Factors associated with institutional delivery in Ghana: the role of decision-making autonomy and community norms

Abstract

BackgroundIn Ghana, the site of this study, the maternal mortality ratio and under-five mortality rate remain high indicating the need to focus on maternal and child health programming. Ghana has high use of antenatal care (95%) but sub-optimum levels of institutional delivery (about 57%). Numerous barriers to institutional delivery exist including financial, physical, cognitive, organizational, and psychological and social. This study examines the psychological and social barriers to institutional delivery, namely women’s decision-making autonomy and their perceptions about social support for institutional delivery in their community.MethodsThis study uses cross-sectional data collected for the evaluation of the Maternal and Newborn Referrals Project of Project Fives Alive in Northern and Central districts of Ghana. In 2012 and 2013, a total of 2,527 women aged 15 to 49 were surveyed at baseline and midterm (half in 2012 and half in 2013). The analysis sample of 1,606 includes all women who had a birth three years prior to the survey date and who had no missing data. To determine the relationship between institutional delivery and the two key social barriers—women’s decision-making autonomy and community perceptions of institutional delivery—we used multi-level logistic regression models, including cross-level interactions between community-level attitudes and individual-level autonomy. All analyses control for the clustered survey design by including robust standard errors in Stata 13 statistical software.ResultsThe findings show that women who are more autonomous and who perceive positive attitudes toward facility delivery (among women, men and mothers-in-law) were more likely to deliver in a facility. Moreover, the interactions between autonomy and community-level perceptions of institutional delivery among men and mothers-in-law were significant, such that the effect of decision-making autonomy is more important for women who live in communities that are less supportive of institutional delivery compared to communities that are more supportive.ConclusionsThis study builds upon prior work by using indicators that provide a more direct assessment of perceived community norms and women’s decision-making autonomy. The findings lead to programmatic recommendations that go beyond individuals and engaging the broader network of people (husbands and mothers-in-law) that influence delivery behaviors.

Mobilising faith-based and lay leaders to address antenatal care outcomes in northern Ghana

“…In particular, in Ghana's Northern region, Moyer et al (2014) concluded that community-based solutions, including working with community leaders, were needed in order to address challenges facing maternal and child health. Similarly, Speizer, Story, and Singh (2014) found a strong positive association between facility deliveries and supportive community attitudes for the behaviour in the same region.…”

“…Organisational barriers to accessing life-saving maternal, neonatal, and child health (MNCH) services have been documented, including providers' attitudes and the services offered (Speizer, Story, and Singh 2014). The costs of accessing ANC services, including cost of transportation, services, and equipment, have also been shown to be important barriers to ANC utilisation in SSA, and Ghana in particular (Asundep et al 2013).…”

“…A recent systematic review and meta-analysis indicated that interventions to involve male household decision-makers in maternal health activities, including ANC, was associated with improved utilisation of maternal health services and reduced odds of postpartum depression (Yargawa and Leonardi-Bee 2015). Additionally, Speizer, Story, and Singh (2014) demonstrated the positive effects of supportive community norms on institutional delivery in northern Ghana.…”

“…In general, Ghana has demonstrated improved ANC statistics relative to other SSA countries, with 92% of rural women ever receiving ANC, 83% receiving at least four ANC visits, and over 60% attending ANC in the first trimester of pregnancy (Ghana Statistical Service, Ghana Health Service, and ICF International 2015). However, wide variability in early and regular ANC attendance exists in Ghana, with the Northern region demonstrating the lowest uptake of these behaviours (Ghana Statistical Service, Ghana Health Service, and ICF International 2015; Pell et al 2013;Speizer, Story, and Singh 2014). Data from a knowledge, attitudes, and practice survey conducted as part of unpublished formative research in the East Mamprusi district in the Northern region showed that 80% of mothers with children aged 0 to 23 months received four or more ANC visits and only 50% reported that their first visit took place during the first trimester (Tuli, Wilcox, and Catholic Relief Services 2015).…”

A Mixed-Methods Evaluation of a Community-Based Behavior Change Program to Improve Maternal Health Outcomes in the Upper West Region of Ghana

“…Several studies have shown that community beliefs and attitudes influence a woman’s decision to seek care (Kruk, Rockers, Mbaruku, Paczkowski, & Galea, 2010; Stephenson, Baschieri, Clements, Hennink, & Madise, 2006). Previous research in Ghana has found that women who live in communities where more women perceive higher use of facility delivery are more likely to deliver in a facility (Speizer, Story, & Singh, 2014). While these studies show an association between community attitudes and a woman’s health-seeking decisions, they do not explain how the woman engages with the community, including the nature of her relationships, the types of advice or support received, and the characteristics of her social network that may increase her receptivity to these attitudes.…”