Knowledge of place of delivery and postnatal care among reproductive women in urban Ghana: a longitudinal qualitative study

Abstract

Place of delivery continues to be a burden to maternal healthcare despite the introduction of interventions and policies aimed to promote maternal health. Outcomes on the choice of place of delivery have not been captured using rigorous qualitative approaches, which are empirically proven. This study investigated the accounts of mothers who have delivered in the last five years either at home, or at health facilities, and evaluated the reasons for their choice of delivery in urban Ghana. The longitudinal case study design was employed using in-depth interviews and focus groups on women of reproductive age (15-49) in the pre- and post-COVID eras. The study investigated women’s opinions and experiences of care in terms of factors that influenced their place of delivery, service satisfaction, and whether they would recommend services to neighbours. Study results reveal that 2 out of 16 mothers delivered home and assisted by TBAs despite the introduction of the free maternal delivery in addition to other available interventions such as focused ANC aimed at improving maternal healthcare. Findings suggest that human-induced aspects of care during delivery are key to women’s expectations, which in turn build up satisfaction. Service improvements, which address aspects of care, are likely to have impact on health-seeking behaviour and utilisation.

Keywords:

• Delivery
• maternal health
• thematic analysis
• staff attitude
• TBA
• Ghana

REVIEWING EDITOR:

• Joe Thomas, Institute of Health and Management, Australia

SUBJECTS:

• Allied Health
• Breastfeeding
• Sexual & Reproductive Health
• Nursing
• Allied Health

Introduction

Low use of prenatal and maternal healthcare services including health facility delivery is evident as the major cause of adverse birth outcomes globally (Fotso et al., 2009). As a result, more than half a million women worldwide die each year because of complications arising from pregnancy and childbirth (Akowuah et al., 2018). It is reported that Africa has the highest rates of maternal mortalities, mostly due to direct obstetric causes, puerperal sepsis, and hypertensive disorders, which are related to environmental factors (Ronsmans & Graham, 2006). These high cases of maternal mortalities have been the major reason pregnant women are encouraged to seek early health care services globally, and especially in sub-Saharan Africa due to its environment (Lozano et al., 2011; Mulogo et al., 2006). Many of these deaths could be avoided through pragmatic crosscutting interventions including emergency obstetric care for women with complications and skilled delivery care. A key among these interventions aimed at controlling maternal mortalities is antenatal care (ANC).

Despite improved maternal healthcare delivery using standardised procedures and protocols, several pregnant women in the sub-Saharan region still deliver in places other than health facilities (Titaley et al., 2010; Kruk et al., 2009). The reasons behind these observations are varied, and demand the broad engagement of politicians, policymakers, researchers, healthcare practitioners, and the lay with the view to reaching out to lasting pragmatic solutions. Hence, there is the need to put both local and scientific knowledge on equal footing, since such synergies have always proven to work (Wilcox, 1994). There has been extensive research on the influences of health facility delivery including, those in Ghana (Moyer et al., 2014; Gabrysch & Campbell, 2009; d’Ambruoso et al., 2005) Tanzania (Lwelamira & Safari, 2012; Kruk et al., 2009) indonesia (Titaley et al., 2010) Nepal (Khatri et al., 2021; Karkee et al., 2013) and Cameroon (Annette et al., 2016). Most of these studies dwell extensively in the quantitative tradition of enquiry except a very few adopting the constructivist paradigm including those of (Moyer et al., 2014; Titaley et al., 2010; Gabrysch & Campbell, 2009).

The work of Gabrysch et al. (2009) only reviews the available literature using secondary data and broad themes to reflect the foundations of their research outcomes. The study of d’Ambruoso et al. (2005) empirically uses in-depth interviews and focus groups to investigate women’s perceptions and experiences that influenced their place of pregnancy delivery; however, the free maternal care policy was only scaled out to their region of study in 2005 (Akowuah et al., 2018). Again, the work of Moyer et al. (2014) was systematically conducted but in a rural setting in northern Ghana compared to the setting of this study, being urban.

