Factors influencing the free maternal health care policy under the national health insurance scheme's provision for skilled delivery services in Ghana: a narrative literature review.

BACKGROUND: Skilled Birth Attendance (SBA) is important in achieving the Sustainable Development Goals (SDGs) targets 3.1, 3.2 and 3.3.1. Ghana has made steady progress in SBA, yet, unsupervised deliveries still occur. The introduction of the Free Maternal Health Care Policy under the National Health Insurance Scheme (FMHCP under the NHIS) has improved the uptake of SBA but with some implementation challenges. This narrative review sought to explore the factors influencing the FMHCP under the NHIS provision for skilled delivery services in Ghana. METHODS: Electronic searches were conducted of databases including PubMed, Popline, Science direct, BioMed Central, Scopus and Google scholar for peer reviewed articles as well as grey articles from other relevant sources, published between 2003 and 2021 on factors influencing FMHCP/NHIS provision for skilled delivery services in Ghana. Keywords used in the literature search were in various combinations for the different databases. The articles were screened to determine the inclusion and exclusion criteria and quality was assessed using a published critical appraisal checklist. A total of 516 articles were retrieved for initial screening based on their titles, of which 61 of them, were further screened by reading their abstracts and full text. Of this number, 22 peer-reviewed and 4 grey articles were selected for the final review based on their relevance. RESULTS: The study revealed that the FMHCP under the NHIS does not cover the full costs associated with skilled delivery and low socioeconomic status of households affects SBA. Also, funding and sustainability, hinders the quality-of-service delivery offered by the policy. CONCLUSION: For Ghana to achieve the SDGs above and further improve SBA, the cost associated with skilled delivery should be fully covered by the NHIS. Also, the government and the key stakeholders involved in the policy implementation, must put in place measures that will enhance the operation and the financial sustainability of the policy.

Charge midwives' awareness of and their role in promoting respectful maternity care at a tertiary health facility in Ghana: A qualitative study.

BACKGROUND: Evidence suggests that the implementation of respectful maternity care (RMC) interventions is one of the surest and most effective means of minimising mistreatment during intrapartum care services. However, to ensure the successful implementation of RMC interventions, maternity care providers would have to be aware of RMC, its relevance, and their role in promoting RMC. We explored the awareness and role of charge midwives in promoting RMC at a tertiary health facility in Ghana. METHODS: The study adopted an exploratory descriptive qualitative study design. We conducted nine interviews with charge midwives. All audio data were transcribed verbatim and exported to NVivo-12 for data management and analyses. RESULTS: The study revealed that charge midwives are aware of RMC. Specifically, ward-in-charges perceived RMC as consisting of showing dignity, respect, and privacy, as well as providing women-centred care. Our findings showed that the roles of ward-in-charges included training midwives on RMC and leading by example, showing empathy and establishing friendly relationships with clients, receiving and addressing clients' concerns, and monitoring and supervising midwives. CONCLUSION: We conclude that charge midwives have an important role to play in promoting RMC, which transcends simply providing maternity care. Policymakers and healthcare managers should ensure that charge midwives receive adequate and regular training on RMC. This training should be comprehensive, covering aspects such as effective communication, privacy and confidentiality, informed consent, and women-centred care. The study also underscores a need for policymakers and health facility managers to prioritise the provision of resources and support for the implementation of RMC policies and guidelines in all healthcare facilities. This will ensure that healthcare providers have the necessary tools and resources to provide RMC to clients.

Promoting respectful maternity care: challenges and prospects from the perspectives of midwives at a tertiary health facility in Ghana.

