Use of Health Professionals for Obstetric Care in Northern Ghana

Volume 36 Number 1 March 2005 45

Samuel Mills is a physician and recent graduate of thedoctoral program in public health and Jane T. Bertrand isProfessor, Johns Hopkins School of Public Health, PostOffice Box 1165, 615 North Wolfe Street, Baltimore, MD21205. Email: [email protected].

Use of Health Professionals forObstetric Care in Northern Ghana

Samuel Mills and Jane T. Bertrand

This study explores the role of access versus traditional beliefs in the decision to seek obstetric carefrom health professionals. Eighteen purposively sampled homogenous groups in Kassena-NankanaDistrict of northern Ghana participated in focus-group discussions about traditional beliefs, barriersto the use of health professionals, and ways to improve obstetric care. All the groups were knowledgeableabout the life-threatening signs and symptoms of complications of pregnancy and labor. Decisionsabout place of delivery generally were made after the onset of labor. Accessibility factors (cost, distance,transport, availability of health facilities, and nurses’ attitudes) were major barriers, whereas traditionalbeliefs were reported as less significant. Informants made pertinent recommendations on how toimprove obstetric services in the district. These findings demonstrate that even in this district, whereAfrican traditional religion is practiced by a third of the population, compared with a national averageof 4 percent, lack of access was perceived as the main barrier to seeking professional obstetric care.(STUDIES IN FAMILY PLANNING 2005; 36[1]: 45–56)

As of 1996, the demographic surveillance estimate of thematernal mortality ratio (MMR) for Kassena-NankanaDistrict of northern Ghana was 637 deaths per 100,000live births (Ngom et al. 1999). The United Nations Gen-eral Assembly recommends increasing the proportion ofbirths assisted by health professionals (doctors, nurse–midwives, and nurses with midwifery skills) to 80 per-cent to reduce the number of maternal deaths in devel-oping countries (UN General Assembly 1999). In sub-Saharan Africa, the proportion of pregnant women whoseek antenatal care is disproportionately higher thanthose whose deliveries are assisted by health profession-als (Stewart et al. 1997). This disproportion varies by geo-graphical area. In Ghana as of 2003, the proportion ofdeliveries supervised by health professionals was 80 per-cent in urban areas compared with only 31 percent in ru-ral areas (GSS et al. 2004). A household survey conductedin Kassena-Nankana District (Mills 2004), carried outconcomitantly with this study, reports that 94 percent ofpregnant women received antenatal care whereas 44 per-cent delivered with a health professional in attendance.

Previous studies have highlighted several factors, in-cluding access (cost, distance, transportation, and avail-

ability of health facilities) and traditional beliefs, to ac-count for the low levels of use of health professionals forobstetric care. In this study, traditional beliefs and prac-tices, which can be categorized as psychosocial accessi-bility (Bertrand et al. 1995), are described separately fromaccess to care. In sub-Saharan Africa, where almost allthe deliveries attended by health professionals take placein health-care facilities (Stewart et al. 1997), a major bar-rier to the use of health professionals is the lack of ad-equate obstetric facilities. Long travel distances to facili-ties and lack of transportation also discourage the useof professional services (Thaddeus and Maine 1994).Available evidence suggests that women who live closerto health-care facilities are more likely to use professionalobstetric services (Rose et al. 2001). Another barrier tosuch use is the low quality of care available, which ischaracterized by long admission-to-treatment time in-tervals and a lack of drugs and supplies at the health-care facilities (Ifenne et al. 1997; Opoku et al. 1997; Sabituet al. 1997). African women recognize the risks associ-ated with home delivery but sometimes have no alter-native if they consider obstetric facilities to be inacces-sible or of poor quality (Obermeyer 2000).

Several studies conducted in Nigeria have reportedthat traditional beliefs and practices are major barriers tothe use of health professionals. One study undertaken inZaria, Nigeria, revealed that the majority of women whodied there during childbirth had ready access to trans-portation and lived within two kilometers of all-weatherroads, but their decision to seek care was delayed when

REPORTS

46 Studies in Family Planning

their husbands were not available to give them permis-sion to seek care (Wall 1998). A study in the Borno stateof Nigeria also revealed that eclampsia was perceived tobe caused by evil spirits and that traditional medicationswere required for treatment (El-Nafaty and Omotara1998). Bleeding in pregnancy was also attributed to su-pernatural powers and could only be stopped by divin-ers (Okolocha et al. 1998). Moreover, Hausa women innorthern Nigeria did not use health professionals be-cause they disliked episiotomies and did not want to ex-pose their genitals to strangers (Wall 1998). These tradi-tional beliefs and practices cannot be generalized to all thediverse ethnic groups in Nigeria, however (Okafor 2000).

The barriers to the use of health professionals forobstetric care mentioned above must be placed in spe-cific local contexts. The reasons for high levels of mater-nal mortality may differ from one region to another(Miller et al. 2003), so that interventions to reduce ma-ternal mortality (Allotey 1999) must be context-specific.In one report, a tertiary obstetric facility was upgradedand more obstetric staff were trained, but use decreasedin part because pregnant women could not afford theservices (Ifenne et al. 1997). Maternity waiting homesthat offer temporary residence to women who live faraway from health-care facilities have been instituted suc-cessfully in some countries (Poovan et al. 1990; Chan-dramohan et al. 1995; Figá-Talamanca 1996), but one es-tablished in Ghana was poorly patronized partly becauseit did not meet the needs of the local populace (Wilsonet al. 1997). In addition to ascertaining what barriers ex-ist to the use of health professionals, researchers mustdetermine which interventions will suit a community’sneeds and gain its support.