This study seeks to fill this grey area using an empirical qualitative approach to explore the reasons for place of delivery and postnatal care in urban Ghana. Sociologically, the health-seeking behaviours of population groups have been conceptualised by several theoretical models including (Yadav & Jena, 2022; Prochaska et al., 1997; Ajzen, 1991), Among the widely used theoretical models in health care use include the health belief model (HBM), transtheoretical model (TTM), theory of planned behaviour (TPB), social cognitive theory (SCT). The current paper adapts Andersen’s healthcare utilisation model, which demonstrates factors that lead to the use of healthcare services (Andersen, 1995). The theory has three dimensions namely; predisposing, enabling, and need (PEN) factors. Specifically, predisposing factors comprise demographic, social, structural, and attitudinal (belief systems) dynamics that increase the likelihood of a person to seek for health care. Enabling factors include the influences that empower people’s use of health care services. They include the social and community networks found within the family and society, and cut across local, national, and global spectrums. Need factors indicate the actual problem of discomfort that patients experience and the severity of this condition. Thus, the greater the severity the greater the need for health care use.

Available studies reveal that some pregnant women still use the services of Traditional Birth Attendants (TBAs) for varied reasons in less developed societies (Nunu et al., 2019; Titaley et al., 2010). Data from the Kwabre East Municipal Health Directorate (Kwabre East Health Directorate, 2013), show that both doctor-to-mother and nurse-to-mother ratios are not inspiring. Doctor to patient ratio was 1:71,753 in 2014, and 1:74,841 in 2015. It was recorded as 1:75,015 in 2020, and 1:77,752 in 2021. These ratios are for women aged 15-49 and are all above the WHO’s standards of 1:600. The story is no different on the side of Nurse-patient ratio. The Nurse-mother ratio was 1:3,567 in 2014, and 1: 1,728 in 2015. In 2020, it was recorded as 1: 1,857, and 1:1,978 in the year 2021 (Kwabre East Health Directorate, 2013; Ghana Ministry of Health, 2007).These are also above the WHO standards of 1:500 (Ghana Ministry of Health, 2007). This pattern of maternal health care accessibility and utilisation have serious health implications and risks. This study, therefore, seeks to explore the knowledge and experiences of the choice of place of delivery and postnatal care among reproductive women in urban Ghana. The total annual ANC attendance in 2014 was astronomically recorded as 166,089 with 1,825 as daily average visits, compared to postnatal visits of 88,918 with daily average of 244 (Kwabre East Health Directorate, 2013). In 2015, total annual attendance for ANC visits surprisingly fell to 22,863 with daily average of 63 while 2,517 turnouts were recorded as postnatal with 7 visits as the daily average. Again, total ANC cases increased in 2020 to 22,912 with daily average of 69 while postnatal visits further increased to 3,530 with a daily average of 10 visits. However, the Antenatal visits in 2021 fell again to 18,625 with daily average of 62 while postnatal cases recorded further increased to 2,579 with daily average of 41 visits (Kwabre East Health Directorate, 2013).

The Ghana free maternal healthcare policy under the National Health Insurance Scheme (NHIS) offers low-risk pregnancy care by consultants and other skilled health personnel, in addition to the focused antenatal care (FANC), which provides personalised care to pregnant women and highlights their overall health status, preparation for childbirth and readiness for complications (Ghana Ministry of Health. , 2007; Kwabre East District Assembly, 2014). However, some pregnant women still use the services of Traditional Birth Attendants (TBAs) for varied reasons in less developed societies (Nunu et al., 2019; Titaley et al., 2010).This study, therefore, seeks to explore the knowledge and experiences on the choice of place of delivery and postnatal care among reproductive women in urban Ghana.

