This study reinforced and elaborated on findings of other studies in sub-Saharan Africa (and elsewhere) showing the significant contribution community members make to community health programs [11, 12, 17, 26–28]. Several authors from South Africa, Burkina Faso, Tanzania, and Peru have written previously about the pivotal role communities play in increasing skilled attendants at birth and reducing maternal deaths in rural areas [11, 12, 17, 26–28]. Haines et al. demonstrated how community health workers contributed to high child survival coverage and other health programs that improved health outcomes .
Contributions of TBAs
TBAs have been an integral part of the health system in Ghana. TBAs were initially trained to provide delivery services in rural communities to augment the work of the few skilled attendants in those settings . The introduction of the CHPS program in rural communities strengthened the collaboration between TBAs and health professionals for the former to refer their clients for skilled attendance at birth. Our findings revealed that TBAs referred or accompanied their clients to CHPS compounds for skilled delivery services. Our results are consistent with previous studies that revealed that this kind of collaboration resulted in TBAs referring or accompanying many more pregnant women to health facilities for skilled delivery care . This study also demonstrated that some TBAs would only refer their clients when there are complications. Yousuf et al. also reported that a trained TBA would refer a pregnant woman for skilled delivery care after an abnormal presentation, prolonged labor, obstructed labour, and excessive blood loss . However; our study is in contrast with a study that found that training of TBAs was not associated with client referrals .
The Ghana Health Service is sending trained midwives to rural communities and the roles and responsibilities of TBAs are being redefined. In many instances, community members had to contribute to transport the TBAs and the pregnant women to the CHPS compounds for skilled care, and that probably motivated the TBAs to refer or accompany their clients for the skilled delivery services. Also, the “respect” and “recognition” community members accorded TBAs for their role in the skilled delivery program might have served as an incentive to them. Likewise the incentives the CHO-midwives gave to the TBAs could also be a motivational factor for referring their clients for skilled delivery. Communities’ accessibility to the CHPS compounds and availability of trained professionals undoubtedly serve as an incentive for the TBAs referring or accompanying their clients to the health facility for skilled delivery services. However, some TBAs continue to practice for a living or for traditional, cultural and financial reasons.
Contributions of community health volunteers
Much previous research has underscored the contributions of community health volunteers to health programs [8, 9, 11–13]. In Ghana, too, community volunteerism has been an essential part of health systems over time [8, 9, 11]. Our findings indicate that volunteers took part in a range of health activities embedded in the CHPS-based CHO-midwifery program, including the weighing of children, drug administration for minor ailments, health education as well as referring or accompanying pregnant women to the CHPS compounds for skilled delivery services. The basic criteria for selecting volunteers were their good attributes that included good character, spirit of voluntarism, diligence, trustworthiness and honesty. Selecting the right people to occupy the volunteer positions likely contributed to the critical role the volunteers played in promoting skilled attendants at birth in rural areas. Incentives to volunteers offered by CHO-midwives most likely contributed to their active role in referring or accompanying their clients to health facilities for maternity services.
The supervision of volunteers is also crucial to ensure that they operate within the scope of their expertise. The Ghana Health Service only identifies and rewards trained TBAs and community health volunteers, who refer or accompany pregnant women for skilled delivery, but the question is what happens to the other key players such as the untrained volunteers, TBAs, and older women and mothers-in-law, who also provide delivery services in rural communities? It is necessary for health professionals to identify all stakeholders, who provide the services and involve them in educating pregnant women to seek skilled delivery care. These stakeholders, if identified and motivated, can be “agents of change” by actively participating in the skilled delivery program. Sustaining the interest of these key players is a key challenge if the program continues and is disseminated to other regions.
Incentives for community health volunteers and TBAs
Attempts have been made to motivate trained TBAs and health volunteers for their services in rural communities. Our results show that health volunteers were delighted that community members recognized and respected them for their contribution to the skilled delivery program. In almost all the communities, the CHO-midwives used a percentage of funds generated from the deliveries to purchase soap to motivate women who sought skilled delivery and for trained TBAs and health volunteers, who accompanied pregnant women to the CHPS compounds for skilled delivery care. In some communities, volunteers were given money as incentives for referring pregnant women for skilled delivery services.
