University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA, LEGON FACTORS ASSOCIATED WITH UTILIZATION OF SKILLED DELIVERY AMONG WOMEN IN ABOR SUB-DISTRICT IN THE KETA MUNICIPALITY BY PATIENCE CHARLOTTE SEGBEDZI 10293179 THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH (MPH) DEGREE JULY, 2017 University of Ghana http://ugspace.ug.edu.gh DECLARATION I hereby declare that excluding precise references which have been duly acknowledged, this submission is my own work towards my MPH dissertation and that, to the best of my knowledge, it contains no material which has been accepted for the award of any degree of this University or elsewhere. PATIENCE CHARLOTTE SEGBEDZI (STUDENT) ……………………………………….. DATE…………………………………. CERTIFIED BY: DR. JOHN KUUMUORI GANLE (ACADEMIC SUPERVISOR) …… ……… DATE………31/07/2017… i University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this work to my husband, Courage, my children; Klenam and Kekeli and my mum Aku for their encouragement and tolerance. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT First and foremost, I thank God Almighty for His mercy and grace that enabled me to carry out this study. My heartfelt gratitude goes to my supervisor, Dr. John Kuumuori Ganle for his guidance, support and encouragement. I owe Prof. Augustine Ankomah tons of thanks for his fatherly role and words of motivation that kept me going. To Mr. Joseph Jerela of the Keta Municipality health Directorate, I say God richly bless you for all the time and attention you devoted for me to make this work a success. I appreciate the support of the Management of Sacred Heart Hospital, Weme –Abor. To the mothers and the public health nurses especially Ms. Margaret Dorvlo of the Abor sub district, I owe this work to you for the great sacrifices you made for me. My lovely husband, wonderful kids, mum and in-law, without you the story will definitely be different. I acknowledge every bit of your support and sacrifice. To everyone whose contribution made this work successful; God richly bless you. iii University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENT Content Page DECLARATION ................................................................................................................... i DEDICATION ...................................................................................................................... ii ACKNOWLEDGEMENT .................................................................................................. iii TABLE OF CONTENT ....................................................................................................... iv LIST OF TABLES .............................................................................................................. vii LIST OF FIGURES .......................................................................................................... viii LIST OF ABBREVIATONS ............................................................................................... ix ABSTRACT .......................................................................................................................... x CHAPTER ONE ................................................................................................................... 1 INTRODUCTION ................................................................................................................ 1 1.0 Background of the Study ............................................................................................. 1 1.1 Problem Statement ...................................................................................................... 2 1.2 Research Objectives .................................................................................................... 3 1.3 Research Questions ..................................................................................................... 4 1.4 Significance of the study ............................................................................................. 4 1.5 Structure of the dissertation ......................................................................................... 5 CHAPTER TWO .................................................................................................................. 6 LITERATURE REVIEW...................................................................................................... 6 2.0 Introduction. ................................................................................................................ 6 2.1 The Importance of Skilled Delivery ............................................................................ 6 2.2 Trends in Skilled Delivery and Place of Delivery ....................................................... 7 2.3 Factors Associated with Skilled Birth Assistance Utilization ..................................... 8 2.3.1 Socio-demographic characteristics ....................................................................... 8 2.3.1.1 Mother’s Age ..................................................................................................... 8 2.3.3 Parity ..................................................................................................................... 9 2.3.4 Rural –urban residence ......................................................................................... 9 2.3.5 Maternal Education ............................................................................................. 10 2.4 Socio-cultural factors ................................................................................................ 11 2.5 Distance and Transportation to Health Facility ......................................................... 12 2.6 Health System Factors ............................................................................................... 13 2.7 Conceptual Framework ............................................................................................. 16 2.8 Chapter Summary ...................................................................................................... 18 CHAPTER THREE ............................................................................................................. 19 METHODS ......................................................................................................................... 19 3.0 Introduction ............................................................................................................... 19 3.1 Study Design ............................................................................................................. 19 3.2 Study Location .......................................................................................................... 19 3.3 Study Population ....................................................................................................... 21 iv University of Ghana http://ugspace.ug.edu.gh 3.3.1 Inclusion criteria ................................................................................................. 21 3.4 Sample Size Determination ....................................................................................... 21 3.5 Sampling technique and Procedure ........................................................................... 22 3.6 Data collection methods and instrument ................................................................... 23 3.7 Pre-testing of the questionnaire ................................................................................. 23 3.8 Quality Control and Data Management ..................................................................... 23 3.9 Data Analysis ............................................................................................................ 24 3.9.1 Variables ............................................................................................................. 24 3.9.1.1 Outcome/Dependent ..................................................................................... 24 3.9.1.2 Independent .................................................................................................. 24 3.9.1.3 Analysis ........................................................................................................ 24 3.10 Ethical Considerations ............................................................................................. 24 3.10.1 Potential risk/ benefits ...................................................................................... 25 3.10.2 Privacy and Confidentiality .............................................................................. 25 3.10.3 Compensation ................................................................................................... 25 3.10.4 Consent ............................................................................................................. 25 3.11 Chapter summary .................................................................................................... 25 CHAPTER FOUR ............................................................................................................... 26 RESULTS ........................................................................................................................... 26 4.0 Introduction ............................................................................................................... 26 4.1 Socio-demographic characteristics of respondents ................................................... 26 4.2 Place of delivery ........................................................................................................ 29 4.3 Assisted Delivery ...................................................................................................... 29 4.4 Decision making on assisted delivery ....................................................................... 31 4.5 Women’s satisfaction with skilled delivery services received during last birth ....... 31 4.6 Factors associated with skilled delivery utilization ................................................... 32 4.7 Multiple logistic regression analysis of factors associated with skilled delivery ...... 35 4.8 Chapter summary ...................................................................................................... 37 CHAPTER FIVE ................................................................................................................. 38 DISCUSSION ..................................................................................................................... 38 5.1 Introduction ............................................................................................................... 38 5.2 Summary of findings ................................................................................................. 38 5.3 Consistency with previous research .......................................................................... 39 5.3.1 Assisted delivery ................................................................................................. 39 5.3.2 Factors associated with skilled delivery ............................................................. 40 5.4 Explanation of findings and implications .................................................................. 41 5.5 Strengths and limitations of the study ....................................................................... 43 5.6 Chapter summary ...................................................................................................... 43 v University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX ................................................................................................................... 