J Community Health (2009) 34:6472

DOI 10.1007/s10900-008-9120-x

ORIGINAL PAPER

On the Spatial Inequalities of Institutional Versus Home Births

in Ghana: A Multilevel Analysis
Fiifi Amoako Johnson Sabu S. Padmadas
James J. Brown

Published online: 2 October 2008

Springer Science+Business Media, LLC 2008

Abstract Spatial inequalities related to the choice of

delivery care have not been studied systematically in SubSaharan Africa where maternal and perinatal health outcomes continue to worsen despite a range of safe
motherhood interventions. Using retrospective data from
the 1998 and 2003 Demographic and Health Surveys, this
paper investigates the extent of changes in spatial
inequalities associated with type of delivery care in Ghana
with a focus on ruralurban differentials within and across
the three ecological zones (Savannah, Forest and Coastal).
More than one-half of births in Ghana continue to occur
outside health institutions without any skilled obstetric
care. While this is already known, we present evidence
from multilevel analyses that there exist considerable and
growing inequalities, with regard to birth settings between
communities, within rural and urban areas and across the
ecological zones. The results show evidence of poor and
disproportionate use of institutional care at birth; the
inequalities remained high and unchanged in both urban
and rural communities within the Savannah zone and
widening in urban communities of the Forest and Coastal
zones. The key policy challenges in Ghana, therefore,
include both increasing the uptake of institutional delivery
care and ensuring equity in access to both public and private health institutions.

F. Amoako Johnson
GeoData Institute, School of Geography, University of
Southampton, Highfield Campus, Southampton SO17 1BJ, UK
S. S. Padmadas (&)
J. J. Brown
Southampton Statistical Sciences Research Institute and Division
of Social Statistics, School of Social Sciences, University of
Southampton, Highfield Campus, Southampton SO17 1BJ, UK
e-mail: ssp@soton.ac.uk

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Keywords Institutional births
Home births

Demographic health surveys
Ghana

Multilevel modelling

Introduction
Birth outcomes and maternal health in poor settings,
especially in Sub-Saharan Africa, are determined by three
factors; accessibility to maternal health care services,
availability and affordability of skilled care at birth and
quality of delivery care services [15]. The extent to which
these factors vary in a society depend on how communities
differ spatially, both across and within, in terms of health
and wealth. Spatial inequality is a dimension of overall
inequalities which refer to uneven distribution of resources
across different spatial locations at the individual and
community levels [6]. The strategies to improving maternal
health and reducing child mortality in Africa, as articulated
in the United Nations Millennium Development Goals
(MDGs), emphasise a holistic approach specifically aimed
towards minimising spatial inequalities associated with the
distribution and use of maternal health care services [79].
Spatial inequalities related to the choice of delivery care
have not been studied systematically in Sub-Saharan Africa
where maternal and perinatal health outcomes continue to
worsen despite a range of safe motherhood interventions.
This is particularly a concern in Ghana where more than
50% of births take place at home under the supervision of
unskilled birth attendants and in unhygienic surroundings
[1012]. Hospital based studies in Ghana show that both
maternal and perinatal mortality continue to remain stagnantly high, which are primarily attributed to the lack of
skilled care in maternal health services [1, 1316]. It can be
argued that the concept of a planned institutional delivery

J Community Health (2009) 34:6472

is almost nonexistent particularly in the rural Ghanaian

context. Whilst poor access to maternal health care services
partly explains this observation, the underlying reason for
poor use of services is poverty [17]. Poverty in Ghana is
spatially distributed not only at the individual level but also
at the community level; five out of 10 regions had more
than 40% of their population living in poverty, especially
those in the poorly developed rural areas of the Savannah
zone [17]. Recent research in Sub-Saharan Africa shows
that while rural areas are still trapped in a vicious cycle of
poverty, those in urban areas continue to worsen at a
phenomenal rate [2, 18]. The association between poverty
and uptake of maternal health care is well documented in
the literature [1821]; however, little is explored in
understanding how changing poverty trends are reflected in
the uptake of maternal health care.
The goal of this paper is to investigate the extent of
changes in spatial inequalities associated with type of
delivery care in Ghana considering a range of individual
and household factors that mediate these inequalities both
within and across different communities. It has to be noted
that the concept of care at birth defined in this paper is
essentially the place where a birth occurred either at home
or in an institution (public/private).

