Educational Expansion and Access in Ghana a Review of 50 Years of Challenge and Progress

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Equity and admission to maternal and kid wellness services in Ghana a cross-sectional study

BMC Wellness Services Research book 21, Commodity number:864 (2021) Cite this commodity

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Abstract

Background

Inequities in the distribution of and admission to maternal and kid wellness care services is pervasive in Ghana. Agreement the drivers of inequity in maternal and child health (MCH) is important to achieving the universal health coverage component of the Sustainable Evolution Goals (SDGs) and poverty reduction in developing countries. However, there is increasing disparities in MCH services, especially in rural -urban, and income quintiles. The study aimed to examine the disparities in maternal and child health care services in Ghana for policy intervention.

Methods

Information for this report was extracted from the nationally representative Ghana Statistical Service (GSS) Multiple Indicator Cluster Survey (MICS) circular iv, 2011. Respondents of this survey were women of reproductive age 15–49 years with a sample size of ten,627 households. The models were estimated using multivariate regression analysis together with concentration index (CI) and hazard ratio (RR) to appraise the distribution of MCH indicator groups across the household wealth index.

Results

The results bear witness that women with secondary school level and above were more likely to receive family planning, prenatal intendance, and delivery past a skilled wellness professional than those without formal education. Mothers with low level of educational attainment were 87% more likely to accept their first pregnancy before the age of xx years, and 78% were more likely to have children with nether-five mortality, and 45% more probable to have children who had diarrhoea. teenage pregnancy (CI = − 0.133, RR =0.679), prenatal intendance by skilled health worker (CI = − 0.124, RR =0.713) under five mortality, child underweight, reported diarrhoea, and suspected pneumonia, though not statistically meaning, were more than concentrated in the poorer than in the richer households, The RR between the elevation and bottom quintiles ranged from 0.77 for child underweight to 0.82 for child wasting.

Decision

Geographic location, income condition and formal education are central drivers of maternal and child health inequities in Ghana. Authorities tin partner the private sector to implement wellness policies to address inequalities in MCH services through main health care, and resources allocation skewed towards rural areas and the lower wealth quintile to span the inequality gaps and amend MCH outcomes. The government and the private sectors should prioritize female educational activity, as that can improve maternal and child health.

Peer Review reports

Groundwork

Improved maternal and child health is imperative for the survival of every nation and global population. All the same, inequities in the distribution of and access to maternal and child health care services is pervasive in Ghana. Understanding the drivers of inequity in maternal and kid health (MCH) is important to achieving the universal health coverage component of the Sustainable Evolution Goals (SDGs) and poverty reduction in Low – and Center-Income Countries. The study aimed to examine inequities in maternal and child health care services among population groups particularly, the upper and lower wealth quintiles on one hand and geographical (Rural-Urban) disparities in access to MCH on the other paw. The report contributes to filling in the gaps in literature and inadequacy of equity in MCH data in Low -and Middle-Income Countries (LMICs) for testify-based MCH policy and programme implementation. Knowing the gaps and the determinant factors of inequities in MCH can aid in effective resources allotment and MCH programs implementation to meliorate health outcomes.

Republic of ghana has embarked on several interventions and efforts aimed at preventing and reducing maternal and infant bloodshed. These interventions bridge enhancing utilisation of health care through the National Health Insurance Scheme (NHIS), Free Maternal Care programme, launched in 2007 for meaning women to enhance their utilisation of delivery intendance services, Healthcare Network (CHN)-On-The-Become, Kangaroo Baby Care, Mobile Engineering science for Community Wellness (MOTECH), and Millennium Development Goal Dispatch Framework (MAF), and Expanded Program on Immunization, amidst others. It is expected that the NHIS volition improve provision of basic health care services to persons resident in the country.

Inequities in the distribution of health intendance services is gaining global attending in public health [i]. Inequities in maternal and child health services are among the prominent reasons for high maternal and child morbidities and mortalities in Sub-Saharan Africa and the world at big [ii]. Like other Sub-Saharan countries, Ghana experiences unequal distribution in maternal and child wellness care services [3]. Quality and equitably access to MCH is critical for the improvement of health outcomes and wellness condition of women and children. Notwithstanding, inequitable spread of MCH services increases mortality in resource poor regions. Babe, kid, and maternal bloodshed are highest in Northern Ghana, where poverty is rife and access to MCH services are woefully in short supply. The poor MCH services in Northern Ghana is worse than the economically endowed Southern Ghana (Greater Accra and Ashanti) regions. It is estimated that 1 in 27 infants in Ghana die before their first birthday, and one in 19 children die before historic period five [4].