BACKGROUND: Evidence shows that women in Ghana experience disrespectful care (slapping, pinching, being shouted at, etc.) from midwives during childbirth. Hence, evidence-based research is needed to advance the adoption of respectful maternity care (RMC) by midwives. We therefore sought to explore and document midwives' perspectives concerning challenges faced and prospects available for promoting RMC in a tertiary health facility. METHODS: We employed an exploratory descriptive qualitative study design. In total, we conducted 12 interviews with midwives educated on RMC. All audio data were transcribed verbatim and exported to NVivo-12 for data management and analyses. We relied on the Consolidated Criteria for Reporting Qualitative Research guideline in reporting this study. RESULTS: The findings were broadly categorised into three themes: emotional support, dignified care and respectful communication which is consistent with the WHO's quality of care framework. For each theme, the current actions that were undertaken to promote RMC, the challenges and recommendations to improve RMC promotion were captured. Overall, the current actions that promoted RMC included provision of sacral massages and reassurance, ensuring confidentiality and consented care, and referring clients who cannot pay to the social welfare unit. The challenges to providing RMC were logistical constraints for ensuring privacy, free movement of clients, and alternative birthing positions. Poor attitudes from some midwives, workload and language barrier were other challenges that emerged. The midwives recommended the appointment of more midwives, as well as the provision of logistics to support alternative birthing positions and privacy. Also, they recommended the implementation of continuous training and capacity building. CONCLUSION: We conclude that in order for midwives to deliver RMC services that include emotional support, dignified care, and respectful communication, the government and hospital administration must make the required adjustments to resolve existing challenges while improving the current supporting activities.

Prevalence, progress, and social inequalities of home deliveries in Ghana from 2006 to 2018: insights from the multiple indicator cluster surveys.

BACKGROUND: Delivery in unsafe and unsupervised conditions is common in developing countries including Ghana. Over the years, the Government of Ghana has attempted to improve maternal and child healthcare services including the reduction of home deliveries through programs such as fee waiver for delivery in 2003, abolishment of delivery care cost in 2005, and the introduction of the National Health Insurance Scheme in 2005. Though these efforts have yielded some results, home delivery is still an issue of great concern in Ghana. Therefore, the aim of the present study was to identify the risk factors that are consistently associated with home deliveries in Ghana between 2006 and 2017-18. METHODS: The study relied on datasets from three waves (2006, 2011, and 2017-18) of the Ghana Multiple Indicator Cluster surveys (GMICS). Summary statistics were used to describe the sample. The survey design of the GMICS was accounted for using the 'svyset' command in STATA-14 before the association tests. Robust Poisson regression was used to estimate the relationship between sociodemographic factors and home deliveries in Ghana in both bivariate and multivariable models. RESULTS: The proportion of women who give birth at home during the period under consideration has decreased. The proportion of home deliveries has reduced from 50.56% in 2006 to 21.37% in 2017-18. In the multivariable model, women who had less than eight antenatal care visits, as well as those who dwelt in households with decreasing wealth, rural areas of residence, were consistently at risk of delivering in the home throughout the three data waves. Residing in the Upper East region was associated with a lower likelihood of delivering at home. CONCLUSION: Policies should target the at-risk-women to achieve complete reduction in home deliveries. Access to facility-based deliveries should be expanded to ensure that the expansion measures are pro-poor, pro-rural, and pro-uneducated. Innovative measures such as mobile antenatal care programs should be organized in every community in the population segments that were consistently choosing home deliveries over facility-based deliveries.

"I wouldn't have hit you, but you would have killed your baby:" exploring midwives' perspectives on disrespect and abusive Care in Ghana.

BACKGROUND: Quality maternal health reduces maternal and neonatal mortality and morbidity. Healthcare professionals, including midwives, are significant agents for the promotion of quality maternal health. Frequents reports of disrespect and abuse of childbearing women by midwives during intrapartum care are becoming common, suggesting that many of these agents are engaging in care practices that compromise quality maternal health. Thus, understanding midwives' descriptions and experiences of the phenomenon is critical to addressing the threat. This paper, therefore, explored the understanding of midwives on D&AC and their occurrence in professional practice in a tertiary health facility in Kumasi, Ghana. METHODS: An exploratory descriptive qualitative research design using an interpretative approach was employed in the study. Data were generated through individual in-depth interviews. Data saturation was reached with fifteen interviews. The interviews were audio-recorded and transcribed verbatim. Open Code 4.03 was used to manage and analyse the data. RESULTS: The midwives understood D&AC. They also confirmed meting out or witnessing colleagues engage in D&AC in their professional practice. The midwives described D&AC as the provision of inadequate care and the overlooking of patient-centred care, and verbal, physical, and psychological abuse. The themes revealed that socio-economic inequalities, provider perception and victim-blaming, and health system-related factors facilitate D&AC. It emerged that the following marginalized groups were at high risk for D&AC: the non-compliant, mentally ill, HIV/AIDs+, teenagers, poor, and childbearing women on admission at the general labour ward. CONCLUSION: The midwives understood D&AC and revealed that it frequently occurred in their professional practice. Frequent in-service training on respectful maternity care and monitoring of care provision in healthcare facilities are needed to eliminate the incidence of D&AC.