Methods
We used two successive rounds of Ghana Demographic
and Health Surveys (GDHS) conducted during 1998 and
2003, respectively [1012]. The GDHS data consist of a
hierarchical structure with three levelsindividual,
household and community. The response variable of
interest was place of delivery. A two-level (individual and
community) multinomial random intercept model [2225]
was considered for the analysis to account for the levels of
heterogeneity of observations in the sample. The multilevel
analysis was conducted using pooled data from the 1998
and 2003 GDHS to capture the time effects on delivery
care choices between the two surveys and also separately
for the two surveys in order to compare the differences in
magnitude of the predictor variables. We did not consider
household as a level in the analysis because the degree of
nesting of women within households was very low. The
information on place of childbirth for each individual
woman (level 1) was nested within a Primary Sample Unit
(level 2). A total number of 2,342 and 2,757 mothers, who
had a birth (last) in the 5 years preceding the surveys, were
selected for the analysis. These observations were clustered
within 397 and 410 Primary Sample Units (PSUs) for the
1998 and 2003 GDHS, respectively. It is important to note
that the PSUs are sampled from censual enumeration areas;
therefore they represent the communities to which they

65

belong. In this study, we have categorized the PSUs into

rural and urban PSUs. Rural PSUs were sampled from
communities within villages, while urban PSUs were
sampled from communities within towns and cities.
The present analysis is restricted to last birth only due to
high dependency in the choice of place of delivery for
successive births [26]. In other words, a considerable
proportion of mothers who had birth experiences tend to
seek similar type of care for successive deliveries. For
example, the 1998 and 2003 GDHS show that more than
80% of mothers who had two or more births utilised the
same place of delivery [10].
The response variable was coded into three categories;
births at home (reference) and those in the institutions
which were further categorised into private and public
institutions. The publicprivate categorisation is made in
order to understand the publicprivate share of service
provision and utilisation related to delivery care. Studies
have also shown considerable heterogeneity in the quality,
access, and use of public and private sectors for maternity
care [27, 28]. Data on place of childbirth are believed to be
fairly accurate as it is unlikely that a mother would misreport the place where she had a birth. Although it would
have been of interest to investigate the differentials in
home births supervised by untrained and traditional birth
attendants, the 2003 GDHS did not distinguish between the
two types of birth attendants. It is important to note that
someone who has been trained need not necessarily be
skilled [29]. The home births defined in our analysis refer
to those which occurred under the supervision of untrained
birth attendants including TBAs.
The analysis considered a range of spatial, demographic,
socioeconomic and health care variables. The spatial
characteristics identified included place of residence
(urban/rural) and ecological zones. The ecological zones
were categorised into three: Savannah, Coastal and Forest
zones. The Savannah zone is the most poorly developed
zone in terms of extreme poverty incidence [17, 30]. The
Coastal zone is characterised by a conglomeration of economically vibrant districts of Ghana (ports, harbours,
industries and political and commercial headquarters). The
Forest zone is the prime cocoa, timber and mineral producing areas, while the Savannah zone is dry low
grassland. From policy perspectives, it is imperative to
disaggregate the analysis by the three different ecological
zones and rural and urban areas because of their distinct
geographical features and socioeconomic and cultural differences. To incorporate the spatial effects, we allowed the
variance terms from the multinomial random intercept
model to vary by ruralurban residence and the three
ecological zones of Ghana. The random area effect is an
area specific parameter that shows how one area differs
from another. The estimated variance represents the extent

123

66

to which women in the same community would seek the

same care even if they have different individual characteristics [31]. We can then interpret this as evidence of
inequalities in use between communities (PSUs), for
instance births in public or private facilities relative to
those at home. In statistical parlance, the higher the estimated variance the higher is the level of inequality. Since
we are comparing variance estimates from two surveys, it
is important to test for the difference between the variances. This explains how the variance within each time
point differs significantly from the other. We used the test
of difference between two variances and compared the test
statistic (S21/S22) to the F-distribution on n1 - 1 and n2 - 1
degrees of freedom, where S12 [ S22; S21 is the estimate for
the survey with a larger variance, S22 is the estimate for the
survey with a smaller variance; and n1 and n2 are the
number of PSUs sampled in each rural-urban ecological
zone for S12 and S22, respectively.

