A qualitative study of health system barriers to accessibility and utilization of maternal and newborn healthcare services in Ghana after user-fee abolition

Study design

The qualitative data reported in this paper were extracted from within a larger, original study that the authors 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. The design of this larger study followed a mixed methods approach; involving analysis of a nationally representative retrospective household survey data in combination with qualitative exploration using data generated from anthropological research techniques of focus group discussions (FGDs), key informant interviews (KIIs), case studies and structured field observations. While other aspects of the qualitative data from the larger study have been analysed, written up and submitted for peer-review by other journals, this paper focuses on and report findings from an aspect of the qualitative study that explored aspects of Ghana’s maternity care delivery system that discourage use of skilled care.

Study setting

Empirical research was conducted in Ghana during a total of 6 months 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. We chose Ghana for this research not only because maternal health is seen as a ‘national emergency’, but also because Ghana presents an interesting ideal case study. It is one of only a handful of countries in Sub-Saharan Africa to have actively started implementing both universal maternity care and health insurance policies at the national level. The economic and political conditions in Ghana also make the country an interesting case study. Ghana is situated within the predominantly economically marginalized and politically unstable region of West Africa, but forms an exception. Relatively, Ghana is a small fledgling multicultural, multi-ethnic, multi-religious, and multi-party constitutional democracy, characterized by vibrant civil society activism and media pluralism. It is politically stable; a rebasing of its economy in November 2010 saw the country leap into the category of lower-middle-income countries [16]; it also recently started producing oil in commercial quantities; and is often touted as one of the most politically and economically progressive countries in the region. Although Ghana has since 2013 been experiencing economic deterioration - with some private healthcare providers including the Christian Health Association of Ghana (CHAG) cancelling their contracts with the National Health Insurance Scheme due to heavy indebtedness, thereby forcing all patients whether insured or not to resort to the old cash-and-carry system – the country is still often considered ‘an example of global good practice’ [16],[18]. Despite the ‘exceptional status’ Ghana enjoys in the sub-region, maternal, neonatal and infant mortality ratios have remained persistently high.

Ethics

We obtained clearance 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, both informed written and verbal consent were obtained from all research participants. In all cases, consent was obtained after it was thoroughly explained to participants that their participation was entirely voluntary and that information obtained will be used for the purposes of this research only. To thank research participants, we bought biscuits and soft drinks to refresh them.

Research participants

The research participants were drawn from a population of pregnant women and lactating mothers from the six research communities, and from health personnel from the two regional and district health directorates. For the purposes of this research, we classified participants into ‘Women’ and ‘Healthcare Providers’. ‘Women’ here refers to women who were pregnant at the time of this research or had given birth between January 2011 and May 2012 in the six study communities. Healthcare providers comprised 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 rationale for interviewing diverse actors at multiple levels was to allow for an exploration of multiple perspectives.

In all, 205 participants took part in the study. Of this number, 90% (185) were pregnant women and lactating mothers. The remaining 10% (20) consisted of healthcare providers.

Sampling and recruitment procedures

Our strategy for recruiting research participants involved both probability and non-probability sampling procedures. For all research participants under the ‘healthcare providers’ category, a purposive sampling technique was used. This was a judgmental selection based on the participant’s knowledge of the subject of study, the participant’s role in the selected health institutions, and our evaluation and/or perception of the relevance of that role and knowledge to the research topic [19].

For the women however, a simple random sampling procedure was used. The actual sampling and recruitment procedure involved four main steps. First, we enumerated all pregnant and lactating mothers in each of the study communities using a five-item short questionnaire that we designed. The questionnaire asked whether a woman was currently pregnant or had given birth since January 2011, the name of the woman, age and house number/name. Second, after the listing was completed, we randomly selected the required number of participants from the pool of names in each study community. We predetermined the required number of participants (5% of the total enumerated population of pregnant and lactating mothers of each study community). We believe sampling 5% of the enumerated population in each community yielded sufficient numbers of participants whose views on the research topic could fairly approximate the views of the majority of women in the community. Third, the randomly chosen participants were further randomly allocated to either focus group or in-depth interview. Finally, we took the randomly selected names to the various communities wherein the research was introduced and the selection procedures thoroughly explained to each of the randomly selected women. Thereafter, the women were invited to participate in the study. Where any of the randomly selected women was not available or declined to participate in the study – and there were only 2 of such cases – we repeated the selection process to get a replacement.

