HIPC FUNDS, ACCESS TO SKILLED

ANTENATAL AND DELIVERY CARE AND OUTCOMES

FOR MOTHERS AND NEONATES IN THE NORTHERN
REGION OF GHANA

BY
DR. ELIAS SORY
DR. KOFI ISSAH
KEN GBEVE
AMAMATA SUMANI

1
 TITLE: HIPC FUNDS, ACCESS TO SKILLED
ANTENATAL AND DELIVERY CARE AND OUTCOMES
FOR MOTHERS AND NEONATES IN THE NORTHERN
REGION OF GHANA

Authors
1. Dr Elias K.Sory; Regional Director of Health Services Ghana Health Service,
Northern Region. Health Directorate.
2. Dr Kofi Issah: Senior Medical Officer, Head Clinical Care unit Ghana Health
Service, Northern Region.
3. Mr. Ken Gbeve: Regional Health Information Officer Ghana Health Service,
Northern Region.
4. Miss Amamata Sumani: Public Health Nurse Ghana Health Service, Northern
Region.

Correspondence to: Kofi Issah, Ghana Health Service, Northern Regional Health
Directorate. P.O.Box 99 Tamale. Ghana.
E-mail: kofiissah@yahoo.co.uk. Phone: + 233 71 22912; Fax: + 233 71 22941.

.Funding source: HIPC FUNDS

2
1.0 ABSTRACT
TITLE: HIPC funds, access to skilled antenatal and delivery care and outcomes for
mothers and neonates in the Northern Region.
AUTHORS: Elias Sory, Kofi Issah, Ken Gbeve, Amamata Sumani

OBJECTIVES: To determine the level of utilization, knowledge and outcomes of

maternity services under the HIPC funds initiative.
To describe perceptions of stakeholders and establish factors hindering uptake of
exemption services.
METHODS: A descriptive study involving collection of service delivery data for the
years 2003 and 2004 from randomly selected facilities in each district.
Qualitative data was collected from seven focus group discussions with mothers and in –
depth interviews with five key informants from each district.
RESULTS: Record reviews show almost universal utilization of antenatal care services
but most deliveries take place at home. Most women (90.7%) had information about the
HIPC funds exemption package yet 46.5% of them paid fees for services. Outcomes of
services in 2004 did not show appreciable improvement over the previous year.
Poor staff attitudes, religious beliefs, low status of women and their lack of decision
making power concerning the choice of place of delivery are the main barriers to the
uptake of services.
CONCLUSION: The HIPC funds exemption initiative alone cannot improve access to
skilled attendance at delivery and reduced mortality. Determinants such as decision-
making power of women, cultural rituals surrounding labour and delivery and poor staff
attitudes when addressed will make exemption an effective strategy to improve access
and ensure equity in health care for the poor.
Key words: exemptions, skilled attendance, HIPC funds, maternal mortality, infant
mortality