A 1993 review of the training of traditional birth at-tendants (TBAs) in Kassena-Nankana District of north-ern Ghana indicated that the populace adhered stronglyto traditional beliefs related to pregnancy and delivery(Allotey 1999). Whether the populace continues to holdthese beliefs is an important consideration, because theproportion of women of reproductive age (15–44) in thisdistrict who practice African traditional religion has de-creased from 69 percent in 1993 to 31 percent in 2002,while the proportion of Christians has increased from 27percent to 62 percent in the same period (Akazili et al.2003). Previous studies of obstetric care in parts of sub-Saharan Africa where African traditional religion pre-dominates have not described changes in traditional prac-tices in favor of professional care during delivery.

This study presents the findings of focus-group dis-cussions that explored the role of access to professionalcare versus traditional beliefs in decisionmaking concern-ing whether to seek professional obstetric care in Kassena-Nankana District and the question of why the majorityof women seek the assistance of health professionals for

antenatal care but not for obstetric care. Informants’ rec-ommendations on how to improve obstetric services inthe district were also solicited. Focus-group research is anappropriate methodology for this subject matter becausegroup interaction elicits an abundance of informationabout beliefs, opinions, and perceptions (Carey 1994).

Methods

The focus-group research reported here was conductedin Kassena-Nankana District in November and Decem-ber 2002. This remote district is one of 110 districts inGhana and shares borders with districts in the threenorthern regions of Ghana. It has guinea savannah veg-etation and two main seasons: rainy (May–October) anddry (November–April). Settlements are scattered; a typi-cal compound houses an extended family and is sur-rounded by a field where crops are cultivated and cattleare kept. The district is 10 percent urban and 90 percentrural with a population of approximately 142,000, includ-ing some 30,000 women of reproductive age (15–44 years)(Debpuur et al. 2002). About 60 percent of these womenare married. More than half of the population (aged sixand older) have no primary education (Nyarko et al.2001). The two main ethnic groups are the Kassenas (54percent) and the Nankanas (42 percent). The remaining4 percent are Builsa and other minority tribes (Nyarkoet al. 2001). The Kassenas occupy the northwestern andcentral parts of the district while the Nankanas live inthe eastern and southern areas. African traditional reli-gion is practiced by about one-third of the population(Akazili et al. 2003), compared with the national aver-age of 4 percent (GSS 2004). More than half of the popu-lation is Christian (Akazili et al. 2003).

Within the district are a hospital, three health cen-ters, and five health posts, but no private obstetric facil-ity. The Navrongo Health Research Centre (NHRC), aninternationally recognized organization in northernGhana that conducts policy-linked research for the Min-istry of Health, is situated in the district. As part of theNavrongo Community Health and Family PlanningProject, the NHRC has stationed community healthnurses in selected communities in the district (Binka etal. 1995). The Institutional Review Boards of the JohnsHopkins School of Public Health and the NHRC grantedapproval for the study.

Recruitment of Informants and Sampling

The inhabitants of the district are grouped in ten para-mount chiefdoms (Mensch et al. 1999). Prior to the study,the investigator (the first author), accompanied by a prin-cipal field supervisor from the NHRC, met with each of


the ten paramount chiefs in the district to discuss thebackground and objectives of the focus-group research.The chiefs, in turn, informed their respective communi-ties about the study. The investigator employed purpo-sive sampling to select 18 homogenous groups (describedin Table 1) from the ten chiefdoms. Community contactpersons were enlisted to recruit informants who were eli-gible for a designated homogenous group. The separategroups’ characteristics varied, but before each session theinvestigator ensured that the composition of each groupwas homogenous. The diversity of the groups allowedthe perspectives of a number of segments of the commu-nity (women, men, traditional birth attendants and heal-ers, and community leaders) to be captured. Moreover,for all but two of the Kasem-speaking groups, a corre-sponding Nankam-speaking group was represented. Theage range of the young Nankam women was changedfrom 15–29 to 15–19 because women older than 20 domi-nated the 15–29-year-old Kasem group discussion. Eachgroup numbered nine to 12 participants, with an aver-age number of ten. Participants were selected from house-holds that were not sampled for a concomitant householdsurvey (Mills 2004). The investigator, a physician, as-sisted in setting up the location for each session but wasnot present during the focus-group discussions so as toreduce the deference effect.

Recruitment of Moderators and Discussion Guide

One male and one female social science researcher fromthe NHRC who have experience in handling focus groupsand who speak the local dialects were recruited andtrained as moderators for the sessions. One male and onefemale assistant moderator were recruited to take notes.

The focus-group guide covered the following top-ics: symptoms and complications of pregnancy; pros andcons of using a traditional birth attendant versus usinga health professional for antenatal care; signs, causes,and treatment of labor complications; cultural beliefs as-sociated with pregnancy and delivery; preparedness fordelivery; pros and cons of using a traditional versus pro-fessional for obstetric care; decisionmaking about placeof delivery during pregnancy and labor; the role of thevuru (soothsayer) in decisionmaking; community sup-port for transportation and referral; and ways to improveobstetric care in the community.

The Focus-group Sessions

Separate sessions were held for each of the 18 homoge-nous groups. The discussions were held in local primaryschools after classes or at other locations in the commu-nity where the discussions could not be overheard. Noneof the discussions was held in a health-care facility soas to reduce the deference effect. In each focus group, themoderator and assistant were of the same sex as the par-ticipants. Each session began with an exchange of greet-ings between the moderator and the informants, followedby a consent procedure. The moderator read aloud a con-sent form in the language spoken by the group’s partici-pants, which stated that participation was entirely vol-untary. The informants signed or thumbprinted the con-sent forms. Parental consent was obtained in cases wherethe informant was younger than 17 and unmarried.

