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Addressing Socio-cultural Barriers to Maternal Healthcare in Ghana:

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Ganle, J Womens Health, Issues Care 2014, 3:6
http://dx.doi.org/10.4172/2325-9795.1000171
Research Article
Addressing Socio-cultural
Barriers to Maternal Healthcare
in Ghana: Perspectives of Women
and Healthcare Providers
John Kuumuori Ganle1*
Abstract
Background: One of the main challenges to achieving the
maternal health-related Millennium Development Goals in sub-
Saharan African countries is poor access to skilled maternal
healthcare services. In Ghana, maternal mortality accounts for
14% of all female deaths, and only 55% of births are attended
by skilled birth attendants. Many previous studies that examine
norms of childbirth and care-seeking behaviours have therefore
focused on identifying the norms of non-use of services rather
than factors that can promote service use.
Purpose: To explore and identify strategies for addressing socio-
cultural barriers to women’s use of skilled maternal healthcare
services in Ghana.
Methods: Primary qualitative research was conducted with a
total of 185 expectant and lactating mothers, and 20 healthcare
providers in six purposively sampled communities in Ghana
using focus group discussions, individual interviews, and key
informant interviews. The Attride-Stirling’s thematic network
analysis framework was used to analyse and present qualitative
data.
Results: Women and healthcare providers identified and
reported a number of strategies that could potentially be adopted
to address socio-cultural barriers to utilization of existing skilled
maternal healthcare services. These include cultural adaptation
of birthing services, greater male involvement in maternity care,
health education, community mobilization and engagement, and
promotion of domiciliary maternity care.
Conclusion: The findings improve understanding of the socio-
cultural barriers women face in accessing and using maternal
healthcare services, and as well add new insights to the corpus
of existing evidence about how these access barriers could
be addressed. In particular, the findings highlight the need for
maternity care services to be organized and delivered in a way
that is medically appropriate, socially sensitive, and culturally
responsive. This requires structural changes to maternity clinics
and routine nursing practices, including cultural competence
training for healthcare providers.
Keywords: Maternal healthcare; Access; Socio-cultural barriers;
Solutions to socio-cultural barriers; Ghana
*Corresponding author: John Kuumuori Ganle, D.Phil, The Ethox Centre, Nuffield
Department of Population Health, University of Oxford, Rosemary Rue Building, Old
Road Campus, Headington, Oxford OX3 7LF, UK, Tel: +233(0) 249957505; E-mail:
johnganle@yahoo.com
Received: August 18, 2014 Accepted: October 22, 2014 Published: October 27,
2014
All articles published in Journal of Women’s Health, Issues & Care are the property of SciTechnol, and is protected by
International Publisher of Science, copyright laws. Copyright © 2014, SciTechnol, All Rights Reserved.
Technology and Medicine
Journal of Women’s
Health, Issues & Care
a SciTechnol journal
Introduction
Over the last decade, improving maternal health has become a
global priority, and quantified reductions in maternal mortality have
been included in the Millennium Development Goals (MDGs). Since
the Millennium Declaration of 2000, one area of policy focus felt to
be of particular importance to the reduction of maternal mortality is
to increase the proportion of women who receive skilled antenatal
care, deliver with a skilled health professional in attendance, and
as well receive postnatal care from a skilled health professional [1].
There is evidence to suggest that access to, and use of skilled maternal
healthcare services can ensure that skilled personnel attend to women
during childbirth and also link women to the referral system in case
of any obstetric complications [2-5].
Despite the renewed focus on maternal health and the emphasis
on skilled attendance during pregnancy and childbirth, in many sub-
Saharan African countries with high burden of maternal deaths, only
a few women have access to skilled birthing services [5]. While in high-
income countries coverage of skilled birthing services is almost universal,
in Africa only 47% of women give birth with a skilled healthcare provider
[6]. In the specific case of Ghana, recent survey data suggest that only
55% of women receive skilled assistance during delivery or postnatal care
following delivery despite the fact that the government of Ghana has
since 2003 implemented a free maternal healthcare policy in all public
and mission health facilities [7]. The survey also suggests that more than
45% of births still occur at home without any form of skilled care [7]. In
2012, the WHO estimated that Ghana’s maternal mortality ratio was 350
maternal deaths per 100, 000 live [8]. Maternal mortality, which accounts
for 14% of all female deaths, is currently the second largest cause of
female deaths in Ghana [9].
Empirical studies have identified a number of factors that act as
barriers to women’s access to and use of maternal healthcare services.
Some of these barriers include long distance to health facilities,
transportation problems, costs of services (including informal
charges and opportunity costs from time lost), and poor quality of
care [10-13]. The socio-cultural beliefs, preferences and practices
of women and communities, as well as women’s lack of autonomy
or decision-making power, have also been implicated as important
access barriers [13-22]. While these studies have contributed to better
understanding of why women may choose home-delivery, what is
lacking is a focus on how to promote access and service use [23].
A focus on such factors, particularly how to address socio-cultural
barriers from the perspective of childbearing women and healthcare
providers could be critical for learning more about how to promote
effective access to, and use of skilled maternal healthcare services.
The purpose of this paper was to identify and describe strategies for
addressing socio-cultural barriers to women’s use of skilled maternal
healthcare services in Ghana.
Materials and Methods
Study design
The data reported in this paper were extracted from within a
larger, original study that the author conducted to examine women’s
maternity care seeking experience, equity of access, and barriers to
Citation: Ganle JK (2014) Addressing Socio-cultural Barriers to Maternal Healthcare in Ghana: Perspectives of Women and Healthcare Providers. J Womens
Health, Issues Care 3:6.
accessibility and utilization of maternal and newborn
healthcare services in Ghana. This larger study was designed
as a mixed methods study, and involved analysis of a nationally
representative retrospective household survey data alongside
qualitative exploration using focus group discussions (FGDs),
individual interviews (IIs), key informant interviews (KIIs), case
studies and structured field observations. In this paper, the focus
is on reporting findings from the qualitative component of the
larger research, which examined women and healthcare
providers perspectives on how to redress socio-cultural barriers
to access, and promote use of skilled maternal healthcare services.
