Free Maternal Health Care Research Articles

Why “free maternal healthcare” is not entirely free in Ghana: a qualitative exploration of the role of street-level bureaucratic power

BackgroundGhana introduced a free maternal healthcare policy within its National Health Insurance Scheme (NHIS) in 2008 to remove financial barriers to accessing maternal health services. Despite this policy, evidence suggests that women incur substantial out-of-pocket (OOP) payments for maternal health care. This study explores the underlying reasons for these persistent out-of-pocket payments within the context of Ghana’s free maternal healthcare policy.MethodsCross-sectional qualitative data were collected through interviews with a purposive sample of 14 mothers and 8 healthcare providers/administrators in two regions of Ghana between May and September 2022. All interviews were audio-recorded, transcribed and imported into the NVivo 14.0 software for analysis. An iteratively developed codebook guided the coding process. Our thematic data analysis followed the Attride-Sterling framework for network analysis, identifying basic, organising themes and global themes.ResultsWe found that health systems and demand-side factors are responsible for the persistence of OOP payments despite the existence of the free maternal healthcare policy in Ghana. Reasons for these payments arose from health systems factors, particularly, NHIS structural issues – delayed and insufficient reimbursements, inadequate NHIS benefit coverage, stockouts and supply chain challenges and demand-side factors – mothers’ lack of education about the NHIS benefit package, and passing of cost onto patients. Due to structural and system level challenges, healthcare providers, exercising their street-level bureaucratic power, have partly repackaged the policy, enabling the persistence of out-of-pocket payments for maternal healthcare.ConclusionsUrgent measures are required to address the structural and administrative issues confronting Ghana’s free maternal health policy; otherwise, Ghana may not achieve the sustainable development goals targets on maternal and child health.

Burden of out-of-pocket payment for maternal healthcare and its catastrophic effects in the era of free maternal and child health policy in Ghana

BackgroundGhana introduced a free maternal healthcare policy within its national health insurance program in 2008. Despite this, there are reports of significant out-of-pocket (OOP) payments for maternal healthcare in Ghana. This study examines OOP payments for maternal healthcare services and their catastrophic effects, including the correlates of catastrophic OOP payments. MethodsCross-sectional quantitative data were collected from 414 mothers through health facility exit interviews in two regions of Ghana. Catastrophic OOP payments were computed by expressing total health expenditure as a percentage of household total expenditure and non-food expenditure at various thresholds (5 %, 10 %, 20 % and 25 %). The correlates of catastrophic OOP payments were assessed using logistic regression models. ResultsThe median OOP payments for maternal healthcare was GH₵866.5(US$109.3). The median non-medical OOP cost (GH₵479[US$ 59.9]) was higher than the median medical OOP cost (GH₵296.5[US$ 37.1]). The median OOP cost was higher for delivery (GH₵454[US$56.8]) compared to ANC (GH₵356.5[US$44.5]) and PNC (GH₵21.5[US$2.6]). Non-medical supplies comprise 58 % of the total OOP payments. About 73 % and 90 % of respondents spent more than 5 % of their annual household total and non-food expenditure on maternal healthcare, respectively. Rural areas and care at private facilities were significantly associated (AORs<1; p-values<0.05) with lower probabilities of incurring catastrophic OOP expenditure. Tertiary education was associated (AORs> 1; p-values<0.05) with a higher probability of incurring catastrophic OOP payments. ConclusionOOP payments for maternal care are still prevalent in Ghana. We call for a reform of Ghana’s free maternal healthcare policy to include non-medical supplies within its benefit package.

Correlates of adverse outcomes of adolescent pregnancy in Sidama region, Ethiopia. An unmatched case-control study

