SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA EFFECTS OF DELIVERY CARE USER FEES EXEMPTION POLICY ON UTILIZATION AND OUTCOMES OF EMERGENCY OBSTETRIC CARE SERVICES IN TEMA GENERAL HOSPITAL BY FRANCIS SMART A DISSERTATION SUBMITTED IN PARTIAL FULFILMENT FOR THE AWARD OF THE MASTER OF PUBLIC HEALTH (MPH) DEGREE JULY, 2010 University of Ghana http://ugspace.ug.edu.gh ii DECLARATION Dr. Francis Smart, Principal Investigator of “Effects of Delivery Care User Fees Exemption Policy on Utilization and Outcomes of Emergency Obstetric Care Services in Tema General Hospital”, hereby faithfully declare that except for the duly acknowledged citations and ideas, this is an original work produced by me in fulfillment of my MPH Degree in the Department of Population, Family and Reproductive Health, undertaken under the supervision of my academic supervisor, Dr G. K. Norgbe. Signed: ………………………………………………………………… Student Name: Dr. Francis Smart ACADEMIC SUPERVISOR Signed: ………………………………………………………………….. Dr G. K. Norgbe University of Ghana http://ugspace.ug.edu.gh iii DEDICATION This work is dedicated to all women; and specifically to my Mother, Wife and Daughter(s) and friends, in recognition of their social and reproductive roles in maintaining relationships, families and populations; and the determination to pursue reproductive rights of all women through advocacy in Public Health for their improved well-being. University of Ghana http://ugspace.ug.edu.gh iv ACKNOWLEDGEMENT I thank God for his endowed divine inspiration, guidance and strength to pursue a professional discipline that is the focus of humanity and my proclivity. I wish to acknowledge the support of the Ministry of Health and Sanitation and United Nations Population Fund (UNFPA) in Sierra Leone for providing funds for this project. I also wish to particularly acknowledge the contributions of my academic supervisor, Dr G. K. Norgbe, Head, Department of Population, Family and Reproductive Health. I wish to acknowledge the approval and support of the Medical Superintendent of Tema General Hospital, Dr. Charity Sarpong; the Head of Maternity Unit, Dr Sylvia Deganus; Sister-in-Charge of the Maternity Unit, Ms. Perdita Barnnerman, Tema General Hospital; and all other staff of Tema General Hospital who assisted me in diverse ways to put the data together; fervently acknowledge the contributions of my in-depth interview respondents in Tema General Hospital. Additionally, I wish to acknowledge the contributions of the academic staff and the MPH students of the School of Public Health Class of 2009/2010, who helped to shape my proposal; and the administrative staff of the Department of Population, Family and Reproductive Health for their kind support services. Finally, I remain equally indebted to all authors whose work and ideas served as sources of reference for my research work. University of Ghana http://ugspace.ug.edu.gh v ABSTRACT Background Global challenge and commitment to reduce maternal mortality and morbidity burden in developing countries, particularly in Sub-Saharan Africa required Ghana to improve maternal health and achieve the Millennium Development Goal 5 targets. Ghana in 2003 introduced delivery care user fees exemption policy in four regions to remove financial access barrier to maternal health care services and increase utilization of facility delivery and caesarean section; extended to Tema General Hospital in July 2008. The implementation of delivery fees exemption policy has been extensively evaluated in four regions. This research assessed the effects of delivery care user fees exemption policy on utilization and outcomes of emergency obstetric care services in Tema General Hospital, located in the industrial municipality of Tema District, Greater Accra Region, Ghana. Methods The study design was cross-sectional and descriptive. Obstetric admissions in 2007 and 2009 were used to assess the effects of delivery fees exemption policy on utilization and outcomes of emergency obstetric care services. Non-probability sampling was applied. Quantitative and qualitative data were collected in June 2010 in Tema General Hospital. The data was processed and analyzed manually and with Epi Info. Results The delivery fees exemption policy implemented in Tema General Hospital significantly increased utilization of emergency obstetric care services (p<0.05 at 95% confidence University of Ghana http://ugspace.ug.edu.gh vi level for deliveries and caesarean sections). The policy had no significant effects on outcomes of emergency obstetric care (p>0.05): maternal mortality (p=0.738) and stillbirths (p=0.217). However, the policy statistically significantly reduced maternal deaths due to abortion complications (Fisher exact 1-tailed p=0.009). The introduction of the policy was not informed by any implementation plan and consequently, increased utilization overwhelmed the unprepared capacity of the hospital, resulting in poor quality of care, low client satisfaction, and reduction in Internally Generated Funds (IGF). Conclusion The delivery care user fees exemption policy introduced in Tema General Hospital significantly increased the utilization of the emergency obstetric care services but did not significantly affect the outcomes. The increased utilization with inadequate supportive policy context and policy measures, and lack of capacity to implement policy effectively resulted to poor quality of care. University of Ghana http://ugspace.ug.edu.gh vii Table of Contents DECLARATION ............................................................................................................................. ii DEDICATION .............................................................................................................................. iii ACKNOWLEDGEMENT ................................................................................................................ iv ABSTRACT ................................................................................................................................... v LIST OF TABLES ........................................................................................................................... x LIST OF FIGURES........................................................................................................................ xii LIST OF ABBREVIATIONS ............................................................................................................ xiii CHAPTER 1 .................................................................................................................................. 1 ORIENTATION TO THE STUDY .................................................................................................. 1 1.1 INTRODUCTION ....................................................................................................... 1 1.2 BACKGROUND ......................................................................................................... 2 1.3 GEOGRAPHICAL AREA .............................................................................................. 3 1.4. RATIONALE OF THE STUDY ....................................................................................... 4 1.5 STATEMENT OF THE PROBLEM ................................................................................. 4 1.6 PURPOSE OF THE STUDY .......................................................................................... 6 1.7 SIGNIFICANCE OF THE STUDY ................................................................................... 7 1.8 RESEARCH DESIGN AND METHODOLOGY ................................................................. 8 1.9 VALIDITY AND RELIABILITY ..................................................................................... 10 1.10 ETHICAL CONSIDERATION ...................................................................................... 10 1.11 DEFINITION OF TERMS ........................................................................................... 11 1.12 OUTLINE OF THE STUDY ......................................................................................... 13 1.13 SUMMARY ............................................................................................................. 14 CHAPTER 2 ................................................................................................................................ 15 LITERATURE REVIEW ............................................................................................................. 15 University of Ghana http://ugspace.ug.edu.gh viii 2. 1 INTRODUCTION ..................................................................................................... 15 2.2 HEALTH FINANCING REFORMS ............................................................................... 17 2.3 HEALTH FINANCING APPROACHES ......................................................................... 18 2.4 HEALTH FINANCING IN GHANA .............................................................................. 19 2.5 FINANCIAL ACCESS AND SERVICE UTILIZATION ....................................................... 19 2.6 FINANCIAL ACCESS AND SERVICE OUTCOMES ........................................................ 21 2.7 MILLENNIUM DEVELOPMENT GOAL 5 .................................................................... 22 2.8 STRATEGIES FOR REDUCING MATERNAL MORTALITY ............................................. 23 2.9 EMERGENCY OBSTETRIC CARE ............................................................................... 23 2.10 DELIVERY CARE USER FEES EXEMPTION POLICY IMPLEMENTATION .................... 25 2.11 THE PROCESS OF IMPLEMENTING EMERGENCY OBSTETRIC CARE........................... 26 2.12 SUMMARY ............................................................................................................. 28 CHAPTER 3 ................................................................................................................................ 29 RESEARCH DESIGN AND METHODOLOGY .............................................................................. 29 3.1 INTRODUCTION ..................................................................................................... 29 3.2 PURPOSE OF THE STUDY ........................................................................................ 29 3.3 RESEARCH DESIGN ................................................................................................. 30 3.4 POPULATION AND SAMPLE .................................................................................... 34 3.5 DATA COLLECTION AND DATA COLLECTION INSTRUMENT ..................................... 35 3.6 DATA ANALYSIS ...................................................................................................... 37 3.7 VALIDITY AND RELIABILITY ..................................................................................... 38 3.8 TRIANGULATION .................................................................................................... 39 3.9 BIAS ....................................................................................................................... 39 3.10 ETHICAL CONSIDERATIONS................................................................................. 40 3.11 STUDY LIMITATIONS........................................................................................... 41 University of Ghana http://ugspace.ug.edu.gh ix 3.12 SUMMARY ............................................................................................................. 42 CHAPTER 4 ................................................................................................................................ 43 RESUTS AND INTERPRETATION .............................................................................................. 