Research setting
Intensive empirical research was conducted in Ghana
between November 2011 and June 2012 in a total of 6
purposively sampled communities in the Bosomtwe district of
the Ashanti region and the Central Gonja district of the
Northern region. Ghana is a West African country, covering a
total land area of 238,305 square kilometres. Table 1 highlights
selected demographic, socio-economic, and health indicators for
Ghana.
Ghana is a lower middle-income country, whose social,
economic and political conditions make the country an
interesting case study. Ghana is situated within the
predominantly economically marginalized and politically
unstable region of West Africa, but forms an exception. Ghana
is relatively a fledgling multicultural and multi-party constitutional
democracy, characterised by vibrant civil society activism and
media pluralism. It is politically stable, and also recently started
producing oil in commercial quantities [24]. Also, Ghana is one
of only a handful of countries in Sub-Saharan Africa to actively
started implementing both universal maternity care and health
insurance policies at the national level. Because of this, Ghana is
often touted as an example of global good practice [24,25]
Despite these developments, maternal mortality ratio has remained
Indicator
Total population (2010) 24,658823 (48.8% male; 51.2% female)
Proportion of population below 15 years (%) (2010)
Proportion of population above 60 years (%) (2010)
Proportion of population living in urban areas (%) (2010)
Adult literacy rate (%) (2008)
Percentage of Population with No Education (2008)
Percentage of Population with No Education (Rural) (2008)
Percentage of Population with No Education (Urban) (2008)
Total gross domestic product (US$ in billion) (2009)
Gross national income (GNI) per capita (US$) (2009)
Annual economic growth rate (%) (2009)
Population living on less than 1 US$ dollar per day (2005)
Multi-dimensional poverty Index (2008)
Human development Index (2009)
Adult mortality rate per 1,000 population (2007)
Life expectancy at birth (in years) (2009)
Infant Mortality Rate (per 1,000 live births) (2008)
Under 5 Mortality Rate (per 1,000 live births) (2008)
Neonatal Mortality Rate (per 1,000 live births) (2008)
Post-Neonatal Mortality Rate (per 1,000 live births) (2008)
Crude Birth Rate (per 1,000) (2008)
Crude Death Rate (per 1,000) (2008)
Total Fertility Rate (2008)
Table 1: Key Socio-demographic Indicators of Ghana.
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persistently high, and women in Ghana are still generally more
disadvantaged from a young age. Educational and economic
opportunities for women are limited, and a significant number of
women experience genital cutting as well as early and/ or arranged
marriages. In most societies in Northern Ghana where the kinship
system is patrilineal, women are transferred between patrilines at the
time of marriage. That is, they go to live with their husbands’ family
after marriage, and husbands are often recognized as having authority
over their wives. In such societies, daughters are not considered
permanent members of their natal homes, and any material goods
that are given to, or acquired by a daughter automatically belong
to the patriline into which she has been married. In such contexts,
the place of women in society revolves around their reproductive
capacities, particularly their ability to bear male children. In most
cases, the organization of kinship structure around patrilines,
property, ownership, and right in most societies in Northern Ghana
very often marginalizes women. In most societies in Southern Ghana
where communities have historically organized themselves along
matrilineal kinship lines however, women are able to exert some
degree of authority and control. But as Gray argues even in matrilineal
societies, men always exercise greater control over the processes of
decision-making and resource allocation [26]. In practice therefore,
men significantly dominate both the private and public spheres of
decision-making in most matrilineal societies in Ghana.
Participants
Participants comprised childbearing women, and healthcare
providers. The women consisted of those who were pregnant at the
time of this research or had given birth between January 2011 and
May 2012. The ages of these women ranged from 17 to 40 years. The
majority of the women had no formal education. A few of the women
were unemployed while most were engaged in diverse self-employed
occupations such as farming, trading, hairdressing, dressmaking, and
teaching. Several of the women were also married or living with a
Statistic Source of Statistic
Ghana 2010 Population and Housing Census
38.3 Ghana 2010 Population and Housing Census
4.7 Ghana 2010 Population and Housing Census
50.9 Ghana 2010 Population and Housing Census
57.9 Ghana Demographic & Health Survey 2008
13.3 (male); 21.2 (female) Ghana Demographic & Health Survey 2008
19.9 (male); 30.8 (female) Ghana Demographic & Health Survey 2008
5.6 (male); 10.9 (female) Ghana Demographic & Health Survey 2008
34.0 Schieber et al. [24]
700 Schieber et al. [24]
6.3 Schieber et al. [24]
30 Schieber et al. [24]
0.14 Schieber et al. [24]
0.526 Schieber et al. [24]
343 (male); 291 (female) World Health Statistics 2009
59 (male); 60.7 (female) World Health Statistics 2009
50 World Health Statistics 2009
80 World Health Statistics 2009
30 World Health Statistics 2009
21 World Health Statistics 2009
29 World Health Statistics 2009
9.4 World Health Statistics 2009
4 World Health Statistics 2009
• Page 2 of 10 •
Citation: Ganle JK (2014) Addressing Socio-cultural Barriers to Maternal Healthcare in Ghana: Perspectives of Women and Healthcare Providers. J Womens
Health, Issues Care 3:6.
male partner. The majority of the women also had between 3 and 5
children.
The healthcare providers category of respondents included health
professionals (i.e. doctors, nurses, midwives, healthcare managers,
and health policy-makers or implementers) from health facilities in
the study communities, district and regional health directorates, and
the Ghana Health Service at the national level.
Sampling and recruitment procedures
For all research participants under the ‘healthcare providers’
category, a purposive sampling technique was used. This was a
judgmental selection of research participants based on the researcher’s
evaluation of the relevance of their roles to the research topic. In total,
20 healthcare providers were interviewed as key informants.
