1002483WHE0010.1177/17455065211002483Women’s HealthTabong et al. research-article2021 Primary Women’s Health Reasons for the utilization of the services Volume 17: 1– 10© The Author(s) 2021 Article reuse guidelines: of traditional birth attendants during sagepub.com/journals-permissions DhttOpsI::/ /1d0o.i1.o1r7g/71/01.17147575/1076452501615020121400823483 childbirth: A qualitative study in Northern journals.sagepub.com/home/whe Ghana Philip Teg-Nefaah Tabong1 , Joseph Maaminu Kyilleh2 and William Wilberforce Amoah3 Abstract Background: Skilled delivery reduces maternal and neonatal mortality. Ghana has put in place measures to reduce geographical and financial access to skilled delivery. Despite this, about 30% of deliveries still occur either at home or are conducted by traditional birth attendants. We, therefore, conducted this study to explore the reasons for the utilization of the services of traditional birth attendants despite the availability of health facilities. Method: Using a phenomenology study design, we selected 31 women who delivered at facilities of four traditional birth attendants in the Northern region of Ghana. Purposive sampling was used to recruit only women who were resident at a place with a health facility for an in-depth interview. The interviews were recorded and transcribed into Microsoft word document. The transcripts were imported into NVivo 12 for thematic analyses. Results: The study found that quality of care was the main driver for traditional birth attendant delivery services. Poor attitude of midwives, maltreatment, and fear of caesarean section were barriers to skilled delivery. Community norms dictate that womanhood is linked to vaginal delivery and women who deliver through caesarean section do not receive the same level of respect. Traditional birth attendants were believed to be more experienced and understand the psychosocial needs of women during childbirth, unlike younger midwives. Furthermore, the inability of women to procure all items required for delivery at biomedical facilities emerged as push factors for traditional birth attendant delivery services. Preference for squatting position during childbirth and social support provided to mothers by traditional birth attendants are also an essential consideration for the use of their services. Conclusion: The study concludes that health managers should go beyond reducing financial and geographical access to improving quality of care and the birth experience of women. These are necessary to complement the efforts at increasing the availability of health facilities and free delivery services. Keywords childbirth, Ghana, quality of care, reasons, traditional birth attendants Date received: 16 February 2021; revised: 16 February 2021; accepted: 17 February 2021 1 Background D epartment of Social and Behavioural Sciences, School of Public Health, College of Health Sciences, University of Ghana, Legon, Ghana 2 About 800 women are reported to die every day from preg- Nursing and Midwifery Training College, Tamale, Ghana3D 1 epartment of Nursing and Midwifery, Faculty of Health and Allied nancy and childbirth-related causes. The majority (>90%) Sciences, Catholic University College of Ghana, Sunyani, Ghana of these deaths occur in low- and middle-income countries (LMICs).1 The lifetime risk of maternal mortality in sub- Corresponding author: Philip Teg-Nefaah Tabong, Department of Social and Behavioural Saharan Africa is 1 in 38 women compared to 1 in 3700 in Sciences, School of Public Health, College of Health Sciences, developed countries.1 A key component of the strategy to University of Ghana, Box LG 13, Legon, Ghana. reduce maternal morbidity and mortality has been to Email: ptabong@ug.edu.gh Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 Women’s Health increase rates of skilled birth attendance and facility-based childbirth.2 While global skilled birth attendance rates rose by 12% in LMICs over the past two decades, almost one- third of women in these regions still deliver without a skilled birth attendant.2 The importance of skilled attendance at birth lies in the fact that access to and use of maternity care facilities and skilled personnel, particularly skilled attendance at birth is often associated with substantial reductions in mortality and Figure 1. Social–ecological model showing reasons for the morbidity for the mother over home births.3–7 Despite this utilization of the services of TBAs. recognition, not all women seek skilled care during preg- nancy or childbirth. Globally, several factors have been iden- that are paramount and that are the object of study.28 This tified as barriers to skilled maternal healthcare access. design was, therefore, deemed appropriate as the study Studies have shown that delivering in a health facility may aimed at documenting the lived experiences of women be hampered by distance to facilities.8–10 Other studies indi- who delivered at TBA facility and the reason for their cate that structural factors, including lack of financial or eco- choice of facility. nomic resources, transportation, and delivery