44 CONCLUSION AND RECOMMENDATIONS ................................................................ 44 6.1 Conclusion ................................................................................................................. 44 6.2 Recommendations ..................................................................................................... 44 REFERENCES .................................................................................................................... 46 APPENDICES .................................................................................................................... 51 Appendix A: Informed Consent Form ............................................................................. 51 Appendix B: Questionnaire ............................................................................................. 53 Appendix C: Ethical Clearance ....................................................................................... 60 vi University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 4.1: Socio-demographic characteristics of respondents ............................................ 27 Table 4.2: Bivariate analysis of factors associated with skilled delivery during recent birth ............................................................................................................................ 33 Table 4.3: Logistic regression analysis of factors associated with skilled delivery............ 36 vii University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1. Conceptual framework depicting factors that may influence utilisation of skilled delivery. Adapted from Catherine Enchill (2010) .............................................. 17 Figure 2: Map of Keta Municipality showing study area ................................................... 20 Figure 4.1: Place of delivery of last baby (N=300). ............................................................ 29 Figure 4.2: Proportion of skilled birth delivery among respondents (N=300) ................... 30 Figure 4.3: Percentage of deliveries assisted by Skilled birth Attendants (January 2016 - December 2016) (N=234) ................................................................................... 30 Figure 4.4: Decision making on choice of place of delivery and birth attendant (N=234) 31 Figure 4.5: Satisfaction with services offered during delivery (N=234) ........................... 32 viii University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATONS ABBREVIATON MEANING ANC Antenatal Care CHPS Community- based Health Planning Services CHW Community Health Worker DHIMS District Health Information Management System GDHS Ghana Demographic Health Survey GFR General Fertility Rate GSS Ghana Statistical Service KVIP Kumasi Ventilated Improved Pit LMICs Low and Middle Income Countries MDGs Millennium Development Goals MMR Maternal Mortality Ratio MOH Ministry Of Health NHIS National Health Insurance Scheme PPH Postpartum Hemorrhage SBA Skilled Birth Attendant SSA Sub-Saharan Africa TBA Traditional Birth Attendant TFR Total Fertility Rate UNICEF United Nations Children’s Emergency Fund UNFPA United Nations Population Fund VRHD Volta Regional Health Directorate WIFA Women in Fertile Age WHO World Health Organization ix University of Ghana http://ugspace.ug.edu.gh ABSTRACT Background: Unsupervised delivery is associated with high maternal morbidity and mortality. About 50 percent of the world’s mothers each year deliver without a skilled attendant. In spite of the several safe motherhood initiatives being ran in Ghana, many women still do not access skilled delivery services, especially in the Abor sub-district of the Keta Municipality of the Volta region. At the same time, few studies have been done in the Abor sub-district to understand the factors influencing utilization of skilled birth services. The purpose of this study was therefore to examine the factors that influence the utilization of skilled delivery in the Abor sub- district of the Keta municipality. Methods: A population based cross sectional survey was carried out in 7 Child Welfare Clinics (CWC) in the sub-district of Abor with a sample of 300 mothers with babies born between January and December, 2016. Structured questionnaires were used to collect data. Descriptive statistics such as frequency and percentage distribution were used to describe characteristics of participants. Inferential statistical analyses such as chi-square, bivariate and logistic regression analyses were used to examine factors associated with utilisation of skilled delivery. Results: Results suggested that skilled delivery utilization was high (78%). Factors such as age, marital status, type of marriage, religion, ANC attendance, staff friendliness, NHIS registration and time taken to reach the health facility were found to influence skilled delivery utilization significantly. Skilled delivery usage was also found to be low in women with increased parity. Conclusion: A number of factors including time taken to reach a health facility, maternal age and NHIS registration influence skilled delivery utilization. x University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.0 Background of the Study The number of women dying annually from pregnancy and childbirth-related issues still remains a global health problem. Recent trends in maternal mortality as reported by World Health Organisation (WHO) shows that there has been a reduction in maternal mortality; however, there has not been much progress in sub-Saharan Africa (SSA), including Ghana (WHO, 2015). The global maternal mortality ratio was 210 per 100,000 live births in 2013 (WHO, 2014). Of the 289,000 global maternal deaths recorded in 2013, SSA accounted for 179,000 (i.e. 62%) (WHO, 2014). In Ghana, the maternal mortality ratio as at 2015 was 240 deaths per 100,000 live births (WHO, 2015). Thus, Ghana could not achieve its Millennium Development Goal 5 target of reducing maternal mortality by 75 percent by 2015. According to the WHO (2014), the world’s neonatal mortality for 2013 was 20 per 1,000 live births and that of sub-Saharan Africa was recorded as of31 per 1,000. Out of the global 2,763,000 neonatal deaths recorded in 2013, sub-Saharan Africa contributed 1,066,000 (39%) and Ghana’s neonatal mortality ratio stood at 28 deaths per 1,000 live births (UNICEF, 2015). Research has shown that utilization of skilled delivery is a crucial factor in reducing maternal mortality (WHO, 2014). In Ghana, there are several interventions including free maternal services and focused antenatal care that have been instituted so that women will be encouraged to use skilled maternal health services. Despite all these, Ghana continues to record high maternal mortality rate and low skilled delivery utilization rate (Dzakpasu et al., 2012). For example, 26 percent of Ghanaian women (GSS, 2014) and 31.1 percent of women in the Keta Municipality still do not access skilled delivery services during childbirth (DHIMS, 2015). 1 University of Ghana http://ugspace.ug.edu.gh Several studies have explored the determinants of health facility deliveries in Ghana (Smith et al. 2008; Nketiah-Amponsah et al, 2009; Essena and Sappor, 2013; Gudu and Addo, 2017). The factors identified from these studies include socio-economic status, maternal and partner education, distance from the health facility, health staff attitude and others were associated with skilled delivery (Smith et al. 2008; Essena & Sappor, 2013). While these studies have provided insight into the determinants of skilled care utilisation, none of these studies was conducted in the Keta municipality of the Volta region to determine the factors that account for the 31.1 percent of women who do not take up skilled delivery . It was against this background that this study was aimed at examining the factors that determine skilled delivery utilization in Abor sub-district in the Keta municipal assembly. 1.1 Problem Statement Most countries had challenges meeting the Millennium Development Goal 5 and now Sustainable Development Goal 3(UN, 2015). Evidence has shown that skilled delivery is the simplest and most effective intervention that can contribute to reduction in maternal and neonatal fatalities in under resourced countries (UN, 2015). About 50 percent of the women worldwide deliver every year with a skilled attendant, whiles the other 50 percent mostly have home deliveries (WHO, 2014). About 11 to 17 percent of maternal deaths occur during the delivery process and between 50 and 71 percent; within few hours after delivery (WHO, 2014). Almost half of postpartum deaths occur within the first 24 hours, and more than 60 percent within the first week (UNFPA, 2004; WHO, 2014). It is therefore recommended that every delivery is attended by a professional for safety. This is proven to prevent complications and reduce maternal and neonatal mortality to minimal levels (Abeje et al, 2014). 2 University of Ghana http://ugspace.ug.edu.gh However, data from 2012-2015 from the District Health Information Management System (DHIMS) from the Keta Municipal Health Directorate and Abor sub-district show that efforts aimed at achieving MDG-5 were declining (VRHD Annual Report, 2014). The District recorded 28 maternal deaths throughout the planned period (2012-2015). In 2014, there was an increase in maternal death from 7 in 2012 to 12 in 2014 (DHIMS, 2012- 2015) skilled delivery was 4,354 (71%) in 2012 as against 4,062 (60.1%) for 2014 (DHIMS, 2012-2015). Despite the increase in maternal mortality in the specific case of the Abor sub-district, the factors influencing utilization of skilled delivery services are not clearly known. Moreover, despite the high rate of skilled delivery, a significant number (about 40%) did not deliver in a healthcare facility in the presence of high ANC coverage. the same time, a search of the available published literature revealed that no studies have been done in the district to document the factors associated with skilled delivery. This research, therefore, proposed to examine the factors that influence utilization of skilled delivery in Abor sub-district. 1.2 Research Objectives The general objective of this research was to examine factors that influence utilization of skilled delivery among women who delivered between January 2016 and December 2016 in the Abor sub-district of the Keta municipality. The study specifically sought to: 1. Determine the proportion of women who had supervised deliveries between January 2016 and December 2016. 2. Determine the place of delivery and type of healthcare provider among women who delivered between January 2016 and December 2016 3 University of Ghana http://ugspace.ug.edu.gh 3. Define the associated factors that influence the usage of skilled delivery among women who delivered between January 2016 and December 2016. 1.3 Research Questions The following were the questions formulated. i. What was the proportion of women who delivered with skilled birth attendant between January 2016 and December 2016? ii. Which places did women go for delivery, and what type of healthcare provider attended the delivery? iii. What were the factors that are linked with choosing skilled delivery among mothers who had their babies between January 2016 and December 2016? 1.4 Significance of the study The findings of this study revealed some of the factors that are associated with skilled delivery in the study area. It will enable managers and directors to better inform service organisation and delivery. For example, findings of this research could help the Municipal Health Directorate plan and target specific interventions, policies and programmes at identified groups of mothers who need to be persuaded to resort to the use of skilled delivery services in order to reduce maternal and neonatal mortality. In addition, policy makers will be equipped with the findings to improve healthcare services. This is important as quality of care has been shown to affect utilisation of skilled delivery services. 