In 2017, the Maternal Mortality Ratio was estimated at 310 per 100,000 deaths, with a lifetime hazard of maternal death estimated at i% of all women dying from maternal causes. A stunning 517 pregnant women die of maternal causes, annually in Republic of ghana, for lack of quality maternal health care services, and caitiff distribution of MCH services [4]. Surprisingly, well-nigh of the maternal and baby mortalities are preventable [5]. Republic of ghana's key health status indicators on MCH, such every bit maternal mortality charge per unit (MMR), infant bloodshed rate (IMR), family planning, and neonatal mortality rate (NMR) improved steadily over the MDG period. This achievement was praised by the international community as a remarkable success. Nonetheless, there were large inequalities in health coverage and strong overall performance marks significant disparities between income groups and regions [half-dozen]. Much is still left to be accomplished in the areas of equity in maternal and child health status among the lower wealth quintile of the population. The 2017/2018 Ghana Multiple Indicator Cluster Survey (MICS), circular six study showed a reduction in infant mortality rate (IMR) from 49 per every thou to 41 children per 1000 alive births, according to the Republic of ghana Statistical Services data in 2018. This statistic is far from achieving the SDG Goal 3-Target 3.2 of "ending preventable deaths of new-borns and children under five years with all countries aiming to reduce neonatal mortality.

Low or no education of mothers besides hampers their maternal and child health status and well-being. In Ghana low education of mothers is notwithstanding a problem, considering that as many as 79 maternal deaths were associated with mothers with no educational activity while 53 deaths for mothers with at least secondary education [7]. Inequality creates serious obstacles to achieving the Sustainable Development Goals (SDGs), particularly, overcoming poverty, achieving universal health coverage and reduced inequalities by the year 2030 (SDG1, iii and 10). The widening and persistent inequality in the distribution of social services including maternal and child wellness care is harmful to countries too as individuals equally agreed by policy makers [8]. Between 2016 and 2017, 82% of the wealth generated went to the richest 1% of the global population, while the poorest one-half saw no increase [half dozen]. Over 800 women die globally every twenty-four hour period from complications in pregnancy and childbirth due to the disparities in maternal and kid wellness services utilization [7]. For every woman who dies, approximately 20 others suffer serious injuries, infections or disabilities and near all maternal deaths (99%) occur in developing country regions [7]. Co-ordinate to the Population Reference Agency [ix] the maternal mortality rates (MMR) for Africa and West Africa are 490 per 100,000 live births and 674 per 100,000 live births, respectively. These statistics are worrying since no woman should die giving nascency. The survival of mothers has become very important since saving them implies saving the lives of the more than than one million children who are left motherless.

Research shows that educated women are more probable to commencement antenatal care (ANC) visits earlier than less educated women [ten], and utilisation of commitment care depends largely on the women's educational level [xi]. Well-nigh maternal wellness studies in Ghana [12, 13], have focused by and large on the full general population, and in some instances on some regions. Arthur (2012), for instance, identified wealth, age, education, number of children, transportation, and health insurance amidst women between 15 and 49 years to influence antenatal use in Ghana every bit contributory factors of maternal wellness care service utilisation. Other variables such as long travel distance and long waiting times affect the utilise of ANC within communities [14]. Nosotros present in the next few paragraphs, previous literature on maternal health, family unit planning, and child health in Ghana.

Maternal health

Ghana has fabricated good progress in contempo years in many social development indicators including health. Maternal and child wellness status are adamant by several variables such every bit the conditions of the place of residence, schoolhouse surroundings, and work environment, which determines their health risks and outcomes. Ecology and social variables such every bit, health care and early health care seeking and treatment; educational attainment of households especially mothers, employment, social support and economical opportunities, family incomes, health insurance coverage, significantly influence maternal health care behaviors and wellness status [thirteen]. These variables that influence maternal wellness as bear on pregnancy outcomes and child health status [15].

Evidence suggests high unmet need for family planning among unmarried adolescents while modern use of family unit planning methods is college among married than unmarried adolescents [iii]. Adolescent girls in rural areas and those amongst the poorest and less educated are at a higher risk of early on childbearing in Ghana [3]. Aplenty evidence indicates that 14% of adolescent women aged 15–19 are mothers or pregnant with their starting time child [3].

Family planning

Family planning has been an integral component of regime of Republic of ghana's maternal health programs for decades. Family Planning is an of import cistron in the population management and national development outlined in many national development plans [sixteen].

Family planning aims to assistance couples and individuals of reproductive historic period to achieve their reproductive aspirations. Despite the high premium placed on family planning programs in Ghana, funding remains a daunting challenge. Family planning intake is highest (69%) amidst women between 15 and 19 years and everyman (33%) amongst women inside 45–49 years. The demand for family planning is also highest (59%) amid women in rural areas. Those women with at least master or loftier school didactics utilise more family planning services and women in the middle three quintiles (lx–61%) [17].

Although there is a huge progress in family planning services intake, there is withal about 50% unmet demand for family planning services in Ghana, especially among young women within the xv–xix years (51%) and lowest amidst women anile 45–59 (fourteen%). Too women in rural home have slightly college (31%) unmet needs of family unit planning than their counterparts in urban areas (29%) [17].

