How intra-familial decision-making affects women's access to, and use of maternal healthcare services in Ghana: a qualitative study.
BACKGROUND
There is some evidence to suggest that within the household, family and community settings, women in sub-Saharan Africa often have limited autonomy and control over their reproductive health decisions. However, there are few studies that examine how intra-familial decision-making power may affect women's ability to access and use maternal health services. The purpose of this paper is to examine how intra-familial decision-making affects women's ability to access and use maternal health services.


METHODS
We conducted 12 focus group discussions and 81 individual interviews with a total of 185 expectant and lactating mothers in six communities in Ghana. In addition, 20 key informant interviews were completed with healthcare providers. Attride-Stirling's thematic network analysis framework was used to analyse the data.


RESULTS
Findings suggest that decision-making regarding access to and use of skilled maternal healthcare services is strongly influenced by the values and opinions of husbands, mothers-in-law, traditional birth attendants and other family and community members, more than those of individual childbearing women. In 49.2%, 16.2%, and 12.4% of cases in which women said they were unable to access maternal health services during their last pregnancy, husbands, mothers-in-law, and husband plus mothers-in-law, respectively, made the decision. Women themselves were the final decision-makers in only 2.7% of the cases. The findings highlight how the goal of improving access to maternal healthcare services can be undermined by women's lack of decision-making autonomy through complex processes of gender inequality, economic marginalisation, communal decision-making and social power.


CONCLUSIONS
Interventions to improve women's use of maternity services should move beyond individual women to target different stakeholders at multiple levels, including husbands and mothers-in-law.
Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Accra, Ghana. johnganle@yahoo.com.
John Kuumuori
JK
Ganle
Department of Sociology & Social Work, Faculty of Social Sciences, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana. obeng368@gmail.com.
Bernard
B
Obeng
Population, Health and Gender Research Group, Department of Geography and Rural Development, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana. segbefia@yahoo.com.
Alexander Yao
AY
Segbefia
Population, Health and Gender Research Group, Department of Geography and Rural Development, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana. vitalisfbi@yahoo.com.
Vitalis
V
Mwinyuri
Population, Health and Gender Research Group, Department of Geography and Rural Development, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana. bigjoedk2003@yahoo.com.
Joseph Yaw
JY
Yeboah
Population, Health and Gender Research Group, Department of Geography and Rural Development, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana. leonard.baatiema@acu.edu.au.
Leonard
L
Baatiema
D000328:Adult; D003657:Decision Making; D036861:Delivery, Obstetric / Q000706:statistics & numerical data*; D005195:Family Relations; D005260:Female; D017144:Focus Groups; D005869:Ghana; D000066502:Grandparents; D006297:Health Services Accessibility; D006801:Humans; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D008880:Midwifery; D026684:Personal Autonomy; D011247:Pregnancy; D036301:Qualitative Research; D018454:Spouses; D055815:Young Adult