Background
Methodology
Research team and reflexivity
Study design
Participant recruitment process and sampling
Setting
Activities | 2019 | 2020 | 2021 |
---|---|---|---|
Number of births | 6814 | 6247 | 5909 |
Number of caesarean births | 3033 | 3174 | 2982 |
Number of ANC attendants | – | 12,827 | 14,615 |
Number of OPD attendants | 32,795 | 22,245 | 29,446 |
Average number of births per week | 131 | 118 | 111 |
Average number of births per month | 568 | 521 | 492 |
Data collection
Ethical issues
Data management and analyses
Rigour and trustworthiness
Results
Demographic characteristics of participants
Participants ID | Age | Educational attainment | Marital status | Parity | Years of experience |
---|---|---|---|---|---|
P1 | 34 | Tertiary (Diploma) | Single | 0 | 5 |
P2 | 37 | Tertiary | Married | 3 | 12 |
P3 | 35 | Tertiary | Single | 0 | 11 |
P4 | 34 | Tertiary | Married | 3 | 5 |
P5 | 38 | Tertiary | Married | 0 | 3 |
P6 | 38 | Tertiary | Single | 0 | 5 |
P7 | 32 | Tertiary | Married | 0 | 2 |
P8 | 28 | Tertiary | Single | 0 | 4 |
P9 | 51 | Tertiary | Married | 3 | 11 |
P10 | 35 | Tertiary | Married | 3 | 11 |
P11 | 26 | Tertiary | Married | 1 | 1 |
P12 | 30 | Tertiary | Single | 1 | 4 |
Main findings
Themes | Sub-themes | ||
---|---|---|---|
Actions | Challenges | Recommendations | |
Emotional support | • Provision of sacral massages and reassurance • Encouraging male involvement | • Inadequate staff • Non-cooperation from women • Partner’s lack of courage • Inadequate material resource and limited space | • Increasing staff strength • Logistical support for a timely response |
Dignified care | • Ensuring confidentiality • Provide information and seek consent • Referring mothers who cannot pay bills to social welfare | • Logistical constraint on alternative birthing positions • Facility environment limits privacy and movements • Clients’ condition limits movement | • Logistical support for alternative birthing • Capacity building and training • Logistical support for privacy and free movement • Motivating midwives |
Respectful communication | • Ask relatives to excuse patient-provider conversations • Introducing ourselves as caregivers | • Poor attitudes of midwives • Language barrier | • Peer monitoring • Demonstrating good attitudes |
Providing emotional support
Actions implemented to provide emotional support
“Usually, women in labour are tensed and anxious. As such, it is critical to de-stress them and make them feel comfortable. So, what we do is that, we give them sacral massages (locally called apemfo amamia). In addition to that, we give them words of encourage so that they (woman) will feel reassured.” (P10, 35 years).
“Some of the patients are emotional. They are often fearful and anxious. Possibly, it is because they have not given birth before but may have heard that the process is painful. For some other clients, the way people may have described the process to them would have put a frightening aura around the birth process for the. In such instances, we try to calm the woman by encouraging and assuring her that she is in safe hand, and that everything is going to be alright. We keep her informed by describing the stages of labour to her. This helps us to calm the person and gain their cooperation because they are now aware of all the stages of birth and all other expectations.” (P4, 34 years).
“Over here, we try as much as possible to involve the males throughout the process. As such, we normally encourage them to come in and support the women. You know; women can be more cooperative when it is their husband who is giving them sacral massage or when it is their partner who is encouraging them to push the baby out. So, we encourage room-in and involve the men the birthing process” (P7, 32 years).
“… it got to do with the inadequate staff. If we’re not busy we can attend to the patient promptly but if we are two (2) on duty and we are all busy we can’t attend to the third person. We attend to the emergency cases and later to those that can hold on with their condition but if there were to be enough staff, we can attend to all” (P1, 34 years).
“… with respect to emotional support, it is quite challenging because of our staff strength. There could be more labour cases which makes it difficult to promptly attend to a patient’s emotional support one after the other but we reassure them” (P3, 35 years).
“… sometimes, here [referring to the hospital], we do seventeen (17) deliveries at night so in case there’s workload and you call we can’t attend to you; [this is] not intentional though, but the midwives [are] not enough” (P11, 26 years).