Commitment past skilled health personnel is another key indicator of maternal health. There has been progress in this indicator, about 68% of all births in the last two years preceding the MICS survey round 6 were delivered past skilled personnel. Didactics plays an important function in deliveries by skilled health personnel. Educated woman were more likely to have assisted delivered by a skilled health personnel. Assisted commitment by skilled health personnel for mothers with no formal education constituted only 44% of all deliveries compared to 95% for women with secondary or higher teaching. Too, poor women were less likely to evangelize using skilled personnel (39%), compared to rich women (98%). Despite the progress made in delivery past skill personnel deliveries at home is still highly significant as one in 3 births accept place at dwelling without a skilled health personnel [18]. This needs to be addressed to reduce preventable maternal mortality which might emanate from complications or blood loss.

Promoting and ensuring deliveries in health facilities can reduce the health risks to both the mother and the baby. Proper medical attending and hygienic conditions during commitment tin besides reduce the risks of complications and infection that can cause morbidity and mortality to either the mother or the baby [18].

Kid wellness

The health of children is a global business concern. Over the years, many countries and institutions have worked towards improving the health of children to reduce infant mortality. Despite the significant investments and improvement in kid health in the by few decades, many children all the same lose their lives to diseases before their fifth altogether globally, and inequity in health is still a huge challenge [19]. Technical and medical solutions such as illness control and medical intendance of illnesses that cause the most deaths in children are disquisitional in making primal improvements in health equity.

Diarrhoea and pneumonia have been the virtually frequent childhood illnesses and causes of attendance at health facilities in depression-income and centre-income countries [twenty]. These diseases have been regarded every bit the "biggest child killers" in the last century [21]. In 2011 for instance, diarrhoea and pneumonia caused well-nigh 700,000 and 1, 300,000 global deaths respectively in children nether 5 years [xx]. The plan was necessitated past some alarming statistics that pneumonia and diarrhoea together accounted for 30% of all childhood deaths [22]. The prevalence rate of diarrhoea in children nether 5 years in Ghana is reported to exist 13% in the 2011MICS, with Oral Rehydration Treatment (ORT) being higher in urban areas (64%) than in rural areas (56%) [eighteen]. Babyhood diarrhoea in Ghana is also said to show inequities that are to the disadvantage of the poorest [23]. Thus, cases recorded in urban areas or in relatively rich homes are properly managed compared to those in rural and/or poor homes. In 2011, the incidence of suspected pneumonia in children under five years in Ghana was three% [eighteen]. The main intervention in treating pneumonia is antibiotics. Of the 3% suspected pneumonia cases reported in Ghana, 41% of them were taken to an advisable wellness provider and 56% received antibiotics. Children in rural areas and/or poor homes are disadvantaged in terms of care seeking behaviour [18].

WHO estimates that at to the lowest degree 10 million deaths were prevented between 2010 and 2015 globally due to vaccinations; and many lives were protected from suffering and disability associated with diseases such equally pneumonia, diarrhoea, whooping cough, measles, and polio [21]. However, in Ghana many children withal suffer from nutrition deficiency illnesses and other preventable babyhood diseases. For instance, children under five years suffered from stunting (18.8%) underweight (11.0%) and wasting (4.seven%) [18]. There are too significant variations in stunting, underweight, and wasting beyond wealth quintiles and geographic regions [24]. An estimated 19% of Ghanaian children are chronically malnourished, with stunting less than ii standard deviations (SD) below the national average, and five% are stunted (beneath − 3 SD). This represents a 17% decrease (comeback) since the MICS in 2011 and a 47% decrease (improvement) since the DHS in 2008 [22].

Stunting becomes more common as children get older, peaking at 28% amid children anile 24–35 months. Stunting affects a significantly higher pct of males (20%) than females (17%), and stunting is more prevalent in rural areas (22%) than in urban areas (15%). Stunting rates vary by expanse, ranging from 10% in Greater Accra to 33% in the Northern region. Teaching and income are inversely linked to stunting. For instance, 25% of children in the lowest 2 wealth quintiles are stunted, while only 9% of children in the highest quintile are stunted [22].

Methods

Data sources

Data for this study was extracted from the 2011 Ghana Multiple Indicator Cluster Survey, round iv (MICS4 (nineteen). The Ghana Multiple Cluster Indicator survey (MICS) is a nationally representative survey which contains valuable data on the condition of children, women, and men in Ghana. Unlike the previous MICS, the Republic of ghana MICS4 2011 included 3 "malaria biomarkers," such every bit anaemia testing, malaria testing using rapid diagnostic tests (RDTs), and thick blood smear samples prepared on microscope slides.

