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Background: Skilled birth attendance from a trained health professional during labour and delivery can prevent up to 75 % of maternal deaths. However, in low- and middle-income rural communities, lack of basic medical infrastructure and limited number of skilled birth attendants are significant barriers to timely obstetric care. Through analysis of self-reported data, this study aimed to assess the effect of an intervention addressing barriers in access to skilled obstetric care and identified factors associated with the use of unskilled birth attendants during delivery in a rural district of Ghana. Methods: A cross-sectional survey was conducted from June to August 2012 in the Amansie West District of Ghana among women of reproductive age. Multi-stage, random, and population proportional techniques were used to sample 50 communities and 400 women for data collection. Weighted multivariate logistic regression analysis was used to identify factors associated with place of delivery. Results: A total of 391 mothers had attended an antenatal care clinic at least once for their most recent birth; 42.3 % of them had unskilled deliveries. Reasons reported for the use of unskilled birth attendants during delivery were: insults from health workers (23.5 %), unavailability of transport (21.9 %), and confidence in traditional birth attendants (17.9 %); only 7.4 % reported to have had sudden labour. Other factors associated with the use of unskilled birth attendants during delivery included: lack of partner involvement aOR = 0.03 (95 % CI; 0.01, 0.06), lack of birth preparedness aOR = 0.05 (95 % CI; 0.02, 0.13) and lack of knowledge of the benefits of skilled delivery aOR = 0.37 (95 % CI; 0.11, 1.20). Conclusions: This study demonstrated the importance of provider-client relationship and cultural sensitivity in the efforts to improve skilled obstetric care uptake among rural women in Ghana.
This cross sectional study, was carried out over the period June – August 2012, in the Amansie West District, a rural district located in the south-western part of the Ashanti Region of Ghana. Amansie West is one of the 30 administrative districts in the Ashanti Region, and one of the most deprived [13]. The district has seven (7) sub-districts with 162 communities. Amansie West district has only one health facility capable of offering comprehensive emergency obstetric care; this facility is far from the reach of many expectant mothers [14]. The district has 54 traditional birth attendants (TBAs) who conduct deliveries in the communities. The study sites were communities in seven sub-districts including Keniago and Tontokrom, which received the intervention package from the Millennium Village’s Project (MVP) in 2006. A baseline assessment of skilled deliveries in these sub-districts was conducted prior to the inception of MVP with a reported, skilled delivery rate of 29 % [15]. The intervention package consisted of; construction of health centres, improved road infrastructure, and the provision and support of health staff (midwives, laboratory technologists, laboratory assistants, pharmacy technicians) to the health centres. In addition, MVP deployed health workers and health care assistants to the communities to provide free antenatal care […REF]. A sample size of 400 mothers was estimated based on 40.9 % reported skilled deliveries in the district [14] with 5 % degree of error and 10 % non-response rate. A multi-stage sampling method was used (Fig. (Fig.1).1). First, communities were selected by simple random sampling technique. The seven (7) sub-districts were then listed and 50 out of 162 communities in the district were randomly selected, out of which 15 were from the MVP intervention sub-districts. The second stage of selection involved sampling from a census list of local health officials-Community Health volunteers (CHW) and child welfare clinic personnel (CWC). Data obtained from the community health volunteers ensured that unskilled deliveries were captured. The two lists were put together and checked for consistency. The eligible study population was identified and a sampling frame (6,402 women attending post-partum care) from which mothers with children under-12 months were selected for inclusion from each community was prepared. Mothers aged 15–49 years in each community who had given birth in the year preceding the survey were eligible for inclusion in the study. Finally, the study participants were selected from the sampling frame from the 50 communities; we ensured representation from different age groups using a sampling proportional to size approach for each sub-district. Study design and sampling A structured questionnaire was used to collect data on participants’ socio-demographics, antenatal and postnatal care attendance. Also knowledge of the benefits of skilled delivery, and reasons for use or non-use of skilled birth attendants’ services during delivery were elicited. The structured questionnaire was pre-tested in Abuoboso, a community with similar characteristics as the study communities. A pregnant woman is considered birth prepared if she and/or her family identifies a skilled birth attendant; identifies the location of the closest appropriate healthcare facility; has funds for birth-related and emergency expenses; has transport to the health facility for the birth and obstetric emergency, and has identified compatible blood donors in case of emergency [16]. Skilled birth attendant: persons with midwifery skills (doctor, nurse, midwives and health officer) who can manage normal deliveries and diagnose, manage or refer obstetric complications. The Committee of Human Research, Publications and Ethics of the Kwame Nkrumah University of Science and Technology-School of Medical Sciences and Komfo Anokye Teaching Hospital, Kumasi, Ghana provided ethical approval for the study. Permission was obtained from the Amansie West District Health Directorate prior to the survey. Written informed or thumb print as well as verbal consent was obtained from all participants and no personal identifiers were collected. Filled questionnaires were checked immediately for completeness and accuracy for each respondent survey for completeness. Data were entered into Microsoft Access (Redmond, WA, USA) and exported into STATA version 12 (College Station, TX, USA) for cleaning and analysis. Data were analyzed using survey-sampling weights. Each sub-district total population size was taken from the Ghana 2010 Housing and Population Census. Population level weights (Wpi) and women in communities with children under 12 months weight (Wwci) were estimated for each community. The overall weight (WTOTi) was obtained by multiplying Wpi and Wpci. The knowledge level of participants on the risk of unskilled delivery was assessed using a Likert scale and described using the median value. Poor knowledge was considered below the median and high knowledge above the median. Proportions were presented for categorical variables and their associations determined by Chi-square test. A logistic regression model was fitted to estimate independent associations between unskilled delivery and predictor variables that were independently significant (p ≤ 0.05) in the univariate analysis. In the subsequent steps, variables that were not predictors were entered into the final model one at a time and retained as multivariate predictors using the Hosmer-Lemeshow goodness-of-fit test. A backward stepwise analysis was performed containing all the variables to identify the variables that were removed from the model. The most non-significant variables were considered first for removal. A goodness-of-fit test using Hosmer-Lemeshow test was conducted and found that the final model was appropriate (p = 0.99).
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