Anna Cofie

Date of Award

Summer 2020

Document Type

Open Access Dissertation


Health Services and Policy Management

First Advisor

Jan Ostermann


The pace of improvements in maternal mortality has been slow in Ghana. While Ghana’s maternal mortality ratio (MMR) decreased from 635 per 100,000 live births to 319 per 100,000 live births between 1990 and 2015, the country failed to meet the 75% reduction target set by Millennium Development Goal (MDG) goal 5A, to reduce maternal mortality ratio by 75% between 1990 and 2015. Antenatal care (ANC) is critical to improving maternal morbidity and mortality and child deaths. In 2003, Ghana introduced the National Health Insurance Scheme to ensure that all pregnant women have access to free maternal care, and in 2016, the WHO changed its recommendation from four or more to 8 or more ANC visits for developing regions. The objectives of this study were: 1) to identify correlates of pregnant mothers’ use of recommended health services, including the number of ANC visit and the initiation of ANC in the first trimester of pregnancy; and 2) develop an in-depth understanding of women’s experiences using ANC services in Ghana, nearly fifteen years after the introduction of the National Health Insurance Scheme in urban Ghana. The 2017 Ghana Maternal Health Survey was used for the quantitative part of this study. For the qualitative component, semi-structured in-depth interviews were conducted at the Korle Bu Teaching Hospital in Accra, Ghana.

Our results showed health insurance to be significantly correlated with the number of ANC visits, but not with the timing of first ANC visits. On average, older women, women with higher educational status, and women from wealthier households, women who were married, and those who had fewer than four children had greater numbers of ANC visits. Media exposure (radio) was significantly associated with ANC visits. There appeared to be decline over time in the likelihood of women seeking eight or more ANC visits and initiating ANC in their first trimester. Qualitative data suggest that social support, the health status of baby and mother, and confidence in doctors were reasons for women’s use of ANC services. Barriers to ANC included poor system and process structures, lack of friendliness of staff, high medical costs, negative relationships with providers, and geographical accessibility.

This study provided insight into factors associated with women’s ANC utilization and the timing of their first ANC visit, and reasons why women may seek or not seek recommended maternal health services. Findings may help inform public health policies aimed at improving maternal service use in the region.


© 2020, Anna Cofie