43 4.1 INTRODUCTION ..................................................................................................... 43 4.2 Effects of Delivery Care User Fees Exemption Policy on Utilization of Emergency Obstetric Care Services in Tema General Hospital .............................................................. 44 4.3 Effects of Delivery Care User Fees Exemption Policy on Outcomes of Emergency Obstetric Care Services in Tema General Hospital .............................................................. 59 4.4 SUMMARY ................................................................................................................... 74 CHAPTER 5 ................................................................................................................................ 75 DISCUSSIONS ........................................................................................................................ 75 5.1 Changes in Utilization and Outcomes of Emergency Obstetric Care Services in Tema General Hospital................................................................................................................ 75 5.2 Comparison of Changes in Utilization of Emergency Obstetric Care Services in Tema General Hospital................................................................................................................ 76 5.3 Capacity of Tema General Hospital and Utilization of Emergency Obstetric Care Services ............................................................................................................................. 80 5.4 SUMMARY ............................................................................................................. 82 CHAPTER 6 ................................................................................................................................ 83 CONCLUSION AND RECOMMENDATIONS .............................................................................. 83 6.1 Recommendations ................................................................................................. 85 REFERENCES ............................................................................................................................. 89 APPENDICES .............................................................................................................................. 92 Appendix I - Data Collection Tools ..................................................................................... 92 Appendix II ........................................................................................................................ 94 Appendix III ……. Consent From ......................................................................................... 96 University of Ghana http://ugspace.ug.edu.gh x LIST OF TABLES Table 4.1 Facility Case Summary of Emergency Obstetric Care Services in Tema General Hospital, 2007 and 2009………………. 44 Table 4.2 Percentage Change in Utilization of Emergency Obstetric Care Services in Tema General Hospital, 2007 and 2009........................... 46 Table 4.3 Significance of Change in Caesarean Sections in Tema General Hospital, 2007 & 2009...…………………………… 53 Table 4.4 Significance of Change in Deliveries in Tema General Hospital, 2007 & 2009................................................................... 55 Table 4.5 Percentage Changes in Utilization of Emergency Obstetric Care Services in Tema General Hospital, 2007 & 2009………… 56 Table 4.6 Immediate Outcomes of Emergency Obstetric Care Services in Tema General Hospital, 2007 & 2009 ………………. 60 Table 4.7 Significance of Change in Maternal Mortality in Tema General Hospital, 2007 & 2009 ...…………………………………. 61 Table 4.8 Significance of Change in Stillbirths in Tema General Hospital, 2007 & 2009 ………………………………………………………… 62 Table 4.9 Indicators of Outcomes of Emergency Obstetric Care Services in Tema General Hospital, 2007 & 2009 ………………………… 63 University of Ghana http://ugspace.ug.edu.gh xi Table 4.10 Outcomes of Obstetric Complications (Selected) in Tema General Hospital, 2007 & 2009 ……………………………… 64 Table 4.11 Significance of Reduction in Maternal Deaths due to Five Major Direct Causes in Tema General Hospital, 2007 & 2009 ……. 67 Table 4.12 Case Fatality Rates for Five Major Obstetric Complications in Tema General Hospital, 2007 & 2009 ………………………… 69 Table 4.13 Significance of Change in Maternal Deaths due to Haemorrhage in Tema General Hospital, 2007 & 2009 …………… 71 Table 4.14 Significance of Change in Maternal Deaths due to Abortion Complications in Tema General Hospital, 2007 & 2009 ……………………………………………………… 72 University of Ghana http://ugspace.ug.edu.gh xii LIST OF FIGURES Figure 2.1 Conceptual Frameworks Showing the Interplay of Structures, Processes and Outcomes of Emergency Obstetric Care Services …… 26 Figure 2.2 The “Building Blocks Model” of Essential Components for Setting up EmOC Services ……………………………………… 27 Figure 4.1 Utilization of Emergency Obstetric Care Services in Tema General Hospital, 2007 and 2009 …………………………… 45 Figure 4.2 Monthly Obstetric Admissions in Tema General Hospital, 2007 & 2009……………………………………………………… 49 Figure 4.3 Monthly Caesarean Sections in Tema General Hospital, 2007 & 2009………………………………………………………… 52 Figure 4.4 Monthly Deliveries in Tema General Hospital, 2007 and 2009 ……………………………………………………… 54 Figure 4.5 Percentage Changes in Obstetric Admissions, Deliveries and Caesarean Sections in Tema General Hospital, 2007 & 2009……….. 57 Figure 4.6 Direct Causes of Maternal Deaths in Tema General Hospital, 2007……………………………………………… 66 Figure 4.7 Direct Causes of Maternal Deaths in Tema General Hospital, 2009……………………………………………... 66 University of Ghana http://ugspace.ug.edu.gh xiii LIST OF ABBREVIATIONS AMDD – Averting Maternal Death and Disability ANC – Antenatal Clinic ART – Anti-Retro-Viral Therapy BEmOC – Basic Emergency Obstetric Care BJOG – British Journal of Obstetrics and Gynaecology CEmOC – Comprehensive Emergency Obstetric Care CFR – Case Fatality Rate CHPS – Community-based Health Planning and Services CR – Central Region CS - Caesarean Section CSR – Caesarean Section Rate CSSD – Central Sterilization Supply Department ECG – Electrocardiograph EmOC – Emergency Obstetric Care ENT – Ear Nose and Throat IGF – Internally Generated Funds IMR - Infant Mortality Ratio LB – Live Birth MDG – Millennium Development Goal University of Ghana http://ugspace.ug.edu.gh xiv MMR – Maternal Mortality Ratio MVA – Manual Vacuum Aspiration NGOs – Non-Governmental Organizations NHIS – National Health Insurance Scheme Ob/Gyn – Obstetrics and Gynaecology OPD - Out-Patient Department PMM – Prevention of Maternal Mortality PMTCT – Prevention of Mother-to-Child Transmission PPH – Postpartum Haemorrhage QI – Quality Improvement RHCS – Reproductive Health Commodity Security RHRC – Reproductive Health Response in Conflict SBR – Still Birth Rate UN – United Nations VCT – Voluntary Counseling and Testing VR – Volta Region WHO – World Health Organization University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER 1 ORIENTATION TO THE STUDY 1.1 INTRODUCTION Maternal mortality and morbidity has always been a global issue and prevention of maternal deaths resulting from obstetric complications is still a huge challenge for developing countries, particularly in Sub-Sahara Africa. The reduction of maternal mortality remains on the international agenda in order to achieve the fifth Millennium Development Goal (MDG-5), improve maternal health. Women die from life-threatening medical conditions that are presented as emergencies and occur during pregnancy, childbirth or the immediate postnatal period (Ronsmans & Graham, 2006). Emergency obstetric care is one of the key strategies known to reduce maternal mortality. In a bid to improve maternal health, the Ministry of Health, Ghana in September 2003 introduced the delivery care user fees exemption policy in four regions and was extended to the Tema General Hospital in July 2008. This study focused on the effects of the delivery care user fees exemption policy on utilization and outcomes of emergency obstetric care services in Tema General Hospital. The admission and treatment outcomes of women with pregnancy-related complications were assessed before and after the introduction of delivery care user fees exemption policy in the maternity unity of Tema General Hospital. This study was conducted in June 2010. University of Ghana http://ugspace.ug.edu.gh 2 1.2 BACKGROUND Globally, many women are dying from obstetric complications (Horton, 2006) and majority of the maternal deaths occur in developing countries (Graham, 2009), especially in Sub-Saharan Africa and Asia, with most of them occurring in Sub-Saharan Africa. Ghana has an unacceptable number of women dying from pregnancy-related complications (Ghana Statistical Service, 2007). Sierra Leone is another example where maternal mortality has been estimated to be very high (Statistics Sierra Leone, 2008). Thus, maternal mortality and morbidity continue to be global and national issues for Ghana, Sierra Leone and other countries in the sub-region. Prevention of maternal deaths resulting from life-threatening obstetric complications is still a huge challenge for developing countries, particularly in Sub-Sahara Africa including Ghana. Reduction of maternal mortality therefore remains on the international and national agendas in order to achieve the MDG-5. The Ministry of Health, Ghana in September 2003 introduced the delivery user fees exemption policy directed at making delivery care free in a bid to reduce maternal mortality and achieve the MDG 4 & 5. The policy aimed at improving uptake, quality, financial and geographic access to delivery care services by covering normal deliveries, assisted deliveries including caesarean sections and management of medical and surgical complications arising out of deliveries in public, private and faith-based health facilities (Ofori-Adjei, 2007; Witter et al, 2008). University of Ghana http://ugspace.ug.edu.gh 3 The delivery care user fees exemption policy was initiated in four regions and incrementally extended to cover the entire country over time. The funding source of the policy was replaced by the National Health Insurance Scheme in 2007 and was started in the Tema General Hospital in July 2008. 1.3 GEOGRAPHICAL AREA The study was conducted in Tema General Hospital, located in the Tema Metropolis. Tema Metropolis is one of the 10 districts in the Greater Accra Region and is a vibrant commercial and industrial city. The population of Tema Metropolis was estimated at 403,934 (projection from 2000 Population Census), making it the second largest populated district in the Greater Accra Region. The Tema General Hospital is the largest Public Health Institution in the Team Metropolis, which exists to promote, protect and ensure good health and well-being of clients and the community at large. The geographic location of the Hospital is surrounded by road networks, making the Hospital the major referral point for all other clinics/hospitals, public and private in and around the Metropolis. Thus the catchment area includes the whole of Tema Metropolis, its satellite towns and villages. The Tema General Hospital had ten (10) Wards and 280-bed capacity. It provides 24 hours specialist and general services to both out-patients and in-patients. It serves approximately a total population of 628,058. University of Ghana http://ugspace.ug.edu.gh 4 1.4. RATIONALE OF THE STUDY The facts that user fees exemption policies increase utilization of maternal health care services (Borghi et al, 2006; Kruk et al, 2007) and emergency obstetric care (EmOC) is one of the key known strategies to reduce maternal mortality (Paxton et al, 2005; Campbell & Graham, 2006) was a compelling reason to assess the effects of delivery care user fees exemption policy on utilization and outcomes of emergency obstetric care services in Tema General Hospital. Implementations of delivery care user fees exemption policy that started in four regions in 2003 have been extensively evaluated. The findings of previous evaluations motivated the researcher to study the effects of delivery care user fees exemption policy on utilization and outcomes of emergency obstetric care services in Tema General Hospital. Ghana and Sierra Leone are implementing National Health Insurance Schemes as national strategy to increase access to maternal and child health and consequently improve maternal health. Early understanding of the effects of this funding mechanism on the utilization and outcomes of EmOC services is a critical motivation for this study. 