“Some patients don’t comply with instructions. How do we apply the massage? We do the sacral massage but some mothers don’t cooperate so we can’t do it” (P11, 26 years).
“Let’s say there are some patients, you approach them in this way: ‘Ma’am, the pain you are going through …. especially after labour has started …. that is what propels the baby down the birth channel to the outside, but no matter what you say to such a patient, she will ignore you. No matter what you say, she will ignore you. It is rather what your advice against that she will actually do …. And it seems like whatever you’ve been saying to her does not really register in her mind but rather passes over her ears. So, it can cause you to be reluctant: you can actually make up your mind not say anything further” (P5, 38 years).
“What I can say is, it is also their relatives. I don’t know, because this facility is a referral centre when they are being referred and then they come here, even when it is not labour, I mean it is a condition they came in with, the relatives don’t give us that space. You tell them to, maybe the patient is in pain, they are around, you tell them (relatives) to go, they (patients) are in your hands now, you are taking care of them, together with the doctors. Every point in time, you see a relative trooping in, especially when they see that the patient that they brought, the relative that they brought, the person is in pain, they (relatives) want to be involved in whatever is going on. I am not saying that they shouldn’t be involved, but I think so far as you’ve brought the patient into the facility, you’ve left her in the care of the doctor and the midwife or the nurse. So, whatever is going on, they should just allow us to do our job. Yeah, they should help us do it as they should just give us that space, that room to perform our jobs and after that, we will communicate whatever is going on to them” (P8, 28 years).
“Many men don’t like it that way they don’t want to see their wife going through that pain. I remember I invited a husband and he even collapsed before seeing the baby’s head (laughs). Some will refuse if you offer the opportunity because he can’t watch. Few ones that are eager we have a way of letting them in. I gave some husbands the opportunity” (P2, 37 years).
“So far, the hospital has no waiting room for relatives so if they come, they’ve to wait outside” (P1, 34 years).
“We have two (2) delivery beds in one room and two (2) women delivering at the same time with no curtains. Now here we have curtains. But the entrance is the problem where the husband will pass because the labour ward is connected to the theatre so entry is a problem” (P2, 37 years).
“So, if two (2) or three (3) ladies become ‘full’ simultaneously, we will do the others on beds, and the others right here (indicating). Therefore, for the ones that we have to perform our duties on a bed, the husband cannot practically be there, because, right beside the wife, there will be another patient lying there. If you do that, you will be invading someone else’s privacy” (P5, 38 years).
“More staff needs to be employed. We cannot have one (1) the patient is to one (1) midwife but at least there should be extra so that activities can be shared among us” (P1, 34 years).
We need to increase staff and some staff needs to change their attitude. We are not the same. Some will work hard others will not so mostly the patient expect the hard workers to treat them but you may be tired. We have to advise ourselves not all of us but at times we are the problem (P12, 30 years).
We need more equipment with foetal heart monitor we have two (2) so in case there are three (3) labour cases it means you’ve to use the manual one for the other patient which requires your presence but for the electric one you can listen to the feedback while doing other things. It will help us if we had enough and at times, we don’t get the number of consumables we request for. Meanwhile, the one been provided is not enough for the unit work (P3, 35 years).
Provision of dignified care: awareness, challenges, and recommendations
Actions implemented to provide dignified care
Oh, in such situations, I will be able to admit you and put you in a bed and then when I am taking the FH, your vitals and such inside, I can ask you that. It doesn’t exactly have to be at the time of admission that I have to get all the required information, for when I am taking the vitals, the relative is not with us. Uh huh, so I am alone with you in the cubicle, ‘OK, Sister, please, for the medications, have you started treatment? Have you done this or that?’ and when we get to such a stage, the client is capable of telling you everything, knowing it is just between the two of you (P4, 34 years).
If you can’t provide privacy, you have to talk in a lower tone because if it is abortion and you alarm it for relatives to hear they can divorce her. All you need is to talk under tone to prevent others from hearing (P9, 51 years).