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2.0 INTRODUCTION:
Access to maternal health care has been a priority of many governments in the
developing world. The need for skilled attendance at delivery is very important as two
thirds of maternal deaths are said to occur during or soon after child birth1 The need to
provide evidence based practices such as magnesium sulphate for managing eclampsia,
iron/folate supplements for anaemia, and neonatal resuscitation for asphyxiated neonates
has been the basis for reducing maternal and neonatal deaths. Several barriers including
financial however act to reduce access of most women to these evidence based
interventions.
The commitment of the world leaders to reduce maternal mortality by two thirds
and reduce infant mortality by the year 2015 is a call for health care services to provide
greater equity and access to effective maternal and neonatal interventions. This means
finding effective health care financing mechanisms which are pro-poor and are
sustainable.
The Health Sector in Ghana has for the 2 nd five-year programme not only made
access but also equity in service delivery a priority with the Government of Ghana under
the GPRS (Ghana Poverty Reduction Strategy) instituting measures to help improve the
maternal health situation in 4 regions of the country. One of these measures is the release
of funds from the HIPC (Highly Indebted Poor Country) initiative to provide free
antenatal and delivery care. This is because the key findings of the Ghana demographic
and Health Survey (GDHS 1998) showed the three Northern regions and the Central
region had the poorest maternal and child health indicators. The 2003 GDHS also shows
a decline in maternal and infant health indicators in these regions in comparison to the
year 19982 .
In 1997 the Northern Regional Health Services included free antenatal and
delivery services in the exemptions package initiated by the Government of Ghana. After
a few months of implementation of the exemptions package was beset with difficulties of
reimbursement and documentation. It is not therefore very clear as to how many health
facilities were fully implementing the exemptions for services by June 2003. Secondly it
was not known whether after 6 years of implementation the exemptions were effective in
improving maternal and neonatal health outcomes in all districts of the region. This was
against the background of a study conducted in the Yendi District which showed that
antenatal service utilization increased from 58.5% in 1996 to 83.4% in 1999. Delivery
service coverage however had a less dramatic increase for the same period moving from
29.3% to 31.1% during the period under study.
The implementation of the HIPC funds started in October 2003 in some districts
and in all districts of the region by January 2004. In the northern region of Ghana where
poverty is prevalent is the removal of payment of user fees through the HIPC initiative
alone enough to improve utilization of skilled attendance at delivery and improve
maternal health outcomes. On the other hand is the HIPC exemption package facing
difficulties in implementation as was the case of the package started in 1997?
This study seeks to provide a description of how the HIPC funds initiative is
being implemented and the changes in utilization of services by mothers in the region

4
3.0 BACKGROUND OF THE STUDY AREA

Geography and Administration: The Northern Region is the largest of the 10

administrative regions of Ghana, occupying an area of 70,000 square kilometres and a
population of 2,021,000 (in 2003) and a growth rate of 2.9% per annum. This population
is distributed sparsely in 6,000 settlements of which 54.4% of them have populations of
less than 200 people3.
There are 13 administrative districts each run by a local government authority and
headed by a district chief executive with local legislative power in the hands of a partly
elected district assembly.
Economy: Economic activity in the region is mainly subsistence agriculture with main
crops cultivated being maize, millet, yam and rice. There are no major manufacturing
industries and most of the workforce is employed in the informal government sector with
seven out every ten inhabitants of the region living in poverty 4.
Socio-Culture: The major ethnic groups include the Dagomba, Gonja, Konkomba,
Mamprusi and Nanumba.
Like in most societies in the developing world men and women of the region
experience poverty and suffer from the same diseases, but the women tend to bear a
more than proportionate part of the burden due to structural factors in society. Women
have to frequently depend on men for resources and are therefore accorded a lower
status5.
Pregnancy and childbirth is viewed as a normal phenomenon in the life of women
in the region and are expected to signify joyous occasions with the arrival of the newborn
child. These events are however greatly influenced by cultural practices coupled with
socio-economic factors acting as barriers to a safe and uneventful outcome of each
pregnancy. The influence of these factors can be seen in the low utilization of skilled
attendance at delivery (when the complications of delivery can be effectively managed)
in the region.
Health Care System: Formal health sector facilities in the region include one regional
hospital, eight district hospitals and 125 health centres and clinics. Over 2000 health
personnel of whom 146 are practicing midwives staff these facilities. Five districts have
no hospitals and no facilities to handle emergency obstetric cases needing surgery. These
districts have to refer patients to the nearest hospital in the neighbouring districts, which
are on the average about 40 kilometres away. Data from the health system in the region is
from two sources namely the facility based and the community based surveillance
systems.
In the year 2003 antenatal service coverage was almost universal but utilization of
skilled attendance at delivery was only 37.4% of all deliveries in the region. A total of 72
maternal deaths of which 43 were audited have been recorded by the health facilities
whilst the community based surveillance system also reported a total of 42 maternal
deaths though these are yet to be audited

5
4.0 MATERIALS AND METHODS
A descriptive study was conducted in seven out of the thirteen districts of the
Northern region from the 9th-29th September 2004. The districts were sampled based on
the following criteria.
• Two districts with government district hospitals
• Two districts with CHAG district hospitals
• Two districts without district hospitals
• The Tamale Metropolis due to its cosmopolitan character.