The moderator led the discussion using the guide andencouraging participation. Each session lasted between45 and 90 minutes; most ran for about an hour. The ses-sions were recorded with a digital voice recorder andlater downloaded onto a computer. The assistant tooknotes on the setting, content of the discussion, and non-verbal communication. After the discussion, the mod-erator thanked the participants and presented each witha bar of soap. Immediately after each session, the mod-erator and assistant discussed emerging themes with theinvestigator.

Data Management and Analysis

The audio files were translated and transcribed verba-tim into English at the NHRC using Olympus DSS Protranscription software. The transcriptions were carriedout concurrently with the fieldwork. The investigatorand a moderator reviewed the transcripts for accuracyand completeness.

The investigator created initial topical codes by read-ing through the 18 transcripts for themes. He applied thetopical codes to all the transcripts using ATLAS.ti soft-ware (SCOLARI/Sage Publications 2003). All texts con-

Table 1 Characteristics of groups purposively sampled forfocus-group discussions, by language, Kassena-NankanaDistrict, Ghana, 2002

Group Language

1 Women aged 15–29, delivered in past five years Kasem2 Women aged 15–19, delivered in past five years Nankam3 Women aged 30–44, delivered in past five years Kasem4 Women aged 30–44, delivered in past five years Nankam5 Trained traditional birth attendants (females) Kasem6 Trained traditional birth attendants (female) Nankam7 Untrained traditional birth attendants (female) Kasem8 Untrained traditional birth attendants (female) Nankam9 Traditional healers (male) Kasem

10 Traditional healers (male) Nankam11 Female opinion leaders Kasem12 Female opinion leaders Nankam13 Heads of households (male) Kasem14 Heads of households (male) Nankam15 Male opinion leaders Kasem16 Male opinion leaders Nankam17 Female opinion leaders Kasem18 Heads of households Kasem


taining each selected code in all the transcripts were gen-erated and printed. Comments on the coded text werewritten while the various groups of participants werecompared for unanimity and inconsistencies. Illustrativequotes from the discussions were noted and reported.

At dissemination seminars held in the district inJanuary 2004, the first author discussed the study’s find-ings and policy implications with senior staff at the Min-istry of Health, with NHRC staff, with the paramountchiefs, and with other community leaders.

Results

In general, health professionals performed deliveries inhealth-care facilities and not in the women’s homes. InKassena-Nankana District, nurse–midwives ran antena-tal clinics and referred clients to doctors when necessary.

By and large, all of the focus-group participants wereknowledgeable about the signs and symptoms of com-plications of pregnancy and labor. Complications of la-bor that were discussed include prolonged labor, largefetus, malposition, antepartum hemorrhage, postpartumhemorrhage, anemia, severe vaginal tears, retained pla-centa, umbilical cord wound around the fetus’s neck, ma-ternal exhaustion, and uterine prolapse. Most of the fe-male participants indicated that when such problemsoccurred, they preferred to deliver at the hospital. Thetraditional birth attendants and healers indicated thatwhen they realize they are unable to deal with a com-plication, they refer the woman to a health-care facility.A few participants, including male opinion leaders andheads of households, explained that cesarean section wasthe only option for resolving complications such as ob-structed labor, as illustrated by the following statement:

If the baby grows fat in the womb, [the woman]can labor for long without giving birth. In theolden days, there were herbs that were used, butnow we go to the hospital for an operation ifthe baby can’t come out. (Untrained traditionalbirth attendant, Nankam)

Traditional Beliefs and Practices

Although traditional beliefs and practices associated withpregnancy and labor were discussed at length in the fo-cus groups, the majority of participants indicated thatmost such practices were no longer in use. Some of thetraditions associated with pregnancy were describedthus: Pregnant women (as well as other members of thehousehold) were forbidden in some instances to visit thehospital, so that only the traditional birth attendants wereallowed to assist them during labor; pregnant women

were not allowed to sit on stones or wood, which werebelieved to harbor bad spirits; they were forbidden toeat food rich in protein, including meat, fish, and freshmilk, in order to prevent the fetus from becoming over-weight, thereby prolonging labor; and special herbs boiledin water were used to determine the time of the day thata woman would deliver.

Traditional beliefs and practices associated with la-bor include the following: Women who engaged in ex-tramarital affairs could have prolonged labor; specialherbs were given to women when the umbilical cord be-came wrapped around the neck of the fetus and in in-stances of breech presentation; hot water was pouredon the abdomen and okra smeared on the vagina to ex-pedite delivery; women who retained the placenta weregiven a bottle into which to blow air in order to forcethe placenta out; the placenta was always buried out-side the house to indicate that the household’s ances-tors had accepted the baby; and a calabash of hot waterwas placed on the abdomen of women who experiencedpostpartum hemorrhage to stop the bleeding.

After delivery, women were expected to remain in-doors and to avoid lifting cooking utensils for three daysif the baby was male and for four days if female; other-wise the baby’s navel would become infected. Womenwere given herbal teas to drink to prevent blood clotsin the uterus. Breast milk was tested before being givento the baby by being expressed into a calabash. An antwas placed in the milk and if the ant died, the milk wasconsidered unwholesome.

