In total, 42 healthcare workers and pregnant women participated in the study. Of this number 41% were service providers, 59% were pregnant women (the free policy users). Of the service providers, 65% were females, while 35% were males. The majority of service provider participants were midwives, 70.5%. This was not unexpected, giving they constitute the larger population of health professional directly linked to the ‘free’ maternal healthcare policy implementation.
Medical doctors at post to the antenatal clinics and the labour wards made up of 18%. The other participants were Hospital Administrators/Managers and a Regional Director of Health of Health Service. The mean age of pregnant women was 20.5 with 19 years’ minimum age and 39 years’ maximum. Over 90% of the pregnant women claimed they were married and had two or more children, while 76% of them responded that there were gainfully employed.
All pregnant women had their vital sings checked for normalcy and table 10.2 show that all participants recorded vital signs within a normal range. The mean temperature, pulse and respiration was 36.3 degree degrees Celsius, 86.12 beats per minute and 18.12 cycles per minute respectively.
Themes were deductive, using pre-defined phrases for the purpose of contextualization. However, sub-themes emerged inductively for flexibility of analysis. In all, 5 themes and 2 sub-themes capture the report, whereas figures 2, 3 and 4 are word cloud output of NVIVO 10 (attached as appendix).
Pregnant women experience
Pregnant women participants disclosed that they regularly pay for laboratory services from start to confinement. Laboratory tests are unavoidable for expectant mothers, thus, out of pocket payment is not uncommon among pregnant women. Cost is incurred at the point of service delivery for a laboratory test. One of the pregnant women gave her an account as follows;
“I went to the lab and paid 8.50 and 15Gh each. I did the lab up to three times. I also bought red and yellow drugs. My first test was expensive. They took blood for sickle cell….and this was done in a private lab. I paid Gh47…and then paid 20 for scan…" (PW2, FG1, Zebilla District)
Cost reasons lead to concealment of ailment as a way of mitigating economic consequences. Financial difficulties also prevent others from accessing some of the recommended medicines, which potentially, could affect their health status and that of the unborn baby. A participant puts it thus;
“…The lab fee is plenty so when you come and you want to complain they will let you pay more. So sometimes we don’t say all our problems for fear that they might ask you to pay…I bought some and it is finished, but I have no money to buy yet.” (PW6, FG4, Bongo District)
Indeed, the cost of doing the test has been observed by the midwives as a challenge and hence influences their approach to assessing pregnant women so that they might not be overburden with the cost. This is a concern for users, as some feel, they deserve comprehensive obstetric care, regardless of cost. A focus group participant explains further;
“Yes…there are some important test which is 50.00 which the midwives didn’t tell her when she called one midwife, she asked why it was not done, and the midwives said that because of the high cost because the pregnant women always complain that they don’t have money…” (PW5, FG3, Bongo District)
Another critical experience shared by pregnant women is the purchasing of sanitary materials for delivery. Significantly, every health facility requires expectant mothers to have some sanitary pads purchased either commercially or from the midwives in the ward, also, pregnant women will have to purchase a rubber for the protection of their delivery bed. These are sold by midwives and is almost a model in all labor ward, regardless of one's NHIS status.
“Rubber, chamber pot, soap (four), and I paid bed fees. This was 2017. They also said I should pay 20gh and I paid. I used the Dettol and I sent the soap home. The remaining Dettol the midwives took it. When I did deliver the baby had no problem…” (PW8, FG4, Bongo District)
Pregnant women in the Zebilla District, however, testifies that pads availability in the ward for sale to pregnant women is a good arrangement and explained how pregnant women may even get to use delivery items and pay later. She said;
“…. The pads are very helpful to us ooo. If you don't have they will remove the pads for you... And later you can pay. They won’t deny you…” (PW4, FG1, Zebilla District)
Irregular supply of medicines in facility dispensary shops also creates a situation where the policy users almost always buy drugs form the market. Buying medicines is a well-documented experience among pregnant women. This observation has been reported comprehensively under the theme "shortages of medicines". However, a quote below from one of the pregnant women sums the rampant natures of asking private purchasing of drugs among the 'free' policy users.