Women's experiences of midwifery care immediately before and after caesarean section deliveries at a public Hospital in the Western Region of Ghana.

BACKGROUND: Childbirth remains a uniquely multifaceted, mental-cognitive and a major life experience to women. It is composed of a variety of psycho social and emotional aspects and creates memories, sometimes bad experiences and unmet expectations which leaves the mother with lasting scars. Therefore, this study aimed at exploring post-caesarean section delivered mothers experiences of midwifery care in a public hospital in Ghana. METHODS: This descriptive exploratory qualitative research used an interpretative approach to explore mothers' experiences of midwifery care immediately before and after caesarean section (CS). The study employed a purposive sampling technique in recruiting 22 participants who had knowledge of the phenomenon under study. Data collection was guided by an interview guide, which involved face to face individual interviews and focus group discussion at the postnatal ward and clinic. All interviews were audio-recorded and lasted 30-40 min. Audio recordings were transcribed verbatim and inductive thematic data analysis employed. RESULTS: Four major themes emerged from the analysis of participants' transcripts: Support by Midwives (physical and psychological, and attitude towards patients' pain management); Protection of mothers (provision of privacy, confidentiality and physical environment); Provision of information/communication (before caesarean section, and before a minor task) and midwives' attitude (attitude towards delivery care). CONCLUSION: Mothers delivered by caesarean section had varied experiences of midwifery care which were both positive and negative ones. Provision of psychological support and adequate pain management were positive experiences. The challenges experienced were related to provision of information, privacy, and physical support. Participants, who underwent emergency CS in particular, were dissatisfied with the provision of information concerning the surgical procedure. Provision of privacy and physical support were also issues of great concern. We therefore, recommend supportive and sensitive midwifery care particularly for mothers undergoing emergency CS. Documenting women's diverse experiences of midwifery care before and after CS delivery is important to healthcare providers, hospital managers and policy makers as the feedback garnered can be used to improve maternity services and inform decisions on midwifery care.

Exposure to disrespectful patient care during training: Data from midwifery students at 15 midwifery schools in Ghana.

OBJECTIVE: to determine what midwifery students throughout Ghana were witnessing, perceiving, and learning with regard to respectful care during labour and childbirth. DESIGN: cross-sectional survey. SETTING: public midwifery schools in all 10 regions of Ghana. PARTICIPANTS: all graduating midwifery students in Ghana. MEASUREMENTS: 929 final-year students at 15 public midwifery schools in Ghana were asked to complete a self-administered computerised survey addressing a range of topics, including experiences during training. All data were collected anonymously and analyzed using Stata 13.0. FINDINGS: 853 students completed the questionnaire (91.8% response rate): 72.0% said maltreatment was a problem in Ghana and 77.4% said women are treated more respectfully in private than public facilities. Students described providers: telling women to stop making noise (78.5%), shouting at women (68.8%), scolding women if they didn't bring birth supplies (54.5%), treating educated/wealthy women better than less educated / poor women (41.5%/38.9%), detaining women who couldn't pay (37.9%), and speaking disrespectfully to women (34%). Only 4% of students reported not witnessing any disrespectful treatment. Students reported providers being overworked (76.5%), stressed (74.2%), and working without adequate resources (64.1%). Where students performed their clinical training (teaching hospital, district hospital, public health clinic, private facility) had no effect on perception of maltreatment as a problem. However, students who trained in district hospitals witnessed more types of disrespectful care than those who did not train in district hospitals (p=0.01). CONCLUSIONS AND IMPLICATIONS: a majority of midwifery students throughout Ghana witness disrespectful care during their training. Implications include the need for provider curricula that address psychosocial elements of care, as well as the need to improve monitoring, accountability, and consequences for maltreatment within facilities without creating a culture of blame.

Home birth without skilled attendants despite millennium villages project intervention in Ghana: insight from a survey of women's perceptions of skilled obstetric care.

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.