supplies, and We adopted the social–ecological model. This model lack of coordination of referrals between traditional birth considers the complex interplay between individual, rela- attendants (TBAs) at the community level and facilities pre- tionship, community, and societal factors in affecting the vent women from using facility-based services11–15 Some phenomenon of interest.29 The structures at each of the studies also indicate that client’s negative perceptions of constructs in the model overlap and illustrate how factors healthcare staff, including reports of unfriendliness at deliv- at one level influence factors at another level. ery serve as barriers to obtaining skilled care.11,15–17 The individual constructs in the content of this study refer Ghana has expanded its healthcare facilities to reduce to the personal-level factors such as age, education, and geographical access to healthcare and also introduced the income that influence individual health-seeking behaviour.30 Community-based Health Planning and Services (CHPS) The relationship which is the second level examines close strategy in both urban and rural areas to bring healthcare to relationships that may influence the likelihood of using the doorsteps of communities.18–20 Free maternal and deliv- TBAs for delivery. An individual’s closest social circle peers, ery services were also introduced to break financial barriers partners, and family members influences their behaviour and to antenatal, skilled delivery, and postnatal services in contribute to their range of experience. The relationship fac- 2008.21,22 Despite this, there is growing concern that many tors also include previous experience with biomedical facili- pregnant women still have unskilled delivery. For example, ties or TBAs during childbirth. The third level (community) the most recent (2014) demographic and health survey explores the settings, such as health facilities and neighbour- showed that while the percentage of women making the hoods, in which social relationships occur and seeks to iden- World Health Organization’s (WHO) recommended four tify the characteristics of these settings that are associated antenatal care visits is 87%, skilled attendance at birth is with health-seeking behaviour31 during labour. The fourth 74%.23 This implies that 26% of women delivered at home or and final level (societal) looks at the broad societal factors used the services of traditional birth attendants. Again, a sec- that help create a climate that drives people towards using the ondary data analysis conducted on the 2017 Ghana Maternal services of TBAs (Figure 1). Health Survey showed that approximately 98.7% of mater- nal deaths completed less than four antenatal visits, and only 38.4% utilized skilled birth attendance during delivery.24 Study area Unskilled delivery rates are higher in Northern Ghana.25 An The study was conducted in Tolon District and Yendi earlier study showed that in the Northern part of Ghana about Municipality in the Northern region of Ghana. The Tolon 39.1% of births occur at TBA facilities.26 This study was, district is divided into three sub-districts for the delivery of therefore, conducted to identify the reasons for women’s healthcare. There are health centres in each of the sub-dis- preference for the service of TBAs when they live in com- tricts and CHPS compounds in communities in the district. munities with accessible health facilities and free service. Access to health facilities has been reported to be higher than the regional average.32 The Yendi municipality has a Methods and materials government hospital located in Yendi and four health cen- Study design tres located at Yendi, Bunbonayili, Ngani, and Adibo. The municipality also has four7 CHPS compounds at Sunson, This study adopted the phenomenology approach to quali- Kuni, Kamshegu, Oseido, Montondo, Yimahegu, and tative enquiry.27 In phenomenological research, it is the Kpasanado. There is also a clinic at Malzeri and a private participants’ perceptions, feelings, and lived experiences clinic at the Church of Christ premises in Yendi.33 Tabong et al. 3 The selection of the district was based on information guides were pretested with five women who utilized the gathered from the Regional Health Directorate and avail- services of TBA in another suburb of Tamale. All the inter- able literature. These two districts are noted for a high views were conducted by trained research assistants with number of TBA deliveries in the region despite the avail- previous experience in conducting qualitative interviews. ability of health facilities. In Tolon, it has been reported We collected socio-demographic data such as age, educa- that each community has more than two TBAs.34 Yendi tion level, religion, and reproductive history at the end of was also selected because of the number of TBAs in the the interview. The interviews for each day were transcribed district and had served as a district for the training of TBAs before proceeding to conduct more interviews. The daily in the region in the past. As a result, the district has more review and coding