UNIVERSITY FOR DEVELOPMENT STUDIES

SCHOOL OF NURSING AND MIDWIFERY

DEPARTMENT OF MIDWIFERY AND WOMEN`S HEALTH

TOPIC: EXPLORING FACTORS INFLUENCING INSTITUTIONAL

CHILDBIRTH: A STUDY AMONG PREGNANT WOMEN IN TOLON

DISTRICT

NAMES INDEX NUMBERS

JIDOH U. JOSEPH MW/0268/17

ASINGA LARIBA RUFINA MW/0247/17

ABDUL-NAFIWU ALHASSAN MW/0231/17

2022

1
 UNIVERSITY FOR DEVELOPMENT STUDIES

SCHOOL OF NURSING AND MIDWIFERY

DEPARTMENT OF MIDWIFERY AND WOMEN`S HEALTH

TOPIC: EXPLORING FACTORS INFLUENCING INSTITUTIONAL CHILDBIRTH:

A STUDY AMONG PREGNANT WOMEN IN TOLON DISTRICT

NAMES INDEX NUMBERS

JIDOH U. JOSEPH MW/0268/17

ASINGA LARIBA RUFINA MW/0247/17

ABDUL-NAFIWU ALHASSAN MW/0231/17

A DISSERTATION SUBMITTED TO THE SCHOOL OF NURSING AND

MIDWIFERY, NIVERSITY FOR DEVELOPMENT STUDIES, TAMALE, IN
PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF BSC.
MIDWIFERY”

FEBRUARY, 2022

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 DECLARATION

We certify that this dissertation is the result of our own work and that no previous

submissions for a degree have been made here or elsewhere. Also, works by others,

which served as sources of information, have been duly acknowledged by making

references to the authors where applicable.

JIDOH U. JOSEPH (MW/0268/17) Signature: _______________Date:___________

ASINGA LARIBA RUFINA (MW/0247/17) Signature: ___________Date:__________

ABDUL-NAFIWUALHASSAN (MW/0231/17) Signature: __________Date:________

Certification

I certify that the preparation and presentation of this dissertation was supervised in

accordance with the guidelines for supervision of dissertation laid down by the University

for Development Studies, Tamale

NAME OF SUPERVISOR: MR HAMIDU NABILA YAKUBU

Signature:_____________________________ Date: ________________________

NAME OF HEAD OF DEPARTMENT: MADAM GIFTY MARY WUFFELE

Signature: _____________________________ Date:________________________

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 ACKNOWLEDGEMENT

We wish to express my profound gratitude to the Almighty God for seeing us

successfully through this programme.

And to our supervisor Mr Hamidu Nabila Yakubu for his patience and guidance as we

journeyed through putting this piece together.

Our profound gratitude also goes to the DDHS of Tolon district and her entire team, and

to all staff of the kasulyilli sub-district for the assistance given.

We are also grateful to all members of the School of Nursing and Midwifery, department

of midwifery and women’s health, University for development studies for their guidance

and input during our course of study.

Finally, our gratitude goes to our families, friends and colleagues whose encouragement

and support has contributed in diverse ways to make this dream a reality. I say Kudos to

you all.

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 DEDICATION

This work is dedicated to our lovely families for their love, patience and prayers as we

were embarking on this project.

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 ABSTRACT

Background: Sub-Saharan Africa remains one of the regions with modest health

outcomes, evidenced by high maternal mortality ratios. Some complications occur during

and following pregnancy and childbirth that can contribute to maternal deaths, most of

which are preventable or treatable.

In Ghana, more especially in the northern region, several factors may affect the choice of

place of delivery among pregnant women. However, few studies have examined the

choice of place of delivery. Women’s utilization of healthcare facilities for delivery is a

significant health issue regarding the well-being and survival of both the mother and her

child during childbirth which has implications for the maternal and child mortality rate in

human society. However, in most of the middle and low-income countries including

Ghana and Tolon in particular, institutional childbirth has low rates. This study explored

factors influencing institutional childbirth among pregnant women in Tolon District

settings in the northern region of Ghana.

Methodology: The study was conducted in Tolon District in the northern region of

Ghana. An exploratory descriptive qualitative design and semi-structured interview guide

were used to guide data collection. The sample consists of pregnant women between the

ages of 15 and 49 years and fourteen (14) pregnant women were interviewed before data

saturation was reached.

Results: Fourteen (14) pregnant women were interviewed from the sub-district selected.

The study revealed that satisfaction with health services, the attitude of health workers,

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examinations, support and care, Transport and cost, Traditional and cultural practices and

women’s expectations towards health service delivery are explored factors influencing

institutional childbirth among pregnant women.

Conclusion: Socio-cultural and health service factors which include traditional and

cultural practices, support and care, previous experience of the pregnant women, and low

expectations of the pregnant women when they visit the health facilities were the most

repeatedly recognized exploring factors influencing institutional childbirth among

pregnant women in this study.

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 TABLE OF CONTENT

DECLARATION.............................................................................................................................3

ACKNOWLEDGEMENT...............................................................................................................4

DEDICATION.................................................................................................................................5

ABSTRACT....................................................................................................................................6

TABLE OF CONTENT...................................................................................................................8

LIST OF TABLES.........................................................................................................................12

LIST OF FIGURE.........................................................................................................................13

LIST OF ABBREVIATIONS........................................................................................................14

CHAPTER ONE............................................................................................................................15

INTRODUCTION.........................................................................................................................15

1.1 Background of the study...............................................................................................15

1.2 Problem statement.............................................................................................................18
1.3 purpose of the study...........................................................................................................20
1.4 Specific objectives...............................................................................................................20
1.5 Specific questions.........................................................................................................21
1.6 Significance of the study.....................................................................................................21
1.7 Operational definition of terms..........................................................................................21
1.8 Organization of the study...................................................................................................22
CHAPTER TWO...........................................................................................................................23

LITERATURE REVIEW..............................................................................................................23

2.0 Introduction........................................................................................................................23

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 2.1 knowledge about the benefits of delivering in the health facility among pregnant women
..................................................................................................................................................23
2.2 Acceptance of institutional childbirth among pregnant women.........................................25
2.3 Facilitating factors (enablers) of institutional childbirth among pregnant women.............28
CHAPTER THREE.......................................................................................................................32

METHODOLOGY........................................................................................................................32

3.0 Introduction........................................................................................................................32
3.1 Study area...........................................................................................................................32
3.2 Study design........................................................................................................................32
Figure 1 Map of Tolon District Source: Ghana Statistical Service 2011......................................33

3.3 study population.................................................................................................................34

3.3.1 Inclusion criteria..............................................................................................................34
3.3.2 Exclusion criteria..............................................................................................................34
3.4 Sample size determination.................................................................................................35
3.5 Sampling technique............................................................................................................35
3.6 Data collection instrument/tool.........................................................................................35
3.7 Pre-testing..........................................................................................................................35
3.8 Methodological Rigor..........................................................................................................36
3.9 Data collection procedure...................................................................................................37
3.10 Data analysis.....................................................................................................................38
3.11Data management.............................................................................................................38
3.12 Ethical consideration........................................................................................................38
CHAPTER FOUR.........................................................................................................................40

FINDINGS.....................................................................................................................................40

4.1 Socio-Demographic Characteristics of Participants.............................................................40

4.2 Organization of Themes......................................................................................................41
Table 4.2.1: Main Themes and Subthemes...............................................................................41
4.3 Knowledge about the benefits............................................................................................41
4.3.1 Satisfaction with health services......................................................................................42

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 4.3.2 Attitude of health workers...............................................................................................43
4.4 Factors influencing the acceptability..................................................................................44
4.4.1 Examinations....................................................................................................................45
4.4.2 Support and care.............................................................................................................45
4.4.3 Transport and cost...........................................................................................................47
4.4.4 Traditional and cultural practices....................................................................................48
4.5 Facilitating factors (enablers) of institutional childbirth.....................................................49
4.5.1 Expectation......................................................................................................................49
CHAPTER FIVE...........................................................................................................................52

DISCUSSION OF FINDINGS........................................................................................................52
5.1 Socio-Demographic Characteristics of Participants.............................................................52
5.2 Knowledge about the benefits............................................................................................53
5.3 Acceptance of institutional childbirth among pregnant women.........................................53
5.4 Facilitating factors (enablers) to increase institutional childbirth among pregnant women
..................................................................................................................................................55
CHAPTER SIX..............................................................................................................................57

SUMMARY, LIMITATION, CONCLUSION AND RECOMMENDATIONS..........................57

6.1 Summary of the study.........................................................................................................57

