title: The Association Between Health Insurance Coverage and Skilled Birth Attendance in Ghana: A National Study.
abstract: OBJECTIVE
  Skilled birth attendance (SBA) is a key health intervention used by roughly two-thirds of women in Ghana. The National Health Insurance Scheme provided by the Government of Ghana is widely expected to improve maternal health outcomes by removing financial barriers to health services. In this paper, we examine if indeed health insurance is able to improve SBA, a key maternal outcome.
  
  
  METHODS
  We use data from the 2011 Ghana Multiple Indicator Cluster Survey implemented by the Ghana Statistical Services with support from the United Nations Children's Fund (UNICEF). We use a multivariate logistic model controlling for a number of enabling and predisposing factors and past experience with the health system to examine the effect of health insurance on skilled birth attendance. The sample is 2528 women.
  
  
  RESULTS
  Our results show that women with health insurance are 47 % more likely to use SBA than women without health insurance. Results also underscore that women with repetitive contact with the health system (such as antenatal care) are more likely to have a skilled delivery (OR 3.00, p value 0.000). We also find that higher parity, rural and poor women are much less likely to use SBA.
  
  
  CONCLUSIONS
  Health insurance may indeed be a useful mechanism to improve coverage of SBA, though many barriers to delivery care still exist for women. Further work to understand the effect of health insurance on other maternal outcomes is also warranted.
authors.affiliation: Data and Analytics Section, Division of Data, Research and Policy, United Nations Children's Fund (UNICEF), Three United Nations Plaza, New York, NY, 10017, USA. smkhan@unicef.org.|Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. smkhan@unicef.org.
authors.forename: Shane M
authors.identifier: http://orcid.org/0000-0002-8252-0602
authors.initials: SM
authors.lastname: Khan
authors.affiliation: Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. kavita_singh@unc.edu.|Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. kavita_singh@unc.edu.
authors.forename: Kavita
authors.initials: K
authors.lastname: Singh
mesh_terms: D000293:Adolescent; D000328:Adult; D003266:Continuity of Patient Care; D036861:Delivery, Obstetric / Q000191:economics / Q000706:statistics & numerical data*; D005260:Female; D005869:Ghana; D019538:Health Care Surveys; D006801:Humans; D019458:Insurance Coverage / Q000706:statistics & numerical data*; D007348:Insurance, Health; D007407:Interviews as Topic; D016015:Logistic Models; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D008875:Middle Aged; D008880:Midwifery; D009313:National Health Programs; D010820:Physicians; D011247:Pregnancy; D011256:Pregnancy Outcome; D011295:Prenatal Care / Q000191:economics / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires; D055815:Young Adult
keywords: Antenatal care; Continuum of care; Ghana; Health insurance; Multiple Indicator Cluster Surveys; Skilled delivery