In general, no differences were found in the tradi-tional beliefs and practices discussed among the Kas-senas and Nankanas. Some of the informants indicatedthat they had not heard of some of the traditions men-tioned for a long time and that most of the practices wereno longer in use:

In the olden days, pregnant women were not al-lowed to go to their fathers’ houses when preg-nant, and if they did, there were problems. Thiswas a local belief and a certain herb was usedfor this situation. But now we have forgotten ourherbs because there are hospitals around. Mostof the herbs can’t even be found today, and wedon’t know the laws of the herbs. The hospitalis good, but most of us can’t afford to go there.(Head of household, Kasem)

Informants were aware of the adverse effects of sometraditional practices. For example, a male Nankam opin-ion leader spontaneously explained that female genitalcutting could partially seal the vaginal opening andcause problems during delivery. Participants in the malegroups, including the traditional healers, emphasizedthe importance of women’s being faithful to their hus-


bands and remarked that extramarital affairs lead to pro-longed labor:

A promiscuous woman would definitely haveproblems if she is giving birth. She would haveto tell everybody present the number of menwho have slept with her apart from her husbandbefore she would be able to give birth. (Maleopinion leader, Kasem)

Female participants countered this claim:

If the soothsayer knows you and doesn’t likeyou, he can lie to the compound head [and say]that you are suffering because you have beensleeping with other men, and that is what thecompound head would [believe]. (Female opin-ion leader, Kasem)

The female opinion leaders, compared with partici-pants of the other groups, were more opposed to harm-ful traditional beliefs, such as not allowing pregnantwomen to eat meat. The trained traditional birth atten-dants explained that some traditional beliefs and prac-tices were a source of punishment to women. Despite theirawareness of obstetric traditions, participants in all of thegroups, including the traditional healers, indicated thatthe hospital was the ultimate source for obstetric care:

I remember when I gave birth, the placentawould not come out. They gave me all the localtreatment and medicine, but it would not comeout. In the end, I was taken to the hospital. Theplacenta came out only after I received an in-jection. (Woman, aged 30–44, delivered in pastfive years, Kasem)

Although the traditional healers pointed out thatthey referred pregnant women to health professionals,they maintained that spiritual healing was necessary indaily life.

Decisionmaking and the Role of the Soothsayer

Focus-group participants reported that decisions aboutthe place to go for delivery are made after the onset oflabor and not during pregnancy.

I think we don’t normally talk about thosethings during pregnancy. [That is decided] onlywhen [the woman] is in labor. The time that ittakes and the suffering that she goes throughhelp us to decide where she should deliver. Somewomen go to the well [to fetch water] and endup giving birth there, so why do we have to de-cide where she should give birth when she is notin labor? (Head of household, Kasem)

Although the decision to deliver with professional as-sistance is made after the onset of labor, during pregnancythe health professional can advise the woman to deliverat the hospital, especially if the woman is experiencing ahigh-risk pregnancy. In such instances, arrangements aremade to go to the hospital as soon as labor begins:

Sometimes during the antenatal clinics, the nursesadvise some women not to attempt to deliver athome. So those women will go to the hospital assoon as they are in labor, without the consent oftheir husbands. (Trained traditional birth atten-dant, Kasem)

During labor, the husband usually makes the deci-sion about where to deliver because a woman in labor isin pain and is considered unable to think clearly enoughto make the decision. Where the husband is not the com-pound head, however, all the groups agreed that thecompound head usually has the final say:

It’s only the compound head who gives you thego-ahead to go to the hospital or asks you not go,depending on what the gods have asked him todo. He has the final say. In some instances, thehead refuses to allow the woman to go to thehospital because the gods do not allow her togo, but later they allow her to go when [her situ-ation] becomes worse. (Woman, aged 30–44, de-livered in past five years, Kasem)

Some household heads make the final decision in con-sultation with a soothsayer. Libations are poured at thesoothsayer’s request to ensure safe delivery of the baby.Soothsayers play important roles in the lives of some in-habitants of the district. A soothsayer can predict com-plications of labor, and when the right rituals are per-formed, the woman is expected to have a safe delivery:

The soothsayer helps in several ways. For in-stance, if you want your wife to have a safe de-livery, you can go and plead with your ancestorsthrough the soothsayer. The soothsayer givesyou sacrifices to perform, and if you do every-thing right, your wife will actually have a safedelivery. (Male, traditional healer, Kasem)

Divergent views were offered concerning the edictsof the soothsayer in different communities. Some do notdepend on the soothsayer to make decisions about la-bor, whereas others do:

It depends on the compound. Those who don’tbelieve in traditional ideas will act fast uponhearing that a pregnant woman is in danger, butthose who believe in them will first have to sendsomebody to the soothsayer, and until that per-


son returns, no decision will be made. (Trainedtraditional birth attendant, Kasem)

Most women do not consult with the soothsayer;they obtain information on the edicts of the soothsayerfrom men. Some female participants did not concur withthe soothsayer’s decisions and indicated that depend-ing on a soothsayer’s advice can be harmful:

I don’t waste time at home if a woman is in la-bor. It is always by coincidence that the sooth-sayers predict things and [those things] happen,but I don’t think the soothsayers are helpful.(Untrained traditional birth attendant, Kasem)

In the olden days, people worked with the sooth-sayers and acted on their advice. (Untrained tra-ditional birth attendant, Kasem)

After much deliberation about the role of the sooth-sayer in one of the male groups, participants explainedthat with respect to illness, the soothsayer was not al-ways right:

It is not that we don’t believe what the sooth-sayer says, but in terms of illness, I will neverkeep a sick person in the house because of whatthe soothsayer says. In terms of illness, the sooth-sayers have no truth. If someone runs short ofblood, for instance, the soothsayer can’t give theperson blood. [That can be done] only in the hos-pital. (Head of household, Nankam)

Sometimes, also, the soothsayers can advise youto come and perform many rituals, and if youactually do everything, you might end up los-ing your baby. (Head of household, Kasem)

