Introduction

Globally, the World Health Organization (WHO) [1] estimated that about 295 000 women died due to causes related to pregnancy and childbirth in 2017. Perhaps, two reasons account for this state of affairs—low skilled delivery and poor quality of antenatal care [2]. For these reasons, the Sustainable Development Goal (SDG) Three has prioritised reducing maternal, under-5 and neonatal mortalities as core global health policy objectives [3]. Place of delivery—the place where expectant mothers choose to deliver their babies has a direct effect on maternal health outcomes. The literature suggests that health facility-based or institutional delivery, manned by trained personnel has the tendency of reducing maternal and new-born mortalities and morbidities than home-based delivery [2]. Studies have shown that 50% of women in the world give birth at home without any professional supervision [1]. Scholarship from sub-Saharan Africa, reported that 60% of mothers do not have a skilled birth attendant (SBA) present during childbirth, and that out of 95% of pregnant women who attended antenatal care (ANC) in health facilities, almost half (47%) of them delivered at home [4].

The Government of Ghana has been promoting institutional delivery through a number of interventions, notably the Community-based Health Planning and Services (CHPS) and the Free Maternal Healthcare Policy (FMHP), under Ghana’s National Health Insurance Scheme (NHIS). The CHPS is a community-led participatory planning approach for delivering basic preventive and curative healthcare services to deprived communities, by stationing nurses called Community Health Officers (CHOs) in communities. The core aim of CHPS is to bridge geographical barriers in access to healthcare, by bringing healthcare to the doorsteps of communities. The FMHP sought to address financial barriers in accessing maternal healthcare because persons in need of antenatal, delivery and post-natal healthcare services are entitled to these services, free of charge [5].

Despite these interventions by Government, findings from the 2017 Ghana Maternal Health Survey revealed that 79% of births were delivered at a health facility conducted by professionals, of which 90% occurred in urban areas, compared to 68% in rural areas [6]. In Northern Ghana (including Upper West Region), health professionals attended to only 37% of births [7]. Ghana Health Service reported that more than 95% of pregnant women in the Upper West Region attended at least one ANC visit [8] and approximately 80% attended the recommended four (4) or more ANC visits but less than 60% of them delivered at a health facility assisted by a SBA [8]. Ghana Health Service [9] reported that infant mortality in the Upper West Region stood at 64 per 1,000 live births, while under-5 mortality stood at 92 per 1,000 live births, against the national averages of 41 and 60 per 1,000 live births in 2017 respectively [9]. Particularly in the Jirapa Municipality of the Upper West Region, evidence suggests that during the period 2012–2017, among 14,314 women who attended four (4) or more ANC visits, only 5,351 (37.4%) delivered at the health facility, and the remaining 8,963 (62.6%) delivered at home [9]. At these numbers of institutional deliveries, the Municipality did not meet the national target of 60% institutional deliveries [10]. The Jirapa Municipal Health Directorate reports that one major challenge to improving skilled delivery is poor geographical access and some unfavourable cultural norms and traditions [10].

This trend ignites great research interest, to unravel the factors that contribute to women delivering at home, despite attending the recommended ANC. Even so, there is relatively little literature on the reasons why women in Sub-Saharan Africa still deliver at home. Previous studies established that household level factors such as husband’s occupation, and the financial status of families, and individual level factors such as age and educational level of women, greatly influence their choices of a place of delivery [2, 11]. Interestingly, most of these studies concentrated on quantifying the number of women who delivered at health facilities, without going beyond these numbers to interrogate and understand the institutional and socio-cultural factors that influenced the women’s choice. Understanding these factors is crucial to identifying gaps in the existing research, designing appropriate interventions, and developing effective policies for addressing low facility-based delivery rates [12]. It will also help improve maternal health outcomes and contribute to achieving the health-related SDGs. The purpose of this study is to explore the institutional and socio-cultural factors that influence women’s decision to deliver at home after attending ANC.

