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The Association Between Health Insurance Coverage and Skilled Birth Attendance in Ghana: A National Study

Abstract

Objectives Skilled birth attendance (SBA) is a key health intervention used by roughly two-thirds of women in Ghana. The National Health Insurance Scheme provided by the Government of Ghana is widely expected to improve maternal health outcomes by removing financial barriers to health services. In this paper, we examine if indeed health insurance is able to improve SBA, a key maternal outcome. Methods We use data from the 2011 Ghana Multiple Indicator Cluster Survey implemented by the Ghana Statistical Services with support from the United Nations Children’s Fund (UNICEF). We use a multivariate logistic model controlling for a number of enabling and predisposing factors and past experience with the health system to examine the effect of health insurance on skilled birth attendance. The sample is 2528 women. Results Our results show that women with health insurance are 47 % more likely to use SBA than women without health insurance. Results also underscore that women with repetitive contact with the health system (such as antenatal care) are more likely to have a skilled delivery (OR 3.00, p value 0.000). We also find that higher parity, rural and poor women are much less likely to use SBA. Conclusions Health insurance may indeed be a useful mechanism to improve coverage of SBA, though many barriers to delivery care still exist for women. Further work to understand the effect of health insurance on other maternal outcomes is also warranted.

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References

  1. World Health Organization. (2004). Making pregnancy safer: The critical role of the skilled attendant: A joint statement by WHO. Geneva: World Health Organization, ICM and FIGO.

    Google Scholar 

  2. de Bernis, L., Sherratt, D. R., AbouZahr, C., & Van Lerberghe, W. (2003). Skilled attendants for pregnancy, childbirth and postnatal care. British Medical Bulletin, 67, 39–57.

    Article  PubMed  Google Scholar 

  3. Lawn, J. E., Cousens, S., & Zupan, J. (2005). 4 million neonatal deaths: When? where? why? Lancet, 365(9462), 891–900.

    Article  PubMed  Google Scholar 

  4. Singh, K., Brodish, P., & Suchindran, C. (2014). A regional multilevel analysis: Can skilled birth attendants uniformly decrease neonatal mortality? Maternal and Child Health Journal, 18(1), 242–249.

    Article  PubMed  Google Scholar 

  5. Yakoob, M. Y., Ali, M. A., Ali, M. U., et al. (2011). The effect of providing skilled birth attendance and emergency obstetric care in preventing stillbirths. BMC Public Health, 11(Suppl 3), S7-2458-11-S3–S7-2458-11-S7.

  6. UN Inter-agency Group for Child Mortality Estimation (IGME). (2014). Child mortality estimates CME info: Ghana. http://www.childmortality.org/index.php?r=site/graph#ID=GHA_Ghana. Accessed August 2014.

  7. UN Maternal Mortality Estimation Inter-agency Group (MMEIG). (2013). Maternal mortality estimates: Ghana. http://www.maternalmortalitydata.org/inner.html?country_selection=O. Accessed August 2014.

  8. UN Statistics Division. (2015). Millennium Development Indicators: Births attended by skilled personnel, percentage: Ghana. http://mdgs.un.org/unsd/mdg/SeriesDetail.aspx?srid=570&crid=288 Accessed July 2015.

  9. Zere, E., Kirigia, J. M., Duale, S., & Akazili, J. (2012). Inequities in maternal and child health outcomes and interventions in Ghana. BMC Public Health, 12(1), 252. doi:10.1186/1471-2458-12-252.

    PubMed Central  Article  PubMed  Google Scholar 

  10. Vandemoortele, M. (2010). The MDG fundamentals: Improving equity for development. Briefing paper no. 59. London. Overseas Development Institute.

  11. Xu, K., Saksena, P., Jowett, M., et al. (2010). Exploring the thresholds of health expenditure for protection against financial risk. World Health Report (pp. 328–333). Geneva: World Health Organization.

  12. Xu, K., Evans, D. B., Kawabata, K., et al. (2003). Household catastrophic health expenditure: A multicountry analysis. Lancet, 362(9378), 111–117.

    Article  PubMed  Google Scholar 

  13. Wagstaff, A. (2002). Poverty and health sector inequalities. Bulletin of the World Health Organization, 80(2), 97–105.