were useful in determining the point of than 30 TBAs across various communities.35 saturation.37 Eligible women who refused to participate in the study were replaced. Four women who were eligible Study population and selection of participants and recruited refused to participate for personal reasons. Interviews were conducted between March 2019 and June The study population were women who had live birth in the 2019. Interview sections lasted for 30–40 min. TBA facilities in one selected district and a municipality. Health workers in the selected districts were used to identify Reflexivity and bracketing the TBAs who have high attendance based on their district report. Their facilities were visited and women who had Reflexivity relates to the degree of influence that the childbirth with TBA pending their discharge were recruited researcher brings to bear on the research either intention- for the study. An initial screening sheet was used to select ally or unintentionally.38 Reflexivity enhances the quality eligible women. To be eligible, the person should be resid- of research and also boosts understanding of how the ing in a community with a health facility and should be researcher’s own interest could affect the research pro- gainfully employed with a monthly income of more than the cess.39 Bracketing, on the contrary, refers to an investiga- minimum wage of GHȻ310.00 ($53.13). Financial access tor’s identification of vested interests, personal experience, and travel distance have been reported as known barriers to cultural factors, and assumptions that could influence how skilled delivery. This strategy was, therefore, employed to he or she views the study’s data.40 In qualitative research exclude people who had to use TBA services because of adopting phenomenology, it is important for researchers to non-availability of a health facility. Higher costs associated disclose their personal biases and measures that were put with seeking supervised maternity services have been noted in place to improve rigour, trustworthiness, and credibility as very critical to the uptake of care for many women in of the research findings. Several strategies were adopted in Ghana and other developing nations.5,36 Free maternal reflexivity and bracketing. health service was introduced in Ghana as a pro-poor strat- First, the research team did not have preconceived ideas egy to reduce the financial barrier to healthcare during preg- and interest regarding the outcome of the study findings. The nancy and childbirth. The free maternal health policy was study was mainly informed by available literature that clearly implemented in Ghana in July 2008 under the National shows that some women still have unskilled delivery despite Health Insurance Scheme (NHIS). The policy allows all the expansion of health facilities and introduction of free pregnant women to have free registration with the NHIS maternal healthcare policy. Furthermore, the research team after which they would be entitled to free services through- and the research assistants were very open to study partici- out pregnancy, childbirth, and three months postpartum. pants during data elicitation. There was no social or biologi- cal relationship between study participants and researchers. Data collection tool and procedure Although all the researchers have clinical training and prac- tice, at the point of data collection and the research, none of An in-depth interview (IDI) topic guide was used for the the researchers was involved in clinical care. data collection. The topic guide was designed in English In addition, research assistants with experience in con- and translated into the local language (Dagbanli). The ducting qualitative interviews were recruited and trained topic guide was designed according to the four constructs by the lead investigator. They were informed on the need (individual, relationship, community, societal) in the to have a neutral mind and behaviour towards study par- social–ecological framework. For example, we asked ticipants during interviews or data collection. They were questions about the reasons for utilizing the services of the further told that any biased behaviour, preconceived TBA, the various actors in the decision-making process, beliefs, or values could affect the data that would be col- and their views about the type of services provided by the lected and that could further have a negative effect on the TBA. For those who indicated they had previous experi- outcome of the study findings. ence with health facility delivery, we asked them to com- Recorded interviews were replayed to participants to pare the services at the health facility with those rendered make inputs and corrections. The interviews were tran- by the TBAs (see Supplementary file 1). These topic scribed verbatim. After the data collection and analysis, 4 Women’s Health the findings were shared with some of the participants Table 1. Socio-demographic and reproductive history of through a dissemination workshop. This enabled the par- study participants. ticipant to review and agree with the findings of the