IntroductionAdolescent pregnancy has received little attention, despite being it is the leading cause of maternal mortality and morbidity in low-income countries, including Ethiopia. Sidama regional state is one of the regions in Ethiopia that has high rates of adolescent pregnancy. This study aimed to identify factors related to adverse outcomes of adolescent pregnancy, in the Sidama region, Ethiopia. MethodsA hospital-based unmatched case-control study was conducted among 120 cases and 240 controls of pregnant adolescents. Structured interviews and patient record reviews were used to examine the potential correlates and adverse outcomes of adolescent pregnancy. Using binary logistic analysis, adjusted odds ratio (AOR) with 95% confidence intervals, were computed to identify factors related to adverse outcomes of adolescent pregnancies. ResultsA monthly income below the poverty level (AOR: 3.40; 95% CI, 1.21–9.58), lack of antenatal care follow-up (AOR: 4.22; 95% CI, 1.97–9.04), experiencing gender-based violence (AOR: 2.03; 95% CI, 1.16–3.57), and referral to a specialized health facility (AOR: 2.79; 95% CI,1.39, 5.62) were associated with higher odds of adverse pregnancy outcomes. ConclusionSeveral socio-economic and health care system-related determinants are associated with adverse outcomes of adolescent pregnancy. Therefore, it is crucial to improve free and accessible maternal health care services for adolescents, focusing on education, challenging social norms that condone gender-based violence as well as enhancing the referral system to lessen the burden of adverse outcomes of adolescent pregnancy.

Hidden cost of hospital-based delivery and associated factors among postpartum women attending public hospitals in Gamo zone, southern Ethiopia

BackgroundSince 2005, the healthcare system in Ethiopia has implemented policies to promote the provision of free maternal healthcare services. The primary goal of these policies is to enhance the accessibility of maternity care for women from various socioeconomic backgrounds. Additionally, the aim is to increase the utilization of maternity services, such as institutional deliveries, by removing financial obstacles that pregnant women may face. Even though maternity services are free of charge. The hidden cost has unquestionably been a key obstacle in seeking and utilizing health care services. Significant payments due to delivery services could create a heavy economic burden on households.ObjectivesTo determine the hidden cost of hospital-based delivery and associated factors among postpartum women attending public hospitals in Gamo zone, southern Ethiopia 2023.MethodsA facility-based cross-sectional study was conducted on 411 postpartum women in Gamo Zone Public Health Hospitals from December 1, 2022, to January 30, 2023. The systematic sampling technique was applied to reach study units. Data was collected using the Kobo Toolbox Data Collection Tool and exported to SPSS statistical software version 27 for analysis. Simple linear regression and multiple linear regression were done to see the association of variables. The significance level was declared at a P-value < 0.05 in the final model.ResultThe median hidden cost of hospital-based delivery was 1142 Ethiopian birr (ETB), with a range (Q) of 2262 (504–2766) ETB. Monthly income of the family (β = 0.019), obstetrics complications (β = 0.033), distance from the health facility (β = 0.003), and mode of delivery (β = 0.072), were positively associated with the hidden cost of hospital-based delivery. While, rural residence (β = −0.041) was negatively associated with the outcome variable.ConclusionThis study showed the hidden cost of hospital based delivery was relatively high. Residence, monthly income of the family, obstetric complications, mode of delivery, and distance from the health facility were statistically significant. It is important to take these factors into account when designing health intervention programs and hospitals should prioritize the availability of essential drugs and medical supplies within their facilities to address direct medical costs in hospitals.

Effects of free maternal healthcare on stunting in children under five years of age: Evidence from Ghana

AbstractMotivationAddressing stunting in early childhood can have lasting effects on an individual's health, productivity, and well‐being in adulthood. By understanding the relationship between maternal healthcare policies and stunting, policy‐makers can design interventions that contribute to a healthier and more productive society.PurposeThis study investigated the effect of providing free healthcare to pregnant mothers on child stunting.Approach and methodThe article uses doubly robust difference‐in‐difference estimator, drawing on Ghana Demographic and Health Survey.FindingsFree healthcare to mothers reduced stunting in the treatment regions by 12.3%. Evidence suggests the reform may have influenced children under the age of five through antenatal and delivery care attendance during pregnancy. Assistance during antenatal care and childbirth by health professionals improved significantly.Policy implicationsMaternal health investment yields great health benefits for children from in utero to their fifth birthday. Maternal fee exemptions should be continued to maintain and further improve stunting reduction in children. Government should prioritize improving access to quality maternal healthcare services, including antenatal and skilled birth attendance and emergency obstetric care.

