https://orcid.org/0000-0002-0840-3512
Figures
Abstract
Background
Maternal health services utilization is essential in the reduction of maternal mortality. Despite the implementation of a national health insurance scheme in 2003, Ghana still reports universal health coverage service index below the global average. This study investigates the association between health insurance coverage and maternal health service utilization.
Methods
This study utilized data from the Ghana Demographic and Health Survey (GDHS) conducted in 2022. The independent variable of the study was health insurance coverage, and the outcome variable was maternal health service utilization by assessing indicators including the timing of the first ANC visit, completing the recommended number of ANC visits, skilled birth attendance, facility-based delivery, and post-natal care. The data was analyzed for both descriptive statistics and logistic regression.
Results
The study sample consisted of 4303 women of reproductive age who had live births within the past 5 years of the survey. Health insurance coverage is associated with the likely odds of post-natal care (aOR 1.56; 1.15–2.12). Counterintuitively, women who were insured were less likely to give birth in a health facility (aOR 0.59; 0.45–0.78) in the presence of a skilled birth attendant (aOR 0.70; 0.57–0.86).
Conclusion
This study shows that while health insurance coverage can boost maternal health service utilization, the implementation mechanisms of these policies play a more critical role. Addressing challenges like out-of-pocket payments for insured individuals is essential to enhance service utilization under the policy.
Citation: Osei KM, Prasiska DI, Chapagain DD, Rajaguru V, Kang SJ, Kim TH, et al. (2025) Health insurance enrollment and maternal health service utilization using Ghana Demographic and Health Survey, 2022. PLoS One 20(6): e0325240. https://doi.org/10.1371/journal.pone.0325240
Editor: Mubarick Nungbaso Asumah, Nurses' and Midwives Training College, GHANA
Received: November 14, 2024; Accepted: May 10, 2025; Published: June 26, 2025
Copyright: © 2025 Osei et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Data was collected from http://www.dhsprogram.com. All relevant details are within the paper and its Supporting Information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: No authors have competing interest.
Background
Global maternal and child mortality has declined significantly over the past decades due to Millennium Development Goals (MDGs) and Sustainable Development Goals (SDGs) policies and programs, as well as national and international efforts [1,2]. SDG target 3.1 aims to reduce maternal mortality to less than 70 maternal deaths per 100,000 live births by 2030 [3]. However, as of 2020, the global maternal mortality ratio (MMR) was estimated to be 223 maternal deaths per 100,000 live births with sub-Saharan Africa accounting for a higher share of global maternal deaths with about 69% [2]. Ghana reported an MMR of 310 maternal deaths per 100,000 live births in 2022 [4].
SDG target 3.8 aims to achieve Universal Health Coverage (UHC) including financial risk protection, healthcare services access, and safe, effective, quality, and affordable essential medicines and vaccines for all [3]. Despite the introduction of a National Health Insurance Scheme (NHIS) in 2003, Ghana recorded a UHC service coverage index of 48% well below the global average of 68% as reported by the World Health Organization (WHO) [5,6]. The NHIS provides free maternal health services for all pregnant women at both public and accredited private health facilities provided the women are registered with the scheme and hold a valid NHIS card at the point of service [7,8]. The premium and processing fees required for registering and obtaining a valid NHIS card sometimes become a barrier to accessing this ostensibly free maternal health services. This exposes a substantial portion of the population to financial risk in accessing essential health services including maternal healthcare services.
Improvement in maternal healthcare services through the provision of antenatal care, skilled birth attendance, facility-based delivery, and post-natal care are essential in the reduction of maternal and child mortality [9]. However, several barriers hinder the optimal utilization of maternal healthcare services especially in low-middle-income countries (LMICs). Healthcare cost is a fundamental barrier to the optimal utilization of essential health services in most LMICs. Previous studies in other low middle-income countries have associated health insurance coverage (HIC) with essential health services utilization including maternal health services [10–13].
This study explores the association between health insurance coverage and maternal health services utilization based on Andersen’s Health Care Utilization Model [14]. The model espouses three factors associated with healthcare utilization: social and demographic factors, enabling factors and individuals’ perceptions of their health.
There is considerable evidence on the association of health services utilization and health insurance coverage globally, however, few studies have specifically dealt with this association in West Africa and specifically Ghana. The need for further studies in Ghana is bolstered by the relatively high maternal mortality rate even though the NHIS was implemented some two decades ago. Hence this study seeks to fill the gap in the literature to assess the association between health insurance coverage and maternal health service utilization by analyzing the most recently available 2022 Demographic and Health Survey (DHS) data.
