**5. The evidence**

#### **5.1 Background characteristics of respondents**

The results show that the maximum age of respondents was 42 years whereas the minimum age was 15 years with a median of 25 (Mean = 25.94; Std Deviation = 6.32;

**17**

processing fees.

*Access to Maternal Healthcare Services under the National Health Insurance Policy…*

Skewness = .749) with a quartile deviation of 4.5 years. This finding agrees with WHO [41] that reproductive age of women ranges between 15 and 49 years. The results also indicate that 93.9% of the respondents were married while the rest were single. As shown in **Table 1**, 48% of the respondents have no formal education whereas only 4.2% attained tertiary education. Also, 41% of them were engaged in farming and another 19.3% were indulged in petty trading while only 2.8% were involved in weaving as their means of living. This finding is consistent with GSS [25, 39] discovery that many people in both districts were illiterates and their main

No formal education 102 48.1 Basic 81 38.2 Secondary 20 9.4 Tertiary 9 4.2 Total 212 100

Farming 87 41 Petty trading 41 19.3 Housewife 34 16 Dress making 28 13.2 Weaving 16 7.5 Food vending 6 2.8 **Total 212 100**

Access to maternal healthcare services was analysed first, on aggregate and later based on location. The results of the analysis show that 93.9% of the respondents had enrolled unto the national health insurance scheme whereas the rest had not registered to benefit from the exemption of pregnant women from paying the premium. Further analysis was conducted based on community of origin to determine whether differences exist with respect to enrolment unto the NHIS. The results indicate that 89.8% of the respondents had enrolled unto the NHIS in the Wa-East district, whereas 97.4% of them were registered with the scheme in the Wa-West district. This suggests that the Wa West district had more women registered under the NHIS than Wa East district. A chi-square test for independence (with Yates Continuity Correction) was carried out to determine whether there is an association between enrollment unto the NHIS and seeking maternal healthcare services. The test results revealed no significant association between registration for NHIS

This finding is in line with Twum et al.'s [7] discovery that in Ghana, pregnant women do not pay a premium for fresh registration or renewal of membership and

(1, *n* = 212) = 0.00, *p* = 1.00, *phi* = −0.03].

**Frequency Percent (%)**

*DOI: http://dx.doi.org/10.5772/intechopen.88982*

occupation is agriculture.

**Educational attainment**

**Occupation of respondent**

*Source: Field survey, 2019.*

**Table 1.**

**5.2 Access to maternal healthcare**

*Educational achievement and occupational distribution of respondents.*

and seeking maternal health care [χ<sup>2</sup>

*Access to Maternal Healthcare Services under the National Health Insurance Policy… DOI: http://dx.doi.org/10.5772/intechopen.88982*

Skewness = .749) with a quartile deviation of 4.5 years. This finding agrees with WHO [41] that reproductive age of women ranges between 15 and 49 years. The results also indicate that 93.9% of the respondents were married while the rest were single. As shown in **Table 1**, 48% of the respondents have no formal education whereas only 4.2% attained tertiary education. Also, 41% of them were engaged in farming and another 19.3% were indulged in petty trading while only 2.8% were involved in weaving as their means of living. This finding is consistent with GSS [25, 39] discovery that many people in both districts were illiterates and their main occupation is agriculture.


#### **Table 1.**

*Healthcare Access - Regional Overviews*

Yamane's statistical formula: n = \_N

**Figure 1.**

size for the study was 212 households.

The mixed research approach with the aid of the cross-sectional design which requires taking a snapshot of the phenomenon under consideration. However, the study was tilted towards the quantitative approach. The total number of households in the four sampled communities was 454. The sample size was computed using

*Map of Wa East and Wa West show zonal centres sampled for the study. Source: adapted from GSS [25, 39].*

the study population, and e is the margin of error [40]. In this study, N = 454 and

The multi-stage sampling technique was deployed in selecting zonal centres, communities and households. First, Wa East district has four zonal centres: Funsi, Bulenga, Kulkpong, and Baayiri, whereas Ga, Gurungu, Vieri and Wechiau constitute the zonal centres for the Wa West District. Two zonal centres from each district (Bulenga, Baayiri, Vieri and Ga) (see **Figure 1**) were randomly selected to participate in the study. In each zonal centre, the names of the communities were compiled and one community was randomly selected. In all, four communities (Guonuo, Tampala, Ga, and Berenyasi) were randomly sampled for the study. Following on that one house was randomly selected and the subsequent houses were then systematically sampled after every fourth house. Finally, women within the reproductive ages of 15–49 years [41] who have had children between 2015 and 2019 were identified and interviewed. Interviewing was the method used to collect the data with the aid of an interview schedule which contained both open-ended and closed-ended questions. Descriptive statistics, chi-square test for independence, Man-Witney test and thematic analysis were deployed in the analysis of the data.

The results show that the maximum age of respondents was 42 years whereas the minimum age was 15 years with a median of 25 (Mean = 25.94; Std Deviation = 6.32;

; where n is the sample size, N is the size of

= 212. Therefore, the samples

1 + 454(0.05) 2

1 + N(e) 2

e = 0.05. The sample size was computed as: n = \_\_\_\_\_\_\_\_\_\_\_\_ <sup>454</sup>

The results were presented in tables, text and narration.

