Skilled Delivery, Neonatal Survival and the Integration of Community Engagement Mechanisms in Two Rural Ghanaian Municipalities: A Mixed-Methods Study

Aims: To compare skilled delivery and neonatal survival between two rural Ghanaian municipalities implementing pregnancy schools, community-financed emergency transport and community-led advocacy, and to explore how participants link these mechanisms to each other and to maternal and newborn outcomes. Study Design: Convergent mixed-methods study combining a cross-sectional survey with focus group discussions (FGDs) and key informant interviews (KIIs). Place and Duration of Study: Nkwanta South (Oti Region) and Gushegu (Northern Region) municipalities, Ghana, January to August 2026. Methodology: We surveyed 420 women (210 per municipality; response rate 97.7%) and conducted 6 FGDs and 20 KIIs. Outcomes were compared using chi-square tests, risk differences and adjusted logistic regression; qualitative data were analysed thematically and integrated in a joint display. Results: Skilled delivery was reported by 66.2% of women: 72.9% in Nkwanta South and 59.5% in Gushegu (difference 13.3 percentage points, 95% CI 4.4 to 22.3; adjusted odds ratio 2.7, 95% CI 1.8 to 4.1). Reported neonatal survival was 94.3% and 89.5% (difference 4.8 points, 95% CI -0.4 to 10.0; p = 0.074), with about 44% power. Six qualitative themes described an integrated pathway to safe delivery, supplies linked to survival, earlier arrival, and trust and accountability. Findings converged for delivery and diverged in strength for neonatal survival. Conclusion: Skilled delivery was substantially higher where engagement structures were better developed, and participants described the mechanisms as reinforcing one another. Both municipalities remained below national coverage, and the survey could not show a difference in reported neonatal survival. Community engagement may help women reach skilled care, but newborn survival also depends on facility-level capacity.