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	Addressing Socio-cultural Barriers to Maternal Healthcare in Ghana: Perspectives of Women and Healthcare Providers

Abstract 
Background: One of the main challenges to achieving the maternal health-related Millennium Development Goals in sub-Saharan African countries is poor access to skilled maternal healthcare services. Many previous studies that examine norms of childbirth and care-seeking behaviours have therefore focused on identifying the norms of non-use of services rather than factors that can promote service use.  
Purpose: To explore and identify strategies for addressing socio-cultural barriers to women�s use of skilled maternal healthcare services in Ghana.
Methods: Primary qualitative research was conducted with a total of 185 expectant and lactating mothers, and 20 healthcare providers in six purposively sampled communities in Ghana. The Attride-Stirling�s thematic network analysis framework was used to analyse and present qualitative data.
Results: Women and healthcare providers identified and reported a number of strategies that could potentially be adopted to address socio-cultural barriers to utilization of existing skilled maternal healthcare services. These include cultural adaptation of birthing services, greater male involvement in maternity care, health education, community mobilization and engagement, and promotion of domiciliary maternity care. 
Conclusion: The findings in this paper not only improve understanding of the socio-cultural barriers women face in accessing and using maternal healthcare services, but also significantly add new insights to the corpus of existing evidence about how these access barriers could be addressed. In particular, the findings highlight the need for maternity care services to be organized and delivered in a way that is medically appropriate, socially sensitive, and culturally responsive. This requires structural changes to maternity clinics and routine nursing practices, including cultural competence training for healthcare providers. 

Keywords: maternal healthcare, access, socio-cultural barriers, solutions to socio-cultural barriers, Ghana.


















Introduction
Over the last decade, improving maternal health has become a global priority, and quantified reductions in maternal mortality have been included in the Millennium Development Goals (MDGs). Since the Millennium Declaration of 2000, one area of policy focus felt to be of particular importance to the reduction of maternal mortality is to increase the proportion of women who receive skilled antenatal care, deliver with a skilled health professional in attendance, and as well receive postnatal care from a skilled health professional [1]. There is evidence to suggest that access to, and use of skilled maternal healthcare services, especially delivery in health facilities, can ensure that skilled personnel attend to women during childbirth and also link women to the referral system in case of any obstetric complications [2-5]. 
Despite the renewed focus on maternal health and the emphasis on skilled attendance during pregnancy and childbirth, in many sub-Saharan African countries with high burden of maternal deaths, only a few women have access to skilled birthing services [5]. While in high-income countries coverage of skilled birthing services is almost universal, in Africa only 47% of women give birth with a skilled healthcare provider [6]. In the specific case of Ghana, recent survey data suggest that only 55% of women receive skilled assistance during delivery or postnatal care following delivery despite the fact that the government of Ghana has since 2003 implemented a free maternal healthcare policy in all public and mission health facilities [7]. The survey also suggests that more than 45% of births still occur at home without any form of skilled care [7]. In 2012, the WHO estimated that Ghana�s maternal mortality ratio was 350 maternal deaths per 100, 000 live [8]. Maternal mortality, which accounts for 14% of all female deaths, is currently the second largest cause of female deaths in Ghana [9].
Empirical studies, particularly in several developing country contexts, have identified a number of factors that act as barriers to women�s access to and use of maternal healthcare services. Some of these barriers include long distance to health facilities, transportation problems, costs of services (including informal charges and opportunity costs from time lost), and poor quality of care [10-13]. But the socio-cultural beliefs, preferences and practices of women and communities, as well as women�s lack of autonomy or decision-making power, have also been implicated as important barriers to access and use of maternity care services [13-22, 34]. While these studies have contributed to better understanding of why women may choose home-delivery as a preferred option, what is lacking is a focus on how to overcome these access barriers and factors that promote access and service use [23]. A focus on such factors, particularly how to address socio-cultural barriers from the perspective of childbearing women and healthcare providers could be critical for learning more about how to promote effective access to, and use of skilled maternal healthcare services. The purpose of this paper was to identify and describe strategies for addressing socio-cultural barriers to women�s use of skilled maternal healthcare services in Ghana.

Materials and Methods
Study design
The data reported in this paper were extracted from within a larger, original study that the author conducted to examine women�s maternity care seeking experience, equity of access, and barriers to accessibility and utilization of maternal and newborn healthcare services in Ghana. The design of this larger study involved analysis of a nationally representative retrospective household survey data alongside qualitative exploration using focus group discussions (FGDs), key informant interviews (KIIs), case studies and structured field observations. In this paper, the focus is on reporting findings from the qualitative component of the larger research, which examined women and healthcare providers perspectives on how to redress socio-cultural barriers to access, and promote use of skilled maternal healthcare services.
 
