Inclusion criteria.

Included in the search were peer reviewed publications and grey literature written in English Language and were published between the years 2005 and 2022. The papers were selected from 2005 due to the nationwide implementation of Ghana’s Free Maternal Health Care Policy (FMHCP) and its integration into the National Health Insurance Scheme in 2008. Additionally, articles up to 2022 were included to ensure the incorporation of current information on the topic. The study included articles specifically focused on Ghana, encompassing both descriptive and evaluative studies.

Exclusion criteria.

Articles that did not meet the inclusion criteria such as those written in languages other than English or with publication dates prior to 2005 were excluded from the study.

Health workforce.

An SBA is any professional for example, a nurse, doctor or midwife, competent and proficient in midwifery skill, to manage and conduct normal deliveries as well as refer complications [23]. Many studies conducted in Ghana, highlight the shortage of SBAs as an eminent problem of the health system [15,18,19,22,25–27]. The shortage is in part due to the emigration of doctors and nurses, largely to the United Kingdom and the United States [24]. In connection with this, the government has increased the training of SBAs, consequently leading to an increase in the percentage of nurses and midwives from 58% to 370% between 2008 and 2018. Also, the density of SBAs thus, doctors, nurses and midwives has improved significantly from 1.07 per 1000 population to 2.5 per 1000 population between 2005 and 2017 [25].

Notwithstanding, the distribution of SBAs remain a major challenge [24,25]. In Ghana, the distribution of health workforce including SBAs, is skewed towards the southern parts of the country which are considered the most affluent regions compared to the northern parts [25,28]. There are also disparities in the rural/urban distribution of health workers in the country. According to GHWO [27], about 70% of high cadre health workers example medical doctors, professional nurses/midwives, and pharmacists are situated in the urban areas which implies that, there are only few highly skilled professionals in the rural areas to provide health service delivery. More so, Appiah-Denkyira, Herbst [24] mentioned that, the prolong delay by the government in recruiting SBAs to fill vacant positions also contributes to shortages of these SBAs especially in areas where their services would have been needed immediately. However, some highly skilled SBAs also refuse postings to rural areas which also explain the reasons for the shortages of these cadres of skilled professionals in remote areas. Some reasons stated for refusal of posting to these areas are lack of career-based incentives and professional development opportunities, poor health infrastructure and working conditions, as well as delay or refusal of granting transfers to urban areas after working in the rural area for a long period.

Additionally, lack of competence of some SBAs in the management of obstetric cases has been widely reported as one of the health systems challenges that should be critically looked into [15,19,25,29]. In the study of Lohela, Nesbitt [29], they revealed that, lack of competent SBAs might hinder service delivery even more than lack of medical products and logistics. Appiah-Denkyira, Herbst [24] and Asamani, Amertil [25] concur with the above, further stating that, the quality of training nurses and midwives is deficient in infrastructure and technical capacities, thus contributing to the lack of competencies. This is further aggravated by limited access to in-service trainings and workshops for SBAs to enhance practical proficiency in managing maternal conditions and complications [19,25,26].

Asamani, Amertil [25] documents an interesting finding in their studies, which revealed that, before 2008, about 88% of midwives were older than 46 years compared to 3% being less than 35 years, which called for the introduction of the direct midwifery training to compensate for future attrition in the workforce from retirement. Consequently, the demographic shift has changed significantly in 2018, where about 71% of midwives were between the ages of 25 to 35 years and just 12% were older than 46 years. The implication is that the older midwives are perceived by the communities to be more experienced than the younger ones in the management of obstetric cases but have almost faded from the system which might impact on quality of skilled delivery. For example in the study of Rishworth, Dixon [17] some of the participants (midwifery students) mentioned that, most laboring women do not comply with service delivery protocols because they feel they are old enough to even be mothers of the midwives attending to them. This suggests that recruitment of SBAs should be well mixed, especially in terms of age categories, considering the Ghanaian culture where values and norms are held in high esteem by the society.

Besides the problem of incompetence, unacceptable attitudes of SBAs are also widely reported barriers to skilled delivery. Some of which are: unofficial demands from pregnant women, for example soap and other disinfectants after delivery [7,15,16,19,20,22,23,31–36] and abusive behaviors [7,23,37]. Further, high workloads have also been documented as one of the challenges that SBAs experience which needs to be compensated for, by the provision of additional incentives [25,26].

Health information system.