Maternal health care utilization following the implementation of the free maternal health care policy in Ghana: analysis of Ghana demographic and health surveys 2008–2014

BackgroundIn July 2008, Ghana introduced a ‘free’ maternal health care policy (FMHCP) through the national health insurance scheme (NHIS) to provide comprehensive antenatal, delivery and post-natal care services to pregnant women. In this study, we evaluated the ‘free’ policy impact on antenatal care uptake and facility-level delivery utilization since the policy inception.MethodsThe study used two rounds of repeated cross-sectional data from the Ghana Demographic and Health Survey (GDHS, 2008–2014) and constructed exposure variable of the FMHCP using mothers’ national health insurance status as a proxy variable and another group of mothers who did not subscribe to the policy. We then generated the propensity scores of the two groups, ex-post, and matched them to determine the impact of the ‘free’ maternal health care policy as an intervention on antenatal care uptake and facility-level delivery utilization, using probit and logit models.ResultsAntenatal care uptake and facility-level delivery utilization increased by 8 and 13 percentage points difference, observed coefficients; 0.08; CI: 95% [0.06–0.10]; p < 0.001 and 0.13; CI: 95% [0.11–0.15], p < 0.001, respectively. Pregnant women were 1.97 times more likely to make four plus [a WHO recommended number of visits at the time] antenatal care visits and 1.87 times more likely to give birth in a health care facility of any level in Ghana between 2008 and 2104; aOR = 1.97; CI: 95% [1.61–2.4]; p < 0.001 and aOR = 1.87; CI: 95% [1.57–2.23]; p < 0.001, respectively.ConclusionsAntenatal care uptake and facility-level delivery utilization improved significantly in Ghana indicating a positive impact of the FMHCP on maternal health care utilization in Ghana since its implementation.

What predicts health facility delivery among women? analysis from the 2021 Madagascar Demographic and Health Survey

BackgroundOne of the pivotal determinants of maternal and neonatal health outcomes hinges on the choice of place of delivery. However, the decision to give birth within the confines of a health facility is shaped by a complex interplay of sociodemographic, economic, cultural, and healthcare system-related factors. This study examined the predictors of health facility delivery among women in Madagascar.MethodsWe used data from the 2021 Madagascar Demographic and Health Survey. A total of 9,315 women who had a health facility delivery or delivered elsewhere for the most recent live birth preceding the survey were considered in this analysis. Descriptive analysis, and multilevel regression were carried out to determine the prevalence and factors associated with health facility delivery. The results were presented as frequencies, percentages, crude odds ratios and adjusted odds ratios (aORs) with corresponding 95% confidence intervals (CIs), and a p-value < 0.05 was used to declare statistical significance.ResultsThe prevalence of health facility delivery was 41.2% [95% CI: 38.9–43.5%]. In the multilevel analysis, women aged 45–49 [aOR = 2.14, 95% CI = 1.34–3.43], those with secondary/higher education [aOR = 1.62, 95% CI = 1.30–2.01], widowed [aOR = 2.25, 95% CI = 1.43–3.58], and those exposed to mass media [aOR = 1.18, 95% CI = 1.00-1.39] had higher odds of delivering in health facilities compared to those aged 15-49, those with no formal education, women who had never been in union and not exposed to mass media respectively. Women with at least an antenatal care visit [aOR = 6.95, 95% CI = 4.95–9.77], those in the richest wealth index [aOR = 2.74, 95% CI = 1.99–3.77], and women who considered distance to health facility as not a big problem [aOR = 1.28, 95% CI = 1.09–1.50] were more likely to deliver in health facilities compared to those who had no antenatal care visit. Women who lived in communities with high literacy levels [aOR = 1.54, 95% CI = 1.15–2.08], and women who lived in communities with high socioeconomic status [aOR = 1.72, 95% CI = 1.28–2.31] had increased odds of health facility delivery compared to those with low literacy levels and in communities with low socioeconomic status respectively.ConclusionThe prevalence of health facility delivery among women in Madagascar is low in this study. The findings of this study call on stakeholders and the government to strengthen the healthcare system of Madagascar using the framework for universal health coverage. There is also the need to implement programmes and interventions geared towards increasing health facility delivery among adolescent girls and young women, women with no formal education, and those not exposed to media. Also, consideration should be made to provide free maternal health care and a health insurance scheme that can be accessed by women in the poorest wealth index. Health facilities should be provided at places where women have challenges with distance to other health facilities. Education on the importance of antenatal care visits should also be encouraged, especially among women with low literacy levels and in communities with low socioeconomic status.

