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Okonofua F, Ntoimo LF, Ekezue B, Ohenhen V, Agholor K, Imongan W, Ogu R, Galadanci H. Outcome of interventions to improve the quality of intrapartum care in Nigeria's referral hospitals: a quasi-experimental research design. BMC Pregnancy Childbirth 2023; 23:614. [PMID: 37633892 PMCID: PMC10464082 DOI: 10.1186/s12884-023-05893-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 08/02/2023] [Indexed: 08/28/2023] Open
Abstract
BACKGROUND Evidence indicates that Nigeria's high maternal mortality rate is attributable primarily to events that occur during the intrapartum period. This study determines the effectiveness of multifaceted interventions in improving the quality of intrapartum care in Nigeria's referral hospitals. METHODS Data collected through an exit interview with 752 women who received intrapartum care in intervention and control hospitals were analyzed. The interventions were designed to improve the quality indicators in the WHO recommendations for positive childbirth and assessed using 12 quality indicators. Univariate, bivariate, Poisson, and logistic regression analyses were used to compare twelve quality indicators at intervention and control hospitals. RESULTS The interventions showed a 6% increase in composite score of quality of care indicators at intervention compared with control hospitals. Five signal functions of intrapartum care assessed were significantly (< 0.001) better at intervention hospitals. Quality scores for segments of intervention periods compared to baseline were higher at intervention than in control hospitals. CONCLUSIONS We conclude that multiple interventions that address various components of the quality of intrapartum care in Nigeria's referral hospitals have demonstrated effectiveness. The interventions improved five of ten quality indicators. We believe that this approach to developing interventions based on formative research is important, but a process of integrating the implementation activities with the normal maternal health delivery processes in the hospitals will enhance the effectiveness of this approach. TRIAL REGISTRATION The study was registered at the Nigeria Clinical Trials Registry. Trial Registration Number NCTR No: 91,540,209 (14/04/2016) http://www.nctr.nhrec.net/ and retrospectively with the ISRCTN. Trial Registration Number 64 ISRCTN17985403 (14/08/2020) https://doi.org/10.1186/ISRCTN17985403 .
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Affiliation(s)
- Friday Okonofua
- Centre Leader, Centre of Excellence in Reproductive Health Innovation, University of Benin, Benin City, Nigeria.
- Department of Obstetrics and Gynaecology, University of Benin, University of Benin Teaching Hospital, Benin City, Nigeria.
- Women's Health and Action Research Centre (WHARC), Benin City, Nigeria.
| | - Lorretta Favour Ntoimo
- Women's Health and Action Research Centre (WHARC), Benin City, Nigeria
- Department of Demography and Social Statistics, Federal University Oye-Ekiti, Ekiti, Nigeria
| | - Bola Ekezue
- Fayetteville State University, Fayetteville, USA
| | - Victor Ohenhen
- Department of Obstetrics and Gynaecology, Central Hospital Benin City, Benin City, Nigeria
| | - Kingsley Agholor
- Department of Obstetrics and Gynaecology/Anti-Retroviral Therapy Centre, Central Hospital, Warri, Delta State, Nigeria
| | - Wilson Imongan
- Women's Health and Action Research Centre (WHARC), Benin City, Nigeria
| | - Rosemary Ogu
- Department of Obstetrics and Gynaecology, University of Port Harcourt, Choba, Rivers State, Nigeria
| | - Hadiza Galadanci
- Department of Obstetrics and Gynaecology, Bayero University, Kano, Nigeria
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Clarke-Deelder E, Opondo K, Oguttu M, Burke T, Cohen JL, McConnell M. Immediate postpartum care in low- and middle-income countries: A gap in healthcare quality research and practice. Am J Obstet Gynecol MFM 2023; 5:100764. [PMID: 36216312 DOI: 10.1016/j.ajogmf.2022.100764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 09/16/2022] [Accepted: 10/03/2022] [Indexed: 11/09/2022]
Abstract
The immediate postpartum period carries significant risks for complications such as postpartum hemorrhage and sepsis. Postpartum monitoring, including taking vital signs and monitoring blood loss, is important for the early identification and management of complications, but many women in low- and middle-income countries receive minimal attention in the period following childbirth to facility discharge. The World Health Organization recently released new guidelines on postnatal care, which include recommendations for immediate postpartum monitoring. In light of the new guidelines, this presented an opportune moment to address the gaps in postpartum monitoring in low- and middle-income countries. In this commentary, we bring attention to the importance of immediate postpartum monitoring. We identified opportunities for strengthening this often overlooked aspect of maternity care through improvements in quality measurement and data availability, research into barriers against high-quality care, and innovations in service delivery design.