1.5 STATEMENT OF THE PROBLEM Ghana has a maternal mortality ratio of 451 per 100,000 live births (Ghana Statistical Service, 2007) and infant mortality of 50 per 1,000 live births (Ghana Statistical Service, 2008). Sierra Leone has an estimated 857 maternal deaths per 100,000 live births and an infant mortality rate of 89 per 1,000 live births (Statistics Sierra Leone, 2008). University of Ghana http://ugspace.ug.edu.gh 5 The exemption policy covers normal deliveries and EmOC services (Ofori-Adjei, 2007). However, evaluation reports of the delivery care user fees exemption policy introduced by the Government of Ghana in 2003 indicated that the implementation of the policy did not reduce maternal mortality significantly (Witter et al, 2008; Immpact, 2008). The adequacy of support for EmOC strategy, known to be an essential requirement for reduction of substantial proportion of maternal mortality (Campbell & Graham, 2006) needs to be evaluated in order to make recommendations for improvement in services. The previous evaluation studies did not particularly examine the adequacy of funds, reproductive health commodities, human resource, health systems performance and institutional efficiency, community factors and quality improvement in relation to the effects of the exemption policy on the utilization and outcomes of EmOC services. Borghi et al in 2006 had noted the concern that government funding needs to increase to avoid the risk of shortage of drugs and medical supplies and reduce the risk of an increase in informal charges when implementing exemption polices for EmOC services. The delivery care user fees exemption policy initiative was introduced in the Tema General Hospital in July 2008 and therefore was not part of the earlier assessments of the delivery care user fees exemption policy implementation. University of Ghana http://ugspace.ug.edu.gh 6 1.6 PURPOSE OF THE STUDY The purpose of this study was to answer the following research questions: 1. What are the effects of the introduction of delivery care user fees exemption policy on the utilization and outcomes of emergency obstetric care services in Tema General Hospital? 2. How do operational capacity challenges posed by the introduction of the delivery care user fees exemption policy in Tema General Hospital affect the utilization and outcomes of emergency obstetric care services? The following general and specific objectives were set and pursued to answer the above research questions. 1.6.1 General Objective To assess the effects of delivery care user fees exemption policy on utilization and outcomes of emergency obstetric care services in the Tema General Hospital. 1.6.2 Specific Objectives 1. To determine changes in utilization of emergency obstetric care services in Tema General Hospital, one year before (2007) and one year after (2009) the introduction of delivery care user fees exemption policy. University of Ghana http://ugspace.ug.edu.gh 7 2. To determine and compare the changes in outcomes of emergency obstetric care services in Tema General Hospital, one year before (2007) and one year after (2009) the introduction of delivery care user fees exemption policy. 3. To describe how the capacities of Tema General Hospital facilities for the provision of emergency obstetric care services affect service utilization and outcomes, one year before (2007) and one after (2009) the introduction of delivery care user fees exemption policy. 1.7 SIGNIFICANCE OF THE STUDY The results of this study will give insight into the capacity needs of the Tema General Hospital for provision of EmOC services to operationalize delivery care user fees exemption policies. The changes in utilization and outcomes of EmOC services influenced by introduction of the delivery care user fees exemption policy will provide a comprehensive picture of mortality patterns needed for effective EmOC planning. Changes in outcomes of EmOC services in particular will also bring to attention issues of specialized obstetric care including quality of care associated with implementation of the delivery care fees exemption policy. Policy-makers and funding agencies will understand and appreciate the resource implications of implementing delivery care user fees exemption policies for sustainability of interventions and impact. Answers to the research questions will also inform and guide decision-making processes during formulation and implementation of delivery care user fees exemption policies with focus on EmOC services. The information on cause-specific deaths will be beneficial to the Tema Government Hospital; will inform community mobilization and programmatic planning. University of Ghana http://ugspace.ug.edu.gh 8 1.8 RESEARCH DESIGN AND METHODOLOGY Designing a study is a complex research process that involves number of decisions. Research design provides complete guidelines for data collection. The design and methodology determines the selection of the research approach, design of sampling plan, design of experiment and design of questionnaire (Panneerselvam, 2008). This research design involved identification of the problem, formulation of the research questions and objectives, selection of an observational technique (cross-sectional), data collection and analysis to obtain appropriate and accurate findings that answer the research questions. 1.8.1 Population The population of a study is the universe of investigation and includes all the possible observations of the same kind; and may be considered the total number of all units of the phenomenon to be investigated that exits in the area of investigation (Kumekpor, 2002). Projection from the 2000 population census estimates that out of 115,121 women of reproductive age in Tema District, 16,157 were expected to be pregnant in 2009. The Obstetrics and Gynaecology Department in the Tema General Hospital had an estimated number of 80 midwives and 6 doctors and conducted about 7,500 deliveries annually. The study population was all normal deliveries and obstetric complications admitted in 2007 and 2009 for the quantitative method and hospital staff from units relevant for EmOC services for the qualitative method. University of Ghana http://ugspace.ug.edu.gh 9 1.8.2 Sample and Sampling A sample is a carefully selected portion of the study population, considered to be representative of the total population. It is that proportion of the number of units selected for investigation. Sampling is the use of definite procedures to examine a carefully selected proportion of the units of a phenomenon under study in order to help extend knowledge gained from the study of the part to the whole from which the part was selected (Kumekpor, 2002). In this study non-probability sampling was applied and the entire population of normal deliveries and obstetric complications were examined. 1.8.3 Data Collection and Data Collection Instrument Data collection involves search for, measure and record of the phenomenon under investigation. For this process to be objective and purposeful, the collection of research data was well planned and controlled. Scientific observation is governed by a code of objectivity which forms the basis for selecting what to observe and how the observation is carried. Data collection instruments are used to achieve the objectives of the study objectively. Therefore the data source is very important. In this research secondary data was used. Secondary data is an existing data base to investigate research questions other than those for which the data were originally gathered. 1.8.4 Data Analysis Secondary analysis is use of existing data sets to investigate research questions other than those for which the data were originally gathered. There are two types of secondary data University of Ghana http://ugspace.ug.edu.gh 10 sets. The individual data means that there is separate information for each member of a list of individuals. The aggregate data means that no information is available for specific individuals, only for groups. Both types were used in this study for the quantitative data; and in-depth interviews were conducted to obtain the qualitative data. The data were manually processed. Epi Info software was used to analyze the quantitative data and determine particularly the association between the delivery care user fees exemption policy and the utilization and outcomes of EmOC in Tema Genera Hospital. 1.9 VALIDITY AND RELIABILITY Validity and reliability describe the process of drawing and applying the study conclusions. The internal validity of the study denotes the degree to which the researcher’s conclusions correctly describe what exactly happened in the study and external validity, the degree to which the conclusions were appropriate when applied to the population outside the study. The validity in this study was maximized by including all normal and obstetric complications admitted in 2007 and 2009. Research findings are considered to be reliable when they are not very different from the findings of other similar researches conducted using similar methodology. These research findings were consistent with findings of previous evaluations of the delivery fees exemption policy. 1.10 ETHICAL CONSIDERATION Three general ethical principles of respect for persons and research subjects, of beneficence and of justice were considered during the conduct of the research. Consent University of Ghana http://ugspace.ug.edu.gh 11 forms were signed and permissions granted to conduct the research by the appropriate persons, body and institution. 