Quality along the continuum: a health facility assessment of intrapartum and postnatal care in Ghana

PLoS One. 2013 Nov 27;8(11):e81089. doi: 10.1371/journal.pone.0081089. eCollection 2013.


Objective: To evaluate quality of routine and emergency intrapartum and postnatal care using a health facility assessment, and to estimate "effective coverage" of skilled attendance in Brong Ahafo, Ghana.

Methods: We conducted an assessment of all 86 health facilities in seven districts in Brong Ahafo. Using performance of key signal functions and the availability of relevant drugs, equipment and trained health professionals, we created composite quality categories in four dimensions: routine delivery care, emergency obstetric care (EmOC), emergency newborn care (EmNC) and non-medical quality. Linking the health facility assessment to surveillance data we estimated "effective coverage" of skilled attendance as the proportion of births in facilities of high quality.

Findings: Delivery care was offered in 64/86 facilities; only 3-13% fulfilled our requirements for the highest quality category in any dimension. Quality was lowest in the emergency care dimensions, with 63% and 58% of facilities categorized as "low" or "substandard" for EmOC and EmNC, respectively. This implies performing less than four EmOC or three EmNC signal functions, and/or employing less than two skilled health professionals, and/or that no health professionals were present during our visit. Routine delivery care was "low" or "substandard" in 39% of facilities, meaning 25/64 facilities performed less than six routine signal functions and/or had less than two skilled health professionals and/or less than one midwife. While 68% of births were in health facilities, only 18% were in facilities with "high" or "highest" quality in all dimensions.

Conclusion: Our comprehensive facility assessment showed that quality of routine and emergency intrapartum and postnatal care was generally low in the study region. While coverage with facility delivery was 68%, we estimated "effective coverage" of skilled attendance at 18%, thus revealing a large "quality gap." Effective coverage could be a meaningful indicator of progress towards reducing maternal and newborn mortality.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Clinical Competence / statistics & numerical data
  • Ghana
  • Health Facilities / statistics & numerical data*
  • Humans
  • Postnatal Care / statistics & numerical data*
  • Quality Assurance, Health Care*

Grant support

Sabine Gabrysch is paid by the University of Heidelberg through a Margarete von Wrangell Fellowship supported by the European Social Fund and by the Ministry of Science, Research and the Arts Baden-Württemberg. She is also supported by postdoctoral fellowships of the Daimer and Benz Foundation and the Baden-Württemberg Foundation. The latter funded part of the fieldwork and funds Robin Nesbitt who is employed as a doctoral student at the University of Heidelberg. The HFA was partly funded by WHO, Save the Children’s Saving Newborn Lives (SNL) programme from the Bill and Melinda Gates Foundation, and the UK Department of International Development (DFID) for the benefit of developing countries; the views expressed are not necessarily those of DFID. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.