Health systems failures contributing to high maternal

mortality in Ghana

By
Robert Henry Suapim

Maternal Mortality which is the death of a woman during pregnancy, childbirth and the postpartum period still remains one of the major developmental and public health challenges facing
Ghana despite various programmes geared towards reducing it. All over the world, females
within the reproductive age group (15-49years) are at a higher risk to maternal death which
accounts for 1,500 women deaths each day according to the World Health Organisation (WHO).

Ghanas Maternal Mortality Ratio

The most widely used indicator in determining the quality of maternal health is the Maternal
Mortality Ratio (MMR) which is the number of maternal deaths occurring per year per 100,000
live births is the. In addressing this challenge, the Millennium Development Goals (MDG) 5
target is aimed at improving maternal health by reducing by 75 percent (that is 185 per 100,000
live births) the MMR by 2015. As indicated by WHO report of 2010, Ghanas MMR decreased
from 580 per 100,000 live births in 1990 to 590 in 1995, 550 in 2000, 440 in 2005 and currently
350 per 100,000 live births which make it unlikely for Ghana to meet the MDG 5 target by 2015.

Direct and indirect causes of Maternal Mortality

In Ghana, leading causes of maternal mortality can be divided into indirect and direct
causes. The indirect causes result from pre-existing disease condition which includes infectious
diseases such as malaria, HIV/ AIDS, hepatitis, respiratory infections, etc. and non-infectious
diseases including anaemia, cardiovascular diseases, etc. According to Ghana Health Service,
Malaria accounted for 53.6%, viral hepatitis (13.1%), non-specified infections constituting 7.1%
and tuberculosis accounted for 2.4% of maternal deaths in 2010. Furthermore, the Maternal
Health Survey of 2007 noted that anaemia accounts for 41.3% of maternal deaths, followed by
disease of blood and blood-forming organs accounting for 17.3%, respiratory diseases (14.6%)
and circulatory diseases constituting 12.0%. The leading direct causes of maternal mortality
include haemorrhage, sepsis, obstructed labour, pre-eclampsia, miscarriage, abortion, etc. The
Maternal Health Survey of 2007 notes that haemorrhage accounts for approximately 23% of
maternal deaths followed by infectious diseases (13.9%), abortion (13.7%), miscellaneous
(13.6%) and other non-infectious diseases contributing 12.4%. Other direct causes of maternal
mortality include ruptured uterus, embolism, obstetric surgery and anaesthesia complications.

Health system failures

WHO defines a health system as all organisations which include people and actions with the
fundamental aim of promoting and restoring the health of the population. Thus every health
system encompasses a range of stakeholders from both the health sector and other public sectors.
The health sector which provides health services has its main objective of delivering effective,
safe health interventions to the population at risk. Public sector stakeholders of the health system
include ministries such as education, agriculture, roads and transport, sanitation, trade, etc, NonProfit Sector, for-profit, private sector, donor organisations etc. Hence whiles the health service
focuses on health prevention and curative activities, the health system involves in addition to
activities performed by the health service, promotive interventions which makes use of
community engagement and inter-sectorial collaboration. Health system failures that contributes
to Ghanas maternal mortality includes, lack of adequate human resources, the three delays in
accessing service, financial constraints, unsafe abortion, demographic, socio-economic and
cultural barriers, poor community engagement and poor inter-sectorial collaboration.

Low numbers and disparities in distribution of health professionals

The shortage of health staff cripples the health delivery system which threatens the provision
of essential, life-saving interventions such as maternal health services. A major challenge with
the distribution is the difficulty in attracting and retaining health professionals in certain regions
especially the four most deprived and marginalised regions namely Upper East, Upper West,
Central and Northern Region. Most health professionals want to live in urban areas especially
Accra and Kumasi since these areas provide better opportunities such as education for their
children, better social amenities, extra work opportunities to supplement income, etc.
In Ghana, there exists low numbers of health professionals which is complicated by their
poor geographical distribution which is skewed towards regional capitals to the extent that many
health workers especially doctors refuse posting to rural communities and marginalized regions.
Ghana has extremely low Supervised Birth Attendants (SBA) hence supervised deliveries remain
low with disparities occurring amongst geographical regions with rural and marginalised regions
badly affected. According to Ghana Demographic and Health Survey for 2008, out of the 62%
births, 43% were attended to by SBA. Furthermore, in 2008 for example, out of the 180 newly
qualified Medical Officers and Dental Officers posted by Ministry of Health to Ghana Health
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Service and Christian Health Association of Ghana facilities, 123 accepted postings. Of this
number, only 9 (6%) reported to the three Northern Regions namely, Upper West (2), Upper East
(3) and Northern Regions (4).

