Background
Skilled birth care during childbirth play an important role in reducing maternal morbidity and mortality [
1]. Skilled birth care describes the type of care by which a woman is provided with adequate care during labour, delivery and the immediate postpartum period by a trained health care professional [
1]. Skilled care at birth occurs in a health facility or homebirth setting, assisted by trained professionals, including midwives. Evidence reported that about 15% of pregnant women, particularly in developing countries such as Ghana, develop some form of obstetric complications during pregnancy and childbirth which in some cases, result in maternal death [
2,
3]. The World Health ‘Organisation’s (WHO) report indicated that globally in 2015, an estimated 303,000 women died due to obstetric complications [
4]. While almost of the global maternal deaths occurred in developing countries, about two-thirds of these deaths took place in sub-Saharan Africa [
5]. Though the occurrence of obstetric complications sometimes is often unpredictable [
6], there exist evidence that ensuring skilled birth attendance during childbirth plays an important role in reducing obstetric complications and maternal deaths [
7].
The World Health Organisation (WHO) associates inadequate utilisation of skilled birth care provided by skilled birth attendants such as midwives and doctors in Sub-Saharan Africa as a major hindrance to efforts aimed at improving the health of women, especially during childbirth [
8]. Skilled birth care provided by skilled birth attendants during childbirth is one of the key indicators for reflecting progress towards the achievement of the Sustainable Development Goals [
1].
Despite the importance of birth care provided by skilled birth attendants, women in rural areas of northern Ghana still give birth utilising the services of Traditional Birth Attendants. The World Health Organisation (WHO) defines a traditional birth attendant as “a person who assists the mother during childbirth and initially acquired her skills by delivering babies herself or through apprenticeship to other traditional birth attendants” [
9]. Traditional Birth Attendants (TBAs) continue to play a significant role in assisting childbirth care services, particularly in rural areas of Ghana [
10]. The recent maternal health statistics from Ghana Health Service 2016 report shows that more than 80% of pregnant women had at least one contact with a skilled provider during pregnancy and only 56.2% of deliveries were attended by skilled birth attendants [
11]. This implies that more than 40% of women still give birth at home, utilising the services of Traditional Birth Attendants (TBAs). This inadequate utilisation of birth care provided by skilled birth attendants makes it difficult to achieve the national target of 80% unless strategies are put in place to motivate women to utilise skilled birth attendants.
Previous studies have shown that in Ghana, women, traditionally prefer to deliver at home because it is cheaper, and easier as women who deliver at home receive social support from their extended families and do not have to pay much for the delivery services [
10,
12,
13]. Other studies [
14‐
17] indicate that lack of financial or economic resources, transportation, and delivery of supplies, lack of coordination and referral between Traditional Birth Attendants at the community level and facilities can all inhibit women from using facility-based services. However, most of these studies have been urban-focused, and consequently, rural ‘women’s perspectives have been less discussed or studied. Besides, most of the studies have adopted quantitative approaches which limit a deeper understanding of the factors associated with home births in rural northern Ghana where there is underutilisation of skilled birth care services.
The aim of this study, therefore, is to explore and describe the factors and experiences of a small group of rural women choosing homebirth in rural northern Ghana.
Methods
The aim of this study, therefore, is to explore and describe the factors and experiences of a small group of rural women choosing homebirth in rural northern Ghana.
Research design
A qualitative explorative and descriptive research approaches were used to gain an understanding of the reasons accounting for home birth in rural areas of northern Ghana. This design enabled the researchers to explore and understand rural women’s reasons for utilising unskilled birth services provided by Traditional Birth Attendants in rural northern Ghana [
18].
Study setting
The research was carried out in a small District in the Upper East Region of Ghana. The District is one of most rural and deprived districts in Ghana which has all the characteristics of a typical rural area in Ghana [
18]. The District has 94 % (94%) of its population residing in rural areas. Also, the District was chosen because it recorded low utilisation of skilled birth care provided by skilled birth attendants at the time of data collection.
The District has one district hospital in the district capital with four reproductive health clinics, and seven completed Community Health-based Planning Services (CHPS) compounds, sixty-two outreach points, ten feeding centres and one rehabilitation centre. Records from the District Health Directorate, showed there was only one medical doctor and sixty-five nurses in the entire district [
19]. Midwives mostly provide primary maternity care for women during pregnancy and childbirth. It is imperative to mention that women in the district are exposed to a variety of alternative childbirth sources. Among these include TBAs, traditional healers and herbalists, spiritual healers and diviners.
Research population
The purpose of this study was to understand why women give birth at home by utilising birth services provided by Traditional Birth Attendants in rural northern Ghana. The research population in this study comprised of women who gave birth using birth care provided by Traditional Birth Attendants in the rural areas in the Bongo District of Ghana.
Inclusion criteria
To qualify to participate in this study, a participant should be a:
-
Mothers who gave birth to live babies at home assisted by traditional birth attendants or family relatives within the past six ‘months’ period.
