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• Research article
• Open access
• Published: 05 February 2015

A qualitative study exploring the determinants of maternal health service uptake in post-conflict Burundi and Northern Uganda

• Primus Che Chi 1 , 2 ,
• Patience Bulage 3 ,
• Henrik Urdal 1 &
• Johanne Sundby 2  

BMC Pregnancy and Childbirth volume  15 , Article number:  18 ( 2015 ) Cite this article

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Armed conflict has been described as an important contributor to the social determinants of health and a driver of health inequity, including maternal health. These conflicts may severely reduce access to maternal health services and, as a consequence, lead to poor maternal health outcomes for a period extending beyond the conflict itself. As such, understanding how maternal health-seeking behaviour and utilisation of maternal health services can be improved in post-conflict societies is of crucial importance. This study aims to explore the determinants (barriers and facilitators) of women’s uptake of maternal, sexual and reproductive health services (MSRHS) in two post-conflict settings in sub-Saharan Africa; Burundi and Northern Uganda, and how uptake is affected by exposure to armed conflict.

This is a qualitative study that utilised in-depth interviews and focus group discussions (FGDs) for data collection. One hundred and fifteen participants took part in the interviews and FGDs across the two study settings. Participants were women of reproductive age, local health providers and staff of non-governmental organizations. Issues explored included the factors affecting women’s utilisation of a range of MSRHS vis-à-vis conflict exposure. The framework method, making use of both inductive and deductive approaches, was used for analyzing the data.

A complex and inter-related set of factors affect women’s utilisation of MSRHS in post-conflict settings. Exposure to armed conflict affects women’s utilisation of these services mainly through impeding women’s health seeking behaviour and community perception of health services. The factors identified cut across the individual, socio-cultural, and political and health system spheres, and the main determinants include women’s fear of developing pregnancy-related complications, status of women empowerment and support at the household and community levels, removal of user-fees, proximity to the health facility, and attitude of health providers.

Conclusions

Improving women’s uptake of MSRHS in post-conflict settings requires health system strengthening initiatives that address the barriers across the individual, socio-cultural, and political and health system spheres. While addressing financial barriers to access is crucial, attention should be paid to non-financial barriers as well. The goal should be to develop an equitable and sustainable health system.

Peer Review reports

Although the 2013 UN Millennium Development Goals (MDGs) progress report shows that many regions of the world have made progress on the fifth goal of improving maternal health, the region of sub-Saharan Africa (SSA) is still lagging behind, and will not be able to meet the agreed targets of ‘reducing by three quarters, between 1990 and 2015, the maternal mortality ratio’ and ‘achieving, by 2015, universal access to reproductive health’ [ 1 ]. Within SSA, countries in or emerging from armed conflicts are among the hardest hit. The deteriorating impact of armed conflict on maternal health is well acknowledged, and tends to linger even after the end of the conflict [ 2 - 4 ]. Armed conflicts are associated with higher total fertility and maternal mortality rates [ 5 ]. A 2010 review [ 6 ] of maternal mortality in 181 countries spanning 1980–2008 revealed that in 2008, 50% of all maternal deaths occurred in only six countries (India, Nigeria, Pakistan, Afghanistan, Ethiopia, and the Democratic Republic of the Congo); all of which have experienced recent armed conflict. For over a decade, the 10 countries ranked lowest on the Save the Children’s ‘State of the World’s Mothers Index’ have been conflict and post-conflict states [ 7 ]. Similarly, the 10 countries ranked lowest in the UN Human Development Index for the last decade are either in conflict or emerging from conflict. In this regard, armed conflict has been described as an important contributor to the social determinants of health [ 8 - 10 ] and a driver of health inequity [ 11 ]. Armed conflicts tend to limit access to maternal, sexual and reproductive health services (MSRHS) due to high levels of insecurity and high opportunity costs of accessing such services.

The uptake of MSRHS is closely associated with improvements in maternal health. For instance, quality antenatal care (ANC) should optimally reduce the risk of poor pregnancy outcomes, and a caesarean section can be obtained only when a woman seeks care at a health facility. To enhance women’s utilisation of these health services in post-conflict societies, an important step will be to explore the factors that may hinder and facilitate their uptake of services in these contexts. While much work has been done on the determinants of maternal health utilisation [ 12 - 16 ] including demographic, socio-economic, cultural, and health related factors, a general conclusion appears to be that the importance and impact of the factors varies from one setting to another. With health systems in conflict and post-conflict countries faced with challenges such as damaged infrastructure, limited human resources, weak stewardship and a proliferation of non-governmental organisations without proper coordination, this results in the delivery of disrupted and fragmented health services [ 17 ]. Hence, the utilisation of MSRHS is likely to be affected.

Burundi and Uganda are among the countries in Sub-Saharan Africa that are not poised to meet the fifth MDG goal of improving maternal health. They have both experienced brutal civil wars that claimed tens of thousands [ 18 ] of lives and displaced millions of people. Burundi experienced an ethnic conflict from 1993–2005 that led to the displacement of approximately 1.2 million people [ 19 ]. Although the country has been experiencing some gradual improvements in general population health, the population life expectancy stands at 53.9 years, with one of the highest maternal mortality ratios (800 deaths per 100,000 live births) and total fertility rates (6.1) in the world (UN World Fertility Patterns 2013; UN MDG indicator monitoring database). The Northern region of Uganda is recovering from over 20 years of armed conflict between the Lord’s Resistance Army and the Ugandan Government that resulted in the disruption of health services, massive population displacement and erosion of traditional and family structures [ 20 ]. The number of people displaced by the conflict was estimated at 2 million [ 17 , 20 ]. With a total fertility rate of 6.3, the Northern region ranks the highest in the country, with a median age at first birth of 17.8 years [ 21 ]. Uganda has a life expectancy of 59 years and maternal mortality ratio of 310 per 100,000 live births (UN World Fertility Patterns 2013; UN MDG indicator monitoring database), and the corresponding data for the Northern region might be worse.

The health system in Burundi is organized as a pyramid structure with three levels, comprising the central, intermediate and peripheral levels. The central level involves the Office of the Minister with its associated directorates, departments, programmes and related services, and it is responsible for formulating sector policy, strategic planning, coordination, mobilization and allocation of resources and oversight-evaluation. The intermediate level is comprised of 17 provincial health bureaus, in charge of coordinating all health activities of the province, supporting the health districts and ensuring proper collaboration between sectors. The peripheral level is responsible for the delivery of healthcare, and as of 2010 it was comprised of 45 health districts, including 63 hospitals and 735 health centres (423 public, 105 approved religious facilities and 207 private facilities) distributed throughout the 129 cities in the country [ 22 ]. All health centres are expected to offer a minimum package of services, including treatment and prevention consultation services, laboratory, pharmacy, health promotion and health education services, as well as in-patient observation. However, a recent survey found that 45% of health centres were unable to provide the complete recommended minimum package due to lack of personnel, infrastructure, equipment or medication [ 22 ]. For example, the survey reported that the physician-to-resident, and midwife-to-woman of child bearing age ratios are 1 per 19,231 (WHO recommended ratio is 1 per 10,000) and 1 per 123,312 (WHO recommended ratio is 1 per 5,000), respectively. Furthermore, a 2010 national survey of emergency obstetric and neonatal care (EmONC) facilities found that only five health centres were offering the recommended basic EmONC services, while 17 hospitals could provide comprehensive EmONC services – with the latter having a poor geographical distribution nationally [ 22 ]. These are recurrent challenges that appear to be happening against the backdrop of low government expenditure on health, as shown in Table  1 . The current health situation in Burundi is described as precarious, with a fragile health system characterized by a high burden of communicable and non-communicable diseases, particularly affecting pregnant women and children [ 23 ]. According to the 2009 statistics, the diseases that were the primary causes of morbidity and mortality were malaria, acute respiratory infections, diarrheic diseases, malnutrition, HIV/AIDS and tuberculosis [ 22 ]. Following the end of the armed conflict in 2007, Burundi has been gradually restructuring the health system, with the introduction of the district health system to implement primary health care, coupled with the implementation of a performance-based financing (PBF) programme [ 24 ]. Furthermore, the government has introduced a free health care policy for pregnant women and children under 5, and a health insurance scheme for the informal sector. With these reforms in place, it is estimated that about 50% of the population (mainly pregnant women and under-fives) have universal access to health care [ 23 ]. The reforms have equally led to an increase in the use of health services, better quality of treatment, and a greater number of health personnel in rural areas [ 23 ].

Uganda equally operates on the district health system model, with the decentralization of health service delivery to the health district and health sub-district levels. The delivery of healthcare is done by both public and private actors, with the government owning 2,242 health centres and 59 hospitals, compared to 613 health facilities and 46 hospitals run by private not-for-profit actors (PNFP), and 269 health centres and 8 hospitals run by private health practitioners as of 2010 [ 25 ]. A major proportion of the PNFP providers are faith-based religious organizations, including the Uganda Catholic, Protestant, Orthodox and Muslim Medical Bureaus. A minimum package of health services is provided at all levels of health care in both the public and private sectors. Since 2001, user fees have been abolished in all public health facilities, but utilisation of health services has been hampered by poor infrastructure, lack of medicines and other health supplies, shortage of health workers, and low salaries [ 25 ]. Furthermore, concerns around long waiting times, unofficial fees in public facilities, and poor attitudes among health workers have also limited the utilisation of health services [ 26 ]. The disease burden in the country is dominated by communicable diseases, with maternal and perinatal health conditions contributing to the high mortality [ 27 ]. While Uganda is experiencing a shortage of health workers (as highlighted in Table  1 ), following a recent government recruitment exercise, overall staffing levels at higher level health centres such as Health Centres IV and III has improved from 57% in 2012 to approximately 70% in 2013 [ 27 ].

Some key reproductive health indicators in Burundi and Uganda are displayed in Figure  1 . While ANC coverage for at least one visit in both countries is quite satisfactory, the other health indicators such as contraceptive uptake, unmet need for family planning and ANC coverage for at least four visits are disappointing and require some improvement.

Reproductive health outlook for Burundi and Uganda. Source of data: UN MDG indicators monitoring database ( http://mdgs.un.org/unsd/mdg/data.aspx ). SBA: Skilled birth attendance; CPR: Current contraceptive use among married women 15–49 years old, any method; ANC 1: Antenatal care coverage, at least one visit; ANC 4: Antenatal care coverage, at least four visits; FP: Family planning.

This study aims to explore the determinants of women’s utilisation of MSRHS in the post-conflict settings of Northern Uganda and Burundi and how exposure to armed conflict may affect these factors. Our main research question was ‘ what are the factors that encourage and discourage women’s uptake of maternal and reproductive health services and how does exposure to armed conflict affect these factors? ’ Through this study, we seek to contribute to the broader literature on determinants of maternal health and health-seeking behaviour in conflict and post-conflict settings.

Study settings

The study was undertaken in two provinces in Burundi (Bujumbura Marie and Ngozi) and a district in Northern Uganda (Gulu). In Burundi, participants were recruited from the cities of Bujumbura and Ngozi and the rural and semi-urban communes of Ruhororo in Ngozi Province and Kinama in Bujumbura Mairie province respectively. In Gulu district, the participants were recruited from the rural sub-counties of Koro, Bobi and Bungatira, and the municipality of Gulu, which comprises of four sub-counties. Maps of the study areas are found in Additional file 1 .

Data collection method

This is a qualitative study based on in-depth interviews (IDIs) and focus group discussions (FGDs). Interviews and FGDs were conducted in the local languages (Kirundi in Burundi and Luo in Northern Uganda), French or English (where applicable). All English interviews and FGDs were carried out by the principal investigator (PCC), while those in the local languages and French were conducted by trained local research assistants. The fieldwork took place from June until September 2013.

Study participants

Study participants were recruited from staff members of local and international NGOs and local health providers (LHPs) working in the domain of maternal, sexual, and reproductive health (MSRH). The second group of participants consists of women of reproductive age, living in rural and semi-urban areas. Since we are interested in also capturing the effect the conflict had on MSRHS, NGOs and health providers invited to participate in the study had developed, supported and/or provided MSRHS during the conflict or shortly after the conflict. Similarly, the women we invited to participate in the study had sought or attempted to seek for such services as well during such periods.

Issues discussed

The interviews and FGDs focused specifically on the general state of MSRH in Burundi and Northern Uganda, aimed at describing the general state of maternal health and understanding the factors affecting women’s utilisation of basic MSRHS, taking into consideration the possible effects of the recent conflict. The detailed guides for the interviews and FGDs for each of the participant categories can be found in Additional file 2 . A sample of some of the questions posed to participants during the interviews and FGDs include:

What factors do you think affects women’s utilisation of health services during pregnancy and childbirth? (explore possible factors such as quality of care/treatment provided by health provider, costs for services, travel distance, lack of knowledge on when to seek care etc).

Have these factors changed over time? (probe to inquire how?).

Do you have any ideas how the past conflict might have affected this? (probe to inquire how was the use before and after etc).

Ethical considerations

Ethics approval for the study was obtained from the Regional Committee for Medical and Health Research Ethics, South-East (Norway); le Comité National d’Ethique pour la Protection des êtres Humains Participant à la Recherche Biomédicale et Comportementale (Burundi); and Gulu University Institutional Review Committee (Uganda). We also received permission from local administrative and health authorities. All participants/informants gave their informed consent before participating in the study, and their anonymity, privacy and confidentiality was respected. Written or oral consent was acceptable and approved by the relevant ethics committees.

Data management and analysis

All interviews and FGDs were audio-recorded and later transcribed and translated into English (where applicable). English transcripts were imported into the QRS Nvivo (QSR International, 2012). Considering the multidisciplinary nature of the research team and that the data were mainly made up of semi-structured interview transcripts, the framework method [ 28 ] was used to manage and analyze the data. Three team members open-coded the transcripts on Nvivo and Microsoft® Word. Microsoft® Word was used for coding and analysis by one of the co-authors who did not have access to Nvivo. The codes were descriptions or labels of specific ideas identified as the transcripts were read. Two team members reviewed the codes that were developed, and the inter-coder reliability was high. Inter-related or similar codes were then clustered into different categories, and the categories were subsequently grouped into specific themes. The themes were inductively and deductively developed. Inductive means that they were anticipated from the design of the interview and FGD guides and consciously explored in the interviews and FGDs. Deductive means that they were not anticipated during the design, but rather identified during the review of the transcripts. There was a constant interplay between data collection, analysis and theme development, with new and dominant ideas that emerged in earlier interviews and FGDs being explored deeper in subsequent and later interviews and discussions. The themes were also developed taking into consideration the main factors affecting women’s utilisation of maternal health services proposed by Wild et al.’s [ 29 ] multilayered explanatory model (i.e. individual, social, cultural, political and health system factors).

A detailed description of the methods is provided in Additional file 1 .

Characteristics of study participants

As shown in Table  2 , we had 63 interviews and 8 FGDs across the study settings in Burundi and Northern Uganda. A total of 115 individuals participated in the study: 46 women of reproductive age (‘women’), 32 ‘LHPs’ and 37 NGO staff. The LHPs included those working at the facility (LHP) and senior administrative officials working at the local ministry of health (LHP-Policy maker). Within the NGO category we had three sub-categories of respondents: NGO, NGO-Health providers (NGOs that also provide health services) and NGO-Policy makers (mainly UN-based NGOs).