6.2 Limitations..........................................................................................................................59
6.3 Conclusion..........................................................................................................................59
6.4 Recommendations..............................................................................................................60
6.5.1 Ministry of Health (MoH).................................................................................................60
6.5.2 The internal management committee of Tolon district health directorate.....................60
6.5.3 Non-Governmental Organizations (NGOs).......................................................................61
6.5.4 Nurse Researchers...........................................................................................................61
REFERENCES..............................................................................................................................62

APPENDICES...............................................................................................................................71

Appendix I.....................................................................................................................................71

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Semi-structured interview guide for Expectant mothers (Who meet the inclusion criteria)

.......................................................................................................................................................71

Appendix II Introductory letter......................................................................................................73

Appendix III: Informed Consent...................................................................................................74

Appendix IV: CONSENT FORM.................................................................................................77

Appendix V: Data Collection Instrument (verbal interview)........................................................78

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 LIST OF TABLES

Table 4.2.1: Main Themes and Subthemes................................................................. 44

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 LIST OF FIGURE

Figure 1 Map of Tolon District Source………………………………………………36

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 LIST OF ABBREVIATIONS

CHPS………………………………..Community Based Health Planning and Service

DHIMS2……………………………..District Health Information Management System 2

EPMM………………………………..Ending Preventable Maternal Mortality

GHS……………………………….……………Ghana Health Service

GMHS…………………………………………..Ghana Maternal Health Survey

MMR ……………………………………………Maternal Mortality Ratio

PRMR…………………………………………...Pregnancy Related Mortality Ratio

SBA …………………………………………….Skill Birth Attendant

SDG’s……………………………………….…..Sustainable Development Goals

TBA……………………………………………...Traditional Birth Attendant

UHC……………………………………………..Universal Health Coverage

WIFA……………………………………………Women in Fertility Age

WHO……………………………………………World Health Organization

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 CHAPTER ONE

INTRODUCTION

1.1 Background of the study

Maternal mortality includes deaths of women during pregnancy, delivery, and 42 days

after delivery or end of pregnancy excluding deaths that were due to accidents or violence

(WHO 2019).

The Sustainable Development Goals (SDGs) were launched on 25 September 2015 and

came into force on 1 January 2016 for 15 years until 31 December 2030. Among the 17

SDGs, the direct health-related targets come under SDG 3: Ensure healthy lives and

promote well-being for all at all ages (U.N. 2015).

In anticipation of the launch of the SDGs, the World Health Organization (WHO 2015)

and partners released a consensus statement and full strategy paper on ending preventable

maternal mortality (EPMM). The EPMM target for reducing the global maternal

mortality ratio (MMR) by 2030 was adopted as SDG target 3.1: reduce global MMR to

less than 70 per 100 000 live births by 2030.

According to estimates in 2015, there were 303,000 maternal deaths with most of them

occurring due to complications related to pregnancy and childbirth. Almost all of the

303,000 deaths occurred in low-resource settings such as sub-Saharan Africa and most of

these deaths could be prevented (Doctor et al.2018).

Health facility deliveries have been targeted as one of the most effective measures to

avoid maternal mortality and morbidities and to improve the health of newborns. Despite

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this measure, a significant percentage of deliveries still occur outside health facilities in

low-income countries (Dankwah et al., 2019).

In this study, we aimed at exploring factors influencing institutional childbirth. Maternal

deaths are very sad issues because the necessary interventions are well known.

According to the World Health Organization, maternal mortality is one of the most

sensitive indicators of health. For instance, the risk of losing one’s life through pregnancy

in advanced countries is 1: 7,300 compared to 1: 75 in developing countries. Almost 95%

of these cases happen in low- and middle-income countries.

Access to maternal health services, including a skilled birth attendant (SBA), has been

proven to be significant in reducing maternal deaths. The WHO recommends the

presence of an SBA during delivery because complications can arise anytime during

labour and delivery (Boah et al. 2018).

The maternal mortality ratio (MMR) for Ghana is 310 deaths per 100,000 live births for

the period (1988, 1993, 1998, 2003, 2007, and 2014) before the 2017 Ghana maternal

mortality survey (GMHS). The confidence interval for the MMR ranges from 217 to 402

deaths per 100,000 live births. Across zones, there are differences in the MMR point

estimates but the confidence intervals overlap, meaning the differences are not

statistically significant. The pregnancy-related mortality ratio (PRMR) for Ghana is 343

deaths per 100,000 live births for the period (1988, 1993, 1998, 2003, 2007, and 2014)

before the 2017 Ghana maternal mortality survey (GMHS). The confidence interval for

PRMR ranges from 240 to 446 deaths per 100,000 live births. The 2017 GMHS is not

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significantly different from the 2007 GMHS PRMR estimate of 451 deaths per 100,000

live births (GMHS 2017).

In Ghana, more than three-quarters (79%) of live births or stillbirths are delivered in a

health facility, primarily in public sector facilities, while 1 in 5 births or stillbirths are

delivered at home. Women with more than secondary education (98%) and those in the

wealthiest households (97%) are most likely to give birth in a health facility. Health

facility deliveries range from 59% in the Northern region to 92% in the Greater Accra

region. Health facility deliveries have increased since 2007 when only 54% of live births

or stillbirths were delivered in a health facility. Home deliveries have declined by more

than half, from 45% in 2007 to 20% in 2017 (GMHS 2017).

The SDGs include a direct emphasis on reducing maternal mortality while also

highlighting the importance of moving beyond survival. Despite the ambition to end

preventable maternal deaths by 2030, the world will fall short of this target by more than

1 million lives at the current pace of progress. There is a continued urgent need for

maternal health and survival to remain high on the global health and development

agenda; the state of maternal health interacts with and reflects efforts to improve

accessibility and quality of care. (U.N 2015) (WHO 2015)

The 2018 Declaration of Astana repositioned primary health care as the most cost-

effective and inclusive means of delivering health services to achieve the SDGs. Primary

health care is thereby considered the cornerstone of achieving universal health coverage

(UHC), which only exists when all people receive the quality health services they need

without suffering financial hardship. Health services that are unaccessible or of poor

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quality, however, will not support the achievement of UHC, as envisioned. Instead, they

will increase the provision of skilled and competent care to more women before, during

and after childbirth.

In consideration of the above, it must be noted that this report on the levels and trends of

maternal mortality provides just one critical facet of information, which synthesizes and

draws from the available data, to assess progress in reducing maternal mortality towards

achieving the SDG target 3.1. (U.N. 2015) (WHO 2015)

1.2 Problem statement

Globally, over 70% of maternal deaths are due to complications of pregnancy and

childbirth such as haemorrhage, hypertensive disorders, sepsis and abortion (Daniels J, et

al. 2014).

Maternal mortality is a serious problem. Estimates for 2017 show that some 810 women

die every day from pregnancy- or childbirth-related complications around the world. In

2017, 295 000 women died during and following pregnancy and childbirth. The vast

majority occurred in low-resource settings, and most could have been prevented. SDG

3.1 targets to reduce the global maternal mortality ratio to fewer than 70 deaths per

100,000 live births by 2030. Meeting this target will require average reductions of about

three times the annual rate of reduction achieved during the Millennium Development

Goal era, an enormous challenge. At the current pace of progress, the world will fall short

of meeting SDG-3 at the cost of more than 1 million lives (WHO, UNICEF, UNFPA,

World Bank 2019).

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A study by (WHO) on standards for improving the quality of maternal and newborn care

in health facilities reveals that 800 women and 7700 newborns still die each day from

complications during pregnancy and childbirth and in the postnatal period.

An additional 7300 women experience stillbirth. With increasing numbers of maternal

health services, more avoidable maternal and perinatal mortality and morbidity still

occurs.

Institutional childbirth attended to by skilled and trained health workers is a measure of

reducing maternal mortality. Low uptake of skilled delivery services can lead to high

maternal and infant mortality, which are some of the problems the SDGs were created to

address. Maternal death worldwide is a critical issue that many countries with high rates

are working vehemently to address (Mahiti et al., 2015).

In northern Ghana, in particular, pregnancy-related death is seen as a major socio–

cultural issue. Traditional beliefs and practices or taboos have gone a long way to deter

women from delivering at the facility (Kifle et al. 2018).

