Browsing by Author "Armar-Klemesu, Margaret"

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Effect of delivery care user fee exemption policy on institutional maternal deaths in the Central and Volta regions of Ghana
(Ghana Medical Association, 2007-09) Bosu, W.K.; Bell, Jacqueline S.; Armar-Klemesu, Margaret; Ansong-Tornui, Janet; University of Aberdeen, School of Medicine & Dentistry, Division of Applied Health Sciences
Background: To improve access to skilled attendance at delivery and thereby reduce maternal mortality, the Government of Ghana introduced a policy exempting all women attending health facilities from paying delivery care fees. Objective: To examine the effect of the exemption policy on delivery-related maternal mortality. Methods: Maternal deaths in 9 and 12 hospitals in the Central Region (CR) and the Volta Region (VR) respectively were analysed. The study covered a period of 11 and 12 months before and after the introduction of the policy between 2004 and 2006. Maternal deaths were identified by screening registers and clinical notes of all deaths in women aged 15-49 years in all units of the hospitals. These deaths were further screened for those related to delivery. The total births in the study period were also obtained in order to calculate maternal mortality ratios (MMR). Results: A total of 1220 (78.8%) clinical notes of 1549 registered female deaths were retrieved. A total of 334 (21.6%) maternal deaths were identified. The delivery-related MMR decreased from 445 to 381 per 100,000 total births in the CR and from 648 to 391 per 100,000 total births in the VR following the implementation of the policy. The changes in the 2 regions were not statistically significant (p=0.458) and (p=0.052) respectively. No significant changes in mean age of delivery-related deaths, duration of admission and causes of deaths before and after the policy in both regions. Conclusion: The delivery-related institutional maternal mortality did not appear to have been significantly affected after about one year of implementation of the policy. In late 2003, the Government of Ghana introduced a policy exempting women in the four poorest regions of the country (the three northern regions and the Central Region) attending public and private health facilities from paying user fees for delivery care. An amount of about USD 2 million was voted for this purpose. The ‘fee-free’ delivery policy aimed to improve levels of skilled attendance at birth and thereby reduce maternal morbidity and mortality. In 2005, the policy was extended to the remaining six regions of the country1. As part of a multi-component study evaluating this policy, we investigated the effect of the policy on institutional maternal mortality in two regions. The objectives of the study were to measure any effect of the intervention on hospital maternal mortality ratios (MMRs) for all maternal deaths, and focus, in particular, on delivery-related deaths, as these should be most influenced by the policy. Reported figures from the Central Region demonstrate a significant reduction in total institutional MMR from 2001 through to 20042,3. We anticipated, this trend could reverse if increasing numbers of complicated cases referred from lower level facilities or reported directly to the district hospitals in response to the free delivery care policy. We also analysed the change in the distribution of causes of the maternal death over the study period.
Evaluating the economic outcomes of the policy of fee exemption for maternal delivery care in Ghana
(Ghana Medical Association, 2007-09) Asante, F.A.; Chikwama, C.; Daniels, Aba; Armar-Klemesu, Margaret
Background: The Government of Ghana’s fee exemption policy for delivery care introduced in September 2003, aimed at reducing financial barriers to using maternal services. This policy also aimed to increase the rate of skilled attendance at delivery, reduce maternal and perinatal mortality rates and contribute to reducing poverty. Objective: To evaluate the economic outcomes of the policy on households in Ghana. Methods: Central and Volta regions were selected for the study. In each region, six districts were selected. A two stage sampling approach was used to identify women for a household cost survey. A sample of 1500 women in Volta region (made up of 750 women each before and after the exemption policy) and 750 women after the policy was introduced in Central region. Outcome Measures: Household out-of-pocket payment for maternal delivery and catastrophic out-of-pocket health payments. Results: There was a statistically significant decrease in the mean out-of-pocket payments for caesarean section (CS) and normal delivery at health facilities after the introduction of the policy. The percentage decrease was highest for CS at 28.40% followed by normal delivery at 25.80%. The incidence of catastrophic out-of-pocket payments also fell. At lower thresholds, the incidence of catastrophic delivery payment was concentrated more amongst the poor. For the poorest group (1st quintile) household out-of-pocket payments in excess of 2.5% of their pre-payment income dropped from 54.54% of the households to 46.38% after the exemption policy. The policy had a more positive impact on the extreme poor than the poor. The richest households (5th quintile) had a decline in out-of-pocket payments of 21.51% while the poor households (1st quintile) had a 13.18% decline. Conclusions: The policy was beneficial to users of the service. However, the rich benefited more than the poor. There is need for proper targeting to identify the poorest of the poor before policies are implemented to ensure maximum benefit by the target group.
Hospital based maternity care in Ghana : findings of a confidential enquiry into maternal deaths
(Ghana Medical Association, 2007-09) Ansong-Tornui, Janet; Armar-Klemesu, Margaret; Arhinful, Daniel; Penfold, Suzanne; Hussein, Julia; University of Aberdeen, School of Medicine & Dentistry, Division of Applied Health Sciences
Background: In Ghana, a universal free delivery policy was implemented to improve access to delivery care in health facilities, thereby improving access to skilled attendance and reducing maternal mortality. Objective: A confidential enquiry was conducted to ascertain if changes had occurred in the care provided by reviewing the care given to a sample of maternal deaths before and after introduction of the policy. Method: Twenty women who died as a result of pregnancy-related complications (maternal deaths) in selected hospitals in two regions were assessed by a clinical panel, guided by a maternal death assessment form. Unlike the traditional confidential enquiry process, both adverse and favourable factors were identified. Findings: Clinical care provided before and after the introduction of the fee exemption policy did not change, though women with complications were arriving in hospital earlier after the introduction of the policy. On admission, however, they received very poor care and this, the clinical panel deduced could have resulted in many avoidable deaths; as was the case before the implementation of the policy. Consumables, basic equipment and midwifery staff for providing comprehensive emergency obstetric care were however found to be usually available. Conclusion: Our findings suggest that the already poor delivery care services women received remained unchanged after introduction of the policy.