FREE MATERNAL HEALTH CARE POLICY AND ACCESS TO SUPERVISED CARE AT BIRTH: EXPERIENCES FROM THE CENTRAL REGION OF GHANA

ABSTRACT

Improving maternal healthcare remains a major public health concern globally but particularly in Sub-Saharan Africa. In Ghana, maternal mortality continues to be pervasive and improvements have been rather slow. Investing in supervised and emergency obstetric care resources has been touted as one major strategy to avoiding preventable maternal deaths. The clustering of mortality around delivery, and the dominance of hemorrhage, infections, and hypertensive disorders as major causes of death, brings out the significance of skilled attendance at birth and immediately after. To improve access to supervised care at birth, the Ghanaian government in 2003 introduced the user fee exemption policy for maternal healthcare. Some studies have identified some level of increase in access to supervised care after the introduction of the policy. There is however a gap in the literature on community experiences with accessing and utilizing services under the policy which is critical to understanding utilization patterns.

This study used in-depth/semi-structured interviews and a questionnaire survey to investigate women and health provider experiences with delivery care use under the policy in the Central Region of Ghana, a region with worsening skilled attendance at birth even though it remains one of the policy’s pilot regions. Aday and Andersen’s (1974) theoretical model of access to medical care was adapted for the study.

The results showed that awareness of the free maternal healthcare policy amongst mothers was very high (97.3% of respondents). This was however not matched by comprehensive knowledge on the full benefit package women are entitled to under the policy particularly emergency delivery and post-delivery services. Generally, use of delivery care was relatively lower (65%) compared with the very high awareness level.

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Comparing utilization patterns across the study districts, use was higher for women residing in the Cape Coast metropolitan area than for those in the Assin North municipal area. Maternal age, religion, parity, place of residence, awareness and knowledge about the free maternal healthcare policy were identified as main predictors of delivery service use under the policy.

Findings on women’s delivery experiences under the policy showed that most women were motivated to access care under the policy because they understood the need for skilled care particularly around the time of delivery which the policy offers at no cost. Even though delivery care was largely free as stipulated by the policy, access to and use of care was hampered by transportation challenges primarily related to poor road infrastructure and non-availability of regular transport. Health system challenges related to healthcare infrastructure and personnel and attitudes and competence of staff were also noted.

The study also found that healthcare providers were enthusiastic about the policy, as it had offered them the opportunity to provide timely maternity services to clients who were able to report to facilities early because maternity services are offered for free. Majority of the midwives interviewed were, however, concerned about limited infrastructure and medical supplies as well as staff with midwifery skills to cater for the increasing numbers of women who access care under the policy.

Two important development policy and research agenda have emerged from the results of the study. With regards to research agenda, the findings have brought to bear the need

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for research into actual gaps in the availability of midwives and projections into future midwifery requirements to improve women’s access to supervised care at birth.

The main policy recommendation from the work is that there should be increased education on the full benefit package of the free maternal healthcare policy to ensure optimum use of ante-natal, delivery and post-natal care (PNC) services among women in all accredited facilities.

Overall, the study provides a more comprehensive understanding of utilization of healthcare services under the policy from the micro level. Additionally, it contributes to current scientific literature and on-going debates regarding fee exemption initiatives for maternal healthcare and achieving MDG 5 on maternal health.