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Affiliation(s)
- Emma Clarke-Deelder
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA (Drs Clarke-Deelder, Burke, Cohen, and McConnell); Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland (Dr Clarke-Deelder).
| | - Kennedy Opondo
- Kisumu Medical and Education Trust, Kisumu, Kenya (Mr Opondo and Dr Oguttu); Vayu Global Health Foundation, Boston, MA (Mr Opondo and Dr Burke)
| | - Monica Oguttu
- Kisumu Medical and Education Trust, Kisumu, Kenya (Mr Opondo and Dr Oguttu)
| | - Thomas Burke
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA (Drs Clarke-Deelder, Burke, Cohen, and McConnell); Vayu Global Health Foundation, Boston, MA (Mr Opondo and Dr Burke); Global Health Innovation Laboratory, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (Dr Burke); Harvard Medical School, Boston, MA (Dr Burke)
| | - Jessica L Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA (Drs Clarke-Deelder, Burke, Cohen, and McConnell)
| | - Margaret McConnell
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA (Drs Clarke-Deelder, Burke, Cohen, and McConnell)
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Sacks E, Finlayson K, Brizuela V, Crossland N, Ziegler D, Sauvé C, Langlois ÉV, Javadi D, Downe S, Bonet M. Factors that influence uptake of routine postnatal care: Findings on women's perspectives from a qualitative evidence synthesis. PLoS One 2022; 17:e0270264. [PMID: 35960752 PMCID: PMC9374256 DOI: 10.1371/journal.pone.0270264] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 06/07/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Effective postnatal care is important for optimal care of women and newborns-to promote health and wellbeing, identify and treat clinical and psychosocial concerns, and to provide support for families. Yet uptake of formal postnatal care services is low and inequitable in many countries. As part of a larger study examining the views of women, partners, and families requiring both routine and specialised care, we analysed a subset of data on the views and experiences of women related to routine postnatal care. METHODS We undertook a qualitative evidence synthesis, using a framework analysis approach. We included studies published up to December 2019 with extractable qualitative data, with no language restriction. We focused on women in the general population and their accounts of routine postnatal care utilization. We searched MEDLINE, PUBMED, CINAHL, EMBASE, EBM-Reviews, and grey literature. Two reviewers screened each study independently; inclusion was agreed by consensus. Data abstraction and scientific quality assessment were carried out using a study-specific extraction form and established quality assessment tools. The analysis framework was developed a priori based on previous knowledge and research on the topic and adapted. Due to the number of included texts, the final synthesis was developed inductively from the initial framework by iterative sampling of the included studies, until data saturation was achieved. Findings are presented by high versus low/middle income country, and by confidence in the finding, applying the GRADE-CERQual approach. FINDINGS Of 12,678 papers, 512 met the inclusion criteria; 59 articles were sampled for analysis. Five themes were identified: access and availability; physical and human resources; external influences; social norms; and experience of care. High confidence study findings included the perceived low value of postnatal care for healthy women and infants; concerns around access and quality of care; and women's desire for more emotional and psychosocial support during the postnatal period. These findings highlight multiple missed opportunities for postnatal care promotion and ensuring continuity of care. CONCLUSIONS Factors that influence women's utilization of postnatal care are interlinked, and include access, quality, and social norms. Many women recognised the specific challenges of the postnatal period and emphasised the need for emotional and psychosocial support in this time, in addition to clinical care. While this is likely a universal need, studies on mental health needs have predominantly been conducted in high-income settings. Postnatal care programmes and related research should consider these multiple drivers and multi-faceted needs, and the holistic postpartum needs of women and their families should be studied in a wider range of settings. REGISTRATION This protocol is registered in the PROSPERO database for systematic reviews: CRD42019139183.