Methods

Study setting and design

Using the longitudinal case study design, this study sought to explore the experiences of reproductive women on their choice of place of delivery and postnatal care in the Kwabre East Municipality of the Ashanti region of Ghana. The study design was used since the research question focuses on contemporary phenomenon and there was no control over behavioural events among study parameters (Bowling, 2014; De Vaus, 2001). Again, the study questions ‘why’ some women still use the services of TBAs after the free maternal delivery services were mainstreamed in the healthcare system of Ghana. The Municipality has a total land area of 123 square kilometres constituting approximately 0.51 percent of the total land area of the Ashanti region. The Municipality lies within latitudes 60°45′and 60°50′North and longitudes 10°30′and 10°35′West (Kwabre East District Assembly, 2014). The study setting as peri urban has the settlement characteristics as involving primary production, wide disparity in wealth, good roads, poor telecommunications, and social services. It is different with regard to its distance from Kumasi, the capital of the Ashanti region. Its proximity to Kumasi is sometimes accompanied with mixed thoughts due to intense traffic. For the purpose of this study, four facilities, namely, Mamponteng, Asonomaso, Antoa, and Sakora Wonoo, all of which are publicly owned facilities, were selected. Asonomaso and Mamponteng hospitals are the only 2nd tier facilities in the Municipality with the rest rendering primary health services.

Sampling and study population

This study considered mothers who had either attended ANC or delivered either at the facility assisted by health professionals or home assisted by TBAs within a six-year internal. The study population was sought from the municipal health information management system software of the Ghana health service (Kwabre East Health Directorate, 2013), which contains the profile of all women from prenatal to postnatal care. The convenience sampling technique, as prescribed by Bowling (2014) was used to select study respondents due to time, logistics, and financial constraints. This sampling technique was adopted due to the availability and willingness of participants to get involved with the study to share their experiences.

Research instrument and data collection

This qualitative study was conducted between 15th June and 15th October 2015 and 7th July to 31st august 2021 in the Kwabre East Municipality of Ghana. To discover the dynamics which stimulated the knowledge and perceptions of factors influencing the choice of place of delivery, two focus groups were conducted in the research enquiry. 17 participants were conveniently sampled upon availability and willingness to participate in the study. The first group comprising 4 women who had just delivered before the study with 2 nurses and 2 midwives which spanned from 15th June and 15th October 2015. The other group had 4 mothers receiving postnatal care with 2 nurses and 2 midwives took place from 7th July to 31st august 2021, in addition to an in-depth interview with the Municipal Health Nurse (MHN), which was a face-to-face interaction to obtain information on hygiene, obstetric management, and postnatal care. The focus groups were conducted using semi-structured guides and included open-ended questions to obtain data on participants’ knowledge of the place of delivery and the attitude of caregivers. Focus groups were conducted in Twi (a major Ghanaian local language) and later translated into English but the interview with the MHN was conducted in English. Data saturation was reached when study participants gave repeated responses and developing themes had reappeared satisfactorily.

Data analysis

Themes that emanated from the focus groups were transcribed verbatim and analysed using thematic analysis by means of “exact” words from participants since this technique helps to categorise, deduce and account for themes in one’s dataset (Braun & Clarke, 2006). This helps portray the interpretations, beliefs, experiences, and observations of respondents about the epistemological positions of a research enquiry (Braun & Clarke, 2006). Again, the study employed manifest coding in its transcription to develop some deeper appreciation of contents through “thick description”, to identify themes, and stay flexible and open-minded (Davies & Hughes, 2014; Fereday & Muir-Cochrane, 2006). Study data were shared among authors individually for familiarisation to draw codes and themes. Afterward, emerged manifest codes and themes from data were exchanged among authors for further consideration. Finally, the authors gathered together to agree in common on the emerged codes and themes from the study data. After coding was done, themes and analysis of transcripts were serialised, shared, and discussed as prescribed by authorities (Creswell & Creswell, 2017; Booth et al., 2014; Davies & Hughes, 2014; Ghana Ministry of Health, 2007).

Ethical consideration

Ethical clearance with reference CHRPE/AP/407/15 was sought from the Committee on Human Research and Publications Ethics from the Kwame Nkrumah University of Science and Technology and the Komfo Anokye Teaching Hospital, Kumasi. Again, formal consent was obtained from participants who agreed to be part of the study. Study participants were assured of privacy and confidentiality of study outcomes. Study participants were informed of their right to voluntary participation in the study and to retire anytime without fear of intimidation. Participation in the study was strictly voluntary, and so participants could withdraw from the study if they felt any inconvenience at any time. The authors assigned unique identifiers to audio recordings and transcripts to maintain absolute confidentiality. Again, this qualitative study was directed by the guideline framework used for reporting qualitative health research (Booth et al., 2014).