Study settings

The information were collected in all regions of Ghana namely, Greater Accra, Central, Western, Volta, Eastern, Volta, Ashanti, Brong Ahafo, Northern, Eastern, Upper Eastward and Upper Due west regions. The estimated population of Ghana, as of July 2021 was estimated at 31,754,995 people based on Worldometer elaboration of the latest United Nations data. The population density is estimated at 137 per Kmⁱⁱ (354 people per miⁱⁱ), and the Urban Population was 56.seven% (17,625,567 people in 2020). The total land area is 227,540 Km2 (87,854 sq. miles). https://www.worldometers.info/world-population/ghana-population

Sample design

The MICS 2011 used a cross-exclusive sample design to collect data on multiple indicators most children, women, and men, nationwide, stratified into urban and rural areas and the 10 geographical regions of Republic of ghana.

Questionnaires/instruments

The Republic of ghana MICS4, 2011, used 4 different sets of questionnaires in the survey:1) Household questionnaire which collected information on usual residents, the household, and the habitation, 2) Women'southward questionnaire information on women aged 15–49 years, 3) Under-5 questionnaire administered to mothers or caretakers for all children under 5 living in the household, 4) Men's questionnaire administered in each tertiary household to all men anile fifteen–59 years.

The household questionnaire independent Household list grade, Educational activity, H2o and Sanitation, Household Characteristics, Insecticide Treated Nets, Indoor Residual Spraying, Kid Labor, Kid Discipline, Handwashing, and Salt Iodization.

The Women questionnaire included Women's Background, Access to Mass Media and Use of Data/Communication Technology, Child Mortality, Desire for Concluding Birth, Maternal and Newborn Wellness, Post-natal Health Checks, Illness Symptoms, Contraception, Unmet Need, Female person Genital Mutilation/Cutting, Behaviour Change Communication on Malaria, Attitudes Towards Domestic Violence, Marriage/Wedlock, Sexual Behaviour, HIV/AIDS, and National Health Insurance.

The Children Under-Five Questionnaire (administered to mothers or caretakers of children under- 5 years of age) included, Age, Birth Registration, Early Childhood, Development, Breastfeeding, Diet Multifariousness, Intendance of Affliction, Malaria, Immunization, National Wellness Insurance, Anthropometry, Anaemia, and Malaria Testing.

The Men Questionnaire (administered to men aged 15–59 years living in each third Household) contained Men'due south Groundwork, Access to Mass media and utilize of Information/Communication Applied science, Matrimony/Union, Mental attitude Towards Contraception, Behaviour Change Communication on Malaria, Attitudes Towards Domestic Violence, Sexual Behaviour, HIV/AIDS National, Wellness Insurance.

The questionnaires were pre-tested in ii districts: Ga West district in Greater Accra region and Akwapim Due south district in Eastern region and finalized. For the study, nosotros used the composite household questionnaire.

Sampling method

The sampling frame used for the sampling was the 2000 Ghana Population and Housing Demography data. The urban and rural areas of each region served as the key sampling strata. Two stage sampling method was used. In each stratum, the established population census enumeration areas were then systematically selected using probability proportional to size. There is no cocky-weighting considering some of the regions namely Central, Northern, Upper East and Upper West regions were over-sampled. Still, sample weights are used in reporting national level results.

The sample consists of women within the ages of 15–49 years with a live nativity in the final v years preceding the survey. Of the 12,150 households sampled, 10,963 women aged 15–49 years were interviewed, with a response rate of 97%. Children under the age of 5 years constituted 7626. Responses were obtained from their mothers or caregivers with a response rate of 99%. The male survey involved 3511 men aged 15–59 years with a response charge per unit of 95%. The questionnaire had questions on demographic indicators, wellness status, illness and visits to a doctor, health behaviour such as smoking, drinking alcohol, physical action, and eating habits. We obtained our variables from the blended household survey, cleaned for missing values, and analyzed.

Inclusion and exclusion criteria

Only the composite household questionnaires with questions on MCH were included for the analysis based on our variables. All the other questionnaires were not included in the analysis which did not have data on the central variables of interest were non included.

Data assay

Measurement of inequities

We measured inequities in maternal and kid wellness outcomes and access to wellness care interventions by three steps: i) Identification of the wellness effect or intervention whose distribution is to be measured; ii) classification of the population into different strata by a selected equity stratifier; and iii) measuring the degree of inequality [23]. Finally, nosotros tried to understand the drivers of these inequities in MCH utilization. The variables of involvement, maternal and child health outcomes and interventions are listed in Table 1. In the Multiple Indicator Cluster Survey, the socio-economic stratifier used is household wealth, which is derived from the household ownership of assets such equally television, car etc. and dwelling house characteristics such equally flooring material and source of drinking water. In this written report, nosotros have used wealth quintiles that are provided in the MICS iv report [18]. Each asset was assigned a weight (factor score) generated through principal components analysis, and the resulting asset scores were standardised in relation to a normal distribution with a mean of null and standard deviation of ane. Each household was and so assigned a score for each asset, and the scores were summed for each household; individuals were ranked co-ordinate to the total score of the household in which they resided. The sample was then divided into quintiles from one (lowest) to v (highest). A single asset index was developed for the whole sample; separate indices were not prepared for the urban and rural populations [24].

