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Background: There is some evidence to suggest that within the household, family and community settings, women in sub-Saharan Africa often have limited autonomy and control over their reproductive health decisions. However, there are few studies that examine how intra-familial decision-making power may affect women’s ability to access and use maternal health services. The purpose of this paper is to examine how intra-familial decision-making affects women’s ability to access and use maternal health services. Methods: We conducted 12 focus group discussions and 81 individual interviews with a total of 185 expectant and lactating mothers in six communities in Ghana. In addition, 20 key informant interviews were completed with healthcare providers. Attride-Stirling’s thematic network analysis framework was used to analyse the data. Results: Findings suggest that decision-making regarding access to and use of skilled maternal healthcare services is strongly influenced by the values and opinions of husbands, mothers-in-law, traditional birth attendants and other family and community members, more than those of individual childbearing women. In 49.2 %, 16.2 %, and 12.4 % of cases in which women said they were unable to access maternal health services during their last pregnancy, husbands, mothers-in-law, and husband plus mothers-in-law, respectively, made the decision. Women themselves were the final decision-makers in only 2.7 % of the cases. The findings highlight how the goal of improving access to maternal healthcare services can be undermined by women’s lack of decision-making autonomy through complex processes of gender inequality, economic marginalisation, communal decision-making and social power. Conclusion: Interventions to improve women’s use of maternity services should move beyond individual women to target different stakeholders at multiple levels, including husbands and mothers-in-law.
The qualitative data reported in this paper were extracted from within a larger, original study that was conducted to examine the effects of Ghana’s free maternal healthcare policy on women’s maternity care seeking experience, equity of access, and barriers to accessibility and utilization of maternal and newborn healthcare services [2–6]. The design of this larger study was mixed – it involved analysis of a nationally representative retrospective household survey data in combination with qualitative exploration using focus group discussions (FGDs), individual interviews, (IIs), key informant interviews (KIIs), case studies and structured field observations. The focus in this paper is on reporting findings from the qualitative component of this larger study, which examined how intra-familial decision-making affected women’s ability to access and use maternal health services. For details on the quantitative component of study, see [2, 6]. Empirical research was conducted between November 2011 and May 2012 in a total of 6 purposively sampled communities, namely Kuntanase, Abono, and Piase in the Bosomtwe district of the Ashanti region; and Mpaha, Sankpala and Tidrope in the Central Gonja district of the Northern region of Ghana. Ghana is a West African country, covering a total land area of 238,305 square kilometres. Tables 1 and and22 give a summary of selected demographic, socio-economic, and health indicators of Ghana and the 6 study communities. Selected demographic, socio-economic, and health indicators of Ghana Characteristics of the study communities Preventive and curative healthcare services delivery in Ghana is generally decentralised, and the healthcare system is organised under four main categories of delivery systems: public, private-for-profit, private-not-for-profit, and traditional systems [39]. Community-based Health Planning and Services (CHPS) compounds, health centres, mission clinics and private midwifery homes provide basic obstetric and antenatal care services in most communities. Each health centre serves a population of approximately 20,000 [8]. In most rural areas, untrained traditional birth attendants (TBAs) carry out deliveries. Comprehensive skilled emergency obstetric care is mostly available from urban district and regional hospitals, as well as national referral hospitals. But some private hospitals also provide comprehensive care. The Ghana Health Service runs most hospitals though the mission sector plays a significant role, especially in more remote regions. The payment mechanism for healthcare is a combination of fee-exemption, health insurance and out-of-pocket [11, 12]. As noted earlier, many societies in Ghana, particularly societies in northern Ghana, are patriarchal. Women in Ghana are also still generally more disadvantaged – educational and economic opportunities for women are limited – from a young age compared to men [4, 5]. These socio-economic and cultural contexts make Ghana an ideal case for investigating how intra-familial decision-making influences women’s maternal health-seeking behaviours. The six communities were chosen not only to capture a divide between a relatively destitute and patriarchal northern Ghana and a relatively prosperous and matrilineal southern Ghana, but also to provide a diversity of social and health situations (see Table 2). For example, Kuntanase and Mpaha were selected to represent urban communities in the Bosomtwe and Central Gonja districts respectively; Piase and Sankpala were chosen to represent rural communities with health facilities in the Bosomtwe and Central Gonja districts respectively; while Abono and Tidrope were selected to represent rural communities without any health facilities in the Bosomtwe and Central Gonja districts respectively. These differences should allow for some comparative analysis. The research participants comprised pregnant women and lactating mothers, and healthcare providers. The women consisted of those who were pregnant at the time of this research or had given birth between January 2011 and May 2012. Table 3 shows the socio-demographic characteristics of women participants. Socio-demographic characteristics of women participants (N = 185) The majority of the participants (65 %) were rural women. The ages of these women