**5.1 Background characteristics of respondents**

**16**

**5. The evidence**

*Educational achievement and occupational distribution of respondents.*

#### **5.2 Access to maternal healthcare**

Access to maternal healthcare services was analysed first, on aggregate and later based on location. The results of the analysis show that 93.9% of the respondents had enrolled unto the national health insurance scheme whereas the rest had not registered to benefit from the exemption of pregnant women from paying the premium. Further analysis was conducted based on community of origin to determine whether differences exist with respect to enrolment unto the NHIS. The results indicate that 89.8% of the respondents had enrolled unto the NHIS in the Wa-East district, whereas 97.4% of them were registered with the scheme in the Wa-West district. This suggests that the Wa West district had more women registered under the NHIS than Wa East district. A chi-square test for independence (with Yates Continuity Correction) was carried out to determine whether there is an association between enrollment unto the NHIS and seeking maternal healthcare services. The test results revealed no significant association between registration for NHIS and seeking maternal health care [χ<sup>2</sup> (1, *n* = 212) = 0.00, *p* = 1.00, *phi* = −0.03]. This finding is in line with Twum et al.'s [7] discovery that in Ghana, pregnant women do not pay a premium for fresh registration or renewal of membership and processing fees.

We sought to find out whether respondent paid money to be registered under the NHIS in the sampled communities. The results showed that 75% of the respondents mentioned that they did not pay money to register under the scheme while the rest indicated that they paid money to register at the time they were pregnant. This means that the 25% who paid money to be registered under the scheme did not go to any health facility to confirm their pregnancy before they went for the NHIS registration. This is because a confirmation of the pregnancy is required by the NHIS to exempt a pregnant woman from premium payment. The results further indicate that in the Wa East District, 70.4% of the respondents noted that they did not pay money to be registered whereas the rest of them stated that they paid money to be registered. On the other hand, 78.9% of the respondents in the Wa West District reported that they did not pay money to register under the NHIS while the rest specified that they paid money to register under the NHIS. This hints that government expenditure on the exemption of pregnant women from paying the premium amount to the proposition of a key tenet of the access theory that concerns expending resources for individual/or collective benefit [4].

The distance of the nearest health facility from the sampled communities was considered. The results indicate that the minimum distance was 1 km whereas the maximum distance to the nearest health facility was 17 km with a mean of 6.5 (Median = 6.2; Quartile Deviation = 3; Skewness of 0.94) and an associated Standard Deviation of 5.22. The distance of the nearest health facility was also examined based on location and the results in the Wa East district indicate that the longest distance to the nearest health facility was 17 km while the shortest distance was 6.2 km and a median of 6.2 (Mean = 9.8; Std Deviation = 5.2 Skewness = 0.697) and with an associated quartile deviation of 5.4. However, in the Wa West District, the minimum distance to the nearest health facility was 1 km radius whereas the maximum distance was 12 km and a median of 1 (Mean = 3.7; Std Deviation = 3.2; Skewness = 0.41) with a related quartile deviation of 3. Comparing the medians, it is noticed that the median distance for Wa East is higher (6.2 km) than that of Wa West with a value of 1 km. This is inconsistent with Banik's [38] finding that the majority of pregnant women had their nearest health centre within a one-kilometre distance in Bangladesh. This difference is probably attributed to the variation in economic resources between Ghana and Bangladesh.

The amount of time spent travelling to a health facility to access healthcare has implication for the utilisation of services at the health facility. Therefore, the time spent to reach the nearest health facility was analysed first at the aggregate level and later based on location. The results indicate that the least time spent to reach the nearest health facility was 30 min or less whereas the maximum time spent was 3 h with a median of 45 min (Mean = 59.7; Std Deviation = 41.7; skewness = 1.54) and with an associated quantile deviation of 15. In the Wa East District, the maximum time spent to reach the nearest health facility was 3 h while the minimum time was 45 min and a median of 1 h (Mean = 86; Std Deviation = 42; Skewness = 1.18) and a corresponding quantile deviation of 45. On the contrary, the shortest time spent to reach the nearest health facility in the Wa West District was 30 min or less whereas the longest time was 2½ h and a median of 30 min (Mean = 43; Std Deviation = 25.9; Skewness = 2.92) and an associated quartile deviation of 15. Juxtaposing the medians, it is realised that the median time spent to reach the nearest health facility in the Wa East District is more than that of the Wa West District. This signals that women in the Wa East District spend more than travelling to the nearest health facility than their counterparts in the Wa West District. This finding contradicts Nussbaum [16] view that efforts should be geared towards removing obstacles that perpetuate differences, marginalisation or discrimination based on geographical locations to ensure equal access to resources.

**19**

in Ghana.

*Access to Maternal Healthcare Services under the National Health Insurance Policy…*

before being seen by the nurses or doctors in Northern Bangladesh.

The utilisation of antenatal care services helps reduce stillbirths and neonatal death as well as prevents and manage risk associated with pregnancy [5, 30]. In this respect, the utilisation of maternal healthcare services was analysed. On a whole, the results show that 98.6% of the respondents went for antennal care during the last pregnancy while the rest did not attend because they had not registered under NHIS. Out of the 98 respondents in the Wa East District, 99% stated that they attended ANC and 98.2% of the 114 respondents in the Wa West District mentioned they attended ANC. Further, we wanted to know whether respondents completed the compulsory ANC attendance. The results at the aggregate level indicated that 86.9% of the respondents completed the recommended ANC attendance, whereas the rest did not complete the required attendance. The data was further disaggregated based on district of origin to determine whether differences existed as regards ANC attendance in the two districts. The results showed that 79.6% of the respondents in the Wa East district completed the recommended four ANC attendances, while the rest did not. Conversely, 93% of the respondents indicated that they completed the four mandatory ANC attendances in the Wa West District while the remainder did not fulfil it. This compares with the findings made by Wang et al. [28] that the majority of pregnant women reported at least one antenatal care visit