Results

This paper sought to explore the knowledge, perceptions, views, and opinions influencing the choice of place of delivery among women in urban Ghana after the introduction of the free facility delivery, a component of the free maternal healthcare policy. Table 1 below outlines the details of the study findings.

Table 1. Key emerging themes.

Themes	Sub-themes	Quotes
Theme 1: knowledge on place of delivery	Intense ANC education Safety in facility delivery Confidence in TBAs Proximity to facility Religious beliefs of Clients Focused ANC	“You know… erh, I believe in my local people that they are good, that is why I always want to deliver at home. You see…they (TBAs) advised me to have the scan and do some tests and that is why I came here” (A pregnant mother from Sakora Wono, FG1) “…this is my fourth child and all were delivered here since the Nurse said my babies will be strong and fine” (A recently delivered mother from Antoa, FG2) “The Nurses told me that facility delivery is the safest and I should use it anytime I become pregnant” (A pregnant woman from Mamponteng, FG1) “Personally, I see the hospital to be close to me so I visit it anytime I become pregnant” (A pregnant woman from Asonomaso, FG1)
Theme 2: Attitude of caregivers	Poor attitude of staff Insensitivity among caregivers Disrespect for mothers Verbal abuse	“Here is different ooo… they (health staff) do not respect us at all, when you go in the morning they will say why are you coming so early? When you go there in the afternoon they will say why did not you come in the morning?…. In fact, they are insensitive and do not respect us all.” (A recently delivered woman from Antoa facility; FG2) “… Me for instance, I like them because they chat and smile to me anytime I come here even before my labour. I think this is why more people come here (Recently delivered woman from Asonomaso facility, FG1) “I came here one late afternoon and some Nurses gave me cheeky looks. They then asked why will I come here so late but I felt fearful to tell them my problem” A pregnant woman from Asonomaso, FG1
Theme 3: Knowledge on postnatal care	Intensive care Improved mother care Enhanced newborn care BP, HIV, hepatitis B tests Uterus checking Birth weight	“As I told you earlier, ehmm…what we as the Municipal health directorate do is that, mothers and their newborn babies are always put under intensive care for at least six hours to make sure their conditions are normal and free from any form of complications” (Municipal Public Health Nurse) “Sir, they checked for my blood pressure, and did hepatitis B and HIV test. It is good for me I now know all those things, though I was afraid of COVID” (Recently delivered woman from Asonomaso facility, FG1) They took care of my baby and myself some hours after I delivered. The Nurses say they do that to check against complications after birth. (FG2, a recently delivered woman from Antoa facility) “We as a health directorate, offer all services to both pregnant and recently delivered women” (Municipal Health Nurse)
Theme 4: satisfaction on place of delivery	Service satisfaction There is comfort Punctuality of nurses Family support	“My family supports me all the time, especially during the COVID lockdown, my husband was at home and will drive me here anytime I come to see the Nurses. They also advised me not to miss my ANC sessions.” (A pregnant woman from Asonomaso, FG1) “Since I am a government worker, I always come here early before I go to work and the Nurses here aren’t late to duty. I feel comfortable here.” (A pregnant woman from Mamponteng, FG1) “Due to family support, this is my third pregnancy and I always deliver with the help of the TBA although my family always advises me to come for ANC and this is why I am here.” (FG 2, a pregnant woman from Antoa facility)

Themes

The themes acknowledged by the study, are presented and supported in Table 1.

Theme 1: Knowledge of the place of delivery

Study participants shared and described their knowledge of their choice of place of delivery. The current study discovered that respondents’ early ANC attendance increased their knowledge of the place of delivery as a result of the intense education given to them by the Municipal Health Directorate. Thus, respondents revealed that holistic health which encompasses aspects of environmental, psychological, physical, emotional, intellectual, spiritual, physical, and social health is among the key services rendered to clients alongside the FANC (see Table 1). Women responded that early detection of pregnancy complications and other potential problems that could affect the outcomes of pregnancies were among the reasons they used facility delivery. Thus, most participants delivered in facilities with the motive of averting pregnancy and delivery complications (see Table 1). Some study participants shared their views as follows:

