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Background: Over the years, governments and stakeholders have implemented various policies/programmes to improve maternal health outcomes in low-middle-income countries. In Ghana, Community Health Officers were trained as midwives to increase access to skilled maternal healthcare. The government subsequently banned traditional birth attendants from providing direct maternal healthcare in 2000. Despite these, there is an unprecedented utilisation of TBAs’ services, including herbal uterotonics. This has attempted to defeat stakeholders’ campaigns to improve maternal health outcomes. Thus, we explored and highlighted herbal uterotonic consumption in pregnancy and birth and the implications on maternal and newborn health outcomes in North-Western Ghana. Methods: This was an exploratory qualitative study that investigated traditional birth attendants (n = 17) and healthcare providers’ (n = 26) perspectives on the intake of herbal uterotonics in pregnancy and childbirth in rural Ghana, using in-depth interviews. A combination of convenience, purposive and snowball sampling procedures were employed in selecting participants. Results: Findings were captured in two domains: (1) perceived rationale for herbal uterotonic intake, and (2) potential adverse impacts of herbal uterotonic intake in pregnancy and labour, and nine topics: (i) confidence in unskilled attendance at birth, (ii) cost and a shortage of essential medicines, (iii) herbal uterotonics as a remedy for obstetric problems, (iv) herbal uterotonics facilitate birth, (v) attraction of home birth for cultural reasons, (vi) affordability of herbal uterotonics, (vii) unintended consequences and adverse outcomes, (viii) risks using herbal uterotonics to manage fertility and (ix) risks using herbal uterotonics to facilitate home birth. Conclusion: The findings have suggested that the intake of non-conventional herbal uterotonic is widespread in the study area, although the constituents of the herb are unknown. However, complex and multiple factors of healthcare cost, desire for homebirth, unawareness of the negative effects of such substances, perceived way of addressing obstetric problems and cultural undertones, among others, accounted for herbal uterotonics consumption. We also encourage research into the constituents of ‘mansugo’ and the potential benefits and adverse effects. We recommend qualitative studies involving previous users of this herbal uterotonic to inform policy and healthcare provision.
The study was conducted at Nadowli-Kaleo and Daffiama-Bussie-Issa districts of the Upper West Region (UWR) of Ghana. Of the population aged 11 years and over, in Nadowli-Kaleo, only 51% of the population were classified as literate (53% males vs 47% females). In contrast, in Daffiama-Bussie-Issa District, only 42.3% met the literacy criteria (48.2% males vs 37% females. Broadly, residents had very low secondary or tertiary level education (males 5%, females 2.8%) [23, 24]. Nadowli-Kaleo and Daffiama-Bussie-Issa districts are impoverished areas dominated by subsistence farming. More than 80% of the population (estimated population of 98,000 people) had no formal sector employment [23, 24]. Most of the population comprises youth (15–35 years) who live on less than the Ghana Cedi equivalent of five United States dollars a day. This exploratory qualitative study investigated herbal uterotonic uptake by women in the Nadowli-Kaleo and Daffiama-Bussie-Issa districts in the Upper West Region (UWR) of Ghana from the perspectives of TBAs and healthcare providers. Healthcare providers (n = 26) and traditional birth attendants (n = 17) participated in the study. The healthcare providers comprised of, a Physician, a Pharmacist, Midwives, Community Health Nurses, and Enrolled Nurses. All participants were between the ages of 18 to 70 years. Overall, 43 participants (n = 40 female, n = 3 male) were included in the study. A combination of convenience, purposive, and snowball sampling approaches was used in selecting participants for the study. Each participant participated in an individual in-depth interview (IDI). Under the snowballing approach, we first identified a TBA through the Community-based Health Surveillance Volunteers (CHSVs). This TBA referred the research team to other TBAs, that resided within the study communities. Overall, twenty TBAs were identified, and seventeen gave consent and participated in the study. Cultural reasons were cited for declining the consent to participate in the study. Information sheets containing the study aims, and data use, were given to the healthcare providers in selected health facilities. After reading, those who gave consent to participate were contacted and interviews were arranged at a mutually agreeable time. The Health and Medical Directors were invited to participate through a specific letter of invitation. A semi-structured interview topic guide was used in collecting data. The guide was prepared based on the evidence in the literature and informed by cultural knowledge and previous experiences of members of the research team. In addition, the interview topic guide content was checked by members of the research team, including experienced researchers and academics. As a result, the content of the instruments was the same for both participant groups. Table 1 contains the interview topic guide. Interview guide • Perceived benefits of using uterotonic substances • Perceived risk of using the uterotonic substance • Indications for use and dosage • Knowledge and experience with local herbal uterotonic/uterotonic substance • Traditional birth attendant motivation for maternal care and uterotonic use. Individual face-to-face interview techniques were used to collect data from all participants. The questioning focused on the topic areas presented in Table Table1.1. Using the two types of participants helped to explore and cross-validate perspectives that motivated the utilisation of the herbal uterotonics and uptake of TBA services during pregnancy, labour, and birth. We interveiwed TBAs in the local language (Dagaare) and English for the Healthcare Providers, between October 2020 and June 2021. Interviews were audiotaped and transcribed verbatim. Interviews lasted between 15 to 20 minutes. Three field assistants with a minimum of an undergraduate degree in social science and public health fields who were proficient in the local language “Dagaare,” were recruited and trained by the researchers for a week on ethics in research, questionnaire administration, data integrity, and confidentiality issues of participants. The training included interpretation of interview questions and data management. To achieve the data’s accuracy and dependability, all audio recordings were first transcribed (hand-written) in “Dagaare” and then translated into English. Two language experts at the Ghana Institute of Languages were engaged to validate the transcriptions and translations. Transcripts were exported into qualitative data management software (NVivo version 7.5) for coding. A coding framework was developed to code the text. Both computerised and manual coding was used. The computerised coding was complemented by topics identified in the manual coding process and professional experience. During the manual coding, data were thoroughly read and re-read to identify domains and themes. The research team conducted the coding independently and reconciled any differences that emerged. Patterns in the codes were identified and grouped into topics [25]. The topics were subsequently summarised into domains based on similarities, the content, and the meaning. Participants quotes were used to support the topics. Qualitative data arising from open-ended interview questions were transferred into NVivo™ software and analysed using Gibbs’s framework, which entails transcription and familiarisation, code building, theme development, and data consolidation and interpretation [26]. The data analysis involved prolonged engagement with the data. After each interview, notes were made. Emergent issues on herbal uterotonics (local herbal uterotonic) were grouped as factors and broad themes from the interview transcripts, written notes, and researchers’ reflections. The research team discussed emergent codes and organisation of themes to reach a consensus of themes and to manage dissenting findings. The views of TBAs and health providers were then grouped. The trustworthiness of the study was achieved using several procedures: investigated (member checking) until saturation was achieved; prolonged engagement with each participant; field notes were also taken to record non-verbal cues/observations during the interviews and then independent coding and checking of transcripts ensured that the data and analysis were credible.
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