Background: Improving access to supervised and emergency obstetric care resources through fee reduction/exemption maternity care initiatives has been touted as one major strategy to avoiding preventable maternal deaths. Evaluations on the effect of Ghana’s fee exemption policy for maternal healthcare have largely focused on how it has influenced health outcomes and patterns of use of supervised care with little attention to understanding the main factors influencing use. This study therefore sought to explore the main individual and health system factors influencing use of delivery care services under the policy initiative in the Central Region. Methods: A cross-sectional study was conducted using 412 mothers with children aged less than one year in one largely rural and another largely urban districts in the Central Region of Ghana from September to December 2013. Data were collected using a questionnaire survey on the socio-demographic characteristics of mothers, their knowledge and use of care under the fee free policy. Chi-square and Binary Logistic Regression tests were used to evaluate the main determinants of delivery care use under the policy. Results: Out of the 412 mothers interviewed, 268 (65 %) reported having delivered their most recent birth under the fee exemption policy even though awareness about the policy was almost universal 401 (97.3 %) among respondents. Utilization however differed for the two study districts. Respondents in the Cape Coast Metropolis (largely urban) used delivery service more (75.7 %) than those in the largely rural Assin North Municipal area (54.4 %). Binary logistic regression results identified maternal age, parity, religion, place of residence, awareness and knowledge about the fee exemption policy for maternal healthcare as significantly associated with the likelihood of delivery care use under the policy. The likelihood of using supervised delivery care under the policy was lower for mothers aged 20-29 compared to those in the age bracket of 40-49 (Odds ratio (OR) = 0.069, p = 0.003). For their index (last child), mothers who already had 1, 2 or 3 births were more likely to deliver under the policy than those with five or more births. Mothers living in urban areas were 3.79 times more likely to use delivery services under the policy than those living in rural areas (OR = 3.793, p = 0.000). The likelihood of using delivery services under the policy was higher for mothers who were aware and had full knowledge of the total benefit package of the policy (OR = 13.820, p = 0.022 and OR = 2.985, p = 0.001 for awareness and full knowledge respectively). Conclusions: Delivery service use under the free maternal healthcare policy is relatively low (65 %) when compared with nearly universal awareness (97.3 %) about the policy. Factors influencing delivery service use under the policy operate at both individual and policy implementation levels. Effective interventions to improve delivery service use under the policy should target the underlying individual and health policy implementation factors identified in the study.
The Central Region was selected for the study based on the following reasons: (i) the region was selected among the first four pilot regions in which the fee exemption policy for maternal deliveries was implemented in 2003. (ii) compared to the three other pilot regions (Northern, Upper East and Upper West), the Central Region has not witnessed improvements in skilled attendance rate particularly between 2008 and 2012 when services under the policy was administered through the NHIS. (iii) Contrastingly the region also has a Maternal Mortality Ratio of 520/100,000 live births [16] a ratio which is far higher than the national average of 350/100,000 live births [1]. Two districts (Cape Coast Metropolitan Area and Assin North Municipal Area) in the Central Region were purposively selected from the seventeen districts of the region for the study. The two districts compared to the others have the highest maternal mortality ratios [17]. Cape Coast Metro is also largely urban whereas Assin North is largely rural [16] a scenario that provides an opportunity to assess differences in care received under the policy within rural and urban settings. The primary study population was mothers of reproductive age (15–49 years) with children under one year of age. The choice of women with these characteristics was based on the study goal that aims to examine factors influencing delivery service use under the ‘free maternal healthcare’ policy. The target population largely serves as the potential users and benefactors of services under the policy. Secondly, mothers whose most recent birth occurred 12 months prior to the survey are most likely to recall and give a better account of their experiences. A total of 412 mothers were selected from the study districts (Cape Coast, n = 206; Assin North, n = 206) using a combined multi-staged, stratified and simple random sampling techniques. The sample size was determined with recourse to Kish [18] since the population under study was homogeneous and the total population of mothers with at least a child under one is not known [18]. The study participants were selected from eight different localities (4 rural and 4 urban) identified from a list of all rural and urban localities in the study areas through a simple random approach. The calculated sample populations for rural and urban areas from the total sample was shared equally across the study localities as the study population was homogeneous and therefore likely to share similar views and experiences. This was followed