Incentive schemes have been documented as effective strategies to inspire motivation and performance of health workers in the health system in Ghana and elsewhere [31, 32]. The efficiency of public health services in Ghana has been linked to provision of incentives . However, provision of incentives to community health workers is often challenging and unsustainable since the majority of volunteers often expect to be compensated even if they are located in poor and resource constrained communities . Nevertheless, it is not all compensation that must be in cash or gifts. Communities can assist their volunteers in diverse ways, such as helping them on their farms or household chores, as long as the incentives are culturally appropriate.
Contributions of traditional leaders
Chiefs and elders exercise considerable influence in their communities. They are heads of the traditional setup, hence arbitrate and supervise development programs in their areas of jurisdiction. The traditional leaders contributed significantly to execute the CHPS program by soliciting community support and cooperation for implementing the program. They also served as philanthropists by donating land and logistics for constructing the CHPS compounds, organizing community members for communal labor and contacting health authorities for assistance in building the CHPS compounds. Some of the traditional leaders also ensured that pregnant women delivered with skilled attendants; they did so by sanctioning women and their families who refused to deliver with the CHO-midwives: Families that violated the law were supposed to pay a sheep, but reports from such communities revealed that such sanctions had never been implemented because of the level of cooperation from community members. This indeed was not in compliance with community participation, but traditional leaders have power to institute bylaws to ensure the safety of their people. In the traditional settings, communities entrust their powers in the leadership to govern them. In most cases, the leaders informed and encouraged community members to attend meetings and that contributed to the active involvement of these traditional leaders and community members. In most instances, the traditional leaders initiated the activities of the CHPS program before other community members got involved. These findings corroborate earlier studies on antenatal care coverage and skilled attendance in rural Tanzania, which demonstrated the importance of traditional leaders’ approval for Maasai and the Watemi families to gladly seek services for pregnant women within the health system .
Contributions of political leaders
The political leadership played a key role in implementing the maternal health program. The government introduced a policy of free medical care for pregnant women under the National Health Insurance Scheme, aimed at offering rural women the opportunity to seek skilled birth attendance. The majority of women in rural areas have already benefited from this initiative . Also, the CHPS program relied heavily on the District Assemblies for support to construct the CHPS compounds and mobilize communities for health programs. The District Assemblies built some of the CHPS compounds for the CHPS program and provided tipper trucks to carry sand for constructing other CHPS compounds. They also constructed boreholes for clean and safe drinking water for the midwives and connected some of the CHPS compounds to the national electrification program. In many instances, the assembly members organized communities for health talks and also presided over the durbars. It is important that the government through the District Assemblies is investing in health care, which confirmed their commitment to the skilled delivery program. The study informed us about the importance of involving political leaders in the maternal health program and other health programs, and confirmed the need for the Ghana Health Service to continue to involve the District Assemblies in the design, implementation, evaluation and dissemination of health programs.
Health professionals in a collaborative effort with communities provided skilled delivery care to pregnant women to prevent injuries or death of women during delivery. Key stakeholders told us repeatedly that women no longer suffer complications or die during delivery in rural areas because of the presence of the skilled attendants coupled with community involvement. Findings from Burkina Faso also revealed that community mobilization could help reduce maternal and perinatal deaths .
Our findings also show that the training and deployment of CHO-midwives to rural areas together with community participation in the UER have contributed to improved skilled delivery access and utilization for rural women. Our findings are confirmed by a study of 407 mothers that revealed expanded skilled delivery care access and use since CHO-midwives were trained and deployed to work in CHPS zones .
We need further evaluation to understand the extent to which the CHO-midwifery program has led to recent improvements in maternal health in the UER in general, and more specifically, the particular contribution of community participation. However, our findings of this qualitative study allow us to argue that community mobilization is a significant strategy for improving maternal health in Ghana. The presence and services of the midwives in villages coupled with community active role in the program probably improved the use of skilled attendants at birth and averted many deaths that would have occurred in the hands of unskilled attendants.