J Community Health (2009) 34:6472

Table 1 Place of delivery by background characteristics (%): 1998
GDHS
Background characteristics

Home

Public

Private

No. of births

All

54.1

34.5

11.4

2,342

Place of residence***
Rural

65.5

26.0

8.5

1,794

Urban

21.8

58.7

19.5

548

Savannah

83.6

15.0

1.4

709

Forest
Coastal

45.8
50.8

40.0
36.6

14.2
12.6

779
854

Ecological zone***

Year of birth**
1993/94

45.7

40.1

14.2

231

1995

55.4

34.3

10.2

325

1996

50.5

37.3

12.3

445

1997

54.5

33.1

12.4

627

1998

58.5

32.3

9.2

714

\20

49.3

39.0

11.7

208

2034

52.7

34.5

12.8

1,593

35?

60.4

32.8

6.8

541

Maternal age (in years)***

Results
Descriptive Analysis
Tables 1 and 2 present the distribution of births classified
according to the place of delivery and individual (maternal)
and household characteristics. The percentages shown are
based on weighted data for the 1998 and 2003 GDHS. In
general, there is little change in home births between the
two survey periods. The ruralurban differentials are
highly pronounced with regard to the choice of care. Home
births in rural areas show a modest increase between surveys, which indicate the poor uptake of skilled care during
birth in rural Ghana. It has to be noted that the 1998 GDHS
shows that one-half of home births were attended by TBAs;
however, this information is not available in the 2003
GDHS. The percentage of institutional births shows a slight
decline in rural areas between the two survey periods
whereas the changes in urban areas are trivial. Most
institutional births took place in the public sector.
The percentage of home births remains considerably
high around 80% in the Savannah zone. Mothers with no
formal education, those from poor background, those other
than Muslims and Christians, and those who did not seek
any antenatal care seem likely to have had a birth at home.
Home births are common among recent cohorts. The percentage of home births shows a steady increase as the birth
order increases. With regard to institutional births, delivery
care in public sectors is common among mothers and their
spouses who have secondary level or higher education and
those belonging to rich households. Mothers who had frequent antenatal contacts and those who had initiated

123

Maternal education***
No formal education

74.4

20.0

5.6

1,047

Primary

59.6

30.9

9.5

429

34.3

48.6

17.1

866

Akan

44.6

42.2

13.2

1,033

Ga/Dangbe/Guan/Ewe

51.5

34.6

13.9

454

Mole-Dagbani

84.9

12.6

2.5

285

Grussi/Gruma/Hausa

82.0

15.5

2.5

355

Other

67.4

25.1

7.4

215

Secondary or higher
Ethnicity***

Religion***
Christian

46.4

39.9

13.7

1,511

Muslim

65.1

29.1

5.8

323

Other

77.7

16.6

5.7

508

41.0

45.0

14.1

504

23

51.1

35.1

13.7

787

4?

63.1

28.8

8.1

1,051

Birth order***

Frequency of antenatal visits***

No antenatal care
13

80.2
77.2

14.3
16.4

5.6
6.4

301
561

46

53.6

35.0

11.4

822

7?

25.6

56.7

17.7

658

14.3

5.6

301

Timing of first antenatal care***

No antenatal care

80.2

After first trimester

57.7

43.2

14.8

1,147

Within first trimester

42.0

32.2

10.1

894

22.0

5.7

918

Partners educational status***

No formal education

72.2

J Community Health (2009) 34:6472

67

Table 1 continued
Background characteristics

Table 2 continued
Home

Public

Private

No. of births

Primary

67.6

24.5

8.0

187

Secondary or higher

43.1

42.1

14.7

1,237

Poor

85.0

12.1

2.9

457

Modest

59.3

31.3

9.4

1,415

Rich

20.0

57.8

22.3

470

Household wealth status***

** P \ 0.05; *** P \ 0.01

Table 2 Place of delivery by background characteristics (%): 2003
GDHS
Background characteristics

Home

Public

Private

All

56.4

35.0

Rural

71.2

23.8

5.0

812

Urban

20.9

61.8

17.2

1,945

Savannah

78.5

19.8

1.6

912

Forest
Coastal

44.5
46.5

44.5
40.2

10.9
13.3

979
866

8.6

No. of births
2,757

Place of residence***

Ecological zone***

Background characteristics

Home

Public

Private

No. of births

Frequency of antenatal visits***

No antenatal care

77.6

18.2

4.2

313

13

80.5

15.6

3.9

569

46

56.4

34.6

9.0

1,087

7?

