Abstract: The survival and wellbeing of a mother is important in addressing the Millennium Development Goal (MDG 5) which aims at improving maternal health by reducing maternal mortality. The health care that a mother receives during conception, delivery and postnatal is crucial in preventing complications which lead to disability or death of the mother or child. Even with the best possible antenatal care, any delivery can become complicated. Therefore skilled assistance is essential (GSS 2009). In the more developed countries, skilled attendance is about 99.5% whereas that of Africa is 46.5% (WHO, 2008) and Ghana was 59% in 2008 (GSS 2012) below the WHO target of 85% in 2010 (WHO, 2005). The Ga East Municipality of Ghana has a skilled delivery trend of 29.8% in 2008, 31.6% in 2009 and 37.5% in 2010 respectively (Ga East District Annual Report, 2010). Factors associated with this trend is unknown and needs to be investigated. The main objective of this study is to determine the various factors associated with utilization of skilled delivery services in the Ga East Municipality. Specifically it seeks to determine the proportion of births attended to by skilled birth attendants, identify the socio- demographic characteristics associated with access to skilled delivery services, and also to identify the barriers to the utilization of skilled delivery services. A cross sectional descriptive study design was used. Quantitative research methods were employed using structured pretested questionnaire. A study population of women (15- 49 years) who have delivered within one year prior to the study in the Ga East Municipal area was used. Stratified sampling and simple random sampling were employed using a sample size of (394) participants. The data entry and analysis was done using the Statistical Package For Social Sciences (SPSS) software. Association between variables was determined using the Chi Squared Test. The findings showed that a majority of respondents 371 (94.1 %) attended ANC. About 79 % had skilled assistance at delivery with the remaining 21% delivering at home. Maternal education, occupation and household income as well as religion showed statistical association with the utilization of skilled delivery. The study sort to find out what the barriers to utilization of skilled delivery and these include: transportation difficulty 43%, high cost of care 27.7%, high cost of transport (25.3 %). A few cited influence of family decisions, poor attitude of health workers and poor quality care as some of the challenges. The rest were traditional / cultural or religious reasons. These challenges need to be addressed to improve skilled delivery services in the district.
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as a reasonable standard of physical environment else they consciously change their place of delivery and make same recommendations to others if they experience degrading and unacceptable behaviour from health professionals. Perceived quality of care, which only partly overlaps with medical quality of care, is thought to be an important influence on health care-seeking. A study by Thaddeus and Maine confirmed that assessment of quality of services "largely depends on people's own experiences with the health system and those of people they know". Although some elements such as waiting times can be measured objectively, the perception of whether these are a problem and affect quality is more subjective. Elements of satisfaction cover satisfaction with the outcome, the interventions and with the service received including staff friendliness, availability of supplies and waiting times. In many cases, the woman may dislike the health facility protocols such as the situation when family members are not allowed to be present, supine birthing position is imposed or privacy not respected; this may lead to perceptions of poor quality (Thaddeus and Maine 1994)
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Generally, experts agree that about 20.0% of stillbirths or deaths due to intrapartum-related complications can be reduced if births are attended to by skilled personnel . Worldwide, it is estimated that about one in every four births (25.0%) occur without the assistance of a skilled birth attendant. In low and middle-income coun- tries, this figure translated into more than 40 million in 2015. Ninety percent (90.0%) of these happened in South Asia and sub-Saharan Africa . In Ghana, recent esti- mates by the 2014 GDHS indicated that only 73.0% of births occurred in health facilities, of which the public sector accounted for the largest proportion. This per- centage was an increase since the 2008 GDHS (57.0%). This implies that some 27.0% of women did not utilize health facilities, but rather for reasons such as cost, distance to health facility and concerns about quality of care delivered at home . The survey further showed that close to three-quarters of births (74.0%) in Ghana occured with the assistance of a skilled health profes- sional. The 74.0% comprised of 14.0% deliveries assisted by a doctor; 57.0% deliveries assisted by a nurse or mid- wife; and 3.0% deliveries assisted by a community health officer/nurse. Sixteen percent (16.0%) of births were de- livered by a traditional birth attendant, 7.0% were assisted by a relative or other person and 3.0% of deliver- ies were not assisted by anyone. The survey also indi- cated only 60.0% of rural women were delivered by a skilled provider as compared to 90.0% in urban areas . Studies on utilization of skilled delivery services have demonstrated that the decision to use such a service is influenced by multiple factors. Interestingly, while certain factors have been found to be significant in determining the use of skilled delivery services in some studies, these same factors were found to be insignificant in others . This difference in study results notwith- standing, individual factors such as maternal age, educa- tion, marital status, parity, household factors also including family size, household wealth and community and environmental factors including region, community health infrastructure, available health facilities and dis- tance to health facilities have been identified to operate in diverse contexts to determine place of delivery .
