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Background: The burden of maternal mortality in sub-Saharan Africa is enormous. In Ghana the maternal mortality ratio was 350 per 100,000 live births in 2010. Skilled birth attendance has been shown to reduce maternal deaths and disabilities, yet in 2010 only 68% of mothers in Ghana gave birth with skilled birth attendants. In 2005, the Ghana Health Service piloted an enhancement of its Community-Based Health Planning and Services (CHPS) program, training Community Health Officers (CHOs) as midwives, to address the gap in skilled attendance in rural Upper East Region (UER). The study determined the extent to which CHO-midwives skilled delivery program achieved its desired outcomes in UER among birthing women. Methods. We conducted a cross-sectional household survey with women who had ever given birth in the three years prior to the survey. We employed a two stage sampling techniques: In the first stage we proportionally selected enumeration areas, and the second stage involved random selection of households. In each household, where there is more than one woman with a child within the age limit, we interviewed the woman with the youngest child. We collected data on awareness of the program, use of the services and factors that are associated with skilled attendants at birth. Results: A total of 407 households/women were interviewed. Eighty three percent of respondents knew that CHO-midwives provided delivery services in CHPS zones. Seventy nine percent of the deliveries were with skilled attendants; and over half of these skilled births (42% of total) were by CHO-midwives. Multivariate analyses showed that women of the Nankana ethnic group and those with uneducated husbands were less likely to access skilled attendants at birth in rural settings. Conclusions: The implementation of the CHO-midwife program in UER appeared to have contributed to expanded skilled delivery care access and utilization for rural women. However, women of the Nankana ethnic group and uneducated men must be targeted with health education to improve women utilizing skilled delivery services in rural communities of the region. © 2014 Sakeah et al.; licensee BioMed Central Ltd.
The study was conducted in the Kassena-Nankana East (KNE), Kassena-Nankana West (KNW), and Bongo Districts of the Upper-East region (UER) of Ghana. The UER, in northern Ghana, is one of the two regions in Ghana which is most remote from Accra, the capital. According to the 2010 census, the total population of the region is 1,046,545. The KNE district had an estimated population of 109,944 whereas the KNW district, newly carved out of the Kassena-Nankana District in UER, had an estimated population of 70,667 in 2012. Bongo district’s 2010 estimated census population was 84,545. KNE and KNW are predominately Kassenas and Nankanas and the Bulsas as a minority group in KNE. In the Bongo district, the people are mostly Frafras [21]. The people of UER share similar social and cultural practices such as funeral and widowhood rites, festivals, marriage customs and child naming [17]. Households are grouped into extended family units or compounds, each headed by a male. Lineage, customs, religious practices, marriage patterns, and other social characteristics of the population are traditional, but social changes such as construction of roads, schools and hospitals, among other things, are taking place [17]. We obtained ethical approval for this study from the Navrongo Health Research Centre, Ghana and the Boston University (BU) Institutional Review Boards (BU IRB reference number H-31245). We conducted a household survey with women who had ever given birth in the three years prior to the study to ascertain their awareness of the CHPS program, use of the services, and determine factors that are associated with skilled attendants at birth. The predictor variables included ethnicity, husband’s education, woman’s education, age group, employment status, type of employment, religion, distance to health facility and number of children. The sample size was calculated based on a proportion of deliveries supervised by trained professionals of 50% in the UER with annual births of 8,918 in the three districts and 95% confidence interval as well as a corresponding p < 0.05 for significance. We used the formula sample size n = [DEFF*Np (1-p)]/[(d2/Z21-α/2*(N-1) + p*(1-p)] [22] and this gave us the sample size of 369 women. Assuming a refusal rate of 10%, the total sample size for the three districts was 407. In each district, women were included in the study based on the proportion of deliveries in that district. A two-stage sampling method was employed. The primary sampling unit was the enumeration area (EA), defined as the geographic area canvassed by one census representative. The EAs ranged from 96–187 in the three districts. Sampling EAs and households was based on the assumptions that: (1) CHO-midwives were working in most of these EAs in each of the three districts and (2) there is homogeneity in receipt of CHO-midwives services across the EAs. A CHO-midwife supervises or covers at least 24 EAs in a district. The three districts were included because they were the only districts having CHO-midwives providing skilled delivery services in CHPS zones. In the first stage, 10 EAs were selected proportional to the size of the EAs with at least one CHO-midwife working. The research team obtained a list of all the compounds and households in the EAs with women who had given birth in three years prior to the survey by visiting households and compiling a comprehensive list of women in compounds and households with children under five years. In the second stage, we selected households randomly from the compound and household listing developed and the interviewers visited each randomly selected household and interviewed the woman with a child within the age limit. In each household, where there is more than one woman with a child within the age limit, we interviewed the woman with the youngest child. A total of 1,300 women were on the compound and household list compiled for the study. The data was collected using a structured questionnaire from January 13, 2012 to May 31, 2012. The questionnaire had sections on women’s social and demographic characteristics, knowledge and utilization of skilled delivery services, reasons for use or non-use of skilled delivery services, and decision-making on place of birth. Validated questions used in similar surveys were adopted wherever possible. The research team identified and selected field supervisors and fieldworkers who are literate for the survey data collection. The training of field supervisors and fieldworkers consisted of lectures, role playing and pretesting. They were instructed on how to number the questionnaire, and check for consistency of responses, among others. We pre-tested the questionnaire in selected communities in the three districts which were not part of the study. The interviews offered the fieldworkers the opportunity to practice interviewing techniques, and the questionnaire was further revised based on the pre-test. In order to ensure that data collected was of good quality, trained supervisors, and research team closely monitored and supervised the fieldworkers and checked the consistency of the responses. Descriptive statistics (frequencies and percentages) were used and where appropriate chi-square test was used to test for group differences. All p-values were two-tailed, and a value of p < 0.05 was considered statistically significant. To adjust for multiple determinants of women’s decision to have skilled attendants at birth, logistic multivariate regression was performed using STATA version 11. The outcome variable was women’s utilization of skilled attendants at birth (yes, no), and the explanatory variables included ethnicity, husband’s education, women’s education, and employment status, type of employment, religious affiliation, age group, number of children and distance to health facility. We adjusted for community effect in the analysis, but this was not found to be significant (P = 0.44).
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