WHO [30] notes that the early uptake of ANC services enables skilled health personnel to identify risk, prevent risk and manage pregnancy-related diseases as well as engage in health education and promotion among pregnant women. As such, it is important to know when the first ANC was initiated. The results (**Table 2**) indicate that 29.2% of the respondents initiated the first ANC attendance during the first month of the pregnancy while 24.5% of them initiated it during the second month of the pregnancy and another 18.9% started attending ANC during the third month of their last pregnancy. The results further showed that an accumulated 1.9% of the respondents initiated after the seventh month of their last pregnancy. This signals that the majority of the respondents sought antenatal care early. This implies that they are likely to avoid pregnancy related complications and have safe delivery. The results of the current study appear to disagree with the finding made by Kibusi et al. [8] that timing of the first ANC visit was also low and few women

Waiting time at the facility before respondents were attended to was also considered. On aggregate, the results indicated that the median time spent waiting was 1 h and the minimum time was 30 min or less, while the maximum time was 3 h (Mean = 62; Std Deviation = 35.31; Skewness = 1.15) with an associated quartile deviation of 30. The data was further disaggregated based on location. The results show that in the Wa East, the maximum time respondents waited to be attended to was 3 h whereas the minimum time was 30 min or less with a median of 1 h (Mean = 55.7; Std Deviation = 34.9; a skewness = 1.77) and with a related quartile deviation of 15 min. On the other hand, the longest time spent waiting to be attended to in the Wa West was 3 h while the least time was 30 min and a median of 1 h (Mean = 67; Skewness = 0.73; Std Deviation = 34.7) and a corresponding quartile deviation of 19. Matching the medians, it is noted that there is no difference in the amount of time spent waiting to be attended to at the health facility in the two districts. The time spent at the health facility could be a disincentive for women to seek maternal healthcare if they have other activities to undertake. This finding confirms Banik [38] calculation that majority of pregnant women had to wait for about an hour

*DOI: http://dx.doi.org/10.5772/intechopen.88982*

**5.3 Utilisation of maternal health services**

completed the recommended ANC visits.

*Access to Maternal Healthcare Services under the National Health Insurance Policy… DOI: http://dx.doi.org/10.5772/intechopen.88982*

Waiting time at the facility before respondents were attended to was also considered. On aggregate, the results indicated that the median time spent waiting was 1 h and the minimum time was 30 min or less, while the maximum time was 3 h (Mean = 62; Std Deviation = 35.31; Skewness = 1.15) with an associated quartile deviation of 30. The data was further disaggregated based on location. The results show that in the Wa East, the maximum time respondents waited to be attended to was 3 h whereas the minimum time was 30 min or less with a median of 1 h (Mean = 55.7; Std Deviation = 34.9; a skewness = 1.77) and with a related quartile deviation of 15 min. On the other hand, the longest time spent waiting to be attended to in the Wa West was 3 h while the least time was 30 min and a median of 1 h (Mean = 67; Skewness = 0.73; Std Deviation = 34.7) and a corresponding quartile deviation of 19. Matching the medians, it is noted that there is no difference in the amount of time spent waiting to be attended to at the health facility in the two districts. The time spent at the health facility could be a disincentive for women to seek maternal healthcare if they have other activities to undertake. This finding confirms Banik [38] calculation that majority of pregnant women had to wait for about an hour before being seen by the nurses or doctors in Northern Bangladesh.

### **5.3 Utilisation of maternal health services**

The utilisation of antenatal care services helps reduce stillbirths and neonatal death as well as prevents and manage risk associated with pregnancy [5, 30]. In this respect, the utilisation of maternal healthcare services was analysed. On a whole, the results show that 98.6% of the respondents went for antennal care during the last pregnancy while the rest did not attend because they had not registered under NHIS. Out of the 98 respondents in the Wa East District, 99% stated that they attended ANC and 98.2% of the 114 respondents in the Wa West District mentioned they attended ANC. Further, we wanted to know whether respondents completed the compulsory ANC attendance. The results at the aggregate level indicated that 86.9% of the respondents completed the recommended ANC attendance, whereas the rest did not complete the required attendance. The data was further disaggregated based on district of origin to determine whether differences existed as regards ANC attendance in the two districts. The results showed that 79.6% of the respondents in the Wa East district completed the recommended four ANC attendances, while the rest did not. Conversely, 93% of the respondents indicated that they completed the four mandatory ANC attendances in the Wa West District while the remainder did not fulfil it. This compares with the findings made by Wang et al. [28] that the majority of pregnant women reported at least one antenatal care visit in Ghana.

WHO [30] notes that the early uptake of ANC services enables skilled health personnel to identify risk, prevent risk and manage pregnancy-related diseases as well as engage in health education and promotion among pregnant women. As such, it is important to know when the first ANC was initiated. The results (**Table 2**) indicate that 29.2% of the respondents initiated the first ANC attendance during the first month of the pregnancy while 24.5% of them initiated it during the second month of the pregnancy and another 18.9% started attending ANC during the third month of their last pregnancy. The results further showed that an accumulated 1.9% of the respondents initiated after the seventh month of their last pregnancy. This signals that the majority of the respondents sought antenatal care early. This implies that they are likely to avoid pregnancy related complications and have safe delivery. The results of the current study appear to disagree with the finding made by Kibusi et al. [8] that timing of the first ANC visit was also low and few women completed the recommended ANC visits.