The women who delivered from home were considered very strong, and people who

worshipped lesser gods relied on their gods for help; even in most ethnic groups, burying

the corpses in their homes was taboo. A woman who dies as a result of pregnancy-related

death is usually buried in valleys or bushes and the family is seen by others as a “bad luck

family or a curse meted to them as a result of a grievous crime that they might have

committed”. (Abugri 2013). This implies maternal mortality is not only a developmental

problem but also a socio–cultural issue and everyone is concerned.

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In Ghana to address these barriers, the government was able to scale up the Community-

based Health Planning and Services (CHPS) initiative nationwide in 2002. This was all

aimed at improving access to quality health care and encouraging communities to take

full control of their health. (Awoonor-Williams et al. 2015).

The CHPS initiative was established from the “Navrongo experiment”, known as the

Community Health and Family Planning (CHFP) project, to improve geographical access

to quality health care and family planning services while empowering local communities

to take greater control over their health (Enuameh et al. 2016).

Also, the free maternal health care policy and national health insurance scheme were

introduced with the aim of providing free services to every pregnant woman from

conception till three months after delivery and also to reduce financial barriers to

accessing maternal health. (Dickson et al 2016) but maternal mortality is unacceptably

high.

In a low-resource setting in Ghana institutional childbirth remains an increasingly

pressing concern for the achievement of the SDGs of reducing maternal and infant

mortality (O'Rourke et al., 2018).

Most childbirth is still happening outside health facilities and this poses more risk and

puts the health of pregnant women and unborn babies in increased danger. This leads the

researchers to ask; what influences pregnant women's birthplace choices?

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1.3 purpose of the study

The purpose of this study was to explore factors influencing institutional childbirth in

Tolon district in the Northern region of Ghana.

1.4 Specific objectives

1. To assess pregnant women’s knowledge about the benefits of delivering in the

health facility in Tolon district.

2. To determine the factors influencing the acceptability of institutional childbirth

among pregnant women in Tolon district.

3. To describe the facilitating factors (enablers) of institutional childbirth in Tolon

district

1.5 Specific questions

1. What is the knowledge of pregnant women about the benefits of delivering in the

health facility in Tolon district?

2. What are the factors influencing the acceptability of institutional childbirth in

Tolon district?

3. What factors facilitate (enablers) institutional childbirth in Tolon district?

1.6 Significance of the study

The results of the study will help plan strategies to educate pregnant women about the

benefits of institutional childbirth. They will also be relevant and useful to reproductive

health services planners for designing measures and targeting educational and preventive

policy initiatives in the Tolon district of northern Ghana.

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Finally, it serves as a source of information to support further studies related to

institutional childbirth.

1.7 Operational definitions of terms

Maternal mortality: WHO defines it as the death of a woman while pregnant or within

42 days of termination of pregnancy, irrespective of the duration and site of the

pregnancy, from any cause related to or aggravating by the pregnancy or its management

but not from accidental or incidental causes (WHO, 2012).

Skilled birth attendance: The World Health Organization (WHO) defines her as a

person who assists the mother during childbirth and learns her skills through an

apprenticeship that involves both observation and imitation, and is often highly regarded

by the community that chooses her to assist women in childbirth.

Knowledge: the awareness, understanding or information acquired through experience,

education or learning (Prah et al., 2013).

Institutional childbirth: deliveries conducted, with assistance from skilled birth

attendants, at a health facility.

Birthplace: refers to either a health facility or a traditional home.

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1.8 Organization of the study

Chapter one consists of an introduction. This outlines the background information,

problem statement, purpose of the study, specific objectives, specific questions,

significance of the study, operational definitions and organization of the study.

Chapter two presents the relevant literature for the study. This section contains an

outline of how the entire study is organized and presented.

Chapter three presents the research methodology, which includes a description of the

study area and study design. It also includes the sample size determination and sampling

techniques, Data collection Instrument, Pretesting, Validity and Reliability data collection

procedure, data analysis, data management and Ethical Considerations.

Chapter four will present the study results.

Chapter five will discuss the results of previous work.

Chapter six will summarize the findings from which conclusions are drawn and relevant

recommendations made.

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 CHAPTER TWO

LITERATURE REVIEW

2.0 Introduction

This chapter however reviewed available studies related to exploring factors influencing

institutional childbirth among pregnant women. The search was done using the following

range of cardinal features in the search for relevant research material for this study:

search by publication date, search by author name, search by keywords, and search by

subject or topic.

Major databases like Academic Search, African Journals Online, BioMed Central,

Bielefeld Academic Search Engine, Cochrane Library, Google Scholar, JournalSeek,

Journal Storage, PubMed, and Science Open were used to review published studies. All

published articles from 2010 to 2021 were included in the review. The organization of

this review was determined by the study objectives.

2.1 Knowledge of the benefits of delivering in a health facility among pregnant

women

Knowledge is awareness, understanding or information acquired through experience,

education or learning. Pregnant women’s knowledge of information and understanding is

very significant and guides one's choice of decision-making towards institutional

childbirth (Prah et al., 2013). Improving the quality of care in health facilities is

becoming increasingly recognized as a key focus in the quest to end preventable

mortality and morbidity among mothers and newborns. (WHO, 2016).

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Access to maternal health information increases women’s knowledge and understanding

of maternal health issues (Abimbola et al., 2017). Ensuring access to skilled birth

attendance and essential obstetric care that is effective and of high quality helps reduce

maternal and newborn mortality and morbidity (Raven JH et al., 2012).

A study in Nigeria on the Demographic and Health Survey 2013 shows myths about

health facility delivery in some settings such as northern Nigeria.

A study in Eritrea (Kifle et al 2018) shows factors that are related to the perceived

need/benefit of receiving quality care. Newspapers and television were largely

inaccessible to most women compared to radio. Perhaps mothers who read newspapers

are more educated and therefore more receptive to health messages regarding maternal

and child health and the importance of institutional delivery.

A study in Zambia shows that knowledge about complications during delivery has been

recognized as a predictor of health facility delivery in case complications arise. In this

study, respondents who were knowledgeable about the complications that may arise

during delivery were four times more likely to have a delivery in a health facility than

women who did not have adequate knowledge. Knowledge about complications

increased with increasing maternal age, but less so among mothers above 35 years of age.

This pattern was also seen in health facility delivery. Mothers who were aware of

obstetric complications had more facility deliveries, as well as women who reported

having attended at least one antenatal care. Past experiences with obstetric complications

were not associated with the level of knowledge. This suggests that the reported

knowledge may be largely derived from exposure to health information gained while

25
utilizing health services. Almost half (58.9%) of respondents were not knowledgeable

about complications during delivery (Campbell OMR et al. 2011).

Also, limited exposure to information about institutional childbirth can result in a high

level of ignorance. In the case of Eritrea, women who live in rural areas have limited

decision-making power and hence lack control over their reproductive health decisions,

which can be dangerous to both the mother and baby (Kifle et al., 2018).

Furthermore, a qualitative study revealed that the low rate of deliveries taking place in

healthcare facilities in Bawku Municipality is a result of the interplay of both health

service and socio-cultural factors (Abugri 2013).

2.2 Acceptance of institutional childbirth among pregnant women

Health facilities are a more convenient and safer environment for delivery than home,

particularly in low- and middle-income countries where resources are scarce. A

systematic review concluded that the risk of death of neonates in low and middle-income

countries was reduced by about 25% when institutional delivery services were accessed

(Tura 2013). Ghana has about 5,850 health facilities (DHIMS 2014) throughout the

country. However, most of these facilities are concentrated in an urban setting. This

means that pregnant women living in rural areas have to travel long distances to access

health care, which is often a barrier to access. According to the Government of Ghana,

the number of maternity beds per population was 26.3 per 1000 deliveries in 2010 which

is almost close to the international standard of 30 to 32 per 1000 deliveries (GOG et al.

2011).

26
A survey by Baba Ibrahim Mahama in northern Ghana shows the majority of rural

women prefer home delivery to facility delivery. This is compared to the low rate of

home delivery by urban women. These may be due to several factors that may influence a

person's choice of delivery place. A significant majority (60.1%) of the study participants

in rural areas opted for home delivery compared to 20.7% in urban areas.

In this study, the dynamics further revealed that whereas 79.3% of respondents were from

urban, 39.9% of respondents were from rural (Mahama et al. 2019).

Also, a study in South Africa revealed findings that showed that women with one birth

were more likely to utilize health facilities at delivery than those with two or more births

confirmed (Umurungi et al. 2011). There is an argument that women with one birth are

usually more likely to deliver their next birth at a health facility.

A similar finding was reported in Uganda by (Anyait et al 2012) in a cross-sectional

study that women with more than four births had less use of health facilities for

deliveries.

