Background
Despite efforts to reduce maternal and infant mortality, low and middle income countries continue to report significant mortality rates, with some of the reasons being poor access to or low quality of professional care [
1,
2]. In Africa, traditional birth attendants (TBAs) have historically been the major caregivers for women during childbirth [
3,
4]. Like many low and middle-income countries, pregnant women in Ghana continue to either give birth at home or with TBAs [
5]. A Traditional birth attendant (TBA), according to WHO is “a person who assists a mother during childbirth and who initially acquired her skills by delivering babies herself or through apprenticeship to other traditional birth attendants” [
6].
In Ghana, traditional midwifery has been a part-time work for unskilled persons who mediate pregnancy and birth with some spiritual practices. Many TBAs rely on herbal medicines which are culturally inherited to assist women before, during and after labour [
7]. Meanwhile, research suggests that these TBAs have had very little training and education that might integrate them into the larger health care system and even those with training need the support of skilled back up services [
8,
9].
In 1987, introduction and adoption of safe motherhood programmes in Ghana drew attention to the need for women to patronize professional healthcare services during pregnancy and childbirth [
10,
11]. However, these services are limited and not easily accessible or of low quality. In rural communities, over 30% of pregnant women do not have access to skilled birth attendants. Therefore, some of these women continue to access the services of TBAs. According to the Ghana Maternal Health Survey of 2014, 16% of deliveries were supervised by TBAs [
12]. However, there is a dearth of information on the type of support and remedies they provide to women during pregnancy [
13].
TBA care has been known to cut across pregnancy, labour, postpartum and care of the newborn [
14]. Preference for TBAs has also been attributed to the fact that they provide affordable [
15] and accessible services as well as conduct delivery at home- an environment familiar to the woman [
16,
17]. Understanding and respect for the religious beliefs of clients is also associated with the preference for TBAs [
18]. Furthermore, in a country like Ghana where health services are inadequate, the services of TBAs continue to be in demand [
19,
20]. It is thus, observed that health policies that neglect the impact of TBAs would not be effective because some women still prefer home delivery and TBA services [
5,
17]. Hence, an in-depth understanding of the initiation, traditional and spiritual practices of TBAs is relevant for policy making.
Previous authors report that initiation into TBA practice includes formal training by district health staff and organizations [
21], sacred calling through dreams or visions [
22] and inheriting or apprenticeship from close relatives such as mothers [
3]. The apprenticeship has the duration of two to five years under a family member but one to two years when the trainer of the TBA is not a family member [
23] probably because of commitment and paid training for those who are not family members. The findings also pre-suppose that TBAs learn on the job and hence may not benefit from scientific and standard processes of childbirth. The literature reports that TBAs keep the pregnancy status of a woman secret until signs of pregnancy are obvious in order to protect both mother and baby [
24]. They also assess the vagina for cervical dilatation during labour and some listen to fetal heartbeats by positioning a bamboo on the abdomen [
25]. Some TBAs place women in labour in a pounding mortar and when labour unduly delays, the woman is accused of concealing secrets such as infidelity and that labour will only progress after confession [
25,
26]. Traditional birth attendants also use herbal medicine [
27] to manage prolonged labour and retained placenta [
28] but when overwhelmed by complications they refer to health facilities [
29].
Some TBAs add spiritual practices to their care [
19] with the belief that pregnant women are susceptible to spiritual attacks that can hinder successful outcome [
30]. In view of this, before childbirth TBAs offer prayers [
28] for effortless and safe birth [
31]. Some believe that a jerk of a right arm or eye is an indication of uncomplicated labour but complications are anticipated if the left was involved [
22]. For most cultures, placenta and other birth products are associated with rituals [
32]. For instance, in some cultures people believe that the placenta is buried, burnt or thrown into a river just after childbirth because contact with vaginal blood could cause ill-health or premature death [
33]. However, there is fear that when the placenta is disposed of inappropriately, evil people can use it to harm the baby [
34].
Although, the literature presented some knowledge on the initiation and practices of TBAs from various contexts including Ghana, the authors of this study observed a need for further insight as most of the studies have inadequately explored the topic. It is noted that most authors emphasized the need for the training of TBAs to promote maternal and neonatal wellbeing [
35,
36]. Improved care could reduce maternal and neonatal deaths [
19]. The authors of this study anticipate that understanding the practices of TBAs will inform future training programmes that could enhance maternal care and wellbeing. Hence, this qualitative study was designed to explore the initiation of TBAs and the spiritual practices they employ during pregnancy and childbirth in Ghana.
Methods
Design
The study adopted an exploratory qualitative design to gain in-depth understanding of the initiation and practices of TBAs as well as spiritual influences of their initiation and practice. The qualitative design allows probing and further exploration of emerging findings and was deemed appropriate for the study [
37,
38]. This design was useful because we did not use an existing theory or framework but rather we used probes to follow-up on participants’ responses. This process afforded a deeper understanding of emerging themes.