Research Setting
Intensive empirical research was conducted in Ghana between November 2011 and June 2012 in a total of 6 purposively sampled communities in the Bosomtwe district of the Ashanti region and the Central Gonja district of the Northern region. Ghana is a West African country, covering a total land area of 238,305 square kilometres. Table 1 highlights selected demographic, socio-economic, and health indicators for Ghana. 

TABLE 1 HERE

Ghana is a lower middle-income country, whose social, economic and political conditions make the country an interesting case study. Ghana is situated within the predominantly economically marginalized and politically unstable region of West Africa, but forms an exception. Ghana is relatively a fledgling multicultural and multi-party constitutional democracy, characterised by vibrant civil society activism and media pluralism. It is politically stable, and also recently started producing oil in commercial quantities [24]. Also, Ghana is one of only a handful of countries in Sub-Saharan Africa to actively started implementing both universal maternity care and health insurance policies at the national level. Because of this, Ghana is often touted as �an example of global good practice� [24, 25]. 
Despite these developments, maternal mortality ratio has remained persistently high, and women in Ghana are still generally more disadvantaged from a young age. Educational and economic opportunities for women are limited, and a significant number of women experience genital cutting as well as early and/ or arranged marriages. In most societies in Northern Ghana where the kinship system is patrilineal, women are transferred between patrilines at the time of marriage. That is, they go to live with their husbands� family after marriage, and husbands are often recognized as having authority over their wives. In such societies, daughters are not considered permanent members of their natal homes, and any material goods that are given to, or acquired by a daughter automatically belong to the patriline into which she has been married. In such contexts, the place of women in society revolves around their reproductive capacities, particularly their ability to bear male children. In most cases, the organization of kinship structure around patrilines, property, ownership, and right in most societies in Northern Ghana very often marginalizes women. In most societies in Southern Ghana where communities have historically organized themselves along matrilineal kinship lines however, women are able to exert some degree of authority and control. But as Gray argues even in matrilineal societies, men always exercise greater control over the processes of decision-making and resource allocation [26]. In practice therefore, men significantly dominate both the private and public spheres of decision-making in most matrilineal societies in Ghana. 
	
Participants
Participants comprised childbearing women, and healthcare providers. The women consisted of those who were pregnant at the time of this research or had given birth between January 2011 and May 2012. The ages of these women ranged from 17 to 40 years. The majority of the women had no formal education. A few of the women were unemployed while most were engaged in diverse self-employed occupations such as farming, trading, hairdressing, dressmaking, and teaching. Several of the women were also married or living with a male partner. The majority of the women also had between 3 and 5 children.
	The healthcare providers category of respondents included health professionals (i.e. doctors, nurses, midwives, healthcare managers, and health policy-makers or implementers) from health facilities in the study communities, district and regional health directorates, and the Ghana Health Service at the national level. 

Sampling and recruitment procedures
For all research participants under the �healthcare providers� category, a purposive sampling technique was used. This was a judgmental selection of research participants based on the researcher�s evaluation of the relevance of their roles to the research topic. In total, 20 healthcare providers were interviewed as key informants.
	For the women however, a simple random sampling procedure was followed. A simple random sampling technique was used as a pragmatic approach to eliminating community members� worries and questions about why one woman was included and another excluded from the study. Four main steps were followed to sample and recruit participants. First, all pregnant and lactating mothers in each of the study communities were enumerated using a five-item short questionnaire. The questionnaire asked whether a woman was currently pregnant or had given birth since January 2011, the name of the woman, age and house number/name. Second, the required number of participants was randomly selected from the pool of names in each study community after the listing was completed. The required number of participants was predetermined at 5% of the total enumerated population of pregnant and lactating mothers of each study community. This took into account the availability of time and resources to the researcher. This generated a total of 185 participants. Third, the randomly chosen women were further randomly allocated to either focus group or key informant interview. Finally, all the selected women were contacted, and the research was introduced and the selection procedures thoroughly explained to each of the randomly selected women. Thereafter, the women were invited to participate in the study.  Where any of the randomly selected women was not available or declined to participate in the study � and there were only 2 of such cases �the selection process was repeated to get a replacement. 