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In conclusion, health insurance coverage was low in Tanzania. Also, maternal services utilization such as rec- ommended timing of ANC initiation, completion of rec- ommended number of ANC visits, and skilled birth delivery was low. Having health insurance was associated with recommended timing the first ANC visit and in- creases the chances for health facility delivery under skilled health worker. Our results highlight the potential role of health insurance in improving maternal health and therefore address areas of improvement in the newly in- troduced Sustainable Development Goals number three and five. These study findings also provide guidance for policy makers in low- and middle-income countries on the role of health insurance coverage in utilization of ma- ternal health services. Increase in health insurance cover- age alone may not bring about the desirable changes in maternal health. It is also important to address other health system challenges to attain and sustain better ma- ternal health in this settings. Such challenges are on the health system pillars such as poor human resource for health, medical supplies, information technology, and stewardship.
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We therefore recommend that improved quality service delivery would be an important and critical intervention to increase the access of rural women to antenatal and de- livery care in PHCs. In this regard, attention needs to be paid by policymakers and health providers to addressing physical distance of PHCs, improving PHC infrastructure, availability of health personnel, reliability of drugs and equipment supplies, constancy of opening times and re- duction in costs of services. Innovations and creativity around transportation of women to PHCs when in labor, community support for costs alleviation such as health in- surance, community health education, and linkages to higher level care through the development of an effective- ness referral system would build confidence in the use of PHCs for antenatal and delivery care among rural women. Contrary to our expectation, cultural preference for home births did not significantly feature as a reason for non-use of PHCs for antenatal and delivery care. Among the cohort of women, only two reported that they preferred traditional birth attendants while five reported that culture forbids the use of facility delivery. Also, the fact that being a Muslim in the LGAs (with multiple religious affiliations) increased the odds of PHC delivery suggests that religion is not an im- portant deterrent, with all religious faiths in the two LGAs showing substantial use of health facilities. We believe that community health education can counter the effect of cul- ture and tradition and increase the use of PHCs by rural women for skilled pregnancy care.
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Inadequate of access to antenatal, intrapartum and postnatal health care services are among the prominent reasons for high maternal and child morbidities and mortalities in SSA and the world at large [5, 6]. Maternal health care services continue to be important indicators for monitoring the improvement of maternal health out- comes, as well as maternal mortality. In addition, ante- natal care, institutional health delivery with skilled birth attendant, and postnatal care strengthen prompt man- agement and treatment of pregnancy related complica- tions to reduce maternal mortality. Besides the benefits of institutional based delivery in the prevention of ma- ternal death, more women give birth utilizing alternative places such as home and Traditional Birth Attendants (TBA) who are not knowledgeable in modern obstetric care . One of the major pillars of the Safe Mother- hood Initiative is antenatal care, which helps to provide interventions that are essential for positive pregnancy outcomes . World Health Organization (WHO) re- mark that receiving antenatal care not less than four times increases the odds of receiving valuable health care promotion and preventive maternal health care in- terventions during antenatal visits [9, 10]. Furthermore, family planning is also a vital indicator of the Safe Motherhood Initiative to reduce pregnancy related com- plications and death in developing countries .