Methods
Data source
This study utilized data from the Ghana Demographic and Health Survey (GDHS) conducted in 2022 by the Ghana Statistical Service in collaboration with the Ministry of Health. The Demographic and Health Survey, which is conducted in over 80 low- and middle-income countries is a nationally representative survey that collects data on health indicators including maternal health service utilization. The survey employs a two-stage sampling method for data collection using a standardized questionnaire [15].A total of 4,303 women of childbearing age (15–49 years), who had given birth within the five years preceding the survey, were included in this study. The data were obtained from the Individual Women’s Data (Individual Recode – IR) file, which includes one record for every eligible woman as identified in the household schedule. This dataset contains all information collected through the women’s questionnaire, along with selected variables from the household questionnaire. The variables used is this study is defined in Table S3 in the supplementary document...
Ethical considerations
The required data for this study was obtained from the official DHS website: http://www.dhsprogram.com on request by email. The protocol for DHS surveys is approved by the Ethics Committee of ORC Macro Inc. This study utilized anonymized secondary data available in the public domain of DHS. The DHS program explicitly seeks the consent of survey respondents. However, the authors obtained approval from DHS for the reuse of the data. This study adheres to the STROBE guidelines for reporting observational studies.
Variables
Outcome variables.
This study examines five indicators of maternal health service utilization based on the WHO and Ghana Health Service (GHS) recommended guidelines on essential MHC services including the timing of the first Antenatal care (ANC) visit, completion of the recommended number of ANC visit, facility-based delivery and post-natal Care (PNC). A first ANC visit within the first trimester of pregnancy is recommended for pregnant women. A minimum of four ANC visits is the recommended number of ANC visits, giving birth at a healthcare facility under the supervision and care of a qualified healthcare worker is recommended by the guideline.
Independent variable of interest.
The primary variable of interest in this study was the respondent’s enrollment in the national health insurance scheme using the question “Are you registered with the National Health Insurance Scheme” and the response was considered as “Yes” and “No” for insured and non-insured respondents respectively.
Covariates.
To account for confounding in the analysis, this study controlled for maternal age groups which were categorized into four groups: 15–24, 25–34, 35–42, and 42–49. Marital status was classified as either single or married. The education level was categorized into four groups: primary, secondary, higher, and no education. Employment (employed and unemployed) and residence (urban and rural) were segmented into two categories. The region of residence was defined as one of 16 administrative regions. Parity was categorized into 3 groups (3 children or less, more than 3 but less than 6 children and more than 6 children) and religion was divided into 4 categories (no religion, Christianity, Islam and Traditional religion). Respondents were classified into wealth index (lowest, second, middle fourth, and highest), and exposure to the internet was defined by 4 categories (not at all, less than once a week, at least once a week, and almost every day). Wealth index and region of residence were employed to determine inequalities in access to Maternal health services. In our analysis, we included covariates that have been identified as significant predictors in previous research. Specifically, these studies have demonstrated that variables such as age, education level, wealth index, religion, and region of residence are crucial for accurately modeling the relationship between health insurance enrolment and maternal health service utilization. By incorporating these covariates, we aim to control potential confounding factors and ensure that our findings are robust and comparable to existing literature [16–20].
Data analysis
Our study analyzed data using both descriptive and regression model methods with SAS 9.4. Primary analyses to determine the distribution of respondents’ socio-demographic characteristics and Health insurance coverage by MHC services utilization were performed. Further analysis was done to determine the predictors of health insurance coverage among women of childbearing age. The analysis focused on MHC services utilization, including the timing of the first ANC visit, completion of the 4 or more recommended number of ANC visits, childbirth with skilled labor attendance, facility-based delivery, and post-natal care. A significance level of p < 0.05 (two-tailed) was used for all analyses. A multivariate logistic regression was done to determine the association between HIC and maternal health services utilization indicators. The adjusted odds ratios (aOR) were calculated to assess the strength of the associations, and 95% confidence intervals (CIs) were used to test for statistical significance. To assess the presence of multicollinearity among the independent variables, we calculated the Variance Inflation Factor (VIF) for each predictor in the regression model. The Variance Inflation Factor (VIF) values for the independent variables in the model ranged from 1.028 to 2.121, with a mean VIF of 1.44. The standard error ranges from 0.00032 to 0.001174 for all independent variables. These values suggest that there is no significant multicollinearity, indicating that the independent variables are not correlated. Details of the VIF results are shown in the supplementary document Table S1.
Results
Health insurance coverage and utilization of maternal healthcare services among women of reproductive age
The study sample consisted of 4303 women of reproductive age who had live births within the past 5 years of the survey. Among all the respondents, 76.74% indicated health insurance coverage. Age, education level, residence, employment status, religion, wealth quintile, parity, media exposure(internet), and region of residence were determined to have an association with health insurance coverage. (Table 1). A total of 2923 respondents reported their first ANC visit within the first trimester of pregnancy representing 67.93% of the sample size while 1380 did not report their first ANC visit within the recommended first trimester of their pregnancy. For at least 4 ANC visits during pregnancy, 92.77% of the respondents reported having completed 4 or more ANC visits. A similarly high proportion (81.66%) of the respondents reported having a skilled birth attendant during childbirth compared with 18.34% who did not have a skilled birth attendant present during childbirth. The proportion of the respondents reporting facility-based delivery and post-natal care was 89.98% and 94.93% respectively as shown in Table S2.