Table 1 Concentration index and ratio of richest to poorest quintile or decile for maternal health indicator of maternal and child health

Total size tabular array

To appointment, various measures take been used in the measurement of inequities in health and health care. Nonetheless, of the available measures only the slope index of inequality (SII), the relative index of inequality (RII) and the concentration index (CI) take been commonly used giving their desirable characteristics: (i) they reflect the socio-economic dimension of health inequalities; (two) they reflect the experience of the entire population rather than only two groups such as wealth quintiles one and v and (iii) they are sensitive to changes in the distribution of the population across socio-economic groups [25].

The concentration index

In this report, inequities in maternal and child health are measured using the concentration index. The concentration index is defined with reference to the concentration curve, which is used to identify whether socioeconomic inequality in some health sector variable exists and whether it is more pronounced at one point in time than another or in one land than some other. Simply a concentration curve does not give a measure of the magnitude of inequality that tin can be compared conveniently across many fourth dimension periods, countries, regions, or whatsoever may be called for comparison. However, the concentration index quantifies the degree of socioeconomic related inequality in a health variable [26, 27]. The CI has been used, for example, to measure and to compare the caste of socioeconomic-related inequality in child mortality [28], child malnutrition [29], wellness subsidies [30], and health care utilization [31].

Formally, the concentration index is defined as:

$$ C=i-2\underset{0}{\overset{ane}{\int }}{50}_h(p) dp. $$

(1)

The index is bounded between − 1 and i. For a discrete living standards variable, information technology tin exist written equally:

$$ \boldsymbol{C}=\frac{\mathbf{ii}}{{\boldsymbol{N}}_{\boldsymbol{\mu}}}\sum \limits_{\boldsymbol{i}=\mathbf{ane}}^{\boldsymbol{n}}{\boldsymbol{h}}_{\boldsymbol{i}}{\boldsymbol{r}}_{\boldsymbol{i}}-\mathbf{1}-\frac{\mathbf{one}}{\boldsymbol{Northward}} $$

(2)

where h _i is the wellness sector variable, μ is its hateful, and r _i = i , North is the fractional rank of individual i in the living standards distribution, with i  = 1 for the poorest and i  =North for the richest. For ciphering, a more convenient formula for the concentration index defines it in terms of the covariance between the health variable and the fractional rank in the living standards distribution [26, 32, 33].

$$ \boldsymbol{C}=\frac{\mathbf{2}}{\boldsymbol{\mu}}\boldsymbol{\operatorname{cov}}\ \left(\boldsymbol{h},\boldsymbol{r}\right) $$

(iii)

The sign of the concentration index indicates the management of whatever relationship between the health variable and position in the living standards distribution, and its magnitude reflects both the strength of the relationship and the degree of variability in the health variable.

Equity stratifies and measures

Health disinterestedness is the absence of unjust, avoidable differences in health care access, quality, or outcomes. Measuring health inequalities allows us to identify differences that can be acted on and tin can be used to measure progress toward achieving health equity. Disaggregating health indicators using disinterestedness stratifiers can identify inequalities between subpopulations. An equity stratifier refers to a characteristic such as a demographic, social, economical, racial, or geographic descriptor that can identify population subgroups for the purpose of measuring differences in health and health care that may be considered unfair or unjust [34].

To assess wealth, the report used selected assets and durables in a sample household, because asset buying tends to fluctuate less than individual income or expenditure. The assets considered in houses were permanent floors, roofs, or walls; affluent or pour-affluent toilets; transportation - including bicycles, motorcycles, cars or trucks; and electric equipment, including radios, televisions, line or mobile telephones, refrigerators and computers. Households with these avails were considered richer than those without. The written report also used chief component assay of all household samples to generate a wealth alphabetize for each household and use this equally an equity stratifier. This was done by measuring final utilise of goods and services, and coin payments to obtain them and measures asset buying, housing and/or access to services. This was then used to construct asset indices using methods such as principal component analysis. Using the concentration standard method, the study summarized the distribution of each MCH indicator over a slope of the wealth index by a concentration index (CI) and a concentration curve (CC). The CI, which ranges from − 1.0 to + 1.0, captures the extent to which wellness outcomes and service employ were concentrated amidst different population groups: the richest and the poorest. A CI of aught means an equal distribution of a detail indicator throughout the economic gradients. A negative CI indicates a concentration among those who are poorer (i.e., the CC lies to a higher place the equality line of 45 degrees), and a positive CI reflects a concentration among those who are richer (i.eastward. the CC lies below the equality line).

The report also compared the prevalence of health outcomes and the coverage of the MCH interventions between the richest and the poorest subgroups using a risk ratio (RR). All households were ranked co-ordinate to their wealth indices, which was divided equally into quintile [5] and decile [9] subgroups. Merely the top (richest) and lesser (poorest) quintiles and deciles were selected for the RR calculation, to demonstrate any disparity betwixt rich and poor urban and rural domiciles and educated and uneducated.

