location preferences on pregnant women’s experiences is important to understanding delays in care seeking in the event of complications. We explored the influence of birth location preference on women’s pregnancy, labor and birth outcomes.MethodsA qualitative study conducted in rural Ghana consisted of birth narratives of mothers (n = 20) who experienced pregnancy/labor complications, and fathers (n = 18) whose partners experienced such complications in their last pregnancy. All but two women in our sample delivered in a health facility due to complications. We developed narrative summaries of each interview and iteratively coded the interviews. We then analyzed the data through coding summaries and developed analytic matrices from coded transcripts.ResultsBirth delivery location preferences were split for mothers (home delivery–9; facility delivery–11), and fathers (home delivery–7; facility delivery–11). We identified two patterns of preferences and birth outcomes: 1) preference for homebirth that resulted in delayed care seeking and was likely associated with several cases of stillbirths and postpartum morbidities; 2) Preference for health facility birth that resulted in early care seeking, and possibly enabled women to avoid adverse effects of birth complications.ConclusionSafe pregnancy and childbirth interventions should be tailored to the birth location preferences of mothers and fathers, and should include education on the development of birth preparedness plans to access timely delivery related care. Improving access to and the quality of care at health facilities will also be crucial to facilitating use of facility-based delivery care in rural Ghana.
Quality improvement (QI) is used to promote and strengthen maternal and child health services in middle and low-income countries. Very little research has examined community-level factors beyond the confines of health facilities that create demand for health services and influence health outcomes. We examined the role of community outreach in the context of Project Fives Alive!, a QI project aimed at improving maternal and under-5 outcomes in Ghana. Qualitative case studies of QI teams across 6 regions of Ghana were conducted. We analyzed the data using narrative and thematic techniques. QI team members used two distinct outreach approaches: community-level outreach, including health promotion and education efforts through group activities and mass media communication; and direct outreach, including one-on-one interpersonal activities between health workers and pregnant women and/or mothers of children under-5. Specific barriers to community outreach included structural, cultural, and QI team-level factors. QI efforts in both rural and urban settings should consider including context-specific community outreach activities to develop ties with communities and address barriers to health services. Sustaining community outreach as part of QI efforts will require improving infrastructure, strengthening QI teams, and ongoing collaboration with community members.
Background Expanding health insurance coverage is a priority under Sustainable Development Goal 3. To address the intersection between poverty and health and remove cost barriers, the government of Ghana established the National Health Insurance Scheme (NHIS). Government further linked NHIS with the Livelihood Empowerment Against Poverty (LEAP) 1000 cash transfer program by waiving premium fees for LEAP 1000 households. This linkage led to increased NHIS enrolment, however, large enrolment gaps remained. One potential reason for failure to enroll may relate to the poor quality of health services. Methods We examine whether LEAP 1000 impacts on NHIS enrolment were moderated by health facilities’ service availability and readiness. Results We find that adults in areas with the highest service availability and readiness are 18 percentage points more likely to enroll in NHIS because of LEAP 1000, compared to program effects of only 9 percentage points in low service availability and readiness areas. Similar differences were seen for enrolment among children (20 v. 0 percentage points) and women of reproductive age (25 v. 10 percentage points). Conclusions We find compelling evidence that supply-side factors relating to service readiness and availability boost positive impacts of a cash transfer program on NHIS enrolment. Our work suggests that demand-side interventions coupled with supply-side strengthening may facilitate greater population-level benefits down the line. In the quest for expanding financial protection towards accelerating the achievement of universal health coverage, policymakers in Ghana should prioritize the integration of efforts to simultaneously address demand- and supply-side factors. Trial registration This study is registered in the International Initiative for Impact Evaluation’s (3ie) Registry for International Development Impact Evaluations (RIDIE-STUDY-ID-55942496d53af).
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