Maternal and Child Health Journal

, Volume 12, Issue 4, pp 509–518 | Cite as

Use of Health Professionals for Delivery Following the Availability of Free Obstetric Care in Northern Ghana

  • Samuel Mills
  • John E. Williams
  • Martin Adjuik
  • Abraham Hodgson


Objectives To assess the factors associated with the use of health professionals for delivery following the implementation of a free obstetric care policy in the poorest regions of Ghana. Methods All 4,070 women identified in the Navrongo demographic surveillance system with pregnancy outcomes in the Kassena-Nankana district between January 1 and December 31, 2004 were eligible for the study. Three thousand four hundred and thirty three women completed interviews on socio-demographic and pregnancy related factors. Information on 259 communities including travel distance to the nearest health facility was also obtained. Multilevel logistic regression analyses were conducted. Results ninety eight percent of women received antenatal care but only 38% delivered with the assistance of health professionals. In a multilevel logistic model, physical access factors {such as availability of public transport, odds ratio (OR) = 1.50 (1.15–1.94), travel distance to the district hospital [for 20+ km, OR = 0.31 (0.23–0.43)] as well as community perception of access to the nearest health facility [for highest quintile, OR = 4.44 (2.88–6.84)]} showed statistically significant associations with use of health professionals at last delivery. Women who knew that delivery care was free of charge were 4.6 times more likely to use health professionals. Higher parity was strongly negatively associated with use of health professionals [OR = 0.37 (0.29–0.48) for parity ≥4 compared to parity 0–1]. However, community perception of quality of care was not associated with use of health professionals for delivery. Conclusion Physical access factors remain strong determinants of use of professional delivery care in rural northern Ghana.


Obstetric care factors Perceived quality Perceived access Travel distance Free care 



We thank the staff of the Navrongo Health Research Centre for their assistance in conducting this study and particularly Peter Wontuo for the data management. We also wish to express our gratitude to Eduard Bos and Elizabeth Lule of the World Bank as well as other anonymous individuals for their support. We acknowledge the financial assistance of the World Bank-Netherlands Partnership Program.


