Delivery trends
The single most essential intervention for reducing morbidity and mortality is to ensure that a health worker with midwifery skills is present at every child birth [
21]. Considering this fact, the proportion of births attended by a skilled health personnel is used as one of the major indicators to monitor progress towards the achievement of the Millennium Development Goal of reducing maternal mortality ratio [
22,
23]. We found in this study that there was a persistent increase in the proportion of births attended by skilled personnel in a health facility, ranging from 68 % in 2010 to 99 % in 2014 with the overall prevalence of 84 % during the 5 year time frame. This result corroborates with what is contained in the 2014 Ghana demographic and health survey (GDHS) report, where the proportion of births occurring in a health facility increased progressively from 42 % in 1988 to 73.1 % in 2014. In the Upper East Region, 84.1 % of births occurred in a health facility [
24]. The closeness of the results lends credibility to our study findings. Dzakpasu et al., also reported a significant increase in health facility delivery over time in the Brong Ahafo Region, Ghana [
25].
Our finding, however, is in contrast to findings observed in other African studies. Gitimu and colleagues [
26] reported in a study in Kenya that only 40.3 % of births were attended by skilled personnel. Meselech et al. found in a qualitative study in South Central Ethiopia that majority of women gave birth at home and home delivery is taken as a common practice [
27]. This difference could be attributed to the differences in financial access to maternal health services. In an attempt to increase skilled birth attendance and reduce inequality in use of services, the Government of Ghana in September 2003, introduced a policy exempting women in its four poorest regions including the region of the study site from paying for delivery services. Subsequently, in July 2008, the government introduced a policy exempting pregnant women from paying the National Health Insurance Scheme (NHIS) registration and premium fees when funding for the delivery fee exemption policy was running out [
28]. These policies may have accounted for the high utilization of health facility deliveries. On the contrary, births conducted by TBAs expectedly reduced substantially from 546 births in 2010 to 68 births in 2014 representing about 87 % reduction. This downward trend observed in the TBAs deliveries could be as a result of Ghana Health Services decision of fading away TBAs deliveries due to the risk it places on the lives of both mother and child as a result of poor delivery conditions. For this reason TBAs are encourage and are given incentives to refer all labouring women to the nearest health facility and therefore the trends of deliveries conducted by them are expected to decline [
17]. Meselech et al., however concluded in their study that women relied on Traditional Birth Attendants for delivery as a result of varying reasons including cost of service [
27].
Seasonal patterns of births
Using birth data from January 2010 to December 2014, this study was able to identify a strong birth peak in May, September and October and a nadir in January, February and July. Also, this study observed significant variations in average monthly frequency of births and this is in agreement with reports from other parts of the world. In India, the maximum number of births occurred in August to October and minimum in the month of January [
3,
29]. Odegard observed a September peak in Norway and hypothesised that this could be due to maximum conception during the traditional mid-winter festivities [
30]. Eriksson et al. [
31] reported two peaks of birth in March/April and another in September/October in their record based study in Finland for the period 1650 to 1950. The National vital statistics report of the United States, indicates that births peak generally in August and reach a minimum in February [
32]. However, the findings of this study contradict what was observed in other African countries. In rural Senegal, spikes of birth were observed for the month of February through May [
33]. Another recent Nigerian hospital based study showed slightly sinusoidal pattern of birth with two peaks: a major peak spanning through April and May and another in October. Minimum number of births occurred in the months of July, August and December [
34].
The pattern of birth seasonality exhibited by human populations around the world possibly stems from several factors, with the most important factors varying between populations and through time. Three groups of these factors have been proposed as playing important roles. These are, social factors affecting the frequency of intercourse; climatological factors affecting fecundity; and energetic factors principally affecting female ovarian function [
14]. The seasonal variation in births observed in our study suggests that the women in the study site were more likely to get pregnant in the months of December/January (dry season) with births occurring in September/October (rainy season) and less likely to get pregnant in the months of April/May (rainy season) with births occurring in January/February (dry season).