We acknowledge that the emphasis of qualitative research is not always on generalisation hence randomisation might not be a necessary requirement [40]. However, we used simple random sampling in this study as a pragmatic and ethical strategy to assure justice by using a fair and transparent sampling procedure that ensured that every pregnant and lactating mother in the study communities had a fair chance of taking part in the research. In fact, the idea of chance - which was embedded in our sampling procedures - helped to eliminate questions about why one woman was included and another excluded from the study.

Data collection methods

Focus group discussions and key informant interviews were the main data collection methods. We adopted focus groups partly because we believe it had the capability to reproduce women’s experiences of seeking maternity care in a normal peer-group interpersonal exchange. Six (6) focus group discussions – one in each community and involving a total of 104 pregnant women and lactating mothers - were completed. Groups consisted of 17–24 participants. This difference was mainly due to differences in the sizes of the target populations. All focus groups were held in the study communities, at venues chosen in consultation with participants and community gatekeepers. Each focus group lasted 1.30 to 2 hours, and ended when a point of saturation was reached i.e. when no new ideas and 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. This is not only because the literacy [written or spoken English] rates are low among the study participants, but also because we wanted to ensure that the interview language was not a barrier to effectively exploiting the full benefits of focus groups.

Because our knowledge of the interview language was limited, we engaged one female research assistant from each community to facilitate the discussions. Prior to the interviews, these research assistants were trained for three days. The training took the form of classroom lectures on the objectives of the research, a question-by-question explanation of the content of the topic guides, instructions on field and interviewing procedures to be followed, and instructions on how to ask sensitive questions. To reinforce the training interviewers had received and to reduce potential bias in questioning, the training also involved mock or practice field interviewing, during which each of the research assistants interviewed 3 women using the relevant interview language. These pilot interviews were transcribed and translated into English by independent language translators. The results of the pretest suggested that all research assistants performed well in terms of asking questions in the correct way. Where any errors were detected, they were discussed with the appropriate interviewer to ensure that the same errors did not reoccur in the main interview.

To further explore the research question, we conducted key informant interviews to complement the focus groups. The need for a mixed data collection technique in the social aspects of disease and health research has been widely discussed [20]. In particular, it has been argued that people may not necessarily tell the truth in any objective sense when it comes to sensitive issues such as health and disease within a group context [21]. To overcome this, we complemented our focus groups by conducting key informant interviews. Key informant interviews were also used because it was difficult to organise focus group discussions with healthcare providers. This was largely because it was extremely difficult to get a group of healthcare workers to agree on a common time period to hold FGDs. This was due to the different duty-schedules of individual healthcare workers. This was overcome more appropriately by conducting individual interviews. One major advantage of the method was its ability to address sensitive issues such as personal experiences and perceptions with regard to distribution, accessibility to, and utilization of maternity care services.

In all, a total of 101 key informant interviews were completed – 81 with pregnant and lactating mothers, and 20 with selected healthcare providers. The distribution of the 81 women across the six study communities was 21, 11, 15, 12, 13, and 9 in Kuntanase, Abono, Piase, Sankpala, Mpaha, and Tidrope respectively. Interviews lasted 10 to 15 minutes. All interviews with women were conducted in Twi, Dagbani, and Gonja. Interviews with healthcare providers were however conducted in English.

Research instruments

In all focus groups and key informant interviews, we used an open-ended thematic topic guide. The instrument was designed to ensure that similar themes were covered in each discussion or interview. The instrument however had built-in flexibility that allowed questioning to flow naturally while permitting us to pick at random and probe more on any pertinent but unexpected issues that arose during the interview process. The instruments focused primarily on exploring women’s experiences of seeking or not seeking maternity care services, issues regarding coverage, utilization and access, women’s interaction with maternal and newborn healthcare services, the barriers to access and use of services, and perceptions of in/equities in maternal health services accessibility and utilisation. In addition, a more structured questionnaire instrument that sought to collect specific socio-demographic information as well as elicit specific response (e.g. did you or will you give birth at the hospital, clinic or home?) from all women was designed and administered individually to all women.

To ensure that the instrument was reliable, we engaged in a continuous review of the questions and the interview process to ensure that they were eliciting the right answers to the right questions. This proved valuable in enabling us to reframe questions, clarify and use more appropriate or easily understandable concepts as the research progressed. All discussions and interviews were tape-recorded alongside hand-written field notes.