A case study of Lubumbashi city shows that this may be because primiparous women are

considered to be naturally at a higher risk of maternal complications than multiparous

women (Ntambue et al. 2012).

A study in Ga East Municipality of Ghana shows that women of this age group access

health facility deliveries more than multiparous women (Esena et al. 2013). The high

proportion of home deliveries realized among multiparous women may be due to their

preference for Traditional Birth Attendants (TBAs) as posited by (Ntambue et al. 2012).

27
The authors argued that TBAs were preferred because they were considered to be more

caring and friendly. In addition, they also provide complementary services such as food

and bathing water to the women when they give birth to them compared to their health

facility deliveries.

Furthermore, the World Health Statistics 2017 study (WHO) also found that the pattern

of health facility deliveries varies within clusters or communities as well as within

countries. While considering the fact that women from the same community will

experience a similar likelihood of delivering in a health facility, the results of this study

highlight the importance of clustering effects in explaining differences in health facility

delivery in sub-Saharan Africa. These effects are also observed at the country level.

Building on the results of this study, available data show that globally, births under the

supervision of skilled personnel increased from 58% in 1990 to 78% in 2015. This

increase was influenced by increases in facility births in urban areas.

Women may decide where to obtain delivery services due to transportation challenges,

which range from unavailability to affordability. A study conducted in Ghana found that

43% of respondents who failed to use a health facility for delivery cited transportation

challenges as the reason (Esena & Sappor 2013). Some of these challenges include a lack

of vehicles, high transportation costs, and a poor road network. This is similar to the

finding reported by (Lekberg et al 2014) on transport costs in Zambia. Regarding the

ecological zone, women from the savannah zone had the highest proportion of home

deliveries (52.7%) compared to women from the forest zone which had the highest

proportion of health facility deliveries (65.6%). Women who had a big problem getting

28
the money needed for treatment (46%), Gurmas (73.9%), women with four births or more

(46.1%), and those who saw the distance to a health facility as a big problem (51.8%) had

the highest proportion of births delivered at home (K. S. Dickson et al. 2016).

2.3 Facilitating factors (enablers) of institutional childbirth among pregnant women

A study conducted in Uganda looked into why women who were faced with

complications during pregnancy or delivery continued to choose high-risk options leading

to severe morbidity and even death. The finding demonstrates that adherence to

traditional birthing practices and the belief that pregnancy is a test of endurance and

maternal death is a sad but normal event are critical factors (Kyomuhendo GB 2010).

The skilled attendant can only be available in health institutions to reduce maternal

mortality and morbidity, and to attain the SDGs target 3.1 which is improving Maternal

Health outlined as one of which set a target of maternal mortality ratio reduction by

three-quarters of the 1990 levels by the year 2015.

A study in Bangladesh shows the fact that a partner’s education predicted the choice of

place of delivery among women, however, supports the argument that men usually

control decision-making in the home, including women’s health decision-making

(Mainuddin et al., 2015).

A study in Tanzania shows that wealth plays a major role in the choice of place of

delivery among women in rural settings. We realized, for instance, that health facility

delivery was dominated by the wealthy in both the descriptive and inferential analyses

conducted. For instance, the richest women were three times more likely to deliver at a

29
health facility than the poorest ones. This finding is in line with previous findings

regarding the choice of place of delivery and the disparity between poor and rich women

regarding health facility delivery ( Kruk et al. 2010).

The findings where the poorest women had the poorest utilization of health care facilities

for delivery were probably because they have to pay for health care. This is usually

problematic for them as argued. The role of wealth in predicting the place of delivery

among rural women is also corroborated by our findings which showed that women who

said getting the money needed for treatment was a big problem were less likely to deliver

at a health facility than those who said getting the money needed for treatment was not a

big problem (Dickson et al., 2016).

A study in the latest national review of maternity services in England, Better Births,

stated that the process of decision-making should fully involve the woman and her

personal preferences. This requires a relationship of trust and mutual respect to enable her

to make empowered decisions and to feel respectfully supported by maternity

professionals (NHS England 2016).

A study in Ghana reveals that midwives are the key providers of maternity services,

which makes their recruitment, retention and equitable distribution worth considering in

any conversation regarding the maternal health workforce (Mahama 2019).

A study in Ghana shows education plays a significant role in the choices women make

regarding the place of delivery. Thus, it was realized that the probability of giving birth at

a health facility increased through education, not only for the women but also for their

30
partners. These findings are thus in congruence with previous studies which found

education as a strong determinant of health care service and facility use (Dickson et al.,

2016).

A study in Ghana found that wealth index, maternal education, ecological zone, getting

money for treatment, ethnicity, partner’s education, parity, and distance to a health

facility are the determinants of place of delivery among women in rural Ghana. It thus

behoves the relevant stakeholders including the Ghana Health Service and the Ministry of

Health to pay attention to these demographics in their decisions regarding the delivery of

care in rural Ghana, which includes citing health facilities and public education on the

need for health facility delivery. Specifically, consideration should be given to the poor,

multiparous women, those with no or low levels of education, and coastal dwellers

(Dickson et al. 2016).

The Government of Ghana through the National Insurance Authority introduced a free

maternal health care program as a measure to remove financial barriers to maternal

services. Some of the most common problems reported by health facilities accredited by

the National Health Insurance is persistent late reimbursement of the cost of services

provided (Witter 2013).

A study by (Lisa Cutajar et al 2020) highlighted that there is a gap regarding the language

and communication used during antenatal education for labour and birth. While

communication has been identified as a component of respectful maternity care, a lack of

evidence as to what effective communication entails exists.

31
A study done in the Ga East Municipality of Ghana to identify barriers to the utilization

of skilled delivery services found no associations between women's marital status at birth

and the use of skilled delivery services (Esena & Sappor 2013).

Also, this is not limited to Ghana as a study by Chubike and Constance (2013) done in

Nigeria also found women below the age of 19 years to be the least users of skilled birth

care. It is therefore suggestive that maternal age at birth is a significant predictor of the

uptake of institutional delivery services.

32
 CHAPTER THREE

METHODOLOGY

3.0 Introduction

The purpose of the study was to explore factors influencing institutional childbirth in

Tolon District settings in the northern part of Ghana. This section presents the various

techniques and tools that were used to collect data from participants. It also describes the

type of study, study location, sampling plan, and analytical tools that were used to

analyze data.

3.1 Study area

The study was conducted in the Tolon district in the Northern region of Ghana. It is one

of 26 administrative local government units in the Northern Region. It shares boundaries

to the north with Kumbungu, North Gonja to the west, Central Gonja to the south and

Sagnarigu Districts to the east.

3.2 Study design

The study was conducted in the Tolon District in the northern part of Ghana. An

exploratory descriptive design was employed, using qualitative data collection where

information was required directly from pregnant women and time and resources are

limited (Carmel Bradshaw et al. 2017). The exploratory descriptive design allowed the

researchers to have in-depth information from the perspective of pregnant women on the

phenomenon under study (SAGE PUBLICATION 2010).

33
Figure 1 Map of Tolon District Source: Ghana Statistical Service 2011

34
3.3 study population

The district had a total projected population of 94,742, a Target Population for WIFA

(24%) of 21,799 and Expected Pregnancies (4%) of 3,633 (GHS DHIM 2). The average

household size in the district is 6.4 persons. In terms of religion, the majority of the

population are Muslims followed by Christians. Tolon just like the rest of the districts in

the Northern Region is known for having a low level of educational attainment. They are

mainly into agricultural activities and most women are involved in petty trading as a

source of livelihood (Ghana District Profile Series 2017).

Administratively, the district is divided into six (6) sub-districts namely Kasuliyili,

Kpendua, Linbgunga, Nyankpala, Tolon and Wantugu. The Tolon district consists of 20

communities. However, some of these communities still lack basic social and economic

infrastructure such as proper road networks, school blocks, hospitals, markets, and

recreational centres, thereby hindering socio-economic development and poverty

reduction. The district has 1 hospital operational, 1 clinic, four (4) health centres, and

fifteen CHPS (DHIMS2).

3.3.1 Inclusion criteria

Pregnant women between 15-49 years old and had no pregnancy complications, no

mental problems and were willing to take part

35
3.3.2 Exclusion criteria

Any pregnant woman who came in from a different community not long ago (less than 3

months) during the period of data collection was excluded from the study.