by the identification of households in each locality from which women were interviewed. The identification of households began with a surveillance exercise that was undertaken by the research assistants through the help of local opinion leaders and healthcare volunteers in the respective localities. Having identified households in which mothers eligible for the interviews reside, a list/sampling frame of these mothers was produced for each locality. From the sampling frame of mothers produced for each locality, a simple random approach (writing the names of each eligible respondent on pieces of papers, shaking them arbitrarily and selecting required number from the whole) was later employed to select the total number of respondents earmarked for each settlement or locality. Data were collected through the administration of a standardized questionnaire. The data collection exercise was undertaken concurrently in the two study districts between the months of September to December 2013. The questionnaire was administered to all 412 mothers and consisted of sections that asked questions related to their background characteristics such as age, marital status, education, religion and ethnicity, place of residence, employment status and parity. Similar questions were asked for the background information of their spouses/partners. The other sections had questions related to their obstetric history, their knowledge and perceived need of services provided under the free delivery policy; and experiences with use of delivery care under the delivery fee exemption policy. The dependent variable is use of delivery services under the fee exemption policy. It was derived from the question, “Did you deliver for free under the ‘free delivery policy’ or you paid for delivery services?” The dependent variable was measured by using the labels 1 and 2 with 1 being ‘Delivery for free’ and 2, ‘Delivery not for free. The independent variables were selected with reference to what has been used in previous studies. They comprised of those related to the socio-demographic characteristics of women as well as their partners and others on the free delivery policy. The variables selected on the socio-demographic characteristics of women and their husbands/partners included age, religion, level of education, employment status, marital status, parity, place of residence and ethnicity. The variables were defined and measured as follows. Education was defined as completed educational status and was ranked from 1 to 5 with label 1 for No formal education, 2 for primary education, 3 for Middle/Junior High School (JHS), 4 for Secondary/Senior High School (SHS)/Technical education, 5 for higher than secondary. Employment status was defined as the category of work respondents were engaged in and was ranked from 1 to 5 with 1 for ‘unemployed’, 2 (Self-employed), 3 (Paid employee), 4 (Paid informal worker) and 5 (Other forms of employment mostly seasonal employment). Parity referred to the total number of live births a woman had and was ranked from 1 to 5 with 1 for parity one, 2 for parity two, 3 for parity three, 4 for parity 4 and 5 for parity five and above. Place of residence was ranked 1 and 2 with 1 being Urban and 2, Rural. The marital status of respondents was ranked into three categories. Those who were currently married or cohabiting were assigned rank 1, formerly married, rank 2 and single, never married women given rank 3. The variables for the free delivery policy were awareness about the ‘free delivery’ policy and knowledge about benefit package for the ‘free delivery’ policy. Awareness of the free delivery policy was defined as having heard about the existence of the policy and ranked 1 for a ‘Yes’ and 2 for a ‘No’. Knowledge about the policy was also ranked as 1 and 2 with 1 referring to answering yes to having knowledge about the full benefit package of the policy and 2 for answering no to having knowledge about the policy. The Statistical Package for the Social Sciences (SPSS) software version 20.0 was used to analyze the quantitative data. Descriptive statistics were used for frequency counts and percentage distribution of background characteristics of respondents as well as prevalence of use of delivery services under the free maternal healthcare policy. The Chi-Square test was used to test for the statistical associations between use of delivery care and other independent variables. The binary-logistic regression model was used for identifying the main determinants of use of delivery care under the fee exemption policy. Three models containing variables of interest were fitted for the outcome variable (use of delivery care). The first model contained variables on the socio-demographic characteristics of mothers. This model was used to assess the association between their socio-demographic characteristics and use of delivery services. The second model contained variables on the demographic characteristics of the selected mothers and that of their husbands/partners. This helped to assess whether the husband’s/partner’s characteristics influenced the association between the background characteristics of the woman and the outcome variable. A third model containing variables on the socio-demographic characteristics of the woman as well as that of their husbands/partners and the free delivery policy was also estimated. The final model (Model 3) was used to estimate whether health policy and husbands’/partners’ socio- demographic characteristic factors moderate the association between mothers’ socio-demographic characteristics and delivery care use.
N/A
DIMA AI Care