For the women however, a simple random sampling procedure
was followed. A simple random sampling technique was used as a
pragmatic approach to eliminating community members’ worries
and questions about why one woman was included and another
excluded from the study. Four main steps were followed to sample
and recruit participants. First, all pregnant and lactating mothers in
each of the study communities were enumerated using a five-item
short questionnaire. The questionnaire asked whether a woman was
currently pregnant or had given birth since January 2011, the name
of the woman, age and house number/name. Second, the required
number of participants was randomly selected from the pool of
names in each study community after the listing was completed. The
required number of participants was predetermined at 5% of the total
enumerated population of pregnant and lactating mothers of each
study community. This took into account the availability of time and
resources to the researcher. This generated a total of 185 participants.
Third, the randomly chosen women were further randomly allocated
to either focus group or individual interview. Finally, all the selected
women were contacted, and the research was introduced and the
selection procedures thoroughly explained to each of the randomly
selected women. Thereafter, the women were invited to participate
in the study. Where any of the randomly selected women was not
available or declined to participate in the study – and there were only 2
of such cases –the selection process was repeated to get a replacement.
Data collection methods
For the women, focus group discussions (FGDs) were the
main data collection methods. This data collection technique was
adopted partly because of its practical relevance in reproducing
women’s experiences of socio-cultural barriers to seeking skilled
maternal health services, and how to address such barriers in a
normal peer-group interpersonal exchange. What made the
outcome of FGDs relatively better than individual interviews was
that, because FGDs were interactive participants were able to
query and challenge each other as well as explain themselves; hence
offering validated data on the extent of consensus or diversity.
Thus FGDs became a form of collective testimony. Rina
Benmayor, as cited in Madriz, has pointed out the
transformative experience of the collective testimony that
FGDs generate [27]. Benmayor argues that group
testimonies empower people, particularly women, and this
empowerment enables people to speak and speaking
empowers [27]. Even though FGDs in this research were
envisaged to be only a method for generating qualitative data,
the interactions that occurred within the groups accentuated and
fostered self-disclosure and self-validation.
Volume 3 • Issue 6 • 1000171
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In all, 6 focus group discussions – one in each of the study
communities and involving a total of 104 women - were completed.
Groups consisted of 17 - 24 participants. This difference was mainly
due to differences in the sizes of the enumerated populations. All
focus groups were held in the study communities. Each FGD lasted
2.30 to 3 hours, and ended when a point of saturation was reached i.e.
when no new issues seemed to arise. All discussions were conducted
in the local dialects – Twi in Kuntanase, Abono and Piase; Dagbani in
Sankpala and Tidrope; and Gonja in Mpaha. The decision to conduct
the discussions in the local dialects was influenced by the fact that the
literacy [written or spoken English] rates were low among the study
participants. Because the researcher’s knowledge of the interview
language was limited, 6 native Twi, Dagbani and Gonja speaking
female teachers – one in each study community - were recruited,
trained and engaged as research assistants to facilitate the discussions
and conduct interviews.
To complement the FGDs, individual interviews were also
conducted with 81 women. These women were not the same women
who participated in the focus group discussions. The choice of this
data collection technique was informed by arguments that people
may not necessarily tell the truth in any objective sense when it comes
to sensitive issues such as health within a group context [28]. For this
reason, the FGDs data were triangulated with individual interviews.
A major advantage of this method was that it addressed sensitive
issues such as personal experiences and perceptions with regard to
accessibility to, and utilization of maternity care services. Interviews
with individual women lasted 15 to 20 minutes, and were conducted
in Twi, Dagbani, and Gonja.
Finally, key informant interviews (KIIs) were also completed
with 20 healthcare providers. KIIs were used because it was extremely
difficult to organise FGDs with healthcare providers. This created
special recruitment problem. This was however appropriately
overcome by conducting individual interviews. In all, 20 KIIs were
completed with healthcare providers. Interviews lasted 15 to 20
minutes. All interviews with healthcare providers were done in
English.
Study instruments
The research instrument consisted of an open-ended thematic
topic guide, which was designed to ensure that similar themes were
covered in each discussion or interview. However, the instrument was
designed to include a built-in flexibility that allowed the researcher
to pick at random and probe more on any pertinent but unexpected
issues that arose during the interview process. The instrument focused
primarily on exploring women’s experiences of seeking or not seeking
maternity care services, issues regarding coverage, access, service
utilization, women’s interaction with maternal healthcare services
as well as service providers, socio-cultural barriers to access and
use of services, and how socio-cultural barriers could be addressed.
All FGDs and some KIIs were audio-recorded using a digital voice
recorder alongside hand-written field notes.
Ethical clearance
Ethical clearance was obtained from the University of Oxford
Social Sciences and Humanities Inter-divisional Research Ethics
Committee (Ref No.: SSD/CUREC1/11‐051), and the Ghana Health
Service Ethical Review Committee (Protocol ID NO: GHS-ERC
18/11/11). In addition, informed written and verbal consent was
obtained from all research participants.
• Page 3 of 10 •
Citation: Ganle JK (2014) Addressing Socio-cultural Barriers to Maternal Healthcare in Ghana: Perspectives of Women and Healthcare Providers. J Womens
Health, Issues Care 3:6.
Data analysis
Following the completion of interviews, qualitative data was
analysed using the Attride-Stirling’s thematic network analysis
framework [29]. The Attride-Stirling thematic network analysis
framework is a method for conducting thematic analysis of qualitative
or textual data, which allows for open and methodical discovery of
emergent concepts, themes and relationships through the application
of principles of inductive reasoning to generating themes while
also employing predetermined (deductive) code types to guide data
analysis and interpretation [29]. This involved four main steps. Th e
first step involved t ranscription a nd reading of transcripts a nd fi eld
notes for overall understanding. During and after qualitative data
collection, three language specialists - Twi, Dagbani and Gonja -
transcribed all audio-recorded interviews. The author then reviewed
all transcripts and interview notes for overall understanding and
comprehension of meaning. This first step was completed
with separate summaries of each transcript outlining the key
points participants made. In the second step, interview
transcripts were exported to NVivo 9 qualitative data analysis
software, where the data were both deductively and inductively
coded. Codes were labels that were assigned to whole or segments of
transcripts and interview notes to help catalogue key concepts [30].