4 University of Ghana http://ugspace.ug.edu.gh 1.5 Structure of the dissertation This dissertation is organised into six chapters. Chapter one focused on introduction, which discussed the research background, research objectives and questions, and justification. Chapter two focused on literature review, and discussed literature related to utilisation of skilled delivery. Chapter two also included a discussion on the conceptual framework of the study. Chapter three focused on research methods. It looked at the research design, sampling methods, data collection procedures and data analysis procedures. Chapter four focused on presenting findings from the study. Chapter five entailed discussions of the results of the study while chapter six summarised the study’s findings, conclusions and as well made recommendations for policy and future research. 5 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.0 Introduction. This is the section that reviewed and synthesized prevailing literature in relation to the determinants of skilled care utilisation during childbirth. The review focused on the importance of skilled delivery, trends in skilled delivery rates and place of delivery, and the factors associated with skilled delivery utilization. The chapter also discussed the conceptual framework of the study. 2.1 The Importance of Skilled Delivery To decrease the incidence of maternal mortality, one critical intervention to employ is skilled delivery (WHO, 2014). This is because 75 percent of all maternal losses occur within the first 24 hours of delivery due to the complications that surround labour and delivery (Khans et al, 2006). Skilled delivery is when a woman receives appropriate care during labour and delivery and immediately after delivery (Graham et al, 2001). The requirement is that labour and delivery takes place in an environment where there is appropriate infrastructure, equipment and supplies in addition to effective referral and communication systems (Graham et al, 2001). Although complications during childbirth are highly unpredictable, they can be managed effectively and deaths prevented if they are recognized and treated promptly. It is then highly recommended by the World Health Organization (WHO) that all deliveries must be conducted by a skilled birth attendant (SBA)—a professional who is able to recognize and manage normal labour and delivery; treat complications and refer appropriately (Graham et al, 2001; Khans et al, 2006). Despite this recommendation, prevalence of supervised delivery is still very low in sub-Saharan Africa; only 50 perent of deliveries are supervised 6 University of Ghana http://ugspace.ug.edu.gh (Moyer and Mustafa, 2013). In the event of unexpected birth complications, which occur in approximately one out of every ten deliveries (Bacak et al, 2005), every moment of delay in receiving skilled care significantly increases the risks of stillbirth, neonatal death and maternal death (Lee et al, 2009). It is estimated that achieving universal skilled birth attendance could reduce maternal mortality by 16-33% and neonatal mortality 20-30 percent globally (Graham et al, 2001; Darmstadt et al, 2005). Skilled delivery ensures the procedure is attended by a person with the right knowledge, skills and equipment and also provide post-partum care to mother and baby (Kabir, 2007). In addition to professional attention, it is important that mothers deliver their babies in an appropriate setting, where life-saving equipment and hygienic conditions are ensured. This can also help reduce the risk of complications that may cause death or illness to mother and child (Campbell et al, 2006; Kesterton et al, 2010). Implementation of an effective intrapartum-care strategy therefore is an overwhelming priority for decreasing maternal mortality. 2.2 Trends in Skilled Delivery and Place of Delivery One critical strategy for reducing maternal and neonatal mortality and morbidity is ensuring that every baby is born with the assistance of a skilled birth attendant. Worldwide, about one in four births (25%) take place without the assistance of a skilled birth attendant (UNICEF, 2015). In 2015 alone, this translated into more than 40 million unattended births in low and middle-income countries, about 90 percent of which were in South Asia (UNICEF, 2015). In Ghana, deliveries occurring in health facilities have increased from 42 percent in 1988 to 74 percent in 2014 (GSS, 2014). The Volta Region also saw an increase in skilled 7 University of Ghana http://ugspace.ug.edu.gh delivery. The region recorded 57.4 percent skilled delivery in 2013, as against 47 percent in 2012, with 43.1 percent and 38.8 percent in 2011 and 2010 respectively (VRHD Annual Report, 2014). The situation in the Keta Municipality was rather different as it recorded 71 percent skilled delivery in 2012 and 60.1 percent in 2014 (DHIMS, 2012-2014). In summary, the rate of skilled delivery has increased in the whole world as mentioned above but the fact still remains that the targets set by the MDGs and SDGs have still not been met. This suggests the need for continuous research and interventions to help increase skilled delivery rates, especially in low income contexts like Ghana. 2.3 Factors Associated with Skilled Birth Assistance Utilization A number of factors have been found to influence the choice of skilled delivery. These factors may be related to the individual or health system which include the availability of the requisite health institutions and accessibility. These factors may be categorized into socio-demographic, socio-cultural, distance and cost, and health system factors. 2.3.1 Socio-demographic characteristics 2.3.1.1 Mother’s Age Maternal age at birth has been reported to have an influence on the health seeking behaviour of mothers particularly during child birth (Reynold et al. 2006). In Ghana, studies have shown an association between maternal age and the use of health facilities for deliveries. From the 2008 GDHS, expectant mothers within age group 20-34 years had a higher likelihood to use a health facility for delivery (58.9%). They were followed by those between 35 and 49 years (53.8%). Those below the age of 20 years had the least uptake of 50.9 percent (GSS et al. 2009a). This is not unique to Ghana, as a study by Chubike and Constance (2013) in Nigeria also found women below the age of 19 years to 8 University of Ghana http://ugspace.ug.edu.gh be the least users of skilled delivery services. It is therefore suggestive that maternal age at birth is an important predictor for an uptake of institutional delivery service. 2.3.3 Parity Various studies have demonstrated the influence of parity on women’s choice of place of birth (Gabrysch& Campbell 2009; Moyer et al. 2013; Tey& Lai 2013). A study done by Stephenson et al. (2008) in Ghana, Malawi, Tanzania and Kenya found high preference of home delivery among women with high parity. In Ghana, low parity women (84%) utilize skilled birth more than women with six or more children (54%) in Ghana (GSS et al., 2014). The same study also noted a decrease in uptake of SBAs with an increasing number of births. A similar finding was reported in Uganda by Anyait et al. (2012) in a cross sectional study: that women with more than four births had less use of health facilities for deliveries. The low uptake of institutional delivery services by multiparous women has been linked to a perceived maternity experience coupled with high confidence of these women (Tey & Lai, 2013). This is also the case in other parts of the world. For instance, in Pakistan, health facilities are mostly used by women during first birth (Agha & Thomas, 2011). It is reported from the same study that more than 50 percent of women employ the service of SBAs during their first birth as compared with only 28 percent after the fifth birth (Agha & Thomas, 2011). 2.3.4 Rural –urban residence The demographic health surveys of Ghana consistently show that urban residents are two and half times likely to deliver at a hospital than their rural counterparts. Say & Raine (2007) established from a systematic review they conducted on inequalities in the use of maternal health care in developing countries that the prevalence of skilled 9 University of Ghana http://ugspace.ug.edu.gh delivery usage was more among women resident in urban settings as compared to their rural counterparts (Say & Raine et al., 2007). In Ghana, 90 percent of urban residents utilized health facilities for childbirth as against only 59 percent of rural dwellers (GSS, 2014). According to the 2010 Population and Housing Census, 50.9 percet of Ghanaians live in urban areas and 49.1 percent reside in rural areas (GSS 2014). Place of residence may be associated with many factors, for example improved socio-economic status and level of education, and this could explain why urban residents are more likely to used SBAs during delivery (Gabrysch & Campbell, 2009). The high rate of institutional deliveries in urban areas is not exclusive to Ghana; similar findings have been reported from other SSA countries (Babalola & Fatusi 2009; Ononokpono & Odimegwu 2014). It can be concluded from the findings above that place of residence is a determinant for the use of institutional delivery service for birth by women. 2.3.5 Maternal Education The level of education of a woman has been established as having a strong influence on the usage of skilled delivery (Addai, 2000; Celik and Hotchkiss, 2000; Say &Raine 2007; Moyer & Mustafa 2013). For example the Ghana Demographic Health Survey (GDHS) 2014 reported that 95 percent of women who had a minimum of secondary education had their deliveries conducted by skilled birth attendants whiles their counterparts who had no formal education recorded 52 percent (GSS, 2014). 10 University of Ghana http://ugspace.ug.edu.gh A cross sectional study done by Esena and Sappor (2013) in Ghana found that mother’s educational level significantly influences skilled delivery uptake. The study concluded that women who spent more years in school prefer to their babies delivered in healthcare facilities than their peers with no formal education (Esena & Sappor, 2013). 2.3.6 Income Generally, poor health is associated with poverty and studies have established that people who belong to a higher socio-economic class have better health seeking behavior. Likewise, the income of a woman or her household has been found to play a significant role in her seeking skilled delivery (Tey and Lai, 2013). 