Theoretical model of the study

This paper draws on the Andersen and Newman’s Behavioural Model for health service utilization [13] to explore the factors that influenced expectant mothers’ decisions to deliver at home. According to Andersen and Newman [13] an individual’s use of health services is a function of three important interrelated factors—predisposing, enabling/inhibiting and need factors [13]. The predisposing factors include socio-cultural characteristics of individuals such as education, occupation, ethnicity, culture, health beliefs, values, health status, and knowledge that people have about the health system, and demographic factors such as sex and age [13]. The enabling/inhibiting factors refer to the resources available or otherwise, that enable or inhibit the individual’s ability to use health services. The fact is that individuals may be predisposed to use health services but may lack the means or resources to enable them do so [14]. Enabling factors are proxied by individual or family resources such as income, health insurance coverage, and community level factors such as, the availability of health personnel and facilities. The need factors represent the most immediate cause of health service use [14]. Two important types of need factors arise here—perceived need and evaluated need. Perceived need refers to, “how people view their own general health and functional state, as well as how they experience symptoms of illness, pain, and worries about their health and whether or not, they judge their problems to be of sufficient importance and magnitude to seek professional help” [14]. Evaluated need represents professional judgment about people’s health status and their need for medical care [14]. Our study therefore posits that the interaction of these factors—predisposing, enabling and need factors, within the peculiar institutional and socio-cultural contexts of childbirth, influence women’s decisions to deliver at home.

Materials and methods

Study setting

The study was conducted in the Jirapa Municipality of the Upper West Region of Ghana, between November 2019 and June 2020. According to the 2010 Population and Housing Census of Ghana, the Jirapa Municipality has a population of 88,402, representing 12.6 percent of the Region’s total population. Females constitute 53% of the population, yet only 48% of the females are literate [7]. The Municipality has 44 health facilities, comprising seven health centres, 35 functional CHPS, one Polyclinic and a hospital—the St. Joseph’s Hospital. The St. Joseph’s Hospital is managed by the Catholic Church and serves as a referral point for the health centres and CHPS in several communities within and outside the Municipality [15]. The hospital has six medical doctors and 43 midwives [9]. Between 2014 and 2017, the Jirapa Municipal Hospital (the St. Joseph’s Hospital) recorded fifteen maternal deaths—five in 2014, three in 2015, two in 2016 and five in 2017 [9, 15]. Data available showed that in 2017, about 2,359 expectant mothers registered for ANC and 58.1% of them attended at least one ANC visit. In 2018, 2,398 expectant mothers registered for ANC, of which 58.3% attended one ANC visit [15]. Of this figure, 1,600 women registered for ANC in the first trimester [15]. Fig 1 details a map of Ghana showing the Jirapa Municipality and the communities, where the study was conducted.

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Fig 1. Map of the study area.

https://doi.org/10.1371/journal.pone.0261316.g001

Results

Discussion

Drawing on the Andersen and Newman’s Behavioural Model, this paper explored the important question: Why do women attend ANC but deliver at home? Our study revealed a number of intriguing factors—socio-cultural and institutional level factors that explained why some women attended ANC but ended up delivering at home. Our analysis established that socio-cultural factors—faithfulness to husbands, religion, and illiteracy predisposed most women to deliver at home. Our results demonstrate the community’s strong affinity to their traditional belief system, believing in the power of their gods to guarantee safe pregnancy and delivery. Our results are consistent with earlier studies on the subject matter in Ghana and elsewhere. For example, Barbi et al’s. [18] study in the Volta region of Ghana reported that socio-cultural practices and beliefs were obstacles preventing women from ANC visits because they believed that God will take care of them throughout the period of pregnancy and delivery. In Nepal, Paudel et al’s. [19] paper reported that the health- seeking behaviour of families is a function of their belief in God’s will in disease and death and that God has the capacity to affect their lives both negatively and positively. Similarly, studies in Sierra Leone, Liberia and Zimbabwe reported that obstructed labour was considered a sign of infidelity to one’s husband [20]. To prove their fidelity to their husbands, or bring honour to both husbands and families, many women prefer to deliver at home without professional assistance. These strongly- held traditional beliefs have implications for the use of maternal health services in general, and delivery services in particular. Indeed, other studies in the Tallensi District in the Upper East region of Ghana, attributed women’s non-use of maternal health care services to strong traditional belief systems [21]. These traditional beliefs could be attributed to the low educational status of women and their husbands in the study context. Studies in Pakistan, Ethiopia and Guinea-Bissau reported that educational status was a major predisposing factor associated with health facility delivery. For instance, existing quantitative studies [22–24], reported that women without formal education were more likely to deliver at home compared to women with higher levels of formal education. These findings demonstrate the empowering effect of education on women. Women with higher levels of education are more likely to have increased knowledge of the benefits of health facility delivery, increased socialisation to interact with formal services outside the home environment, familiarity with modern medical culture, and access to increased financial resources. At the same time, husbands with higher levels of education are more likely to facilitate their wives’ motivation to deliver at the health facility [25].