The three delays in accessing service

Ghanas health system is also challenged by the three delays in accessing maternal health
services namely delay in taking the appropriate decision, delay in arriving at the health facility
and delay within the facility. Even during emergency situations women fail to take the required
prompt action to access maternal health services. This delay may be due to women not having
the autonomy in deciding which health service to consume, their lack of knowledge of the
nearest health facility, lack or inadequate financial resources for transportation, user fees, drugs
etc. With respect to delay in arriving at the health facility, even when women have decided to
access health services, there is delay in arriving at the facility due to lack of means of transport,
poor road infrastructure, poor means of transport, high transport fares and poor road network and
the road being unmotorable especially during rainy seasons. Moreover, mothers especially from
deprived communities have to travel long distances before accessing health services. Delay also
occurs within the health facility due to inadequate human resources, financial resources,
equipment, logistics, medicines etc. Also, inadequate ambulatory services for transporting
mothers to referral facilities for further management also contributes to high maternal mortality.

Financial barriers to access

Marginalized and vulnerable women still face the challenge in accessing health services. To
the extent that, even with the implementation of interventions to eliminate financial barrier to
service use such as National Health Insurance Scheme (NHIS) and the free delivery care, many
women especially impoverish households are unable to access services due to their inability to
pay the NHIS premium. Even for those who are registrants of NHIS and for the free delivery
care, many are unable to pay for the cost of transportation thus inhibiting access to health
services.

Unsafe abortion

Even though abortion is legal under certain circumstances in Ghana, many women still
engage in illegal, unsafe abortions through employing the services of fake doctors, drinking
concoctions etc. They engage in it due to lack of awareness of the legality of abortion under
certain circumstances and also due to the social stigma attributed with abortion which deters such
ones from legally accessing it. This has resulted in high maternal deaths as a result of unsafe
abortions.

Demographic, socio-economic, and cultural barriers

Demographic characteristic comprises of education of women and place of resident.
Educational level of women determines their use of maternal health services. Female literacy has
been recognised as an important variable influencing the use of maternal health services. In
Ghana the illiteracy rate is high for women. The WHO notes that whereas it is 40 per cent for
women, it is 22 per cent for men. Education of women enhances their autonomy thereby seek for
higher quality services and have greater ability to use health care inputs to produce better care.
Lack of female education also inhibits them from having access to adequate information and
benefiting from health services. Place of residence (rural or urban) is another variable that affects
the utilisation of maternal health services. In Ghana, urban dwellers may be relatively closer to
health care facilities than their rural counterparts. Rural women have to travel more than 5 km to
access health services in Ghana thus, accessibility to health care services is much easier for the
urban dwellers than the rural dwellers.
Socio-economic factors encompass family income and female autonomy. Higher levels of
family income are associated with increased utilisation of modern health care services since it
empowers women to take part in decision-making processes about health care in the family.
Women who are involved in gainful employment are more likely to use modern health care
services to treat complications during their pregnancy. In addition, female autonomy affects
womens capacity to access and use health services in developing countries. The patriarchal
system in Ghana inhibits female autonomy and empowerment which creates gender inequalities.
This contributes to oppression of women which creating barriers to womens access to maternal
health services. In Ghana, females are seen as housewives thus not having the autonomy to take
decisions concerning their health. Traditional and religious beliefs are the key components of
cultural factors. In Ghana, traditional belief and knowledge society has on childbirth influences
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women to deliver at home. Also, religious beliefs and practices also influence utilisation of
maternal health services.

Poor community engagement and poor inter-sectorial collaboration

Ghanas high maternal deaths can also be attributed to poor community engagement and
poor inter-sectorial collaboration. In Ghana, community members are not fully engaged in
contributing towards attainment of MDG 5. There is lack of planned community durbars to seek
views and concerns of community members. Also inter-sectoral collaboration in Ghana is very
weak. This is attributed to the fact that due to limited resources other sectors directly involved in
the enhancement of health such as education; food and agriculture, etc. concentrate on their own
individual agendas.

