title: Can community health officer-midwives effectively integrate skilled birth attendance in the community-based health planning and services program in rural Ghana?
abstract: BACKGROUND
  The burden of maternal mortality in sub-Saharan Africa is very high. In Ghana maternal mortality ratio was 380 deaths per 100,000 live births in 2013. Skilled birth attendance has been shown to reduce maternal mortality and morbidity, yet in 2010 only 68 percent of mothers in Ghana gave birth with the assistance of skilled birth attendants. In 2005, the Ghana Health Service piloted a strategy that involved using the integrated Community-based Health Planning and Services (CHPS) program and training Community Health Officers (CHOs) as midwives to address the gap in skilled attendance in rural Upper East Region (UER). The study assesses the feasibility of and extent to which the skilled delivery program has been implemented as an integrated component of the existing CHPS, and documents the benefits and challenges of the integrated program.
  
  
  METHODS
  We employed an intrinsic case study design with a qualitative methodology. We conducted 41 in-depth interviews with health professionals and community stakeholders. We used a purposive sampling technique to identify and interview our respondents.
  
  
  RESULTS
  The CHO-midwives provide integrated services that include skilled delivery in CHPS zones. The midwives collaborate with District Assemblies, Non-Governmental Organizations (NGOs) and communities to offer skilled delivery services in rural communities. They refer pregnant women with complications to district hospitals and health centers for care, and there has been observed improvement in the referral system. Stakeholders reported community members' access to skilled attendants at birth, health education, antenatal attendance and postnatal care in rural communities. The CHO-midwives are provided with financial and non-financial incentives to motivate them for optimal work performance. The primary challenges that remain include inadequate numbers of CHO-midwives, insufficient transportation, and infrastructure weaknesses.
  
  
  CONCLUSIONS
  Our study demonstrates that CHOs can successfully be trained as midwives and deployed to provide skilled delivery services at the doorsteps of rural households. The integration of the skilled delivery program with the CHPS program appears to be an effective model for improving access to skilled birth attendance in rural communities of the UER of Ghana.
authors.affiliation: Social Science Unit, Navrongo Health Research Centre, Upper East Region, Navrongo, Ghana. Evelyn.Sakeah@navrongo-hrc.org.
authors.forename: Evelyn
authors.initials: E
authors.lastname: Sakeah
authors.forename: Lois
authors.initials: L
authors.lastname: McCloskey
authors.forename: Judith
authors.initials: J
authors.lastname: Bernstein
authors.forename: Kojo
authors.initials: K
authors.lastname: Yeboah-Antwi
authors.forename: Samuel
authors.initials: S
authors.lastname: Mills
authors.forename: Henry V
authors.initials: HV
authors.lastname: Doctor
mesh_terms: D000328:Adult; D003695:Delivery of Health Care; D005260:Female; D005869:Ghana; D006282:Health Personnel; D006285:Health Planning; D006801:Humans; D007407:Interviews as Topic; D008427:Maternal Health Services / Q000592:standards*; D008428:Maternal Mortality; D008880:Midwifery / Q000592:standards*; D010342:Patient Acceptance of Health Care; D011247:Pregnancy; D015397:Program Evaluation; D019035:Rural Health Services / Q000592:standards*; D012424:Rural Population