This section addresses the first objective of the study and is organized into three main sub- themes describing the nature of women’s knowledge relating to the MEP. The first category includes women who had knowledge of the MEP prior to pregnancy. The second consists of
women with no knowledge of the MEP prior to pregnancy or during the initial stages of pregnancy (1-3 months), while the third captures misperceptions surrounding the MEP.
5.2.1
Women with Knowledge of MEP Prior to Pregnancy
Findings of both interviews and focus groups revealed women were somewhat aware of the MEP prior to pregnancy. This was attributed to policy knowledge dissemination from health personnel at facilities or education sessions in the village, with fewer women obtaining knowledge through the radio:
…the nurses normally gather women together to educate them. If you’ve missed your first period they tell you to go and get tested, and if you’re pregnant you go and get registered, then you attend free antenatal care and everything else until you give birth (Abena, IDI, 26).
Once enrolled, some women were aware of the provided services through the MEP, most often noting the use of antenatal care and its benefits for child development:
Sometimes they do laboratory tests on us (urine, fecal). For me it’s through the antenatals that you actually know if you can have a safe delivery, if you’ll have complications, or if you need a caesarean section. I had two caesarean sections, and it was because of the care (FGD, 1).
Despite awareness surrounding antenatal care, fewer women were informed of the services covered during the postnatal period. This may suggest poor education of the coverage under MEP during the postnatal period, or may suggest district-to-district variations in the way knowledge is disseminated
.
5.2.2
Women with No MEP Knowledge Prior to Pregnancy or During
Initial Stages (1-3 months)
A second group, women with no knowledge of the MEP emerged during the analysis. Here it was revealed that MEP information was acquired only once these participants realized they were pregnant and sought care at a facility:
I wasn’t aware of the maternal exemption and free registration for pregnant women. It was only when I went to the clinic for care when I recognized I was pregnant that I found out about the free service (Alice, IDI, 21).
Women expressed that free coverage under the MEP was only realized once accessing a health facility to enroll in NHIS. Given the delayed timing for procurement of the MEP, many women lacked proper health care during initial stages of pregnancy.
5.2.3
Misunderstandings of the MEP
A third group of women in both interviews and focus groups held a high level of misunderstanding regarding the MEP, with dominant sub-themes pertaining to the MEP’s implementation, provision of services, and the benefits of MEP enrollment.
While some women agreed they could access services at health facilities unconditionally, others reported irregularities in treatment, expressing one antenatal care visit was allowed every three weeks. These women revealed if care was sought before the three week period, they were refused services:
I go every month but would like it to be more regular. You have to go in the third weeks’ time after you had seen a nurse. If you go in the second week and you are sick they’ll turn you away. It has to be in the third week. I’d want it to be more regular so anytime I could go if I had problems (Lydia, IDI, 22).
On the contrary, health personnel said women can access care unconditionally if they are sick, while normal antenatal assessments are to be done once a month:
They can come once a month, that is if you’re ok, but if you’re sick, you come every two weeks and it’s free (Nurse, KI).
Conflicting responses by women and health personnel expose a high level of uncertainty surrounding proper functions and services provided under the MEP, which was experienced by many women.
Further problems relating to the availability of services provided at CHPS were discussed by many women, revealing a discrepancy in actual availability of services, compared to suggested
care provision. Despite clear signs outside CHPS compounds presenting the services to be provided at the clinic and statements from health personnel specifying 24-hour care provision, women revealed many irregularities surrounding available health services:
When you go to the CHPS, after 3pm no matter what’s worrying you they will tell you they’ve closed and won’t care for you. The nurse will be there and you’re knocking, but they won’t mind you….the nurse will say “Oh I’m tired, you go home, we can’t treat you today” (Mary, IDI, 20).
Moreover, women specified all designated CHPS intended to provide maternal health care and delivery do not actually support and deliver women. Even though the Ghana Health Services implemented CHPS to facilitate community access to health care, including MHC, women spoke frequently about the scarcity of services provided at CHPS:
It’s easier to get to the CHPS, but you can’t deliver there… They’ll refer you to Jirapa hospital, but you have to get there yourself and that’s about seven miles (FGD, 7). These shortcomings in health system management posed accessibility challenges for pregnant women in remote locations when seeking MHC, especially when labour occurs. Despite the government intentions of creating accessible health care, results from this study indicate
accessibility difficulties endured by many women highly problematize maternal health outcomes. Additionally, participant’s responses reveal various levels of understanding of the MEP and the provision of health services, which clearly portrays a disconnect between the national narrative of “free maternal health care for all” and the reality of women’s knowledge of maternal health care availability in the UWR. As discussed below, misunderstanding surrounds MEP services, threaten access and utilization for further maternal health needs.