Data analysis

To ensure that the qualitative data analysis process was methodical and transparent, we followed the Attride-Stirling’s thematic network analysis framework [22]. Several steps were followed before the analysis proceeded to an interpretative phase in which the networks were connected into an explanatory framework consistent with the text. The first step involved transcription and reading of transcripts and field notes for overall understanding. During and after qualitative data collection, the first author and three other language specialists - Twi, Dagbani and Gonja – transcribed all tape-recorded interviews. The first author then immersed himself in all transcripts and interview notes through reading and reviewing for overall understanding and comprehension of meaning. This first step was completed with a separate summary of each transcript outlining the key points participants made in response to the questions.

Once the data was reviewed and a general understanding of the scope and contexts of key experiences was attained, the interview transcripts were exported to NVivo 9 qualitative data analysis software, where the data was both deductively and inductively coded. Codes, according to Miles and Huberman [23] are labels, which are assigned to whole or segments of transcripts and interview notes to help catalogue key concepts while preserving the context in which these concepts occur. Coding provided us with a formal system to organise the data, uncovering and documenting additional links within and between concepts and experiences in the data. Data coding continued until theoretical saturation was reached. This was a point where no new concepts emerged from successive reviewing and coding of data [24]. At this stage, the code structure was deemed complete and then applied to develop and report themes. Themes simply captured something important about the data in relation to the research question, and represented some level of patterned response or meaning within the data set [25].

To ensure that the thematic chart reflected and supported the data, we went through the data segments related to each basic, organising, and global theme. Where necessary, refinements were made. In total, 23 codes were identified. These were grouped into 11 basic themes that were further clustered into 4 organising themes, and 2 global themes (Table 2). These global, organising and basic themes form the structure of our findings and discussion section. Where appropriate, we use verbatim quotations from interview transcripts to illustrate responses related to relevant themes.

Basic characteristics of the women participants

Our study sampled women who have had personal experience of pregnancy and childbirth, and who were fully qualified to have benefitted from maternity care interventions such as the free maternity care policy. The ages of these women varied between 20 and 45 years. The majority of the women had no formal education. A few of the women were unemployed while most were engaged in diverse occupations such as farming, trading, hairdressing, dressmaking, and teaching. Several of the women were also married or living with a partner. The majority of the women had between 1 and 3 children.

Our research participants’ accounts in relation to health system factors that discourage use of skilled maternal and newborn healthcare services in Ghana converged on a number of specific common themes, which are explored below.

Childbirth and women’s maternity care experiences

Discussions and interviews with women show that childbirth is of special value to men and women in Ghana, whether they are married or not. A woman needs to have children to ensure the perpetuity of her own lineage in a matrilineal society, or that of her husband’s in a patrilineal society in Ghana. For this reason, not only is there joy in pregnancy and childbirth, but also most women spoke of pregnancy and childbirth as role fulfilment, self-actualisation and empowerment.

For me, I was really happy when I became pregnant. It made me felt fulfilled and accomplished because people now respect me more (Lactating Mother, FGD, Tidrope).

Because of the importance of childbirth in the life of a Ghanaian woman, several women reported that a pregnant woman needs care, love and empathy to be able to deliver safely. In this regard, there was a general sense of awareness among women about the potential benefits of seeking skilled antenatal care (ANC), delivery care (DC) and postnatal care (PNC) services from a health facility. ‘I believe it is important for every pregnant woman to go to hospital to check their pregnancy’ (Lactating Mother, FGD, Sankpala). Indeed, coupled with the numerous maternal health education campaigns that are being undertaken by the Ghana Health Service, the birth place choice of many Ghanaian women appears to be shifting from the home (where skilled-birth attendants are not available) towards formal healthcare institutions (where skilled-birth attendants are likely to be available). In Sankpala for example, skilled delivery rose from 18.1% in 2009 to 22.2% and 36.1% in 2010 and 2011 respectively [17]. During the same period, skilled delivery in the entire Central Gonja district rose from 13.4% in 2009 to 14.4% and 24.3% in 2010 and 2011 respectively. In Kuntanase, skilled attendance at birth has similarly risen from 68% in 2009 to 74% in 2010.

