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DIWA Summit 2025

Impact of Free Maternal Health Policy on Family Planning and Infant and Child Feeding Practices in Ghana

August 26-27, 2025| Accra, Ghana

Grace Alenoma, SDD-UBIDS (PhD)

Hamdiyah Alhassan |University for Development Studies / PhD, Prof.

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#E2A2023

Grace Alenoma, PhD., Simon Diedong Dombo University of Business and Integrated Development Studies, Wa, Ghana
Hamdiyah Alhassan, PhD., Prof. University for Development Studies, Tamale, Ghana
Adefunke Ekine, PhD., Prof., Tai Solarin University of Education, Ijagun, Ijebu Ode Ogun State
Oyeteju Odufuwa, PhD., University of Ibadan, Ibadan, Oyo State, Nigeria
Alan Griffith, PhD., Prof., University of Washington, USA

TEAM MEMBERS

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What we will be discussing:

Does a fee-free maternal health insurance policy in Ghana impact maternal attitudes towards family planning and their feeding practices for infants and young children?

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HEALTHCARE ACCESS CHALLENGES:

Proper infant and young child feeding practices are important outcomes of prenatal and postal care

But out-of-pocket payments are barriers to access

Average of $17 USD per delivery in Ghana (Dalinjong et al, 2017; Johnson et al, 2015).
Few women deliver in health facilities where user fees are charged

Access to healthcare impacts fertility and child feeding outcomes

Total Fertility Rate (TFR) in Ghana is reducing but still high compared to other African countries

Ghana’s TFR: 3.9 in 2022 vs. to 4.2 (previous survey)
Kenya’s TFR: 3.3 and South Africa’s FR: 2.3

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In 2008, the Government of Ghana introduced the “Free Maternal Health Care Policy” under the National Health Insurance Scheme (NHIS):

exempts pregnant women from NHIS premiums for maternity and neonatal care.
covers maternity care, childbirth, and neonatal care up to 3 months.
pregnant women receive sensitization and schooling on exclusive breastfeeding, proper infant and young child feeding practices
Expect education will yield positive attitudes towards family planning

300,000+ pregnant women in Ghana registered in the fee-free health insurance policy between 2008-2012.

DESCRIPTION OF POLICY

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We already know some positive impacts of the policy:

Those enrolled in the insurance policy had a reduced risk of neonatal mortality (Lambon-Quayefio & Owoo, 2017; Dwomoh et al, 2020)

But, we need more data to assess policy’s impact on:

Exclusive breastfeeding rates
Dietary diversity for children aged 6 to 23 months
Fertility desires for women aged 15-49 who already have 2+ children to have more children

RATIONALE FOR STUDY

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METHODOLOGY AND DATA SOURCES

CAPTION OR PHOTO CREDIT: RIGHT HERE

Mixed-methods comprising of both quantitative and qualitative approaches.

Quantitative, secondary data: 2022 Ghana Demographic and Health Survey (GDHS)

15,014 women and 4,935 children

Qualitative, primary data: 72 Key Informant Interviews (KII)

60 female beneficiaries
12 healthcare providers (including a policymaker) from government healthcare facilities

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QUANTITATIVE ANALYSIS

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QUANTITATIVE ANALYSIS CONTINUED

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Based on the estimated Average Treatment Effect (ATE), having access to valid NHIS::

Reduced the probability of exclusive breastfeeding by 4.3%
Is associated with a 1.66-point improvement in children’s dietary diversity
Had no significant effect on attitudes toward family planning among women aged 15–49 who are interested in having two or more children

OVERVIEW OF RESULTS

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(ATE), on average, access to NHIS has a negative effect on exclusive breastfeeding, decreasing the likelihood of practicing exclusive breastfeeding by 4.3%.

Qualitative data: mothers and health professionals indicate that most female beneficiaries do not comply with exclusive breastfeeding for up to 6 months

Most babies are given water at first bath and it continues
Most of the mothers introduce food and water to the babies at 3 months old

Mothers and mother-in-laws are key contributors to noncompliance to exclusive breastfeeding.

