Introduction
Research context
Material and methods
Research setting
Research design
Study population
Sampling and recruitment procedures
Research instruments
Interview topics | |
• Perceived benefits of using uterotonic substances • Perceived risk of using the uterotonic substance • Indications for use and dosage • Knowledge and experience with local herbal uterotonic/uterotonic substance • Traditional birth attendant motivation for maternal care and uterotonic use. |
Data collection
Data processing and management
Data analysis
Quality control
Results
Perceived rationale for herbal uterotonic intake
“If they even come here (health facility) they will still go and do their black magic to see whether the baby inside is actually a human being. Whether the outcome will be positive. Those are some of the things – that’s why they still patronise their services. The women believe the TBAs are spiritually strong, not that she only palpates but she’s also like a soothsayer. She also foretells the future occurrence. That is their confirmation point. They believe that she has ‘four eyes’, and she sees double. That’s why they go there. If they even go and do scanning and the scan says the baby is in breech position, they will go there, that she’s capable of repositioning the baby to cephalic. They will go there for the palpation so that she can turn the baby into cephalic and they will come and deliver per vagina instead of caesarean section” [Midwife, 42 years].
“We have herbal uterotonics administered to expectant mothers to ensure safe pregnancy and smooth childbirth. The product is more potent for labour than what is given at the clinic now. The herbal uterotonic is a multipurpose herb. It has the potency to stop threats of miscarriage and other complications. Also, labour progresses very fast when the “hot” herbal uterotonic is taken orally. We, however, wished the government could endorse it for expectant mothers to administer it freely” [TBA, 62 years].
In the case of the health centres in Ghana, other health professionals noted that medical suppliers were often reluctant to restock essential medicines in health facilities due to delayed reimbursements for claims for services by the National Health Insurance Authority (NHIA).“Yes, especially, uterotonic [allopathic], which is very important to give to the woman immediately or within the first few minutes of birth, but health insurance has made it impossible for CHPS facilities to provide uterotonic [allopathic] post-birth, even though these medicines also prevent PPH. It can even contract the uterus and help expel the retained products – the placenta and other matter” [Midwife, 29 years].
Another healthcare professional highlighted the significant problems in safely managing birth if medicines were required:“If you do not pay at least part of your debt, they [suppliers] will not give you the drugs [medicine]. Besides, sometimes, when we go to the Diocesan Pharmacy and do not find uterotonic drugs, it is all because of our indebtedness to them. Meanwhile, we need these essential medicines to treat maternal cases” [Midwife, 32 years].
“If we manage to give the drugs during labour, the health insurance will not pay. As health centres, we are required to refer them. With what we are having here, I think at our level it’s okay. We have magnesium sulphate, that one we can use… If the blood pressure (BP) is going higher, we can use Nifedipine, but the Dexamethasone we must refer to Nadowli and other infections associated with childbirth, we cannot give medicines. The truth is that we must refer to the hospital” [Midwife, 36 years].
Both posed challenges for pregnant women to obtain relevant medicines from those facilities when they seek care. Herbal uterotonic was an obvious choice for pregnant women because of the lower price compared to prescribed modern interventions and medication from a health facility.“The NHIS has removed some essential medicines, such as antibiotics. They have been taken out of the approved drug list because CHPS compounds are small facilities. If we prescribe it, they (NHIA) will not pay. Therefore, we sell it to them (mothers/families), which they always complain they do not have money to pay for medicines” [Healthcare provider, 35years].
“Pregnant women’ resort to traditional medicines because of the cost of fuelling someone’s motorbike to send them [pregnant women] to hospital, health screening, and ANC classes. Also, anytime they sought care, drugs, basic essential items, and medicines such as ringers’ lactate, and other infusions were prescribed for them to buy. Even with the active NHIS subscription, only the older mothers usually benefited. Still, all medicines are prescribed for them to purchase from ‘over the counter licensed medicine sellers’ or pharmacy shops” [Healthcare provider, 48 years].
“When the baby is in breech presentation, and then I grind the “charcoal-like” herbal uterotonic and mix it with a drink for her to drink, it corrects [repositions the baby to cephalic] it. Some of the problems in the womb are usually the cause of complications. Therefore, it will improve her health condition when a pregnant woman administers it according to my [TBA’s] prescribed dosage. Also, I often ask mothers [clients] to come back for review and as well purchase the herbal shrub for body wash and oral consumption. Once she bathes and drinks that mixture/concoction, there will be no further complications” [TBA, 41 years].
“When mothers are in their ninth month, they expect labour, especially when they know about their Expected Date of Birth (EDB). However, once the EDB elapses, they don’t come to the facility; instead, they go to the TBAs for “hot” herbal uterotonic. It is taken orally and smeared on the abdomen to speed up labour, thus inducing labour early” (Healthcare Provider, 45 years).