Validating the implementation of an indicator reporting policies and laws on free public maternal health-related services in the era of universal health coverage: A multi-country cross-sectional study.

The concept of universal health coverage (UHC) encompasses both access to essential health services and freedom from financial harm. The World Health Organization's Maternal Newborn Child and Adolescent Health (MNCAH) Policy Survey collects data on policies that have the potential to reduce maternal morbidity and mortality. The indicator, "Are the following health services provided free of charge at point-of-use in the public sector for women of reproductive age?", captures the free provision of 13 key categories of maternal health-related services, to measure the success of UHC implementation with respect to maternal health. However, it is unknown whether it provides a valid measure of the provision of free care. Therefore, this study compared free maternal healthcare laws and policies against actual practice in three countries. We conducted a cross-sectional study in four districts/provinces in Argentina, Ghana, and India. We performed desk reviews to identify free care laws and policies at the country level and compared those with reports at the global level. We conducted exit interviews with women aged 15-49 years who used a component service or their accompanying persons, as well as with facility chief financial officers or billing administrators, to determine if women had out-of-pocket expenditures associated with accessing services. For designated free services, prevalence of expenditures at the service level for women and reports by financial officers of women ever having expenditures associated with services designated as free were computed. These three sources of data (desk review, surveys of women and administrators) were triangulated, and chi-square analysis was conducted to determine if charges were levied differentially by standard equity stratifiers. Designation of services as free matched what was reported in the MNCAH Policy Survey for Argentina and Ghana. In India, insecticide-treated bed nets and testing and treatment for syphilis were only designated as free for selected populations, differing from the WHO MNCAH Policy Survey. Among 1046, 923, and 1102 women and accompanying persons who were interviewed in Argentina, Ghana, and India, respectively, the highest prevalence of associated expenditures among women who received a component service in each setting was for cesarean section in Argentina (26%, 24/92); family planning in Ghana (78.4%, 69/88); and postnatal maternal care in India (94.4%, 85/90). The highest prevalence of women ever having out of pocket expenditures associated with accessing any free service reported by financial officers was 9.1% (2/22) in Argentina, 64.1% (93/145) in Ghana, and 29.7% (47/158) in India. Across the three countries, self-reports of out of pocket expenditures were significantly associated with district/province and educational status of women. Additionally, wealth quintile in Argentina and age in India were significantly associated with women reporting out of pocket expenditures. Free care laws were largely accurately reported in the global MNCAH policy database. Notably, we found that women absorbed both direct and indirect costs and made both formal and informal payments for services designated as free. Therefore, the policy indicator does not provide a valid reflection of UHC in the three settings.

Improving access and quality of maternal and newborn care through the newly established Ayaan Specialist Hospital in Bosaso City, Puntland State of Somalia

Somalia has one of the highest maternal mortality ratios globally, constituting an important public health issue for the country. The availability of free and quality obstetric and newborn care services is critical for reducing maternal and newborn deaths. The Ayaan Foundation for humanitarian assistance has established a specialized hospital in Bosaso, Puntland, Somalia and created a cost-free service for normal deliveries and caesarean sections with assistance from the UN Population Fund. The Ayaan Specialist Hospital aims to provide better health and free basic and emergency obstetric and neonatal services to reduce maternal and neonatal morbidity and mortality. The hospital has high standard facilities, equipment, and supplies and is run by a highly specialized medical team implementing advanced quality services and supported by well-trained midwives and nurses that are available around the clock. The hospital has a clinical diagnostic laboratory, medical imaging facilities and provides quality drugs. Services were initially paid out-of-pocket, which was a problem for low-income clients. Pregnant women now have access to a comprehensive package of services at the hospital regardless of their socioeconomic status. During the initial period of January 2020 to June 2021, only 223 pregnant women attended the hospital; however upon easing the requirement for payment between July 2021 and June 2022, a total of 1,213 women of childbearing age attended the hospital. Among the full-term mothers, 218 had a normal vaginal delivery (36%), while 386 (63%) underwent caesarean section. The majority (84%) of these were treated as situations of emergencies. This approach has successfully increased facility-based births among poor women in the city and its surrounding rural districts. The initiative to establish the hospital was taken in view of the need to promote a free maternal health care policy to effectively realize universal access to and the full utilization of facility-based delivery across the country.

