Social costs of skilled attendance at birth in rural Ghana

International Journal of Gynecology and Obstetrics (2008) 102, 91–94 a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m w w w. e l s e v i e r. c o m / l o c a t e / i j g o SOCIAL ISSUES IN REPRODUCTIVE HEALTH Social costs of skilled attendance at birth in rural Ghana Alessandra Nina Bazzano a,b,⁎, Betty Kirkwood a , Charlotte Tawiah-Agyemang b,c , Seth Owusu-Agyei a,c , Philip Adongo d a Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK Public Health Program, College of Health Sciences, Touro University, California, CA, United States c Kintampo Health Research Centre, Ghana Health Services, Ghana d Navrongo Health Research Centre, Ghana Health Services, Ghana b Received 1 January 2008; received in revised form 4 February 2008; accepted 4 February 2008 KEYWORDS Care seeking; Childbirth; Ghana; Maternal health; Skilled attendance Abstract Objective: To examine the social costs to women of skilled attendance at birth in rural Ghana. Method: Ethnographic data were obtained through participant observation, interviews, case histories, and focus groups and were analyzed alongside data from a birth cohort of 2878 singletons born in the Kintampo study district between July 2003 and June 2004. Results: Most women delivered at home. Home delivery raises a woman's status in her community, while seeking skilled attendance lowers it. Women feel that seeking assistance in childbirth wastes other people's time and they value secrecy in labor. Negative treatment by health providers and expensive supplies needed for delivery also act as barriers. Conclusion: The social costs of obtaining skilled attendance at birth must be offset by community level strategies such as mobilization of older women and husbands, and ensuring health providers extend professional, humane care to laboring women. © 2008 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. 1. Introduction Maternal and newborn mortality remain at unacceptably high levels in low-income countries. Every year, 60 million women give birth at home with no skilled care, and more than 500 000 women die from complications of pregnancy and childbirth [1]. Over 4 million neonatal deaths and the same number of stillbirths occur each year [2]. Improving access to skilled care at delivery, ideally through health centers, has been recognized as a critical need [3,4]. ⁎ Corresponding author. London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. Tel.: +44 20 7958 8105; fax: +44 20 7958 8111. E-mail address: [email protected] (A.N. Bazzano). One approach has been to reduce financial burdens on families who seek skilled attendance by removing user fees. This is now national policy in a number of countries including Ghana where the present study was conducted. There may also be significant nonfinancial costs that prevent women and families from seeking skilled attendance at delivery. In order to understand the social barriers to improving skilled attendance at delivery, the present study investigated women's experiences of pregnancy and childbirth in rural Ghana and the potential of community-based intervention strategies. 2. Materials and methods The study took place in Kintampo District (which has become Kintampo North and South Districts) in Brong Ahafo Region, Ghana, 0020-7292/$ - see front matter © 2008 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2008.02.004 92 A.N. Bazzano et al. Table 1 study Local health care providers interviewed during the Study Site Doctor Nurse Midwife TBA/ Drug CHTA Total TMP sellers Kintampo 2 Apesika Jema Kawampe Total 2 2 1 1 1 1 3 3 2 5 4 5 16 1 2 2 1 6 2 2 8 8 8 8 32 Abbreviations: TBA, traditional birth attendant; TMP, traditional medical practitioner; CHTA, community health technical assistant. in 2004. This predominantly rural area is located in the rainforestsavanna transitional zone, with a population of 165 000. Health facilities consist of 1 district hospital, 7 health centers, and 7 maternity homes. Four sites (2 villages and 2 towns) were chosen specifically to represent variations in community size, ethnic composition, and access to health facilities consistent with those in the region. The study received ethical clearance from the ethics committees of the Ghana Health Services, WHO, and the London School of Hygiene and Tropical Medicine. Informed consent was obtained from all participants. Several methods were used to obtain information on pregnancy, childbirth, and the period 4 weeks post partum: 84 hours of participant observation (including 3 prenatal clinic visits, 1 cesarean delivery operation, 2 postpartum inpatient visits); indepth interviews with 14 older mothers/grandmothers; semistructured interviews with 45 mothers; 28 case histories from women who had recently given birth; expert interviews with 32 local health providers (Table 1); and 13 focus groups with men and women (maximum 9 participants). Mixed parities were included and education levels varied only slightly because most of the women in the study area were illiterate. Data on all 2878 singleton live births in the study district between July 2003 and June 2004 were extracted from a cluster-randomized trial of the impact of weekly vitamin A supplementation on maternal mortality (the “ObaapaVita” trial conducted by the London School of Hygiene and Tropical Medicine and the Kintampo Health Research Centre), while the qualitative portion included women who may have had a child that died. Interviews were tape recorded and transcribed before analysis. 