But while many women spoke of the need to have children and the joy that childbirth brings, there were also stories about the grimmer side of pregnancy and childbirth. Women reported that pregnancy and childbirth was dangerous as ‘you either die or live’. It is the combination of the need to procreate, the joy and fulfilment that childbirth comes with, and the fear that one might die in the process of giving birth, that sometimes warrants care-seeking. At the same time however, the majority of women reported how the organisation and delivery of maternity care services was making it extremely difficult or impossible for some women to access and use these services. While several of these accounts were characterized by both negative and positive experiences, negative experiences dominated women’s daily encounters. In both their collective and individual response, these women were unanimous that these negative experiences were not only endemic under the current free maternal healthcare policy regime, but also that they were so disabling for the majority of women that some women now prefer not to seek any care during pregnancy and labour, or opt for alternative care such as care provided by traditional birth attendants (TBAs). In what follows, we present women’s accounts about how these different health system factors inhibit their access and use of maternity services.

Service availability, distribution and access

For women to have the ability to access and utilise maternity care services, there must be adequate supply of these services [26]. A fundamental assumption of Ghana’s free maternal health policy is that an adequate supply network of skilled care services are available and if only such services could be made costless or affordable, all women would access and use them. Interviews with women and healthcare providers, which were corroborated by systematic observations, reveal that this is not the case in many districts and communities in Ghana. Our interview data suggest that while the policy of free maternity care should in principle benefit all women, in reality the success of the policy depends on access to health facilities which many women, especially poor rural women, lack because of long distance or transport and other opportunity costs constraints during referrals or emergency situations. For example, in Tidrope and Abono, there is no health facility hence the provision of maternal health services is not readily available. The distance from any of these communities to the nearest health facility is approximately 12 km. In these communities, pregnant and lactating women tell of how a consideration of the prohibitive costs involved in travelling to access or utilise birthing services often lead several families to decide in favour of non-access and use or resort to self-medication. A lactating mother illustrates:

You see, in this community there is no doctor or nurse whom we can easily go to for help. Sometimes, we really want to go and check if all is well with our pregnancies or babies. Some women even want a doctor or nurse to deliver them, but look at where the hospital is…very very far away. Even some times when we want to go, how to get car is a problem…because of the long distance, many women just stay at home (Lactating Mother, FGD, Abono).

Indeed, available anecdotal data (see Table 1) as regards the availability and distribution of healthcare facilities and healthcare personnel largely corroborated the women’s accounts. For instance, whereas the doctor to patient ratio in 2010 was 1: 9,997 in the Bosomtwe district, the Central Gonja district had 1:110,576. Similarly, the nurse to patient ration was approximately 1: 1,111 in the Bosomtwe district compared to 1: 2,572 in the Central Gonja District. These ratios are far above the WHO recommended doctor-to-patient ratio of 1: 6000 and nurse-to-patient ratio of 1: 500.

Interviews with healthcare providers on the subject of service availability and distribution also corroborated the accounts several women gave. However, most healthcare providers related the problem to resource constraints and the geographic spread of communities.

The thing is, not all the communities in this district have health facilities. But the problem is that the resources to do this are limited. Even if we do have resources, it is not feasible to have a health facility in every community due to the scattered nature of settlements Male Healthcare Provider, KII, Mpaha).

Interviews with women and healthcare providers in Mpaha, as well as our own systematic observations in Buipe, graphically illustrate the effect of the unequal distribution of services on access to birthing care. Women and healthcare providers in Mpaha alike reveal that the absence of a midwife, coupled with the incompetence of existing available nursing staff to manage deliveries was a major factor impeding access to skilled care at the Mpaha health centre. At the Buipe rural clinic, we observed that the number of nurses attending to women who had come for ANC was not only very limited, but also they [nurses] were regularly intermittently called upon to attend to other patients presenting with different ailments. A healthcare provider at the Buipe rural clinic summed the issues thus:

You are doing research on maternal health access…you have been here, you have seen our staff strength and you have seen the kind of resources and equipment we are working with. How can we ensure that all women have access to good care? Just look at me, I am the only midwife, and look at all the women sitting outside, how can one person take proper care of all of them. Sometimes, I believe the women are right for not coming to us (Female Healthcare Provider, KII, Buipe).

Quality of care and access

Interviews with women also indicate that the quality of maternal healthcare offered at health facilities and the time it takes to receive it from a skilled provider is another more important factor determining access and utilisation. Discussions and interviews with women in Kuntanase, Piase, Sankpala and Mpaha - where skilled maternal healthcare services are readily available - showed that women’s experiences of overcrowding and delays in maternity wards, inefficient referral systems, substandard care, and lack of critical healthcare staff to provide needed care have led to widespread dissatisfaction and unwillingness to access and use skilled care despite these services being free. A lactating mother makes the point thus:

I don’t know whether I should say the apimfuo insurance [the free maternity care policy] has come to help heal our sickness or kill us. When we used to pay, the doctors were taking good care of us. But now that it is free, you go to hospital and they tell you there is no medicine because the government didn’t give them more money…so now most of us will even travel far to get good care (Lactating Mother, KII, Kuntanase).