2.4 Socio-cultural factors Another important factor that determines maternal health seeking behaviour is the cultural perceptions about pregnancy and labour (Addai, 2000). Indeed, the correlation between cultural norms, values and beliefs and skilled delivery is well documented in literature (Moyer, 2013; Dako-Gyeke et al. 2013). Cultural and social norms; as well as religious and other belief systems influence utilization of maternal health services even when they are within reach and readily available. For instance, in most African societies decision are taken by the head of the household which is the man (Ganle et al., 2015). Religion has also been found to be one of the socio-cultural factors that discourage women especially pregnant ones from going to the hospital. Ganle et al. (2015) in their study titled; ‘Socio-cultural Barriers to Accessibility and Utilization of Maternal and Newborn Healthcare Services in Ghana after User-fee Abolition’ found that the Islamic religion does not allow a female to be seen naked by anybody especially a male. The study went further to discover that certain Christians like the Zionist believe that God is the ultimate 11 University of Ghana http://ugspace.ug.edu.gh healer hence there is no need seeking medical care, for that matter skilled delivery (Ganle et al, 2015). A study carried out in Northern Ghana also found ethnicity as a predictor for utilization of skilled birth attendance. The study noted that women belonging to the Nankanas ethnic group had a lower likelihood of using skilled delivery services than other ethnic majorities in the region. This was found to be due to the Nankanas strong affiliation to traditional religion (Sakeah et al., 2014). 2.5 Distance and Transportation to Health Facility Access to health facility that offers care at birth is of great importance; however, poor geographical access to the nearest facility can become a disincentive for most women to utilize institutional delivery services (Karnwendo et al., 2006; Anwar et al., 2008). Poor road network coupled with scarcity of vehicles, especially in remote areas, and poor road conditions can make it extremely difficult for women to reach even relatively nearby facilities. Walking is the basic mode of transportation. Gething et al. (2012) found in Ghana that, the majority of women (90%) in their reproductive age have access to health facilities that provide care at birth. However, those living in rural areas were highly disadvantaged due to poor road network, poor communication and inadequate referral system. The same study pointed out that about a third of these women spend about two hours to reach the nearest health facilities (Gething et al., 2012). Also, long distance to health facilities was cited in the latest GDHS as one reason why women do not use facility-based delivery (GSS et al., 2014). In rural Ghana, distance to the nearest health facilities is estimated at 3-5km (MOH, 2014). 12 University of Ghana http://ugspace.ug.edu.gh Similarly, in Kenya, Mwaliko et al. (2014) found that health facilities that were within 2km from the respondents’ homes with emergency obstetric care (EmOC) services were more likely to be accessed. In Tanzania, 50 percent women residing within 5km from the health facility received skilled delivery services as against only 20 percent of women living beyond 5km from the nearest health facility (Mpembeni et al., 2007). Transport cost to health facilities has been found to be nearly half of total cost of uncomplicated delivery and 25 percent of the expenditure of complicated labour and delivery in Nepal and Tanzania (Borghi et al., 2006). This was noted to be a barrier to access for most Nepalese women leading to introduction of cash payment policy covering the cost of transport of women in hard to reach areas (Borghi et al. 2006). A study conducted in Ghana found that 43 percent of respondents who failed to use a health facility for delivery cited transportation challenges as reason (Esena & Sappor, 2013). Some of these challenges included lack of vehicle, high cost of transport and poor road network. This is similar to finding reported by Lerberg et al. (2014) in Zambia. 2.6 Health System Factors A number of health system factors have also been found to influence the utilization of skilled delivery services. They include cost of delivery services, attitude of health staff, inadequate health staff and poor quality health service. To increase the utilization of essential obstetric care, including SBA, 17 African countries have adopted subsidy policies in the last decade (Dzakpasu et al, 2013). Previous studies have suggested that subsidizing maternal services has a positive impact on SBA utilization in African settings including Burkina Faso (Ridde et al. 2011). In Ghana, the policy on free delivery care seemed to yield a greater increase in SBA rate among the poorest (Dzakpasu et al, 2013). 13 University of Ghana http://ugspace.ug.edu.gh A Lancet series revealed that services that are offered in a respectful way with a mixture of interpersonal skills are what women need from their providers (Renfrew et al., 2014). A positive attitude of the provider devoid of rudeness, shouting and demoralization but full of encouragement, reassurance and politeness has been found to increase the use of skilled birth attendance for delivery (Baral et al., 2010). In Ghana, a qualitative study which explored midwives’ and pregnant women’s perspectives on maltreatment during labour and delivery revealed different forms of abuse pregnant women face in labour wards (Yakubu et al., 2014). Different disciplinary actions such as yelling, beating and neglect were found to be the tool used by midwives to achieve positive delivery outcome (deliver live baby) (Yakubu et al., 2014). The study noted that the relationship between client and service providers were not different from that of a mother and daughter (Yakubu et al. 2014). This is not only peculiar to Ghana; similar findings have been reported in other SSA countries. For instance, in Kenya, it was revealed that poor attitude of health providers offered TBA competitive advantage over them thereby increasing the number of birth at home (Byford-Richardson et al., 2013). The study noted that TBAs were described by women as non- judgmental, full of encouraging words, readiness to offer them warm bath after delivery, feed and clean their new born after delivery, hence their preferred choice (Byford-Richardson et al,. 2013). Workforce shortage is a major issue in most countries and Ghana is no exception (Witter, 2007). WHO recommends that every country should have a 2.3 essential health worker per 1000 population. However Ghana is estimated to have only 1.24 health workers per 1000 14 University of Ghana http://ugspace.ug.edu.gh population (Selah, 2013). Distribution of SBAs in Ghana is inequitable and it is more skewed in favour of urban over rural areas and also to hospitals over clinics (MoH, 2010). Greater Accra and Ashanti regions have the highest number of SBAs, with the three Northern regions having the lowest number. This is due to the majority of SBAs unwillingness to accept postings to these areas coupled with staff retention challenges (Selah, 2013; GHS 2011). A recent study conducted in health facilities in Ghana revealed that 7 percent of health centers lacked midwives; 9 percent of health clinics did not have midwives at post; and 57 percent of CHPS compounds also lacked midwives (GOG et al., 2011). The care women receive at health facilities has an influence on subsequent use of the service. Maternal health service is documented to be poor in many countries according to a previous Lancet series publication (Koblinsky et al., 2006). The health information accessible to a woman empowers her to decide to seek modern general healthcare including skilled delivery. Educated women have been found to have better understanding of seeking modern healthcare. However, a cross-sectional study in primary health care facilities in Ghana, Burkina Faso and Tanzania showed that one in three women interviewed never had any information on danger signs related to pregnancy. About 22 percent of the respondents could not mention one danger sign of pregnancy in Ghana. From the study, less than 50 percent of the women were offered counseling on danger signs of pregnancy during ANC (Duysburgh et al., 2013). Lack of opportunity for midwives to update their knowledge on current maternal and neonatal health issues has been shown in Ghana to have an influence on their service 15 University of Ghana http://ugspace.ug.edu.gh provision, thus level of quality of service. Bachani and Tenkorang (2014) reported that in- service training offered to health providers in Ghana were not frequent and also fell short of quality to build participants capacity enough to reform current practice. At the same time, perceived quality from women’s point of view is an important determinant of health service utilization. It was revealed from a study done in Tanzania that, women were more comfortable embarking on a long journey to seek quality care in other facilities bypassing the closest local health centres to their homes (Kruk et al., 2009). This was because they perceived the service provided at the nearby health centre as of poor quality (Kruk et al., 2009). 2.7 Conceptual Framework Figure1 presents the conceptual framework for the study. The framework depicts factors that may influence the choice of having delivery conducted by a skilled person. The factors are mainly person and facility-related. The factors that are linked to the individual include; the mother’s socio-demographic characteristics such as mother’s age, occupation, income, religion/beliefs, parity, educational background and the religious environment and how it supports the use of health care facility before, during and after childbirth. Delay in decision-making and place of residence are also important person-related factors. The facility-related factors include the attitude of health care professionals towards women who seek attention during pregnancy, birth and post-natal care, health care personnel training and knowledge level, availability of equipment and drugs, health education given during ante-natal care (ANC), inadequate hospital staff, absence of skilled attendance, All the above points directly and indirectly influence women’s use of health facilities during pregnancy, birth and after birth. When these factors hinder supervised birth and 16 University of Ghana http://ugspace.ug.edu.gh complications are not managed then it will certainly lead to infant mortality and maternal death, maternal disability and its aftermath. Person-related Socio-demographic Health System factors characteristics factors  Mother’s age Cultural factors  Occupation  Income  Negative  Religion/beliefs attitude of  Parity Educational level health staff of mothers  Unavailability of equipment and drugs  Poor health education given during ANC LOW UPTAKE OF  Inadequate  Home-health SKILLED DELIVERY hospital staff facility distance  Competent  Place of level of health residence staff  Delay in  Poor referral decision-making High maternal system mortality rate Increased infant High disability rate morbidity and of mother mortality Figure 1. Conceptual framework depicting factors that may influence utilisation of skilled delivery. Adapted from Catherine Enchill (2010) 17 University of Ghana http://ugspace.ug.edu.gh 2.8 Chapter Summary Skilled deliveries in Ghana are low (73%) in 2014 as compared to WHO’s target of 90 percent by 2015. Literature has identified factors such as maternal age and education, parity, cultural, religious and traditional practices and place of residence as predictors of utilization of institutional delivery services in Ghana. In addition, health services-related factors including perceived negative attitude of some SBAs, limited numbers of health facilities and SBAs, low quality of services and long distance to health facilities were also identified. However, no literature has been found on the subject pertaining to the Volta Region and the Keta Municipality. That was why this study sought to examine factors that influence utilization of skilled delivery among women who delivered between January 2016 and December 2016 in the Abor sub-district of the Keta municipality. 