Socioeconomic Inequalities in Access to Skilled Birth Attendants During Childbirth in Ghana: A Decomposition Analysis


 Background: Equitable access to, and use of skilled birth attendance during delivery is vital for the achievement of the Sustainable Development Goals (SDGs) in reducing global maternal deaths to 70 deaths per 100, 000. Although several initiatives have been implemented to reduce maternal mortality in Ghana, inequities in the use of skilled birth attendance during delivery still exist among women of different socioeconomic groups. This study assessed the socioeconomic inequalities related to the use of skilled birth attendants during delivery in Ghana.Methods: This study analyzed data from the 2014 Ghana Demographic and Health Survey (GDHS). Concentration index (CI) and concentration curves (CC) were employed to measure the magnitude of socioeconomic inequality in the use of skilled birth attendants during child delivery. The concentration index was decomposed to identify the underlying factors driving the inequalities.Results: Out of a total of the 1,305 women who gave birth in the year prior to the interview, 28% of the deliveries had no skilled birth attendants of which 60% lives in rural compared to 40% in urban. A concentration index of 0.147 showed a pro-rich utilization of skilled birth attendance during delivery. The decomposition analysis revealed that wealth, education and location of residence were the major contributors to socioeconomic inequalities in the use of skilled birth attendants during child delivery among Ghanaian women.Conclusion: This study suggests that factors such as wealth, area of residence and education are worthy of increased attention and policy interventions because they are amenable to the reduction of observed inequality.


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Background 48 "Having a health worker with midwifery skills (for example doctors, midwives or nurses) present 49 at childbirth especially in rural areas, supported by adequate equipment, supplies and drugs, 50 regulations that permit them to carry out necessary procedures and transport for referral in case 51 of emergency is required, is perhaps the most critical intervention for making motherhood 52 safer." [1]. 53 Maternal health care services are critical inputs in addressing the problem of maternal 54 morbidities and mortalities, hence, remains a global priority. The Safe Motherhood Initiative 55 was a global collaborative effort to raise awareness for the scope of high maternal mortality 56 and to entreat the international community, countries and stakeholders to take steps to 57 address this public health concern. This was the beginning for a number of advocacy 58 conferences on reducing maternal mortality, with the most recent being the United Nations 59 Agenda 2030 on Sustainable Developments Goals (SDGs) to encourage developing countries 60 to prioritise skilled birth attendants during delivery to reduce maternal mortality [2]. The 61 proportion of births assisted by skilled birth attendants is a potential process indicator and 62 there is evidence of a strong positive association with the level of maternal mortality [3]. 63 Although several international conferences have tried to tackle this problem by reducing 64 maternal mortality ratio, progress in most countries have proven slow and challenging due 65 to lack of equitable access and use of maternal health services as well as the absence of a 66 functioning health care system [4]. The firm resolve with which skilled birth attendance has 67 been promoted as a global priority indicates the urgent need to offer policymakers and key 68 stakeholders a feasible, comparatively discrete and intuitively effective intervention [5].  Maternal mortality is unacceptably high in the least developed countries in the world 1 .  It has been confirmed that the majority of maternal deaths occur during childbirth with the 82 common causes being haemorrhage, infections, unsafe abortions, hypertensive disorders of 83 pregnancy and obstructed labour [1]. Estimates suggest that about 16% to 33% of these 84 complications can be prevented by the assistance of a skilled attendant at childbirth [5]. 85 The key findings from the Ghana  coverage of 74% of births that were delivered five years prior to the survey were assisted by 102 skilled attendants. However, this national coverage, though high may hide disparities among 103 socioeconomic groups in the country. The same report estimated that 90% of births by women 104 in urban settlements were assisted by skilled birth attendants compared to only 58% of birth 105 being assisted in rural areas. Yet, 96% of births were assisted by skilled birth attendants among 106 the rich, and only 49% were assisted for the poor [11]. These differences in the use of skilled 107 birth attendants during childbirth may be due to the existence of some socioeconomic 108 inequalities that contribute to women's health, before, during and after pregnancy, that 109 prevents women from using available health services. These inequalities may be demand or showed that wealth-related inequities were statistically significant in skilled delivery to the 121 benefit of women from economically better-off households. After decomposing, it was 122 observed that the main drivers of inequities were household wealth and mother's education 123 [21].

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It is in this regard that the study seeks to examine the extent to which socioeconomic 125 inequalities contribute to the use of skilled birth attendants and the underlying factors that 126 contribute to these inequalities in the Ghanaian context.  The outcome variable for this study is whether women who had delivered in year preceding 152 the interview year had deliveries assisted by skilled birth attendants or not. The outcome 153 variable is a binary outcome; a value of "1" was given if the delivery was assisted by a skilled 154 birth attendant and "0" if the delivery was not. A skilled birth attendant in this study was  In this study, occupation will be measured using employment status which is categorized into 204 two groups: employed or unemployed.

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We included 1305 women in the analysis who had at least one birth in the past year preseeding 303 the survey. We considered women who accessed skilled birth attendants during childbirth in 304 their last pregnancy.   Table 3 presents the results of the decomposition analysis that clarifies the degree to which

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The results of decomposition analysis are shown in Table 3

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The study has attempted to assess inequities in accessing skilled birth attendants among In urban areas, transportation may not be a problem and the mother does not need to walk a 398 long distance to seek skilled birth attendants during child delivery.