In each district 2 facilities were chosen with District hospitals being automatic
choices. The second facility in districts with hospitals was then randomly chosen from a
list of facilities in the district. For districts without hospitals, the facility with the highest
client load was picked and random sampling used to choose the second facility.
A total of 80 (forty three pregnant mothers and thirty seven post partum women) were
chosen by random sampling using the antenatal and delivery registers of the health
facility. They were interviewed on antenatal and delivery care using a closed ended
questionnaire made up of 22 questions for antenatal mothers and 23 for post partum
mothers. The ages of the women ranged from 18-43 years and parity between one and
nine. Sixty percent of the women however had less than 3 children. Interviews with the
pregnant women or nursing mothers were held in their household or at any place found to
provide privacy for the interview
Seven focus group discussions were held each consisting of antenatal or postnatal
mothers depending on which group was more accessible at the time of data collection in
the district. Each group made up of eight to ten participants and had ages ranging from
17-41 years and was chosen by convenience of residence.

In-depth interviews were conducted in each district with the following key informants:

• One midwife at the facility/facility Head

• One male opinion leader
• DCE/DCD or the officer in charge of HIPC funds
• One traditional women's leader (Magazia).
In all the 29 key informants including one district chief executive and one traditional
chief and seven women leaders (magazia) were interviewed at their place of work or in
their homes
The research team collected secondary data from the registers of the facilities chosen
for the study. Data included utilization rates of maternal health services, outcomes for
mothers and neonates for January-June 2003 and 2004. The total number of maternal and
neonatal health events recorded by the community based surveillance system (CBS) was
also gathered for comparison.
The data gathered from the interviews with the pregnant women and nursing mothers
was coded and entered into a computer and analyzed using EPI 2002.
Qualitative data gathered from the key informant interviews and focus group
discussions were coded and transcribed according to themes under which the responses of
participants were made and analyzed manually.

6
 The research team sought permission from the Regional Director of Health Services
to conduct study in health facilities in the region. Permission for the women to participate
in the study was sought from Chiefs, Community leaders or Spouses where applicable.
Each woman was required to give verbal or written consent to take part in the study.
This study took into consideration the social and cultural rites and beliefs surrounding
pregnancy and childbirth in most societies of the Northern Region. It therefore had to
observe the necessary norms regarding community entry to conduct studies on sensitive
areas such as pregnancy and childbirth.

7
5.0 RESULTS
The utilization of antenatal care services is high (above 85%) in all the districts,
delivery at health facilities is however still low and at below 40% of all expected
deliveries. coverage. In addition the numbers of women using both antenatal and delivery
services did not show any appreciable increase in 2004 over that in 2003(graph 1). The
community based surveillance system also showed there were more deliveries at home
than in the health facilities for the two half years under review (graph 2).
This degree of utilization of services has occurred despite a large proportion of
women (90%) interviewed saying they had information about the existence of the HIPC
exemptions package. The health worker was cited as the main source of information with
relatives, the mosques and churches as the other important sources of information on the
free delivery and antenatal services.
Only 40.5% of post partum women confirmed that they had utilized the services
of a health facility for delivery at least once. With increasing number of deliveries there
was a decrease to 10.8% of the women delivering in the health facility for more than 3
times.
Fifty percent of the antenatal mothers chose the health facility as the first choice
for a place for their delivery and the other half women citing the unpredictable nature of
the onset of labour as the main reason why they will not be at a health facility to deliver.

GRAPH 1

1600

The interviews and focus group discussions stated culture as the main reason for
low patronage of delivery services despite utilization of antenatal services being almost
universal. Cultural practices surrounding childbirth and pregnancies are still strong in all
communities in the Northern Region. One vivid example was given during the FGD in

1400
East Mamprusi where it was stated that all primates in most communities had to undergo

1331
8
an initiation ceremony when they are five months pregnant. This is to convey to the
public that the girls are no longer children. The girl is given a local concoction by the
sister in law. It is only after such ceremonies that the girl is given permission to attend
antenatal clinic or to go to the hospital when there are complications of labour and
delivery.
In West Gonja it was mentioned that fetishes have to be consulted to ensure a
safe delivery in times of prolonged labour. This was widespread in all the seven districts
and a midwife gave the following as a common occurrence in some communities in the
Yendi district.