*Healthcare Access - Regional Overviews*

ing resources for individual/or collective benefit [4].

economic resources between Ghana and Bangladesh.

locations to ensure equal access to resources.

We sought to find out whether respondent paid money to be registered under the NHIS in the sampled communities. The results showed that 75% of the respondents mentioned that they did not pay money to register under the scheme while the rest indicated that they paid money to register at the time they were pregnant. This means that the 25% who paid money to be registered under the scheme did not go to any health facility to confirm their pregnancy before they went for the NHIS registration. This is because a confirmation of the pregnancy is required by the NHIS to exempt a pregnant woman from premium payment. The results further indicate that in the Wa East District, 70.4% of the respondents noted that they did not pay money to be registered whereas the rest of them stated that they paid money to be registered. On the other hand, 78.9% of the respondents in the Wa West District reported that they did not pay money to register under the NHIS while the rest specified that they paid money to register under the NHIS. This hints that government expenditure on the exemption of pregnant women from paying the premium amount to the proposition of a key tenet of the access theory that concerns expend-

The distance of the nearest health facility from the sampled communities was considered. The results indicate that the minimum distance was 1 km whereas the maximum distance to the nearest health facility was 17 km with a mean of 6.5 (Median = 6.2; Quartile Deviation = 3; Skewness of 0.94) and an associated Standard Deviation of 5.22. The distance of the nearest health facility was also examined based on location and the results in the Wa East district indicate that the longest distance to the nearest health facility was 17 km while the shortest distance was 6.2 km and a median of 6.2 (Mean = 9.8; Std Deviation = 5.2 Skewness = 0.697) and with an associated quartile deviation of 5.4. However, in the Wa West District, the minimum distance to the nearest health facility was 1 km radius whereas the maximum distance was 12 km and a median of 1 (Mean = 3.7; Std Deviation = 3.2; Skewness = 0.41) with a related quartile deviation of 3. Comparing the medians, it is noticed that the median distance for Wa East is higher (6.2 km) than that of Wa West with a value of 1 km. This is inconsistent with Banik's [38] finding that the majority of pregnant women had their nearest health centre within a one-kilometre distance in Bangladesh. This difference is probably attributed to the variation in

The amount of time spent travelling to a health facility to access healthcare has implication for the utilisation of services at the health facility. Therefore, the time spent to reach the nearest health facility was analysed first at the aggregate level and later based on location. The results indicate that the least time spent to reach the nearest health facility was 30 min or less whereas the maximum time spent was 3 h with a median of 45 min (Mean = 59.7; Std Deviation = 41.7; skewness = 1.54) and with an associated quantile deviation of 15. In the Wa East District, the maximum time spent to reach the nearest health facility was 3 h while the minimum time was 45 min and a median of 1 h (Mean = 86; Std Deviation = 42; Skewness = 1.18) and a corresponding quantile deviation of 45. On the contrary, the shortest time spent to reach the nearest health facility in the Wa West District was 30 min or less whereas the longest time was 2½ h and a median of 30 min (Mean = 43; Std Deviation = 25.9; Skewness = 2.92) and an associated quartile deviation of 15. Juxtaposing the medians, it is realised that the median time spent to reach the nearest health facility in the Wa East District is more than that of the Wa West District. This signals that women in the Wa East District spend more than travelling to the nearest health facility than their counterparts in the Wa West District. This finding contradicts Nussbaum [16] view that efforts should be geared towards removing obstacles that perpetuate differences, marginalisation or discrimination based on geographical

**18**

The month of the pregnancy in which the first ANC was initiated was examined based on location. As shown in **Table 2**, 33.7% of the respondents in Wa East initiated ANC attendance during the first month of the pregnancy whereas 20.4% started attending ANC during the second month and another 13.3% of them initiated ANC visits during the third month of their last pregnancy and the rest started attending ANC from the fourth month forward. Similarly, in the Wa West District, majority of the respondents initiated ANC attendance during the first 4 months of their last pregnancy. The results noted that 28.1% of the respondents in the district mentioned that they initiated ANC during the second month of their last pregnancy whereas 25.4 started attending ANC during the first month and another 23.7% of them stated that they began attending ANC during the third month of their last pregnancy. The rest initiated their first ANC visit from the fourth month onwards. This hints that more women in Wa East District initiate early ANC attendance than their colleagues in the Wa West District.


#### **Table 2.**

*Distribution of the first month ANC was initiated.*

The NHIS policy exempts women from paying the minimum contribution to the scheme [23]. In this regard, it is vital to know whether pregnant women made payments before they sought antenatal care. The results indicated that 58.5% of the respondents mentioned that they did not pay for anything during antenatal care whereas a smaller proportion (41.5%) stated that they made payment during ANC attendance. The data was further disaggregated based on the district of origin. The results showed that 55.1% of the respondents in the Wa East district noted that they pay for services when they sought for antenatal care whereas the rest indicated that they did not pay for anything when they sought antenatal care services. As regards Wa West District, 70.2% of the respondents said that they did not pay any money during antenatal care while the rest mentioned they paid money during the time they attended antenatal care. This hints that more women in the Wa East District paid money for services during antenatal care than their counterparts in the Wa West District. The respondents indicated that they purchased items such as drugs, scan, and laboratory test. The results compare with the findings reported by Dalinjong et al. [10] that women still paid for drugs, supplies, and laboratory services including ultrasound scans in rural northern Ghana.

