Shifting norms: pregnant women's perspectives on skilled birth attendance and facility-based delivery in rural Ghana.

Skilled birth attendance (SBA) and healthcare facility (HCF) delivery are effective means of reducing maternal mortality. However, their uptake remains low in many low-income countries. The present study utilized semi-structured interviews with 85 pregnant women attending an antenatal clinic in Akwatia, Ghana (May-July 2010) to better understand the barriers to SBA and HCF delivery through the underrepresented perspective of pregnant women. Interview transcripts were analyzed using grounded theory methodology. Participants described community support for and uptake of HCF delivery as increasing and becoming normalized, but barriers remain: (1) maltreatment by midwives; (2) cost associated with HCF delivery despite waived facility fees; (3) the need for a support person for HCF delivery; (4) difficulties in transportation; and (5) precipitous labor. Given the importance of community in Ghanaian health care decision-making, increasing community support for HCF delivery suggests progress toward increasing uptake of SBA and HCF delivery, however important actionable barriers remain.