The main barrier to skilled attendance at birth was accessibility. Although CHPS brings health services to the doorsteps of the people, some communities are very remote and far from the CHPS compounds, hence those affected recommended that CHPS compounds be built in their areas to help them access health care. Although the ideal is to establish a CHPS compound in every village, the cost involved in bringing that about makes the idea impracticable in the short run for the government. It is not practical to put a CHPS compound in every village, but it is possible to make health services available and accessible to most rural communities.
Skilled delivery care is free, but community members who reside far from the CHPS compounds cited transportation as a major reason for not accessing maternity services. The long distance to the health facilities and the absence of public transport in remote communities is a major obstacle to the use of professional delivery services. In rural northern Ghana, the common means of transportation is a bicycle, which is inappropriate for conveying pregnant women to health facilities for delivery care. In most rural communities both public and private vehicles are rarely available for those routes because they are not motorable. The absence of viable transport for pregnant women contributed significantly to the challenges communities faced in assuring universal access to health facilities for maternity services. Community members, who have motorbikes, sometimes manage to carry pregnant women to health facilities, but at a risk because those motorbike riders usually do not have safety measures to protect themselves and their passengers. Mills and colleagues (2007) also confirmed that lack of transportation is an obstacle to accessing health care in Ghana .
Some communities mentioned inadequate medicine, logistics and poor infrastructure in health facilities as further obstacles for the provision of efficient and effective services. It is crucial for the Ghana Health Service to guarantee a regular supply of medicines and logistics and adequate infrastructure if the CHPS skilled delivery program is to succeed. After all, rural communities can only build their trust in the system, if they may gain access to its services.
In addition to medicine, logistics, infrastructure, transportation challenges, community-sanctioned customs and taboos that prohibit visiting health facilities for care, stand in the way of skilled birth attendance for some pregnant women and their unborn babies. However, the key informants explained that such taboos are becoming outmoded, with more and more families seeking health care from CHO-midwives. A survey conducted in rural communities of UER confirmed our results that nearly all of them (99 percent) said there were no taboos that prevent women from giving birth with the assistance of a doctor, a midwife or a nurse (Evelyn S: Utilizing the Community-Based Health Planning and Services Program to Promote Skilled Attendants at Delivery in Rural Ghana, unpublished PhD thesis, Boston University School of Public Health).
Our findings also indicate that the attitude of some nurses towards their clients/patients is abysmal, which prevents some pregnant women from seeking skilled delivery services. Mills also reported the attitude of nurses as a major barrier for women accessing skilled delivery services (Mills S: Utilization of Obstetric Services in northern Ghana: A Quantitative and Qualitative Assessment of Skilled Health Professionals at Delivery, unpublished PhD thesis Johns Hopkins University School of Public Health).
The research included a limited number of respondents, some selected based on the virtue of their position or role in the community. The small numbers and the uniqueness of the setting might not make the findings generalizable to other settings. On the other hand, the open-ended interview techniques allowed us to capture the views of the respondents in their own words. This study is focused on community participation in skilled delivery within the context of the CHPS program and might not be generalizable to other contexts because of the uniqueness of the design and implementation of the CHPS program in the UER. That said, our findings have salience to other similar programs in developing countries, geared towards reducing maternal morbidity and mortality in rural areas through the training of locally-placed community health practitioners as midwives. Social desirability and politeness biases may have been a possibility in this work, but study procedures and training protocols were designed to reduce these kinds of biases, and interviewers were university graduates who had no links to the delivery of health services. Respondent bias may have occurred since respondents were direct implementers of the skilled delivery program, and it may have been unlikely to identify stakeholders who were critical of the program. Despite these challenges, it is important to note that the people we interviewed were forthcoming with challenges and shortcomings of the program. Overall, the intervention in a remote and under resourced setting is perceived as a big leap toward improving people's health and access to health services.