Uneven distribution of health care workers contributes to the continued inequity in health outcomes . The staffing of public sector health facilities in remote rural areas is a serious challenge for many ministries of health in low- and middle-income countries. One of the biggest challenges of under-resourced health systems is the difficulty they face in producing, recruiting, and retaining health professionals, particularly in remote areas . Confronting geographical imbalances in the workforce continues to test health systems and contributes to the lack of progress in achieving MDG Five.
In a study of 31 sub-Saharan African countries, attendance by a skilled health care provider at birth between 1990 and 2000 remained stagnant with less than 40% of births attended by a doctor, nurse or midwife . This shortage often impacts heavily on the poorest people in the least developed regions of the world . Health care systems face numerous difficulties in adequately staffing rural, remote areas.
The mal-distribution of the health care workforce has been widely documented [7–10] but focuses mainly on physicians and nurses. According to the WHO  the shortage of qualified health workers in rural areas – where half of the world’s population lives – significantly impacts the attainment of the MDGs. A clear understanding of the specific situation, cultural context and needs of a country and its workforce are advocated if we are to make an impact on the development of programs and policies to attract workers to rural, remote areas .
Overall, the WHO African Region, which carries 24% of the global burden of disease, is served by only 3% of the world’s health care workers . The shortage of qualified health care workers in rural areas of Ghana continues to be an obstacle to achievement of MDG Five.
Maternal death in Ghana is currently estimated at 350 per 100 000, in part a reflection of the low rates of skilled support during birth . According to the Demographic Health Survey, 43% of Ghanaian women give birth alone or with a non-skilled attendant  although 62.8% of women surveyed had attended the minimum standard of four antenatal visits . A breakdown of maternal mortality by region indicates pregnant women have unequal chances of survival across the country, with mothers in the Greater Accra area experiencing the highest chances of survival .
Like most sub-Saharan African countries, Ghana is experiencing a critical shortage of midwives. In 2000, the exodus of more than 500 nurses and midwives from Ghana to industrialized countries accounted for more than twice the number of new nurses and midwives graduating from programs in the country that year . In 2006 there were approximately 17 322 nurses and midwives working in Ghana, while 2267 migrated to developed countries. This figure represents 13% of the total nurse and midwife workforce, placing Ghana fourth in the rankings of sub-Saharan countries suffering from nurse and midwife migration . In 2011, there were 3780 midwives practicing in Ghana, representing 5 midwives per 1000 live births or 84 midwives per 100 000 population. Midwives attend approximately 65% of all births in urban settings and 35% of births in rural areas .
An aging midwifery population also contributes to the diminishing cadre of practicing midwives in Ghana. In a survey of 145 midwives , 79% of those surveyed were between 41 and 60 years old (39% between ages 41 and 50 and 40% between ages 51 and 60), 10% were between 20 and 40 years, and 6% between 61 and 80 years of age. Of the midwives surveyed, 5% did not report their age. With mandatory retirement at age 60 in Ghana, the pool of practicing midwives will soon diminish. There are currently 14 midwifery training colleges in Ghana, with at least 1 school in each of the country’s 10 regions, graduating 500 to 600 midwives per year .
A literature review examining staffing in remote, rural areas in middle- and low-income countries found that 1247 (87.2%) general physicians in Ghana worked in urban regions although 66% of the population resides in rural areas . The Ghana Ministry of Health employs a number of incentives to recruit and retain health staff to rural, deprived areas. These include a 20% to 30% salary top up for health staff in deprived areas implemented from 2004 and a staff vehicle purchase scheme since 1997 .
There is currently very little data examining the motivation for midwives to accept rural postings after graduation. This paper examines perceived barriers and motivating factors that influence student midwives’ willingness to work in remote, rural areas of Ghana.