Setting
The study was conducted in a rural community in the Greater Accra Region (Kasseh) with the participants drawn from an organized group in Kasseh which includes TBAs. The Greater Accra Region is the smallest region in Ghana and is made up of 16 administrative areas. It is bordered on the north by the Eastern Region, on the east by Lake Volta, on the south by the Gulf of Guinea, and on the west by the Central Region. According to institutional data, maternal mortality ratio has worsened in the Greater Accra Region since 1992 as compared to the other administrative regions in the country [
39]. It is thus imperative to understand the basis for the unexpected outcome by examining quality of care provided to women in this region which includes TBAs services.
Kasseh is a major town located between Sege and Sogakope on the Accra-Aflao road. Kasseh has the biggest market in four districts (Ada West, Ada East, South Tongu and North Tongu) in its area. It is connected by road to the district capital, Ada-Foah and a town called Big Ada. Although it is the most easily accessible town in the district, poverty is widespread. Majority of the indigenous people are subsistence farmers using non-mechanized rain fed agriculture and the minority being fishermen and traders. They are also highly religious with the majority of the population being Christians.
This setting was chosen because its communities were mainly emerging developments with limited access to health facilities that provide pregnancy and delivery care. It was also deemed as the appropriate place to get the targeted participants as there is also an organized group of TBAs in the town. The group includes TBAs from rural communities within the district who were believed to have adequate experience in traditional practices during childbirth. It is called “Association of TBAs, Herbalists and Spiritual Healers”. The association was established with 83 members but currently has a membership of 42. That is, 16 males and 26 females. The group at the time of data collection was made up of Christian TBAs. The group was formed as a means of bringing together all TBAs, Herbalists and Spiritual Healers in the community to network and share ideas. Members of the association meet every third Monday of the month to discuss progress, shortfalls and other relevant issues pertaining to their practices.
Sampling and data collection procedure
Using a purposive sampling technique, both males and females were recruited. To be included in the study, TBAs should have practiced for two years. Permission was obtained from the leaders of the associations to enable the researcher book appointments according to the meeting days of the groups. A trained research assistant who could speak the Ada language fluently assisted the first author as a translator during the interviews of participants who only spoke Ada language. The interviewer (first author) does not speak the Ada language fluently. Other interviews were conducted in Twi and Ga. Only one participant spoke English during the interview. The interviews lasted between 30 and 45 min. The interviews started with a general question such as: ‘Please tell me how you became a TBA’ and responses were probed. Follow-up questions such as: ‘Please tell me what you do for pregnant women when they come to you’. In-depth understanding was achieved in this study and concurrent analysis helped in full exploration of emerging themes. Privacy was ensured during interviews and permission was obtained to record the interviews. The interviews were conducted in an enclosed place near the meeting grounds. Participation in the study was also voluntary.
Data management and analysis
Interviews were transcribed in English and an expert in the local language who conducted the interviews checked the transcripts for accuracy. The research team read the transcripts several times to fully understand the perspectives of the participants. Concurrent analysis was undertaken using the techniques of content analysis. Inductive analysis processes were followed to develop themes and sub-themes since no theoretical framework informed the formulation of themes. The researchers independently coded the transcripts, grouped the codes and generated themes and sub-themes [
40]. The themes and sub-themes were discussed among team members to ensure the data were faithfully captured. The data were subsequently managed using the NVivo software version 11. Relevant data were sifted to support themes and sub-themes and the findings were presented with supporting verbatim quotes from participants.
Rigour
Rigour or trustworthiness of the study was achieved using a number of procedures. Emerging themes were further investigated in subsequent interviews (member checking) until saturation was achieved. The researchers undertook prolonged engagement with 16 participants and this ensured that the phenomenon under investigation was fully understood. Also field notes were taken to record non-verbal observations and decision trails during the study. Again, independent coding and checking of transcripts ensured that the data and analysis were credible. Identification codes were used to present verbatim quotes. The ID numbers were assigned chronologically as participants were recruited. For example TBA1M – TBA4M.
Ethical considerations
Ethical clearance for the study was obtained from the Institutional Review Board of the Noguchi Memorial Institute for Medical Research at the University of Ghana. Informed consent was obtained from all participants and the data was anonymized. Participants consented to the use of data for teaching and publication. Participants were also made aware of their right to withdraw from the study at any given time.
Discussion
The finding that TBAs were initiated into their work through apprenticeship from family members or other experienced TBAs, spiritual revelation and dreams or visions corroborated other findings regarding initiation of TBAs or their acquisition of skills [
22,
27,
28]. Given that most of the respondents had no formal education, it is imperative that TBAs are formally trained since such knowledge will enable them to recognise early signs of complications and refer early so that lives can be preserved [
27]. Training programs should also be made simpler in order to facilitate easy understanding. Training of TBAs will also promote the use of standard procedures during pregnancy and labour and prevent infections and other related intrapartum and postnatal problems [
42,
43].