Coding of the data continued until theoretical saturation was
reached i.e. when no new concepts emerged from successive
coding of data. In the third step, the code structure that was
developed in the previous step was applied to develop and report
themes. Themes simply represented some level of patterned response
within the data [31]. Finally, all the themes identified were collated into
a thematic chart to reflect basic themes, organizing themes, and
global themes (Table 2). In total, 17 codes were identified. These
were grouped into 5 basic themes, and further clustered into 1
organizing theme, and 1 global theme (Table 2). These form the
basic structure of the findings and discussion sections of this paper.
Results
Discussions and interviews with the women and healthcare
providers who participated in this research revealed that most
women do want professional assistance in a health facility setting
during pregnancy, childbirth, and immediately after childbirth if
their maternal healthcare needs are met. Several of the accounts
these women gave suggested that their birthplace choice was rapidly
shifting from the home towards formal healthcare institutions
where skilled-birth attendants were likely to be available. This shift,
participants reported, stemmed largely from the abolition of user-fees
Codes
-Women have different cultural values
-Respect for Women’s cultural values is important
- Women’s cultural values should be incorporated into skilled maternity care
-Men influence women’s care- seeking behaviours
-Men should be partners in maternity care -Men can support women to seek care
-Women’s autonomy in the family is the key
-Some women don’t like hospitals
-Some women want to give birth at home
-Women want privacy
-Domiciliary care is important to take care of women’s cultural values and privacy issues
-Many women don’t understand the importance of skilled care
-Women must be understand to understand the risk of unskilled care
-Maternal health is a collective responsibility
_Communities have a role to play
-Communities must be engaged
-Trust and partnership building is critical
Table 2: Thematic Network Analysis Framework (from codes to global themes).
Volume 3 • Issue 6 • 1000171
doi:http://dx.doi.org/10.4172/2325-9795.1000171
for maternity care services.
Despite the fact that many women expressed their preference
for skilled attendance, it was reported that, in practice, a number
of socio-cultural factors at the levels of the household, family and
community significantly hindered women’s ability to access and use
skilled maternal healthcare services. One participant said:
The reason why some of us don’t go to give birth in the hospital is
because our family and community members say that it is only weak or
irresponsible women who do that. That is why some women do not go
to hospital to deliver (Lactating Mother, FGD, Kuntanase).
Another participant said:
In most of the communities we serve, the social and cultural
barriers that women face any time they want to access and use skilled
birthing services are simply grave. For instance a woman who gets
pregnant outside or before a legitimately constituted marriage is not
only likely to face rejection and ridiculing from her family and the
wider society, but also her opportunities for seeking proper medical care
during pregnancy, labour and post-labour may be heavily restricted
(Female Healthcare Provider, KII, Tamale).
Accordingly, these socio-cultural barriers have combined to
discourage many women from using skilled birthing services despite
these services being provided free at the point of delivery. In both
focus groups and interviews, the researcher therefore focused on
exploring participants’ experiences and perspectives on how to
overcome these socio-cultural barriers.
Women’s and Healthcare Providers’ Proposed Solutions to
Socio-cultural Barriers
Table 3 provides a summary count of statements women
and healthcare providers made in relation to how to address
socio-cultural barriers that discourage women from accessing and
using skilled maternal healthcare services in Ghana.
Participants’ accounts in this regard converged around five broad
thematic areas, namely 1) cultural adaptation of birthing services; 2)
greater male involvement in maternity care; 3) promotion of domiciliary
maternity care; 4) health education; and 5) community mobilization and
engagement. Each of these is discussed in detail below.
Cultural adaptation of birthing services
A substantial number of women reported that insensitivities of
Basic Themes Organizing Themes Global Themes
Cultural adaptation of birthing
Culturally responsive Solution to socio-
services can address women’s
care cultural barriers
maternity needs
Greater male involvement in
maternity care is the key
Promoting domiciliary maternity
care is important for addressing
socio-cultural barriers
Health education is critical for
behaviour change
Community mobilization and
engagement can reduce socio-
cultural barriers
• Page 4 of 10 •
 Citation: Ganle JK (2014) Addressing Socio-cultural Barriers to Maternal Healthcare in Ghana: Perspectives of Women and Healthcare Providers. J Womens
Health, Issues Care 3:6.
Women and healthcare providers proposed Frequency of
solutions to socio-cultural barriers statement(Women)
Cultural adaptation of birthing services 53
Greater male involvement in maternity care 76
Promotion of domiciliary maternity care 91
Health education 3 1.3
Community mobilization and engagement 8 3.5
Total 231
Table 3: Women and Healthcare Providers Proposed Solutions to Socio-cultural Barriers.
the healthcare system to the cultural values and preferences (including
privacy) of child bearing women was one reason why many opt
for non-skilled, home-based maternity care. To make the
healthcare system culturally responsive, participants argued for
a ‘culturally appropriate birthing care model’ in which there is
adaptation and/ or integration of modern birthing services with
traditionally or culturally acceptable pregnancy and childbirth
management practices to ensure that skilled maternal healthcare
services are attentive to the specific needs of individual women. In
particular, women spoke passionately about the need to make
antenatal clinics and labour wards more private and home-like so
as to reduce the apprehension that the set-up of maternity wards
including the apparatuses for technological intervention inspire
and to provide a reassuring environment that guarantees
familiarity and comfort.
I believe if the nurses want more women to come to the hospital
to deliver, then they should realize that most women come from
communities where there are rules or ways in which childbirth is
conducted. In this community for example, when you go into labour,
you are kept in a quiet or shielded room where nobody can see your
nakedness. But in the hospital, the ward is open and anybody can see
you. There is no privacy at all. This is why some women prefer home
birth (Lactating Mother, FGD, Tidrope).
Another discussant continued:
Also, if a woman is delivering at home, she wears her own clothing,
but in the hospital, they will not allow, they will give you cloths that
so many people have already worn. This is not proper. After delivery
at home too, your family members usually bury the placenta in a very
warm place so that the woman’s recovery can go on well, but in the
hospital, you don’t even know where your placenta is send to…whether
it is burnt, thrown into the toilet or to the dogs, you would never know.