“…Whenever we come we have been buying the drugs. Most of the time when we come they do write for us to go and buy the drugs. The yellow and the red drugs, because they don’t have them here…” (PW1, FG3, Bongo District)
Service providers perspectives
This theme is presented in two sub-themes, thus, service providers’ perspectives on the ‘free’ maternal health care policy on utilization, and service provider perspectives on stillbirth in the health care facilities. Under each sub-theme, the expert view is reported as a validation to the field level data in an in-depth assessment.
Maternal healthcare utilization
Services providers observed that pregnant women still report to healthcare facilities without active NHIS cards, a situation that compels healthcare professionals to intervene, in a form of negotiation, lobbying. The doctors view these interventions as collaborative in the interest of the patient. In some instances, service providers have to employ plea strategies to facilitate access to the NHIS card.
“Hmmm…Our collaboration with health insurance. A woman is highly pregnant, occasionally because the claims officers are friends, you call them and tell them…looking at this person right now, after delivery, the person will not be able to pay what you can do for me? Can I please let one of the nurses bring her so that you can register her for me?” (Doctor 1, IDI, UER)
The one key reason for the 'free' policy introduction was to reduce financial burden, by eliminating the need for out of pocket payment. However, it was observed pregnant women are required to purchase certain items to facilitate their care. These items range from medicine to minor items like rubber and pads. The following quotes explain;
…"There are few items that the midwives will write for you to bring. For instance, you will need a sanitary pad after you have delivered…. They may be some basic things that I cannot enumerate. Like they ask them to come with a certain rubber that the usually use to spread on the bed for you to deliver without coming into contact with but…. a few of them will come without a sanitary pad, so they [midwives] will ask them to pay for sanitary pads” (Doctor 1, IDI, UER)
“…Sanitary pads and rubber…and after they pay for vitamin k, which we give it to the child…that is when it normal delivery. When it is CS, antibiotic, cefuroxime, Amoxyclav, and Gentamycin. If it is not there they go to buy. It always happens that when they come and it is finished and the lorry that distributes the drugs is not yet in…." (Midwife 5, IDI, KNNM)
It is not uncommon for pregnant women to be asked to purchase services outside the health facility, particularly, laboratory, and scan services. Typically, clinicians routinely put pregnant women expectant mothers on a certain drug to facilitate their care. Their efforts are frustrated by the lack of medicine and diagnostic services within healthcare facilities, thus, the easy approach for doctors and midwives seem to be reliant on private purchasing.
A Medical Superintendent of Bongo District Hospital, who also doubles as the doctor in charge of the labour ward had this to say:
“…Our environment is not good. Personal hygiene is not so good. Unlike other places where they think that labour is a sterile procedure, here, we routinely put all our clients on antibiotic cover, whether you're on episiotomy, assisted delivery, or not." (Doctor 1, IDI, UER)
The Regional Director of Health Services for the Upper East Region admitted that the policy implementation bottlenecks emerged and the senior management detected and attempted to deal with the issues. He explained it this way;
"…women were being asked to buy the logistics…and we said no because, essentially this policy is to reduce financial burden if you ask women to come and ask them to buy this and that, and some of those things were been sold in the ward, some of the women won't come again….so we said, no, the midwives, nurses or whoever should stop selling those things in the ward. In recognition of that, we put in the reward system." (RDHS, KII, UER)
Stillbirth numbers on the rise
Service providers expressed worry about the increasing figures of stillbirth. However, they attributed the numbers to increased attendance and adequate record keeping. Study participants were of the view the increase utilization has also seen the record keeping prowess improved and hence muffles the impact of the ‘free’ policy in the Region, as though the policy is ineffective.
“…In the region, when you look at the picture, despite the so many interventions, one will say SBs are still high. But when you look at it critically, it is the reporting which is also going up, so it makes you think that the policy is not helping…” (Doctor 1, IDI, UER)
“…We have a high rate. This time we are getting mothers who are coming with Intra-Uterine Fetal Death (IUFD). This year in particular we had 15 for the first 6months. When you compare, I will say because we are taking records, that is why the numbers are high…previously there was no documentation…" (Midwife 1, IDI, Zebilla District)
Doctors and midwives also observed that macerated stillbirths were being reported more, which suggest that babies die in the womb in the house before they arrive at the facility, and hence, should not be blamed on the healthcare worker. Service providers were also of the view that pregnant women report to facilities late, probably due to previous experience and consequently, endangers the life of the unborn child.