"One of the main problems with utilization of delivery care services is the fetish. Some
families claim that the fetishes have ordained that newborn children should not be seen
by outsiders. It is therefore not advisable to go for deliveries in the health facility as the
baby would be seen by "outsiders" and this is a bad omen".

The importance of cultural barriers to access to delivery services was echoed by

some of the women leaders "Magazia". The Magazia were unanimous in their opinion
that women considered it a pride to deliver at home and with TBAs since they were more
approachable than midwives. In addition women who have their deliveries in health
facilities are considered to be the lazy ones who want things cheap without enduring the
pains of labour as every brave woman should.

GRAPH 2

800

9
 Despite the removal of financial barriers through exemptions 90%, of key
informants mentioned poor staff attitudes as another reason why women refused having
deliveries at a health facility. Furthermore 46.5% of antenatal women said they still paid
for services despite the fact that they knew services were for free. In estimating the
amounts paid quarter of the women interviewed pointed out that they had to pay various
fees ranging from one to ¢50,000 (fifty thousand cedis) during delivery yet the reasons
for these payments were not explained to them.

"We are promptly referred to Yendi Hospital these days when we have complications
during labour and delivery. When we reach there we still pay but nothing is explained to
us (FGD Gushegu/Karaga).

However the situation was different in two districts where key informants stated
that midwives were respectful to their women and did not share the views expressed by
key informants in other districts.
The lower status of the woman in all societies in Northern Region was
acknowledged in all seven focus group discussions. The woman is dependent on other
members of the household to take the decision on whether she should be sent to hospital
or not when the pregnancy or labour is complicated.

"In Dagbon a woman has no say. A woman can not get up and take decisions on her
own because somebody owns her". (FGD Gushegu/Karaga).

The outcome of pregnancies of the women interviewed revealed that most women
had live births. One woman had a still birth and the other the early neonatal death of her
child. The two children were delivered at home and not in health facilities. The health
facilities recorded the following outcomes in January-June 2003 and 2004 as shown in
table 1.

TABLE 1
FACILI MATERNAL NEONATAL CAESAREAN
TY LIVE BIRTHS STILL BIRTHS DEATHS DEATHS SECTION
2003 2004 2003 2004 2003 2004 2003 2004 2003 2004
ADIBO
H/C 40 46 0 0 0 0 0 0 0 0
YENDI
HOSPITAL 413 551 29 22 10 5 11 7 91 90
GUSHEG
U H/C 228 277 17 12 1 0 0 0 0 0
KARAGA
H/C 175 81 0 0 0 0 0 0 0 0
BAPTIST
MED
CENTRE 371 377 46 38 1 3 - 14 81 85
GAMBAG
A H/C 90 94 0 1 0 0 0 0 0 0
BOLE
HOSPITAL 88 129 6 4 0 0 0 0 0 12
WEST
GONJA
HOSPITAL 95 128 11 0 0 0 1 3 18 15

10
 The high level of poverty was cited by 63% of the women and 29 key informants
as the main rationale for government instituting the HIPC initiative to cater for antenatal
and delivery services. It is significant to note that the women leaders (Magazia) went
further than any other group of key informants to state that the goodwill shown by
government by making deliveries free should be reciprocated.

"As the health facilities are not charging fees for these services it is good, this will enable
us go for these services anytime the need arises. We however need to prove to the
government that the initiative is good by utilizing the services. It is like somebody has
given you a gift; you collect the gift and do not use it or regard it. I therefore urge all
pregnant women to go to hospital for delivery" (Magazia, East Mamprusi District).