3.4 Sample size determination

Fourteen (14) pregnant women were interviewed. This sample was arrived at based on

data saturation when no updated data is emerging

3.5 Sampling technique

A purposive sampling technique was employed and one sub-district that had low facility

births was selected. From this sub-district, pregnant women who met the inclusive criteria

were identified and included. Upon reaching the district health directorate through the

director of health services to the district public health officer their source data (DHIMS2)

revealed that among the six sub-districts, the Kasulyilli sub-district was the least

performing sub-district in terms of comparing expected pregnancy and institutional

childbirth in Tolon district.

3.6 Data collection instrument/tool

A semi-structured interview guide was developed by the researchers and divided into four

sections with demographic/obstetric data, the first of which was the

demographic/obstetric data. The other three were in line with the objectives of the study.

A recording device was used as a tool for data collection to facilitate further

36
investigations/questioning of respondents for clarity of expression. The tool was flexible

and allowed further investigation/questioning for clarity of expression.

3.7 Pre-testing

The tool was pretested among two pregnant women in the sub-district. This was to

correct any ambiguous questions and ensure that the interview guide answered the

objectives of the study.

3.8 Methodological rigor

Research rigor may also be considered a measure of the trustworthiness of the collection,

analysis, and interpretation of data (Prion & Adamson, 2014). A study’s outcome can be

said to be trustworthy if the reader of the research report says so (Murphy & Yielder,

2010). The degree of rigour of study findings is determined by the extent to which the

findings are credible, transferable, dependable and confirmable (Grove et al., 2015).

Credibility contributes a great deal to defining the extent of the veracity of the data and

its subsequent interpretation. This refers to the extent to which the information gathered

represents the exact view of the respondents (Murphy & Yielder, 2010). It is achieved by

validating the data and its results (Prion & Adamson, 2014). Thus, the researcher

recruited only participants who met all the inclusion criteria. At the end of each

interview, member checks were conducted to ensure that the exact views of respondents

were obtained. Coding of the interviews was done separately by the researchers and

37
handed over to the supervisor to identify areas of disagreement, discuss them and come to

consensus.

Confirmability also refers to neutrality, the absence of researchers’ bias or the extent to

which results obtained could be confirmed by others (Kusi, 2012; Murphy & Yielder,

2010; Prion & Adamson, 2014). To ensure this, the researchers kept an audit trail

comprising field notes, audio recordings, analysis notes and coding details. The

researcher also presented a draft of the final study for supervisors to peruse.

Dependability was ensured by using the same interview guide to gather data from all

respondents. Also, the researchers outlined a detailed description of the research setting,

sampling and sampling methods and the procedure for data collection and analysis. The

printed transcripts, emerging themes and the tape were made available to the supervisor

(Murphy & Yielder, 2010).

Transferability refers to the ability to transfer the findings of the qualitative study to

other contexts with similar groups (Petty, Thomson & Stew, 2012). To achieve this, the

researchers outlined a detailed description of the methodology that was followed in

carrying out the study (Prion & Adamson, 2014). Furthermore, the processes of

participant selection, inclusion and exclusion criteria were outlined in detail in the study.

3.9 Data collection procedure

The purpose of the study was explained to the women and they were allowed to agree to

be part of the study by signing/thumb-printing a consent form. Gatekeepers of the

community (Assemblymen, Chiefs and Elders) and the head of the household were

38
contacted to help in accessing the prospective women. Individual face-to-face interviews

were held with selected pregnant women to collect information on exploring factors

influencing institutional childbirth in the Tolon district in the northern part of Ghana until

additional interviews could not provide additional evidence about the main themes of

interest and were conducted by 3 researchers. On average each interview lasted 30-45

minutes. Each pregnant woman completed only one interview. After the interviews,

appreciation was shown to the participant and then moved to the next participant until the

sample size was reached.

3.10 Data analysis

The tape-recorded interviews were turned into English by the researchers. The translated

data was exported into Open Code software to facilitate coding and analysis. Each

translated document was coded line-by-line to flag ideas and statements related to the

study objective, and then codes were grouped to identify themes that were related to the

factors that influence institutional childbirth among pregnant women. A prior theme was

coded based on the study objectives and emerging themes were identified based on the

narratives of research participants.

3.11 Data management

Data management in qualitative research involves reducing a huge chunk of information

into smaller units that can be dealt with or managed (Polit & Beck, 2010). Transcripts in

a word document on the personal computer of the researchers were stored in identifiable

folders. A security code was provided to make them inaccessible to anyone except the

39
researchers and their supervisor. The printed-out transcripts, the field notes and the tape

recorder used for data collection were kept in a drawer under lock and key but only

accessible to the researchers and supervisor for audit trail purposes. The data would be

kept for at least five years before they are discarded according to the data protection Act.

3.12 Ethical consideration

An introductory letter from the School of Nursing and Midwifery was used to seek

permission from the Director of Health Service, Tolon district Health Directorate.

Participation was completely voluntary. Written consent was sought from each

participant before the commencement of the interviews. The purpose of the study was

explained to study participants as well as their right to participate in or withdraw from the

study at any time without any punishment.

All participants received an individual identification number that was used in the

recorded interviews, on the transcripts and also during publication. The entire interview

was recorded, and after transcription, the recording and access to the raw data were

limited only to the research team members and possibly, the supervisor. To ensure

privacy, all interviews were conducted at a place convenient to the women without the

presence of unauthorized persons. The input of participants was greatly appreciated, and

snacks (biscuits and soft drinks) and nose masks were given out as gifts.

40
 CHAPTER FOUR

FINDINGS

In this study, we sought to identify and compare the factors that influence institutional

childbirth among pregnant women in the Tolon district of Ghana. This chapter presents

the results of interviews that were conducted using a semi-structured interview guide.

The chapter contains socio-demographic characteristics of participants followed by

findings which are grouped under three main themes with subthemes under each. The

subthemes are supported by verbatim quotes from the interviews.

4.1 Socio-demographic Characteristics of Participants

Twelve (14) participants took part in this study. All participants were females and their

ages ranged from twenty (20) to thirty-six (36) years. They were all married. There were

eleven (11%) Muslims among them, one (1) Christian, and three (2) traditionalists in the

minority. With regards to the educational background, ten (10) participants had no formal

education, two (2) participants dropped out of primary school, and one (1) participant

each had junior and senior secondary education. Among the participants, one (1) was a

trader, ten (10) were housewives, and three (3) were farmers. All participants were

Dagombas from the tribe. One (1) participant was Gravida 6 Para 1, one (1) participant

was Gravida 5 three (3) participants were Gravida 4 Para 3, five (5) participants were

Gravida 3 Para 2 and two (2) participants were Gravida 2 Para 1 and one (1) participant

was Gravida 1 Para 0. Total pregnancies were 32 with sixteen (16) facility deliveries and

fifteen (15) home deliveries. A total of 28 live births and four (4) deaths were recorded.

41
4.2 Organization of themes

The findings of the study are organized according to the objectives of the study. The table

below, therefore, presents three (3) main themes and seven (7) subthemes

Table 4.2.1: Main Themes and Subthemes

Theme Subthemes

1. Knowledge about the benefits  Satisfaction with health services

 Attitude of health workers

2. Factors influencing the acceptability  Examinations

 Support and care

 Transport and cost

 Traditional and cultural

practices

3. Facilitating factors (enablers) to  Expectation

increase

4.3 Knowledge of the benefits

Almost all women stated that delivery at the hospital was best for the mother and child.

They also started knowing the benefits of institutional childbirth could make a long way

to preventing complications and guiding their decision to seek facility-based delivery

care. Participants had obtained information about potential maternal/newborn

complications through health education provided to them during ANC visits

42
4.3.1 Satisfaction with health services

During the study, participants had pleasant experiences with the health system and

discovered that it was an encouraging factor for using health facilities. Some of the issues

raised included:

In the hospital, you can have a very good delivery because they will take care of you very

well, deliver you and deliver the placenta. Also, they will take good care of your baby,

but how can they deliver the placenta properly if you don't go to the hospital? Again if

you visit the hospital they will see if your baby is lying well or not. However, if it is at

home they won't be able to tell you all this. So to me, hospital delivery is good.”

(Participant #10)

Another woman added:

“I seek out ANC at the health centre because of my health and that of my unborn baby. If

I do not come to the hospital for these services, I would not be able to find out if I and my

baby are doing well. If there is a problem with your baby lying in your stomach, they can

ask you to go to Nyankpala for a scan. If you choose to be in the house, how will they

know all this?" (Participant # 1)

“Yes, I know the importance because if you deliver at the hospital they will take care of

you and your baby’s health if there is any problem then they will tell you then you know

what to do” (Participant # 4).