Women’s autonomy also stood out prominently as a predisposing factor associated with home delivery, largely based on their weak economic position. The women interviewed depended entirely on their husbands’ largesse, and as such would not challenge their husbands’ position as to where to deliver, in order to secure their marriages. These findings fit in neatly with Ameyaw et al’s. [26] study in Ghana, that reported that women with health decision-making autonomy have higher chances of health facility delivery, as compared to those who are not autonomous. Lowe et al. [27] and Kifle et al. [28], in their research in Gambia and Eritrea respectively also found that women’s decision to receive care by trained personnel during delivery was beyond their control because women do not have control over material and financial resources in the household; and that even women with higher educational levels may fail to translate their preference for a delivery place into actual behaviour if their husbands are opposed to their choice. Kifle et al. [28] argued that a woman’s choice to deliver at a facility is seriously undermined by women’s lack of decision-making autonomy through complex processes of gender inequality. Kifle et al. [28] assert that family decision-making power regarding the use of maternal healthcare services is strongly influenced by the values and opinions of husbands, mothers-in-law and other close relatives.

Remarkably, this study established that institutional-level factors—rude behaviour, negligence, general poor attitude of health professionals, inadequate midwives, lack of privacy and confidentiality, and hidden charges at health facilities, played a double role of enabling some women to deliver at home and at the same time acted as obstacles to health facility delivery for others. Some health providers are reportedly rude, negligent, and unfriendly towards women during ANC and delivery visits [29, 30]. In fact, the issue of negligence is particularly worrying because women in labour are left unattended, while midwives played with their mobile phones. These issues relate directly to the care environment, where women give birth, regarding the perceived quality of care received. The perceived quality of care is an important determinant of health services use. Perceived quality of care increased the number of women giving birth in health facilities, and women even travelled farther than expected to give birth at facilities, where the quality of care is perceived to be good [31]. The perceived quality of care further speaks to the issue of ‘respectful maternity care (RMC)’—defined as friendly and woman-centred [32]. Hajizadeh et al. argued that RMC is a fundamental human right that includes respecting women’s beliefs, independence, emotions, dignity and preferences [32]. The authors observed that there is a direct relationship between RMC and positive childbirth experience, and that disrespect and abuse violate the basic principles of ethics, human rights, and basic obligations in providing care for patients [32]. Like the women’s account in this study, Bulto et al’s. [33] study in Ethiopia revealed that the proportion of women who received RMC during labour and childbirth was low (35.8%) and recommended monitoring and reinforcing accountability mechanisms for health workers to improve RMC [33].