30.6

56.2

13.2

788

Timing of first antenatal care***

No antenatal care

77.6

18.2

4.2

313

After first trimester

45.7

43.7

10.6

1,248

Within first trimester

61.4

30.8

7.8

1,196
1,249

Partners educational status***

No formal education

73.3

22.5

4.2

Primary

69.5

24.4

6.1

213

Secondary or higher
38.0
Household wealth status***

48.8

13.2

1,295

Poor

75.8

21.9

2.3

549

Modest

55.5

35.6

8.9

1,656

Rich

31.7

51.8

16.5

552

*** P \ 0.01

1998/99

46.0

41.7

12.3

350

2000

52.0

40.4

7.6

458

2001

56.1

35.5

8.4

597

2002

57.7

33.3

9.0

787

2003

65.0

28.3

6.7

565

antenatal care in the first trimester are likely to give births

in institutions, especially in the public sector. Delivery care
in the private sector is more likely among mothers who are
well-off in terms of their socioeconomic status such as
education and household wealth status. In general, most of
the characteristics show more or less similar pattern
between the two surveys.

\20

55.3

34.4

10.2

244

Regression Analysis

2034

55.3

35.6

9.1

1,839

35?

59.8

33.7

6.5

674

Year of birth***

Maternal age (in years)

Maternal education***
No formal education

74.0

21.8

4.1

1,260

Primary

57.1

34.8

8.0

574

31.9

53.1

15.1

923

Akan

43.9

42.9

13.2

1,074

Ga/Dangbe/Guan/Ewe

51.3

38.7

9.9

563

Mole-Dagbani

72.7

24.6

2.7

670

Grussi/Gruma/Hausa

75.9

21.7

2.4

249

Other

59.2

33.3

7.5

201

Christian

47.9

41.4

10.7

1,847

Muslim

66.5

27.8

5.7

561

Other

85.1

12.9

2.0

349

43.2

45.0

11.8

576

23

54.9

34.7

10.4

936

4?

63.6

30.6

5.8

1,245

Secondary or higher
Ethnicity***

Religion***

Birth order***

The estimated coefficients from the two-level multinomial

regression models are presented in Table 3. Due to high
multicollinearity between year of survey and year of birth,
we did not adjust for year of birth in the pooled data
analysis, but adjusted for it in the separate models. Also,
we tested for the assumptions of normality and constant
variance to determine the robustness of the model.
The results show that there has not been any significant
change in the individual choices for delivery care between
the two surveys, even after adjusting for relevant control
variables. Rural women are relatively more likely to have
had a birth at home when compared to urban women. There
are also marked zonal differentials associated with home
births in both the time periods. Institutional births are
significantly more likely to occur in the Forest and Coastal
zones when compared to the Savannah zone. The parameter estimates show that first order births, women with
secondary level or higher education and those who had
frequent antenatal visits are more likely to seek institutional delivery care. Also, women belonging to poorer

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J Community Health (2009) 34:6472

Table 3 Estimated coefficients from the multinomial logistic regression showing the effect of selected characteristics on institutional versus
home births
Background characteristics

Pooled data

1998 GDHS

2003 GDHS

Public versus
home

Private versus
home

Public versus
home

Private versus
home

Public versus
home

Private versus
home

-3.63

-5.98

-4.20

-5.87

-2.82

-5.52

1998

na

na

na

na

2003

0.09 (0.12)

-0.08 (0.11)

na

na

na

na

Savannah (base)

Coastal

0.46 (0.18)**

1.51 (0.21)***

0.59 (0.29)**

1.49 (0.32)***

0.36 (0.27)

