Evaluating the impact of the community-based health planning and services initiative on uptake of skilled birth care in Ghana

Background: the Community-based Health Planning and Services (CHPS) initiative is a major government policy to improve maternal and child health and accelerate progress in the reduction of maternal mortality in Ghana. However, strategic intelligence on the impact of the initiative is lacking, given the persistent ?problems of patchy geographical access to care for rural women. This study investigates the impact of proximity to CHPS on facilitating uptake of skilled ?birth care in rural areas.Methods and findings: data from the ?2003 and 2008 Demographic and Health Survey, ? on 4,349 births from 463 rural communities were linked to georeferenced data on health facilities, CHPS and topographic data on national road-networks. Distance to nearest health facility and CHPS was computed using the closest facility functionality in ArcGIS 10.1. Multilevel logistic regression was used to examine the effect of proximity to health facilities and CHPS on use of skilled care at birth, adjusting for relevant predictors and clustering within ?communities.? The results show that a substantial proportion of births continue to occur in communities more than 8 km from both ?health facilities and CHPS. Increases in uptake of skilled birth care are more pronounced where both health ?facilities and CHPS compounds are within 8 km, but not in communities within 8 km of CHPS but lack access to health facilities. Where both health facilities and CHPS are within 8 km, the odds of skilled ?birth care is 16% higher than ?where there is only a health facility within 8km. Conclusion: where CHPS compounds are set up near health facilities, there is improved access to care, demonstrating the facilitatory role of CHPS in stimulating access to better care at birth, in areas where health facilities are accessible. <br/

Two decades of maternity care fee exemption policies in Ghana: have they benefited the poor?

Objective: To investigate the impact of maternity-related fee payment policies on the uptake of skilled birth care amongst the poor in Ghana. Methods: Population data representing 12,288 births between November 1990 and October 2008 from four consecutive rounds of the Ghana Demographic and Health Surveys were used to examine the impact of four major maternity-related payment policies: the full-cost recovery cash and carry scheme; antenatal care fee exemption; delivery care fee exemption and the National Health Insurance Scheme. Concentration curves were used to analyse the rich-poor gap in the use of skilled birth care by the four policy interventions. Multilevel logistic regression was used to examine the effect of the policies on the uptake of skilled birth care, adjusting for relevant predictors and clustering within communities and districts. Findings: The uptake of skilled birth care over the policy periods for the poorest women was trivial when compared to their non-poor counterparts. The rich-poor gap in skilled birth care use was highly pronounced during the ?cash and carry ?and free antenatal care policies period. The benefits during the free delivery care and ?National ?Health Insurance Scheme policy periods accrued more for the rich than the poor. ?There exist significant differences in skilled birth care use between and within communities and districts, even after adjusting for policy effects and other relevant predictors. Conclusion: The maternal care fee exemption policies specifically targeted towards the poorest women had limited impact on the uptake of skilled birth care. <br/

Geographical access to care at birth in Ghana: a barrier to safe motherhood.

BACKGROUND: Appropriate facility-based care at birth is a key determinant of safe motherhood but geographical access remains poor in many high burden regions. Despite its importance, geographical access is rarely audited systematically, preventing integration in national-level maternal health system assessment and planning. In this study, we develop a uniquely detailed set of spatially-linked data and a calibrated geospatial model to undertake a national-scale audit of geographical access to maternity care at birth in Ghana, a high-burden country typical of many in sub-Saharan Africa. METHODS: We assembled detailed spatial data on the population, health facilities, and landscape features influencing journeys. These were used in a geospatial model to estimate journey-time for all women of childbearing age (WoCBA) to their nearest health facility offering differing levels of care at birth, taking into account different transport types and availability. We calibrated the model using data on actual journeys made by women seeking care. RESULTS: We found that a third of women (34%) in Ghana live beyond the clinically significant two-hour threshold from facilities likely to offer emergency obstetric and neonatal care (EmONC) classed at the 'partial' standard or better. Nearly half (45%) live that distance or further from 'comprehensive' EmONC facilities, offering life-saving blood transfusion and surgery. In the most remote regions these figures rose to 63% and 81%, respectively. Poor levels of access were found in many regions that meet international targets based on facilities-per-capita ratios. CONCLUSIONS: Detailed data assembly combined with geospatial modelling can provide nation-wide audits of geographical access to care at birth to support systemic maternal health planning, human resource deployment, and strategic targeting. Current international benchmarks of maternal health care provision are inadequate for these purposes because they fail to take account of the location and accessibility of services relative to the women they serve

Geographical access to care at birth in Ghana: a barrier to safe motherhood

Background: Appropriate facility-based care at birth is a key determinant of safe motherhood but geographical access remains poor in many high burden regions. Despite its importance, geographical access is rarely audited systematically, preventing integration in national-level maternal health system assessment and planning. In this study, we develop a uniquely detailed set of spatially-linked data and a calibrated geospatial model to undertake a national-scale audit of geographical access to maternity care at birth in Ghana, a high-burden country typical of many in sub-Saharan Africa. Methods: We assembled detailed spatial data on the population, health facilities, and landscape features influencing journeys. These were used in a geospatial model to estimate journey-time for all women of childbearing age (WoCBA) to their nearest health facility offering differing levels of care at birth, taking into account different transport types and availability. We calibrated the model using data on actual journeys made by women seeking care. Results: We found that a third of women (34%) in Ghana live beyond the clinically significant two-hour threshold from facilities likely to offer emergency obstetric and neonatal care (EmONC) classed at the ‘partial’ standard or better. Nearly half (45%) live that distance or further from ‘comprehensive’ EmONC facilities, offering life-saving blood transfusion and surgery. In the most remote regions these figures rose to 63% and 81%, respectively. Poor levels of access were found in many regions that meet international targets based on facilities-per-capita ratios. Conclusions: Detailed data assembly combined with geospatial modelling can provide nation-wide audits of geographical access to care at birth to support systemic maternal health planning, human resource deployment, and strategic targeting. Current international benchmarks of maternal health care provision are inadequate for these purposes because they fail to take account of the location and accessibility of services relative to the women they serve. <br/