Data collection methods
For the women, focus group discussions (FGDs) were the main data collection methods. This data collection technique was adopted partly because of its practical relevance in reproducing women�s experiences of socio-cultural barriers to seeking skilled maternal health services, and how to address such barriers in a normal peer-group interpersonal exchange. What made the outcome of FGDs relatively better than individual interviews was that, because FGDs were interactive participants were able to query and challenge each other as well as explain themselves; hence offering validated data on the extent of consensus or diversity. Thus FGDs became a form collective testimony. Rina Benmayor, as cited in Madriz, has pointed out the transformative experience of the collective testimony that FGDs generate [27]. Benmayor argues that group testimonies empower people, particularly women, and this empowerment enables people to speak and speaking empowers [27]. Even though FGDs in this research were envisaged to be only a method for generating qualitative data, the interactions that occurred within the groups accentuated and fostered self-disclosure and self-validation. 
In all, 6 focus group discussions � one in each of the study communities and involving a total of 104 women - were completed. Groups consisted of 17 - 24 participants. This difference was mainly due to differences in the sizes of the enumerated populations. All focus groups were held in the study communities. Each FGD lasted 1.30 to 2 hours, and ended when a point of saturation was reached i.e. when no new issues seemed to arise. All discussions were conducted in the local dialects � Twi in Kuntanase, Abono and Piase; Dagbani in Sankpala and Tidrope; and Gonja in Mpaha. The decision to conduct the discussions in the local dialects was influenced by the fact that the literacy [written or spoken English] rates were low among the study participants. Because the researcher�s knowledge of the interview language was limited, 6 native Twi, Dagbani and Gonja speaking female teachers � one in each study community - were recruited, trained and engaged as research assistants to facilitate the discussions and conduct interviews. 
 To complement the FGDs, key informant interviews (KIIs) were also conducted. The choice of this data collection technique was informed by two main factors. First, it is often argued that people may not necessarily tell the truth in any objective sense when it comes to sensitive issues such as health within a group context [28]. For this reason, the FGDs data were triangulated with KIIS. Second, KIIs were used because it was extremely difficult to organise FGDs with healthcare providers. This created special recruitment problem. This was however appropriately overcome by conducting individual interviews. A major advantage of this method was that it addressed sensitive issues such as personal experiences and perceptions with regard to accessibility to, and utilization of maternity care services. In all, 101 KIIs were completed � 81 with women and 20 with healthcare providers. Interviews lasted 15 to 20 minutes. All interviews with women were conducted in Twi, Dagbani, and Gonja, while interviews with healthcare providers were done in English. 

Study instruments
The research instrument consisted of an open-ended thematic topic guide, which was designed to ensure that similar themes were covered in each discussion or interview. However, the instrument was designed to include a built-in flexibility that allowed the researcher to pick at random and probe more on any pertinent but unexpected issues that arose during the interview process. The instrument focused primarily on exploring women�s experiences of seeking or not seeking maternity care services, issues regarding coverage, access, service utilization, women�s interaction with maternal healthcare services as well as service providers, socio-cultural barriers to access and use of services, and how socio-cultural barriers could be addressed. All FGDs and some KIIs were audio-recorded using a digital voice recorder alongside hand-written field notes.

Ethical clearance
Ethical clearance was obtained from the University of Oxford Social Sciences and Humanities Inter-divisional Research Ethics Committee (Ref No.: SSD/CUREC1/11 051), and the Ghana Health Service Ethical Review Committee (Protocol ID NO: GHS-ERC 18/11/11). In addition, informed written and verbal consent was obtained from all research participants. 

Data analysis
Following the completion of interviews, qualitative data was analysed using the Attride-Stirling�s thematic network analysis framework [29]. This involved four main steps. The first step involved transcription and reading of transcripts and field notes for overall understanding. During and after qualitative data collection, three language specialists - Twi, Dagbani and Gonja - transcribed all audio-recorded interviews. The author then reviewed all transcripts and interview notes for overall understanding and comprehension of meaning. This first step was completed with separate summaries of each transcript outlining the key points participants made. In the second step, interview transcripts were exported to NVivo 9 qualitative data analysis software, where the data were both deductively and inductively coded. Codes were labels that were assigned to whole or segments of transcripts and interview notes to help catalogue key concepts [30]. Coding of the data continued until theoretical saturation was reached i.e. when no new concepts emerged from successive coding of data. In the third step, the code structure that was developed in the previous step was applied to develop and report themes. Themes simply represented some level of patterned response within the data [31]. Finally, all the themes identified were collated into a thematic chart to reflect basic themes, organizing themes, and global themes (Table 2). In total, 17 codes were identified. These were grouped into 5 basic themes, and further clustered into 1 organizing theme, and 1 global theme (Table 2). These form the basic structure of the findings and discussion sections of this paper. 