43
One woman, who delivered her second child at home, clearly stated:

“I preferred to deliver at a health facility” and that “it was an accident” I gave birth at

home. Delivering at a health centre is better for me and my child. When you give birth at

home, so many problems can happen” (Participant # 3).

“The truth is that when you give birth at home it is of importance and when you also give

birth at the hospital it is equally important. You can deliver at home and be safe and you

can also give birth at the hospital and be in good hands. Both have the same importance.

It is possible to deliver at home and be safe. The same applies to hospital delivery

(Participant # 14)

4.3.2 Attitude of health workers

Providers who don't take a lot of time to assess patients during ANC and labour may be

seen as having a poor attitude towards their clients.

(Participant # 6) “For the truth, any time I visit, the nurses are always around and they

take care of you very well and you return safely, but in my previous pregnancy, it was my

delivery month and I had severe abdominal pain and water coming out of my private

part. When I was taken to the Kasulyilli health centre I was examined by the midwife.

However, I was asked to return to my house because the nurse felt I was not in labour. I

came back home and labour started and I delivered. So that baby I delivered home.”

44
“When I was in labour they placed me on the delivery bed and they stepped out to sit until

the baby was coming out and then came in to receive the baby. When they delivered the

baby I lost her and she was my only female baby” (Participant # 14)

Some are there they say when you go, some nurses are there they shout at them so they

won’t go there again. However, here the nurses take proper care of us. Participant #9)

Another woman added:

“I told you that delivering at home was an accident. It was difficult and wasn’t easy

because I struggled until I gave birth but when I delivered successfully and was healthy I

didn’t return to the hospital because at the hospital when you return some will yell at you

and blame you just because I didn't return” (Participant # 7).

A woman expressed some level of worry because of her long waiting hours:

“We pregnant women come to the health facility early in the morning but more often

spend long hours waiting for nurses who mostly reside in Tamale to arrive and take care

of us. Even when they come, because we are waiting a long time, they always just do

things fast to finish attending to us without even explaining anything to you after

examinations” (Participant # 6).

4.4 Factors influencing acceptability

Women accepted that there were some influencing factors leading to the acceptance to

deliver at the health facility. These factors could either be positive or negative.

45
4.4.1 Examinations

In every delivery process, women realized the importance of vaginal examination.

Women are subjected to this during labour and delivery. This is often viewed and

expressed as painful, frequent and often cited as a factor inhibiting the use of health

facilities for delivery.

"I was referred to Tolon hospitals for delivery. The nurses kept inserting their hands into

my vagina. Different nurses examined me and it was very painful and hurtful. They never

told me and I was wondering if they knew what they were looking for” (Participant # 8).

“There are too many examinations. They will insert their hand into your vagina many

times that one alone when I am about to deliver as if I should find somewhere to deliver

because at Tolon hospital I won’t be there to deliver." (Participant # 12)

4.4.2 Support and care

Most of the women in this study expressed satisfaction with the care nurses rendered to

pregnant women, especially the male nurses.

“I delivered at the hospital. It got to a point where two women were labouring in the

labour room. She was the only one. She was really confused and under pressure with her

situation and always shouted at us. Many of them haven't delivered yet and are unaware

of the situation because many things happen during labour. "They should treat us with

patience and care, which will encourage us to deliver at the hospital.” (Participant # 6).

46
Another woman, who had given birth at the Tamale West hospital, commended the

nurses at the Kasulyilli health centre for a prompt and quick referral.

“The very fortunate thing about my situation is that I have competent nurses and a

doctor. I had a big baby and it was difficult for me. With their help, thanks to God, it was

okay (Participant # 9).

Another woman shared this:

“I was reassured not to be stressed when labour pain comes. If I shout or scream or pass

stool it is not a disgrace and I was encouraged to be strong” (Participant # 13)

Some women opt to deliver at home as opposed than in a medical facility. Some

testimonies:

I lost my second-born baby at the health facility, who was the only girl, and all my

children delivered at home are boys. In the hospital, you are permitted to climb and lay

on the delivery bed without any support. The nurses do not stand by your side but they

only assist when the baby is coming out, just like me delivering at home. I am always

alone with the TBA until the baby is coming then she receives the newborn" (Participant

# 2).

“I remembered my previous delivery at the Kasulyilli health centre. I arrived when a

woman was also in labour but there was only one bed and only one female nurse with

both of us in the labour room. She was really confused and under pressure about her

47
situation. I was fortunate to deliver on the bed but the woman I met delivered on the floor

which is just like delivering at home” (Participant # 6).

4.4.3 Transport and cost

Utilizing services rendered by health professionals plays a crucial role in influencing

many factors including distance to a facility, availability of transport and the cost of

receiving care. Some women’s inability to provide easy and available means of transport

prevents them from visiting health facilities even during delivery.

“I planned to deliver at the hospital, but when labour started, it was late in the night and

my husband did not have any transport to get me there. So I delivered at home”

(Participant # 5).

Some women stated that:

"Here and my house is far away, so I have to walk for a long distance when coming to

ANC. I have always pleaded with my husband to bring me but he never listens to me and

tells me why don't I see my colleagues walking in groups. So I am left with no other

option than to deliver at home when labour sets in” (Participant # 10).

In Ghana, maternal health care is free and covered by the National Health Insurance

Scheme (NHIS) from ANC, delivery and postnatal care. A woman explained:

As for me, when I was about to deliver I was told that delivering at the hospital was a

very free experience. After I went to deliver, I lost my baby, and my husband had to pay

48 cedis and buy 2 soaps and Dettol, so I cannot encourage my colleagues to deliver

48
there. We were told that if you have NHIS the service is free but we paid and even lost my

baby” (Participant # 14)

Some participants explained that:

Every time I go for ANC services, the nurses write on a piece of paper a list of drugs that

I must always buy, even though I have a national health insurance card. Whenever I try

asking the nurses they tell me the office hasn’t supplied them so where do I want them to

get me drugs?" (Participant # 12)

4.4.4 Traditional and cultural practices

Traditional and cultural activities were viewed by women as a deterrent to using medical

facilities for delivery. This was because it contraindicated policies in health care facilities

during ANC and labour.

A woman narrated:

“In the village, you cannot just make a wish unless those for you say it is worrying her

let’s send her but you the labouring pregnant woman cannot say it is worrying me send

me to the clinic” (Participant # 5).

“The truth is that I always want to deliver at the hospital because I know the dangers

involved in home delivery but as we are in our various homes our husbands are

responsible for taking care of us and they are the family heads so if a woman is in labour

until they ask them to send you to the hospital you the woman have no way to ask them to

send you to deliver at the hospital” (Participant # 3)

49
4.5 Facilitating factors (enablers) of institutional childbirth

It is critical to identify enabling factors that will improve institutional childbirth coverage

or targets in health institutions that will help reduce maternal mortality and morbidity.

This will help to achieve SDG 3.1, which is improving maternal health.

4.5.1 Expectation

Women are generally governed by experience which influences their future expectations.

Women expressed a desire to have staff with a positive attitude. Some women expressed

a sense of expectation regarding the attitude of the staff. These included encouragement,

politeness, giving reassurance and being available by the bedside.

Some women narrated:

Also, this concerned our nurses. When I was going to deliver my second child, I was

referred to Tamale. This is because I was told my baby was big so I delivered in Tamale.

If we had such nurses were brought here in our village to also help us with such cases

when the need arises.” (Participant # 7).

In the end, it's all about taking good care of yourself so that when you go, you don't know

anything, but they won't have the patience to explain.

As a result, they will shout at you, but when there is patience, you can keep coming back.

It is not all of us who know this work. If you don’t know how to do something, they will

teach you with patience. This will bring your attention to the facility (Participant 8).

50
Some participants do not believe that nurses have the same character and think that all

nurses are different. They say others will leave you lying down on the bed without being

attended to when you need their support or need their help. However, others are there to

help and make you feel more comfortable, especially nurses who have delivered before

because they know how it feels

Women expect that the nurses attending to them should be knowledgeable and competent

and apply their skills when providing health care services to them during ANC and

labour.

“Delivering at the health facility to me is very critical and the very best, but we have lots

of problems. Most times we do not get what we expect yet we are not given the

opportunity or chance to even ask questions" (Participant # 4).

Accessibility of drugs and supplies in health facilities is high Lack of drugs and being

given empty prescriptions only to buy the drugs in a community drug store is an issue

that concerns them too.