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Affiliation(s)
- Emma Sacks
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, United States of America
| | - Kenneth Finlayson
- School of Community Health and Midwifery, University of Central Lancashire, Preston, United Kingdom
| | - Vanessa Brizuela
- Department of Reproductive Health and Research, World Health Organization, Genève, Switzerland
| | - Nicola Crossland
- School of Community Health and Midwifery, University of Central Lancashire, Preston, United Kingdom
| | - Daniela Ziegler
- Centre Hospitalier de l’Universite de Montreal, Montreal, Canada
| | - Caroline Sauvé
- Centre Hospitalier de l’Universite de Montreal, Montreal, Canada
| | - Étienne V. Langlois
- Partnership for Maternal, Newborn, and Child Health, World Health Organization, Genève, Switzerland
| | - Dena Javadi
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Soo Downe
- School of Community Health and Midwifery, University of Central Lancashire, Preston, United Kingdom
| | - Mercedes Bonet
- Department of Reproductive Health and Research, World Health Organization, Genève, Switzerland
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Roed MB, Engebretsen IMS, Mangeni R, Namata I. Women's experiences of maternal and newborn health care services and support systems in Buikwe District, Uganda: A qualitative study. PLoS One 2021; 16:e0261414. [PMID: 34914783 PMCID: PMC8675744 DOI: 10.1371/journal.pone.0261414] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 12/02/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Uganda continues to have a high neonatal mortality rate, with 20 deaths per 1000 live births reported in 2018. A measure to reverse this trend is to fully implement the Uganda Clinical Guidelines on care for mothers and newborns during pregnancy, delivery and the postnatal period. This study aimed to describe women's experiences of maternal and newborn health care services and support systems, focusing on antenatal care, delivery and the postnatal period. METHODS We used triangulation of qualitative methods including participant observations, semi-structured interviews with key informants and focus group discussions with mothers. Audio-recorded data were transcribed word by word in the local language and translated into English. All collected data material were stored using two-level password protection or stored in a locked cabinet. Malterud's Systematic text condensation was used for analysis, and NVivo software was used to structure the data. FINDINGS Antenatal care was valued by mothers although not always accessible due to transport cost and distance. Mothers relied on professional health workers and traditional birth attendants for basic maternal services but expressed general discontentment with spousal support in maternal issues. Financial dependency, gender disparities, and lack of autonomy in decision making on maternal issues, prohibited women from receiving optimal help and support. Postnatal follow-ups were found unsatisfactory, with no scheduled follow-ups from professional health workers during the first six weeks. CONCLUSIONS Further focus on gender equity, involving women's right to own decision making in maternity issues, higher recognition of male involvement in maternity care and improved postnatal follow-ups are suggestions to policy makers for improved maternal care and newborn health in Buikwe District, Uganda.
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Affiliation(s)
- Marte Bodil Roed
- Department of Global Public Health and Primary Care, Centre for International Health, University of Bergen, Bergen, Norway
| | | | - Robert Mangeni
- Department of Social Work and Social Administration, College of Humanities and Social Sciences, Makerere University, Kampala, Uganda
| | - Irene Namata
- Faculty of Social Culture and Development Studies, Muteesa 1 Royal University, Masaka, Uganda
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Why women utilize traditional rather than skilled birth attendants for maternity care in rural Nigeria: Implications for policies and programs. Midwifery 2021; 104:103158. [PMID: 34700126 DOI: 10.1016/j.midw.2021.103158] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 09/18/2021] [Accepted: 09/26/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Data from the Nigeria Demographic and Health Survey indicate that many pregnant women in rural Nigeria use traditional birth attendants (TBAs) rather than skilled birth attendants (SBAs) for maternal health care. This is one factor that accounts for the persistently high rate of maternal mortality in Nigeria. The objective of this study was to identify the pervading reasons that women use TBAs for pregnancy care in rural Nigeria and to make recommendations for policy and programmatic reform. DESIGN Qualitative research design consisting of focus group discussions, key informant interviews, and community conversations, followed by inductive thematic analysis. SETTING Twenty rural communities (villages) in Etsako East, and Esan South East Local Government Areas of Edo State, South-South, Nigeria. PARTICIPANTS Twenty focus group discussions with men and women in a marital union; 15 key informant interviews with policymakers, senior health providers, and women leaders; and 10 community conversations with key community leaders. FINDINGS Some reasons proffered for using TBAs included perceptions of higher efficacy of traditional medicines; age-long cultural practices; ease of access to TBAs as compared to SBAs; higher costs of services in health facilities; and friendly attitude of TBAs. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE The continued use of TBA is a major challenge in efforts to achieve the Sustainable Development Goal 3 in Nigeria. We conclude that efforts to address the factors identified by community stakeholders as inhibiting the use of SBAs will promote skilled birth attendance and reduce maternal mortality in rural Nigeria.