1.11 DEFINITION OF TERMS The formal definitions of terms are those quoted and referenced, and the operational definitions are those designed to apply to this research. These are as follow: Case Fatality Rate is percentage of deaths from specific cause (Gordis L, 2008). In this study the case fatality rate means the percentage of women who died from cause-specific obstetric complications at the Tema General Hospital. Emergency Obstetric Care Services: Constellation of series of processes and crucial life-saving signal functions ideally performed in a medical facility to prevent the death of a woman experiencing the start of complications during pregnancy, delivery, or the post- partum period (Reproductive Health Response in Conflict (RHRC) Consortium, 2005). Emergency obstetric care services in this study imply all obstetric complications attended to, including basic and comprehensive emergency obstetric care signal functions performed and the processes applied to ensure 24 hours emergency obstetric care coverage in one year before and after the introduction of the delivery care fee exemption policy in the Tema General Hospital Maternity Unit. Emergency preparedness refers to prenatal anticipation of obstetric complications and planning for readiness to avoid delays in preventing or treating the prevailing condition(s) University of Ghana http://ugspace.ug.edu.gh 12 WHO, 2006). In this study, emergency preparedness refers to capacity of Tema General Hospital Maternity Unit to handle obstetric emergencies promptly and adequately. Infant Mortality Rate is the number of infant (0-12 months) deaths per 1,000 live births in one year in a given country (Rowland, 2003); same meaning applied in this research. Maternal Death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes (WHO, 2004). In this study, the same meaning was applied. Maternal Mortality Ratio is the number of maternal deaths in a period to 100,000 live births in the same period (Ronsmans & Graham, 2006). Obstetric complications are defined as life-threatening medical conditions presenting as emergencies that occur during pregnancy, childbirth or the immediate postnatal period (Ronsmans & Graham, 2006). This study looked at the top five obstetric complications that were direct causes of maternal deaths, in the Tema General Hospital. Outcomes of emergency obstetric care services are defined as the immediate outputs of emergency obstetric care interventions which usually measure the effectiveness of the services (RHRC, 2005). For this study, the outcomes are maternal deaths, facility-based University of Ghana http://ugspace.ug.edu.gh 13 maternal mortality ratio, stillbirths, cause-specific case fatality rates of the top five obstetric complications, stillbirth rate and caesarean section rate. Stillbirth is any fetus born with no life, after 24 weeks’ gestation (Campbell & Lees, 2000). This study looked at fetuses borne after 28 weeks gestation, either fresh or macerated. Utilization of emergency obstetric services measures the number of patients that used specific emergency obstetric care services (Kruk et al, 2007). In this study, the total number of deliveries, caesarean sections and obstetric admissions in one year before and after the introduction of the delivery care fees exemption policy in the Tema General Hospital Maternity Unit were used as process indicators to measure the utilization of emergency obstetric care services. 1.12 OUTLINE OF THE STUDY The outline of this study shows the order in which the research was conducted and reported. Chapter 1 discusses the orientation of the study. It summarizes the proceedings of the study and explains why the research was conducted and provides a summary of how it was done. Chapter 2 presents the literature review. The literature review informed and guided the study using the previous approaches of other researchers. University of Ghana http://ugspace.ug.edu.gh 14 Chapter 3 presents and discusses in detail how the research was conducted; what was done and how it was done in relation to the research protocols and instruments. Chapter 4 presents the findings of the research. It includes data presentation and analysis. The findings are presented as obtained from the analysis without any additional expressions outside the findings obtained. Chapter 5 presents the discussions. Here, the researcher compares and contrasts his results with other findings using information contained in the literature review. The researcher presents here his perspective of the results in relation to the research problem and puts forward his insight and position based on the data. Chapter 6 presents the conclusion of research findings and recommendations. 1.13 SUMMARY This chapter presented the summary of the proceedings of the research, the background including global and local situations of the problem, the geographic focus of the study, the motivation for the study, the specific problem and problem statement, the importance of the findings of the study, basis for the research design and data collection methods, ethical principles and noted the definitions of terms in the study. The next section of the dissertation, Chapter 2 presents the literature review which formed the basis of the preceding and proceeding chapters. University of Ghana http://ugspace.ug.edu.gh 15 CHAPTER 2 LITERATURE REVIEW Literature review is the process of reading and gathering relevant information from a wide range of existing literatures with the view of enriching your knowledge and information base to inform and guide your research processes, procedures and methods. 2. 1 INTRODUCTION Each year globally, over 500,000 women die from pregnancy-related complications (Horton, 2006) and about 99.2% of maternal deaths occur in developing countries and 0.8% in developed countries (Graham, 2009). More than 90% of the maternal deaths occur in Sub-Saharan Africa and Asia, most of them occurring in Sub-Saharan Africa. The global maternal mortality ratio estimate indicated that 400 women die during childbirth per 100,000 live births (WHO, 2005) and nearly 1,000 per 100,000 live births for Sub-Saharan Africa. The global estimate for the lifetime risk is one in 74, one in 16 for Sub-Saharan Africa and one in 6 for Sierra Leone (Ronsmans & Graham, 2006). However, a recent publication of The Lancet (Hogan et al, 2010) indicates considerable progress in reducing maternal mortality worldwide. The health of mothers and children became a public health priority during the 20th century (WHO, 2005). The Primary Health Care Declaration in 1978 at Alma Ata catalyzed the global campaign to reduce maternal mortality. This was formally launched in 1987 in Nairobi, Kenya, as the Safe Motherhood Initiative (Starrs, 2006). In the opening years of the 21st century, the MDGs placed maternal and child health at the core University of Ghana http://ugspace.ug.edu.gh 16 of the struggle against poverty and inequality, and considered it as a matter of human rights. Notwithstanding, over 300 million women in the world suffer from long-term or short-term illness brought about by pregnancy or childbirth (WHO, 2005). For centuries, care for mothers and young children was regarded as a domestic affair, the realm of mothers and midwives (WHO, 2005). Despite the complexity of maternal mortality, today’s technological advancement, including research suggests that only few strategic choices need to be made to reduce maternal mortality (Campbell & Graham, 2006). Empirical research and reviews of options for reduction of maternal mortality lucidly show that emergency care strategies are an essential requirement for reduction of a substantial proportion of maternal mortality, given that 15% of all pregnancies will end with life-threatening complications. To ensure a ready supply of EmOC services, health centers and hospitals have to be equipped to deal with the emergencies that reach them so that timely care is not slowed down by the need to pay at point of contact for life-saving treatments, or to purchase drugs and consumables outside the facility or organize blood donations, or to wait for skilled health personnel (Campbell & Graham, 2006). To avoid delays to save lives, many countries have resorted to health care financing mechanisms, including government-funded delivery care user fees exemption policies. The impact of maternal mortality on social and economic development at community and national levels is insidious and vicious. High maternal mortality perpetuates poverty, making the poor poorer. As a result of the economic and social demises of maternal mortality, infant and child mortality are correspondingly high in poor countries with high maternal mortality rates. Women are intensely vulnerable to the effects of costs incurred University of Ghana http://ugspace.ug.edu.gh 17 during childbirth (Filippi et al, 2006). Therefore, reducing financial barriers to health services will improve the utilization of maternal health services, and consequently reduce maternal mortality in developing countries (Kruk et al, 2007). 2.2 HEALTH FINANCING REFORMS The user fees policy was among the health reform strategies of the 1990’s as part of the structural adjustment policy of the International Monetary Fund. The internal (ruling governments) and external (World Bank, International Monetary Fund) pressure to introduce user fees was stronger than the civic opposition to such reforms in Africa. Countries in the 1990’s attempted to increase governments financing through charging the users as part of the health sector reforms initiated in Africa. It was difficult for most African governments to effectively implement the exemptions targeted at the poor and vulnerable groups. During implementation of the health sector reforms in many developing countries in the 1990’s, the user-fees policies required government capacity for routine data collection, accounting, administrative functions as well as financial management roles at central and sub-national levels. The user fees policies failed due to the inadequate supportive policy context and policy measures, and the lack of government capacity to implement policy effectively in many African countries. In 1983, government financing of health care in Ghana was only 20% of its level in 1975. The acute shortages of commodities and pressure from doctors and managers to maintain professional expectations of service standards caused a radical revision of the cost recovery policy and user fees were instituted (Mills et al, 2001). University of Ghana http://ugspace.ug.edu.gh 18 2.3 HEALTH FINANCING APPROACHES Alternative approaches to financing health-care exist (Green, 2002). Fees for service and private insurance is the most basic form of health-care financing, where a fee is charged to cover all or part of cost of the service provided. Tax revenue and social insurance schemes which widen the base of private schemes with payments tied to wage-levels are often compulsory. Where finance is raised from income tax, this is progressive (individuals receiving higher income pay more tax) as long as all incomes can be assessed and tax collected. This may be regressive, where the funding is raised from an indirect tax, depending on the goods on which such taxes are levied (and, in particular, whether these are essentials or luxury items). Other tax options include payroll taxes, import duties, and export levies (Ackon, 2003). Community financing, alternative methods of raising finance at the community level are often suggested by agencies such as UNICEF under the Bamako Initiative. Some of these are linked to service use (Revolving Drug Funds, which are essentially a form of user charge with the income retained at the level of the facility), whereas others are genuinely community-based levy. Loans and grants may be provided in cash or in kind, through means such as technical assistance or the supply of free drugs. In the case of drugs, this has the effect of directly subsidizing the service. Loans are more usually for capital financing. Loans and grants may also be tied in different ways. Conditions may be placed on how the money is spent, and in particular on where it is to be spent. University of Ghana http://ugspace.ug.edu.gh 19 2.4 HEALTH FINANCING IN GHANA The financing of health care in recent years has been dynamic in Ghana; it moved from “cost recovery” to user charges, through delivery care user fees exemption policy to National Health Insurance Schemes in 2007. In Ghana, health service is financed through public funds, private contribution through user charges, internally generated funds and external aid (Ackon, 2003). Public funding is from budgetary allocation of the consolidated vote to public sector health services and subventions to mission hospitals. Private funding is from user charges from hospital fees: Internally generated funds (IGF), Cash and carry scheme, instituted in 1992. Revolving drug funds contributed to drugs and overhead costs. External aid funding includes bilateral, multilateral and United Nations (UN) agencies recurrent funding, spent mainly on projects and programmes. Other sources of financing options include community financing which include contributions by beneficiary individuals and groups to support part of the cost of the health care service, in cash or kind for community clinics at Level A and health posts at level B. Health Insurance covers individuals and families, from first visit of a patient to a general practitioner, to a specialist, through to treatment in hospital. 