18 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODS 3.0 Introduction This chapter discussed the research methods. The discussion focused on the research design, study area, study population, sample size determination, sampling procedures, data collection techniques, research instrument and data analysis. Ethical issues were also discussed in the chapter 3.1 Study Design This study was a cross-sectional study. The choice of this design was informed by literatures reviewed on similar studies (Esena and Sappor, 2013; Okoth, 2014). A survey was conducted on a representative sample of women in order to get responses that were relatively applicable to the larger population in the sub-district. 3.2 Study Location The study was conducted in the Abor sub-district of the Keta Municipality (see figure 2). The population of Keta Municipality, according to the 2010 Population and Housing Census, is 147,618 representing 7.0 percent of the region’s total population. Males constitute 68,556 (46.4%) and females, 79,062; representing 53.6 percent of the total population of the municipality. More than half (53.3%) of the population live in urban areas. The sex ratio of the municipality is 87 males per 100 females and the estimated female population for 2016 is 91,688, the population of women in fertility age (WIFA) is 3,167 and expected pregnancy of 528 for 2016 (GSS, 2014). 19 University of Ghana http://ugspace.ug.edu.gh Figure 2: Map of Keta Municipality showing study area The Total Fertility Rate (TFR) for the municipality is 3.1 which is lower than the regional rate of 3.4. The General Fertility Rate (GFR) is 88.7 births per 1000 women aged 15-49 years and family planning acceptor rate for 2015 was 22.7 percent (DHIMS, 2016). The sub-district has three (3) health facilities – one each of hospital, health centre and maternity home. There are also 12 child welfare clinic locations (DHIMS, 2016). The 2010 Population and Housing Census indicates that, 59.9 percent of the population are Christians, 25.4 percent are Traditionalists, 1.0 percent belong to Islam, 12. 9 percent have no religion and 0.8 percent are of other unspecified religions (GSS, 2014). Majority 20 University of Ghana http://ugspace.ug.edu.gh of households (61.6%) are headed by men, hence the responsibility of decision-making is usually for men. The main occupation of the people is farming (GSS, 2014). 3.3 Study Population The target population for the study were women who delivered either in hospital or at home between January 2016 and December 2016. 3.3.1 Inclusion criteria The study subjects who were included for the study were all women living in Abor sub- district who delivered between January 2016 and December 2016 prior to the study and who were willing to participate in the study by giving their consent. 3.4 Sample Size Determination The sample size for this study was determined using the Cochran formula, which is: n = Z2xpq e2 Where n= sample size, Z = confidence level of 95% (standard value of 1.96), e= margin of error = 0.05, p = prevalence of skilled delivery =74% (national prevalence in 2014) and q = 1-p n = Z2xpq = 1.962x0.74(1-0.74) = 0.7392 =295.6 e2 0.052 0.052 To make up for non-response, 14 participants (5% of 295.6) were added. This came to a total of 310 respondents. 21 University of Ghana http://ugspace.ug.edu.gh 3.5 Sampling technique and Procedure To select a representative sample, a multistage sampling technique was followed. First, there were 12 child welfare clinics in the sub-district - 5 were located in the urban area of Abor and 7 in the rural areas. Three (3) child welfare clinics out of the five urban clinics, and four (4) clinics out of the 7 rural clinics were randomly selected. This was done by giving numbers to the various clinics, writing the numbers on pieces of folded paper, mixing the numbers in a bowl, and asking a blind folded person to pick the required number from the two categories of child welfare clinics. Once the selection was completed, the total sample size of 310 was shared equally among the 7 child welfare clinics. This gave an average of 44 respondents per clinic. Second, the randomly selected child welfare clinics were visited. A simple random sampling procedure was used to select individual mothers with children born between January and December, 2016 who attended the child welfare clinics. All the child welfare clinics have registers that contained the names of mothers who attend the clinic for child welfare services. The registers for each clinic were obtained and all eligible mothers were listed and given numbers (e.g. C1, C2 …Cn). Based on this information, an electronic or computer-based number generator was used to randomly select the required number of respondents (i.e. 44 for each clinic). Thirdly, the researcher visited the clinics to interview the randomly selected mothers individually on the days that such women were attending the child welfare clinic. Finally, where a randomly selected mother was not willing to participate in the study, the selection procedure was repeated to get a replacement. 22 University of Ghana http://ugspace.ug.edu.gh 3.6 Data collection methods and instrument The primary source of data for the study was responses from participants, which were obtained using a structured questionnaire with closed and open-ended questions. It was composed of questions that aimed at collecting data on respondents’ demographics as well as birth history and skilled delivery experience. Validated questionnaire from one previous study (Okoth, 2014) in Central Division, Kajiado County, Kenya, titled ‘Utilization of Skilled Birth Attendants Among Women of Reproductive Age’ was adapted and modified for use in this study. 3.7 Pre-testing of the questionnaire Pre-testing of the questionnaire was done in neighbouring Anyako which has a population with similar demographic characteristics. It was to ensure that the questions were clear enough to yield answers to the research questions. 3.8 Quality Control and Data Management Research assistants were recruited and trained. Administered were also examined for accuracy and completeness after each field visit and errors corrected as necessary and each valid questionnaire was given a serial number to avoid double entry. Data was securely handled by using a password-protected computer that stored the data that has been entered as a soft copy as soon as it was collected. Only the researcher handled the computer that stored the data. After all the data has been entered and stored in the computer, the hard copy of the questionnaires was stored in a locker and locked for safe keeping. 23 University of Ghana http://ugspace.ug.edu.gh 3.9 Data Analysis 3.9.1 Variables 3.9.1.1 Outcome/Dependent The outcome variable was skilled delivery at a health facility. 3.9.1.2 Independent The independent variables were socio-demographic characteristics such as mother’s age, parity, education, distance and transportation to health facility. Socio-cultural 
factors included religion, ethnicity and beliefs. Also, health system factors were also included cost of delivery service, attitude of health staff, health staff strength and quality health service provided . 3.9.1.3 Analysis Descriptive statistics such as frequency and percentage distribution were used to describe characteristics of participants. Inferential statistical analyses such as chi-square, bivariate and logistic regression analyses were also used to examine factors associated with utilisation of skilled delivery. A confidence level of 95 percent was used, and a p < 0.05 was considered to be statistically significant. All the data analysis was performed using STATA 14 software. 3.10 Ethical Considerations The Ghana Health Service Ethical Review Board gave the approval (GHS-ERC: 21/03/17) for this study through the School of Public Health, University of Ghana. Approval was also obtained from the Municipal Health Director as well as the facility and child welfare clinic managers. In addition, the mothers’ consent was sought and participation was voluntary. 24 University of Ghana http://ugspace.ug.edu.gh 3.10.1 Potential risk/ benefits Neither drugs nor chemicals were given to the respondents hence there was no exposure to risk. However, participants indirectly benefitted as findings of the study may inform interventions to improve skilled delivery services. 3.10.2 Privacy and Confidentiality These were ensured during and after data collection. Interviews were conducted in privacy and information taken from participants was kept to the study alone and not shared with any other person or persons. 3.10.3 Compensation A cake of soap was given to every participant for their time. 3.10.4 Consent The consent of participants was obtained by the participants voluntarily signing the consent form provided after understanding the terms of participation. Withdrawal from participation at any time was allowed. 3.11 Chapter summary This chapter presented the methods used to carry out this research which included the study design, study population, sampling, data collection and analysis. The results obtained from the study are presented in the next chapter. 25 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS 4.0 Introduction This chapter presents the results of the research. The presentation focuses on the socio- demographic characteristics of respondents, place of delivery, prevalence of assisted delivery, decision-making on assisted delivery, satisfaction with services offered during delivery, and factors associated with skilled delivery. 4.1 Socio-demographic characteristics of respondents Table 4.1 shows data on the socio-demographic characteristics of respondents. In total, 300 mothers participated in the survey. The minimum age was 15 and the maximum age was 45 years; the mean age was 27.98 years. The majority (34%) of respondents were within the age group 15-24 years. On marital status, majority (60.0%) were married. Among the married, 22.7 percent were in polygamous unions. The majority of mothers (47.2%) had 2-3 children. Majority (70.7%) of the respondents belonged to the Christians; 12.7 percent were Moslems, and traditional believers were 9.3 percent. Regarding educational status of mothers, 48.7 percent of them had senior high school education, tertiary 25.3 percent had JSS/Middle school education, and 12.7 percent of them had primary school level. About 13.3 percent of them had no formal education. 26 University of Ghana http://ugspace.ug.edu.gh Table 4.1: Socio-demographic characteristics of respondents (N=300) Characteristics Number Percentage Age group 15 – 24 102 34.0 25 – 29 66 22.0 30 – 34 60 20.0 35 + 72 24.0 Mean Age(SD) 27.98(±7.39) Age Range 15 – 45 Educational Level No Education 40 13.3 Primary 38 12.7 JSS/Middle School 76 25.3 Secondary+ 146 48.7 Marital Status Unmarried 120 40.0 Married 180 60.0 Type of Marriage Monogamous 112 37.3 Polygamous 68 22.7 N/A 120 40.0 Number of Children 1-3 children 212 70.7 4+ children 88 29.3 NHIS registered Yes 234 78.0 No 66 22.0 Place of residence Rural Area 182 60.7 Peri-Urban 70 23.3 Urban area 48 16.0 Religion None 22 7.3 Christian 212 70.7 Muslim/Islam 38 12.7 Traditional 28 9.3 Occupation Unemployed 130 43.3 Employed 170 56.7 Partner's Education No Education 38 12.7 Table 4.1 continued Primary 20 6.7 JSS/Middle School 50 16.7 Secondary+ 192 64 27 University of Ghana http://ugspace.ug.edu.gh Partner's Occupation Unemployed 100 33.3 Employed 200 66.7 Number of ANC visits ≤3 56 18.7 4+ 244 81.3 Staff friendliness Yes 244 81.3 No 56 18.7 Means of Transport to place of delivery Walk 94 31.2 Motorbike 79 26.3 Public transport(bus) 51 17.0 Public transport(taxi) 76 25.5 Does your community have any cultural practices associated with delivery Yes 20 6.7 No 280 93.3 Time taken to reach the facility 15 min. or less 112 37.3 16 to 30 min. 86 28.7 31 to 60 min. 60 20.0 More than 60 min. 42 14.0 The majority of mothers (56.7%) were employed or had something to do for a living. Majority of the mothers (78.0%) were registered on NHIS. Among the participants, 70.7 percent had 1-3 children and 31 percent had 4 or more children with a mean of 2.8 children per woman. Furthermore, the time one spends to travel to the nearest healthcare facility, in minutes, showed that 37.3 percent of women reached the health facility within 15 minutes or less, while 28.7 percent took 16 to 30 minutes to reach the nearest healthcare facility. 