Increasing Supervised Delivery through Leadership Development


The USAID Systems for Health Project is supporting the Ghana Health Service (GHS) to achieve the goal of reducing maternal deaths through a broad range of interventions across the life cycle and service delivery continuums. This includes activities designed to address the three delays that contribute to maternal mortality: seeking care, reaching care, and receiving adequate, facility-based care.

The supervised delivery rate in the Volta Region remains one of the lowest in Ghana. While 56 percent of pregnant women in Ghana give birth with a skilled attendant (GHS Report 2015), only 44 percent of women in Volta do so, meaning over half of women in Volta are at risk of developing an adverse perinatal outcome.

Strategic Approach

Health systems are linked to obstetric outcomes through the resources that are made available to service providers. However, additional resources are often needed to support service delivery, particularly at the district level and below. Developing capacity among managers at the regional and district level can strengthen a health system’s ability to deliver quality services. These managers are well placed to understand the context-specific needs of their districts. Investing in their development generates a new cadre of leaders who can apply leadership skills and creativity to enhance performance and solve emerging service delivery problems.

The USAID Systems for Health Project uses a capacity-building strategy that provides interactive trainings, enabling participants to work through the problem-solving process for a particular leadership issue. It is designed for district-level health leaders, and includes a leader-initiated project and follow-up visits to enhance skills. The training program covers topics such as leadership, team building, coaching and mentoring, and models for improvement. Although the training may not seem directly connected to obstetric outcomes, decisions made by health system leaders greatly influence resources available for the delivery of quality health services.

Project Activities

A cohort of leaders from the 15 District Health Directorates (DHD) in Volta Region participated in the leadership training in 2015. Each participant used local data to identify barriers to service delivery at the local and sub-district level, and created improvement projects to overcome the barriers.

Some Wego, one of six sub-districts in Ketu South in Volta Region, has a health center and three Community-Based Health Planning and Services (CHPS) clinics, and a staff of 29 health workers, including one physician assistant, one midwife, nurses, and community health workers. The health facilities offer a package of primary health services to over 32,999 people, including an estimated 8,052 women of reproductive age.

In the first nine months of 2016, only three supervised deliveries took place in the subdistrict (out of 37 total deliveries). This was due to a variety of challenges: the only midwife in the sub-district lived an hour’s walk from the facility, few pregnant women are insured, the referral system is weak, communities lack emergency transport, and patients do not follow through on referrals.

Mr. Edmund Adzah, a DHD Health Information Officer, initiated a project in Some Wego to improve supervised delivery. He worked with Ms. Benedicta Tsao (the midwife) and Mr. Philimon Ametorwodufia (a senior community health nurse), with support from Mr. Joseph Degley, the District Director of Health Services, to implement the changes listed below in an effort to decrease delays and improve care. While some changes required financial input, others were simple, and required few resources.

Reducing barriers to seeking care

  • Uninsured pregnant women were identified via antenatal care visits, and referred to the district health insurance manager to enroll in insurance
  • A midwife from one of the Volta sub-districts trained nurses and community health nurses to provide antenatal services at CHPS facilities
  • Community meetings and home visits were used to advertise the availability of antenatal care at CHPS clinics

Bringing care closer to home

  • The district provided financial support to the midwife for an apartment only 10 minutes away from the health center
  • For women who cannot afford to travel to the health center for antenatal care visits, the midwife conducts the initial appointment, then transfers the antenatal care plan to CHPS clinics, where follow-up appointments can be conducted without incurring travel costs
  • Health center and CHPS clinic staff were trained by a midwife to provide services at the sub-district level, so that women do not have to travel to a hospital or private facility

Making it easier to reach a skilled provider during labor

  • The midwife now provides pregnant women with her phone number so that they can call when they start labor; the health center security guard is also able to contact the midwife when the women cannot reach her
  • The midwife created a partnership with a vehicle owner in the community, who now provides emergency transportation for pregnant women

Strengthening referrals

  • In emergency cases, the midwife travels with women to the district hospital and contacts hospital staff to alert them to her arrival and the nature of the emergency


Calls from pregnant women in labor

On average, 77 percent of women in labor now call the midwife to alert her, leading the team to believe that this small change in communication has played an important role in improving outcomes (data source: delivery register).

100 percent supervised delivery

From January through September 2016, only 12 percent of reported deliveries in Some Wego were supervised by a skilled attendant. In the eight months since the innovations training began in October 2016, 92 percent of women delivered with a skilled attendant. Even more impressively, since January 2017, 100 percent of births have been supervised.

Lessons Learned

Access to a service provider in real time is critical to service delivery – changes as simple as providing a telephone number and having a midwife live close by can significantly enhance antenatal and perinatal care. The training of CHPS nurses and community health nurses to provide antenatal care is low cost and can be easily replicated, building resilience into the service delivery system.

Improved health outcomes can be achieved when leaders implement targeted changes to address specific system problems in service delivery, and they don’t have to come at a high cost. Regional Health Directorates and District Health Directorates can use existing resources to generate creative solutions, as evidenced by the innovations in Some Wego. In some cases, changes may even lead to additional revenue – Some Wego has seen an increase in National Health Insurance Scheme reimbursement with the increase in supervised deliveries.


Ms. Benedicta Tsa, midwife, conducting a pregnancy scan on a pregnant woman at the Health Center in Some Wego
Ms. Benedicta Tsa, midwife, conducting a pregnancy scan on a pregnant woman at the Health Center in Some Wego, Ghana
September 01, 2017
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