-
Mothers who were above eighteen years at the time of data collection
Exclusion criteria
This study did not consider participants who fell within the under listed criteria:
-
Mothers who gave birth to live babies in health facilities assisted by skilled attendants within the past six ‘months’ period and whose babies at the time of the study were still alive and well.
-
Mothers who were below eighteen years at the time of data collection
-
Mothers who were sick or whose children were sick at the time of data collection
Sampling strategy and sample size
A purposive sampling technique was used to select ten (10) participants for individual semi-structured interviews. The sample size of 10 women was based on data saturation [
20]. In qualitative inquiry, the sample size is determined based on informational needs. The guiding principle, therefore, is data saturation, that is sampling to the point at which no new information is obtained, and redundancy is achieved [
20]. Ten interviews were conducted, and saturation of the data occurred at the 10th participant. The researcher selected participants based on who could give the most and the best information about the objectives of the study. Bongo District is sub-divided into six sub-districts or zones according to the Bongo District Health Directorate. Two Zones were used for the study. The two sub-districts were purposefully selected for the study because of the rural nature of these communities. The researchers contacted nurses and Community Key Informants (CKIs) who provided them with a list of potential participants (women) who delivered at home within six months and also utilised birth care provided by Traditional Birth Attendants in each of the selected zones. Also, only women who were willing to participate in the study and also met the inclusion criteria were recruited for the study. The purpose of the study was then explained to them in order to help them to appreciate what was required of them.
Data collection
Data were collected through semi-structured interviews using a flexible interview guide to explore to the reasons why women prefer to deliver at home in rural areas of northern Ghana. Thus, participants had the opportunity to tell their story with minimal interruption. The interviews took place in safe, quiet, comfortable, private and mutually agreed-upon locations. The individual interviews were initially planned to take place at the health facilities in the district, but after interviews with two of the participants, it was realised that the participants were distracted by clients accessing maternal health care services in the facilities of the participants. Some of the participants suggested their home as the most preferred venues for the individuals because those venues were free from interruptions. All the participants who agreed to take part in the research were asked to sign an informed consent after reading and receiving information about what was involved in the study. The consent form was read in the Grune, a language spoken in the study area to participants who could not read or write. Such participants were made to thumbprint the consent forms. Interviews were conducted in a Grune language, preferred by participants. The interviews lasted between 45 and 60 min and were recorded. The same questions were posed to all participants (
See Supplementary file 1). The audio-taped interviews were transcribed within 24 h of the interview. A language expert translated the interviews into the English language to enable the researchers of the study to understand the content of the interviews.
Data analysis
Data analysis occurred concurrently with data collection. Our goals were to condense raw data and provide a detailed and thick description of the phenomenon of interest. Data collected through the semi-structured interviews were transcribed verbatim and analysed according.
to the six-step guide proposed by Braun & Clark e[
20]. The first step was reading the transcripts to become familiar with the data. The transcripts were read many times while taking down notes and were reviewed independently by two researchers with rich experience in qualitative research for accuracy and to ensure objectivity. The next step was that the data were coded using the NVivo version 12 software and initial codes were generated from the coded data. The coding was done according to the themes of the research questions of this study. After generating many codes, we searched for themes and sub-themes which relevant to the research questions. Codes were put together into themes. Initially, we identified six themes. The identified themes were later merged into four main themes after the reviewed of themes by two of the researchers.
Discussion
This study sought to explore and describe why women in rural northern Ghana give birth at home without utilising the skilled birth attendants available in health facilities. The findings of this study brought to light an understanding that accounted for women giving birth at home in rural areas in Ghana. The results of this current study showed that one of the reasons why participants preferred to give birth at home despite the importance of skilled birth attendance was poor quality of care and attitude of skilled birth attendants. It was reported in this study that poor quality of care and attitude of skilled birth attendants such as using harsh words on women during childbirth, subjecting labouring women to physical abuse, verbal abuse, neglect, discrimination, and denial of traditional practices during labour and delivery were exhibited by midwives. Participants indicated that because they had ever experienced poor conduct of skilled birth attendants during childbirth, and neglected by nurses and midwives in their previous child birth, they were deterred them from going to give birth in such facilities again. A ‘woman’s perceptions of the attitude of health care providers due to her previous experience of care can affect her future decision to seek care, especially during childbirth. In common with the current study findings, a recent study conducted in rural northern Ghana, revealed that women reported that midwives and nurses shouted at women, insulted them, and spoke harshly to them [
21]. Similarly, a study in Tanzania reported that women described the fear of arriving at a facility and being ignored or being verbally abused by skilled birth providers as the major reason that accounted for women giving birth at home utilising the birth care provided by TBAs in Tanzania [
22]. It is important to note that poor conduct of skilled birth attendants occur in Ghana and other developing countries, deterring women from going to give birth in a health facility [
23].