I have seen a woman who has died as a resultof [a delay in decisionmaking]. The compoundhead delayed before allowing [the woman’s fam-ily] to take her to the hospital, and by the timehe permitted them to go, there was no car andthe woman died. (Woman, aged 30–44, deliveredin past five years, Kasem)

In such critical situations, the compound headsometimes followed the traditional birth attendant’s ad-vice concerning the best course of action. The cost in-volved in seeking care from health professionals wassometimes the primary reason men did not allow theirwives to deliver at the hospital:

The husbands of some women do not allow themto deliver at the hospital. They prefer that thewomen deliver at home, and that is why someof us bear the pain of labor until we deliver athome and not because we like it. It isn’t forbid-

den for women to deliver at the hospital, but themoney isn’t there. If there is only one goat in thehouse, your husband wouldn’t sell it for you togo to the hospital. (Untrained traditional birthattendant, Kasem)

Some women made their own decision without wait-ing for the household head’s approval, especially thosewomen who could afford to go to the health-care facility:

Yes, it is those who are fools who will wait fortheir husbands to decide for them. But the wiseones will start getting their money ready duringthe pregnancy and go to the hospital during la-bor without telling their husbands. (Trained tra-ditional birth attendant, Kasem)

I don’t even wait for them to tell me what to dobecause I’m carrying the pregnancy and knowwhat it means. Therefore, if there is any prob-lem, I go to the hospital. (Woman, aged 30–44,delivered in past five years, Kasem)

Once you have the money, you go to the hospi-tal when you are due after discussing it withyour husband. (Woman, aged 30–44, deliveredin past five years, Kasem)

Participants in a few of the groups explained thatwomen who have expedited labor sometimes deliverbefore they arrive at the hospital, so those women shoulddeliver at home. In addition, those who have had nor-mal pregnancies do not have to deliver at the hospitalunless complications arise.

Antenatal Care

All the groups indicated that antenatal care obtainedfrom a health professional was necessary for safe deliv-ery. The following comment illustrates the traditionalhealers’ explanations of the necessity for antenatal care:

I don’t think there is any reason for not seekingantenatal care. It was in the olden days that peo-ple had [negative] beliefs [about it], but every-body is enlightened now, and we have seen thebenefits of going for antenatal care and wouldalways encourage our pregnant women to [ob-tain it]. (Male, traditional healer, Kasem)

The main reasons mentioned for seeking antenatalcare were to determine that the pregnancy was normaland that the fetus was well-positioned in the womb.Other reasons for obtaining antenatal care were to learnthe probable date of delivery, for tetanus immunization,for diagnosis and treatment of illnesses associated withthe pregnancy, for nutritional advice and multivitamins,for registration of the pregnancy so that during labor the


nurses would give the woman the necessary attention,and to determine whether a cesarean section would berequired.

Participants also mentioned a few reasons for notseeking antenatal care, including travel distance to thehealth-care facilities and the high cost and unavailabil-ity of transportation. Other reasons mentioned were thatdrugs were not available at the facilities, that the hoursof operation at the clinics were short (a problem for thosewho had to walk to the clinics), that some nurses pre-dicted the wrong date for delivery, and that some fami-lies forbade women to seek care from a hospital. Womenwho did not want others to know they were pregnantusually waited until the pregnancy was more than threemonths advanced before seeking antenatal care.

Trained traditional birth attendants provide routineantenatal care, but untrained attendants and traditionalhealers usually do not. The main reasons participants men-tioned for consulting traditional birth attendants were tonotify them of a pregnancy, for treatment of minor ail-ments, and because their services were cheaper than thoseof professional health-care providers. Informants in all thegroups pointed out that consulting a health professionalwas preferable, but that a traditional birth attendant wouldalso have to be consulted, because the attendant lives inthe community and is called upon, especially at night, toassist at the delivery. The informants considered that thetraditional attendants are less skilled and poorly equippedcompared with the nurses. The traditional birth atten-dants explained that their services complement those ofthe health professionals and that they refer women whoare at high risk of developing delivery complications(such as those with anemia, swollen hands and feet,jaundice, and short stature) to the health professionals.

Birth Preparedness

Participants in all of the focus groups agreed that mak-ing preparations for delivery is essential. Those in theheads-of-household-group (Kasem) explained that in thepast, women were discouraged from making prepara-tions for delivery, but that this practice has changed be-cause “everyone” has been enlightened. At the antena-tal clinics, the nurse–midwives advise pregnant womento gather items such as soap, baby clothes, and clean oldclothes, and to set money aside for the delivery. Arrange-ments for blood transfusion, however, are not made dur-ing pregnancy, but only during labor at the doctor’s re-quest. Plans to garner community support for women’stransportation to the health-care facility during emer-gencies were lacking in all of the communities. The malegroups pointed out that saving money for delivery wasthe most important of the preparations, but lamentedthat some of them could not afford to save.

Pros and Cons of Professional Obstetric Care

The two main reasons mentioned for not seeking pro-fessional obstetric care were the attitudes of the mid-wives at the health-care facilities and poverty. Althoughparticipants in all the groups acknowledged the efficacyof modern obstetric care, the attitudes of the nurse–mid-wives were a source of concern generally. Women ex-plained that the midwives shouted at them for present-ing late, sneered at some of them, especially those whowere poor, embarrassed them by telling them that theywere dirty, slapped them when they delayed in push-ing during the second stage of labor, and left them un-attended. Sometimes, in fact, the women had to deliverwithout assistance. The following comment illustrateshow the informants feel about the nurses:

Some of them [the nurses] are so irresponsible.At times, the baby is even coming out, and youwould call them and they wouldn’t help you.Some of them don’t sit in the ward, they leaveus alone on the bed. We even deliver sometimeswithout them being around. You feel that it wouldhave been better to deliver at home where youcould get care. (Female opinion leader, Nankam)

A few of the informants, however, acknowledgedthat some midwives were sympathetic. These womenalso understood that the hospitals are short-staffed andthe nurses overworked.