3. Results Pregnancy is kept secret by women for as long as possible and is seen as a dangerous and vulnerable time; it is sometimes equated with a state of illness. Most women questioned in the study reported feeling antisocial during pregnancy, arguments with their husband, “thinking too much,” or feeling depressed. Relocation during pregnancy was also mentioned; for example, staying with relatives for support toward the end of the pregnancy. Fears were described, including illness and death during childbirth. Participants reported that during delivery, women “walk between life and death.” Most women attend prenatal facilities at least once during their pregnancy. Birth cohort analysis found that 85.8% of women had at least 1 prenatal clinic visit, but that only 30% made the recommended 4 visits. There was also confusion over whether these services were free; prenatal clinic visits with a nurse/midwife are free in Ghana, but drugs and vitamins are not. Prenatal visits are often perfunctory and some participants reported that they only attend to obtain a pink-color admittance card in case of an eventual hospital delivery. Two prenatal clinic visits were observed during the present study; the patients were seen for 5 minutes or less and were asked a series of questions relating to their health before undergoing a physical examination. They received no counseling or encouragement toward a hospital delivery. Participants reported that they did not want to take up the nurses' time asking questions. Despite high levels of prenatal care, few women reported an intention to deliver at a health facility. The ability to deliver at home without the attendance of a skilled provider, such as a midwife or doctor, was described as the ideal situation and was believed to represent a normal or “easy” delivery. Culturally, home birth is valued highly. The majority of women in the birth cohort (73.1%) gave birth at home. Participants who were able to deliver by themselves spoke of it as an achievement that would increase their status within their family and community. One respondent stated: “I delivered one of my children alone in the room, so I had that one very easy… but in a situation where you have to take the person to hospital, that is where we say this person's delivering is very difficult.” Women who deliver in hospital or who are “operated on” are seen as unfortunate, while those who deliver at home with minimum assistance and maximum secrecy are seen as lucky or talented, and their status is enhanced. The most commonly stated cause of a facility-based delivery was that the laboring woman had not been honest about the identity of the baby's father. Numerous participants said that misattribution of paternity led to a hospital delivery. One traditional birth attendant reported: “The woman may not give the responsibility for the pregnancy to the right man and may give it to an innocent man, and when the woman is in labor she cannot deliver until she tells the truth. When the woman does not tell the true person responsible for the pregnancy, her delivery becomes very difficult. And I will tell her, ‘you have found yourself in problems, and then you will have to go to the hospital.’” Preference for home birth is also rooted in fears about medical operations. A social concept valued highly among women is the ability to “keep the pain” and not cause disruption or appear to need assistance, medical or otherwise. One woman said: “Each person has her own kind of delivery. Some have easy deliveries. If I started labor I would have a long delivery time, but when you come you will not even know that I have given birth. That is how God made me.” Delivery at home is considered optimum because it saves a family from financial hardship and disruption to subsistence activities. Since childbirth is seen as a time of intense danger, it is viewed as an accomplishment if a woman can deliver without assistance. Conversely, hospital delivery can be stigmatizing. Women who keep early labor secret are able to maintain control over delivery and avoid onlookers, “loose talk” about their ability to deliver, and “gossip.” In addition, it prevents enemies practicing witchcraft. This desire for secrecy is extreme and women endanger themselves in their attempts to hide labor. Local health staff say that this secrecy results in women waiting too long to seek medical attention. Social costs of skilled attendance at birth in rural Ghana The expectation that women should deliver at home and manage the early stages of labor alone is strong. Women repeatedly mentioned not wanting to ask for assistance, even from family members, because they feared “wasting other people's time.” One woman said: “You may not deliver as soon as you start labor so when you call someone, the person will become annoyed saying that you have wasted my time here, but you are not delivering and I have left my work