2.5 FINANCIAL ACCESS AND SERVICE UTILIZATION Empirical evidences associate greater government participation in health financing and higher levels of health spending including introduction of health care delivery fees exemption policies with increased utilization of maternal health services (Kruk et al, 2007), particularly for emergency obstetric care. University of Ghana http://ugspace.ug.edu.gh 20 Kruk et al in 2007 conducted a study on “Health care financing and utilization of maternal health services in developing countries” to determine the association between government versus private financing of health services and utilization of antenatal care, skilled birth attendants and caesarean section in 42 low-income and lower-middle-income countries. The study used a cross-national analysis to examine whether greater government participation in health care financing is associated with utilization of essential maternal health services. Utilization of a skilled birth attendant was defined as having a doctor, nurse or midwife present at the delivery. The primary dependent variables of interest in their analysis were rates of utilization of three maternal health services: antenatal care, skilled birth attendants and caesarean section. The key independent variable in that analysis was government health expenditure as a percentage of total health expenditure. The results show that utilization of skilled birth attendants and caesarean sections were far below international target levels, defined by WHO as 100% and 5–15% of pregnant women, respectively. Penfold et al (2007) assessed how the free delivery policy affected utilization, quality of services and health and non-health outcomes for households in the Central and Volta Regions of Ghana. In the same study pre- and post- intervention implementation cluster- sampled household survey design was used although health facility data already showed increased numbers of deliveries after the introduction of the fee exemption scheme. The study population was women who delivered a baby during the fee exemption phase, and those who had delivered during an equivalent duration of time prior to the fee exemption University of Ghana http://ugspace.ug.edu.gh 21 phase. Witter et al, in another study conducted in 2007 showed a significant increase in facility deliveries; and in deliveries with a skilled attendant. Maine (1997) conducted a study which showed that EmOC can be improved not only by concentrating on hospitals and physicians, but also by focusing on peripheral facilities and other qualified staff. The teams' findings regarding utilization of EmOC suggest that more people utilize services when they know them to be functioning well. 2.6 FINANCIAL ACCESS AND SERVICE OUTCOMES Bosu et al in 2007 conducted another evaluation study and found that delivery-related maternal mortality ratio (MMR) decreased in the Central Region (CR) and in the Volta Region (VR) following the implementation of the delivery care user fees exemption policy; but changes were not statistically significant. Interventions to improve access to care at the Juaben Teaching Health Centre in the Ashanti Region of Ghana led to a three- fold increase among women with complications seeking care and a 67% drop in referrals for treatment. The increase in uptake of delivery care observed in the study conducted by Bosu et al (2007) supported data from routine reports and a community survey. In a qualitative study conducted by Witter et al (2007), perceptions of increased utilization were triangulated with routine reports, where available. These showed different patterns in different districts. For example, in one district in the Central Region, skilled attendance rates had remained constant, but with evidence of a switch to facility based deliveries. In other districts the policy appeared to be linked to increases in facility based deliveries. University of Ghana http://ugspace.ug.edu.gh 22 The Ghana Maternal Health Survey Report 2007, the Ghana Demographic Health Survey 2008 Report and other recent evaluation reports of implementation of the delivery care user fees exemption policy showed that the maternal mortality ratio is not only high but has increased since 2005; and the proportion of deliveries attended by skilled health personnel has declined from 54% to 35% between 2005 and 2007 (Immpact, 2008). The evaluation reports on the implementation of the delivery care user fees exemption policy in Ghana further indicated that the intervention was not quite successful but the studies fell short of providing information on the patterns of effects of the exemption policy on the outcomes of EmOC services (Bosu et al, 2007). 2.7 MILLENNIUM DEVELOPMENT GOAL 5 The Millennium Development Goal (MDG) 5, “improve maternal health” calls for 75% reduction in maternal mortality between 1990 and 2015 (Horton, 2006). Maternal death was chosen as the outcome with which to judge progress towards this goal. In Ghana nationally, access to caesarean section has increased from 4 percent in 2003 to 7 percent in 2008; and the percentage of births assisted by a skilled provider has increased to about 59% (Ghana DHS, 2008); with wide regional variations. To achieve MDG 5 obliges to meet targets 5A and 5B, which in turn require the implementation of strategies known to reduce maternal mortality in combination, including family planning. Greater government participation in health financing and higher levels of health spending are associated with increased utilization of two maternal health services: skilled birth attendants and caesarean section. Hence greater absolute levels of health spending will be University of Ghana http://ugspace.ug.edu.gh 23 required if developing countries are to achieve the MDG on maternal health (Kruk et al, 2007). Supportive of the above, Ghana delivery care fees exemption policy covers normal deliveries and emergency obstetric care services (Ofori-Adjei, 2007; Witter et al, 2008). 2.8 STRATEGIES FOR REDUCING MATERNAL MORTALITY Emergency care is an essential requirement for reduction of a substantial proportion of maternal mortality (Paxton et al, 2005; Campbell & Graham, 2006). Skilled birth attendance and emergency obstetric care, including caesarean section, are two of the most important interventions to reduce maternal mortality (Kruk et al, 2007). In fact, historical evidence shows that no country has managed to bring its maternal mortality ratio below 100 per 100,000 live births without ensuring that all women are attended by an appropriately skilled health professional during labour, birth and the period immediately afterwards (WHO, 2006). However, the financial cost of developing a skilled attendance strategy is substantial and payment exemptions in public facilities must be better financed to overcome both supply and demand-side barriers to care seeking (Borghi et al, 2006). Additionally, it has long been recognized that some women need specialist obstetric care to prevent maternal death, and access to essential obstetric care, particularly caesarean sections, is vital to the success of making pregnancy safer. 2.9 EMERGENCY OBSTETRIC CARE Emergency obstetric care (EmOC) is a medical response to childbirth-related life- threatening condition(s) and is not a standard for all deliveries. The EmOC signal functions are often divided into two categories: Basic EmOC, which can take place at a University of Ghana http://ugspace.ug.edu.gh 24 health centre and be performed by a nurse, midwife or doctor; trained and proficient in managing normal delivery and capable of detecting obstetric complications for treatment and referral. Comprehensive EmOC usually requires the facilities of a district hospital with an operating theatre. Basic EmOC signal functions include: parenteral antibiotics, oxytocics and anticonvulsants, assisted vaginal delivery, manual removal of placenta, removal of retained products and neonatal resuscitation. Comprehensive EmOC signal functions include Basic EmONC, PLUS: blood transfusion and caesarean section. Extensive local studies on emergency obstetric care are generally limited, particularly in the sub-region where maternal mortality burden is highest. The Prevention of Maternal Mortality (PMM) Network conducted the early studies on emergency obstetric care in West Africa; designed and tested projects for reducing maternal deaths. The focus was on improving the availability, quality and utilization of EmOC for women with serious complications. The PMM Projects were initiated by Dr Deborah Maine and others from the Averting Maternal Death & Disability (AMDD) Programme, Mailman School of Public Health in Columbia University, USA. Recent research initiatives in the area of maternal mortality assessment are being conducted by the Initiative for Maternal Mortality Programme Assessment (Immpact), Aberdeen University, UK. Training institutions, UN agencies, bilateral, multilateral donor agencies and other non- governmental organizations (NGOs) have conducted limited studies (operations research and programmes/projects evaluation research) in response to the high maternal mortality in Sub-Saharan Africa. Particularly, evaluations of policies on free emergency obstetric University of Ghana http://ugspace.ug.edu.gh 25 care are not abounding. The evaluations of the delivery care user fees exemption policy implementation in Ghana have however generated much insight into the outcomes of the policy but without describing the effects of health financing policies on emergency obstetric care services in particular. 2.10 DELIVERY CARE USER FEES EXEMPTION POLICY IMPLEMENTATION Delivery care user fees exemption policy is usually a government policy that provides a funding mechanism for free provision of maternal and child health care services in order to increase targeted health services utilization, improve maternal and child health status and to reduce maternal and child mortality and morbidity (Kruk et al, 2007). The implementation of delivery care user fees exemption policy at the district level increases access to and utilization of Antenatal Care (ANC) services. Good quality ANC services consequently increase facility-based delivery, resulting to increased number of women having access to EmOC services. This increases the utilization and improves the outcomes of obstetric care services where the policy implementation meets the resource requirements for the provision of EmOC services. Implementation of the policy should improve obstetric service and administrative data management to tract output results. Thus, EmOC service provision requires a “building block” approach, where structures including material and human resources are linked to the processes and in turn to utilization of services as illustrated below (RHRC Consortium, 2005). The researcher used this conceptual framework together with the “Building Block Model” to assess the preparation that existed before and during the implementation of the delivery care user University of Ghana http://ugspace.ug.edu.gh 26 fees exemption policy in Ghana in relation to the utilization and outcomes of EmOC services in Tema General Hospital. District Level Exemption Policy CHPS/ANC Community •Outreach •Referral •Mobilization •Facility Maintenance •RHCS •Training •Placement •Team Building •QI Processes Data Outcomes •MD •SB •CSR •CFR •LB/SB 24/7 EmONC On-going Readiness Utilization •Ob. Compls. •CS •Live Births 9 QI – Quality Improvement Figure 2.1 Conceptual Frameworks Showing the Interplay of Structures, Processes and Outcomes of Emergency Obstetric Care Services Source: Field-friendly Guide to Integrated Emergency Obstetric Care in Humanitarian Programs, RHRC Consortium, 2005. 