study Background information Number Percentage (%) as a form of member checking.41 In addition, a codebook was developed, reviewed, and Age accepted by the research team. Double coding of the data <20 years 8 25.8 was done and compared. The coding trail was reviewed by 20–30 years 14 45.2 an independent person for verification. Using the NVivo >30 years 9 29.0 software, a coding comparison query showed a high level ANC attendance of agreement with a Kappa score of 0.92.42,43 Yes 23 74.2 No 8 25.8 Parity Data analysis 1 6 19.3 2 7 22.6 All IDIs were recorded during the interview. The inter- 3 8 25.8 views were played to the interviewee after the interview >3 10 32.3 for them to make the necessary corrections and addition. Previous hospital delivery The recordings were transcribed verbatim. The transcripts Yes 10 32.2 were reviewed by an independent person who listened to No 21 67.8 the recordings and compared the content with the tran- scriptions. Daily interviews were shared with other ANC: antenatal care. authors to review and provide feedback on the process. This iterative approach strengthened the data elicitation Ethical approval process. Interviews continued until data saturation was achieved.44 Hybrid inductive and deductive framework45 The protocol for the study was reviewed and approved by were used in developing the codebook, coding of the tran- the Ethics Review Committee of Ghana Health Service scripts, and developing the themes. Conceptual dimen- (GHS-ERC 18/02/2019). All participants signed an sions of the interview guides guided the preliminary informed consent form before participation. development of the codebook. This was then revised to include the emerging themes from the data. This code- book was discussed and accepted by all authors. The tran- Results scripts were imported into QSR NVivo 12 for textual Background information of participants analysis. We used the case classification function in NVivo to identify each respondent and their attributes Fourteen (45.2%) of the participants were between 20 and (socio-demographic and reproductive history). We first 30 years with majority of them (74.2%) having attended at read through selected transcripts in NVivo and created least one ANC. Ten women (32.2%) have even delivered nodes from the emerging issues in the data. Both free and in a health facility (Table 1). free nodes were created during the coding until all the transcripts were coded. During coding, memos were writ- Good interpersonal relationship and practices ten to key reflection from the data. The memos were linked to both the data sources and the nodes. Coded sec- by TBAs tions were regrouped into relevant categories and themes Participants in this study revealed that they patronize the ser- for presenting the results. Direct quotations were used, vices of TBAs because of their good services and interper- where appropriate, to support the themes. The main sonal relationship. This according to respondents in this study themes that depict reasons for patronizing the services of makes them feel confortable at their facilities. They are also TBAs could basically be divided into biomedical health able to discuss freely with TBAs their personal feelings and facility push factors and TBAs pull factors. These factors, challenges. A participant shared her experience as follows: which emerged from data, could be put into six sub- themes; good interpersonal relationship and practices by I came here to deliver because the woman has a very good TBAs, post-delivery baby care and provision of special interpersonal relationship. When you come, she will welcome food by TBAs, requirements for labour in biomedical you and have time to listen to all your problems. So, we feel health facilities, preference for vaginal delivery and fear very comfortable discussing issues with her. (28 years, para 2) of caesarean section (C/S), perception about poor services in biomedical facilities and inexperienced midwives, and Interviewees also indicated that TBAs allow women to poor attitude of health workers during antenatal care assume any position of their choice during childbirth. So, (ANC) and facility delivery. individuals who opt to squat are allowed as it is believed Tabong et al. 5 this helps in pushing the baby out faster. They juxtaposed pregnant woman in labour who goes to the biomedical the squatting position with the lithotomy position at bio- health facilities without all the items risk being scolded by medical facilities which in their opinion gives discomfort. midwives. Hence, women prefer to attend ANC at the bio- One interviewee revealed, medical health facilities and then go to TBA when labour starts. This concern was mostly raised by women who had This woman treats us differently. When you come and you previously delivered at a biomedical health facility. The feel comfortable squatting to give birth, she will allow you, following illustrates this point: and her place is designed to suit that and this position helps to push the baby out faster but in the hospital, I was made to lie I attended ANC at the health facility where I was