In the following paragraphs we present the participants’ perceived current status of MSRH and level of utilisation of MSRHS, and the determinants of women’s utilisation of these services vis-à-vis the possible effects of exposure to conflict. The individual determining factors were quantified by obtaining the percentage of participants within each of the categories that mentioned a specific factor during an interview or FGD.

Current status of maternal and reproductive health

Over two-thirds of the LHP and NGO respondents in both Northern Uganda and Burundi felt that the general status of MSRH is poor, but has been improving in the aftermath of the conflict. They mentioned positive evolution of some MSRH indicators such as maternal mortality, skilled attendance at birth and contraceptive uptake coupled with the initiation of some specialized services like cervical cancer screening as key pointers to improvements in maternal health.

“ During the time of the war maternal mortality was very high in this region. But currently it is between 300 and 400 per 100 000. But around that time it was around 600 to 700… ” NGO, FGD – Gulu, Northern Uganda “[In Ngozi Province] in 2005, the percentage of women who deliver at the health facility was 40 percent but now it is about 70 percent. The uptake of family planning in 2005 was 10 percent but now it is around 25 percent. ” LHP-Policy maker, IDI – Ngozi, Burundi

The positive observations made by the LHP and NGO respondents were also affirmed by the women, most of whom felt that the number of pregnant women from their communities attending ANC and delivering at the health facility had been increasing since the conflict ended. The increasing uptake of these services was largely associated with improved physical safety, an increase in the number of health facilities that has reduced the distance people have to travel to seek care, and an ongoing government health policy of free healthcare for all in government health facilities (for Uganda), and free healthcare for pregnant women and children under five years (for Burundi).

“ With the president’s law ( free health care for pregnant women and children under five ), things have evolved in a positive way. Death rate for pregnant women has reduced considerably…Today a death of a pregnant woman is considered as an accident. ” Woman, IDI – Kinama, Burundi “ In the past it was very difficult to reach the hospital but now services are closer…If you compare the time that one would take to reach the hospital in the past, you will find that it is better now ” Woman, IDI – Bungatira, Northern Uganda

Determinants of women’s utilisation of MSRHS and the effect of conflict exposure

A combination of complex and inter-related factors affecting the utilisation of MSRHS by women were identified across the study sites. A number of these factors were associated with exposure to past conflict. Using the Wild et al. [ 29 ] multilayered person-centred exploratory model on the utilisation of maternal health services we grouped the factors into the following themes: individual, socio-cultural, and political/health system levels. Table S2 (Additional file 3 ) shows the main factors identified by the different categories of participants across the study sites. The perspectives of the LHP and NGO categories of respondents were highly similar, hence these were merged. The determinants were largely presented as ‘push’ (barrier) or ‘pull’ (facilitating) factors and included both supply and demand side factors. The factors identified are presented vis-à-vis the various participant categories.

Individual level

The most common individual level factor that encouraged women across the study sites to utilise MSRHS like family planning was the difficulty with catering for existing children. This factor was raised by over 80% of the women. This is because following the end of the conflict there has been a very strong cultural desire to replace family members lost during the conflict. The demand for family planning services was also facilitated by desire for women to recuperate after child birth, prevailing pressure on the existing limited land resources, and high incidence of land disputes following relocation of families back to their communities from internally displaced persons (IDP) camps as the insurgency ended. This has limited the quantity of food that can be cultivated.

“ In general, the living conditions are very difficult. You cannot give birth to too many children when you do not have something to give them. Nowadays, there is not enough space for those children. These are some of the reasons why women seek for family planning services ” Woman, IDI – Koro, Northern Uganda

Previous experience with or fear of a complicated or abnormal delivery and the development of an obstetric danger sign (as well as the severity of the manifestation of the sign) were also important individual level facilitating factors (76%). Most of these decisions tended to have been undertaken with the backdrop of little or no help with household chores for many of these women.

In Burundi, the desire to ensure that the newborn was registered and granted a birth certificate which gave free access to healthcare under the new targeted healthcare policy was a very strong ‘pull’ factor (90%) for facility delivery.

“ The reason why women are motivated to visit the health facility when pregnant is because they are afraid of delivering at home. When you deliver at home, your baby is not registered .” Women, FGD - Ruhororo, Burundi

Normally, the birth notification document that is required to make a birth certificate is provided at the facility after delivery, hence women who do not deliver at the facility often struggle to have a birth certificate issued for their newborn. Other ‘pull’ factors that emerged included the desire to know their HIV status and to learn about the evolution of the pregnancy.

One main barrier identified across the sites, and especially in Northern Uganda, included past unpleasant experiences or fear of such experiences at the hands of health providers at the health facility, discouraging some women from seeking services (60%). With extensive impoverishment among the rural women who were temporarily displaced from their communities during the conflict, many of them felt despised, looked down upon, and poorly received by health personnel when visiting the health facility. Also, 43% of the women cited past experience of severe side effects of contraceptives, such as heavy bleeding and increase in weight, as a barrier to the uptake of modern contraceptives. In Burundi, approximately 20% of the women reported that some women were discouraged from seeking maternal health services for fear of being diagnosed with HIV infection. A few respondents mentioned the lack of ‘good clothes’ to wear as a barrier to facility delivery. Some who could not afford ‘good’ clothes preferred to deliver at home, especially within urban and semi-urban areas.

“ The things that discourage some are…lack of good clothes to wear in order to go to the hospital or health centre without being laughed at; lack of clothes for the newborn; and ashamed of being laughed at if they do not have something to eat whereas other patients have relatives to bring them good food .” Woman, IDI - Kinama, Burundi

The educational level was also mentioned (24%) as an individual level determinant for women’s utilisation of MSRHS, with more educated women being more likely to seek these services. Lack of safety was identified as an important barrier to education during the conflict. Some respondents (41%) also felt that the high burden of domestic chores that some women have to undertake, ranging from cooking, cleaning, and farming, may discourage the use of facility-based health care.

“… I think that it is because of the too much work that women have at home that stops them from going to the hospital. ” Woman, IDI – Bobi, Northern Uganda

LHPs and NGOs

Most of the individual level factors that the LHP and NGO respondents felt affected women’s utilisation of MSRHS were largely similar to those mentioned by the women themselves across the study settings. In Northern Uganda, the main facilitators mentioned only by LHPs and NGOs included availability of contraceptive methods that could be concealed from the male partners/husband (such as implants) (60%); and a deep sense of trust that their privacy and confidentially would be respected by the health providers (50%) – especially for HIV positive women, and for those secretly requesting family planning and post-abortion care services. The corresponding facilitators for Burundi included HIV positive women’s desire to protect their unborn child from HIV infection (70%); and realization of the importance of family planning – including personal positive experiences with contraceptive use (65%); improving knowledge; and understanding the evolution of their pregnancy. The barriers were similar across the participant categories in Northern Uganda, and many respondents (74%) in this participant category felt that the poor health-seeking behaviour of some women was due to the conflict-engendered low literacy levels among the population.

Barriers mentioned only by LHPs and NGOs in Burundi were ignorance of the importance of these services, lack of money for transport and medication, in some areas confidence in traditional birth attendants to undertake home deliveries, and personal religious convictions.

Socio-cultural level

The most common socio-cultural factors raised across the study sites were poverty (85%), community- and male-partner perceptions about modern contraceptives (80%), and the ease of reaching the health facility (70%), including the distance to the facility and the nature of the road network. These were to some extent associated with the conflict, as huge segments of the population, especially in rural areas, are still struggling to rebuild their livelihoods destroyed by the conflict. Infrastructure, including roads, schools and health facilities, was generally disrupted during the conflict. With respect to contraceptive uptake, rumours and myths about modern contraceptives, fear of side effects, and male-partner opposition to uptake were perceived as important barriers.

“ There are some women who do not believe the contraceptive methods because they think that these methods will prevent them from reproducing in the future ” Woman, IDI – Kinama, Burundi “ Some say that family planning [modern contraceptive] is going to kill their eggs…While others think family planning can make one produce children without a head. ” Woman, IDI – Koro, Northern Uganda

While the main barriers to the uptake of modern family planning methods in Northern Uganda were linked to strong male-partner opposition and fears of possible side effects, in Burundi concerns about male-partner opposition were less common.

The main facilitator for utilisation of family planning services was pressure on limited resources (60%), including land on which cultivation is done. This was considered a growing problem in some of the sites as the incidence of land disputes was reported to have sharply increased, especially following the return of displaced populations.

Factors that were raised only by women in Northern Uganda included the perception of women on contraceptives as ‘men’ or ‘without womanhood’, discouraging some from seeking such services; male-partner opposition to spousal uptake of HIV voluntary counselling and testing (VCT) services for fear of being diagnosed with HIV; and fear of undergoing a caesarean section.

Most of the socio-cultural level factors mentioned by the women were also emphasised by the LHPs and NGO respondents. Factors that were only mentioned by the LHPs and NGOs in Northern Uganda included a great respect for and availability of traditional birth attendants (TBAs) to undertake deliveries in some rural areas (40%); and a cultural perception of pregnancy as a normal condition that may discourage some women from seeking ANC and facility delivery services (50%). In some settings, pregnant women who regularly attended ANC sessions were perceived as ‘ not strong enough ’.

“ People think that when you are pregnant it is a normal condition and you do not have to go to the health facility. They feel that when you go there you are a coward .” NGO-health provider, IDI – Gulu, Northern Uganda

Respondents to some extent associated the great respect for TBAs to the conflict, as skilled birth attendance was almost non-existent for huge segments of the population during conflict, and TBAs were regarded as heroines within some communities.

Other sociocultural factors were the perception among some men that women on contraceptives are stubborn (difficult to control) and sexually promiscuous (25%); a desire to replace family members lost during the war (85%); and the cultural desire for large family size (77%). These factors also accounted for the often mentioned male-partner opposition to contraceptive use by their spouses. The strong position of the Catholic Church against the use of modern contraceptives was reported to be a key barrier (70%) for the uptake of family services in both Burundi and Northern Uganda, as more than 60% of the population are Catholics. The strong negative impact of the Catholic Church on the uptake of modern family planning services observed among these categories of respondents was not mentioned as a major concern among the women respondents.

In Burundi, a few respondents (26%) identified the cultural practice of concealing a pregnancy for the first trimester as a major barrier to early ANC service uptake. This is a practice that is not only limited to uneducated women in rural areas, but also common among educated women in the cities.

The occasional financial costs incurred by women at the level of the facility also discouraged some women from seeking services, while the improved security situation has been an important pull factor.

Political and health system level

Most of the women (95%) in both Burundi and Northern Uganda felt that the most important political and health system level pull factor for uptake of MSRHS is the universal and selective healthcare policy for Uganda and Burundi respectively that facilitates access to services through the removal of user fees. All respondents in Burundi were generally more appreciative of the health system, especially the manner in which they are received and treated at the level of the health facility, compared to their counterparts from Northern Uganda. As such, most respondents from Burundi felt that no barriers existed at the level of the political and health system domain.

“ Women are well treated and whenever you go [to the health facility] when you are pregnant, they receive you and they treat you well .” Woman, IDI – Ruhororo, Burundi “W e know that there are nurses at the health centres and hospitals who are ready on a daily basis to receive a woman who is coming to bear a child. They are always ready to help that woman. We thank the government for this. They do not discriminate in receiving patients. ” Woman, FGD – Kinama, Burundi

On the other hand, over half of the women respondents from Northern Uganda felt that although the cost of basic health care is free, some health providers tend to extort money from them. A number of women narrated incidents at the health facility where health providers requested unauthorised financial tips following the delivery of a service.

“ Sometimes you can go [to the health facility] and you are told by the nurses to give them some money for the help they have given to you … ” Woman, IDI – Bobi, Northern Uganda “ When I went to give birth, the nurse told me that ‘since you have given birth well I want you to give me something but don’t tell the in-charge (supervisor)’. Then I removed 5,000 Shillings and gave her .” Woman, IDI – Bungatira, Northern Uganda

Furthermore, the provision of some services such as family planning, ANC, and VCT through mobile outreach clinics and village health teams in the case of Northern Uganda, and TBAs and community health workers in the case of Burundi was also a strong pull factor for the demand for these MSRHS. Of all the women respondents, especially in Northern Uganda, 40% reported that they are drawn to attending ANC services and undertake delivery at a health facility because of material incentives provided along with the services, such as bed nets and delivery kits.

“ Some women go to the health facilities because another woman has gotten that incentive and you hear them saying that ‘if my friend has gotten this there, then I have to also give birth from the hospital in order to get mine’ .” Woman, FGD – Koro, Northern Uganda

A common barrier discouraging some women from seeking facility services was that the attitude of some health providers was occasionally perceived as abusive and degrading to the clients (57%), at times because of their perceived state of poverty. This perceived barrier was, however, very uncommon in Burundi.

“ Some women fear those nurses because they like harassing women when they go to seek for services and some can even abuse you ” Woman, IDI – Bobi, Northern Uganda

Specifically in Burundi, most women (90%) felt that the construction of more health facilities, hence reducing the travel distance, and the recruitment of more health personnel were other facilitators, especially in rural areas. In Northern Uganda, the common barriers raised were the irregular presence and frequent absence of personnel at some facilities (60%), especially in the rural areas, and the policy of insisting that pregnant women must be accompanied by the male partner during some ANC consultations if they are to receive prompt service delivery (63%).

“ If the child the woman is carrying does not have a father, it discourages the woman from going for ANC visits because some facilities require you to come with your husband. ” Woman, IDI – Bungatira, Northern Uganda

A number of women felt that tying prompt ANC service delivery to being accompanied by the male partner unfairly treated women without partners, and women whose partners refused to accompany them or were unavailable for other reasons. The prevailing practice of insisting on male partner involvement was also associated with the reluctance of some women to seek other MSRHS, such as family planning and VCT. In many situations women that were unaccompanied by their spouse were reportedly attended to much later, or even sent away unattended. This practice of prioritizing accompanied women, or even not providing some services to unaccompanied women, was a major concern among some women in Northern Uganda.

“ I would think the health personnel should improve the way they treat mothers when they go for maternal and other services available in the health unit. Not that if they do not go with their husband they should leave without services because there are men who are also very difficult to deal with and so their wives should not be dropped out from services because of their husband’s conduct. ” Woman, IDI – Bobi, Northern Uganda

The political and health system level factors that were identified by the health providers and NGOs were highly similar to those reported by the women. The common facilitating factors that emerged across the study sites included the policy of removal of user-fees (100%), the increasing level of community sensitization on health issues (90%), the prohibition of TBAs from undertaking deliveries, which had directly pushed some women to deliver at health facilities (75%), and the delivery of some services at community level.

In Burundi, the introduction of the performance-based financing (PBF) programme was highlighted as the most important facilitating factor to the delivery and uptake of MSRHS (100%). Through the PBF scheme health personnel are remunerated specifically for the quantity and quality of specific services provided in addition to their regular salary. Facilities are also better stocked with basic supplies than before, the range of services offered has increased, and more lay health workers have been trained from the community to intensify community health sensitization activities. Also, competent personnel tend to always be at the facility, TBAs have been trained and assigned a new role in health promotion and community sensitisation, and the attitude of personnel towards the clients has reportedly improved. All these have encouraged more women to seek MSRHS. On the downside, some respondents (25%) felt that the strong increase in the number of women seeking MSRHS following the introduction of the selective health care and PBF policies has not been sufficiently matched with a corresponding increase in the number of skilled personnel at the facility, nor in the quantity of medical supplies. The end result has been a decline in service quality and delays in the provision of services, which has negatively affected the demand for some services.

