Background
In Ghana, between 1,400 and 3,900 women and girls die each year due to pregnancy related complications [
1,
2]. In 2013, approximately 3,100 women in Ghana died from pregnancy-related complications [
3]. An estimated two-thirds of these deaths occur in late pregnancy through to 48 hours after delivery [
2]. Recent statistics point to a maternal mortality ratio (MMR) in Ghana of 380 deaths per 100,000 live births. This MMR is high when compared with that of other sub-Saharan African countries such as Namibia, which has a MMR of 130 deaths per 100,000 live births but is lower than the sub-Saharan African regional estimated average of 510 maternal deaths per 100,000 live births [
3].
In sub-Saharan Africa, only half of women delivered with the assistance of skilled attendants [
4]. In Ghana, skilled delivery rate is slightly higher (68 percent); but there are rural–urban disparities. In 2011, only 54 percent of rural women were delivered by skilled attendants at their birth compared to 88 percent of urban women [
5]. In rural areas of the Upper East Region (UER) which is the focus of this paper, the level is higher (67 percent) than in other rural areas in Ghana [
5].
Experts agree that access to skilled attendants at birth (doctors, nurses, midwives) is one way to decrease maternal deaths, and such access should be available to women in rural areas as well as urban areas [
6]. Since 2000, the government of Ghana has had an innovative program to promote primary health care in rural communities—the Community-based Health Services and Planning (CHPS) Program. In 2005, the Ghana Health Service piloted a program that involved training Community Health officers (CHOs) as midwives to address the gap in skilled attendance in rural UER. Community participation was an integral part of CHPS and the CHO-midwifery pilot project from its inception, and results are promising [
7].
Community participation is a significant part of health service delivery in developing countries. Community health volunteers have been used elsewhere to encourage community involvement and to compensate for severe shortages of health professionals [
7‐
9]. The 1978 Alma-Ata Conference reiterated the goal of “Health for All by the Year 2000” and approved primary health care (PHC) as key to achieving this goal [
10]. Social intervention have demonstrated the active engagement of communities in primary health care that resulted in improved health [
11‐
15].
Evidenced-based interventions have demonstrated the significant role communities played in PHC that resulted in improved health [
11‐
16]. For instance, the Danfa comprehensive rural health and family planning project demonstrated how village health workers improved health services in rural Ghana [
16]. The Bamako Initiative which was implemented to increase access to PHC by engaging village committees in health delivery management resulted in improved child health [
11]. Haines et al. cited how field interventions have established community health workers contributions to high child survival coverage and other health programs and suggested evaluating the role community participation played in increasing coverage of essential interventions [
14]. These programs have demonstrated the effective role of communities in improving health service delivery and pointed out the need for rigorous evaluation to determine the level of community participation and appreciate the contributions of communities to health intervention programs.
A study on the use of safe motherhood promoters to improve patronage of health facilities for skilled delivery and antenatal care in Tanzania showed an increase in skilled deliveries and antenatal attendance after a successful program implementation [
12]. In rural Burkina Faso, the use of health professionals and community members in providing maternal and child care significantly increased institutional births and reduced maternal and perinatal deaths [
17]. Other studies have demonstrated that the combined efforts of communities and CHOs in the Community Health and Family Planning (CHFP) project in northern Ghana revealed a 15 percent reduction in fertility, equivalent to one birth per woman in the general population [
9]. Doctors established that the shared contribution of community health volunteers and CHOs to health delivery care in rural northern Ghana motivated communities’ preference for smaller families through changes in reproductive behavior [
15]. The success of the CHFP project led to the implementation of the CHPS Program [
7] and later the introduction of the midwifery program to bring maternal health services to the doorsteps of women and their families.
The CHPS program, an initiative of the Ghana Health Services launched in 2000, was designed to increase access to health care and family planning services in rural areas of Ghana [
7]. A CHPS zone has a population of 3,000 to 4,500 people–covering two to three unit committees of the District Assembly [
18]. All sub-districts are divided into zones and these zones are based on the local government of decentralization, where the District Assemblies and unit committees cover a population of approximately 1,500 [
18]. From its inception, community participation was a significant component of the program. Local communities provided land and labor for building CHPS compounds and community health volunteers undertook health education and management of minor ailments. CHO-midwives partnered with traditional birth attendants (TBAs), community health volunteers and other community members to provide skilled delivery in rural areas. As the program seeks to ensure that all women in remote villages have access to skilled attendants during and after delivery, strong partnership between TBAs and health professionals and between all community members and the CHO-midwives are essential [
7].
A CHO-midwife is an auxiliary nurse with a two-year training in basic nursing and another two-year training in midwifery by WHO standards to provide basic health services including skilled delivery care in rural areas [
7]. Results of the CHPS program showed that nearly 80 percent of women were supervised by skilled attendants at birth in CHPS zones from 2009 to 2012 in three districts of the UER [
19]. Other studies have also shown the positive impact of CHPS on maternal and child health in Ghana [
20‐
22].
This study examined the extent to which community residents and leaders participated in the skilled delivery program as part of the CHPS program, and the specific roles they played in its implementation and effectiveness.