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Fasawe O, Adekeye O, Carmone AE, Dahunsi O, Kalaris K, Storey A, Ubani O, Wiwa O. Applying a Client-centered Approach to Maternal and Neonatal Networks of Care: Case Studies from Urban and Rural Nigeria. Health Syst Reform 2020; 6:e1841450. [PMID: 33270477 DOI: 10.1080/23288604.2020.1841450] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
In Nigeria, two maternal and neonatal health Networks of Care (NOC) focus on extending the reach and quality of routine and emergency maternal and neonatal health services tailored to the different contexts. This paper uses the four domains of the NOC framework-Agreements and Enabling Environment, Operational Standards, Quality, Efficiency and Responsibility, and Learning and Adaptation-to describe the NOC, highlighting how each developed to address specific local needs. In Northern Nigeria, the NOC were established in collaboration among Clinton Health Access Initiative and the government to reduce maternal and neonatal morbidity and mortality. Health centers and communities in the network were supported to be better prepared to provide maternal and neonatal care, while birth attendants at all levels were empowered and equipped to stabilize and treat complications. The approach brought services closer to the community and facilitated rapid referrals. The NOC in Lagos State extended the reach of routine and emergency maternal and neonatal health services through organically developed linkages among registered traditional birth attendant clinics, private and public sector facilities, the Primary Healthcare Board, and the Traditional Medicine Board. Traditional birth attendants are registered, trained, and monitored by Apex Community Health Officers, whose responsibilities include collection and review of data and ensuring linkages to postpartum services, such as family planning and immunizations. While differing in their approaches, both NOC provide locally appropriate, pragmatic approaches to supporting women birthing in the community and encouraging institutional delivery to ensure that women and their babies have access to timely, appropriate, and safe services.
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Affiliation(s)
| | | | - Andy E Carmone
- Clinton Health Access Initiative , Boston, Massachusetts, USA
| | | | | | - Andrew Storey
- Clinton Health Access Initiative , Boston, Massachusetts, USA
| | - Osy Ubani
- Lagos Mainland Local Government Area (LGA), Lagos State Ministry of Health , Lagos, Nigeria
| | - Owens Wiwa
- Clinton Health Access Initiative , Abuja, Nigeria
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Chukwuma A, Mbachu C, McConnell M, Bossert TJ, Cohen J. The impact of monetary incentives on referrals by traditional birth attendants for postnatal care in Nigeria. BMC Pregnancy Childbirth 2019; 19:150. [PMID: 31104629 PMCID: PMC6526614 DOI: 10.1186/s12884-019-2313-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 04/24/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Gaps in postnatal care use represent missed opportunities to prevent maternal and neonatal death in sub-Saharan Africa. As one in every three non-facility deliveries in Nigeria is assisted by a traditional birth attendant (TBA), and the TBA's advice is often adhered to by their clients, engaging TBAs in advocacy among their clients may increase maternal and neonatal postnatal care use. This study estimates the impact of monetary incentives for maternal referrals by TBAs on early maternal and neonatal postnatal care use (within 48 h of delivery) in Nigeria. METHODS We conducted a non-blinded, individually-randomized, controlled study of 207 TBAs in Ebonyi State, Nigeria between August and December 2016. TBAs were randomly assigned with a 50-50 probability to receive $2.00 for every maternal client that attended postnatal care within 48 h of delivery (treatment group) or to receive no monetary incentive (control group). We compared the probabilities of maternal and neonatal postnatal care use within 48 h of delivery in treatment and control groups in an intention-to-treat analysis. We also ascertained if the care received by mothers and newborns during these visits followed World Health Organization guidelines. RESULTS Overall, 207 TBAs participated in this study: 103 in the treatment group and 104 in the control group. The intervention increased the proportion of maternal clients of TBAs that reported attending postnatal care within 48 h of delivery by 15.4 percentage points [95% confidence interval (CI): 7.9-22.9]. The proportion of neonatal clients of TBAs that reportedly attended postnatal care within 48 h of delivery also increased by 12.6 percentage points [95% CI: 5.9-19.3]. However, providers often did not address the issues that may have led to maternal and newborn postnatal complications during these visits. CONCLUSIONS We show that motivating TBAs using monetary incentives for maternal postnatal care use can increase skilled care use after delivery among their maternal and neonatal clients, who have a higher risk of mortality because of their exposure to unskilled birth attendance. However, improving the quality of care is key to ensuring maternal and neonatal health gains from postnatal care attendance. TRIAL REGISTRATION The trial was retrospectively registered in clinicaltrials.gov ( NCT02936869 ) on October 18, 2016.