**21**

*Access to Maternal Healthcare Services under the National Health Insurance Policy…*

Access to maternal healthcare services entails the ability of women to obtain prenatal, antenatal, facility-based delivery and postnatal services [5, 37]. Therefore, it is important to know whether respondents delivered at a health facility. On aggregate, the results indicate that 66.5% of the respondents mentioned that they delivered at a health facility while the rest did not. With respect to the districts, the result show that 81.6% of the respondents in the Wa West District delivered at a health facility whereas the rest did not. On the other hand, 51% of the respondents in the Wa East District they delivered at a health facility against 49% of them who did not deliver at a health facility. This suggests that more women had facilitybased delivery in the Wa West District than in the Wa East District. Kibusi et al. [8] findings that majority of the respondents delivered at health facilities under skilled

Those who did not deliver at a health facility mentioned reasons for their inability to deliver at the nearest health facility. The absence of health personnel at the facility at the time they were ready to deliver was cited as a prime factor. They indicate that when they were due to deliver, they made it to the health facility but upon arrival the health personnel were not at post to assist them deliver. Also, some respondents explicate that the time of delivery came at midnight and thus they could not wait and travel to the nearby health facility. Another set of respondents asserted that there was no means of transport to convey them to the nearest health facility. The quotation taken from field notes in the Wa West District illustrates the

*"The unborn baby started disturbing me at about 2:30 pm and I reported it to my mother-in-law. Some few minutes later, she brought a tricycle to convey me to the nearest health facility (at Kataa) which is 6.2 km away from our community. Upon arrival at the health facility, we were informed that the health personnel were not at post to attend to us. We had to return to our community and I delivered* 

The quotation shed light on the difficult situation some pregnant women had to go through to deliver their babies. This finding is in contravention of the key tenet of the access theory that maintains that individuals/or group such as pregnant women should be able to benefit from material objects, persons and institutions such as health facilities and personnel [18] without hindrance. This finding equally disagrees with the social justice theory that proclaims that all individuals including pregnant women have the right to societal benefits such as access to health facilities and in accordance with acceptable procedures, norms and rules that promote basic rights, liberties and entitlement of individuals and or groups as well as improves the

Ghana introduced a free maternal healthcare programme (FMHCP) under the NHIS in 2008 to alleviate the cost burden associated with seeking maternal healthcare [7]. In this respect, it is crucial to know whether women incur cost in seeking delivery care at the health facilities. The result shows that 79.7% of the respondents indicated that they incur cost in seeking delivery care whereas the rest mentioned that they did not incur cost in seeking delivery care at health facilities. The data was further disaggregated based on district of origin. Out of the 98 respondents in the Wa East District, 68.4% mentioned they incur cost when seeking delivery care whereas the rest did not. Similarly, the results indicate that 89.5% of the 114 respondents stated that they incurred cost when they sought delivery care while the rest did not in the Wa West District. According to the respondents, the cost element includes soap, sanitary pad, hand gloves, detergents, blade, bucket, and rubber sheet. This signals that more women in the Wa West district incurred cost during

*just at the entrance to my room" [42-year old woman, July 7, 2019].*

situations of the disadvantaged within a society [13, 15].

*DOI: http://dx.doi.org/10.5772/intechopen.88982*

attendants is consistent with the results of this study.

situation of some pregnant women:

*Access to Maternal Healthcare Services under the National Health Insurance Policy… DOI: http://dx.doi.org/10.5772/intechopen.88982*

Access to maternal healthcare services entails the ability of women to obtain prenatal, antenatal, facility-based delivery and postnatal services [5, 37]. Therefore, it is important to know whether respondents delivered at a health facility. On aggregate, the results indicate that 66.5% of the respondents mentioned that they delivered at a health facility while the rest did not. With respect to the districts, the result show that 81.6% of the respondents in the Wa West District delivered at a health facility whereas the rest did not. On the other hand, 51% of the respondents in the Wa East District they delivered at a health facility against 49% of them who did not deliver at a health facility. This suggests that more women had facilitybased delivery in the Wa West District than in the Wa East District. Kibusi et al. [8] findings that majority of the respondents delivered at health facilities under skilled attendants is consistent with the results of this study.

Those who did not deliver at a health facility mentioned reasons for their inability to deliver at the nearest health facility. The absence of health personnel at the facility at the time they were ready to deliver was cited as a prime factor. They indicate that when they were due to deliver, they made it to the health facility but upon arrival the health personnel were not at post to assist them deliver. Also, some respondents explicate that the time of delivery came at midnight and thus they could not wait and travel to the nearby health facility. Another set of respondents asserted that there was no means of transport to convey them to the nearest health facility. The quotation taken from field notes in the Wa West District illustrates the situation of some pregnant women:

*"The unborn baby started disturbing me at about 2:30 pm and I reported it to my mother-in-law. Some few minutes later, she brought a tricycle to convey me to the nearest health facility (at Kataa) which is 6.2 km away from our community. Upon arrival at the health facility, we were informed that the health personnel were not at post to attend to us. We had to return to our community and I delivered just at the entrance to my room" [42-year old woman, July 7, 2019].*

The quotation shed light on the difficult situation some pregnant women had to go through to deliver their babies. This finding is in contravention of the key tenet of the access theory that maintains that individuals/or group such as pregnant women should be able to benefit from material objects, persons and institutions such as health facilities and personnel [18] without hindrance. This finding equally disagrees with the social justice theory that proclaims that all individuals including pregnant women have the right to societal benefits such as access to health facilities and in accordance with acceptable procedures, norms and rules that promote basic rights, liberties and entitlement of individuals and or groups as well as improves the situations of the disadvantaged within a society [13, 15].