28 University of Ghana http://ugspace.ug.edu.gh 4.2 Place of delivery Figure 4.1 shows the place where women had their last birth. Generally, institutional delivery service utilization was very high. Between January 2016 and December 2016, 78.0 percent of mothers gave birth at the health (HF) for their recent child; 17.3 percent took place at home compared to 4.7 percent births on their way to the health facility 4.7% 17.3% 78% Health facility Home On the way to the facility Figure 4.1: Place of delivery of last baby (N=300). 4.3 Assisted Delivery In terms of assisted delivery, the proportion of deliveries assisted by skilled birth attendants was also high (78.0%) as shown in Figure 4.2. 29 University of Ghana http://ugspace.ug.edu.gh 22% 78% Unskilled delivery Skilled delivery Figure 4.2: Proportion of skilled birth delivery among respondents (N=300) Among mothers who received skilled birth attendance, 67.5percent were assisted by midwives, 28.2 percent and 4.3 percent were attended by doctors and community health workers (CHW) respectively (see figure 4.3). 67.5 70.0 60.0 50.0 40.0 28.2 30.0 20.0 10.0 4.3 0.0 Community Health Doctors Midwives Workers Type of Skilled birth attendant Figure 4.3: Percentage of deliveries assisted by Skilled birth Attendants (January 2016 - December 2016) (N=234) 30 Percentage of respondents University of Ghana http://ugspace.ug.edu.gh 4.4 Decision making on assisted delivery Majority (36.7%) of the mothers took the decision independently to seek skilled delivery at a health facility. However, in 17.1 percent of the cases, both woman and her partner took collective decision to access skilled delivery service with a few having the decision taken by the family (see figure 4.4). 40 36.7 35 30 25 20.5 20 17.1 15 12.0 8.5 10 4.3 5 0.9 0 Decision maker on place of delivery and birth attendant Figure 4.4: Decision making on choice of place of delivery and birth attendant (N=234) 4.5 Women’s satisfaction with skilled delivery services received during last birth Of the total 300 respondents interviewed, 78.0 percent of them had skilled delivery during their last birth (Figure 4.2). A question was therefore asked to examine women’s satisfaction with the skilled birth delivery services that they received. Among mothers who had skilled delivery, more than 90.0 percent were satisfied with delivery service offered at the health facility (Figure 4.5). 31 Percentage of respondents University of Ghana http://ugspace.ug.edu.gh 60 53.0 50 37.6 40 30 20 10 6.03.4 0 Very Satisfied Satisfied Less satisfied Not satisfied Satisfaction with skilled birth delivery Figure 4.5: Satisfaction with services offered during delivery (N=234) 4.6 Factors associated with skilled delivery utilization A key objective of this study was to examine the factors that are associated with skilled delivery among women who delivered between January 2016 and December 2016. To this end, bivariate analyses were conducted to determine the association between various socio-demographic, community and health system factors and skilled delivery. Mother’s age (p=0.006), religion (p=0.001), marital status, NHIS registration (p=0.003), number of ANC visits (p=0.003), time taken to reach health facility (p=<0.001) and a partner’s level of education (p=0.054), were significantly associated with skilled delivery (Table 4.2). However, parity, place of residence, type of marriage, employment status, mother’s education, partners employment status, and cultural practices were not significantly associated with skilled delivery (p>0.05) (Table 4.2). 32 Percentage of respondents University of Ghana http://ugspace.ug.edu.gh Table 4.2: Bivariate analysis of factors associated with skilled delivery during recent birth (N=300) Skilled Birth Delivery No Yes Total P -value n(%) n(%) n(%) A ge group a 15 – 24 32(48.5) 7 0(29.9) 102(34.0) 25 – 29 6(9.1) 60(25.6) 66(22.0) 0.006* 30 – 34 4(6.1) 56(23.9) 60(20.0) 35 + 24(36.4) 48(20.5) 72(24.0) Educational Levela No Education 1 6(24.2) 2 4(10.3) 40(13.3) Primary 8(12.1) 30(12.8) 38(12.7) 0.138 JSS/Middle School 10(15.2) 66(28.2) 76(25.3) Secondary+ 32(48.5) 114(48.7) 146(48.7) Marital Status Unmarried 38(57.6) 82(35) 1 20(40.0) 0.02* Married 28(42.4) 152(65) 180(60.0) Type of Marriage Monogamous 10(15.2) 102(43.6) 1 12(37.3) Polygamous 18(27.3) 50(21.4) 68(22.7) 0.01* N/A 38(57.6) 82(35) 120(40.0) Number of Children 1-3 children 4 2(63.6) 1 70(72.6) 2 12(70.7) 0.315 4+ children 24(36.4) 64(27.4) 88(29.3) NHIS registered Yes 36(54.5) 198(84.6) 234(78) 0.01* No 30(45.5) 36(15.4) 66(22) Place of residencea Rural Area 4 0(60.6) 142(60.7) 182(60.7) Peri-Urban 20(30.3) 50(21.4) 70(23.3) 0.342 Urban area 6(9.1) 42(17.9) 48(16) a Fisher’s exact test 33 University of Ghana http://ugspace.ug.edu.gh Table 4.2 cont’d Skilled Birth Delivery No Yes T otal P-value n(%) n(%) n(%) R eligiona None 12(18.2) 1 0(4.3) 2 2(7.3) Christian 30(45.5) 182(77.8) 212(70.7) 0.001* Muslim/Islam 18(27.3) 20(8.5) 38(12.7) Traditional 6(9.1) 22(9.4) 28 (9.3) Occupation Unemployed 30(45.5) 1 00(42.7) 1 30(43.3) 0.781 Employed 36(54.5) 134(57.3) 170(56.7) Partner's Educationa No Education 1 6(24.2) 22(9.4) 3 8(12.7) Primary 6(9.1) 14(6) 20(6.7) 0.054* JSS/Middle School 14(21.2) 36(15.4) 50(16.7) Secondary+ 30(45.5) 162(69.2) 192(64) Partner's Occupation Unemployed 20(30.3) 80(34.2) 100(33.3) 0.676 Employed 46(69.7) 154(65.8) 200(66.7) Number of ANC visits ≤3 24(36.4) 32(13.7) 5 6(18.7) 0.003* 4+ 42(63.6) 202(86.3) 244(81.3) Staff friendliness Yes 4 2(63.6) 2 02(86.3) 2 44(81.3) 0.003* No 24(36.4) 32(13.7) 56(18.7) Presence of cultural beli efs against skill ed delivery in com munity Yes 6(9.1) 14(6) 20(6.7) No 60(90.9) 220(94) 280(93.3) 0.527 Time taken to get to the facility a 15 min. or less 12(18.2) 74(31.6) 8 6(28.7) 16 to 30 min. 46(69.7) 66(28.2) 112(37.3) < 0.001* 31 to 60 min. 4(6.1) 56(23.9) 60(20.0) More than 60 min. 4(6.1) 38(16.2) 42 (14.0) a Fisher’s exact test *Significant variables 34 University of Ghana http://ugspace.ug.edu.gh 4.7 Multiple logistic regression analysis of factors associated with skilled delivery From the bivariate analysis, variables that were significantly associated with skilled delivery were pulled into a logistic regression model where the strength of association for each variable was investigated. The results are shown in table 4.3. The results suggest that mothers within 30-34 age group were 7.6 times more likely to use a skilled birth attendant (adjusted OR 7.581, 95% CI: 1.73-33.26) while those within 25-29 age group were about 4 times more likely to use a skilled birth attendant during delivery (adjusted OR 3.64, 95% CI 1.03-12.87) compared with those within 15– 24 age group. Further, the unadjusted analysis demonstrated an association between NHIS registration and skilled birth delivery. Compared to mothers who registered for NHIS, non-NHIS registered mothers were 0.2 times more likely to use a skilled birth service (UOR: 0.22; 95% CI: 0.09-0.51). With adjusted analysis however, non-NHIS registered mothers were 0.4 times more likely to use a skilled birth attendant as compared with those with those who registered for NHIS (adjusted OR 0.40, 95% CI 0.13-1.25). Further, time taken to reach a health facility significantly influences the use of skilled delivery. Women who used more than 60 minutes to reach a health facility was also significantly associated with higher likelihood of skilled birth attendance (AOR: 8.08, 95% CI: 1.99-32.83) compared with those who used 15minutes or less to go to a health facility. Besides, other individual-level factors were associated with skilled birth attendance in the adjusted analysis (Table 4.3).Women who were married were about 5 times more likely to receive skilled birth attendance (AOR:5.01; 95% CI: 1.09-23.12). With unadjusted analysis, Women whose partners had secondary education and beyond were about four times more likely to receive skilled birth attendance (UOR:3.93; 95% CI: 1.35-11.43). 35 University of Ghana http://ugspace.ug.edu.gh Also, compared to non-religious women, the chance of receiving skilled birth attendance by Christian women was over seven times better (UOR: 7.28; CI 1.96 - 27). Table 4.3: Logistic regression analysis of factors associated with skilled delivery Characteristics UOR(95%CI) P-value AOR(95%CI) P-value Age group (in years)** 15 – 24 1 1 25 – 29 4.57(1.21-17.29) 0.030 3.64(1.03-12.87) 0.04 30 – 34 6.40(1.35-30.36) 0.020 7.58(1.73-33.26) 0.01 35 + 0.91(0.37-2.28) 0.850 0.77(0.33-1.77) 0.54 Marital Status* Unmarried 1 1 Married 2.52(1.14-5.55) 0.020 5.01(1.09-23.12) 0.04 Type of marriage* Monogamous 1 1 Polygamous 0.27(0.08-0.9) 0.030 0.45(0.12-1.74) 0.25 N/A 0.21(0.07-0.62) <0.001 1.89(0.53-6.72) 0.33 NHIS registered* Yes 1 1 No 0.22(0.09-0.51) <0.001 0.40(0.13-1.25) 0.11 Religion* None 1 1 Christian 7.28(1.96-27) <0.001 1.34(0.24-7.58) 0.74 Muslim/Islam 1.33(0.3-5.94) 0.710 0.95(0.2-4.43) 0.95 Traditional 4.4(0.77-25.29) 0.100 1.56(0.43-5.7) 0.50 Partners Education* No Education 1 1 Primary 1.7(0.33-8.71) 0.530 1.34(0.24-7.58) 0.74 JSS/Middle School 1.87(0.53-6.63) 0.330 0.95(0.2-4.43) 0.95 Secondary+ 3.93(1.35-11.43) 0.010 1.56(0.43-5.7) 0.50 Number of ANC visits* ≤3 1 1 4+ 3.61(1.49-8.76) <0.001 1.69(0.48-5.93) 0.41 Staff friendliness* Yes 1 1 No 0.28(0.11-0.67) <0.001 0.68(0.22-2.13) 0.51 Time to get to the facility** 15 min. or less 1 1 16 to 30 min. 4.3(1.55-11.88) <0.001 3.51(1.31-9.42) 0.01 31 to 60 min. 9.76(2.1-45.3) <0.001 10.34(2.17-49.27) <0.001 More than 60 min. 6.62(1.4-31.4) 0.020 8.08(1.99-32.83) <0.001 AOR: Adjusted Odd Ratio; UOR: Unadjusted Odd Ratio; CI: Confidence inter val *Adjusted for marital status, type of marriage, NHIS registered, religion, partners’ education, number of ANC visit, staff friendliness **Adjusted for age, time to get the facility and Number of ANC visits 36 University of Ghana http://ugspace.ug.edu.gh 4.8 Chapter summary The result of the study as presented in this chapter indicated that skilled birth utilization is high. Factors such as mother’s age, religion, marital status, NHIS registration, number of ANC visits, time taken to reach health facility and partner’s level of education were significantly associated with skilled delivery utilization. These results are discussed in the next chapter. 37 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSION 5.1 Introduction This chapter discusses the key findings reported in Chapter four. The chapter details how the findings are related or deviated from exiting literature as well as possible explanations of the results and the implications for policy and practice. The linkages between the findings and the conceptual framework are also discussed. 