Open Access Open Access  Restricted Access Subscription or Fee Access

Shifting norms: pregnant women’s perspectives on skilled birth attendance and facility–based delivery in rural Ghana

Halley P. Crissman, Cyril E Engmann, Richard M Adanu, Doris Nimako, Keesha Crespo, Cheryl A Moyer


Skilled birth attendance (SBA) and healthcare facility (HCF) delivery are effective means of reducing maternal mortality. However, their uptake remains low in many low-income countries. The present study utilized semi-structured interviews with 85 pregnant women attending an antenatal clinic in Akwatia, Ghana (May-July 2010) to better understand the barriers to SBA and HCF delivery through the underrepresented perspective of pregnant women. Interview transcripts were analyzed using grounded theory methodology. Participants described community support for and uptake of HCF delivery as increasing and becoming normalized, but barriers remain: (1) maltreatment by midwives; (2) cost associated with HCF delivery despite waived facility fees; (3) the need for a support person for HCF delivery; (4) difficulties in transportation; and (5) precipitous labor. Given the importance of community in Ghanaian health care decision-making, increasing community support for HCF delivery suggests progress toward increasing uptake of SBA and HCF delivery, however important actionable barriers remain.  (Afr J Reprod Health 2013; 17[1]: 15-26).


Les services des accoucheuses qualifiés (SAQ) et des établissements de santé (SES) sont des moyens efficaces de réduire la mortalité maternelle. Cependant, leur acceptation reste faible dans de nombreux pays à faible revenu. La présente étude s’est servie des entretiens semi-structurés recueillis auprès des 85 femmes enceintes  qui fréquentaient un dispensaire prénatal à  Akwatia, Ghana (entre les mois de mai et juillet 2010) afin de mieux comprendre les obstacles à la prestation des SAQ et SES à travers les perspectives sous-représentées chez les femmes enceintes.  Les transcriptions des entrevues ont été analysées en utilisant une méthodologie basée sur le « grounded theory ».  Les participants ont signalé que le soutien communautaire pour l’accouchement   dans les SES  et de l’adoption des SES  augmentent et se normalisent, mais que des obstacles demeurent: (1)  les mauvais traitements infligés par des sages-femmes,  (2) le coût associé à la prestation des SES en dépit des frais d'établissement supprimés;  (3) la nécessité d'une personne de soutien pour l’accouchement dans les SES,  (4) des difficultés de transport, et   (5) du travail précipité.  Compte tenu de l'importance de la communauté concernant la prise de décision en matière de soins de santé au Ghana la hausse du soutien communautaire pour l’accouchement dans les SES est une indication du progrès vers l’utilisation croissante de la prestation des SAQ et des SES  mais il reste toujours d’importants obstacles réalisables (Afr J Reprod Health 2013; 17[1]: 15-26).

Keywords: qualitative, grounded theory, childbirth, delivery location, sub-Saharan Africa

Full Text:



United Nations, Millennium Development Goals Report 2011, June 2011, ISBN 978-92-1-101244-6, available at:

[accessed 19 March 2012]

WHO, UNICEF, UNFPA, & The World Bank: Maternal Mortality in 2005: estimates developed by WHO, UNICEF, UNFPA, and the World Bank. Geneva:

WHO; 2007.

WHO/UNFPA/UNICEF/World Bank: Reduction of maternal mortality. Geneva; 1999.

Hussein J, Bell J, Nazzar A, Abbey M, Adjeu S, Graham W: The Skilled Attendance Index: Proposal for a new measure of skilled attendance at delivery. Reproductive Health Matters 2004; 12:160-170.

Safe Motherhood Inter-Agency Group: Skilled attendance at delivery: a review of the evidence. New York:

Family Care International; 2000.

Bell J, Hussein J, Jentsch B, Scotland G, Bullough C, Graham W: Improving skilled attendance at delivery: A preliminary report of the SAFE strategy development tool. Birth 2003; 30:227-234.

Magadi M, Diamond I, Rodrigues R: The determinants of delivery care in Kenya. Social Biology 2000; 47(3-


Blum L, Sharmin T, Ronsmans C: Attending home vs. clinic-based deliveries: perspectives of skilled birth attendants in Matlab, Bangladesh. Reproductive Health Matters 2006; 14(27):51-60.

Kruk ME, Galea S, Prescott M, Freedman LP. Heath care financing and utilization of maternal health services in developing countries. Health Policy and Planning

; 22:303-310.

UNICEF: The State of the World’s Children 2009, Maternal and Child Health. New York; 2008.