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Affiliation(s)
- Adanna Chukwuma
- Health, Nutrition, and Population Global Practice, World Bank Group, Washington, DC 20433 USA
| | - Chinyere Mbachu
- Health Policy Research Group, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Margaret McConnell
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115 USA
| | - Thomas J. Bossert
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115 USA
| | - Jessica Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115 USA
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Haruna U, Kansanga MM, Bagah DA. Repositioning traditional birth attendants to provide improved maternal healthcare services in rural Ghana. Int J Health Plann Manage 2019; 34:e987-e994. [PMID: 30945362 DOI: 10.1002/hpm.2779] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 03/04/2019] [Indexed: 11/10/2022] Open
Abstract
Following the World Health Organization's recommendation for developing countries to discontinue the use of Traditional Birth Attendants (TBAs) in rural areas, the government of Ghana banned TBAs from offering maternal health care services. Since this ban, community-level conflicts have intensified between TBAs, (who still see themselves as legitimate culturally mandated traditional midwives) and nurses. In this articles, we propose a partnership model for a sustainable resolution of these conflicts. This article emanates from the apparent ideological discontent between people from mainstream medical practice who advocate for the complete elimination of TBAs in the maternal health service space and individuals who argue for the inclusion of TBAs in the health sector given the shortage of skilled birth attendants and continued patronage of their services by rural women even in context where nurses are available. In the context of the longstanding manpower deficit in the health sector in Ghana, improving maternal healthcare in rural communities will require harnessing all locally available human resources. This cannot be achieved by "throwing out" a critical group of actors who have been involved in health-care provision for many decades. We propose a win-win approach that involve retraining of TBAs, partnership with health practitioners, and task shifting.
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Affiliation(s)
- Umar Haruna
- Department of Social, Political and Historical Studies, Faculty of Integrated Development Studies, University for Development Studies, Wa, Ghana
| | - Moses M Kansanga
- Department of Geography, University of Western Ontario, London, Canada
| | - Daniel A Bagah
- Department of Social, Political and Historical Studies, Faculty of Integrated Development Studies, University for Development Studies, Wa, Ghana
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Haruna U, Kansanga MM, Galaa S. Examining the unresolved conundrum of Traditional Birth Attendants' involvement in maternal and child health care delivery in Ghana. Health Care Women Int 2018; 40:1336-1354. [PMID: 30481128 DOI: 10.1080/07399332.2018.1540006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Traditional Birth Attendants (TBAs) have been a critical human resource in maternal health care delivery in Ghana. However, following the World Health Organization's directive for countries to discontinue using TBAs, the government of Ghana has since emphasized the use of skilled birth attendants. This policy shift created tensions between TBAs and Community Health Nurses. We examine this conundrum in this paper. We find that despite the ban, TBAs still attend a significant number of births - a situation which has produced intense contestations and continuous jostling for "functioning space" and clients between TBAs and nurses. We recommend a consensus-based partnership approach that promotes cultural competence and is sensitive to contextual cultural practices that underpin pregnancy and childbirth.
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Affiliation(s)
- Umar Haruna
- Department of Social Political and Historical Studies, University for Development Studies, Wa, Ghana
| | | | - Sylvester Galaa
- Department of Social Political and Historical Studies, University for Development Studies, Wa, Ghana
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