Some facilitating factors that were mentioned only by LHPs and NGOs in Northern Uganda are effectiveness in the integration and follow-up of clients, especially in the domains of VCT and prevention of mother-to-child transmission of HIV; professional competence of personnel with respect to safeguarding clients’ privacy and confidentiality; payment of the cost for skilled birth attendance and related services at a reputable private hospital by some local politicians; and availability of youth-focused and youth-friendly services. Moreover, the availability of free antiviral therapy coupled with the provision of nutrition support for HIV positive mothers, and the provision of some incentives (such as a delivery kit and a washing basin) for women who deliver at the facility, were also important pull factors. The main barriers mentioned only by LHPs and NGOs were poor management of pregnant teenagers and teenage mothers; the poor drug supply policy and regular stock-out of some essential supplies at the facility level; and in some areas, the poor coordination among NGOs, health facilities and the district health office affecting the pattern of service delivery.

This study has demonstrated that a complex and inter-related set of factors affect women’s utilisation of MSRHS in post-conflict settings, and that armed conflict are among them. These factors cut across the individual, socio-cultural, and political and health system spheres, and the main determinants include women’s fear of developing pregnancy-related complications, situation of women empowerment and support at the community and household levels, removal of user-fees, proximity to the health facility, and attitudes of health providers. The main negative effects on family planning service uptake related to the exposure to conflict were associated with a generally low level of appreciation of the importance of some services, due to low educational attainment partly as a result of the conflict. Another effect has been a strong cultural desire for a large family size, especially among men, partly as a response to the loss of family members during the conflict. Furthermore, the disruption of infrastructural development such as roads and health facilities during the conflict, means that proximity to functional health facilities for many rural dwellers remains a considerable problem in some areas. While related studies have been undertaken in Uganda, largely employing a quantitative design, we are not aware of any such studies undertaken in Burundi.

Our findings are consistent with those of other researchers in related settings. Previous studies in Northern Uganda have identified lack of finance, of information, and of decision-making powers as key challenges to access to health care services for women [ 30 ]. Also, the abusive and unwelcoming attitude of some health providers towards women, financial demands by some health providers, and uncooperative husbands, have been reported in other regions of Uganda as important barriers to the uptake of family planning, ANC visits, and other health services by women [ 31 ]. A systematic review of access to and utilisation of health services for the poor in Uganda [ 32 ] identified distance to service points, perceived quality of care, and availability of drugs as key determinants. In addition the review concluded that perceived lack of skilled staff in public facilities, late referrals, health worker attitudes, costs of care, and lack of knowledge were important barriers to service utilisation. Although many women appreciate the importance of ANC visits and facility delivery, when they cannot find someone to take care of their families, (especially their children) while they are away at the facility, they opt not to go, as was observed in post-conflict Sierra Leone [ 33 ]. In post-conflict Timor-Leste, women’s choice of delivery in a health facility has been linked to previous perinatal deaths or complications, such as prolonged or painful labour, bleeding, or referral in a past pregnancy, as well as the parity status, with primiparous women more likely to deliver at the facility [ 29 ]. In post-conflict Liberia, Lori et al. [ 34 ] reported that there was a strong sense of secrecy around pregnancy and childbirth, similar to our observation in Burundi, and distrust of the health care system among a proportion of the population, factors that in our study were associated with late attendance of ANC consultations and possibly with home deliveries among some women. Secrecy around such issues might be linked to concerns about witchcraft, in particular that an enemy may bewitch the unborn child or prolong its delivery. Similar views were expressed by some of our study participants. During the 2006 conflict in Lebanon, Kabakian-Khasholian et al. [ 35 ] equally observed that the key determinants for seeking maternal care were the availability of health services and experiences of complications. In some conflict settings, the choice of place of delivery is affected by the availability of appropriate clothing to wear to the facility, and the preference of key decision makers in the family, such as mothers-in-law and husbands [ 36 ].

In the aftermath of the internal conflict in Timor-Leste in 2006, the country was plagued with similar challenges to those we observed in Burundi and Northern Uganda, and one key response employed by the authorities was the institution of a maternity waiting camp for pregnant women [ 37 ]. At one of the facilities we visited in Northern Uganda, such a home was recently introduced especially to deal with pre-identified clients in rural remote areas with the risk of an abnormal delivery. Although this practice seems to be uncommon in our study settings it might be an important intervention to extend to other major health facilities. Accommodating the women and their companions may be a particularly important intervention for those who have to travel over a long distance to come to the facility.

Both Uganda and Burundi have waived user fees for maternal health related services; Uganda introduced a universal healthcare policy in March 2001, while Burundi introduced a selective healthcare policy for women giving birth and children under 5 years in May 2006. This policy seems to be the most important determinant of women’s uptake of MSRHS in our study settings, highlighting the importance of financial barriers in determining the demand for health services. A study in rural Burkina Faso showed that substantial reductions in user fees for ANC and skilled attendance at birth improved equity in access to these services across socio-economic groups, but did not ensure that all women benefited from the services [ 38 ]. These observations highlight the importance of also focusing on policies aimed at addressing other barriers. For instance, the current strategy of community provision of some MSRHS such as contraceptives, ANC, and postnatal care through mobile outreaches and local community structures, including traditional birth attendants, community health workers and village health teams, is a welcome model for delivering services, and needs to be strengthened. Furthermore, the level of engagement of the health system and other key community structures with males in the community on the importance of utilisation of MSRHS, including contraceptive uptake, also has to be intensified. Men might not have been appropriately engaged on these issues, and their knowledge of the services may be erroneous, which possibly accounts for the level of resistance that has been observed among some men vis-à-vis the uptake of MSRHS. Health providers might therefore have to coin their messages more efficiently to enhance male partner support for the utilisation of maternal and child health services. For example, a study of Northern Uganda concluded that the introduction of community and health facility capacity strengthening interventions such as training of health workers, provision of medical supplies including delivery kits, and community mobilization using village health teams, dance, drama and “male partner access clubs”, led to improvements in first ANC visit attendance, in VCT service uptake for attendants of first ANC visits, in facility delivery, and in VCT service uptake by couples [ 39 ]. While the current free healthcare policy for pregnant women and children under five has had a positive influence on the number of women going for ANC and facility delivery, other associated expenses such as transportation to the health facility, food to eat, clothes for the baby and the mother, and care for the other children at home when the mother is away continue to prevent some women from utilising ANC and facility-based delivery services. Similar observations in Timor-Leste are reported by Wild et al. [ 29 ]. In war-torn Afghanistan, Hadi et al. found that with appropriate conditions in place, many women and families will continue to seek facility-based delivery [ 40 ]. These conditions include providing free services and transport facilities at night, incentives to health providers, maintaining privacy in the delivery room, and the quality of services.

In many settings where stimulating demand for health services has largely been sought through the removal of user fees, but where proper planning and coordination has been lacking, other challenges on the supply side have arisen [ 41 , 42 ]. This happened in Burundi in May 2006 following the sudden abolition by the president of all user fees for children under five, and for women giving birth in all public health centres and hospitals. This was closely followed by a reduction in financial flows to the facilities, resulting in frequent drug stock-outs, reduced quality of the services, and disruption of the referral system [ 42 ]. These are similar challenges to those that we observed across the sites, although these challenges were more acute in the case of Northern Uganda. In Burundi, the nationwide introduction of the PBF programme in April 2010 to complement the earlier introduced free health care policy for children under five and pregnant women, seems to have mitigated some of the challenges that were observed following the introduction of the free healthcare policy. This has led to a generally more positive perception of the health system among women in Burundi compared to the women in Northern Uganda, as we observed in our study. The PBF scheme is a supply-side results-based financing programme which involves a ‘fee-for-service–conditional-on-quality of care’ mechanism that rewards hospitals and health facilities with monthly payments determined by service utilisation levels and performance on quality measures [ 43 ]. In the absence of a similar and well-coordinated personnel remuneration system like the PBF, health personnel in Northern Uganda may be more demoralized, less enthusiastic in the delivery of basic health services, and more prone to request unofficial payments from clients. The initial challenges faced by Burundi in the wake of the introduction of the selective healthcare policy, and nowadays in Northern Uganda, where a universal healthcare policy is in place, points to the importance of careful planning, implementation and coordination of such policies. However, failure to do so may seriously compromise the quality of services, as was observed across the study sites, and especially those in Northern Uganda. While the positive impact of the PBF programme on the utilisation and quality of maternal and child health services was widely reported by participants in Burundi, a few participants equally acknowledged that challenges with respect to staff burn-out and service quality as a result of the increasing demand for services remain. Although a number of post-conflict countries in Africa including Burundi and Rwanda have rolled-out nationwide PBF schemes as a means of improving health worker performance and as a tool for health sector reform, Ireland et al. have questioned the validity of PBF as a tool for health sector reform. They argue that the “debate surrounding PBF is biased by insufficient and unsubstantiated evidence that does not adequately take account of context nor disentangle the various elements of the PBF package” [ 44 ] (p. 695).

Based on our findings and those of previous studies [ 12 - 16 ], the determinants seem to be largely the same in post-conflict and non-conflict settings except for the fact that the barriers in post-conflict settings tend to be more widespread and exacerbated . We demonstrate that exposure to armed conflict affected women’s utilisation of MSRHS mainly through low educational attainment for both men and women translating into ignorance of the importance of health services and into high levels of impoverishment. Another commonly observed effect was the strong desire, especially among men, to replace lost family members, resulting in their general opposition to modern contraceptives. Working in the opposite direction, great pressure on limited land for cultivation coupled with reported increased incidence of land disputes as conflict-displaced populations return to their communities, appear to encourage some women to consider modern family planning services for birth control.

Our findings also highlight some similarities and differences in the perceived determinants of women’s uptake of MSRHS between and within the categories of participants and study settings. For example, almost all factors identified by the women were also highlighted by the LHP and NGO respondents. This is not particularly surprising, as the latter serve within the communities where these women reside, and have a generally good knowledge of the socio-cultural context of these women. Also, a number of the NGOs and local health providers have local community projects within our study areas that may further improve their level of engagement with the women in those communities. This possible practice of engagement of health personnel with local communities is worth encouraging and supporting as it may improve the delivery of services, thus providing better client satisfaction. However, while the LHP and NGO respondents across the study sites perceived the Catholic Church as having a very strong negative effect on the uptake of modern contraceptives, this was not a concern among the women respondents. The major barriers for the women were opposition from their male partner and the fear of possible side effects. The non-mention of a strong religious influence on modern contraceptives uptake by the women might reflect the fact that the religious values that some women hold may not necessarily be in keeping with the official teachings of their religion, or that their local cultural values may have a much stronger impact on their belief systems. Alternatively, the women might simply not want to apportion blame on their religion as a sign of respect. It is also important to note that the issue of seeking facility delivery in Burundi was strongly associated with the desire to obtain a birth certificate for the child. This highlights the importance that women in rural Burundi place on the free healthcare policy, as the birth certificate of the child might be required at times in public facilities before services are provided free of charge. The issue of limited land that has served as a facilitator to family planning uptake was raised only by the women, across the study sites. This might reflect the reality these women go through on a daily basis to raise their children and put food on the table for their families. Since the women were largely based in rural areas, with farming as their main occupation, they might have personally experienced the challenges of having a large family living off a limited piece of land, and how such pressure affects household- and community cohesion. This may explain why some women disregard personal risk and seek for concealable modern contraceptives against the backdrop of male-partner- and cultural opposition. The other concerns raised about the uptake of modern contraceptives are not unique to our study. A study in Ghana found that a third of women considered modern contraceptives as unsafe, 20% reported opposition from their male partner as a barrier to uptake, and 65% of users reported at least one side-effect [ 45 ]. Therefore, in order to improve the uptake and continual usage of modern contraceptives in these areas, these concerns have to be addressed.

The challenges of delivering health care and rebuilding health systems in conflict and post-conflict settings have been well acknowledged. The major challenges are the lack of security; acute shortage of skilled health professionals due to migration to safer areas; lack of infrastructure and medical supplies and drugs; obstruction of access to health facilities by warring parties; security forces harassing, arresting and prosecuting health providers; poor coordination among government, health care providers and humanitarian organizations; and assaults on patients within hospitals, among others [ 46 - 50 ]. These challenges make the health system non-functional, resulting in limited availability of, limited access to, and poor quality of health services. As such, rebuilding health systems must take into consideration the prevailing challenges to ensure efficient use of limited resources and provide maximum impact. In this regard, experts have recommended that health system strengthening programmes in such settings should put more emphasis in the short-term on the provision of primary health care services, using existing human resources for health, community structures, NGOs and mobile outreach clinics [ 51 ]. Programmes such as the renovation and construction of health facilities and the development of human resources for healthcare are more likely to succeed in the medium- and long term. This happens to be the approach that both governments have eventually embarked on, although in the earlier post-conflict years in Northern Uganda so many resources were channeled into the construction of health facilities, especially in rural areas, that to date many remain non-functional due to acute shortage of human and material resources. A more stepwise approach, rather than thinning out the limited resources over a large area without much progress taking place, could have been more effective. Furthermore, governments of post-conflict settings along with their development partners must carefully design the core elements of the health system to provide reliable essential health while ensuring that it addresses issues around equity, government accountability to citizens, and governments’ capacity to manage important social programs [ 47 ].

Limitations

A limitation of the study was that the women participants were mainly staying within the catchment areas of some local health centre or had regular weekly access to basic healthcare services through mobile outreach clinics. We were unable to recruit women participants in much disadvantaged remote areas that were not regularly served with basic health services. As such, the perspectives of that group of women are not well captured in our study.

In post-conflict settings, a vast and complex set of factors affect women’s utilisation of MSRHS ranging from the individual, socio-cultural, political to health system levels. The main determinants include the removal of financial barriers to access; level of household, community and facility support for women; proximity to health services; and community perceptions of some services. Exposure to conflict generally exacerbated the barriers to women’s uptake of services, mainly through low educational attainment and stronger cultural desire for increased fertility to replace family members lost to the conflict. To improve women’s uptake of MSRHS in such settings, robust health system strengthening programmes addressing the barriers across the individual, socio-cultural and political spheres are needed. While addressing financial barriers to access is important, attention should also be paid to non-financial barriers. The goal should be developing an equitable and sustainable health system.

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Acknowledgements

We are grateful to all the participants who took time off to participate in the study. Ms. Foglabenchi Lily Haritu assisted with coding the transcripts. We thank our local collaborators across all the study sites for logistic and administrative support. We thank the reviewers, Kate Teela and Maree Porter, and the editor for their comments. This fieldwork received funding from Folke Bernadotte Academy, Sweden and the Institute of Health and Society, University of Oslo, Norway. The entire work has been supported by: the EU 7th Framework Marie Curie ITN ‘Training and Mobility Network for the Economic Analysis of Conflict’ – TAMNEAC (Grant agreement 263905), the Research Council of Norway – Project 230861 ‘Armed Conflict and Maternal Health in Sub-Saharan Africa’, and the Peace Research Institute Oslo (PRIO).

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PCC: Participated in the conception and design, data collection and analysis, and drafting and revising the first manuscript; PB: participated in data analysis, and drafting and reviewing the manuscript; HU: participated in the conception and design, data interpretation, and reviewing the manuscript; JS: participated in the conception and design, data interpretation, and reviewing the manuscript. All authors participated sufficiently in the work to take public responsibility for appropriate portions of the content. All authors reviewed and approved the final manuscript.