Ghana introduced a free maternal healthcare programme (FMHCP) under the NHIS in 2008 to alleviate the cost burden associated with seeking maternal healthcare [7]. In this respect, it is crucial to know whether women incur cost in seeking delivery care at the health facilities. The result shows that 79.7% of the respondents indicated that they incur cost in seeking delivery care whereas the rest mentioned that they did not incur cost in seeking delivery care at health facilities. The data was further disaggregated based on district of origin. Out of the 98 respondents in the Wa East District, 68.4% mentioned they incur cost when seeking delivery care whereas the rest did not. Similarly, the results indicate that 89.5% of the 114 respondents stated that they incurred cost when they sought delivery care while the rest did not in the Wa West District. According to the respondents, the cost element includes soap, sanitary pad, hand gloves, detergents, blade, bucket, and rubber sheet. This signals that more women in the Wa West district incurred cost during

*Healthcare Access - Regional Overviews*

The month of the pregnancy in which the first ANC was initiated was examined based on location. As shown in **Table 2**, 33.7% of the respondents in Wa East initiated ANC attendance during the first month of the pregnancy whereas 20.4% started attending ANC during the second month and another 13.3% of them initiated ANC visits during the third month of their last pregnancy and the rest started attending ANC from the fourth month forward. Similarly, in the Wa West District, majority of the respondents initiated ANC attendance during the first 4 months of their last pregnancy. The results noted that 28.1% of the respondents in the district mentioned that they initiated ANC during the second month of their last pregnancy whereas 25.4 started attending ANC during the first month and another 23.7% of them stated that they began attending ANC during the third month of their last pregnancy. The rest initiated their first ANC visit from the fourth month onwards. This hints that more women in Wa East District initiate early ANC attendance than their colleagues in the Wa West District.

**Aggregate Wa East Wa West**

**Month Frequency Percent Frequency Percent Frequency Percent** First month 62 29.2 33 33.7 29 25.4 Second month 52 24.5 20 20.4 32 28.1 Third month 40 18.9 13 13.3 27 23.7 Fourth month 32 15.1 16 16.3 16 14 Fifth month 16 7.5 11 11.2 5 4.4 Sixth month 6 2.8 3 3.1 3 2.6 Seventh month 1 0.5 0 0 1 0.9 Eighth month 2 0.9 2 2 0 0 Ninth month 1 0.5 0 0 1 0.9 **Total 212 100.0 98 100 114 100**

The NHIS policy exempts women from paying the minimum contribution to the scheme [23]. In this regard, it is vital to know whether pregnant women made payments before they sought antenatal care. The results indicated that 58.5% of the respondents mentioned that they did not pay for anything during antenatal care whereas a smaller proportion (41.5%) stated that they made payment during ANC attendance. The data was further disaggregated based on the district of origin. The results showed that 55.1% of the respondents in the Wa East district noted that they pay for services when they sought for antenatal care whereas the rest indicated that they did not pay for anything when they sought antenatal care services. As regards Wa West District, 70.2% of the respondents said that they did not pay any money during antenatal care while the rest mentioned they paid money during the time they attended antenatal care. This hints that more women in the Wa East District paid money for services during antenatal care than their counterparts in the Wa West District. The respondents indicated that they purchased items such as drugs, scan, and laboratory test. The results compare with the findings reported by Dalinjong et al. [10] that women still paid for drugs, supplies, and laboratory

services including ultrasound scans in rural northern Ghana.

**20**

*Source: Field Survey, 2019.*

*Distribution of the first month ANC was initiated.*

**Table 2.**

delivery compared to their counterparts in the Wa East District. This finding contradicts the assertion that health insurance protects the poor in particular against the risk of incurring medical and related financial costs at the point of service utilisation [9].

The cost involved in seeking delivery care was, therefore, examined. The cost here does not include service cost but rather the cost of detergents (Dettol antiseptic, soap and parozone bleach) and other materials such as rubber, blade, hand gloves etc. The detergents are usually collected by the health facilities from the pregnant women and used to clean and disinfect the labour ward after delivery. The least cost involved in seek delivery care was GH¢10.00 whereas the highest was GH¢400 with a median of GH¢40 (Mean = 57.64; Std Deviation = 69.23; Skewness = 3.4) and a related quartile deviation of 17.5. The data was further disaggregated based on location and the result indicated that in the Wa East District, the maximum cost was GH¢400.00 while the minimum was GH¢10.00 with a median of 35 (Mean = 59.55; Std Deviation = 82; Skewness = 3.5) and with an associated quartile deviation of 12.5. On the other hand, the lowest cost involved in seeking delivery care in the Wa West District was GH¢10 whereas the highest cost was GH¢345.00 and a median of GH¢45 (Mean = 56.60; Std Deviation = 61; Skewness = 3.06) and a corresponding quartile deviation of 18. Balancing the medians, it is realised that the median cost in Wa West is higher than the median cost in Wa East. Also, a Mann-Whitney U Test was conducted to test for differences in the cost of delivery care in the two districts. The test revealed no significant difference in the cost of seeking delivery care for Wa East (*Md* = 35, *n* = 45) and that of Wa West (*Md* = 45, *n* = 82), *z* = −0.715, *p* = 0.475. This finding agrees with Dalinjong et al. [10] assertion that pregnant women still purchase certain items for childbirth under the free maternal health policy in rural Northern Ghana. However, some of the respondents admitted that the cost of these items required for delivery sometimes deters them from going to the health facilities for delivery due to the high poverty levels in the study areas. This partly explains why some women still deliver at home.