The other main reason for not delivering at health-care facilities was cost. Some informants complained thatthe hospital charges are high and that they could notafford items such as soap, baby clothes, clean clothes andrags, and a blade for cutting the umbilical cord, all ofwhich, they explained, were necessary for giving birthat a hospital:

There is no woman who would not like to go tothe hospital when she is in labor, but the prob-lem is that when she delivers at the hospital, herhusband is always called upon to pay some mon-ey. Most of the time, the husband cannot afford[the fee], and that is why most women deliverat home. And when they deliver at home safely,the money that would have been used to pay forthe hospital bills can then be used to buy thingsfor the women to use. (Head of household, Kasem)

Some women were embarrassed to go to the hospi-tal because they did not have nice clothes for themselvesand the newborn. They would rather deliver at homewhere nobody could see that they were poor. The highcosts of transportation also hindered women from de-livering at the health-care facilities. In communities lack-ing clinics or hospitals, emergency transportation is al-


ways a problem. Most of the communities had no ve-hicles, so someone has to bicycle to the nearest town (asfar as 40 kilometers away) to fetch a commercial vehicle.This process takes so long that by the time a vehicle isavailable, it is often too late:

My mother took a woman who lives near myhouse to the hospital after my mother had triedto help her, but the lady could not give birth.They boarded a taxi that charged ¢15,000.00 ($2)to travel from here to the health center. We want-ed the driver to reduce the charge; he refused,and the life of the baby was in danger. When hefinally agreed to reduce the fare, we got to thehospital late, and the baby died. (Male, tradi-tional healer, Kasem)

Transportation to a facility could cost as much as US$12. Vehicles were easier to obtain on market day. Foremergencies, communities usually provided some sort oftransportation. Where no vehicle or motorcycle was avail-able, the woman was pushed on a bicycle or hand truck.

Reasons for not delivering at a health-care facilitythat were mentioned less frequently included the lack ofsupplies at hospitals such as needles and syringes; thefact that some women have acquired infections as a re-sult of delivering at the hospital; and some doctors’ pro-pensity to perform cesarean sections for the slightestcomplication.

All focus-group participants acknowledged that de-livery was best undertaken with the assistance of a healthprofessional. Health professionals were considered ca-pable of dealing with a retained placenta, inducing oraccelerating labor, performing a cesarean section for pro-longed labor, giving a blood transfusion for postpartumbleeding, and detecting a dead fetus. The following re-marks illustrate women’s perceptions of health profes-sionals’ capabilities:

At home, the old ladies force us to push toomuch, even if the baby is not coming, becausethey don’t know the time that you will givebirth. But in the hospital, they know when youwill deliver and only allow you to lie on the bedat that time. (Woman, aged 30–44, delivered inpast five years, Nankam)

Some women bleed a lot after delivery, and thenurses can stop the bleeding only if you go [tothe hospital]. (Woman, aged 30–44, delivered inpast five years, Nankam)

Women who have had complications during previ-ous deliveries were expected to deliver in the hospital:

Any woman who went through a bad experienceduring delivery and was saved at the hospital

will always want to deliver there, even if she isin no imminent danger. (Female opinion leader,Kasem)

As expected (Ronsmans and Campbell 1998; Pauland Rumsey 2002), participants in the younger women’sgroup explained that those giving birth for the first timeshould deliver at the hospital:

If it is your first time giving birth, you’ll wantto deliver at the hospital, even if there is noth-ing wrong with the pregnancy. (Woman, aged15–29, delivered in past five years, Kasem)

When women deliver their first child at the hospitaland all goes well, they tend not to seek assistance fromhealth professionals for subsequent deliveries becausethey feel that their risk of complication is minimal.

Some women preferred to deliver at the hospital be-cause the midwife alone sees their genitals, whereas athome several people are involved and see them:

Only the nurse sees your private part at the hos-pital, but at home the birth attendant and all theold ladies who conduct deliveries in the areawould see it. That is why some prefer to deliverat the hospital. (Female opinion leader, Kasem)

The heads of household (Nankam) reiterated thatmany women see the expectant mother’s genitals whenshe delivers at home.

Reasons for Choosing Traditional Obstetric Care

The majority of women delivered at home with the as-sistance of the traditional birth attendants. Two youngwomen summed up their reasons:

It is only because of the cost that most prefer todeliver at home and pray that the birth attendantsare able to help them deliver safely. (Woman,aged 15–29, delivered in past five years, Kasem)

There are also instances where you labor through-out the night hoping that at daybreak you willbe taken to the hospital. At such a time you arealmost giving birth, and they are the only peopleavailable who can help. (Woman, aged 15–29,delivered in past five years, Kasem)

Participants in the majority of groups pointed outthat traditional birth attendants are the first point of con-tact in the community during labor because they livethere and are always ready to help. They assist in bath-ing the newborn, give advice on breastfeeding and in-fant care, and their services are cheaper than professionalcare. They are particularly helpful in cases of uncom-plicated labor, and they refer women to health-care fa-cilities when complications arise:


It is good for women to deliver with the traditionalattendants because not every woman would liketo deliver at the hospital and not every womanhas delivery complications. Some women normal-ly just need assistance when in labor, and theydon’t have to go to the hospital. The traditionalattendants are there to help this type of woman.(Male opinion leader, Nankam)

Those who delivered with the help of traditional at-tendants, however, expected to be promptly referred toprofessionals in the event of a complication:

A young lady in this community suffered in thehands of a traditional attendant. She was in la-bor for three days and was not taken to the hos-pital. Later, the attendant took her to the hospi-tal when she had become very weak. At the hos-pital she was given fluids intravenously, and sherecovered and delivered safely, so I think everyapproach has its own limitations. (Male opinionleader, Nankam)

The traditional healers and birth attendants indi-cated that their relationships with the nurses were cor-dial and that sometimes the health-center staff assistedthem in arranging transportation for patients referredto the hospital. They explained that if they delayed insending pregnant women to the health-care facility, themidwives became angry. Some midwives allowed theminto the labor ward, and some did not.