If it is MagSulf (magnezium sulphate) – MagSulf is given every four (4) hours – you tell the patient that …. they, the patients refer to MagSulf as ‘the needle that extremely burns’, so ‘Madam, I am about to give you the injection that is extremely painful or burns. You seek for their consent before you do that: everything you do for a patient; I think you have to explain and seek consent (P8, 28 years).
Like …. Mmmmm … … I see it that anything you have to do, you have to make the client aware, you have to tell her and explain what you are about to do and why you are to do it, if she will give you the permission (P10, 35 years).
If a client cannot pay her bills, we turn her over to the social welfare department. Yeah. So, we no longer detain them as we use to … …. (P5, 38 years).
We come in when the patient tells us that maybe ‘I was charged a thousand cedis (1000GHC), I have five hundred (500GHC). So our new approach as midwives is to involve the social welfare department … … ’. So, we refer them to social welfare. Then they take it over from there. But before the RMC training, we use to detain them …… yes …. of course, because that is the hospital protocol (P8, 28 years).
Hmmm right now if a patient delivers and she has no money to pay it is your shift that you’ve discharged her and the link system your name and everything is on it so if there’s any follow up, they’ll know you’re the one that didn’t collect money and the hospital will ask you to pay so a midwife won’t put herself in such situation so you pay before you leave (P2, 37 years).
Challenges
We don’t have the necessary equipment and the way clients may behave, if we decide to improvise on the squatting, it is not going to go well. It will not work well at all (P7, 32 years).
There is position like the squatting position but here we don’t have the resources to support the squat birthing. We are used to the lithotomy and all the delivery beds are in that form. We would have adapted to patient’s preferred position such as squatting if we had the needed equipment (P2, 37 years).
For water birth, hmmmm … … we are aware of such position. However, we don’t have it [equipment] here. Nothing even shows that we are actually preparing ourselves to do water birthing! Should a patient request for this, then, hmmm …… we cannot meet this need. Let us see what the future holds for all other birthing positions. (P1, 34 years).
… … ahaaa, so they are all bunched together inside and if you are working on a patient and you even use the screens, there are holes within the screens so someone can see through these (holes) and take a peep at naked patients. This too doesn’t help us (P5, 38 years).
the environment is not spacious enough to accommodate fee movement. There is always overcrowding due to the patient turn out. Hence, so we restrict walking around (P9, 51 years).
Ideally, the hospital has to provide drapes but we don’t have so we cover clients with their own sheet. Assuming the client comes in an emergency with no clothes, then ensuring privacy becomes a challenge (P3, 35 years).
As for the drapes, we don’t have any in this ward. So, the alternative we have here is the screen. So, we screen the patient and we do our thing (P5, 38 years).
The drape itself isn’t available (smiles) and let say the ward has only three (3) and it has been used. With my previous ward, the screens were scarce and even if it is available, it is faulty. Thus, providing privacy becomes a challenge (P1, 34 years).
Yes, when the fluid comes out so you can’t allow her to move about with the fear that as the fluid leaks it could rupture for the cord to slip to cause cord prolapse that’s why we restrict them but if everything is fine without rupture, they’re allowed to move around because the force of gravity is even necessary so we encourage them to walk (P3, 35 years).
Well, when it comes to walking, you are allowed to walk but it depends on each stage and what you expect from the client. Let’s say the client is at eight cm (8 cm) … 8–9, at that stage, this is difficult. It is a transitional stage and she is traumatized and such, there is also the possibility of prolapse, and other complications too (P4, 34 years).
Midwives’ recommendation for improving dignified care
The hospital has to acquire all the necessary equipment that will enable us to practice alternative birthing like the water birth (P1, 34 years).
We need the beds and the instruments they will use for those positions. As long as we have those, we will allow them to use them (P10, 35 years).
Oh OK, we have to get the different equipment performing those positions, like the birthing chair you talked about when we came (for the workshop) (P4, 34 years).
Then, there should be a training on that [alternative birthing positions] for midwives. Though we’ve been taught about the new ones in school but we never practiced it so if the hospital is to provide it has to organise workshop for us (P1, 34 years).
when I had not yet come (to the workshop) to learn about respectful care, some of my attitudes and behaviours were not really optimal but once I came and got educated on these, things have changed. And a lot of things have changed. Therefore, we should go to the district, and other sectors and educate them the more, and even if it is possible, let us take the education to the schools so that by the time the person is coming (the healthcare worker is being sent to the ward), she would have picked it (the desirable concepts of respectful maternal care) already. And we need to continually re-educate, so our minds would be drawn to certain things all the time (P10, 35 years).