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Among the social factors, education of mothers appeared to be the most important predictor in deter- mining the utilization of institutional delivery care after controlling other variables. Many previous studies con- ducted in developing countries have found education of mothers to be among the most important determinants of skilled delivery care utilization [20,21]. There are a number of explanations that speculate as to why educa- tion is a key determinant of skilled care demand. For ex- ample education is likely to enhance female autonomy so that mothers develop greater confidence and capabil- ities to make decision regarding their own health, as well as their children. It is also more likely that educated women demand higher quality service and pay more at- tention to their health in order to insure better health for themselves. Moreover, educated women are more likely to be aware of difficulties during pregnancy and as a result, they are more likely to use maternal health care services .
In Bangladesh, the reduction of maternal mortality and expansion of safe motherhood services have been the cen- tral policy focus since the late 1990s. This is reflected in the Health and Population Sector Strategy (HPSS) and the rights’ based National Policy for Maternal Health of 2001. This policy placed greater importance on improving ma- ternal health and advancing access to maternal health care in rural area. A central program feature has been to de- liver an Essential Services Package (ESP) that includes comprehensive services for pregnancy, delivery and neo- natal care at primary level health care facilities throughout the country . The maternal health related MDG tar- gets for Bangladesh include reducing MMR from 574 per 100,000 live births in 1990 to 143 per 100,000 live births by 2015 (a 75% reduction), increasing the proportion of births attended by skilled health personnel from 5% in 1990 to 50% by 2015 and obtaining universal coverage of at least one ANC visit by 2015. Over the last two decades, Bangladesh has made commendable progress in achieving these goals. For instance, MMR has dropped from 574 per 100,000 live births in 1990 to 170 per 100,000 live births in 2013 . In addition, approximately 79% of pregnant women had at least one ANC visit to any healthcare pro- vider in 2014 .
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Safe motherhood initiative recommended the importance of access to quality maternal healthcare services and the need of presence of skilled professional at every delivery.(9). The MDG has the aim of reducing maternal mortality ratio by two third and achieving universal coverage of reproductive health by 2015. Skilled attendant at delivery has on improving maternal health outcomes.(9, 10) ANC service is important as it offers pregnant women an opportunity to get different services (11, 12). Deaths due to the other common causes of maternal death like sepsis, hemorrhage and obstructed labour started to decrease during the 20th century. (11,13). A focused ANC model in addition to its direct contribution to better health can also contribute to safe delivery (14, 15) The ANC utilization has increased more than 20% in all the regions of the world except the sub-Saharan regions where only 4% increase was noted.(16,17) Studies reported that a mother‟s positive perception of birth experience has been linked to positive feelings toward her infant and adaptation to the mothering role (18, 19, and 24). ANC utilization coverage is not high in Ethiopia. Those even have ANC follow up attend delivery at home though Safe delivery service is a single most important area that actions and interventions should address in all rounds to achieve the MDGs concerning maternal health. There is a need to identify some areas of disparity in this regard where the findings can guide to design appropriate package. Hence this study aims assessing utilization of ANC and level of satisfaction of mothers‟ with delivery service in selected public health facilities of Wolaita Zone, Southern Ethiopia.
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Skilled maternal care refers to maternity services (antenatal, delivery, and postnatal care) by a health professional with midwifery skill that can be provided at different levels (home, health centers or hospitals). In order to provide such skilled maternal care, we need to have an enabling environment and skilled providers. An enabling environment include; functional health facilities and a reliable referral system to link the different levels, awareness and readiness of the community for utilizing skilled care as well as supporting the policy and political commitment . Health professionals who have been educated and trained to proficiency in the skills needed to manage normal pregnancies, childbirth and the immediate postnatal period, and in the identification, management or referral of complications are categorized as skilled care providers [7,8]. In the study, skilled providers include midwives, nurses, health officers and doctors.
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Post-natal period is defined by World Health Organization (WHO, 2010), as the period one hour after the delivery of the placenta and includes the six weeks that follow. This period is called postpartum period when referring to the mother alone and post-natal when referring to both mother and baby. The services provided during this period are referred to as post-natal care (PNC) services. WHO (2013) suggests that there are some "crucial" moments when contact with the formal health system during the post-natal period by skilled attendants could be instrumental in identifying and responding to needs and complications after childbirth. These are: the first few hours after birth (whether at home or in a health facility), between three to seven days, and at six weeks (Lawn & Kerber, 2006). However, it has been noted that many women who give birth at health facilities in the developing world are discharged within hours after childbirth without any indication where they can obtain further care or support (Titaley, Dibley & Roberts, 2009).