A multilevel analysis of social determinants of skilled birth attendant utilisation among married and cohabiting women of Madagascar.

Maternal mortality ratio (MMR) in Madagascar is 392 deaths per 100000 live births, and this is a major public health concern. One of the strategies for reducing MMR and achieving target 3.1 of the Sustainable Development Goals (i.e. reducing the global MMR below 70 per 100000 live births) is the utilisation of skilled birth attendants (SBAs). This analysis examined the prevalence and social determinants of SBA utilisation among married and cohabiting women of Madagascar. Data from the 2021 Madagascar Demographic and Health Surveys was analysed on a weighted sample of 6997 married and cohabiting women. A multilevel regression was carried out to determine the social determinants of utilising SBAs. The results are presented as odds ratios (ORs) associated with 95% confidence intervals (CIs) and a p-value <0.05 to determine the significant associations. The prevalence of SBAs among married and cohabiting women of Madagascar was 64.4% (95% CI 0.62 to 0.68). In model 3 of the multilevel regression, women 35-39y of age (adjusted OR [aOR] 1.86 [95% CI 1.30 to 2.60]), women with secondary/higher education (aOR 1.67 [95% CI 1.32 to 2.10]), women whose partners had secondary/higher education (aOR 1.58 [95% CI 1.25 to 1.99]), cohabiting women (aOR 1.33 [95% CI 1.07 to 1.65]), women who had four or more antenatal care visits (aOR 2.05 [95% CI 1.79 to 2.35]), female household head (aOR 1.44 [95% CI 1.06 to 1.95]), Muslims (aOR 1.58 [95% CI 0.71 to 3.53]), those of the richest wealth index (aOR 4.32 [95% CI 2.93 to 6.36]) and women who lived in communities with high literacy levels (aOR 2.17 [95% CI 1.57 to 3.00]) had higher odds of utilisation of SBA. This current analysis revealed low SBA utilisation among married and cohabiting women in Madagascar. The analysis points to the fact that understaffing and inaccessibility of health facilities remain major contributors to the low utilisation of SBAs. The findings call on the government and stakeholders in Madagascar to consider implementing programs that will empower women and focus on disadvantaged groups. These programs could include providing free maternal healthcare services to all pregnant women and intensifying health education programs that target women and their partners with no formal education.

Influence of Stakeholder Dynamics on Performance of Free Maternal Healthcare Project in Kenya, a Case of Homabay County

Purpose: The study examined the influence of sponsor, client, project team and regulatory dynamics, on project performance of free maternity in Homabay County, Kenya.The research focused on factors other than healthcare costs to ensure adequate infrastructure and health personnel in order to offer quality care for the growing number of clients. Besides it added to the existing body of knowledge pertaining to the delivery of free maternity services thereby reducing and eliminating maternal and perinatal deaths. It was conducted in eight sub-county hospitals in the county.&#x0D; Methodology: A total of 167 respondents were selected to participate in the study. The data were entered and analyzed by SPSS version 16. The coefficient of determination showed that sponsor dynamics had a major contribution to the project performance.&#x0D; Findings: There was a significant positive relationship between sponsor dynamics and project performance of free maternal healthcare in Homabay County, Kenya.&#x0D; Unique contribution to theory, practice and policy: The study therefore recommended that Donors and other implementing agencies ought to make their procedures flexible in order to accommodate input from other project stakeholders.

Information Needed, Sources of Information, and Barriers of Acquiring Required Information by Pregnant Women in Southern Sri Lanka