If they want more women to come to them, they can try and make
it possible for women to wear their own cloths during delivery. They
should also provide quiet rooms, and after delivery they should hand
over the placenta or at least ask the woman and her family members
how they want it disposed (Lactating Mother, FGD, Tidrope).
In this way, several women called for culture care
preservation (i.e. integrating their cultural values into the care
system when there is no risk of harm), culture care re-patterning
(i.e. assisting them in adopting new patterns of care behaviours if
instituting a particular cultural care practice would bring harm
to the client or anyone else), and cultural matching of patients to
care providers (i.e. linking women to healthcare providers who
understand or share similar cultural beliefs and practices). In
addition, several women shared their positive experiences of how
traditional birth attendants and family members usually provide
labouring women with not only physical and emotional support
but also continuous companionship when birth took place at
home. In the hospital however, it was reported that nurses and
midwives often concentrated on using their instrument to the
neglect of women’s emotional needs. The women therefore
Volume 3 • Issue 6 • 1000171
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Frequency of statement
Percent (%) Percent (%)
(Healthcare providers)
22.9 3 8.6
32.9 7 20
39.4 1 2.8
16 45.7
8 22.9
100 35 100
suggested that community traditional birth attendants and
family members should be allowed into delivery wards to offer
emotional support and physically help with pushing out the baby.
The idea of adapting birthing services to preserve privacy and
take account of women’s specific cultural values and practices
regarding childbirth however appeared less favoured by the formal
healthcare system in Ghana. Only 3 of the statements participant
from the healthcare providers category made suggested that cultural
adaptation of birthing services was necessary for encouraging more
women to patronize maternal health services.
Promoting male involvement
In both focus groups and interviews, it was reported that
maternal health issues in Ghana were still largely treated as a uniquely
feminine matter, and maternity units as spaces exclusively meant
for women. As a result, there has been very little focus on men and
their involvement in helping women access care. However, several
women reported that not only do husbands influence women’s
healthcare-seeking decisions through for example financing, but
also they exercise considerable power in either permitting or
restricting women’s access to, and use of services. Several
participants therefore called for the defeminisation of maternity care
and the promotion of men’s involvement in maternal healthcare.
My view is that if the healthcare providers want every woman in
this community to attend antenatal clinic or deliver their babies at
the hospital, then they need to talk to our men and involve them to
understand why it is important. I say this because although we the
women get pregnant and give birth, men are often responsible for
our pregnancy and therefore they have a lot of say in terms of how
the pregnancy is cared for or how the baby should be born (Pregnant
Woman, FGD, Piase).
Another participant said:
You see when some women don’t go to see the nurses for check-
up or delivery, they don’t do so on their own will, but because their
husbands don’t allow them…I can use myself as an example…When
I was pregnant, I didn’t go to check my pregnancy for almost seven
months because my husband said it was time wasting for me to be going
to the clinic when I was not sick. I only went when I fell very sick. It
was my husband who picked me on his bike to the health centre. When
we got to the clinic and the nurse saw me, she was very angry. She was
angry because I did not attend antenatal care. But when I told her I
didn’t come because I didn’t want to have problems with my husband,
she called my husband to come and then she talked a lot to him. She
explained that I was suffering from very severe malaria which could
affect my baby, and that it was all because I didn’t attend antenatal
early. Since then, my husband understood the whole thing…in fact he
is always asking me when my next visit will be, and he is now very
supportive (Lactating Mother, FGD, Mpaha).
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Citation: Ganle JK (2014) Addressing Socio-cultural Barriers to Maternal Healthcare in Ghana: Perspectives of Women and Healthcare Providers. J Womens
Health, Issues Care 3:6.
Among healthcare providers, however, the idea of promoting
men’s involvement in maternal healthcare in Ghana is yet to be
popular. Only 7 of the statements healthcare providers made
indicated that policies directed towards improving women’s access
and use of skilled maternity care services must involve men. For the
few healthcare providers who made this proposal, Ghana was still a
country in which patriarchy and machismo are manifested in both
public and private lives, so that men especially husbands are usually
the most influential household decision-makers, including regulating
women’s mobility and autonomy in accessing and using skilled care
services.
I think one problem is the failure of the healthcare system to actively
engage all stakeholders…especially the men in all efforts to promote
good maternal health. But we’re still living in a country where men have
more control over household decisions, including reproductive health
decisions like how many children to have and whether a woman should
give birth in the hospital. So I believe that if we want to ensure that all
women have access to or use skilled maternal healthcare services at the
time that the services are most needed, then we the healthcare providers
must also engage the men in the process (Female Healthcare Provider,
KII, Tamale).
Promoting domiciliary skilled maternity care
Within the current framework of Ghana’s maternal healthcare
system, hospitals, clinics, health centres, community-based health
planning and services (CHPS) compounds are the only places where
women may receive free maternity care. Focus discussions and
interviews with women however revealed that the unpredictability of
the onset of labour, coupled with difficulties with arranging
appropriate transportation as well as the unfamiliarity and
apprehension that these health facilities usually inspire, often greatly
limit the ability of many women to access these facilities and
utilize their services. For this reason, several women
recommended a maternity care system that supported and
promoted supervised domiciliary delivery. This, the women
argued, would not only eliminate the complications that may arise
due to delays associated with travel, but will also directly address the
issues of fear and privacy as well as tailoring birthing services to
meet individual women’s needs within the familiar environment of
their home.
I think if the government really wants to reduce maternal deaths,
then it should make it possible for the nurses to come to our houses to
help. This is because, when you are pregnant, you don’t normally know
when the baby will come. It can come at any time…even midnight.
So if the government can make it possible…say if the nurses can give
out telephone numbers that we can call them to come when we go into
labour suddenly, then that will help since nurses usually have cars or
motor bikes (Pregnant Woman, FGD, Abono).