Intergenerational transfer of practices associated with infant feeding which are inconsistent with professional recommendations

RESULTS: EXCLUSIVE BREASTFEEDING

Treatment Effects

“We usually ask them to do the exclusive breast feeding but I can say one third of them do it. This is because when they come for post-natal and you interrogate them they tell us that because of the weather we give the babies only water and they assume they are doing exclusive breast feeding, because they are only complimenting the breast milk with only water. Some also give the babies both food and water. However we hardly get them in this facility, because they know we have educated them to do exclusive breastfeeding. When you pursue them further they will be shifting the blames of giving the babies food and water to their mothers and mother in-laws” (Midwife 1).

“Normally 36 weeks onwards we start giving them [pregnant women] education on the exclusive breast feeding. Mostly right after delivery we give them education on exclusive breast feeding but the challenges are that most of them do not comply by the “ Midwife 2).

One of the study women’s response on the age of child before child was introduced to water and any kind of food

As for water, she was given the first day, at this time the weather was always very warm. Any little time her throat was dried up and she will be crying, as such we started giving her water (23 years, live with mother-in-law, 7 antennal visits before delivery)

Another response suggests decisions on exclusive breastfeeding is a collective one.

“We use to give the baby water when bathing him when he was less than six months but, I started giving him water after six months”

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(ATE) shows a significant overall improvement of 1.66 in dietary diversity scores for children whose mothers had valid NHIS, compared to those whose mothers did not

Qualitative data: mothers and health professionals indicate most female beneficiaries feed infants with nutrients from diverse food groups, but carbohydrate-based foods dominate, especially among women who do not attend antenatal clinics

Treatment effects (dietary diversity scores)

RESULTS: DIETARY DIVERSITY

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RESULTS: FAMILY PLANNING AND FERTILITY PREFERENCES

Over all, NHIS access on attitudes toward family planning is 0.0013 (ATE, positive), but, statistically insignificant

Qualitative data: 24 of 51 beneficiaries prefer modern family planning methods to traditional ones.

I do not think that the policy has any influenced on the number of children I currently have. My mother gave birth to nine (9) children when this policy was not implemented (33 years, 5 children, attended antennal clinic 12 times before delivery of youngest child).

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	ATFP		Treatment effects
	Access	Non-access	ATT	ATU	ATE
Valid NHIS (access)	0.0633	0.6550	−0.5917 ***
Valid NHIS (non-access)	0.0202	0.2555		-0.2353***
Average Treatment Effect	0.0856	0.0843			0.0013

“No, I don’t think the NHIS can influence any woman to keep pregnancy if she does not want it, despite the fact that it will cover some bills. It has never had any influence on myself and I do not know any anyone that has ever been influenced.”(20 years, 5 children)

…There are instances whereby those (beneficiary mothers) who gave birth to 5 or 6 children are still willing to give birth to more children. This is because of competition with their rivals. And, at times when considering the sex of the child. Most people need males and end up giving birth ‘plenty’. “For example, someone can give birth to 8 or 9 females and still be expecting a male child. More births at times [sometimes] is as a result of the preference for male children. “At first the misconception is that the contraceptive implants make the children pale and that is what they used to go around saying .There used to be a myth that when you use a family planning method (modern one) you may end up not giving birth again. So, people were afraid but now there is huge patronage. Modernity has now cleared their doubts.” Now I have seen an improvement in family planning. .. (Nurse, Ponyentanga Health center, Wa West, district).

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Ghana Health Service (GHS) should complement health service access with robust community engagement

Include sensitization and counselling to grandmothers

GHS should sustain and intensify sensitization efforts on dietary diversity for children age 6 months through midwifes, health officers and health centers

Consider behavioral change initiatives to reinforce breastfeeding recommendations.

In family planning counselling discussions, healthcare providers should address social norms, fertility preferences, personal beliefs, and societal expectations.

Start conversations with pregnant women at health facilities to engender positive attitudes towards family planning

SOUND! AND! COLOR!

POLICY RECOMMENDATIONS

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Let’s keep

in touch.

THANKS FOR LISTENING!

galenoma@ubids.edu.gh

ahamdiyah@uds.edu.gh