Another young mother reports:

Why I didn’t go to hospital? The problem is even if I go, the people are many…everywhere is crowded and I have to wait for long hours or even a whole day. Sometimes too you’ll go and they [referring to nurses] will tell you that the midwife is not there. If they decide to help you too, they will just rush and say go home…no blood testing, no medicine, nothing! I don’t know…but I think because the nurses no longer collect money from us, they are very reluctant to help us (Lactating Mother, FGD, Piase).

Our observations and interviews with healthcare providers reveal that delays and overcrowding were often exacerbated by the fact that people came at random or without prior appointment to seek care in healthcare facilities. This was because there is no booking system in place to enable women book appointments prior to visiting healthcare facilities. Several women reported that standards of care were particularly poor in government healthcare facilities compared to private facilities. Thus the idea that, government healthcare centres offer low quality maternal healthcare services was widely cited for both non-use of the services and a high level of preference for services offered by non-government healthcare providers. At both Buipe rural clinic and Sankpala health centre where we were able to systematically observe the doings of ANC clinics, overcrowding and long delays were evident. Women were found sleeping on benches or sitting on cemented floors for long hours before they were hurriedly attended to. It is within the above context that some of the women interviewed for this study were willing in some instances to travel further in order to access quality care.

While many women believed the quality of care they were receiving under the free maternal healthcare policy was generally poor, a number of the healthcare providers interviewed gave conflicting answers. One male healthcare provider puts the quality of care problem this way:

I think our pregnant women are smart…they know that they can benefit from ANC or DC services and therefore they come to the clinic/hospital. At the same time they know that in an ANC clinic or a labour ward in a health facility they are hardly better off, so they choose not to come or simply deliver at home (Male Healthcare Provider, KII, Accra).

Others however believed quality of care had actually improved. Even where they acknowledged that the care quality was sub-standard, they often justified it by reference to lack of monetary resources to purchase medical equipment and drugs or limited number of health staff or the increased workload wrought by the free maternity care policy itself.

One of the good things about the free maternity care policy is that we have been able to considerably improve the quality of the services we now provide. As you may know, the policy itself has led to more patients coming to the hospitals… sometimes workers and the facilities are over stretched (Female Healthcare Provider, KII, Kumasi).

While it was not possible for us to independently determine whether the overcrowding, delays and poor quality of care women reported receiving were caused by the free maternal healthcare policy, our observations, coupled with interviews with nurses and midwives as well as reviews of secondary literature, suggest that the quality of maternal healthcare may indeed be deteriorating.

Trust and access

Aside from imbalances in the distribution of health resources, perceptions of declining quality of care, and a healthcare system that is technocratic and impersonal, one of the recurrent themes from our interview data is the issue of trust in both the healthcare system and the providers of care. A pre-requisite for effective patient-provider interaction is the patient’s trust that the provider is knowledgeable and motivated to provide the best care available [32]. In the districts where this research took place however, women’s narratives and testimonies - which were largely, corroborated by healthcare workers – show that increasing distrust in the knowledge, skills, practices and competence of maternity care facilities and caregivers (nurses and midwives) and the safety and efficacy of the ANC, delivery and post-delivery care they provide to women, is undermining access.

I think many women are not going to hospitals because of the people there…I mean the nurses. Some time ago we had good nurses and midwives at the hospital… they understood what it is like to be pregnant or be in labour because they themselves have been through it. But nowadays, all those old nurses are not there… the place is filled with small, small, small nurses and midwives who don’t know how to take care of pregnant women because they have no experience of giving birth. So when you go to them for help, you are in trouble… they don’t take proper care of you (Pregnant Woman, FGD, Tidrope).

A lactating mother also said:

You see those young nurses and midwives at the hospital are not doing well at all. Normally they feel that they know book, but in fact they don’t know how to deliver a woman properly because they all have never given birth. One of the midwives…she is younger than my daughter, how can she deliver me? How can they help you deliver when they have never even been pregnant themselves? Look… Antie Maggie [referring to a TBA] who doesn’t even know book, when you are in labour and they call her to come and deliver you, you will see how she will run to you…even the way she will talk to you…you will not even be aware and the baby will just come out (Lactating Mother, FGD, Kuntanase).

