Spatial inequalities in skilled attendance at birth in Ghana: a multilevel analysis integrating health facility databases with household survey data

Abstract

Objective This study aimed at using survey data to predict skilled attendance at birth (SBA) across Ghana from healthcare quality and health facility accessibility. Methods Through a cross‐sectional, observational study, we used a random intercept mixed effects multilevel logistic modelling approach to estimate the odds of having SBA and then applied model estimates to spatial layers to assess the probability of SBA at high‐spatial resolution across Ghana. We combined data from the Demographic and Health Survey (DHS), routine birth registers, a service provision assessment of emergency obstetric care services, gridded population estimates and modelled travel time to health facilities. Results Within an hour's travel, 97.1% of women sampled in the DHS could access any health facility, 96.6% could reach a facility providing birthing services, and 86.2% could reach a secondary hospital. After controlling for characteristics of individual women, living in an urban area and close proximity to a health facility with high‐quality services were significant positive determinants of SBA uptake. The estimated variance suggests significant effects of cluster and region on SBA as 7.1% of the residual variation in the propensity to use SBA is attributed to unobserved regional characteristics and 16.5% between clusters within regions. Conclusion Given the expansion of primary care facilities in Ghana, this study suggests that higher quality healthcare services, as opposed to closer proximity of facilities to women, is needed to widen SBA uptake and improve maternal health.

The influence of travel time to health facilities on stillbirths: A geospatial case-control analysis of facility-based data in Gombe, Nigeria

“…Travel time was chosen to model physical geographic access because it is a better measure that incorporates elevation, road network, and travel speed among other factors that influence geographic accessibility compared to network and straight-line distances [30]. Furthermore, we used AccessMod5.0 because it is free software, simple to use and widely used for analysing geographic accessibility to health services [21,31]. Travel times were modelled to two destinations, first to the nearest government health facility (i.e., public primary and secondary facilities, excluding dispensaries) then to FTHG (the major referral facility in Gombe) where all the cases and controls delivered their babies.…”

“…Most studies focus on reporting stillbirth prevalence rates and exploring their clinical determinants [16][17][18][19]. Also, available studies investigated geographic accessibility factors known to strongly influence the use of skilled birth attendant and EmONC for pregnant women but not stillbirth outcome [20,21]. Furthermore, existing local stillbirth literature shows substantial regional disparity as they are mainly focused on southern Nigeria [16][17][18][19].…”

Multilevel geospatial analysis of factors associated with unskilled birth attendance in Ghana

“…We further contribute to the maternal and child health literature in Ghana by highlighting hotspots for unskilled birth attendance and the factors associated with such observations. Previous geospatial studies have focused on inadequate variables [ 21 ] or focused on skilled birth attendance [ 22 ]. Understanding the predictors of unskilled birth attendance and its geospatial coverage in Ghana is of high relevance to both local and public health understanding of unskilled birth attendance and highlight areas where national interventions will yield cost-effective results.…”

Assisted Birth Delivery In Ghana: Evidence From Ghana Demographic And Health Survey 1988 - 2014

“…In a study conducted at Nigeria con rms that Region was statistically signi cant factor that affected the use of skilled delivery [36]. A study by [37] posited different nding when they concluded that Region was not found to predict skilled attendance during delivery in their study in Ghana Using the 2008 Ghana Demographic and Health Survey. With reference to the occupation of the respondents, it was clear that women working in the clerical sector were two times more likely to utilize the services of nurses/midwives compared with those not working.…”

“…The study concluded that respondents from these places were more likely to utilize the services of Traditional birth attendants during birth delivery. In a study conducted to identify demographic, maternal and community predictors of skilled attendance at delivery among women, region was found to be associated with delivery assisted by traditional birth attendants [37].…”