5.2 Summary of findings The objective of this study was to examine the factors that influence utilization of skilled delivery among women who delivered between January 2016 and December 2016 in Abor sub-district of the Keta municipality. The results as presented in the previous chapter showed that prevalence of skilled delivery was relatively high (78%) compared to the 70.1% which was recorded by the entire district in 2015 (DHIMS, 2015) and national prevalence of 74% (GDHS, 2014). The age of the respondents ranged from 15 years to a maximum age of 45 years with the mean age at 27.98years . Of those who did not opt for skilled, majority (48.5%) belonged to 15-24 years age group followed by those who were 35+ years (36.4%) indicating that the younger and older aged women are more unlikely to choose skilled delivery. Most of the mothers surveyed had between 2-3 children with majority of them reporting that they were Christians by way of religious affiliation. Married women (65%) especially those in monogamous marriage (43.6%) were found to be more likely to utilize skilled delivery. Also, prevalence of skilled delivery was directly proportional to level of education of the woman. Women with higher education (48.7%) were found to utilize skilled birth more than those with lower or no education and women 38 University of Ghana http://ugspace.ug.edu.gh with higher parity of four or more were less likely to have skilled delivery (27.4%) than those who had 1-3 children (72.6%). Furthermore, findings indicated that more rural dwellers (60.7%) were more likely not to seek skilled delivery as compare to urban residents (39.3%). ANC attendance was found to influence skilled birth utilization in that, 86.3% of women who had four and more visits delivered in the health facility. Time spent to get to the health facility was also found to influence the utilization of skilled delivery. Interestingly, women who spend 15 minutes or less (31.6%) to reach health facility, were less likely to deliver at healthcare facility compared to those who spend 60 minutes or more to get to health facility. In brief, factors such as age, marital status, type of marriage, religion, ANC attendance, staff friendliness, NHIS registration and time taken to reach the health facility were found to influence skilled delivery utilization significantly. 5.3 Consistency with previous research Findings from this study are comparable to findings from other previous studies. The similarities are discussed in the sections below. 5.3.1 Assisted delivery From the findings presented in the preceding chapter, it will be noticed that more than half of the respondents who delivered within the period under study were assisted by skilled birth attendants including midwives, doctors and community health workers. This is consistent with the results obtained by Moyer and Mustafa (2013) which indicated that within sub-Saharan Africa (SSA) about half of deliveries are assisted by SBAs. 39 University of Ghana http://ugspace.ug.edu.gh 5.3.2 Factors associated with skilled delivery Age of mother From the results, mothers within the age group of 30-34 years were found to be five times more likely to utilize skilled delivery compared to those within the age group of 25-29 years who were 3 times more likely to engage the service of a skilled attendant during child birth. This supports earlier studies in Ghana that proven a linkage between mother’s age and the usage of health facilities for delivery (GSS, 2014). A similar finding was reported by a recent study conducted in Nigeria by Chubike and Constance (2013), which indicated that women below the age of 24 years had the least likelihood of using skilled birth care. Time taken to reach health facility Access to health facilities and skilled delivery by women remains a critical factor to consider in improving child birth associated maternal morbidity and mortality, since it often serves as a disincentive for most women in the use of skilled and institutional delivery (Karnwendo et al,. 2006; Anwar et al. 2008). This study has established that time spent to reach a health institution significantly influenced the use of skilled delivery among the women in the study area. The regression results indicated that time spent to get to a health facility significantly influenced the usage of skilled delivery. Women who spent more time (60 minutes or more) were more likely to utilize skilled delivery than those who spent 15 minutes. This does not fall in line with the findings of many studies including a study conducted in Ghana which revealed that 43% of respondents who failed to use a health facility for delivery cited transportation challenges as reason (Esena and Sappor, 2013; Gething et a,2012 l; GSS et al., 2014). . 40 University of Ghana http://ugspace.ug.edu.gh NHIS registration From the regression results, it was establish that possessing valid National Health Insurance card has some influence on usage of skilled delivery in the study area. Specifically, women who were non-NHIS registered mothers were found to be less likely to opt for skilled delivery compared to those who registered with NHIS (UOR: 0.22; 95% CI: 0.09-0.51). This finding is consistent with that of Dzakpasu et al. (2013), which indicated that the policy on free delivery care in Ghana seemed to have yielded a greater increase in skilled delivery among the poorest as pregnant women are registered for free on the NHIS. Religion Christian women (77.8%) were found to be the majority of skilled birth users as compared to those who belonged to traditional religion and then, Muslims (8.5%). This confirms the findings of a study carried out by Gyimah et al. (2006) which indicated that skilled delivery utilization was higher among Christian women as compared to Islamic and traditional faithful in Ghana. Similar findings have been previously reported by Sakeah et al. (2014) and Stephenson et al. (2006) in Ghana. 5.4 Explanation of findings and implications Maternal age at birth continues to be an important predictor for uptake of institutional delivery service in Ghana and other African countries. Women in 15-24 and 35+ age groups were found to be the least consumers of skilled delivery services. The general effect is that, they may not be able to afford the cost associated with deliveries in health facilities such as transportation cost and other unofficial charges. Also inabilities to purchase items that are listed by service providers. For the elderly women who might also 41 University of Ghana http://ugspace.ug.edu.gh be multiparous, the so-called experience gained over the period could explain why they are less likely to use SBAs during delivery. This study revealed that the respondents who registered with NHIS patronized skilled delivery services more than those who were not NHIS registered mothers. This implies that most of the women in the study area may not afford skilled delivery unless it is highly subsidized. This study has also shown that health service-related factors such as nurses’ attitudes to pregnant women play a significant role in the use of supervised delivery services. Unsatisfactory attitude of nurses were found to deter women from using skilled delivery services. It is a known fact that most health facilities are under staffed and nurses work under unfavorable conditions especially in rural Ghana. These include attending to a large number of clients and in most cases, one nurse working both day and night. These conditions may influence the negative attitudes of nurses in the context of Abor. Furthermore, the failure of clients to comply with lessons learnt during ANC and the negative behaviours of some clients’ relatives can frustrate midwives who are already stressed by the high work demand. This is demonstrated by the health provider in anger and negative expressions which are interpreted as “cruelty”. Undoubtedly some midwives naturally have poor provider-client relationship; however it is important to establish the underlying causes influencing attitudes of these providers particularly nurses and midwives in environment such as Ghana. 42 University of Ghana http://ugspace.ug.edu.gh 5.5 Strengths and limitations of the study This study was community based with subjects from both rural and urban areas of the sub- district which provided a good rural-urban balance. However, the participants were solely the source of data and there was no means of validating the information they provided hence biases in the response to some of the questions were very likely. There might also be some recall bias in events surrounding labour and delivery since the participants were mothers who delivered between January and December, 2016. This study was limited to the sub-district of Abor. 5.6 Chapter summary This chapter deliberated on the outcomes of this study which revealed that the prevalence of skilled delivery utilization is quite high in the study area. A number of factors like mother’s age, distance and time taken to reach the health facility, NHIS registration amongst others have been found to influence skilled delivery utilization significantly. The next chapter concludes the study and makes recommendations to address a number of the challenges and issues identified in this study. 43 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX CONCLUSION AND RECOMMENDATIONS 6.1 Conclusion This research was carried out to assess the factors that influence skilled delivery utilization in Abor, a sub-district of the Keta municipality. Participants of the study were mothers, who delivered between January and December, 2016. A total of 300 subjects were sampled and interviewed using a structured questionnaire. The results indicated that a high proportion of women in Abor are using skilled delivery and a woman who is not registered with NHIS is less likely to opt for skilled delivery. Also, women who used 60 minutes or more to reach a health facility are more likely to use skilled delivery. It is therefore concluded that time taken to reach a health facility, maternal age and NHIS registration significantly influenced skilled delivery utilization in Abor. 6.2 Recommendations From the results of this research, the following recommendations were made. 1. The National Health Insurance Authority (NHIA) in collaboration with National Commission for Civic Education (NCCE) should educate community members on the need to register with the NHIS. Due to the difficult economic situations in the country, medical bills overburden many families hence individuals who are not registered with the national health insurance scheme are reluctant to seek medical care when the need arises. 2. Legislators must ensure that policies such as free maternal health care are fully implemented. Health facility management must ensure that hidden charges are removed to encourage the vulnerable groups in society to use the services. 44 University of Ghana http://ugspace.ug.edu.gh 3. A study to explain the reason why women who spent more time to get to a healthcare facility have higher likelihood of utilizing skilled delivery than those who spent less time should be conducted 4. Further study in the subject area for the entire municipality is recommended. 5. It is hoped that results of this study would inform the formulation of policies to increase the utilization of skilled delivery Abor sub-district and the entire Keta municipality. 45 University of Ghana http://ugspace.ug.edu.gh REFERENCES Abeje G, Azage M, Setegn T (2014). Factors associated with Institutional delivery service utilization among mothers in Bahir Dar City administration, Amhara region: a community based cross sectional study. Reproductive Health, 11(22).doi: 10.1186/1742-4755-11-22 Addai I, (2000). Determinants of use of maternal-child health services in rural Ghana. Journal of Biosocial Science, vol. 32, no. 1, pp. 1–15. Agha S, Carton T W (2011). 