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Background: Since the 1994 International Conference on Population and Development, male involvement in reproductive health issues has been advocated as a means to improve maternal and child health outcomes, but to date, health providers have failed to achieve successful male involvement in pregnancy care especially in rural and remote areas where majority of the underserved populations live. In an effort to enhance community participation in maternity care, TBAs were trained and equipped to ensure better care and quick referral. In 1997, after the advent of the World Health Organization’s Safe Motherhood initiative, the enthusiasm turned away from traditional birth attendants (TBAs). However, in many developing countries, and especially in rural areas, TBAs continue to play a significant role. This study explored the interaction between men and TBAs in shaping maternal healthcare in a rural Ugandan context. Methods: This study employed ethnographic methods including participant observation, which took place in the process of everyday life activities of the respondents within the community; 12 focus group discussions, and 12 in-depth interviews with community members and key informants. Participants in this study were purposively selected to include TBAs, men, opinion leaders like village chairmen, and other key informants who had knowledge about the configuration of maternity services in the community. Data analysis was done inductively through an iterative process in which transcribed data was read to identify themes and codes were assigned to those themes. Results: Contrary to the thinking that TBA services are utilized by women only, we found that men actively seek the services of TBAs and utilize them for their wives’ healthcare within the community. TBAs in turn sensitize men using both cultural and biomedical health knowledge, and become allies with women in influencing men to provide resources needed for maternity care. Conclusion: In this study area, men trust and have confidence in TBAs; closer collaboration with TBAs may provide a suitable platform through which communities can be sensitized and men actively brought on board in promoting maternal health services for women in rural communities.
The study was carried out in Luwero, a sub-county in central Uganda with an estimated population of 29,904 [38]. Luwero is an ethnically mixed district, with the Baganda constituting about 76 % of the district population followed by Baluli and Nubians at 3 % each. The minority ethnic groups have assimilated to the Ganda culture, and especially language. The predominant religious group is the Anglicans at 37 % followed by Catholics at 32 % and Moslems at 22 % the other being Pentecostal sects and Orthodox church. Though Christian and Islamic religion has become the main stream worship, African traditional beliefs and practices are still prevalent among most communities. Both systems of beliefs inform practice of rituals concerning, birth, death, marriage, and funeral rites. People belong to cultural units called clans, which form cultural organizations to which every member of community must belong. Many people have settled along clan and family units and therefore, many live in proximate distances with people with whom they share blood relationship. Marriage among people of the same clan is culturally prohibited, and therefore, many are related through marriage to the members of the surrounding clans. Being mainly rural, the population is mainly, engaged in peasant agriculture and roadside petty trade in agricultural and household items. The district is served by three main towns, Kasana-Luwero, Bombo and Wobulenzi, with a number of small trading centres along the main arterial highway that connects the capital with the northern region and South Sudan. According to the tiered national health delivery system of Uganda [37], a district is supposed to have a general hospital, followed by health centre IV at county level, health centre IIIs at sub-county, health centre II at parish level and village health teams (VHTs) working as a health centre I at the bottom majorly for referral purposes. This hierarchy reflects the level of equipment and services that are accessed. Full maternity services apart from emergency obstetric care are available at health centre III. Luwero district does not have a district general hospital but rather a health centre IV, and Luwero sub-county where the ethnography was done does not have a health centre III and II. Residents access treatment at the nearest health centre IV which doubles as the main district health facility, about 4 miles away from most of the catchment villages with transport costs averaging about Ugx, 3000 (1$) by motorcycle taxis which are the most available modes of public transportation. The only general district hospital that is equipped to provide full services including emergency obstetric care is approximately 20 miles from the community. In 2012, only 52 % of deliveries were attended by a skilled birth attendant [48]. This study was carried out as part of a broader study entitled Development of Sustainable Community Health Resources (CoHeRe) in resource-poor communities of Uganda under a partnership between Makerere University and University of Amsterdam. It involved extended ethnographic fieldwork between February 2013 and March 2014. Three authors (EBT, LKM and JTR) lived in the area for an extended period and collected the ethnographic data. The rest participated in other data collection and analysis activities including, field notes during spot checks, member checks, FGDs, dissemination and feedback activities, and supervision of data collection. Initially, purposive sampling was employed, targeting people and events that would give the researchers as much insight as possible. We observed daily life in the community and special events like community-wide meetings, weddings, burials and funeral rites. While observing such activities, data was collected through random and spontaneous conversations that were then analysed to identify recurrent issues and concepts; these comprised themes for further investigation. When the theme of TBAs as helpers in the event of pregnancy and childbirth emerged, we investigated it further through other ethnographic data collection methods. Twelve focus group discussions were held in the community: 6 with women, 3 with men and 2 with male VHT members. Twelve in-depth interviews were conducted: 5 with TBAs, 3 with VHT members, 2 with men, and 2 with district health officials. These were complemented with field notes taken during observational activities in the community on everyday life activities, and also with field notes taken by the researchers during visits to the antenatal clinic. All respondents were purposively selected to represent certain segments of the population—namely, men, women, youths, community leaders, TBAs and members of the village health teams. All interviews were tape-recorded after seeking and gaining permission of the respondents. The researchers were explicitly introduced as such to all community members at the beginning of the fieldwork period so that all people understood that the community was being studied for academic purposes. The social situations observed did not expose the studied community to any adverse effects. All collected data was secured under password-protected files that were accessible only to the research group. Pseudonyms have been used in reporting on this study in order to ensure confidentiality. Study approval was obtained from the ethical advisory board at the University of Amsterdam and Makerere University School of School of Public Health Higher Degrees, Research and Ethics Committee and registered by the Uganda National Council for Science and Technology [protocol number SS3420]. Data analysis was done concurrently with data collection in order to identify and rectify errors during interviews and focus group discussions. Detailed field notes were discussed by the research team in order to identified points to subject to member checks with the respondents. Researchers carried out the member checks through interviews with respondents in order to ensure narrative accuracy and interpretive validity. In addition, dissemination workshop by the research team was organized at the end of fieldwork where pre-liminary analysis was shared and respondents gave feedback. After field work, all taped data were transcribed into English and together with field notes were entered into Nvivo 10 software for analysis. Of these raw data consisting of 42 sources, a query was conducted using the search terms “TBA”, “TBAs”, “Mulerwa”. This query led to a total of identified usages of any of these terms within 12 focus group discussions, 12 in depth interviews, 10 field notes. For each of these 34 documents the broad context of these search terms were researched and coded using an inductive coding strategy. Coding trees were created roughly falling with the following coding structure: a) TBAs appreciation of biomedical superiority in their practice, b) TBAs ban and stealth practice c) myths about TBA practice and pregnancy, d) TBA negotiation for women’s access to pregnancy services, e) TBA sensitization of men on pregnancy related services, f) Men’s trust of TBAs, g) TBAs roles in men’s birth preparedness. These codes were then analyzed to create the narrative structure of the case study which the research team discussed and came to agreement in cognizance of the respondents feedback and the experience of the researchers in the field. Data included direct quotes from participants; these were edited for grammar without altering original meanings.
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