given a very down and raise my leg and I could not breathe very well. (30 long list of items to get for myself and baby and should come years, para 2) to the hospital with those items if I am coming to deliver. I cannot afford those items, so I came here and the woman can manage with what I have. But I am sure if I had gone to the Post-delivery baby care and provision of special hospital without those items, I will be shouted at. (32 years, food by TBAs para 3) Participants in this study indicated one of the reasons for I delivered my first child at the hospital. When I got there in the use of the TBA during labour is the care of the baby labour instead of the nurses attending to me they were busy after birth. In their opinion, the baby receives a special checking the items I brought and started shouting at me why I bath and massage, which is believed to make the baby didn’t bring this and that? But here the woman knows that strong. Moreover, some women patronize the services of some people cannot afford so whatever you bring the women TBA because they are served with some special food after will make do with it. (29 years, para 2) delivery. This food in their view promotes lactation. The mothers are also fed on these hot meals until they are dis- charged from the facility. Two participants shared their Preference for vaginal delivery and fear of C/S experiences as follows: Respondents in this study also utilized the services of TBAs because of what they perceive as unnecessary oper- When you deliver here [TBA facility] you are given special ations in the hospital. To some of them, when you go to the food until you are discharged. Unlike the hospital where hospital and there is any delay in labour, C/S is performed. nobody cares if you have eaten or not. This special soup is Unlike the TBAs where you may be given some herbal prepared for people who also deliver at home by our mother preparations to facilitate vaginal delivery. This was neces- which helps bring breastmilk. (27 years, para 3) sary because in their view, motherhood is linked to vaginal delivery and women take pride in their ability to give birth The women (TBAs) are very good. I had my first baby here and she provided us with food and bathed the baby and through the vagina. Interviewees were also of the view that applied good oil to massage the baby and my boy is very babies delivered through the vagina are stronger and more strong. He is the one playing over there. So that is why I have intelligent than those delivered through C/S. The follow- come here again. (29 years, para 2) ing quotes illustrate these points: Respondents in this study also patronize TBAs because My friend went to the hospital and experience some delay in they provide them with some concoctions, which promote the baby coming out [being delivered] and they operate on lactation and recovery as illustrated: her. She was unhappy so I was afraid that may happen to me too. The woman gave me something to drink and shortly the baby came out. (25 years, para 1) We can get some herbal preparations which are very good for our health, so it is one of the reasons why we come to her. After delivering you become strong instantly after taking All women prefer vaginal delivery because that makes you a woman and a mother. If they operate you to remove the baby what she gives to you. people do not respect you. Children born through the vagina are also stronger and intelligent. (31 years, para 2) Requirements for labour in biomedical health facilities Perception about poor services in biomedical facilities and inexperienced midwives Furthermore, the inability of some women to acquire items requested for labour in biomedical facilities emerged as Interviewees were unanimous of the poor quality of ser- one of the reasons for unskilled delivery at TBAs. vice rendered at biomedical health facilities. Quick service Participants believed that the list provided to prospective and good medical attention were mentioned as key quality mothers during ANC deter women from going to biomedi- indicators in this study. Generally, respondents were of the cal health facilities during labour. In their opinion, a opinion that there were always delays at biomedical health 6 Women’s Health facilities. Therefore, they prefer to utilize the services of have now become so insensitive to the concerns of women TBAs who provide their clients better and quick service. A in labour. One shared her experience where she was in dis- participant shared her experience as follows: tress but was ignored by the midwife on duty. This accord- ing to her resulted in stillbirth after an initial ultrasound Usually these days when you go to the health centre or the had shown that the baby was alive: hospital, you spend a lot of time waiting and when it is even time for you to see the doctor or nurses, their services do not This is my second delivery. On my first birth, I went to the meet our expectation. So, for me, I prefer to use TBA. They hospital when I started feeling pain. So, I got to the hospital will listen to you very well and provide you with the best of and was