“To me the ANC when you come after providing services, they write drugs for you to

purchase and buy. To me, if the routine drugs were available or were available in stock

whenever we come for ANC services then it is served to us. This is because they told us if

we had NHIS, it will be taken care of for free. Yet we have it, but they still write for us to

purchase it. If it is always that no drug at the health facility then is it not better I go to the

drug store than waste time at the health facility?" (Participant # 7).

51
“I have always asked myself, what is the use of receiving quality care at the health centre

but no drugs are made available? Not all of us can afford to buy drugs in drug stores.

They are sometimes very expensive” (Participant # 3).

Another woman added:

“We always hear that drugs are available, but when we visit the health facilities we are

given prescriptions to buy from the drug store. If it is always that no drug at the health

care facility, is it not better I go to the drug store than wasting my time at the health

facility” (Participant # 9).

52
 CHAPTER FIVE

DISCUSSION OF FINDINGS

This chapter discusses the findings of the study and the literature that was reviewed on

institutional childbirth. The discussion is organized according to the main themes and

sub-themes that were presented in chapter four to achieve all the objectives that were set

to guide the study. The areas discussed were socio-demographic characteristics of

participants, the knowledge of pregnant women about the benefits of delivering in a

health facility, factors influencing the acceptability of institutional childbirth and

facilitating factors (enablers) to increase institutional childbirth.

5.1 Socio-demographic Characteristics of Participants

The findings indicated a high illiteracy rate among women who participated and were

believed to play a crucial role in this study. All participants were legally married and it

revealed that participants older than 35 had more intentions of giving birth to more

children. The vast majority were therefore in a monogamous marriages and were Muslim.

This is acceptable in the Islamic religion to marry up to four wives which is consistent

with a study conducted in Ghana by Naab et al. (2014)

The ethnic background of participants also revealed that they were Dagombas (100%).

This is expected, as the study area is largely dominated by the Dagombas. There was no

deviation from the three main religions of Islam, Christianity, or traditional religion

among the participants.

53
5.2 Knowledge of the benefits

It was evident from the participants that this concept wasn't new to them and that they

understood the importance of the choice of decision-making for institutional childbirth.

They have all heard of institutional childbirth. In terms of benefits, the findings align with

a study in Eritrea (Kifle et al., 2018).

In the present study, participants stated that delivery at a health facility is more

comfortable for the mother and child. Additionally, one participant stated that she was

visiting the health centre to avoid complications for herself and her unborn baby.

This finding agrees with that of Campbell OMR et al. (2011) Having a better

understanding of the benefits of institutional childbirth demonstrates a long way to

preventing complications and guiding decisions to seek facility-based delivery care.

This finding aligns with Raven JH et al (2012) which revealed that not only the

participants needed to be knowledgeable but also health service providers needed to have

the best knowledge to ensure essential obstetric care that is effective and of good quality

to help pregnant women reduce maternal and newborn mortality and morbidity. In this

study, pregnant women were aware of their condition, but a healthcare provider failed to

diagnose it. A woman who reported when labour started was sent home for false labour

and delivered at home.

54
5.3 Acceptance of institutional childbirth among pregnant women

In spite of this knowledge, this study revealed the positive and negative effects of certain

factors such as support and care, examinations, traditional and cultural practices,

transport, and cost on pregnant women's acceptability of institutional childbirth.

It was also revealed that nurses were doing their duty to provide support and quality care.

However, this was not enough because most participants did not know the complete

requirements for birth preparation. Also only one out of the three facilities visited had

focal personnel (midwives) to conduct most deliveries and vital delivery equipment

needed at various facilities to render health services in terms of delivery was not

available.

This finding agrees with that of Ntambue et al. (2012). The service rendered to pregnant

women at home is more familiar and is considered to be more caring and friendly than in-

hospital delivery. Compared to home delivery, it was also revealed that most women

would not like to deliver in a facility. This is due to what they pass through as a result of

frequent vaginal examinations.

This finding aligns with Esena & Sappor (2013) who revealed that transportation and cost

play a significant role in influencing many factors including distance to a facility,

availability of transport and cost of receiving care. Men were not involved during birth

preparation in the aspect of transportation.

55
This finding aligns with Mahama (2019). The study reveals that due to the unavailability

of health service personnel (midwives) at some service points of delivery, women have to

travel to Tolon health centre during labour which increases the cost of transportation.

This finding agrees with that of Witter (2013) which reveals that pregnant women relying

on free maternal health seem not to understand why they should be asked to pay

additional money at health facilities during labour and sometimes for ANC routine drugs

since they are fully covered or insured under the national health insurance scheme

(NHIS).

Study findings reveal that family heads mostly make decisions about when pregnant

women should take part in health care during prenatal care and where to deliver when

labour starts, leading to most of the deliveries taking place at home. It is also revealed

that most women around this catchment area need to undergo a ritual ceremony to unveil

themselves before they can fully have access to ANC health services. On the other hand,

the finding is at variance with that of Mainuddin et al. (2015) a study in Bangladesh

found that men usually control decision-making in the home, including women’s health

decision-making.

5.4 Facilitating factors (enablers) to increase institutional childbirth among

pregnant women

Women will always be faced with complications of pregnancy or delivery, and if their

expectations in terms of quality healthcare services are not met, they will continue to

56
choose high-risk options of delivering at home leading to severe morbidity and even

death.

This finding agrees with that of Lisa Cutajar et al. (2020). The foremost expectation of

some of the participants was that they should have a lot of interpersonal relationships

with staff and clients. In addition, they should also be allowed to express their concerns

to health service providers during service delivery.

This finding aligns with Mahama (2019) who also revealed that pregnant women’s

expectations were high and believed that if taken care will increase institutional childbirth

that is by intensifying the health training given to nurses (midwives) and increasing their

number of service delivery posts to render quality health care services.

This finding aligns with Dickson et al (2016) which reveals that User-fees and

unavailability of drugs and supplies in health facilities prevent the use of health facilities

not only for delivery but for other services.

57
 CHAPTER SIX

SUMMARY, LIMITATION, CONCLUSION AND RECOMMENDATIONS

This chapter contains the summary, limitations, conclusion, and recommendations.

6.1 Summary of the study

In Ghana, more especially in the northern region, several factors may affect the choice of

place of delivery among pregnant women.

Women’s utilization of healthcare facilities for delivery is a major health issue regarding

the well-being and survival of both the mother and her child during childbirth which has

implications for the maternal and child mortality rate in human society. This study seeks

to explore factors influencing institutional childbirth among pregnant women in Tolon

District settings in the northern part of Ghana.

Specific objectives were formulated and a literature review was then carried out on

factors influencing institutional childbirth among pregnant women to lay the groundwork

for a discussion of findings.

The study was qualitative research with a descriptive exploratory design. Fourteen (14)

pregnant women were carefully selected from the Kasulyilli sub-district who met the

inclusion criteria. Data collection was carried out using a face-to-face interview using a

semi-structured interview guide. Each interview lasted 30-45 minutes and was audio

recorded.

58
The interviews were transcribed into English by researchers. The translated data were

exported into Open Code software to facilitate coding and analysis. Each translated

document was coded line-by-line to flag ideas and statements related to the study

objective, and then codes were grouped to identify themes that will be related to the

factors that influence institutional childbirth among pregnant women. The findings

resulted in three (3) main themes which were coded based on the study objectives and

seven (7) subthemes which were also identified based on the narratives of research

participants.

According to the study, all participants were females between the ages of twenty (20) and

36 (36) years. Dagombas comprised 100% of the participants. The majority of eleven

(11) of them were Muslims, two (2) were Traditionalists and one (1) was Christian.

Almost all pregnant women had an idea of the meaning of institutional childbirth. They

stated that delivery at the health facility was appropriate for mother and child but there

was a knowledge gap regarding knowledge of institutional childbirth. Participants had

received relatively limited information about potential maternal/newborn complications

through health education provided to them.

The study revealed that the benefits of institutional childbirth extend a long way to

preventing complications and guiding their decision to seek facility-based delivery care.

The study revealed perceived barriers to institutional childbirth such as transport and

cost, examinations, support and care and traditional and cultural practices. The sources of

information on institutional childbirth were health staff, community members, religious

bodies and the mass media. Some of the pregnant women expressed a great desire to

59
deliver at the facility by skilled health personnel while others were indecisive regarding

institutional childbirth.

