Perceived barriers to maternal and newborn health services delivery: A qualitative study of health workers and community members in low and middle-income settings

Objectives In considering explanations for poor maternal and newborn health outcomes, many investigations have focused on the decision-making patterns and actions of expectant mothers and families, as opposed to exploring the â € supply side’ (health service provider) barriers. Thus, we examined the health system factors impacting on access to and delivery of quality maternal and newborn healthcare in rural settings. Design A semistructured qualitative study using face-to-face in-depth interviews with health professionals, and focus group sessions with community members, in eight project sites in two districts of Upper West Region, Ghana, was employed. Participants were purposively selected to generate relevant data to help address the study objective. The survey was guided by WHO standard procedures and Ghana Health Ministry’s operational work plan for maternal and newborn care. Setting Nadowli-Kaleo and Daffiama-Bussie-Issa districts in Upper West Region, Ghana. Participants Two hundred and fifty-three participants were engaged in the study through convenient and purposive sampling: healthcare professionals (pharmacist, medical doctor, two district directors of health services, midwives, community health and enrolled nurses) (n=13) and community members comprising opinion leaders, youth leaders and adult non-pregnant women (n=240 in 24 units of focus groups). Results Results show significant barriers affecting the quality and appropriateness of maternal and neonatal health services in the rural communities and the Nadowli District Hospital. The obstacles were inadequate medical equipment and essential medicines, infrastructural challenges, shortage of skilled staff, high informal costs of essential medicines and general limited capacities to provide care. Conclusion Implementation of the birth preparedness and complication readiness strategy is in its infancy at the health facility level in the study areas. Increasing the resources at the health provider level is essential to achieving international targets for maternal and neonatal health outcomes and for bridging inequities in access to essential maternal and newborn healthcare. The study was a semistructured qualitative design using face-to-face interviews to explore barriers to skilled service delivery and utilisation in eight purposively selected study sites in the UWR of Ghana: four in Nadowli/Kaleo and four in Daffiama/Bussie/Issa. The study area had a two-tier health system: the district level (the hospital) and 29 subdistrict level health facilities (13 health centres (HCs) and 16 Community-Based Health Planning and Services (CHPS) compounds that are the lowest order in the Ghana Health Service structure)29 30 (figure 1). The CHPS compounds provide preventive services and obstetric first aid including immunisations, vaccinations, health promotion and health education activities, while the HCs provide both preventive and curative services to the communities. Six of these communities did not have access roads to the nearest hospital (Nadowli Hospital). Study communities and health facilities. The population of Nadowli/Kaleo district was 61 561 (46.7% males and 53.3% females), constituting 8.8% of the region’s population.30 Daffiama/Bussie/Issa Districts had a population of 32 827 (48.7% males and 51.3% females) representing 4.7% of the people of UWR.29 Health facility outputs are measured by the number of interventions for normal and emergency healthcare provision.31–33 In order to achieve skilled maternal and newborn attendance, a prerequisite to reducing avoidable infections and other morbidities and mortalities, the Ghana Health Service, in accordance with WHO policies, instituted measures to improve access to skilled and quality care in the country. The quality of MNH service delivery is assessed using benchmarks: human resources, logistics, referral policy/processes and service delivery space/physical infrastrure.24 31 32 The monitoring and evaluation frameworks for accessing health facility practices in relation to BPCR by Johns Hopkins Program for International Education in Gynaecology and Obstetrics (JHPIEGO)31 was adapted to guide the design, interpretation and reporting of the findings. The policy document prioritise timely access to relevant and quality care, in compliance with referral procedures, management of emergency obstetric complications, infection control procedures and strict adherence to the appropriate protocols and professional standards (table 1) to improve maternal and newborn care quality in facilities.23 32 33 Indicators for monitoring health facility practice of BPCR Source: adapted from existing literature and the BPCR toolkit by JHPIEGO.31 BPCR, birth preparedness and complication readiness; MNH, maternal and neonatal health. Health services delivery and related factors influencing BPCR are complex,19 20 23 25 which necessitates the need to explore them from the perspectives of both community members and service providers. A qualitative approach was considered to be most appropriate, using focus group discussions (FGDs) and in-depth interviews (IDIs). The district health management provided time series data using a structured survey of their resource capacities and logistics, and referral management prospects and challenges. Written informed consent was obtained from each participant. Participants were selected in the following ways: A combination of key informant and purposive sampling procedures was adopted to