Furthermore, the finding that spiritual directions or revelations guide practices of most TBAs resonated that of Adegoke et al. where the roles of TBAs and their spiritual practices during childbirth were linked [
19]. The belief by some TBAs that voices originated from the “Holy Spirit” through prayers and directed them in their practice and in the use of herbs was attributed to the fact that the respondents were Christians. Such beliefs may not be held by non-christian participants. Revelations of evil acts that cause a baby’s inability to turn in the womb, are rooted in the predominant African belief that occurrences do not only have physical but also spiritual causes. The finding also confirmed the belief that pregnant women are susceptible to spiritual attacks targeting pregnancy destruction and poor delivery outcomes [
27]. Majority of TBAs reported praying, fasting and performing certain rituals to counteract evil spirits or activities intending to cause negative results of pregnancy or delivery [
19]. This finding was reasonable given that most respondents had received no formal training to enable them attend to obstetric emergencies. Also, since some pregnant women in Ghana believe in spiritual influences in pregnancy and childbirth [
44], incorporation of spiritual activities could continue to attract pregnant women for their services. Hence, the need for training of TBAs to do proper assessment of women in labour is necessary so that the life of a woman and her baby is not jeopardized.
Findings on infidelity are consistent with the literature where the phenomenon is linked to prolonged labour, excessive pain during labour, caesarean section or even death [
45]. Women suspected of infidelity were compelled to confess [
27], using anointed oil for safe delivery. This was one of the reasons that women preferred symphysiotomy because they then still had a vaginal delivery [
46]. When practices such as this persist, TBAs could miss the opportunity of timely referral of pregnant women to health facilities. Findings on the use of anointing oil and prayers during delivery are consistent with the literature [
28,
39].
Use of artefacts by TBAs in our study are similar to that of Aziato et al., where Ghanaian women enumerated a number of artefacts used in pregnancy and labour [
39]. Religion and societal norms have some influence on the TBAs’ belief systems as well as their practices [
47] and could possibly explain the concurrent utilization of religious artefacts in the TBAs’ practices with respect to pregnancy and delivery.
The study confirmed that the use of herbs is embedded in the practices of TBAs [
27]. While some boiled trees bark and sap, others prepared herbs to excrete water and trigger foetal activity and others also ground fresh okro to excrete discharges and realign malpresentation and enema to enhance delivery.
During prolonged labour some of the herbs were chewed with salt while others were used to improve the blood level of women [
28]. These herbs when not well treated could serve as a source of infection. Nonetheless, some Ghanaians prefer herbal medicine because of the belief that it is effective and has no side effect [
48]. Pregnant women may patronize TBAs to obtain herbs. However, health professionals do not use herbs routinely for fear that such herbs, for example
Cytisusscoparius, may trigger preterm labour, rupture the uterus, and affect the unborn baby and mother [
49,
50].
Most TBAs reportedly diagnosed pregnancy by feeling for an abdominal lump using their fingers as reported in other studies [
25]. TBAs used their fingers to assess cervical dilatation and the amniotic membranes. Nevertheless, this is a concern because TBAs scarcely use examination gloves during these assessments or delivery raising a high risk of transmission of infections and the introduction of bacteria from the vagina to the fetus (chorioamnionitis). The TBAs could also handle more than one pregnant woman routinely and could therefore transmit infections from client to client [
28]. The need for the provision of resources for TBAs emphasized.
Delayed cord clamping is considered an international best practice for improving maternal and neonatal outcomes [
51]. This shows that although TBAs may not have scientific explanations for some of their practices and try to explain things in metaphysical terms, their practices are not entirely harmful as portrayed by some professional health practitioners. However, problems could result from their failure to recognize danger signs, their inability to implement simple evidence-based interventions for complications, and delayed referral [
46]. It is also emphasized that the cord should be cut with sterile instruments; hence, TBAs should be educated on this to prevent infections. One challenge encountered by TBAs is birthing of the placenta and burial by the family or in their presence according to their customs. Hadwiger & Hadwiger [
52] recorded similar beliefs where the spouse buried the placenta at the dripping spot of roof water so that the baby will grow to be intelligent and courteous. This suggests that TBAs understand and respect the religious beliefs of their clients and adhere to their requests. In relation to this, the assertion can be made that some women would still continue to seek the services of TBAs since they perceive them as people who share in their values and beliefs.
From the study, it is revealed that most TBAs engaged in much trial and error which includes many traditional interventions during delivery. This suggests that services provided by some TBAs in the Kasseh district do not have defined guidelines that determine when they cannot manage a complication and this may lead to late referral with fatal consequences [
52,
53]. This again calls for the need of training TBAs to consider early referral in order to save lives. As compared to other studies where most participants were females [
4,
8,
46], we recruited four males indicating that a general socio-cultural preference for female TBAs in sub-Saharan Africa although this is not speedily but gradually changing.
The study involved only TBAs of African Christian orientation and perhaps TBAs of other religious systems may have different experiences. Future studies should investigate TBAs with other religious backgrounds to corroborate findings of this study.
The limitation of this study relates to the involvement of only TBAs from the Christian faith because other TBAs from other religions may have different practices that were not captured. Therefore our findings may not apply to other religious groups and comparison should be done with caution. Bias was minimized in this study through the use of the same research instrument and verification of transcripts using an expert in Ada language. The authors concede that TBAs from other religions and those who have formal education could have different experiences. Thus, the findings from this study should be generalized with caution.