Reducing maternal and child mortality in rural Ghana
Joseph Adu1,&, Shree Mulay2, Mark Fordjour Owusu3
1Faculty of Health Sciences, Department of Health and Rehabilitation
Sciences, Western University, 1201 Western Rd, London, ON N6G 1H1, London,
Ontario, Canada, 2Faculty of Medicine, Department of Community Health
and Humanities, Memorial University of Newfoundland, 300 Prince Philip Dr,
St. John's, NL A1B 3V6, St. John´s, Newfoundland, Canada, 3School of Health Sciences, University of Canterbury, Christchurch, New Zealand
Joseph Adu, Faculty of Health Sciences, Department of Health and Rehabilitation
Sciences, Western University, 1201 Western Rd, London, ON N6G 1H1, London, Ontario,
The lack of health infrastructure in developing countries to provide
women with modern obstetric care and universal access to maternal and
child health services has largely contributed to the existing high maternal
infant deaths. Access to basic obstetric care for pregnant women and
their unborn babies is a key to reducing maternal and infants´ deaths,
especially at the community-level. This calls for the strengthening
of primary health
care systems in all developing countries, including Ghana. Financial
access and utilization of maternal and child health care services need
the community-level across rural Ghana to avoid preventable deaths.
Financial access and usage of maternal and child health services in
rural Ghana is
poor. Lack of financial access is a strong barrier to the use of maternal
and child health services, particularly in rural Ghana. The sustainability
of the national health insurance scheme is vital in ensuring full access
to care in remote communities.
Sub-Saharan Africa (SSA) accounted for the highest Maternal Mortality Ratio (MMR) in Africa, with 546 deaths/100,000 live births in 2015 compared to any other region in the world . The MMR for SSA represented 65% of all maternal deaths in the developing world . Improvements in maternal and infant mortality in developing countries over the years have not been uniform due to disparities in the distribution of human resources, infrastructural facilities, essential drugs, and quality of care . Previous studies highlight poor quality of care, non-availability of care and cultural beliefs/ignorance of the need for obstetric care for these disparities [2, 3]. Many women do not want to deliver in institutions because of the poor quality of care and risk dying during perinatal period, especially in the rural areas of developing countries .
Ghana, a country in SSA made progress by reducing its MMR and Infant Mortality
Ratio (IMR) from 740 to 319/100,000 live births and 80 to 41 infant deaths/
1000 live births, respectively, between 1990 and 2015 (Ghana Statistical Service
. Ghana´s improvement in MMR and IMR was facilitated
by rolling out innumerable policies by Ghana Health Services (GHS)/Ministry
of Health (MOH) which brought about an increased usage of facility delivery
and postnatal care . These policies include the Ghanaian
Government policies of exempting pregnant women from delivery fees in all public
and religious health institutions since September 2003, followed by implementation
of free maternal healthcare policy in July 2008, as well as the free maternal
healthcare policy under the National Health Insurance Scheme (NHIS) .
While the improvements made are commendable, Ghana still needs to focus on
increasing its rates of live births and universal access to maternal healthcare.
According to the Ghana Maternal Health Survey (GMHS) 2017 show that maternal
mortality in Ghana accounted for 14% of all deaths; 10% from direct maternal
4% from indirect maternal causes. suggesting that two-thirds of deaths (67%)
were direct maternal deaths . In addition, more than
one quarter (27%) were indirect maternal deaths, and another 6% were due to
unspecified maternal causes.
The common causes of direct maternal deaths are obstetric haemorrhage (30%),
followed by hypertensive disorders (14%), and sepsis (10%) which results from
complications due to non-medical abortions. The management of both obstetric
haemorrhage and pregnancy-induced hypertension requires services of nurses,
and doctors who are scarce in rural-Ghana [4, 5].
Neonatal deaths result from poor infant outcomes which account for 71% of all
infant deaths in Ghana according to the Ghana Statistical Services figures
in 2015. The GHS estimate that a neonate dies every fifteen minutes in Ghana,
with over 21,000 deaths occurring annually as confirmed by the Ghana News Agency
in 2017. The GMHS (2017) reported also IMR of 37 deaths/1000 live births and
under-five mortality ratio of 52 deaths/1000 live births; implying 1 in 27
before their first birthday, whereas 1 in 19 children die before age five .