2.11 THE PROCESS OF IMPLEMENTING EMERGENCY OBSTETRIC CARE Based upon worldwide field experience in EmOC programmes, the process of implementing EmOC has been demonstrated by the “Building Blocks Model” (Reproductive Health Response in Conflict (RHRC) Consortium, 2005), which shows the University of Ghana http://ugspace.ug.edu.gh 27 key elements of planning and implementing EmOC programmes. The “Building Block Model” (Figure 2.2) is a theoretical, logical sequence; in steps of the preparation and service delivery stages, which emphasize the cohesion between structures, processes and outcomes of EmOC services. A break in the continuity of any aspect of the preparation stage affects the on-going processes and readiness for 24 hours EmOC services, which is critical for saving lives of women with obstetric complications. Any policy targeting free delivery services with the Service Delivery Stage Preparation Stage QI – Quality Improvement Figure 2.2 The “Building Blocks Model” of Essential Components for Setting up EmOC Services Source: Field-friendly Guide to Integrated Emergency Obstetric Care in Humanitarian Programs, RHRC Consortium, 2005. Utilization On-site QI Process External Supervision On-going Readiness Placement Team Building Renovation & Maintenance Supplies & Equipment Facility Setup Data Collection 24/7 EmOC Training University of Ghana http://ugspace.ug.edu.gh 28 aim of reducing maternal mortality must fully address and ensure sustainability of these components for operationalizing quality emergency obstetric care services. 2.12 SUMMARY Chapter 2 presented the literature review on global and local maternal mortality, health financing mechanisms, financial access and health care utilization and outcomes, Millennium Development Goal 5, emergency obstetric care and the exemption policy. The next chapter discusses how the research data was collected and analyzed. University of Ghana http://ugspace.ug.edu.gh 29 CHAPTER 3 RESEARCH DESIGN AND METHODOLOGY 3.1 INTRODUCTION Research method is a scientific method which involves specified procedures, techniques, ideas, and thoughts processes followed in getting specific things done, and, or in achieving particular ends or objectives (Kumekpor, 2002). The methods explain how this study attained the objectives and answered the research questions. The research methodology explains why certain choices of tools were made and how they are linked to the research questions and the conceptual framework. Each objective was given variables that measured the objectives appropriately. The steps were specific but the approach holistically put the steps together and gave meaning and understanding to the research problem. The tools used also highlighted the limitations to the research findings. The results were anticipated, and selected tools and scientific approaches were used, focusing on the objectives to obtain the findings without any biased influence. 3.2 PURPOSE OF THE STUDY The study assessed the changes in utilization and outcomes of emergency obstetric care services in Tema General Hospital before (2007) and after (2009) the introduction of the delivery care user fees exemption policy; associated the effects to the introduction of the policy. The study also described how the introduction of the policy affected the operational environment that contributed to changes in utilization and outcomes of emergency obstetric care in Tema General Hospital. The objectives were focused on the essentials of the study (research topic, problem statement, research questions) and guided the design and methods of investigation, University of Ghana http://ugspace.ug.edu.gh 30 including the selection of the appropriate utilization and outcome (dependent) variables to answer the research questions; directed the data collection, analysis and interpretation of the results. 3.3 RESEARCH DESIGN The study design was cross-sectional and descriptive. The researcher employed mixed (quantitative and qualitative) methods to collect data in June 2010 on utilization and outcomes of emergency obstetric care services in Tema General Hospital. 3.3.1 Secondary data Secondary data is an existing data base to investigate research questions other than those for which the data were originally gathered. The main advantages of secondary data are speed and economy. Secondary data sets have some serious limitations, with the selection of which data, the quality of the data gathered and the method of entry are all predetermined. Key advantages of secondary data analysis include economy of time and resources, breath of data available (months and all years) and the data collection process was informed by expertise and professionalism of the maternity staff using national data management standard registers and procedures. Key disadvantages to analyzing these secondary data are that the data were not originally collected to answer specific research questions and the researcher did not participate in University of Ghana http://ugspace.ug.edu.gh 31 the original planning and execution of the data collection processes. For instance, in the Tema General Hospital, aggregate data on obstetric complications were not classified as direct and indirect, instead direct and indirect admissions were recorded. In this study, the quantitative data was collected using secondary data form Tema General Hospital in June 2010. The data sets used were not originally collected by the researcher for the purpose of answering the specific research questions; instead the data were collected by maternity staff for some other purpose. The researcher had no involvement in the design and data collection process but only analyzed data sets, collected from daily registers and summary forms, monthly and quarterly reports. Therefore, focus was put on selecting data that were appropriate to answer the research questions. 3.3.2 Quantitative Quantitative method usually designs closed-ended questions in questionnaires to collect data (Blanche et al, 2008). Here, semi-closed questionnaires were designed. Specific questions were asked but optional answers were not provided; instead space was provided to fill-in corresponding specific answers from existing data sources that required time and expertise. Variables are characteristics of the study subjects to measure. The independent (exposure) variable was time (year) and categorized as: 1) before (2007) and 2) after (2009) introduction of delivery care user fees exemption policy. The following dependent (outcome) variables were used as process indicators to measure utilization; the first University of Ghana http://ugspace.ug.edu.gh 32 objective (% change in utilization of EmOC services): total number of obstetric admissions, total number of deliveries and total number of caesarean sections. Other dependent variables were used as process and proxy indicators to measure the second objective (% change in outcomes of EmOC): total maternal deaths, total stillbirths, cause- specific case fatality rates, stillbirth rate and caesarean section rate. The researcher assigned aggregated secondary data to respective variables, one at a time. The independent variable and specific dependent variables were used in the semi-closed questionnaires to measure the objectives. 3.3.3 Cross-sectional Measurements are taken on a snap-shot in time in cross-sectional designs (Bowling, 2002). The researcher chose a cross-sectional study because of relative economy of resources and time. In this study data was collected for one year before (2007) and one year after (2009) the delivery care user fees exemption policy was started in July 2008. 3.3.4 Descriptive Descriptive research tries to explain characteristics using specific objective(s) which result to definite conclusions (Panaeerselvam, 2008). This study described the effects of delivery care user fees exemption policy on utilization and outcomes of emergency obstetric care services in Tema General Hospital. 3.3.5 Qualitative University of Ghana http://ugspace.ug.edu.gh 33 Qualitative research is a type of scientific research that provides valuable insights into the local perspectives of the study population. Qualitative research involves detailed, verbal descriptions of characteristics, cases, settings, people or systems obtained by interacting with, interviewing and observing the subjects. In qualitative studies, open-ended questionnaires are applied and the questions seek an answer in the respondents own words. Qualitative methods are time consuming and expensive but used in getting respondents view and opinions due to the flexibility in asking questions. In this study structured in-depth interviews were conducted. 3.3.6 In-Depth Interview The in-depth interview is a technique designed to elicit a vivid picture of the participant’s perspective on the research topic. Interview data consist of tape recordings, typed transcriptions of tape recordings and the interviewer’s notes. In this study seven in-depth interviews were conducted. The perceptions in the in-depth interviews were triangulated with the quantitative data. The third objective was measured using the dependent variables relating to institutional capacity for EmOC set out in the in-depth interview guides, which were grouped into the following themes after the interviews: facility infrastructure, reproductive health commodities/supplies, human resource, administrative logistics, data management, community attitude and quality of care. University of Ghana http://ugspace.ug.edu.gh 34 3.4 POPULATION AND SAMPLE The study used the labour ward secondary data on obstetric cases admitted in one year before (2007) and in one year after (2009) the introduction of the delivery care user fees exemption policy in Tema General Hospital. The study population comprised of women who delivered in Tema General Hospital including those who were treated for obstetric complications in 2007 and 2009. The data on women who had normal deliveries were included in measuring the variables for utilization; and data on normal deliveries and on obstetric complications were used to measure variables for outcomes of obstetric care services in the study periods. Data on top five direct causes of maternal deaths and proxy indicators of outcomes of EmOC services as variables were included in the study. The total facility live births and stillbirths were collected to measure outcomes of delivery services as influenced by the independent variable. The study population also included hospital units’ managers for the in-depth interviews. Non-probability sampling is often more practical for many clinical research projects than probability sampling. The researcher used non-probability sampling because the individual information in the clinical charts in the record section were not complete and charts were missing. The researcher used individual and aggregate data from the maternity records including delivery and theatre registers and progress reports. Aggregate data do not give information on individual subjects. Non-probability sampling was applied in the selection of participants for the quantitative and qualitative methods of the study. The researcher used all the relevant available data on EmOC services in 2007 and University of Ghana http://ugspace.ug.edu.gh 35 2009 in Tema General Hospital for the quantitative study. A sample size of seven participants was determined for the in-depth interviews based on relevance to the study. The researcher used non-probability, consecutive sampling method to collect the quantitative data. Probability sampling method could not be used in the quantitative method since there was need to calculate case fatality rates (CFRs) and proportions of maternal deaths for which full representations of numerators and denominators were required. Besides, data storage method and capacity of Tema General Hospital could not allow random sampling. The researcher did not get adequate access to patient folders for the planned systematic random sampling and therefore used individual and aggregate data on relevant EmOC services in 2007 and 2009 available in maternity registers and archive. Purposive and snowballing sampling methods were applied to select seven participants (n=7) for the in-depth interviews to collect qualitative data on capacity of hospital facilities for EmOC services in 2007 and 2009. 