Methods
Study setting
The study was conducted in the Kassena-Nankana East (KNE), Kassena-Nankana West (KNW), and Bongo districts of UER of Ghana. The UER is situated in the north-eastern corridor of the country and share borders with Burkina Faso to the north, and Upper West Region to the west, Togo to the east and Northern region to the south. The estimated population from the 2010 census was 1,046,545. The settlement pattern is highly dispersed in 911 communities. The KNE district had an estimated population of 109,944 [
23] whereas the KNW district, newly carved out of the Kassena-Nankana district in UER, had an estimated population of 70,667 in 2010. Bongo district’s 2010 estimated census population was 84,545 [
23].
In rural UER, households are grouped into extended family units or compounds, each headed by a male patriarch. Compounds are located far from each other, but the people have a communal life style, where support systems exist for community development activities [
24]. Lineage customs, religious practices, marriage patterns, and other social characteristics of the population are traditional, but changes such as construction of roads, schools, hospitals/clinics, modern houses are gradually taking place. The three districts share a homogeneous social and cultural system [
24]. The region has one regional hospital located in Bolgatanga, the regional capital; 5 district hospitals; 26 health centers and 35 clinics run by the government health service, mission institutions and the private sector and 200 functional CHPS compounds [
23].
We obtained ethical approval from the Navrongo Health Research Centre and the Boston University (BU) Institutional Review Boards (BU IRB reference number H-31245). We also obtained written informed consent from participants before they took part in the study.
Study design and methods
We employed an intrinsic case study design with qualitative methodology. We conducted in-depth interviews (IDIs) with key informants such as chiefs, TBAs, community health volunteers, women leaders and elders: Both trained and untrained community health volunteers and TBAs were included in the interviews. We also interviewed health professionals (CHO-midwives, District Directors of Health Services and the CHPS Coordinator) to (1) assess the extent to which communities know and use the skilled delivery services, and (2) identify contributions community residents made to the program and to explore successes and challenges of implementing the program. We also looked at the Navrongo Health and Demographic Surveillance System (NHDSS) data to determine trends in unskilled deliveries in the KNE and KNW districts.
The Navrongo health and demographic surveillance system
The NHDSS is located in the Kassena-Nankana districts of northern Ghana; the NHDSS was established in 1992 by the Navrongo Health Research Centre (NHRC). The main objective of the Navrongo Demographic Surveillance System (NHDSS) is to maintain a longitudinal follow up of the population dynamics of the Kassena-Nankana district (152,000 people in 32,000 households.) Every 4 months the NDSS collects and computer processes routine information on pregnancies, births, morbidity, deaths, migration, marriages and vaccination coverage. NHRC also conduct biomedical and socio-economic studies and trained volunteers to routinely report key events, such as births and deaths as they occur in their locality and the verbal autopsy system for determining the probable causes of deaths that occur in the community [
25].
Sampling and sample size
A total of 79 CHPS compounds were located in the three districts and of that a total of 25 CHPS compounds had CHO-midwives. Our target population has 25 CHO-midwives working in CHPS zones in the three districts: Ten CHO-midwives in the KNW district, eight in the KNE district and seven CHO-midwives in the Bongo district of the CHPS zones. We randomly selected 12 from the list of 25 CHO-midwives to participate in the IDIs: 4 CHO-midwives from each of the three districts. And out of the 12 CHO-midwives selected for the interview, 10 CHO-midwives participated. The other two participants were not available for interview after several attempts to meet and interview them. Three District Directors of Health Services and the Regional Coordinator of the CHPS program were purposively selected because of their role in the CHPS program in the study areas. Fifteen community stakeholders were recruited for the in-depth discussions in the three districts. We recruited the community stakeholders through speaking with key community members such as opinion leaders, chiefs, and elders. We gathered names of those in each group who were most knowledgeable about the program. Among those identified as potential respondents (7 Chiefs, 10 Elders, 8 TBAs, 10 Community health volunteers and 8 Women Group Leaders), we randomly selected one in each group within each district to approach for an interview. In each district, we included five community stakeholders and a total of 15 stakeholders were interviewed. In all, 29 key informants (10 CHO-midwives, 3 District Directors of Health Services, 1 Regional Coordinator of the CHPS program and 15 community stakeholders) were interviewed.
Training of data collectors
We recruited two university graduates who are also experienced research assistants and trained them to conduct the IDIs. The training included lectures, demonstration and practice. They were trained to moderate the interviews and use the interview guide in local languages of the three districts. The research assistants were coached to ask questions, probe for more answers and prompt respondents for clarifications on issues related to the interview. The training lasted for a week after which the interviewers were sent to the field for the data collection. The interviews were recorded on an audiotape. An experienced transcriber, who was not part of the interviewing team, translated and transcribed the data from the audiotapes before analysis of the transcripts.
The interview formats focused on the extent and type of participation by community stakeholders in the skilled delivery program, successes and challenges of the program from their perspectives.