1.54 (0.37)***

Forest

0.70 (0.18)***

1.65 (0.22)***

0.77 (0.28)***

1.73 (0.34)***

0.63 (0.26)**

1.57 (0.36)***

Rural (base)

Urban

1.93 (0.14)***

1.86 (0.23)***

1.48 (0.22)***

1.27 (0.23)***

2.31 (0.21)***

2.41 (0.23)***

na

Constant
Year of survey

Spatial
Ecological zone of residence

Rural-urban residential status

Individual
Year of birth 1998 GDHD
19931994 (base)a

na

na

na

19951996

na

na

0.01 (0.17)

0.04 (0.43)

na

na

19971998

na

na

-0.02 (0.19)

-0.27 (0.27)

na

na

na

na

na

na

2003 GDHS
19981999 (base)b
20002001

na

na

na

na

-0.21 (0.17)

-0.54 (0.27)**

20022003

na

na

na

na

-0.48 (0.19)**

-0.62 (0.25)**

1519

-0.58 (0.21)***

-0.21 (0.28)

-0.44 (0.32)

-0.04 (0.43)

-0.64 (0.28)**

-0.25 (0.40)

2034

-0.27 (0.13)**

0.01 (0.18)

-0.33 (0.20)

0.22 (0.28)

-0.20 (0.17)

-0.10 (0.26)

35? years (base)

Maternal age (in years)

Educational status
No formal education (base)

Primary

-0.05 (0.13)

-0.20 (0.17)

0.05 (0.19)

-0.11 (0.29)

-0.12 (0.18)

-0.27 (0.27)

0.48 (0.13)***

0.45 (0.17)**

0.57 (0.19)***

0.49 (0.27)*

0.40 (0.18)**

0.36 (0.25)

Secondary or higher
Religion
Christian

0.58 (0.16)***

0.53 (0.25)**

0.72 (0.23)***

0.62 (0.33)*

0.33 (0.27)

0.21 (0.48)

Muslim

0.36 (0.21)*

0.24 (0.30)

0.39 (0.30)

-0.23 (0.47)

0.21 (0.32)

0.31 (0.52)

Other

0.76 (0.14)***

0.74 (0.0.19)***

0.91 (0.22)***

0.74 (0.29)***

0.66 (0.19)***

0.75 (0.29)***

Birth order
1
23

0.04 (0.11)

0.26 (0.15)*

0.24 (0.17)

0.32 (0.23)

-0.09 (0.16)

0.21 (0.22)

4? (base)

No antenatal care (base)

13

-0.19 (0.19)

-0.30 (0.29)

0.11 (0.29)

-0.13 (0.42)

-0.40 (0.29)

-0.50 (0.43)

Frequency of antenatal visits

46

0.92 (0.18)***

0.69 (0.25)***

1.19 (0.27)***

0.66 (0.35)*

0.71 (0.27)***

0.65 (0.38)*

7?

1.67 (0.18)***

1.28 (0.26)***

2.15 (0.28)***

1.50 (0.37)***

1.29 (0.27)***

0.97 (0.39)**

123

J Community Health (2009) 34:6472

69

Table 3 continued
Background characteristics

Pooled data

1998 GDHS

Public versus
home

Private versus
home

No formal education (base)

Primary
Secondary or higher

-0.07 (0.18)
0.40 (0.11)***

Poor (base)
Modest
Rich

2003 GDHS

Public versus
home

Private versus
home

Public versus
home

Private versus
home

0.13 (0.25)
0.44 (0.16)***

-0.23 (0.28)
0.21 (0.17)

0.08 (0.41)
0.27 (0.27)

0.03 (0.24)
0.52 (0.15)***

0.22 (0.40)
0.54 (0.23)**

0.47 (0.13)***

0.84 (0.22)***

0.63 (0.23)***

0.69 (0.37)*

0.44 (0.17)**

1.06 (0.32)***

0.98 (0.16)***

1.53 (0.24)***

1.18 (0.30)***

1.51 (0.43)***

1.08 (0.27)***

1.93 (0.36)***

1.11 (0.07)***

0.70 (0.09)***

1.08 (0.11)***

0.47 (0.14)***

1.17 (0.11)***

0.76 (0.14)***

Household
Partners educational status

Household wealth status

PSU level variance (rij)

