Prevalence and determinants of Skilled Birth Attendance Among Women Who Delivered in the Past 12 Months in Sene East District, Ghana: A Community-Based Cross-Sectional Study

Technical Summary: Prevalence and Determinants of Skilled Birth Attendance in Sene East District, Ghana

Problem Statement
Despite global and national efforts to improve maternal health, the utilization of Skilled Birth Attendance (SBA) remains suboptimal in rural Ghana, particularly in hard-to-reach districts like Sene East. While the Ghana Health Service has implemented policies such as the Free Maternal Healthcare Policy to reduce financial barriers, significant gaps persist in service utilization. Existing literature on SBA determinants in Ghana largely focuses on regional or urban populations, leaving a critical evidence gap regarding the specific socio-demographic, obstetric, and health system factors influencing delivery choices in dispersed rural communities. This study addresses the need for context-specific evidence to inform targeted interventions aimed at reducing maternal and neonatal morbidity and mortality in the Sene East District.

Methodology
The study employed a community-based cross-sectional design conducted in the Sene East District, a predominantly rural area characterized by dispersed mainland and island settlements along the Volta Lake and Sene River.

• Study Population: 430 women aged 15–49 years who had delivered within the 12 months preceding the survey and were residing in the district.
• Sampling: Participants were recruited from Child Welfare Clinics (CWC) using simple random sampling (lottery method) to minimize selection bias.
• Data Collection: A structured questionnaire was administered using Kobo Toolbox on mobile devices. The instrument captured socio-demographic characteristics, obstetric history, and health system factors (e.g., distance to facilities, provider attitude).
• Variables: The dependent variable was SBA (binary: yes/no). Independent variables included maternal age, education, income, parity, antenatal care (ANC) attendance, previous delivery location, distance to health facilities, and decision-making dynamics.
• Analysis: Data were analyzed using Stata version 18. Bivariate logistic regression identified associations, and variables with $p < 0.05$ were entered into a multivariable logistic regression model to determine independent predictors. Statistical significance was set at $p < 0.05$.
• Ethics: Ethical approval was granted by the Committee on Human Research, Publication, and Ethics (CHRPE) of Kwame Nkrumah University of Science and Technology (KNUST).

Key Results
The study found a prevalence of skilled birth attendance of 64.9% among the respondents. Multivariable analysis revealed that the following factors were independently associated with the likelihood of using skilled birth attendants:

1. Previous Delivery Experience: This was the strongest predictor.
   • Women who previously delivered at home were significantly less likely to use SBA compared to first-time mothers (AOR = 0.1; 95% CI: 0.02–0.41).
   • Women who previously delivered at a Traditional Birth Attendant's (TBA) place had significantly lower odds of SBA (AOR = 0.1; 95% CI: 0.01–0.44).
   • Conversely, women with a history of facility delivery were six times more likely to use SBA in their most recent pregnancy compared to first-time mothers (AOR = 6.3; 95% CI: 1.32–30.7).
2. Distance to Health Facilities: Geographic accessibility remained a significant barrier. Mothers living more than 10 km from the nearest health facility were 70% less likely to use SBA compared to those living within 5 km (AOR = 0.3; 95% CI: 0.14–0.80).

Notably, while several factors (including maternal age, education, income, ANC attendance, and partner involvement) showed significant associations in the bivariate analysis, they did not remain statistically significant in the multivariable model after adjusting for confounders. This suggests that previous delivery experience and physical accessibility are the dominant drivers of SBA utilization in this specific context.

Significance and Claims
The authors claim that this study provides crucial community-level evidence for the Sene East District, a setting previously underrepresented in Ghanaian maternal health literature. The findings highlight that while general socio-economic factors are relevant, the history of previous delivery location and physical distance to facilities are the primary determinants of current behavior.

The paper posits that to improve maternal health outcomes in rural Ghana, interventions must be tailored to these specific determinants. Specifically, the authors suggest that:

• Enhancing physical access to health facilities is critical for women in remote areas.
• Strategies must address the "cycle" of home delivery by converting previous home-delivery experiences into positive facility-based experiences to encourage future SBA use.
• Strengthening antenatal care services and addressing barriers to skilled delivery are necessary to improve utilization rates.

The study concludes that the current uptake of SBA in Sene East is suboptimal and that targeted, context-specific interventions are required to bridge the gap between policy (free maternal care) and actual service utilization in rural communities.