Additional files

Additional file 1:.

Methods. This is a detailed description of the materials and methods used for undertaking the study. It includes a description of the study settings and participants, data collection, management and analysis methods, collaborative partnership, recruitment of participants and ethical considerations.

Additional file 2:

Data Collection Tool: Interview and Focus Group Discussion Guides. This is a detailed description of the interview and focus group discussion guides for the various categories of research participants. The guides are for the entire study from which this paper is one of the outcomes.

Additional file 3: Table S2.

Factors affecting women’s utilisation of Maternal, Sexual and Reproductive Health Services (MSRHS) in post-conflict Burundi and Northern Uganda. This is a summary of the factors affecting women’s utilisation of maternal, sexual and reproductive health services in Burundi and Northern Uganda as perceived by women of reproductive age, local health providers and staff of NGOs working in the domain of maternal and reproductive health. The factors are further classified into individual level factors, socio-cultural level factors and political and health system level factors.

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Chi, P.C., Bulage, P., Urdal, H. et al. A qualitative study exploring the determinants of maternal health service uptake in post-conflict Burundi and Northern Uganda. BMC Pregnancy Childbirth 15 , 18 (2015). https://doi.org/10.1186/s12884-015-0449-8

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DOI : https://doi.org/10.1186/s12884-015-0449-8

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Swanepoel, Daniël Christiaan De Wet. "Infant hearing screening at maternal and child health clinics in a developing South African community." Pretoria : [s.n.], 2004. http://upetd.up.ac.za/thesis/available/etd-08242005-093303.

Kerber, Katherine J. "The continuum of care of maternal, newborn and child health : coverage, co-coverage and equity analysis from demographic and health surveys." Master's thesis, University of Cape Town, 2007. http://hdl.handle.net/11427/7441.

Quillin, Stephanie I. M., and L. Lee Glenn. "Interaction Between Feeding Method and Co-Sleeping on Maternal-Newborn Sleep." Digital Commons @ East Tennessee State University, 2004. https://dc.etsu.edu/etsu-works/7524.

McLaughlin, Thomas J., Onesky Aupont, Claudia A. Kozinetz, David Hubble, Tiffany A. Moore-Simas, Doborah Davis, Christina Park, et al. "Multilevel Provider-Based Sampling for Recruitment of Pregnant Women and Mother-Newborn Dyads." Digital Commons @ East Tennessee State University, 2016. https://dc.etsu.edu/etsu-works/1496.

Mukinda, Fidele Kanyimbu. "Forms and Functioning of Local Accountability Mechanisms for Maternal, Newborn and Child Health: A Case Study of Gert Sibande District, South Africa." University of the Western Cape, 2021. http://hdl.handle.net/11394/8276.

Bergen, Nicole. "Health Equity as a Priority in the 2030 Agenda for Sustainable Development: A Nested Qualitative Case Study of Maternal, Newborn and Child Health in Ethiopia." Thesis, Université d'Ottawa / University of Ottawa, 2020. http://hdl.handle.net/10393/40465.

Ijumba, Petrida. "Intervention for improved newborn feeding and survival where HIV is common : Perceptions and effects of a community-based package for maternal and newborn care in a South African township." Doctoral thesis, Uppsala universitet, Internationell mödra- och barnhälsovård (IMCH), 2014. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-232110.

Romesberg, Tricia L. "Midline Catheter Use in the Newborn Intensive Care Unit." UNF Digital Commons, 2014. http://digitalcommons.unf.edu/etd/544.

Shah, Darshan, Stacy Brown, Nick Hagemeier, Shimin Zheng, Amy Kyle, Jason Pryor, Nilesh Dankhara, and Piyuesh Singh. "Predictors of Neonatal Abstinence Syndrome in Buprenorphine Exposed Newborn: Can Cord Blood Buprenorphine Metabolite Levels Help?" Digital Commons @ East Tennessee State University, 2016. https://dc.etsu.edu/etsu-works/46.

Henriksson, Dorcus Kiwanuka. "Health systems bottlenecks and evidence-based district health planning : Experiences from the district health system in Uganda." Doctoral thesis, Uppsala universitet, Internationell mödra- och barnhälsovård (IMCH), 2017. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-329082.

Nixon, Christopher E. "2ND TIER ASSAY FOR THE DETECTION OF CONGENITAL ADRENAL HYPERPLASIA BY VIRGINIA’S NEWBORN SCREENING LABORATORY: STEROID PROFILE BY HPLC-MS/MS." VCU Scholars Compass, 2019. https://scholarscompass.vcu.edu/etd/6075.

Nicol, Edward Fredrick. "Evaluating the process and output indicators for maternal, newborn and child survival in South Africa : a comparative study of PMTCT information systems in KwaZulu-Natal and the Western Cape." Thesis, Stellenbosch : Stellenbosch University, 2015. http://hdl.handle.net/10019.1/97073.

Lino, Amanda de Assunção. "Encontros de diálogos no pré-natal e o cuidado materno às intercorrências com o recém-nascido." Universidade Federal de São Carlos, 2016. https://repositorio.ufscar.br/handle/ufscar/8295.

Pertmer, Tamera Marie. "Characterization of Immune Responses Following Neonatal DNA Immunization: A Dissertation." eScholarship@UMMS, 2000. https://escholarship.umassmed.edu/gsbs_diss/84.

Meira, Denise Sayuri Maruo. "Analise das praticas de humanização do SUS = acompanhamento multidisciplinar em ambulatorio de follow up de bebes de risco - CRDI Fenix." [s.n.], 2010. http://repositorio.unicamp.br/jspui/handle/REPOSIP/311692.

Farr, Shirley Marie. "A developmental care program in the Neonatal Intensive Care Unit at Arrowhead Regional Medical Center." CSUSB ScholarWorks, 2005. https://scholarworks.lib.csusb.edu/etd-project/2741.

Pikora, Cheryl A. "Type-Specific Immunity in HIV-1 Vertically Infected Infants." eScholarship@UMMS, 1995. https://escholarship.umassmed.edu/gsbs_diss/83.

Aihara, Yoko Sirikul Isaranurug. "Effect of maternal and child health handbook on maternal and child health promoting belief and action /." Abstract, 2005. http://mulinet3.li.mahidol.ac.th/thesis/2548/cd375/4737949.pdf.

Smith, Emily Rose. "Maternal and Child Health, Nutrition, and Hiv." Thesis, Harvard University, 2016. http://nrs.harvard.edu/urn-3:HUL.InstRepos:32644541.

Bodas, Mandar V. "Three Essays on Maternal and Child Health." VCU Scholars Compass, 2018. https://scholarscompass.vcu.edu/etd/5543.

Sosa-Rubi, Sandra Gabriela. "Maternal health care utilisation and the production function of the health of the newborn." Thesis, University of York, 2006. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.434158.

Olaniran, A. A. "Community health workers for maternal and newborn health : case studies from Africa and Asia." Thesis, University of Liverpool, 2017. http://livrepository.liverpool.ac.uk/3018942/.

Chilvers, R. "Planning framework for human resources for health for maternal and newborn care." Thesis, London School of Hygiene and Tropical Medicine (University of London), 2014. http://researchonline.lshtm.ac.uk/2124342/.

Herbst, Andreas. "Acidemia at birth risk factors, diagnosis and prognosis, with special reference to maternal fever in labour /." Lund : Dept. of Obstetrics and Gynaecology, University of Lund, 1997. http://books.google.com/books?id=dF9rAAAAMAAJ.

Nicolais, Christina J. "Maternal Health and Child Behaviors as Risk Factors for Child Injury." VCU Scholars Compass, 2014. http://scholarscompass.vcu.edu/etd/3381.

Hagan, Teresa. "Under-utilisation of maternal and child health care." Thesis, Sheffield Hallam University, 1988. http://shura.shu.ac.uk/3084/.

Wood, David L. "Child Poverty and Its Impact on Child Health." Digital Commons @ East Tennessee State University, 2017. https://dc.etsu.edu/etsu-works/5178.

M'soka, Namakau C. S. "Beliefs of women receiving maternal and child health services at Chawama Clinic in Lusaka, Zambia regarding pregnancy and child birth." Thesis, University of Limpopo (Medunsa Campus), 2010. http://hdl.handle.net/10386/509.

Leiferman, Jennifer Ann. "The effect of maternal depressive symptomatology on maternal behaviors associated with child health /." Digital version accessible at:, 2000. http://wwwlib.umi.com/cr/utexas/main.

Carreon-Bailey, Rebecca Socorro. "Influences of maternal parenting behaviors: Maternal mental health, attachment history and eduction." CSUSB ScholarWorks, 2006. https://scholarworks.lib.csusb.edu/etd-project/2989.

Percy, Ray. "Maternal verbal communication and the treatment of children with anxiety disorders in the context of maternal anxiety disorder." Thesis, University of Southampton, 2014. https://eprints.soton.ac.uk/370404/.

Parmar, Natasha. "Apprehension of Newborn Infants by Child Protection Services: Experiences of Mothers." Thesis, Université d'Ottawa / University of Ottawa, 2021. http://hdl.handle.net/10393/42503.

O'Keefe, Maree Frances. "Maternal perspectives of child health consultations by medical students." Title page, contents and abstract only, 2002. http://web4.library.adelaide.edu.au/theses/09PH/09pho4121.pdf.

Silva, Grazielle Roberta Freitas da. "EstimulaÃÃo visual: prÃtica educativa com mÃes na enfermaria mÃe-canguru." Universidade Federal do CearÃ, 2005. http://www.teses.ufc.br/tde_busca/arquivo.php?codArquivo=973.

Moucheraud, Corrina. "Evaluation of Strategies and Outcomes in Maternal and Child Health." Thesis, Harvard University, 2015. http://nrs.harvard.edu/urn-3:HUL.InstRepos:16121157.

Gonzalez, Citlalli R. "Maternal Behavioral Determinants and Child Dietary Quality in Latino Families." Thesis, California State University, Long Beach, 2018. http://pqdtopen.proquest.com/#viewpdf?dispub=10784465.

The purpose of this study was to conduct a secondary analysis to examine the association between the change from baseline to follow-up in Latino mothers’ self-reported nutrition knowledge, self-efficacy, intentions, food label use, and role modeling from baseline to follow-up with their reports of children’s dietary intake measured at follow-up. Data were obtained from from Sanos y Fuertes, a culturally-tailored community-based nutrition education intervention. The participants were Latino mothers and their children ages 2 to 8 years old. A dietary quality scoring system was created using food frequency data. To account for reported frequencies, five set points were created to define criteria for high dietary quality. Logistic regression tests were conducted for the five set points. The change in nutrition knowledge ( p = .019) and role modeling ( p = .034) of the mothers significantly predicted probability of higher child dietary quality at follow-up. Findings suggest the need for interventions that focus on increasing parental dietary knowledge while emphasizing the importance of role modeling. Further research is needed to explore cultural-related dietary differences between Latinos and non-Latinos.

Kanu, Alhassan Fouard. "Health System Access to Maternal and Child Health Services in Sierra Leone." ScholarWorks, 2019. https://scholarworks.waldenu.edu/dissertations/7394.

Moonesar, Immanuel Azaad. "The Role of UAE Health Professionals in Maternal and Child Health Policy." ScholarWorks, 2015. https://scholarworks.waldenu.edu/dissertations/1649.

Clements, Andrea D., A. L. Acuff, Wallace E. Jr Dixon, and C. Snyder. "Maternal and Child Temperament and Parenting Style." Digital Commons @ East Tennessee State University, 2008. https://dc.etsu.edu/etsu-works/4936.

Winstanley, Alice. "Maternal and infant contributions to development following premature deliveries." Thesis, Cardiff University, 2012. http://orca.cf.ac.uk/47366/.

Nasrullah, Muazzam [Verfasser]. "Child marriage and its impact on maternal and child health in Pakistan / Muazzam Nasrullah." Bielefeld : Universitätsbibliothek Bielefeld, 2015. http://d-nb.info/1077605277/34.

Fertuck, Deborah. "Children with chronic physical disorder : maternal characteristics and child outcomes." Thesis, McGill University, 1992. http://digitool.Library.McGill.CA:80/R/?func=dbin-jump-full&object_id=56618.

Tauheed, Jannah. "Arsenic, Lead and Manganese as Risk Factors for Child and Maternal Neurotoxicity." Thesis, Harvard University, 2016. http://nrs.harvard.edu/urn-3:HUL.InstRepos:27201739.

Plant, Dominic. "When one childhood meets another : maternal child maltreatment and offspring child psychopathology." Thesis, Canterbury Christ Church University, 2016. http://create.canterbury.ac.uk/15001/.

Kachimanga, Chiyembekezo. "Improving utilization of maternal health related services: the impact of a community health worker pilot programme in Neno Malawi." Master's thesis, University of Cape Town, 2018. http://hdl.handle.net/11427/29240.

Panjsheri, Saiqa. "Child health: mother knows best the association between child malnutrition and maternal education in Nepal /." CONNECT TO ELECTRONIC THESIS, 2007. http://hdl.handle.net/1961/6769.

Islam, Farzana. "Quality Improvement System for Maternal and Newborn Health Care Services at District and Sub-district Hospitals in Bangladesh." Doctoral thesis, Örebro universitet, Institutionen för hälsovetenskaper, 2016. http://urn.kb.se/resolve?urn=urn:nbn:se:oru:diva-48416.

Singogo, Irene Miti. "Perinatal deaths in Lusaka, Zambia : mothers’ experiences and perceptions of care." Master's thesis, University of Cape Town, 2014. http://hdl.handle.net/11427/6015.

Hood, Robert Baltasar. "Hepatitis C virus and maternal and child health in the United States." The Ohio State University, 2020. http://rave.ohiolink.edu/etdc/view?acc_num=osu1587213372856517.

Carvalho, Natalie. "Health Impacts and Economic Evaluations of Maternal and Child Health Programs in Developing Countries." Thesis, Harvard University, 2012. http://dissertations.umi.com/gsas.harvard:10264.

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Maternal and child health care access to skilled delivery services among Ghanaian rural mothers

• Original Paper
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• Published: 24 April 2024
• Volume 3 , article number  6 , ( 2024 )

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• Awinaba Amoah Adongo   ORCID: orcid.org/0000-0002-0261-3295 1 ,
• Jonathan Mensah Dapaah   ORCID: orcid.org/0000-0002-9349-6273 1 ,
• Francess Dufie Azumah   ORCID: orcid.org/0000-0001-6023-8000 1 &
• John Nachinaab Onzaberigu 1  

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Introduction

Most new-born babies are born at home in rural communities which is not new phenomenon due to lack of access to primary healthcare services and trained skilled health attendants, exposing mothers and children to a high risk of labour complications. The purpose of this study was to better understand factors influence rural women's access to primary health care and skilled delivery services as well as their reasons for using or not using maternal health care and skilled delivery services.

The study employed a social survey design with a quantitative approach to data analysis. Cluster Sampling was used, possibly based on rural communities, to efficiently collect data from different geographic locations. Simple random sampling individuals from each cluster ensures that all eligible individuals have an equal chance of being included in the study. This enhances the representativity of the sample. A total of 366 mothers were selected from four rural communities in the North East Region of Ghana. The choice of sample size considered factors like the study's objectives, available resources, and the desired level of statistical power. Data was primarily gathered through the administration of a questionnaire to the respondents. Factors considered for achieving representativity include, geographic representation, accessibility, healthcare infrastructure and healthcare professionals’ attitudes .