A quarterly verification of data was introduced for all regions to implement, as efforts to ensure and promote the quality and timely reporting of data on health. Monthly feedback is also provided on performances at the regional levels regarding completeness and timeliness of data submitted, which are publicly made available and shared with other regions. Also, the Ghana health service in partnership with Christian Health Association of Ghana (CHAG) have initiated guidelines for data verification that will promote data quality as well as ensure standardized performances [37]. However, data collection and storage on obstetric care, especially at the peripheral levels in the health system, is a major challenge which affects planning and allocation of resources for improving maternal care. Both the public and private facilities are often unable to provide reliable data which makes it difficult to link data to service provision [18]. There is also evidence of low commitment among some senior officials at all levels of the health system in supporting the use of District Health Information System (DHIMS) data for reporting, as well as for decision making [37].

Medical products, equipment, and infrastructure.

The procurement of medical products in Ghana is decentralized from the national central stores and controlled by the Ministry of Health (MOH) procurement department, through the regional and district stores to the facilities. And these medical products are usually procured from ‘revolving drug funds’ of facilities. However, there are challenges in the procurement procedures often due to shortages of drugs from the central stores, and high cost of drugs which causes most facilities to procure essential drugs from private providers which might not be of good quality [39,40]. Additionally, Bossert, Bowser [38], revealed that existing national guidelines on inventory control of medical logistics were not being adhered to in most facilities and these together with poor procurement decisions, led to poorer health performance. Lack of adequate supply of drugs on the National Health Insurance drug list in health facilities, have a detrimental effect on the quality-of-service delivery, including skilled delivery care [20,41].

Some studies also mentioned inadequate medical equipment and infrastructure such as limited space in delivery rooms, and poor facility conditions, as other eminent challenges [19,25,27,42]. In the rural areas most especially where the problem of lack of medical supplies and equipment is more profound, it undermines the provision of quality maternal health care [24]. Nonetheless, some studies also report a general improvement in the availability of required drugs and equipment [30,42].

Health financing.

During the mid-2000s, Ghana was close to achieving the target of 15% allocation of public expenditure on health, however, this has reduced in recent times. The national health budget has increased largely as a result of increasing expenditure on salaries estimated at 94%, and less than 10% on goods and services. Since 2012 to 2017, the general government expenditure on health was 2.8%, but in addition to National Health Insurance Fund (NHIF) (5.9%) and Internally Generated Fund (IGF), it added up to an average of 9.3%. This generally reveals government’s relatively low investment into the health system [42]. Public health facilities thus, rely mostly on IGF to sustain the continuous provision of health services to the people [43].

NHIS sustainabilty. The NHIF adds significantly to the health sector budget but is not growing at pace with the rest of the MOH budget [39]. Other sources of funding for health such as donor contributions also remain small [40]. This affects the funding of the free delivery care policy under the NHIS thus to some extent threatens its sustainability [41]. This also leads to delays in payment of claims to service providers thus, results in informal charges which subsequently impacts on the provision of quality maternal health care including skilled delivery care [17,43]. For instance, in a report, the Ghana Medical Association (GMA) called on the government and NHIA to urgently pay claims that were due for September 2018 to May 2019 or else providers will resort to ‘cash and carry’ system [44].

Governance/Leadership.

The MOH performs the overall leadership role over the health system, however, authority is delegated to the Ghana Health Service (GHS) and CHAG [24]. The health service administrative organizational hierarchy begins from top to bottom thus; central, regional, district and sub-districts which also corresponds to the political administrative structure [24]. There are reported failures in management practices which impacts on the health system in general and affects the provision of quality maternal health care [15,25].

Some studies highlight the inefficient budgeting for health service as one management challenge which affects allocation of resources [15,46]. Evidence suggests that, the decision of resources allocation to the health sector is politically influenced, an example of which is seen in the government’s commitment in investing more in building big hospitals while the CHPS strategies remain highly underfunded [45].

Appiah-Denkyira, Herbst [24] illustrates the ineffective decentralization of authority over human resource management in the GHS unlike CHAG, especially in recruitment of health workforce, as a challenging issue which affects effective management of human resource.

There are also concerns about poor supervision of leaders across all management levels in the health system, which is reflected in the poor quality of service provision and the poor attitude of health workers [24].

Asamani, Amertil [25] particularly noted that some facilities have upgraded junior nurses to the level of nurse managers or ward in-charges without any prior leadership preparations, thus might undermine their ability to perform leadership roles effectively. These may affect the organization of services and quality of care provided, thus subsequently impacting on SBA.

Geographical barriers to SBA.

Geographical accessibility such as distance, poor road networks and lack of transport to health facilities, have been widely reported as factors associated with home deliveries in some parts of the country [17,33,36,47–50]. Some women especially those living in the rural regions are faced with challenges accessing skilled delivery due to supply side issues such as lack of health facilities and personnel [16,18,51]. Meanwhile, Millogo, Musenge [51] found a sharp decline in home births particularly in the rural areas than the urban districts of Kassena-Nankana districts in the UE/R, between 2003 and 2009, which may partly be due to the fact that the CHPS programme was first implemented in that district. Similarly, Gudu and Addo [52] reported high uptake of skilled delivery in a rural district in UE/R.