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Institutional delivery in rural India: the relative importance of accessibility and economic status. BMC Pregnancy and Childbirth, 10(30). Khan K S, Wojdyla D, Say L, Gulmezoglu A M, Van Look P F, (2006). WHO analysis of causes of maternal death: a systematic review. Lancet. 2006; 367: 1066–1074. PMID: 16581405 Koblinsky, M., Z. Matthews, J. Hussein, D. Mavalankar, M.K. Mridha and I. Anwar, (2006). Lancet Maternal Survival Series steering group. Going to scale with professional skilled care. The Lancet 2006: 368. Kruk ME, Paczkowski M, Mbaruku G, de Pinho H, Galea S, (2009). Women's preferences for place of delivery in rural Tanzania: A population-based discrete choice experiment. Am J Public Health, 99(9):1666–1672. 48 University of Ghana http://ugspace.ug.edu.gh Lee A C, Lawn J E, Cousens S, Kumar V, Osrin D, Bhutta Z A, et al. (2009). Linking families and facilities for care at birth: What works to avert intrapartum-related deaths? 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BMC Pregnancy Childbirth; 7: 29. Mwaliko, E, Downing, R, Wendy O’Meara, W, Chelagat, D, Andrew Obala, A, Downing, T ,Simiyu, C, Odhiambo, D, Ayuo, P, Menya, D and Khwa-Otsyula, B, (2014). Not too far to walk: the influence of distance on place of delivery in a western Kenya health demographic surveillance system. BMC Health Services Research vol.14, no. 212 Ononokpono D N, Odimegwu C O, (2014). Determinants of Maternal Health Care Utilization in Nigeria: a multilevel approach. Pan African Medical Journal;17(Supp 1):2 Okoth,(2014).Utilization of Skilled Birth Attendants Among Women of Reproductive Age in Central Division, Kajiado County. Accessed online on 30th September, 2016. Renfrew, MJ, Homer, CS, E, Downe S, Mcfadden, A, Muir, N, Prentice, T, Hoope-Bender PT (2014).Midwifery is a vital solution to the challenges of providing high- quality maternal and newborn care for all women and newborn infants, in all countries. The Lancet Renolds HW, Wong EL, Tucker H, (2006). 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Open Journal of Obstetrics and Gynecology, no 4, pp. 383-39 50 University of Ghana http://ugspace.ug.edu.gh APPENDICES Appendix A: Informed Consent Form Before taking consent and administering questionnaire Background: My name is Patience C. Segbedzi, a student from the School Of Public Health, University of Ghana, Legon. The purpose of my study is to examine the factors that influence utilization of skilled delivery among women who delivered between January 2016 and December 2016 in the Abor sub-district of the Keta municipality. The findings on factors associated with skilled delivery could equip local policy makers and stakeholders at the facilities with the relevant information to inform quality improvement of their health services. This was important as quality of care has been shown to affect utilisation of skilled delivery services. Potential risk and benefits There are no potential risk since no drugs or chemicals were administered. However, participants may indirectly benefit from the study as findings may inform interventions to improve skilled delivery services. Right to refuse: Participation is free without any force. You can decide to opt out of this study at any stage or decline to response to a specific question. Anonymity and confidentiality: No name is linked to any comment in this study. Participants are assured of confidentiality. Compensation The researcher will give a cake of soap to participants for your time. Informed Consent Before taking consent: Do you have any questions on this study? Yes No Question…………………………………………………………………………………… ………. 51 University of Ghana http://ugspace.ug.edu.gh If you have any questions you may contact Patience Charlotte Segbedzion 0243279522/ E- mail patiencesegbedzi@gmail.com or Ms. Hannah Frimpong on 0243235225 /0507041223/ Email Hannah.Frimpong@ghsmail.com Consent: I……………………………………………………. having fully understood the study after a thorough explanation, hereby consent to be a participant. Signature/thump print of participant:-……………………………………. Date:-……………………………… Interviewer’s statement: I, ……………………………………have explained this consent form to this participant in the language he/she understands including the purpose, potential risk and benefits, right to refuse and the confidentiality of this study and she has freely agreed to be a participant of this study. Signature of interviewer:-…………………… Date: -……………… 52 University of Ghana http://ugspace.ug.edu.gh Appendix B: Questionnaire Title:Factors associated with utilization of skilled delivery among women who delivered between January 2016 and December 2016 in Abor Sub-district in the Keta Municipality Socio-Demographic Characteristics 1. How old are you? __ __ years 2. What is the highest level 1. No education of education you have 2. Primary attained? 3. JSS/Middle school 4. Secondary/SSS 5. Vocational/Technical 6. Tertiary 7. Other specify................................................... 3. What is your marital 1. Single status? 2. Cohabiting/living together 3. Married (Go to Qn 4) 4. Divorced 5. Separated 6. Widowed 4. If you are married, what 1. Monogamous type of marriage is it? 2. Polygamous 3. Others specify.................................................. 5. How many children do you have? (in total) _ _ _ _ 6. How many children do you have? (# of children alive) 7. How old is your last child? __ __ years __ __ months 8. How many times have you given birth in the past five __ years? 9. Do you have a NHIS card? 1. Yes 2. No 10. What is the birth interval 1. < 24 months between your current child 2. > 24 months and the child before this 3. Not Applicable one? 11. Where do you live? 1. Rural area 2. Peri-urban area 3. Urban area 12. What is your religion? 1. None 53 University of Ghana http://ugspace.ug.edu.gh 2. Christian 3. Muslim/Islam 4. Traditionalist 5. Other specify………....................................... 13. What is your main 1. Unemployed occupation? 2. House wife 3. Maid servant 4. Farmer 5. Merchant/trader 6. Civil Servant 7. Fishmonger 8. Apprentice 9. Student 10. Other specify………........................................ ... 14. What is your husband’s 1. No education highest level of education 2. Primary you have attained? 3. JSS/Middle school 4. Secondary/SSS 5. Vocational/Technical 6. Tertiary 7. Other specify....................................... 15. What is your husband’s 1. Unemployed main occupation? 2. Domestic servant 3. Farmer 4. Merchant/trader 5. Civil Servant 6. Fisherman 7. Apprentice 8. Student 9. Other specify………........................................ ... 16. What is your average family (household) income GH¢ __ __ __ __ . __ __ per month? 17. What source of lighting do 1. Electricity you use? 2. Kerosene lamp 3. Other specify……………………………. 18. What do you use as 1. Gas cooking fuel? 2. Charcoal 3. Firewood 4. Other specify............................ 54 University of Ghana http://ugspace.ug.edu.gh 19. What is the material of 1. Tiles your dwelling floor? 2. Cement 3. Wood 4. Mud 5. Other specify……………………………. 20. What is your source of 1. Tap drinking water? 2. Rainwater 3. Borehole 4. River 5. Other specify............................................. 21. What type of toilet facility 1. None do you use? 2. Water closet/pour flush 3. KVIP 4. Other specify.................................................... Access and quality of care 22. How many antenatal visits did you making during the entire duration of your last __ __ pregnancy? 23. Was the staff friendly to 1. Yes you during your Antenatal 2. No visit? 24. Where did you deliver 1. Health facility your last baby? 2. Home (skip to Qn 26) 3. On the way to the health facility (skip to Qn 27) 4. Other specify.................................................... 25. If you delivered at a health 1. Doctor facility, who assisted your 2. Midwife delivery? 3. CHW 4. Other specify………………………………… . 26. How much were you charged for last delivery? GH¢ __ __ __ . __ __ 27. Who supported your last 1. Self delivery? 2. Husband 3. Both of us 4. Mother 5. Mother in law 6. Close relative/friends 55 University of Ghana http://ugspace.ug.edu.gh 7. Other specify………………………………… 28. How did you get to the 1. Walk place of delivery? 2. Bicycle 3. Motorbike 4. Public transport (bus) 5. Public transport (taxi) 6. Got a lift 7. Other specify………………………………… 29. How long did it take you __ __ Hours to reach where you delivered? __ __ Minutes 30. If you delivered at home, 1. SBA who assisted your 2. CHW delivery? 3. TBA 4. Close relatives/friends 5. Other specify.................................................... 6. Not Applicable 31. Why did you choose to deliver with the above mentioned person? (probe for as many reasons as possible) 32. Who decided who to assist 1. Self your delivery? 2. Husband 3. Both of us 4. Mother 5. Mother in law 6. SBA 7. TBA 8. CHW 9. Other specify................................................... 33. In your opinion, who is the 1. SBA best person to assist a 2. CHW woman during child birth? 3. TBA 4. Close relatives/friends 5. Others specify.................................................. 56 University of Ghana http://ugspace.ug.edu.gh 34. Give reasons for your answer above (probe for as many reasons as possible) 35. Who would you prefer to 1. SBA assist for your next 2. TTBA delivery? 3. CHW 4. TBA 5. Close relatives/friends 6. Other specify................................................... 36. If married, who would 1. SBA your husband prefer to 2. TTBA assist for your next 3. CHW delivery? 4. TBA 5. Close relatives/friends 6. Not Applicable 7. Other specify................................................... 37. What services were you offered during delivery by your delivery assistant? 38. To what extent were you 1. Very satisfied satisfied with the services 2. Satisfied you received from your 3. Less satisfied delivery attendant? 4. Uncertain 5. Not satisfied 39. Does your community 1. Yes have any practices 2. No (if No skip to Qn 43) associated with delivery? 40. What are some of the traditional practices in your community associated with delivery? 57 University of Ghana http://ugspace.ug.edu.gh 41. What are some of the cultural practices performed in your community during delivery? 42. What religious beliefs may affect your choice of delivery assistance? To what extent would you agree with the following statements? 43. Before I delivered, I 1. Strongly agree planned for the person to 2. Agree deliver the baby 3. Uncertain 4. Disagree 5. Strongly disagree 44. Before I delivered, I 1. Strongly agree planned for complications 2. Agree during delivery. 3. Uncertain 4. Disagree 5. Strongly disagree 45. Before delivery, I arranged 1. Strongly agree for transport. 2. Agree 3. Uncertain 4. Disagree 5. Strongly disagree 46. Before delivery, I arranged 1. Strongly agree for money to use during 2. Agree the process 3. Uncertain 4. Disagree 5. Strongly disagree To what extent do you agree with the following statements? 47. Excessive bleeding(PPH) 1. Strongly agree is a danger sign during 2. Agree delivery 3. Uncertain 4. Disagree 5. Strongly disagree 48. Retained placenta is a 1. Strongly agree danger sign during 2. Agree delivery 3. Uncertain 4. Disagree 5. Strongly disagree 58 University of Ghana http://ugspace.ug.edu.gh 49. Obstructed 1. Strongly agree labour/prolonged labour is 2. Agree a danger during delivery 3. Uncertain 4. Disagree 5. Strongly disagree 50. Abnormal fetal positioning 1. Strongly agree is a danger sign during 2. Agree delivery 3. Uncertain 4. Disagree 5. Strongly disagree 51. Cord around the child’s 1. Strongly agree neck is a danger sign 2. Agree during delivery 3. Uncertain 4. Disagree 5. Strongly disagree Thank you for your time! 59 University of Ghana http://ugspace.ug.edu.gh Appendix C: Ethical Clearance 60