TABLE 2 HERE

Results 
Discussions and interviews with the women and healthcare providers who participated in this research revealed that most women do want professional assistance in a health facility setting during pregnancy, childbirth, and immediately after childbirth if their maternal healthcare needs are met.  Several of the accounts these women gave suggested that their birthplace choice was rapidly shifting from the home towards formal healthcare institutions where skilled-birth attendants were likely to be available. This shift, participants reported, stemmed largely from the abolition of user-fees for maternity care services. 
Despite the fact that many women expressed their preference for skilled attendance, it was reported that, in practice, a number of socio-cultural factors at the levels of the household, family and community significantly hindered women�s ability to access and use skilled maternal healthcare services. One participant said:
The reason why some of us don�t go to give birth in the hospital is because our family and community members say that it is only weak or irresponsible women who do that. That is why some women do not go to hospital to deliver (Lactating Mother, FGD, Kuntanase).
Another participant said:
In most of the communities we serve, the social and cultural barriers that women face any time they want to access and use skilled birthing services are simply grave. For instance a woman who gets pregnant outside or before a legitimately constituted marriage is not only likely to face rejection and ridiculing from her family and the wider society, but also her opportunities for seeking proper medical care during pregnancy, labour and post-labour may be heavily restricted (Female Healthcare Provider, KII, Tamale). 
Accordingly, these socio-cultural barriers have combined to discourage many women from using skilled birthing services despite these services being provided free at the point of delivery. In both focus groups and interviews, the researcher therefore focused on exploring participants� experiences and perspectives on how to overcome these socio-cultural barriers. 

Women�s and Healthcare Providers� Proposed Solutions to Socio-cultural Barriers
Table 3 provides a summary count of statements women and healthcare providers made in relation to how to address socio-cultural barriers that discourage women from accessing and using skilled maternal healthcare services in Ghana. 

TABLE 3 HERE 

Participants� accounts in this regard converged around five broad thematic areas, namely 1) cultural adaptation of birthing services; 2) greater male involvement in maternity care; 3) promotion of domiciliary maternity care; 4) health education; and 5) community mobilization and engagement. Each of these is discussed in detail below.

Cultural adaptation of birthing services
A significant number of women reported that insensitivities of the healthcare system to the cultural values and preferences (including privacy) of childbearing women was one reason why many opt for non-skilled, home-based maternity care.  To make the healthcare system culturally responsive, participants argued for a �culturally appropriate birthing care model� in which there is adaptation and/ or integration of modern birthing services with traditionally or culturally acceptable pregnancy and childbirth management practices to ensure that skilled maternal healthcare services are attentive to the specific needs of individual women. In particular, women spoke passionately about the need to make antenatal clinics and labour wards more private and home-like so as to reduce the apprehension that the set-up of maternity wards including the apparatuses for technological intervention inspire and to provide a reassuring environment that guarantees familiarity and comfort. 
I believe if the nurses want more women to come to the hospital to deliver, then they should realize that most women come from communities where there are rules or ways in which childbirth is conducted. In this community for example, when you go into labour, you are kept in a quiet or shielded room where nobody can see your nakedness. But in the hospital, the ward is open and anybody can see you. There is no privacy at all. This is why some women prefer home birth (Lactating Mother, FGD, Tidrope).   
Another discussant continued:
Also, if a woman is delivering at home, she wears her own clothing, but in the hospital, they will not allow, they will give you cloths that so many people have already worn. This is not proper. After delivery at home too, your family members usually bury the placenta in a very warm place so that the woman�s recovery can go on well, but in the hospital, you don�t even know where your placenta is send to�whether it is burnt, thrown into the toilet or to the dogs, you would never know. If they want more women to come to them, they can try and make it possible for women to wear their own cloths during delivery. They should also provide quiet rooms, and after delivery they should hand over the placenta or at least ask the woman and her family members how they want it disposed (Lactating Mother, FGD, Tidrope).  
In this way, several women called for culture care preservation (i.e. integrating their cultural values into the care system when there is no risk of harm), culture care re-patterning (i.e. assisting them in adopting new patterns of care behaviours if instituting a particular cultural care practice would bring harm to the client or anyone else, and cultural matching of patients to care providers (i.e. linking women to healthcare providers who understand or share similar cultural beliefs and practices). In addition, several women shared their positive experiences of how traditional birth attendants and family members usually provide labouring women with not only physical and emotional support but also continuous companionship when birth took place at home. In the hospital however, it was reported that nurses and midwives often concentrated on using their instrument to the neglect of women�s emotional needs. The women therefore suggested that community traditional birth attendants and family members should be allowed into delivery wards to offer emotional support and physically help with pushing out the baby. 
The idea of adapting birthing services to preserve privacy and take account of women�s specific cultural values and practices regarding childbirth however appeared less favoured by the formal healthcare system in Ghana. Only 3 of the statements participant from the healthcare providers category made statements that suggested that cultural adaptation of birthing services was necessary for encouraging more women to patronize maternal health services.
 
