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Background: Prior to the advent of modern obstetric services, traditional birth attendants (TBAs) have rendered services to pregnant women and women in labour for a long time. Although it is anticipated that women in contemporary societies will give birth in hospitals and clinics, some women still patronize the services of TBAs. The study therefore sought to gain an in-depth understanding of the initiation of TBAs and their traditional and spiritual practices employed during pregnancy and childbirth in Ghana. Methods: The design was an exploratory qualitative one using in-depth individual interviews. Data saturation was reached with 16 participants who were all of Christian faith. Interviews were conducted with a semi-structured interview guide, audiotaped and transcribed verbatim. Content analysis was employed to generate findings. Results: The findings showed that TBAs were initiated through apprenticeship from family members who were TBAs and other non-family TBAs as well as through dreams and revelations. They practice using both spiritual and physical methods and their work was founded on spiritual directions, use of spiritual artefacts, herbs and physical examination. TBAs delay cutting of the cord and disposal of the placenta was associated with beliefs which indicated that when not properly disposed, it will have negative consequences on the child during adulthood. Conclusion: Although, TBAs like maternal health professionals operate to improve maternal health care, some of their spiritual practices and beliefs may pose threats to their clients. Nonetheless, with appropriate initiation and training, they can become useful.
The study adopted an exploratory qualitative design to gain in-depth understanding of the initiation and practices of TBAs as well as spiritual influences of their initiation and practice. The qualitative design allows probing and further exploration of emerging findings and was deemed appropriate for the study [37, 38]. This design was useful because we did not use an existing theory or framework but rather we used probes to follow-up on participants’ responses. This process afforded a deeper understanding of emerging themes. The study was conducted in a rural community in the Greater Accra Region (Kasseh) with the participants drawn from an organized group in Kasseh which includes TBAs. The Greater Accra Region is the smallest region in Ghana and is made up of 16 administrative areas. It is bordered on the north by the Eastern Region, on the east by Lake Volta, on the south by the Gulf of Guinea, and on the west by the Central Region. According to institutional data, maternal mortality ratio has worsened in the Greater Accra Region since 1992 as compared to the other administrative regions in the country [39]. It is thus imperative to understand the basis for the unexpected outcome by examining quality of care provided to women in this region which includes TBAs services. Kasseh is a major town located between Sege and Sogakope on the Accra-Aflao road. Kasseh has the biggest market in four districts (Ada West, Ada East, South Tongu and North Tongu) in its area. It is connected by road to the district capital, Ada-Foah and a town called Big Ada. Although it is the most easily accessible town in the district, poverty is widespread. Majority of the indigenous people are subsistence farmers using non-mechanized rain fed agriculture and the minority being fishermen and traders. They are also highly religious with the majority of the population being Christians. This setting was chosen because its communities were mainly emerging developments with limited access to health facilities that provide pregnancy and delivery care. It was also deemed as the appropriate place to get the targeted participants as there is also an organized group of TBAs in the town. The group includes TBAs from rural communities within the district who were believed to have adequate experience in traditional practices during childbirth. It is called “Association of TBAs, Herbalists and Spiritual Healers”. The association was established with 83 members but currently has a membership of 42. That is, 16 males and 26 females. The group at the time of data collection was made up of Christian TBAs. The group was formed as a means of bringing together all TBAs, Herbalists and Spiritual Healers in the community to network and share ideas. Members of the association meet every third Monday of the month to discuss progress, shortfalls and other relevant issues pertaining to their practices. Using a purposive sampling technique, both males and females were recruited. To be included in the study, TBAs should have practiced for two years. Permission was obtained from the leaders of the associations to enable the researcher book appointments according to the meeting days of the groups. A trained research assistant who could speak the Ada language fluently assisted the first author as a translator during the interviews of participants who only spoke Ada language. The interviewer (first author) does not speak the Ada language fluently. Other interviews were conducted in Twi and Ga. Only one participant spoke English during the interview. The interviews lasted between 30 and 45 min. The interviews started with a general question such as: ‘Please tell me how you became a TBA’ and responses were probed. Follow-up questions such as: ‘Please tell me what you do for pregnant women when they come to you’. In-depth understanding was achieved in this study and concurrent analysis helped in full exploration of emerging themes. Privacy was ensured during interviews and permission was obtained to record the interviews. The interviews were conducted in an enclosed place near the meeting grounds. Participation in the study was also voluntary. Interviews were transcribed in English and an expert in the local language who conducted the interviews checked the transcripts for accuracy. The research team read the transcripts several times to fully understand the perspectives of the participants. Concurrent analysis was undertaken using the techniques of content analysis. Inductive analysis processes were followed to develop themes and sub-themes since no theoretical framework informed the formulation of themes. The researchers independently coded the transcripts, grouped the codes and generated themes and sub-themes [40]. The themes and sub-themes were discussed among team members to ensure the data were faithfully captured. The data were subsequently managed using the NVivo software version 11. Relevant data were sifted to support themes and sub-themes and the findings were presented with supporting verbatim quotes from participants. Rigour or trustworthiness of the study was achieved using a number of procedures. Emerging themes were further investigated in subsequent interviews (member checking) until saturation was achieved. The researchers undertook prolonged engagement with 16 participants and this ensured that the phenomenon under investigation was fully understood. Also field notes were taken to record non-verbal observations and decision trails during the study. Again, independent coding and checking of transcripts ensured that the data and analysis were credible. Identification codes were used to present verbatim quotes. The ID numbers were assigned chronologically as participants were recruited. For example TBA1M – TBA4M. Ethical clearance for the study was obtained from the Institutional Review Board of the Noguchi Memorial Institute for Medical Research at the University of Ghana. Informed consent was obtained from all participants and the data was anonymized. Participants consented to the use of data for teaching and publication. Participants were also made aware of their right to withdraw from the study at any given time.
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