“…this is my fourth child and all were delivered here since the Nurse said my babies will be strong and fine” (A recently delivered mother from Antoa, FG2)

“The nurses told me that facility delivery is the safest and I should use it anytime I get pregnant” (A pregnant woman from Mamponteng, FG1)

However, it was evident that even during the intense COVID lockdowns, some pregnant women still used the services of health facilities. A participant who used home delivery with assistance from TBAs shared her experience:

“You know…eeerh, I believe in local medicine, that is why I always want to deliver at home. You see, I was even happy not to come for checkups during the COVID lockdown…they (TBAs) advised me to have the scan and do some tests and that is why I came here” (A recently delivered mother from Sakora Wonoo, FG2)

Theme 2: Attitude of caregivers

The study sought to explore the knowledge, perceptions, views, and beliefs of caregivers that influence mothers’ choice of place of delivery. Most participants declared that the attitude of caregivers (Doctors, Nurses, Midwives, laboratory technicians, etc) influenced their use of facility delivery and other health care services. Study respondents indicated that caregivers with a good attitude help to reduce stress and make it easier to get through the tough days of pregnancy and delivery and would want to be with such health staff. A recently delivered woman recounted her experience below.

“… Me for instance, I like them because they chat and smile to me anytime I come here even before my labour. I think this is why more people want to come here.” (Recently delivered woman from Asonomaso facility, FG1)

Notwithstanding the above experience, a section of study respondents narrated that their experience with the attitude of caregivers would have made them choose the services of TBAs but due to unforeseen complications, they are compelled to deliver at the facility. They further argued that the impact of caregivers’ stress has decreased their quality of life, led to a decline in their health, and increased mental health needs with increased stress responses, and exposure to depression and anxiety. Below is the account of a study participant after delivery.

“Here is different ooo… they (health staff) do not respect us at all, when you go in the morning, they will say why are you coming so early? When you go there in the afternoon they will say why did you not come in the morning?…. In fact, they are insensitive and do not respect at all.” (FG2, A recently delivered woman from Antoa facility; FG2). Hence, the current study confirmed mixed feelings among participants on the attitude of caregivers toward their choice of place of delivery.

Theme 3: Knowledge of postnatal care

Some study participants shared their personal experiences that postnatal care services are important to prevent complications after delivery and ensure maximum care for the mother and newborn. Comprehensive tests including HIV and hepatitis B are conducted on newborn babies, with uterus checking and BP conducted on mothers. Due to the need for postnatal care services, study participants defied the COVID lockdown restrictions to access such services even with some women who delivered with the help of TBAs. A participant recounted the experience below:

“Sir, they checked for my blood pressure and did hepatitis B and HIV tests also. It is good for me I now know all those things, although I was afraid to come here during the COVID-19 lockdown” (Recently delivered woman from Asonomaso facility, FG1)

A revealing experience of the current study indicates that women who use home delivery go for the services of caregivers in health facilities under postnatal care. The municipal health nurse shared her experience below:

“As I told you earlier, ehmm…what we as the Municipal health directorate do is that mothers and their newborn babies are always put under intensive care for at least six hours to make sure their conditions are stable and are free from any form of complications” (Interview 1 with the Municipal Public Health Nurse)

Theme 4: satisfaction with the place of delivery

The study sought to analyse the personal knowledge that respondents have experienced in their past deliveries about their current pregnancy and their choice of place of delivery. Study results revealed that enabling service satisfaction enticed more women to use both prenatal care and postnatal care. Most participants were satisfied with facility delivery and wished to recommend such services to others.

“My family supports me all the time, especially during the COVID lockdown, my husband was at home and will drive me here anytime I come to see the Nurses. They also advised me not to miss my ANC sessions.” (A recently delivered woman from Asonomaso, FG1)

Notwithstanding, a participant shared a different view below:

“Due to family support, this is my third pregnancy and I always deliver with the help of the TBA although my family always advises me to come for ANC and this is why I am here.” (FG 2 with a pregnant woman from Antoa facility.