The cause of these deaths included complications associated with preterm birth,
difficult labour, inadequate access to quality healthcare, financial constraints
faced by mothers, mismanagement of the NHIS, and poor nutrition amongst pregnant
women . The GHS attributes the country´s setbacks
on the poor performance of maternal and child health department of the GHS
the inadequate number of trained and certified midwives in the country, particularly
within rural communities, where midwives and nurses often refuse rural posting
after training as reported by the Ghana News Agency in 2017. Clearly, the GHS/MOH
have a good grasp of the challenges in providing quality care for women and
infants in hard-to-reach areas of the country however, there are no robust
policies to address these problems. This paper explores policies implemented
to improve access to maternal health services in rural Ghana and
ways to strengthen the Ghanaian NHIS for better uptake of maternal health services
in rural Ghana. As well, strategies to improve pregnancy and childbirth outcomes
to further reduce the high rates of maternal and infant mortality in rural-Ghana
will be suggested.
Improving maternal and infant health in rural Ghana.
The enhancement of women´s health in Ghana largely depends on the reproductive
and child health policies of the MOH and GHS. Available policy documents on maternal
and child healthcare services by MOH/GHS indicate that Ghana has adequate policies
in place to provide the needed services to improve maternal and child healthcare
as shown in the 2013 annual report of the GHS. Undeniably, the maternal and child
health policy guidelines follow the recommendations made by the International
Conference on Population and Development in Cairo in 1994. Key components of
these policies focus on improving access to universal education, reducing rates
of infant, child, and maternal mortality, and increasing access to reproductive
and sexual health services as outlined in the GHS 2013 annual performance report
of the Family Health Division in 2014. However, progress in achieving these goals
has been limited due to from inconsistent and insufficient human and financial
capital as well as infrastructural constraints. Investments in these areas require
attention from central government and Civil Society Organizations (CSOs) to improve access to basic obstetrics
to all pregnant women and newborns in Ghana. The GHS has failed to implement
some of the policies outlined by the MOH due to lack of funding and human resources
Nevertheless, the implementation of the Community-Based Health Planning and Services
(CHPS) program by the MOH/GHS in 2000 to improve access to maternal and child
health services at the community-level to achieve MDG targets were effective
[4, 6]. The CHPS contributed to scaling-up
universal access to healthcare, especially maternal and child healthcare services
in rural-Ghana [5, 6]. The CHPS provided
entry point access to the Ghanaian healthcare system at the community-level,
where community health nurses with basic knowledge in obstetrics examined a
pregnant woman, provided antenatal care, and assisted during labour or referred
to a more advanced health center for further management. In addition, women
received free maternal healthcare through a policy issued by the NHIS that
enabled them to access to antenatal care (ANC), facility-based delivery (FBD),
(PNC) services. The publicly insured program played a significant roles in
improving maternal and infant outcomes, as indicated in 2007 by the increased
of ANC and PNC, as well as increased rates in FBD .
Prior to the inception of the NHIS in 2004, access to healthcare services
women was privatized, and attendance was based on having financial resources.
Women and families who lived in poverty could not afford services
in some public and private hospitals where there was a cost, including having
an FBD. The free maternal health policy under the NHIS made it possible for
all pregnant women to access free healthcare, including FBD and Caesarean delivery.
For example, the findings of previous studies in Ghana indicate an increase
in FBD from 50.1% in 2004 to 71.2% in 2009 compared to 46 % between 1998 and
2003 when the NHIS was not instituted . This clearly
indicates that, before the inception of NHIS in 2004, about 53% of pregnant
women delivered at home without the help of skilled attendants.
Despite the success of the new policy under the NHIS, a 2017 analysis of 2014
data from MOH and GHS showed that 90.1 % of pregnant women had ANC and 54.7%
had FBD, respectively . Even with the progress made,
it appears that 45.3% of pregnant women still delivered at home without the
services of a skilled birth attendant. These women likely risk maternal death
or post-delivery complications which could increase the already high MMR in
It also calls for needs assessment at the community-level to ascertain why
significant proportions of women deliver at home instead of health facilities.