Background: A correct understanding of pregnancy and related issues would facilitate pregnant women to manage their pregnancies well. The objective of this study was to assess the pregnancy-related information needed by pregnant women in Sri Lanka and the obstacles that they face when acquiring such information. Materials and Methods: A descriptive cross-sectional study was conducted among 420 pregnant women admitted to a teaching hospital in Southern Sri Lanka. Data related to demography, information needed, sources of information seeking, and barriers that they face in acquiring such information were collected using an interviewer-administered questionnaire. Mean scores of the information needed (ranges 0–4) in different areas and a total score of the information needed were calculated. Regression analysis was used to identify possible predictors of information needed by the target group. Results: Family members, visiting obstetrician and gynecologist, antenatal clinical staff, and midwives were the common sources of information for nearly 80% of the participants. Psychological and physical complications after delivery (2.61 ± 1.21), special tests during pregnancy (2.44 ± 1.26), development and growth of the fetus (2.40 ± 1.26), and nutrition during pregnancy (2.36 ± 1.26) were the main areas where accurate and more information was sought by the participants. Failures in making a distinction between correct and incorrect information received ( n = 113 [26.9%]) and poor interactions between healthcare providers and pregnant women ( n = 103 [24.5%]) were the main barriers identified in acquiring trustworthy information. About one-fourth of the participants had used pregnancy-related apps. Information needs were high among pregnant women with less number of children ( β = −0.14, p &lt; .01). Age, income, and area of living (rural or urban) did not significantly predict information needs in this target population. Conclusion: The free maternal and child healthcare system prevailing in the country seems to be the main source of information gathering for pregnant mothers. Physical, psychological, and nutritional facts related to pregnancy and its management should be increased among pregnant mothers, and it is imperative to empower them in the identification of correct information from authenticated sources. Primigravida women need more educational support. Electronic platforms should be effectively used in the future to disseminate information required by pregnant women in the country.

Social Protection Supports and Management of Non-Communicable Diseases in Ghana: A Qualitative Cross-Sectional Perspective of Health Stakeholders

Introduction: Africa faces a double burden of communicable and non-communicable diseases (NCDs). Already, health systems in Africa are overwhelmed with a high burden of communicable diseases with perennial outbreaks of highly infectious diseases. The rise in NCDs comprises an already fragile health system challenging its ability to provide comprehensive care to people living with these diseases. Without responsive social support systems, NCDs will draw more people into catastrophic health financing, worsening health outcomes, and poverty. This study explores how vulnerable people negotiate major disease burdens with the social protection supports available in Ghana. Methods: The study applied a cross-sectional design with a qualitative approach involving healthcare professionals and non-healthcare professionals in 4 regions in Ghana with a total of 32 qualitative interviews analyzed thematically. Results: The main social protection support for the health sector in Ghana is the National Health Insurance Scheme. Other social protection supports such as free maternal healthcare, Livelihood Empowerment Against Poverty, and conventional informal social protection mechanisms do not directly target people afflicted with NCDs. Even though national health insurance covers about 90% of diseases, the quality of care is questionable. Again, the exclusion of diagnostic investigations makes national health insurance a setback to NCD disease management. Also, NCD patients still do out-of-pocket expenses though they have valid national health insurance. Informal social protection supports which used to be effective sometime back are dwindling due to the rising cost of living, gradual breakdown of the African system of reciprocity, and infiltration of Western lifestyles. Conclusion: NCD patients have very limited social protection for the management of their condition. Health insurance which is the only option for many has limited applications. A multidisciplinary body is established by the government to outline more effective ways of offering social protection support for health services, especially chronic conditions such as NCDs which affect a greater proportion of the population.

Maternal health care policy intervention and its impact on perinatal mortality outcomes in Ghana: evidence from a quasi-experimental design

ObjectiveThis study aimed to evaluate the impact of Ghana's free maternal health care policy on stillbirth and perinatal death since its implementation a decade ago. Study designThe study used the propensity score matching method, a quasi-experimental design technique and secondary data to construct two groups of mothers with a history of perinatal deaths who subscribed to the ‘free’ maternal health care policy versus mothers who did not. MethodThe study merged two rounds of repeated cross-sectional data sets obtained from the Ghana Demographic and Health Survey (GDHS), 2008 and 2014, and generated exposure variables; pregnant women policy holding status and outcome variables; stillbirth and perinatal death by constructing binary outcomes from the under-five mortality variables of the DHS data sets. Fetal and early neonatal deaths within the data set were categorized into two groups: those exposed to the free maternal health care policy and those who did not. The propensity scores of the two groups were then generated and analyzed after checking for bias and common support. The analysis applied sample weighting to account for clustering and stratification due to the complex design of the DHS. All analyses were done with STATA 15 and adjusted for confounding using independent covariates. ResultsStillbirth (43.3%) and perinatal death (60.2%) were high in the intervention group compared to the comparison group, and the differences were statistically significant (stillbirth, 0.0156, and perinatal death, 0.0012). Stillbirth and perinatal deaths were 12 and 13 percentage points higher in the intervention group, and these were statistically significant: adj. coef. = 0.12; 95% CI: [0.03–0.19]; P = 0.005 and adj. coef. = 0.13; 95% CI: [0.03–0.22]; P = 0.005. ConclusionThe results show that stillbirth and perinatal death were high in the maternal health care policy group, poorly reflecting as outcomes. However, the percentage point difference between stillbirth and perinatal death suggests a decline in early neonatal mortality and a positive impact of the ‘free’ maternal health care policy on perinatal death over stillbirth.

