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Limited and inequitable access to skilled maternal and newborn healthcare has been identified as a major contributory factor to poor maternal and newborn health in sub-Saharan African countries, including Ghana. To address the problem of access, the government of Ghana, in 2003, pioneered and is implementing a new maternal healthcare policy that provides free maternity care at the point of delivery in all public and mission health facilities to ensure increased and equitable access and use of skilled maternal and newborn healthcare services. The aim of this doctoral study is to explore how the introduction of the free maternal health policy in Ghana affects access, equity of access, and to investigate barriers to accessibility and utilization of skilled maternal and newborn health services. It does this using data from the Ghana Maternal Health Survey 2007, in combination with qualitative data generated from ethnographic-style in-depth interviews and focus group discussions that the author originally conducted with a total of 185 expectant and lactating mothers, and 20 healthcare providers and policy-makers in six communities in Ghana between November 2011 and June 2012. Survey data suggest that accessibility to, and utilization of skilled antenatal care, delivery in a health facility, delivery with a skilled birth attendant, as well as other post-natal care services have increased by an average of 8% since the introduction of the policy (i.e. between 2003 and 2007). However, both survey and qualitative data indicate that while the free maternity care policy in Ghana removes important financial barriers to access and use of life-saving maternal and newborn health services, most skilled care services remain underutilized, while inequities in skilled care services accessibility and utilization persist. Qualitative findings suggest that this is largely because not only is the provision of skilled maternal and newborn healthcare services in Ghana very limited and unequally available to the population, but also even where these services are available at no or minimal cost, and can be physically accessed, they can be unfriendly, culturally unacceptable, socially degrading or even abusive to women. These factors have combined to discourage a disproportionate number of expectant mothers from accessing and using skilled maternal and newborn health services although these services are free. This doctoral research argues for a move beyond free maternity care and stresses the importance of organizing and delivering services in ways that are medically appropriate, socially sensitive, and culturally responsive. The thesis also argues that the development of a diversity responsive maternal healthcare system would go a long way to first redress the health system and socio-cultural barriers to equitable access, and then promote increased and equitable access for different groups of women.

Background Midwifery units (MUs) provide midwife-led care for women at low risk of complications. They may be located on the same site as an obstetric unit (OU), in a hospital without obstetric services or separate from any hospital. In MUs, if unforeseen complications arise, transfer to an OU may be necessary. Aim To provide evidence to contribute to the improvement of the transfer process, help make transfer safer and less distressing for women, thereby improving the care and experience of women planning to give birth in MUs. Methods A structured literature review of existing evidence was followed by three integrated component studies using different methods. The content and quality of local NHS transfer guidelines were evaluated. Data from the Birthplace national prospective cohort study were analysed to estimate transfer rates, describe the transfer process and identify factors associated with transfer. The experiences of women transferred were explored in qualitative interviews. Findings Transfer is a common event, affecting around 25% of women planning birth in MUs, although rates in different units vary. Primiparous women are more likely to be transferred than women having a second or subsequent baby. The risk of transfer for primiparous women increases with increasing age; around 50% of women having their first baby aged 40 years or over are transferred. Local NHS transfer guidelines are generally of poor quality and pay little attention to women’s experience. Women interviewed after transfer report feeling unprepared for transfer. Sensitive care and clear communication from midwives during labour facilitate feelings of control in women and help women accept transfer as the right decision and not a 'negative' event. Transfer that is perceived by women as “too late” can have potentially serious and long-lasting negative effects. Women’s experience of the transfer journey could be improved by the offer of choice in a number of areas which would help women feel 'cared for' rather than 'transported'. Having the MU midwife continue to care for the woman after transfer should be considered 'best practice'; where this is not possible a good handover is essential. Women who have experienced transfer should be offered the opportunity to talk to a midwife about their experience.