title: A qualitative study of health system barriers to accessibility and utilization of maternal and newborn healthcare services in Ghana after user-fee abolition.
abstract: BACKGROUND
  To reduce financial barriers to access, and improve access to and use of skilled maternal and newborn healthcare services, the government of Ghana, in 2003, implemented a new maternal healthcare policy that provided free maternity care services in all public and mission healthcare facilities. Although supervised delivery in Ghana has increased from 47% in 2003 to 55% in 2010, strikingly high maternal mortality ratio and low percentage of skilled attendance are still recorded in many parts of the country. To explore health system factors that inhibit women's access to and use of skilled maternal and newborn healthcare services in Ghana despite these services being provided free.
  
  
  METHODS
  We conducted qualitative research with 185 expectant and lactating mothers and 20 healthcare providers in six communities in Ghana between November 2011 and May 2012. We used Attride-Stirling's thematic network analysis framework to analyze and present our data.
  
  
  RESULTS
  We found that in addition to limited and unequal distribution of skilled maternity care services, women's experiences of intimidation in healthcare facilities, unfriendly healthcare providers, cultural insensitivity, long waiting time before care is received, limited birthing choices, poor care quality, lack of privacy at healthcare facilities, and difficulties relating to arranging suitable transportation were important health system barriers to increased and equitable access and use of services in Ghana.
  
  
  CONCLUSIONS
  Our findings highlight how a focus on patient-side factors can conceal the fact that many health systems and maternity healthcare facilities in low-income settings such as Ghana are still chronically under-resourced and incapable of effectively providing an acceptable minimum quality of care in the event of serious obstetric complications. Efforts to encourage continued use of maternity care services, especially skilled assistance at delivery, should focus on addressing those negative attributes of the healthcare system that discourage access and use.
authors.affiliation: Department of Geography and Rural Development, Population, Health and Gender Studies Group, Faculty of Social Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana. johnganle@yahoo.com.
authors.forename: John Kuumuori
authors.initials: JK
authors.lastname: Ganle
authors.affiliation: Nuffield Department of Population Health, The Ethox Centre, University of Oxford, Rosemary Rue Building, Old Road Campus, Headington, Oxford, OX3 7LF, United Kingdom. michael.parker@ethox.ox.ac.uk.
authors.forename: Michael
authors.initials: M
authors.lastname: Parker
authors.affiliation: Nuffield Department of Population Health, University of Oxford, Rosemary Rue Building, Old Road Campus, Headington, Oxford, OX3 7LF, United Kingdom. raymond.fitzpatrick@nuffield.ox.ac.uk.
authors.forename: Raymond
authors.initials: R
authors.lastname: Fitzpatrick
authors.affiliation: Department of Community Health, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana. easmono@yahoo.com.
authors.forename: Easmon
authors.initials: E
authors.lastname: Otupiri
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D054521:Cultural Competency; D036861:Delivery, Obstetric / Q000191:economics / Q000592:standards / Q000706:statistics & numerical data*; D005260:Female; D005869:Ghana; D006297:Health Services Accessibility; D006801:Humans; D007231:Infant, Newborn; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D018743:Perinatal Care / Q000191:economics / Q000592:standards / Q000706:statistics & numerical data*; D011295:Prenatal Care / Q000191:economics / Q000592:standards / Q000706:statistics & numerical data*; D018907:Privacy; D036301:Qualitative Research; D013997:Time Factors; D014186:Transportation; D035502:Trust; D055815:Young Adult