Key informants from district Assemblies and male opinion leaders thought the
initiative to improve access to care could only succeed if it was linked up with an
improved road network and transport system. It was suggested that there should be an
attempt to have dialogue with transport owners plying certain routes to reduce their fares
for pregnant women in times of emergency.
The midwives and magazias were however of the view that intensified health
education campaigns on the availability of the exemptions need to be carried out. Health
Education should also be targeted at men and opinion leaders to allow their women to
utilize the antenatal and delivery services. On measures to improve skilled attendant care
a positive change in staff attitudes was ranked highest. In the West Gonja and Yendi a
suggestion was made to educate the women themselves about what to expect during
labour. This was to prevent situations of the midwives having to be harsh on the women.

"It is good to discourage patients who exaggerate and negatively portray what happens
at the hospital. For instance the beating of women too is the fault of the women in
labour themselves. At the time the child starts coming that is when they stop pushing.
The nurses will have no alternative than to beat the woman to push and deliver the baby
alive (FGD, Yendi).

11
6.0 DISCUSSION
Poverty is the main factor contributing to reduce access to maternal health care
services in the Northern Region. However cultural factors, negative staff attitudes
towards clients, the low status and lack of decision making power by women in most
societies of the region also contribute significantly to low utilization of services. The
removal of financial barriers to health care by the poor alone does not therefore translate
into an appreciable increase in rates of utilization of services over time.
This study used both qualitative and qualitative methods to gather data on the
HIPC exemptions package. The use of interviews to collect quantitative data was
triangulated with qualitative data collection through in-depth interviews and focus group
discussions. On the other hand the use of health personnel to conduct some of the
interviews had the tendency to introduce observer bias in the results of the study. In
addition the criteria used to conduct the sampling of districts and facilities could possibly
have left out districts where the effects of the HIPC exemptions scheme could have
resulted in a dramatic increase in utilization of services.
The absence of primary baseline data on maternal health service utilization prior
to the introduction the exemptions scheme denies the study the opportunity to make a
“before and after” comparison of the effects of the intervention rather we have sought to
the use of secondary data from the health facilities. In addition data gathered from health
facilities is for the period of six months of the existence of the scheme. This short period
of time may not constitute an appreciable length of time to assess the effects of an
intervention and so constitutes a weakness in the study.
The study could not also ascertain whether the clients and health facilities made a
distinction between the HIPC funds exemption package and the older exemptions
package instituted in 1997 or considered the former as a continuation of the latter. It has
to be assumed that from the client perspective it is the benefits of a health care financing
package rather than the name that matters. Despite the observations made above there is
no cause to doubt that data collected might not be a valid and reliable indication on the
situation of the HIPC exemptions package and utilization of maternal health care
services.

Knowledge of exemptions scheme

The fact that most of the women interviewed (90.7%) had heard of the HIPC
exemptions scheme was good. However the level of knowledge of the scope of services
exempted from payment under the scheme was low. It can be justifiably said that the low
level of knowledge on what services were exempted contributed significantly to the
payment of illegal fees by almost 46.5 % of antenatal mothers interviewed.
The main source of information on the exemptions scheme being the health
worker gave an indication that education of women was actively going on in the health
facilities. The only draw back is the lack of adequate information on the scope of services
exempted under the exemptions scheme.

Factors hindering uptake of services

The high level of knowledge about the scheme has not been translated to a
dramatic increase in utilization of services. Except for antenatal services where utilization