Environmental conditions such as temperature, sunlight and humidity have been associated with birthing and birth outcomes [
35,
36]. The dry season also referred to as the hot season in Ghana is characterised by high temperature, increased duration of sunlight and low humidity. The present study reports low birthing in the dry season as compared to the wet season. This may relate to the proportion of women birthing in healthcare facilities during the dry season. Access to healthcare facilities in the dry season may be affected by high temperature and increased duration of sunlight. In northern Ghana, women have to travel long distances (about 8 km) in order to access healthcare facilities. The heat and stress of walking long distances in the sun may encourage the patronage of substandard health services such as the Traditional birth attendance (TBA) which are within close radius to the women.
Additionally, prolonged exposures to high ambient temperatures may induce dehydration which has implications for poor pregnancy outcomes. Data from Nepal showed that the highest preterm birthing corresponded to high temperature exposures [
37], possibly due to greater risk of labour induction as a result of decreased uterine blood flow when dehydration sets in [
38]. On the other hand, the low birthing during the dry season can be attributed to increased risk of infection such as malaria during the rainy season. During the raining season, pregnant women in malaria endemic areas like Ghana become at higher risk of contracting malaria infection that leading to poor pregnancy outcomes such as foetal loss [
36].
The seasonality patterns examined in this study may improve our understanding of the environmental factors associated with birthing and birth outcomes. The variation in the monthly frequency of births described may also have implications for public health policies and programmes on the optimal timing of interventions in the Northern part of the country aimed at improving birth outcomes and child health. A surge in a local infant population is likely to subtly influence the pattern of outbreaks of childhood diseases. When many babies are born around the same time, they become susceptible to a disease simultaneously and might thus transmit the disease more readily. Health managers may use this knowledge to plan targeted interventions to stop any possible disease outbreak.
Trends of perinatal outcomes
According to the World Health Organization (WHO), it is unjustified to have CS rate above 15 % [
39]. The observed overall CS rate for the study period was 14.6 %, close to the upper limit of the WHO’s recommended rate. The 2007 Ghana Maternal Health Survey reported CS rate of 12 % in the country and 5.1 % in the Upper East Region where this study was located. The Regional hospital being the only referral centre in the Upper East Region where this study was located receives high risk obstetric referrals from across the region and beyond, which inevitably led to increased caesarean deliveries, thus explaining our much higher proportion of caesarean sections compared to the regional estimate. Our finding is however, lower than several other studies [
40‐
42].
The overall prevalence of stillbirths observed in this study was 26 per 1000 births, which compares favourably with reported rates in other hospital-based studies in Ghana [
43‐
45] and other Sub-Saharan African studies [
46‐
49]. The previous Ghanaian studies were conducted in two tertiary hospitals (Korle-Bu and Okomfo Anokye Teaching Hospitals), and being the major referral centres in the country, the hospitals receive high risk obstetric referrals which predictably result in increased adverse pregnancy outcomes, thus explaining the discrepancies in still birth rates reported in the aforementioned studies in Ghana and in this present study. The still birth prevalence reported here is consistent with the national estimate of 21 per 1000 births [
50]. About 40 % of the observed stillbirths were fresh, an indication that a number of these cases could likely have been prevented [
51].
According to the World Health Organization (WHO), any baby with a birth weight below 2500 g is considered to have low birthweight [
52]. This study also demonstrated that LBW among live babies decreased significantly between 2010 and 2014. The decline was more pronounced from 2010 to 2011. The overall prevalence of LBW in this study was 10 %. This is slightly lower than LBW estimates from Ethiopia (11.2 %) [
47]. Similarly, this finding is far lower than reports from other Ethiopian studies [
53,
54]. This high discrepancy could mainly be due to methodological variations. The aforementioned studies were limited to tertiary hospital data. However, data from this present study were aggregated mainly from secondary hospitals, health centres and clinics where relatively most normal deliveries take place.
One limitation of this study is that it is hospital-based, and therefore, failed to capture all the births in the community. Thus results should be taken with some caution. Nevertheless, this is unlikely to influence the outcome of this study as over 80 % of deliveries were hospital-based.