3.5 DATA COLLECTION AND DATA COLLECTION INSTRUMENT The data was collected in June 2010 for the periods of January to December 2007 and 2009 which covered one year before and one year after the introduction of the delivery care user fees exemption policy in Tema General Hospital. 3.5.1 Development of the Interview Schedule and Guides The interview guides were prepared based on key issues relating to institutional capacity in the literature review; were reviewed and probes were introduced. The participants were University of Ghana http://ugspace.ug.edu.gh 36 selected by snowballing after discussions with the head of obstetric and gynaecology department. Permissions were sought and granted from the hospital superintendent to conduct in-depth interviews with hospital participants. A timetable was drawn with codes and the participants indicated the time they would be available for the interviews. 3.5.2 Pre-test The questionnaires and in-depth interview guides were pre-tested/piloted at the research site but in a different unit of the hospital (gynaecology ward) and among three (3) non- participants since data management differed from facility to facility. Relevant amendments were made before the actual data collection commenced in the labour ward, based on results of the pre-testing. These included the use of monthly summary forms in order to capture any seasonality. The questionnaires and in-depth interview guides were reviewed to include monthly representation of data for seasonality and trend analysis. 3.5.3 Data Collection Data was collected for the first two objectives (utilization and outcomes of emergency obstetric care services) using facility case summary forms as closed-ended questionnaires. The field assistant, Sister in charge of the maternity unit was trained in the research methods and data collection. She assisted in locating all the data the researcher needed for the quantitative study. Relevant data were retrieved from the maternity unit registers and reports: admission and discharge registers, monthly maternal death returns, monthly abortion returns, in-patient mortality and morbidity returns and monthly midwife’s returns. The data were filled into the questionnaires in the aggregated form. The University of Ghana http://ugspace.ug.edu.gh 37 questionnaires contained all variables (independent and dependent), numerators and denominators required to measure the dependent variables for data analysis. Data was also obtained for the third objective using in-depth interview guides. The principal researcher conducted the audio-recorded in-depth interviews. The field notes and audio- tapes were used to obtain responses from participants. Audio recording and consents were approved by all participants who took part in the in-depth interviews. 3.6 DATA ANALYSIS The facility case summary tables were reviewed and modified but the focus of the objectives was maintained. The in-depth interview guides were individualized, improved before interviews were conducted. Data collected were cross-checked for discrepancies from all available sources including archives; verified on-site before departure and data entry. The raw data was reviewed and adeptly scrutinized by the supervisor. Manual analysis of the facility data to determine change in utilization and specific outcome measures was conducted. Field notes of the in-depth interviews were cross- checked; audio recordings transcribed and coded according to the relevant themes. The themes were regrouped according to the opinions of the respondents. The in-depth interview data were manually analyzed. Frequency, percentage changes, proportions and rates were calculated and presented in frequency tables; pie and bar charts were constructed. Associations between independent and dependent variables regarding utilization and EmOC outcomes were explored using Epi Info Version 6 Statcalc. University of Ghana http://ugspace.ug.edu.gh 38 3.7 VALIDITY AND RELIABILITY Validity and reliability describe the process of drawing and applying the study conclusions to the study population and the general population. The validity and reliability of the study findings are governed by errors committed in the secondary data sets. Hospital records from the theatre and maternity units are fairly accurate and therefore, the validity and reliability of these findings are considered satisfactory. 3.7.1 Validity Validity is determined by the verity of the research questions and the method of selection. Thus it is about how the research was planned and conducted. The internal validity of a study denotes the degree to which the researcher’s conclusions correctly describe what exactly happened in the study. External validity describes the degree to which the conclusions are appropriate when applied to population(s) outside the study. The validity in this study must be governed by any errors that existed in the secondary data. However, the validity for Tema General Hospital was maximized by including all normal and obstetric complications admitted in 2007 and 2009 which increased the sample size. 3.7.2 Reliability Research findings are considered to be reliable when they are not very different from the findings of other similar researches conducted using similar methodology. Differences in reliability result from errors in measurements using instruments; whether faulty or incorrectly used. The reliability is determined by errors in measurements in the secondary data sets analyzed. However, findings of this study are consistent with findings of University of Ghana http://ugspace.ug.edu.gh 39 previous evaluations of the delivery care user fees exemption policy conducted in Ghana and other studies on the utilization and outcomes of maternal health care. 3.8 TRIANGULATION Triangulation is the use of multiple methods or theoretical outlooks to build up a fully- rounded analysis of some phenomenon by combining all lines of attack, each probe only revealing certain dimensions of the reality. In this study, the findings of the effects of delivery care user fees exemption policy on utilization and outcomes of obstetric emergency obstetric care obtained through quantitative and qualitative methods were triangulated. The results of the quantitative and qualitative methods are presented together in this study. For example, perceptions of increased utilization obtained from the qualitative method are triangulated with the quantitative results. 3.9 BIAS Bias may be any systematic error in an epidemiological study that results in an incorrect estimate of the association between exposure and risk of disease. The patients and clients were not interviewed because the researcher focused on exploring the effects of the delivery care user fees exemption policy on the institutional capacity of the Tema General Hospital within the short time available for the research. However, interviewer’s knowledge may influence the structure of questions and the manner of presentation, which may influence responses. Misclassification bias, which is due to errors made in classifying either disease or exposure status may only have been University of Ghana http://ugspace.ug.edu.gh 40 inherent in the secondary data. Thus incorrect diagnosis, incorrectly coded information may all be flaws in the database. 3.10 ETHICAL CONSIDERATIONS General ethical principles of respect for persons and research subjects (confidentiality), of beneficence and of justice were considered during the conduct of this research. Before the research work commenced, ethical clearance was requested, approved and granted. The data would strictly be used for academic purpose and the recommendations will be shared with the Tema General Hospital to improve decision-making. Data available in the dissertation will be kept by the School of Public Health, University of Ghana. There was no conflict of interest and the research was funded by the Principal Investigator as partial fulfillment for the MPH degree 3.10.1 Ethical Clearance Ethical clearance was sought from the Ghana Health Service Ethics Review Committee (GHS-ERC) through the Institutional Review Board. The recommendations of the School of Public Health Research Proposal Committee were met. The Tema General Hospital administration approved and granted the permission to conduct this research after due consultations with the Hospital Ethics Committee. University of Ghana http://ugspace.ug.edu.gh 41 3.10.2 Informed Consent Permission and consent were sought and granted from the facility personnel including the participants who took part in the in-depth interviews. Consent forms were signed in all interviews conducted. The quantitative study did not require individual consent since secondary data sets were used in the study. However, all ethical considerations regarding the use of the maternity patient data were respected and observed. 3.10.3 Privacy and Confidentiality Respect for persons and research subjects to ensure confidentiality was among the principles of ethics observed strictly during this study. Data source was secondary and the process of obtaining data therefore proffered no risks or harm to patients and clients. 3.11 STUDY LIMITATIONS Limitations of this study revolve around the facts that secondary data sets were used; the quality of the existing EmOC service data in the maternity unit, specifically obstetric complications that were available and the short time for the study which did not allow probability sampling methods; the data for normal deliveries and obstetric complications were not classified as direct or indirect. The definitions and meanings of direct and indirect admissions were different from that of direct and indirect obstetric complications. The following were the key limitations: 1. The study periods were limited to only one year before and one year after the implementation of the fees exemption policy. A longer period of review would University of Ghana http://ugspace.ug.edu.gh 42 have given a clearer picture of the pattern of effects of the policy on EmOC services and predict success or failure of the policy. 2. The short time available for the dissertation writing did not allow the inclusion of all obstetric complications into the study to get the full pattern of the effects of the fees exemption policy on all the outcomes of EmOC services in Tema General Hospital. 