Another participant adds:

Are you asking why I didn’t go to check my pregnancy? Some of the nurses are to blame…because they don’t take good care of us like some time ago (Pregnant Woman, KII, Abono).

Interestingly, women’s lack of trust in caregivers was based on other criteria than strict evaluation of whether caregivers have been adequately trained to obtain the required clinical skills to give maternity care. Rather, women often made a distinction, albeit tacitly, between having experiential knowledge of pregnancy and childbirth on the one hand, and acquiring book knowledge about pregnancy and childbirth on the other. Women argued that although book knowledge is necessary, a midwife ought to have had a personal experience of pregnancy and childbirth. Such a midwife, the women suggested, did not only possess the ‘technical know how’ of pregnancy and childbirth particularly in times of complications, but also is well positioned to empathise. Empathy and sharing of personal experiences are two elements that all the women in this study believed were important, especially for safe natural delivery. However, the women noted that most of the young midwives possess only book knowledge, but are unable to empathise or relate to their [women] experiences. It is therefore the absence of empathy and sharing in the maternity care practices of young female midwives more generally, and male midwives in particular, that makes older female midwives and TBAs highly preferred.

Interviews with frontline midwives/nurses and healthcare personnel in senior management capacities also reveal their awareness of women’s diminishing trust in the healthcare system.

What we have heard is that, the women don’t come to the health facilities because they feel we are young and have no experiences of childbirth…that we only have book knowledge. To some extent, the women are right. Look at this health centre we serve about 64 communities, and yet there is no midwife. So many times we the community health nurses are the ones conducting ANC, deliveries and post-delivery clinics. But we all have not had training in midwifery, so sometimes there are some problems we are unable to solve. Even there is a lot of new equipment in our stock that we don’t use because we don’t actually know how to use them. So, when we try our best and still there is a problem and we refer the patient to Tamale teaching hospital or Kintampo, the community people say we don’t know anything (Female Healthcare Provider, KII, Mpaha).

District and regional health directors as well as public health nurses were similarly aware of this trust issue. But they explained that they were caught between scarcity/necessity and rejection at the same time. On the one hand over 50% of the already limited qualified midwives are retiring from active service. This has necessitated the training of young midwives. On the other hand however, these young midwives are facing rejection in their various healthcare facilities by the very communities they are suppose to help.

We know that many women prefer the older midwives because of the perception that some of these young midwives have no experience of childbirth or that they are not friendly enough. So if the older midwives are not there, the women choose not to come to the health facility. But, you see we are short of midwives already and there is urgent need to train more so they can take over from the older ones who are leaving the system. (Female Healthcare Provider, KII, Tamale).

That there is a trust problem in Ghana’s maternal health system, which is increasingly undermining efforts to ensure increased and equitable access to skilled care is therefore no exaggeration. What is unclear from our interviews and discussions with women and healthcare providers however is the source of this distrust. Few healthcare providers suggested that distrust in the care system might have existed prior to the implementation of the free maternity care policy. For the majority of women in this study the period of free maternity care in Ghana is also a period of widespread distrust in health facility-base maternity care. Both women and healthcare providers’ accounts suggest that the marginal increase in demand for skilled care services initially occasioned by the implementation of the policy, and the concomitant training and deployment of young midwives to both augment and replace aging midwives, may have aggravated the trust problem.

Intimidation, choice, and access

The implementation of free maternal healthcare policy in Ghana has been accompanied by a progressive and aggressive medicalisation of the human reproductive process – from fertility control, family planning and pregnancy management, to medical interventions during childbirth and postpartum period. Although this is generally seen as essential to reducing maternal and neonatal mortality in Ghana, focus group discussions and interviews with women show that many have found this process intimidating and choice restricting. Consequently, and as a way of both resisting this progressive medicalisation and reclaiming control over their reproductive health, many women are not accessing and using the skilled birthing services that are provided at healthcare facilities.