The study found that distance to health centres limits women's access to skilled delivery services. Lack of primary health facilities in the rural communities hamper maternal and child care services delivery. The attitude of health care professionals determines a mother’s utilisation of maternal health care and skilled delivery services.

The study contributes to the limited research on maternal health services and their impact on mother and child health in the study area. This study is one of the first to investigate into maternal health care as a key predictor of mother and child health in the study area. The study's theoretical lens was the Andersen and Newman Health Behavioural Model theory, which supports the explanation of distance, lack of primary health centres, attitudes and lack of skilled personnel to the non-utilisation of maternal and health services in rural communities. The study recommended that primary healthcare facilities and trained health professionals should be a priority of government in rural communities to promote maternal and child healthcare.

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Maternal and child health (MCH) is an international priority that has been debated for many years and is one of the most important public health service concerns (United Nations [UN], [ 1 ]). According to the United Nations, there were thousands of maternal deaths per year in 2019, and there were 18 infant fatalities per 100,000 live births worldwide. Sub-Saharan Africa and Southern Asia continue to record high maternal mortality rate globally (World Health Organisation [WHO], [ 2 ]). The Sustainable Development Goals (SDGs) set a target of a minimum of 70 maternal deaths per 100,000 babies born alive by 2030, however, maternal and child health issues continues to be an enormous obstacle in many countries. This suggests that the challenge of maternal and child still remains a concern to public particularly in sub-Saharan Africa.

The world's maternal mortality rate (MMR) in 2020 was 223 per 100,000 live births and to achieve a world-wide MMR of less than 70 by 2030 means that a yearly rate of reducing it drastically is required, an objective that has rarely been accomplished at the national level (WHO, [ 3 ]). Countries have banded together in the context of the SDGs to speeds up the decline in the death rate of mothers by 2030. SDG three includes the lofty objective of lowering the global MMR to less than 70 per 100,000 births, with none of the nation’s having an MMR that is more than multiple times the global mean. However, this is a major challenge in countries with limited resource setting, particular sub-Sharan Africa (SSA). There are numerous barriers to maternal and child health issues affecting maternal morbidity reduction in SSA. These factors could be attributed to poor health service location, a lack of health workers, a poor road network, and lack of service quality that put pregnant women at risk [ 4 , 5 , 6 ].

The MMR in Ghana is 310.00 per 100,000 live births, and the infant mortality rate is 31.78 deaths per 100,000 live births, according to Ghana Health Service (GHS, [ 7 ]). This an indication that the maternal and child mortality remains far short of the SDGs three target of 70 per 100,000 live births by 2030 in Ghana. The majority of maternal and infant mortality is triggered by the interaction of various economic, social, and health system factors such as lack of access to healthcare, health seeking behaviour, and socio-demographic behavioural variables [ 4 , 5 , 8 , 9 ]. These variables require further evaluation and comprehension in order to address issues of maternal and infant mortality.

The government of Ghana's key policies for lowering maternal mortality rates include providing free maternal health care services and expanding healthcare facilities in rural communities (GHS, [ 7 ]). These policy interventions can reduce maternal mortality to some extent, the national MMR target of 80% in every 100,000 child births. However, it is unknown the situation of primary healthcare services and skilled trained health professionals in the rural context. Studies have shown that national indicators on women's access to and use of maternal health care services in Ghana, particularly urban areas, and little research focuses on maternal and child health in Ghana's rural communities (Awoonor-Willians, [ 10 ]; [ 11 ]). Furthermore, these factors are understudied and underappreciated in rural Ghana, where the majority of these maternal complications occur. As a result, the goal of this study was to understand maternal and child healthcare access to primary healthcare and skilled delivery services as well as the factors influencing their use of these in rural communities in Northern Ghana. Maternal health service quality has a greater positive effect on utilisation rates than service proximity. Also, the quality of maternal health care in hospitals were higher than in primary care facilities [ 12 ]. Similarly, the cost of medications may discourage mothers from seeking maternal healthcare services. Additionally, the availability of health personnel and maternal health policies were among the majority of reasons for mothers not using medications while pregnant; the review that follows provides empirical research on why mothers do or will not seek medications and health worker assistance when pregnant [ 13 , 14 ].

There is gap in healthcare services in African countries and this often led to few people having access to healthcare facilities (WHO, [ 2 ]). As a result, money from developed countries has been the primary source of support for providing primary health care in many less developed countries worldwide (WHO, [ 15 ]). Donor funding for maternal health in less developed country has increased in recent years. Private clinics and hospitals are funded by entrepreneurs, so services from these health areas are prohibitively expensive for the average person to pay for pregnant women's health [ 16 ]. The improvement of health care centres and health professionals to provide maternal health service to mothers in rural areas, resulting in mothers' use of maternal health services in some rural areas where services are lacking, but most mothers in those areas may not seek maternal health service when they are pregnant because they may not have money or due to distance.

According to Iba et al. [ 17 ], requiring pregnant women to walk long distances and waste time before receiving health care and medication discourages many mothers. Similarly, if mothers do not have access to transportation to health care facilities that are far from their home, it will be difficult for them to access health care while pregnant because they will be unable to walk to the facility due to its location and how far it may be for the mother to go and get medication. There are a lot of literature on maternal health services that provide interesting findings, but there is a scarcity of research on maternal and child healthcare service access and skilled delivery services in rural communities in Ghana, so this study seeks to add to the literature.

Study area and context

The study was conducted in four rural communities which included Yunyoo, Yagaba, Chereponi, and Bunkpurugu which are located in the North East Region of Ghana as indicated in Fig.  1 . According to the GHS [ 7 ], there are the most rural communities in the North East Region of Ghana and lack primary healthcare services.

Map of Ghana, with the number 13 showing the study area

The study used a social survey design with probability techniques to sample mothers from four rural communities in Ghana's North East Region. The probability sampling method was used to select respondents from the larger population. It was necessary to ensure that everyone in the population has an equal chance of being selected for the survey, and that each respondent has an equal chance of being selected for the study, in order to ensure an accurate probability sample. Each person was assigned a number using a random number generator and the key was to avoid overrepresentation. The main benefit of probability sampling is that it allows the researcher to obtain accurate feedback about a larger population without polling the entire population. Simple random sampling was time consuming and tedious, especially with these larger samples [ 18 ].

Sampling in Ghana, like in many countries, is typically based on specific methodologies that aim to ensure representativeness of the population. However, achieving true random sampling can be challenging due to various constraints. Some concerns about potential limitations in achieving true random sampling include access and limited infrastructure and challenging terrain, especially in rural areas, can hinder the ability to reach and survey all segments of the population, leading to potential biases in the sample. Also, language barriers and cultural differences can affect the effectiveness of survey instruments and may result in underrepresentation. Unequal access to technology and digital devices may exclude certain segments of the population from surveys conducted through online or electronic means, introducing a potential bias in the sample. However, these limitations did not influence the results.

Study population

The study population consists of women in fertility age (15–49 years) within four communities which included Yunyoo, Yagaba, Chereponi, and Bunkpurugu in the North East Region. It involved women who had ever become pregnant and were still at their reproductive age. The estimated population was 340,700 women (GHS, [ 7 ]). Women in fertility age 15–49 years were sampled from the four communities in the North East Region. There are approximately 340,700 women in the estimated population (GHS, [ 7 ]). The target population consisted of women aged 15 to 49 who had given birth within the previous five years.

The sample size was derived with the aid of the formular below using a proportionate sample size at a confidence level of 95 per cent and confidence limit of 4. The confidence limit was reduced to 4 so as to get a larger sample size in order to have a more representative sample.

n: This represents the required sample size.

DEFF: Design Effect. It accounts for the design effect or the impact of clustering in the sampling process. If previous data has been collected in clusters or groups, the design effect adjusts the sample size to reflect the fact that observations within the same cluster may be more similar to each other than to observations in other clusters.

N: Total population size.

p: The estimated proportion of the population that has a certain characteristic. It is the proportion the researchers want to estimate.

1 − p: The complement of the estimated proportion.

d 2 : This represents the desired margin of error (precision) in estimating the population proportion.

Z 1  − α/2: The Z-score corresponding to the desired level of confidence (1 − α). This is often denoted as the critical value and is associated with the confidence level for the estimation.

α: The significance level, which is typically set at 0.05 for a 95% confidence level.

How population is organised in Ghana include the National Identification Authority (NIA) which is the primary government agency responsible for the registration and issuance of national identification cards. They conduct mass registration exercises to capture the biometric data of citizens, including fingerprints and facial features. Also, the Birth and Death Registry is responsible for registering all births and deaths in the country. Birth registration is crucial for establishing citizenship and providing individuals with official identification. Ghana Statistical Service (GSS, [ 19 ]) also plays a role in population data collection through censuses and surveys. These initiatives help in obtaining demographic information, economic indicators, and other relevant data. The Electoral Commission manages voter registration, which is a subset of the overall population registration. While its primary focus is on citizens eligible to vote, it contributes to the overall demographic data ([ 20 ], GSS, [ 19 ]).

With regard to completeness of population registration, especially in rural areas achieving complete population registration in rural areas can be challenging due to factors such as limited infrastructure, poor accessibility, and lower awareness of the importance of registration. To address challenges in rural areas, mobile registration units are often deployed. These units travel to remote locations to ensure that residents, even in distant and less accessible areas, have the opportunity to register. The government and relevant agencies conduct public awareness campaigns to educate citizens about the importance of registration. These campaigns often target rural areas where awareness might be lower. Collaborating with local authorities, community leaders, and grassroots organisations is essential for ensuring that registration efforts are accepted and supported at the community level ([ 20 ],GSS, [ 19 ]).

Theoretical context: behavioural model by andersen and newman in 1973

The study used the Andersen and Newman Health Behavioural Model (1973) to identify the factors influence the utilisation of health facilities in the rural communities. Health Behavioural Model states that some feature influence mothers to look for health services when pregnant. These features are in three set that may influence mothers to use health service when pregnant arrive: (1) predispose factor; (2) Enabling resources, (3) Actual or perceived need.

Predisposing characteristics

Factors which influence mothers to use MHS which may be the age at pregnancy, whether the early birth was successful, social factors, the work the mother does, the level the mother has be educated up to, the works the family do and whether the family has enough money [ 21 ]. When a mother has most of these factors, she is most likely to use services at health facility during pregnancy but if not, the mother will even find it difficult to afford health cost given a situation when the mother has no money or from a poor family.

Enabling characteristics

With regards to enabling characteristics, the health behavioural model has it that some factors have to be available for mother to be able to use health service. These factors are termed as enabling since they make access to health service easy to mothers. There are within the community and area the mother lives. Family factors which may include their level of income, family doctor, health insurance policy that mother may be with, the distance of mother’s house and the any nearby health facility [ 21 ].

Families with their own doctors will imply that the mother can easily get treatment for health services when pregnant but those families without a family doctor will have to rely on the community doctors at the private or public health centre. The enabling factors are central to mothers seeking for health services during pregnancy .

The next factor is the need-based factor of mothers and them looking for health services when pregnant. When mothers think that there is the need for them to look for medications during pregnancy then they will look for medications, but when mothers do not foresee the need then they will not look for health when pregnant (Anderson & Newman, [ 22 ]; [ 23 , 24 ]). The Andersen and Newman [ 25 ] model was used in this study to help identify the determinants of one's health service utilisation, assess inequality in access to health services, and facilitate policy-making for equitable access to care and health services in rural communities.

SData collection, management and analysis techniques

SIn this study, the target population included mothers in rural communities within the North East Region of Ghana. Clusters were identified which were the rural communities. A random selection method was to choose clusters from the larger population of rural communities in the North East Region. Contacting participants was done through community engagement. The research established contact with community leaders and members to explain the purpose and importance of the study and seek their support and cooperation. Obtained informed consent from potential participants, ensuring they understand the study and voluntarily agree to participate. The authors used systematic sampling within the selected clusters to identify households or individuals. A structured questionnaire was used to collect quantitative data on factors influencing women's access to primary healthcare and skilled delivery services [ 18 ].

The train enumerators were PhD Candidates who administered the questionnaire. The candidates with training in both quantitative and qualitative research methodologies ensure a robust and nuanced approach to data collection. They were also familiar with the local culture and language to facilitate effective communication to assist participants who could not read. Ensuring inclusivity, the researchers conduct extensive community outreach to ensure that potential participants from diverse backgrounds and situations are aware of the study. Accessibility measures, the researchers implement measures to make the study accessible to all eligible participants, considering factors such as mobility, language barriers, and cultural sensitivity.

The dependent variables were utilisation of maternal health care and skilled delivery services. This variable was operationalised as a binary outcome – utilised or did not utilise maternal health care and skilled delivery services. Based on responses to survey questions regarding participants' utilisation of maternal health care services during pregnancy and delivery. The independent variables were distance to health centres. The distance in kilometres from participants' residences to the nearest health centres. Measured using GIS or self-reported estimates during interviews. Another independent variable was availability of primary health facilities and the presence or absence of primary health facilities in the participants' rural communities. The last independent variable was attitude of health care professionals and participants' perception of health care professionals' attitudes, measured through Likert scale questions in the survey and it was measured based on responses to questions assessing participants' satisfaction or dissatisfaction with the attitudes of health care professionals.

Additional information on previous pregnancies, births, and complications were captured data on the number of previous pregnancies, births, and any complications experienced during these events. Participants provided the number of previous pregnancies and births, and details on complications were recorded based on participants' self-reporting. Assess the impact of genital mutilation on maternal health care utilisation included questions in the survey that inquire about participants' experiences with genital mutilation and its potential influence on seeking maternal health care services (GHS,[ 7 ]; GSS, [ 19 ]).

Data cleaning process the authors identified and addressed missing data through imputation or exclusion, depending on the extent of missingness and patterns. Also, we use statistical methods to identify and investigate outliers that may skew the data. The authors adjusted or removed outliers based on the study's goals. Examined data for inconsistencies, ensuring that responses are logical and coherent. Addressed any conflicting information through cross-validation or follow-up with participants. Validated the coding of categorical variables and ensure consistency in coding schemes throughout the dataset. Checked for errors in data entry and correct any inaccuracies. Cross-verify with original survey instruments [ 26 ].

Quantitative analysis was used which involved descriptive statistics and inferential statistics. The quantitative approach was used to ensure that major variables were numerically measured and to provide statistical data on factors influencing women's use of maternal and skilled delivery care. The quantitative approach helped the researchers to gather empirical data that gave readers and policy makers a better understanding of mother’s use and non-use of maternal and skilled delivery care using quantifiable data [ 18 ].