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[16,26]. This may be due to the fact that women with more ANC visits also showed a higher satisfaction with the care quality and hence more likely to use health serv- ices for delivery. It is also a fact that many ANC visits expose the women to more health education and coun- seling which are both likely to increase service utilization. This finding lead previously to a recommendation that although antenatal care may not be efficient in identifying women who are most in need of obstetric care, if pro- moted it may become an effective instrument to facilitate better use of emergency obstetric care services . Surprisingly women who reported illnesses/pregnancy complications during pregnancy did not have an increased chance to use health facilities. This may be due to wrong perceptions of causation which lead them to seek care from traditional healers instead of modern health facilities.
The prevalence of home deliveries in some parts of Kajiado County is as high as 77.8%. 8 The proportion of mothers assisted by traditional birth attendants during delivery is equally high at 56.7%. This poses a high risk to both the mother and new born. 8 Despite Kajiado District having 145 health facilities, several problems affecting skilled delivery utilization exists. The county is predominantly Maasai pronounce for their strong culture and traditions including female genital mutilation which can pose grave danger to the women during childbirth and especially if unattended by a skilled attendant. It is noted that Maasai’s have unique economic, social, cultural and environmental characteristics which could play a role in that respect as well as the level of knowledge, attitude, practice and their perception towards modern health facilities. No substantive study has related these to utilization in delivery services in Kajiado North. 7 This study therefore aimed to evaluate the interplay of economic and education and other determinants on the choice of place of delivery and utilization of skilled delivery services by Maasai women in Kiekonyokie ward of Kajiado county.
Over the last few decades, there has also been a growing drive towards examining the processes of care and improv- ing these processes (quality improvement) in addition to providing inputs with an aim of improving health out- comes [7-9]. Considerable experiences and results exist on applying quality improvement in resource-rich country set- tings [10-14]. Adaptation and applications of similar meth- odologies in middle- and low-income countries have also demonstrated reasonable success . However, there are several shortcomings of most of the documented evidence on application of quality improvement to strengthen the health sector in low-income country settings. First, many published studies have mainly provided data on the appli- cation of quality improvement to single technical areas such as scaling up active management of third stage of labor, as opposed to integrated health care services . Sec- ond, these studies have mainly concentrated on adherence to standards and guidelines [8,9]. It is worth noting that a majority of the inhabitants in low-income countries espe- cially in sub-Saharan Africa may not reach the health care facility and seek alternative health care from trad- itional healers/practitioners and traditional birth atten- dants [15-17]. Therefore concentrating solely on adherence to clinical standards at points of care without deliberate at- tention to increasing utilization of critical services such as antenatal care (ANC), skilled delivery, prevention of mother-to-child transmission of HIV/AIDS (PMTCT), and early newborn care, among others, may not have a significant impact on population health outcomes in rural resource-poor settings.
There is insufficient use of PPFP services at Ntchisi District Hospital. About 25% of the women do not use the services during the first year of delivery. Furthermore, this proportion was above the national figures. For those who used the services, some started later after they had already resumed sex. Resumption of sex before procur- ing an FP method puts women at the risk of having closely spaced pregnancies and childbirth. There is a need to remove the barriers that hinder effective use of PPFP services which included the participants’ level of educa- tion, desire to have many children, inadequate counselling of the mothers, and parity of the women. Influence of subjective norms such as husbands and parents, past experience with the methods, duration of amenorrhoea and time of resumption of postpartum sexual activity were also major determinants for the use of the services. Myths and misconceptions related to the methods like fear of infertility and malformed babies, abortions and twin pregnancies after stopping using the methods also hindered contraceptive use. There is therefore a need to train the women and their husbands in order to dispel the misconceptions and myths regarding FP which in turn will promote more effective PPFP service utilization in the district.
