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Background: While a number of studies have examined the factors affecting accessibility to and utilisation of healthcare services by persons with disability in general, there is little evidence about disabled women’s access to maternal health services in low-income countries and few studies consult disabled women themselves to understand their experience of care and the challenges they face in accessing skilled maternal health services. The objective of this paper is to explore the challenges women with disabilities encounter in accessing and using institutional maternal healthcare services in Ghana. Methods and Findings: A qualitative study was conducted in 27 rural and urban communities in the Bosomtwe and Central Gonja districts of Ghana with a total of 72 purposively sampled women with different physical, visual, and hearing impairments who were either lactating or pregnant at the time of this research. Semi-structured in-depth interviews were used to gather data. Attride-Stirling’s thematic network framework was used to analyse the data. Findings suggest that although women with disability do want to receive institutional maternal healthcare, their disability often made it difficult for such women to travel to access skilled care, as well as gain access to unfriendly physical health infrastructure. Other related access challenges include: healthcare providers’ insensitivity and lack of knowledge about the maternity care needs of women with disability, negative attitudes of service providers, the perception from able-bodied persons that women with disability should be asexual, and health information that lacks specificity in terms of addressing the special maternity care needs of women with disability. Conclusions: Maternal healthcare services that are designed to address the needs of able-bodied women might lack the flexibility and responsiveness to meet the special maternity care needs of women with disability. More disability-related cultural competence and patient-centred training for healthcare providers as well as the provision of disability-friendly transport and healthcare facilities and services are needed.
The data reported in this paper are part of a larger multi-methods study that was conducted between November 2012 and May 2015 to examine the effects of Ghana’s free maternal healthcare policy on maternal healthcare access, women’s maternity care seeking experience, equity of access, and barriers to accessibility to and utilisation of maternal and newborn care services. The design of this larger study involved analyses of a nationally representative retrospective household survey data in combination with qualitative research using focus group discussions, in-depth interviews, case studies, and structured field observations as data collection methods. The study was conducted in a total of 27 randomly selected communities in two districts. Participants in the study comprised 257 expectant and lactating mothers, 15 traditional birth attendants, and 20 healthcare providers, including community health nurses, midwives, doctors, health facility managers, district and regional public health nurses, district and regional directors of health, and policy makers at the Ministry of health and Ghana Health Services. In this paper, the focus is on reporting findings from a sub-sample of the qualitative component of the larger study in which semi-structured in-depth interviews were used to explore the challenges women with disabilities encounter in accessing and using institutional maternal healthcare services in Ghana. Accessibility in this context is defined as a measure of the opportunity to obtain healthcare when it is wanted or needed, while utilisation is the ‘proof of access’ or the actual entry of a given individual or population group into the healthcare delivery system [21]. As noted above, empirical research was conducted in 27 communities (19 rural and 8 urban) in the Bosomtwe and Central Gonja districts of the Ashanti and Northern regions of Ghana respectively. These two districts were purposively selected to represent northern and southern Ghana in our study. We purposively sampled 72 women with different physical, visual, speech and hearing impairments who were either lactating or pregnant at the time of this research (November 2012 to May 2015). We excluded women with intellectual disabilities partly because of the complexities involved in assessing mental disability and partly because of the research team’s limited knowledge in undertaking such assessment. The women included in the study were identified through screening. An adapted screening tool from the Washington Group on Disability Statistics was used [5]. This screening tool has been successfully used in other low-income contexts to screen and identify women with disabilities [5]. The tool has 35 questions to detect epilepsy, physical, sensory, behavioural, and social function and communication disabilities based on the International Classification of Functioning, Disability and Health (ICF) [22]. The screening tool captures severity of disability by asking respondents to rank their status on a four-point Likert scale [5]. To facilitate easy understanding by participants, the screening tool was translated into the three dominant local dialects–Twi, Dagbani and Gonja–of the study communities. Women were screened at different locations, including their homes, healthcare facilities, market places, and churches/mosques. Women who were either lactating or pregnant at the time of this research and who were identified during the screening process to have any physical, visual, speech and hearing impairment(s) were included in the study. The recruitment process continued until saturation was attained in the data. Community-based surveillance volunteers were recruited and trained to help with the screening and conduct of interviews. These are community members who have been recruited and trained by the Ghana Health Service in various aspects of community health, including but not limited to reporting the outbreak of diseases as well as births and deaths in their communities [23]. Semi-structured in-depth interviews were used to collect data. A semi-structured interview guide was first developed by one of the research team members (AKE) who has extensive experience in working with persons with disability in Ghana. The guide was developed in consultation with women with disabilities. All the research team members then reviewed and agreed on the final interview guide. Majority of the interviews were conducted in the local dialects–Twi (in Bosomtwe District), and Dagbani and Gonja (in Central Gonja District). A few were done in English. Interviews lasted 1 to 1.30 hours. Typically, interviews first captured basic socio-demographic characteristics of participants such as age, level of education, and type of impairment. Interviews then focused on exploring the women’s experiences of pregnancy and childbirth, their desire for children, and their experiences with the health service. Interviews also explored how their disability had affected the maternal healthcare and support they had received in the health facility. Both open and closed questions were asked. For women with speech and hearing impairments, interviews were conducted with the help of the community-based surveillance volunteers, family and friends. Data were recorded and transcribed, and all non-English transcripts were translated into English. Three independent bilingual specialists each checked the quality of translations from Twi, Dagbani and Gonja to English. All transcripts were exported into Nvivo where coding, categorisation and theme identification were done. Data were analysed using Attride-Stirling’s thematic network analysis framework [24]. The Attride-Stirling thematic network analysis framework provides a technique for breaking up qualitative or textual data, and for performing micro-analysis to show how the structure of talk in field interviews and discussions is connected or disconnected [24]. The framework also allows for open and methodical discovery of emergent concepts and themes and their interconnections [24]. Where appropriate, verbatim quotations from interview transcripts were used to illustrate relevant themes. In reporting the findings, we followed the consolidated criteria for reporting qualitative research (COREQ) [25]. The University of Oxford Social Sciences and Humanities Inter-divisional Research Ethics Committee (Ref No.: SSD/CUREC1/11-051), and the Ghana Health Service Ethical Review Committee (Protocol ID NO: GHS-ERC 18/11/11) gave ethical approval. Informed written and verbal consents were obtained from all participants. Individual participants were requested to sign or thumb print a written informed consent form. Participants (and these were the majority) who could not sign or did not feel comfortable signing the written consent form were permitted to give verbal consent. Each verbal consent process was witnessed by at least one family member or friend. Participation in the study was voluntary, and participants could withdraw any time they wanted to. Confidentiality was maintained throughout the study by using number identifiers on audio recordings, interview notes, and transcripts.
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