"…Actually, just this half-year, stillbirth numbers weren't encouraging. It was bad. We had 22, but 13 were macerated. Then we had 9 fresh stillbirths. This year theirrr…the number has hiked…” (Midwife 1, IDI, Bongo District)
“…A few cases also dodge the hospital may they have two previous CS and knows that if they come to the hospital, there will be CS, so they avoid the hospital, when there are complications, then they quickly come...” (Doctor 1, IDI, UER)
Poor health-seeking behaviors was also blamed in some quarters as the which cause rising stillbirth rates. A doctor was categorical that pregnant women don’t comply with professional demands. He shares his experience and doing so, using the numbers of macerated babies (antepartum stillbirth) to justify.
…"The health-seeking behavior is bad in general, otherwise he won't come and deliver macerated babies. And those once are even higher than the fresh stillbirth that we have…Some come and the issue of monitoring and they won't cooperate and you can just operate unless there is indication….so the attitude and the cooperation from the woman is there…." (Doctor 2, IDI, UER)
Ambulance services come as a priority for transporting pregnant women, the absence of which has seen an increasing rate of motor kings transport use. Service providers hold a different view. Some women deliver on the motor king in the process, but the health workers believe there was more to delays than transport. Rather, the decision to go to a hospital is a hindrance for reasons unknown.
“…. they deliver in the motor king, we get a lot, but I think the delay in deciding to even go to the hospital is the issue. So if you look at it the period that the person is delivering on the road, it shouldn't be there. The farthest distance here is Zangbe-Yeri. The point is that there is no place around that it will take 3 hours to reach facility...” (Doctor 2, IDI, UER)
A doctor also disclosed that in their attempt to finding answers, they discovered that some women were averse to vaginal examinations. Some pregnant women claim ignorance of the onset of labour and are suddenly caught in between home and hospital.
“…and when they come we manage them at postnatal care…. they say they didn’t know that labour had started, some say they don’t want the examination. One woman was frank, she said when they come, they put fingers on her vagina and that one she doesn’t like it…” (Doctor 2, IDI, UER)
Essentially, the doctors and midwives shared that Ghana Health Service the mandatory auditing schedules for stillbirth has become routine and helpful, relative to addressing the gaps. A senior doctor puts it thus;
"…Now, all SB are audited. Previously, we will say that it is SB and so what, life goes on, but when you look at what was happing before and what is happening, there is a great improvement...." (Doctor 1, IDI, UER)
The RDHS had this to say when he was interviewed as a key informer in the UER
“…. substantial labour is still not monitored. Using partograph to monitor will tell you the condition of that baby. So that if you realize that the baby has difficulties, that baby can be delivered…a significant proportion is not monitored. Those women who are eligible, it should be 100%..." (RDHS, KII, UER)
The expert views also suggest that some pregnancies arrive late to facilities and thus, running into complication and potentially increases the stillbirth rate. The expert appears to share the comments by the health care worker relative to macerated (intrapartum) stillbirth.
“…Some of the referrals come when they have tried home and they are tired and the condition is getting worse, and they think that the baby is going to die at home and they send it to the facility. The baby might even be dead at home…." (RDHS, KII, UER)
“Little Attention” for the little one
Cultural dimensions describe the undesirable outcomes of stillbirth and perinatal deaths in the Upper East Region. Firstly, there is a culture of little interest in issues of stillbirth compared to maternal mortality. A labour ward doctor explained that this is almost the norm and perhaps explains the urgency attached to stillbirth.
"We don't pay attention to stillbirth as we do for maternal deaths. One mother will die and the whole hospital will here. I don't even know the stillbirths in the labour ward. They don't tell me…unless we are reporting. But when there is maternal mortality, eeeiii!” (Doctor3, IDI, UER)
There is also the believe that human beings are not to be counted, and thus, mothers will give an inaccurate history to midwives, and this turn to affect the kind of care they receive.
“Her record had wrong parity…they still have that notion that they don’t count human being.”