  1. 1.
    United Nations Millennium Declaration. (2000, September 18). United Nations General Assembly New York, No. A/RES/55/2, 55th Session.Google Scholar
  2. 2.
    Department of Reproductive Health and Research. (2006). Skilled attendant at birth 2006 updates. Geneva: World Health Organization.Google Scholar
  3. 3.
    Ifenne, D., Essien, E., Golji, N., Sabitu, K., Alti-Mu’azu, M., Musa, A., et al. (1997). Improving the quality of obstetric care at the teaching hospital, Zaria, Nigeria. International Journal of Gynaecology and Obstetrics, 59(Suppl 2), S37–S46.PubMedCrossRefGoogle Scholar
  4. 4.
    Stekelenburg, J., Kyanamina, S., Mukelabai, M., Wolffers, I., & van Roosmalen, J. (2004). Waiting too long: Low use of maternal health services in Kalabo, Zambia. Tropical Medicine & International Health, 9, 390–398.CrossRefGoogle Scholar
  5. 5.
    Sepehri, A., & Chernomas, R. (2001). Are user charges efficiency- and equity-enhancing? A critical review of economic literature with particular reference to experience from developing countries. Journal of International Development, 13(2), 183–209.CrossRefGoogle Scholar
  6. 6.
    Quaye, R. K. (2004). Paying for health services in East Africa: A research note. Social Theory & Health, 2(1), 94–105.CrossRefGoogle Scholar
  7. 7.
    Afsana, K. (2004). The tremendous cost of seeking hospital obstetric care in Bangladesh. Reproductive Health Matters, 12, 171–180.PubMedCrossRefGoogle Scholar
  8. 8.
    Wagstaff, A., & van Doorslaer, E. (2003). Catastrophe and impoverishment in paying for health care: With applications to Vietnam 1993–1998. Health Economics, 12, 921–934.PubMedCrossRefGoogle Scholar
  9. 9.
    Prata, N., Greig, F., Walsh, J., & West, A. (2004). Ability to pay for maternal health services: What will it take to meet who standards? Health Policy, 70, 163–174.PubMedCrossRefGoogle Scholar
  10. 10.
    Mills, S., & Bertrand, J. T. (2005). Use of health professionals for obstetric care in northern Ghana. Studies in Family Planning, 36, 45–56.PubMedCrossRefGoogle Scholar
  11. 11.
    Debpuur, C., Chirawurah, D., Wontuo, P., Welaga, P., Kangsangbata, C., Seidu, N., et al. (2002). The Navrongo demographic surveillance system 2002 report to the Rockefeller Foundation. Community health and family planning project, July 2002. Report no. 47.Google Scholar
  12. 12.
    Akazili, J., Kuma, I., Kanyomse, E., Asuru, R., Debpuur, C., & Hodgson, A. (2003). 2002 Panel survey report. Community health and family planning project, October 2003. Report no. 47 and 48.Google Scholar
  13. 13.
    Wilson, J. B., Collison, A. H., Richardson, D., Kwofie, G., Senah, K. A., & Tinkorang, E. K. (1997). The maternity waiting home concept: The Nsawam, Ghana experience. International Journal of Gynaecology and Obstetrics, 59(Suppl 2), S165–S172.PubMedCrossRefGoogle Scholar
  14. 14.
    Cham, M., Sundby, J., & Vangen, S. (2005). Maternal mortality in the rural Gambia, a qualitative study on access to emergency obstetric care. Reproductive Health, 2, 3.PubMedCrossRefGoogle Scholar
  15. 15.
    Mills, S., Bos, E., Lule, E., Ramana, G. N. V., & Bulatao, R. (2007). Preventable maternal deaths: Emergency obstetric care is lacking or late in Ghana, Kenya, and India. Washington, DC: Informal Paper, World Bank.Google Scholar
  16. 16.
    Debpuur, C., Phillips, J. F., Jackson, E. F., Nazzar, A., Ngom, P., & Binka, F. N. (2002). The impact of the Navrongo project on contraceptive knowledge and use, reproductive preferences, and fertility. Studies in Family Planning, 33, 141–164.PubMedCrossRefGoogle Scholar
  17. 17.
    Nyarko, P., Wontuo, P., Wak, G., Chirawurah, D., Welaga, P., Nchor, S., et al. (2001). The Navrongo demographic surveillance system 2001 report to the Rockefeller Foundation. Community health and family planning project, June 2001. Report no. 45.Google Scholar
  18. 18.
    Wall, L. L. (1998). Dead mothers and injured wives: The social context of maternal morbidity and mortality among the Hausa of northern Nigeria. Studies in Family Planning, 29(4), 341–359.PubMedCrossRefGoogle Scholar
  19. 19.
    Pebley, A. R., Goldman, N., & Rodriguez, G. (1996). Prenatal and delivery care and childhood immunization in Guatemala: Do family and community matter? Demography, 33, 231–247.PubMedCrossRefGoogle Scholar
  20. 20.
    Bawah, A. A., Akweongo, P., Simmons, R., & Phillips, J. F. (1999). Women’s fears and men’s anxieties: The impact of family planning on gender relations in northern Ghana. Studies in Family Planning, 30, 54–66.PubMedCrossRefGoogle Scholar
  21. 21.
    McDonagh, M. (1996). Is antenatal care effective in reducing maternal morbidity and mortality? Health Policy and Planning, 11, 1–15.PubMedCrossRefGoogle Scholar
  22. 22.
    Carroli, G., Rooney, C., & Villar, J. (2001). How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence. Paediatric and Perinatal Epidemiology, 15(Suppl 1), 1–42.PubMedGoogle Scholar
  23. 23.
    Hussein, J., Hundley, V., Bell, J., Abbey, M., Asare, G. Q., & Graham, W. (2005). How do women identify health professionals at birth in Ghana? Midwifery, 21, 36–43.PubMedCrossRefGoogle Scholar
  24. 24.
    Harvey, S. A., Ayabaca, P., Bucagu, M., Djibrina, S., Edson, W. N., Gbangbade, S., et al. (2004). Skilled birth attendant competence: An initial assessment in four countries, and implications for the safe motherhood movement. International Journal of Gynaecology and Obstetrics, 87, 203–210.PubMedCrossRefGoogle Scholar
  25. 25.
    Maclean, G. D. (2003). The challenge of preparing and enabling ‘skilled attendants’ to promote safer childbirth. Midwifery, 19, 163–169.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • Samuel Mills
    • 1
  • John E. Williams
    • 2
  • Martin Adjuik
    • 2
  • Abraham Hodgson
    • 2
  1. 1.The World BankWashingtonUSA
  2. 2.Navrongo Health Research CentreGhana Health ServiceNavrongoGhana

Personalised recommendations