Koblinsky M, Anwar I, Mridha M, Chowdhury M, Botlero R: Reducing Maternal Mortality and Improving Maternal Health: Bangladesh and MDG 5. Journal of Health, Population and Nutrition 2008;


van Eijk A, Bles H, Odhiambo F, Ayisi J, Blokland I, Rosen D, Adazu K, Slutsker L, Lindblade K: Use of antenatal services and delivery care among women in rural western Kenya: a community based survey. Reproductive Health 2006; 3(2).

Mills S, Williams J, Adjuik M, Hodgson A: Use of health professionals for delivery following the availability of free obstetric care in Northern Ghana. Maternal and Child Health Journal 2008; 12:509-518.

Hounton S, Chapman G, Menten J, De Brouwere V, Ensor T, Sombié I, Meda N, Ronsmans C: Accessibility and utilisation of delivery care within a

Skilled Care Initiative in rural Burkina Faso. Tropical Medicine and International Health 2008; 13(1):44-52.

Addai I: Determinants of use of maternal-child health services in rural Ghana. Journal of Biosocial Science

; 32:1-15. 16. Nwakoby B: Use of obstetric services in rural Nigeria. Journal of the Royal Society of Health 1994; 132-136.

Gabrysch S, Cousens S, Cox J, Campbell O: The influence of distance and level of care on delivery place in rural Zambia: a study of linked national data

in a geographic information system. PLoS Medicine

; 8(1): e1000394. doi:10.1371/journal.pmed.1000394.

Doctor H, Dahiru T: Utilization of non-skilled birth attendants in Northern Nigeria: a rough terrain to the health-related MDGs. African Journal of

Reproductive Health 2010; 14(2):37-45.

Mpembeni R, Killewo J, Leshabari M, Massawe S, Jahn A, Mushi D, Mwakipa H: Use pattern of maternal health services and determinants of skilled care during delivery in Southern Tanzania: implications for achievement of MDG-5 targets. BMC Pregnancy and Childbirth 2007; 7(29).

van den Heuvel O, DeMey W, Buddingh H, Bots M: Use of maternal care in a rural area of Zimbabwe: a population based study. Acta Obstetricia et Gynecologica Scandinavica 1999; 78:838-846.

Kruk M, Rockers P, Mbaruku G, Paczkowski M, Galea S: Community and health system factors associated with facility delivery in rural Tanzania: a multilevel analysis. Health Policy 2010; 97:209-216.

Jansen I: Decision making in childbirth: the influence of traditional structures in a Ghanaian village. International Nursing Reviews 2006; 53:41-46.

Kyomuhendo G: Low use of rural maternity services in Uganda: impact of women’s status, traditional beliefs and limited resources. Reproductive Health Matters

; 11(21):16-26.

Essendi H, Mills S, Fotso J: Barriers to formal emergency obstetric care services’ utilization. Journal of Urban

Health 2010; doi: 10.1007/s11524-010-9481-1

Grossmann-Kendall F, Filippi V, De Koninck M, Kanhonou L: Giving birth in maternity hospitals in Benin: testimonies of women. Reproductive Health Matters 2001; 9(18):90-98.

Choudhury N, Ahmed S: Maternal care practices among the ultra poor households in rural Bangladesh: a qualitative exploratory study. BMC Pregnancy and Childbirth 2011; 11(15).

Magoma M, Requejo J, Campbell O, Cousens S, Filippi V: High ANC coverage and low skilled attendance in a rural Tanzanian district: a case for implementing a birth plan intervention. BMC Pregnancy & Childbirth

; 10(13).

The Prevention of Maternal Mortality Network (PMMN):

Barriers to treatment of obstetric emergencies in rural communities of West Africa. Studies in Family Planning 1992; 23(5):279-291.

Bazzano A, Kirkwood B, Tawiah-Agyemang C, OwusuAgyei S, Adongo P: Social cost of skilled attendance

at birth in rural Ghana. International Journal of Gynecology and Obstetrics 2008; 102:91-94.

D’Ambruoso L, Abbey M, Hussein J: Please understand when I cry out in pain: women’s accounts of maternity services during labour and delivery in Ghana. BMC Public Health 2005; 5(140).

Griffiths P, Stephenson R: Understanding users’ perspectives of barriers to maternal health care in Maharashtra, India. Journal of Biosocial Science

; 33:339-359.

Mills S, Bertrand J: Use of Health Professionals for Obstetric Care in Northern Ghana. Studies in Family Planning 2005; 36(1):45-56.

Amooti-Kaguna B, Nuwaha F: Factors influencing choice of delivery sites in Rakai district of Uganda. Social Science & Medicine 2000; 50:203-213.