Promoting male involvement
In both focus groups and interviews, it was reported that maternal health issues in Ghana were still largely treated as a uniquely feminine matter, and maternity units as spaces exclusively meant for women. As a result, there has been very little focus on men and their involvement in helping women access care. However, several women reported that not only do husbands influence women�s healthcare-seeking decisions, but also they exercise considerable power in either permitting or restricting women�s access to, and use of services. Several participants therefore called for the defeminisation of maternity care and the promotion of men�s involvement in maternal healthcare. 
My view is that if the healthcare providers want every woman in this community to attend antenatal clinic or deliver their babies at the hospital, then they need to talk to our men and involve them to understand why it is important. I say this because although we the women get pregnant and give birth, men are often responsible for our pregnancy and therefore they have a lot of say in terms of how the pregnancy is cared for or how the baby should be born (Pregnant Woman, FGD, Piase).
Another participant said:
You see when some women don�t go to see the nurses for check-up or delivery, they don�t do so on their own will, but because their husbands don�t allow them�I can use myself as an example�When I was pregnant, I didn�t go to check my pregnancy for almost seven months because my husband said it was time wasting for me to be going to the clinic when I was not sick. I only went when I fell very sick. It was my husband who picked me on his bike to the health centre. When we got to the clinic and the nurse saw me, she was very angry. She was angry because I did not attend antenatal care. But when I told her I didn�t come because I didn�t want to have problems with my husband, she called my husband to come and then she talked a lot to him. She explained that I was suffering from very severe malaria which could affect my baby, and that it was all because I didn�t attend antenatal early. Since then, my husband understood the whole thing�in fact he is always asking me when my next visit will be, and he is now very supportive (Lactating Mother, FGD, Mpaha). 
Among healthcare providers, however, the idea of promoting men�s involvement in maternal healthcare in Ghana is yet to be popular. Only 7 of the statements healthcare providers made indicated that policies directed towards improving women�s access and use of skilled maternity care services must involve men. For the few healthcare providers who made this proposal, Ghana was still a country in which patriarchy and machismo are manifested in both public and private lives, so that men especially husbands are usually the most influential household decision-makers, including regulating women�s mobility and autonomy in accessing and using skilled care services. 
I think one problem is the failure of the healthcare system to actively engage all stakeholders�especially the men in all efforts to promote good maternal health. But we�re still living in a country where men have more control over household decisions, including reproductive health decisions like how many children to have and whether a woman should give birth in the hospital. So I believe that if we want to ensure that all women have access to or use skilled maternal healthcare services at the time that the services are most needed, then we the healthcare providers must also engage the men in the process (Female Healthcare Provider, KII, Tamale).