Factors influencing the free maternal health care policy under the national health insurance scheme’s provision for skilled delivery services in Ghana: a narrative literature review

BackgroundSkilled Birth Attendance (SBA) is important in achieving the Sustainable Development Goals (SDGs) targets 3.1, 3.2 and 3.3.1. Ghana has made steady progress in SBA, yet, unsupervised deliveries still occur. The introduction of the Free Maternal Health Care Policy under the National Health Insurance Scheme (FMHCP under the NHIS) has improved the uptake of SBA but with some implementation challenges. This narrative review sought to explore the factors influencing the FMHCP under the NHIS provision for skilled delivery services in Ghana.MethodsElectronic searches were conducted of databases including PubMed, Popline, Science direct, BioMed Central, Scopus and Google scholar for peer reviewed articles as well as grey articles from other relevant sources, published between 2003 and 2021 on factors influencing FMHCP/NHIS provision for skilled delivery services in Ghana. Keywords used in the literature search were in various combinations for the different databases. The articles were screened to determine the inclusion and exclusion criteria and quality was assessed using a published critical appraisal checklist. A total of 516 articles were retrieved for initial screening based on their titles, of which 61 of them, were further screened by reading their abstracts and full text. Of this number, 22 peer-reviewed and 4 grey articles were selected for the final review based on their relevance.ResultsThe study revealed that the FMHCP under the NHIS does not cover the full costs associated with skilled delivery and low socioeconomic status of households affects SBA. Also, funding and sustainability, hinders the quality-of-service delivery offered by the policy.ConclusionFor Ghana to achieve the SDGs above and further improve SBA, the cost associated with skilled delivery should be fully covered by the NHIS. Also, the government and the key stakeholders involved in the policy implementation, must put in place measures that will enhance the operation and the financial sustainability of the policy.

Global economic meltdown and healthcare financing in Ghana.

Global economic meltdown and healthcare financing in Ghana.

An assessment of out of pocket payments in public sector health facilities under the free maternal healthcare policy in Ghana

BackgroundThe free maternal healthcare policy was introduced in Ghana in 2008 under the national health insurance scheme as a social intervention to improve access to maternal health services. This study investigated the prevalence of out of pocket (OOP) payment among pregnant women with valid national health insurance who sought skilled delivery services at public sector health facilities in Ghana. The study also assessed the health system factors associated with OOP payment.MethodsWe used data from the Ghana Maternal Health Survey (GMHS), which was conducted in 2017. The study comprised 7681 women who delivered at a public sector health facility and had valid national health insurance at the time of delivery. We used multivariable logistic regression analysis to assess factors associated with OOP payment, whiles accounting for clustering, stratification, and sampling weights.ResultsThe prevalence of OOP payment for skilled delivery services was 19.0%. After adjustment at multivariable level, hospital delivery services (adjusted Odds Ratio [aOR] = 1.23, 95% Confidence Interval [CI] = 1.00, 1.52), caesarean section (aOR = 1.73, 95% CI = 1.36, 2.20), and receiving intravenous infusion during delivery (aOR = 1.31, 95% CI = 1.08, 1.60) were associated with higher odds of OOP payment. Women who were discharged home 2 to 7 days after delivery had 19% lower odds of OOP payment compared to those who were discharged within 24 hours after delivery.ConclusionThis study provides evidence of high prevalence of OOP payment among women who had skilled delivery services in public sector health facilities although such women had valid national health insurance. Government may need to institute measures to reduce OOP payment in public sector facilities especially at the hospitals and for women undergoing caesarean sections.