Population Council, Ministry of Health [Ghana],

UNFPA/Ghana, and Ghana Health Services: Priority setting for reproductive health at the district level in the context of health sector reforms in Ghana. Accra:

Population Council; 2006.

Ghana Statistical Service (GSS), Ghana Health Service (GHS), and Macro International. Ghana Maternal Health Survey 2007. Calverton, Maryland, USA:GSS,

GHS, and Macro International, 2009.

Adanu RM: Utilization of obstetric services in Ghana between 1999 and 2003. African Journal of

Reproductive Health 2010; 14(3):153-158.

Ghana Statistical Service, Ghana Health Service, and ICF Macro. Ghana Demographic and Health Survey 2008.

Accra, Ghana: GSS, GHS, and ICF Macro, 2009.

Tong A, Sainsbury P, Craig J: Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care

; 19(6): 349–357

Charmaz K: Grounded theory: Objectivist and constructivist methods. In Handbook of Qualitative

Research. 2nd edition. Edited by Denzin N & Lincoln Y. Thousand Oaks, CA: Sage; 2000:509-35.

Glaser B, Strauss A: The Discovery of Grounded Theory: Strategies for Qualitative Research. New York:

Aldine Publishing Company; 1967.

Crissman H, Crespo K, Nimako D, Domena J, Engmann C, Adanu R, Moyer C: Intention to deliver in a healthcare facility and healthcare facility-based delivery rates among women in Akwatia, Ghana. International Journal of Gynecology and Obstetrics

, 113(2):161-162.

Titaley C, Hunter C, Dibley M, Heywood P: Why do some women still prefer traditional birth attendants and home delivery?: a qualitative study on delivery care services in West Jave Province, Indonesia. BMC Pregnancy and Childbirth 2010; 10(43).

Ejembi CL, Alti-Muazu M, Chirdan O, Ezeh HO, Sheidu S, Dahiru T: Utilization of maternal health services by

rural Hausa women in Zaria environs, northern Nigeria: has primary health care made a difference? Journal of Community Medicine and Primary Health Care 2004; 16(2):47-54.

Gage AJ: Barriers to the utilization of maternal health care in Mali. Social Science and Medicine 2007,


Onah HE, Ikeako LC, Iloabachie GC: Factors associated with the use of maternity services in Enugu, southeastern Nigeria. Social Science and Medicine

; 63:1870-1878.

Osubor KM, Fatusi AO, Chiwuzie JC: Maternal HealthSeeking Behavior and Associated Factors in a Rural Nigerian Community. Maternal and Child Health Journal 2006; 10(2):159-169.

Tann CJ, Kizza M, Morison L, Mabey D, Muwanga M, Grosskurth H, Elliot AM: Use of antenatal services and delivery care in Entebbe, Uganda: a community survey. BMC Pregnancy and Childbirth 2007; 7(23).

Ekirapa-Kiracho E, Waiswa P, Rahman MH, Makumbi F, Kiwanuka N, Okui O, Rutebemberwa E, Bua J, Mutebi A, Nalwadda G, Serwadda D, Pariyo GW,

Peters DH: Increasing access to institutional deliveries using demand and supply-side incentives: early results from a quasi-experimental study. BMC International Health and Human Rights 2011; 11(Suppl 1).

Available at:


Faye A, Mariama N, Ibrahim B: Home birth in women who have given birth at least once in a health facility: contributory factors in a developing country. Acta Obstetricia et Gynecologica Scandinavica 2011;


De Allegri M, Ridde V, Louis VR, Sarker M, Tiendrebéogo J, Yé M, Müller O, Albrecht J: Determinants of utilization of maternal care services after the reduction of user fees: A case study from rural Burkina Faso. Health Policy 2011; 99:210-218.

Galaa SZ, Daare K: Understanding barriers to maternal child health services utilization in northern Ghana. Journal of Social Development in Africa 2008;


Hodgkin D: Household characteristics affecting where mothers deliver in rural Kenya. Health Economics

, 5:333-340.

Hounton S, Chapman G, Menten J, De Brouwere V, Ensor T, Sombie I, Medi N, Ronsmans C:

Accessibility and utilization of delivery care within a skilled care initiative in rural Burkina Faso. Tropical Medicine and International Health 2008;


Uyirwoth GP, Itsweng MD, Mpai S, Nchabeleng E, Nkoane H: Obstetric service utilization by the community in Lebowa, Northern Transvaal. East African Medical Journal 1996; 73(2):91-94


  • There are currently no refbacks.