Informants’ Recommendations

Participants in all the focus groups, excluding the tradi-tional birth attendants and healers, were specifically askedwhether they would prefer a midwife to assist deliver-ies at the health-care facility or at home. As expected,those who lived in communities close to a facility indi-cated that they preferred to give birth in the hospital,whereas those living far from a health-care facility pre-ferred to give birth at home. The reasons mentioned forpreferring that midwives assist deliveries in the health-care facility were that blood and intravenous fluids canbe administered only at the facility and that midwivescannot carry equipment home. Others preferred that mid-wives assist in the communities because of the distanceto a facility, the high cost of transportation, and the dif-ficulty of obtaining transportation in an emergency. TheNankam male opinion leaders suggested that the fewnurses available should be stationed in central locationswithin the communities rather than assist births in in-dividual homes. The female opinion leaders suggestedthat the nurses posted to the communities should be ex-perienced in assisting deliveries and, therefore, require

little supervision. They explained that some of the com-munity health nurses posted to the communities as partof the Community Health and Family Planning Project(Binka et al. 1995) did not have midwifery skills. Thesenurses, however, facilitate referral of emergency obstet-ric complications to the health-care facility. Informantsfrom communities lacking health centers suggested thathealth-care facilities be built and were prepared to pro-vide labor and building materials.

The informants also suggested that nurses should becounseled to be understanding of the women who seekhelp with delivery because some cannot read and do notunderstand clinic or hospital procedures. Nurses, theyfelt, should not discriminate against the poor or demanda cash deposit in emergency situations.

Some informants suggested that the District HealthManagement Team (DHMT) should upgrade the skillsof traditional birth attendants because of the difficultywomen face in reaching the health-care facilities. The tra-ditional attendants wanted to be consulted before wom-en went to the professional facilities; if they were not,they felt their services were not valued in the commu-nity. They mentioned that they needed more referralcards to give to pregnant women and soap for washingtheir hands. The traditional healers felt that more atten-tion should be paid to herbal medicine and wanted theDHMT to provide items such as raincoats, flashlights,and identification cards.

The focus-group participants suggested that a ve-hicle or ambulance be provided for referrals, that a del-egation of community members be organized to arrangetransportation to health-care facilities for pregnant wom-en, and that the roads be made safe for driving to encour-age the establishment of commercial taxi service routes.

Informants suggested that regular meetings withhealth-care professionals be arranged to discuss healthissues. They also requested that researchers share studyfindings with them. They mentioned that the NavrongoHealth Research Centre staff, unlike the hospital staff,had discussed health issues with them:

The NHRC people [involve the community indiscussions related to health], but we have neverseen someone from the hospital coming to talkto us. (Head of household, Kasem)

NHRC has really enlightened most of us. They talkto our pregnant women often, and this did nothappen in the past. (Head of household, Kasem)

The NHRC together with the DHMT directs an on-going Community Health and Family Planning Project(Debpuur et al. 2002) in the district, but apparently dis-trict residents have been unaware of the DHMT’s in-volvement.


Discussion

The objectives of this study were to examine the role oftraditional beliefs compared with that of lack of accessas barriers to the use of health professionals for obstet-ric care and to determine why the majority of women usehealth professionals for antenatal care but not for obstet-ric care.

Some limitations of the study’s findings should benoted. First, the deference effect is a potential source ofbias in interviews and focus-group discussions. The re-searchers took steps to reduce this effect. None of the dis-cussions was held at a health-care facility, and staff of theNHRC who are not health professionals moderated thediscussions. Informants were thereby able to discuss free-ly any misgivings they had about the obstetric staff andservices provided at the health-care facilities. Neverthe-less, they may have given responses that they felt themoderators wanted to hear (Adongo et al. 1997). Second,probability sampling would have made the sample rep-resentative of the study population. Purposive sampling,however, which is more appropriate for focus-group re-search, ensured that informants who were knowledge-able about obstetric care in both central and remote com-munities in the district were selected for the discussions.The selection of diverse groups of informants enhancedthe internal validity of the findings. Moreover, infor-mants were recruited by community contact persons andnot by the research team, thereby reducing the likelihoodthat informants would be selected who would provideresponses to support the views of the research team.

The focus-group participants did not mention tra-ditional beliefs and practices as barriers to the use of pro-fessional obstetric care, but such beliefs and practicesmight, nevertheless, constitute effective barriers. Althougha 1993 review of the training of traditional birth attendantsindicated that the inhabitants of this district adheredstrongly to traditional beliefs (Allotey 1999), informantsin this study repeatedly explained that some of these be-liefs and practices associated with delivery were observedonly in the past. Participants in all the groups acknowl-edged the importance of preparing for childbirth; in con-trast, the 1993 qualitative study (Allotey 1999) indicatedthat making preparations for delivery was taboo.