6.2 Limitations

The study was confined to pregnant women living in the Tolon district between the ages

of 15 and 49. Only literature published in English was used. This is because the

researchers could not read French. Therefore, literature from neighbouring countries, for

example, Burkina Faso, Ivory Coast and Togo which might have similar characteristics to

Ghana was missed out in the study. Also, a facility-based study was done. With this,

access to services provided to pregnant women within facilities may be unequal resulting

in biases. The study suffers from the general limitations of qualitative studies. This

limitation has to do with the inability to generalize the findings to a larger population

because of the small sample size involved. Also, the non-involvement of husbands in this

study was a major limitation because their perspective would have been oversized to

allow for a conclusion that would represent both husband and wife as an entity.

6.3 Conclusion

This qualitative study revealed that the low rate of deliveries taking place in the

Kasulyilli sub-district in the Tolon district is a result of the interplay of both health

service and socio-cultural factors. The most prominent health service factors identified

were support and care, previous experience of pregnant women, and low expectations of

pregnant women.

60
Among the socio-cultural factors are traditional and cultural practices. All the above gaps

indicate a wake-up call for intensive education that will prepare the grounds for the

acceptability of institutional childbirth in the Tolon district

6.4 Recommendations

Recommendations based on this study are to the ministry of health, the internal

management committee of the Tolon district health directorate, non-governmental

organizations and nurse researchers.

6.5.1 Ministry of Health (MoH).

The ministry of health should:

1. The need for the development of interpersonal communication skills in the

education and training of health staff.

2. Ensure that there is a current and updated national database on the prevalence of

maternal mortality rates.

3. Encourage and provide funding for research into institutional childbirth that will

lead to the development of a culturally sensitive intervention in Ghana.

4. Post midwives in every health facility and strategies to maintain midwives in the

field, especially in rural areas should be improved.

61
6.5.2 The internal management committee of the Tolon district health directorate

The IMC should:

1. Intensify their health education on the importance of institutional childbirth during

every service delivery rendered to pregnant women.

2. Implementing mechanisms by which patient views might be communicated to the

health system from patient-provider discussions, patient advocates, and patient

comment boxes or complaint contact numbers in health facilities, patient committees,

focus groups, and public meetings.

3. Institute measures to encourage husbands or family members to accompany their

wives during labour might be a possible intervention, to overcome the cultural need

of a family to be around and witness the delivery. It may also reduce the barrier to an

unfamiliar environment.

4. Revamping or creating a community emergency referral and transport system

(CERTS) committee in every community to facilitate easy and prompt referral of

labouring pregnant women to the nearest health facilities for delivery.

6.5.3 Non-Governmental Organizations (NGOs).

NGO's should:

1. Carryout public education through community events on the importance of

institutional childbirth

2. Initiate supportive services for all women who deliver at the health facility.

62
6.5.4 Nurse researchers

Nurse researchers should:

1. Use a quantitative approach to study the factors that are influencing institutional

childbirth

2. Extend the scope of future research to other municipalities or districts where low

institutional childbirth care is provided to enable adequate representation.

3. Include husbands, wives, religious leaders and traditional leaders in future research to

unearth a multidimensional perspective on the concept of institutional childbirth.

63
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 APPENDICES

Appendix I

Semi-structured interview guide for Expectant mothers (Who meet the inclusion

criteria)

Section 1: Socio-demographic and Obstetric data

No. Questions

1 Age (Years)

2 Educational background

3 Marital status

4 Occupation

5 Religion

7 Source and level of income (monthly)

8 Number of previous pregnancies

9 Number of previous births

73
Section 2: Pregnant women’s knowledge about the benefits of delivering in the health

facility.

No. Questions

1 What is your awareness on the importance of health facility delivery?

2 What are your views on access to the health facilities?

3 Where do you often go for maternal health services when pregnant and why?

Section 3: Factors influencing the acceptability of institutional childbirth among

pregnant women

No. Questions

1 Have you ever delivered at the health facility?

A How were you handled?

B Would you like to deliver again at the health facility?

2 Have you ever delivered at home?

A How were you handled?

B Would you like to deliver again at the home?

Section 4: Facilitating factors (enablers) to increase institutional childbirth

No. Questions

1 What are your expectations with the services offered at the health facilities?

74
Appendix II Introductory letter

75
 Appendix III: Informed Consent

General Information about Research

Sub-Saharan Africa remains one of the regions with modest health outcomes, evidenced

by high maternal mortality ratios. Some complications occur during and following

pregnancy and childbirth that can contribute to maternal deaths, most of which are

preventable or treatable. In Ghana, several factors may affect the choice of place of

delivery among pregnant women and few studies have examined the choice of place of

delivery. Women’s utilization of healthcare facilities for delivery is a major health issue

regarding the well-being and survival of both the mother and her child during childbirth

which has implications for the maternal and child mortality rate in human society.

However, in most third-world countries including Ghana and Tolon district in particular,

certain factors inhibit pregnant women from patronizing maternal health facilities during

childbirth. This study seeks to explore factors influencing institutional childbirth among

pregnant women in Tolon District settings in the northern part of Ghana.

Possible benefits

You will not be given anything if you take part in this study. However, the findings from

your responses will help improve the health status of pregnant women in the Tolon

District settings in the northern part of Ghana.

Possible risks and discomforts

There are no anticipated risks involved in this study. However, the study requires

respondents to spend some time during the interview, which may cause inconvenience.

76
We will ensure maximum privacy and be brief as much as possible to ensure that there

will be no wasted time during the interview.

Confidentiality

All information obtained from you will be kept strictly confidential. Your consent form

will be kept separate from the data. The data will not be available to anyone other than

the principal investigators of this study. The information may be used in presentations

and/or research papers. However, your name will never be used in any presentations,

papers, or reports.

Compensation

No compensation for participating in this study, however, snacks will be given for

participating

Withdrawal from study

Participation in this study is not compulsory. You will be free to opt-out at any point in

time if you wish.

What happens after the study or when the participant changes his/her mind?

If you decline to participate or terminate your involvement at any time, there will be no

penalty or future sanction for you after the study. The study data will be stored by the

principal investigators for possible future use until December 2024. The data will be

archived in the Tolon Health Directorate or destroyed. The study results will be published

77
as a written report. A copy will be given to the Tolon Health Directorate for onward

dissemination to the communities. A copy will be given to the University for

Development Studies, Tamale. In addition, there is a chance that the results will be

published in a scientific journal. This would be available online or the researcher could

be contacted at the numbers provided below.

Contact for Additional Information

For any questions or your participation in this research, please contact principal

investigators (JIDOH U. JOSEPH, ASINGA LARIBA RUFINA and ABDUL-NAFIWU

ALHASSAN on 0245145079 or 0247732335 or 0547473722 or [email protected]

Supervisor MR HAMIDU NABILA YAKUBU ON 0506302660

78
 Appendix IV: CONSENT FORM

The information on this sheet has been read to me and I understand it. I have read and

understood the information on this sheet.

I understand what participation in the study means to me.

I understand that the information regarding me that is collected in the course of this study

will remain confidential.

I understand that I am free to take part in the study or refuse and that I can withdraw from

the study at any time, without giving any reason. Deciding not to take part or withdraw

from the study will not affect the care that I am normally entitled to.

I have had a chance to ask questions and have them answered.

Upon signing this consent form, I will receive a copy for my records.

Signature or thumb-print of volunteer…………………………………Date..…………...

________________________________________________________________________

This form has been read by / I have read the above to……………..………………………

Write name of volunteer in a language that he/she understands. I believe that he/she has

understood what I explained and that he/she has freely agreed to take part in the study.

Signature of field worker:

Name of field worker:

Date: /………….…/……………………

79
 Appendix V: Data Collection Instrument (verbal interview)

UNIVERSITY FOR DEVELOPMENT STUDIES, TAMALE

EXPLORING FACTORS INFLUENCING INSTITUTIONAL CHILDBIRTH: A

STUDY AMONG PREGNANT WOMEN IN TOLON DISTRICT

Hello, we are _______________________________________students of University for

Development Studies, Dungu Tamale. We are conducting a study entitled “exploring

factors influencing institutional childbirth: a study among pregnant women in Tolon

district”. The information collected will help the government to provide better health

services. The interview will take about 30-45 minutes. All responses you give will be

confidential and will not be shared with anyone other than members of our study team.

Participation is voluntary, but we hope you will agree to grant us the interview since your

views are essential. If I ask any questions you don't want to answer, just let me know or

you can discontinue the interview at any stage. In case you need further information

about the study, you may contact the persons listed on the forms that have already been

given to you.

Name of Interviewer: ......................................................Interviewer’s

Number………….

Date: ......................................................................

Participant Code: ...................................................

Time Started: .........................................................

80
INTRODUCTORY LETTER

81