During interviews, women spoke passionately about the naturalness of pregnancy and childbirth. Many believed that, as much as possible, there should be limited ‘unnatural’ intervention or interference during pregnancy and childbirth. It is in part the idea of the naturalness of pregnancy and childbirth that causes childbearing women in this study to be apprehensive of any interventions believed to be ‘unnatural’, including caesarean section. Women particularly emphasised the need for choice in terms of place and position of birth as well as the desirability of limited intimidation during pregnancy and childbirth. These were thought to greatly facilitate the natural processes of childbirth. Many however lamented that the care that healthcare facilities and healthcare providers offer were often less choice enhancing and less stress-free.

First, intimidation. For women, the hospital – itself an unnatural environment - with all its modern technological edifices is a rather intimating and disabling environment to give birth. One woman said:

I don’t like the hospital. All those funny funny machines that the doctors use make me fear the place. When I had my first son, it was in the hospital and the doctor put this huge thing … it was like a big scissors [referring to forceps] into my private part. It was terrible! Also, the smell of medicine and the screaming of other patients…it just makes me sicker. So unless I am really suffering or dying, I prefer not to go (Pregnant Women, FGD, Kuntanase).

A lactating mother adds:

I didn’t deliver at the clinic because I wanted to be at a place like my house where I can feel free to spit, urinate, cry and do anything that I feel like doing. In the hospital, the nurses will not allow you or they will even insult you, and this makes it hard for you to relax and deliver well (Lactating Mother, FGD, Sankpala).

But intimidation is not the only thing that prevents women from accessing and using skilled care services. The restrictions placed on their ability to decide on where and how to give birth, is another reason. Women believed that nurses, midwives and doctors limited their choices related to labour and birthing as well as who should witness their birth. For example, women expressed their preference for delivering in an upright position including sitting on a stool or chair, squatting or sitting upon the side of the bed or being held by other women that come to labour. Women who have had home delivery and therefore the opportunity to choose their birth position noted that delivering in an upright position facilitated birth of the baby as well as removal of the placenta. They however noted that the recumbent position favoured by nurses and midwives contributed to general difficulty of delivery. Despite this, delivering on the hospital bed, usually a flat and non-inclining bed, in a supine or recumbent position is the accepted birth position in most healthcare facilities in Ghana. Similarly, family members and friends are usually not permitted into the labour ward. Yet, many women said they feel more confortable delivering with their family members present to offer support. Since nurses and midwives did not usually allow this in the health facility, they found home birth more confortable.

For me, giving birth at home is more comfortable. I gave birth at home where my mother, my mother-in-law and other neighbours were available to support and care for me. In the hospital, I will not get all this support (Lactating Mother, FGD, Piase).

For the women in this study, successful pregnancy and delivery requires that women be given the chance to choose where to deliver and in which position.

Silent care, maltreatment, and access

Several of the women interviewed also recounted their experiences of how they were chided and scolded for not coming to the healthcare facility early to seek care or when they did not attend ANC clinics or when they used an alternative medicine or when they failed to practice birth control or when they asked the nurses/midwives/doctors questions related to their (women) health or that of their baby. Particular reference was made to nurses, midwives and female health providers in general, as exhibiting poor attitude towards pregnant and labouring women. Others related how they were often offered ‘silent treatment’ and treated like ‘children’ and in some instances threatened with treatment withdrawals if they failed to adhere to advice and instructions from healthcare workers. One participant relates her experience thus:

I have made up my mind not to go to that hospital [referring to Kuntanase hospital] again. Because, the nurses are suppose to know and tell me what is wrong. But the last time I went, they told me to go spit my saliva into a container and bring, I did and they ask me to go and bring my urine too. So I asked the nurse what was wrong. She didn’t say anything but asked me do as I am told. But I asked again, and then she became angry and started to say I was a villager and that I didn’t know anything. I was embarrassed and became very angry because everybody at the clinic was looking at me and laughing. We are human beings with emotions and feelings, but they never ask how we feel…they don’t…they really don’t care (Pregnant Woman, FGD, Kuntanase).

Women reported that scolding, maltreatment and silent treatment were particularly worse in government healthcare facilities than in private facilities - a phenomenon, women said, discouraged them from seeking skilled care services when in need. Discussants said that health workers in private health facilities were more hospitable than their counterparts in state-run services that often abused patients. In this way, ownership of a health facility emerged as an important determinant of the nature of treatment received. In Sankpala health centre and Buipe clinic where we observed the conduct of antenatal and post-natal clinics, several medical procedures including blood pressure and temperature check-ups, weighing, and immunisation were conducted on women and their babies without any accompanying explanations of the purpose of the medical procedure or its functions. Women also regularly stood up when responding to questions from nurses. At the same time, nurses seemed unperturbed by the precarious condition of most pregnant women neither did they seem to be mindful of the fact that some of these women were far older than they (nurses) were. Note that age within most Ghanaian societies has social significance. It confers on older persons a right to particular treatment, including respect, especially from younger people. As we later learnt, nurses’ failure to respect elderly women at the clinic is one reason why some women choose not to consult nurses and midwives. A few women however revealed that in order to receive the care and treatment they need or avoid getting into conflicts with nurses, they often have to accept the scolding, intimidation and disrespect in maternity wards without openly expressing their feelings.