One discussant supported the recommendation with an example:
I know one woman who wanted to go to the hospital to give birth,
but she got into a difficult labour…she was bleeding a lot and it was in
the night too, and there were no cars. Her husband called somebody at
the hospital which is located in the next town and asked the person to
go and inform the nurses about the problem; but the nurses said unless
the husband brought the woman to the health facility, they could not
help…her family really suffered. When the woman was finally sent to
the hospital, an operation was done to remove the baby, but the baby
was already dead. If the nurse came fast, this would not have happened
(Lactating Mother, FGD, Abono).
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Another participant agreed and continued:
That is very correct…it will really help because it will be possible for
every women to be delivered by a midwife or doctor even if the woman
is unable to go to hospital or if she doesn’t want to go there at all. This
is what our traditional birth attendants do…they usually come to our
homes if we have problems with our pregnancy or if we go into labour
(Pregnant Woman, FGD, Abono).
Among the healthcare providers interviewed, there appeared to be
widespread resistance to the idea of supervised domiciliary delivery.
Only one female healthcare provider thought domiciliary delivery
was a feasible strategy that could increase access to, and use of, skilled
maternity care services among women. Apart from arguments that it
would be difficult for nurses, midwives and doctors to properly
and safely conduct births, one participant also noted that the idea
was very unpopular because of its rather political nature.
As a woman who has experienced childbirth myself as well as
played a frontline role in the maternity ward, I have always argued
for supervised domiciliary delivery. After all, we conduct child welfare
clinics and sometimes, antenatal clinics right in the communities, and
the results have been very good. But I don’t know… a lot of
colleagues are very uncomfortable with the idea because they fear it will
be difficult or they will lose all the respect they get when patients come
to them in the health facility (Female Healthcare Provider, KII,
Kumasi).
Thus apart from concerns that home deliveries come with a
number of challenges such as delays in access to life-saving equipment,
there was widespread fear and anxiety among healthcare workers that
they may lose the respect, power and control they command within
healthcare facility settings if domiciliary midwifery were incorporated
into the healthcare system.
Health education
The majority of the healthcare providers interviewed also proposed
more health education as a strategy to overcome access barriers
arising from ignorance and socio-cultural factors. In searching for
an explanation for the persistently high maternal mortality as well
as low numbers of skilled maternal healthcare services accessibility
and utilization, these healthcare providers reasoned that most of
the damaging factors lay with women. Specifically, women’s limited
health knowledge and backward cultural beliefs were implicated in
non-attendance at clinics and delivery at home. According to this
account, attracting more women into the formal healthcare system
to access and use skilled birthing services must be preceded and/ or
accompanied by a very aggressive education of women.
There is still ignorance on the part of many women about health issues
including maternal health. I believe the way to make progress is to increase
our health education campaigns using the radio and community durbars
to educate women about the need to seek antenatal care and hospital
delivery (Female Healthcare Provider, KII, Kuntanase).
One healthcare provider added:
The problem is that there are many women…especially in rural
areas who have no formal education. Such woman do not always
understand the risks involved in getting pregnant and giving birth…
they also have funny cultural beliefs about hospital births. So if we
want to make progress towards MDGs 4 and 5, then we must intensify
our health education campaigns to educate women to do away with
traditional and cultural beliefs that don’t help (Female Healthcare
Provider, KII, Buipe).
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Citation: Ganle JK (2014) Addressing Socio-cultural Barriers to Maternal Healthcare in Ghana: Perspectives of Women and Healthcare Providers. J Womens
Health, Issues Care 3:6.
One participant further suggested:
Education…more health education of the women! This is critical if
we want to make progress (Female Healthcare Provider, KII, Kumasi).
Given the low levels of female education in the study communities,
the diagnoses and prognoses offered by the healthcare providers
here might indeed be valid in some instances. This notwithstanding,
discussions and interviews with women did not produce enough
evidence that could support either the diagnosis of the problem or
the solution to it. Only 3 of the statements women made in relation
to how to address socio-cultural barriers suggested that health
education was important. The majority of women did not think
that they needed more health education either for the purposes of
helping them understand the risks of pregnancy and childbirth or for
encouraging them to seek care in health facilities.
Community mobilization and engagement
A few of the women and healthcare providers interviewed also
suggested that improving access to maternal healthcare services for
all women in Ghana would require the formal healthcare system
forcefully mobilizing and engaging with local community members,
including traditional and religious leaders as well as traditional birth
attendants to generate community-wide approval and demand for
routine and emergency maternal healthcare services.
My experience as a midwife and woman who has experienced
childbirth has shown that if we want to make progress with maternal
health, then we must begin to foster more collaboration between
nurses, midwives, TBAs, and community and religious leaders (Female
Healthcare Provider, KII, Piase).
According to this account the approach that must be adopted by
the healthcare system and individual midwives to effectively mobilize
and engage community members to improve access to maternal
health must not merely raise community awareness or persuade
community members to participate in activities already designed
or decided on by midwives and the local healthcare delivery system.
Rather, the approach should be a comprehensive consultative and
participatory strategy, involving series of activities including 1)
formative research to understand factors within every community
that constrain women’s access to services; 2) galvanization of the
support of the traditional authorities as early as possible in the
community mobilization process; 3) raising community awareness
about the maternal health situation; 4) working with community
leaders and other stakeholders to invite and organize participation
of childbearing women and men; 5) participatory design and
implementation of a community maternal healthcare strategy, and 6)
monitoring and evaluation of community maternity care activities.
To move forward, I believe we the healthcare providers must take
steps to effectively mobilize and engage local community members on the
issues of maternal health. We must make communities see the problem
of maternal health as the collective responsibility of communities, local
healthcare providers, and central government. In this sense our approach
to community mobilization should give priority to the use of existing
local social systems and networks; effective engagement with the whole
community through galvanization of the support of the traditional
and religious authorities; the use of a discussion group methodology to
encourage participation and dialogue on maternal health issues among
key stakeholders in the community; raising awareness of core maternal
health issues; generating community-wide behaviour change and social
approval for routine and emergency maternal health services; and the
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use of a community-based maternal health auditing and monitoring
system that can generate data on maternal health activities and
changes in the community. All these should be backed up by door-to-
door visitation to the homes of pregnant women and their families by
trained community-based health workers (Male Healthcare Provider,
KII, Tamale).