* P \ 0.10; ** P \ 0.05; *** P \ 0.01

base base category; na not applicable
a

Base category for pooled data and 1998 data

Base category for 2003 data

Home

Public

Private

1.0

predicted probabilities

0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0

Savannah

Coastal

Forest

Savannah

Rural

Coastal

Forest

Urban

residence / ecological zone

Home

Public

Private

1.0

predicted probabilities

Fig. 1 (a) Estimated

probabilities of place of delivery
by ecological zone and
residence, controlling for
selected characteristics, 1998
GDHS. (b) Estimated
probabilities of place of delivery
by ecological zone and
residence, controlling for
selected characteristics, 2003
GDHS

0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0

Savannah

Coastal

Forest

Savannah

Rural

Coastal

Forest

Urban

residence / ecological zone

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J Community Health (2009) 34:6472

households are less likely to give births in institutions when

compared to their counterparts. We tested for possible
interaction effects in the model but none of the interactions
were significant.
To better understand the level of spatial inequalities of
institutional versus home births, we computed predicted
probabilities controlling for the characteristics reported in
Table 3 (Fig. 1a, b). The figures show that, between the
two surveys, there has been a decline in the probabilities of
home deliveries in urban areas across all the ecological
zones. However, the changes noted in rural areas are trivial. Also, there is a notable increase in the probabilities of
births in private institutions in the urban areas of the
Coastal and Forest zones.
Inequalities within RuralUrban Communities across
Ecological Zones
The variance estimates from the two-level random intercept model and the corresponding changes between surveys
partitioned by place of residence and ecological zones are
presented in Table 4. The estimated community level
variances show the inequalities in the uptake of care in a
public or private facility relative to home within the ecological zones of Ghana. The results shown are adjusted for
relevant individual and household characteristics. The test
of difference between two variances shows a significant
change in the level of inequality in the utilisation of public
facilities relative to home birth care, in both rural and urban

communities of the Forest and Coastal zones. The Savannah zone is an exception in this regard where the
inequalities have remained high with apparently no significant change between surveys. The inequalities
associated with use of public facilities in rural communities
of the Forest and Coastal zones have decreased between the
two surveys (P \ 0.05), while they increased significantly
in urban communities of the same zones. The Coastal zone
which has the lowest inequality in the use of public facilities in the 1998 GDHS showed the highest increase in
inequalities in the subsequent survey.
The inequalities of care in private institutions have also
widened considerably in both rural and urban areas in all
three zones, except the urban Savannah zone where there
has been a 50% decline between the two surveys. Also, the
level of inequalities in the use of private care is lower in the
Savannah zone when compared to the Forest and Coastal
zones. It has to be noted that private health care is not
popular especially in the rural Savannah zone [32] which
probably explain the low use and the lesser inequalities in
this region. Although the level of inequalities in rural areas
is more accentuated in the Forest and Coastal zones, the
rate of increase between the two surveys is the highest in
the Savannah zone. The rate of increase in inequalities is
generally high within urban communities. In particular, the
increase in inequalities associated with care in public sector
is more evident in the urban Coastal zone whereas those
in the private sector are seen more in the urban Forest
zone.

Table 4 PSU level variance associated with place of birth by residence and ecological zone after partitioning the variance estimates by place of
residence and the three ecological zones of Ghana
Residence

Ecological zone

Estimate (SE)
1998 GDHS

Difference

% change

2003 GDHS

Public versus home

Rural

Urban

Savannah

1.29 (0.29)***

1.43 (0.43)***

0.14

Forest

1.24 (0.21)***

0.79 (0.16)***

-0.45**

-36.3

10.9
-38.9

Coastal

0.72 (0.19)***

0.44 (0.22)**

-0.28**

Savannah

1.83 (0.66)***

1.77 (0.44)***

-0.06

Forest

1.12 (0.44)**

1.58 (0.45)***

0.46*

Coastal

0.21 (0.29)

1.17 (0.28)***

0.96***

457.1

-3.3
41.1

Private versus home

Rural

Urban

Savannah

0.09 (0.37)

0.54 (0.52)

0.45***

500.0

Forest

0.64 (0.25)***

1.21 (0.24)***

0.57***

89.1

Coastal
Savannah

0.92 (0.26)***
0.24 (0.30)