    PubMed Central  PubMed  Google Scholar 

  14. Su, T. T., Kouyaté, B., & Flessa, S. (2006). Catastrophic household expenditure for health care in a low-income society: A study from Nouna district, Burkina Faso. Bulletin of the World Health Organization, 84(1), 21–27.

    PubMed Central  Article  PubMed  Google Scholar 

  15. Wagstaff, A. (2007). The economic consequences of health shocks: Evidence from Vietnam. Journal of Health Economics, 26(1), 82–100.

    Article  PubMed  Google Scholar 

  16. Van Doorslaer, E., O’Donnell, O., Rannan-Eliya, R. P., et al. (2007). Catastrophic payments for health care in Asia. Health Economics, 16(11), 1159–1184.

    Article  PubMed  Google Scholar 

  17. Gilson, L. (1997). The lessons of user fee experience in Africa. Health Policy and Planning, 12(4), 273–285.

    Article  CAS  PubMed  Google Scholar 

  18. Nyonator, F., & Kutzin, J. (1999). Health for some? The effects of user fees in the Volta region of Ghana. Health Policy and Planning, 14(4), 329–341.

    Article  CAS  PubMed  Google Scholar 

  19. Waddington, C., & Enyimayew, K. (1990). A price to pay, part 2: The impact of user charges in the Volta region of Ghana. The International Journal of Health Planning and Management, 5(4), 287–312.

    Article  Google Scholar 

  20. Waddington, C. J., & Enyimayew, K. (1989). A price to pay: The impact of user charges in Ashanti-Akim district, Ghana. The International Journal of Health Planning and Management, 4(1), 17–47.

    Article  Google Scholar 

  21. World Health Organization. (2010). The World Health Report: Health systems financing: The path to universal coverage. Geneva: World Health Organization.

    Google Scholar 

  22. Blanchet, N., Fink, G., & Osei-Akoto, I. (2012). The effect of Ghana’s national health insurance scheme on health care utilisation. Ghana Medical Journal, 46(2), 76–84.

    PubMed Central  CAS  PubMed  Google Scholar 

  23. Jehu-Appiah, C., Aryeetey, G., Spaan, E., et al. (2011). Equity aspects of the national health insurance scheme in Ghana: Who is enrolling, who is not and why? Social Science and Medicine, 72(2), 157–165.

    Article  PubMed  Google Scholar 

  24. Sarpong, N., Loag, W., Fobil, J., et al. (2010). National health insurance coverage and socio-economic status in a rural district of Ghana. Tropical Medicine and International Health, 15(2), 191–197.

    Article  CAS  PubMed  Google Scholar 

  25. Dixon, J., Tenkorang, E. Y., & Luginaah, I. (2011). Ghana’s national health insurance scheme: Helping the poor or leaving them behind? Environment and Planning-Part C, 29(6), 1102.

    Article  Google Scholar 

  26. Witter, S., & Garshong, B. (2009). Something old or something new? Social health insurance in Ghana. BMC International Health and Human Rights, 9, 20. doi:10.1186/1472-698X-9-20.

    PubMed Central  Article  PubMed  Google Scholar 

  27. Dixon, J., Tenkorang, E. Y., Luginaah, I. N., et al. (2014). National health insurance scheme enrolment and antenatal care among women in Ghana: Is there any relationship? Tropical Medicine and International Health, 19(1), 98–106.

    Article  PubMed  Google Scholar 

  28. Yilma, Z., van Kempen, L., & de Hoop, T. (2012). A perverse ‘net’ effect? Health insurance and ex-ante moral hazard in Ghana. Social Science and Medicine, 75(1), 138–147.

    Article  PubMed  Google Scholar 

  29. Singh, K., Osei-Akoto, I., Otchere, F., et al. (2015). Ghana’s National Health insurance scheme and maternal and child health: A mixed methods study. BMC Health Services Research, 15(1), 108.

    PubMed Central  Article  PubMed  Google Scholar 

  30. Ghana Statistical Service. (2012). Ghana Multiple Indicator Cluster Survey with an enhanced malaria module and biomarker. Ghana Statistical Service: Accra.

    Google Scholar 

  31. Andersen, R. M. (1995). Revisiting the behavioral model and access to medical care: Does it matter? Journal of Health and Social Behavior, 36(1), 1–10.

    Article  CAS  PubMed  Google Scholar 

  32. Rutstein, S. O., & Johnson, K. (2004). The DHS wealth index. DHS comparative reports no. 6. Calverton, MD. ORC Macro.