Respondents’ background information

According to the data in Table  1 , 15.6% ( n  = 57) of the 366 respondents were single, while 63.1% ( n  = 231) of the respondents were in a marital union recognised by the community. Only 6.8% ( n  = 25) of the respondents had divorced, 10.9% ( n  = 40) had lost their partners (widow), and 3.6% ( n  = 13) were in a cohabitation relationship. Respondents between the ages of 31 and 35 account for the highest percentage of 28.1% ( n  = 103). This was followed by those aged 26–30 years, who had a percentage of 24% ( n  = 88). Respondents aged 46–49 years comprised the minority group, with a valid percentage of 4.4% ( n  = 16). Again, a close examination of the respondents' age range revealed that very few of those who participated in the study were aged years or less. According to the study, 47% of respondents ( n  = 172) had no formal education. At least 24% ( n  = 88) and 20.5% ( n  = 75) of respondents had only basic/primary education, respectively. The valid percentages for senior high school (including technical and vocational education) and tertiary education were 5.5% ( n  = 20) and 3% ( n  = 11), respectively. The majority of them 47.8% ( n  = 175) of respondents were traditional believers, 43.4% ( n  = 159) of respondents were Christians, 7.4% ( n  = 27) of respondents were Muslims, 1.4% ( n  = 5) of respondents were free thinkers, and 92% ( n  = 335) of respondents cannot read.

Mothers’ place of delivery during child birth

The study established that more births by mothers being delivered at home than child births that occurred at the hospital/clinic, with the exception of most mothers having their third child at the hospital. Most mothers who had more than one child (two children) delivered at home 47% of the time, compared to 27.8% and 2.2% of mothers who delivered at the hospital and clinic, respectively. According to the study, only 37.7% ( n  = 138) of mothers had their third delivery in a hospital, while the majority of respondents (63.9%) had their last birth at home. According to field data, most women still deliver at home, according to a general examination of mothers' places of delivery in the North East Region. However, one cannot deny that the factor plays a significant role; 4 out of every 10 mothers had their first child at a hospital/clinic.

Month mothers received ANC during pregnancy

Table 2 shows the months when the majority of respondents visited the hospital during their previous pregnancy, according to the findings. The majority of mothers in the North East Region (37.2% and 38.3%, respectively) began visiting ANC during the second and third months of their pregnancy, according to data in Table  2 . Only 7.1% of mothers sought ANC during the first month of their pregnancy. According to Table  2 , 94.3% ( n  = 345) of respondents had a live birth within the last five years during their most recent childbirth. Only 5.7% ( n  = 21) of those polled experienced a stillbirth during their most recent pregnancy.

Univariate analyses (chi-square testing)

The researchers investigated the factors that influence women's use of maternal health care services in the North East Region, as well as access to skilled delivery services. The dependent variables were ANC use, delivery care at a health centre, and postnatal care at a health centre, while the independent variables were marital status, age, education, religion, distance, and the availability of skilled delivery personnel. The test results are shown in Tables 6 , 7 , and 8 using the Chi-square (2) and an alpha of 0.05 (= 0.05).

The Chi-square ( χ 2 ) was computed to determine whether socio-demographic factors such as marital status, age, education, religion, distance, and availability of skilled delivery personnel have a relationship with mothers' utilisation of ANC. The five married categories were recoded as single and married; age group was recoded as youth and older; education was recoded as not educated and educated; and distance was recoded as within the community and far from the community. This was done to ensure that each cell had at least five respondents, as the initial codes resulted in some cells having fewer than five, which was not consistent with the Chi-square test assumptions.

The Chi-square ( χ 2 ) test results as depicted in Table  3 indicated a statistically significant relationship between marital status χ 2 (1, n  = 366) = 6.281, p -value = 0.012(S), ά = 0.05, age of mothers χ 2 (1, n  = 366) = 8.702, p -value = 0.003, education of mothers χ 2 (1, n  = 366) = 4.007, p -value = 0.045, religion χ 2 (2, n  = 366) = 12.124, p -value 0.002, and distance χ 2 (1, n  = 366) = 5.393, p -value = 0.020, all at ά = 0.05 and mothers’ utilisation of maternal health care services in the North East Region.

The Chi-square χ 2 test results of the mothers' socio-demographic factors, such as married status, age, education, religious background, and distance, were found to have a significant relationship with their use of ANC. When mothers marry, their partners contribute to MHC costs such as transportation to the health care centre. Similarly, older women learn through experience whether they need to access MHCS or not, whereas educated young women have a better understanding of the need for maternal health care services during pregnancy. To determine whether mothers’ socio-demographic factors have relationship on utilisation of delivery care at the health, the Chi-square ( χ 2 ) was used as depicted in Table  4 . The Chi-square ( χ 2 ) in Tables 4 and 5 showed that there is significant relationship between mothers’ marital status, χ 2 (1, n  = 366) = 10.909, p -value = 0.001, age of mothers χ 2 (1, n  = 366) = 5.222, p -value = 0.022, mothers’ education χ 2 (1, n  = 366) = 7.893, p -value = 0.005, religious background χ 2 (2, n  = 366) = 10.020, p -value = 0.007 and distance χ 2 (1, n  = 366) = 7.372, p -value 0.007, at ά = 0.05.

Logistic regression model

To identify socio-demographic factors that influence the likelihood that mothers in the North East Region would use maternal health care services, binary logistic regression was used. Six independent variables were included in the models (Marital status, Age, Education, Religion, Distance and Availability of skilled delivery personnel). Three different models were developed, each with antenatal care, delivery care at a health centre, and postnatal care as separate dependent variables. The first model, which included mothers’ socio-demographics and use of ANC, contained all statistically significant predictors, χ 2 (7, n  = 366) = 29.649, p -value = 0.000, indicating that the model was able to distinguish between mothers who used and did not use ANC during pregnancy and which explained 7.8% (Cox and Snell R square) and 11.2% (Nagelkerke R square) of the variation in mothers' utilisation of antenatal care in the North.

The second model included mothers' socio-demographic information as well as their use of delivery care in the North East Region. This model was also statistically significant, χ 2 (7, n  = 366) = 33.312, p -value = 0.000, implying that the second model could predict mothers who used delivery care at a health centre during childbirth and those who did not in the North East Region. This explained between 8.7% (Cox & Snell R Square) and 12.2% (Nagelkerke R Square) of the variations in mothers' use of delivery care in the district (see Table 7 ).

The last model was computed to determine mothers’ socio-demographic and use of postnatal care in health centre after child birth. This model of showed statistically significant, χ2 (7, n  = 366) = 27.203, p -value = 0.000, meaning that it was able to predict mothers who used postnatal care at health centre after child birth and those who did not, which also explained between 7.2% (Cox & Snell R Square) and 10% (Nagelkerke R Square) of the variation in mothers use of postnatal care at health centre after child birth as showed in Table 8 .

As showed in model 1 (Table  6 ) and model 2 (Table  7 ) only one independent variable (education) made a statistically significant contribution to the models which predicted mothers’ use of ANC and delivery care whilst in model 3 (Table  8 ) only one independent variable (availability of skilled delivery personnel) of mothers made statistically significant contribution to the model which predicted mothers’ use of postnatal care at health centre after child birth. An elaborated interpretation of the results with regards to the various statistics is presented beneath the Tables  6 ,  7 and 8 .

The beta (B) values in the first column of Table  6 represented the co-efficient of the independent variables entered into the model. From the Table  6 , it was observed that education of mothers recorded the highest beta value (0.607) and with the least value of beta recorded for religious (-2.300). This means that education is a strong predictor of utilisation of ANC in the North East Region. Only education influence use of ANC services positively.

The Wald values in the second column of Table  6 also indicated the contribution made by each of the independent variables to the model which predicts the utilisation of ANC services in the North East Region. As indicated Table  6 , it was religion (4.904) and age (4.375) which mostly made significant contribution to mothers’ use of ANC services.

The p -values in the Table  6 also indicated the variable or set of variables that significantly predict mothers’ utilisation of ANC services in the North East Region. From the results in Table  6 , only religion (0.035) and age (0.027) proved to be the only significant determinants or predictors of mothers’ utilisation (model) of ANC in the North East Region, as they recorded p -values less than 0.05. The last column in Table  6 indicated the odds ratios (Exp(B)) for each of the independent’s variables. To determine which socio-demographic factors were strong predictors of mothers’ use of postnatal care services in the North East Region. The beta (B) values in the beta (B) column of Table 8 showed that only NHIS (B = 0.028) influences mothers’ use of postnatal care positively in the North East Region. All the others predictors have negative influence on mothers’ use of postnatal care. The Wald column in Table 8 showed that marital status (9.073) and religion (6.260) made the most contribution to the model in predicting mothers’ socio-demographic factors and use of postnatal care services whilst education and availability of skilled delivery personnel made the less contribution to the model with Wald values of (0.017 and 0.009) respectively.

The model on mothers’ socio-demographic and use of delivery care showed that education recorded that the highest Beta (B) of (1.221) meaning that education is a strong predictor of mothers’ utilisation of delivery care positively. The data in Table  7 showed that religion negatively influence mothers’ use of delivery care than all the others variables. A critical looked at all the Beta (B) showed that all the variables except education and Availability of skilled delivery personnel influence mothers’ use of skilled delivery care negatively. The study further found that marital status with Wald value of (6.345) and religion with Wald value of (4.877) made the most contribution to the model in predicting mothers’ use of skilled delivery care in the North East Region. NHIS made the less contribution to the model with Wald value of (0.065). Only religion with p -value of (0–026) and marital status with p -value of (0.012) were the only significant determinants or predictors of mothers’ use of delivery services. These recorded p -values < 0.05. This means the others variables were not significant predictors of mothers’ use of delivery care services. The odds ratio (Exp(B)) on this model revealed that educated mothers were three times (3.390) more likely than uneducated mothers to use delivery care. In the North East Region, Christians were 90% more likely than non-Christians to use delivery care.

According to the p-values column in Table  8 , the only significant determinants or predictors of mothers' use of postnatal care services in the North East Region were marital status ( p -value = 0.003) and religion ( p -value = 0.012). The p -values for these two socio-demographic factors were less than 0.05.

From the data presented in Table  8 ; the model on mothers’ socio-demographic factors and use of postnatal care, the Exp(B) represents the ratio-change in the odds of mothers’ use of postnatal care for a one-unit change in the predictors (mothers’ socio-demographic). The Exp(B) for availability of skilled delivery personnel is equal to 1.028, which means that the odds of a mothers who had available skilled delivery personnel at the North East Region who utilised postnatal care were 1.028 times the odds of mothers without availability of skilled delivery personnel in the district. In other words, mothers who with availability of skilled delivery personnel were 1.028 times more likely to use postnatal care compared to mothers lack skilled delivery personnel. This study results implied that availability of skilled delivery personnel increases mothers’ use of postnatal by 1.028 times in the region. This means that more mothers were able to utilise postnatal care services following availability of skilled delivery personnel. Educated mothers were 0.941 (94%) more likely to use postnatal care services compared to uneducated women in the North East Region. Compared to non-Christians’ mothers, Christians’ mothers were 0.98 more likely to use postnatal care. This showed that the traditional beliefs made most mothers to fail to use postnatal care services.

The odds ratio, represents the change in odds of being in one of the outcome categories when the value of a predictor increases by one unit. Table 6 showed that, when compared to uneducated women, educated women were more likely to use ANC in the North East Region.

The findings revealed that the majority of the women in the study area gave birth at home due to factors such as distance, a lack of health care, and poverty. This adds to the labour complications during delivery. According to the literature, the location of a woman's delivery during childbirth is critical in reducing complications [ 27 ]. The findings proposed that primary healthcare facilities be established in rural communities in order to save the lives of rural women. Mothers should also be encouraged to give birth in a health care facility (hospital/clinic) in the presence of a trained professional health care practitioner such as a midwife, doctor, or nurse (Alkafaji and Al-Shamery, [ 28 ]). However, due to a lack of health facilities and qualified trained paramedic staff, the communities studied in Ghana lack professionals capable of providing maternal health care delivery services to mothers during childbirth. The findings contradict the literature, which claims that Ghanaian women meet the WHO maternal healthcare requirement by using facilities [ 2 ]. Furthermore, the findings revealed that most rural areas in Ghana lack health care centres and trained health care professionals required to provide rural mothers with delivery care, and the findings are consistent with the findings that most rural communities in Ghana lack healthcare facilities and healthcare professionals (Alkafaji & Al-Shamery, [ 28 ]).

According to the findings, the most common reason given by mothers for not attending ANC during the first month of their pregnancy was that most women are unable to detect pregnancy during the first month. The timing of a mother’s access to ANC services is critical during pregnancy. The findings imply that pregnant women in the study area lack knowledge, which could be attributed to a lack of health education in rural communities. According to WHO [ 29 ] and Ghana Health Services [ 30 ], the first, second, and third months of pregnancy are the most critical for mothers to use ANC because health professionals can examine the mothers and the foetus and make necessary medical recommendations. The findings, however, contradict the WHO recommendation for the first, second, and third months of pregnancy. Furthermore, the findings contradict the Ghana Demographic and Health Survey (GDHS, [ 31 ]), which recommends monthly antenatal visits for the first seven months of pregnancy, after which pregnant women must visit every two weeks for the next eight months (GDHS, [ 32 ]). Mothers should seek ANC as early as the first or second month of their pregnancy. According to the findings, women should be encouraged to begin visiting the health centre during their previous pregnancy.

According to the findings, women usually discover they are pregnant during the second and third month after missing their menstrual period. This implied that most mothers, regardless of educational level, recognise the value of ANC. Surprisingly, some mothers were unable to recall the month in which they first visited ANC during their pregnancy. These mothers couldn’t tell you how many times they were admitted to the hospital during their previous pregnancy. This implied that some mothers do not see the need for ANC during pregnancy and, as a result, place less emphasis on the number of visits to the hospital for ANC. The findings contradict the literature, which suggests that maternal educational level has a significant influence on healthcare utilisation [ 6 , 33 ].

According to the study’s findings, some mothers in the North East Region have had stillbirths in the last five years. This meant that some children died during delivery in the study area, which is concerning for the mothers who live there. Mothers who had no idea how many times they had attended ANC and those who did not visit ANC services in the early months of their pregnancy may have been among the few respondents who had stillbirths. The findings contradict previous research that found that family planning and fertility preference, as well as free maternal healthcare, reduced maternal and stillbirth rates in Ghana [ 34 ],[ 35 ] [ 36 , 37 ].

According to the findings, socio-demographic factors such as women’s marital status, age, education, religious background, and distance have a significant relationship with mothers' use of health-care delivery services. The findings corroborated Dalaba et al. [ 8 ] and Dotse-Gborgbortsi et al.’s [ 12 ] findings that married women received assistance from their husbands during delivery to the nearest health facility. According to Banchani and Tenkorang [ 38 ], as well as Bellerose et al. [ 39 ], studies conducted in rural Africa revealed that husbands’ religious backgrounds influenced mothers’ use of skill delivery. The findings also lend support to the Andersen behavioural model, which enables characteristics on access to healthcare facilities.

According to the Chi-square test results, mothers’ marital status, age, education, religious affiliation, and distance have a significant relationship with mothers' use of maternal health care services during delivery in the North East Region. According to the literature, socio-demographic characteristics and behavioural variables have a significant influence on healthcare facility utilisation [ 4 , 5 , 9 , 40 ].

The findings support the Andersen behavioural model, which states that characteristics of pregnancy age influence maternal service utilisation. The findings, however, contradict the literature, which indicates that married and educated women use antennal care services more than unmarried and uneducated women [ 16 , 17 , 41 ].

The problem here is that most mothers do not see the need to visit a health care facility after giving birth. Only married women and those whose religious beliefs support orthodox medicine visit the health care centre after delivery. The findings are consistent with previous research showing that women who receive antenatal and delivery care are more likely to receive postnatal care after childbirth [ 4 , 5 , 11 , 42 ].

