Utilizing the community-based health planning and services program to promote skilled attendants at delivery in rural Ghana

Thesis (Dr.P.H.)--Boston UniversityThe burden of maternal mortality in sub-Saharan Africa is enormous. In Ghana the maternal mortality ratio reached 350:100,000 live births in 2010. Skilled birth attendance (SBA) has been shown to reduce maternal deaths and disabilities, yet in 2008 only 55% of mothers in Ghana gave birth with a SBA. In 2005, the Ghana Health Service piloted an enhancement of its Community-based Health Planning and Services (CHPS) program, training Community Health Officers (CHOs) as midwives, to address the gap in SBA in rural Upper East Region (UER). This dissertation reports findings of a post-hoc evaluation of this CHO-Midwife pilot project, assessing training and practices, community participation and satisfaction, and SBA utilization. Method: The evaluation employed a mixed methods intrinsic case study design, conducting in-depth interviews with a purposive sample of health professionals and community stakeholders (Phase I), and a survey of mothers with children under five in three districts of the UER, identified through three-stage sampling design (Phase II). Findings: In-depth interviews with 41 stakeholders pointed to a successful rollout of the pilot program. CHO-midwives reported high confidence supervising normal deliveries, antenatal and postnatal care, infection prevention, and health education, referring women with prolonged labour, cord prolapse and need for resuscitation to district health centers or hospitals. Lack of ambulances and other equipment, a poor transportation system and insufficient accommodation for CHO-Midwives threaten more complete provision of SBA. Community stakeholders, including volunteers and traditional birth attendants, local leaders, and NGO's are deeply engaged in program implementation. Our survey of 407 mothers revealed increased access to skilled delivery services since CHO-Midwives were trained. From April 2009-March 2012, 79% of the 407 births in twelve CHPS zones of three districts were with skilled attendants; and over half of these skilled births (42% of total) were by CHO-Midwives. Multivariate analyses showed that women of Nankana tribe and those with non-educated husbands were significantly less likely to access SBA in rural settings. Conclusion: Successful implementation of the integrated CHO-midwife program in the UER of Ghana has expanded skilled delivery care access and utilization for rural women. Policy-makers must now address remaining obstacles, and cost-effectiveness research is needed to inform program scale-up throughout Ghana. Key words: Maternal Mortality, Skilled attendants at birth, Community-Based Services, Community Participation, Kassena-Nankana East District, Kassena-Nankana West District, Bongo Distric