Service providers also observed that pregnant women had a laid back attitude towards their unborn babies, with others ignorantly refusing surgery and losing their babies in the process. A midwife narrates her experience as follwos:
“… a woman came and the liquor was small, so the best we could do was CS. When we told them, they told us that if the water is not ok, can’t you fetch water and add. They went home…came back some few days later and the baby was dead…” (Midwife 2, IDI, Zebilla District)
"history taking is key," said a labour ward in-charge. However, certain restrictions played to prevent the realization of clean history from expectant mothers.
"…taking history is key... The woman misled the midwives concerning her parity. We started inducing, and she raptured, then, we asked a relative (her daughter) and she said her mother had 6 children and 1 died. Such a person should be induced…we were misled.” (Midwife 2, IDI, Bongo District)
Findings from the focus group discussion also suggests that, healthcare workers pay little attention to the plight of pregnant women in labor. The discussions suggested that midwives are sometimes less interested in the welfare of the unborn babies. A participant had this to say;
“…Sometimes you can be crying and they won’t mind you. One time I was suffering and the midwives didn’t bother to check on me. I said my baby is coming….by the time they came my baby was gone. They don't care about our babies…" (PW4, FG3, Bongo District)
However, the expert argues that there is a causal relationship between stillbirth and maternal mortality, hence, it could not be the case that healthcare workers are not interested in the numbers of stillbirth. He explains;
"We take it serious…. when a woman loses her baby, there is a good chance that she will get pregnant in the next 6 months. This increases the risk for maternal mortality. But when the baby is alive, it means the woman may go through 2 or 3 years before she gets pregnant. That way the chance of recording maternal mortality is significantly reduced. (RDHS, KII, UER)
From the forgone, it means that not recording stillbirth reduces the risk of maternal mortality and thus, a good reason for equal attention to be given to stillbirth,
Abdominal ultrasound scan
Service providers and pregnant women had a common response for this theme; ultrasound abdominal scan comes with a cost. Despite its inclusion in the free policy package. It is almost impossible to go through pregnancy to safe delivery without being told to go for an abdominal ultrasound scan. However, the challenge is the person to do the scan.
"…If the scan in the facility is working, you also have free scan services without paying anything, but, we need to have a sonographer…” (Doctor 1, IDI, UER)
"…For scan, we don't have a sonographer, but we have a scanning machine in the maternity ward, which we do a quick scan and make a decision, but when others come and cannot afford you do it for them or when you have an emergency. Here, we are only two [doctors], I can't even go on leave…there're some if you think they can afford…. you send them to town..." (Doctor 2, IDI, UER)
“…We have a scan but we don’t have a sonographer, so much of the scan done outside. So that one is a very big challenge. The other one too is that because we are only two [doctors] for the hospital, we don't get time to scan for them. It is the emergency ones that we can, but most of them will have to go outside [for scan] …" (Doctor 3, IDI, UER)
All 3 study site hospitals had no trained sonographers. The absence of one meant that checking the status of the unborn baby has become more of a commercial service that pregnant women must pay for regardless of the free policy status. Pregnant women went to town at some point in their pregnancy, for a scan at a fee ranging between $5.00 and $7.00.
“…I did two scans, one here, one outside the hospital. When I did the scan here I didn't pay, but the one outside I paid GH₵25…” (PW4, FG3, Bongo District)
Apart from gestational age estimation and expected date of delivery for preparations of confinement, an ultrasound scan determines the level of amniotic fluid within the uterus, for clinicians to decide whether or not, a pregnant woman can have normal delivery. Within the context of quality and affordability, pregnant women will need this kind of service to be available. However, the account of one midwife suggests otherwise;
“Early and late scan helps a lot. Through that one, we can use to calculate the estimated gestation for them and to know when the person is likely to deliver and also determine post maturity. You may ask a woman to go and do a scan and it will take the whole week.” (Midwife 3, IDI, Zebilla District)
Curiously, some pregnant women do not trust the results of some scan output in the hospitals, in which case, they seek for a second opinion from the private ultrasound providers. The health care professionals are aware of this practice. A doctor and pregnant woman account triangulates;
"…But there are some you do the scan for them alright, but they don't believe what you are saying so you have to go for a second opinion in for them to believe. So they go to town…” (Doctor3, IDI, UER)
"…I'm sorry the machine they are using, is faulty, one time I was told they were a problem so I should go and do it outside when I went they were many pregnant women there and when I did the scanning, my baby was ok…" (PW3, FG3, Bongo District)
The Key Informer, however, averred that healthcare facilities in the region have been given ultrasound scan machines and users trained, thus, it is expected that mothers will benefit from abdominal scan without cost. He explains that with the help of Non-governmental organizations such as KIOCA, the UER should have no complaint about ultrasound abdominal scan. His account is diverse to the picture gathered from the field.