Promoting domiciliary skilled maternity care
Within the current framework of Ghana�s maternal healthcare system, hospitals, clinics, health centres, community-based health planning and services (CHPS) compounds are the only places where women may receive free maternity care. Focus discussions and interviews with women however revealed that the unpredictability of the onset of labour, coupled with difficulties with arranging appropriate transportation as well as the unfamiliarity and apprehension that these health facilities usually inspire, often greatly limit the ability of many women to access these facilities and utilize their services.  For this reason, several women recommended a maternity care system that supported and promoted supervised domiciliary delivery. This, the women argued, would not only eliminate the complications that may arise due to delays associated with travel, but will also directly address the issues of fear and privacy as well as tailoring birthing services to meet individual women�s needs within the familiar environment of their home.
I think if the government really wants to reduce maternal deaths, then it should make it possible for the nurses to come to our houses to help. This is because, when you are pregnant, you don�t normally know when the baby will come. It can come at any time�even midnight. So if the government can make it possible�say if the nurses can give out telephone numbers that we can call them to come when we go into labour suddenly, then that will help since nurses usually have cars or motor bikes (Pregnant Woman, FGD, Abono).
One discussant supported the recommendation with an example:
I know one woman who wanted to go to the hospital to give birth, but she got into a difficult labour�she was bleeding a lot and it was in the night too, and there were no cars. Her husband called somebody at the hospital which is located in the next town and asked the person to go and inform the nurses about the problem; but the nurses said unless the husband brought the woman to the health facility, they could not help�her family really suffered. When the woman was finally sent to the hospital, an operation was done to remove the baby, but the baby was already dead. If the nurse came fast, this would not have happened (Lactating Mother, FGD, Abono). 
Another participant agreed and continued:
That is very correct�it will really help because it will be possible for every women to be delivered by a midwife or doctor even if the woman is unable to go to hospital or if she doesn�t want to go there at all. This is what our traditional birth attendants do�they usually come to our homes if we have problems with our pregnancy or if we go into labour (Pregnant Woman, FGD, Abono).
Among the healthcare providers interviewed, there appeared to be widespread resistance to the idea of supervised domiciliary delivery. Only one female healthcare provider thought domiciliary delivery was a feasible strategy that could increase access to, and use of, skilled maternity care services among women. Apart from arguments that it would be difficult for nurses, midwives and doctors to properly and safely conduct births at home, this participant also noted that the idea was very unpopular because of its rather political nature. 
As a woman who has experienced childbirth myself as well as played a frontline role in the maternity ward, I have always argued for supervised domiciliary delivery. After all, we conduct child welfare clinics and sometimes, antenatal clinics right in the communities, and the results have been very good. But I don�t know� a lot of colleagues are very uncomfortable with the idea because they fear it will be difficult or they will lose all the respect they get when patients come to them in the health facility (Female Healthcare Provider, KII, Kumasi). 
Thus apart from concerns that home deliveries come with a number of challenges such as delays in access to life-saving equipment, there was widespread fear and anxiety among healthcare workers that they may lose the respect, power and control they command within healthcare facility settings if domiciliary midwifery were incorporated into the healthcare system.

Health education
The majority of the healthcare providers interviewed also proposed more health education as a strategy to overcome access barriers arising from ignorance and socio-cultural factors. In searching for an explanation for the persistently high maternal mortality as well as low numbers of skilled maternal healthcare services accessibility and utilization, these healthcare providers reasoned that most of the damaging factors lay with women. Specifically, women�s limited health knowledge and backward cultural beliefs were implicated in non-attendance at clinics and delivery at home. According to this account, attracting more women into the formal healthcare system to access and use skilled birthing services must be preceded and/ or accompanied by a very aggressive education of women. 
There is still ignorance on the part of many women about health issues including maternal health. I believe the way to make progress is to increase our health education campaigns using the radio and community durbars to educate women about the need to seek antenatal care and hospital delivery (Female Healthcare Provider, KII, Kuntanase).
One healthcare provider added:
The problem is that there are many women�especially in rural areas who have no formal education. Such woman do not always understand the risks involved in getting pregnant and giving birth�they also have funny cultural beliefs about hospital births. So if we want to make progress towards MDGs 4 and 5, then we must intensify our health education campaigns to educate women to do away with traditional and cultural beliefs that don�t help (Female Healthcare Provider, KII, Buipe).  
One participant further suggested:
Education�more health education of the women! This is critical if we want to make progress (Female Healthcare Provider, KII, Kumasi).
Given the low levels of female education in the study communities, the diagnoses and prognoses offered by the healthcare providers here might indeed be valid in some instances. This notwithstanding, discussions and interviews with women did not produce enough evidence that could support either the diagnosis of the problem or the solution to it. Only 3 of the statements women made in relation to how to address socio-cultural barriers suggested that health education was important. The majority of women did not think that they needed more health education either for the purposes of helping them understand the risks of pregnancy and childbirth or for encouraging them to seek care in health facilities.

Community mobilization and engagement
A few of the women and healthcare providers interviewed also suggested that improving access to maternal healthcare services for all women in Ghana would require the formal healthcare system forcefully mobilizing and engaging with local community members, including traditional and religious leaders as well as traditional birth attendants to generate community-wide approval and demand for routine and emergency maternal healthcare services. 
My experience as a midwife and woman who has experienced childbirth has shown that if we want to make progress with maternal health, then we must begin to foster more collaboration between nurses, midwives, TBAs, and community and religious leaders (Female Healthcare Provider, KII, Piase).