there for some time and was asked to go for a scan care. (28 years para 2) which I did and they told me the baby was alive. I spend the whole night in the hospital and when I am in pain and I call Interviewees also indicated that disrespect at biomedical the nurse, she will shout at me that it is not time. Until the health facilities is one of the reasons for patronizing the baby came out and they told me the baby was dead. Since that TBAs. To them, TBAs were experienced women, and respect time, my friend advised me to come to this woman because the dignity of womanhood and, therefore, treat women with she is more experienced than the young nurses in the hospital love and compassion. Interviewees also characterized TBAs these days. (30 years, para 2) as mothers who have gone through labour and, therefore, have a better understanding of the process. In their view, Another woman narrated how she was neglected during some midwives in biomedical health facilities have not expe- labour while the nurses were busy chatting with people on rienced pregnancy and childbirth and, therefore, are less their phones. She, therefore, called on health managers to responsive to the psychosocial needs of women. The follow- ban the use of mobile phones by health workers on duty: ing quotes support these claims by participants: In my case, I went to the hospital and the nurse told me it was too early for me to deliver after examining me. They left me I often hear that when you go to the hospital the nurse will be there in very serious pain whilst they were busy chatting and rude towards you and shout at you. So, I decided to come to one of them was using WhatsApp. The use of phone should be this woman whom I know she has children and will know ban, it has come to increase the neglect that patients receive. what it takes to deliver. (26 years, para 1) The young nurses are always busy chatting with boyfriends whilst on duty. (33 years, para 2) TBAs have children and have experienced the process of giving birth better than some of the nurses in the hospital. Some nurses especially the young ones have never given birth Discussion and therefore do not appreciate the pain and suffering women go through. (34 years, para 3) The poor attitude of midwives emerged as a push factor for facility delivery while encouraging the patronage of TBAs. This finding brings to bear that even though the challenges Poor attitude of health workers during ANC of accessibility are being addressed by providing more and facility delivery health facilities through the scale-up of the CHPS strategy, there are still significant issues relating to the negative atti- Poor quality of services at the health facilities due to non- tude of health workers. It is important to note that the atten- availability of midwives, negative experiences with mid- tion given to women by TBAs and quality of care is a wives during ANC visits emerged as one of the reasons for motivation for many women to access their services. Quality women delivering at TBA. Interviews with postnatal of care has been defined as the difference between how women revealed that they were badly treated or had to wait medical care can optimally be delivered and how it is deliv- for a longer duration in the hospital before receiving care. ered.46 Several studies have demonstrated the role of quality Hence, they did not want that to happen to them during care in producing enhanced maternal health outcomes.46–48 labour as that could lead to the death of the baby which To this end, evidence from diverse settings has suggested they so much desired to have: that increasing facility delivery may not reduce mortality if the quality of care is poor.49–51 For instance, a 2013 analysis . . . If you check my card, you will find that I have attended ANC at [health facility name withheld] but the delays there of WHO multi-country survey data suggest that coverage were just too much. So, I was afraid that may happen to me with life-saving interventions may be insufficient to reduce during childbirth and that can affect my baby or result in the maternal deaths without overall improvements in the quality death of my baby. I have been looking for this pregnancy for of maternal healthcare.52 There is, therefore, the need to put long. (34 years, para 1) in place measures to improve the quality of care and birth experiences of women. Customer care can also be incorpo- Also, previous experience of maltreatment during rated into the training of health workers. labour was mentioned as a reason for TBA delivery. In the Participants in this study were of the view that TBAs have view of such respondents, health workers in labour wards an in-depth understanding of labour and have a better sense Tabong et al. 7 of urgency to act and willing to support mothers. These reported to vary between 3.3 in rural poor women to 10.8 attributes led to expectant mothers’ preference for their ser- in urban richer women. A study conducted at the University vice. In contrast, services at hospitals were seen as poor with of Cape Coast Teaching Hospital found a C/S rate of health workers