Factors influencing health facility delivery in predominantly rural communities across the three ecological zones in Ghana: A cross-sectional study

Background: Maternal and neonatal mortality indicators remain high in Ghana and other sub-Saharan African countries. Both maternal and neonatal health outcomes improve when skilled personnel provide delivery services within health facilities. Determinants of delivery location are crucial to promoting health facility deliveries, but little research has been done on this issue in Ghana. This study explored factors influencing delivery location in predominantly rural communities in Ghana. Methods: Data were collected from 1,500 women aged 15-49 years with live or stillbirths that occurred between January 2011 and April 2013. This was done within the three sites operating Health and Demographic Surveillance Systems, i.e., the Dodowa (Greater Accra Region), Kintampo (Brong Ahafo Region), and Navrongo (Upper-East Region) Health Research Centers in Ghana. Multivariable logistic regression was used to identify the determinants of delivery location, controlling for covariates that were statistically significant in univariable regression models. Results: Of 1,497 women included in the analysis, 75.6% of them selected health facilities as their delivery location. After adjusting for confounders, the following factors were associated with health facility delivery across all three sites: healthcare provider’s influence on deciding health facility delivery, (AOR = 13.47; 95% CI 5.96-30.48), place of residence (AOR = 4.49; 95% CI 1.14-17.68), possession of a valid health insurance card (AOR = 1.90; 95% CI 1.29-2.81), and socio-economic status measured by wealth quintiles (AOR = 2.83; 95% CI 1.43-5.60). Conclusion: In addition to known factors such as place of residence, socio-economic status, and possession of valid health insurance, this study identified one more factor associated with health facility delivery: healthcare provider’s influence. Ensuring care provider’s counseling of clients could improve the uptake of health facility delivery in rural communities in Ghana. This cross-sectional study was conducted in three predominantly rural areas of Ghana from July to September 2013. The study is a part of the Ghana Ensure Mothers and Babies Regular Access to Care (EMBRACE) Implementation Research program, which aimed at strengthening the continuum of care for maternal, newborn and child health (MNCH) and subsequently improving MNCH outcomes [24]. Dodowa, Kintampo, and Navrongo were selected as study sites. The sites have diverse ecological and health delivery systems (Fig 1, Table 1). Each study site has a Health and Demographic Surveillance System (HDSS), which collects longitudinal data on population risks, exposures, and outcomes [25]. Dodowa is located in the southern part of Ghana. Its HDSS covers the Shai-Osudoku and the Ningo Prampram districts [26]. Kintampo is located in the central part of the country. The Kintampo HDSS covers the Kintampo North Municipality and the Kintampo South District [27]. Finally Navrongo, located in the northern part of the country, has its HDSS covering the Kassena-Nankana East and West Districts [28]. The Community-based Health Planning and Services (CHPS) program was introduced to deprived communities in Ghana in 2002 [29, 30], to facilitate geographical equity in MNCH care delivery. CHPS is most developed in Navrongo [31], followed by Dodowa and Kintampo. Community Health Officers (CHOs) in the CHPS compounds have midwifery skills in Navrongo and Dodowa, whereas those in Kintampo do not have these skills. 1 Dodowa Health and Demographic Surveillance System, 2011 [26] 2 Kintampo Health and Demographic Surveillance System, January 2013 [32] 3 Navrongo Health and Demographic Surveillance System, January 2013 [33] The women were recruited according to the following criteria: be aged 15 to 49 years old, should have had a live or stillbirth between January 2011 and April 2013, and be resident in the study area at the time of the study. If women had more than one pregnancy and delivery over the study period, the most recent pregnancy information was collected. Exclusion criteria were those who had an abortion or a miscarriage during the period of the study. Women involved in the study were sampled from the HDSS databases of the three sites. Two-stage random sampling was used to select 22 primary sampling units, from which 1,500 women were recruited (500 from each site). The zone or sub-district was used as the primary sampling unit depending on the study site. The zone as a unit of population representation was developed by the Navrongo HDSS. A sub-district is the lowest unit in the local government structure of Ghana after the Regions and Districts [34]. The questionnaire for the study was developed based on the 2007 Ghana Maternal Health Survey [35] and the National Safe Motherhood Service protocol [36]. The questionnaire covered background characteristics, antenatal history, socio-economic status (SES), services women received during pregnancy, and delivery. The questionnaire was reviewed by Ghanaian experts in the field of MNCH. The questionnaire was finalized based on the findings from pretesting. Additionally, data on ethnicity, religion, and household assets were obtained from the HDSS datasets of the three sites. During data collection, trained field workers administered the questionnaires through face-to-face interviews with women. Data were double entered into Microsoft Foxpro version 9. Verification and consistency checks were performed to ensure completeness of the data. Data were transferred to the Statistical Package for Social Sciences (SPSS) version 22 [37] for statistical analysis. The dependent variable was venue of the last delivery (i.e. health facility delivery or non-health facility delivery). Health facilities included public hospitals/polyclinics, private hospitals/clinics/maternity homes, health centers and CHO offices/CHPS compounds/community clinics. Locations outside of health facilities (non-health facility) included traditional birth attendants’ homes, on the way to the health facility, and the women’s homes. Independent variables were categorized as background characteristics, antenatal history, and socio-economic characteristics. Background characteristics include mothers’ age, partners’ age, current marital status, ethnicity, religion, mothers’ educational attainment, and partners’ educational attainment. Antenatal history consists of number of births at last delivery, frequency of ANC attendance, desire for pregnancy, and education on danger signs of pregnancy during ANC. Socio-economic characteristics include site of residence, person who influenced the decision on place of delivery, possession of valid health insurance card, money readily available to seek healthcare, and SES. Assets used in the generation of wealth quintiles for SES included 19 items. They were ownership of land, house, wall type, roof type, water source, cooking fuel, available electrical power, television, radio, bicycle, bed-net, toilet facility, type of roofing on the building, motor bike, car, cell/landline phone, sewing machine, gas/electric cooker, and fridge/freezer. The wealth quintiles were created based on the methods used by the Demographic and Health Surveys [38]. Descriptive analysis was performed to summarize the background characteristics of the women. Logistic regression was run to identify determinants of health facility delivery at all and individual sites respectively. For all sites, univariable logistic regression was performed to determine the associations between health facility delivery and each independent variable. Multivariable logistic regression was further used to adjust for covariates that were statistically significant in the univariable regression models. For individual sites, univariable and multivariable logistic regression followed a similar method as that used for all the sites. A two-sided p-value of less than 0.05 was considered as statistically significant. Ahead of implementation of the study, ethical approval was obtained from the Dodowa Health Research Centre Institutional Review Board, the Kintampo Health Research Centre Institutional Ethics Committee, the Navrongo Health Research Centre Institutional Review Board, the Ghana Health Service Ethics Review Committee, and the Research Ethics Committee of The University of Tokyo, Japan. Prior to participating in the study, all women endorsed a written informed consent form. Persons below 18 years of age had the consent form signed by their parents or caregivers ahead of taking part in the study. Copies of the consent forms were stored in secured data banks of the three health research centers. Confidentiality of the women was strictly enforced.