being with you for nothing! So you wait until the baby is almost coming, and can't deliver alone, then you call someone for help.” Many women said that they could be turned away from a hospital, or even an untrained traditional birth attendant, if they arrived too early. Older female relatives and traditional birth attendants along with the woman's husband, decide if and when the laboring woman should seek care. One woman reported: “Before you can get your lorry fees and find a taxi you might have delivered already… At times you will deliver and the baby will not be in good condition and at times you will deliver and the baby will die.” Delivery at home is also preferred due to a lack of confidence in health staff. Numerous participants recounted harsh treatment by nurses; others described being turned away from the hospital after a difficult journey to reach the facility because they were not yet in active labor. Maternity staff at hospitals confirmed turning away women in false labor, and said that the women did not usually return later to deliver. However, providers complained that women delayed seeking care until they were too ill to be helped. In the present study, nursing staff were overheard shouting at women or berating them during 5 prenatal clinic and maternity ward observations. Women who do consider delivering in hospital are discouraged by the expensive and mandatory inventory of supplies (disinfectant, napkins, etc) that are required for delivery—whether gathered in advance or purchased at kiosks near the hospital. The inability to acquire supplies, or fear of loss of status over the items, prevented women from seeking hospital delivery. Many reported that the number of cloth diapers (samboto) a pregnant woman could accumulate indicated her social status and resources. 4. Discussion Several social costs are associated with seeking or obtaining skilled attendance at delivery: loss of status, loss of control over the delivery process, loss of secrecy during delivery, and increased vulnerability to negative outside forces. If a woman's status increases in her family and community by delivering at home without a skilled provider (and greatly increases by delivering alone without anyone knowing about it), it follows that many women fear the social cost of delivery at a health facility with a skilled provider. Skilled delivery could incur financial costs such as fees for supplies and transportation, and opportunity costs such as lost time at the farm; it could also compromise the woman's self-esteem and her relationship with family and neighbors. There could be speculation about the identity of the baby's father, or the woman might feel that she had let her family down. Health providers attending a woman's delivery might be rude to the woman or her family, or demand they purchase expensive supplies, which would be difficult and demeaning. 93 A recent study by Edmond et al. [5] noted a high level of intrapartum stillbirth in Kintampo district (37.5%). Data from the present study revealed 20 317 deliveries and 1319 stillbirths and neonatal deaths, giving rates for stillbirth and neonatal mortality of 31.7 per 1000 and 34.3 per 1000, respectively. Intrapartum stillbirth typically arises from complications associated with the delivery. A systematic review of stillbirth in low-income countries [6] found that the most commonly reported causes were obstructed or prolonged labor and associated asphyxia, infection, and birth injury. Improving skilled attendance in the study districts is a necessity. In a 2004 study of provider behavior, Andersen [7] described in detail the differential types of treatment provided to patients in a rural area of Northern Ghana. Similar treatment of pregnant and newly delivered women was observed in our study area. Health staff routinely blamed patients for their ailments and described low education and social status as the main factors in “non compliance.” In the present study, a primipara who attempted to breastfeed after a cesarean delivery was berated by staff. D'Ambruoso et al. [8] investigated women's accounts of the service they received from facilities during labor and delivery in Ghana, although their study covered only the urban area of Greater Accra. They found that women consciously changed their place of delivery and recommendations if they experienced degrading behavior. Attitudes of staff had considerable influence on utilization of health facilities. In a rural area, where patients are likely to be illiterate and of low social status, the treatment is likely to be worse. In Benin, Grossmann-Kendall et al. [9] found that women felt they were unable to ask questions or get explanations from maternity services, and were mistreated and humiliated by health personnel. A sound policy strategy for improving the quality of skilled attendance, and improving demand for it, must include training of health providers in communication and counseling of pregnant and laboring women. Women from rural areas also fear the unfamiliar environment of a health facility. Unfortunately, the women in most need of skilled attendance at delivery–those in poor health who come from impoverished areas in significant distress– are likely