1.26 (0.30)***
0.12 (0.88)

Forest

0.19 (0.51)

1.17 (0.43)***

0.98***

Coastal

1.50 (0.49)***

2.11(0.35)***

0.61*

0.34*
-0.12*

37.0
-50.0
515.8
40.7

* P \ 0.10; ** P \ 0.05; *** P \ 0.01

SE refers to Standard Error. Note: The estimates shown are based on 2-level random intercept model controlling for selected characteristics. The
likelihood ratio tests showed significant variations between rural communities and between urban communities for the 1998 and 2003 surveys

123

J Community Health (2009) 34:6472

Discussion
The present study is the first of its kind that examined the
spatial variations in the use of delivery care services in
Ghana at the national level. More than one-half of births in
Ghana continue to occur outside health institutions without
any skilled obstetric care. While this is already known, we
present evidence from multilevel analyses that there exist
considerable and growing inequalities, with regard to birth
settings between communities, within rural and urban areas
and across the ecological zones. The results highlight poor
and disproportionate use of institutional care at birth within
and across urban and rural communities in all the three
ecological zones of Ghana. The inequalities between
communities with regard to delivery care in public sectors
are considerably high in the Savannah zone with no significant improvement across time. The Savannah zone is
relatively disadvantaged in terms of access to health care
and social development when compared to the other two
zones [17, 30]. Many communities within the Savannah
zone are also deprived in terms of access to institutional
delivery care services [32].
The inequalities with regard to institutional delivery
care seem increasing rapidly in the urban areas of the
Forest and Coastal zones. The increasing inequality gap
with regard to delivery care in public facilities is particularly accentuated in the urban Coastal zone whereas those
for the use of private facilities are striking in the urban
Forest zone. An important reason for this observation could
be the increase in urban poverty alongside high ruralurban
migration and the concomitant expansion of slum populations. Studies have shown that geographic accessibility is
not a major barrier in accessing health care services in
urban settlements of Ghana [32] because urban residents in
developing countries generally have better living conditions than rural ones [2]. However, in recent times, most
urban migrant populations have been characterised by
increasing poverty and social collapse [18]. Arguably,
these observations might explain why inequalities have
grown over time in urban areas particularly in the Coastal
and Forest zones where there is a high influx of migrants
from rural areas. These inequalities are also clearly
reflected in the neonatal mortality rates which show relatively a larger increase by more than 60% in urban areas for
the 10 years preceding the 1998 and 2003 DHS when
compared to 22% in rural areas in the same time period
[10].
While the World Health Organization proposes the need
for a wider coverage of skilled care at birth [33], the
findings reported in this study show that the challenges in
meeting the MDGs related to maternal health by year 2015
seem highly uncertain in Ghana. The MDG efforts to
achieve the 90% target on skilled delivery care provisions

71

[33] seem a distant goal but are still accomplishable

through proper community specific interventions disseminating appropriate knowledge regarding the importance of
skilled maternal health and obstetric care.
There a few caveats in this analysis which are worth
noting. There is a lack of detailed individual and community information in the datasets, for example direct and
indirect costs associated with health care, quality of health
services delivery, and the perceptions and beliefs related to
health care seeking behaviour. It is likely that there are also
problems of correspondence between the response and
explanatory variables. For example, the household wealth
status at the time of survey could be different when compared to the time of a birth. However, these effects are
believed to be negligible since we selected only the last
birth that occurred during the 5 years preceding the survey.
The present findings direct the need for a comprehensive
maternal health care initiative in Ghana that could target
the poorest of the poor and other vulnerable communities
in urban and rural areas. The crucial challenge in urban
areas, where inequalities are widening, would be to initiate
policy measures to ensuring affordable maternal care services whereas the efforts in rural areas should focus on
promoting increased access to skilled birth care. It has to be
acknowledged that a new policy on maternal health care
was introduced in September 2003 that called for the
exemption of fee-payment to those availing antenatal and
delivery care services in both public and private health care
sectors [34, 35]. The impact of this policy is yet to be seen
in the coming years, presumably by means of conducting a
similar analysis as undertaken in this study using data from
the next round of the GDHS.

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