varied between 18 and 45 years. The majority of the women (60.7 %) had no formal education. A few of the women were unemployed while most were engaged in diverse self-employed activities such as farming, trading, hairdressing, dressmaking, and teaching. Majority of the women were also married or living with a male partner, with several of these relationships especially in Mpaha, Sankpala and Tidrope being polygynous. The majority of the women also had between 1 and 3 children. The healthcare providers category of respondents included health professionals (doctors, nurses, midwives, healthcare managers, and health policy-makers or implementers) from health facilities in the study communities, district and regional health directorates, and Ghana Health Service at the national level. The description of the categories of healthcare providers interviewed and their distribution across the study areas are shown in Table 4. These healthcare providers were selected based on their involvement with maternal healthcare at the community, district or national levels. Type and distribution of healthcare providers interviewed (N = 20) For the women, a mix of purposive and convenience sampling techniques was used. The selection was however based on a number of pre-set inclusion criteria: ease of recruitment, participant’s availability, willingness to participate in the study, ability/capacity to consent to participate in the research, and good knowledge or understanding of the interview language. Following consultation with community chiefs and elders, and their subsequent approval of the study, the actual recruitment process involved advertising the study at local churches, mosques, water collection points, and women group meetings in the six study communities via community and religious leaders, women leaders and Community-Based Surveillance Volunteers (CBSVs) (i.e. recruits from local communities who have been trained by the District Health Management Team in various aspects of community health, including but not limited to reporting the outbreak of any disease, and recording births and deaths in their communities). The CBSVs then helped the researchers to recruit interested individual participants for interviewing. Having grown up in the study communities, the CBSVs were very conversant with the local dialect and cultural nuances and were therefore in a good position to advise the researchers on suitable participants as well as arrange interview meetings. In all, 185 women were interviewed. For all research participants under the ‘healthcare providers’ category, a purposive sampling procedure was used. This was also a judgmental selection of participants based on the researchers’ evaluation of the relevance of their roles or knowledge to the research topic. In total, 20 healthcare providers were interviewed. Focus group discussions (FGDs) were the main data collection methods. This data collection technique was adopted partly because of its practical relevance in helping to explore how intra-familial decision-making affects women’s access to, and use of, maternity care services in a normal peer-group conversation. Additionally, because FGDs were interactive, participants were able to query and challenge each other as well as explain themselves; hence offering validated data on the extent of consensus or diversity. In all, 12 focus group discussions – two in each study community – were completed. Women in groups were segmented by age (i.e. 18–30 years, and 31–45 years) because initial discussions with CBSVs suggested that there were age hierarchy conflicts among women in the study communities. In other words, younger women (18-30years) were unlikely to freely express their views in the presence of older women (31-45years) because of cultural norms, which require young people to listen to older people. Segmenting discussants by similar age groups contributed to making participants more confortable when expressing their opinions or sharing their experiences within the group context. To limit the effect of any participant dominating the discussion, all participants were constantly encouraged, especially the quieter ones, to speak, share their opinions as well as agree and disagree with others where they felt the need to do so. Coupled with a mix of directed and non-directed facilitation, the effects of dominant participants on the rest of the other participants’ responses were also significantly minimised. In addition, themes and issues raised and discussed during FGDs were summarised and orally presented to participants to confirm, alter or reject at the end of the discussion. This was to make sure that the information collected accurately represented what participants said. All focus groups were held in the study communities at venues convenient to both women and the research team. Groups consisted of 9–12 participants. Apart from few children under-five years who accompanied their mothers, no other persons were allowed to sit in the discussions. Discussions in the focus groups lasted 2.5 to 3 hours, and ended when a point of saturation was reached (when no new issues seemed to arise). All discussions were conducted in the local dialects – Twi in Kuntanase, Abono and Piase; Dagbani in Sankpala and Tidrope; and Gonja in Mpaha. Three of the seven-member, all Ghanaian research team (JKG, JYY and VM), conducted all the discussions and interviews. While all members of the research team were fluent in English and at least one of the native languages of the study respondents, the three researchers were fluent in English and all the three native languages of the respondents. None of the research team members however resided in the study communities. There were therefore no known relationships between the researchers and participants. To complement the focus groups, 44 % (81) of all women who completed the FGDs were purposively reselected and interviewed individually for a more in-depth discussion of some of the points that were raised during the focus groups. The choice of this data collection technique was informed by both the literature and practical considerations. It has been argued that people may be limited in talking about some sensitive but pertinent healthcare experiences in a group