Although participants acknowledged that community
mobilisation and engagement on issues of maternal health could
be challenging due to lengthy processes and community members’
unwillingness to engage in the process, they argued that it was a viable
potential strategy that could be used to create trust between care
providers and community members, make ordinary members of the
community feel a sense of partnership and collective ownership of the
maternal health services that were being offered at health facilities,
and address issues of socio-cultural barriers and resolve conflicts
between community members and healthcare providers. As one
female healthcare provider remarked:
Community mobilisation and engagement offers opportunities for
we the healthcare providers to built trust and change women’s and
community members’ negative beliefs and attitudes towards hospital-
based maternity care services (Female Healthcare Provider, KII,
Kumasi).
Discussion
It has been observed that at least 80% of global maternal deaths are
preventable, and that simple, costless or cost effective interventions
that can significantly improve survival and quality of life for
childbearing women exist even in resource-poor settings [6,32-34].
While this is probably true in terms of clinical interventions, how
to effectively deliver these interventions and services to ensure they
reach all women, is one of the key challenges currently facing many
low-income countries [35]. The purpose of this study was to explore and
identify strategies that could be adopted to address socio-cultural barriers
to access and use skilled maternal healthcare services in Ghana.
Qualitative analysis of the experiences and perspectives of
childbearing women and healthcare providers in parts of Ghana
suggested that most women do want skilled care during pregnancy
and childbirth, and that the birthplace choice of most women is
rapidly shifting from the home towards formal healthcare institutions
partly because of the abolition of user-fees for maternal healthcare
services. That the abolition of user-fees for maternity care services
in Ghana is contributing to shifts in the birthplace choice of women
from the home towards formal healthcare institutions where skilled
birth attendants are likely to be available suggests that this new
financing policy could potentially be used as a solution to address
financial barriers to access and use of maternity care services. Also
the shift indicates the potential for the user-fee exemption policy to
greatly alter the role of men as key decision-makers when it comes
to access and use of maternal healthcare services. As shown earlier
in this paper, high levels of poverty and economic marginalization
among women particularly in rural Ghana, is one of the reasons why
women are often chronically dependent on men for decision-making
regarding access and use of skilled birthing services. The removal
of user-fees for maternal health services could therefore potentially
reduce the high dependence of women on men’s financial resources
to access needed care.
Findings however showed that despite women’s increasing
preference for skilled attendance, a number of socio-cultural factors,
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Citation: Ganle JK (2014) Addressing Socio-cultural Barriers to Maternal Healthcare in Ghana: Perspectives of Women and Healthcare Providers. J Womens
Health, Issues Care 3:6.
including women’s limited decision-making power were acting as
barriers to women’s ability and willingness to access and use skilled
maternal healthcare services. To address these barriers, both women
and healthcare providers identified a number of strategies,
including cultural adaptation of birthing services, greater
involvement of men in maternity care, promotion of domiciliary
maternity care, more health education, and community
mobilization and engagement on issues of maternity care.
But inevitably, the various proposals for addressing the socio-
cultural barriers themselves present unique challenges. Apart from
the fact that many of these proposals neither considered the question
of feasibility, the existence of an evidence-base, nor the cost and the
broader implications of implementing any of the proposed solutions,
women’s priorities and proposed remedies diverged and converged
with those of healthcare providers in significantly interesting ways. In
terms of convergence, both women and healthcare providers agreed
on the need to mobilize and engage local communities to promote
access to and use of skilled maternal healthcare services. There is also
strong convergence of opinion and strategy on the need to promote
greater male involvement in maternity care. Convergence in terms of
women’s and healthcare providers’ priorities on the above strategies
clearly offers opportunities for instituting the necessary policy
actions to bring about improvement in maternal health in Ghana.
For example in the context of the study communities where men can
prevent women from accessing maternal healthcare, and where there
is convergence of opinion on the need to involve men as partners
in maternal health, the health service in Ghana could take concrete
steps to engage men on maternal health issues. In addition to couple
counselling, existing and future designs of maternity wards could
for example be made more male and couple-friendly, such that both
men and women can be accommodated or if need be create separate
waiting areas for men alone when they accompany the wives to access
maternal healthcare. Of course, cultural perceptions about the role of
men as breadwinners, and maternity care as a feminine domain, might
pose a challenge to men’s active involvement. However, as findings
from this study demonstrate, engaging men on issues of maternal
health could be important for increasing in them an understanding
of the relevance of women’s access to, and use of, skilled birthing
services in a timely manner. Indeed, the strategies on which the ideas
of both women and healthcare providers strongly converged should
be the starting point of real solutions to the problems of socio-cultural
barriers to access and use of maternal healthcare in Ghana.
In terms of divergence, fewer healthcare providers than women
supported the idea of adapting birthing services to preserve privacy
and take account of women’s specific cultural values and practices
regarding childbirth. Similarly, whereas the health centre or hospital
is a place where women felt a loss of status and therefore argued
for health centres and hospitals to be made more into places where
women feel at home and higher status, healthcare professionals
appear to gain status within health facilities, hence are very resistant
to recommendations for domiciliary skilled care. More healthcare
providers than women also supported health education as a strategy
for increasing women’s understanding of the dangers and importance
of skilled care as well as the need to access health facility-based
skilled birthing services. These seeming disjunctions in the above
areas of strategy clearly point to the potential for conflict and policy
failure. It is therefore important that steps are taken to address these
potential conflicts and built consensus on strategy. For example, part
of the reasons why some healthcare providers are less supportive
of domiciliary care are concerns that home deliveries come with a
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number of challenges including difficulties in accessing and using
life-saving equipment in clients’ homes. Since most women appear
to prefer home deliveries, the Ghana’s government and the ministry
of health and the Ghana health service could finance the provision of
well-equipped mobile clinics. Such mobile clinics could be in the form
of mobile vans/ambulances that are adequately stocked with essential
medical consumables so that healthcare providers can quickly and
safely respond to requests for domiciliary maternal healthcare.