  33. Jehu-Appiah, C., Aryeetey, G., Agyepong, I., et al. (2012). Household perceptions and their implications for enrollment in the national health insurance scheme in Ghana. Health Policy and Planning, 27(3), 222–233. doi:10.1093/heapol/czr032.

    Article  PubMed  Google Scholar 

  34. Ghana Statistical Service (GSS), Health Research Unit, Ministry of Health, and ORC Macro. (2003). Ghana service provision assessment survey 2002. Accra: Ghana Statistical Service.

    Google Scholar 

  35. Stanton, C., Blanc, A. K., Croft, T., et al. (2007). Skilled care at birth in the developing world: progress to date and strategies for expanding coverage. Journal of Biosocial Science, 39, 109–120.

    Article  PubMed  Google Scholar 

  36. Adjiwanou, V., & LeGrand, T. (2013). Does antenatal care matter in the use of skilled birth attendance in rural Africa: A multi-country analysis. Social Science and Medicine, 86, 26–34.

    Article  PubMed  Google Scholar 

  37. Ensor, T., Quigley, P., Green, C., et al. (2014). Knowledgeable antenatal care as a pathway to skilled delivery: Modelling the interactions between use of services and knowledge in Zambia. Health Policy and Planning, 29(5), 580–588. doi:10.1093/heapol/czt044.

    Article  PubMed  Google Scholar 

  38. Kerber, K. J., de Graft-Johnson, J. E., Bhutta, Z. A., et al. (2007). Continuum of care for maternal, newborn, and child health: From slogan to service delivery. Lancet, 370(9595), 1358–1369.

    Article  PubMed  Google Scholar 

  39. Jahn, A., Iang, M., Shah, U., et al. (2005). Maternity care in rural Nepal: A health service analysis. Tropical Medicine and International Health, 5(9), 657–665.

    Article  Google Scholar 

  40. Hodgkin, D. (1996). Household characteristics affecting where mothers deliver in rural Kenya. Health Economics, 5(4), 333–340.

    Article  CAS  PubMed  Google Scholar 

  41. Magoma, M., Requejo, J., Campbell, O., et al. (2013). The effectiveness of birth plans in increasing use of skilled care at delivery and postnatal care in rural Tanzania: A cluster randomised trial. Tropical Medicine and International Health, 18(4), 435–443.

    Article  PubMed  Google Scholar 

  42. Yanagisawa, S., Oum, S., & Wakai, S. (2006). Determinants of skilled birth attendance in rural Cambodia. Tropical Medicine and International Health, 11(2), 238–251.

    Article  PubMed  Google Scholar 

  43. Hazarika, I. (2011). Factors that determine the use of skilled care during delivery in India: Implications for achievement of MDG-5 targets. Maternal and Child Health Journal, 15(8), 1381–1388.

    Article  PubMed  Google Scholar 

  44. Mathole, T., Lindmark, G., Majoko, F., & Ahlberg, B. M. (2004). A qualitative study of women’s perspectives of antenatal care in a rural area of Zimbabwe. Midwifery, 20(2), 122–132.

    Article  PubMed  Google Scholar 

  45. Aliyu, M. H., Jolly, P. E., Ehiri, J. E., et al. (2005). High parity and adverse birth outcomes: Exploring the maze. Birth, 32(1), 45–59.

    Article  PubMed  Google Scholar 

  46. Adegoke, A., & Van Den Broek, N. (2009). Skilled birth attendance-lessons learnt. BJOG: An International Journal of Obstetrics and Gynaecology, 116(s1), 33–40.

    Article  Google Scholar 

  47. Moyer, C., Adongo, P., Aborigo, R., et al. (2014). ‘They treat you like you are not a human being’: Maltreatment during labour and delivery in rural northern Ghana. Midwifery, 30(2), 262–268.

    Article  PubMed  Google Scholar 

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Correspondence to Shane M. Khan.

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Khan, S.M., Singh, K. The Association Between Health Insurance Coverage and Skilled Birth Attendance in Ghana: A National Study. Matern Child Health J 20, 534–541 (2016). https://doi.org/10.1007/s10995-015-1851-6

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  • DOI: https://doi.org/10.1007/s10995-015-1851-6

Keywords

  • Health insurance
  • Skilled delivery
  • Ghana
  • Antenatal care
  • Continuum of care
  • Multiple Indicator Cluster Surveys