Discussion

The study was conducted to explore the knowledge and sources of information on mothers’ place of delivery and postnatal care among reproductive women in the pre- and post-COVID-19 eras in the Kwabre East Municipality of Ghana. Study themes are discussed under the guidance of Andersen’s healthcare utilisation model of health-seeking behaviours under predisposing, enabling, and need factors.

Need factors

The knowledge of the need for the best delivery care is significant to influence women’s choice of place of delivery (Andersen, 1995). This section explored the factors that influenced mothers’ perception of the place of delivery with skilled attendants and how beneficial mother and newborn care is to healthcare workers. Need factors for health care use are aspects of individual lifestyle choices which have close linkages with wages, disposable income, availability of work, taxation, and prices of goods and services (Andersen, 1995). This perception is formed by the awareness of the general perceived dangers of childbirth and its associated complications about the available interventions at health facilities and the absence of these services with TBAs. Study outcomes revealed that 14 out of the 16 participants preferred facility delivery since that is where the best care is accessed. We found that active facility care delivery involves the coordination of all stakeholders (eg healthcare system, government, NGOs, family, and social support) towards the broader healthcare system. Study findings, therefore, discovered that the knowledge of the need to receive the best and actual care by pregnant women influenced their choice of place of facility delivery (Annette et al., 2016; Karkee et al., 2013; Lwelamira & Safari, 2012; Mulogo et al., 2006). A revealing finding indicated that even women who have been using home delivery assisted by TBAs attended ANC as prescribed by family members and TBAs themselves (Table 1). Hence, study findings support previous studies including those in Ghana (Moyer et al., 2014) Nepal (Karkee et al., 2013) Cameroun (Annette et al., 2016) Zimbabwe (Nunu et al., 2019) and Ethiopia (Yared & Asnaketch, 2002) that reproductive women are predisposed to utilise facility services due to their conditions and the need for such services.

Enabling factors

The experience of sociological and environmental care rendered to women and their newborns is relevant to influence the use of facility delivery in future pregnancies. The study revealed that most respondents will always prefer facility delivery to the services of TBAs due to the availability of advanced obstetric care arising out of complications. Such services are not universal, and many women narrated receiving excellent care in facilities that are absent in traditional settings. In addition, the availability of modernised equipment, processes, and protocols made pregnant women prefer facility delivery (Table 1). Again, social support systems (Gabrysch & Campbell, 2009) have been reported by most study participants to be among the factors that induced their propensity to use facility services. In the peak of COVID restrictions and lockdowns, some pregnant women were escorted to health facilities by their husbands to receive care (Table 1). This indicates that strong social ties and cohesion work together to ensure healthcare use among women. These outcomes are in agreement with the work of Kruk et al. (Kruk et al., 2009) and d’Ambruoso et al. (d’Ambruoso et al., 2005), that the availability of known family and loved ones and social connectedness influence health care use among people.

This study revealed that postnatal care services rendered to women included checking of BP, HIV test, hepatitis B test, and vitamin A supplements in addition to uterus checking within 24 hours after delivery (Burnett-Zieman et al., 2021; Khatri et al., 2021). Similarly, to ensure maximum care of newly born babies, oral polio drop, BCG injection against TB, cord test, and eye test are undertaken in addition to the taking of birth weight of all newborn babies (Khatri et al., 2021). Our findings discovered that comprehensive care is given to both mother and newborn in health facilities soon after delivery in addition to the FANC services. Study results revealed that these postnatal care services are offered to women who even use home delivery. This agrees with the work of Khatri et al. (Khatri et al., 2021) and Burnett-Zieman et al. (Burnett-Zieman et al., 2021), that the issuance of postnatal services serves as an opportunity to improve the quality and access to maternal health care. Again, these findings corroborate other studies in developing countries including those of Burnett-Zieman et al. (2021), Wang, (2011), Gabrysch and Campbell (2009) and d’Ambruoso et al. (2005) that people’s health care use is influenced by environmental factors which include hygiene, obstetric management, postnatal care and attitude of caregivers.