As Austin et al.  found, some women are reluctant
to go outside of the home to deliver their babies because of previous negative
experiences and perceived poor quality of care. Women clearly want the option
of home delivery, but home delivery needs to be safe to avoid post-delivery
complications. It is important for staff to identify women who are likely to
have a high-risk pregnancy during ANC and encourage them to go to a district
hospital for specialized care at the time of delivery. Policy guidelines, such
as those available in Rwanda are good examples for Ghana to follow, where policymakers
worked to ensure facility improvements in infrastructure and personnel, effective
medicines, and information campaigns, good transport systems, restrictions
in home delivery and encouraging facility-based delivery .
The implementation of the aforesaid policies helped Rwanda to increase its
facility deliveries to 90% . Offering women the
possibility of having a supervised home delivery, whether it is a personal
choice or a cultural preference, needs to be addressed to close the wide gap
home delivery and FBD to reduce the high MMR and IMR in Ghana. That said, the
zero maternal mortality policy of the Shai-Osudoku District Hospital at Dodowa
in the Greater-Accra Region which has yielded amazing results over the past
five years could be adopted by policymakers to reduce preventable deaths in
other district hospitals. While the district hospital documented an annual
delivery of more than 2,000 cases over the years recorded no maternal deaths
as documented by the Ghana News Agency in 2015.
The MOH and GHS can continue to work to achieve targets in rural-maternal health
by strengthening the CHPS with additional infrastructure such as improved housing
to accommodate staff, and other logistical supplies such as consumables and
basic instruments for midwives, community health nurses to use, and incentivize
postings in rural-health centres. Another important facet of accessible healthcare
service is the provision of good road networks and safe transportation. The
absence of safe road networks and transportation, coupled with the long distances
between the CHPS compounds, district hospitals, and the communities that they
serve makes it difficult for women to access a healthcare facility .
This could even affect the triage system within a district should a midwife
or community health nurse at the community clinic identify women with high-risk
pregnancies and refer them to hospital for further management.
Developing infrastructure in rural Ghana requires new road networks, safe transportation
systems, and optimal living conditions to support the CHPS in its mandate to
make healthcare accessible to all. Good social amenities are also necessary
to attract and retain health workers in rural Ghana. Achieving these goals
requires inter-sectoral collaboration of all major sectors of the economy to
address components that reflect each of their respective portfolios. A sustainable
NHIS that provides free access to healthcare is also needed to increase the
uptake of maternal and child health services which could be achieved by making
the Ghana National Health Insurance Authority (NHIA) more financially viable.
The NHIA is a corporate body under the auspices of the Government of Ghana
that implements, operates, and manages the NHIS. The inability of the NHIA
pay providers and the high rates of non-reimbursement of NHIS claims could
cause in the withdrawal of services by providers [5, 10],
which would significantly impact service delivery.
The issues associated with the NHIS could be improved by the NIHA to maintain
its use by the people of Ghana; all activities of the NHIA should be monitored
by independent bodies to oversee fiscal and operational accountability. Continuous
health promotion activities in the form of maternal education should be provided
by healthcare professionals periodically to inculcate maternal health-seeking
behavior among women in communities noted for poor use of healthcare services.
Healthcare professionals could advertise their services by partnering with
local media houses/radio stations to promote the importance of maternal healthcare
services in their communities. Maternal health education should also target
men at the community-level particularly rural-communities where ANC, FBD, and
PNC attendance is low to ensure their full participation in activities around
of skilled attendants during labour and contraceptives to control future pregnancies.
Access to healthcare, including obstetric services, is essential in preventing
maternal and neonatal deaths, especially in rural Ghana. The ability to provide
access to care depends on several sectors working in partnership to develop
more healthcare infrastructure, human resources staffing, effective and safe
road networks, and reliable transportation systems. Well-equipped district
hospitals with emergency obstetrics and neonatal care centers are vital for
referrals from CHPS facilities to prevent deaths and undue complications.
The authors declare no competing interests.
Mr. Joseph Adu conceived and prepared the initial draft of the manuscript.
Drs. Shree Mulay and Mark Fordjour Owusu made considerable changes
to the manuscript; and all authors participated in the final preparation
manuscript. All authors have read and approved the final version
of this manuscript.
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