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Distance to the health facility, perception of mother to availability of adequate equipment in the delivery service in their catchment area, experiencing any complication during childbirth, using antenatal care, lower birth order and having an educated partner were the significant predic- tors of skilled delivery service utilization. Implementing community-based intervention programs that will address the physical accessibility of delivery service, such as the ambulance service and road issues; improving quality mater- nity service; revising the protocol for admission of mothers during the latent phase of labor, especially for those mothers who come from distant places; preparing adequate waiting rooms at the facility; and awareness creation, especially for mothers with high birth order, will likely reduce the current problem.
The political leadership played a key role in implement- ing the maternal health program. The government intro- duced a policy of free medical care for pregnant women under the National Health Insurance Scheme, aimed at offering rural women the opportunity to seek skilled birth attendance. The majority of women in rural areas have already benefited from this initiative . Also, the CHPS program relied heavily on the District Assemblies for support to construct the CHPS compounds and mobilize communities for health programs. The District Assemblies built some of the CHPS compounds for the CHPS program and provided tipper trucks to carry sand for constructing other CHPS compounds. They also constructed boreholes for clean and safe drinking water for the midwives and connected some of the CHPS com- pounds to the national electrification program. In many instances, the assembly members organized communi- ties for health talks and also presided over the durbars. It is important that the government through the District Assemblies is investing in health care, which confirmed their commitment to the skilled delivery program. The study informed us about the importance of involving political leaders in the maternal health program and other health programs, and confirmed the need for the Ghana Health Service to continue to involve the District Assemblies in the design, implementation, evaluation and dissemination of health programs.
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The mean expenditure for delivery was ₹2875 which included the direct and indirect expenditure. Cost of delivery was significantly associated with type of delivery and education status of the mother. Similar studies done in Pakistan maternity government hospital 18 and India also found that there were costs associated with delivery in public hospitals, which may burden for poor families. 19 Mohanty et al analyzed DLHS -3 data found OOP expenditure for a delivery in public health center was US $39. The predicted expenditure for caesarean was six times higher than that for normal delivery. 20 A from Bangladesh found that mothers eligible for free maternity care also incurred hidden cost while using services. 21 A study done by Sahu et al in an urban slum of Bhubaneswar, Odisha found median OOPE for delivery to be ₹2100. They also found that the cost for maternal healthcare was lower as many respondents accessed benefits received from Janani Shishu Suraksha Karyakram, Janani Suraksha Yojana, and "Mamata" schemes of the government. 22
In this study there was no significant relationship between the age of the respondent and delivery in a health facility at a p-value of 0.908 . This concurs with a study which found no significant association between maternal age and place of delivery . Majority of the respondents were young, falling between the ages of 20-34 (67.1%), this may be because of the fact that most of the women are married at a young age, and therefore begin having children early probably as a result of cultural expectations which regard childbearing as an enhancement to women’s status in the society as well as circumcision rites which facilitate entry to adulthood. However the finding contrast with a study done by Wanjira  which found that younger mothers were more likely to utilize skilled attendants during delivery than their elder counterparts.
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of statistical data on health and health related events. Despite this vital arrangement, effective health care delivery and utilization in the Federal Capital Territory is thwarted by so many barriers. The likely barriers ranged from poor medical facilities, negative attitude of health personnel and lots more. These aforementioned factors normally occurred at the health facility level/ supply side of the service. The focus of most studies in this area has been on the aforementioned factors and the extent to which they affect the effective delivery and utilization of the primary health care facilities without taken into cognisance the likely factors affecting the primary health facilities from the community dimension. This study therefore is an investigation of the perculiar social-economic and cultural characteristics of the rural communities and the extent to which they are responsible for the negative health seeking behaviour of the users of the primary health services in the Federal Capital Territory, Abuja. This is not to say that study of this nature has not been carried out elsewhere before. But to the best of the writer’s knowledge, study of this kind has not been done in FCT prior to this write up. This makes it unique and hence close the existing gap in knowledge as far as FCT is concerned.
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