“We have had cases of homebirths among pregnant women. It is common among women whose labour do not keep long (precipitate labour). Also, when the “hot” herbal uterotonic is administered so early, she will give birth at home or on the roadside” [TBA, 63 years].
“They want to deliver in the house so that they (family/community) will know, yeah, she is a woman, and for that matter, a strong woman. That, all her deliveries took place in the house” [Healthcare provider, 48years].
“For some mothers, it is not the cost; they intentionally do it. They will tell us the abdomen did not pain for long. That the moment they felt pains, the baby was coming, so they could not get to the facility. Others say that their great-grandparents practised home deliveries, and they always have it successfully” [Healthcare provider, 59years].
“However, the cost I am talking about is the small items the midwives ask them to buy, such as items required during labour - rubbers, mackintosh mattress, Dettol, et cetera”. [Healthcare provider, 58 years].
“The cost at the hospital when they seek care, and the cost of the transportation were deterrent factors. How to get transport to come to the facility is a problem. For those residing in very remote communities, mothers struggle from Kojokpere or Fian to get to Daffiama. From these communities, getting a lorry to Nadowli hospital is a problem; unless it is a market day or if her husband has a motorbike, it is always a problem. So, transportation cost is one reason for using alternative sources of care. TBAs live in the same or nearby communities of pregnant women, so they are just walk-in for their services or call on them; they need their care” [Healthcare provider, 35 years].
Potential adverse impacts of herbal uterotonic intake
Perspectives of healthcare providers
“It gives us, one a prolonged labour. It is an issue, and sometimes mothers also report to the facility with antepartum haemorrhage. Why? Because of the premature contractions after administering the herbal uterotonic. At the time that the natural contractions are supposed to set in on their own [self-induced]. They will be in the contractions, and their contractions cease when they enter the facility. I will add that this has even contributed to more of our caesarean sections (CS), when local herbs from TBAs are given to them [expectant mothers]. Some mothers have reported bleeding cases, some preterm labour, infections, and other obstetric problems; some even lost their babies through the local herbs because it has no dosage. The TBAs just fetch for them to go and take” [Healthcare provider, 39 years].
“In such an instance, the expectant mother gets irregular contractions, severe ones, and when they do not get to the facility in time for immediate care, the foetus’ breath will reduce. So, the child can get asphyxia. In case it is a home birth, the baby may die” [Healthcare provider, 45 years].
“The herbal uterotonic may also contribute to preterm births, leading to stillbirth” [Healthcare provider, 26 years].
“Therefore, the midwives educate pregnant women to understand that herbal uterotonic brings about vigorous or frequent contractions with poor cervical dilation, resulting in Caesarean birth or loss of both the mother and baby. They are educated more on these harmful practices and beliefs on childbirth” [Healthcare provider, 36years].
Perspectives of traditional birth attendants
Even though pregnant women were warned during ANC against the use of herbal uterotonic and home birth, there was a reported case of maternal death of a TBA’s client who insisted on having a home birth using an herbal uterotonic:“The uterotonic for labour is usually very ‘hot’ in terms of efficacy. They are typically taken when labour starts. The powdered ‘charcoal-like’ one is mixed with a drink for prenatal care medication. Still, a little drop of salt pitter [Potassium nitrate] is added to reduce the herbal uterotonic’s side effects on the woman and the baby. Wicked women do come seeking the “hot” herbal uterotonic so that they could abort their babies illegally, but I have never given any of such women the medicines” [TBA, 70years].
Some TBAs understood that when the “hot” herbal uterotonic is administered too early during the onset of labour, the mother may not be able to reach the healthcare setting before birth. While the herbs have the potency to induce labour, their [herbal uterotonic] intake could also lead to roadside births (born-before-arrival at health facility) and their associated risks.“They [Ghana Health Service] warned me against providing herbal uterotonic to expectant mothers. Their chief complaint was that it was reported some women who administered herbal uterotonic had poor pregnancy outcomes or outright death of the mother. The death occurred when the said mother, who had had a previous CS birth, declined to medical counsel, and administered the hot herbal uterotonic to deliver at home. So, there was a rupture of the uterus, and she failed the attempted home birth. When the family rushed her to the hospital, they found that she suffered profuse uterine bleeding. She died in the process, together with the baby” [TBA, 65years].
“However, the ‘hot’ herbal uterotonic is administered when labour commences, to facilitate the progress of the labour… also, when the ‘hot’ herbal uterotonic is administered so early, the pregnant woman will give birth at home or on the roadside” [TBA, 49years].