Multiple regression models were then used to assess the drivers of inequity in the MCH outcomes using CI and RR as dependent variables. Data was analysed using STATA xiii statistical software.

Results

Disparities among the poor and the rich in MCH

Tables 1, 2, 3 and 4, summarizes equity measures for all MCH indicators in terms of CI and RR betwixt the richest and poorest quintiles and deciles.

Table 2 Concentration index and ratio of richest to poorest quintile or decile for child wellness indicator of maternal and child wellness

Full size table

Table 3 Prevalence and risk ratio with respect to urban–rural areas and educational attainment for maternal wellness indicator of MCH

Full size tabular array

Table iv Prevalence and chance ratio with respect to urban–rural areas and educational attainment for child health indicator of MCH

Full size table

Economical disparities in wellness outcomes

Nosotros discovered substantial differences between income classes and geographic areas, suggesting that household wealth has a significant bear on on child survival and that the poor accept a higher hazard of child bloodshed. Teenage pregnancy (CI = − 0.133, RR =0.679), Prenatal care by skilled health worker (CI = − 0.124, RR =0.713) (See Table i); depression birth weight (CI = − 0.021) (though not statistically significant), under five mortality (CI = − 0.247, RR = 0.426); all child malnourishment indicators: underweight, stunting and wasting (CI =, − 0.055, − 0,029, − 0.003, RR =0.772, 0.738, 0.822) respectively, and child illness all showed economic inequalities in MCH (See Table ii). The poorer subgroups were more than likely to have negative health effects (as shown by the negative CIs in Tables one and 2). The poor had the highest concentration, which was statistically of import for child underweight. The CI for stunting and wasting in children was negative. In terms of magnitude of concentration, teenage pregnancy was ranked third amid the poor. Children under the historic period of 5 years old with suspected pneumonia and diarrhoea were besides more prevalent amidst the poor, though not statistically significant (Table 2). The RRs were compatible with the computed CI when comparing MCH outcomes between the peak and bottom income quintiles. Teenage pregnancy, under-five mortality, underweight children, and confirmed diarrhoea and suspected pneumonia were all more common in poorer households than in wealthier ones. The RR between the upper and bottom quintiles ranged from 0.77 for underweight children to 0.82 for wasting children (Table ii). Low birth weight was less clearly associated with economic disparities. The negative CI represented the fact that information technology was concentrated in relatively poor families, merely it had no statistical significance.

Economic disparities in service coverage

The results indicate that the primary MCH interventions were spread more evenly across economic strata than the health outcomes (Table 2). Prenatal service by a professional health worker was statistically significant and concentrated among the poor, while commitment care in a wellness facility was also statistically significant and concentrated among the wealthy. The magnitude of the CI, on the other hand, was high, and the RR between the wealthiest and poorest groups was non shut to i, suggesting a large disparity between the wealthy and the poor. The poorest quintile had the highest coverage of oral rehydration salts/oral rehydration therapy for diarrhoea. The wealthiest quintile and decile, on the other paw, had the highest coverage of adequate health-care services for suspected pneumonia. Tabular array 2 shows that the CIs of the four vaccine types for childhood immunization coverage ranged from 0.054 to 0.069, and the CI for family planning (at 0.076) is all statistically dissimilar from zero. As a effect, since all the indicators were clustered around the richest quintiles and deciles, at that place were inequalities in service coverage for these indicators. The RR for these indicators had mixed results (Tables 1 and ii); both had more than one for comparisons betwixt the kickoff and fifth quintiles, too every bit betwixt the outset and tenth deciles.

Geographic inequity of MCH

Health outcome prevalence's were as follows: teenage pregnancy among all mothers, 7.93%; low nascency weight, 16.73%; and child stunting, 16.56% (Tabular array iv). Service coverage was less equitable; for example, on average, less than 26% of respondents had prenatal intendance delivered either past skilled wellness workers or in wellness facilities, and less than xv% of children had received all vaccinations.

Tables 3 and 4 besides summarizes the urban–rural and educational disparities in MCH, as reflected past the RR. The four vaccines (BCG, MMR, DPT and xanthous fever) and the coverage indicator appropriate provider for pneumonia were all full-bodied in the urban areas than rural areas (thus, past 47, 52, 53 and 56% respectively) while low nascence, under five mortality, underweight, stunting, wasting, child illness (diarrhoea and suspected pneumonia) and coverage indicator ORS/ORT for diarrhoea were more concentrated in rural than in urban areas. The nearly profound health gap was under-five mortality, which was 33% more prevalent in rural than in urban areas.