Distribution of maternal health utilization across health insurance and other socio-demographic characteristics of participants
The characteristics of the 4303 respondents, categorized according to utilization of maternal health services are shown in Table 2. Assessment of maternal health utilization services across health insurance coverage revealed a statistically significant proportion of respondents utilize maternal health services when they are insured. Among respondents in this study, for those found to have accessed ANC in the first trimester of their pregnancy, 68.78% were insured while 65.13% of those who were not insured with a statistically significant p-value of < 0.05. Statistically similar results were found in other maternal health utilization services; completing the recommended number of ANC visits was recorded 93.22% of insured respondents versus 91.31% of uninsured respondents (p-value < 0.05),. Finally, there was observed a statistically significant association between timing of first ANC visit (p < 0.001), completion of recommended ANC visits (p < 0.001), skilled birth attendance (p < 0.001), and post-natal care (p < 0.01), across different wealth quintiles. Paradoxically, a higher proportion of respondents in the lower wealth quintile accessed maternal health utilization services compared to women in the relatively higher wealth quintile.
Predictors of health insurance coverage among women of reproductive age in Ghana
Respondents having higher education (aOR 3.01; 1.86–4.85), identifying as a Muslim (aOR 2.60; 1.57–4.31) belonging to the fourth (aOR 1.49; 1.10–2.03) and highest (aOR 1.65; 1.12–2.44) wealth quintile were found to be more likely to be insured. Also, other predictors of health insurance coverage among women of reproductive age were residing in the Eastern (aOR 4.22; 2.38–7.50), Western North (aOR 2.34; 1.43–3.83), Ahafo ((aOR 1.94; 1.23–3.07), Bono (aOR 1.88; 1.17–3.02), Bono East (aOR 2.00; 1.29–3.12), Oti (aOR; 1.10-2.03-3.09), North East (aOR 1.67; 1.08–2.58) and Upper East (aOR 1.78; 1.15–2.75). Respondents who are employed (aOR 0.59; 0.49–0.72) were less likely to be enrolled in the health insurance scheme (p-value < 0.001) as shown in Table 3.
Association between health insurance and maternal health services utilization
Multivariate logistic regression to determine the association between health insurance coverage and maternal health insurance utilization adjusted for socio- demographic factors is shown in Table 4. Health insurance coverage is associated with the likely odds of post-natal care (aOR 1.56; 1.15–2.12). Counterintuitively, respondents with health insurance coverage showed reduced odds of having skilled birth attendance (aOR 0.7; 0.57–0.86) and facility-based delivery (aOR 0.59; 0.45–0.78). The likelihood of an early first ANC visit had a significant association with women aged 25–34 (aOR 1.34; 1.13–1.60), 35–42 (aOR 163; 1.28–2.09), higher-educated women (aOR 1.50; 1.02–2.21), and women of the highest wealth quintile (aOR 1.67; 1.18–2.37). Women with 3 or less children are more likely to attend their first ANC visit in the first trimester compared to those with 4 or more children (aOR 0.7; 0.57–0.84) and 6 or more (aOR 0.6; 0.46–0.80).Being married is a predictor for the likely utilization of maternal health services: Timing of first ANC visit (aOR 1.31; 1.08–1.60) and completing the recommended number of ANC visits (aOR 1.57; 1.13–2.17). However, there are reduced odds for when a woman is married to have a facility-based delivery (aOR 0.40; 0.26–0.60) or skilled birth attendance (aOR 0.50; 0.38–0.67) and were statistically significant with p-values of <0.001 and 0.001 respectively
Subgroup analysis of ROC
The performance of the logistic regression model in predicting the outcome was evaluated using the area under the Receiver Operating Characteristic (ROC) curve (AUC). For completing the recommended number of ANC visits and post-natal care subgroups, the model demonstrated an AUC of 0.72 (0.69 to 0.75) and 0.72 (0.69 to 0.75) respectively, indicating acceptable discriminatory ability. All the other models returned AUC within the acceptable discriminatory as indicated in S1 Fig. As a reference, an AUC of 0.5 corresponds to a model with no discriminatory ability, while the observed AUC are all between 0.62 and 0.72 suggests that the model performs better than random chance. These statistics further support the models’ moderate ability to differentiate between the outcome categories within each subgroup.