Predisposing factors

The current study revealed there is intense education acquired by participants on their awareness and knowledge of the use of facility-based delivery coupled with their belief systems, values, and attitudes. Several studies including Lwelamira and Safari (2012), Titaley et al. (2010), Kruk et al. (2009), Gabrysch and Campbell (2009), and d’Ambruoso et al. (2005) have documented the relationship between lower socio-economic status and lower rates of facility delivery. The reasons are one’s ability to pay for services rendered, proximity and access to higher-quality health care, and ability to seek transport to a facility. What has not been explored, however, is the relationship between the healthcare structure and some of the social factors that influence the place of delivery, including the attitude of health staff, punctuality of nurses, service satisfaction, and family support, using first-hand observations. The results presented here suggest that healthcare structures and human-induced factors are potential risk factors for a place of delivery (Table 1). Thus, findings revealed that the attitude of caregivers expels patients from accessing healthcare (Table 1). Again, the study discovered mixed opinions on women’s levels of satisfaction with both prenatal and postnatal care. In some facilities within the study area, women narrated the positive attitude exhibited by healthcare workers and this increased their use of facility services with satisfaction. However, some participants complained of the poor attitude of some caregivers and this affected their level of satisfaction with the care received. The attitude of caregivers and satisfaction of care received highly influenced health care use and have a significant influence on women’s choice of place of delivery Lwelamira and Safari (2012) and Kruk et al. (2009). These findings corroborate the work of Moyer et al. (Moyer et al., 2014) in northern Ghana that both systems and human-induced factors influence the place of delivery.

Conclusions

Study findings suggest that healthcare structures and human-induced aspects of care are key to women’s expectations of the place of delivery, which in turn build up satisfaction or otherwise. Hence, service improvements, which address aspects of care, are likely to have an impact on health-seeking behaviour and utilisation. Findings recommend that the Municipal health directorate adopts more user-friendly approaches and methods to attract mothers who use home delivery and retain those who deliver in facilities. Finally, the study recommends institutions and individuals whose primary purpose is to improve health such as the Information Services Department (ISD) and the National Commission for Civic Education (NCCE) intensify campaigns on maternal healthcare use.

Limitations

The current study was, however, limited to women who have had experience in birth delivery and were either, receiving prenatal, or postnatal care. The knowledge and experiences of past deliveries could probably have influenced their responses in the focus groups and could have affected the trustworthiness of the study results. Likewise, the study purposively selected the participants involved and this could raise questions about the reflexivity of study outcomes. Nevertheless, the study adopted several strategies outlined in previous literature for ensuring scientific scrutiny using rigorous qualitative methods of enquiry to ensure credibility, dependability, and confirmability (Creswell & Creswell, 2017; Booth et al., 2014; Bowling, 2014; Davies & Hughes, 2014; Braun & Clarke, 2006; Fereday & Muir-Cochrane, 2006; De Vaus, 2001).

Consent to publish

Not applicable.

Acknowledgments

The authors are grateful to the municipal health nurse, facility nurses, and midwives in selected facilities. They are also grateful to all the study participants for their support during the data collection. Lastly, they would like to thank the Kwabre East Municipal Health Directorate for both personnel and logistic support.

Disclosure statement

The authors declare that they have no competing interests.

Data availability statement

All data supporting findings are available upon request.

Additional information

Notes on contributors

Jones Asafo Akowuah

Jones Asafo Akowuah is an MPhil holder from the Department of Agricultural Economics, Agribusiness, and Extension, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.

Kwame B. Bour

Kwame B. Bour is a Ph.D. holder from the Kwame Nkrumah University of Science and Technology. He is an ardent lecturer in the Department of Built Environment, University of Environment and Sustainable Development, Somanya-Ghana.

Ama Antwiwaa Opuni

Ama Antwiwaa Opuni holds a Master’s degree in Public Health and is serving as the Chief Nursing & Midwifery Officer, at Ashanti Regional Health Directorate, Kumasi-Ghana.

Dina Sarpong

Dina Sarpong is a holder of B.Sc. Nursing and works as a Nursing Officer at the Maternal and Child care unit at the Municipal Hospital, Mamponteng, Kumasi-Ghana.

Roland Owusu Aboagye

Roland Owusu Aboagye holds a Master of Education degree from the Institute of Education; Department of Teacher Education, University of Cape Coast-Ghana.