“…For the scan, I think we have made tremendous improvements. Apart from every hospital having scan services, even the lower-level facilities have scan machines. Last year we had 14 portable scans. Those were bought by KOICA. If you go to Paga now, they have a portable one with a screen like IPad, so the midwives will just do the scan for you…" (Regional Director, KII, UER)
This is rather a case of downstream policy implementation challenges, which may not be known by the top-level management.
Routine Drugs & Antibiotics
Study participants had one language to this; medicines, more than any other, are in short supply in accredited facilities, and this was attributed to the irregular payment of claims by the national health insurance claims. Pregnant women are told to buy for themselves. A medical superintendent shares his frustrations;
“…when you visit the facility and certain medication is not available, they are written for you in a prescription. When you take the prescription, then you may be forced to procure those drugs with cash. So far as our facility is concern…at the time you delivered if a medication is not available…we put it on a prescription for you to find a pharmacy shop to procure…” (Doctor 1, IDI, UER)
"…sometime we do have challenges from the acquisition of drugs from the Regional Medical Stores or suppliers…. Most often we have methyldopa, but if it is not there, we add another drug (nifedipine). Sometimes we don't have these drugs…, then they will have to go out and buy outside…” (Doctor 2, IDI, UER)
“…The issue has to do with drugs. The challenge here is that most of the time the hospital runs out of stock. When they run out of stock, the patient must buy. From our setting here because of the poverty level, most of them cannot afford the drugs…” (Doctor 3, IDI, UER)
The midwives echoed the difficulty in getting drugs at the facility level, and some of these drugs are giving to the newborn.
"…and after that, they pay for vitamin k, which we give to the child…that is when it is a normal delivery. When it is a Cesarean section, antibiotics like Cefuroxime, Amoxyclav, and Gentamycin are ordered by the doctor. If it is not there they go to buy…” (Midwife 2, KNNM, UER)
Apart from vitamin K which must necessarily paid for, antibiotics are often purchased as prophylaxis for mothers who may have gone through a surgical procedure during delivery. Then there is iron III, the absence of which causes anaemia in pregnancy. Iron III is routinely giving to pregnant women as a supplement, during antenatal days to safeguard anemia in pregnancy.
Within this context, pregnant women are left to buy for themselves, and the uncertainty may lead to some pregnant women reporting to the hospital with anaemia, an one antenatal clinic In-charges explains;
“…the difficulty is the delay in claims. When the dispensary does not have hematinic (iron III), you ask them to go and buy, it is a problem…. what about if she comes for ANC and you write for her and in the end she goes and not buy? She will come back with anaemia…” (Midwife 3, IDI, Bongo District)
A doctor disclosed that drug efficacy issues also contribute to the syndrome of private purchasing among pregnant women. Some preferences are not in the hospital’s dispensary shops.
“…we use Antibiotic and pain killers for Cesarean Section. Then we also have hematinic. The better once, usually we want them to buy those outsides…. eenh! And IV fluids too. There are certain times we go virtually down, they have to buy virtually everything” (Doctor 3, IDI, UER)
Drugs supplied by hospitals under the national health insurance scheme are deemed cheap and not potent. NHIS simply do not pay enough for drugs of generic products. Pregnant women buy those at their own cost, and this also fuels the rate of private purchasing of drugs. This assertion from the doctors and midwives are supported by the pregnant women account during the group discussions.
“…Whenever we come we have been buying the drugs. Most of the time when we come they do write for us to go and buy the drugs. The yellow and the red drugs, because they don’t have them here….” (PW1, FG1, Bongo District).