According to this account the approach that must be adopted by the healthcare system and individual midwives to effectively mobilize and engage community members to improve access to maternal health must not merely raise community awareness or persuade community members to participate in activities already designed or decided on by midwives and the local healthcare delivery system. Rather, the approach should be a comprehensive consultative and participatory strategy, involving series of activities including 1) formative research to understand factors within every community that constrain women�s access to services; 2) galvanization of the support of the traditional authorities as early as possible in the community mobilization process; 3) raising community awareness about the maternal health situation; 4) working with community leaders and other stakeholders to invite and organize participation of childbearing women and men; 5) participatory design and implementation of a community maternal healthcare strategy, and 6) monitoring and evaluation of community maternity care activities. 
To move forward, I believe we the healthcare providers must take steps to effectively mobilize and engage local community members on the issues of maternal health. We must make communities see the problem of maternal health as the collective responsibility of communities, local healthcare providers, and central government. In this sense our approach to community mobilization should give priority to the use of existing local social systems and networks; effective engagement with the whole community through galvanization of the support of the traditional and religious authorities; the use of a discussion group methodology to encourage participation and dialogue on maternal health issues among key stakeholders in the community; raising awareness of core maternal health issues; generating community-wide behaviour change and social approval for routine and emergency maternal health services; and the use of a community-based maternal health auditing and monitoring system that can generate data on maternal health activities and changes in the community. All these should be backed up by door-to-door visitation to the homes of pregnant women and their families by trained community-based health workers (Male Healthcare Provider, KII, Tamale). 
Although participants acknowledged that community mobilisation and engagement on issues of maternal health could be challenging due to lengthy processes and community members� unwillingness to engage in the process, they argued that it was a viable potential strategy that could be used to create trust between care providers and community members, make ordinary members of the community feel a sense of partnership and collective ownership of the maternal health services that were being offered at health facilities, and address issues of socio-cultural barriers and resolve conflicts between community members and healthcare providers. As one female healthcare provider remarked:
Community mobilisation and engagement offers opportunities for we the healthcare providers to built trust and change women�s and community members� negative beliefs and attitudes towards hospital-based maternity care services (Female Healthcare Provider, KII, Kumasi).