12
is high over the years 3 deliveries by a skilled attendant remains low with only 40.6% of
women interviewed indicating that they had at least one delivery at a health facility.
The assertion by women during the in-depth interviews that labour is a highly
unpredictable event and can occur anywhere makes home the most convenient place for
delivery. An attempt to reach the health facility for a delivery then brings into play the
various physical and socio-cultural barriers to seeking health care. Each woman wanting
to have a delivery is confronted by difficulties of decision making, rituals surrounding
childbirth and transportation to the nearest health facility.
One of these difficulties is the network of old women that serve as birth attendants
for each extended family system. These older women are most likely to have acted as
attendants at the birth of most of the younger generation in the family and therefore to by-
pass this network and make the health facility the first point of call for delivery requires a
reason which is strong, compelling and culturally acceptable.
Addai in his research states that socio-cultural barriers exert great influence on
health care seeking behaviour. These barriers are most noticeable in the use of a doctor
for maternal health care, antenatal checkup, place of delivery and contraceptive use 8.The
conduct of ceremonies at five months gestation for the primigravida as mentioned by the
participants constitutes a barrier to seeking early antenatal care and is confirmed by
studies in other parts of Northern Ghana 9.
The focus group discussion brought up the issue of the low status of women in the
region.
The simple statement “in Dagbon a woman has no say. A woman can not get up
and take decisions on her own because someone owns her” summarizes the situation of
women in the region. It has been established that in this region both men and women face
poverty and suffer from the same diseases; women tend to bear a more than proportionate
part of the burden due to structural factors in society. Women therefore have to
frequently depend on men for resources, which contribute significantly to them being
accorded a lower status 5.
The structural factors in society such as the extended family system places vital
decision-making in the hands of other members of a woman’s family. A woman would
be lucky if the fetishes consulted by the household come out with a decision favouring
her being promptly sent to a health facility for a delivery.
The above stated barriers notwithstanding it is difficult to explain why the same
communities have wholly accepted and greatly patronize antenatal care services while
delivery at a health facility is low. A possible explanation for this discrepancy might be
that the art of conducting deliveries is existent in all societies in the world since ancient
times. The act of delivering a baby is viewed by most communities as a normal social or
physiological event rather than giving it a medical tag by having to attend a health
facility. The undocumented experience of health personnel in the region suggests that
most communities view the health facility as a place to sort complications of labour and
delivery.
If this knowledge exists in the communities why barring any socio- cultural
factors and transportation difficulties do women not report at all or report late with
complications of labour to the health facilities.
This introduces a significant but often forgotten barrier to access to skilled
attendant care and this is negative staff attitudes towards clients. It is a source of worry

13
that during the key informant interviews none of the health personnel mentioned staff
attitudes as a barrier to uptake of services. The situation in the districts of Bole and West
Gonja is however different as focus group discussions seem to indicate that staff attitudes
towards clients were good. It can not be ascertained by this study whether this claim by
the focus group discussion refer to specific groups of midwives they have come in to
contact with or the generality of nurses in the two districts. The findings from the two
districts cannot negate the fact that intensive efforts have to be made towards improving
the attitudes of health staff towards clients. This is because clients are more likely to
patronize services where they are respected and treated with dignity so it is not surprising
the TBA remains the first choice as a place to have a delivery 10.
Jewkes in his work in South Africa recommends that in order to improve staff
attitudes nursing curricula would benefit greatly by the introduction of medical
anthropology. He goes further to state that the introduction of this subject will go a long
way to assist nurses understand the relationship between lay and biomedical knowledge
and develop greater respect for lay knowledge 11. Finally it should be borne in mind that
user fees are not the only expenditure patients have to take care of. In addition are cost of
transport, under the counter fees and feeding caregivers of the patient among a few.

Comparison of utilization of services

Increases registered in antenatal and delivery services in the first half of 2004 in
comparison to the same period in 2003 are not appreciable in the light of the
implementation of the HIPC funds exemption scheme. It is natural to expect that the
absolute figures in service delivery increase each year as the population continues to
grow and the demographic profile for the region shows a pro natalist trend with fertility
at seven children per woman 2.
The effect of the scheme on service utilization is further confounded by changes
occurring in the district health services. In 2003 no case of caesarian section were
recorded at the Bole Hospital. The conduct of 12 caesarian sections in 2004 could be
attributed to the posting of medical officers to the facility. The surgeries conducted
represent an increase in access to skilled attendance by virtue of the skills being available
and not the removal of financial barriers. On the other hand anecdotal evidence suggests
that the old exemptions scheme instituted in 1997 was still in place though not effectively
carried out in the health facilities in the region. Women were therefore already using the
antenatal and delivery services and as such were not likely to markedly see an increase in
attendances.
The community based surveillance system remains a vital area of data collection
for health related events in all communities in the region. The table showing births
recorded in the communities goes to buttress the point that a greater proportion of births
occur at home despite the existence of exemption schemes since 1997. There is the need
therefore to look at not only issues of the numbers utilizing services but also to assess the
quality of care the women receive. This is because the quality of care could possibly
have improved as seen in the improved attitudes of midwives in two districts despite a
not too dramatic increase in utilization of services.

