Social determinants and the role of maternal health care services for equity in maternal health in Ghana from 1988 – 2008

University dissertation from Department of Clinical Sciences, Lund University

Abstract: Maternal health services are the least equitable health care services in most low- and middle-income countries. Improving maternal health in Ghana continues to be a major public health challenge. Socio-economic inequalities within the country are greatly reducing the use of maternal health care services despite government policy reforms to improve access to maternal health care services and interventions. The overall aim of this thesis was to assess equity in maternal health by socio-economic factors in Ghana from 1988 to 2008 and relate that to the role of policy and maternal health services. Studies I and II were based on data derived from the Ghana Maternal Health Survey (GMHS) 2007 and Studies III and IV used the Ghana Demographic and Health Surveys (GDHS) 1988, 1993, 1998, 2003, and 2008. We used logistic regression as our major analytical tool and Total Attributable Fraction (TAF) as our main index of inequality. Results from Study I showed that there exist socio-demographic disparities in dying from particular causes of maternal mortality in Ghana. Older and married women were the most vulnerable group to die from haemorrhage, the foremost cause of maternal mortality, whereas the highest risk population for deaths due to induced abortion was single young women below age 25. Further analysis of deaths due to induced abortion in Study II revealed a significant association with alcohol consumption. Studies III and IV demonstrated that there exist education- and income-related inequalities in modern contraceptive use, fertility, use of skilled birth attendants and antenatal care utilization. Meanwhile, the observed inequality trends differed by equity stratifier and the specific maternal health indicator used. There is a general development toward equity in the use of modern contraception that is not mirrored in the equity trends seen in the fertility rate. In terms of modern contraception and fertility, education-related inequalities are very pronounced, whereas income inequalities are the most prominent with antenatal care and skilled birth attendant utilization. However, income-related inequality in the use of maternal health care services is rapidly growing worse over time. We recommend that policy actions aimed at reducing inequality in maternal health in Ghana should target education- and income-related inequalities simultaneously. This could be done through 1) addressing financial loopholes in the free maternal health care policy in Ghana to eliminate direct and indirect financial barriers that hinder the use of maternal health care services; 2) sex education and family planning should be made an integral part of basic education so that even women at the lowest level would learn about adverse maternal health consequences; 3) government and other stakeholders should support informal education through mass media such radio and television so that women who lack formal education or those no longer in school can benefit from on-going interventions; and 4) adopting a youth-friendly approach in providing family planning and contraception services.