Charlotte et al. [33] intimated that PNC ensures continuity of care for mother and baby as well as helps to support healthy behaviours. Thus, PNC contributes to the beneficial health outcome for the baby and the mother [5]. In this regard, it is important to know whether women continued seeking PNC. The results of the study noted that 91.5% of the respondents mentioned that they attended PNC while the rest stated that they did not attend PNC. In addition, the data was disaggregated based on location and the results indicate that majority of the respondents (81.6%) in the Wa East District attended PNC but the rest mentioned that they did not. In the Wa West District, however, all respondents stated that they attended PNC. The results of this study contradict the discovery made by Twum et al. [7] that women did not go for postnatal care. The probable reason for the difference in these findings is that our study area is rural where the nurses visit the communities for PNC whereas Twum et al. [7] conducted their study in an urban setting.

Health insurance coverage appears to provide a window of opportunity to reduce or eliminate Out-of-pocket expenditures at the point of service utilisation [17]. In this regard, it is prudent to determine whether women incurred cost when seeking PNC. The results denoted that 75% of the respondents stated that they did not incurred cost while the rest mentioned they expended money when they sought for PNC. Furthermore, the data was segregated based on location to determine whether differences exist between the districts as regards cost incurred during PNC. The results showed that in the Wa East District, 68.4% of the respondents stated that they did not incur cost when they sought for PNC while the rest mentioned that they expended money. As regards the Wa West District, majority (80.7%) of the respondents indicated they did not make payment during PNC whereas the rest

**23**

*Access to Maternal Healthcare Services under the National Health Insurance Policy…*

signalled they incurred expenditure. Those who admitted they made payments alluded to contribution to construct a delivery room and paying for the security of

The person who makes the decision to seek maternal healthcare tends to influence attendance. As such, it is crucial to know whether the wife alone, the husband only or a joint decision influenced the utilisation of maternal healthcare services. The results (**Table 3**) indicate that majority of the respondents (54.2%) mentioned that it was the wife who initiated the decision to seek maternal healthcare services while 24.5% of them indicated that the decision was jointly made by the husband and wife. The data was also disaggregated based on district of origin to determine whether differences exist between the two districts. The results show that 35.7% of the respondents in the Wa East District indicated that it was the wife who took the initiative while 34.7% mentioned that the decision was jointly made. With respect to the Wa West District, 70.2% of them indicated that the decision was taken by the wife and another 15.8% stated that the man and wife jointly took the decision to seek maternal healthcare services. This finding does not fall in line with that of Banik [38] who reported that decisions about seeking maternal healthcare services made by both husband and wife were higher compared to those made by husband or wife alone. The contradiction in these findings could be due to cultural differences

Health insurance coverage appears to contribute to improved access and utilisation of maternal healthcare services. In this respect, majority of the respondents had enrolled unto the NHIS in both districts even though some pregnant women paid for the registration and renewal of their cards which was inappropriate since it was supposed to be free for them. Equally, women largely sought for antenatal and post-natal care during pregnancy and after delivery respectively. Furthermore, some pregnant women incurred cost at the point of registration or renewal of their NHIS cards. Still, some pregnant women deliver at home due to lack of transport, unavailability of health personnel, and the timing of delivery. In addition, a significant proportion of the pregnant women who sought delivery care spend money to purchase certain items at health facilities or from the market before they are admitted to deliver. Moreover, the decision to utilise maternal healthcare services

**Aggregate Wa East Wa West**

**Spouse Frequency Percent Frequency Percent Frequency Percent** Wife 115 54.2 35 35.7 80 70.2 Joint 52 24.5 34 34.7 18 15.8 Husband 45 21.2 29 29.6 18 14 **Total 212 100 98 100 114 100**

Together, a number of steps can be taken to ensure the full realisation of providing free maternal healthcare to all women. First, it will be prudent for the government to station at least one trained health personal particularly midwives

*DOI: http://dx.doi.org/10.5772/intechopen.88982*

between Ghana and Bangladesh.

*Source: Field Survey, 2019.*

**Table 3.**

**6. Conclusions and policy implications**

*Distribution of decision about seeking maternal healthcare services.*

was made mostly by the women themselves.

the health facility.

*Access to Maternal Healthcare Services under the National Health Insurance Policy… DOI: http://dx.doi.org/10.5772/intechopen.88982*

signalled they incurred expenditure. Those who admitted they made payments alluded to contribution to construct a delivery room and paying for the security of the health facility.

The person who makes the decision to seek maternal healthcare tends to influence attendance. As such, it is crucial to know whether the wife alone, the husband only or a joint decision influenced the utilisation of maternal healthcare services. The results (**Table 3**) indicate that majority of the respondents (54.2%) mentioned that it was the wife who initiated the decision to seek maternal healthcare services while 24.5% of them indicated that the decision was jointly made by the husband and wife. The data was also disaggregated based on district of origin to determine whether differences exist between the two districts. The results show that 35.7% of the respondents in the Wa East District indicated that it was the wife who took the initiative while 34.7% mentioned that the decision was jointly made. With respect to the Wa West District, 70.2% of them indicated that the decision was taken by the wife and another 15.8% stated that the man and wife jointly took the decision to seek maternal healthcare services. This finding does not fall in line with that of Banik [38] who reported that decisions about seeking maternal healthcare services made by both husband and wife were higher compared to those made by husband or wife alone. The contradiction in these findings could be due to cultural differences between Ghana and Bangladesh.