3. The in-depth interview was limited to hospital participants (managers) and beneficiaries (clients) were excluded from the interviews and the study. The views of the clients and patients were not accounted for in the study due to the explorative nature of the research work. 3.12 SUMMARY Chapter 3 presented and discussed how the research was conducted; started with the purpose of the study which put cross-sectional design into perspective. Quantitative and qualitative methods were applied using secondary data sets and in-depth interviews respectively to collect data. Data analysis, validity, reliability and ethical considerations were discussed in detail. The next chapter presents the research findings, presented in tables, graphs and pie charts. University of Ghana http://ugspace.ug.edu.gh 43 CHAPTER 4 RESUTS AND INTERPRETATION 4.1 INTRODUCTION The findings of this study are based on emergency obstetric care (EmOC) services provided in Tema General Hospital before (2007) and after (2009) the introduction of the delivery care user fees exemption policy in July 2008. The findings are based on the following specific objectives and the quantitative method results are triangulated with the qualitative method findings: 1. To determine percentage changes in utilization of emergency obstetric care services in Tema General Hospital, one year before (2007) and one year after (2009) the introduction of delivery user fees exemption policy in Tema General Hospital. 2. To determine and compare the percentage changes in outcomes of emergency obstetric care services one year before (2007) and one year after (2009) the introduction of delivery care user fees exemption policy in Tema General Hospital. 3. To describe how the capacities of Tema General Hospital facilities for the provision of emergency obstetric care services affect utilization and outcomes, one year before (2007) and one year after (2009) the introduction of delivery care user fees exemption policy. University of Ghana http://ugspace.ug.edu.gh 44 4.2 Effects of Delivery Care User Fees Exemption Policy on Utilization of Emergency Obstetric Care Services in Tema General Hospital The key issues of the first objective included utilization of EmOC services before (2007) and after (2009) the introduction of delivery care user fees exemption policy in Tema General Hospital, and indicators of utilization of EmOC services. The three indicators of utilization of emergency obstetric care services considered were: total number of obstetric admissions, total number of deliveries and total number of caesarean sections. Table 4.1 Facility Case Summary of Emergency Obstetric Care Services in Tema General Hospital, 2007 and 2009 VARIABLES 2007 2009 Caesarean sections 1,230 1,665 Deliveries 6,474 7,484 Stillbirths 99 95 Obstetric admissions 7,466 9,055 FIVE TOP DIRECT CAUSES OF MATERNAL DEATHS Obstetric complications Admission Death Admission Death 1. Haemorrhage 221 8 239 6 2. Eclampsia 212 6 386 12 3. Abortion complications 488 6 574 0 4. Obstructed labour/Ruptured uterus 511 2 606 2 5. 5. Sepsis 17 0 33 1 TOTAL 1449 22 1838 21 The results of the above objective and indicators used to measure the utilization of EmOC services provided before (2007) and after (2009) the introduction of the delivery care user University of Ghana http://ugspace.ug.edu.gh 45 fees exemption policy in July 2008 in Tema General Hospital are presented in tables, graphs and quotations. Table 4.1 above shows case summaries of emergency obstetric care services before (2007) and after (2009) introduction of the delivery care user fees exemption policy in Tema General Hospital. More obstetric complications among the top five causes of maternal death were admitted in 2009 (1,838) than in 2007 (1,449). In terms of immediate outcomes, less stillbirths occurred in 2009 (95) than in 2007 (99). From admissions of top five obstetric complications, fewer maternal deaths occurred in 2009 (21) compared to 2007 (22). 1,665 1,230 6,474 7,4847,466 9,055 0 2,000 4,000 6,000 8,000 10,000 2007 2009YearsN u m b er o f E m O N C S er v ic es Total Number Caesarean Sections Total Number of Deliveries Total Number of Obstetric Admissions Figure 4.1 Utilization of Emergency Obstetric Care Services in Tema General Hospital, 2007 and 2009 Figure 4.1 shows comparison of utilization of EmOC services before (2007) and after (2009) introduction of delivery care user fees exemption policy in Tema General University of Ghana http://ugspace.ug.edu.gh 46 Hospital. As immediate results, utilization of EmOC services measured by numbers of obstetric admissions, deliveries and caesarean sections increased in 2009 compared to 2007. One thousand five hundred and eighty-nine (1,589) more obstetric cases were admitted in Tema General Hospital in 2009 than in 2007, Table 4.2 Percentage Change in Utilization of Emergency Obstetric Care Services in Tema General Hospital, 2007 and 2009 No. Indicators of EmOC Services Percentage Change (%) 1. Total number of obstetric admissions 21.3 2. Total number of deliveries 15.6 3. Total number of caesarean sections 35.4 Table 4.2 shows percentage changes in process indicators of utilization of EmOC services utilization of EmOC services before (2007) and after (2009) introduction of delivery fees exemption policy in Tema General Hospital. In 2009, 21.3% more obstetric cases were admitted in Tema General Hospital than in 2007; 1,010 more deliveries were conducted in 2009 than in 2007, representing 15.6% increase over 2007; 435 caesarean sections more were performed in 2009 than in 2007, an increase of 35.4%. Tables 4.1, 4.2 and Figure 4.1 show marked increase in the utilization of EmOC services after introduction of the delivery care user fees exemption policy in Tema General Hospital in July 2008. The results were supported by the responses obtained from the in- University of Ghana http://ugspace.ug.edu.gh 47 depth interviews conducted during this study. All respondents agreed that the utilization of emergency obstetric care services increased with introduction of the delivery care user fees exemption policy. This is how one respondent from the maternity unit put it: “We have noticed a jump for example in our labour and delivery from 15 women delivering per day in 2007 to 30 women delivering in a day in 2009. We are now currently dealing with 7,000 to 8,000 deliveries in a year”. A respondent interviewed from the laboratory unit described the increase in uptake of service as thus: “Initially, people were put off because there was a fee attached to it and the money is not there and they will not come. They will wait until they are in trouble before they will come and access them. Now they know is free, therefore they are encouraged to come and it saves lives to help them identify their clinical needs. We attend to 250-300 samples a day, from various institutions”. Another respondent from general administration said: “The concept of free maternal care or exemption has been greatly accepted. And once again it improved access, because unlike previously, now you might find a lot females, girls, women, adolescents being brought to the OPD with sepsis, dying. Now majority of them are aware”. However, all the respondents interviewed in Tema General Hospital during the study strongly opined that there were no operational plans for implementing the exemption policy. An example of a strong opinion of a maternity unit respondent on the introduction of the delivery user fees exemption policy for the provision of EmOC services indicated that the whole policy would have been planned, implemented and managed differently and better: “Nothing was even discussed with the unit prior to the introduction of the policy. All we heard was its announcement on air and we had to figure out a way to implement the policy. I think the policy should be better managed and implemented than it was. And I think also that the policy should have been selective. For example, it should be not in University of Ghana http://ugspace.ug.edu.gh 48 the hospital, but if you went to health centres, then you got free care so that non- emergencies should all go to the health centre and the hospital still be left to deal with emergencies. So you re-direct the traffic but here you make it uniform and people could go from anywhere and everybody knows that people know you can get free delivery from the hospital and they all come here. The planning of the implementation was poor. No provision for the pictures. Even in 2009 no antenatal folders were provided for. It could have been done better!” The laboratory unit respondent expressed serious concerns about the lack of preceding administrative logistical arrangements that would have addressed the problems of immediate increase in utilization of laboratory regents and machinery. In her views: “Nothing was done about logistics inputs. I will say that it is how to offer hope to the hopeless, in that sense but it hasn’t come with the needed inputs”. Other examples of administrative remiss according to the respondents in implementing the delivery care user fees exemption policy were evident in the opinions of the finance unit respondent who noted the following: “We just heard an information and directive from government. So we were supposed to add all processing of the free maternal to the National Health Insurance Scheme until further notice. So we were then under directive and then the insurance thing. It was the same normal things we were using, nothing was increased, and nothing was added to it. No preparation for the policy! No accountant was part of the people who did these tariff allocations. If they want it to be successful, the financial aspect must be apt because when you define the activities, somebody must allocate cost to it”. Further expressions of the absence of preparedness to implement the delivery care user fees exemption included the views of the respondent from general administration: “This was a hastily implemented policy. The free maternal policy was that implemented! There was no proper administrative preparedness. The policy was rolled on, and we had to embrace it. To even do with basic management of this policy, part of which had to do with taking photographs! The basic tenet of this policy is for basic women to take photographs. You have to prove of being pregnant and all that. There are lots of teething problems, due to the administrative lapses. But I believe if the administrative steps were taken prior to the implementation of this policy, we would University of Ghana http://ugspace.ug.edu.gh 49 have been able to sort out all these issues. Being part of it is that the pregnant woman might need to have a proof of pregnancy. Who bears the cost? All these issues are part of the administrative problems that were not really sorted out and the problems got rolled on!” 745 509 763 661 994 0 200 400 600 800 1000 1200 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Months N u m b er o f O b st et ri c A d m is si o n s 2007 2009 Figure 4.2 Monthly Obstetric Admissions in Tema General Hospital, 2007 & 2009 Figure 4.2 compares monthly trend in obstetric admissions before (2007) and after (2009) introduction of the delivery care user fees exemption policy in Tema General Hospital. It shows an overall increase in obstetric admissions in 2009 compared to 2007; the 2007 line graph lies below the 2009 line graph. The 2007 line graph in figure 4.2 shows a wave-like (arise and fall) pattern in obstetric admissions with a sharp increase in April (855) followed by marked drop in May (509) and another noticeable rise in June (743) and September (745). The 2009 graph line in figure 4.2 shows a pattern above the 2007 line with marked increase in May (994) and the obstetric admission in September (661) 2009 fell below that of September (745) 2007. The possible explanation for the sharp fall University of Ghana http://ugspace.ug.edu.gh 50 in September is yet unknown. However, the results of this study show increased obstetric admissions in 2009 with nearly two folds increase in May (994). Relating increased obstetric admissions (Figure 4.2) to ensuing administrative problems, all respondents said no new infrastructure, space, equipment and maintenance facilities were provided to implement the delivery care user fees exemption policy. The problem of space was mentioned as concern by almost all respondents and the issue of space for clients, pa