We pre-tested the interview guides in communities of the three districts excluded from the study, but have similar characteristics, in order to improve the relevance and appropriateness of the questions. The pre-testing was a learning session for the research assistants to improve their interviewing skills, and we revised the guides appropriately after the pre-test. Data were collected from January 13, 2012 to March 31, 2012.
Data analysis
The analysis of narrative data on similar topics from multiple sources allows for comparison of perspectives and triangulation of our findings across sources. Members of the team (the Principal Investigator and the two research assistants) began the analysis by reading all transcripts multiple times and discussing broad themes that emerged across respondents and areas of inquiry (community participation and benefits/challenges). The team developed a coding scheme that reflected these areas and the sub-themes within each, and proceeded to code each transcript using the qualitative data software (QSR NVIVO software version 8). We produced reports on each of the broad and specific themes, which allowed us to synthesize key findings and compare responses within and between groups (e.g., community stakeholders and health professionals). The broad and specific themes included knowledge and contribution by community leaders: contributions of TBAs, community health volunteers, traditional and political leaders; each stakeholder groups’ perspectives on the successes and challenges of the program in key areas, such as promoting the use of skilled attendants at birth, the perceived contribution of program in preventing complications and deaths, and challenges such as long distance, lack of transportation, insufficient infrastructure, attitudes of health professionals and inadequate medicines.
Discussion
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 [
14].
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 [
17]. 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 [
29]. 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 [
30]. However; our study is in contrast with a study that found that training of TBAs was not associated with client referrals [
30].
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.
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.
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 [
33]. 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 [
34]. 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 [
35].
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 [
36]. 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.
Benefits
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 [
17].
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 [
19].
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.
Challenges
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 [
37].
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).
Study limitations
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.
Conclusions
The CHPS program is one of many public health interventions of the Ghana Health Service that, by design and in practice, relies on community engagement for its implementation, widespread use, and ultimate success. Our study has shown that such mutual collaboration and engagement is possible. Community leaders, trained volunteers, TBAs, and other female and male members were all instrumental in unique ways to the success of the skilled delivery program in UER. Traditional leaders provided land and labor for the building of the CHPS compounds and collaborated with CHO-midwives to provide health education and information to rural communities. Political leaders also constructed some of the CHPS compounds and provided building materials for the building of others. The assembly members often presided on health programs at durbars. TBAs and community health volunteers collaborated with the CHO-midwives by referring or accompanying their clients to the CHPS compounds for skilled care at birth, and they provided health education to promote skilled attendance at birth. These volunteers were motivated by financial and non-financial incentives for their active engagement in the program. Overall, community members and health professionals appeared to demonstrate the key lessons of collaborative work: respect, dialogue and mutual cooperation. Nevertheless, the primary challenges that must be addressed include insufficient transportation; infrastructure weaknesses; poor attitudes among some health professionals toward their clients; inadequate drugs and other logistics; and to some extent, customs and taboos that prevent women from accessing maternal health services.
If the Ghana Health Services moves to scale up the CHO-midwifery program in CHPS zones beyond the UER, our study yields key recommendations to further enhance community participation in the program’s effectiveness:
-
Health professionals should continue to intensify health education on maternal health in rural areas to enable all community members to embrace and participate in the program.
-
Community health volunteers and TBAs should be engaged as “agents of change” to promote skilled attendants at birth, although their activities must be circumscribed and supervised to ensure that they do not act beyond their scope of services.
-
The CHO-midwives should identify all TBAs, older women, mothers-in-law who still supervise deliveries and encourage them to refer or accompany their clients to the health centers or CHPS compounds for skilled delivery care.
-
Volunteerism is free, but both the Ghana Health Service and community members could provide both financial and non-financial incentives to motivate community health volunteers and TBAs for their services. However, these incentives should be culturally appropriate without compromising the program. For instance, community members could assist the volunteers and TBAs on their farms and household chores to motivate them to continue to stay and work in rural areas. The communities could also give them certificates of recognition for the role they play in health service delivery.
-
Community support systems should be instituted to assist pregnant women to seek maternity care on time; communities should collaborate with non-governmental organizations (NGOs), transport unions and individuals to institute transport systems to help convey pregnant women to health facilities for maternity services. NGOs should organize capacity building training for community members before these systems are set up.
In addition, our findings among community participants lead to several broader recommendations:
-
The regional medical stores should ensure regular supply of drugs and other logistics to the CHPS compounds to guarantee the continuation of the program and build community confidence in the operations of the health system.
-
The health professionals should be given regular in-service training to equip them to handle their clients and patients with respect and dignity.
-
The health professionals should continue to embark on health promotion and education targeting families that taboo accessing modern health services to change their attitudes and practices.
Competing interests
The author(s) declare that they have no competing interests.
Authors’ contributions
ES conceived and designed the study. ES performed the data analysis, interpreted the results and wrote the manuscript. LM helped in planning and supervised all parts of the study and contributed to the methodology and writing of the manuscript. JB, KYA, SM and HVD contributed to the planning of the study, supervised all parts of the study and contributed to the methodology and revision of the manuscript. All authors read and approved the final version of the manuscript.