treating the expectant mother with discon- 26.9%.63 Though there is inconsistency in the rate of C/S, tent. These negative attitudes prevented women from utiliz- it is clear the rates are relatively high. Moving forward ing skilled delivery. Similarly, a study in Northern Ghana has there is, therefore, the need to do case reviews of C/S con- shown that women refused to patronize facility-based deliv- ducted in different hospitals to inform policy. ery because of poor quality and maltreatment during labour.34 The findings of this study underscore the need for nurses to Limitations of the study change their attitude towards clients that seek healthcare. The study found squatting position as one of the reasons Even though this study provides useful insights and rea- for the use of TBA facilities. Another reason cited for deliv- sons for the continuous patronage of the services of the ery at TBA facilities is the use of herbs, which is believed TBAs, it is important to note a few limitations. One weak- to be effective and facilitate the labour process. As found in ness in qualitative studies is the inability to generalize the some studies, women’s preference for TBAs during preg- findings.27 Nonetheless, we employed maximum variation nancy and labour, compared to the healthcare facilities, was sampling technique involving women from different com- due to the use of herbal medications, which was preferred munities and TBAs operating at different locations to to the drugs and vaccines administered at the ANC clin- strengthen the findings of the study while increasing the ics.53 In light of these, health education offered to women credibility, dependability, and trustworthiness64 of the evi- during ANC visits should highlight the necessity for the dence from the study. continuum of care that includes skilled attendance at birth In addition, some of the interviews were conducted in and postnatal care. Again studies have reported that even the local languages and translated into English, hence women who attend ANC still go to deliver at TBA facili- some words could have lost their original meanings as a ties.54 As more than 65% of maternal deaths occur during result of the translation. To minimize the effects of possi- delivery, the importance of having a skilled attendant in a ble distortions due to translations, each translation was facility with adequate healthcare services during the time of done by two people and the research team reviewed the birth cannot be overemphasized.55 Furthermore, orthodox translations from the local languages. Nevertheless, given healthcare providers are guided by procedures that may be the limitations of such a procedure, little weight was placed at variance with the cultural inclinations of pregnant on the specific wording or phrasing of responses but on the women.56–58 It is, therefore, critical for health facilities to overarching themes from the data. identify some of the good practices of the TBAs and incor- porate them into biomedical healthcare services. Conclusion Collaboration between TBAs and health workers in bio- medical facilities can provide an opportunity for the train- The study concludes that health managers should go ing of TBAs on danger signs during labour and encouraging beyond reducing financial and geographical access to them to refer such cases to avert complications. improving the quality of care and birth experience of Another barrier to utilization of skilled delivery was the women. Financial and geographical access is necessary fear of C/S section and perceived belief of the high inci- but not sufficient to guarantee skilled delivery. Quality of dence of C/S. This fear is related to community beliefs that care is necessary to complement the efforts at increasing motherhood was generally related to vagina delivery. the availability of health facilities and free delivery ser- Hence women who give birth through C/S did not receive vices. Accepting harmless social practices during labour the same recognition as those who deliver through the will improve trust and cater for community’s worldview vagina. However, since the TBAs did not have expertise in about childbirth. performing C/S, respondents were of the view that using their outlet was an assurance that one could avoid C/S out- Acknowledgements come. An earlier study showed Ghanaian women’s prefer- We thank all study participants for accepting to be part of the ence for vaginal delivery,59 but our study highlights the study. reasons for their preference. An earlier study has shown that women generally prefer vaginal delivery with about Author contributions 11.6% of C/S deliveries refusing this mode of delivery in 60 P.T.-N.T. was involved in the conceptualization, methodol-developing countries. Low preference for C/S has been ogy, data collection, formal analysis, and writing – original reported across the world in a systematic and meta-analy- draft of the article. J.M.K. also was involved in the conceptu- sis of observational studies.61 Per the WHO standards, C/S alization of the article. 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