Several explanations may be put forth as to why tra-ditional beliefs may no longer function as major barri-ers to the use of health professionals for obstetric carein the district. The trained traditional birth attendantsexplained that their training had demystified some tradi-tional beliefs that hitherto had discouraged women fromusing professional care during delivery. Moreover, somewomen believed that soothsayers had victimized themand, therefore, they did not always accept the edicts of

the soothsayer. The NHRC, which has conducted a num-ber of operations research projects in the district since1989, has also enlightened communities about harmfultraditional practices: For example, it has an ongoingproject to eradicate female genital cutting (Akazili et al.2003). A recent report revealed that the predominant re-ligion in the district has changed from African traditionalreligion in 1993 to Christianity in 2002 (Akazili et al.2003). This change may account for the waning influ-ence of traditional beliefs on the use of professional ob-stetric services. Nevertheless, other studies have shownthat Christians in the district commonly also practiceanimism (Adongo et al. 1997; Mensch et al. 1999).

Previous studies have described Kassena-NankanaDistrict as having a male-dominated society in which maleheads of households make decisions for women (Nazzaret al. 1995; Adongo et al. 1998). Women with relativelyhigh socioeconomic status, however, such as the femaleopinion leaders included in this study, tend to maketheir own decisions about where their children are born.Moreover, in the upper-east region of Ghana (which in-cludes Kassena-Nankana District), 82 percent of womenwho earn an income indicated that they have autonomyconcerning how the money they earn is spent (GSS 2004).

In all of the study’s focus groups, informants wereknowledgeable about the signs and symptoms of obstet-ric complications (this awareness has also been observedby the Prevention of Maternal Mortality Network in WestAfrica [PMMN et al. 1992]), and they accepted moderninterventions such as cesarean section and blood trans-fusion as appropriate. Not all women’s self-reports of ob-stetric complications may be valid, however (Sloan etal. 2001).

Participants in all of the focus groups emphasizedtheir preference for delivery with the help of health pro-fessionals, but said that the major obstacle to obtainingprofessional help is accessibility. Many women could notafford to pay the hospital bills or the high cost of trans-portation to a facility. The long travel distances to health-care facilities and the poor conditions of the roads wereother barriers they cited. Some mentioned that essentialdrugs and supplies were lacking in some facilities, mak-ing the cost of medications the patient’s responsibility.Indeed, the district’s communities are so poor that thenominal fee charged for modern contraceptives has beena barrier to family planning (Adongo et al. 1998). Infor-mants in all of the groups were critical of the condescend-ing and hostile attitude of many obstetric nurses. Thisattitude has been observed elsewhere (Chukudebelu etal. 1997; Oyesola et al. 1997; Senah et al. 1997; Amooti-Kaguna and Nuwaha 2000; ). Research conducted priorto the implementation of the Community Health andFamily Planning Project in the district in 1994 revealed


that all the communities had requested the establishmentof clinics (Health on Wheels 2001).

The present study offers several explantations for whya high proportion of pregnant women sought antenatalbut not obstetric care from health professionals: The ma-jority of the criticisms concerning the hostile attitude ofnurses were more often associated with delivery care thanwith antenatal care. The focus-group discussions revealedthat many pregnant women were concerned about mal-position of the fetus and believed that the health profes-sionals could correct the problem. They misinterpretedabdominal palpation as a corrective procedure for mal-position and, hence, sought professional antenatal care.Women hoped to obtain information about their date ofdelivery, so they sought professional care and were oftendisappointed when the date they were given was inac-curate. Estimating a delivery date is difficult because morethan half of the women in the district have had no for-mal education (Nyarko et al. 2001) and could not be cer-tain of the time of their last menstrual period. Ultrasono-graphy is not used routinely in the district to date preg-nancies; therefore, a nurse estimating a woman’s deliverydate would have to explain that the date is not guaranteed.

Women who were informed at antenatal clinics thattheir pregnancy was normal expected the delivery to benormal as well and, therefore, did not seek a health pro-fessional’s assistance, particularly if access to such helpwas difficult.

The focus-group informants explained that womenwho have had a previous uncomplicated delivery shoulddeliver at home, because they might deliver on the wayto the hospital if it were far away.

Some of the women register for antenatal care as aprecaution so that the nurses will not shout at them ifthey seek help when they are in labor (Amooti-Kagunaand Nuwaha 2000). If they do not develop complications,they do not seek a health professional’s assistance.

Antenatal care has been offered free of charge in thedistrict for several years, whereas obstetric care was pro-vided for free as of only three months prior to the begin-ning of the study. As more women become aware thatno fees are charged for obstetric care, those who werepreviously discouraged from seeking care by high hos-pital costs may choose to deliver with the assistance ofhealth professionals.

Labor cannot be scheduled in advance, but womencan arrange to attend antenatal care on a market daywhen transportation is available.

The barriers related to access that are noted abovemust be addressed in order to encourage women to seekobstetric care provided by health professionals (Ober-meyer 2000). Diverse recommendations were made bythe informants, reflecting the needs of their respectivecommunities, a diversity that underscores the necessity

of implementing various interventions throughout thedistrict that are tailored to particular communities.

The findings of this study demonstrate that even inthis district, where African traditional religion is prac-ticed by a third of the population, compared with a na-tional average of 4 percent, lack of access to professionalobstetric care was perceived as the main barrier to re-ceiving such care. Nevertheless, traditional beliefs andpractices continue to play a role in decisionmaking con-cerning where a woman will give birth.

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Acknowledgments

The Bill and Melinda Gates Institute and the Population Coun-cil provided funding for this study. The authors are gratefulto the Navrongo Health Research Centre staff, particularly toSalomey Dery, Genevieve Avogo, Godwin Apaliya, and Ro-land Apulah, for their assistance with the focus-group discus-sions. The authors also wish to thank the women and men ofKassena-Nankana District for participating in the study.

Use of Health Professionals for Obstetric Care in Northern Ghana

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