Comprehensive Primary Health Care strategies for reducing

maternal mortality

For a district-based CPHC programme, its key components are 1) service delivery, 2) human
resources for health, 3) information, 4) medical products, vaccines and technologies, 5) financing
arrangements and 6) leadership (WHO, 2007). The service delivery building block involves the
organization and management of inputs to ensure equitable access, safe, continuous quality care
is provided irrespective of geographical location, religion, ethnicity, etc. (WHO, 2007). Thus, an
effective and efficient health service at the district level should provide quality MH interventions
for women in the reproductive age which should also utilisation resources efficiently. In addition
since human resources (HR) play an important role in decreasing MM, the district HS should
have an effective and efficient HR who are always available, capable, responsive and productive
(WHO, 2007). HR should be of the right mix and of the appropriate number consisting of
different categories of health professionals such as doctors, nurses, SBAs, Pharmacists etc. All
these cadres of health professionals should be appropriately distributed within the district based
on need that is, sections of the district with higher MM and larger pregnant women should have
more cadres of health staff than areas with lower MM. These staff should also have the requisite
training, up-to-date with current strategies through re-training/ refresher courses, have easy
access to medicines, equipment, and logistics to respond adequately to the needs of women.
An effective district HS should also have a well-functioning information system (IS) to ensure
the production, analysis, dissemination, utilisation of reliable and timely information on ??
(WHO, 2007). Furthermore, the availability of essential medical products (example antibiotics,
anti-malaria drugs etc) and technologies of the required quantity, safety, efficacy and costeffectiveness (WHO, 2007) are key to effective functioning of the district based CPHC HS.
Another building block which is financial access to Maternal Health Services (MHS) is key to
reducing MM. Thus, for an effective MH system at the district level, there should be an effective
health financing system to raise adequate funds for MH. As indicated by WHO report (2007), an
effective HS should protect clients most importantly vulnerable ones especially during
emergency situations. The last building block being leadership is important in attainment of
MDG 5 which encompasses developing and ensuring strategic policy in the short, medium and
long term whiles adhering to regulations and accountability (WHO, 2007). Leadership also
entails community engagement (that is community support, participation and involvement) and
inter-sectorial collaboration with other sectors (Ministries, Departments and Agencies, NGOs,
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etc). According to WHO (1997) inter-sectorial collaboration ensures relationship between

components of the health sector with parts of another sector such as education, agriculture etc., to
achieve improvement in health outcomes using cost-effective and efficient mechanisms.
A district-based CPHC programme aimed at reducing MM should provide strategies to address
all the six components of the HS enumerated above. The programme will thus encompass
individual (disease prevention, curative and rehabilitative interventions) and population-based
(preventive and promotive interventions - community empowerment and inter-sectoral
collaboration) programmes. For effective service delivery, curative interventions will involve the
effective treatment of complications during pregnancy and related conditions which will include
administering anti-malaria medicines for prevention of malaria in pregnancy, hypertensive
medicines, antibiotics etc. In addition, rehabilitative interventions will involve restoring mothers
who have suffered complications during delivery to a state of better health. This will be achieved
through health education during post natal visits and house to house visits.
Reduction in MM can also be achieved through supervised delivery. Hence the CPHC
programme will ensure the provision of skilled health professionals most importantly SBA
during childbirth posted to various health facilities within the district based on need. For health
professional to provide quality care, their knowledge in obstetric management is key. In view of
that one component of the strategy will encompass the continuous (on the job training, refresher
etc) training of health professional quarterly to update their knowledge for effective delivery of
service. However, due to limited health professionals to tackle maternal health needs one costeffective strategy will be to train additional skilled TBA at the community level. This strategy
will empower community members to actively involve themselves in addressing MM. TBAs will
be trained on effective strategies of delivering babies in a clean environment using sterilised
instruments and to refer clients promptly to the nearest health facilities for further management.
Also an effective IS will be implemented which will provide weekly, monthly, quarterly and
yearly performance maternal health indicators. Thus, Maternal Health IS at the district level will
help in the analysis, monitoring, evaluating and dissemination of MM data.
Since regular supply of medicines is key to decreasing MM, the District Health Management
team (DHMT) which is the leadership at the district level will liaise with Central Medical Stores
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to prevent shortage of medicines. Also, DHMT will ensure rational use of medicines by adhering
to recommended guidelines and strategies of Ghana Health Service. Also, for effective financial
resource mobilization, the DHMT will ensure efficient revenue collection by minimising illegal
fees and siphoning, efficient use of financial resources and minimizing misappropriation of
funds. DHMT will also collaborate with all other sectors including regional ministries,
departments and agencies whose activities influence MM. Maternal education will be another
strategy to reduce MM. In achieving this, CHN will undertake daily facility and communitybased education moving from house to house educating women and their households on the need
to eat balanced diet especially during pregnancy, need to attend at least four ante natal clinics
(ANC) and attending post natal clinics after delivery. CHNs will also through community
durbars espouse the importance of ANC visits which is for early detection of maternal risk
factors and pregnancy related complications such as malaria, anaemia, infections, etc. Another
strategy will be to promote family planning services through the use of contraceptives.
Contraceptives play an important role in reducing MM by preventing unwanted pregnancies and
illegal abortions (Hagan, 2013). Thus to achieve reduction in unwanted pregnancies, the
programme will promote the use of contraceptives especially the male and female condoms
through facility and community based health education programmes on daily basis.
For an effective CPHC programme geared towards reducing MM at the district level, the
intervention should engage

community members

in

the planning, organizing and

implementation. Engaging community members in the design of health programmes will make
them appreciate the importance on contributing to achieving reduction in MM.