According to the study, the majority of mothers do not seek medical attention after giving birth. After giving birth, few mothers visited health care centres or used postnatal care services unless their child was sick. This could be due to the fact that the North East Region has many traditional healers who can administer herbal medicine to mothers and their children after birth, and thus mothers did not consider the need for postnatal care. The findings contradict the literature, which claims that free maternal health care has increased utilisation [ 36 , 43 ],GHS, [ 30 ]).

The findings of this study confirmed the findings of the Ghana Demographic and Health Survey [ 31 ] and Ghana Demographic and Health Survey [ 44 ] studies, which found that a woman’s education was important in ANC utilisation in Ghana. Also, Vizheh et al. [ 14 ] discovered, through an analysis of DHS data from Bangladesh, Malawi, Bolivia, and the Philippines, that a woman’s education was a key determinant of mothers’ use of ANC services, just as Stanton et al. [ 24 ] did in their review of DHS data from developing countries. The North East Region's high percentage of educated mothers using ANC services calls for girl-child education.

The study also discovered that young mothers (those under the age of 30) were 40% less likely to use ANC services than older mothers. This supported the findings of Vasconcelos et al. [ 45 ]. In Bangladesh, women’s age was found to have a significant influence on their use of ANC. In addition, mothers with NHIS cards were more likely to use ANC than those without. This meant that the implementation of NHIS had had a significant impact on mothers' use of ANC services in the North East Region. The study also discovered that Christians were more likely than non-Christians in the North East Region to use ANC. According to the study findings, non-Christians seek advice from traditional healers and traditional birth attendants during pregnancy. This study confirmed the findings of Sunguya et al. [ 46 ], who found that only 32.7% of traditional believers visited ANC in Uganda in 2020. The study found that the people of the North East Region’s traditions influence their use of ANC.

The study confirmed the findings of Saaka et al. [ 47 ], Nachega et al. [ 48 ], and Misu and Alam [ 49 ], which found that educated women were more likely than uneducated women to use delivery care. Most educated women emphasise the importance of delivery care and the importance for mothers to deliver at a centre under the supervision of skilled trained health professionals to reduce the risks during childbirth and the potential consequences that may occur during delivery. In addition, Anwar et al. [ 42 ] discovered that religious believers have a significant influence on maternal health care utilisation in Bangladesh. Similarly, Anselmi et al. [ 13 ] and Adamu [ 23 ] confirmed this by indicating that religious beliefs in developing countries such as Africa made achieving the SDGs of improved maternal health difficult. The findings of this study confirmed the findings of Bolduc [ 50 ] and Esena and Sappor [ 51 ], who found that marital status significantly predicts women's use of postnatal care services. The findings are consistent with the literature that the availability of skilled delivery personnel influence the health seeking behaviour of mothers (Adong et al., [ 4 ],Ghana Health Servivr Human Resource Annual Report, [ 52 ] and 2018; [ 53 ]).

The findings of the study demonstrated a theoretical relationship between the availability of skilled delivery paramedical staff, knowledge of pregnancy age, access, distance, and enabling characteristics such as poverty, gender, and traditional treatment, and the use of maternal healthcare services in rural communities. The study discovers a new relationship between the availability of skilled delivery professionals and access and distance, which has implications for the development of public health theories and models.

The study implications and recommendations

According to the findings of the study, the following policy prescriptions should be implemented: increase access to skilled delivery care in the North East Region, as the study discovered that a lack of skilled delivery care limits mothers' access and use of MHCS. To supplement the availability of traditional healers and traditional birth attendants in the area, people should have access to health centres and professional health personnel. Furthermore, the Ghana Health Service should increase public health education in rural areas.

The findings strongly demonstrate that the Ministry of Health and the Ghana Health Service must take practical steps to increase education about the importance of having ANC with a skilled provider, as well as having the first 24 h of recommended primary healthcare services. The findings also show that education level, wealth status, marital status, antenatal care utilisation, health insurance coverage, getting medical help for self-getting permission to go, and distance to health facility all have a significant relationship with MCH utilisation. This implies that tailored educational and pro-MCH interventions must be streamlined in order to recognise the tones influenced by these factors.

The study recommended that mothers be educated about the importance of using skilled delivery care once more. By increasing MHS utilisation, women should be educated on the importance of maternal and child health. Women must regain economic empowerment in order to pay their own MHCS bills. Unemployed mothers should look for work, whether through trade, farming, or raising farm animals, to enable them to earn a living and pay their own medical bills while receiving MHS and they must not rely solely on their partners.

The study also recommended that the government organise training services for the area’s traditional birth attendants (TBAs) in order to provide them with the professional skills required to handle child delivery. The government should create a framework for regulating the activities of traditional herbal practitioners. They should also be trained, and the government should, if possible, integrate traditional and orthodox medicine in the area’s public hospital/clinic.

According to the study, health personnel who accept postings to the North East Region should be given special motivation packages by the local people and district assembly in order to help increase the number of health personnel in the area and solve the problem of insufficient health personnel in the area. The nurse and other health workers in the area educated mothers about the importance of receiving postnatal care after giving birth, as most did not appear to be doing so. To encourage others to learn from the few mothers who used all of these MHCS, the government should implement policies that reward mothers who use ANC, skilled delivery care, and postnatal care.

Limitations of the study

There is no research without limitations (Prince & Murnan, [ 54 ]). Survivor bias may occur as this sample may not be the representative of the entire population due to the exclusion of individuals who did not survive or participate until the end of the study. To Ensure that the study’s data collection period was sufficiently long to capture a diverse range of participants, reducing the impact of survivor bias. Also, inclusion criteria to avoid unintentional exclusions. Another limitation was selection bias which may occurred in certain groups of the population and were more or less likely to be included in the study, leading to a non-representative sample. The simple random sampling was employed to minimise selection bias. Sampling bias was another potential limitation as selected sample may not accurately represent the entire population. Employing random sampling techniques to ensure that each member of the population has an equal chance of being selected. The study's findings may have limited generalisability if the sample did not represent entire population. The authors clearly defined the population of interest and acknowledge any limitations in generalisability. While these mitigation strategies can reduce the impact of biases, it's essential to acknowledge that this study is not entirely free from these limitations (Prince & Murnan, [ 54 ]).

The study has contributed to a better understanding of the factors that influence mothers’ access to and utilisation of skilled delivery care services in rural communities throughout Ghana, particularly in the North East Region. According to the findings of the study, mothers' socio-demographic factors such as married status, age, education, religious background, and distance to health centre, as well as the availability of skilled delivery personnel, have a significant relationship with their access to and use of maternal care and skilled delivery care services. The study’s findings on access to skilled delivery care revealed that women’s marital status, age, education, religious background, and distance have a significant relationship with their use of skilled delivery care at health care facilities. Finally, the Chi-square (2) test results for postnatal care revealed that only mothers’ marital status and religious background were found to have a significant relationship with mothers’ use of postnatal care. Finally, in the North East Region, the only significant determinants or predictors of mothers' use of postnatal care services were marital status ( p -value = 0.003) and religion ( p -value = 0.012).

Ethical statement and informed consent

The study was ethically approved by the Committee on Human Rights, Publication, and Ethics College of Health Sciences, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology. All participants signed/thumb printed written informed consent forms.

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Awinaba Amoah Adongo, Jonathan Mensah Dapaah, Francess Dufie Azumah & John Nachinaab Onzaberigu

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Awinaba Amoah Adongo conceptualised the research topic. He was in charge of the write-up. The data collection and the data analysis of the findings were carried out by Awinaba Amoah Adongo and John Nachinaab Onzaberigu. Professor Jonathan Mensah and Dr. Francess Dufie Azumah were the supervisors for the study. They edited and gave technical assistance in the conduct of the study. They also suggested the methods to use in conducting the study. They also provided technical advice on the statistical techniques used in the analysis.

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Adongo, A.A., Dapaah, J.M., Azumah, F.D. et al. Maternal and child health care access to skilled delivery services among Ghanaian rural mothers. Res Health Serv Reg 3 , 6 (2024). https://doi.org/10.1007/s43999-024-00042-0

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DOI : https://doi.org/10.1007/s43999-024-00042-0

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Healthcare Dissertation Topics

Published by Carmen Troy at January 4th, 2023 , Revised On August 16, 2023

Health care education brings together the science and arts of medicine along with the practice of general education. Healthcare is an education program that is tremendously significant for humans and society.

Medicine, nursing, and all other related health care fields provide a substantial understanding of living beings, disease trends, treatment, treatment outcomes, functional abilities, disabilities, and much more.

The primary purpose of healthcare is to ensure people’s health, look after the patients, and provide information about health risks and their effects. Health care education provides knowledge and information about life and helps survival, to say the least.

We all rely on the health care system to get physically well and resume the mundane course of life after getting affected by a health risk.

Therefore, studying health care is of immense importance as it offers you the opportunity to serve humanity by looking after their health. If you are studying health care science, you will need to complete a dissertation to complete a degree and practice its laws and principles.

It is always a highly complex task to begin the dissertation or even find the motivation. Choosing the right topic can help you cross their mental barrier, however. Look at some of the potential healthcare dissertation topics mentioned below to take an idea for starting your dissertation.

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2022 Healthcare Dissertation Topics

Topic 1: investigating the impact of household air pollution (hap) on the respiratory health of people and recommend measures of intervention.

Research Aim: The research aims to investigate the impact of household air pollution (HAP) on the respiratory health of people and recommend measures of intervention

Objectives:

• To analyse the contributors of HAP.
• To determine the impact of harmful particulate matter on the respiratory health of people.
• To suggest measure for controlling HAP through intervention with biomass fuels.

Topic 2: An assessment of the bioethics issues arising during medicine development and administration to patients and how ethics of public health can be improved

Research Aim: The research aims to conduct an assessment of the bioethics issues arising during medicine development and administration to patients and how ethics of public health can be improved

• To analyse the bioethics challenges associated with medicine development and patent administration.
• To examine the measures of improvement of ethics associated with public health.
• To conduct an assessment of the bioethics issues arising during medicine development and administration to patients and how ethics of public health can be improved

Topic 3: Investigating the present global health security infrastructure and its capacity to detect and prevent the spread of infectious diseases. A case study of the outbreak of Covid-19.

Research Aim: The research aims to investigate the present global health security infrastructure and its capacity to detect and prevent the spread of infectious diseases. A case study of the outbreak of Covid-19.

• To analyse the concept of global health security.
• To determine the current infrastructure of global health security and the position of WHO in detecting and preventing the spread of infectious diseases.
• To investigate the effectiveness of the present global health security infrastructure in dealing with the Coviud-19 pandemic and recommendations for future scenarios.

Topic 4: Investigating the importance of vaccines and childhood nutrition on improving maternal and child health

Research Aim: The research aims to investigate the importance of vaccines and childhood nutrition on improving maternal and child health

• To determine the present challenges of material and child health and its significance in society.
• To analyse the role of vaccines and childhood nutrition on safeguarding the health of the mother and child.
• To recommend the measures to improve maternal and child health for ensuring wellbeing of the families with pre-natal and well-child care for infant and material mortality prevention.

Topic 5: An analysis of the risks of tobacco and second-hand smoke exposure on the cardiovascular health of people in the UK.

Research Aim: The research aims to conduct an analysis of the risks of tobacco and second-hand smoke exposure on the cardiovascular health of people in the UK.

• To contextualise the risk factors of tobacco and second-hand smoke.
• To determine the cardiovascular health impact of the people of the UK due to tobacco and second-hand smoke.
• To recommend measures for reducing and minimising tobacco risks and prevent health impact due to passive smoke.

Topic. 1: COVID-19 and health care system:

Research aim: The prime focus of the research will be analysing the impact of COVID-19 on the health care system and how the health care system was able to handle the health emergency in different regions of the world. The research can pinpoint one location and study its health care system from the perspective of the COVID-19 outbreak.

Topic 2: UN health care policy and its implications

Research aim: UN has a major health department that oversees the health sector around the world. United Nations plays an important role in bringing sustainability in human life such physically, economically, and in so many other ways. The main goal of the research will be to understand and analyse the UN health care policy and identify to what extent it is improving health care systems around the world.

Topic 3: WHO's response to COVID-19:

Research aim: It is an undisputed argument that the World Health organisation was at the forefront when the tsunami of pandemics hit the world. From keeping people informed to ensure the formulation of vaccines, WHO’s role was comprehensive. The aim of the research is to identify how WHO responded to the outbreak and helped people stay protected. The research will critically analyse the plans that were formulated and executed in response to the covid-9.

Topic no.4: The spread of the variant during Olympics and Paralympics:

Research Aim:  Olympics were called from July to August in 2021 in Tokyo, Japan, when delta variant had been engulfing lives around the world. While many people opposed the decision of arranging the Olympics, it ended up with flying colours. But it is said that due to the Olympics and Paralympics, in which athletes from all over the world participated, the delta variant transcended easily.

The aim of the research is to find out whether or not the Olympics and Paralympics helped the widespread of the delta variant. 

Topic no. 5: The Covid-19 Vaccination drive and people's response:

Research Aim: There is a large proportion of people who are still unvaccinated against Covid-19 in the world. The aim of the research is to track the covid-19 vaccination drive around the world. The researcher will also find the key motivations behind their denial.

Topic no. 6: Poverty and its impact on childhood diseases:

Research aim: The aim of the research will be to find out the relationship between poverty and childhood diseases. The researcher can conduct quantitative research by finding out the figures of most affected childhood diseases and their financial data in the world.

Topic no. 7: The motivation towards a healthy:

Research Aim: By and large, it is said that people in a few regions in the world are more motivated towards attaining a healthy life than in other places. The purpose of the research is to find relative and varying motivations to live healthy around the world.

Topic 8: Health crisis in warzone countries

Research aim: Children and women are the most suffered creatures in the warzone areas of the world. The purpose of the research is to identify the health crisis of women and children in places where there is no rule of law.

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Also Read: Medicine and Nursing Dissertation Topics

Topic 9: Scope of Health care research

Research aim: The research aims to identify and analyse the significance of health care research and its effects on humans and society. The researcher will identify the necessity of the study in the field and its overall impact. 

Topic 10: The future of telemedicine

Research aim: Telemedicine refers to the use of technology to disseminate medical information, diagnose, or interact with a patient. Currently, it is gaining tremendous importance, especially due to the pandemic, but it is important to figure out how it will work out in the future.

The research aim of the research would be to find the significance of telemedicine and its prospects.

Topic 11: Controlling infectious diseases

Research aim: The research will aim to find out whether or not infectious diseases are difficult to deal with. The paper will identify all the elements responsible for making infectious diseases unstoppable. The researcher can make arguments in the context of the COVID-19.

Topic 12: Effective health care policies around the world

Research aim: Different countries have different health care systems with different policies around the world. The aim of the research will be to find out the most effective health care systems around the world. The research can incorporate both quantitive and qualitative methods for the study.

The researcher can pinpoint a respective area for the study—for example, the health care system of Nigeria, the United States, or South Asia etc.

Topic 13: Technology and health care system

Research aim: The advancements in technology have transformed all aspects of our life, and the health care system is no exception.

The main aim of the research will be to find out the impact of technology on the health care system.

Topic 14: Health care system in 2030

Research aim: The aim of the research will be to identify trends and forecast the future on their basis. The researcher will examine the health care system today and study the elements that may bring about change and may modify it in the future. The projections must base on evidence.