identify and select a convenient sample of opinion leaders (n=80), youth leaders aged 18–35 years (n=80) and nonpregnant women (who had childbirth experiences) (n=80) to provide data in 24 different group discussions, three in each community. The community representative, who is a non-partisan but statutorily elected official representing each community at the district level, assisted in identifying potential participants for the FGDs. The sample sizes were predetermined to facilitate data saturation and potential transferability of the findings to other contexts and settings (see the link for the detailed questionnaire and interview guide for all participant groups https://doi.org/10.1371/journal.pone.0185537.s001). Skilled healthcare staff were included in the study to provide their opinions on health services delivery and outcomes. On receiving written support from the health directorates, the staff in charge of each of the healthcare facilities in the study area were asked to participate in the study. Three ‘other nurses’ who were providing health services but not in managerial positions were purposively selected to submit further insights into expectant mother–ANC provider relationships and uptake of medical advice. A summary of all participants can be found in table 2. Study participants, data types and sex disaggregation An interview schedule containing structured and unstructured questions was applied to health professionals and surveyed staffing and logistical capacities to provide quality maternal health services, healthcare financing issues and preparedness for birth and complications. A similar semistructured discussion guide was used for the FGDs with the community members, which enabled in-depth investigation into community perspectives of BPCR interventions, the causes of maternal and neonatal morbidities and mortalities, sociocultural beliefs and practices impacting the use of maternal and newborn health services and barriers to healthcare uptake. The semistructured interview guides were not pretested and were conducted in ‘Dagaare’ (the local language). The FGDs were completed first, before the IDIs with the healthcare providers. This arrangement provided the opportunity to cross-examine relevant issues emerging from the discussions. Some of the key emergent issues identified included the sale of ANC routine drugs and other essential medicines to clients with active health insurance subscriptions and the challenges associated with the insurance scheme, as well as patronage of the services of TBAs. Convenient venues were arranged within the communities for the FGDs. All discussions and surveys were in the local language (Dagaare), as illiteracy was high.29 30 The IDIs were conducted in English at scheduled locations in the health facilities. JS received training from the Charles Sturt University Research Office on survey design, data collection and analysis, supervised by JC and SW. Two experienced researchers (JS and FT) collected the data. All surveys, IDIs and FGDs, were completed as planned, thereby resulting in a higher than anticipated response rate. Data were collected within two periods: February–June 2016 and January–May 2017. All interviews and group sessions were tape-recorded with the informed consent of the participants. To achieve accuracy and dependability of the data, all audio recordings, except those of the health professionals, were first transcribed (hand written) in ‘Dagaare’ and then translated into English by JS. JS is a native of the region and writes and speaks the local dialect. The interviews with healthcare staff were transcribed in English. Two separate individuals from the Ghana Institute of Languages were engaged to verify the recordings with the transcripts. WHO’s four-stage process for translation and adaptation of instruments guided the transcription process.34 Analysis of the qualitative data began in the field. After each interview, notes were made containing: (A) emerging opinions from the participants and how they could be noted and applied to other interviews,5 (B) what went well or not so well; (C) what should be done differently in future interviews and (D) physical observations of health facilities, surface nature of roads and interactions among participants and nurses. This interim analysis enabled the researcher to add follow-up questions to the interview schedule to clarify issues as they emerged. NVivo (V.7.5) was used to analyse the qualitative data. Analytical text categories and themes related to ‘logistics, equipment, staffing, essential medicines’ emerged from the computerised coding using the NVivo, which were complementary themes to a priori topics and subthemes identified in the quantitative analysis and existing literature and experience. The different factors affecting service delivery and skilled healthcare utilisation emerged as significant themes from the data (interview/FGD transcripts, right notes, field observations/reflections). These were thoroughly read and re-read to identify index topics and categories. Participant opinions were subsequently chosen to support the themes. Finally, both the predetermined and emerged themes were pooled together to address the research question. The study design emerged from the implementation of the UNFPA CP6. Thus, the participants and the public were not directly involved in the conceptualisation and design of the study. Nevertheless, the findings of the study would contribute to policy and service delivery interventions in Ghana and similar geographical locations, which is the reason that the views of the intended beneficiaries were obtained for the study.