The urban–rural gap for MCH service coverage was quite large. For instance, women living in rural areas were 30% less probable than those in urban areas to receive prenatal and commitment care from a skilled health worker. Although family planning was full-bodied in the urban areas than rural, this was not statistically meaning. Once again, teenagers in urban areas were 73% less risky in getting expose to teenage issues compared to their counterparts in the rural areas. Too, there was a precipitous gap between urban and rural women usage of print/electronic media and engineering, thus women in urban areas were 4.nine–78% more than likely to use newspapers, radio, tv, computer, and net than their counterparts in the rural areas.

Educational inequity and MCH disparity

Mothers' or caregivers' formal schooling is a meaning determinant of MCH inequity. Our findings show that more than educated mothers or caregivers did better on all issue indicators. The disparity was almost noticeable when it came to teenage pregnancy. Women with less than a secondary school education were 87% more probable than those with a secondary school instruction to have their first pregnancy before the age of twenty. Mothers or caregivers with no formal didactics were more than likely (78% and 45%, respectively) to have under-5 mortality and children with diarrhoea than those with a secondary education (Table iii).

Women with education across secondary school were 30–46% more likely than those without whatever formal education to receive family unit planning, maternal care, and delivery by a professional health worker or in a health facility. College educational attainment was besides associated with a consequent improvement in maternal care coverage, with a large deviation (RR: 1.304–ane.457; P < 0.01). Surprisingly, children built-in to mothers or cared for by someone with a post-secondary education were 57–66% more than likely than those who were not in this subgroup to receive all forms of vaccination before the historic period of one yr.

Word

The study analysed data from the Ghana Statistical Service'due south (GSS) Multiple Indicator Cluster Survey (MICS 4, 2011) to unearth inequities in maternal and kid health services delivery and admission in Ghana. The results can inform policy planning to improve maternal and child health services, especially in the disadvantage areas and populations subgroups.

In 2016, Ghana's MMR was 319 per 100,000 live births [32]. This demonstrates that MDG 5 [5], which aimed to reduce maternal mortality by three-quarters (190 deaths per 100,000 live births) by 2015, was non met. This means that if Ghana is to meet the Sustainable Development Goal (SDG) iii [3], information technology will need to make more than thoughtful and pragmatic efforts. Addressing and endmost the disparities betwixt rich and poor, educated, and uneducated, and social gradients in general are important offset steps toward improving the well-being of mothers, infants, and children. Mothers' and children'south health and socioeconomic well-existence volition have an impact on time to come generations' health and make predicting future public health challenges for families, societies, and the health-care system easier. Much has been accomplished in terms of necessary child immunization, merely ANC still has much room for improvement [22]. The sharp drop in ANC threatens to undo the country'southward advances in maternal wellness care. With regional, location, mothers' instruction, and wealth quintile inequalities, ANC coverage has dropped from 93.08% in 2012 to 81.3% in 2017 [33].

Major differences in MCH care measures were discovered in the literature across many geographical areas, maternal, economic, and socio-demographic factors in many developing countries. What is unknown are the factors that contribute to inequities in MCH service access and distribution.

Regime health expenditure has a less progressive effect on inequality in Ghana than in many other nations, accounting for only one-third of the reduction in Gini Co-efficient [iv]. Again, the government'due south annual resource allotment to the wellness sector has fluctuated and remains beneath the Abuja Declaration target of 15% (ISSER, 2018), implying that less money is going into Maternal and Child Health services, further widening the country'due south health disparities.

Assessing inequalities' drivers is critical for making evidence-based decisions and allocating scarce public resources to those who are most in need. The beingness of health-care inequities that disadvantage the poor, rural dwellers, and women with depression educational activity makes achieving the relevant health-related SDG targets difficult. This study sends a potent policy message: universal access to health care is disquisitional to achieving the objective of health equity or reducing inequalities between sub-groups such as the poor and the wealthy, rural and urban dwellers, and those who have completed secondary school and those who take not completed secondary schoolhouse.

In Ghana, child immunization was given to all mothers or caregivers regardless of their economic status. Surprisingly, immunization coverage was marginally higher in urban areas and among children whose mothers or caregivers had completed secondary school than in rural areas and amid those who had not completed secondary school. These results bespeak that urban areas accept higher service coverage than rural areas.

Government'south low commitment to investment in health infrastructure and expansion of health insurance coverage over the past decades can explicate Ghana's relatively unequal distribution of MCH service coverage – between the wealthy and the poor, urban and rural populations [7]. Over the last few decades, the regional attain of district hospitals and sub-district health centers has tended to increase in favor of the urban and wealthy. Commune wellness systems, which include hospitals and health centers, are leading the way in offering a broad variety of curative, preventative, and wellness-promotion programs, including MCH.

In Ghana, at that place is still some difference in child health results between the rich and the poor, as well as between urban and rural areas. The country's CIs for diarrhoea, malnutrition, underweight, and stunting, for example, are equivalent to the MICS for developing countries.