#### **Table 3.**

*Healthcare Access - Regional Overviews*

why some women still deliver at home.

utilisation [9].

delivery compared to their counterparts in the Wa East District. This finding contradicts the assertion that health insurance protects the poor in particular against the risk of incurring medical and related financial costs at the point of service

The cost involved in seeking delivery care was, therefore, examined. The cost here does not include service cost but rather the cost of detergents (Dettol antiseptic, soap and parozone bleach) and other materials such as rubber, blade, hand gloves etc. The detergents are usually collected by the health facilities from the pregnant women and used to clean and disinfect the labour ward after delivery. The least cost involved in seek delivery care was GH¢10.00 whereas the highest was GH¢400 with a median of GH¢40 (Mean = 57.64; Std Deviation = 69.23; Skewness = 3.4) and a related quartile deviation of 17.5. The data was further disaggregated based on location and the result indicated that in the Wa East District, the maximum cost was GH¢400.00 while the minimum was GH¢10.00 with a median of 35 (Mean = 59.55; Std Deviation = 82; Skewness = 3.5) and with an associated quartile deviation of 12.5. On the other hand, the lowest cost involved in seeking delivery care in the Wa West District was GH¢10 whereas the highest cost was GH¢345.00 and a median of GH¢45 (Mean = 56.60; Std Deviation = 61; Skewness = 3.06) and a corresponding quartile deviation of 18. Balancing the medians, it is realised that the median cost in Wa West is higher than the median cost in Wa East. Also, a Mann-Whitney U Test was conducted to test for differences in the cost of delivery care in the two districts. The test revealed no significant difference in the cost of seeking delivery care for Wa East (*Md* = 35, *n* = 45) and that of Wa West (*Md* = 45, *n* = 82), *z* = −0.715, *p* = 0.475. This finding agrees with Dalinjong et al. [10] assertion that pregnant women still purchase certain items for childbirth under the free maternal health policy in rural Northern Ghana. However, some of the respondents admitted that the cost of these items required for delivery sometimes deters them from going to the health facilities for delivery due to the high poverty levels in the study areas. This partly explains

Charlotte et al. [33] intimated that PNC ensures continuity of care for mother and baby as well as helps to support healthy behaviours. Thus, PNC contributes to the beneficial health outcome for the baby and the mother [5]. In this regard, it is important to know whether women continued seeking PNC. The results of the study noted that 91.5% of the respondents mentioned that they attended PNC while the rest stated that they did not attend PNC. In addition, the data was disaggregated based on location and the results indicate that majority of the respondents (81.6%) in the Wa East District attended PNC but the rest mentioned that they did not. In the Wa West District, however, all respondents stated that they attended PNC. The results of this study contradict the discovery made by Twum et al. [7] that women did not go for postnatal care. The probable reason for the difference in these findings is that our study area is rural where the nurses visit the communities for PNC

Health insurance coverage appears to provide a window of opportunity to reduce or eliminate Out-of-pocket expenditures at the point of service utilisation [17]. In this regard, it is prudent to determine whether women incurred cost when seeking PNC. The results denoted that 75% of the respondents stated that they did not incurred cost while the rest mentioned they expended money when they sought for PNC. Furthermore, the data was segregated based on location to determine whether differences exist between the districts as regards cost incurred during PNC. The results showed that in the Wa East District, 68.4% of the respondents stated that they did not incur cost when they sought for PNC while the rest mentioned that they expended money. As regards the Wa West District, majority (80.7%) of the respondents indicated they did not make payment during PNC whereas the rest

whereas Twum et al. [7] conducted their study in an urban setting.

**22**

*Distribution of decision about seeking maternal healthcare services.*

## **6. Conclusions and policy implications**

Health insurance coverage appears to contribute to improved access and utilisation of maternal healthcare services. In this respect, majority of the respondents had enrolled unto the NHIS in both districts even though some pregnant women paid for the registration and renewal of their cards which was inappropriate since it was supposed to be free for them. Equally, women largely sought for antenatal and post-natal care during pregnancy and after delivery respectively. Furthermore, some pregnant women incurred cost at the point of registration or renewal of their NHIS cards. Still, some pregnant women deliver at home due to lack of transport, unavailability of health personnel, and the timing of delivery. In addition, a significant proportion of the pregnant women who sought delivery care spend money to purchase certain items at health facilities or from the market before they are admitted to deliver. Moreover, the decision to utilise maternal healthcare services was made mostly by the women themselves.

Together, a number of steps can be taken to ensure the full realisation of providing free maternal healthcare to all women. First, it will be prudent for the government to station at least one trained health personal particularly midwives in all communities to provide delivery services to pregnant women. Second, the government, through the District Health Directorate should provide the basic items that are needed to provide safe and smooth delivery at the health facilities. Third, the communities should be encouraged to provide a communal means of transport to convey pregnant women who are due for delivery to nearby health facilities. Fourth, management of the NHIS in collaboration with the health personnel should embark on continuous sensitization of women on the need to always visit a health facility to confirm their pregnancy before they register or renew their NHIS cards so as to benefit from the free maternal healthcare policy of government. Above all, the District Health Directorates should monitor the movement of health personnel to ensure that at least one personnel (especially the Midwives) is always at post to provide maternal health services for women.