Yeah, when the screens are not enough, we can use the curtains. All you have to do is draw the curtains. So, if we were provided with more curtains or if they gave us more screens, we could ensure privacy. But albeit the problems, we do ensure privacy all the same (P6, 38 years).
Maybe in our ward, we should separate the labour cases from our ward to a different place, or let’s say for Cubicle One (1), let’s make it into a cubicle for only labour cases. So, we can use curtains to separate the place into individual rooms for each client that comes in. So, if you are in labour, your relative can stand beside you during the process (P5, 38 years).
Mm we have talked about all but I will add up that the hospital should add a bit of motivation to staffs although they are being paid for all they do but a bit of motivation will do to encourage us because at times you will realize they don’t appreciate what we are doing (P1, 34 years).
Provision of respectful communication: awareness, challenges, and proposed solution
Actions that promote respectful communication
When referrals come at the same time. Even if is second stage we attend to them first before we take other history, at times we ask other patient to excuse us if only the energy is there to wake and excuse us (P2, 37 years).
So, you just have to excuse the relatives … allow the relatives to excuse you so that the woman can be, the person can be truthful enough to tell you whatever (there is). Because, some people wouldn’t feel comfortable if their husbands or their spouses are around, or their family members, their relatives are around to tell you whatever, especially when they have their top-sending (P8, 28 years).
But if she sees a relative around … I walked up and told the relatives to excuse us for a while so we can get closer to the client and take better care of her, but they got offended even though I did not say it in a bad way (P4, 34 years).
For communication we’re very good at it. After shift handing-over, we introduce ourselves to them so if they’ve problems they complain to us if we need to call a doctor we do if we can handle it, we do the needful (P3, 35 years).
Yeah. So, when we introduce ourselves to the clients, even if not by name, then when you go to perform a procedure for the client, she already knows you are part of the staffs and so she already has confidence in you. Then she goes like ‘Madam, what is your name?’ and you tell her your name and maybe she also says ‘I am also called this’. Ahaaa … .and then you proceed to conduct the care you have to give to her (P4, 34 years).
Challenges
At times (laughs) let me say is their character or some encounter she had before come to work so it annoys her seeing you the patient. The moment you ask question she will scold you not really good but not all of us are like that so we have to advise ourselves (P12, 30 years).
Some midwives call patients by condition they have. Professionally it is not done. A patient has a real name and must be called by that not her condition. We have to put a stop to that it is a condition and won’t stay forever (P9, 51 years).
In some cases, it is the language; there are situations in which the language being spoken by the client is not understood by me. She speaks a different language: she doesn’t speak Twi and neither does she speak English. In a scenario like that, it has to fall on the family member present who speaks the language (of the health worker). So, you speak to the relative, and the relative then translates for the client (P10, 35 years).
Erm...it depends on the level of communication of the relatives maybe language barrier you’ve to explain things to their understanding but at times you’ve to seek the patients consent rather so that she can relay the information to relatives to her satisfaction (P2, 37 years).
Midwives’ recommendation for improving respectful communication
Hmm … for now I think we have to be each other’s keeper. There may be somethings that you will do and it will feel odd. But if we check on each other and become each other’s keeper, then we will be able to help ourselves at the ward. We can talk to ourselves, and also involve the senior midwives so that each student nurses and rotational nurses will be practicing professionalism in communicating to patients when they come here to give birth. All these are taught in school and doesn’t need any workshop or training. If you treat a patient right, they deem it much offer you’ve done them. (P2, 37 years).
No but with respectful maternal care we’ve to be each other’s keeper so patients should take it easy with us in order for us to deliver care to them (P3, 35 years).
We don’t need anything special but it is up to us to have good attitude and know how to deal with patients. We have to educate them on when to ask questions it may seem emergency to them but they’ve to bear with us. Most of the problem is our attitude so no matter what we’ve to portray good attitude towards our patient (P3, 35 years).