Sociocultural barriers to SBA.

Religious and cultural practices. Further, some women are hindered by religious and cultural factors which limit their access to SBA [14]. For example, among some cultural groups, it is considered a ‘taboo’ to deliver in a hospital, thus, laboring women are required to deliver in a place which ensures adequate privacy such as homes and where cultural practices surrounding birth can be performed [7,15,54]. Women who violate this and go on to have facility deliveries are expected to welcome misfortunes during birth [26]. Home births are reported to give a woman some prestige in certain communities since they are considered strong and brave, thus a woman who delivers in health facilities are often regarded weak, irresponsible or perceived to be engaged in infidelity [15,27,32,54]. Additionally, some women prefer home delivery because they believe that the way the placenta is discarded following childbirth significantly impacts the prospects of the offspring in the future. This is because the placentas are usually burnt in the health facilities rather than giving the women or their families the opportunity to bury them in their homes [35]. Others also choose home deliveries because of the fear of caesarean section or assisted delivery [26].

Preference for traditional birth attendants. The existence of TBAs in most communities (despite the ban imposed on them from conducting deliveries), also influences people’s decision to have unskilled deliveries. This is because, deliveries with TBAs are perceived to be associated with culturally appropriate birth practices and an alternate source for unavailability of SBAs as well as distance and cost barriers to accessing skilled care. More so, some women have perception of poor quality of skilled delivery care thus, prefer home deliveries [16,18,34,36,55]. Haruna, Kansanga [55] and Rishworth, Dixon [17], therefore, strongly argue for the re-training of TBAs in the light of inadequacy of SBAs and integrating them into the health system as a sound strategy to improve facility deliveries, promote healthy cultural practices and reduce maternal mortalities.

Women’s decision-making autonomy. Also, women are reported to lack autonomy in decisions regarding seeking skilled attendant at delivery, thus are influenced largely by their husbands and households [54,57]. However, Gudu and Addo [52] in their study found that majority of the women made the decision themselves to have skilled delivery. Similarly, Cofie, Barrington [57] and Cofie, Barrington [58] in their study found that the availability of a network of family and social support, improved women’s uptake of facility delivery.

Socioeconomic barriers to SBA.

Socio-economic characteristics such as low education, unemployment, and poverty are some cited factors for unskilled deliveries [50,60–62]. It is reported that women who are older, multiparous, do not have existing medical conditions or complications in pregnancy, practices Islamic or traditional religions or belong to minority ethnicity are also less likely to seek skilled delivery [8,60,61]. Further, many studies highlight the cost associated with skilled delivery despite the ‘free’ delivery care policy under the national health insurance, such as the cost involved in buying delivery items (layette), as the main determinant to accessing skilled attendant at birth considering the low household income status of families [7,10,20,33,49]. In this regards, Haruna, Kansanga [55] suggested that women should be given incentives such as a small pack containing detergents and baby accessories in health facilities to encourage them to have skilled delivery. Moyer, Adongo [53] revealed that while socioeconomic factor serves as a major determinant of skilled delivery especially in the rural north of Ghana, it is often a mediator of sociocultural factors.

Additionally, evidence available from the 2014 GDHS on the most serious barriers to SBA showed that, out of the total respondents (women) interviewed, 51% admitted they encountered at least one barrier to accessing health care including SBA. Among those respondents, 42% complained of (financial barriers), 25% (distance barriers), 16% (lack of companion to health facility) and only 6% complained about (lack of autonomy) [6].

Fig 3 is the graphical presentation of the findings from this review, in a fishbone diagram. Fishbone/Ishikawa diagram is also referred to as the cause and effect diagram and it is originally generated by Kaoru Ishikawa [63]. This fishbone diagram will provide a graphical understanding of the factors that influence SBA in Ghana.

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Fig 3. Fishbone analysis of the residual barriers to achieving SBA target in Ghana.

The inscriptions in bold, have been identified as the major factors influencing the utilization of SBA in Ghana. Poor health financing and management, inefficient health governance, inefficient supply and organization of medical products/infrastructure, couple with insufficient and inefficient health workforce, results in the overall inefficient health service delivery, such as poor organization/coordination of services and poor quality of health service delivery. Other community factors such as geographical, sociocultural, and economic barriers to SBA, and poor maternal health seeking behavior also impact on SBA in Ghana.

https://doi.org/10.1371/journal.pgph.0002902.g003