Similarly, difficulty with arranging appropriate transportation to
transport pregnant women to health facilities is one reason why
women want domiciliary care. Government or the health service
could therefore invest more resources in providing efficient and
effective ambulatory services, particularly in remote communities.
Put together, the findings in this paper can broadly be viewed
as ‘strategies for promoting culturally responsive care’. From
recommendations for domiciliary skilled care, cultural adaptation
of birthing services, promotion of greater male involvement in
maternity care, to health education and community mobilisation, the
study clearly highlights the importance of organising and delivering
maternity care services in a manner that is culturally responsive to
childbearing women and local communities. A culturally responsive
health system is one in which healthcare services are respectful
of, and relevant to, the health beliefs, health practices, cultural
needs of diverse patient populations [36]. Cultural responsiveness
further involves acknowledging and respecting cultural values and
preferences of groups that impact their health and health-seeking
behaviours and applying this awareness to healthcare delivery [37]. In
the context of the study reported in this paper, cultural responsiveness
acknowledges that cultural diversity of childbearing women poses
unique challenges to maternal healthcare access in Ghana: it
influences women’s experience, expression, care-seeking behaviours,
and responses to maternal health promotion and care interventions.
As such, there is need for culturally responsive care that understands
and works with patients whose beliefs, values, and histories may be
significantly similar or different from those of the healthcare system.
For instance, this research has revealed that some of the socio-cultural
barriers to skilled care such as traditional values attached to burying of
placenta closer to home or in a warm place are highly context specific.
A culturally responsive care regime would move beyond one-size-fit-
all templates to focus on addressing the specificity of socio-cultural
beliefs and concerns of different communities that negatively affect
access to, and use of skilled care services. In changing, modifying
and accommodating some of the socio-cultural barriers to maternal
healthcare access, a culturally responsive care system would also
adopt health education campaigns that not only communicate the
importance of women delivering their babies with a relatively well-
resourced skilled health professional in attendance, but also challenge
negative socio-cultural beliefs and practices that constrain women’s
ability to access and use skilled delivery services.
Other strategies that could be pursued to make the maternal
healthcare system culturally responsive include cultural competency
training for healthcare providers and cultural matching. Cultural
matching in particular has the potential to reduce the social
distance (i.e. differences in culture, ethnicity, religion, behaviour
and expectations etc.) between maternity caregivers and women.
As one previous study in Ghana found women preferred to travel
further, and face higher opportunity costs to see maternal healthcare
providers who were the same ethnic or religious group as them
[38]. The study revealed that this was because a provider from the
same ethnic or religious group was perceived as having a smaller
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Citation: Ganle JK (2014) Addressing Socio-cultural Barriers to Maternal Healthcare in Ghana: Perspectives of Women and Healthcare Providers. J Womens
Health, Issues Care 3:6.
social distance and therefore worth travelling the extra distance for.
Indeed, it is not just the empirical findings from this research that
can be invoked to justify the argument for cultural responsiveness
in maternity care in Ghana. One key argument in the international
health research literature is that lack of culturally responsive care
is, in fact, a major contributor to health disparities [39]. Previous
studies have also found that providing culturally responsive care has
the potential to lead to improved access and equity for all groups in
the population [37]. It has also been observed that health disparities
and lower quality care are exacerbated when healthcare organisations
fail to address the links between culture and health service provision
[39]. The findings in this paper therefore re-echo previous calls for
maternity care services to be made more responsive to women’s
cultural values, beliefs and preferences related to pregnancy and
childbirth [32,36,40].
The findings and recommendations in this paper should however
be read against the backdrop of certain limitations. The research
reported in this paper was conducted in only six communities and
with a relatively smaller number of participants. While focusing on
a small number of participants and communities enabled greater
in-depth understanding of how to address socio-cultural barriers
to maternal healthcare, the limitation of generalizing the findings
to other parts of the country is acknowledged. This is more so
because childbearing women are not a homogenous group, hence
the perspectives of those interviewed in this study might not be
representative of what is prevalent across the entire population in
Ghana. This notwithstanding, important lessons can be drawn from
the findings in this paper to inform policies that seek to encourage
women to use skilled maternity care services in other parts of the
country and beyond.
Conclusion
Together, the findings in this paper not only improve
understanding of the socio-cultural barriers women face in accessing
and using maternal healthcare services, but also significantly add
new insights to the corpus of existing evidence about how these
access barriers could be addressed. The fi ndings suggest that the
extent to which the maternal healthcare system in Ghana becomes
more responsive to the socio-cultural hindrances that women face
in accessing care would be an important determinant of increased
and equitable access to skilled maternal healthcare. Similarly
the balance that would be struck between women’s own
circumstances and valuation of their maternal healthcare needs,
priorities and preferences, and those of state and of healthcare
providers, would also be an important factor. This demands a
number of policy and practical actions, including cultural
adaptation of birthing services, greater male involvement in
maternity care, promotion of domiciliary maternity care, and
community mobilization and engagement in addition to
rolling out health education campaigns that both communicate
the importance of women delivering their babies with a relatively
well-resourced skilled health professional in attendance, and
challenge negative societal beliefs and practices which constrain
women’s ability to access and use skilled delivery services.
Acknowledgement
This research was funded by a Wellcome Trust Doctoral
Studentship as part of a Wellcome Trust Enhancement Award
(Number 087285) to the Ethox Centre, Nuffield Department of
Population Health, University of Oxford.
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doi:http://dx.doi.org/10.4172/2325-9795.1000171
The work of the Ethox Centre in Global Health Bioethics is
supported by a Wellcome Trust Strategic Award (096527). However,
the funder played no role in the design, data collection, analysis,
interpretation of data, writing of the manuscript, and the decision to
submit the manuscript for publication. The author is grateful to all
the study participants, especially the pregnant and lactating mothers.
The author also acknowledges the dedication and hard work of the
research assistants.
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