One of the most significant social determinants of health inequity is instruction. The education disparities for measures of teenage pregnancy and child malnutrition were far greater than the urban–rural differential, co-ordinate to this study. Every bit the mother's or caregiver's formal education level increased, the prevalence of adolescent pregnancy and baby malnutrition decreased. Teenage pregnancy was found to be much less common amongst those who had completed high school. This and other studies [12] show that maternal didactics is an important component of MCH policies.

In Ghana, access to MCH services is caitiff in the form of universal health coverage. Inequity in health outcomes is a problem, and social determinants (such equally poverty, maternal educational activity, and other structural social inequities) are meaning, even though they are often beyond the wellness sector'southward mandate. In this written report, 16.thirteen% of children were underweight, 16.56% were stunted, and 16.76% of children were wasting. Wasting in children suggests acute malnutrition, whereas stunting indicates chronic malnutrition, which is usually caused by long-term poverty in the home. Policies should tackle inequity from birth; for instance, they should address problems including low nascency weight, teen pregnancy, and infant malnutrition, for which the Globe Wellness Organization recommends multi-sectoral interventions. Inequity at birth has long-term consequences; undernutrition, for example, is linked to a loss of human capital (i.due east., the skills and knowledge that enable people to work and thus produce economic value).

Limitation of the study

The information for the study is somehow former and could have potential policy gaps. Many factors might take changed inside the period 2011 to 2021. However, current literature on MCH has been incorporated into the paper to account for the limitations. Though the MICS4 data is somewhat onetime, the analysis is relevant for comparing the results with hereafter studies that uses current MICS data. Also, the written report would accept benefited from in-depth qualitative understanding of the inequalities in MCH which was non conducted. Farther qualitative research is needed to complement and raise the understanding of the drivers of inequalities in MCH in Ghana.

Conclusion

Major challenges remain in inequity in health outcomes, particularly in the areas of child mortality, teenage pregnancy, kid malnourishment. The gaps between rich and poor and between urban and rural areas reveal a similar blueprint. Mothers' education is the main determinant of wellness inequity. Fundamental policy leverage and multi-sectoral deportment are needed to close these gaps. Inequities in most of the maternal and child wellness interventions in Republic of ghana are widespread among sub-groups (rich-poor, urban-rural and high educated-less educated) to the detriment of poor, rural dwellers, and less-educated. Thus, tackling inequalities in resources allotment through principal health care services is cardinal to fighting the extreme geographical and wealth inequality in Ghana. For instance, upping maternal and child health teaching and promotion, and improving the quality of primary health care clinics in the most disadvantage rural districts resources allocation using equity formulas can improve quality and equity of maternal and child health care in Ghana. Further enquiry, especially qualitative research is needed to unravel the social dimensions of the inequalities and the congruent factors responsible for the MCH inequalities.

Availability of information and materials

The data that support the findings of this study are bachelor from Ghana Statistical Service, simply restrictions apply to the availability of these information, which were used under license for the current study, and and then are not publicly available. Data are however available from Mubarik Salifu, (our writer who managed the data) upon reasonable request and with permission of Ghana Statistical Service.

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Acknowledgments

We dully acknowledge the contribution of Dr. Mahamudu Akudugu, the coordinator of the Ghana Inclusive Development Research Network, of the University for Development Studies, Tamale for his technical advice and coordination of the research. We are very grateful to UNICEF for their funding support, and the Ghana Statistical Service for providing the datasets for this research. Finally, we extend our gratitude to our mentor, Professor Seidu Al-hassan for his coaching in carrying out this enquiry.

Funding

Funding for this study was fabricated possible by grants from UNICEF through the Ghana Inclusive Development Research Network (GIDRN)-University for Development Studies, Tamale.

Author information

Affiliations

1. School of Public Wellness, Department of Health Services, Policy, Planning, Management and Economics (HSPPME), University for Development Studies, Tamale, Ghana

   Samuel George Anarwat

2. School of Practical Economic science and Management Sciences, Section of Economics, University for Development Studies, Tamale, Ghana

   Mubarik Salifu & Margaret Atosina Akuriba

Contributions

SGA, MS, and MA contributed to the conception of the report and design. MS managed data assay, while all authors contributed to the methodological design, interpretation of results, discussions and findings, determination, and the intellectual content including, writing, editing and proof reading for accuracy. The author(s) read and approved the terminal manuscript.

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Correspondence to Samuel George Anarwat.

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Anarwat, Due south.G., Salifu, Thou. & Akuriba, M.A. Disinterestedness and access to maternal and kid wellness services in Ghana a cantankerous-exclusive written report. BMC Wellness Serv Res 21, 864 (2021). https://doi.org/10.1186/s12913-021-06872-9

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• Received: 12 Apr 2021

• Accustomed: 09 August 2021

• Published: 24 August 2021

• DOI : https://doi.org/ten.1186/s12913-021-06872-ix

Keywords

• Maternal and child health
• Equity
• Health service admission and delivery
• Concentration index
• Risk ratios
• Ghana
• Universal health coverage

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