context [40]. In several cases, some women in this study declined to tell their reasons for not accessing and using skilled birthing services offered at healthcare facilities in the group. Instead, they suggested that if the researchers wanted to know their reasons, they were happy to discuss those reasons and personal experiences privately with the researchers. For this reason, the focus groups data were triangulated with individual interviews. A major advantage of this method was that it addressed sensitive issues such as personal experiences of childbirth and questions regarding how intra-familial decision-making affect women’s ability to access and use maternity care services. In particular, and compared to discussions in focus groups, many women talked more openly and in greater detail about instances where their husbands and mothers-in-law prevented them from accessing maternal healthcare services. These women felt that openly discussing such matters in the group context could lead to undesirable consequences, including gossips, and possible spousal confrontation and abuse, which may then threaten the stability of their family. Finally, key informant interviews were conducted with 20 healthcare providers (see Table 4). All interviews with individual women were conducted in Twi, Dagbani, and Gonja, while interviews with healthcare providers were done in English. Interviews lasted between 20 and 30 minutes. The individual and key informant interviews with women and healthcare providers were relatively shorter because each interview focused on the specific maternity care experiences of individual women, and explored very specific questions in relation to intra-familial decision-making and access to skilled care. All discussions and interviews were audio-recorded alongside hand-written field notes. An open-ended thematic topic guide was designed and used to facilitate the conduct of all focus group discussions. This instrument was modified into two relatively shorter versions, which were used for individual interviews with women and key informant interviews with healthcare providers. These instruments were complemented by a short multi-item demographic questionnaire, which was used to obtain socio-demographic information from all women participants. All the topic guides were designed to ensure that similar themes and questions were covered in each discussion or interview. The instruments however had built-in flexibility that allowed for any pertinent but unexpected issues that arose during the interview process to be further probed. The instruments focused on exploring women’s maternity care needs, experiences of seeking or not seeking care, women’s participation in decision-making related to maternal healthcare services utilisation, women’s mobility and women’s agency at the household, family and community levels. To ensure that the instruments were valid, we pilot-tested them in two of the study communities. During the data collection phase, we also engaged in a continuous review of the questions and interview process. This helped to reframe questions, clarify and use more appropriate or easily understandable concepts as the research progressed. Following the completion of interviews, the data were analysed using the Attride-Stirling thematic network analysis framework [41]. The Attride-Stirling thematic network analysis framework is a method for conducting thematic analysis of qualitative or textual data, which allows for open and methodical discovery of emergent concepts, themes and relationships. This involved several steps. The first step involved transcription and reading of transcripts and field notes for overall understanding. During and after qualitative data collection, three language specialists – one each for Twi, Dagbani and Gonja – were contracted to transcribe and translate all audio-recorded interviews into English. The three research team members who conducted the interviews then performed back-to-back translations into English on selected transcripts. The aim here was to verify the accuracy of the translations. Only a few errors were noted and these were corrected before coding. All the transcripts and interview notes were then read and reviewed thoroughly by all members of the research team. Notes were made on hard copies of transcripts. This first step was completed with separate summaries for each transcript outlining the key points participants made. Also a preliminary coding structure and a codebook were agreed upon. Second, all transcripts were then exported into NVivo 9 qualitative data analysis software, where the data was both deductively and inductively coded. Data coding continued until theoretical saturation was reached (i.e. when no new concepts emerged from successive coding of data). Third, the completed code structure was applied to develop and report themes. Themes simply represented some level of patterned response or meaning within the data set [42]. Finally, all the themes identified were collated into a thematic chart to reflect basic themes, organising themes, and global themes in line with the Attride-Stirling’s thematic network analysis framework [41]. To ensure that the thematic chart reflected the data, the data segments related to each theme were thoroughly examined. Where necessary, refinements were made. The final thematic framework constitutes the structure of the findings and discussion sections of this paper. Where appropriate, verbatim quotations from interview transcripts were used to illustrate relevant themes. We followed Tong, Sainbury and Craig’s [43] recommended consolidated criteria for reporting qualitative research (COREQ) to guide our analysis and reporting of findings from this qualitative study. Ethical clearance was obtained from 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). In addition, informed written and verbal consent was obtained from all research participants. Participants did not receive any monetary compensation for participating in the research. However, two participants who travelled to participate in the study were reimbursed for transport. Refreshment with soft drinks and biscuits were also provided after focus group discussions.
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