The potency of a free maternal healthcare policy in achieving universal health coverage a cross-sectional qualitative study

Background: The main focus of Ghana’s free maternal healthcare policy under the national health insurance scheme was to reduce the maternal mortality ratio. Aim: This study aims at ascertaining the potency of this policy in the achievement of universal health coverage in Ghana. Method: A cross-sectional qualitative study was conducted in the Bibiani-Anwiaso-Bekwai Municipality from June to December 2021 among women in their reproductive age (15-49 years) to ascertain how the policy has enhanced women’s access to maternal healthcare thereby facilitating the attainment of universal health coverage. Written informed consent and permission to participate in the study was obtained from each participant. In the case of those under 18 years, consent was sought from their parents/guardians A multistage sampling technique was used to select districts, health facilities and study participants. Focus group discussion and four key informants interviews were conducted among two nurses and two midwives who were selected using purposive sampling. The data obtained from respondent was analysed using content analysis. Results: Generally the women included in this study were knowledgeable about the policy as they recounted that, through the policy, health services they could not afford before are now accessible without any financial constraints. This means that the policy has provided many women and neonates access to maternal healthcare and healthcare in general and therefore has contributed to the attainment of universal health coverage in the municipality. Conclusions: The policy has provided financial access to women in maternal healthcare in particular and healthcare in general. This shows that the policy has a strong potential to contribute to the attainment of universal health coverage in the municipality and the country at large. Therefore, women should be encouraged to subscribe to the health insurance policy

How a supply-side intervention can help to increase caesarean section rates in Burkina Faso facilities-Evidence from an interrupted time-series analysis using routine health data.

In Burkina Faso, only 2.1% of women give birth by caesarean section (CS). To improve the use of maternal health services during pregnancy and childbirth, many interventions were implemented during the 2010s including performance-based financing (PBF) and a free maternal health care policy (the gratuité). The objective of this study is to evaluate the impact of a supply-side intervention (PBF) combined with a demand-side intervention (gratuité) on institutional CS rates in Burkina Faso. We used routine health data from all the public health facilities in 21 districts (10 that implemented PBF and 11 that did not) from January 2013 to September 2017. We analysed CS rates as the proportion of CS performed out of all facility-based deliveries (FBD) that occurred in the district. We performed an interrupted time series (ITS) analysis to evaluate the impact of PBF alone and then in conjunction with the gratuité on institutional CS rates. CS rates in Burkina Faso increased slightly between January 2013 and September 2017 in all districts. After the introduction of PBF, the increase of CS rates was higher in intervention than in non-intervention districts. However, after the introduction of the gratuité, CS rates decreased in all districts, independently of the PBF intervention. In 2017, despite high FBD rates in Burkina Faso as well as the PBF intervention and the gratuité, less than 3% of women who gave birth in a health facility did so by CS. Our study shows that the positive PBF effects were not sustained in a context of user fee exemption.

"I don't like to be seen by a male provider": health workers' strike, economic, and sociocultural reasons for home birth in settings with free maternal healthcare in Nigeria.

Ending maternal mortality has been a significant global health priority for decades. Many sub-Saharan African countries introduced user fee removal policies to attain this goal and ensure universal access to health facility delivery. However, many women in Nigeria continue to deliver at home. We examined the reasons for home birth in settings with free maternal healthcare in Southwestern and North Central Nigeria. We adopted a fully mixed, sequential, equal-status design. For the quantitative study, we drew data from 211 women who reported giving birth at home from a survey of 1227 women of reproductive age who gave birth in the 5y before the survey. The qualitative study involved six focus group discussions and 68 in-depth interviews. Data generated through the interviews were coded and subjected to inductive thematic analysis, while descriptive statistics were used to analyse the quantitative data. Women faced several barriers that limited their use of skilled birth attendants. These barriers operate at multiple levels and could be grouped as economic, sociocultural and health facility-related factors. Despite the user fee removal policy, lack of transportation, birth unpreparedness and lack of money pushed women to give birth at home. Also, sociocultural reasons such as hospital delivery not being deemed necessary in the community, women not wanting to be seen by male health workers, husbands not motivated and husbands' disapproval hindered the use of health facilities for childbirth. This study has demonstrated that free healthcare does not guarantee universal access to healthcare. Interventions, especially in the Nasarawa state of Nigeria, should focus on the education of mothers on the importance of health facility-based delivery and birth preparedness.