The inadequate number of midwives reported in this study is perhaps, attributable to the considerable distributional inequalities in clinical health staff within and across all the regions in Ghana. For example, in 2018, out of 5,582 midwives produced, the Upper West Region, which is more rural in outlook, got only 219 representing 3.9%, whereas the more urbanised regions of Greater Accra and Ashanti had 973 and 1,281 representing, 17.4% and 23% of midwives respectively [34]. The irony of this situation, is that the Jirapa Municipality, where this study was conducted, has a reputed midwifery training school. Consistent with the existing evidence, studies in Nepal reported that poor health infrastructure, and inadequate nurses/midwives were critical factors associated with home delivery [35]. The issue of lack of privacy and confidentiality, to the extent that unauthorised personal information of women, relating to their HIV/AIDS statuses is given to third parties, is an indictment on health staff, and a violation of the ethical code of conduct because the divulged information could lead to discrimination and stigmatisation against the affected women. The lack of privacy in terms of adequate accommodation and space in the labour room for husbands and relative to have access to a woman in labour, has also been reported in earlier studies in Ghana and elsewhere as a barrier to health facility delivery [34, 36]. More intriguing is the revelation that it is not free to deliver at the hospital, as women in labour incur several hidden costs, including buying Dettol, soap and other detergents because the delivery room according to the narratives, has “nothing”. The belief that some of the midwives appropriate some items bought by the women in labour, speaks to corruption in the health sector. These hidden costs run contrary to the FMC policy under Ghana’s flagship NHIS and question the effectiveness of the policy because the policy clearly enunciates free access to maternal healthcare services. Studies in the Kassena-Nankana Municipality earlier reported that, the implementation of the NHIS did not eliminate all charges and that women still made out-of-pocket payments for ANC services [37–39]. Financial constraints have been cited as one of the major factors for home delivery, while the reverse holds true—that is, women from wealthy homes have higher odds of seeking health facility delivery [18, 40]. Indeed, it is argued that the rise in maternal deaths, especially in developing countries, may be associated with increasing costs that act to delay the decision to use the hospital until the woman’s condition is critical [19].

Lack of, and cost of transportation to the nearest facility promoted home delivery. Most of the respondents relied on tricycles as the only means of transport. Thus, the farther away respondents reside from the health facility, the more likely they are to deliver at home rather than delivering in a hospital. Most of these women are reluctant to deliver in the hospital because they do not readily have means of transport when labour starts. Our findings resonate well with earlier studies. For example, Dotse-Gborgbortsi et al’s. [41], study in the Eastern Region of Ghana, reported that a kilometre increase in distance significantly reduced the prevalence of women giving birth in health facilities by 6.7%. The distance is compounded by the timing of labour, especially in the night. A study in the Upper East Region of Ghana reported that when labour starts at night, women could not walk to the health facility to deliver [21].

Finally, the fear of caesarean section or assisted delivery has been established in this study as the only need-based factor influencing home delivery. The fear of caesarean section or assisted delivery may be appropriately placed under institutional level factors because it occurs only at the health facility or institution. As the results suggest, it appears most of the respondents have a fear for assisted delivery because health professionals may become negligent and forget needles and other materials in the wombs of women, the perception that the procedure may weaken women for life, and death. Earlier scholarship from rural Bangladesh also reported that when expectant mothers go to health facilities, the doctors hurriedly conducted caesarean delivery instead of trying for a normal vaginal delivery. Based on these fears, some women prefer to deliver at home [42].

Conclusion and recommendations

This paper investigated the factors that influenced women to deliver at home, despite receiving ANC at a healthcare facility. The paper established that socio-cultural and institutional level factors influenced women’s decision to deliver at home. Socio-cultural factors such as faithfulness to husbands, religious beliefs, women’s autonomy, and the lack of, and cost of transportation, predisposed most women to home delivery. Institutional- level factors such as rude, negligent and unfriendly behaviour from health professionals, inadequate midwives, lack of privacy and costs, and the fear of caesarean sections, were found to be crucial barriers for health facility delivery. Our findings have far- reaching policy implications for increasing health facility delivery and reducing maternal and child mortalities, in consonance with SDG Three. We recommend that, given the low levels of literacy and the strong traditional beliefs in the study area, the Ghana Health Service should collaborate with civil society organizations and community leaderships to organize educational programmes, aimed at sensitising communities on the importance of health facility delivery, and reshaping some of the traditional belief systems facilitating home delivery. Additionally, women empowerment should be promoted, to enhance their decision-making autonomy relating to health seeking. We also recommend that Ghana Health Service recruits and posts more midwives to the study area and give them incentives, to motivate them to stay in these deprived areas. Finally, the Ghana Health Service should also equip the labour rooms in health facilities, with the requisite delivery kits to facilitate the work of midwives, to give meaning to the FMHP.