Topic 15: The emotional impacts of COVID-19

Research aim: The COVID-19 affected normal life significantly. People were locked in the homes, and the roads and streets were empty. In that perspective, it is significant to understand how(if it did) affected people emotionally.

The main aim of the research will be to find out how and to what extent COVID-19 affected people emotionally. 

Topic 16: Beauty standards and how they impact the health of humans

Research aim: Neither being skinny is healthy, nor starvation is the solution to getting a perfect body shape. The standard beauty standards have persistently put social pressure on individuals to become as per se. Otherwise, they will be neglected or segregated. The research will aim to find out how people who try to meet the standard beauty standards affect their health. 

Topic 17: Depression and anxiety in adults in developed countries

Research aim: Depression and anxiety are some common instances that occur to almost all people. It may apparently look like people in developed countries, having access to their basic needs, must not have anything to worry about. It might not be what looks from the outside. The research will measure the rate of increase or decrease in depression and anxiety in adults in developed countries and identify the key determining factors.

Topic 18: Creating awareness of Breast cancer in third world countries

Research aim: The aim of the research will be to identify why it is important to create awareness about breast cancer in third-world countries and identify how to do so.

Topic 19: Gene therapy for hemoglobinopathies

Research aim: Haemoglobinopathies are genetic problems that affect the structure or formation of haemoglobin. One recent research identifies gene therapy as a solution to the disorders. The research will aim to identify how effective gene therapy is and in what capacity it can be used in medicine in the future.

Topic 20: The unspoken problems of health care managemnt

Research aim: While it is so much it is stressed on ensuring the treatment of patients and advancing healthy life of humans in generals; there is a very little say about what problems, who are responsible for managing, may face. The research aims to identify the undiscussed problems faced by health care management to ensure a healthy life for people.

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Frequently Asked Questions

How to find healthcare dissertation topics.

To find healthcare dissertation topics:

• Examine emerging health issues.
• Analyze gaps in healthcare.
• Review medical literature.
• Consider policy or technology impacts.
• Explore patient perspectives.
• Select a topic that aligns with your passion and career aspirations.

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Are you having trouble finding a good music dissertation topic? If so, don’t fret! We have compiled a list of the best music dissertation topics for your convenience.

Consumer psychology has always been a well-known yet understudied field in psychology. The psychology of consumption describes how people adopt, use, and eventually dispose of goods, services, or concepts.

Go through some of the dissertation topics related to entrepreneurship given below, with their research aim, and get an idea to begin your dissertation.

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Centering Maternal and Infant Health in the Workplace

In a radio interview, DGHI's Aunchalee Palmquist says a lack of paid maternal leave forces many mothers to give up on breastfeeding, and that's bad for mothers and babies.

Aunchalee Palmquist, an associate professor of the practice of global health, studies breastfeeding and lactation.

Published May 2, 2024 under Commentary

In the U.S., relatively few employers offer long-term paid maternal leave, which creates a challenge for mothers who want to breastfeed their infants. And that, says DGHI associate professor Aunchalee Palmquist , Ph.D., needs to change. 

Palmquist, a medical anthropologist who studies breastfeeding and lactation, discussed the structural barriers that force many women to abandon breastfeeding during an April 21 episode of “ Conversations on Health Care ,” a program co-hosted by DGHI professor Gavin Yamey, M.D., on Duke’s radio station, WXDU. 

Without paid leave, many women have no choice but to return to work to afford food and health coverage. But continuing breastfeeding while working can be complicated, forcing many mothers to switch. 

“[Because of] these circumstances, it’s impossible to establish and sustain lactation and breastfeeding as recommended,” Palmquist said during the interview. “This policy failure is one of the primary reasons why breastfeeding is so poor in this country.”

Conversations on Health Care, Episode 4

Palmquist advocated for longer paid maternal leave as one of the policy changes that could help more women continue to breastfeed their babies, which she noted is critical to infant health and providing natural immunity to diseases. She also urged a stronger voice for women and a greater emphasis on maternal and infant health in shaping workplace policies.

“Any situation where women’s health, well-being or rights are at stake, women should be at the table and leading those changes,” she said. “You want to listen to the people who are closest to the problem.” 

At Duke, Palmquist recently was awarded a university fellowship to  incorporate climate and sustainability into her teaching. She is revamping a course on global maternal and child health to include a focus on the impact of climate change on mothers and children. 

“I think about participating in a legacy of women from all over the world who have been doing this for a long time,” she said during the radio interview. “This is what keeps me going, knowing in some small way, the teaching I do moves us toward a place centering maternal and child health.” 

Palmquist appeared on the fourth episode of Conversations on Health Care, which Yamey co-hosts with Duke students Daniel Robelo, who’s majoring in neuroscience and philosophy, and Gareth Kelleher, a Class of 2024 graduate with a double major in biology and global health. Each episode of the radio program features a pre-recorded syndicated interview with a national health expert, followed by a live in-studio interview with a guest from the Triangle.

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• Maternal, adolescent and child health
• United States
• Aunchalee Palmquist ,
• Gavin Yamey

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Alumni Highlight: Hannah Davidson

Meet hannah davidson.

Hannah Davidson—a recent ScM in Genetic Counseling alum—reflects on pursuing genetic counseling training following her experience as a doula, gaining critical clinical and research skills during her time as a student, and navigating post-grad life as an early-career, rare disease genetic counselor.

• Program:  ScM in Genetic Counseling
• Graduation year:  2024
• Fun fact: “Growing up, I was not your typical ‘STEM’ student! I loved English/language arts and the arts in general and thought for a very long time that I was going to be an art teacher or arts therapist.”
• Hometown:  Western Massachusetts (although Baltimore/the DMV has become a second home)

Finding a Path to Public Health

What sparked your interest in public health?

My interest in public health began in my early 20s, when I made the decision to do birth and postpartum doula training. I had always been interested in childbirth and child-rearing and had heard about doulas from some family friends. I was really fortunate to be trained by a seasoned homebirth midwife. Although doulas do not deliver babies themselves, we provide skilled support on things like movement in birth, postpartum care when a parent returns home, and empowering families to advocate for themselves in an often-challenging medical environment. 

Doing this work introduced me to the complex considerations of maternal health in the United States. It left me curious about how we apply scientific knowledge to care, how we account for those who are systematically left behind to improve healthier outcomes for all, and importantly, how we can provide care that is informed by rigorous research but also continues to center interpersonal connection. 

My training as a doula brought me back to college, first as a community college student in the sciences, and later to Hampshire College, where I designed a major in maternal health, medical anthropology, and human biology.

What led you to join the Department of Health, Behavior and Society ?

After graduating from undergrad, I thought very carefully about where in healthcare I wanted to land. I knew that I wanted to build clinical skills and expertise, but I also didn't want to completely neglect my growing interest in research. I was also starting to come to terms with the fact that medical school was maybe not the best fit for me personally or professionally. 

My last year of undergrad, I was a NIH Undergraduate Scholarship Program recipient. This award was tied into a ‘payback’ year in a lab of my choosing at NIH. I ended up in Dr. Laura Koehly's lab at the National Human Genome Research Institute. NHGRI is a social science research group that explores how the social network and communal coping comes to bear on the rare disease caregiving experience. This work introduced me to the world of rare disease and genetic medicine, including (importantly) genetic counselors. 

Genetic counseling felt like a great marriage of my interests in science, research, and the human element of care. When it came time to apply, I wanted to attend a genetic counseling program that would emphasize these elements in equal measure. The ScM in Genetic Counseling, which is a part of HBS, is a rigorous program that does not sacrifice any of these components of genetic counseling training. They are really invested in us leaving the program as strong social science researchers, counselors, and clinicians.

Building Knowledge, Skills, and Community

What were some academic, research, or practice highlights you experienced when you were an ScM student? 

My first year of graduate training, I was a fellow the Center for Medical Humanities and Social Medicine at Johns Hopkins. This was a great interdisciplinary team of graduate students from the Anthropology, Philosophy, Public Health, and History of Medicine Departments. Our conversations were often humbling and perspective-shifting for me, especially during my first year of genetic counseling training.

I would also be remiss if I didn't talk a little about my thesis experience, which was born in part out of a summer rotation with the National Institutes of Allergy and Infectious Disease. This was a combined clinical and research rotation, where I saw patients as part of NIAID's centralized sequencing program while also supporting an interview study with patients living with an inborn error of immunity. These interviews were very general in nature, covering patients' illness narratives, experiences with anxiety and depression, and strategies for adapting to their illness. We also asked a few brief questions about reproductive planning, which later informed the development of my thesis. 

Another important part of my thesis process was my committee. In addition to Morgan Similuk, the genetic counselor and PI for NIAID's study, I had an amazing committee including Jill Owczarzak (my advisor), Leila Jamal , and Rebecca Mueller from Penn's Bioethics department. Jill really championed my prior interest in medical anthropology and bringing this work in conversation with my data. A standout class during my time in HBS was Jill's ethnographic methods class, which wasn't required for my degree but afforded me the opportunity to underscore my interest in an area of social science research that few genetic counselors are exposed to.

How did you build your sense of community during your time as an HBS student?

The genetic counseling ScM program is tiny! My cohort was the largest in our program's history, with seven students. We got very close over time, both with our cohort as well as the cohorts above and below us. I also have a close community of friends in Massachusetts who I remain very connected to and used Bumble BFF to make some friends outside of the Hopkins bubble. Building community matters a lot to me!

And of course, my fiancé, who I met shortly after I moved to Baltimore for grad school, has been a huge support and source of community for me, and I am very thankful for them!

Outside of public health, what are some of your hobbies, interests, and personal passions?  T

The arts are still a huge outlet for me. During grad school I was involved with Tendon , the medical humanities journal at Johns Hopkins, and I like to take advantage of the free museums in the city (including the Baltimore Museum of Art and the Walters) and creative events in Baltimore. In the last year, I've gotten especially into experimental forms of expression, like contact improvisation and experimental music performance.

Transitioning to Post-Graduate Life

What was your experience like navigating life after graduating from HBS?

I am a few months out from graduation and really settling into the role of early-career genetic counselor! I ultimately followed my continuing interest in research and was fortunate to secure a position as a research genetic counselor with the Telomere Center at Johns Hopkins. We are a translational research lab focused on understanding the role of telomeres in disease. 

In my role as a genetic counselor for the team, I support the enrollment of individuals affected by, or suspected to be affected by, telomere disorders. This work includes day-to-day operations like consenting participants and interpreting genetic variants, but also broader gene discovery efforts and clinical management considerations. Long-term, I am hoping to have a role in clinician education on these conditions as well as involvement   in research on genetic counseling considerations for telomere syndromes.

What professional, educational, or other opportunities have you been pursuing since graduating from HBS?

The reality is that even the most rigorous genetic counseling program cannot account for the myriad dimensions of genetic medicine. The disease context I work in presently—telomere syndromes—is rare enough that I encountered these conditions once in my training through a 30-minute lecture! So, there is a lot to learn about the genetics of telomere syndromes. I am excited to be attending a short course in mammalian and human genetics this summer, where I'll get to learn alongside Hopkins medical genetics residents and genetics PhD students about experimental genetics. 

Outside of my work, I am also actively planning the dissemination activities for my graduate thesis, which explored reproductive planning considerations for patients living with inborn errors of immunity, which are another set of rare diseases that impact the immune system. I'll be presenting my thesis at ELSIcon this summer and will hopefully (fingers crossed) be submitting my thesis to a journal soon.

How did you find and land your role?

My partner and I knew that we wanted to stay in Baltimore (he is developing a zero-waste cooperative in the city). I knew specifically that I wanted to work in a research-related role. I was drawn to the idea of working with individuals affected by a rare condition for which we were still developing our clinical understanding and expertise. 

My position had been open for some time, and I reached out a few months before graduating just to see if they'd consider a December 2023 grad. Fortunately for me, they were really waiting for the right person to fill my role, and they decided that person was me!

What advice do you have for prospective or current public health students?

Follow your curiosity, even if it takes you down unexpected paths! When I look at where I am now, it is leagues away from where I thought I would have landed were you to talk to me 10 years ago. At each turn I have grown and come to know myself in profound ways that I may not have if my path were to look a little more linear and conventional. 

In a similar vein, do not be afraid to challenge dominant narratives within your profession or public health in general. Some of my most meaningful developments as a genetic counselor and researcher came from moments where I listened to the feeling that a dominant narrative didn't feel “right" or like it accounted appropriately for the complexity of human experience. It is these moments where it has felt like the tools and knowledge my training gave me really got to be put into action.

Is there anything else about your public health journey that you'd like to add? 

There are only a few genetic counseling programs nationally which are housed within schools of public health. I do not think I had a full sense of the value that this perspective lends to genetic counseling practice! 

The work I am doing now makes full use of the skills I developed as an HBS student, and in the areas where I am intellectually stretched, I feel I have the capacity to learn and grow from this reaching because of my education in public health. In that sense, I think public health training is fundamentally the start, and not the end, of a fulfilling intellectual and professional journey that may not always be clear-cut at the start. If you can embrace that uncertainty, you'll be in for an exciting and meaningful ride.

This interview has been edited for length and clarity. Views expressed are the subject's own.

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Essays on Maternal and Child Health, Fertility, and Economic Well-Being in Low- and Middle-Income Countries

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Victor Mukhin

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Title : Active carbons as nanoporous materials for solving of environmental problems

However, up to now, the main carriers of catalytic additives have been mineral sorbents: silica gels, alumogels. This is obviously due to the fact that they consist of pure homogeneous components SiO2 and Al2O3, respectively. It is generally known that impurities, especially the ash elements, are catalytic poisons that reduce the effectiveness of the catalyst. Therefore, carbon sorbents with 5-15% by weight of ash elements in their composition are not used in the above mentioned technologies. However, in such an important field as a gas-mask technique, carbon sorbents (active carbons) are carriers of catalytic additives, providing effective protection of a person against any types of potent poisonous substances (PPS). In ESPE “JSC "Neorganika" there has been developed the technology of unique ashless spherical carbon carrier-catalysts by the method of liquid forming of furfural copolymers with subsequent gas-vapor activation, brand PAC. Active carbons PAC have 100% qualitative characteristics of the three main properties of carbon sorbents: strength - 100%, the proportion of sorbing pores in the pore space – 100%, purity - 100% (ash content is close to zero). A particularly outstanding feature of active PAC carbons is their uniquely high mechanical compressive strength of 740 ± 40 MPa, which is 3-7 times larger than that of  such materials as granite, quartzite, electric coal, and is comparable to the value for cast iron - 400-1000 MPa. This allows the PAC to operate under severe conditions in moving and fluidized beds.  Obviously, it is time to actively develop catalysts based on PAC sorbents for oil refining, petrochemicals, gas processing and various technologies of organic synthesis.

Victor M. Mukhin was born in 1946 in the town of Orsk, Russia. In 1970 he graduated the Technological Institute in Leningrad. Victor M. Mukhin was directed to work to the scientific-industrial organization "Neorganika" (Elektrostal, Moscow region) where he is working during 47 years, at present as the head of the laboratory of carbon sorbents.     Victor M. Mukhin defended a Ph. D. thesis and a doctoral thesis at the Mendeleev University of Chemical Technology of Russia (in 1979 and 1997 accordingly). Professor of Mendeleev University of Chemical Technology of Russia. Scientific interests: production, investigation and application of active carbons, technological and ecological carbon-adsorptive processes, environmental protection, production of ecologically clean food.   

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