14
Perceptions of key stakeholders

The removal of financial barriers to care is seen by key informants as a step in the
right direction considering the high levels of poverty in the region. This initiative is
however affected by several factors already enumerated in this discussion. The call by
the Magazias for the women to reciprocate the good gesture of government by attending
the clinic means some members of the community have come to the realization that the
desired effects of the scheme are not being met. The success or otherwise of the HIPC
funds exemption scheme can be said to have been built upon the experiences and lessons
learnt under the implementation of the1997 exemptions package.
Free from payment schemes like the HIPC funds exemptions directed towards the
poor ensure equity in access to health care services but the rate of utilization of services
however can only fully be appreciated when the scheme is part of a comprehensive
package to improve access to skilled attendance at antenatal and delivery services. The
package of interventions should include efforts at instituting vigorous campaigns in
behaviour change in our communities and the breaking down of negative socio- cultural
practices.

7.0 CONCLUSIONS
• Exemption policies mainly aimed at improving financial access to maternal health
care for the poor are faced by problems of implementation and a host of barriers
affecting health care seeking behaviour.

• The HIPC exemptions scheme in itself has not resulted in an appreciable increase in
the utilization of maternal health care services.

• Socio-cultural barriers and negative staff attitudes to uptake of health care services
seem to have a greater influence over the use of skilled attendant care services.

• The need for clients to reciprocate the goodwill of government by changing their
behaviour and utilizing services is a good call by the magazias.

15
LITERATURE
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safe motherhood Technical Consultation in Sri Lanka 18th - 23rd October 1997
[online] 1997 [cited 2004 September 16]. Available from:
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2. Ghana statistical Service (GSS), Noguchi Memorial Institute for Medical

Research (NMIMR), and ORC Macro. 2004 Ghana Demographic and Health
Survey 2003 Calverton, Maryland: GSS, NMIMR, and ORC Macro.

3. Ghana Health Service, Northern Region Annual Report RHD 2003

4. Government of Ghana. Ghana Poverty Reduction Strategy. An agenda for

growth and prosperity. Analysis and Policy Statement. Accra: Government of
Ghana 2002.

5. MOH/HRU, Ghana. Promoting Gender Equity in Health. A framework for

action. MOH Accra: MOH/HRU; 1999. In: MOH Ghana. The Health of the
Nation. Reflections of the first five-year health sector programme of work 1997-
2001, Accra MOH: 2001.

6. MOH Ghana. The health of the Nation. Reflections of the first five-year health
sector programme of work 1997-2001 MOH; 2001.

7. Campbell Oona M.R. Measuring Progress in safe motherhood: Uses and

Limitations of health outcome indicators. In: Ravindran T.K.S, Berer M. editors.
Reproductive Health Matters. Safemotherhood Initiatives: Critical Issues.
London: Blackwell Science Ltd. p-31-42.

8. Addai I. Demographic and Socio-cultural factors influencing maternal health

services in Ghana. African Journal of Reproductive Health 1998; 2(1), 73-79.

9. Allotey P. Where There's No Tradition of Traditional Birth Attendants: Kassena

Nankana District, Northern Ghana. In: Ravindran T.K.S, Berer M, editors.
Reproductive Health Matters. Safemotherhood Initiatives: Critical Issues London:
Blackwell Science Ltd 1999.p147-154.

10. Ofosu A.A. Factors Affecting utilization of maternity services in the Yendi
district. Thesis in partial fulfillment of Masters of Public Health Degree,
University of Ghana 1999.

11. Jewkes R, Abrahams N, Mvo Z. Why do nurses abuse patients? Reflections from
South African Obstetric Services. Social Science and Medicine 1998; 47 (11),
1781-1795.

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