Most of the healthcare workers interviewed appeared quite aware of what the women called the silent care and maltreatments. However, they either underestimated the effects this has on women’s health-seeking behaviours or justified it by reference to work overload and tiredness that often stressed healthcare workers. Others also justified silent treatment on grounds of language differences between healthcare workers and patients, which sometimes made it difficult for nurses and midwives to effectively communicate health information and treatment procedures to women.

Our interviews with women showed that the lack of open and non-judgemental patient-doctor relationships that allow communication, mutual trust and respect to flow between caregivers and women did have a disabling effect on uptake of services. This is because any time that a woman makes the decision to access and use maternity care services at a healthcare facility, her general expectation is to be able to enter into a positive relationship with the healthcare provider so as to enable her address her healthcare needs and concerns. Women expect warm conversation, sharing, and empathy to develop between them and their healthcare provider. Women also expect that when they seek care at the health facility, not only should nurses/midwives/doctors offer them the necessary treatments but also they [caregivers] should help them [women] to understand their health problems, provide guidance needed for making informed decisions about their health as well as answer their questions or respond to any health concerns they may have. Because most women have limited education, they strongly depend on the oral advice and information from healthcare workers. Unfortunately, several women reported that their expectations are very often not met. Rather, authority and passivity heavily characterise the interactions between healthcare workers and women, especially in the ANC clinic or labour ward. Thus doctor-patient relationships are structured around power and control. This created a significant gap between existing maternal health services and women’s requirements for supportive care. This gap was often compounded by the cultural and functional adjustments women often have to undergo when a visit or referral is made to an unfamiliar health facility setting or healthcare provider. The combined effect of this has been to discourage access to, and utilisation of services.

Privacy and access

Women also reported that under the current maternal and newborn healthcare regime in Ghana, hospital and clinical structures and practices make it extremely difficult to maintain privacy when treatment is being received or when discussing their healthcare concerns with nursing staff.

You see, I can get up and go to Antie Maggie [referring to a community TBA] to check my pregnancy and nobody in this house will know. But if I go to the clinic, there are so many other people sitting there. Everybody is listening to what you are telling the nurses…sometimes, there are things you want to tell only the nurse or you want to ask the nurse alone. But because there are other patients, you can’t (Pregnant Woman, FGD, Tidrope).

One participant also relates:

I didn’t deliver at the hospital because the first time I gave birth at the hospital…it was not too good for me. I didn’t like the way the place was open. There were other patients, nurses, midwives and doctors in the labour ward. So everyone could see you or hear what you are doing. I think it would be better if every patient had their own delivery room, or even if they can use curtains to cover you (Lactating Mother, FGD, Abono).

Despite the importance women attached to privacy, interviews with nurses, midwives and healthcare managers showed that ensuring privacy was often not an issue of primary concern. The few who acknowledged the relevance of preserving privacy in ANC clinics and labour wards even countered the argument by highlighting the limitations imposed by infrastructural constraints.

I think that it is good that we maintain some level of privacy in our maternity wards. But the issue is, when you don’t have space or when you have only one person attending to several hundreds of women, how are we supposed to maintain privacy? We really can’t, unless we choose to take care of few women and ignore the rest (Female Healthcare Provider, KII, Sankpala).

Indeed, our observations around ANC clinics and maternity wards showed that privacy was neither ensured nor given serious importance. For example, case histories and clinical examination of pregnant women took place in the midst of others waiting to be attended to. This was confounded by nurses’ penchant for interviewing women in loud voices. This made it very easy for those waiting to hear the health problems or concerns of other women. For fear of ones health problems being subjects of gossip, many women said they felt constrained telling nurses all their health concerns within those settings. For these women, the limited privacy within the health facility setting and the way in which caregivers ignored this crucial aspect of care was an important barrier to accessibility and utilisation of skilled care services.