Spatial inequalities in skilled attendance at birth in Ghana: A multilevel analysis integrating health facility databases with household survey data

Objective: This study aimed at using survey data to predict skilled attendance at birth (SBA) across Ghana from healthcare quality and health facility accessibility. Methods: Through a cross-sectional, observational study, we used a random intercept mixed effects multilevel logistic modelling approach to estimate the odds of having SBA and then applied model estimates to spatial layers to assess the probability of SBA at high-spatial resolution across Ghana. We combined data from the Demographic and Health Survey (DHS), routine birth registers, a service provision assessment of emergency obstetric care services, gridded population estimates and modelled travel time to health facilities. Results: Within an hour's travel, 97.1% of women sampled in the DHS could access any health facility, 96.6% could reach a facility providing birthing services, and 86.2% could reach a secondary hospital. After controlling for characteristics of individual women, living in an urban area and close proximity to a health facility with high-quality services were significant positive determinants of SBA uptake. The estimated variance suggests significant effects of cluster and region on SBA as 7.1% of the residual variation in the propensity to use SBA is attributed to unobserved regional characteristics and 16.5% between clusters within regions. Conclusion: Given the expansion of primary care facilities in Ghana, this study suggests that higher quality healthcare services, as opposed to closer proximity of facilities to women, is needed to widen SBA uptake and improve maternal health.