Inequities in the utilization of obstetric care services in Ghana and its implications for policy: Evidence from a population-based study

Maternal and newborn morbidity, as well as deaths, are disproportionately high in the African region, especially in sub-Saharan Africa. The majority of newborn and maternal mortality happens either during childbirth or immediately after childbearing. Although the use of obstetric services has proven to be vital in decreasing mortality arising from pregnancy complications, only antenatal care service has received significant attention across the West Africa region. Still substantial proportions of women in sub-Saharan Africa, including Ghana, miss life-saving obstetric interventions such as labor and delivery care in health facilities, caesarean section (CS) delivery, and postnatal care (PNC) services. In many low-income countries, the high rates of non-use of obstetric services are a major impediment to attaining the sustainable development goals (SDGs) on maternal and child health. Thus, evidence-informed policy interventions need to consider the determinants of under- and non-use of obstetric services among women of childbearing age. Research exploring the usage of obstetric services in developing nations, particularly in Ghana, tended to focus on limited individual-level factors of non-utilization using facility-based studies or convenience samples. Studies done thus far offer mixed empirical findings on the utilization of obstetric services, rendering policymaking in this area difficult and without clear direction. In addition to examining individual-level factors, exploring utilization of obstetric services at a more aggregate level, for example, at the level of community, are also warranted. The objectives of this thesis are to (1) identify the social determinants of delivery in a health facility among women in Ghana; (2) examine the association between socio-economic factors and CS delivery among reproductive aged women in Ghana; (3) to assess the population attributable risk of socio-demographic characteristics on the usage of PNC services; (4) explore spatial patterns of non-utilization of PNC services across communities and determine community-level factors linked to PNC services in Ghana. The research has yielded the following results: 1. An increased risk for delivering outside a health institution was identified among women who had lower levels of education, low-income, who live in rural locality, have experienced childbirth, and who lack knowledge about pregnancy-related complications. 2. Wealth-associated disparities in caesarean delivery was observed in Ghana. Further, affluent and well-educated women had greater likelihood to overutilize CS delivery. 3. In the study population, a substantial proportion of PNC services use were attributable to wealthier, highly educated, urban women who were Christians or Muslims. 4. From the 2-level mixed-method model, the community a woman resides in explains part of the unobserved heterogeneity in PNC services utilization. Also, spatial patterns identified hotspots of non-utilization of postnatal care services. The central message from this dissertation is that inequalities in the use of obstetric services exist in Ghana and measures to address the disproportionate utilization of this vital services call for targeted policies that consider both individual and community-level factors