Discussion
This paper aimed to investigate the association between health insurance coverage and maternal health services utilization among women of reproductive age in Ghana by using timing of ANC first visit, completion of ANC visits during pregnancy, skilled birth attendance, facility-based delivery, and post-natal care as indicators. The study also investigated health insurance enrollment across different socio-demographic categorizations using the most recent national survey data. Women enrolled in the NHIS in Ghana are eligible for free maternal health services from all NHIS-accredited health facilities under the free maternal care policy. It is reported that, as of 2021, the NHIS had about 15 million active members registered with the scheme which leaves almost 50% of the population uninsured [21].
In this study, 76.74% of the respondents reported having registered with the NHIS. This finding is comparable to the other studies though this study reports a slightly higher proportion of respondents having health insurance coverage [16,22]. This seems to show a steady increase in the enrollment in the health insurance scheme by women compared to previous years where in 2018 about 40% of participants were reported to have insurance [23]. Maternal health utilization from the findings of this study is associated with having insurance. This could be because of the benefits of the free maternal care policy when registered with the scheme. The policy covers a wide range of services from ANC through to post-natal care. Uninsured women seeking maternal care services are required to pay out-of-pocket for all services. Similar findings were observed in a study done in Tanzania where health insurance coverage was associated with maternal health service utilization [24].This finding also confirms studies done in Ghana but on a much smaller scale [16,25,26].Findings in this study suggest that age, education level, employment status, religion, wealth quintile, parity, exposure to the internet and region of residence are associated with the timing of first ANC visit and completion of the recommended number of ANC visits. Other studies have determined similar observations of associations between timing of first ANC and these above-listed socio-demographic characteristics [27]. Apart from post-natal care, marital status is associated with all other maternal health service indicators. The education level of respondents was not a predictor of having skilled birth attendance, facility-based delivery or post-natal care, which was an unexpected finding. The outcome maybe be due to the study population and further in-depth studies may be required to unravel the attributable factors for the outcome.
The findings of this study revealed that having health insurance coverage did increase the odds of initiating timing of ANC visit on time or completing the recommended number of ANC visits there was no statistical difference. This finding was similar to other studies where health insurance coverage did not statistically increase the odds of initiating ANC on time and completion of ANC visits [23,28]. However, the finding is at variance with publications of studies from other sub-Saharan African countries and Asian countries where there was a statistical difference between insured and uninsured women with regards to initiation of ANC and completion of the recommended ANC visits [29–31]. However, post-natal care was influenced by having health insurance coverage. Curiously, the finding of this study found there were decreased odds of insured women having skilled birth attendance and facility-based delivery. the reasons for this may require further investigation, however, the implementation health insurance scheme in Ghana has been fraught with many challenges. More often than not, health facilities still demand out-of-pocket payments for services supposedly covered by the health insurance due to inadequate funding mechanisms of the health insurance and subsequent late reimbursement of providers [32–36]. This may account for the dissatisfaction with service provision under the health insurance and resulting in abstinence from services utilization by insured women. This assertion could be buttressed by the finding that women within the highest wealth quintile were 67% more likely to initiate ANC on time and 327% more likely to complete the recommended number of ANC visits compared to the women in the lowest quintile, however, the highest wealth quintile was proportionally the lowest insured category. This seems to suggest that the most insured population, which is the women in the lowest wealth quintile are not utilizing some maternal health services as expected pointing to some level of dissatisfaction with the service provision under the insurance policy.
Socio-demographic factors like marital status, age, and employment increase the likelihood of facility-based birth among respondents of this study. This finding is concurrent with other studies conducted in other low-and-middle-income countries [37,38].
This study utilized the data from the latest national survey and is reflective of the association between health insurance coverage and maternal health utilization among women of reproductive age in Ghana. However, this study has some limitations. First, this study used cross-sectional data and as such the findings cannot infer causality. Second, the survey questions about health insurance enrollment were administered to women not at the time of pregnancy or delivery but at the time of the interview. Third, this study however narrowed out the sample size to women who have had previous pregnancies within the past five years of before the study. Despite these limitations, this study provides evidence of the associations between the utilization of maternal health services and health insurance coverage among women of reproductive age in Ghana based on the latest nationally representative data.
Conclusion
Evidence from this study reveals that even though health insurance coverage may increase the likelihood of maternal health services utilization, the implementation practices of these policies may have a more profound impact. This study also revealed the influence of other socio-demographic factors on health insurance enrollment and maternal health service utilization. Challenges faced by the health insurance policy like out-of-pocket payments while insured should be addressed to further improve the utilization of health services covered under the policy.
Supporting information
S1 File. Multicollinearity Assessment, Frequency distribution of outcome variables, Variable List and ROC analysis.
https://doi.org/10.1371/journal.pone.0325240.s001
(PDF)
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