Factors affecting skilled delivery service utilization: a mixed-methods study in Ghana's West Akim Municipality in the Eastern Region

Background Maternal mortality remains a critical public health challenge in Ghana. Despite the country's ‘free’ Maternal Healthcare Policy, skilled delivery service utilization remains suboptimal, particularly in rural and semi-urban areas such as the West Akim Municipality. This study aimed to identify and contextualize the factors influencing the utilization of skilled delivery services in the West Akim municipality, with the goal of generating evidence to inform targeted interventions and health system strengthening. Methods A convergent parallel mixed-methods, cross-sectional study was conducted in January 2025. The quantitative component surveyed 402 women aged 15–49 who had a live birth in the preceding year, using a structured questionnaire. Multivariable logistic regression was conducted to identify factors associated with skilled delivery service utilization. Concurrently, qualitative data were collected through 4 focus group discussions ( n = 28), 20 in-depth interviews, and 16 key informant interviews with healthcare workers and community stakeholders. The data were analyzed using inductive thematic analysis. Results The skilled delivery utilization rate was 75.4%. Key quantitative predictors included higher household income (AOR=2.8, 95% CI: 1.3–5.9), health insurance coverage (AOR=3.2, 95% CI: 1.8–5.7), and secondary/tertiary education (AOR=2.4, 95% CI: 1.2–4.6). Factors reducing utilization were husband-dominated decision-making (AOR=0.5, 95% CI: 0.3–0.9), living ≥5 km from a facility (AOR=0.4, 95% CI: 0.2–0.7), and perceived poor staff attitudes (AOR=0.4, 95% CI: 0.2–0.7). Qualitative findings revealed persistent indirect costs despite insurance, strong cultural trust in traditional birth attendants, prohibitive transportation barriers, and experiences of receipt of disrespectful care as key contextual barriers. Conclusion Skilled delivery services utilization is influenced by a complex intersection of socio-economic, cultural, and health system factors. To improve coverage, policies must move beyond removing formal fees to addressing hidden costs, engage men and traditional providers, improve geographical access, and mandatorily promote respectful maternity care to rebuild community trust in the health system.