Moreover, the finding of this study showed that, one of the reasons that accounted for home births was women’s perception that traditional birth attendants gave better care than the birth care provided by skilled birth attendants at the healthcare facilities in rural areas. Participants expressed that care provided by TBAs were adequate and TBAs approach to childbirth fulfils the expectations of the labouring mothers and their immediate families in a way that the modern health system does not. Participants in this current study semphasised the close bond they felt with TBAs, due to their status in the community and their trustworthiness. Previous studies have consistently reported women perception of quality of care provided by TBAs as a major setback to achieving the goal of reducing maternal mortality in rural communities in developing countries such as Ghana [
24‐
28]. For instance, a recent study conducted in Ghana reported that women continued to give birth at home because of the perception that TBAs give better care as compared to the poor quality of care at health facilities in the rural areas [
29]. These findings highlight the importance of collaborative maternity care between skilled birth attendants and TBAs in order to meet the needs of labouring women and as well reduce maternal mortality in rural areas.
Furthermore, financial constraint was largely cited by majority of the participants in this current study as a major reason that motivated them to opt for home births. The participants explained that although they knew about the importance of delivering at a health facility, and probably would have wished to deliver in a health facility, however, financial barriers (such as money to pay for transportation and other indirect costs involved in seeking skilled birth care) involved in seeking care in the established health facilities, they were unable to utilise skilled birth care during childbirth. Although, maternity care is free in Ghana for all women following the introduction of the Free Maternal Policy by the government of Ghana in 2008, women during childbirth still incur indirect costs that are not taken care of by the policy. The purpose of the policy was to eliminate financial barriers that could hinder uptake of maternal health services by women especially the poor, thus increasing skilled attendance at delivery. However, because of the indirect cost (expenses incurred not on treatment) incurred by women such as paying for transportation to get to the facility which is not covered under the free maternal care policy, and these costs could prove to be expensive and might have deterred some women from utilising facility-based delivery services. A study in Ghana states that in the rural communities where much of the population is extremely poor and where most families rely on subsistence agriculture for survival, despite the free maternal policy, financial challenges such as paying for transportation to health facility still impede facility-based deliveries [
15]. Another study states that even in settings where direct delivery costs were subsidised, families were expected to pay for transportation to the facility and still buy drugs, medical supplies (i.e. gloves, needles, gauze), blood for transfusions, laboratory services, food during the hospital stay, bribes to health service providers, and laundry services which are usually expensive for the poor woman in the deprived community [
30]. Sometimes, the above-mentioned additional costs often came as a surprise to women after they attended the facility, which may impact their future choice of delivery location.
Also, the lack of access to maternal healthcare facilities by labouring women was reported in this current study as a major reason associated with home birth. The availability and accessibility of health facilities play an important role in the utilisation of skilled birth care in developing countries like Ghana. According to the participants of this study, issues such as long distance to health facilities, lack of transportation, inadequate skilled birth attendants in health facilities were some of the factors that contributed to their of lack access to healthcare facilities during childbirth. Bongo district is one of the deprived districts in Ghana with extremely poor infrastructure, inadequate health facilities with the required qualified midwives and nurses and it is compounded with deplorable roads. The district has only one hospital and five health centres and clinics with few qualified midwives that provide skilled birth care. The ‘researchers’ observation confirmed that some women in some communities in the district travel long distance to access skilled birth care. Poor roads, rivers and valley in some of the communities meant that during the rainy season or in case of obstetric emergencies, pregnant women could only reach health facilities if they were carried by men, which could be risky and cause delay in seeking care. In consistent with the finding of this study, lack of access to essential maternal healthcare services has been identified as the main underlying causes of maternal deaths in Sub-Saharan Africa and other developing countries [
31]. It was reported in a previous study conducted in rural northern Ghana that sometimes women in labour would attempt to risk their lives by going through the rains to a health centre to give birth only to realise that the rivers were full to the brim making it impossible for them to cross over [
27]. The researchers in this current study observed that almost all the roads in the study communities were not tarred and they were not suitable for transport especially during the rainy season. Most villages are connected to the health facilities only by footpaths. The flat terrain coupled with rivers, poor drainage of water predisposes the land to perennial floods which last several months.
Conclusion
The findings of this study brought has to light the barriers to the utilisation of birth care services provided by skilled birth attendants in rural northern Ghana. The study also revealed that women in rural and deprived areas like the Bongo district of Ghana lack access to skilled birth care due to unavailability of healthcare facilities, absence of skilled birth attendants during night and weekends as well as geographical barriers such as bad road networks, long distances to health facilities and lack of means of transport. Management of healthcare facilities in rural communities should facilitate the implementation of a supportive supervision in the maternity units to improve the quality of care and attitude delivered by skilled birth attendants in maternity care in rural communities.
Implication for nursing and midwifery practice
-
Management of healthcare facilities should facilitate the implementation of a supportive supervision in the maternity units to improve the quality of care and attitude delivered by skilled birth attendants in maternity care in rural communities.
-
Management of healthcare facilities should facilitate the implementation of capacity training programmes for skilled birth attendants to improve their skills and competency
-
Management of healthcare facilities should facilitate the implementation of health education programmes for pregnant women to create ‘women’s awareness about the importance of skilled birth attendance and birth preparedness.
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