to be the ones whose social status affords them the least respect, and whose lack of familiarity with clinical settings makes them afraid to seek out skilled care for their deliveries. Two studies from other regions in rural Ghana have investigated decision making about care-seeking during childbirth. Both Jansen [10] and Geurts [11] found that decision making about location for childbirth (home vs health facility) was a complicated process that primarily involved the woman's older female relatives and in-laws. Jansen noted that older female relatives used rational judgments to weigh the possibilities of risks, interests, and advantages related to their cultural, spiritual, and social system. Other factors were unfriendly health facility staff and lack of respect for women from rural areas. Since the costs of near-miss maternal events (those in which a woman's life is endangered but she survives) are likely to be even greater than fees for normal delivery at a health facility [12], older female relatives and husbands– often responsible for the family's finances–are likely to 94 continue to encourage women not to seek help even in an emergency. Mobilizing older female relatives and husbands is an important strategy in order to influence those who can physically help a laboring woman get to a health facility and the sociocultural environment in which obtaining skilled attendance can begin to be considered normal. A similar preference for delivery at home has been documented in many other studies [13–15]. Cham et al. [16] found that delivery care was sought, but was mishandled by providers. In a recent study from Tanzania, Mrisho et al. [17] reported similar social factors to the present study that create an environment where delivery at home is preferred, including issues of paternity, obstructed labor, attitudes of hospital staff, and household decision making. In rural Ghana, women continue to prefer to deliver at home owing to their fear of hospitals and operations, lowered status in the household or community, intolerant staff, and financial costs. In order to improve maternal and newborn survival in rural areas where births take place at home, it is essential to involve older women and husbands in interventions, and ensure that health providers extend equal and professional treatment to women who want to deliver in hospital. Acknowledgements Funding for the study was provided by the WHO Department of Child and Adolescent Health and Development and the UK's Department for International Development (DFID). References [1] WHO, UNICEF, UNFPA. Maternal Mortality in 2000: estimates developed by WHO, UNICEF, UNFPA. Geneva: World Health Organization; 2004. [2] Lawn JE, Cousens S, Zupan J, Lancet Neonatal Survival Team. 4 million neonatal deaths: when? where? why? Lancet 2005;365: 891–900. A.N. Bazzano et al. [3] Filippi V, Ronsmans C, Campbell OM, Graham WJ, Mills A, Borghi J, et al. Maternal health in poor countries: the broader context and a call for action. Lancet 2006;368:1535–41. [4] Campbell OM, Graham WJ. Strategies for reducing maternal mortality: getting on with what works. Lancet 2006;368:1284–99. [5] K.M. Edmond, M. Quigley, H. Zando, S. Danso, C. Hurt, S. Owusu-Agyei, et al., Aetiology of stillbirths and neonatal deaths in rural Ghana. Pediatr Perintal Epidemiology, in press. [6] McClure EM, Nalumbamba-Phiri M, Goldenberg RL. Stillbirth in developing countries. Int J Gynecol Obstet 2006;94:82–90. [7] Andersen HM. “Villagers”: differential treatment in a Ghanaian hospital. Soc Sci Med 2004;59:2003–12. [8] D'Ambruoso, Abbey M, Hussein J. Please understand when I cry out in pain: women's accounts of maternity services during labor and delivery in Ghana. BMC Public Health 2005;5:140. [9] Grossmann-Kendall F, Filippi V, De Koninck M, Kanhonou L. Giving birth in maternity hospitals in Benin: testimonies of women. Reprod Health Matters 2001;9:90–8. [10] Jansen I. Decision making in childbirth: the influence of traditional structures in a Ghanaian village. Int Nurs Rev 2006;53:41–6. [11] Guerts KL. Well-Being and Birth in Rural Ghana: Local Realities and Global Mandates. Paper presented at the Fifth Annual Penn African Studies Workshop; October 17 1997. Available at: http://www.africa.upenn.edu/Workshop/geurts.html. [12] Borghi J, Ensor T, Somanathan A, Lissner C, Mills A, Lancet Maternal Survival Series steering group. Mobilising financial resources for maternal health. Lancet 2006;368:1457–65. [13] Hunt L, Glantz NM, Halperin DC. Childbirth care-seeking behavior in Chiapas. Health Care Women Int 2002;23:98–118. [14] Moran AC, Winch PJ, Sultana N, Kalim N, Afzal KM, Koblinsky M, et al. Patterns of maternal care seeking behaviors in rural Bangladesh. Trop Med Int Health 2007;12:823–32. [15] Niang CI. Formative research on peri/neonatal health in Kebemer health district (Senegal): final report. Arlington, Virginia: BASICS II, USAID; 2004. [16] Cham M, Sundby J, Vangen S. Maternal mortality in the rural Gambia, a qualitative study on access to emergency obstetric care. Reprod Health 2005;2:3. [17] Mrisho M, Schellenberg JA, Mushi AK, Obrist B, Mshinda H, Tanner M, et al. Factors affecting home delivery in rural Tanzan. Trop Med Int Health 2007;12: 862–72.