Discussion
It has been observed that at least 80% of global maternal deaths are preventable, and that simple, costless or cost effective interventions that can significantly improve survival and quality of life for childbearing women exist even in resource-poor settings [6, 32-34]. While this is probably true in terms of clinical interventions, how to effectively deliver these interventions and services to ensure they reach all women, is one of the key challenges currently facing many low-income countries [35]. The purpose of this study was to explore and identify strategies that could be adopted to address socio-cultural barriers to access and use skilled maternal healthcare services in Ghana. 
Qualitative analysis of the experiences and perspectives of childbearing women and healthcare providers in parts of Ghana identified a number of strategies - which can broadly be viewed as �strategies for promoting culturally responsive care� -for addressing socio-cultural barriers to access and use skilled maternal healthcare services. From recommendations for domiciliary skilled care, cultural adaptation of birthing services, promotion of greater male involvement in maternity care, to health education and community mobilisation, this study highlights the importance of organising and delivering maternity care services in a manner that is culturally responsive to childbearing women and local communities. A culturally responsive health system is one in which healthcare services are respectful of, and relevant to, the health beliefs, health practices, cultural needs of diverse patient populations [36]. Cultural responsiveness further involves acknowledging and respecting cultural values and preferences of groups that impact their health and health-seeking behaviours and applying this awareness to healthcare delivery [37]. 
In the context of the study reported in this paper, cultural responsiveness acknowledges that cultural diversity of childbearing women poses unique challenges to maternal healthcare access in Ghana: it influences women�s experience, expression, care-seeking behaviours, and responses to maternal health promotion and care interventions. As such, there is need for culturally responsive care that understands and works with patients whose beliefs, values, and histories may be significantly similar or different from those of the healthcare system. For example in the context of the study communities where men can prevent women from accessing maternal healthcare, culturally responsive care would argue for an appreciation of this fact by caregivers, acknowledge the possible roles men could play as partners in maternal health, and take concrete steps to engage men on maternal health issues. Of course, cultural perceptions about the role of men as breadwinners, and maternity care as a feminine domain, might pose a challenge to men�s active involvement. However, as findings from this study demonstrate, engaging men on issues of maternal health could be important for increasing in them an understanding of the relevance of women�s access to, and use of, skilled birthing services in a timely manner. In this regard, it would be important to make existing and future designs of maternity wards male and couple-friendly, such that both men and women can be accommodated or if need be create separate waiting areas for men alone.
In addition, this research has revealed that some of the socio-cultural barriers to skilled care such as traditional values attached to burying of placenta closer to home or in a warm place are highly context specific. A culturally responsive care regime would move beyond one-size-fit-all templates to focus on addressing the specificity of socio-cultural beliefs and concerns of different communities that negatively affect access to, and use of skilled care services. In changing, modifying and accommodating some of the socio-cultural barriers to maternal healthcare access, a culturally responsive care system would also adopt health education campaigns that not only communicate the importance of women delivering their babies with a relatively well-resourced skilled health professional in attendance, but also challenge negative socio-cultural beliefs and practices that constrain women�s ability to access and use skilled delivery services. Other strategies that could be pursued to make the maternal healthcare system culturally responsive include cultural competency training for healthcare providers and cultural matching. Cultural matching in particular has the potential to reduce the social distance (i.e. differences in culture, ethnicity, religion, behaviour and expectations etc.) between maternity caregivers and women. As one previous study in Ghana found women preferred to travel further, and face higher opportunity costs to see maternal healthcare providers who were the same ethnic or religious group as them [38]. The study revealed that this was because a provider from the same ethnic or religious group was perceived as having a smaller social distance and therefore worth travelling the extra distance for. 
Indeed, it is not just the empirical findings from this research that can be invoked to justify the argument for cultural responsiveness in maternity care in Ghana. One key argument in the international health research literature is that lack of culturally responsive care is, in fact, a major contributor to health disparities [39]. Previous studies have also found that providing culturally responsive care has the potential to lead to improved access and equity for all groups in the population [37]. It has also been observed that health disparities and lower quality care are exacerbated when healthcare organisations fail to address the links between culture and health service provision [39]. The findings in this paper therefore re-echo previous calls for maternity care services to be made more responsive to women�s cultural values, beliefs and preferences related to pregnancy and childbirth [32, 36, 40]. 
But inevitably, the various proposals for addressing the socio-cultural barriers themselves present unique challenges. For example, the majority of these recommendations were based on assumptions, rather than evidential knowledge that if implemented, they would address the cultural barriers that inhibited women�s access to skilled maternal healthcare services. Thus, many of these proposals neither considered the question of feasibility, the existence of an evidence-base, nor the cost and the broader implications of implementing any of the proposed solutions. Similarly, women�s priorities and proposed remedies diverged as well as converged with those of healthcare providers in significantly interesting ways. For example, whereas the health centre or hospital is a place where women felt a loss of status and therefore argued for health centres and hospitals to be made more into places where women feel at home and higher status, healthcare professionals gain status within health facilities, hence are very resistant to recommendations for domiciliary skilled care. Convergence in terms of women�s and healthcare providers� priorities clearly offers an opportunity for instituting the necessary policy actions to bring about improvement in maternal health. However, the seeming disjunctions in the various proposals point to the potential for conflict, and provide another lens through which policy failure or success could be anticipated. The divergence also contributes to understanding of why government efforts (including the deployment of the free maternity care policy) to stimulate access to skilled care can easily fail to meet the needs and priorities of childbearing women in Ghana.

Conclusion
Together, the findings in this paper not only improve understanding of the socio-cultural barriers women face in accessing and using maternal healthcare services, but also significantly add new insights to the corpus of existing evidence about how these access barriers could be addressed. The findings suggest that the extent to which the maternal healthcare system in Ghana becomes more responsive to the socio-cultural hindrances that women face in accessing care would be an important determinant of increased and equitable access to skilled maternal healthcare. Similarly the balance that would be struck between women�s own circumstances and valuation of their maternal healthcare needs, priorities and preferences, and those of state and of healthcare providers, would also be an important factor. This demands a number of policy and practical actions, including cultural adaptation of birthing services, greater male involvement in maternity care, promotion of domiciliary maternity care, and community mobilization and engagement in addition to rolling out health education campaigns that both communicate the importance of women delivering their babies with a relatively well-resourced skilled health professional in attendance, and challenge negative societal beliefs and practices which constrain women�s ability to access and use skilled delivery services.

Acknowledgement 

This research was funded by a Wellcome Trust Doctoral Studentship as part of a Wellcome Trust Enhancement Award (Number 087285) to the Ethox Centre, Nuffield Department of Population Health, University of Oxford. The work of the Ethox Centre in Global Health Bioethics is supported by a Wellcome Trust Strategic Award (096527). However, the funder played no role in the design, data collection, analysis, interpretation of data, writing of the manuscript, and the decision to submit the manuscript for publication. The author is grateful to all the study participants, especially the pregnant and lactating mothers. The author also acknowledges the dedication and hard work of the research assistants.





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Youez - 2016 - github.com/yon3zu
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